Your 2021 Western Health Advantage 3-Tier Preferred Drug List

Effective October 1, 2021

Health Plan Products: • City of Sacramento HSA HDHP HMO Prime • Deductible First HDHP HMO Prime • Prescription A • Prescription D • Prescription E • Prescription G • Prescription H • Prescription H2 • Prescription N • Prescription W • Rx 10/20/30 • Rx 10/20/30-2X • Rx 10/20/35-2X • Rx 10/25/35-2X • Rx 10/30/50 • Rx 10/30/50 Deductible • Rx 10/30/50-2X • Rx 10/30/50-2X Deductible For the most current list of covered medications • Rx 10/40/60 or if you have questions: • Rx 5/20/50 Call Member Services: • Rx 5/20/50-2X • 1-916-563-2250 or 1-888-563-2250, toll free • Western 1400/0/0 HDHP HMO Prime • TDD/TYY, 1-888-877-5378 • Western 1400/20/250 HDHP HMO Prime • Western 1800/0/0 HDHP HMO Prime Visit optumrx.com to: • Western 2800/0/0 HDHP HMO Prime • Find a participating retail pharmacy by ZIP code. • Look up possible lower-cost medication alternatives. • Western 2800/40/500 HDHP HMO Prime • Compare medication pricing and options. • Western 3000/30/30% HDHP HMO Prime • Find an electronic copy of the formulary. • Western 4000/40%/40% HDHP HMO Prime • Get plan coverage information. • Western 4500/50/40% HMO Prime This PDL includes a list of medications covered by Western Health • Western 5500/0/0 HDHP HMO Prime Advantage (WHA). This list is updated at least monthly and is subject to change. All previous versions are no longer in effect.

Updated October 1, 2021 3-Tier Plan Western Health Advantage

Table of Contents Informational Section...... 3 ANTIHISTAMINE DRUGS - Drugs for Allergy...... 9 ANTI-INFECTIVE AGENTS - Drugs for Infections...... 13 ANTINEOPLASTIC AGENTS - Drugs for Cancer...... 53 ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES - DRUGS FOR THE IMMUNE SYSTEM...... 75 AUTONOMIC DRUGS - Drugs for the Nervous System...... 89 BLOOD DERIVATIVES - Drugs for the Blood...... 114 BLOOD FORMATION, COAGULATION, THROMBOSIS - Drugs for the Blood...... 115 CARDIOVASCULAR DRUGS - Drugs for the Heart...... 132 CELLULAR AND GENE THERAPY - Drugs for Cancer...... 177 CENTRAL NERVOUS SYSTEM AGENTS - Drugs for the Nervous System...... 178 DENTAL AGENTS - Oral Care...... 249 DEVICES - Medical Supplies and Durable Medical Equipment...... 249 DIAGNOSTIC AGENTS...... 258 DISINFECTANTS (FOR NON-DERMATOLOGIC USE) - Disinfectants...... 268 ELECTROLYTIC, CALORIC, AND WATER BALANCE...... 268 ENZYMES...... 298 EYE, EAR, NOSE AND THROAT (EENT) PREPS...... 301 GASTROINTESTINAL DRUGS...... 322 GASTROINTESTINAL DRUGS - Drugs for the Stomach...... 322 GOLD COMPOUNDS...... 337 HEAVY METAL ANTAGONISTS - Drugs to Reduce Iron...... 337 HORMONES AND SYNTHETIC SUBSTITUTES - Hormones...... 339 LOCAL ANESTHETICS (PARENTERAL) - Drugs for Numbing...... 408 MISCELLANEOUS THERAPEUTIC AGENTS...... 413 NONHORMONAL CONTRACEPTIVES - Drugs for Women...... 449 OXYTOCICS - Drugs for Women...... 450 PHARMACEUTICAL AIDS...... 451 RADIOACTIVE AGENTS...... 451 RESPIRATORY TRACT AGENTS - Drugs for the Lungs...... 452 SKIN AND MUCOUS MEMBRANE AGENTS - Drugs for the Skin...... 467 SMOOTH MUSCLE RELAXANTS - Drugs to Relax Muscles...... 503 VITAMINS...... 505

TOC-2 Understanding your Preferred Drug List

What if I have questions about my prescription drug benefit? About this PDL Where differences between this PDL and your benefit You can contact Member Services at the phone number listed plan exist, the benefit plan documents rule. This may not on your Western Health Advantage (WHA) ID card or located be a complete list of medications that are covered by on the cover of this booklet. Member Services can help you your plan. Please review your benefit plan for full details. with these and other questions: The presence of a prescription medication on the PDL • Submitting prior authorization and step therapy exception does not guarantee an enrollee will be prescribed that requests drug by a provider for a particular medical condition. • Providing your cost share amount under your pharmacy benefit for drugs subject to a copayment or coinsurance Category List: Drugs are grouped into AHFS therapeutic • Answering questions about medications that may be a categories, which are listed under the Table of Contents in part of your medical benefit, or you can also contact your the PDL. If you know what category your medication is in, doctor for more information. refer to the Table of Contents to find the page. If a generic equivalent for a brand name is not available on What is a Preferred Drug List (PDL)? the market, the generic drug will not be listed separately. A PDL is a list of prescribed medications chosen by your The presence of a drug on the PDL does not guarantee that plan for their safety, cost, and effectiveness. Medications your doctor will prescribe the drug for a particular medical are listed by categories or classes and are placed into cost condition. levels known as tiers. It includes both brand and generic prescription medications approved by the U.S. Food and What are tiers? Drug Administration (FDA). The drug list in this PDL is Tiers are the different cost levels you pay for a medication. organized by the American Hospital Formulary Service (AHFS) Each tier is assigned a cost, set by your employer or plan Pharmacologic-Therapeutic Classification system. sponsor. This is how much you will pay when you fill a Western Health Advantage is guided by the Pharmacy and prescription. Therapeutics Committee (a group of doctors, nurses, and When does the PDL change? pharmacists) who reviews which medications will be covered, how well the drugs work, and overall value. They also make • Medications may move to a lower tier at any time. sure there are safe and covered options. • Medications may move to a higher tier when a generic equal becomes available. How do I use my PDL? • Medications may move to a higher tier or be excluded from You and your doctor can use the PDL to help you choose the coverage on January 1 or July 1 of each year. However, most cost-effective prescription medications. This PDL booklet if new information about drug safety or effectiveness tells you if a medication is generic or brand, and if special is released, or the drug is removed from the market, rules apply. Bring this PDL with you when you see your medications may move to a new tier immediately. doctor or use website link located on the cover page. If your medication is not listed here, please visit the plan website or When a medication changes tiers, you may have to pay a call the number on your member ID card. different amount for that medication if: You can find out if your medication is listed in the PDL and if • We add prior authorization, quantity limits and/or step it is covered by the plan by using the alphabetical index by its therapy requirements. brand or generic name, or by using the Category list. • The medication moves to a higher tier. The index at the end of the PDL lists the names of drugs by Please note: We will notify you 60 days before the change both generic and brand name, in alphabetical order. Once becomes effective if you currently take the medication or at you find the drug name, go to the page number listed to the time you request a refill (you will receive a 30-day supply). locate the coverage information.

3 Understanding your Preferred Drug List continued

Why are some medications excluded What is the copay amount for oral from coverage? anti-cancer drugs? A medication may be excluded from coverage under your Oral anti-cancer drugs are subject to a maximum copayment pharmacy benefit when it works the same as or similar to for each 1-month supply, after any deductible has been met. another prescription or over-the-counter (OTC) medication. What if I don’t agree with a decision about an excluded medication? You or your authorized representative and your doctor can ask for a coverage request by calling the number on your member ID card. WHA member services representatives can help guide you further.

Medication tips

What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent for a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. What if my doctor writes a brand-name prescription? Over-the-counter If your doctor gives you a prescription for a brand-name medication, ask if a medications generic or lower-cost option could be right for you. Generic medications are usually An over-the-counter (OTC) your lowest-cost option. medication may be the right What are my pharmacy options for filling a prescription? treatment for some conditions. Talk to your doctor about OTC options. WHA uses the OptumRx pharmacy network, which allows you to fill your Even though OTC medications may prescription at one of the participating retail pharmacies. This includes most U.S. not be covered by your pharmacy chain pharmacies and many independent pharmacies. To find a participating benefit, they may cost less than a pharmacy near you, visit mywha.org and select pharmacy, or call WHA at the prescription medication. number on your member ID card or listed on the front cover of this booklet. Can I use a mail order pharmacy? For certain types of medications, you can save time and money by receiving a 90-day supply through OptumRx home delivery or by using the Select90 program at Walgreens or CVS Pharmacy. The medications available through home delivery or Select90 are drugs that you may be taking on a regular basis for a chronic or long-term medical condition. What if I am taking a specialty medication? Specialty medications are for rare or complex medical conditions. They are oral or injectable medications that can cost more than $600 for a 30-day supply. Please note, not all specialty medications are listed in this PDL. Most specialty medications require PA for coverage and all are limited to up to a 30-day supply through WHA’s exclusive specialty pharmacy network. Optum® Specialty Pharmacy can provide most of your specialty medications along with helpful programs and services. Call Optum Specialty Pharmacy at 1-855-427-4682 and have your prescriptions delivered right to your home. You may also contact NorthBay healthcare, UC Davis onsite pharmacies, or St. Joseph’s McAuley pharmacy of Dignity Health. WHA will allow up to 2 initial fills at local retail pharmacies to make sure you get started on your medications in a timely manner. All other fills will be limited to WHA’s exclusive specialty network, unless otherwise restricted by the manufacturer or FDA. Please refer to your Copayment Summary for specific copayment amounts.

4 Definitions

Brand-name drug is a drug that is marketed under a Nonformulary drug is a prescription drug that is not listed proprietary, trademark protected name. The brand name on the health plan’s formulary. drug shall be listed in all CAPITAL letters. Out-of-pocket cost are copayments, coinsurance, and the Coinsurance is a percentage of the cost of a covered health applicable deductible, plus all costs for health care services care benefit that an enrollee pays after the enrollee has paid that are not covered by the health plan. the deductible, if a deductible applies to the health care Prescribing provider is a health care provider authorized to benefit, such as the prescription drug benefit. write a prescription to treat a medical condition for a health Copayment is a fixed dollar amount that an enrollee pays for plan enrollee. a covered health care benefit after the enrollee has paid the Prescription is an oral, written, or electronic order by a deductible, if a deductible applies to the health care benefit, prescribing provider for a specific enrollee that contains the such as the prescription drug benefit. name of the prescription drug, the quantity of the prescribed Deductible is the amount an enrollee pays for covered drug, the date of issue, the name and contact information health care benefits before the enrollee’s health plan begins of the prescribing provider, the signature of the prescribing payment for all or part of the cost of the health care benefit provider if the prescription is in writing, and if requested by under the terms of the policy. the enrollee, the medical condition or purpose for which the Drug Tier is a group of prescription drugs that corresponds drug is being prescribed. to a specified cost sharing tier in the health plan’s prescription Prescription drug is a drug that is prescribed by the drug coverage. The tier in which a prescription drug is placed enrollee’s prescribing provider and requires a prescription determines the enrollee’s portion of the cost for the drug. under applicable law. Enrollee is a person enrolled in a health plan who is entitled Prior Authorization is a health plan’s requirement that to receive services from the plan. All references to enrollees the enrollee or the enrollee’s prescribing provider obtain the in this formulary template shall also include subscribers as health plan’s authorization for a prescription drug before the defined in this section below. health plan will cover the drug. The health plan shall grant Exception request is a request for coverage of a prescription a prior authorization when it is medically necessary for the drug. If an enrollee, his or her designee, or prescribing health enrollee to obtain the drug. care provider submits an exception request for coverage of a Step therapy is a process specifying the sequence in which prescription drug, the health plan must cover the prescription different prescription drugs for a given medical condition drug when the drug is determined to be medically necessary and medically appropriate for a particular patient are to treat the enrollee’s condition. prescribed. The health plan may require the enrollee to try Exigent circumstances are when an enrollee is suffering one or more drugs to treat the enrollee’s medical condition from a health condition that may seriously jeopardize the before the health plan will cover a particular drug for the enrollee’s life, health, or ability to regain maximum function, condition pursuant to a step therapy request. If the enrollee’s or when an enrollee is undergoing a current course of prescribing provider submits a request for step therapy treatment using a nonformulary drug. exception, the health plans shall make exceptions to step therapy when the criteria is met. Formulary is the complete list of drugs preferred for use and eligible for coverage under a health plan product, and Subscriber means the person who is responsible for includes all drugs covered under the outpatient prescription payment to a plan or whose employment or other status, drug benefit of the health plan product. Formulary is also except for family dependency, is the basis for eligibility for known as a prescription drug list. membership in the plan. Generic drug is the same drug as its brand name equivalent in dosage, safety, strength, how it is taken, quality, performance, and intended use. A generic drug is listed in bold and italicized lowercase letters.

5 Reading your formulary

The formulary gives you choices so you and your doctor can decide your best course of treatment. In this PDL, a drug is listed alphabetically by its brand and generic name in its therapeutic category and class to which it belongs. The generic drug name for a brand name drug is included after the brand name in parenthesis. If a generic equal for a brand name is both available and covered, the generic drug will be listed separately from the brand name in all bold and italicized lowercase letters. Brand example:

sovaldi oral tablet 400 mg (sofosbuvir) 3 PA; SP; QL (30 day supply per 1 fill)

If a generic drug is marketed under a proprietary, trademark-protected brand name, the brand name will be listed after the generic name in parentheses and regular typeface in all CAPITAL letters. Generic drug example:

triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1

Generic drug marketed under a proprietary brand name example:

levothyroxine sodium (LEVOXYL) TABS 1

Tier information Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high-deductible plan, the tier cost levels will apply once you meet your deductible.

Drug tier Includes Helpful tips Tier 1 Preferred generic and certain Use tier 1 drugs for the lowest out-of-pocket costs. preferred brand-name medications Tier 2 Preferred brand name and certain Use tier 2 drugs instead of tier 3 to help reduce your out-of-pocket costs. non-preferred generic medications Tier 3 Non-preferred (generic or brand) Many tier 3 drugs have lower-cost options in tier 1 or 2. Ask your doctor medications if they could work for you. SI Self-injectable medications ED Erectile dysfunction medications INF Infertility medications OA Office administered medications May be considered under the medical benefit of the enrollee’s contract. Contact your doctor for more information and refer to your Evidence of Coverage (EOC) for coverage information and exceptions.

6 Reading your formulary continued

Drug list information In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan decides how these medications may be covered.

AL Age Limit — These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations. AC Anti-Cancer — These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary. PA Prior Authorization — Your doctor is required to give Western Health Advantage more information to determine coverage. QL Quantity Limit — Medication may be limited to a certain number of doses or other limit on the amount that will be covered. Your doctor must request PA approval from WHA for a higher quantity of the drug. ST Step Therapy — Must try lower-cost medication(s) before a higher-cost medication can be covered. PV Preventive Health Benefit— Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit. SP Specialty Medication — May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only. * Copayments waived for this medication; any plan deductible still applies.

How do I request a prior authorization? If your medication requires prior authorization (PA), your doctor can fax a completed PA form (available at westernhealth.com/provider) to Western Health Advantage at 1-916-568-5280. Should you or your doctor need additional information on how to request PA, please call the number on your member ID card. Once your doctor’s request is received, we will notify your doctor of our decision within 72 hours. If WHA fails to respond to a completed PA or step therapy exception request within 72 hours of receiving a non-urgent request and 24 hours of receiving a request based on exigent circumstances, the request is deemed approved, and the health insurer may not deny the request thereafter. If your doctor believes that waiting 72 hours for a standard decision could be harmful to your health, your doctor can ask for a fast decision. This applies only to requests for medications that you have not already received. We must make expedited decisions within 24 hours after we get your doctor’s supporting statement. In some cases, our plan requires you to first try certain medications to treat your medical condition before we will cover another drug for that condition. This is called step therapy. The required first step medication or preferred drug is a proven, cost-effective medication. Unless an exception is made, one or more preferred medications must be tried before progressing to a drug that is subject to step therapy. A request for an exception to a step therapy requirement may be submitted by your doctor in the same manner as a request for PA. If a request for step therapy exception is denied, you or your doctor may appeal the denial. The denial documents provide more information on the appeal rights and procedures. If you have already tried and failed the preferred drug(s), or if you are already taking a drug that is subject to step therapy when you are enrolled in your WHA plan, step therapy won’t be required. Also, the medication will be approved for coverage when guidelines are met for being medically necessary. If we approve your medication PA or step exception, the approval continues for the date range noted on the exception, which may be for a specified number of prescription fills and for a period up to a maximum of 1 year. To keep the exception in place, you must remain enrolled in our plan, your doctor must continue to prescribe your medication at the same dosage and frequency of use, and your drug must be safe for treating your condition.

7 Reading your formulary continued

Are all contraceptives covered? Contraceptive benefits include coverage for a variety of FDA-approved prescription contraceptive methods. Refer to your Evidence of Coverage (EOC) and Copay Summary for coverage information and limitations. If your doctor determines that none of the covered methods on the PDL booklet or if a covered therapeutic equivalent of a drug, device, or product is not available, and it is medically necessary for you, coverage will be provided through the PA process. Prior authorization or step therapy may be required for some other FDA-approved prescription contraceptive drugs, devices, or products prescribed by your doctor. Contraceptive devices (including IUDs) and implantable contraceptives are not covered under the pharmacy benefit. They are covered under the medical benefit as described in your EOC. What blood glucose supplies are covered? Specific brands of blood glucose testing strips, lancets, and insulin syringes are covered as shown in this booklet. A prescription from your doctor is required to obtain these from a pharmacy using your pharmacy benefit. Other diabetes supplies, equipment, and services may be covered under your medical benefit, including blood glucose monitors, insulin pumps and supplies, ketone urine testing strips, and insulin pen delivery systems. Please refer to your EOC and Copay Summary for coverage information specifics and exceptions.

8 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTIHISTAMINE DRUGS - Drugs for Allergy ANTIHISTAMINE DRUGS - Drugs for Allergy promethazine hcl oral tablet 25 mg 1 ETHANOLAMINE DERIVATIVES - Drugs for Allergy carbinoxamine maleate oral solution 4 mg/5ml 1 carbinoxamine maleate oral tablet 4 mg, 6 mg 1 clemastine fumarate oral syrup 0.67 mg/5ml 1 clemastine fumarate oral tablet 2.68 mg 1 diphen oral elixir 12.5 mg/5ml 1 di-phen oral elixir 12.5 mg/5ml 1 diphenhydramine hcl injection solution 50 mg/ml 1 PA diphenhydramine hcl oral elixir 12.5 mg/5ml 1 KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE 4 3 MG/5ML (carbinoxamine maleate) ryvent oral tablet 6 mg 1 FIRST GEN. ANTIHIST. DERIVATIVES, MISC. - Drugs for Allergy cyproheptadine hcl oral syrup 2 mg/5ml 1 cyproheptadine hcl oral tablet 4 mg 1 FIRST GENERATION ANTIHISTAMINES - Drugs for Allergy ANTIVERT ORAL TABLET 50 MG (meclizine hcl) 3 BROMPHENIRAMINE MALEATE INTRAMUSCULAR 3 SOLUTION 10 MG/ML carbinoxamine maleate oral solution 4 mg/5ml 1 carbinoxamine maleate oral tablet 4 mg, 6 mg 1 clemastine fumarate oral syrup 0.67 mg/5ml 1 clemastine fumarate oral tablet 2.68 mg 1 cyproheptadine hcl oral syrup 2 mg/5ml 1 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 9 Coverage Requirements & Prescription Drug Name Drug Tier Limits cyproheptadine hcl oral tablet 4 mg 1 dimenhydrinate injection solution 50 mg/ml OA diphen oral elixir 12.5 mg/5ml 1 di-phen oral elixir 12.5 mg/5ml 1 diphenhydramine hcl injection solution 50 mg/ml 1 PA diphenhydramine hcl oral elixir 12.5 mg/5ml 1 hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml OA hydroxyzine hcl oral syrup 10 mg/5ml 1 hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 1 KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE 4 3 MG/5ML (carbinoxamine maleate) meclizine hcl oral tablet 12.5 mg, 25 mg 1 PHENERGAN INJECTION SOLUTION 25 MG/ML, 50 MG/ML OA PA (promethazine hcl) promethazine hcl injection solution 25 mg/ml, 50 mg/ml OA PA promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 50 mg 1 promethazine hcl rectal suppository 12.5 mg, 25 mg 1 promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 1 ryvent oral tablet 6 mg 1 VISTARIL ORAL CAPSULE 25 MG, 50 MG (hydroxyzine 3 pamoate) OTHER ANTIHISTAMINES - Drugs for Allergy cimetidine hcl oral solution 300 mg/5ml, 400 mg/6.67ml 1 cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 10 Coverage Requirements & Prescription Drug Name Drug Tier Limits famotidine intravenous solution 20 mg/2ml, 200 mg/20ml, OA 40 mg/4ml famotidine oral suspension reconstituted 40 mg/5ml 1 famotidine oral tablet 20 mg, 40 mg 1 famotidine premixed intravenous solution 20-0.9 mg/50ml- OA % hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml OA hydroxyzine hcl oral syrup 10 mg/5ml 1 hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 1 LASTACAFT OPHTHALMIC SOLUTION 0.25 % (alcaftadine) 3 nizatidine oral capsule 150 mg, 300 mg 1 nizatidine oral solution 15 mg/ml 1 olopatadine hcl nasal solution 0.6 % 1 olopatadine hcl ophthalmic solution 0.1 %, 0.2 % 1 PATANASE NASAL SOLUTION 0.6 % (olopatadine hcl) 3 PEPCID ORAL TABLET 20 MG, 40 MG (famotidine) 3 VISTARIL ORAL CAPSULE 25 MG, 50 MG (hydroxyzine 3 pamoate) PHENOTHIAZINE DERIVATIVES - Drugs for Allergy PHENERGAN INJECTION SOLUTION 25 MG/ML, 50 MG/ML OA PA (promethazine hcl) promethazine hcl injection solution 25 mg/ml, 50 mg/ml OA PA promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1 promethazine hcl rectal suppository 12.5 mg, 25 mg 1 promethazine vc oral syrup 6.25-5 mg/5ml 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 11 Coverage Requirements & Prescription Drug Name Drug Tier Limits promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml 1 promethazine-codeine oral solution 6.25-10 mg/5ml 1 promethazine-codeine oral syrup 6.25-10 mg/5ml 1 promethazine-dm oral syrup 6.25-15 mg/5ml 1 promethazine-phenyleph-codeine oral syrup 6.25-5-10 1 mg/5ml promethazine-phenylephrine oral syrup 6.25-5 mg/5ml 1 promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 1 PROPYLAMINE DERIVATIVES - Drugs for Allergy BROMPHENIRAMINE MALEATE INTRAMUSCULAR 3 SOLUTION 10 MG/ML hydrocodone polst-chlorphen polst er susp oral 1 suspension extended release 10-8 mg/5ml pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml 1 RYCLORA ORAL SOLUTION 2 MG/5ML 3 PA (dexchlorpheniramine maleate) TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 3 HOUR 10-8 MG (hydrocod polst-chlorphen polst) TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 HOUR 3 54.3-8 MG (chlorpheniramine-codeine) TUZISTRA XR ORAL SUSPENSION EXTENDED RELEASE 3 PA 14.7-2.8 MG/5ML (codeine polst-chlorphen polst) SECOND GENERATION ANTIHISTAMINES - Drugs for Allergy ALOMIDE OPHTHALMIC SOLUTION 0.1 % (lodoxamide 2 tromethamine) cetirizine hcl oral solution 1 mg/ml, 5 mg/5ml 1 CLARINEX ORAL TABLET 5 MG (desloratadine) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 12 Coverage Requirements & Prescription Drug Name Drug Tier Limits CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 3 12 HOUR 2.5-120 MG (desloratadine-pseudoephedrine) desloratadine oral tablet 5 mg 1 desloratadine oral tablet dispersible 2.5 mg, 5 mg 1 levocetirizine dihydrochloride oral solution 2.5 mg/5ml 1 levocetirizine dihydrochloride oral tablet 5 mg 1 QUZYTTIR INTRAVENOUS SOLUTION 10 MG/ML (cetirizine OA hcl) ANTI-INFECTIVE AGENTS - Drugs for Infections 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS - Antibiotics cefadroxil oral capsule 500 mg 1 cefadroxil oral suspension reconstituted 250 mg/5ml, 500 1 mg/5ml cefadroxil oral tablet 1 gm 1 CEFAZOLIN IN SODIUM CHLORIDE INTRAVENOUS OA SOLUTION 2-0.9 GM/100ML-%, 3-0.9 GM/100ML-% cefazolin sodium injection solution reconstituted 1 gm, 10 OA gm, 100 gm, 300 gm, 500 mg CEFAZOLIN SODIUM INTRAVENOUS SOLUTION OA PREFILLED SYRINGE 1 GM/10ML, 2 GM/20ML cefazolin sodium intravenous solution reconstituted 1 gm OA cefazolin sodium-dextrose intravenous solution 1-4 OA gm/50ml-%, 2-4 gm/100ml-% CEFAZOLIN SODIUM-DEXTROSE INTRAVENOUS OA SOLUTION 2-5 GM/100ML-% cefazolin sodium-dextrose intravenous solution OA reconstituted 1-4 gm-%(50ml), 2-3 gm-%(50ml) cephalexin oral capsule 250 mg, 500 mg, 750 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 13 Coverage Requirements & Prescription Drug Name Drug Tier Limits cephalexin oral suspension reconstituted 125 mg/5ml, 250 1 mg/5ml cephalexin oral tablet 250 mg, 500 mg 1 KEFLEX ORAL CAPSULE 750 MG (cephalexin) 3 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS - Antibiotics cefaclor er oral tablet extended release 12 hour 500 mg 1 cefaclor oral capsule 250 mg, 500 mg 1 cefaclor oral suspension reconstituted 125 mg/5ml, 250 1 mg/5ml, 375 mg/5ml CEFOTAN INJECTION SOLUTION RECONSTITUTED 1 GM, 2 OA GM (cefotetan disodium) cefotetan disodium injection solution reconstituted 1 gm, 2 OA gm cefotetan disodium-dextrose intravenous solution OA reconstituted 1-3.58 gm-%(50ml), 2-2.08 gm-%(50ml) cefoxitin sodium injection solution reconstituted 10 gm OA cefoxitin sodium intravenous solution reconstituted 1 gm, 2 OA gm CEFOXITIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION OA RECONSTITUTED 1-4 GM-%(50ML), 2-2.2 GM-%(50ML) cefprozil oral suspension reconstituted 125 mg/5ml, 250 1 mg/5ml cefprozil oral tablet 250 mg, 500 mg 1 cefuroxime axetil oral tablet 250 mg, 500 mg 1 cefuroxime sodium injection solution reconstituted 750 mg OA cefuroxime sodium intravenous solution reconstituted 1.5 OA gm

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 14 Coverage Requirements & Prescription Drug Name Drug Tier Limits 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS - Antibiotics AVYCAZ INTRAVENOUS SOLUTION RECONSTITUTED 2.5 OA (2-0.5) GM (ceftazidime-avibactam) cefdinir oral capsule 300 mg 1 cefdinir oral suspension reconstituted 125 mg/5ml, 250 1 mg/5ml cefixime oral capsule 400 mg 1 cefixime oral suspension reconstituted 100 mg/5ml, 200 1 mg/5ml cefotaxime sodium injection solution reconstituted 1 gm, 2 OA gm cefpodoxime proxetil oral suspension reconstituted 100 1 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 200 mg 1 ceftazidime and dextrose intravenous solution OA reconstituted 1-5 gm-%(50ml), 2-5 gm-%(50ml) ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 OA gm ceftriaxone sodium in dextrose intravenous solution 20 OA mg/ml, 40 mg/ml ceftriaxone sodium injection solution reconstituted 1 gm, OA 100 gm, 2 gm, 250 mg, 500 mg ceftriaxone sodium intravenous solution reconstituted 1 OA gm, 10 gm, 2 gm ceftriaxone sodium-dextrose intravenous solution OA reconstituted 1-3.74 gm-%(50ml), 2-2.22 gm-%(50ml) FORTAZ INJECTION SOLUTION RECONSTITUTED 1 GM, OA 500 MG (ceftazidime)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 15 Coverage Requirements & Prescription Drug Name Drug Tier Limits FORTAZ INTRAVENOUS SOLUTION RECONSTITUTED 2 GM OA (ceftazidime) SUPRAX ORAL CAPSULE 400 MG (cefixime) 3 SUPRAX ORAL SUSPENSION RECONSTITUTED 100 3 MG/5ML, 200 MG/5ML, 500 MG/5ML (cefixime) SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG 3 (cefixime) tazicef injection solution reconstituted 1 gm, 2 gm, 6 gm OA TAZICEF INTRAVENOUS SOLUTION 1 GM/50ML OA (ceftazidime sodium in dextrose) tazicef intravenous solution reconstituted 1 gm, 2 gm OA ZERBAXA INTRAVENOUS SOLUTION RECONSTITUTED 1.5 OA (1-0.5) GM (ceftolozane-tazobactam) 4TH GENERATION CEPHALOSPORIN ANTIBIOTICS - Antibiotics cefepime hcl injection solution reconstituted 1 gm, 2 gm OA cefepime hcl intravenous solution 1 gm/50ml, 2 gm/100ml OA cefepime hcl intravenous solution reconstituted 100 gm OA cefepime-dextrose intravenous solution reconstituted 1-5 OA gm-%(50ml), 2-5 gm-%(50ml) 5TH GENERATION CEPHALOSPORIN ANTIBIOTICS - Antibiotics TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 OA MG, 600 MG (ceftaroline fosamil) ADAMANTANE ANTIVIRALS - Drugs for Viral Infections amantadine hcl oral capsule 100 mg 1 amantadine hcl oral syrup 50 mg/5ml 1 amantadine hcl oral tablet 100 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 16 Coverage Requirements & Prescription Drug Name Drug Tier Limits GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR PA; SP; QL (30 day supply 3 137 MG, 68.5 MG (amantadine hcl) per 1 fill) OSMOLEX ER ORAL TABLET ER 24 HOUR THERAPY PACK 3 PA 129 & 193 MG (amantadine hcl) OSMOLEX ER ORAL TABLET EXTENDED RELEASE 24 3 PA HOUR 129 MG, 193 MG, 258 MG (amantadine hcl) rimantadine hcl oral tablet 100 mg 1 ALLYLAMINE ANTIFUNGALS - Drugs for Fungus terbinafine hcl oral tablet 250 mg 1 AMEBICIDES - Drugs for the Mouth and Throat FLAGYL ORAL CAPSULE 375 MG (metronidazole) 3 HUMATIN ORAL CAPSULE 250 MG (paromomycin sulfate) 3 metronidazole in nacl intravenous solution 5-0.79 mg/ml-%, OA 500-0.74 mg/100ml-%, 500-0.79 mg/100ml-% metronidazole oral capsule 375 mg 1 metronidazole oral tablet 250 mg, 500 mg 1 metronidazole vaginal gel 0.75 % 1 NUVESSA VAGINAL GEL 1.3 % (metronidazole) 2 paromomycin sulfate oral capsule 250 mg 1 vandazole vaginal gel 0.75 % 1 AMINOGLYCOSIDE ANTIBIOTICS - Antibiotics amikacin sulfate injection solution 1 gm/4ml, 500 mg/2ml OA ARIKAYCE INHALATION SUSPENSION 590 MG/8.4ML PA; SP; QL (30 day supply 3 (amikacin sulfate liposome) per 1 fill) BETHKIS INHALATION NEBULIZATION SOLUTION 300 SP; QL (56 day supply per 1 3 MG/4ML (tobramycin) fill) gentamicin in saline intravenous solution 0.8-0.9 mg/ml-%, 1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.6-0.9 mg/ml-%, 2-0.9 OA mg/ml-%

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 17 Coverage Requirements & Prescription Drug Name Drug Tier Limits gentamicin sulfate injection solution 10 mg/ml, 40 mg/ml OA HUMATIN ORAL CAPSULE 250 MG (paromomycin sulfate) 3 neomycin sulfate oral tablet 500 mg 1 paromomycin sulfate oral capsule 250 mg 1 SODIUM CITRATE-GENTAMICIN SULF INTRAVENOUS OA SOLUTION 4-320 %-MCG/ML streptomycin sulfate intramuscular solution reconstituted 1 OA gm TOBI NEBULIZER INHALATION NEBULIZATION SOLUTION PA; SP; QL (56 day supply 3 300 MG/5ML (tobramycin) per 1 fill) TOBI PODHALER INHALATION CAPSULE 28 MG SP; QL (56 day supply per 1 3 (tobramycin) fill) SP; QL (56 day supply per 1 tobramycin inhalation nebulization solution 300 mg/4ml 1 fill) tobramycin nebulization solution 300 mg/5ml inhalation 300 PA; SP; QL (56 day supply 1 mg/5ml per 1 fill) TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML PA; SP; QL (56 day supply 1 INHALATION 300 MG/5ML per 1 fill) tobramycin sulfate injection solution 1.2 gm/30ml, 10 OA mg/ml, 2 gm/50ml, 80 mg/2ml tobramycin sulfate injection solution reconstituted 1.2 gm OA ZEMDRI INTRAVENOUS SOLUTION 500 MG/10ML OA (plazomicin sulfate) AMINOMETHYLCYCLINES - Antibiotics NUZYRA INTRAVENOUS SOLUTION RECONSTITUTED 100 OA PA MG (omadacycline tosylate) NUZYRA ORAL TABLET 150 MG (omadacycline tosylate) 3 PA SEYSARA ORAL TABLET 100 MG, 150 MG, 60 MG 3 PA (sarecycline hcl)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 18 Coverage Requirements & Prescription Drug Name Drug Tier Limits AMINOPENICILLIN ANTIBIOTICS - Antibiotics amoxicill-clarithro-lansopraz oral 1 amoxicillin oral capsule 250 mg, 500 mg 1 amoxicillin oral suspension reconstituted 125 mg/5ml, 200 1 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg 1 amoxicillin oral tablet chewable 125 mg, 250 mg 1 amoxicillin-potassium clavulanate er oral tablet extended 1 release 12 hour 1000-62.5 mg amoxicillin-potassium clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 1 mg/5ml, 600-42.9 mg/5ml amoxicillin-potassium clavulanate oral tablet 250-125 mg, 1 500-125 mg, 875-125 mg amoxicillin-potassium clavulanate oral tablet chewable 200- 1 28.5 mg, 400-57 mg ampicillin oral capsule 500 mg 1 ampicillin sodium injection solution reconstituted 1 gm, OA 125 mg, 2 gm, 250 mg, 500 mg ampicillin sodium intravenous solution reconstituted 1 gm, OA 10 gm, 2 gm ampicillin-sulbactam sodium injection solution OA reconstituted 1.5 (1-0.5) gm, 3 (2-1) gm ampicillin-sulbactam sodium intravenous solution OA reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm, 3 (2-1) gm AUGMENTIN ES-600 ORAL SUSPENSION RECONSTITUTED 3 600-42.9 MG/5ML (amoxicillin-pot clavulanate) AUGMENTIN ORAL SUSPENSION RECONSTITUTED 250- 3 62.5 MG/5ML (amoxicillin-pot clavulanate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 19 Coverage Requirements & Prescription Drug Name Drug Tier Limits AUGMENTIN ORAL TABLET 500-125 MG (amoxicillin-pot 3 clavulanate) OMECLAMOX-PAK ORAL 500-500-20 MG (amoxicill- 3 clarithro-omeprazole) UNASYN INJECTION SOLUTION RECONSTITUTED 1.5 (1- OA 0.5) GM, 3 (2-1) GM (ampicillin-sulbactam sodium) UNASYN INTRAVENOUS SOLUTION RECONSTITUTED 15 OA (10-5) GM (ampicillin-sulbactam sodium) ANTHELMINTICS - Drugs for Parasites albendazole oral tablet 200 mg 1 ALBENZA ORAL TABLET 200 MG (albendazole) 3 BILTRICIDE ORAL TABLET 600 MG (praziquantel) 3 EGATEN ORAL TABLET 250 MG (triclabendazole) 3 EMVERM ORAL TABLET CHEWABLE 100 MG 3 (mebendazole) ivermectin oral tablet 3 mg 1 praziquantel oral tablet 600 mg 1 STROMECTOL ORAL TABLET 3 MG (ivermectin) 3 ANTIFUNGALS, MISCELLANEOUS - Drugs for Fungus BREXAFEMME ORAL TABLET 150 MG (ibrexafungerp 3 PA citrate) griseofulvin microsize oral suspension 125 mg/5ml 1 griseofulvin microsize oral tablet 500 mg 1 griseofulvin ultramicrosize oral tablet 125 mg, 250 mg 1 ANTI-INFECTIVES (SYSTEMIC), MISC. - Drugs for Infections HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) 3 PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- 3 metronid-tetracyc)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 20 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTIMALARIALS - Drugs for the Mouth and Throat ACTICLATE ORAL TABLET 150 MG, 75 MG (doxycycline 3 hyclate) ARAKODA ORAL TABLET 100 MG (tafenoquine succinate) 3 PA ARTESUNATE INTRAVENOUS SOLUTION RECONSTITUTED OA 110 MG atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 1 mg avidoxy oral tablet 100 mg 1 chloroquine phosphate oral tablet 250 mg, 500 mg 1 COARTEM ORAL TABLET 20-120 MG (artemether- 3 lumefantrine) SP; QL (30 day supply per 1 DARAPRIM ORAL TABLET 25 MG (pyrimethamine) 3 fill) DORYX MPC ORAL TABLET DELAYED RELEASE 120 MG 2 PA (doxycycline hyclate) DORYX ORAL TABLET DELAYED RELEASE 200 MG, 50 MG, 3 PA 80 MG (doxycycline hyclate) doxy 100 intravenous solution reconstituted 100 mg OA doxycycline hyclate intravenous solution reconstituted 100 OA mg doxycycline hyclate oral capsule 100 mg, 50 mg 1 doxycycline hyclate oral tablet 100 mg, 150 mg, 50 mg, 75 1 mg doxycycline hyclate oral tablet delayed release 100 mg, 150 1 PA mg, 200 mg, 50 mg, 75 mg DOXYCYCLINE HYCLATE ORAL TABLET DELAYED 3 PA RELEASE 80 MG doxycycline monohydrate oral capsule 100 mg, 50 mg 1 doxycycline monohydrate oral capsule 150 mg, 75 mg 1 PA Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 21 Coverage Requirements & Prescription Drug Name Drug Tier Limits doxycycline monohydrate oral suspension reconstituted 25 1 mg/5ml doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 1 mg, 75 mg hydroxychloroquine sulfate oral tablet 100 mg, 200 mg, 300 1 mg, 400 mg KRINTAFEL ORAL TABLET 150 MG (tafenoquine succinate) 3 PA MALARONE ORAL TABLET 250-100 MG, 62.5-25 MG 3 (atovaquone-proguanil hcl) mefloquine hcl oral tablet 250 mg 1 MINOCIN INTRAVENOUS SOLUTION RECONSTITUTED 100 OA MG (minocycline hcl) minocycline hcl oral capsule 100 mg, 50 mg, 75 mg 1 minocycline hcl oral tablet 100 mg, 50 mg, 75 mg 1 PA mondoxyne nl oral capsule 100 mg 1 mondoxyne nl oral capsule 75 mg 1 PA morgidox oral capsule 100 mg 1 PLAQUENIL ORAL TABLET 200 MG (hydroxychloroquine 3 sulfate) primaquine phosphate oral tablet 26.3 (15 base) mg 1 SP; QL (30 day supply per 1 pyrimethamine oral tablet 25 mg 1 fill) QUALAQUIN ORAL CAPSULE 324 MG (quinine sulfate) 3 quinidine gluconate er oral tablet extended release 324 mg 1 quinidine sulfate oral tablet 200 mg, 300 mg 1 quinine sulfate oral capsule 324 mg 1 TARGADOX ORAL TABLET 50 MG (doxycycline hyclate) 3 tetracycline hcl oral capsule 250 mg, 500 mg 1 VIBRAMYCIN ORAL CAPSULE 100 MG (doxycycline hyclate) 3 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 22 Coverage Requirements & Prescription Drug Name Drug Tier Limits VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED 25 3 MG/5ML (doxycycline monohydrate) VIBRAMYCIN ORAL SYRUP 50 MG/5ML (doxycycline 3 calcium) ANTIMYCOBACTERIALS, MISCELLANEOUS - Antibiotics dapsone oral tablet 100 mg, 25 mg 1 ANTIPROTOZOALS, MISCELLANEOUS - Drugs for the Mouth and Throat ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML 3 (nitazoxanide) ALINIA ORAL TABLET 500 MG (nitazoxanide) 3 atovaquone oral suspension 750 mg/5ml 1 BACTRIM DS ORAL TABLET 800-160 MG (sulfamethoxazole- 3 trimethoprim) BACTRIM ORAL TABLET 400-80 MG (sulfamethoxazole- 3 trimethoprim) BENZNIDAZOLE ORAL TABLET 100 MG, 12.5 MG 2 QL (60 EA per 365 days) dapsone oral tablet 100 mg, 25 mg 1 FLAGYL ORAL CAPSULE 375 MG (metronidazole) 3 HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) 3 IMPAVIDO ORAL CAPSULE 50 MG (miltefosine) 2 PA; QL (30 EA per 1 fill); AL LAMPIT ORAL TABLET 120 MG, 30 MG (nifurtimox) 3 (Min 18 Years) MEPRON ORAL SUSPENSION 750 MG/5ML (atovaquone) 3 metronidazole in nacl intravenous solution 5-0.79 mg/ml-%, OA 500-0.74 mg/100ml-%, 500-0.79 mg/100ml-% metronidazole oral capsule 375 mg 1 metronidazole oral tablet 250 mg, 500 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 23 Coverage Requirements & Prescription Drug Name Drug Tier Limits NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 3 PA MG (pentamidine isethionate) nitazoxanide oral tablet 500 mg 1 PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG OA PA (pentamidine isethionate) pentamidine isethionate inhalation solution reconstituted 1 PA 300 mg pentamidine isethionate injection solution reconstituted OA PA 300 mg PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- 3 metronid-tetracyc) SOLOSEC ORAL PACKET 2 GM (secnidazole) 2 PA sulfamethoxazole-trimethoprim intravenous solution 400-80 OA mg/5ml sulfamethoxazole-trimethoprim oral suspension 200-40 1 mg/5ml sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800- 1 160 mg sulfatrim pediatric oral suspension 200-40 mg/5ml 1 tinidazole oral tablet 250 mg, 500 mg 1 ANTITUBERCULOSIS AGENTS - Antibiotics CAPASTAT SULFATE INJECTION SOLUTION OA RECONSTITUTED 1 GM (capreomycin sulfate) CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML 3 (5%), 500 MG/5ML (10%) (ciprofloxacin) CIPRO ORAL TABLET 250 MG, 500 MG (ciprofloxacin hcl) 3 ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 1 mg ciprofloxacin in d5w intravenous solution 200 mg/100ml, OA 400 mg/200ml

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 24 Coverage Requirements & Prescription Drug Name Drug Tier Limits clarithromycin er oral tablet extended release 24 hour 500 1 mg clarithromycin oral suspension reconstituted 125 mg/5ml, 1 250 mg/5ml clarithromycin oral tablet 250 mg, 500 mg 1 cycloserine oral capsule 250 mg 1 DEXAMETHASONE-MOXIFLOXACIN INTRAOCULAR OA SOLUTION 1-5 MG/ML DEXAMETH-MOXIFLOX-KETOROLAC INTRAOCULAR OA SOLUTION 1-0.5-0.4 MG/ML ethambutol hcl oral tablet 100 mg, 400 mg 1 isoniazid injection solution 100 mg/ml OA isoniazid oral syrup 50 mg/5ml 1 isoniazid oral tablet 100 mg, 300 mg 1 levofloxacin in d5w intravenous solution 250 mg/50ml, 500 OA mg/100ml, 750 mg/150ml levofloxacin intravenous solution 25 mg/ml OA levofloxacin oral solution 25 mg/ml 1 levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1 moxifloxacin hcl in nacl intravenous solution 400 mg/250ml OA MOXIFLOXACIN HCL INTRAOCULAR SOLUTION 1 MG/ML, 5 OA MG/ML MOXIFLOXACIN HCL INTRAVENOUS SOLUTION 400 OA MG/250ML moxifloxacin hcl oral tablet 400 mg 1 MYAMBUTOL ORAL TABLET 400 MG (ethambutol hcl) 3 MYCOBUTIN ORAL CAPSULE 150 MG (rifabutin) 3 PA; QL (182 EA per 365 PRETOMANID ORAL TABLET 200 MG 3 days); AL (Min 18 Years)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 25 Coverage Requirements & Prescription Drug Name Drug Tier Limits PRIFTIN ORAL TABLET 150 MG (rifapentine) 3 pyrazinamide oral tablet 500 mg 1 rifabutin oral capsule 150 mg 1 RIFADIN INTRAVENOUS SOLUTION RECONSTITUTED 600 OA MG (rifampin) rifampin intravenous solution reconstituted 600 mg OA rifampin oral capsule 150 mg, 300 mg 1 SIRTURO ORAL TABLET 100 MG, 20 MG (bedaquiline 2 PA fumarate) streptomycin sulfate intramuscular solution reconstituted 1 OA gm TRECATOR ORAL TABLET 250 MG (ethionamide) 3 TRIAMCINOLONE-MOXIFLOXACIN INTRAOCULAR OA SUSPENSION 15-1 MG/ML ANTIVIRALS, MISCELLANEOUS - Drugs for Viral Infections foscarnet sodium intravenous solution 6000 mg/250ml OA FOSCAVIR INTRAVENOUS SOLUTION 6000 MG/250ML OA (foscarnet sodium) PREVYMIS INTRAVENOUS SOLUTION 240 MG/12ML, 480 OA MG/24ML (letermovir) PREVYMIS ORAL TABLET 240 MG, 480 MG (letermovir) 3 PA XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY PACK 1 QL (1 fill per 180 days); AL 2 X 40 MG, 2 X 20 MG (baloxavir marboxil) (Min 12 Years) XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY PACK 1 QL (1 fill per 180 days); AL 2 X 80 MG, 2 X 40 MG (baloxavir marboxil) (Min 12 Years) AZOLE ANTIFUNGALS - Drugs for Fungus CRESEMBA INTRAVENOUS SOLUTION RECONSTITUTED OA PA 372 MG (isavuconazonium sulfate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 26 Coverage Requirements & Prescription Drug Name Drug Tier Limits CRESEMBA ORAL CAPSULE 186 MG (isavuconazonium 3 PA sulfate) DIFLUCAN ORAL SUSPENSION RECONSTITUTED 10 3 MG/ML, 40 MG/ML (fluconazole) DIFLUCAN ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 3 (fluconazole) fluconazole in sodium chloride intravenous solution 200- OA 0.9 mg/100ml-%, 400-0.9 mg/200ml-% fluconazole oral suspension reconstituted 10 mg/ml, 40 1 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg 1 itraconazole oral capsule 100 mg 1 itraconazole oral solution 10 mg/ml 1 ketoconazole oral tablet 200 mg 1 NOXAFIL INTRAVENOUS SOLUTION 300 MG/16.7ML OA (posaconazole) NOXAFIL ORAL SUSPENSION 40 MG/ML (posaconazole) 3 NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG 3 (posaconazole) posaconazole oral tablet delayed release 100 mg 1 SPORANOX ORAL CAPSULE 100 MG (itraconazole) 3 SPORANOX ORAL SOLUTION 10 MG/ML (itraconazole) 3 SPORANOX PULSEPAK ORAL CAPSULE 100 MG 3 (itraconazole) TOLSURA ORAL CAPSULE 65 MG 3 VFEND IV INTRAVENOUS SOLUTION RECONSTITUTED 200 OA PA MG (voriconazole) VFEND ORAL SUSPENSION RECONSTITUTED 40 MG/ML 3 PA (voriconazole)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 27 Coverage Requirements & Prescription Drug Name Drug Tier Limits VFEND ORAL TABLET 200 MG, 50 MG (voriconazole) 3 PA voriconazole intravenous solution reconstituted 200 mg OA PA voriconazole oral suspension reconstituted 40 mg/ml 1 PA voriconazole oral tablet 200 mg, 50 mg 1 PA BACITRACIN ANTIBIOTICS - Antibiotics bacitracin intramuscular solution reconstituted 50000 unit OA CARBAPENEM ANTIBIOTICS - Antibiotics ertapenem sodium injection solution reconstituted 1 gm OA imipenem-cilastatin intravenous solution reconstituted 250 OA mg, 500 mg INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM OA (ertapenem sodium) meropenem intravenous solution reconstituted 1 gm, 500 OA mg MEROPENEM-SODIUM CHLORIDE INTRAVENOUS OA SOLUTION RECONSTITUTED 1 GM/50ML, 500 MG/50ML PRIMAXIN IV INTRAVENOUS SOLUTION RECONSTITUTED OA 500-500 MG (imipenem-cilastatin) RECARBRIO INTRAVENOUS SOLUTION RECONSTITUTED OA 1.25 GM (imipenem-cilastatin-relebactam) VABOMERE INTRAVENOUS SOLUTION RECONSTITUTED 2 OA (1-1) GM (meropenem-vaborbactam) CEPHAMYCIN ANTIBIOTICS - Antibiotics CEFOTAN INJECTION SOLUTION RECONSTITUTED 1 GM, 2 OA GM (cefotetan disodium) cefotetan disodium injection solution reconstituted 1 gm, 2 OA gm cefotetan disodium-dextrose intravenous solution OA reconstituted 1-3.58 gm-%(50ml), 2-2.08 gm-%(50ml)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 28 Coverage Requirements & Prescription Drug Name Drug Tier Limits cefoxitin sodium injection solution reconstituted 10 gm OA cefoxitin sodium intravenous solution reconstituted 1 gm, 2 OA gm CEFOXITIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION OA RECONSTITUTED 1-4 GM-%(50ML), 2-2.2 GM-%(50ML) CHLORAMPHENICOL ANTIBIOTICS - Antibiotics chloramphenicol sod succinate intravenous solution OA reconstituted 1 gm CYCLIC LIPOPEPTIDE ANTIBIOTICS - Antibiotics CUBICIN INTRAVENOUS SOLUTION RECONSTITUTED 500 OA MG (daptomycin) CUBICIN RF INTRAVENOUS SOLUTION RECONSTITUTED OA 500 MG (daptomycin) daptomycin intravenous solution reconstituted 350 mg, 500 OA mg ECHINOCANDIN ANTIFUNGALS - Drugs for Fungus CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 50 OA MG, 70 MG (caspofungin acetate) caspofungin acetate intravenous solution reconstituted 50 OA mg, 70 mg ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 OA MG, 50 MG (anidulafungin) micafungin sodium intravenous solution reconstituted 100 OA mg, 50 mg MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED OA 100 MG, 50 MG (micafungin sodium) ERYTHROMYCIN ANTIBIOTICS - Antibiotics E.E.S. 400 ORAL TABLET 400 MG (erythromycin 3 ethylsuccinate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 29 Coverage Requirements & Prescription Drug Name Drug Tier Limits E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 3 200 MG/5ML (erythromycin ethylsuccinate) ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 3 MG/5ML (erythromycin ethylsuccinate) ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 2 MG/5ML (erythromycin ethylsuccinate) ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 3 MG, 500 MG (erythromycin base) ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION OA RECONSTITUTED 500 MG (erythromycin lactobionate) ERYTHROCIN STEARATE ORAL TABLET 250 MG 3 (erythromycin stearate) erythromycin base oral capsule delayed release particles 1 250 mg erythromycin base oral tablet 250 mg, 500 mg 1 erythromycin base oral tablet delayed release 250 mg, 333 1 mg, 500 mg erythromycin ethylsuccinate oral suspension reconstituted 1 200 mg/5ml, 400 mg/5ml erythromycin ethylsuccinate oral tablet 400 mg 1 erythromycin oral tablet delayed release 250 mg, 333 mg, 1 500 mg EXTENDED-SPECTRUM PENICILLINS - Antibiotics piperacillin sod-tazobactam so intravenous solution reconstituted 13.5 (12-1.5) gm, 2.25 (2-0.25) gm, 3.375 (3- OA 0.375) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm ZOSYN INTRAVENOUS SOLUTION 2-0.25 GM/50ML, 3-0.375 OA GM/50ML, 4-0.5 GM/100ML (piperacillin-tazobactam in dex)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 30 Coverage Requirements & Prescription Drug Name Drug Tier Limits FLUOROCYCLINES - Antibiotics XERAVA INTRAVENOUS SOLUTION RECONSTITUTED 100 OA MG, 50 MG (eravacycline dihydrochloride) GLYCOPEPTIDE ANTIBIOTICS - Antibiotics DALVANCE INTRAVENOUS SOLUTION RECONSTITUTED OA 500 MG (dalbavancin hcl) FIRVANQ ORAL SOLUTION RECONSTITUTED 25 MG/ML, 50 3 MG/ML (vancomycin hcl) KIMYRSA INTRAVENOUS SOLUTION RECONSTITUTED OA 1200 MG (oritavancin diphosphate) ORBACTIV INTRAVENOUS SOLUTION RECONSTITUTED OA 400 MG (oritavancin diphosphate) VANCOCIN HCL ORAL CAPSULE 125 MG (vancomycin hcl) 3 VANCOCIN ORAL CAPSULE 250 MG (vancomycin hcl) 3 VANCOMYCIN HCL IN DEXTROSE INTRAVENOUS OA SOLUTION 1.25-5 GM/250ML-%, 1.5-5 GM/250ML-% vancomycin hcl in dextrose intravenous solution 1-5 OA gm/200ml-%, 500-5 mg/100ml-%, 750-5 mg/150ml-% vancomycin hcl in nacl intravenous solution 1-0.9 OA gm/200ml-%, 500-0.9 mg/100ml-% VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 1- 0.9 GM/250ML-%, 1.25-0.9 GM/250ML-%, 1.5-0.9 GM/250ML- OA %, 1.5-0.9 GM/500ML-%, 1.75-0.9 GM/250ML-%, 2-0.9 GM/500ML-% VANCOMYCIN HCL IN NACL SOLUTION 750-0.9 MG/150ML- OA % INTRAVENOUS 750-0.9 MG/150ML-% vancomycin hcl in nacl solution 750-0.9 mg/150ml-% OA intravenous 750-0.9 mg/150ml-% vancomycin hcl intravenous solution 1000 mg/200ml, 1250 mg/250ml, 1500 mg/300ml, 1750 mg/350ml, 2000 mg/400ml, OA 500 mg/100ml, 750 mg/150ml Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 31 Coverage Requirements & Prescription Drug Name Drug Tier Limits vancomycin hcl intravenous solution reconstituted 1 gm, 1.25 gm, 1.5 gm, 10 gm, 100 gm, 1000 mg, 250 mg, 5 gm, OA 500 mg, 750 mg vancomycin hcl oral capsule 125 mg, 250 mg 1 vancomycin hcl oral solution reconstituted 250 mg/5ml 1 VIBATIV INTRAVENOUS SOLUTION RECONSTITUTED 750 OA MG (telavancin hcl) GLYCYLCYCLINE ANTIBIOTICS - Antibiotics tigecycline intravenous solution reconstituted 50 mg OA TYGACIL INTRAVENOUS SOLUTION RECONSTITUTED 50 OA MG (tigecycline) HCV POLYMERASE INHIBITOR ANTIVIRALS - Drugs for Viral Infections EPCLUSA ORAL TABLET 200-50 MG, 400-100 MG PA; SP; QL (30 day supply 2 (sofosbuvir-velpatasvir) per 1 fill) HARVONI ORAL PACKET 33.75-150 MG, 45-200 MG PA; SP; QL (30 day supply 2 (ledipasvir-sofosbuvir) per 1 fill) HARVONI ORAL TABLET 45-200 MG, 90-400 MG (ledipasvir- PA; SP; QL (30 day supply 2 sofosbuvir) per 1 fill) PA; SP; QL (30 day supply LEDIPASVIR-SOFOSBUVIR ORAL TABLET 90-400 MG 2 per 1 fill) PA; SP; QL (30 day supply SOFOSBUVIR-VELPATASVIR ORAL TABLET 400-100 MG 2 per 1 fill) PA; SP; QL (30 day supply SOVALDI ORAL PACKET 150 MG (sofosbuvir) 3 per 1 fill) PA; SP; QL (30 day supply SOVALDI ORAL PACKET 200 MG (sofosbuvir) 2 per 1 fill) PA; SP; QL (30 day supply SOVALDI ORAL TABLET 200 MG, 400 MG (sofosbuvir) 3 per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 32 Coverage Requirements & Prescription Drug Name Drug Tier Limits VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50 PA; SP; QL (30 day supply 3 &250 MG (ombitas-paritapre-ritona-dasab) per 1 fill) VOSEVI ORAL TABLET 400-100-100 MG (sofosbuv- PA; SP; QL (30 day supply 2 velpatasv-voxilaprev) per 1 fill) HCV PROTEASE INHIBITOR ANTIVIRALS - Drugs for Viral Infections MAVYRET ORAL TABLET 100-40 MG (glecaprevir- PA; SP; QL (30 day supply 3 pibrentasvir) per 1 fill) VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50 PA; SP; QL (30 day supply 3 &250 MG (ombitas-paritapre-ritona-dasab) per 1 fill) VOSEVI ORAL TABLET 400-100-100 MG (sofosbuv- PA; SP; QL (30 day supply 2 velpatasv-voxilaprev) per 1 fill) PA; SP; QL (30 day supply ZEPATIER ORAL TABLET 50-100 MG (elbasvir-grazoprevir) 3 per 1 fill) HCV REPLICATION COMPLEX INHIBITORS - Drugs for Viral Infections EPCLUSA ORAL TABLET 200-50 MG, 400-100 MG PA; SP; QL (30 day supply 2 (sofosbuvir-velpatasvir) per 1 fill) HARVONI ORAL PACKET 33.75-150 MG, 45-200 MG PA; SP; QL (30 day supply 2 (ledipasvir-sofosbuvir) per 1 fill) HARVONI ORAL TABLET 45-200 MG, 90-400 MG (ledipasvir- PA; SP; QL (30 day supply 2 sofosbuvir) per 1 fill) PA; SP; QL (30 day supply LEDIPASVIR-SOFOSBUVIR ORAL TABLET 90-400 MG 2 per 1 fill) MAVYRET ORAL TABLET 100-40 MG (glecaprevir- PA; SP; QL (30 day supply 3 pibrentasvir) per 1 fill) PA; SP; QL (30 day supply SOFOSBUVIR-VELPATASVIR ORAL TABLET 400-100 MG 2 per 1 fill) VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50 PA; SP; QL (30 day supply 3 &250 MG (ombitas-paritapre-ritona-dasab) per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 33 Coverage Requirements & Prescription Drug Name Drug Tier Limits VOSEVI ORAL TABLET 400-100-100 MG (sofosbuv- PA; SP; QL (30 day supply 2 velpatasv-voxilaprev) per 1 fill) PA; SP; QL (30 day supply ZEPATIER ORAL TABLET 50-100 MG (elbasvir-grazoprevir) 3 per 1 fill) HIV ENTRY AND FUSION INHIBITORS - Drugs for Viral Infections FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 PA; QL (30 day supply per 1 SI MG (enfuvirtide) fill) RUKOBIA ORAL TABLET EXTENDED RELEASE 12 HOUR 3 PA 600 MG (fostemsavir tromethamine) SELZENTRY ORAL SOLUTION 20 MG/ML (maraviroc) 3 SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG 2 (maraviroc) TROGARZO INTRAVENOUS SOLUTION 200 MG/1.33ML OA QL (30 day supply per 1 fill) (ibalizumab-uiyk) HIV INTEGRASE INHIBITOR ANTIRETROVIRALS - Drugs for Viral Infections BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir- 2 emtricitab-tenofov) CABENUVA INTRAMUSCULAR SUSPENSION EXTENDED OA RELEASE 400 & 600 MG/2ML, 600 & 900 MG/3ML DOVATO ORAL TABLET 50-300 MG (dolutegravir- QL (1 EA per 1 day); AL (Min 2 lamivudine) 18 Years) GENVOYA ORAL TABLET 150-150-200-10 MG (elviteg-cobic- 2 emtricit-tenofaf) ISENTRESS HD ORAL TABLET 600 MG (raltegravir 2 potassium) ISENTRESS ORAL PACKET 100 MG (raltegravir potassium) 3 ISENTRESS ORAL TABLET 400 MG (raltegravir potassium) 2

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 34 Coverage Requirements & Prescription Drug Name Drug Tier Limits ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG 3 (raltegravir potassium) JULUCA ORAL TABLET 50-25 MG (dolutegravir-rilpivirine) 3 PA STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg- 3 cobic-emtricit-tenofdf) TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG (dolutegravir 2 sodium) TIVICAY PD ORAL TABLET SOLUBLE 5 MG (dolutegravir 2 sodium) TRIUMEQ ORAL TABLET 600-50-300 MG (abacavir- 2 dolutegravir-lamivud) VOCABRIA ORAL TABLET 30 MG 3 PA HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. - Drugs for Viral Infections ATRIPLA ORAL TABLET 600-200-300 MG (efavirenz- 3 emtricitab-tenofovir) BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir- 2 emtricitab-tenofov) CABENUVA INTRAMUSCULAR SUSPENSION EXTENDED OA RELEASE 400 & 600 MG/2ML, 600 & 900 MG/3ML COMPLERA ORAL TABLET 200-25-300 MG (emtricitab- 2 rilpivir-tenofovir) DELSTRIGO ORAL TABLET 100-300-300 MG (doravirin- 3 PA lamivudin-tenofov df) EDURANT ORAL TABLET 25 MG (rilpivirine hcl) 2 efavirenz oral capsule 200 mg, 50 mg 1 efavirenz oral tablet 600 mg 1 efavirenz-emtricitab-tenofovir oral tablet 600-200-300 mg 1 efavirenz-lamivudine-tenofovir oral tablet 400-300-300 mg, 1 600-300-300 mg

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 35 Coverage Requirements & Prescription Drug Name Drug Tier Limits etravirine oral tablet 100 mg, 200 mg 1 INTELENCE ORAL TABLET 100 MG, 200 MG (etravirine) 3 INTELENCE ORAL TABLET 25 MG (etravirine) 2 JULUCA ORAL TABLET 50-25 MG (dolutegravir-rilpivirine) 3 PA methocarbamol oral tablet 500 mg 1 nevirapine er oral tablet extended release 24 hour 100 mg, 1 400 mg nevirapine oral suspension 50 mg/5ml 1 nevirapine oral tablet 200 mg 1 ODEFSEY ORAL TABLET 200-25-25 MG (emtricitab-rilpivir- 2 tenofov af) PIFELTRO ORAL TABLET 100 MG (doravirine) 3 PA SUSTIVA ORAL CAPSULE 200 MG, 50 MG (efavirenz) 3 SUSTIVA ORAL TABLET 600 MG (efavirenz) 3 SYMFI LO ORAL TABLET 400-300-300 MG (efavirenz- 3 lamivudine-tenofovir) SYMFI ORAL TABLET 600-300-300 MG (efavirenz- 3 lamivudine-tenofovir) VIRAMUNE ORAL SUSPENSION 50 MG/5ML (nevirapine) 3 VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 3 HOUR 400 MG (nevirapine) HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS - Drugs for Viral Infections abacavir sulfate oral solution 20 mg/ml 1 abacavir sulfate oral tablet 300 mg 1 abacavir sulfate-lamivudine oral tablet 600-300 mg 1 abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg 1 ATRIPLA ORAL TABLET 600-200-300 MG (efavirenz- 3 emtricitab-tenofovir) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 36 Coverage Requirements & Prescription Drug Name Drug Tier Limits BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir- 2 emtricitab-tenofov) CIMDUO ORAL TABLET 300-300 MG (lamivudine-tenofovir) 2 COMBIVIR ORAL TABLET 150-300 MG (lamivudine- 3 zidovudine) COMPLERA ORAL TABLET 200-25-300 MG (emtricitab- 2 rilpivir-tenofovir) DELSTRIGO ORAL TABLET 100-300-300 MG (doravirin- 3 PA lamivudin-tenofov df) DESCOVY ORAL TABLET 200-25 MG (emtricitabine- 2 PV tenofovir af) DOVATO ORAL TABLET 50-300 MG (dolutegravir- QL (1 EA per 1 day); AL (Min 2 lamivudine) 18 Years) efavirenz-emtricitab-tenofovir oral tablet 600-200-300 mg 1 efavirenz-lamivudine-tenofovir oral tablet 400-300-300 mg, 1 600-300-300 mg emtricitabine oral capsule 200 mg 1 emtricitabine-tenofovir df oral tablet 100-150 mg, 133-200 1 PV mg, 167-250 mg, 200-300 mg EMTRIVA ORAL CAPSULE 200 MG (emtricitabine) 3 EMTRIVA ORAL SOLUTION 10 MG/ML (emtricitabine) 2 EPIVIR HBV ORAL SOLUTION 5 MG/ML (lamivudine) 3 EPIVIR HBV ORAL TABLET 100 MG (lamivudine) 3 EPIVIR ORAL SOLUTION 10 MG/ML (lamivudine) 3 EPIVIR ORAL TABLET 150 MG, 300 MG (lamivudine) 3 EPZICOM ORAL TABLET 600-300 MG (abacavir sulfate- 3 lamivudine) GENVOYA ORAL TABLET 150-150-200-10 MG (elviteg-cobic- 2 emtricit-tenofaf)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 37 Coverage Requirements & Prescription Drug Name Drug Tier Limits lamivudine oral solution 10 mg/ml 1 lamivudine oral tablet 100 mg, 150 mg, 300 mg 1 lamivudine-zidovudine oral tablet 150-300 mg 1 ODEFSEY ORAL TABLET 200-25-25 MG (emtricitab-rilpivir- 2 tenofov af) RETROVIR INTRAVENOUS SOLUTION 10 MG/ML OA (zidovudine) RETROVIR ORAL CAPSULE 100 MG (zidovudine) 3 RETROVIR ORAL SYRUP 50 MG/5ML (zidovudine) 3 stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg 1 STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg- 3 cobic-emtricit-tenofdf) SYMFI LO ORAL TABLET 400-300-300 MG (efavirenz- 3 lamivudine-tenofovir) SYMFI ORAL TABLET 600-300-300 MG (efavirenz- 3 lamivudine-tenofovir) SYMTUZA ORAL TABLET 800-150-200-10 MG (darun-cobic- 2 ST emtricit-tenofaf) TEMIXYS ORAL TABLET 300-300 MG (lamivudine-tenofovir) 2 tenofovir disoproxil fumarate oral tablet 300 mg 1 PV TRIUMEQ ORAL TABLET 600-50-300 MG (abacavir- 2 dolutegravir-lamivud) TRIZIVIR ORAL TABLET 300-150-300 MG (abacavir- 3 lamivudine-zidovudine) TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 3 PV MG, 200-300 MG (emtricitabine-tenofovir df) VIREAD ORAL POWDER 40 MG/GM (tenofovir disoproxil 2 fumarate) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG (tenofovir 2 disoproxil fumarate) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 38 Coverage Requirements & Prescription Drug Name Drug Tier Limits VIREAD ORAL TABLET 300 MG (tenofovir disoproxil 3 fumarate) ZIAGEN ORAL SOLUTION 20 MG/ML (abacavir sulfate) 3 ZIAGEN ORAL TABLET 300 MG (abacavir sulfate) 3 zidovudine oral capsule 100 mg 1 zidovudine oral syrup 50 mg/5ml 1 zidovudine oral tablet 300 mg 1 HIV PROTEASE INHIBITOR ANTIRETROVIRALS - Drugs for Viral Infections APTIVUS ORAL CAPSULE 250 MG (tipranavir) 2 atazanavir sulfate oral capsule 150 mg, 200 mg, 300 mg 1 CRIXIVAN ORAL CAPSULE 400 MG (indinavir sulfate) 2 EVOTAZ ORAL TABLET 300-150 MG (atazanavir-cobicistat) 3 PA fosamprenavir calcium oral tablet 700 mg 1 INVIRASE ORAL TABLET 500 MG (saquinavir mesylate) 2 KALETRA ORAL SOLUTION 400-100 MG/5ML (lopinavir- 3 ritonavir) KALETRA ORAL TABLET 100-25 MG, 200-50 MG (lopinavir- 3 ritonavir) LEXIVA ORAL SUSPENSION 50 MG/ML (fosamprenavir 2 calcium) LEXIVA ORAL TABLET 700 MG (fosamprenavir calcium) 3 lopinavir-ritonavir oral solution 400-100 mg/5ml 1 lopinavir-ritonavir oral tablet 100-25 mg, 200-50 mg 1 NORVIR ORAL PACKET 100 MG (ritonavir) 3 NORVIR ORAL SOLUTION 80 MG/ML (ritonavir) 2 NORVIR ORAL TABLET 100 MG (ritonavir) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 39 Coverage Requirements & Prescription Drug Name Drug Tier Limits PREZCOBIX ORAL TABLET 800-150 MG (darunavir- 2 cobicistat) PREZISTA ORAL SUSPENSION 100 MG/ML (darunavir 3 ethanolate) PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG 2 (darunavir ethanolate) REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG 3 (atazanavir sulfate) REYATAZ ORAL PACKET 50 MG (atazanavir sulfate) 3 ritonavir oral tablet 100 mg 1 SYMTUZA ORAL TABLET 800-150-200-10 MG (darun-cobic- 2 ST emtricit-tenofaf) VIRACEPT ORAL TABLET 250 MG, 625 MG (nelfinavir 2 mesylate) INTERFERON ANTIVIRALS - Drugs for Viral Infections ALFERON N INJECTION SOLUTION 5000000 UNIT/ML OA (interferon alfa-n3) INTRON A INJECTION SOLUTION 10000000 UNIT/ML, PA; SP; QL (30 day supply SI 6000000 UNIT/ML (interferon alfa-2b) per 1 fill) INTRON A INJECTION SOLUTION RECONSTITUTED PA; SP; QL (30 day supply 10000000 UNIT, 18000000 UNIT, 50000000 UNIT (interferon SI per 1 fill) alfa-2b) PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML, PA; SP; QL (30 day supply SI 180 MCG/ML (peginterferon alfa-2a) per 1 fill) LINCOMYCIN ANTIBIOTICS - Antibiotics CLEOCIN ORAL CAPSULE 150 MG, 300 MG, 75 MG 3 (clindamycin hcl) CLEOCIN ORAL SOLUTION RECONSTITUTED 75 MG/5ML 3 (clindamycin palmitate hcl)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 40 Coverage Requirements & Prescription Drug Name Drug Tier Limits CLEOCIN PHOSPHATE INJECTION SOLUTION 300 MG/2ML, 600 MG/4ML, 9 GM/60ML, 900 MG/6ML (clindamycin OA phosphate) clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 1 clindamycin palmitate hcl oral solution reconstituted 75 1 mg/5ml clindamycin phosphate in d5w intravenous solution 300 OA mg/50ml, 600 mg/50ml, 900 mg/50ml CLINDAMYCIN PHOSPHATE IN NACL INTRAVENOUS SOLUTION 300-0.9 MG/50ML-%, 600-0.9 MG/50ML-%, 900- OA 0.9 MG/50ML-% clindamycin phosphate injection solution 300 mg/2ml, 600 OA mg/4ml, 9 gm/60ml, 900 mg/6ml, 9000 mg/60ml LINCOCIN INJECTION SOLUTION 300 MG/ML (lincomycin OA hcl) lincomycin hcl injection solution 300 mg/ml OA MONOBACTAM ANTIBIOTICS - Antibiotics AZACTAM INJECTION SOLUTION RECONSTITUTED 1 GM, 2 OA GM (aztreonam) aztreonam injection solution reconstituted 1 gm, 2 gm OA CAYSTON INHALATION SOLUTION RECONSTITUTED 75 SP; QL (30 day supply per 1 3 MG (aztreonam lysine) fill) MONOCLONAL ANTIBODY ANTIVIRALS - Drugs for Viral Infections BAMLANIVIMAB INTRAVENOUS SOLUTION 700 MG/20ML OA CASIRIVIMAB INTRAVENOUS SOLUTION 1332 MG/11.1ML, OA 300 MG/2.5ML IMDEVIMAB INTRAVENOUS SOLUTION 1332 MG/11.1ML, OA 300 MG/2.5ML

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 41 Coverage Requirements & Prescription Drug Name Drug Tier Limits REGEN-COV INJECTION SOLUTION 600-600 MG/10ML OA (casirivimab-imdevimab) SOTROVIMAB INTRAVENOUS SOLUTION 500 MG/8ML OA SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, 50 OA QL (30 day supply per 1 fill) MG/0.5ML (palivizumab) NATURAL PENICILLIN ANTIBIOTICS - Antibiotics BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION OA 900000-300000 UNIT/2ML (penicillin g benzathine & proc) BICILLIN C-R INTRAMUSCULAR SUSPENSION 1200000 OA UNIT/2ML (penicillin g benzathine & proc) BICILLIN L-A INTRAMUSCULAR SUSPENSION 1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000 UNIT/ML (penicillin g OA benzathine) PENICILLIN G POT IN DEXTROSE INTRAVENOUS OA SOLUTION 20000 UNIT/ML, 40000 UNIT/ML, 60000 UNIT/ML penicillin g potassium injection solution reconstituted OA 20000000 unit, 5000000 unit penicillin g procaine intramuscular suspension 600000 OA unit/ml penicillin g sodium injection solution reconstituted 5000000 OA unit penicillin v potassium oral solution reconstituted 125 1 mg/5ml, 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg 1 PFIZERPEN INJECTION SOLUTION RECONSTITUTED OA 20000000 UNIT, 5000000 UNIT (penicillin g potassium) NEURAMINIDASE INHIBITOR ANTIVIRALS - Drugs for Viral Infections oseltamivir phosphate oral capsule 30 mg 1 QL (20 EA per 180 days) oseltamivir phosphate oral capsule 45 mg, 75 mg 1 QL (10 EA per 180 days)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 42 Coverage Requirements & Prescription Drug Name Drug Tier Limits oseltamivir phosphate oral suspension reconstituted 6 1 QL (180 ML per 180 days) mg/ml RAPIVAB INTRAVENOUS SOLUTION 200 MG/20ML OA (peramivir) RELENZA DISKHALER INHALATION AEROSOL POWDER 3 QL (20 EA per 180 days) BREATH ACTIVATED 5 MG/BLISTER (zanamivir) TAMIFLU ORAL CAPSULE 30 MG (oseltamivir phosphate) 3 QL (20 EA per 180 days) TAMIFLU ORAL CAPSULE 45 MG, 75 MG (oseltamivir 3 QL (10 EA per 180 days) phosphate) TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML 3 QL (180 ML per 180 days) (oseltamivir phosphate) NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS - Drugs for Viral Infections acyclovir oral capsule 200 mg 1 acyclovir oral suspension 200 mg/5ml 1 acyclovir oral tablet 400 mg, 800 mg 1 acyclovir sodium intravenous solution 50 mg/ml OA adefovir dipivoxil oral tablet 10 mg 1 BARACLUDE ORAL SOLUTION 0.05 MG/ML (entecavir) 2 BARACLUDE ORAL TABLET 0.5 MG, 1 MG (entecavir) 3 cidofovir intravenous solution 75 mg/ml OA entecavir oral tablet 0.5 mg, 1 mg 1 famciclovir oral tablet 125 mg, 250 mg, 500 mg 1 GANCICLOVIR INTRAVENOUS SOLUTION 500 MG/250ML OA ganciclovir sodium intravenous solution 500 mg/10ml OA ganciclovir sodium intravenous solution reconstituted 500 OA mg HEPSERA ORAL TABLET 10 MG (adefovir dipivoxil) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 43 Coverage Requirements & Prescription Drug Name Drug Tier Limits REMDESIVIR INTRAVENOUS SOLUTION RECONSTITUTED OA 100 MG REMDESIVIR INTRAVENOUS SOLUTION RECONSTITUTED OA 150 MG PA; SP; QL (30 day supply ribavirin inhalation solution reconstituted 6 gm 1 per 1 fill) PA; SP; QL (30 day supply ribavirin oral capsule 200 mg 1 per 1 fill) PA; SP; QL (30 day supply ribavirin oral tablet 200 mg 1 per 1 fill) SITAVIG BUCCAL TABLET 50 MG (acyclovir) 3 valacyclovir hcl oral tablet 1 gm, 500 mg 1 VALCYTE ORAL SOLUTION RECONSTITUTED 50 MG/ML 3 (valganciclovir hcl) VALCYTE ORAL TABLET 450 MG (valganciclovir hcl) 3 valganciclovir hcl oral solution reconstituted 50 mg/ml 1 valganciclovir hcl oral tablet 450 mg 1 VALTREX ORAL TABLET 1 GM, 500 MG (valacyclovir hcl) 3 VEKLURY INTRAVENOUS SOLUTION 100 MG/20ML OA (remdesivir) VEKLURY INTRAVENOUS SOLUTION RECONSTITUTED 100 OA MG (remdesivir) VEMLIDY ORAL TABLET 25 MG (tenofovir alafenamide 2 PA fumarate) VIRAZOLE INHALATION SOLUTION RECONSTITUTED 6 GM PA; SP; QL (30 day supply 3 (ribavirin) per 1 fill) ZOVIRAX ORAL SUSPENSION 200 MG/5ML (acyclovir) 3 OTHER MACROLIDE ANTIBIOTICS - Antibiotics amoxicill-clarithro-lansopraz oral 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 44 Coverage Requirements & Prescription Drug Name Drug Tier Limits azithromycin intravenous solution reconstituted 500 mg OA azithromycin oral packet 1 gm 1 azithromycin oral suspension reconstituted 100 mg/5ml, 1 200 mg/5ml azithromycin oral tablet 250 mg, 500 mg, 600 mg 1 clarithromycin er oral tablet extended release 24 hour 500 1 mg clarithromycin oral suspension reconstituted 125 mg/5ml, 1 250 mg/5ml clarithromycin oral tablet 250 mg, 500 mg 1 DIFICID ORAL SUSPENSION RECONSTITUTED 40 MG/ML 3 PA (fidaxomicin) DIFICID ORAL TABLET 200 MG (fidaxomicin) 2 OMECLAMOX-PAK ORAL 500-500-20 MG (amoxicill- 3 clarithro-omeprazole) ZITHROMAX INTRAVENOUS SOLUTION RECONSTITUTED OA 500 MG (azithromycin) ZITHROMAX ORAL PACKET 1 GM (azithromycin) 3 ZITHROMAX ORAL SUSPENSION RECONSTITUTED 100 3 MG/5ML, 200 MG/5ML (azithromycin) ZITHROMAX ORAL TABLET 250 MG, 500 MG (azithromycin) 3 ZITHROMAX TRI-PAK ORAL TABLET 500 MG (azithromycin) 3 ZITHROMAX Z-PAK ORAL TABLET 250 MG (azithromycin) 3 OXAZOLIDINONE ANTIBIOTICS - Antibiotics linezolid in sodium chloride intravenous solution 600-0.9 OA mg/300ml-% linezolid intravenous solution 600 mg/300ml OA linezolid oral suspension reconstituted 100 mg/5ml 1 linezolid oral tablet 600 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 45 Coverage Requirements & Prescription Drug Name Drug Tier Limits SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED OA 200 MG (tedizolid phosphate) SIVEXTRO ORAL TABLET 200 MG (tedizolid phosphate) 3 ZYVOX INTRAVENOUS SOLUTION 200 MG/100ML, 600 OA MG/300ML (linezolid) ZYVOX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML 3 (linezolid) ZYVOX ORAL TABLET 600 MG (linezolid) 3 PENICILLINASE-RESISTANT PENICILLINS - Antibiotics dicloxacillin sodium oral capsule 250 mg, 500 mg 1 NAFCILLIN SODIUM IN DEXTROSE INTRAVENOUS OA SOLUTION 1 GM/50ML, 2 GM/100ML nafcillin sodium injection solution reconstituted 1 gm, 2 gm OA nafcillin sodium intravenous solution reconstituted 1 gm, OA 10 gm, 2 gm OXACILLIN SODIUM IN DEXTROSE INTRAVENOUS OA SOLUTION 1 GM/50ML, 2 GM/50ML oxacillin sodium injection solution reconstituted 1 gm, 2 OA gm oxacillin sodium intravenous solution reconstituted 10 gm OA PLEUROMUTILINS - Antibiotics XENLETA INTRAVENOUS SOLUTION 150 MG/15ML OA (lefamulin acetate) XENLETA ORAL TABLET 600 MG (lefamulin acetate) 3 POLYENE ANTIFUNGALS - Drugs for Fungus ABELCET INTRAVENOUS SUSPENSION 5 MG/ML OA (amphotericin b lipid) AMBISOME INTRAVENOUS SUSPENSION OA RECONSTITUTED 50 MG (amphotericin b liposome)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 46 Coverage Requirements & Prescription Drug Name Drug Tier Limits amphotericin b intravenous solution reconstituted 50 mg OA nystatin mouth/throat suspension 100000 unit/ml 1 nystatin oral tablet 500000 unit 1 POLYMYXIN ANTIBIOTICS - Antibiotics colistimethate sodium (cba) injection solution reconstituted OA 150 mg COLY-MYCIN M INJECTION SOLUTION RECONSTITUTED OA 150 MG (colistimethate sodium) polymyxin b sulfate injection solution reconstituted 500000 OA unit PYRIMIDINE ANTIFUNGALS - Drugs for Fungus ANCOBON ORAL CAPSULE 250 MG, 500 MG (flucytosine) 3 flucytosine oral capsule 250 mg, 500 mg 1 QUINOLONE ANTIBIOTICS - Antibiotics BAXDELA INTRAVENOUS SOLUTION RECONSTITUTED 300 OA PA MG (delafloxacin meglumine) BAXDELA ORAL TABLET 450 MG (delafloxacin meglumine) 3 PA CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML 3 (5%), 500 MG/5ML (10%) (ciprofloxacin) CIPRO ORAL TABLET 250 MG, 500 MG (ciprofloxacin hcl) 3 ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 1 mg ciprofloxacin in d5w intravenous solution 200 mg/100ml, OA 400 mg/200ml DEXAMETHASONE-MOXIFLOXACIN INTRAOCULAR OA SOLUTION 1-5 MG/ML DEXAMETH-MOXIFLOX-KETOROLAC INTRAOCULAR OA SOLUTION 1-0.5-0.4 MG/ML

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 47 Coverage Requirements & Prescription Drug Name Drug Tier Limits levofloxacin in d5w intravenous solution 250 mg/50ml, 500 OA mg/100ml, 750 mg/150ml levofloxacin intravenous solution 25 mg/ml OA levofloxacin oral solution 25 mg/ml 1 levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1 moxifloxacin hcl in nacl intravenous solution 400 mg/250ml OA MOXIFLOXACIN HCL INTRAOCULAR SOLUTION 1 MG/ML, 5 OA MG/ML MOXIFLOXACIN HCL INTRAVENOUS SOLUTION 400 OA MG/250ML moxifloxacin hcl oral tablet 400 mg 1 ofloxacin oral tablet 300 mg, 400 mg 1 TRIAMCINOLONE-MOXIFLOXACIN INTRAOCULAR OA SUSPENSION 15-1 MG/ML RIFAMYCIN ANTIBIOTICS - Antibiotics AEMCOLO ORAL TABLET DELAYED RELEASE 194 MG 3 PA (rifamycin sodium) MYCOBUTIN ORAL CAPSULE 150 MG (rifabutin) 3 PRIFTIN ORAL TABLET 150 MG (rifapentine) 3 rifabutin oral capsule 150 mg 1 RIFADIN INTRAVENOUS SOLUTION RECONSTITUTED 600 OA MG (rifampin) rifampin intravenous solution reconstituted 600 mg OA rifampin oral capsule 150 mg, 300 mg 1 XIFAXAN ORAL TABLET 200 MG, 550 MG (rifaximin) 3 PA SIDEROPHORE CEPHALOSPORINS - Antibiotics FETROJA INTRAVENOUS SOLUTION RECONSTITUTED 1 OA GM (cefiderocol sulfate tosylate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 48 Coverage Requirements & Prescription Drug Name Drug Tier Limits STREPTOGRAMIN ANTIBIOTICS - Antibiotics SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED OA 150-350 MG (quinupristin-dalfopristin) SULFONAMIDE ANTIBIOTICS (SYSTEMIC) - Antibiotics AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 3 500 MG (sulfasalazine) AZULFIDINE ORAL TABLET 500 MG (sulfasalazine) 3 BACTRIM DS ORAL TABLET 800-160 MG (sulfamethoxazole- 3 trimethoprim) BACTRIM ORAL TABLET 400-80 MG (sulfamethoxazole- 3 trimethoprim) sulfadiazine oral tablet 500 mg 1 sulfamethoxazole-trimethoprim intravenous solution 400-80 OA mg/5ml sulfamethoxazole-trimethoprim oral suspension 200-40 1 mg/5ml sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800- 1 160 mg sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1 sulfatrim pediatric oral suspension 200-40 mg/5ml 1 TETRACYCLINE ANTIBIOTICS - Antibiotics ACTICLATE ORAL TABLET 150 MG, 75 MG (doxycycline 3 hyclate) avidoxy oral tablet 100 mg 1 coremino oral tablet extended release 24 hour 135 mg, 45 1 PA mg, 90 mg demeclocycline hcl oral tablet 150 mg, 300 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 49 Coverage Requirements & Prescription Drug Name Drug Tier Limits DORYX MPC ORAL TABLET DELAYED RELEASE 120 MG 2 PA (doxycycline hyclate) DORYX ORAL TABLET DELAYED RELEASE 200 MG, 50 MG, 3 PA 80 MG (doxycycline hyclate) doxy 100 intravenous solution reconstituted 100 mg OA doxycycline hyclate intravenous solution reconstituted 100 OA mg doxycycline hyclate oral capsule 100 mg, 50 mg 1 doxycycline hyclate oral tablet 100 mg, 150 mg, 20 mg, 50 1 mg, 75 mg doxycycline hyclate oral tablet delayed release 100 mg, 150 1 PA mg, 200 mg, 50 mg, 75 mg DOXYCYCLINE HYCLATE ORAL TABLET DELAYED 3 PA RELEASE 80 MG doxycycline monohydrate oral capsule 100 mg, 50 mg 1 doxycycline monohydrate oral capsule 150 mg, 75 mg 1 PA doxycycline monohydrate oral suspension reconstituted 25 1 mg/5ml doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 1 mg, 75 mg doxycycline oral capsule delayed release 40 mg 1 PA HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) 3 MINOCIN INTRAVENOUS SOLUTION RECONSTITUTED 100 OA MG (minocycline hcl) MINOCYCLINE HCL ER ORAL CAPSULE EXTENDED 3 PA RELEASE 24 HOUR 135 MG, 45 MG, 90 MG minocycline hcl er oral tablet extended release 24 hour 105 1 PA mg, 115 mg, 135 mg, 45 mg, 55 mg, 65 mg, 80 mg, 90 mg minocycline hcl oral capsule 100 mg, 50 mg, 75 mg 1 minocycline hcl oral tablet 100 mg, 50 mg, 75 mg 1 PA Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 50 Coverage Requirements & Prescription Drug Name Drug Tier Limits MINOLIRA ORAL TABLET EXTENDED RELEASE 24 HOUR 3 PA 105 MG, 135 MG (minocycline hcl) mondoxyne nl oral capsule 100 mg 1 mondoxyne nl oral capsule 75 mg 1 PA morgidox oral capsule 100 mg 1 ORACEA ORAL CAPSULE DELAYED RELEASE 40 MG 3 PA (doxycycline) PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- 3 metronid-tetracyc) SOLODYN ORAL TABLET EXTENDED RELEASE 24 HOUR 3 PA 105 MG, 115 MG, 55 MG, 65 MG, 80 MG (minocycline hcl) TARGADOX ORAL TABLET 50 MG (doxycycline hyclate) 3 tetracycline hcl oral capsule 250 mg, 500 mg 1 VIBRAMYCIN ORAL CAPSULE 100 MG (doxycycline hyclate) 3 VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED 25 3 MG/5ML (doxycycline monohydrate) VIBRAMYCIN ORAL SYRUP 50 MG/5ML (doxycycline 3 calcium) XIMINO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 PA 135 MG, 45 MG, 90 MG (minocycline hcl) URINARY ANTI-INFECTIVES - Drugs for the Urinary System BACTRIM DS ORAL TABLET 800-160 MG (sulfamethoxazole- 3 trimethoprim) BACTRIM ORAL TABLET 400-80 MG (sulfamethoxazole- 3 trimethoprim) fosfomycin tromethamine oral packet 3 gm 1 HIPREX ORAL TABLET 1 GM (methenamine hippurate) 3 MACROBID ORAL CAPSULE 100 MG (nitrofurantoin 3 monohyd macro)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 51 Coverage Requirements & Prescription Drug Name Drug Tier Limits MACRODANTIN ORAL CAPSULE 100 MG, 25 MG, 50 MG 3 (nitrofurantoin macrocrystal) me/naphos/mb/hyo1 oral tablet 81.6 mg 1 methenamine hippurate oral tablet 1 gm 1 MONUROL ORAL PACKET 3 GM (fosfomycin tromethamine) 3 nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 1 mg nitrofurantoin monohydrate macrocrystals oral capsule 100 1 mg nitrofurantoin oral suspension 25 mg/5ml 1 PHOSPHASAL ORAL TABLET 81.6 MG (meth-hyo-m bl-na 3 phos-ph sal) PRIMSOL ORAL SOLUTION 50 MG/5ML (trimethoprim hcl) 2 sulfamethoxazole-trimethoprim intravenous solution 400-80 OA mg/5ml sulfamethoxazole-trimethoprim oral suspension 200-40 1 mg/5ml sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800- 1 160 mg sulfatrim pediatric oral suspension 200-40 mg/5ml 1 trimethoprim oral tablet 100 mg 1 URIMAR-T ORAL TABLET 120 MG (meth-hyo-m bl-na phos- 3 ph sal) urin ds oral tablet 81.6 mg 1 UROGESIC-BLUE ORAL TABLET 81.6 MG (methen-hyosc- 3 meth blue-na phos) USTELL ORAL CAPSULE 120 MG (meth-hyo-m bl-na phos- 3 ph sal) UTIRA-C ORAL TABLET 81.6 MG (meth-hyo-m bl-na phos- 3 ph sal) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 52 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTINEOPLASTIC AGENTS - Drugs for Cancer ANTINEOPLASTIC AGENTS - Drugs for Cancer PA; SP; AC; QL (30 day abiraterone acetate oral tablet 250 mg, 500 mg 1 supply per 1 fill) ABRAXANE INTRAVENOUS SUSPENSION OA QL (30 day supply per 1 fill) RECONSTITUTED 100 MG (paclitaxel protein-bound part) ADCETRIS INTRAVENOUS SOLUTION RECONSTITUTED 50 OA QL (30 day supply per 1 fill) MG (brentuximab vedotin) adriamycin intravenous solution 2 mg/ml OA adriamycin intravenous solution reconstituted 10 mg OA adriamycin intravenous solution reconstituted 50 mg OA AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 PA; SP; AC; QL (30 day 3 MG (everolimus) supply per 1 fill) AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG PA; SP; AC; QL (30 day 3 (everolimus) supply per 1 fill) PA; SP; AC; QL (30 day ALECENSA ORAL CAPSULE 150 MG (alectinib hcl) 3 supply per 1 fill) ALFERON N INJECTION SOLUTION 5000000 UNIT/ML OA (interferon alfa-n3) ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 100 OA MG, 500 MG (pemetrexed disodium) ALIQOPA INTRAVENOUS SOLUTION RECONSTITUTED 60 OA QL (30 day supply per 1 fill) MG (copanlisib hcl) ALKERAN INTRAVENOUS SOLUTION RECONSTITUTED 50 OA MG (melphalan hcl) ALKERAN ORAL TABLET 2 MG (melphalan) 3 AC ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG PA; SP; AC; QL (30 day 3 (brigatinib) supply per 1 fill) ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 MG PA; SP; AC; QL (30 day 3 (brigatinib) supply per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 53 Coverage Requirements & Prescription Drug Name Drug Tier Limits anastrozole oral tablet 1 mg 1 AC ARIMIDEX ORAL TABLET 1 MG (anastrozole) 3 AC AROMASIN ORAL TABLET 25 MG (exemestane) 3 AC ARRANON INTRAVENOUS SOLUTION 5 MG/ML (nelarabine) OA QL (30 day supply per 1 fill) arsenic trioxide intravenous solution 10 mg/10ml, 12 OA mg/6ml ARZERRA INTRAVENOUS CONCENTRATE 100 MG/5ML, OA QL (30 day supply per 1 fill) 1000 MG/50ML (ofatumumab) ASPARLAS INTRAVENOUS SOLUTION 3750 UNIT/5ML OA (calaspargase pegol-mknl) AVASTIN INTRAVENOUS SOLUTION 100 MG/4ML, 400 OA QL (30 day supply per 1 fill) MG/16ML (bevacizumab) AYVAKIT ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, PA; SP; AC; QL (1 EA per 1 3 50 MG (avapritinib) day); AL (Min 18 Years) azacitidine injection suspension reconstituted 100 mg OA QL (30 day supply per 1 fill) AZEDRA DOSIMETRIC INTRAVENOUS SOLUTION 15 OA MCI/ML (iobenguane i 131) AZEDRA THERAPEUTIC INTRAVENOUS SOLUTION 15 OA MCI/ML (iobenguane i 131) PA; SP; AC; QL (30 day BALVERSA ORAL TABLET 3 MG, 4 MG, 5 MG (erdafitinib) 3 supply per 1 fill) BAVENCIO INTRAVENOUS SOLUTION 200 MG/10ML OA QL (30 day supply per 1 fill) (avelumab) BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 500 MG (belinostat) BELRAPZO INTRAVENOUS SOLUTION 100 MG/4ML OA QL (30 day supply per 1 fill) (bendamustine hcl) BENDEKA INTRAVENOUS SOLUTION 100 MG/4ML OA QL (30 day supply per 1 fill) (bendamustine hcl)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 54 Coverage Requirements & Prescription Drug Name Drug Tier Limits BESPONSA INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 0.9 MG (inotuzumab ozogamicin) SP; AC; QL (30 day supply bexarotene oral capsule 75 mg 1 per 1 fill) bicalutamide oral tablet 50 mg 1 AC BICNU INTRAVENOUS SOLUTION RECONSTITUTED 100 OA MG (carmustine) BLENREP INTRAVENOUS SOLUTION RECONSTITUTED 100 OA PA; SP MG (belantamab mafodotin-blmf) bleomycin sulfate injection solution reconstituted 15 unit, OA 30 unit BLINCYTO INTRAVENOUS SOLUTION RECONSTITUTED 35 OA QL (30 day supply per 1 fill) MCG (blinatumomab) BORTEZOMIB INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 3.5 MG BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG PA; SP; AC; QL (30 day 3 (bosutinib) supply per 1 fill) PA; SP; AC; QL (30 day BRAFTOVI ORAL CAPSULE 75 MG (encorafenib) 3 supply per 1 fill) BREYANZI INTRAVENOUS SUSPENSION (lisocabtagene OA maraleucel) PA; AC; QL (4 EA per 1 day); BRUKINSA ORAL CAPSULE 80 MG (zanubrutinib) 3 AL (Min 18 Years) busulfan intravenous solution 6 mg/ml OA BUSULFEX INTRAVENOUS SOLUTION 6 MG/ML (busulfan) OA CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG PA; SP; AC; QL (30 day 3 (cabozantinib s-malate) supply per 1 fill) PA; SP; AC; QL (30 day CALQUENCE ORAL CAPSULE 100 MG (acalabrutinib) 3 supply per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 55 Coverage Requirements & Prescription Drug Name Drug Tier Limits CAMPTOSAR INTRAVENOUS SOLUTION 100 MG/5ML, 300 OA MG/15ML, 40 MG/2ML (irinotecan hcl) SP; AC; QL (30 day supply capecitabine oral tablet 150 mg, 500 mg 1 per 1 fill) PA; SP; AC; QL (30 day CAPRELSA ORAL TABLET 100 MG, 300 MG (vandetanib) 3 supply per 1 fill) carboplatin intravenous solution 150 mg/15ml, 450 OA mg/45ml, 50 mg/5ml, 600 mg/60ml carmustine intravenous solution reconstituted 100 mg OA CASODEX ORAL TABLET 50 MG (bicalutamide) 3 AC cisplatin intravenous solution 100 mg/100ml, 200 mg/200ml, OA 50 mg/50ml CISPLATIN INTRAVENOUS SOLUTION RECONSTITUTED 50 OA MG cladribine intravenous solution 10 mg/10ml OA clofarabine intravenous solution 1 mg/ml OA CLOLAR INTRAVENOUS SOLUTION 1 MG/ML (clofarabine) OA COMETRIQ ORAL KIT 20 MG, 3 X 20 MG & 80 MG, 80 & 20 PA; SP; AC; QL (30 day 3 MG (cabozantinib s-malate) supply per 1 fill) SP; AC; QL (30 day supply COPIKTRA ORAL CAPSULE 15 MG, 25 MG (duvelisib) 3 per 1 fill) COSMEGEN INTRAVENOUS SOLUTION RECONSTITUTED OA 0.5 MG (dactinomycin) PA; SP; AC; QL (30 day COTELLIC ORAL TABLET 20 MG (cobimetinib fumarate) 3 supply per 1 fill) cyclophosphamide injection solution reconstituted 1 gm, 2 OA gm, 500 mg CYCLOPHOSPHAMIDE INTRAVENOUS SOLUTION 1 OA PA; SP GM/5ML, 500 MG/2.5ML cyclophosphamide oral capsule 25 mg, 50 mg 1 AC

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 56 Coverage Requirements & Prescription Drug Name Drug Tier Limits CYCLOPHOSPHAMIDE ORAL TABLET 25 MG, 50 MG 3 AC CYRAMZA INTRAVENOUS SOLUTION 100 MG/10ML, 500 OA QL (30 day supply per 1 fill) MG/50ML (ramucirumab) cytarabine (pf) injection solution 100 mg/ml, 20 mg/ml OA cytarabine injection solution 20 mg/ml OA dacarbazine intravenous solution reconstituted 100 mg, OA 200 mg DACOGEN INTRAVENOUS SOLUTION RECONSTITUTED 50 OA QL (30 day supply per 1 fill) MG (decitabine) dactinomycin intravenous solution reconstituted 0.5 mg OA DANYELZA INTRAVENOUS SOLUTION 40 MG/10ML OA (naxitamab-gqgk) DARZALEX FASPRO SUBCUTANEOUS SOLUTION 1800- OA 30000 MG-UT/15ML (daratumumab-hyaluronidase-fihj) DARZALEX INTRAVENOUS SOLUTION 100 MG/5ML, 400 OA QL (30 day supply per 1 fill) MG/20ML (daratumumab) daunorubicin hcl intravenous solution 20 mg/4ml, 50 OA mg/10ml DAURISMO ORAL TABLET 100 MG, 25 MG (glasdegib PA; SP; AC; QL (30 day 3 maleate) supply per 1 fill) decitabine intravenous solution reconstituted 50 mg OA QL (30 day supply per 1 fill) docetaxel intravenous concentrate 160 mg/8ml, 20 mg/ml, OA 80 mg/4ml docetaxel intravenous solution 160 mg/16ml, 20 mg/2ml, 80 OA mg/8ml DOXIL INTRAVENOUS INJECTABLE 2 MG/ML (doxorubicin OA hcl liposomal) doxorubicin hcl intravenous solution 2 mg/ml OA doxorubicin hcl intravenous solution reconstituted 10 mg OA doxorubicin hcl liposomal intravenous injectable 2 mg/ml OA Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 57 Coverage Requirements & Prescription Drug Name Drug Tier Limits DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG 2 (hydroxyurea) ELIGARD SUBCUTANEOUS KIT 22.5 MG (leuprolide acetate OA QL (30 day supply per 1 fill) (3 month)) ELIGARD SUBCUTANEOUS KIT 30 MG (leuprolide acetate (4 OA QL (30 day supply per 1 fill) month)) ELIGARD SUBCUTANEOUS KIT 45 MG (leuprolide acetate (6 OA QL (30 day supply per 1 fill) month)) PA; QL (30 day supply per 1 ELIGARD SUBCUTANEOUS KIT 7.5 MG (leuprolide acetate) OA fill) ELLENCE INTRAVENOUS SOLUTION 200 MG/100ML, 50 OA MG/25ML (epirubicin hcl) ELZONRIS INTRAVENOUS SOLUTION 1000 MCG/ML OA QL (30 day supply per 1 fill) (tagraxofusp-erzs) EMCYT ORAL CAPSULE 140 MG (estramustine phosphate 2 AC sodium) EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 300 MG, 400 MG (elotuzumab) ENHERTU INTRAVENOUS SOLUTION RECONSTITUTED OA 100 MG (fam-trastuzumab deruxtec-nxki) epirubicin hcl intravenous solution 200 mg/100ml, 50 OA mg/25ml ERBITUX INTRAVENOUS SOLUTION 100 MG/50ML, 200 OA QL (30 day supply per 1 fill) MG/100ML (cetuximab) PA; SP; AC; QL (30 day ERIVEDGE ORAL CAPSULE 150 MG (vismodegib) 3 supply per 1 fill) PA; SP; AC; QL (30 day ERLEADA ORAL TABLET 60 MG (apalutamide) 3 supply per 1 fill) PA; SP; AC; QL (30 day erlotinib hcl oral tablet 100 mg, 150 mg, 25 mg 1 supply per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 58 Coverage Requirements & Prescription Drug Name Drug Tier Limits ERWINASE INJECTION SOLUTION RECONSTITUTED 10000 OA QL (30 day supply per 1 fill) UNIT (asparaginase erwinia chrysanth) ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED OA 100 MG (etoposide phosphate) etoposide intravenous solution 1 gm/50ml, 100 mg/5ml, 500 OA mg/25ml etoposide oral capsule 50 mg 1 AC PA; SP; AC; QL (30 day everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg 1 supply per 1 fill) EVOMELA INTRAVENOUS SOLUTION RECONSTITUTED 50 OA QL (30 day supply per 1 fill) MG (melphalan hcl) exemestane oral tablet 25 mg 1 AC FARESTON ORAL TABLET 60 MG (toremifene citrate) 3 AC FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG PA; SP; AC; QL (30 day 3 (panobinostat lactate) supply per 1 fill) FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML OA (fulvestrant) FEMARA ORAL TABLET 2.5 MG (letrozole) 3 AC FIRMAGON (240 MG DOSE) SUBCUTANEOUS SOLUTION OA QL (30 day supply per 1 fill) RECONSTITUTED 120 MG/VIAL (degarelix acetate) FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 80 MG (degarelix acetate) floxuridine injection solution reconstituted 0.5 gm OA fludarabine phosphate intravenous solution 50 mg/2ml OA fludarabine phosphate intravenous solution reconstituted OA 50 mg fluorouracil intravenous solution 1 gm/20ml, 2.5 gm/50ml, 5 OA gm/100ml, 500 mg/10ml flutamide oral capsule 125 mg 1 AC

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 59 Coverage Requirements & Prescription Drug Name Drug Tier Limits FOLOTYN INTRAVENOUS SOLUTION 20 MG/ML, 40 MG/2ML OA QL (30 day supply per 1 fill) (pralatrexate) PA; SP; AC; QL (30 day FOTIVDA ORAL CAPSULE 0.89 MG, 1.34 MG (tivozanib hcl) 3 supply per 1 fill) fulvestrant intramuscular solution 250 mg/5ml OA PA; SP; AC; QL (30 day GAVRETO ORAL CAPSULE 100 MG (pralsetinib) 3 supply per 1 day) GAZYVA INTRAVENOUS SOLUTION 1000 MG/40ML OA QL (30 day supply per 1 fill) (obinutuzumab) gemcitabine hcl intravenous solution 1 gm/10ml, 1 gm/26.3ml, 1.5 gm/15ml, 2 gm/20ml, 2 gm/52.6ml, 200 OA mg/2ml, 200 mg/5.26ml gemcitabine hcl intravenous solution reconstituted 1 gm, 2 OA gm, 200 mg GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG (afatinib PA; SP; AC; QL (30 day 3 dimaleate) supply per 1 fill) GLEEVEC ORAL TABLET 100 MG, 400 MG (imatinib PA; SP; AC; QL (30 day 3 mesylate) supply per 1 fill) GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG 2 AC (lomustine) GLIADEL WAFER IMPLANT WAFER 7.7 MG (carmustine in OA polifeprosan) HALAVEN INTRAVENOUS SOLUTION 1 MG/2ML (eribulin OA QL (30 day supply per 1 fill) mesylate) HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600- OA 10000 MG-UNT/5ML (trastuzumab-hyaluronidase-oysk) HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 150 MG (trastuzumab) HERZUMA INTRAVENOUS SOLUTION RECONSTITUTED OA 150 MG, 420 MG (trastuzumab-pkrb)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 60 Coverage Requirements & Prescription Drug Name Drug Tier Limits HYCAMTIN INTRAVENOUS SOLUTION RECONSTITUTED 4 OA QL (30 day supply per 1 fill) MG (topotecan hcl) SP; AC; QL (30 day supply HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG (topotecan hcl) 3 per 1 fill) HYDREA ORAL CAPSULE 500 MG (hydroxyurea) 3 AC hydroxyprogesterone caproate intramuscular solution 1.25 SI QL (30 day supply per 1 fill) gm/5ml hydroxyurea oral capsule 500 mg 1 AC IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG PA; SP; AC; QL (30 day 3 (palbociclib) supply per 1 fill) IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG PA; SP; AC; QL (30 day 3 (palbociclib) supply per 1 fill) ICLUSIG ORAL TABLET 10 MG, 15 MG, 30 MG, 45 MG PA; SP; AC; QL (30 day 3 (ponatinib hcl) supply per 1 fill) IDAMYCIN PFS INTRAVENOUS SOLUTION 10 MG/10ML, 20 OA MG/20ML, 5 MG/5ML (idarubicin hcl) idarubicin hcl intravenous solution 10 mg/10ml, 20 OA mg/20ml, 5 mg/5ml IDHIFA ORAL TABLET 100 MG, 50 MG (enasidenib PA; SP; AC; QL (30 day 3 mesylate) supply per 1 fill) IFEX INTRAVENOUS SOLUTION RECONSTITUTED 1 GM, 3 OA GM (ifosfamide) ifosfamide intravenous solution 1 gm/20ml, 3 gm/60ml OA ifosfamide intravenous solution reconstituted 1 gm, 3 gm OA PA; SP; AC; QL (30 day imatinib mesylate oral tablet 100 mg, 400 mg 1 supply per 1 fill) PA; SP; AC; QL (30 day IMBRUVICA ORAL CAPSULE 140 MG, 70 MG (ibrutinib) 3 supply per 1 fill) IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 PA; SP; AC; QL (30 day 3 MG (ibrutinib) supply per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 61 Coverage Requirements & Prescription Drug Name Drug Tier Limits IMFINZI INTRAVENOUS SOLUTION 120 MG/2.4ML, 500 OA QL (30 day supply per 1 fill) MG/10ML (durvalumab) IMLYGIC INTRALESIONAL SUSPENSION 1000000 UNIT/ML, OA QL (30 day supply per 1 fill) 100000000 UNIT/ML (talimogene laherparepvec) INFUGEM INTRAVENOUS SOLUTION 1200-0.9 MG/120ML- %, 1300-0.9 MG/130ML-%, 1400-0.9 MG/140ML-%, 1500-0.9 MG/150ML-%, 1600-0.9 MG/160ML-%, 1700-0.9 MG/170ML-%, OA 1800-0.9 MG/180ML-%, 1900-0.9 MG/190ML-%, 2000-0.9 MG/200ML-%, 2200-0.9 MG/220ML-% (gemcitabine hcl-nacl) PA; SP; AC; QL (30 day INLYTA ORAL TABLET 1 MG, 5 MG (axitinib) 3 supply per 1 fill) PA; SP; AC; QL (30 day INQOVI ORAL TABLET 35-100 MG (decitabine-cedazuridine) 3 supply per 1 fill) PA; SP; AC; QL (30 day INREBIC ORAL CAPSULE 100 MG (fedratinib hcl) 3 supply per 1 fill) INTRON A INJECTION SOLUTION 10000000 UNIT/ML, PA; SP; QL (30 day supply SI 6000000 UNIT/ML (interferon alfa-2b) per 1 fill) INTRON A INJECTION SOLUTION RECONSTITUTED PA; SP; QL (30 day supply 10000000 UNIT, 18000000 UNIT, 50000000 UNIT (interferon SI per 1 fill) alfa-2b) PA; SP; AC; QL (30 day IRESSA ORAL TABLET 250 MG (gefitinib) 3 supply per 1 fill) irinotecan hcl intravenous solution 100 mg/5ml, 300 OA mg/15ml, 40 mg/2ml, 500 mg/25ml ISTODAX (OVERFILL) INTRAVENOUS SOLUTION SP; QL (30 day supply per 1 OA RECONSTITUTED 10 MG (romidepsin) fill) IXEMPRA KIT INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 15 MG, 45 MG (ixabepilone) JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG PA; SP; AC; QL (30 day 3 (ruxolitinib phosphate) supply per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 62 Coverage Requirements & Prescription Drug Name Drug Tier Limits JELMYTO SOLUTION RECONSTITUTED 80 (2 X 40) MG OA (mitomycin) JEMPERLI INTRAVENOUS SOLUTION 500 MG/10ML OA PA (dostarlimab-gxly) JEVTANA INTRAVENOUS SOLUTION 60 MG/1.5ML OA QL (30 day supply per 1 fill) (cabazitaxel) KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED 100 OA QL (30 day supply per 1 fill) MG, 160 MG (ado-trastuzumab emtansine) KANJINTI INTRAVENOUS SOLUTION RECONSTITUTED 150 OA MG, 420 MG (trastuzumab-anns) KEYTRUDA INTRAVENOUS SOLUTION 100 MG/4ML OA QL (30 day supply per 1 fill) (pembrolizumab) KISQALI FEMARA ORAL TABLET THERAPY PACK 200 & 2.5 PA; SP; AC; QL (30 day 3 MG (ribociclib-letrozole) supply per 1 fill) KISQALI ORAL TABLET THERAPY PACK 200 MG (ribociclib PA; SP; AC; QL (30 day 3 succinate) supply per 1 fill) KOSELUGO ORAL CAPSULE 10 MG, 25 MG (selumetinib PA; SP; AC; QL (30 day 3 sulfate) supply per 1 fill) KYPROLIS INTRAVENOUS SOLUTION RECONSTITUTED 10 OA QL (30 day supply per 1 fill) MG, 30 MG, 60 MG (carfilzomib) PA; SP; AC; QL (30 day lapatinib ditosylate oral tablet 250 mg 1 supply per 1 fill) LENVIMA ORAL CAPSULE THERAPY PACK 10 & 4 MG, 10 PA; SP; AC; QL (30 day MG, 10 MG & 2 X 4 MG, 2 X 10 MG, 2 X 10 MG & 4 MG, 2 X 4 3 supply per 1 fill) MG, 3 X 4 MG, 4 MG (lenvatinib mesylate) letrozole oral tablet 2.5 mg 1 AC LEUKERAN ORAL TABLET 2 MG (chlorambucil) 2 AC LIBTAYO INTRAVENOUS SOLUTION 350 MG/7ML OA QL (30 day supply per 1 fill) (cemiplimab-rwlc) LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG PA; SP; AC; QL (30 day 3 (trifluridine-tipiracil) supply per 1 fill) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 63 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SP; AC; QL (30 day LORBRENA ORAL TABLET 100 MG, 25 MG (lorlatinib) 3 supply per 1 fill) PA; SP; AC; QL (30 day LUMAKRAS ORAL TABLET 120 MG (sotorasib) 3 supply per 1 fill) LUMOXITI INTRAVENOUS SOLUTION RECONSTITUTED 1 OA QL (30 day supply per 1 fill) MG (moxetumomab pasudotox-tdfk) LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 PA; QL (30 day supply per 1 OA MG, 7.5 MG (leuprolide acetate) fill) LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 OA QL (30 day supply per 1 fill) MG, 22.5 MG (leuprolide acetate (3 month)) LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG OA QL (30 day supply per 1 fill) INTRAMUSCULAR KIT 30 MG (leuprolide acetate (4 month)) LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG OA QL (30 day supply per 1 fill) INTRAMUSCULAR KIT 45 MG (leuprolide acetate (6 month)) LUTATHERA INTRAVENOUS SOLUTION 370 MBQ/ML OA (lutetium lu 177 dotatate) PA; SP; AC; QL (30 day LYNPARZA ORAL TABLET 100 MG, 150 MG (olaparib) 3 supply per 1 fill) LYSODREN ORAL TABLET 500 MG (mitotane) 2 AC MARGENZA INTRAVENOUS SOLUTION 250 MG/10ML PA; SP; QL (30 day supply OA (margetuximab-cmkb) per 1 fill) MARQIBO INTRAVENOUS SUSPENSION 5 MG/31ML OA QL (30 day supply per 1 fill) (vincristine sulfate liposome) SP; AC; QL (30 day supply MATULANE ORAL CAPSULE 50 MG (procarbazine hcl) 2 per 1 fill) megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml 1 AC megestrol acetate oral suspension 625 mg/5ml 1 megestrol acetate oral tablet 20 mg, 40 mg 1 AC MEKINIST ORAL TABLET 0.5 MG, 2 MG (trametinib dimethyl PA; SP; AC; QL (30 day 3 sulfoxide) supply per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 64 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SP; AC; QL (30 day MEKTOVI ORAL TABLET 15 MG (binimetinib) 3 supply per 1 fill) melphalan hcl intravenous solution reconstituted 50 mg OA melphalan oral tablet 2 mg 1 AC mercaptopurine oral tablet 50 mg 1 AC methotrexate oral tablet 2.5 mg 1 AC methotrexate sodium (pf) injection solution 1 gm/40ml, 250 PA; QL (30 day supply per 1 SI mg/10ml, 50 mg/2ml fill) methotrexate sodium injection solution 250 mg/10ml, 50 PA; QL (30 day supply per 1 SI mg/2ml fill) methotrexate sodium injection solution reconstituted 1 gm OA methotrexate sodium oral tablet 2.5 mg 1 AC mitomycin intravenous solution reconstituted 20 mg, 40 OA mg, 5 mg MITOMYCIN INTRAVESICAL SOLUTION PREFILLED OA SYRINGE 20 MG/40ML mitoxantrone hcl intravenous concentrate 20 mg/10ml, 30 OA mg/15ml mitoxantrone hcl intravenous concentrate 25 mg/12.5ml OA QL (30 day supply per 1 fill) MONJUVI INTRAVENOUS SOLUTION RECONSTITUTED 200 OA PA; SP MG (tafasitamab-cxix) mutamycin intravenous solution reconstituted 20 mg, 40 OA mg, 5 mg MVASI INTRAVENOUS SOLUTION 100 MG/4ML, 400 OA MG/16ML (bevacizumab-awwb) MYLERAN ORAL TABLET 2 MG (busulfan) 2 AC MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 4.5 MG (gemtuzumab ozogamicin) NAVELBINE INTRAVENOUS SOLUTION 10 MG/ML, 50 OA MG/5ML (vinorelbine tartrate) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 65 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SP; AC; QL (30 day NERLYNX ORAL TABLET 40 MG (neratinib maleate) 3 supply per 1 fill) SP; AC; QL (30 day supply NEXAVAR ORAL TABLET 200 MG (sorafenib tosylate) 3 per 1 fill) NILANDRON ORAL TABLET 150 MG (nilutamide) 3 AC nilutamide oral tablet 150 mg 1 AC NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG (ixazomib PA; SP; AC; QL (30 day 3 citrate) supply per 1 fill) NIPENT INTRAVENOUS SOLUTION RECONSTITUTED 10 OA MG (pentostatin) PA; SP; AC; QL (30 day NUBEQA ORAL TABLET 300 MG (darolutamide) 3 supply per 1 fill) PA; SP; AC; QL (30 day ODOMZO ORAL CAPSULE 200 MG (sonidegib phosphate) 3 supply per 1 fill) OGIVRI INTRAVENOUS SOLUTION RECONSTITUTED 150 OA MG, 420 MG (trastuzumab-dkst) ONCASPAR INJECTION SOLUTION 750 UNIT/ML OA (pegaspargase) ONIVYDE INTRAVENOUS INJECTABLE 43 MG/10ML OA QL (30 day supply per 1 fill) (irinotecan hcl liposome) ONTRUZANT INTRAVENOUS SOLUTION RECONSTITUTED OA 150 MG, 420 MG (trastuzumab-dttb) PA; SP; AC; QL (30 day ONUREG ORAL TABLET 200 MG, 300 MG (azacitidine) 3 supply per 1 fill) OPDIVO INTRAVENOUS SOLUTION 100 MG/10ML, 240 OA QL (30 day supply per 1 fill) MG/24ML, 40 MG/4ML (nivolumab) OPDIVO INTRAVENOUS SOLUTION 120 MG/12ML OA (nivolumab) PA; SP; AC; QL (30 day ORGOVYX ORAL TABLET 120 MG (relugolix) 3 supply per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 66 Coverage Requirements & Prescription Drug Name Drug Tier Limits oxaliplatin intravenous solution 100 mg/20ml, 200 mg/40ml, OA 50 mg/10ml oxaliplatin intravenous solution reconstituted 100 mg, 50 OA mg paclitaxel intravenous concentrate 100 mg/16.67ml, 100 PA; SP; QL (30 day supply OA mg/16.7ml, 150 mg/25ml, 30 mg/5ml, 300 mg/50ml per 1 fill) PADCEV INTRAVENOUS SOLUTION RECONSTITUTED 20 OA MG, 30 MG (enfortumab vedotin-ejfv) paraplatin intravenous solution 1000 mg/100ml, 150 OA mg/15ml, 450 mg/45ml, 50 mg/5ml, 600 mg/60ml PEMAZYRE ORAL TABLET 13.5 MG, 4.5 MG, 9 MG PA; SP; AC; QL (0.667 EA 3 (pemigatinib) per 1 day) PEPAXTO INTRAVENOUS SOLUTION RECONSTITUTED 20 PA; SP; QL (30 day supply OA MG (melphalan flufenamide hcl) per 1 fill) PERJETA INTRAVENOUS SOLUTION 420 MG/14ML OA QL (30 day supply per 1 fill) (pertuzumab) PHESGO SUBCUTANEOUS SOLUTION 60-60-2000 MG-MG- PA; SP; QL (30 day supply U/ML, 80-40-2000 MG-MG-U/ML (pertuz-trastuz-hyaluron- OA per 1 fill) zzxf) PHOTOFRIN INTRAVENOUS SOLUTION RECONSTITUTED OA 75 MG (porfimer sodium) PIQRAY ORAL TABLET THERAPY PACK 2 X 150 MG, 200 & PA; SP; AC; QL (30 day 3 50 MG, 200 MG (alpelisib) supply per 1 fill) POLIVY INTRAVENOUS SOLUTION RECONSTITUTED 140 PA; SP; QL (30 day supply OA MG, 30 MG (polatuzumab vedotin-piiq) per 1 fill) POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PA; SP; AC; QL (30 day 3 (pomalidomide) supply per 1 fill) PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50ML OA QL (30 day supply per 1 fill) (necitumumab) POTELIGEO INTRAVENOUS SOLUTION 20 MG/5ML OA QL (30 day supply per 1 fill) (mogamulizumab-kpkc)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 67 Coverage Requirements & Prescription Drug Name Drug Tier Limits PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 22000000 UNIT (aldesleukin) PURIXAN ORAL SUSPENSION 2000 MG/100ML SP; AC; QL (30 day supply 3 (mercaptopurine) per 1 fill) PA; SP; AC; QL (30 day QINLOCK ORAL TABLET 50 MG (ripretinib) 3 supply per 1 fill) QUADRAMET INTRAVENOUS SOLUTION 1850 MBQ/ML OA (samarium sm 153 lexidronam) PA; SP; AC; QL (30 day RETEVMO ORAL CAPSULE 40 MG, 80 MG (selpercatinib) 3 supply per 1 fill) REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, PA; SP; AC; QL (30 day 3 25 MG, 5 MG (lenalidomide) supply per 1 fill) RIABNI INTRAVENOUS SOLUTION 100 MG/10ML, 500 OA MG/50ML (rituximab-arrx) RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400-23400 SP; QL (30 day supply per 1 MG -UT/11.7ML, 1600-26800 MG -UT/13.4ML (rituximab- 3 fill) hyaluronidase human) RITUXAN INTRAVENOUS SOLUTION 100 MG/10ML, 500 OA QL (30 day supply per 1 fill) MG/50ML (rituximab) ROMIDEPSIN INTRAVENOUS SOLUTION 27.5 MG/5.5ML OA PA; SP; AC; QL (30 day ROZLYTREK ORAL CAPSULE 100 MG, 200 MG (entrectinib) 3 supply per 1 fill) RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG PA; SP; AC; QL (30 day 3 (rucaparib camsylate) supply per 1 fill) RUXIENCE INTRAVENOUS SOLUTION 100 MG/10ML, 500 OA MG/50ML (rituximab-pvvr) RYBREVANT INTRAVENOUS SOLUTION 350 MG/7ML OA PA (amivantamab-vmjw) PA; SP; AC; QL (30 day RYDAPT ORAL CAPSULE 25 MG (midostaurin) 3 supply per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 68 Coverage Requirements & Prescription Drug Name Drug Tier Limits RYLAZE INTRAMUSCULAR SOLUTION 10 MG/0.5ML PA; SP; QL (30 day supply 3 (asparaginase erwinia chry-rywn) per 1 fill) SARCLISA INTRAVENOUS SOLUTION 100 MG/5ML, 500 OA MG/25ML (isatuximab-irfc) SIKLOS ORAL TABLET 100 MG, 1000 MG (hydroxyurea) 3 SOLTAMOX ORAL SOLUTION 10 MG/5ML (tamoxifen citrate) 3 PV; AC SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, PA; SP; AC; QL (30 day 3 70 MG, 80 MG (dasatinib) supply per 1 fill) PA; SP; AC; QL (30 day STIVARGA ORAL TABLET 40 MG (regorafenib) 3 supply per 1 fill) STRONTIUM CHLORIDE SR-89 INTRAVENOUS SOLUTION 1 OA MCI/ML sunitinib malate oral capsule 12.5 mg, 25 mg, 37.5 mg, 50 SP; AC; QL (42 day supply 1 mg per 1 fill) SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG SP; AC; QL (42 day supply 3 (sunitinib malate) per 1 fill) SYLVANT INTRAVENOUS SOLUTION RECONSTITUTED 100 OA QL (30 day supply per 1 fill) MG, 400 MG (siltuximab) SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED PA; QL (30 day supply per 1 OA 3.5 MG (omacetaxine mepesuccinate) fill) TABLOID ORAL TABLET 40 MG (thioguanine) 2 AC PA; SP; AC; QL (4 EA per 1 TABRECTA ORAL TABLET 150 MG, 200 MG (capmatinib hcl) 3 day) TAFINLAR ORAL CAPSULE 50 MG, 75 MG (dabrafenib PA; SP; AC; QL (30 day 3 mesylate) supply per 1 fill) TAGRISSO ORAL TABLET 40 MG, 80 MG (osimertinib PA; SP; AC; QL (30 day 3 mesylate) supply per 1 fill) TALZENNA ORAL CAPSULE 0.25 MG, 1 MG (talazoparib PA; SP; AC; QL (30 day 3 tosylate) supply per 1 fill) tamoxifen citrate oral tablet 10 mg, 20 mg 1 PV; AC

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 69 Coverage Requirements & Prescription Drug Name Drug Tier Limits TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG (erlotinib PA; SP; AC; QL (30 day 3 hcl) supply per 1 fill) SP; AC; QL (30 day supply TARGRETIN ORAL CAPSULE 75 MG (bexarotene) 3 per 1 fill) TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG (nilotinib SP; AC; QL (30 day supply 3 hcl) per 1 fill) PA; SP; AC; QL (8 EA per 1 TAZVERIK ORAL TABLET 200 MG (tazemetostat hbr) 3 day) TECARTUS INTRAVENOUS SUSPENSION (brexucabtagene OA PA; SP autoleucel) TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/20ML, 840 OA QL (30 day supply per 1 fill) MG/14ML (atezolizumab) TEMODAR INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 100 MG (temozolomide) TEMODAR ORAL CAPSULE 100 MG, 140 MG, 180 MG, 250 SP; AC; QL (30 day supply 3 MG (temozolomide) per 1 fill) temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, SP; AC; QL (30 day supply 1 250 mg, 5 mg per 1 fill) temsirolimus intravenous solution 25 mg/ml OA QL (30 day supply per 1 fill) TEPADINA INJECTION SOLUTION RECONSTITUTED 100 OA MG, 15 MG (thiotepa) PA; SP; AC; QL (30 day TEPMETKO ORAL TABLET 225 MG (tepotinib hcl) 3 supply per 1 fill) thiotepa injection solution reconstituted 100 mg, 15 mg OA PA; SP; AC; QL (30 day TIBSOVO ORAL TABLET 250 MG (ivosidenib) 3 supply per 1 fill) TICE BCG INTRAVESICAL SUSPENSION RECONSTITUTED OA 50 MG (bcg live) toposar intravenous solution 1 gm/50ml, 100 mg/5ml, 500 OA mg/25ml

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 70 Coverage Requirements & Prescription Drug Name Drug Tier Limits topotecan hcl intravenous solution 4 mg/4ml OA QL (30 day supply per 1 fill) topotecan hcl intravenous solution reconstituted 4 mg OA QL (30 day supply per 1 fill) toremifene citrate oral tablet 60 mg 1 AC TORISEL INTRAVENOUS SOLUTION 25 MG/ML OA QL (30 day supply per 1 fill) (temsirolimus) TRAZIMERA INTRAVENOUS SOLUTION RECONSTITUTED OA PA; SP 150 MG (trastuzumab-qyyp) TRAZIMERA INTRAVENOUS SOLUTION RECONSTITUTED OA 420 MG (trastuzumab-qyyp) TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 100 OA QL (30 day supply per 1 fill) MG, 25 MG (bendamustine hcl) TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG, 22.5 MG, 3.75 MG (triptorelin OA pamoate) tretinoin oral capsule 10 mg 1 AC TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 2 AC (methotrexate sodium) TRISENOX INTRAVENOUS SOLUTION 12 MG/6ML (arsenic OA trioxide) TRODELVY INTRAVENOUS SOLUTION RECONSTITUTED OA 180 MG (sacituzumab govitecan-hziy) TRUSELTIQ (100MG DAILY DOSE) ORAL CAPSULE PA; SP; AC; QL (30 day 3 THERAPY PACK 100 MG (infigratinib phosphate) supply per 1 fill) TRUSELTIQ (125MG DAILY DOSE) ORAL CAPSULE PA; SP; AC; QL (30 day 3 THERAPY PACK 100 & 25 MG (infigratinib phosphate) supply per 1 fill) TRUSELTIQ (50MG DAILY DOSE) ORAL CAPSULE PA; SP; AC; QL (30 day 3 THERAPY PACK 25 MG (infigratinib phosphate) supply per 1 fill) TRUSELTIQ (75MG DAILY DOSE) ORAL CAPSULE PA; SP; AC; QL (30 day 3 THERAPY PACK 25 MG (infigratinib phosphate) supply per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 71 Coverage Requirements & Prescription Drug Name Drug Tier Limits TRUXIMA INTRAVENOUS SOLUTION 100 MG/10ML, 500 OA MG/50ML (rituximab-abbs) PA; SP; AC; QL (4 EA per 1 TUKYSA ORAL TABLET 150 MG (tucatinib) 3 day) PA; SP; AC; QL (8 EA per 1 TUKYSA ORAL TABLET 50 MG (tucatinib) 3 day) PA; SP; AC; QL (30 day TURALIO ORAL CAPSULE 200 MG (pexidartinib hcl) 3 supply per 1 fill) PA; SP; AC; QL (30 day TYKERB ORAL TABLET 250 MG (lapatinib ditosylate) 3 supply per 1 fill) PA; SP; AC; QL (30 day UKONIQ ORAL TABLET 200 MG (umbralisib tosylate) 3 supply per 1 fill) UNITUXIN INTRAVENOUS SOLUTION 17.5 MG/5ML OA QL (30 day supply per 1 fill) (dinutuximab) valrubicin intravesical solution 40 mg/ml OA VALSTAR INTRAVESICAL SOLUTION 40 MG/ML (valrubicin) OA PA; QL (365 day supply per VANTAS SUBCUTANEOUS KIT 50 MG (histrelin acetate) OA 1 fill) VECTIBIX INTRAVENOUS SOLUTION 100 MG/5ML, 400 OA QL (30 day supply per 1 fill) MG/20ML (panitumumab) VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG OA QL (30 day supply per 1 fill) (bortezomib) VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG PA; SP; AC; QL (30 day 3 (venetoclax) supply per 1 fill) VENCLEXTA STARTING PACK ORAL TABLET THERAPY PA; SP; AC; QL (30 day 3 PACK 10 & 50 & 100 MG (venetoclax) supply per 1 fill) VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG PA; SP; AC; QL (30 day 3 (abemaciclib) supply per 1 fill) VIDAZA INJECTION SUSPENSION RECONSTITUTED 100 OA QL (30 day supply per 1 fill) MG (azacitidine)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 72 Coverage Requirements & Prescription Drug Name Drug Tier Limits vinblastine sulfate intravenous solution 1 mg/ml OA vincristine sulfate intravenous solution 1 mg/ml OA vinorelbine tartrate intravenous solution 10 mg/ml, 50 OA mg/5ml VITRAKVI ORAL CAPSULE 100 MG, 25 MG (larotrectinib PA; SP; AC; QL (30 day 3 sulfate) supply per 1 fill) PA; SP; AC; QL (30 day VITRAKVI ORAL SOLUTION 20 MG/ML (larotrectinib sulfate) 3 supply per 1 fill) VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG PA; SP; AC; QL (30 day 3 (dacomitinib) supply per 1 fill) PA; SP; AC; QL (30 day VOTRIENT ORAL TABLET 200 MG (pazopanib hcl) 3 supply per 1 fill) VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED OA QL (30 day supply per 1 fill) 44-100 MG (daunorubicin-cytarabine lipo) WELIREG ORAL TABLET 40 MG (belzutifan) 3 PA; AC PA; SP; AC; QL (30 day XALKORI ORAL CAPSULE 200 MG, 250 MG (crizotinib) 3 supply per 1 fill) XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) 3 AC SP; AC; QL (30 day supply XELODA ORAL TABLET 150 MG, 500 MG (capecitabine) 3 per 1 fill) PA; SP; AC; QL (56 day XOSPATA ORAL TABLET 40 MG (gilteritinib fumarate) 3 supply per 1 fill) XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET THERAPY PA; SP; AC; QL (30 day 3 PACK 50 MG (selinexor) supply per 1 fill) XPOVIO (40 MG ONCE WEEKLY) ORAL TABLET THERAPY PA; SP; AC; QL (30 day 3 PACK 40 MG (selinexor) supply per 1 fill) XPOVIO (40 MG TWICE WEEKLY) ORAL TABLET THERAPY PA; SP; AC; QL (30 day 3 PACK 40 MG (selinexor) supply per 1 fill) XPOVIO (60 MG ONCE WEEKLY) ORAL TABLET THERAPY PA; SP; AC; QL (30 day 3 PACK 60 MG (selinexor) supply per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 73 Coverage Requirements & Prescription Drug Name Drug Tier Limits XPOVIO (60 MG TWICE WEEKLY) ORAL TABLET THERAPY PA; SP; AC; QL (30 day 3 PACK 20 MG (selinexor) supply per 1 fill) XPOVIO (80 MG ONCE WEEKLY) ORAL TABLET THERAPY PA; SP; AC; QL (30 day 3 PACK 40 MG (selinexor) supply per 1 fill) XPOVIO (80 MG TWICE WEEKLY) ORAL TABLET THERAPY PA; SP; AC; QL (30 day 3 PACK 20 MG (selinexor) supply per 1 fill) PA; SP; AC; QL (30 day XTANDI ORAL CAPSULE 40 MG (enzalutamide) 3 supply per 1 fill) PA; SP; AC; QL (30 day XTANDI ORAL TABLET 40 MG, 80 MG (enzalutamide) 3 supply per 1 fill) YERVOY INTRAVENOUS SOLUTION 200 MG/40ML, 50 OA QL (30 day supply per 1 fill) MG/10ML (ipilimumab) YESCARTA INTRAVENOUS SUSPENSION (axicabtagene OA QL (30 day supply per 1 fill) ciloleucel) YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED 1 OA QL (30 day supply per 1 fill) MG (trabectedin) PA; SP; AC; QL (30 day YONSA ORAL TABLET 125 MG (abiraterone acetate) 3 supply per 1 fill) ZALTRAP INTRAVENOUS SOLUTION 100 MG/4ML, 200 OA QL (30 day supply per 1 fill) MG/8ML (ziv-aflibercept) ZANOSAR INTRAVENOUS SOLUTION RECONSTITUTED 1 OA GM (streptozocin) PA; SP; AC; QL (30 day ZEJULA ORAL CAPSULE 100 MG (niraparib tosylate) 3 supply per 1 fill) PA; SP; AC; QL (30 day ZELBORAF ORAL TABLET 240 MG (vemurafenib) 3 supply per 1 fill) ZEPZELCA INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; SP; QL (30 day supply OA MG (lurbinectedin) per 1 fill) ZEVALIN Y-90 INTRAVENOUS KIT 3.2 MG/2ML (ibritumomab OA tiuxetan for y-90)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 74 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZIRABEV INTRAVENOUS SOLUTION 100 MG/4ML, 400 OA MG/16ML (bevacizumab-bvzr) ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG (goserelin OA QL (90 day supply per 1 fill) acetate) ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG (goserelin OA QL (30 day supply per 1 fill) acetate) SP; AC; QL (30 day supply ZOLINZA ORAL CAPSULE 100 MG (vorinostat) 3 per 1 fill) PA; SP; AC; QL (30 day ZYDELIG ORAL TABLET 100 MG, 150 MG (idelalisib) 3 supply per 1 fill) PA; SP; AC; QL (30 day ZYKADIA ORAL TABLET 150 MG (ceritinib) 3 supply per 1 fill) ZYNLONTA INTRAVENOUS SOLUTION RECONSTITUTED 10 OA PA MG (loncastuximab tesirine-lpyl) ZYTIGA ORAL TABLET 250 MG, 500 MG (abiraterone PA; SP; AC; QL (30 day 3 acetate) supply per 1 fill) ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES - DRUGS FOR THE IMMUNE SYSTEM ALLERGENIC EXTRACTS (THERAPEUTIC) - DRUGS FOR THE IMMUNE SYSTEM ACACIA SUBCUTANEOUS SOLUTION 1:20 OA ACREMONIUM SUBCUTANEOUS SOLUTION 20000 PNU/ML OA ALDER SUBCUTANEOUS SOLUTION 1:20 OA ALTERNARIA SUBCUTANEOUS SOLUTION 20000 PNU/ML OA AMERICAN BEECH SUBCUTANEOUS SOLUTION 1:20 OA AMERICAN COCKROACH SUBCUTANEOUS SOLUTION 1:20 OA AMERICAN ELM SUBCUTANEOUS SOLUTION 1:20 OA ARIZONA CYPRESS SUBCUTANEOUS SOLUTION 1:20 OA AUREOBASIDIUM SUBCUTANEOUS SOLUTION 10000 OA PNU/ML, 20000 PNU/ML Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 75 Coverage Requirements & Prescription Drug Name Drug Tier Limits AUSTRALIAN PINE SUBCUTANEOUS SOLUTION 1:20 OA BAHIA SUBCUTANEOUS SOLUTION 1:20 OA BALD CYPRESS SUBCUTANEOUS SOLUTION 1:20 OA BAYBERRY (WAX MYRTLE) SUBCUTANEOUS SOLUTION OA 1:20 BERMUDA GRASS INJECTION SOLUTION 10000 BAU/ML OA BERMUDA GRASS SUBCUTANEOUS SOLUTION 10000 OA BAU/ML BLACK WILLOW SUBCUTANEOUS SOLUTION 1:20 OA BOTRYTIS SUBCUTANEOUS SOLUTION 20000 PNU/ML OA BROME SUBCUTANEOUS SOLUTION 1:20 OA CALIFORNIA PEPPER TREE SUBCUTANEOUS SOLUTION OA 1:20 CANDIDA ALBICANS EXTRACT SUBCUTANEOUS OA SOLUTION 10000 PNU/ML CAT HAIR EXTRACT INJECTION SOLUTION 10000 BAU/ML, OA 5000 BAU/ML CAT HAIR EXTRACT SUBCUTANEOUS SOLUTION 10000 OA BAU/ML CATTLE EPITHELIUM SUBCUTANEOUS SOLUTION 1:20 OA CEDAR ELM SUBCUTANEOUS SOLUTION 1:20 OA CLADOSPORIUM CLADOSPORIOIDES INTRADERMAL OA SOLUTION 1:20 CLADOSPORIUM CLADOSPORIOIDES SUBCUTANEOUS OA SOLUTION 10000 PNU/ML, 20000 PNU/ML CLADOSPORIUM SPHAEROSPERMUM SUBCUTANEOUS OA SOLUTION 20000 PNU/ML COCKLEBUR SUBCUTANEOUS SOLUTION 1:20 OA CORN POLLEN SUBCUTANEOUS SOLUTION 1:20 OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 76 Coverage Requirements & Prescription Drug Name Drug Tier Limits CURVULARIA SUBCUTANEOUS SOLUTION 20000 PNU/ML OA DOG EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 1:20 OA DOG FENNEL SUBCUTANEOUS SOLUTION 1:20 OA DRECHSLERA SUBCUTANEOUS SOLUTION 10000 PNU/ML, OA 20000 PNU/ML DUST MITE MIXED ALLERGEN EXT INJECTION SOLUTION OA PA 10000 AU/ML, 15000-15000 AU/ML DUST MITE MIXED ALLERGEN EXT SUBCUTANEOUS OA PA SOLUTION 10000 AU/ML EASTERN COTTONWOOD SUBCUTANEOUS SOLUTION OA 1:20 EPICOCCUM SUBCUTANEOUS SOLUTION 20000 PNU/ML OA FIRE ANT SUBCUTANEOUS SOLUTION 1:10 , 1:20 OA FUSARIUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, OA 20000 PNU/ML GERMAN COCKROACH SUBCUTANEOUS SOLUTION 1:20 OA GOLDENROD SUBCUTANEOUS SOLUTION 1:20 OA GRASS POLLEN(K-O-R-T-SWT VERN) INJECTION OA SOLUTION 100000 BAU/ML GRASTEK SUBLINGUAL TABLET SUBLINGUAL 2800 BAU 3 (timothy grass pollen allergen) HACKBERRY SUBCUTANEOUS SOLUTION 1:20 OA HONEY BEE VENOM PROTEIN INJECTION SOLUTION OA RECONSTITUTED 550 MCG (honey bee venom) HONEY BEE VENOM SUBCUTANEOUS SOLUTION OA RECONSTITUTED 1100 MCG, 120 MCG HORSE EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , OA 1:20 JOHNSON GRASS SUBCUTANEOUS SOLUTION 1:20 OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 77 Coverage Requirements & Prescription Drug Name Drug Tier Limits JUNE GRASS POLLEN STANDARDIZED SUBCUTANEOUS OA SOLUTION 100000 BAU/ML KAPOK SUBCUTANEOUS SOLUTION 1:20 OA KOCHIA SUBCUTANEOUS SOLUTION 1:20 OA MEADOW FESCUE GRASS POLLEN SUBCUTANEOUS OA SOLUTION 100000 BAU/ML MELALEUCA SUBCUTANEOUS SOLUTION 1:20 OA MESQUITE SUBCUTANEOUS SOLUTION 1:20 OA MITE (D. FARINAE) SUBCUTANEOUS SOLUTION 10000 OA AU/ML MITE (D. PTERONYSSINUS) SUBCUTANEOUS SOLUTION OA 10000 AU/ML MIXED ASPERGILLUS SUBCUTANEOUS SOLUTION 20000 OA PNU/ML MIXED FEATHERS SUBCUTANEOUS SOLUTION 1:20 OA MIXED RAGWEED SUBCUTANEOUS SOLUTION 1:20 OA MIXED VESPID VENOM PROTEIN INJECTION SOLUTION OA RECONSTITUTED 550-550-550 MCG mixed vespid venom protein subcutaneous solution OA reconstituted 1100-1100-1100 mcg MIXED VESPID VENOM PROTEIN SUBCUTANEOUS OA SOLUTION RECONSTITUTED 120-120-120 MCG MOUNTAIN CEDAR SUBCUTANEOUS SOLUTION 1:20 OA MOUSE EPITHELIUM SUBCUTANEOUS SOLUTION 1:20 OA MUCOR INTRADERMAL SOLUTION 1:20 OA MUCOR SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 OA PNU/ML MUGWORT SUBCUTANEOUS SOLUTION 1:20 OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 78 Coverage Requirements & Prescription Drug Name Drug Tier Limits ODACTRA SUBLINGUAL TABLET SUBLINGUAL 12 SQ-HDM 3 PA (dust mite mixed allergen ext) OLIVE TREE SUBCUTANEOUS SOLUTION 1:20 OA ORCHARD GRASS POLLEN SUBCUTANEOUS SOLUTION OA 100000 BAU/ML PALFORZIA ORAL 0.5 & 1 & 1.5 & 3 & 6 MG (peanut powder- OA PA dnfp) PALFORZIA ORAL 2 X 1 MG & 10 MG, 2 X 100 MG, 2 X 20 MG, 2 X 20 MG & 2 X 100 MG, 20 MG, 20 MG & 100 MG, 3 X 1 3 PA MG, 3 X 20 MG & 100 MG, 4 X 20 MG, 6 X 1 MG (peanut powder-dnfp) PALFORZIA ORAL PACKET 300 MG (peanut powder-dnfp) 3 PA PENICILLIUM NOTATUM SUBCUTANEOUS SOLUTION OA 10000 PNU/ML, 20000 PNU/ML PERENNIAL RYE GRASS POLLEN INJECTION SOLUTION OA 100000 BAU/ML PHOMA EXIGUA SUBCUTANEOUS SOLUTION 20000 OA PNU/ML PRIVET SUBCUTANEOUS SOLUTION 1:20 OA QUEEN PALM SUBCUTANEOUS SOLUTION 1:20 OA RABBIT EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , OA 1:20 RED MAPLE SUBCUTANEOUS SOLUTION 1:20 OA RED MULBERRY SUBCUTANEOUS SOLUTION 1:20 OA RED TOP GRASS POLLEN SUBCUTANEOUS SOLUTION OA 100000 BAU/ML RHIZOPUS SUBCUTANEOUS SOLUTION 20000 PNU/ML OA ROUGH MARSH ELDER SUBCUTANEOUS SOLUTION 1:20 OA RUSSIAN THISTLE SUBCUTANEOUS SOLUTION 1:20 OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 79 Coverage Requirements & Prescription Drug Name Drug Tier Limits SACCHAROMYCES CEREVISIAE SUBCUTANEOUS OA SOLUTION 20000 PNU/ML SHAGBARK HICKORY SUBCUTANEOUS SOLUTION 1:20 OA SHEEP SORREL SUBCUTANEOUS SOLUTION 1:20 OA SHORT RAGWEED POLLEN EXT SUBCUTANEOUS OA SOLUTION 1:20 SORREL/DOCK MIX SUBCUTANEOUS SOLUTION 1:20 OA SPINY PIGWEED SUBCUTANEOUS SOLUTION 1:20 OA SWEET GUM SUBCUTANEOUS SOLUTION 1:20 OA SWEET VERNAL GRASS POLLEN SUBCUTANEOUS OA SOLUTION 100000 BAU/ML TALL RAGWEED SUBCUTANEOUS SOLUTION 1:20 OA TIMOTHY GRASS POLLEN ALLERGEN INJECTION OA SOLUTION 10000 BAU/ML, 100000 BAU/ML TIMOTHY GRASS POLLEN ALLERGEN SUBCUTANEOUS OA SOLUTION 10000 BAU/ML, 100000 BAU/ML TRICHOPHYTON SUBCUTANEOUS SOLUTION 20000 OA PNU/ML VENOMIL MIXED VESPID VENOM INJECTION SOLUTION OA RECONSTITUTED 550-550-550 MCG (mixed vespid venom) WASP VENOM PROTEIN INJECTION SOLUTION OA RECONSTITUTED 550 MCG WASP VENOM PROTEIN SUBCUTANEOUS SOLUTION OA RECONSTITUTED 1100 MCG, 120 MCG WESTERN JUNIPER SUBCUTANEOUS SOLUTION 1:20 OA WHITE BIRCH SUBCUTANEOUS SOLUTION 1:20 OA WHITE FACED HORNET VENOM SUBCUTANEOUS OA SOLUTION RECONSTITUTED 1100 MCG, 120 MCG WHITE MULBERRY SUBCUTANEOUS SOLUTION 1:20 OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 80 Coverage Requirements & Prescription Drug Name Drug Tier Limits WHITE OAK SUBCUTANEOUS SOLUTION 1:20 OA WHITE PINE SUBCUTANEOUS SOLUTION 1:20 OA WHITE-FACED HORNET VENOM INJECTION SOLUTION OA RECONSTITUTED 550 MCG (white faced hornet venom) YELLOW DOCK SUBCUTANEOUS SOLUTION 1:20 OA YELLOW HORNET VENOM PROTEIN INJECTION SOLUTION OA RECONSTITUTED 550 MCG YELLOW HORNET VENOM PROTEIN SUBCUTANEOUS OA SOLUTION RECONSTITUTED 1100 MCG, 120 MCG YELLOW JACKET VENOM PROTEIN INJECTION SOLUTION OA RECONSTITUTED 550 MCG YELLOW JACKET VENOM PROTEIN SUBCUTANEOUS OA SOLUTION RECONSTITUTED 120 MCG ANTITOXINS AND IMMUNE GLOBULINS - Organ Transplant ANASCORP INTRAVENOUS SOLUTION RECONSTITUTED OA (centruroides (scorpion) im fab) ANAVIP INTRAVENOUS SOLUTION RECONSTITUTED OA (crotalidae immune fab (equine)) ANTIVENIN LATRODECTUS MACTANS INJECTION KIT OA ANTIVENIN MICRURUS FULVIUS INTRAVENOUS SOLUTION OA RECONSTITUTED ASCENIV INTRAVENOUS SOLUTION 5 GM/50ML (immune OA globulin (human)-slra) BIVIGAM INTRAVENOUS SOLUTION 10 GM/100ML, 5 OA QL (30 day supply per 1 fill) GM/50ML (immune globulin (human)) CROFAB INTRAVENOUS SOLUTION RECONSTITUTED OA (crotalidae polyval immune fab) CUTAQUIG SUBCUTANEOUS SOLUTION 1 GM/6ML, 1.65 GM/10ML, 2 GM/12ML, 3.3 GM/20ML, 4 GM/24ML, 8 GM/48ML 3 (immune globulin (human)-hipp)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 81 Coverage Requirements & Prescription Drug Name Drug Tier Limits CYTOGAM INTRAVENOUS INJECTABLE 50 MG/ML OA (cytomegalovirus immune glob) DIGIFAB INTRAVENOUS SOLUTION RECONSTITUTED 40 OA MG (digoxin immune fab) FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0.5 GM/10ML, 10 GM/100ML, 10 GM/200ML, 2.5 GM/50ML, 20 OA QL (30 day supply per 1 fill) GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML (immune globulin (human)) GAMASTAN INTRAMUSCULAR INJECTABLE (immune PA; QL (30 day supply per 1 3 globulin (human)) fill) GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 OA QL (30 day supply per 1 fill) GM/50ML (immune globulin (human)) GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION OA QL (30 day supply per 1 fill) RECONSTITUTED 10 GM, 5 GM (immune globulin (human)) GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 20 GM/200ML, 5 GM/50ML (immune globulin OA QL (30 day supply per 1 fill) (human)) GAMMAPLEX INTRAVENOUS SOLUTION 10 GM/100ML, 10 GM/200ML, 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 OA QL (30 day supply per 1 fill) GM/50ML (immune globulin (human)) GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 40 GM/400ML, 5 OA QL (30 day supply per 1 fill) GM/50ML (immune globulin (human)) HEPAGAM B INJECTION SOLUTION (hepatitis b immune OA globulin) HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 PA; SP; QL (30 day supply GM/50ML, 2 GM/10ML, 4 GM/20ML (immune globulin SI per 1 fill) (human)) HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SYRINGE 1 GM/5ML, 2 GM/10ML, 4 GM/20ML (immune SI per 1 fill) globulin (human))

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 82 Coverage Requirements & Prescription Drug Name Drug Tier Limits HYPERHEP B INTRAMUSCULAR SOLUTION (hepatitis b OA immune globulin) HYPERRAB INJECTION SOLUTION 1500 UNIT/5ML, 300 OA UNIT/ML (rabies immune globulin) HYPERRHO S/D INTRAMUSCULAR SOLUTION PREFILLED OA SYRINGE 1500 UNIT, 250 UNIT (rho d immune globulin) HYPERTET S/D INTRAMUSCULAR INJECTABLE 250 OA UNIT/ML (tetanus immune globulin) HYQVIA SUBCUTANEOUS KIT 10 GM/100ML, 2.5 GM/25ML, PA; SP; QL (30 day supply 20 GM/200ML, 30 GM/300ML, 5 GM/50ML (immune globulin- SI per 1 fill) hyaluronidase) IMOGAM RABIES-HT INJECTION SOLUTION 300 UNIT/2ML OA (rabies immune globulin) KEDRAB INJECTION SOLUTION 1500 UNIT/10ML, 300 OA UNIT/2ML MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 250 UNIT (rho d immune OA globulin) NABI-HB INTRAMUSCULAR SOLUTION (hepatitis b immune OA globulin) OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 20 OA QL (30 day supply per 1 fill) GM/200ML, 25 GM/500ML, 5 GM/100ML, 5 GM/50ML (immune globulin (human)) OCTAGAM INTRAVENOUS SOLUTION 30 GM/300ML OA (immune globulin (human)) PANZYGA INTRAVENOUS SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5 GM/50ML OA (immune globulin (human)-ifas) PANZYGA INTRAVENOUS SOLUTION 30 GM/300ML OA QL (30 day supply per 1 fill) (immune globulin (human)-ifas)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 83 Coverage Requirements & Prescription Drug Name Drug Tier Limits PRIVIGEN INTRAVENOUS SOLUTION 10 GM/100ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML (immune globulin OA QL (30 day supply per 1 fill) (human)) RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT (rho d immune OA globulin) RHOPHYLAC INJECTION SOLUTION PREFILLED SYRINGE OA 1500 UNIT/2ML (rho d immune globulin) VARIZIG INTRAMUSCULAR SOLUTION 125 UNIT/1.2ML OA (varicella-zoster immune glob) WINRHO SDF INJECTION SOLUTION 1500 UNIT/1.3ML, 15000 UNIT/13ML, 2500 UNIT/2.2ML, 5000 UNIT/4.4ML (rho d OA immune globulin) XEMBIFY SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 PA; SP; QL (30 day supply GM/50ML, 2 GM/10ML, 4 GM/20ML (immune globulin 3 per 1 fill) (human)-klhw) ZINPLAVA INTRAVENOUS SOLUTION 1000 MG/40ML OA (bezlotoxumab) TOXOIDS - Vaccines ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 LF- OA MCG/0.5 (tetanus-diphth-acell pertussis) BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 LF- OA MCG/0.5 (tetanus-diphth-acell pertussis) DAPTACEL INTRAMUSCULAR SUSPENSION 23-15-5 OA (diphth-acell pertussis-tetanus) DIPHTHERIA-TETANUS TOXOIDS DT INTRAMUSCULAR OA SUSPENSION 25-5 LFU/0.5ML INFANRIX INTRAMUSCULAR SUSPENSION 25-58-10 OA (diphth-acell pertussis-tetanus) KINRIX INTRAMUSCULAR SUSPENSION (dtap-ipv vaccine) OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 84 Coverage Requirements & Prescription Drug Name Drug Tier Limits PEDIARIX INTRAMUSCULAR SUSPENSION (dtap-hepatitis OA b recomb-ipv) PENTACEL INTRAMUSCULAR SUSPENSION OA RECONSTITUTED (dtap-ipv-hib vaccine) QUADRACEL INTRAMUSCULAR SUSPENSION (dtap-ipv OA vaccine) TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF/0.5ML OA (tetanus-diphtheria toxoids td) TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU (tetanus- OA diphtheria toxoids td) TETANUS-DIPHTHERIA TOXOIDS TD INTRAMUSCULAR OA SUSPENSION 2-2 LF/0.5ML VACCINES - Vaccines ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED OA (haemophilus b polysac conj vac) ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 LF- OA MCG/0.5 (tetanus-diphth-acell pertussis) AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION OA PV; AL (Min 9 Years) (influenza vac split quad) AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML, 0.5 ML (influenza vac split OA PV; AL (Min 9 Years) quad) BCG VACCINE INJECTION INJECTABLE OA BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED OA SYRINGE (meningococcal b recomb omv adj) BIOTHRAX INTRAMUSCULAR SUSPENSION (anthrax OA vaccine adsorbed) BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 LF- OA MCG/0.5 (tetanus-diphth-acell pertussis) DAPTACEL INTRAMUSCULAR SUSPENSION 23-15-5 OA (diphth-acell pertussis-tetanus) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 85 Coverage Requirements & Prescription Drug Name Drug Tier Limits ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 20 OA MCG/ML (hepatitis b vac recombinant) FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION OA PV; AL (Min 9 Years) PREFILLED SYRINGE 0.5 ML (influenza vac split quad) FLUBLOK QUADRIVALENT INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 0.5 ML (influenza vac recomb ha OA PV; AL (Min 9 Years) quad) FLUCELVAX QUADRIVALENT INTRAMUSCULAR OA PV; AL (Min 9 Years) SUSPENSION (influenza vac subunit quad) FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML (influenza vac OA PV; AL (Min 9 Years) subunit quad) FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML (influenza vac OA PV; AL (Min 9 Years) split quad) FLUMIST QUADRIVALENT NASAL SUSPENSION (influenza OA PA; PV; AL (Min 9 Years) virus vac live quad) FLUZONE HIGH-DOSE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.7 ML (influenza vac OA PV; AL (Min 9 Years) high-dose quad) FLUZONE QUADRIVALENT INTRAMUSCULAR OA PV; AL (Min 9 Years) SUSPENSION , 0.5 ML (influenza vac split quad) FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML (influenza vac OA PV; AL (Min 9 Years) split quad) GARDASIL 9 INTRAMUSCULAR SUSPENSION (hpv 9-valent OA recomb vaccine) GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED OA SYRINGE (hpv 9-valent recomb vaccine) HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML, 720 OA EL U/0.5ML (hepatitis a vaccine)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 86 Coverage Requirements & Prescription Drug Name Drug Tier Limits HEPLISAV-B INTRAMUSCULAR SOLUTION PREFILLED OA SYRINGE 20 MCG/0.5ML (hepatitis b vac recomb adj) HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG OA (haemophilus b polysac conj vac) IMOVAX RABIES INTRAMUSCULAR INJECTABLE 2.5 OA UNIT/ML (rabies virus vaccine, hdc) INFANRIX INTRAMUSCULAR SUSPENSION 25-58-10 OA (diphth-acell pertussis-tetanus) IPOL INJECTION INJECTABLE (poliovirus vaccine OA inactivated) IXIARO INTRAMUSCULAR SUSPENSION (japanese OA encephalitis vac inac) KINRIX INTRAMUSCULAR SUSPENSION (dtap-ipv vaccine) OA MENACTRA INTRAMUSCULAR INJECTABLE OA (meningococcal a c y&w-135 conj) MENQUADFI INTRAMUSCULAR INJECTABLE OA (meningococcal a c y&w-135 conj) MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED OA (meningococcal a c y&w-135 olig) M-M-R II INJECTION SOLUTION RECONSTITUTED OA (measles, mumps & rubella vac) PEDIARIX INTRAMUSCULAR SUSPENSION (dtap-hepatitis OA b recomb-ipv) PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5 OA MCG/0.5ML (haemophilus b polysac conj vac) PENTACEL INTRAMUSCULAR SUSPENSION OA RECONSTITUTED (dtap-ipv-hib vaccine) PNEUMOVAX 23 INJECTION INJECTABLE 25 MCG/0.5ML OA (pneumococcal vac polyvalent) PREVNAR 13 INTRAMUSCULAR SUSPENSION OA (pneumococcal 13-val conj vacc) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 87 Coverage Requirements & Prescription Drug Name Drug Tier Limits PREVNAR 20 INTRAMUSCULAR SUSPENSION PREFILLED OA SYRINGE 0.5 ML (pneumococcal 20-val conj vacc) PROQUAD SUBCUTANEOUS SUSPENSION OA RECONSTITUTED (measles-mumps-rubella-varicell) QUADRACEL INTRAMUSCULAR SUSPENSION (dtap-ipv OA vaccine) RABAVERT INTRAMUSCULAR SUSPENSION OA RECONSTITUTED (rabies vaccine, pcec) RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 OA MCG/ML, 5 MCG/0.5ML (hepatitis b vac recombinant) SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML (zoster vac recomb OA adjuvanted) STAMARIL INJECTION SUSPENSION RECONSTITUTED OA TICE BCG INTRAVESICAL SUSPENSION RECONSTITUTED OA 50 MG (bcg live) TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED OA SYRINGE (meningococcal b vac (recomb)) TWINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 720-20 ELU-MCG/ML (hepatitis a-hep b recomb OA vac) TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML OA (typhoid vi polysaccharide vacc) VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 50 OA UNIT/ML (hepatitis a vaccine) VARIVAX SUBCUTANEOUS INJECTABLE 1350 PFU/0.5ML OA (varicella virus vaccine live) YF-VAX SUBCUTANEOUS INJECTABLE (yellow fever OA vaccine)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 88 Coverage Requirements & Prescription Drug Name Drug Tier Limits AUTONOMIC DRUGS - Drugs for the Nervous System ALPHA- AND BETA-ADRENERGIC AGONISTS - Drugs for Heart and Lungs ADRENALIN INJECTION SOLUTION 1 MG/ML, 30 MG/30ML OA (epinephrine) ADRENALIN NASAL SOLUTION 0.1 % (epinephrine hcl 3 (nasal)) AKOVAZ INTRAVENOUS SOLUTION 50 MG/ML (ephedrine OA sulfate (pressors)) ARTICADENT DENTAL INJECTION SOLUTION CARTRIDGE OA 4 %-1:100000 (articaine-epinephrine) AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1 PA; QL (30 day supply per 1 SI MG/0.1ML, 0.15 MG/0.15ML, 0.3 MG/0.3ML (epinephrine) fill) bupivacaine-epinephrine (pf) injection solution 0.25% - OA 1:200000, 0.5% -1:200000 bupivacaine-epinephrine injection solution 0.25% - OA 1:200000, 0.5% -1:200000 CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 3 12 HOUR 2.5-120 MG (desloratadine-pseudoephedrine) DEXAMETH SOD PHOS-BUPIV-EPIN INJECTION SOLUTION 3 PREFILLED SYRINGE 0.01-0.375 %-1:200000 PA; SP; QL (30 day supply droxidopa oral capsule 100 mg, 200 mg, 300 mg 1 per 1 fill) EMERPHED INTRAVENOUS SOLUTION 5 MG/ML (ephedrine OA sulfate (pressors)) EPHEDRINE SULFATE (PRESSORS) INJECTION SOLUTION 3 PREFILLED SYRINGE 25 MG/5ML, 50 MG/10ML, 50 MG/5ML ephedrine sulfate injection solution 50 mg/ml OA ephedrine sulfate intravenous solution 50 mg/ml OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 89 Coverage Requirements & Prescription Drug Name Drug Tier Limits EPHEDRINE SULFATE INTRAVENOUS SOLUTION OA PREFILLED SYRINGE 25 MG/5ML EPHEDRINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MG/ML-%, 100-0.9 MG/10ML-%, OA 25-0.9 MG/5ML-%, 50-0.9 MG/10ML-%, 50-0.9 MG/5ML-% epinephrine (anaphylaxis) injection solution 30 mg/30ml OA EPINEPHRINE HCL-DEXTROSE INTRAVENOUS SOLUTION OA 4-5 MG/250ML-% EPINEPHRINE HCL-NACL INTRAVENOUS SOLUTION 8-0.9 OA MG/250ML-% epinephrine injection solution auto-injector 0.15 mg/0.15ml, SI QL (30 day supply per 1 fill) 0.15 mg/0.3ml, 0.3 mg/0.3ml EPINEPHRINE INTRAVENOUS SOLUTION 1 MG/10ML OA EPINEPHRINE INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 0.1 MG/10ML epinephrine intravenous solution prefilled syringe 1 OA mg/10ml epinephrine pf injection solution 1 mg/ml OA epinephrine solution prefilled syringe 1 mg/10ml injection 1 OA mg/10ml EPINEPHRINE SOLUTION PREFILLED SYRINGE 1 MG/10ML OA INJECTION 1 MG/10ML EPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION 2-5 OA MG/250ML-% EPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION OA PREFILLED SYRINGE 100-5 MCG/10ML-% EPINEPHRINE-NACL INTRAVENOUS SOLUTION 2-0.9 OA MG/250ML-%, 5-0.9 MG/250ML-% EPINEPHRINE-NACL INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 1-0.9 MG/10ML-%

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 90 Coverage Requirements & Prescription Drug Name Drug Tier Limits EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.3 SI QL (30 day supply per 1 fill) MG/0.3ML (epinephrine) EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR SI QL (30 day supply per 1 fill) 0.15 MG/0.3ML (epinephrine) LEVOPHED INTRAVENOUS SOLUTION 1 MG/ML OA (norepinephrine bitartrate) lidocaine-epinephrine injection solution 0.5 %-1:200000, 1 %-1:100000, 1.5 %-1:200000, 2 %-1:100000, 2 %-1:200000, 2 OA %-1:50000 MARCAINE/EPINEPHRINE INJECTION SOLUTION 0.25% - OA 1:200000, 0.5% -1:200000 (bupivacaine-epinephrine) MARCAINE/EPINEPHRINE PF INJECTION SOLUTION 0.25% OA -1:200000, 0.5% -1:200000 (bupivacaine-epinephrine) NOREPINEPHRINE (BASE)-DEXTROSE INTRAVENOUS OA SOLUTION 4-5 MG/250ML-%, 8-5 MG/500ML-% norepinephrine bitartrate intravenous solution 1 mg/ml OA NOREPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION OA 4-5 MG/250ML-%, 8-5 MG/250ML-% NOREPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION OA 8-5 MG/500ML-% NOREPINEPHRINE-SODIUM CHLORIDE INTRAVENOUS SOLUTION 16-0.9 MG/250ML-%, 4-0.9 MG/250ML-%, 8-0.9 OA MG/250ML-%, 8-0.9 MG/500ML-% NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG PA; SP; QL (30 day supply 3 (droxidopa) per 1 fill) ORABLOC INJECTION SOLUTION CARTRIDGE 4 %- OA 1:100000, 4 %-1:200000 (articaine-epinephrine) pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml 1 SENSORCAINE/EPINEPHRINE INJECTION SOLUTION 0.25% OA -1:200000, 0.5% -1:200000 (bupivacaine-epinephrine)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 91 Coverage Requirements & Prescription Drug Name Drug Tier Limits SENSORCAINE-MPF/EPINEPHRINE INJECTION SOLUTION OA 0.25% -1:200000, 0.5% -1:200000 (bupivacaine-epinephrine) SENSORCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 3 0.75-1:200000 % (bupivacaine-epinephrine) SYMJEPI INJECTION SOLUTION PREFILLED SYRINGE 0.15 3 MG/0.3ML (epinephrine) SYMJEPI INJECTION SOLUTION PREFILLED SYRINGE 0.3 SI QL (30 day supply per 1 fill) MG/0.3ML (epinephrine) XYLOCAINE/EPINEPHRINE INJECTION SOLUTION 0.5 %- 1:200000, 1 %-1:100000, 2 %-1:100000 (lidocaine- OA epinephrine) XYLOCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 1 %-1:200000, 1.5 %-1:200000, 2 %-1:200000 (lidocaine- OA epinephrine) ALPHA-ADRENERGIC AGONISTS - Drugs for Heart and Lungs BIORPHEN INTRAVENOUS SOLUTION 0.5 MG/5ML OA (phenylephrine hcl (pressors)) CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY 0.1 3 MG/24HR (clonidine) CATAPRES-TTS-2 TRANSDERMAL PATCH WEEKLY 0.2 3 MG/24HR (clonidine) CATAPRES-TTS-3 TRANSDERMAL PATCH WEEKLY 0.3 3 MG/24HR (clonidine) clonidine hcl (analgesia) epidural solution 100 mcg/ml, 500 OA mcg/ml clonidine hcl er oral tablet extended release 12 hour 0.1 mg 1 clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1 clonidine transdermal patch weekly 0.1 mg/24hr, 0.2 1 mg/24hr, 0.3 mg/24hr

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 92 Coverage Requirements & Prescription Drug Name Drug Tier Limits DURACLON EPIDURAL SOLUTION 100 MCG/ML (clonidine OA hcl (analgesia)) GILPHEX TR ORAL TABLET 10-388 MG (phenylephrine- 3 guaifenesin) KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR 0.1 3 MG (clonidine hcl) LUCEMYRA ORAL TABLET 0.18 MG (lofexidine hcl) 3 PA methyldopa oral tablet 250 mg, 500 mg 1 midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg 1 PHENYLEPHRINE HCL (PRESSORS) INTRAVENOUS OA SOLUTION 0.4 MG/10ML, 0.8 MG/10ML PHENYLEPHRINE HCL (PRESSORS) INTRAVENOUS OA SOLUTION PREFILLED SYRINGE 0.5 MG/5ML, 1 MG/10ML PHENYLEPHRINE HCL INTRACAVERNOSAL SOLUTION 2 ED MG/2ML PHENYLEPHRINE HCL INTRAVENOUS SOLUTION 1 OA MG/10ML phenylephrine hcl intravenous solution 10 mg/ml OA PHENYLEPHRINE HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.4 MG/10ML, 0.8 MG/10ML, 1 OA MG/10ML PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION 10- 0.9 MG/250ML-%, 100-0.9 MG/250ML-%, 20-0.9 MG/250ML-%, OA 25-0.9 MG/250ML-%, 40-0.9 MG/250ML-%, 50-0.9 MG/250ML- %, 80-0.9 MG/250ML-% PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.4-0.9 MG/10ML-%, 0.5-0.9 MG/5ML- OA %, 0.8-0.9 MG/10ML-%, 1-0.9 MG/10ML-%, 100-0.9 MCG/10ML-%, 20-0.9 MG/50ML-%, 5-0.9 MG/50ML-% promethazine vc oral syrup 6.25-5 mg/5ml 1 promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml 1 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 93 Coverage Requirements & Prescription Drug Name Drug Tier Limits promethazine-phenyleph-codeine oral syrup 6.25-5-10 1 mg/5ml promethazine-phenylephrine oral syrup 6.25-5 mg/5ml 1 ROPIV-CLONIDINE-KETOROLAC SOLUTION PREFILLED 3 SYRINGE 123-0.04-15 MG/50ML VAZCULEP INTRAVENOUS SOLUTION 10 MG/ML OA (phenylephrine hcl (pressors)) ANTIMUSCARINICS/ANTISPASMODICS - Drugs for Parkinson ANASPAZ ORAL TABLET DISPERSIBLE 0.125 MG 3 (hyoscyamine sulfate) ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH (umeclidinium- 2 vilanterol) ATROPEN INTRAMUSCULAR SOLUTION AUTO-INJECTOR 0.25 MG/0.3ML, 0.5 MG/0.7ML, 1 MG/0.7ML, 2 MG/0.7ML OA (atropine sulfate) atropine sulfate injection solution 0.4 mg/ml, 1 mg/ml, 8 OA mg/20ml atropine sulfate injection solution prefilled syringe 0.25 OA mg/5ml, 0.5 mg/5ml, 1 mg/10ml atropine sulfate intravenous solution 0.4 mg/ml, 1 mg/ml OA ATROPINE SULFATE INTRAVENOUS SOLUTION OA PREFILLED SYRINGE 0.8 MG/2ML, 1 MG/2.5ML, 1.2 MG/3ML ATROVENT HFA INHALATION AEROSOL SOLUTION 17 2 MCG/ACT (ipratropium bromide hfa) BENTYL INTRAMUSCULAR SOLUTION 10 MG/ML OA (dicyclomine hcl) BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 3 MCG/ACT (glycopyrrolate-formoterol)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 94 Coverage Requirements & Prescription Drug Name Drug Tier Limits BREZTRI AEROSPHERE INHALATION AEROSOL 160-9-4.8 3 PA MCG/ACT (budeson-glycopyrrol-formoterol) chlordiazepoxide-clidinium oral capsule 5-2.5 mg 1 COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 3 20-100 MCG/ACT (ipratropium-albuterol) CUVPOSA ORAL SOLUTION 1 MG/5ML (glycopyrrolate) 3 dicyclomine hcl intramuscular solution 10 mg/ml OA dicyclomine hcl oral capsule 10 mg 1 dicyclomine hcl oral solution 10 mg/5ml 1 dicyclomine hcl oral tablet 20 mg 1 diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml 1 diphenoxylate-atropine oral tablet 2.5-0.025 mg 1 DUAKLIR PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400-12 MCG/ACT (aclidinium br- 3 formoterol fum) DUODOTE INTRAMUSCULAR SOLUTION AUTO-INJECTOR OA 2.1-600 MG (atropine-pralidoxime chloride) ED-SPAZ ORAL TABLET DISPERSIBLE 0.125 MG 3 glycopyrrolate injection solution 0.2 mg/ml, 0.4 mg/2ml, 1 OA mg/5ml, 4 mg/20ml GLYCOPYRROLATE INJECTION SOLUTION PREFILLED OA SYRINGE 0.6 MG/3ML, 1 MG/5ML GLYCOPYRROLATE INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 0.6 MG/3ML, 1 MG/5ML glycopyrrolate oral tablet 1 mg, 2 mg 1 glycopyrrolate pf injection solution prefilled syringe 0.2 OA mg/ml, 0.4 mg/2ml GLYRX-PF INJECTION SOLUTION 0.2 MG/ML, 0.4 MG/2ML OA (glycopyrrolate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 95 Coverage Requirements & Prescription Drug Name Drug Tier Limits GLYRX-PF INJECTION SOLUTION PREFILLED SYRINGE 0.6 OA MG/3ML, 1 MG/5ML (glycopyrrolate) HYCODAN ORAL SYRUP 5-1.5 MG/5ML (hydrocodone- 3 homatropine) hydrocodone-homatropine oral syrup 5-1.5 mg/5ml 1 hydrocodone-homatropine oral tablet 5-1.5 mg 1 hydromet oral syrup 5-1.5 mg/5ml 1 hyoscyamine sulfate injection solution 0.5 mg/ml OA hyoscyamine sulfate oral elixir 0.125 mg/5ml 1 hyoscyamine sulfate oral solution 0.125 mg/ml 1 hyoscyamine sulfate oral tablet 0.125 mg 1 hyoscyamine sulfate oral tablet dispersible 0.125 mg 1 hyoscyamine sulfate sl sublingual tablet sublingual 0.125 1 mg hyoscyamine sulfate sublingual tablet sublingual 0.125 mg 1 hyosyne oral elixir 0.125 mg/5ml 1 hyosyne oral solution 0.125 mg/ml 1 INCRUSE ELLIPTA INHALATION AEROSOL POWDER 2 BREATH ACTIVATED 62.5 MCG/INH (umeclidinium bromide) ipratropium bromide inhalation solution 0.02 % 1 ipratropium bromide nasal solution 0.03 %, 0.06 % 1 ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 LEVSIN INJECTION SOLUTION 0.5 MG/ML (hyoscyamine OA sulfate) LEVSIN ORAL TABLET 0.125 MG (hyoscyamine sulfate) 3 LEVSIN/SL SUBLINGUAL TABLET SUBLINGUAL 0.125 MG 3 (hyoscyamine sulfate) LIBRAX ORAL CAPSULE 5-2.5 MG (chlordiazepoxide- 3 clidinium) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 96 Coverage Requirements & Prescription Drug Name Drug Tier Limits LOMOTIL ORAL TABLET 2.5-0.025 MG (diphenoxylate- 3 atropine) LONHALA MAGNAIR REFILL KIT INHALATION SOLUTION 25 3 ST MCG/ML (glycopyrrolate) LONHALA MAGNAIR STARTER KIT INHALATION SOLUTION 3 ST 25 MCG/ML (glycopyrrolate) me/naphos/mb/hyo1 oral tablet 81.6 mg 1 methscopolamine bromide oral tablet 2.5 mg, 5 mg 1 MOTOFEN ORAL TABLET 1-0.025 MG (difenoxin-atropine) 3 NULEV ORAL TABLET DISPERSIBLE 0.125 MG 3 (hyoscyamine sulfate) oscimin oral tablet 0.125 mg 1 oscimin sublingual tablet sublingual 0.125 mg 1 PHOSPHASAL ORAL TABLET 81.6 MG (meth-hyo-m bl-na 3 phos-ph sal) QBREXZA EXTERNAL PAD 2.4 % (glycopyrronium tosylate) 3 PA QUAD-MIX INTRACAVERNOSAL SOLUTION ED RECONSTITUTED 150-10-0.1-1 MG scopolamine transdermal patch 72 hour 1 mg/3days 1 SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG 2 (tiotropium bromide monohydrate) SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 3 MCG/ACT, 2.5 MCG/ACT (tiotropium bromide monohydrate) STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2 2.5-2.5 MCG/ACT (tiotropium bromide-olodaterol) SUPER QUAD-MIX INTRACAVERNOSAL SOLUTION ED RECONSTITUTED 150-20-0.2-2 MG SYMAX DUOTAB ORAL TABLET EXTENDED RELEASE 0.375 2 MG (hyoscyamine sulfate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 97 Coverage Requirements & Prescription Drug Name Drug Tier Limits SYMAX-SL SUBLINGUAL TABLET SUBLINGUAL 0.125 MG 3 (hyoscyamine sulfate) TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH 72 3 HOUR 1 MG/3DAYS (scopolamine base) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH, 200-62.5-25 2 MCG/INH (fluticasone-umeclidin-vilant) TUDORZA PRESSAIR INHALATION AEROSOL POWDER 3 BREATH ACTIVATED 400 MCG/ACT (aclidinium bromide) URIMAR-T ORAL TABLET 120 MG (meth-hyo-m bl-na phos- 3 ph sal) urin ds oral tablet 81.6 mg 1 UROGESIC-BLUE ORAL TABLET 81.6 MG (methen-hyosc- 3 meth blue-na phos) USTELL ORAL CAPSULE 120 MG (meth-hyo-m bl-na phos- 3 ph sal) UTIRA-C ORAL TABLET 81.6 MG (meth-hyo-m bl-na phos- 3 ph sal) YUPELRI INHALATION SOLUTION 175 MCG/3ML 2 (revefenacin) ANTIPARKINSONIAN AGENTS - Drugs for Parkinson benztropine mesylate injection solution 1 mg/ml OA benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg 1 COGENTIN INJECTION SOLUTION 1 MG/ML (benztropine OA mesylate) diphen oral elixir 12.5 mg/5ml 1 di-phen oral elixir 12.5 mg/5ml 1 diphenhydramine hcl injection solution 50 mg/ml 1 PA diphenhydramine hcl oral elixir 12.5 mg/5ml 1 trihexyphenidyl hcl oral solution 0.4 mg/ml 1 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 98 Coverage Requirements & Prescription Drug Name Drug Tier Limits trihexyphenidyl hcl oral tablet 2 mg, 5 mg 1 AUTONOMIC DRUGS, MISCELLANEOUS - Drugs for the Nervous System PV; QL (180 day supply per APO-VARENICLINE ORAL TABLET 0.5 MG, 1 MG 3 365 days) CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG PV; QL (180 day supply per 3 (varenicline tartrate) 365 days) PV; QL (180 day supply per CHANTIX ORAL TABLET 0.5 MG, 1 MG (varenicline tartrate) 3 365 days) CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X PV; QL (180 day supply per 3 11 & 1 MG X 42 (varenicline tartrate) 365 days) PV; QL (180 EA per 365 goodsense nicotine mouth/throat lozenge 4 mg 1 days) PV; QL (180 day supply per habitrol transdermal patch 24 hour 21 mg/24hr 1 365 days) NICORETTE MOUTH/THROAT GUM 2 MG (nicotine PV; QL (180 day supply per 3 polacrilex) 365 days) NICORETTE MOUTH/THROAT LOZENGE 4 MG (nicotine PV; QL (180 EA per 365 3 polacrilex) days) PV; QL (180 EA per 365 nicotine polacrilex mini mouth/throat lozenge 2 mg 1 days) PV; QL (180 day supply per nicotine polacrilex mouth/throat gum 2 mg, 4 mg 1 365 days) PV; QL (180 EA per 365 nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg 1 days) PV; QL (180 day supply per nicotine step 1 transdermal patch 24 hour 21 mg/24hr 1 365 days) PV; QL (180 day supply per nicotine step 2 transdermal patch 24 hour 14 mg/24hr 1 365 days) PV; QL (180 day supply per nicotine step 3 transdermal patch 24 hour 7 mg/24hr 1 365 days) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 99 Coverage Requirements & Prescription Drug Name Drug Tier Limits PV; QL (180 day supply per nicotine transdermal kit 21-14-7 mg/24hr 1 365 days) PV; QL (180 day supply per NICOTROL INHALATION INHALER 10 MG (nicotine) 3 365 days) PV; QL (180 day supply per NICOTROL NS NASAL SOLUTION 10 MG/ML (nicotine) 3 365 days) CENTRALLY ACTING SKELETAL MUSCLE RELAXNT - Drugs for Relaxing Muscles AMRIX ORAL CAPSULE EXTENDED RELEASE 24 HOUR 15 3 MG, 30 MG (cyclobenzaprine hcl) carisoprodol oral tablet 250 mg, 350 mg 1 carisoprodol-aspirin-codeine oral tablet 200-325-16 mg 1 PA chlorzoxazone oral tablet 250 mg, 375 mg, 500 mg, 750 mg 1 cyclobenzaprine hcl er oral capsule extended release 24 1 hour 15 mg, 30 mg cyclobenzaprine hcl oral tablet 10 mg, 5 mg, 7.5 mg 1 FEXMID ORAL TABLET 7.5 MG (cyclobenzaprine hcl) 3 LORZONE ORAL TABLET 375 MG, 750 MG (chlorzoxazone) 3 metaxalone oral tablet 400 mg, 800 mg 1 methocarbamol injection solution 1000 mg/10ml OA methocarbamol oral tablet 500 mg, 750 mg 1 ROBAXIN INJECTION SOLUTION 1000 MG/10ML OA (methocarbamol) SKELAXIN ORAL TABLET 800 MG (metaxalone) 3 SOMA ORAL TABLET 250 MG, 350 MG (carisoprodol) 3 tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg 1 tizanidine hcl oral tablet 2 mg, 4 mg 1 VANADOM ORAL TABLET 350 MG (carisoprodol) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 100 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZANAFLEX ORAL CAPSULE 2 MG, 4 MG, 6 MG (tizanidine 3 hcl) ZANAFLEX ORAL TABLET 4 MG (tizanidine hcl) 3 DIRECT-ACTING SKELETAL MUSCLE RELAXANTS - Drugs for Relaxing Muscles DANTRIUM INTRAVENOUS SOLUTION RECONSTITUTED 20 OA MG (dantrolene sodium) DANTRIUM ORAL CAPSULE 25 MG, 50 MG (dantrolene 3 sodium) dantrolene sodium intravenous solution reconstituted 20 OA mg dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg 1 revonto intravenous solution reconstituted 20 mg OA RYANODEX INTRAVENOUS SUSPENSION OA RECONSTITUTED 250 MG (dantrolene sodium) GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT - Drugs for Relaxing Muscles baclofen intrathecal solution 10 mg/20ml, 20000 mcg/20ml, OA 40 mg/20ml baclofen intrathecal solution prefilled syringe 50 mcg/ml OA baclofen oral tablet 10 mg, 20 mg, 5 mg 1 GABLOFEN INTRATHECAL SOLUTION 10000 MCG/20ML, OA 20000 MCG/20ML, 40000 MCG/20ML (baclofen) GABLOFEN INTRATHECAL SOLUTION PREFILLED SYRINGE 10000 MCG/20ML, 20000 MCG/20ML, 40000 OA MCG/20ML, 50 MCG/ML (baclofen) LIORESAL INTRATHECAL SOLUTION 0.05 MG/ML, 10 OA MG/20ML, 10 MG/5ML, 40 MG/20ML (baclofen) OZOBAX ORAL SOLUTION 5 MG/5ML (baclofen) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 101 Coverage Requirements & Prescription Drug Name Drug Tier Limits NEUROMUSCULAR BLOCKING AGENTS - Drugs for Relaxing Muscles atracurium besylate intravenous solution 100 mg/10ml, 50 OA mg/5ml cisatracurium besylate (pf) intravenous solution 10 mg/5ml, OA 200 mg/20ml cisatracurium besylate intravenous solution 20 mg/10ml OA NIMBEX INTRAVENOUS SOLUTION 10 MG/5ML, 20 OA MG/10ML, 200 MG/20ML (cisatracurium besylate) pancuronium bromide intravenous solution 1 mg/ml OA rocuronium bromide intravenous solution 100 mg/10ml, 50 OA mg/5ml ROCURONIUM BROMIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 100 MG/10ML, 50 MG/5ML, 75 OA MG/7.5ML SUCCINYLCHOLINE CHLORIDE INJECTION SOLUTION PREFILLED SYRINGE 100 MG/5ML, 140 MG/7ML, 200 3 MG/10ML SUCCINYLCHOLINE CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 100 MG/5ML, 140 MG/7ML, 200 OA MG/10ML VECURONIUM BROMIDE INTRAVENOUS SOLUTION OA PREFILLED SYRINGE 10 MG/10ML vecuronium bromide intravenous solution reconstituted 10 OA mg, 20 mg NON-SEL. BETA-ADRENERGIC BLOCKING AGENTS - Drugs for the Heart BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 (sotalol hcl af) BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG (sotalol 3 hcl)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 102 Coverage Requirements & Prescription Drug Name Drug Tier Limits BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG 3 (nebivolol hcl) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 carvedilol phosphate er oral capsule extended release 24 1 hour 10 mg, 20 mg, 40 mg, 80 mg COREG CR ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 10 MG, 20 MG, 40 MG, 80 MG (carvedilol phosphate) COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG 3 (carvedilol) CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG (nadolol) 3 HEMANGEOL ORAL SOLUTION 4.28 MG/ML (propranolol SP; QL (30 day supply per 1 2 hcl) fill) INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol hcl) INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 3 PA HOUR 120 MG, 80 MG (propranolol hcl sr beads) INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 3 PA HOUR 120 MG, 80 MG (propranolol hcl sr beads) LABETALOL HCL INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 20 MG/4ML labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 labetalol hcl solution 5 mg/ml intravenous 5 mg/ml OA LABETALOL HCL SOLUTION 5 MG/ML INTRAVENOUS 5 OA MG/ML LABETALOL HCL-DEXTROSE INTRAVENOUS SOLUTION OA 200-5 MG/200ML-% LABETALOL HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 100-0.72 MG/100ML-%, 200-0.72 MG/200ML-%, OA 300-0.72 MG/300ML-% nadolol oral tablet 20 mg, 40 mg, 80 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 103 Coverage Requirements & Prescription Drug Name Drug Tier Limits nebivolol hcl oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 pindolol oral tablet 10 mg, 5 mg 1 propranolol hcl er oral capsule extended release 24 hour 1 120 mg, 160 mg, 60 mg, 80 mg propranolol hcl intravenous solution 1 mg/ml OA propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 1 mg sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 SOTALOL HCL INTRAVENOUS SOLUTION 150 MG/10ML OA sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 NON-SEL.ALPHA-1-ADRENERGIC BLOCKING AGTS - Drugs for the Heart CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG 3 (doxazosin mesylate) CARDURA XL ORAL TABLET EXTENDED RELEASE 24 2 HOUR 4 MG, 8 MG (doxazosin mesylate) doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG (prazosin 3 hcl) prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1 terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS - Drugs for the Heart BI-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED ED PA 150-5 MG

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 104 Coverage Requirements & Prescription Drug Name Drug Tier Limits CAFERGOT ORAL TABLET 1-100 MG (ergotamine-caffeine) 3 D.H.E. 45 INJECTION SOLUTION 1 MG/ML PA; QL (30 day supply per 1 SI (dihydroergotamine mesylate) fill) DIBENZYLINE ORAL CAPSULE 10 MG (phenoxybenzamine 3 hcl) PA; QL (30 day supply per 1 dihydroergotamine mesylate injection solution 1 mg/ml SI fill) dihydroergotamine mesylate nasal solution 4 mg/ml 1 QL (0.27 ML per 1 day) ergoloid mesylates oral tablet 1 mg 1 ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG 2 (ergotamine tartrate) ergotamine-caffeine oral tablet 1-100 mg 1 MIGERGOT RECTAL SUPPOSITORY 2-100 MG (ergotamine- 3 caffeine) MIGRANAL NASAL SOLUTION 4 MG/ML (dihydroergotamine 3 QL (0.27 ML per 1 day) mesylate) phenoxybenzamine hcl oral capsule 10 mg 1 phentolamine mesylate injection solution reconstituted 5 OA mg QUAD-MIX INTRACAVERNOSAL SOLUTION ED RECONSTITUTED 150-10-0.1-1 MG SUPER BI-MIX INTRACAVERNOSAL SOLUTION ED PA RECONSTITUTED 150-10 MG SUPER QUAD-MIX INTRACAVERNOSAL SOLUTION ED RECONSTITUTED 150-20-0.2-2 MG SUPER TRI-MIX INTRACAVERNOSAL SOLUTION ED PA RECONSTITUTED 150-10-100 MG-MG-MCG TRI-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED ED PA 150-5-50 MG-MG-MCG

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 105 Coverage Requirements & Prescription Drug Name Drug Tier Limits NON-SELECTIVE BETA-ADRENERGIC AGONISTS - Drugs for Heart and Lungs isoproterenol hcl injection solution 0.2 mg/ml OA ISOPROTERENOL-SODIUM CHLORIDE INTRAVENOUS OA SOLUTION 200-0.9 MCG/50ML-% ISUPREL INJECTION SOLUTION 0.2 MG/ML (isoproterenol OA hcl) PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) - Drugs for Bladder Incontinence ARICEPT ORAL TABLET 10 MG, 23 MG, 5 MG (donepezil 3 hcl) bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg 1 BLOXIVERZ INTRAVENOUS SOLUTION 10 MG/10ML, 5 OA MG/10ML (neostigmine methylsulfate) cevimeline hcl oral capsule 30 mg 1 donepezil hcl oral tablet 10 mg, 23 mg, 5 mg 1 donepezil hcl oral tablet dispersible 10 mg, 5 mg 1 EVOXAC ORAL CAPSULE 30 MG (cevimeline hcl) 3 EXELON TRANSDERMAL PATCH 24 HOUR 13.3 MG/24HR, 3 4.6 MG/24HR, 9.5 MG/24HR (rivastigmine) galantamine hydrobromide er oral capsule extended 1 release 24 hour 16 mg, 24 mg, 8 mg galantamine hydrobromide oral solution 4 mg/ml 1 galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg 1 MESTINON ORAL SOLUTION 60 MG/5ML (pyridostigmine 3 bromide) MESTINON ORAL TABLET 60 MG (pyridostigmine bromide) 3 MESTINON ORAL TABLET EXTENDED RELEASE 180 MG 3 (pyridostigmine bromide)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 106 Coverage Requirements & Prescription Drug Name Drug Tier Limits NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 3 PA & 14 & 21 &28 -10 MG (memantine hcl-donepezil hcl) NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG (memantine hcl- 3 PA donepezil hcl) neostigmine methylsulfate intravenous solution 10 OA mg/10ml, 5 mg/10ml NEOSTIGMINE METHYLSULFATE INTRAVENOUS OA SOLUTION 3 MG/3ML, 5 MG/5ML NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 2 MG/2ML, 3 MG/3ML, 4 OA MG/4ML, 5 MG/5ML PHYSOSTIGMINE SALICYLATE INJECTION SOLUTION 1 OA MG/ML pilocarpine hcl oral tablet 5 mg, 7.5 mg 1 pyridostigmine bromide er oral tablet extended release 180 1 mg pyridostigmine bromide oral solution 60 mg/5ml 1 pyridostigmine bromide oral tablet 30 mg, 60 mg 1 RAZADYNE ER ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 16 MG, 24 MG, 8 MG (galantamine hydrobromide) REGONOL INTRAVENOUS SOLUTION 10 MG/2ML OA (pyridostigmine bromide) rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 1 mg rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 1 mg/24hr, 9.5 mg/24hr SALAGEN ORAL TABLET 5 MG, 7.5 MG (pilocarpine hcl) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 107 Coverage Requirements & Prescription Drug Name Drug Tier Limits SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT - Drugs for the Heart alfuzosin hcl er oral tablet extended release 24 hour 10 mg 1 carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 carvedilol phosphate er oral capsule extended release 24 1 hour 10 mg, 20 mg, 40 mg, 80 mg COREG CR ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 10 MG, 20 MG, 40 MG, 80 MG (carvedilol phosphate) COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG 3 (carvedilol) dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg 1 FLOMAX ORAL CAPSULE 0.4 MG (tamsulosin hcl) 3 JALYN ORAL CAPSULE 0.5-0.4 MG (dutasteride-tamsulosin 3 hcl) LABETALOL HCL INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 20 MG/4ML labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 labetalol hcl solution 5 mg/ml intravenous 5 mg/ml OA LABETALOL HCL SOLUTION 5 MG/ML INTRAVENOUS 5 OA MG/ML LABETALOL HCL-DEXTROSE INTRAVENOUS SOLUTION OA 200-5 MG/200ML-% LABETALOL HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 100-0.72 MG/100ML-%, 200-0.72 MG/200ML-%, OA 300-0.72 MG/300ML-% RAPAFLO ORAL CAPSULE 4 MG, 8 MG (silodosin) 3 PA silodosin oral capsule 4 mg, 8 mg 1 PA tamsulosin hcl oral capsule 0.4 mg 1 UROXATRAL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 10 MG (alfuzosin hcl) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 108 Coverage Requirements & Prescription Drug Name Drug Tier Limits SELECTIVE BETA-1-ADRENERGIC AGONISTS - Drugs for Heart and Lungs dobutamine hcl intravenous solution 250 mg/20ml OA dobutamine in d5w intravenous solution 1-5 mg/ml-%, 2 OA mg/ml, 4-5 mg/ml-% dopamine hcl intravenous solution 40 mg/ml OA dopamine in d5w intravenous solution 0.8-5 mg/ml-%, 1.6-5 OA mg/ml-%, 3.2-5 mg/ml-% SELECTIVE BETA-2-ADRENERGIC AGONISTS - Drugs for Heart and Lungs ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 3 QL (2 EA per 1 day) MCG/DOSE (fluticasone-salmeterol) ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230- 2 QL (0.4 GM per 1 day) 21 MCG/ACT, 45-21 MCG/ACT (fluticasone-salmeterol) AIRDUO DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 3 QL (2 EA per 1 day) 55-14 MCG/ACT (fluticasone-salmeterol) AIRDUO RESPICLICK 113/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT 3 QL (2 EA per 1 day) (fluticasone-salmeterol) AIRDUO RESPICLICK 232/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 232-14 MCG/ACT 3 QL (2 EA per 1 day) (fluticasone-salmeterol) AIRDUO RESPICLICK 55/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 55-14 MCG/ACT 3 QL (2 EA per 1 day) (fluticasone-salmeterol) albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act 1 inhalation 108 (90 base) mcg/act albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act 1 QL (1.2 GM per 1 day) inhalation 108 (90 base) mcg/act

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 109 Coverage Requirements & Prescription Drug Name Drug Tier Limits ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 2 QL (1.2 GM per 1 day) BASE) MCG/ACT INHALATION 108 (90 BASE) MCG/ACT albuterol sulfate inhalation nebulization solution (2.5 1 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 3 MG/ML) 0.5% INHALATION (5 MG/ML) 0.5% albuterol sulfate nebulization solution (5 mg/ml) 0.5% 1 inhalation (5 mg/ml) 0.5% albuterol sulfate oral syrup 2 mg/5ml 1 albuterol sulfate oral tablet 2 mg, 4 mg 1 ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH (umeclidinium- 2 vilanterol) arformoterol tartrate inhalation nebulization solution 15 1 QL (4 ML per 1 day) mcg/2ml BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 3 MCG/ACT (glycopyrrolate-formoterol) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH (fluticasone 2 furoate-vilanterol) BREZTRI AEROSPHERE INHALATION AEROSOL 160-9-4.8 3 PA MCG/ACT (budeson-glycopyrrol-formoterol) BROVANA INHALATION NEBULIZATION SOLUTION 15 3 QL (4 ML per 1 day) MCG/2ML (arformoterol tartrate) BUDESONIDE-FORMOTEROL FUMARATE INHALATION 2 QL (0.34 GM per 1 day) AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 3 20-100 MCG/ACT (ipratropium-albuterol) DUAKLIR PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400-12 MCG/ACT (aclidinium br- 3 formoterol fum)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 110 Coverage Requirements & Prescription Drug Name Drug Tier Limits DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT, 50-5 MCG/ACT (mometasone furo-formoterol 3 QL (0.44 GM per 1 day) fum) fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 1 QL (2 EA per 1 day) mcg/dose FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 3 QL (2 EA per 1 day) MCG/ACT, 55-14 MCG/ACT formoterol fumarate inhalation nebulization solution 20 1 QL (4 ML per 1 day) mcg/2ml ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 levalbuterol hcl inhalation nebulization solution 0.31 1 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT 3 PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 3 QL (4 ML per 1 day) MCG/2ML (formoterol fumarate) PROAIR DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT (albuterol 3 sulfate) PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 2 QL (0.6 GM per 1 day) BASE) MCG/ACT (albuterol sulfate) PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT (albuterol 2 QL (2 EA per 25 days) sulfate) PROVENTIL HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION 108 (90 BASE) MCG/ACT (albuterol 2 sulfate) PROVENTIL HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION 108 (90 BASE) MCG/ACT (albuterol 2 QL (0.5 GM per 1 day) sulfate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 111 Coverage Requirements & Prescription Drug Name Drug Tier Limits SEREVENT DISKUS INHALATION AEROSOL POWDER 2 QL (2 EA per 1 day) BREATH ACTIVATED 50 MCG/DOSE (salmeterol xinafoate) STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2 2.5-2.5 MCG/ACT (tiotropium bromide-olodaterol) STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 3 2.5 MCG/ACT (olodaterol hcl) SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80- 2 QL (0.34 GM per 1 day) 4.5 MCG/ACT (budesonide-formoterol fumarate) terbutaline sulfate injection solution 1 mg/ml OA terbutaline sulfate oral tablet 2.5 mg, 5 mg 1 TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH, 200-62.5-25 2 MCG/INH (fluticasone-umeclidin-vilant) VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 2 QL (1.2 GM per 1 day) BASE) MCG/ACT (albuterol sulfate) wixela inhub inhalation aerosol powder breath activated 1 QL (2 EA per 1 day) 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose XOPENEX CONCENTRATE INHALATION NEBULIZATION 3 SOLUTION 1.25 MG/0.5ML (levalbuterol hcl) XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT 3 (levalbuterol tartrate) XOPENEX INHALATION NEBULIZATION SOLUTION 0.31 3 MG/3ML, 0.63 MG/3ML, 1.25 MG/3ML (levalbuterol hcl) SELECTIVE BETA-ADRENERGIC BLOCKING AGENT - Drugs for the Heart acebutolol hcl oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 betaxolol hcl oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 112 Coverage Requirements & Prescription Drug Name Drug Tier Limits BREVIBLOC IN NACL INTRAVENOUS SOLUTION 2000 OA MG/100ML, 2500 MG/250ML (esmolol hcl-sodium chloride) BREVIBLOC INTRAVENOUS SOLUTION 100 MG/10ML OA (esmolol hcl) BREVIBLOC PREMIXED DS INTRAVENOUS SOLUTION 2000 OA MG/100ML (esmolol hcl-sodium chloride) BREVIBLOC PREMIXED INTRAVENOUS SOLUTION 2500 OA MG/250ML (esmolol hcl-sodium chloride) esmolol hcl intravenous solution 100 mg/10ml OA ESMOLOL HCL INTRAVENOUS SOLUTION 2000 MG/100ML, OA 2500 MG/250ML ESMOLOL HCL INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 100 MG/10ML esmolol hcl-sodium chloride intravenous solution 2000 OA mg/100ml, 2500 mg/250ml KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG (metoprolol 3 succinate) LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol 3 tartrate) metoprolol succinate er oral tablet extended release 24 1 hour 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate intravenous solution 5 mg/5ml OA metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 1 mg, 75 mg TENORMIN ORAL TABLET 100 MG, 25 MG, 50 MG (atenolol) 3 TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 25 MG, 50 MG (metoprolol succinate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 113 Coverage Requirements & Prescription Drug Name Drug Tier Limits SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS - Drugs for Relaxing Muscles BOTOX COSMETIC INTRAMUSCULAR SOLUTION RECONSTITUTED 100 UNIT, 50 UNIT (onabotulinumtoxina OA (cosmetic)) BOTOX INJECTION SOLUTION RECONSTITUTED 100 UNIT, OA QL (168 day supply per 1 fill) 200 UNIT (onabotulinumtoxina) DYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED OA QL (90 day supply per 1 fill) 300 UNIT, 500 UNIT (abobotulinumtoxina) MYOBLOC INTRAMUSCULAR SOLUTION 10000 UNIT/2ML, OA QL (30 day supply per 1 fill) 2500 UNIT/0.5ML, 5000 UNIT/ML (rimabotulinumtoxinb) NORGESIC FORTE ORAL TABLET 50-770-60 MG 3 PA orphenadrine citrate er oral tablet extended release 12 hour 1 100 mg orphenadrine citrate injection solution 30 mg/ml OA orphenadrine-asa-caffeine oral tablet 50-770-60 mg 1 PA ORPHENGESIC FORTE ORAL TABLET 50-770-60 MG 3 PA (orphenadrine-aspirin-caffeine) XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED OA QL (90 day supply per 1 fill) 100 UNIT, 200 UNIT, 50 UNIT (incobotulinumtoxina) BLOOD DERIVATIVES - Drugs for the Blood BLOOD DERIVATIVES - Drugs for the Blood ALBUKED 25 INTRAVENOUS SOLUTION 25 % (albumin OA human) ALBUKED 5 INTRAVENOUS SOLUTION 5 % (albumin OA human) albumin human intravenous solution 25 %, 5 % OA ALBUMINEX INTRAVENOUS SOLUTION 25 %, 5 % (albumin OA human-kjda) albumin-zlb intravenous solution 25 %, 5 % OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 114 Coverage Requirements & Prescription Drug Name Drug Tier Limits alburx intravenous solution 5 % OA ALBUTEIN INTRAVENOUS SOLUTION 25 %, 5 % (albumin OA human) FLEXBUMIN INTRAVENOUS SOLUTION 25 %, 5 % (albumin OA human) HUMAN ALBUMIN GRIFOLS INTRAVENOUS SOLUTION 25 OA % (albumin human) kedbumin intravenous solution 25 % OA OCTAPLAS BLOOD GROUP A INTRAVENOUS SOLUTION OA (plasma human) OCTAPLAS BLOOD GROUP AB INTRAVENOUS SOLUTION OA (plasma human) OCTAPLAS BLOOD GROUP B INTRAVENOUS SOLUTION OA (plasma human) OCTAPLAS BLOOD GROUP O INTRAVENOUS SOLUTION OA (plasma human) PANHEMATIN INTRAVENOUS SOLUTION RECONSTITUTED OA 350 MG (hemin) PLASBUMIN-25 INTRAVENOUS SOLUTION 25 % (albumin OA human) PLASBUMIN-5 INTRAVENOUS SOLUTION 5 % (albumin OA human) PLASMANATE INTRAVENOUS SOLUTION 5 % (plasma OA protein fraction) BLOOD FORMATION, COAGULATION, THROMBOSIS - Drugs for the Blood ANTIANEMIA DRUGS - Vitamins and Minerals ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 PA; SP; QL (30 day supply MCG/ML, 200 MCG/ML, 25 MCG/ML, 40 MCG/ML, 60 MCG/ML SI per 1 fill) (darbepoetin alfa)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 115 Coverage Requirements & Prescription Drug Name Drug Tier Limits ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 100 MCG/0.5ML, 150 PA; SP; QL (30 day supply MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 SI per 1 fill) MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML (darbepoetin alfa) EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 PA; SP; QL (30 day supply UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML SI per 1 fill) (epoetin alfa) PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 PA; SP; QL (30 day supply UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, SI per 1 fill) 40000 UNIT/ML (epoetin alfa) RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 PA; SP; QL (30 day supply UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, SI per 1 fill) 40000 UNIT/ML (epoetin alfa-epbx) ANTICOAGULANTS, MISCELLANEOUS - Drugs to Prevent Blood Clots ACD FORMULA A IN VITRO SOLUTION 0.73-2.45-2.2 3 GM/100ML ACD-A NOCLOT-50 IN VITRO SOLUTION 0.73-2.45-2.2 3 GM/100ML (anticoagulant cit dext soln a) ANTICOAGULANT SODIUM CITRATE IN VITRO SOLUTION 4 3 %, 4 GM/100ML ARIXTRA SUBCUTANEOUS SOLUTION 10 MG/0.8ML, 2.5 SP; QL (30 day supply per 1 MG/0.5ML, 5 MG/0.4ML, 7.5 MG/0.6ML (fondaparinux SI fill) sodium) CEPROTIN INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 1000 UNIT, 500 UNIT (protein c concentrate (human)) fondaparinux sodium subcutaneous solution 10 mg/0.8ml, SP; QL (30 day supply per 1 SI 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml fill) SODIUM CITRATE IN VITRO SOLUTION PREFILLED 3 SYRINGE 4 %

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 116 Coverage Requirements & Prescription Drug Name Drug Tier Limits SODIUM CITRATE LOCK FLUSH INTRAVENOUS SOLUTION OA 4 % SODIUM CITRATE LOCK FLUSH INTRAVENOUS SOLUTION OA PREFILLED SYRINGE 120 MG/3ML SODIUM CITRATE-GENTAMICIN SULF INTRAVENOUS OA SOLUTION 4-320 %-MCG/ML THROMBATE III INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 500 UNIT (antithrombin iii OA (human)) TRICITRASOL IN VITRO CONCENTRATE 46.7 % 3 (anticoagulant sodium citrate) ANTIHEMORRHAGIC AGENTS, MISCELLANEOUS - Drugs to Prevent Bleeding ANDEXXA INTRAVENOUS SOLUTION RECONSTITUTED 200 OA MG (coag fact xa inactivated-zhzo) PRAXBIND INTRAVENOUS SOLUTION 2.5 GM/50ML OA (idarucizumab) ANTIHEPARIN AGENTS - Drugs to Prevent Bleeding protamine sulfate intravenous solution 10 mg/ml OA ANTITHROMBOTIC AGENTS, MISCELLANEOUS - Drugs to Prevent Blood Clots PA; SP; QL (30 day supply CABLIVI INJECTION KIT 11 MG (caplacizumab-yhdp) SI per 1 fill) DEFITELIO INTRAVENOUS SOLUTION 200 MG/2.5ML OA (defibrotide sodium) BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC. - Drugs to Prevent Bleeding ADAKVEO INTRAVENOUS SOLUTION 100 MG/10ML OA (crizanlizumab-tmca) PA; SP; QL (30 day supply OXBRYTA ORAL TABLET 500 MG (voxelotor) 3 per 1 fill) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 117 Coverage Requirements & Prescription Drug Name Drug Tier Limits TAVALISSE ORAL TABLET 100 MG, 150 MG (fostamatinib PA; SP; QL (30 day supply 3 disodium) per 1 fill) COUMARIN DERIVATIVES - Drugs to Prevent Blood Clots jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 1 5 mg, 6 mg, 7.5 mg warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 1 mg, 4 mg, 5 mg, 6 mg, 7.5 mg DIRECT FACTOR XA INHIBITORS - Drugs to Prevent Blood Clots ELIQUIS DVT/PE STARTER PACK ORAL TABLET THERAPY 2 PACK 5 MG (apixaban) ELIQUIS ORAL TABLET 2.5 MG, 5 MG (apixaban) 2 SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG (edoxaban 3 tosylate) XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG 2 (rivaroxaban) XARELTO STARTER PACK ORAL TABLET THERAPY PACK 3 15 & 20 MG (rivaroxaban) DIRECT THROMBIN INHIBITORS - Drugs to Prevent Blood Clots ANGIOMAX INTRAVENOUS SOLUTION RECONSTITUTED OA 250 MG (bivalirudin trifluoroacetate) argatroban in sodium chloride intravenous solution 50-0.9 OA mg/50ml-% argatroban intravenous solution 250 mg/2.5ml, 50 mg/50ml OA BIVALIRUDIN RTU INTRAVENOUS SOLUTION 250 MG/50ML OA bivalirudin trifluoroacetate intravenous solution OA reconstituted 250 mg BIVALIRUDIN-SODIUM CHLORIDE INTRAVENOUS OA SOLUTION 500-0.9 MG/100ML-%

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 118 Coverage Requirements & Prescription Drug Name Drug Tier Limits PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG 2 (dabigatran etexilate mesylate) HEMATOPOIETIC AGENTS - Drugs for Anemia ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 PA; SP; QL (30 day supply MCG/ML, 200 MCG/ML, 25 MCG/ML, 40 MCG/ML, 60 MCG/ML SI per 1 fill) (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 100 MCG/0.5ML, 150 PA; SP; QL (30 day supply MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 SI per 1 fill) MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML (darbepoetin alfa) PA; SP; QL (30 day supply DOPTELET ORAL TABLET 20 MG (avatrombopag maleate) 3 per 1 fill) EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 PA; SP; QL (30 day supply UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML SI per 1 fill) (epoetin alfa) FULPHILA SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 6 MG/0.6ML (pegfilgrastim-jmdb) per 1 fill) GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML, 480 PA; SP; QL (30 day supply SI MCG/1.6ML (tbo-filgrastim) per 1 fill) GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP; QL (30 day supply SI 300 MCG/0.5ML, 480 MCG/0.8ML (tbo-filgrastim) per 1 fill) LEUKINE INJECTION SOLUTION RECONSTITUTED 250 SP; QL (30 day supply per 1 SI MCG (sargramostim) fill) MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 150 MCG/0.3ML, 200 MCG/0.3ML, 30 PA; QL (30 day supply per 1 SI MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML (methoxy peg- fill) epoetin beta) MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2ML PA; SP; QL (30 day supply SI (plerixafor) per 1 fill) PA; SP; QL (30 day supply MULPLETA ORAL TABLET 3 MG (lusutrombopag) 3 per 1 fill) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 119 Coverage Requirements & Prescription Drug Name Drug Tier Limits NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE PA; SP; QL (30 day supply SI KIT 6 MG/0.6ML (pegfilgrastim) per 1 fill) NEULASTA SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 6 MG/0.6ML (pegfilgrastim) per 1 fill) NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 PA; SP; QL (30 day supply SI MCG/1.6ML (filgrastim) per 1 fill) NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE PA; SP; QL (30 day supply SI 300 MCG/0.5ML, 480 MCG/0.8ML (filgrastim) per 1 fill) NIVESTYM INJECTION SOLUTION 300 MCG/ML, 480 SP; QL (30 day supply per 1 SI MCG/1.6ML (filgrastim-aafi) fill) NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE SP; QL (30 day supply per 1 SI 300 MCG/0.5ML, 480 MCG/0.8ML (filgrastim-aafi) fill) NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED OA 125 MCG (romiplostim) NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 250 MCG, 500 MCG (romiplostim) NYVEPRIA SUBCUTANEOUS SOLUTION PREFILLED 3 PA; SP SYRINGE 6 MG/0.6ML (pegfilgrastim-apgf) PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 PA; SP; QL (30 day supply UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, SI per 1 fill) 40000 UNIT/ML (epoetin alfa) PROMACTA ORAL PACKET 12.5 MG, 25 MG (eltrombopag PA; SP; QL (30 day supply 3 olamine) per 1 fill) PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG PA; SP; QL (30 day supply 3 (eltrombopag olamine) per 1 fill) REBLOZYL SUBCUTANEOUS SOLUTION RECONSTITUTED OA 25 MG, 75 MG (luspatercept-aamt) RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 PA; SP; QL (30 day supply UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, SI per 1 fill) 40000 UNIT/ML (epoetin alfa-epbx)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 120 Coverage Requirements & Prescription Drug Name Drug Tier Limits UDENYCA SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 6 MG/0.6ML (pegfilgrastim-cbqv) per 1 fill) ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 PA; SP; QL (30 day supply SI MCG/0.5ML, 480 MCG/0.8ML (filgrastim-sndz) per 1 fill) ZIEXTENZO SUBCUTANEOUS SOLUTION PREFILLED OA SYRINGE 6 MG/0.6ML (pegfilgrastim-bmez) HEMORRHEOLOGIC AGENTS - Drugs for Blood Flow LMD IN D5W INTRAVENOUS SOLUTION 10-5 % (dextran 40 OA in d5w) LMD IN NACL INTRAVENOUS SOLUTION 10-0.9 % (dextran OA 40 in saline) pentoxifylline er oral tablet extended release 400 mg 1 HEMOSTATICS - Drugs to Prevent Bleeding ADVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 OA QL (30 day supply per 1 fill) UNIT, 500 UNIT (antihemophil factor (rahf-pfm)) ADYNOVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 OA QL (30 day supply per 1 fill) UNIT, 750 UNIT AFSTYLA INTRAVENOUS KIT 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 500 UNIT OA QL (30 day supply per 1 fill) (antihemophil fact single chain) ALPHANATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT OA QL (30 day supply per 1 fill) (antihemophilic factor-vwf) ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT OA QL (30 day supply per 1 fill) (coagulation factor ix) ALPROLIX INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 OA QL (30 day supply per 1 fill) UNIT (coagulation factor ix (rfixfc))

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 121 Coverage Requirements & Prescription Drug Name Drug Tier Limits AMICAR ORAL SOLUTION 0.25 GM/ML (aminocaproic acid) 3 AMICAR ORAL TABLET 1000 MG, 500 MG (aminocaproic 3 acid) aminocaproic acid intravenous solution 250 mg/ml OA aminocaproic acid oral solution 0.25 gm/ml 1 aminocaproic acid oral tablet 1000 mg, 500 mg 1 ASTRINGYN EXTERNAL SOLUTION 259 MG/GM (ferric 3 subsulfate) BENEFIX INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 OA QL (30 day supply per 1 fill) UNIT, 3000 UNIT, 500 UNIT (coagulation factor ix (recomb)) COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 250 UNIT, 500 UNIT (coagulation factor x (human)) CORIFACT INTRAVENOUS KIT 1000-1600 UNIT (factor xiii OA QL (30 day supply per 1 fill) concentrate human) CYKLOKAPRON INTRAVENOUS SOLUTION 1000 MG/10ML OA (tranexamic acid) DDAVP INJECTION SOLUTION 4 MCG/ML (desmopressin OA acetate) DDAVP ORAL TABLET 0.1 MG, 0.2 MG (desmopressin 3 acetate) DDAVP PF INJECTION SOLUTION 4 MCG/ML OA (desmopressin acetate) desmopressin ace spray refrig nasal solution 0.01 % 1 desmopressin acetate injection solution 4 mcg/ml OA SP; QL (30 day supply per 1 DESMOPRESSIN ACETATE NASAL SOLUTION 1.5 MG/ML 3 fill) desmopressin acetate oral tablet 0.1 mg, 0.2 mg 1 desmopressin acetate pf injection solution 4 mcg/ml OA desmopressin acetate spray nasal solution 0.01 % 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 122 Coverage Requirements & Prescription Drug Name Drug Tier Limits ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, OA QL (30 day supply per 1 fill) 4000 UNIT, 500 UNIT, 5000 UNIT, 6000 UNIT, 750 UNIT (antihem fact (bdd-rfviiifc)) ESPEROCT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT OA (antihemoph fact rcmb gpeg-exei) FEIBA INTRAVENOUS SOLUTION RECONSTITUTED 1000 OA QL (30 day supply per 1 fill) UNIT, 2500 UNIT, 500 UNIT (antiinhibitor coagulant cmplx) FIBRYGA INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) (fibrinogen concentrate (human)) GELFILM OPHTHALMIC FILM (gelatin adsorbable) 3 HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7ML, 150 OA QL (30 day supply per 1 fill) MG/ML, 30 MG/ML, 60 MG/0.4ML (emicizumab-kxwh) HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1700 UNIT, 250 UNIT, 500 UNIT (antihemophilic OA QL (30 day supply per 1 fill) factor) HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT OA QL (30 day supply per 1 fill) (antihemophilic factor-vwf) IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3500 UNIT, 500 UNIT OA QL (30 day supply per 1 fill) (coagulation factor ix (rix-fp)) IXINITY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT OA QL (30 day supply per 1 fill) (coagulation factor ix (recomb)) JIVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT (ahf (bdd-rfviii peg- OA QL (30 day supply per 1 fill) aucl)) KCENTRA INTRAVENOUS KIT 1000 UNIT, 500 UNIT OA (prothrombin complex conc human)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 123 Coverage Requirements & Prescription Drug Name Drug Tier Limits KOATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 OA QL (30 day supply per 1 fill) UNIT, 250 UNIT, 500 UNIT (antihemophilic factor) KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 1000 UNIT, 500 UNIT (antihemophilic factor) KOGENATE FS INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT (antihem factor recomb OA QL (30 day supply per 1 fill) (rfviii)) KOVALTRY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT OA QL (30 day supply per 1 fill) (antihemophil factor (rahf-pfm)) LYSTEDA ORAL TABLET 650 MG (tranexamic acid) 3 MONONINE INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 1000 UNIT (coagulation factor ix) MONSELS FERRIC SUBSULFATE EXTERNAL SOLUTION 3 NOCDURNA SUBLINGUAL TABLET SUBLINGUAL 27.7 MCG, 3 PA 55.3 MCG (desmopressin acetate) NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 OA QL (30 day supply per 1 fill) UNIT (antihemophil fact bd truncated) NOVOSEVEN RT INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG, 8 MG (coagulation OA QL (30 day supply per 1 fill) factor viia recomb) NUWIQ INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT (antihem fact OA (bdd-rfviii,sim)) NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 OA QL (30 day supply per 1 fill) UNIT, 500 UNIT (antihem fact (bdd-rfviii,sim)) OBIZUR INTRAVENOUS SOLUTION RECONSTITUTED 500 OA QL (30 day supply per 1 fill) UNIT

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 124 Coverage Requirements & Prescription Drug Name Drug Tier Limits PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 1000 UNIT, 1500 UNIT, 500 UNIT (factor ix complex) REBINYN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 500 UNIT (coagulation factor ix OA QL (30 day supply per 1 fill) glycopeg) RECOMBINATE INTRAVENOUS SOLUTION RECONSTITUTED 1241-1800 UNIT, 1801-2400 UNIT, 220-400 OA QL (30 day supply per 1 fill) UNIT, 401-800 UNIT, 801-1240 UNIT (antihem factor recomb (rfviii)) RECOTHROM EXTERNAL SOLUTION RECONSTITUTED OA 20000 UNIT, 5000 UNIT (thrombin (recombinant)) RECOTHROM SPRAY KIT EXTERNAL SOLUTION OA RECONSTITUTED 20000 UNIT (thrombin (recombinant)) RIASTAP INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) (fibrinogen concentrate (human)) RIXUBIS INTRAVENOUS SOLUTION RECONSTITUTED 1000 OA QL (30 day supply per 1 fill) UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT SEVENFACT INTRAVENOUS SOLUTION RECONSTITUTED OA PA; SP 1 MG, 5 MG (coagulation factor viia-jncw) STIMATE NASAL SOLUTION 1.5 MG/ML (desmopressin SP; QL (30 day supply per 1 3 acetate) fill) THROMBIN-JMI EXTERNAL SOLUTION RECONSTITUTED 3 20000 UNIT, 5000 UNIT (thrombin) THROMBOGEN EXTERNAL SOLUTION RECONSTITUTED 3 1000 UNIT, 10000 UNIT (thrombin) tranexamic acid intravenous solution 1000 mg/10ml OA tranexamic acid oral tablet 650 mg 1 TRANEXAMIC ACID-NACL INTRAVENOUS SOLUTION 1000- OA 0.7 MG/100ML-% TRETTEN INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 2000-3125 UNIT (coagulation factor xiii a-sub)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 125 Coverage Requirements & Prescription Drug Name Drug Tier Limits VONVENDI INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 1300 UNIT, 650 UNIT (von willebrand factor (recomb)) WILATE INTRAVENOUS KIT 1000-1000 UNIT, 500-500 UNIT OA QL (30 day supply per 1 fill) (antihemophilic factor-vwf) XYNTHA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 OA QL (30 day supply per 1 fill) UNIT, 500 UNIT (antihem fact (bdd-rfviii,mor)) XYNTHA SOLOFUSE INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT (antihem fact (bdd- OA QL (30 day supply per 1 fill) rfviii,mor)) HEPARINS - Drugs to Prevent Blood Clots SP; QL (14 day supply per 1 enoxaparin sodium injection solution 300 mg/3ml SI fill) enoxaparin sodium subcutaneous solution 100 mg/ml, 120 SP; QL (14 day supply per 1 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 SI fill) mg/0.6ml, 80 mg/0.8ml FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, SP; QL (30 day supply per 1 SI 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 fill) UNIT/3.8ML (dalteparin sodium) heparin (porcine) in nacl intravenous solution 1000-0.9 ut/500ml-%, 12500-0.45 ut/250ml-%, 2000-0.9 unit/l-%, OA 25000-0.45 ut/500ml-% HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 2500-0.9 UT/500ML-%, 30000-0.9 UNIT/L-%, 4000-0.9 UNIT/L- OA %, 500-0.9 UT/500ML-%, 5000-0.9 UNIT/L-%, 5000-0.9 UT/500ML-% heparin (porcine) in nacl intravenous solution 25000-0.45 OA PA ut/250ml-% HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 20-0.9 UNT/20ML-%, 50-0.9 OA QL (30 day supply per 1 fill) UNT/50ML-% heparin lock flush intravenous solution 1 unit/ml, 10 unit/ml OA Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 126 Coverage Requirements & Prescription Drug Name Drug Tier Limits heparin sod (porcine) in d5w intravenous solution 100 OA unit/ml, 25000-5 ut/500ml-%, 40-5 unit/ml-% heparin sodium (porcine) injection solution 1000 unit/ml, PA; QL (30 day supply per 1 SI 10000 unit/ml, 20000 unit/ml, 5000 unit/ml fill) heparin sodium (porcine) injection solution prefilled 1 syringe 5000 unit/0.5ml heparin sodium (porcine) pf injection solution 5000 PA; QL (30 day supply per 1 SI unit/0.5ml fill) heparin sodium (porcine) pf injection solution 5000 unit/ml 1 PA heparin sodium lock flush intravenous solution 100 unit/ml OA LOVENOX INJECTION SOLUTION 300 MG/3ML (enoxaparin SP; QL (14 day supply per 1 SI sodium) fill) LOVENOX SUBCUTANEOUS SOLUTION 100 MG/ML, 120 SP; QL (14 day supply per 1 MG/0.8ML, 150 MG/ML, 30 MG/0.3ML, 40 MG/0.4ML, 60 SI fill) MG/0.6ML, 80 MG/0.8ML (enoxaparin sodium) IRON PREPARATIONS - Vitamins and Minerals ACCRUFER ORAL CAPSULE 30 MG (ferric maltol) 3 PA FERAHEME INTRAVENOUS SOLUTION 510 MG/17ML OA (ferumoxytol) FERRLECIT INTRAVENOUS SOLUTION 12.5 MG/ML (na OA ferric gluc cplx in sucrose) ferrous sulfate oral solution 75 (15 fe) mg/ml 1 PV ferumoxytol intravenous solution 510 mg/17ml OA hematinic/folic acid oral tablet 324-1 mg 1 hemocyte-f oral tablet 324-1 mg 1 INFED INJECTION SOLUTION 50 MG/ML (iron dextran) OA INJECTAFER INTRAVENOUS SOLUTION 750 MG/15ML OA (ferric carboxymaltose) JENLIVA PRENATAL/POSTNATAL ORAL CAPSULE 1 MG 3 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 127 Coverage Requirements & Prescription Drug Name Drug Tier Limits MONOFERRIC INTRAVENOUS SOLUTION 1000 MG/10ML OA (ferric derisomaltose) multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml 1 na ferric gluc cplx in sucrose intravenous solution 12.5 OA mg/ml NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o 3 PV vit a) ONE VITE WOMENS ORAL TABLET 27-0.8 MG 3 PV ONE-A-DAY WOMENS PRENATAL 1 ORAL CAPSULE 28-0.8- 3 PV 235 MG (prenat-fe carbonyl-fa-omega 3) prenatal multi +dha oral capsule 27-0.8-200 mg, 27-0.8-228 1 PV mg, 27-0.8-250 mg prenatal oral tablet 27-0.8 mg 1 PV PRENATVITE RX ORAL TABLET 0.8 MG 3 QUFLORA FE ORAL TABLET CHEWABLE 0.25 MG (multi vit- 3 min-fluoride-fe-fa) RELNATE DHA ORAL CAPSULE 28-1-200 MG 3 PV TRIFERIC HEMODIALYSIS PACKET 272 MG (ferric 3 pyrophosphate citrate) TRIFERIC HEMODIALYSIS SOLUTION 27.2 MG/5ML (ferric 3 pyrophosphate citrate) VENOFER INTRAVENOUS SOLUTION 20 MG/ML (iron OA sucrose) LIVER AND STOMACH PREPARATIONS - Vitamins and Minerals cyanocobalamin injection solution 1000 mcg/ml SI QL (0.04 ML per 1 day) CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML 3 hydroxocobalamin acetate intramuscular solution 1000 OA mcg/ml

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 128 Coverage Requirements & Prescription Drug Name Drug Tier Limits METHYLCOBALAMIN INJECTION SOLUTION 3 RECONSTITUTED 10000 MCG, 50000 MCG NASCOBAL NASAL SOLUTION 500 MCG/0.1ML 3 (cyanocobalamin) PLATELET-AGGREGATION INHIBITORS - Drugs to Prevent Blood Clots adult aspirin regimen oral tablet delayed release 81 mg 1 PV AGGRASTAT INTRAVENOUS CONCENTRATE 3.75 OA MG/15ML (tirofiban hcl) AGGRASTAT INTRAVENOUS SOLUTION 12.5-0.9 OA MG/250ML-%, 5-0.9 MG/100ML-% (tirofiban hcl in nacl) aspirin adult low dose oral tablet delayed release 81 mg 1 PV aspirin adult low strength oral tablet delayed release 81 mg 1 PV aspirin childrens oral tablet chewable 81 mg 1 PV aspirin ec low dose oral tablet delayed release 81 mg 1 PV aspirin ec low strength oral tablet delayed release 81 mg 1 PV aspirin ec oral tablet delayed release 325 mg 1 PV aspirin low dose oral tablet chewable 81 mg 1 PV aspirin low dose oral tablet delayed release 81 mg 1 PV aspirin oral tablet 325 mg 1 PV aspirin oral tablet delayed release 325 mg, 81 mg 1 PV aspirin-dipyridamole er oral capsule extended release 12 1 hour 25-200 mg ASPIRIN-OMEPRAZOLE ORAL TABLET DELAYED RELEASE 3 PA 325-40 MG, 81-40 MG BAYER ASPIRIN EC LOW DOSE ORAL TABLET DELAYED 3 PV RELEASE 81 MG (aspirin) BAYER ASPIRIN ORAL TABLET 325 MG (aspirin) 3 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 129 Coverage Requirements & Prescription Drug Name Drug Tier Limits BAYER ASPIRIN ORAL TABLET DELAYED RELEASE 325 MG 3 PV (aspirin) BRILINTA ORAL TABLET 60 MG, 90 MG (ticagrelor) 3 cilostazol oral tablet 100 mg, 50 mg 1 clopidogrel bisulfate oral tablet 300 mg, 75 mg 1 dipyridamole intravenous solution 5 mg/ml OA dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1 DURLAZA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 PA 162.5 MG (aspirin) EFFIENT ORAL TABLET 10 MG, 5 MG (prasugrel hcl) 3 eptifibatide intravenous solution 20 mg/10ml, 200 OA mg/100ml, 75 mg/100ml goodsense aspirin adults oral tablet 325 mg 1 PV goodsense aspirin low dose oral tablet delayed release 81 1 PV mg KENGREAL INTRAVENOUS SOLUTION RECONSTITUTED OA 50 MG (cangrelor tetrasodium) PLAVIX ORAL TABLET 75 MG (clopidogrel bisulfate) 3 prasugrel hcl oral tablet 10 mg, 5 mg 1 ST JOSEPH LOW DOSE ORAL TABLET DELAYED RELEASE 3 PV 81 MG (aspirin) YOSPRALA ORAL TABLET DELAYED RELEASE 325-40 MG, 3 PA 81-40 MG (aspirin-omeprazole) ZONTIVITY ORAL TABLET 2.08 MG (vorapaxar sulfate) 3 PLATELET-REDUCING AGENTS - Drugs to Prevent Blood Clots AGRYLIN ORAL CAPSULE 0.5 MG (anagrelide hcl) 3 anagrelide hcl oral capsule 0.5 mg, 1 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 130 Coverage Requirements & Prescription Drug Name Drug Tier Limits THROMBOLYTIC AGENTS - Drugs to Prevent Blood Clots ACTIVASE INTRAVENOUS SOLUTION RECONSTITUTED OA 100 MG, 50 MG (alteplase) adult aspirin regimen oral tablet delayed release 81 mg 1 PV aspirin adult low dose oral tablet delayed release 81 mg 1 PV aspirin adult low strength oral tablet delayed release 81 mg 1 PV aspirin childrens oral tablet chewable 81 mg 1 PV aspirin ec low dose oral tablet delayed release 81 mg 1 PV aspirin ec low strength oral tablet delayed release 81 mg 1 PV aspirin ec oral tablet delayed release 325 mg 1 PV aspirin low dose oral tablet chewable 81 mg 1 PV aspirin low dose oral tablet delayed release 81 mg 1 PV aspirin oral tablet 325 mg 1 PV aspirin oral tablet delayed release 325 mg, 81 mg 1 PV BAYER ASPIRIN EC LOW DOSE ORAL TABLET DELAYED 3 PV RELEASE 81 MG (aspirin) BAYER ASPIRIN ORAL TABLET 325 MG (aspirin) 3 PV BAYER ASPIRIN ORAL TABLET DELAYED RELEASE 325 MG 3 PV (aspirin) CATHFLO ACTIVASE INJECTION SOLUTION OA RECONSTITUTED 2 MG (alteplase) goodsense aspirin adults oral tablet 325 mg 1 PV goodsense aspirin low dose oral tablet delayed release 81 1 PV mg RETAVASE HALF-KIT INTRAVENOUS KIT 1 X 10 UNIT OA (reteplase) RETAVASE INTRAVENOUS KIT 2 X 10 UNIT (reteplase) OA ST JOSEPH LOW DOSE ORAL TABLET DELAYED RELEASE 3 PV 81 MG (aspirin) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 131 Coverage Requirements & Prescription Drug Name Drug Tier Limits TNKASE INTRAVENOUS KIT 50 MG (tenecteplase) OA CARDIOVASCULAR DRUGS - Drugs for the Heart ALPHA-ADRENERGIC BLOCKING AGENTS - Drugs for High Blood Pressure CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG 3 (doxazosin mesylate) CARDURA XL ORAL TABLET EXTENDED RELEASE 24 2 HOUR 4 MG, 8 MG (doxazosin mesylate) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 carvedilol phosphate er oral capsule extended release 24 1 hour 10 mg, 20 mg, 40 mg, 80 mg COREG CR ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 10 MG, 20 MG, 40 MG, 80 MG (carvedilol phosphate) COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG 3 (carvedilol) doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 LABETALOL HCL INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 20 MG/4ML labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 labetalol hcl solution 5 mg/ml intravenous 5 mg/ml OA LABETALOL HCL SOLUTION 5 MG/ML INTRAVENOUS 5 OA MG/ML LABETALOL HCL-DEXTROSE INTRAVENOUS SOLUTION OA 200-5 MG/200ML-% LABETALOL HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 100-0.72 MG/100ML-%, 200-0.72 MG/200ML-%, OA 300-0.72 MG/300ML-% MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG (prazosin 3 hcl) prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 132 Coverage Requirements & Prescription Drug Name Drug Tier Limits terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 ALPHA-ADRENERGIC BLOCKING AGT.(HYPOTEN) - Drugs for High Blood Pressure & Angina CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG 3 (doxazosin mesylate) CARDURA XL ORAL TABLET EXTENDED RELEASE 24 2 HOUR 4 MG, 8 MG (doxazosin mesylate) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 carvedilol phosphate er oral capsule extended release 24 1 hour 10 mg, 20 mg, 40 mg, 80 mg COREG CR ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 10 MG, 20 MG, 40 MG, 80 MG (carvedilol phosphate) COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG 3 (carvedilol) doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 LABETALOL HCL INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 20 MG/4ML labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 labetalol hcl solution 5 mg/ml intravenous 5 mg/ml OA LABETALOL HCL SOLUTION 5 MG/ML INTRAVENOUS 5 OA MG/ML LABETALOL HCL-DEXTROSE INTRAVENOUS SOLUTION OA 200-5 MG/200ML-% LABETALOL HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 100-0.72 MG/100ML-%, 200-0.72 MG/200ML-%, OA 300-0.72 MG/300ML-% MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG (prazosin 3 hcl) prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1 terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 133 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANGIOTENSIN II RECEPTOR ANTAGON.(HYPOTN) - Drugs for High Blood Pressure & Angina ATACAND ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG 3 ST (candesartan cilexetil) AVAPRO ORAL TABLET 150 MG, 300 MG, 75 MG 3 ST (irbesartan) BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG (olmesartan 3 ST medoxomil) candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1 ST COZAAR ORAL TABLET 100 MG, 25 MG, 50 MG (losartan 3 ST potassium) DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 MG 3 ST (valsartan) EDARBI ORAL TABLET 40 MG, 80 MG (azilsartan 3 ST medoxomil) irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 losartan potassium oral tablet 100 mg, 25 mg, 50 mg 1 * MICARDIS ORAL TABLET 20 MG, 40 MG, 80 MG 3 ST (telmisartan) olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg 1 telmisartan oral tablet 20 mg, 40 mg, 80 mg 1 valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS - Drugs for the Heart amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 1 ST mg, 5-160 mg, 5-320 mg amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 1 ST mg, 5-40 mg amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10- 1 ST 160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 134 Coverage Requirements & Prescription Drug Name Drug Tier Limits ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 MG, 32- 3 ST 25 MG (candesartan cilexetil-hctz) ATACAND ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG 3 ST (candesartan cilexetil) AVALIDE ORAL TABLET 150-12.5 MG, 300-12.5 MG 3 ST (irbesartan-hydrochlorothiazide) AVAPRO ORAL TABLET 150 MG, 300 MG, 75 MG 3 ST (irbesartan) AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-40 3 ST MG (amlodipine-olmesartan) BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, 40-25 3 ST MG (olmesartan medoxomil-hctz) BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG (olmesartan 3 ST medoxomil) candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1 ST candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 1 ST mg, 32-25 mg COZAAR ORAL TABLET 100 MG, 25 MG, 50 MG (losartan 3 ST potassium) DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320- 12.5 MG, 320-25 MG, 80-12.5 MG (valsartan- 3 ST hydrochlorothiazide) DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 MG 3 ST (valsartan) EDARBI ORAL TABLET 40 MG, 80 MG (azilsartan 3 ST medoxomil) EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG 3 ST (azilsartan-chlorthalidone) ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG 3 PA (sacubitril-valsartan)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 135 Coverage Requirements & Prescription Drug Name Drug Tier Limits EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG 3 ST (amlodipine-valsartan-hctz) EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 MG, 3 ST 5-320 MG (amlodipine besylate-valsartan) HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 3 ST MG (losartan potassium-hctz) irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300- 1 12.5 mg losartan potassium oral tablet 100 mg, 25 mg, 50 mg 1 * losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 1 * 50-12.5 mg MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5 MG, 80- 3 ST 25 MG (telmisartan-hctz) MICARDIS ORAL TABLET 20 MG, 40 MG, 80 MG 3 ST (telmisartan) olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg 1 olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 1 mg, 40-25 mg olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10- 1 ST 12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg telmisartan oral tablet 20 mg, 40 mg, 80 mg 1 telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 1 ST mg, 80-5 mg telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 1 mg TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG (olmesartan- 3 ST amlodipine-hctz)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 136 Coverage Requirements & Prescription Drug Name Drug Tier Limits TWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 80-10 MG, 80- 3 ST 5 MG (telmisartan-amlodipine) valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg 1 valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160- 1 25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg ANGIOTENSIN-CONVERT.ENZYME INHIB(HYPOTN) - Drugs for High Blood Pressure & Angina ACCUPRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG 3 (quinapril hcl) ALTACE ORAL CAPSULE 1.25 MG, 10 MG, 2.5 MG, 5 MG 3 (ramipril) benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1 enalapril maleate oral solution 1 mg/ml 1 enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 enalaprilat intravenous injectable 1.25 mg/ml OA EPANED ORAL SOLUTION 1 MG/ML (enalapril maleate) 3 fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg 1 lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 1 * mg LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG (benazepril 3 hcl) moexipril hcl oral tablet 15 mg, 7.5 mg 1 perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1 PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 MG 3 PA (perindopril arg-amlodipine) PRINIVIL ORAL TABLET 20 MG (lisinopril) 3 quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 137 Coverage Requirements & Prescription Drug Name Drug Tier Limits trandolapril oral tablet 1 mg, 2 mg, 4 mg 1 VASOTEC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG 3 (enalapril maleate) ZESTRIL ORAL TABLET 10 MG, 2.5 MG, 20 MG, 30 MG, 40 3 MG, 5 MG (lisinopril) ANGIOTENSIN-CONVERTING ENZYME INHIBITORS - Drugs for the Heart ACCUPRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG 3 (quinapril hcl) ACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 3 MG (quinapril-hydrochlorothiazide) ALTACE ORAL CAPSULE 1.25 MG, 10 MG, 2.5 MG, 5 MG 3 (ramipril) amlodipine besylate-benazepril hcl oral capsule 10-20 mg, 1 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- 1 12.5 mg, 20-25 mg, 5-6.25 mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1 enalapril maleate oral solution 1 mg/ml 1 enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 enalaprilat intravenous injectable 1.25 mg/ml OA enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 1 mg EPANED ORAL SOLUTION 1 MG/ML (enalapril maleate) 3 fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg 1 fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg 1 lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 1 * mg

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 138 Coverage Requirements & Prescription Drug Name Drug Tier Limits lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- 1 * 12.5 mg, 20-25 mg LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20- 3 25 MG (benazepril-hydrochlorothiazide) LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG (benazepril 3 hcl) LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5- 3 20 MG (amlodipine besy-benazepril hcl) moexipril hcl oral tablet 15 mg, 7.5 mg 1 perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1 PRINIVIL ORAL TABLET 20 MG (lisinopril) 3 QBRELIS ORAL SOLUTION 1 MG/ML (lisinopril) 3 quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- 1 12.5 mg, 20-25 mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1 trandolapril oral tablet 1 mg, 2 mg, 4 mg 1 trandolapril-verapamil hcl er oral tablet extended release 1- 1 240 mg, 2-180 mg, 2-240 mg, 4-240 mg VASERETIC ORAL TABLET 10-25 MG (enalapril- 3 hydrochlorothiazide) VASOTEC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG 3 (enalapril maleate) ZESTORETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 3 MG (lisinopril-hydrochlorothiazide) ZESTRIL ORAL TABLET 10 MG, 2.5 MG, 20 MG, 30 MG, 40 3 MG, 5 MG (lisinopril) ANTIARRHYTHMICS, MISCELLANEOUS - Drugs for Angina digitek oral tablet 125 mcg, 250 mcg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 139 Coverage Requirements & Prescription Drug Name Drug Tier Limits digox oral tablet 125 mcg, 250 mcg 1 digoxin injection solution 0.25 mg/ml OA digoxin oral solution 0.05 mg/ml 1 digoxin oral tablet 125 mcg, 250 mcg 1 LANOXIN INJECTION SOLUTION 0.25 MG/ML (digoxin) OA LANOXIN ORAL TABLET 125 MCG, 250 MCG (digoxin) 3 LANOXIN ORAL TABLET 62.5 MCG (digoxin) 2 LANOXIN PEDIATRIC INJECTION SOLUTION 0.1 MG/ML OA (digoxin) magnesium sulfate in d5w intravenous solution 1-5 OA gm/100ml-% magnesium sulfate intravenous solution 2 gm/50ml, 20 OA gm/500ml, 4 gm/100ml, 4 gm/50ml, 40 gm/1000ml MAGNESIUM SULFATE SOLUTION 50 % INJECTION 50 % OA magnesium sulfate solution 50 % injection 50 % OA MAGNESIUM SULFATE-NACL INTRAVENOUS SOLUTION 2- OA 0.9 GM/50ML-% ANTILIPEMIC AGENTS, MISCELLANEOUS - Drugs for Cholesterol EVKEEZA INTRAVENOUS SOLUTION 1200 MG/8ML, 345 OA PA; SP MG/2.3ML (evinacumab-dgnb) icosapent ethyl oral capsule 1 gm 1 JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 5 MG PA; SP; QL (30 day supply 3 (lomitapide mesylate) per 1 fill) LOVAZA ORAL CAPSULE 1 GM (omega-3-acid ethyl esters) 3 NEXLETOL ORAL TABLET 180 MG (bempedoic acid) 2 PA; QL (1 EA per 1 day) NEXLIZET ORAL TABLET 180-10 MG (bempedoic acid- 2 PA; QL (1 EA per 1 day) ezetimibe)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 140 Coverage Requirements & Prescription Drug Name Drug Tier Limits niacin er (antihyperlipidemic) oral tablet extended release 1 1000 mg, 500 mg, 750 mg NIASPAN ORAL TABLET EXTENDED RELEASE 1000 MG, 3 500 MG, 750 MG (niacin (antihyperlipidemic)) omega-3-acid ethyl esters oral capsule 1 gm 1 VASCEPA ORAL CAPSULE 0.5 GM, 1 GM (icosapent ethyl) 3 BETA-ADRENERGIC BLOCKING AGENTS - Drugs for Abnormal Heart Rhythms acebutolol hcl oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1 BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 (sotalol hcl af) BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG (sotalol 3 hcl) betaxolol hcl oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5- 1 6.25 mg, 5-6.25 mg BREVIBLOC IN NACL INTRAVENOUS SOLUTION 2000 OA MG/100ML, 2500 MG/250ML (esmolol hcl-sodium chloride) BREVIBLOC INTRAVENOUS SOLUTION 100 MG/10ML OA (esmolol hcl) BREVIBLOC PREMIXED DS INTRAVENOUS SOLUTION 2000 OA MG/100ML (esmolol hcl-sodium chloride) BREVIBLOC PREMIXED INTRAVENOUS SOLUTION 2500 OA MG/250ML (esmolol hcl-sodium chloride) BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG 3 (nebivolol hcl) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 141 Coverage Requirements & Prescription Drug Name Drug Tier Limits carvedilol phosphate er oral capsule extended release 24 1 hour 10 mg, 20 mg, 40 mg, 80 mg COREG CR ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 10 MG, 20 MG, 40 MG, 80 MG (carvedilol phosphate) COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG 3 (carvedilol) CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG (nadolol) 3 DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG (metoprolol- 3 hydrochlorothiazide) esmolol hcl intravenous solution 100 mg/10ml OA ESMOLOL HCL INTRAVENOUS SOLUTION 2000 MG/100ML, OA 2500 MG/250ML ESMOLOL HCL INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 100 MG/10ML esmolol hcl-sodium chloride intravenous solution 2000 OA mg/100ml, 2500 mg/250ml HEMANGEOL ORAL SOLUTION 4.28 MG/ML (propranolol SP; QL (30 day supply per 1 2 hcl) fill) INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol hcl) INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 3 PA HOUR 120 MG, 80 MG (propranolol hcl sr beads) INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 3 PA HOUR 120 MG, 80 MG (propranolol hcl sr beads) KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG (metoprolol 3 succinate) LABETALOL HCL INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 20 MG/4ML labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 142 Coverage Requirements & Prescription Drug Name Drug Tier Limits labetalol hcl solution 5 mg/ml intravenous 5 mg/ml OA LABETALOL HCL SOLUTION 5 MG/ML INTRAVENOUS 5 OA MG/ML LABETALOL HCL-DEXTROSE INTRAVENOUS SOLUTION OA 200-5 MG/200ML-% LABETALOL HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 100-0.72 MG/100ML-%, 200-0.72 MG/200ML-%, OA 300-0.72 MG/300ML-% LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol 3 tartrate) metoprolol succinate er oral tablet extended release 24 1 hour 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate intravenous solution 5 mg/5ml OA metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 1 mg, 75 mg metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100- 1 50 mg, 50-25 mg nadolol oral tablet 20 mg, 40 mg, 80 mg 1 nebivolol hcl oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 pindolol oral tablet 10 mg, 5 mg 1 propranolol hcl er oral capsule extended release 24 hour 1 120 mg, 160 mg, 60 mg, 80 mg propranolol hcl intravenous solution 1 mg/ml OA propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 1 mg sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 SOTALOL HCL INTRAVENOUS SOLUTION 150 MG/10ML OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 143 Coverage Requirements & Prescription Drug Name Drug Tier Limits sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 TENORETIC 100 ORAL TABLET 100-25 MG (atenolol- 3 chlorthalidone) TENORETIC 50 ORAL TABLET 50-25 MG (atenolol- 3 chlorthalidone) TENORMIN ORAL TABLET 100 MG, 25 MG, 50 MG (atenolol) 3 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 25 MG, 50 MG (metoprolol succinate) ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG 3 (bisoprolol-hydrochlorothiazide) BETA-ADRENERGIC BLOCKING AGT.(HYPOTEN) - Drugs for High Blood Pressure & Angina acebutolol hcl oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 (sotalol hcl af) BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG (sotalol 3 hcl) betaxolol hcl oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 BREVIBLOC IN NACL INTRAVENOUS SOLUTION 2000 OA MG/100ML, 2500 MG/250ML (esmolol hcl-sodium chloride) BREVIBLOC INTRAVENOUS SOLUTION 100 MG/10ML OA (esmolol hcl) BREVIBLOC PREMIXED DS INTRAVENOUS SOLUTION 2000 OA MG/100ML (esmolol hcl-sodium chloride) BREVIBLOC PREMIXED INTRAVENOUS SOLUTION 2500 OA MG/250ML (esmolol hcl-sodium chloride) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 144 Coverage Requirements & Prescription Drug Name Drug Tier Limits carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 carvedilol phosphate er oral capsule extended release 24 1 hour 10 mg, 20 mg, 40 mg, 80 mg COREG CR ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 10 MG, 20 MG, 40 MG, 80 MG (carvedilol phosphate) COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG 3 (carvedilol) CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG (nadolol) 3 esmolol hcl intravenous solution 100 mg/10ml OA ESMOLOL HCL INTRAVENOUS SOLUTION 2000 MG/100ML, OA 2500 MG/250ML ESMOLOL HCL INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 100 MG/10ML esmolol hcl-sodium chloride intravenous solution 2000 OA mg/100ml, 2500 mg/250ml HEMANGEOL ORAL SOLUTION 4.28 MG/ML (propranolol SP; QL (30 day supply per 1 2 hcl) fill) INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol hcl) INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 3 PA HOUR 120 MG, 80 MG (propranolol hcl sr beads) INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 3 PA HOUR 120 MG, 80 MG (propranolol hcl sr beads) KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG (metoprolol 3 succinate) LABETALOL HCL INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 20 MG/4ML labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 labetalol hcl solution 5 mg/ml intravenous 5 mg/ml OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 145 Coverage Requirements & Prescription Drug Name Drug Tier Limits LABETALOL HCL SOLUTION 5 MG/ML INTRAVENOUS 5 OA MG/ML LABETALOL HCL-DEXTROSE INTRAVENOUS SOLUTION OA 200-5 MG/200ML-% LABETALOL HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 100-0.72 MG/100ML-%, 200-0.72 MG/200ML-%, OA 300-0.72 MG/300ML-% LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol 3 tartrate) metoprolol succinate er oral tablet extended release 24 1 hour 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate intravenous solution 5 mg/5ml OA metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 1 mg, 75 mg nadolol oral tablet 20 mg, 40 mg, 80 mg 1 pindolol oral tablet 10 mg, 5 mg 1 propranolol hcl er oral capsule extended release 24 hour 1 120 mg, 160 mg, 60 mg, 80 mg propranolol hcl intravenous solution 1 mg/ml OA propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 1 mg sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 SOTALOL HCL INTRAVENOUS SOLUTION 150 MG/10ML OA sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 TENORMIN ORAL TABLET 100 MG, 25 MG, 50 MG (atenolol) 3 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 146 Coverage Requirements & Prescription Drug Name Drug Tier Limits TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 25 MG, 50 MG (metoprolol succinate) BILE ACID SEQUESTRANTS - Drugs for Cholesterol cholestyramine light oral packet 4 gm 1 cholestyramine light oral powder 4 gm/dose 1 cholestyramine oral packet 4 gm 1 cholestyramine oral powder 4 gm/dose 1 colesevelam hcl oral packet 3.75 gm 1 colesevelam hcl oral tablet 625 mg 1 COLESTID FLAVORED ORAL GRANULES 5 GM (colestipol 2 hcl) COLESTID FLAVORED ORAL PACKET 5 GM (colestipol hcl) 3 COLESTID ORAL GRANULES 5 GM (colestipol hcl) 2 COLESTID ORAL PACKET 5 GM (colestipol hcl) 3 COLESTID ORAL TABLET 1 GM (colestipol hcl) 3 colestipol hcl oral granules 5 gm 1 colestipol hcl oral packet 5 gm 1 colestipol hcl oral tablet 1 gm 1 prevalite oral packet 4 gm 1 prevalite oral powder 4 gm/dose 1 QUESTRAN LIGHT ORAL POWDER 4 GM/DOSE 3 (cholestyramine light) QUESTRAN ORAL PACKET 4 GM (cholestyramine) 3 QUESTRAN ORAL POWDER 4 GM/DOSE (cholestyramine) 3 WELCHOL ORAL PACKET 3.75 GM (colesevelam hcl) 3 WELCHOL ORAL TABLET 625 MG (colesevelam hcl) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 147 Coverage Requirements & Prescription Drug Name Drug Tier Limits CALCIUM-CHANNEL BLOCK.AGT,MISC(HYPOTEN) - Drugs for High Blood Pressure & Angina CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 3 180 MG, 240 MG (verapamil hcl) CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG (diltiazem 3 hcl coated beads) CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl coated beads) CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG (diltiazem 3 hcl) cartia xt oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg, 300 mg diltiazem hcl er beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 1 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 1 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 1 mg, 60 mg, 90 mg diltiazem hcl er oral capsule extended release 24 hour 120 1 mg, 180 mg, 240 mg diltiazem hcl intravenous solution 125 mg/25ml, 25 mg/5ml, OA 50 mg/10ml diltiazem hcl intravenous solution reconstituted 100 mg OA diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 DILTIAZEM HCL-DEXTROSE INTRAVENOUS SOLUTION OA 125-5 MG/125ML-%

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 148 Coverage Requirements & Prescription Drug Name Drug Tier Limits DILTIAZEM HCL-SODIUM CHLORIDE INTRAVENOUS OA SOLUTION 125-0.7 MG/125ML-%, 125-0.9 MG/125ML-% dilt-xr oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg matzim la oral tablet extended release 24 hour 180 mg, 240 1 mg, 300 mg, 360 mg, 420 mg taztia xt oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg, 300 mg, 360 mg tiadylt er oral capsule extended release 24 hour 120 mg, 1 180 mg, 240 mg, 300 mg, 360 mg, 420 mg TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl er beads) verapamil hcl er oral capsule extended release 24 hour 100 1 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg, 180 1 mg, 240 mg verapamil hcl intravenous solution 2.5 mg/ml OA verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) CALCIUM-CHANNEL BLOCKING AGENTS, MISC. - Drugs for High Blood Pressure & Angina CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 3 180 MG, 240 MG (verapamil hcl) CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG (diltiazem 3 hcl coated beads)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 149 Coverage Requirements & Prescription Drug Name Drug Tier Limits CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl coated beads) CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG (diltiazem 3 hcl) cartia xt oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg, 300 mg diltiazem hcl er beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 1 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 1 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 1 mg, 60 mg, 90 mg diltiazem hcl er oral capsule extended release 24 hour 120 1 mg, 180 mg, 240 mg diltiazem hcl intravenous solution 125 mg/25ml, 25 mg/5ml, OA 50 mg/10ml diltiazem hcl intravenous solution reconstituted 100 mg OA diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 DILTIAZEM HCL-DEXTROSE INTRAVENOUS SOLUTION OA 125-5 MG/125ML-% DILTIAZEM HCL-SODIUM CHLORIDE INTRAVENOUS OA SOLUTION 125-0.7 MG/125ML-%, 125-0.9 MG/125ML-% dilt-xr oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg matzim la oral tablet extended release 24 hour 180 mg, 240 1 mg, 300 mg, 360 mg, 420 mg taztia xt oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg, 300 mg, 360 mg Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 150 Coverage Requirements & Prescription Drug Name Drug Tier Limits tiadylt er oral capsule extended release 24 hour 120 mg, 1 180 mg, 240 mg, 300 mg, 360 mg, 420 mg TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl er beads) trandolapril-verapamil hcl er oral tablet extended release 1- 1 240 mg, 2-180 mg, 2-240 mg, 4-240 mg verapamil hcl er oral capsule extended release 24 hour 100 1 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg, 180 1 mg, 240 mg verapamil hcl intravenous solution 2.5 mg/ml OA verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) CARBONIC ANHYDRASE INHIBITORS(HYPOTEN) - Drugs for High Blood Pressure & Angina acetazolamide er oral capsule extended release 12 hour 500 1 mg acetazolamide oral tablet 125 mg, 250 mg 1 acetazolamide sodium injection solution reconstituted 500 OA mg methazolamide oral tablet 25 mg, 50 mg 1 CARDIAC DRUGS, MISCELLANEOUS - Drugs for Angina CORLANOR ORAL SOLUTION 5 MG/5ML (ivabradine hcl) 3 CORLANOR ORAL TABLET 5 MG, 7.5 MG (ivabradine hcl) 2 RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 3 1000 MG, 500 MG (ranolazine)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 151 Coverage Requirements & Prescription Drug Name Drug Tier Limits ranolazine er oral tablet extended release 12 hour 1000 mg, 1 500 mg VYNDAMAX ORAL CAPSULE 61 MG (tafamidis) 3 VYNDAQEL ORAL CAPSULE 20 MG (tafamidis meglumine PA; SP; QL (30 day supply 3 (cardiac)) per 1 fill) CARDIOTONIC AGENTS - Drugs for Angina digitek oral tablet 125 mcg, 250 mcg 1 digox oral tablet 125 mcg, 250 mcg 1 digoxin injection solution 0.25 mg/ml OA digoxin oral solution 0.05 mg/ml 1 digoxin oral tablet 125 mcg, 250 mcg 1 dobutamine hcl intravenous solution 250 mg/20ml OA dobutamine in d5w intravenous solution 1-5 mg/ml-%, 2 OA mg/ml, 4-5 mg/ml-% dopamine hcl intravenous solution 40 mg/ml OA dopamine in d5w intravenous solution 0.8-5 mg/ml-%, 1.6-5 OA mg/ml-%, 3.2-5 mg/ml-% LANOXIN INJECTION SOLUTION 0.25 MG/ML (digoxin) OA LANOXIN ORAL TABLET 125 MCG, 250 MCG (digoxin) 3 LANOXIN ORAL TABLET 62.5 MCG (digoxin) 2 LANOXIN PEDIATRIC INJECTION SOLUTION 0.1 MG/ML OA (digoxin) milrinone lactate in dextrose intravenous solution 20-5 OA mg/100ml-%, 40-5 mg/200ml-% milrinone lactate intravenous solution 10 mg/10ml, 20 OA mg/20ml, 50 mg/50ml

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 152 Coverage Requirements & Prescription Drug Name Drug Tier Limits CENTRAL ALPHA-AGONISTS - Drugs for High Blood Pressure & Angina CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY 0.1 3 MG/24HR (clonidine) CATAPRES-TTS-2 TRANSDERMAL PATCH WEEKLY 0.2 3 MG/24HR (clonidine) CATAPRES-TTS-3 TRANSDERMAL PATCH WEEKLY 0.3 3 MG/24HR (clonidine) clonidine hcl (analgesia) epidural solution 100 mcg/ml, 500 OA mcg/ml clonidine hcl er oral tablet extended release 12 hour 0.1 mg 1 clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1 clonidine transdermal patch weekly 0.1 mg/24hr, 0.2 1 mg/24hr, 0.3 mg/24hr DURACLON EPIDURAL SOLUTION 100 MCG/ML (clonidine OA hcl (analgesia)) guanfacine hcl oral tablet 1 mg, 2 mg 1 KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR 0.1 3 MG (clonidine hcl) methyldopa oral tablet 250 mg, 500 mg 1 ROPIV-CLONIDINE-KETOROLAC SOLUTION PREFILLED 3 SYRINGE 123-0.04-15 MG/50ML CHOLESTEROL ABSORPTION INHIBITORS - Drugs for Cholesterol ezetimibe oral tablet 10 mg 1 ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 1 mg, 10-80 mg NEXLIZET ORAL TABLET 180-10 MG (bempedoic acid- 2 PA; QL (1 EA per 1 day) ezetimibe)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 153 Coverage Requirements & Prescription Drug Name Drug Tier Limits ROSZET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-5 3 PA MG (ezetimibe-rosuvastatin) VYTORIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10- 3 80 MG (ezetimibe-simvastatin) ZETIA ORAL TABLET 10 MG (ezetimibe) 3 CLASS IA ANTIARRHYTHMICS - Drugs for Angina disopyramide phosphate oral capsule 100 mg, 150 mg 1 NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 2 HOUR 100 MG, 150 MG (disopyramide phosphate) NORPACE ORAL CAPSULE 100 MG, 150 MG (disopyramide 3 phosphate) procainamide hcl injection solution 100 mg/ml, 500 mg/ml OA quinidine gluconate er oral tablet extended release 324 mg 1 quinidine sulfate oral tablet 200 mg, 300 mg 1 CLASS IB ANTIARRHYTHMICS - Drugs for Angina DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG 3 (phenytoin) DILANTIN ORAL CAPSULE 100 MG (phenytoin sodium 3 extended) DILANTIN ORAL CAPSULE 30 MG (phenytoin sodium 2 extended) DILANTIN ORAL SUSPENSION 125 MG/5ML (phenytoin) 3 LIDOCAINE HCL (CARDIAC) INTRAVENOUS SOLUTION OA PREFILLED SYRINGE 100 MG/10ML lidocaine hcl (cardiac) intravenous solution prefilled OA syringe 50 mg/5ml lidocaine hcl (cardiac) pf intravenous solution 100 mg/5ml OA lidocaine hcl (cardiac) pf intravenous solution prefilled OA syringe 100 mg/5ml, 50 mg/5ml

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 154 Coverage Requirements & Prescription Drug Name Drug Tier Limits lidocaine hcl (cardiac) solution prefilled syringe 100 mg/5ml OA intravenous 100 mg/5ml LIDOCAINE HCL (CARDIAC) SOLUTION PREFILLED OA SYRINGE 100 MG/5ML INTRAVENOUS 100 MG/5ML LIDOCAINE IN D5W INTRAVENOUS SOLUTION 2-5 MG/ML- OA % lidocaine in d5w intravenous solution 4-5 mg/ml-%, 8-5 OA mg/ml-% mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg 1 PHENYTEK ORAL CAPSULE 200 MG, 300 MG (phenytoin 3 sodium extended) phenytoin infatabs oral tablet chewable 50 mg 1 phenytoin oral suspension 100 mg/4ml, 125 mg/5ml 1 phenytoin oral tablet chewable 50 mg 1 phenytoin sodium extended oral capsule 100 mg, 200 mg, 1 300 mg phenytoin sodium injection solution 50 mg/ml OA CLASS IC ANTIARRHYTHMICS - Drugs for Angina flecainide acetate oral tablet 100 mg, 150 mg, 50 mg 1 propafenone hcl er oral capsule extended release 12 hour 1 225 mg, 325 mg, 425 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg 1 RYTHMOL SR ORAL CAPSULE EXTENDED RELEASE 12 3 HOUR 225 MG, 325 MG, 425 MG (propafenone hcl) CLASS II ANTIARRHYTHMICS - Drugs for Angina acebutolol hcl oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 (sotalol hcl af)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 155 Coverage Requirements & Prescription Drug Name Drug Tier Limits BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG (sotalol 3 hcl) betaxolol hcl oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 BREVIBLOC IN NACL INTRAVENOUS SOLUTION 2000 OA MG/100ML, 2500 MG/250ML (esmolol hcl-sodium chloride) BREVIBLOC INTRAVENOUS SOLUTION 100 MG/10ML OA (esmolol hcl) BREVIBLOC PREMIXED DS INTRAVENOUS SOLUTION 2000 OA MG/100ML (esmolol hcl-sodium chloride) BREVIBLOC PREMIXED INTRAVENOUS SOLUTION 2500 OA MG/250ML (esmolol hcl-sodium chloride) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 carvedilol phosphate er oral capsule extended release 24 1 hour 10 mg, 20 mg, 40 mg, 80 mg COREG CR ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 10 MG, 20 MG, 40 MG, 80 MG (carvedilol phosphate) COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG 3 (carvedilol) esmolol hcl intravenous solution 100 mg/10ml OA ESMOLOL HCL INTRAVENOUS SOLUTION 2000 MG/100ML, OA 2500 MG/250ML ESMOLOL HCL INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 100 MG/10ML esmolol hcl-sodium chloride intravenous solution 2000 OA mg/100ml, 2500 mg/250ml HEMANGEOL ORAL SOLUTION 4.28 MG/ML (propranolol SP; QL (30 day supply per 1 2 hcl) fill) INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol hcl)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 156 Coverage Requirements & Prescription Drug Name Drug Tier Limits INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 3 PA HOUR 120 MG, 80 MG (propranolol hcl sr beads) INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 3 PA HOUR 120 MG, 80 MG (propranolol hcl sr beads) KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG (metoprolol 3 succinate) LABETALOL HCL INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 20 MG/4ML labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 labetalol hcl solution 5 mg/ml intravenous 5 mg/ml OA LABETALOL HCL SOLUTION 5 MG/ML INTRAVENOUS 5 OA MG/ML LABETALOL HCL-DEXTROSE INTRAVENOUS SOLUTION OA 200-5 MG/200ML-% LABETALOL HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 100-0.72 MG/100ML-%, 200-0.72 MG/200ML-%, OA 300-0.72 MG/300ML-% LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol 3 tartrate) metoprolol succinate er oral tablet extended release 24 1 hour 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate intravenous solution 5 mg/5ml OA metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 1 mg, 75 mg pindolol oral tablet 10 mg, 5 mg 1 propranolol hcl er oral capsule extended release 24 hour 1 120 mg, 160 mg, 60 mg, 80 mg propranolol hcl intravenous solution 1 mg/ml OA propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 157 Coverage Requirements & Prescription Drug Name Drug Tier Limits propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 1 mg sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 SOTALOL HCL INTRAVENOUS SOLUTION 150 MG/10ML OA sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 TENORMIN ORAL TABLET 100 MG, 25 MG, 50 MG (atenolol) 3 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 25 MG, 50 MG (metoprolol succinate) CLASS III ANTIARRHYTHMICS - Drugs for Angina AMIODARONE HCL IN DEXTROSE INTRAVENOUS OA SOLUTION 450-5 MG/250ML-%, 900-5 MG/500ML-% amiodarone hcl intravenous solution 150 mg/3ml, 450 OA mg/9ml, 900 mg/18ml amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg 1 BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 (sotalol hcl af) BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG (sotalol 3 hcl) BRETYLIUM TOSYLATE INJECTION SOLUTION 50 MG/ML 3 CORVERT INTRAVENOUS SOLUTION 1 MG/10ML (ibutilide OA fumarate) dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg 1 ibutilide fumarate intravenous solution 1 mg/10ml OA MULTAQ ORAL TABLET 400 MG (dronedarone hcl) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 158 Coverage Requirements & Prescription Drug Name Drug Tier Limits NEXTERONE INTRAVENOUS SOLUTION 150-4.21 MG/100ML-%, 360-4.14 MG/200ML-% (amiodarone hcl in OA dextrose) PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG 3 (amiodarone hcl) sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 SOTALOL HCL INTRAVENOUS SOLUTION 150 MG/10ML OA sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG 3 (dofetilide) CLASS IV ANTIARRHYTHMICS - Drugs for Angina adenosine intravenous solution 12 mg/4ml, 6 mg/2ml OA CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 3 180 MG, 240 MG (verapamil hcl) CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG (diltiazem 3 hcl coated beads) CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl coated beads) CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG (diltiazem 3 hcl) cartia xt oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg, 300 mg diltiazem hcl er beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 1 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 159 Coverage Requirements & Prescription Drug Name Drug Tier Limits diltiazem hcl er coated beads oral tablet extended release 1 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 1 mg, 60 mg, 90 mg diltiazem hcl er oral capsule extended release 24 hour 120 1 mg, 180 mg, 240 mg diltiazem hcl intravenous solution 125 mg/25ml, 25 mg/5ml, OA 50 mg/10ml diltiazem hcl intravenous solution reconstituted 100 mg OA diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 DILTIAZEM HCL-DEXTROSE INTRAVENOUS SOLUTION OA 125-5 MG/125ML-% DILTIAZEM HCL-SODIUM CHLORIDE INTRAVENOUS OA SOLUTION 125-0.7 MG/125ML-%, 125-0.9 MG/125ML-% dilt-xr oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg matzim la oral tablet extended release 24 hour 180 mg, 240 1 mg, 300 mg, 360 mg, 420 mg taztia xt oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg, 300 mg, 360 mg tiadylt er oral capsule extended release 24 hour 120 mg, 1 180 mg, 240 mg, 300 mg, 360 mg, 420 mg TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl er beads) verapamil hcl er oral capsule extended release 24 hour 100 1 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg, 180 1 mg, 240 mg verapamil hcl intravenous solution 2.5 mg/ml OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 160 Coverage Requirements & Prescription Drug Name Drug Tier Limits verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) DIHYDROPYRIDINES - Drugs for High Blood Pressure & Angina amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1 amlodipine besylate-benazepril hcl oral capsule 10-20 mg, 1 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 1 ST mg, 5-160 mg, 5-320 mg amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10- 40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 1 5-20 mg, 5-40 mg, 5-80 mg amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 1 ST mg, 5-40 mg amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10- 1 ST 160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-40 3 ST MG (amlodipine-olmesartan) CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10- 80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG (amlodipine- 3 atorvastatin) CARDENE IV INTRAVENOUS SOLUTION 20-0.86 MG/200ML- OA %, 40-0.83 MG/200ML-% (nicardipine hcl in nacl) CARDENE IV INTRAVENOUS SOLUTION 20-4.8 MG/200ML- OA % (nicardipine hcl in dextrose) CLEVIPREX INTRAVENOUS EMULSION 25 MG/50ML, 50 OA MG/100ML (clevidipine)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 161 Coverage Requirements & Prescription Drug Name Drug Tier Limits CONJUPRI ORAL TABLET 2.5 MG, 5 MG (levamlodipine 3 PA maleate) CONSENSI ORAL TABLET 10-200 MG, 2.5-200 MG, 5-200 MG 3 (amlodipine besylate-celecoxib) EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG 3 ST (amlodipine-valsartan-hctz) EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 MG, 3 ST 5-320 MG (amlodipine besylate-valsartan) felodipine er oral tablet extended release 24 hour 10 mg, 2.5 1 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg 1 KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine 3 benzoate) LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5- 3 20 MG (amlodipine besy-benazepril hcl) NICARDIPINE HCL IN NACL INTRAVENOUS SOLUTION 20- OA 0.9 MG/200ML-%, 40-0.9 MG/200ML-% NICARDIPINE HCL IN NACL INTRAVENOUS SOLUTION OA PREFILLED SYRINGE 1-0.9 MG/10ML-% nicardipine hcl intravenous solution 2.5 mg/ml OA nicardipine hcl oral capsule 20 mg, 30 mg 1 nifedipine er oral tablet extended release 24 hour 30 mg, 60 1 mg, 90 mg nifedipine er osmotic release oral tablet extended release 1 24 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg 1 nimodipine oral capsule 30 mg 1 nisoldipine er oral tablet extended release 24 hour 17 mg, 1 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 162 Coverage Requirements & Prescription Drug Name Drug Tier Limits NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG (amlodipine 3 besylate) NYMALIZE ORAL SOLUTION 6 MG/ML (nimodipine) 3 olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10- 1 ST 12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 MG 3 PA (perindopril arg-amlodipine) PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 30 MG, 60 MG, 90 MG (nifedipine) SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 3 MG, 34 MG, 8.5 MG (nisoldipine) telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 1 ST mg, 80-5 mg TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG (olmesartan- 3 ST amlodipine-hctz) TWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 80-10 MG, 80- 3 ST 5 MG (telmisartan-amlodipine) DIHYDROPYRIDINES (ANTIHYPERTENSIVE) - Drugs for High Blood Pressure & Angina amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1 CARDENE IV INTRAVENOUS SOLUTION 20-0.86 MG/200ML- OA %, 40-0.83 MG/200ML-% (nicardipine hcl in nacl) CARDENE IV INTRAVENOUS SOLUTION 20-4.8 MG/200ML- OA % (nicardipine hcl in dextrose) CLEVIPREX INTRAVENOUS EMULSION 25 MG/50ML, 50 OA MG/100ML (clevidipine) CONJUPRI ORAL TABLET 2.5 MG, 5 MG (levamlodipine 3 PA maleate) felodipine er oral tablet extended release 24 hour 10 mg, 2.5 1 mg, 5 mg Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 163 Coverage Requirements & Prescription Drug Name Drug Tier Limits isradipine oral capsule 2.5 mg, 5 mg 1 KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine 3 benzoate) NICARDIPINE HCL IN NACL INTRAVENOUS SOLUTION 20- OA 0.9 MG/200ML-%, 40-0.9 MG/200ML-% NICARDIPINE HCL IN NACL INTRAVENOUS SOLUTION OA PREFILLED SYRINGE 1-0.9 MG/10ML-% nicardipine hcl intravenous solution 2.5 mg/ml OA nicardipine hcl oral capsule 20 mg, 30 mg 1 nifedipine er oral tablet extended release 24 hour 30 mg, 60 1 mg, 90 mg nifedipine er osmotic release oral tablet extended release 1 24 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg 1 nimodipine oral capsule 30 mg 1 nisoldipine er oral tablet extended release 24 hour 17 mg, 1 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG (amlodipine 3 besylate) NYMALIZE ORAL SOLUTION 6 MG/ML (nimodipine) 3 PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 30 MG, 60 MG, 90 MG (nifedipine) SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 3 MG, 34 MG, 8.5 MG (nisoldipine) DIRECT VASODILATORS - Drugs for High Blood Pressure & Angina BIDIL ORAL TABLET 20-37.5 MG (isosorb dinitrate- 3 hydralazine) CORLOPAM INTRAVENOUS SOLUTION 10 MG/ML, 20 OA MG/2ML (fenoldopam mesylate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 164 Coverage Requirements & Prescription Drug Name Drug Tier Limits hydralazine hcl injection solution 20 mg/ml OA hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1 minoxidil oral tablet 10 mg, 2.5 mg 1 NIPRIDE RTU INTRAVENOUS SOLUTION 20-0.9 MG/100ML- OA %, 50-0.9 MG/100ML-% (nitroprusside sodium-nacl) nitroprusside sodium intravenous solution 25 mg/ml OA sodium nitroprusside intravenous solution 25 mg/ml OA DIURETICS, MISCELLANEOUS (HYPOTENSIVE) - Drugs for High Blood Pressure & Angina ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 2 THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 1 mg, 450 mg theophylline er oral tablet extended release 24 hour 400 1 mg, 600 mg theophylline oral solution 80 mg/15ml 1 FIBRIC ACID DERIVATIVES - Drugs for Cholesterol ANTARA ORAL CAPSULE 30 MG, 90 MG (fenofibrate 3 micronized) fenofibrate micronized oral capsule 130 mg, 134 mg, 200 1 mg, 43 mg, 67 mg fenofibrate oral capsule 134 mg, 150 mg, 200 mg, 50 mg, 67 1 mg fenofibrate oral tablet 120 mg, 145 mg, 160 mg, 40 mg, 48 1 mg, 54 mg fenofibric acid oral capsule delayed release 135 mg, 45 mg 1 fenofibric acid oral tablet 105 mg, 35 mg 1 FENOGLIDE ORAL TABLET 120 MG, 40 MG (fenofibrate) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 165 Coverage Requirements & Prescription Drug Name Drug Tier Limits FIBRICOR ORAL TABLET 105 MG, 35 MG (fenofibric acid) 3 gemfibrozil oral tablet 600 mg 1 LIPOFEN ORAL CAPSULE 150 MG, 50 MG (fenofibrate) 3 LOPID ORAL TABLET 600 MG (gemfibrozil) 3 TRICOR ORAL TABLET 145 MG, 48 MG (fenofibrate) 3 TRILIPIX ORAL CAPSULE DELAYED RELEASE 135 MG, 45 3 MG (choline fenofibrate) HMG-COA REDUCTASE INHIBITORS - Drugs for Cholesterol ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HOUR 3 20 MG, 40 MG, 60 MG (lovastatin) amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10- 40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 1 5-20 mg, 5-40 mg, 5-80 mg atorvastatin calcium oral tablet 10 mg, 20 mg 1 PV atorvastatin calcium oral tablet 40 mg, 80 mg 1 CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10- 80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG (amlodipine- 3 atorvastatin) CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG 3 (rosuvastatin calcium) EZALLOR SPRINKLE ORAL CAPSULE SPRINKLE 10 MG, 20 3 MG, 40 MG, 5 MG (rosuvastatin calcium) ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 1 mg, 10-80 mg FLOLIPID ORAL SUSPENSION 20 MG/5ML, 40 MG/5ML 3 fluvastatin sodium er oral tablet extended release 24 hour 1 PV 80 mg fluvastatin sodium oral capsule 20 mg, 40 mg 1 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 166 Coverage Requirements & Prescription Drug Name Drug Tier Limits LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 80 MG (fluvastatin sodium) LIPITOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG 3 (atorvastatin calcium) LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG (pitavastatin 3 calcium) lovastatin oral tablet 10 mg, 20 mg, 40 mg 1 PV pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg 1 PV rosuvastatin calcium oral tablet 10 mg, 5 mg 1 PV rosuvastatin calcium oral tablet 20 mg, 40 mg 1 ROSZET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-5 3 PA MG (ezetimibe-rosuvastatin) simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 PV simvastatin oral tablet 80 mg 1 VYTORIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10- 3 80 MG (ezetimibe-simvastatin) ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG 3 (simvastatin) ZYPITAMAG ORAL TABLET 2 MG, 4 MG (pitavastatin 3 PA magnesium) HYPOTENSIVE AGENTS, MISCELLANEOUS - Drugs for High Blood Pressure & Angina DIBENZYLINE ORAL CAPSULE 10 MG (phenoxybenzamine 3 hcl) phenoxybenzamine hcl oral capsule 10 mg 1 phentolamine mesylate injection solution reconstituted 5 OA mg VECAMYL ORAL TABLET 2.5 MG (mecamylamine hcl) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 167 Coverage Requirements & Prescription Drug Name Drug Tier Limits LOOP DIURETICS (HYPOTENSIVE AGENTS) - Drugs for High Blood Pressure & Angina bumetanide injection solution 0.25 mg/ml OA bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1 BUMEX ORAL TABLET 0.5 MG (bumetanide) 3 EDECRIN ORAL TABLET 25 MG (ethacrynic acid) 3 ethacrynate sodium intravenous solution reconstituted 50 OA mg ethacrynic acid oral tablet 25 mg 1 FUROSEMIDE IN SODIUM CHLORIDE INTRAVENOUS OA SOLUTION 100-0.9 MG/100ML-% furosemide injection solution 10 mg/ml OA furosemide oral solution 10 mg/ml, 8 mg/ml 1 furosemide oral tablet 20 mg, 40 mg, 80 mg 1 LASIX ORAL TABLET 20 MG, 40 MG, 80 MG (furosemide) 3 SODIUM EDECRIN INTRAVENOUS SOLUTION OA RECONSTITUTED 50 MG (ethacrynate sodium) torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1 MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS - Drugs for the Heart ALDACTAZIDE ORAL TABLET 25-25 MG (spironolactone- 3 hctz) ALDACTAZIDE ORAL TABLET 50-50 MG (spironolactone- 2 hctz) ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG 3 (spironolactone) CAROSPIR ORAL SUSPENSION 25 MG/5ML 3 (spironolactone) eplerenone oral tablet 25 mg, 50 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 168 Coverage Requirements & Prescription Drug Name Drug Tier Limits INSPRA ORAL TABLET 25 MG, 50 MG (eplerenone) 3 KERENDIA ORAL TABLET 10 MG, 20 MG (finerenone) 3 PA spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 spironolactone-hctz oral tablet 25-25 mg 1 MINERALOCORTICOID(ALDOSTER.)ANTAG(HYPOT) - Drugs for High Blood Pressure & Angina ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG 3 (spironolactone) CAROSPIR ORAL SUSPENSION 25 MG/5ML 3 (spironolactone) eplerenone oral tablet 25 mg, 50 mg 1 INSPRA ORAL TABLET 25 MG, 50 MG (eplerenone) 3 spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 NITRATES AND NITRITES - Drugs for the Heart BIDIL ORAL TABLET 20-37.5 MG (isosorb dinitrate- 3 hydralazine) GONITRO SUBLINGUAL PACKET 400 MCG (nitroglycerin) 3 ISORDIL TITRADOSE ORAL TABLET 40 MG, 5 MG 3 (isosorbide dinitrate) isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 40 mg, 1 5 mg isosorbide mononitrate er oral tablet extended release 24 1 hour 120 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, 20 mg 1 minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 1 0.4 mg/hr, 0.6 mg/hr NITRO-BID TRANSDERMAL OINTMENT 2 % (nitroglycerin) 3 NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 3 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR (nitroglycerin)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 169 Coverage Requirements & Prescription Drug Name Drug Tier Limits NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 2 0.8 MG/HR (nitroglycerin) nitroglycerin in d5w intravenous solution 100-5 mcg/ml-%, OA 200-5 mcg/ml-%, 400-5 mcg/ml-% nitroglycerin intravenous solution 5 mg/ml OA nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 1 0.6 mg nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 1 mg/hr, 0.4 mg/hr, 0.6 mg/hr nitroglycerin translingual solution 0.4 mg/spray 1 NITROLINGUAL TRANSLINGUAL SOLUTION 0.4 MG/SPRAY 3 (nitroglycerin) NITROMIST TRANSLINGUAL AEROSOL SOLUTION 400 3 MCG/SPRAY (nitroglycerin) NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 3 0.4 MG, 0.6 MG (nitroglycerin) NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 2.5 MG, 3 6.5 MG, 9 MG (nitroglycerin) OSMOTIC DIURETICS (HYPOTENSIVE AGENTS) - Drugs for High Blood Pressure & Angina mannitol intravenous solution 20 %, 25 % OA OSMITROL INTRAVENOUS SOLUTION 10 %, 15 %, 20 % OA (mannitol) PCSK9 INHIBITORS - Drugs for Cholesterol PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; QL (30 day supply per 1 SI 150 MG/ML, 75 MG/ML (alirocumab) fill) REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS PA; QL (30 day supply per 1 SI SOLUTION CARTRIDGE 420 MG/3.5ML (evolocumab) fill) REPATHA SUBCUTANEOUS SOLUTION PREFILLED PA; QL (30 day supply per 1 SI SYRINGE 140 MG/ML (evolocumab) fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 170 Coverage Requirements & Prescription Drug Name Drug Tier Limits REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO- PA; QL (30 day supply per 1 SI INJECTOR 140 MG/ML (evolocumab) fill) PHOSPHODIESTERASE TYPE 5 INHIBITORS - Drugs for the Heart PA; SP; QL (30 day supply ADCIRCA ORAL TABLET 20 MG (tadalafil (pah)) 3 per 1 fill) PA; SP; QL (30 day supply alyq oral tablet 20 mg 1 per 1 fill) CIALIS ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG ED QL (0.27 EA per 1 day) (tadalafil) cilostazol oral tablet 100 mg, 50 mg 1 REVATIO INTRAVENOUS SOLUTION 10 MG/12.5ML OA QL (30 day supply per 1 fill) (sildenafil citrate) REVATIO ORAL SUSPENSION RECONSTITUTED 10 MG/ML PA; SP; QL (30 day supply 3 (sildenafil citrate) per 1 fill) PA; SP; QL (30 day supply REVATIO ORAL TABLET 20 MG (sildenafil citrate) 3 per 1 fill) sildenafil citrate intravenous solution 10 mg/12.5ml OA QL (30 day supply per 1 fill) PA; SP; QL (30 day supply sildenafil citrate oral suspension reconstituted 10 mg/ml 1 per 1 fill) sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg ED QL (0.27 EA per 1 day) PA; SP; QL (30 day supply sildenafil citrate oral tablet 20 mg 1 per 1 fill) STENDRA ORAL TABLET 100 MG, 200 MG, 50 MG (avanafil) ED QL (0.27 EA per 1 day) PA; SP; QL (30 day supply tadalafil (pah) oral tablet 20 mg 1 per 1 fill) tadalafil oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg ED QL (0.27 EA per 1 day) vardenafil hcl oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg ED QL (0.27 EA per 1 day) vardenafil hcl oral tablet dispersible 10 mg ED QL (0.27 EA per 1 day)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 171 Coverage Requirements & Prescription Drug Name Drug Tier Limits VIAGRA ORAL TABLET 100 MG, 25 MG, 50 MG (sildenafil ED QL (0.27 EA per 1 day) citrate) POTASSIUM-SPARING DIURETICS (HYPOTEN) - Drugs for High Blood Pressure & Angina ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG 3 (spironolactone) amiloride hcl oral tablet 5 mg 1 CAROSPIR ORAL SUSPENSION 25 MG/5ML 3 (spironolactone) DYRENIUM ORAL CAPSULE 100 MG, 50 MG (triamterene) 3 eplerenone oral tablet 25 mg, 50 mg 1 INSPRA ORAL TABLET 25 MG, 50 MG (eplerenone) 3 spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 triamterene oral capsule 100 mg, 50 mg 1 RENIN INHIBITORS - Drugs for the Heart aliskiren fumarate oral tablet 150 mg, 300 mg 1 TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 3 300-12.5 MG, 300-25 MG (aliskiren-hydrochlorothiazide) TEKTURNA ORAL TABLET 150 MG, 300 MG (aliskiren 3 fumarate) RENIN-ANGIOTEN.-ALDOST. SYS. INHIB, MISC - Drugs for the Heart ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG 3 PA (sacubitril-valsartan) SCLEROSING AGENTS - Drugs for Varicose Veins ABLYSINOL INTRA-ARTERIAL SOLUTION (dehydrated OA alcohol) ASCLERA INTRAVENOUS SOLUTION 0.5 %, 1 % OA (polidocanol)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 172 Coverage Requirements & Prescription Drug Name Drug Tier Limits ETHAMOLIN INTRAVENOUS SOLUTION 5 % (ethanolamine OA oleate) POLIDOCANOL INTRAVENOUS SOLUTION 5 % OA SCLEROSOL INTRAPLEURAL INTRAPLEURAL AEROSOL 3 POWDER 4 GM (talc) sodium tetradecyl sulfate intravenous solution 3 % OA SOTRADECOL INTRAVENOUS SOLUTION 1 %, 3 % (sodium OA tetradecyl sulfate) STERILE TALC POWDER INTRAPLEURAL SUSPENSION 3 RECONSTITUTED 5 GM (talc) STERITALC INTRAPLEURAL POWDER 2 GM, 3 GM, 4 GM 3 (talc) VARITHENA INTRAVENOUS FOAM 180 MG/18ML OA (polidocanol) THIAZIDE DIURETICS(HYPOTENSIVE AGENTS) - Drugs for High Blood Pressure & Angina chlorothiazide sodium intravenous solution reconstituted OA 500 mg DIURIL ORAL SUSPENSION 250 MG/5ML (chlorothiazide) 2 hydrochlorothiazide oral capsule 12.5 mg 1 hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg 1 SODIUM DIURIL INTRAVENOUS SOLUTION OA RECONSTITUTED 500 MG (chlorothiazide sodium) THIAZIDE-LIKE DIURETICS(HYPOTENSIVE AGT) - Drugs for High Blood Pressure & Angina chlorthalidone oral tablet 25 mg, 50 mg 1 indapamide oral tablet 1.25 mg, 2.5 mg 1 metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 173 Coverage Requirements & Prescription Drug Name Drug Tier Limits VASODILATING AGENTS, MISCELLANEOUS - Drugs for the Heart alprostadil injection solution 500 mcg/ml OA amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1 BI-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED ED PA 150-5 MG CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 3 180 MG, 240 MG (verapamil hcl) CARDENE IV INTRAVENOUS SOLUTION 20-0.86 MG/200ML- OA %, 40-0.83 MG/200ML-% (nicardipine hcl in nacl) CARDENE IV INTRAVENOUS SOLUTION 20-4.8 MG/200ML- OA % (nicardipine hcl in dextrose) CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG (diltiazem 3 hcl coated beads) CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl coated beads) CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG (diltiazem 3 hcl) cartia xt oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg, 300 mg CAVERJECT IMPULSE INTRACAVERNOSAL KIT 10 MCG, 20 ED PA; QL (0.27 EA per 1 day) MCG (alprostadil (vasodilator)) CAVERJECT INTRACAVERNOSAL SOLUTION ED PA; QL (0.27 EA per 1 day) RECONSTITUTED 40 MCG (alprostadil (vasodilator)) CONJUPRI ORAL TABLET 2.5 MG, 5 MG (levamlodipine 3 PA maleate) CORLANOR ORAL SOLUTION 5 MG/5ML (ivabradine hcl) 3 CORLANOR ORAL TABLET 5 MG, 7.5 MG (ivabradine hcl) 2

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 174 Coverage Requirements & Prescription Drug Name Drug Tier Limits diltiazem hcl er beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 1 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 1 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 1 mg, 60 mg, 90 mg diltiazem hcl er oral capsule extended release 24 hour 120 1 mg, 180 mg, 240 mg diltiazem hcl intravenous solution 125 mg/25ml, 25 mg/5ml, OA 50 mg/10ml diltiazem hcl intravenous solution reconstituted 100 mg OA diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 DILTIAZEM HCL-DEXTROSE INTRAVENOUS SOLUTION OA 125-5 MG/125ML-% DILTIAZEM HCL-SODIUM CHLORIDE INTRAVENOUS OA SOLUTION 125-0.7 MG/125ML-%, 125-0.9 MG/125ML-% dilt-xr oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg dipyridamole intravenous solution 5 mg/ml OA dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1 EDEX INTRACAVERNOSAL KIT 10 MCG, 20 MCG, 40 MCG ED PA; QL (0.27 EA per 1 day) (alprostadil (vasodilator)) isoxsuprine hcl oral tablet 10 mg, 20 mg 1 KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine 3 benzoate) matzim la oral tablet extended release 24 hour 180 mg, 240 1 mg, 300 mg, 360 mg, 420 mg

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 175 Coverage Requirements & Prescription Drug Name Drug Tier Limits MUSE URETHRAL PELLET 1000 MCG, 250 MCG, 500 MCG ED QL (0.27 EA per 1 day) (alprostadil (vasodilator)) NICARDIPINE HCL IN NACL INTRAVENOUS SOLUTION 20- OA 0.9 MG/200ML-%, 40-0.9 MG/200ML-% NICARDIPINE HCL IN NACL INTRAVENOUS SOLUTION OA PREFILLED SYRINGE 1-0.9 MG/10ML-% nicardipine hcl intravenous solution 2.5 mg/ml OA nicardipine hcl oral capsule 20 mg, 30 mg 1 nifedipine er oral tablet extended release 24 hour 30 mg, 60 1 mg, 90 mg nifedipine er osmotic release oral tablet extended release 1 24 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg 1 nimodipine oral capsule 30 mg 1 NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG (amlodipine 3 besylate) NYMALIZE ORAL SOLUTION 6 MG/ML (nimodipine) 3 papaverine hcl injection solution 30 mg/ml OA PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 30 MG, 60 MG, 90 MG (nifedipine) PROSTIN VR INJECTION SOLUTION 500 MCG/ML OA (alprostadil) QUAD-MIX INTRACAVERNOSAL SOLUTION ED RECONSTITUTED 150-10-0.1-1 MG SUPER BI-MIX INTRACAVERNOSAL SOLUTION ED PA RECONSTITUTED 150-10 MG SUPER QUAD-MIX INTRACAVERNOSAL SOLUTION ED RECONSTITUTED 150-20-0.2-2 MG SUPER TRI-MIX INTRACAVERNOSAL SOLUTION ED PA RECONSTITUTED 150-10-100 MG-MG-MCG

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 176 Coverage Requirements & Prescription Drug Name Drug Tier Limits taztia xt oral capsule extended release 24 hour 120 mg, 180 1 mg, 240 mg, 300 mg, 360 mg tiadylt er oral capsule extended release 24 hour 120 mg, 1 180 mg, 240 mg, 300 mg, 360 mg, 420 mg TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl er beads) TRI-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED ED PA 150-5-50 MG-MG-MCG verapamil hcl er oral capsule extended release 24 hour 100 1 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg, 180 1 mg, 240 mg verapamil hcl intravenous solution 2.5 mg/ml OA verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) VERQUVO ORAL TABLET 10 MG, 2.5 MG, 5 MG (vericiguat) 3 PA CELLULAR AND GENE THERAPY - Drugs for Cancer CELLULAR THERAPY - Drugs for Cancer PROVENGE INTRAVENOUS SUSPENSION (sipuleucel-t) OA QL (30 day supply per 1 fill) GENE THERAPY - Drugs for Cancer ABECMA INTRAVENOUS SUSPENSION (idecabtagene OA vicleucel) BREYANZI INTRAVENOUS SUSPENSION (lisocabtagene OA maraleucel) KYMRIAH INTRAVENOUS SUSPENSION (tisagenlecleucel) OA QL (30 day supply per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 177 Coverage Requirements & Prescription Drug Name Drug Tier Limits LUXTURNA INTRAOCULAR SUSPENSION 5000000000000 OA QL (30 day supply per 1 fill) VG/ML (voretigene neparvovec-rzyl) TECARTUS INTRAVENOUS SUSPENSION (brexucabtagene OA PA; SP autoleucel) YESCARTA INTRAVENOUS SUSPENSION (axicabtagene OA QL (30 day supply per 1 fill) ciloleucel) ZOLGENSMA INTRAVENOUS KIT 1X5.5ML & 2X8.3ML, 1X5.5ML & 3X8.3ML, 1X5.5ML & 4X8.3ML, 1X5.5ML & 5X8.3ML, 1X5.5ML & 6X8.3ML, 1X5.5ML & 7X8.3ML, 1X5.5ML & 8X8.3ML, 2X5.5ML & 1X8.3ML, 2X5.5ML & 2X8.3ML, OA 2X5.5ML & 3X8.3ML, 2X5.5ML & 4X8.3ML, 2X5.5ML & 5X8.3ML, 2X5.5ML & 6X8.3ML, 2X5.5ML & 7X8.3ML, 2X8.3 ML, 3X8.3 ML, 4X8.3 ML, 5X8.3 ML, 6X8.3 ML, 7X8.3 ML, 8X8.3 ML, 9X8.3 ML (onasemnogene abeparvovec-xioi) CENTRAL NERVOUS SYSTEM AGENTS - Drugs for the Nervous System ADAMANTANES (CNS) - Drugs for Parkinson amantadine hcl oral capsule 100 mg 1 amantadine hcl oral syrup 50 mg/5ml 1 amantadine hcl oral tablet 100 mg 1 GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR PA; SP; QL (30 day supply 3 137 MG, 68.5 MG (amantadine hcl) per 1 fill) OSMOLEX ER ORAL TABLET ER 24 HOUR THERAPY PACK 3 PA 129 & 193 MG (amantadine hcl) OSMOLEX ER ORAL TABLET EXTENDED RELEASE 24 3 PA HOUR 129 MG, 193 MG, 258 MG (amantadine hcl) AMPHETAMINE DERIVATIVES - Drugs for the Nervous System ADIPEX-P ORAL TABLET 37.5 MG (phentermine hcl) 3 PA phentermine hcl oral tablet 37.5 mg 3 PA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 178 Coverage Requirements & Prescription Drug Name Drug Tier Limits AMPHETAMINES - Drugs for the Nervous System ADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 3 30 MG, 5 MG, 7.5 MG (amphetamine-dextroamphetamine) ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG 3 ST; AL (Min 6 Years) (amphetamine-dextroamphetamine) ADZENYS ER ORAL SUSPENSION EXTENDED RELEASE 3 ST; AL (Min 6 Years) 1.25 MG/ML (amphetamine) ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 12.5 MG, 15.7 MG, 18.8 MG, 3.1 MG, 6.3 MG, 3 ST; AL (Min 6 Years) 9.4 MG (amphetamine) AMPHETAMINE ER ORAL SUSPENSION EXTENDED 3 ST; AL (Min 6 Years) RELEASE 1.25 MG/ML amphetamine-dextroamphetamine er oral capsule extended 1 AL (Min 6 Years) release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 1 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg DESOXYN ORAL TABLET 5 MG (methamphetamine hcl) 3 DEXEDRINE ORAL CAPSULE EXTENDED RELEASE 24 3 ST; AL (Min 6 Years) HOUR 10 MG, 15 MG, 5 MG (dextroamphetamine sulfate) dextroamphetamine sulfate er oral capsule extended 1 AL (Min 6 Years) release 24 hour 10 mg, 15 mg, 5 mg dextroamphetamine sulfate oral solution 5 mg/5ml 1 dextroamphetamine sulfate oral tablet 10 mg, 15 mg, 20 mg, 1 30 mg, 5 mg DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE 3 ST; AL (Min 6 Years) 2.5 MG/ML (amphetamine) EVEKEO ODT ORAL TABLET DISPERSIBLE 10 MG, 15 MG, 3 PA 20 MG, 5 MG (amphetamine sulfate) EVEKEO ORAL TABLET 10 MG, 5 MG (amphetamine sulfate) 3 PA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 179 Coverage Requirements & Prescription Drug Name Drug Tier Limits methamphetamine hcl oral tablet 5 mg 1 MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 12.5 MG, 25 MG, 37.5 MG, 50 MG (amphetamine- 3 ST; AL (Min 6 Years) dextroamphetamine) PROCENTRA ORAL SOLUTION 5 MG/5ML 3 (dextroamphetamine sulfate) VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 3 ST; AL (Min 6 Years) MG, 60 MG, 70 MG (lisdexamfetamine dimesylate) VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, 30 MG, 3 ST; AL (Min 6 Years) 40 MG, 50 MG, 60 MG (lisdexamfetamine dimesylate) ZENZEDI ORAL TABLET 10 MG, 15 MG, 20 MG, 30 MG, 5 MG 3 (dextroamphetamine sulfate) ZENZEDI ORAL TABLET 2.5 MG, 7.5 MG 2 (dextroamphetamine sulfate) ANALGESICS AND ANTIPYRETICS, MISC. - Drugs for Pain acetaminophen intravenous solution 10 mg/ml, 1000 OA mg/100ml ACETAMINOPHEN INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 100 MG/10ML acetaminophen-codeine #2 oral tablet 300-15 mg 1 acetaminophen-codeine #3 oral tablet 300-30 mg 1 acetaminophen-codeine #4 oral tablet 300-60 mg 1 acetaminophen-codeine oral solution 120-12 mg/5ml 1 acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 1 300-60 mg ALLZITAL ORAL TABLET 25-325 MG (butalbital- 3 acetaminophen) apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg 1 apap-caff-dihydrocodeine oral tablet 325-30-16 mg 1 bac oral tablet 50-325-40 mg 1 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 180 Coverage Requirements & Prescription Drug Name Drug Tier Limits BUPAP ORAL TABLET 50-300 MG (butalbital- 3 acetaminophen) butalbital-acetaminophen capsule 50-300 mg oral 50-300 1 mg BUTALBITAL-ACETAMINOPHEN CAPSULE 50-300 MG ORAL 1 50-300 MG butalbital-acetaminophen oral tablet 25-325 mg, 50-300 mg, 1 50-325 mg butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50- 1 325-40-30 mg butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325- 1 40 mg butalbital-apap-caffeine oral tablet 50-325-40 mg 1 endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5- 1 325 mg ESGIC ORAL CAPSULE 50-325-40 MG (butalbital-apap- 3 caffeine) ESGIC ORAL TABLET 50-325-40 MG (butalbital-apap- 3 caffeine) FIORICET ORAL CAPSULE 50-300-40 MG (butalbital-apap- 3 caffeine) FIORICET/CODEINE ORAL CAPSULE 50-300-40-30 MG 3 (butalbital-apap-caff-cod) gabapentin oral capsule 100 mg, 300 mg, 400 mg 1 gabapentin oral solution 250 mg/5ml, 300 mg/6ml 1 gabapentin oral tablet 600 mg, 800 mg 1 GRALISE ORAL 300 (9) & 600(24) MG (gabapentin (once- 3 daily)) GRALISE ORAL TABLET 300 MG, 600 MG (gabapentin 3 (once-daily))

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 181 Coverage Requirements & Prescription Drug Name Drug Tier Limits hydrocodone-acetaminophen oral solution 10-325 mg/15ml, 1 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 1 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg ILARIS SUBCUTANEOUS SOLUTION 150 MG/ML PA; SP; QL (30 day supply SI (canakinumab) per 1 fill) LORTAB ORAL ELIXIR 10-300 MG/15ML (hydrocodone- 3 acetaminophen) LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 165 MG, 330 MG, 82.5 MG (pregabalin) NALOCET ORAL TABLET 2.5-300 MG 2 NEURONTIN ORAL CAPSULE 100 MG, 300 MG, 400 MG 3 (gabapentin) NEURONTIN ORAL SOLUTION 250 MG/5ML (gabapentin) 3 NEURONTIN ORAL TABLET 600 MG, 800 MG (gabapentin) 3 OXYCODONE-ACETAMINOPHEN ORAL SOLUTION 10-300 3 PA MG/5ML OXYCODONE-ACETAMINOPHEN ORAL TABLET 10-300 MG, 2 2.5-300 MG, 5-300 MG oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 1 mg, 5-325 mg, 7.5-325 mg PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 3 MG, 7.5-325 MG (oxycodone-acetaminophen) PHOSPHASAL ORAL TABLET 81.6 MG (meth-hyo-m bl-na 3 phos-ph sal) pregabalin er oral tablet extended release 24 hour 165 mg, 1 330 mg, 82.5 mg PRIALT INTRATHECAL SOLUTION 100 MCG/ML, 500 OA MCG/20ML, 500 MCG/5ML (ziconotide acetate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 182 Coverage Requirements & Prescription Drug Name Drug Tier Limits PROLATE ORAL SOLUTION 10-300 MG/5ML (oxycodone- 3 PA acetaminophen) PROLATE ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 MG 2 (oxycodone-acetaminophen) TENCON ORAL TABLET 50-325 MG (butalbital- 3 acetaminophen) tramadol-acetaminophen oral tablet 37.5-325 mg 1 TREZIX ORAL CAPSULE 320.5-30-16 MG (apap-caff- 3 dihydrocodeine) ULTRACET ORAL TABLET 37.5-325 MG (tramadol- 3 acetaminophen) URIMAR-T ORAL TABLET 120 MG (meth-hyo-m bl-na phos- 3 ph sal) urin ds oral tablet 81.6 mg 1 USTELL ORAL CAPSULE 120 MG (meth-hyo-m bl-na phos- 3 ph sal) UTIRA-C ORAL TABLET 81.6 MG (meth-hyo-m bl-na phos- 3 ph sal) VTOL LQ ORAL SOLUTION 50-325-40 MG/15ML (butalbital- 2 apap-caffeine) ZEBUTAL ORAL CAPSULE 50-325-40 MG (butalbital-apap- 3 caffeine) ANOREXIGENIC AGENTS AND STIMULANTS, MISC - Drugs for the Nervous System QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 11.25-69 MG, 15-92 MG, 3.75-23 MG, 7.5-46 MG 3 PA; QL (1 EA per 1 day) (phentermine-topiramate) ANOREXIGENIC AGENTS, MISCELLANEOUS - Drugs for the Nervous System CONTRAVE ORAL TABLET EXTENDED RELEASE 12 HOUR 3 PA; QL (4 EA per 1 day) 8-90 MG (naltrexone-bupropion hcl) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 183 Coverage Requirements & Prescription Drug Name Drug Tier Limits IMCIVREE SUBCUTANEOUS SOLUTION 10 MG/ML PA; SP; QL (30 day supply SI (setmelanotide acetate) per 1 fill) ANTICHOLINERGIC AGENTS (CNS) - Drugs for Parkinson benztropine mesylate injection solution 1 mg/ml OA benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg 1 COGENTIN INJECTION SOLUTION 1 MG/ML (benztropine OA mesylate) diphen oral elixir 12.5 mg/5ml 1 di-phen oral elixir 12.5 mg/5ml 1 diphenhydramine hcl injection solution 50 mg/ml 1 PA diphenhydramine hcl oral elixir 12.5 mg/5ml 1 orphenadrine citrate er oral tablet extended release 12 hour 1 100 mg orphenadrine citrate injection solution 30 mg/ml OA trihexyphenidyl hcl oral solution 0.4 mg/ml 1 trihexyphenidyl hcl oral tablet 2 mg, 5 mg 1 ANTICONVULSANTS, MISCELLANEOUS - Drugs for Seizures acetazolamide er oral capsule extended release 12 hour 500 1 mg acetazolamide oral tablet 125 mg, 250 mg 1 acetazolamide sodium injection solution reconstituted 500 OA mg APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG 3 PA (eslicarbazepine acetate) BANZEL ORAL SUSPENSION 40 MG/ML (rufinamide) 3 PA BANZEL ORAL TABLET 200 MG, 400 MG (rufinamide) 3 PA BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML OA (brivaracetam)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 184 Coverage Requirements & Prescription Drug Name Drug Tier Limits BRIVIACT ORAL SOLUTION 10 MG/ML (brivaracetam) 3 BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 3 MG (brivaracetam) carbamazepine er oral capsule extended release 12 hour 1 100 mg, 200 mg, 300 mg carbamazepine er oral tablet extended release 12 hour 100 1 mg, 200 mg, 400 mg carbamazepine oral suspension 100 mg/5ml 1 carbamazepine oral tablet 200 mg 1 carbamazepine oral tablet chewable 100 mg 1 CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 3 HOUR 100 MG, 200 MG, 300 MG (carbamazepine) DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 3 HOUR 250 MG, 500 MG (divalproex sodium) DEPAKOTE ORAL TABLET DELAYED RELEASE 125 MG, 250 3 MG, 500 MG (divalproex sodium) DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED 3 RELEASE SPRINKLE 125 MG (divalproex sodium) DIACOMIT ORAL CAPSULE 250 MG, 500 MG (stiripentol) 3 PA DIACOMIT ORAL PACKET 250 MG, 500 MG (stiripentol) 3 PA divalproex sodium er oral tablet extended release 24 hour 1 250 mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 1 125 mg divalproex sodium oral tablet delayed release 125 mg, 250 1 mg, 500 mg ELEPSIA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 PA 1000 MG, 1500 MG (levetiracetam) PA; SP; QL (30 day supply EPIDIOLEX ORAL SOLUTION 100 MG/ML (cannabidiol) 3 per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 185 Coverage Requirements & Prescription Drug Name Drug Tier Limits epitol oral tablet 200 mg 1 EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 3 100 MG, 200 MG, 300 MG (carbamazepine (antipsychotic)) felbamate oral suspension 600 mg/5ml 1 felbamate oral tablet 400 mg, 600 mg 1 FELBATOL ORAL SUSPENSION 600 MG/5ML (felbamate) 3 FELBATOL ORAL TABLET 400 MG, 600 MG (felbamate) 3 PA; SP; QL (30 day supply FINTEPLA ORAL SOLUTION 2.2 MG/ML (fenfluramine hcl) 3 per 1 fill) FYCOMPA ORAL SUSPENSION 0.5 MG/ML (perampanel) 3 FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 2 8 MG (perampanel) gabapentin oral capsule 100 mg, 300 mg, 400 mg 1 gabapentin oral solution 250 mg/5ml, 300 mg/6ml 1 gabapentin oral tablet 600 mg, 800 mg 1 GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG 3 (tiagabine hcl) GRALISE ORAL 300 (9) & 600(24) MG (gabapentin (once- 3 daily)) GRALISE ORAL TABLET 300 MG, 600 MG (gabapentin 3 (once-daily)) HORIZANT ORAL TABLET EXTENDED RELEASE 300 MG, 3 600 MG (gabapentin enacarbil) KEPPRA INTRAVENOUS SOLUTION 500 MG/5ML OA (levetiracetam) KEPPRA ORAL SOLUTION 100 MG/ML (levetiracetam) 3 KEPPRA ORAL TABLET 1000 MG, 250 MG, 500 MG, 750 MG 3 (levetiracetam)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 186 Coverage Requirements & Prescription Drug Name Drug Tier Limits KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 500 MG, 750 MG (levetiracetam) LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 3 & 100 MG, 42 X 50 MG & 14X100 MG (lamotrigine) LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 MG, 200 3 MG, 25 MG, 50 MG (lamotrigine) LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG 3 (lamotrigine) LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG 3 (lamotrigine) LAMICTAL STARTER ORAL KIT 35 X 25 MG, 42 X 25 MG & 7 3 X 100 MG, 84 X 25 MG & 14X100 MG (lamotrigine) LAMICTAL XR ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 & 3 100 MG, 50 & 100 & 200 MG (lamotrigine) LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG 3 (lamotrigine) lamotrigine er oral tablet extended release 24 hour 100 mg, 1 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral kit 25 & 50 & 100 mg 1 lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1 lamotrigine oral tablet chewable 25 mg, 5 mg 1 lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 1 50 mg lamotrigine starter kit-blue oral kit 35 x 25 mg 1 lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 1 mg lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 1 mg

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 187 Coverage Requirements & Prescription Drug Name Drug Tier Limits levetiracetam er oral tablet extended release 24 hour 500 1 mg, 750 mg levetiracetam in nacl intravenous solution 1000 mg/100ml, OA 1500 mg/100ml, 500 mg/100ml levetiracetam intravenous solution 500 mg/5ml OA levetiracetam oral solution 100 mg/ml 1 levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg 1 LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 3 25 MG, 300 MG, 50 MG, 75 MG (pregabalin) LYRICA ORAL SOLUTION 20 MG/ML (pregabalin) 3 magnesium sulfate intravenous solution 2 gm/50ml, 20 OA gm/500ml, 4 gm/100ml, 4 gm/50ml, 40 gm/1000ml MAGNESIUM SULFATE SOLUTION 50 % INJECTION 50 % OA magnesium sulfate solution 50 % injection 50 % OA NEURONTIN ORAL CAPSULE 100 MG, 300 MG, 400 MG 3 (gabapentin) NEURONTIN ORAL SOLUTION 250 MG/5ML (gabapentin) 3 NEURONTIN ORAL TABLET 600 MG, 800 MG (gabapentin) 3 oxcarbazepine oral suspension 300 mg/5ml 1 oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg 1 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 3 HOUR 150 MG, 300 MG, 600 MG (oxcarbazepine) pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 1 25 mg, 300 mg, 50 mg, 75 mg pregabalin oral solution 20 mg/ml 1 QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 100 3 MG, 150 MG, 200 MG, 25 MG, 50 MG (topiramate) roweepra oral tablet 500 mg 1 rufinamide oral suspension 40 mg/ml 1 PA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 188 Coverage Requirements & Prescription Drug Name Drug Tier Limits rufinamide oral tablet 200 mg, 400 mg 1 PA PA; SP; QL (30 day supply SABRIL ORAL PACKET 500 MG (vigabatrin) 3 per 1 fill) PA; SP; QL (30 day supply SABRIL ORAL TABLET 500 MG (vigabatrin) 3 per 1 fill) SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 3 MG, 250 MG, 500 MG, 750 MG (levetiracetam) subvenite oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1 subvenite starter kit-blue oral kit 35 x 25 mg 1 subvenite starter kit-green oral kit 84 x 25 mg & 14x100 mg 1 subvenite starter kit-orange oral kit 42 x 25 mg & 7 x 100 1 mg TEGRETOL ORAL SUSPENSION 100 MG/5ML 3 (carbamazepine) TEGRETOL ORAL TABLET 200 MG (carbamazepine) 3 TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 3 HOUR 100 MG, 200 MG, 400 MG (carbamazepine) tiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg 1 TOPAMAX ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG 3 (topiramate) TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE 15 MG, 25 3 MG (topiramate) topiramate er oral capsule er 24 hour sprinkle 100 mg, 150 1 mg, 200 mg, 25 mg, 50 mg topiramate oral capsule sprinkle 15 mg, 25 mg 1 topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 TRILEPTAL ORAL SUSPENSION 300 MG/5ML 3 (oxcarbazepine) TRILEPTAL ORAL TABLET 150 MG, 300 MG, 600 MG 3 (oxcarbazepine) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 189 Coverage Requirements & Prescription Drug Name Drug Tier Limits TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 25 MG, 50 MG (topiramate) valproate sodium intravenous solution 100 mg/ml, 500 OA mg/5ml valproic acid oral capsule 250 mg 1 valproic acid oral solution 250 mg/5ml 1 PA; SP; QL (30 day supply vigabatrin oral packet 500 mg 1 per 1 fill) PA; SP; QL (30 day supply vigabatrin oral tablet 500 mg 1 per 1 fill) PA; SP; QL (30 day supply vigadrone oral packet 500 mg 1 per 1 fill) VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML OA (lacosamide) VIMPAT ORAL SOLUTION 10 MG/ML (lacosamide) 3 VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 3 (lacosamide) XCOPRI ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG PA; QL (2 EA per 1 day); AL 3 (cenobamate) (Min 18 Years) XCOPRI ORAL TABLET THERAPY PACK 100 & 150 MG, 14 X PA; QL (2 EA per 1 day); AL 12.5 MG & 14 X 25 MG, 14 X 150 MG & 14 X200 MG, 14 X 50 3 (Min 18 Years) MG & 14 X100 MG, 150 & 200 MG (cenobamate) ZONEGRAN ORAL CAPSULE 100 MG, 25 MG (zonisamide) 3 zonisamide oral capsule 100 mg, 25 mg, 50 mg 1 ANTIDEPRESSANTS, MISCELLANEOUS - Drugs for Depression & Psychosis APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR 3 174 MG, 348 MG, 522 MG (bupropion hbr) bupropion hcl er (smoking det) oral tablet extended release 1 PV; QL (2 EA per 1 day) 12 hour 150 mg

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 190 Coverage Requirements & Prescription Drug Name Drug Tier Limits bupropion hcl er (sr) oral tablet extended release 12 hour 1 100 mg, 150 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hour 1 150 mg, 300 mg BUPROPION HCL ER (XL) ORAL TABLET EXTENDED 2 RELEASE 24 HOUR 450 MG bupropion hcl oral tablet 100 mg, 75 mg 1 FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HOUR 2 450 MG (bupropion hcl) mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg 1 mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg 1 REMERON ORAL TABLET 15 MG, 30 MG (mirtazapine) 3 REMERON SOLTAB ORAL TABLET DISPERSIBLE 15 MG, 30 3 MG, 45 MG (mirtazapine) SPRAVATO (56 MG DOSE) NASAL SOLUTION THERAPY PA; SP; QL (30 day supply OA PACK 28 MG/DEVICE (esketamine hcl) per 1 fill) SPRAVATO (84 MG DOSE) NASAL SOLUTION THERAPY PA; SP; QL (30 day supply OA PACK 28 MG/DEVICE (esketamine hcl) per 1 fill) WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 12 3 HOUR 100 MG, 150 MG, 200 MG (bupropion hcl) WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 150 MG, 300 MG (bupropion hcl) ZULRESSO INTRAVENOUS SOLUTION 100 MG/20ML OA (brexanolone) ANTIMANIC AGENTS - Drugs for Personality Disorder ABILIFY MAINTENA INTRAMUSCULAR PREFILLED PA; QL (30 day supply per 1 SI SYRINGE 300 MG, 400 MG (aripiprazole) fill) ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION PA; QL (30 day supply per 1 SI RECONSTITUTED ER 300 MG, 400 MG (aripiprazole) fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 191 Coverage Requirements & Prescription Drug Name Drug Tier Limits ABILIFY MYCITE MAINTENANCE KIT ORAL TABLET 10 MG, 3 15 MG, 2 MG, 20 MG, 30 MG, 5 MG (aripiprazole) ABILIFY MYCITE ORAL TABLET 10 MG, 15 MG, 2 MG, 20 3 QL (1 EA per 1 day) MG, 30 MG, 5 MG (aripiprazole) ABILIFY MYCITE STARTER KIT ORAL TABLET 10 MG, 15 3 QL (2 fill per 365 days) MG, 2 MG, 20 MG, 30 MG, 5 MG (aripiprazole) ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 3 5 MG (aripiprazole) aripiprazole oral solution 1 mg/ml 1 aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 1 mg aripiprazole oral tablet dispersible 10 mg, 15 mg 1 asenapine maleate sublingual tablet sublingual 10 mg, 2.5 1 mg, 5 mg carbamazepine er oral capsule extended release 12 hour 1 100 mg, 200 mg, 300 mg carbamazepine er oral tablet extended release 12 hour 100 1 mg, 200 mg, 400 mg carbamazepine oral suspension 100 mg/5ml 1 carbamazepine oral tablet 200 mg 1 carbamazepine oral tablet chewable 100 mg 1 CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 3 HOUR 100 MG, 200 MG, 300 MG (carbamazepine) DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 3 HOUR 250 MG, 500 MG (divalproex sodium) DEPAKOTE ORAL TABLET DELAYED RELEASE 125 MG, 250 3 MG, 500 MG (divalproex sodium) DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED 3 RELEASE SPRINKLE 125 MG (divalproex sodium)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 192 Coverage Requirements & Prescription Drug Name Drug Tier Limits divalproex sodium er oral tablet extended release 24 hour 1 250 mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 1 125 mg divalproex sodium oral tablet delayed release 125 mg, 250 1 mg, 500 mg epitol oral tablet 200 mg 1 EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 3 100 MG, 200 MG, 300 MG (carbamazepine (antipsychotic)) GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED PA; QL (30 day supply per 1 SI 20 MG (ziprasidone mesylate) fill) GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 MG 3 (ziprasidone hcl) LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 3 & 100 MG, 42 X 50 MG & 14X100 MG (lamotrigine) LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 MG, 200 3 MG, 25 MG, 50 MG (lamotrigine) LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG 3 (lamotrigine) LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG 3 (lamotrigine) LAMICTAL STARTER ORAL KIT 35 X 25 MG, 42 X 25 MG & 7 3 X 100 MG, 84 X 25 MG & 14X100 MG (lamotrigine) LAMICTAL XR ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 & 3 100 MG, 50 & 100 & 200 MG (lamotrigine) LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG 3 (lamotrigine) lamotrigine er oral tablet extended release 24 hour 100 mg, 1 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral kit 25 & 50 & 100 mg 1 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 193 Coverage Requirements & Prescription Drug Name Drug Tier Limits lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1 lamotrigine oral tablet chewable 25 mg, 5 mg 1 lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 1 50 mg lamotrigine starter kit-blue oral kit 35 x 25 mg 1 lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 1 mg lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 1 mg lithium carbonate er oral tablet extended release 300 mg, 1 450 mg lithium carbonate oral capsule 150 mg, 300 mg, 600 mg 1 lithium carbonate oral tablet 300 mg 1 LITHOBID ORAL TABLET EXTENDED RELEASE 300 MG 3 (lithium carbonate) PA; QL (30 day supply per 1 olanzapine intramuscular solution reconstituted 10 mg SI fill) olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 1 7.5 mg olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 1 mg PERSERIS SUBCUTANEOUS PREFILLED SYRINGE 120 MG, PA; QL (30 day supply per 1 SI 90 MG (risperidone) fill) quetiapine fumarate er oral tablet extended release 24 hour 1 150 mg, 200 mg, 300 mg, 400 mg, 50 mg quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 1 mg, 400 mg, 50 mg RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION PA; QL (30 day supply per 1 RECONSTITUTED ER 12.5 MG, 25 MG, 37.5 MG, 50 MG SI fill) (risperidone microspheres)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 194 Coverage Requirements & Prescription Drug Name Drug Tier Limits RISPERDAL ORAL SOLUTION 1 MG/ML (risperidone) 3 RISPERDAL ORAL TABLET 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG 3 (risperidone) risperidone oral solution 1 mg/ml 1 risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 1 mg risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 1 mg, 3 mg, 4 mg SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 3 MG, 5 MG (asenapine maleate) SECUADO TRANSDERMAL PATCH 24 HOUR 3.8 MG/24HR, PA; QL (1 EA per 1 day); AL 3 5.7 MG/24HR, 7.6 MG/24HR (asenapine) (Min 18 Years) SEROQUEL ORAL TABLET 100 MG, 200 MG, 25 MG, 300 3 MG, 400 MG, 50 MG (quetiapine fumarate) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG (quetiapine 3 fumarate) subvenite oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1 subvenite starter kit-blue oral kit 35 x 25 mg 1 subvenite starter kit-green oral kit 84 x 25 mg & 14x100 mg 1 subvenite starter kit-orange oral kit 42 x 25 mg & 7 x 100 1 mg TEGRETOL ORAL SUSPENSION 100 MG/5ML 3 (carbamazepine) TEGRETOL ORAL TABLET 200 MG (carbamazepine) 3 TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 3 HOUR 100 MG, 200 MG, 400 MG (carbamazepine) valproate sodium intravenous solution 100 mg/ml, 500 OA mg/5ml valproic acid oral capsule 250 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 195 Coverage Requirements & Prescription Drug Name Drug Tier Limits valproic acid oral solution 250 mg/5ml 1 ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg 1 ziprasidone mesylate intramuscular solution reconstituted PA; QL (30 day supply per 1 SI 20 mg fill) ZYPREXA INTRAMUSCULAR SOLUTION RECONSTITUTED PA; QL (30 day supply per 1 SI 10 MG (olanzapine) fill) ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 5 3 MG, 7.5 MG (olanzapine) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION PA; QL (30 day supply per 1 RECONSTITUTED 210 MG, 300 MG, 405 MG (olanzapine SI fill) pamoate) ZYPREXA ZYDIS ORAL TABLET DISPERSIBLE 10 MG, 15 3 MG, 20 MG, 5 MG (olanzapine) ANTIMIGRAINE AGENTS, MISCELLANEOUS - Migraine Treatment acetaminophen intravenous solution 10 mg/ml, 1000 OA mg/100ml ACETAMINOPHEN INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 100 MG/10ML adult aspirin regimen oral tablet delayed release 81 mg 1 PV aspirin adult low dose oral tablet delayed release 81 mg 1 PV aspirin adult low strength oral tablet delayed release 81 mg 1 PV aspirin childrens oral tablet chewable 81 mg 1 PV aspirin ec low dose oral tablet delayed release 81 mg 1 PV aspirin ec low strength oral tablet delayed release 81 mg 1 PV aspirin ec oral tablet delayed release 325 mg 1 PV aspirin low dose oral tablet chewable 81 mg 1 PV aspirin low dose oral tablet delayed release 81 mg 1 PV aspirin oral tablet 325 mg 1 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 196 Coverage Requirements & Prescription Drug Name Drug Tier Limits aspirin oral tablet delayed release 325 mg, 81 mg 1 PV BAYER ASPIRIN EC LOW DOSE ORAL TABLET DELAYED 3 PV RELEASE 81 MG (aspirin) BAYER ASPIRIN ORAL TABLET 325 MG (aspirin) 3 PV BAYER ASPIRIN ORAL TABLET DELAYED RELEASE 325 MG 3 PV (aspirin) butorphanol tartrate injection solution 1 mg/ml, 2 mg/ml OA QL (10 ML per 30 days) butorphanol tartrate nasal solution 10 mg/ml 1 QL (10 ML per 30 days) CAFCIT INTRAVENOUS SOLUTION 60 MG/3ML (caffeine OA citrate) CAFERGOT ORAL TABLET 1-100 MG (ergotamine-caffeine) 3 caffeine citrate intravenous solution 60 mg/3ml OA caffeine citrate oral solution 20 mg/ml, 60 mg/3ml 1 CAFFEINE-SODIUM BENZOATE INJECTION SOLUTION 125- OA 125 MG/ML CAMBIA ORAL PACKET 50 MG (diclofenac 3 PA potassium(migraine)) D.H.E. 45 INJECTION SOLUTION 1 MG/ML PA; QL (30 day supply per 1 SI (dihydroergotamine mesylate) fill) DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 3 HOUR 250 MG, 500 MG (divalproex sodium) DEPAKOTE ORAL TABLET DELAYED RELEASE 125 MG, 250 3 MG, 500 MG (divalproex sodium) DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED 3 RELEASE SPRINKLE 125 MG (divalproex sodium) PA; QL (30 day supply per 1 dihydroergotamine mesylate injection solution 1 mg/ml SI fill) dihydroergotamine mesylate nasal solution 4 mg/ml 1 QL (0.27 ML per 1 day) divalproex sodium er oral tablet extended release 24 hour 1 250 mg, 500 mg Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 197 Coverage Requirements & Prescription Drug Name Drug Tier Limits divalproex sodium oral capsule delayed release sprinkle 1 125 mg divalproex sodium oral tablet delayed release 125 mg, 250 1 mg, 500 mg EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG, 3 500 MG (naproxen) ec-naproxen oral tablet delayed release 375 mg, 500 mg 1 ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG 2 (ergotamine tartrate) ergotamine-caffeine oral tablet 1-100 mg 1 goodsense aspirin adults oral tablet 325 mg 1 PV goodsense aspirin low dose oral tablet delayed release 81 1 PV mg HEMANGEOL ORAL SOLUTION 4.28 MG/ML (propranolol SP; QL (30 day supply per 1 2 hcl) fill) ibuprofen lysine intravenous solution 10 mg/ml OA ibuprofen oral suspension 100 mg/5ml 1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol hcl) INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 3 PA HOUR 120 MG, 80 MG (propranolol hcl sr beads) INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 3 PA HOUR 120 MG, 80 MG (propranolol hcl sr beads) ketoprofen er oral capsule extended release 24 hour 200 1 mg ketoprofen oral capsule 25 mg, 50 mg, 75 mg 1 MIGERGOT RECTAL SUPPOSITORY 2-100 MG (ergotamine- 3 caffeine)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 198 Coverage Requirements & Prescription Drug Name Drug Tier Limits MIGRANAL NASAL SOLUTION 4 MG/ML (dihydroergotamine 3 QL (0.27 ML per 1 day) mesylate) NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 3 PA 375 MG, 500 MG (naproxen sodium) NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 2 PA 750 MG (naproxen sodium) NAPROSYN ORAL SUSPENSION 125 MG/5ML (naproxen) 3 NAPROSYN ORAL TABLET 500 MG (naproxen) 3 naproxen oral suspension 125 mg/5ml 1 naproxen oral tablet 250 mg, 375 mg, 500 mg 1 naproxen oral tablet delayed release 375 mg, 500 mg 1 naproxen sodium er oral tablet extended release 24 hour 1 PA 375 mg, 500 mg NAPROXEN SODIUM ER ORAL TABLET EXTENDED 2 PA RELEASE 24 HOUR 750 MG naproxen sodium oral tablet 275 mg, 550 mg 1 NEOPROFEN INTRAVENOUS SOLUTION 10 MG/ML OA (ibuprofen lysine) propranolol hcl er oral capsule extended release 24 hour 1 120 mg, 160 mg, 60 mg, 80 mg propranolol hcl intravenous solution 1 mg/ml OA propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 1 mg ST JOSEPH LOW DOSE ORAL TABLET DELAYED RELEASE 3 PV 81 MG (aspirin) timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 TOPAMAX ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG 3 (topiramate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 199 Coverage Requirements & Prescription Drug Name Drug Tier Limits TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE 15 MG, 25 3 MG (topiramate) topiramate oral capsule sprinkle 15 mg, 25 mg 1 topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 25 MG, 50 MG (topiramate) valproate sodium intravenous solution 100 mg/ml, 500 OA mg/5ml valproic acid oral capsule 250 mg 1 valproic acid oral solution 250 mg/5ml 1 ANTIPSYCHOTICS, MISCELLANEOUS - Drugs for Depression & Psychosis loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg 1 molindone hcl oral tablet 10 mg, 25 mg, 5 mg 1 PA pimozide oral tablet 1 mg, 2 mg 1 ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC - Drugs for Anxiety & Sleep Disorder AMBIEN CR ORAL TABLET EXTENDED RELEASE 12.5 MG, 3 QL (1 EA per 1 day) 6.25 MG (zolpidem tartrate) AMBIEN ORAL TABLET 10 MG, 5 MG (zolpidem tartrate) 3 QL (1 EA per 1 day) ANESTHESIA S/I-40A INTRAVENOUS KIT 200 MG/20ML OA ANESTHESIA S/I-40H INTRAVENOUS KIT 200 MG/20ML OA ANESTHESIA S/I-40S INTRAVENOUS KIT 200 MG/20ML OA BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG 3 PA (suvorexant) buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg 1 ST; QL (1 EA per 1 day); AL DAYVIGO ORAL TABLET 10 MG, 5 MG (lemborexant) 3 (Min 65 Years)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 200 Coverage Requirements & Prescription Drug Name Drug Tier Limits dexmedetomidine hcl in nacl intravenous solution 200 mcg/50ml, 200-0.9 mcg/50ml-%, 400 mcg/100ml, 80 OA mcg/20ml DEXMEDETOMIDINE HCL IN NACL INTRAVENOUS OA SOLUTION PREFILLED SYRINGE 20-0.9 MCG/5ML-% DEXMEDETOMIDINE HCL INTRAVENOUS SOLUTION 1000 OA MCG/10ML, 400 MCG/4ML dexmedetomidine hcl intravenous solution 200 mcg/2ml OA DEXMEDETOMIDINE HCL-DEXTROSE INTRAVENOUS OA SOLUTION 200MCG/50ML -5%, 400MCG/100ML -5% diphen oral elixir 12.5 mg/5ml 1 di-phen oral elixir 12.5 mg/5ml 1 diphenhydramine hcl injection solution 50 mg/ml 1 PA diphenhydramine hcl oral elixir 12.5 mg/5ml 1 DIPRIVAN INTRAVENOUS EMULSION 100 MG/10ML, 1000 OA MG/100ML, 200 MG/20ML, 500 MG/50ML (propofol) droperidol injection solution 2.5 mg/ml OA DROPERIDOL INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 0.625 MG/ML EDLUAR SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG 3 QL (1 EA per 1 day) (zolpidem tartrate) eszopiclone oral tablet 1 mg, 2 mg, 3 mg 1 QL (1 EA per 1 day) fresenius propoven intravenous emulsion 1000 mg/100ml, OA 200 mg/20ml, 500 mg/50ml FRESENIUS PROPOVEN INTRAVENOUS EMULSION 2000 OA MG/100ML PA; SP; QL (30 day supply HETLIOZ LQ ORAL SUSPENSION 4 MG/ML (tasimelteon) 3 per 1 fill) PA; SP; QL (30 day supply HETLIOZ ORAL CAPSULE 20 MG (tasimelteon) 3 per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 201 Coverage Requirements & Prescription Drug Name Drug Tier Limits hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml OA hydroxyzine hcl oral syrup 10 mg/5ml 1 hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 1 LUNESTA ORAL TABLET 1 MG, 2 MG, 3 MG (eszopiclone) 3 QL (1 EA per 1 day) meprobamate oral tablet 200 mg, 400 mg 1 PHENERGAN INJECTION SOLUTION 25 MG/ML, 50 MG/ML OA PA (promethazine hcl) PRECEDEX INTRAVENOUS SOLUTION 1000 MCG/250ML, 200 MCG/50ML, 400 MCG/100ML, 80 MCG/20ML OA (dexmedetomidine hcl in nacl) PRECEDEX INTRAVENOUS SOLUTION 200 MCG/2ML OA (dexmedetomidine hcl) promethazine hcl injection solution 25 mg/ml, 50 mg/ml OA PA promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1 promethazine hcl rectal suppository 12.5 mg, 25 mg 1 promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 1 propofol intravenous emulsion 1000 mg/100ml, 200 OA mg/20ml, 500 mg/50ml propofol-lipuro intravenous emulsion 1000 mg/100ml OA ramelteon oral tablet 8 mg 1 QL (1 EA per 1 day) ROZEREM ORAL TABLET 8 MG (ramelteon) 3 QL (1 EA per 1 day) VISTARIL ORAL CAPSULE 25 MG, 50 MG (hydroxyzine 3 pamoate) zaleplon oral capsule 10 mg 1 QL (2 EA per 1 day) zaleplon oral capsule 5 mg 1 QL (1 EA per 1 day)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 202 Coverage Requirements & Prescription Drug Name Drug Tier Limits zolpidem tartrate er oral tablet extended release 12.5 mg, 1 QL (1 EA per 1 day) 6.25 mg zolpidem tartrate oral tablet 10 mg, 5 mg 1 QL (1 EA per 1 day) zolpidem tartrate sublingual tablet sublingual 1.75 mg, 3.5 1 QL (1 EA per 1 day) mg ZOLPIMIST ORAL SOLUTION 5 MG/ACT (zolpidem tartrate) 3 QL (0.26 ML per 1 day) ATYPICAL ANTIPSYCHOTICS - Drugs for Depression & Psychosis ABILIFY MAINTENA INTRAMUSCULAR PREFILLED PA; QL (30 day supply per 1 SI SYRINGE 300 MG, 400 MG (aripiprazole) fill) ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION PA; QL (30 day supply per 1 SI RECONSTITUTED ER 300 MG, 400 MG (aripiprazole) fill) ABILIFY MYCITE MAINTENANCE KIT ORAL TABLET 10 MG, 3 15 MG, 2 MG, 20 MG, 30 MG, 5 MG (aripiprazole) ABILIFY MYCITE ORAL TABLET 10 MG, 15 MG, 2 MG, 20 3 QL (1 EA per 1 day) MG, 30 MG, 5 MG (aripiprazole) ABILIFY MYCITE STARTER KIT ORAL TABLET 10 MG, 15 3 QL (2 fill per 365 days) MG, 2 MG, 20 MG, 30 MG, 5 MG (aripiprazole) ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 3 5 MG (aripiprazole) aripiprazole oral solution 1 mg/ml 1 aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 1 mg aripiprazole oral tablet dispersible 10 mg, 15 mg 1 asenapine maleate sublingual tablet sublingual 10 mg, 2.5 1 mg, 5 mg PA; QL (1 EA per 1 day); AL CAPLYTA ORAL CAPSULE 42 MG (lumateperone tosylate) 3 (Min 18 Years) clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 203 Coverage Requirements & Prescription Drug Name Drug Tier Limits clozapine oral tablet dispersible 100 mg, 12.5 mg, 150 mg, 1 200 mg, 25 mg CLOZARIL ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG 3 (clozapine) FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 3 MG, 8 MG (iloperidone) FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG 3 (iloperidone) GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED PA; QL (30 day supply per 1 SI 20 MG (ziprasidone mesylate) fill) GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 MG 3 (ziprasidone hcl) INVEGA HAFYERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 1092 MG/3.5ML, 1560 MG/5ML 3 PA (paliperidone palmitate) INVEGA ORAL TABLET EXTENDED RELEASE 24 HOUR 1.5 3 MG, 3 MG, 6 MG, 9 MG (paliperidone) INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 117 MG/0.75ML, 156 MG/ML, 234 PA; QL (30 day supply per 1 SI MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML (paliperidone fill) palmitate) INVEGA TRINZA INTRAMUSCULAR SUSPENSION PA; QL (30 day supply per 1 PREFILLED SYRINGE 273 MG/0.875ML, 410 MG/1.315ML, SI fill) 546 MG/1.75ML, 819 MG/2.625ML (paliperidone palmitate) LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 3 MG (lurasidone hcl) PA; SP; QL (30 day supply NUPLAZID ORAL CAPSULE 34 MG (pimavanserin tartrate) 3 per 1 fill) PA; SP; QL (30 day supply NUPLAZID ORAL TABLET 10 MG (pimavanserin tartrate) 3 per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 204 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; QL (30 day supply per 1 olanzapine intramuscular solution reconstituted 10 mg SI fill) olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 1 7.5 mg olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 1 mg olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 1 3-25 mg, 6-25 mg, 6-50 mg paliperidone er oral tablet extended release 24 hour 1.5 mg, 1 3 mg, 6 mg, 9 mg PERSERIS SUBCUTANEOUS PREFILLED SYRINGE 120 MG, PA; QL (30 day supply per 1 SI 90 MG (risperidone) fill) quetiapine fumarate er oral tablet extended release 24 hour 1 150 mg, 200 mg, 300 mg, 400 mg, 50 mg quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 1 mg, 400 mg, 50 mg REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 3 MG, 4 MG (brexpiprazole) RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION PA; QL (30 day supply per 1 RECONSTITUTED ER 12.5 MG, 25 MG, 37.5 MG, 50 MG SI fill) (risperidone microspheres) RISPERDAL ORAL SOLUTION 1 MG/ML (risperidone) 3 RISPERDAL ORAL TABLET 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG 3 (risperidone) risperidone oral solution 1 mg/ml 1 risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 1 mg risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 1 mg, 3 mg, 4 mg SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 3 MG, 5 MG (asenapine maleate) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 205 Coverage Requirements & Prescription Drug Name Drug Tier Limits SECUADO TRANSDERMAL PATCH 24 HOUR 3.8 MG/24HR, PA; QL (1 EA per 1 day); AL 3 5.7 MG/24HR, 7.6 MG/24HR (asenapine) (Min 18 Years) SEROQUEL ORAL TABLET 100 MG, 200 MG, 25 MG, 300 3 MG, 400 MG, 50 MG (quetiapine fumarate) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG (quetiapine 3 fumarate) SYMBYAX ORAL CAPSULE 3-25 MG, 6-25 MG (olanzapine- 3 fluoxetine hcl) VERSACLOZ ORAL SUSPENSION 50 MG/ML (clozapine) 3 VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG 3 PA (cariprazine hcl) VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MG 3 PA (cariprazine hcl) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg 1 ziprasidone mesylate intramuscular solution reconstituted PA; QL (30 day supply per 1 SI 20 mg fill) ZYPREXA INTRAMUSCULAR SOLUTION RECONSTITUTED PA; QL (30 day supply per 1 SI 10 MG (olanzapine) fill) ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 5 3 MG, 7.5 MG (olanzapine) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION PA; QL (30 day supply per 1 RECONSTITUTED 210 MG, 300 MG, 405 MG (olanzapine SI fill) pamoate) ZYPREXA ZYDIS ORAL TABLET DISPERSIBLE 10 MG, 15 3 MG, 20 MG, 5 MG (olanzapine) BARBITURATES (ANTICONVULSANTS) - Drugs for Seizures BREVITAL SODIUM INJECTION SOLUTION OA RECONSTITUTED 500 MG (methohexital sodium)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 206 Coverage Requirements & Prescription Drug Name Drug Tier Limits METHOHEXITAL SODIUM INTRAVENOUS SOLUTION OA PREFILLED SYRINGE 100 MG/10ML MYSOLINE ORAL TABLET 250 MG, 50 MG (primidone) 3 phenobarbital oral elixir 20 mg/5ml 1 phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 1 32.4 mg, 60 mg, 64.8 mg, 97.2 mg phenobarbital sodium injection solution 130 mg/ml, 65 OA mg/ml primidone oral tablet 250 mg, 50 mg 1 BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) - Drugs for Anxiety & Sleep Disorder ALLZITAL ORAL TABLET 25-325 MG (butalbital- 3 acetaminophen) AMYTAL SODIUM INJECTION SOLUTION RECONSTITUTED OA 500 MG (amobarbital sodium) ascomp-codeine oral capsule 50-325-40-30 mg 1 PA bac oral tablet 50-325-40 mg 1 BUPAP ORAL TABLET 50-300 MG (butalbital- 3 acetaminophen) butalbital-acetaminophen capsule 50-300 mg oral 50-300 1 mg BUTALBITAL-ACETAMINOPHEN CAPSULE 50-300 MG ORAL 1 50-300 MG butalbital-acetaminophen oral tablet 25-325 mg, 50-300 mg, 1 50-325 mg butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50- 1 325-40-30 mg butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325- 1 40 mg butalbital-apap-caffeine oral tablet 50-325-40 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 207 Coverage Requirements & Prescription Drug Name Drug Tier Limits butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 PA butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 ESGIC ORAL CAPSULE 50-325-40 MG (butalbital-apap- 3 caffeine) ESGIC ORAL TABLET 50-325-40 MG (butalbital-apap- 3 caffeine) FIORICET ORAL CAPSULE 50-300-40 MG (butalbital-apap- 3 caffeine) FIORICET/CODEINE ORAL CAPSULE 50-300-40-30 MG 3 (butalbital-apap-caff-cod) NEMBUTAL INJECTION SOLUTION 50 MG/ML (pentobarbital OA sodium) pentobarbital sodium injection solution 50 mg/ml OA phenobarbital oral elixir 20 mg/5ml 1 phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 1 32.4 mg, 60 mg, 64.8 mg, 97.2 mg phenobarbital sodium injection solution 130 mg/ml, 65 OA mg/ml TENCON ORAL TABLET 50-325 MG (butalbital- 3 acetaminophen) VTOL LQ ORAL SOLUTION 50-325-40 MG/15ML (butalbital- 2 apap-caffeine) ZEBUTAL ORAL CAPSULE 50-325-40 MG (butalbital-apap- 3 caffeine) BARBITURATES (GENERAL ANESTHETICS) - Anesthetics BREVITAL SODIUM INJECTION SOLUTION OA RECONSTITUTED 500 MG (methohexital sodium) METHOHEXITAL SODIUM INTRAVENOUS SOLUTION OA PREFILLED SYRINGE 100 MG/10ML

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 208 Coverage Requirements & Prescription Drug Name Drug Tier Limits BENZODIAZEPINES (ANTICONVULSANTS) - Drugs for Seizures ATIVAN INJECTION SOLUTION 2 MG/ML, 4 MG/ML OA (lorazepam) ATIVAN ORAL TABLET 0.5 MG, 1 MG, 2 MG (lorazepam) 3 clobazam oral suspension 2.5 mg/ml 1 PA clobazam oral tablet 10 mg, 20 mg 1 PA clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 1 mg, 1 mg, 2 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg 1 DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG (diazepam) 3 DIASTAT PEDIATRIC RECTAL GEL 2.5 MG (diazepam) 3 diazepam intensol oral concentrate 5 mg/ml 1 diazepam intramuscular solution auto-injector 10 mg/2ml OA diazepam oral concentrate 5 mg/ml 1 diazepam oral solution 5 mg/5ml 1 diazepam oral tablet 10 mg, 2 mg, 5 mg 1 diazepam rectal gel 10 mg, 2.5 mg, 20 mg 1 diazepam solution 5 mg/ml injection 5 mg/ml OA DIAZEPAM SOLUTION 5 MG/ML INJECTION 5 MG/ML OA KLONOPIN ORAL TABLET 0.5 MG, 1 MG, 2 MG 3 (clonazepam) lorazepam injection solution 2 mg/ml, 4 mg/ml OA lorazepam intensol oral concentrate 2 mg/ml 1 lorazepam oral concentrate 2 mg/ml 1 lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 209 Coverage Requirements & Prescription Drug Name Drug Tier Limits LOREEV XR ORAL CAPSULE ER 24 HOUR SPRINKLE 1 MG, 3 2 MG, 3 MG (lorazepam) NAYZILAM NASAL SOLUTION 5 MG/0.1ML (midazolam ST; QL (10 EA per 30 days); 3 (anticonvulsant)) AL (Min 12 Years) ONFI ORAL SUSPENSION 2.5 MG/ML (clobazam) 3 PA ONFI ORAL TABLET 10 MG, 20 MG (clobazam) 3 PA SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG (clobazam) 3 TRANXENE-T ORAL TABLET 7.5 MG (clorazepate 3 dipotassium) VALIUM ORAL TABLET 10 MG, 2 MG, 5 MG (diazepam) 3 VALTOCO NASAL LIQUID 10 MG/0.1ML, 5 MG/0.1ML 3 (diazepam) VALTOCO NASAL LIQUID THERAPY PACK 10 MG/0.1ML, 7.5 3 MG/0.1ML (diazepam) BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) - Drugs for Anxiety & Sleep Disorder alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 1 mg, 2 mg, 3 mg alprazolam intensol oral concentrate 1 mg/ml 1 alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 1 mg alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 1 mg, 2 mg, 3 mg ATIVAN INJECTION SOLUTION 2 MG/ML, 4 MG/ML OA (lorazepam) ATIVAN ORAL TABLET 0.5 MG, 1 MG, 2 MG (lorazepam) 3 BYFAVO INTRAVENOUS SOLUTION RECONSTITUTED 20 OA MG (remimazolam besylate) chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg 1 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 210 Coverage Requirements & Prescription Drug Name Drug Tier Limits chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 1 mg chlordiazepoxide-clidinium oral capsule 5-2.5 mg 1 clobazam oral suspension 2.5 mg/ml 1 PA clobazam oral tablet 10 mg, 20 mg 1 PA clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 1 mg, 1 mg, 2 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg 1 DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG (diazepam) 3 DIASTAT PEDIATRIC RECTAL GEL 2.5 MG (diazepam) 3 diazepam intensol oral concentrate 5 mg/ml 1 diazepam intramuscular solution auto-injector 10 mg/2ml OA diazepam oral concentrate 5 mg/ml 1 diazepam oral solution 5 mg/5ml 1 diazepam oral tablet 10 mg, 2 mg, 5 mg 1 diazepam rectal gel 10 mg, 2.5 mg, 20 mg 1 diazepam solution 5 mg/ml injection 5 mg/ml OA DIAZEPAM SOLUTION 5 MG/ML INJECTION 5 MG/ML OA DORAL ORAL TABLET 15 MG (quazepam) 3 QL (1 EA per 1 day) estazolam oral tablet 1 mg, 2 mg 1 QL (1 EA per 1 day) flurazepam hcl oral capsule 15 mg, 30 mg 1 QL (1 EA per 1 day) HALCION ORAL TABLET 0.25 MG (triazolam) 3 QL (1 EA per 1 day) KLONOPIN ORAL TABLET 0.5 MG, 1 MG, 2 MG 3 (clonazepam) LIBRAX ORAL CAPSULE 5-2.5 MG (chlordiazepoxide- 3 clidinium) lorazepam injection solution 2 mg/ml, 4 mg/ml OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 211 Coverage Requirements & Prescription Drug Name Drug Tier Limits lorazepam intensol oral concentrate 2 mg/ml 1 lorazepam oral concentrate 2 mg/ml 1 lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 LOREEV XR ORAL CAPSULE ER 24 HOUR SPRINKLE 1 MG, 3 2 MG, 3 MG (lorazepam) midazolam hcl (pf) injection solution 10 mg/2ml, 2 mg/2ml, SI PA 5 mg/5ml, 5 mg/ml midazolam hcl injection solution 10 mg/10ml, 10 mg/2ml, 2 SI PA mg/2ml, 25 mg/5ml, 5 mg/5ml, 5 mg/ml, 50 mg/10ml MIDAZOLAM HCL INTRAVENOUS SOLUTION 150 MG/30ML SI PA MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 100-0.8 MG/100ML-%, 100-0.9 MG/100ML-%, 50- OA 0.8 MG/50ML-%, 50-0.9 MG/50ML-% MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 2-0.9 MG/2ML-%, 5-0.9 OA MG/5ML-%, 55-0.9 MG/55ML-% MIDAZOLAM INTRAVENOUS SOLUTION PREFILLED SYRINGE 2 MG/2ML, 25 MG/25ML, 30 MG/30ML, 50 OA MG/50ML MIDAZOLAM-SODIUM CHLORIDE INTRAVENOUS OA SOLUTION 100-0.9 MG/100ML-%, 50-0.9 MG/50ML-% MIDAZOLAM-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 30-0.9 MG/30ML-%, 50-0.9 OA MG/50ML-%, 55-0.9 MG/55ML-%, 60-0.9 MG/30ML-% ONFI ORAL SUSPENSION 2.5 MG/ML (clobazam) 3 PA ONFI ORAL TABLET 10 MG, 20 MG (clobazam) 3 PA oxazepam oral capsule 10 mg, 15 mg, 30 mg 1 quazepam oral tablet 15 mg 1 QL (1 EA per 1 day) RESTORIL ORAL CAPSULE 15 MG, 22.5 MG, 30 MG, 7.5 MG 3 QL (1 EA per 1 day) (temazepam)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 212 Coverage Requirements & Prescription Drug Name Drug Tier Limits SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG (clobazam) 3 temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg 1 QL (1 EA per 1 day) TRANXENE-T ORAL TABLET 7.5 MG (clorazepate 3 dipotassium) triazolam oral tablet 0.125 mg, 0.25 mg 1 QL (1 EA per 1 day) VALIUM ORAL TABLET 10 MG, 2 MG, 5 MG (diazepam) 3 XANAX ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG 3 (alprazolam) XANAX XR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 0.5 MG, 1 MG, 2 MG, 3 MG (alprazolam) BUTYROPHENONES - Drugs for Depression & Psychosis HALDOL DECANOATE INTRAMUSCULAR SOLUTION 100 PA; QL (30 day supply per 1 SI MG/ML, 50 MG/ML (haloperidol decanoate) fill) haloperidol decanoate intramuscular solution 100 mg/ml, PA; QL (30 day supply per 1 SI 50 mg/ml fill) haloperidol lactate injection solution 5 mg/ml OA haloperidol lactate oral concentrate 2 mg/ml 1 haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 1 mg CALCITONIN GENE-RELATED PEPTIDE ANTAG. - Migraine Treatment AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; QL (30 day supply per 1 SI 140 MG/ML, 70 MG/ML (erenumab-aooe) fill) AJOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 225 PA; QL (30 day supply per 1 SI MG/1.5ML (fremanezumab-vfrm) fill) AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; QL (30 day supply per 1 SI 225 MG/1.5ML (fremanezumab-vfrm) fill) EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION PA; QL (30 day supply per 1 SI PREFILLED SYRINGE 100 MG/ML (galcanezumab-gnlm) fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 213 Coverage Requirements & Prescription Drug Name Drug Tier Limits EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; QL (30 day supply per 1 SI 120 MG/ML (galcanezumab-gnlm) fill) EMGALITY SUBCUTANEOUS SOLUTION PREFILLED PA; QL (30 day supply per 1 SI SYRINGE 120 MG/ML (galcanezumab-gnlm) fill) NURTEC ORAL TABLET DISPERSIBLE 75 MG (rimegepant PA; QL (0.29 EA per 1 day); 2 sulfate) AL (Min 18 Years) PA; QL (0.36 EA per 1 day); UBRELVY ORAL TABLET 100 MG, 50 MG (ubrogepant) 2 AL (Min 18 Years) VYEPTI INTRAVENOUS SOLUTION 100 MG/ML OA (eptinezumab-jjmr) CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB. - Drugs for Parkinson carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5- 1 150-200 mg, 50-200-200 mg COMTAN ORAL TABLET 200 MG (entacapone) 3 entacapone oral tablet 200 mg 1 ONGENTYS ORAL CAPSULE 25 MG, 50 MG (opicapone) 3 PA STALEVO 100 ORAL TABLET 25-100-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 125 ORAL TABLET 31.25-125-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 150 ORAL TABLET 37.5-150-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 200 ORAL TABLET 50-200-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 50 ORAL TABLET 12.5-50-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 75 ORAL TABLET 18.75-75-200 MG (carbidopa- 3 levodopa-entacapone)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 214 Coverage Requirements & Prescription Drug Name Drug Tier Limits TASMAR ORAL TABLET 100 MG (tolcapone) 3 tolcapone oral tablet 100 mg 1 CENTRAL NERVOUS SYSTEM AGENTS, MISC. - Drugs for Attention Deficit Disorder acamprosate calcium oral tablet delayed release 333 mg 1 ADDYI ORAL TABLET 100 MG (flibanserin) 3 PA ADUHELM INTRAVENOUS SOLUTION 170 MG/1.7ML, 300 OA PA MG/3ML (aducanumab-avwa) atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 1 40 mg, 60 mg, 80 mg EXSERVAN ORAL FILM 50 MG (riluzole) 3 PA; QL (2 EA per 1 day) flumazenil intravenous solution 0.5 mg/5ml, 1 mg/10ml OA guanfacine hcl er oral tablet extended release 24 hour 1 1 mg, 2 mg, 3 mg, 4 mg guanfacine hcl oral tablet 1 mg, 2 mg 1 INTUNIV ORAL TABLET EXTENDED RELEASE 24 HOUR 1 3 MG, 2 MG, 3 MG, 4 MG (guanfacine hcl) memantine hcl er oral capsule extended release 24 hour 14 1 mg, 21 mg, 28 mg, 7 mg memantine hcl oral solution 10 mg/5ml, 2 mg/ml 1 memantine hcl oral tablet 10 mg, 28 x 5 mg & 21 x 10 mg, 5 1 mg NAMENDA TITRATION PAK ORAL TABLET 28 X 5 MG & 21 X 3 10 MG (memantine hcl) NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 14 MG, 21 MG, 28 MG, 7 MG (memantine hcl) NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 3 PA & 14 & 21 &28 -10 MG (memantine hcl-donepezil hcl)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 215 Coverage Requirements & Prescription Drug Name Drug Tier Limits NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG (memantine hcl- 3 PA donepezil hcl) PA; QL (1 EA per 1 day); AL NOURIANZ ORAL TABLET 20 MG, 40 MG (istradefylline) 3 (Min 18 Years) NUEDEXTA ORAL CAPSULE 20-10 MG (dextromethorphan- 3 PA quinidine) QELBREE ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 PA 100 MG, 150 MG, 200 MG (viloxazine hcl) RADICAVA INTRAVENOUS SOLUTION 30 MG/100ML OA QL (30 day supply per 1 fill) (edaravone) RILUTEK ORAL TABLET 50 MG (riluzole) 3 riluzole oral tablet 50 mg 1 STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 3 MG, 40 MG, 60 MG, 80 MG (atomoxetine hcl) TIGLUTIK ORAL SUSPENSION 50 MG/10ML (riluzole) 3 VYLEESI SUBCUTANEOUS SOLUTION AUTO-INJECTOR SI PA; QL (8 ML per 30 days) 1.75 MG/0.3ML (bremelanotide acetate) VYNDAMAX ORAL CAPSULE 61 MG (tafamidis) 3 PA; SP; QL (30 day supply XYREM ORAL SOLUTION 500 MG/ML (sodium oxybate) 3 per 1 fill) XYWAV ORAL SOLUTION 500 MG/ML (ca, mg, k, and na PA; SP; QL (30 day supply 3 oxybates) per 1 fill) CYCLOOXYGENASE-2 (COX-2) INHIBITORS - Drugs for Pain CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG, 50 3 MG (celecoxib) celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg 1 CONSENSI ORAL TABLET 10-200 MG, 2.5-200 MG, 5-200 MG 3 (amlodipine besylate-celecoxib)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 216 Coverage Requirements & Prescription Drug Name Drug Tier Limits DOPAMINE PRECURSORS - Drugs for Parkinson carbidopa oral tablet 25 mg 1 carbidopa-levodopa er oral tablet extended release 25-100 1 mg, 50-200 mg carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25- 1 250 mg carbidopa-levodopa oral tablet dispersible 10-100 mg, 25- 1 100 mg, 25-250 mg carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5- 1 150-200 mg, 50-200-200 mg DUOPA ENTERAL SUSPENSION 4.63-20 MG/ML (carbidopa- PA; SP; QL (30 day supply 3 levodopa) per 1 fill) PA; SP; QL (30 day supply INBRIJA INHALATION CAPSULE 42 MG (levodopa) 3 per 1 fill) LODOSYN ORAL TABLET 25 MG (carbidopa) 3 RYTARY ORAL CAPSULE EXTENDED RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG (carbidopa- 3 levodopa) SINEMET ORAL TABLET 10-100 MG, 25-100 MG (carbidopa- 3 levodopa) STALEVO 100 ORAL TABLET 25-100-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 125 ORAL TABLET 31.25-125-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 150 ORAL TABLET 37.5-150-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 200 ORAL TABLET 50-200-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 50 ORAL TABLET 12.5-50-200 MG (carbidopa- 3 levodopa-entacapone) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 217 Coverage Requirements & Prescription Drug Name Drug Tier Limits STALEVO 75 ORAL TABLET 18.75-75-200 MG (carbidopa- 3 levodopa-entacapone) ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS - Drugs for Parkinson bromocriptine mesylate oral capsule 5 mg 1 bromocriptine mesylate oral tablet 2.5 mg 1 cabergoline oral tablet 0.5 mg 1 PARLODEL ORAL CAPSULE 5 MG (bromocriptine mesylate) 3 PARLODEL ORAL TABLET 2.5 MG (bromocriptine mesylate) 3 FIBROMYALGIA AGENTS - Drugs for Nerve Pain CYMBALTA ORAL CAPSULE DELAYED RELEASE 3 PARTICLES 20 MG, 30 MG, 60 MG (duloxetine hcl) duloxetine hcl oral capsule delayed release particles 20 mg, 1 30 mg, 40 mg, 60 mg LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 3 25 MG, 300 MG, 50 MG, 75 MG (pregabalin) LYRICA ORAL SOLUTION 20 MG/ML (pregabalin) 3 pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 1 25 mg, 300 mg, 50 mg, 75 mg pregabalin oral solution 20 mg/ml 1 SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG 3 (milnacipran hcl) SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG 3 (milnacipran hcl) GENERAL ANESTHETICS, MISCELLANEOUS - Anesthetics AMIDATE INTRAVENOUS SOLUTION 2 MG/ML (etomidate) OA ANESTHESIA S/I-40A INTRAVENOUS KIT 200 MG/20ML OA ANESTHESIA S/I-40H INTRAVENOUS KIT 200 MG/20ML OA ANESTHESIA S/I-40S INTRAVENOUS KIT 200 MG/20ML OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 218 Coverage Requirements & Prescription Drug Name Drug Tier Limits DIPRIVAN INTRAVENOUS EMULSION 100 MG/10ML, 1000 OA MG/100ML, 200 MG/20ML, 500 MG/50ML (propofol) etomidate intravenous solution 2 mg/ml OA fresenius propoven intravenous emulsion 1000 mg/100ml, OA 200 mg/20ml, 500 mg/50ml FRESENIUS PROPOVEN INTRAVENOUS EMULSION 2000 OA MG/100ML KETALAR INJECTION SOLUTION 10 MG/ML, 100 MG/ML, 50 OA MG/ML (ketamine hcl) KETAMINE HCL INJECTION SOLUTION 0.6 MG/ML, 1 MG/ML OA ketamine hcl injection solution 100 mg/ml, 50 mg/ml OA KETAMINE HCL INJECTION SOLUTION PREFILLED OA SYRINGE 30 MG/3ML, 50 MG/5ML KETAMINE HCL INTRAVENOUS SOLUTION 100 MG/100ML OA KETAMINE HCL INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 100 MG/2ML, 30 MG/3ML, 50 MG/5ML, 50 MG/ML KETAMINE HCL SOLUTION 10 MG/ML INJECTION 10 MG/ML OA ketamine hcl solution 10 mg/ml injection 10 mg/ml OA KETAMINE HCL-SODIUM CHLORIDE INJECTION SOLUTION OA PREFILLED SYRINGE 50-0.9 MG/5ML-% KETAMINE HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MG/ML-%, 100-0.9 OA MG/10ML-%, 20-0.9 MG/2ML-%, 50-0.9 MG/5ML-% KETOROLAC-BUPIV-KETAMINE INJECTION SOLUTION 3 PREFILLED SYRINGE 60-150-60 MG/50ML KETOROLAC-ROPIV-KETAMINE INJECTION SOLUTION 3 PREFILLED SYRINGE 15-100-30 MG/50ML propofol intravenous emulsion 1000 mg/100ml, 200 OA mg/20ml, 500 mg/50ml propofol-lipuro intravenous emulsion 1000 mg/100ml OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 219 Coverage Requirements & Prescription Drug Name Drug Tier Limits HYDANTOINS - Drugs for Seizures CEREBYX INJECTION SOLUTION 100 MG PE/2ML, 500 MG OA PE/10ML (fosphenytoin sodium) DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG 3 (phenytoin) DILANTIN ORAL CAPSULE 100 MG (phenytoin sodium 3 extended) DILANTIN ORAL CAPSULE 30 MG (phenytoin sodium 2 extended) DILANTIN ORAL SUSPENSION 125 MG/5ML (phenytoin) 3 fosphenytoin sodium injection solution 100 mg pe/2ml, 500 OA mg pe/10ml PHENYTEK ORAL CAPSULE 200 MG, 300 MG (phenytoin 3 sodium extended) phenytoin infatabs oral tablet chewable 50 mg 1 phenytoin oral suspension 100 mg/4ml, 125 mg/5ml 1 phenytoin oral tablet chewable 50 mg 1 phenytoin sodium extended oral capsule 100 mg, 200 mg, 1 300 mg phenytoin sodium injection solution 50 mg/ml OA MONOAMINE OXIDASE B INHIBITORS - Drugs for Parkinson AZILECT ORAL TABLET 0.5 MG, 1 MG (rasagiline mesylate) 3 EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 3 MG/24HR, 9 MG/24HR (selegiline) rasagiline mesylate oral tablet 0.5 mg, 1 mg 1 selegiline hcl oral capsule 5 mg 1 selegiline hcl oral tablet 5 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 220 Coverage Requirements & Prescription Drug Name Drug Tier Limits XADAGO ORAL TABLET 100 MG, 50 MG (safinamide 3 PA mesylate) ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG (selegiline 2 hcl) MONOAMINE OXIDASE INHIBITORS - Drugs for Depression & Psychosis AZILECT ORAL TABLET 0.5 MG, 1 MG (rasagiline mesylate) 3 EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 3 MG/24HR, 9 MG/24HR (selegiline) MARPLAN ORAL TABLET 10 MG (isocarboxazid) 2 NARDIL ORAL TABLET 15 MG (phenelzine sulfate) 3 PARNATE ORAL TABLET 10 MG (tranylcypromine sulfate) 3 phenelzine sulfate oral tablet 15 mg 1 rasagiline mesylate oral tablet 0.5 mg, 1 mg 1 selegiline hcl oral capsule 5 mg 1 selegiline hcl oral tablet 5 mg 1 tranylcypromine sulfate oral tablet 10 mg 1 XADAGO ORAL TABLET 100 MG, 50 MG (safinamide 3 PA mesylate) ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG (selegiline 2 hcl) NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST - Drugs for Parkinson APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 PA; SP; QL (30 day supply SI MG/3ML (apomorphine hcl) per 1 fill) KYNMOBI SUBLINGUAL FILM 10 MG, 15 MG, 20 MG, 25 MG, PA; SP; QL (30 day supply 3 30 MG (apomorphine hcl) per 1 fill) KYNMOBI TITRATION KIT SUBLINGUAL KIT 10/15/20/25/30 PA; SP; QL (30 day supply 3 MG (apomorphine hcl) per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 221 Coverage Requirements & Prescription Drug Name Drug Tier Limits MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 0.375 MG, 0.75 MG, 1.5 MG, 2.25 MG, 3 MG, 3.75 MG, 3 4.5 MG (pramipexole dihydrochloride) MIRAPEX ORAL TABLET 0.125 MG, 0.5 MG, 0.75 MG, 1 MG 3 (pramipexole dihydrochloride) NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR 3 (rotigotine) pramipexole dihydrochloride er oral tablet extended release 24 hour 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 1 4.5 mg pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 1 0.5 mg, 0.75 mg, 1 mg, 1.5 mg ropinirole hcl er oral tablet extended release 24 hour 12 mg, 1 2 mg, 4 mg, 6 mg, 8 mg ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 1 4 mg, 5 mg OPIATE AGONISTS - Drugs for Pain acetaminophen-codeine #2 oral tablet 300-15 mg 1 acetaminophen-codeine #3 oral tablet 300-30 mg 1 acetaminophen-codeine #4 oral tablet 300-60 mg 1 acetaminophen-codeine oral solution 120-12 mg/5ml 1 acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 1 300-60 mg ACTIQ BUCCAL LOZENGE ON A HANDLE 1200 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG (fentanyl 3 citrate) alfentanil hcl intravenous solution 1000 mcg/2ml, 2500 OA mcg/5ml apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 222 Coverage Requirements & Prescription Drug Name Drug Tier Limits apap-caff-dihydrocodeine oral tablet 325-30-16 mg 1 ascomp-codeine oral capsule 50-325-40-30 mg 1 PA butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50- 1 325-40-30 mg butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 PA carisoprodol-aspirin-codeine oral tablet 200-325-16 mg 1 PA codeine sulfate oral tablet 15 mg, 30 mg, 60 mg 1 CONZIP ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG (tramadol hcl) DEMEROL INJECTION SOLUTION 100 MG/2ML, 100 MG/ML, OA 25 MG/ML, 50 MG/ML, 75 MG/ML (meperidine hcl) DILAUDID INJECTION SOLUTION 0.2 MG/ML 3 (hydromorphone hcl) DILAUDID INJECTION SOLUTION 1 MG/ML, 2 MG/ML OA (hydromorphone hcl) DILAUDID ORAL LIQUID 1 MG/ML (hydromorphone hcl) 3 DILAUDID ORAL TABLET 2 MG, 4 MG, 8 MG 3 (hydromorphone hcl) DSUVIA SUBLINGUAL TABLET SUBLINGUAL 30 MCG 3 (sufentanil citrate) duramorph injection solution 0.5 mg/ml, 1 mg/ml OA endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5- 1 325 mg fentanyl citrate (pf) injection solution 100 mcg/2ml, 1000 OA mcg/20ml, 250 mcg/5ml, 2500 mcg/50ml, 500 mcg/10ml fentanyl citrate (pf) injection solution cartridge 100 mcg/2ml OA fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 1 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg FENTANYL CITRATE BUCCAL TABLET 100 MCG, 200 MCG, 3 400 MCG, 600 MCG, 800 MCG Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 223 Coverage Requirements & Prescription Drug Name Drug Tier Limits FENTANYL CITRATE INJECTION SOLUTION 1500 OA MCG/30ML FENTANYL CITRATE INTRAVENOUS SOLUTION 1500 OA MCG/30ML, 2500 MCG/50ML, 5000 MCG/100ML FENTANYL CITRATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 100 MCG/10ML, 100 MCG/2ML, 1000 MCG/20ML, OA 1250 MCG/25ML, 1500 MCG/30ML, 20 MCG/2ML, 250 MCG/5ML, 2750 MCG/55ML, 50 MCG/5ML, 500 MCG/50ML fentanyl citrate pf injection solution prefilled syringe 50 OA mcg/ml FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION 1-0.9 MG/100ML-%, 1.25-0.9 MG/250ML-%, 2-0.9 MG/100ML-%, 2.5- OA 0.9 MG/250ML-% FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MCG/2ML-%, 10-0.9 MCG/ML- OA %, 100-0.9 MCG/10ML-%, 1000-0.9 MCG/50ML-%, 5-0.9 MCG/ML-%, 500-0.9 MCG/50ML-%, 550-0.9 MCG/55ML-% FENTANYL CIT-ROPIVACAINE-NACL EPIDURAL SOLUTION 0.2-0.2-0.9 MG/100ML-%, 0.3-0.2-0.9 MG/150ML-%, 0.4-0.1- OA 0.9 MG/200ML-%, 0.4-0.2-0.9 MG/200ML-%, 0.5-0.2-0.9 MG/250ML-% fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 1 QL (0.34 EA per 1 day) 87.5 mcg/hr FENTANYL-BUPIVACAINE-NACL EPIDURAL SOLUTION 0.2- 0.1-0.9 MG/100ML-%, 0.2-0.125-0.9 MG/100ML-%, 0.5-0.0625- OA 0.9 MG/250ML-%, 0.5-0.1-0.9 MG/250ML-%, 0.5-0.125-0.9 MG/250ML-%, 0.8-0.1667-0.9 MG/200ML-% FENTANYL-BUPIVACAINE-NACL EPIDURAL SOLUTION OA PREFILLED SYRINGE 0.1-0.125-0.9 MG/50ML-% FENTANYL-BUPIVACAINE-NACL INJECTION SOLUTION 2- OA 0.125-0.9 MCG/ML-%-%

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 224 Coverage Requirements & Prescription Drug Name Drug Tier Limits FENTANYL-ROPIVACAINE-NACL EPIDURAL SOLUTION 0.2- OA 0.1-0.9 MG/100ML-% FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 3 600 MCG, 800 MCG (fentanyl citrate) FIORICET/CODEINE ORAL CAPSULE 50-300-40-30 MG 3 (butalbital-apap-caff-cod) hydrocodone bitartrate er oral capsule extended release 12 1 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg hydrocodone bitartrate er oral tablet er 24 hour abuse- deterrent 100 mg, 120 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 1 mg hydrocodone-acetaminophen oral solution 10-325 mg/15ml, 1 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 1 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 1 7.5-200 mg hydromorphone hcl er oral tablet extended release 24 hour 1 12 mg, 16 mg, 32 mg, 8 mg HYDROMORPHONE HCL INJECTION SOLUTION 0.2 MG/ML 3 hydromorphone hcl injection solution 2 mg/ml, 4 mg/ml OA HYDROMORPHONE HCL INTRAVENOUS SOLUTION 0.2 OA MG/ML hydromorphone hcl oral liquid 1 mg/ml 1 hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg 1 hydromorphone hcl pf injection solution 1 mg/ml, 10 mg/ml, OA 2 mg/ml, 4 mg/ml, 50 mg/5ml, 500 mg/50ml hydromorphone hcl rectal suppository 3 mg 1 HYDROMORPHONE HCL SOLUTION 1 MG/ML INJECTION 1 OA MG/ML

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 225 Coverage Requirements & Prescription Drug Name Drug Tier Limits hydromorphone hcl solution 1 mg/ml injection 1 mg/ml OA HYDROMORPHONE HCL-NACL INJECTION SOLUTION 20- OA 0.9 MG/100ML-% HYDROMORPHONE HCL-NACL INJECTION SOLUTION PREFILLED SYRINGE 10-0.9 MG/50ML-%, 30-0.9 MG/30ML- OA % HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION 10-0.9 MG/50ML-%, 100-0.9 MG/50ML-%, 20-0.9 MG/100ML- OA %, 25-0.9 MG/50ML-%, 30-0.9 MG/30ML-%, 50-0.9 MG/50ML- %, 6-0.9 MG/30ML-% HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.2-0.9 MG/0.2ML-%, 0.5-0.9 MG/0.5ML-%, 1-0.9 MG/5ML-%, 1-0.9 MG/ML-%, 10-0.9 OA MG/50ML-%, 15-0.9 MG/30ML-%, 2-0.9 MG/ML-%, 25-0.9 MG/50ML-%, 30-0.9 MG/30ML-%, 5-0.9 MG/25ML-%, 50-0.9 MG/50ML-%, 55-0.9 MG/55ML-%, 6-0.9 MG/30ML-% HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE- DETERRENT 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 3 MG, 80 MG (hydrocodone bitartrate) INFUMORPH 200 INJECTION SOLUTION 200 MG/20ML (10 OA MG/ML) (morphine sulfate microinfusion) INFUMORPH 500 INJECTION SOLUTION 500 MG/20ML (25 OA MG/ML) (morphine sulfate microinfusion) LAZANDA NASAL SOLUTION 100 MCG/ACT, 400 MCG/ACT 3 (fentanyl citrate) levorphanol tartrate oral tablet 2 mg 1 levorphanol tartrate oral tablet 3 mg 1 PA LORTAB ORAL ELIXIR 10-300 MG/15ML (hydrocodone- 3 acetaminophen) meperidine hcl injection solution 100 mg/ml, 25 mg/ml, 50 OA mg/ml

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 226 Coverage Requirements & Prescription Drug Name Drug Tier Limits meperidine hcl oral solution 50 mg/5ml 1 meperidine hcl oral tablet 50 mg 1 methadone hcl injection solution 10 mg/ml OA methadone hcl intensol oral concentrate 10 mg/ml 1 methadone hcl oral concentrate 10 mg/ml 1 methadone hcl oral solution 10 mg/5ml, 5 mg/5ml 1 methadone hcl oral tablet 10 mg, 5 mg 1 methadone hcl oral tablet soluble 40 mg 1 METHADONE HCL-NACL INTRAVENOUS SOLUTION OA PREFILLED SYRINGE 1-0.9 MG/ML-% methadose oral concentrate 10 mg/ml 1 methadose oral tablet soluble 40 mg 1 methadose sugar-free oral concentrate 10 mg/ml 1 mitigo injection solution 200 mg/20ml (10 mg/ml), 500 OA mg/20ml (25 mg/ml) morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 1 mg/ml morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml, OA 10 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml morphine sulfate (pf) intravenous solution 10 mg/ml, 2 OA mg/ml, 4 mg/ml, 8 mg/ml morphine sulfate er beads oral capsule extended release 24 1 hour 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine sulfate er oral capsule extended release 24 hour 1 10 mg, 100 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 80 mg morphine sulfate er oral tablet extended release 100 mg, 15 1 mg, 200 mg, 30 mg, 60 mg MORPHINE SULFATE INJECTION SOLUTION 1 MG/ML OA morphine sulfate injection solution 2 mg/ml, 4 mg/ml OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 227 Coverage Requirements & Prescription Drug Name Drug Tier Limits MORPHINE SULFATE INTRAVENOUS SOLUTION 0.5 MG/ML OA morphine sulfate intravenous solution 50 mg/ml OA morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml 1 morphine sulfate oral tablet 15 mg, 30 mg 1 morphine sulfate rectal suppository 10 mg, 20 mg, 30 mg, 5 1 mg MORPHINE SULFATE SOLUTION 1 MG/ML INTRAVENOUS 1 OA MG/ML morphine sulfate solution 1 mg/ml intravenous 1 mg/ml OA MORPHINE SULFATE-NACL INJECTION SOLUTION 3 PREFILLED SYRINGE 5-0.9 MG/5ML-% MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION 100- OA 0.9 MG/100ML-%, 50-0.9 MG/50ML-%, 500-0.9 MG/100ML-% MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 1-0.9 MG/ML-%, 150-0.9 MG/30ML-%, OA 2-0.9 MG/ML-%, 30-0.9 MG/30ML-%, 4-0.9 MG/ML-%, 50-0.9 MG/50ML-%, 55-0.9 MG/55ML-% MS CONTIN ORAL TABLET EXTENDED RELEASE 100 MG, 3 15 MG, 200 MG, 30 MG, 60 MG (morphine sulfate) NALOCET ORAL TABLET 2.5-300 MG 2 NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG (tapentadol 3 hcl) NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG 3 (tapentadol hcl) OLINVYK INTRAVENOUS SOLUTION 1 MG/ML, 2 MG/2ML, OA 30 MG/30ML (oliceridine fumarate) OXAYDO ORAL TABLET 5 MG, 7.5 MG (oxycodone hcl) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 228 Coverage Requirements & Prescription Drug Name Drug Tier Limits OXYCODONE HCL ER ORAL TABLET ER 12 HOUR ABUSE- DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 2 QL (2 EA per 1 day) 80 MG oxycodone hcl oral capsule 5 mg 1 oxycodone hcl oral concentrate 100 mg/5ml 1 oxycodone hcl oral solution 5 mg/5ml 1 oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 1 mg OXYCODONE-ACETAMINOPHEN ORAL SOLUTION 10-300 3 PA MG/5ML OXYCODONE-ACETAMINOPHEN ORAL TABLET 10-300 MG, 2 2.5-300 MG, 5-300 MG oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 1 mg, 5-325 mg, 7.5-325 mg OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE- DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 2 QL (2 EA per 1 day) 80 MG (oxycodone hcl) oxymorphone hcl er oral tablet extended release 12 hour 10 1 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg oxymorphone hcl oral tablet 10 mg, 5 mg 1 PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 3 MG, 7.5-325 MG (oxycodone-acetaminophen) PROLATE ORAL SOLUTION 10-300 MG/5ML (oxycodone- 3 PA acetaminophen) PROLATE ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 MG 2 (oxycodone-acetaminophen) QDOLO ORAL SOLUTION 5 MG/ML (tramadol hcl) 3 remifentanil hcl intravenous solution reconstituted 1 mg, 2 OA mg, 5 mg

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 229 Coverage Requirements & Prescription Drug Name Drug Tier Limits ROXICODONE ORAL TABLET 15 MG, 30 MG, 5 MG 3 (oxycodone hcl) SUBSYS SUBLINGUAL LIQUID 100 MCG, 1200 (600 X 2) MCG, 1600 (800 X 2) MCG, 200 MCG, 400 MCG, 600 MCG, 3 800 MCG (fentanyl) sufentanil citrate intravenous solution 100 mcg/2ml, 250 OA mcg/5ml, 50 mcg/ml tramadol hcl er (biphasic) oral tablet extended release 24 1 hour 100 mg, 200 mg, 300 mg TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 3 24 HOUR 100 MG, 200 MG, 300 MG tramadol hcl er oral tablet extended release 24 hour 100 1 mg, 200 mg, 300 mg tramadol hcl oral tablet 100 mg, 50 mg 1 tramadol-acetaminophen oral tablet 37.5-325 mg 1 TREZIX ORAL CAPSULE 320.5-30-16 MG (apap-caff- 3 dihydrocodeine) ULTIVA INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, OA 2 MG, 5 MG (remifentanil hcl) ULTRACET ORAL TABLET 37.5-325 MG (tramadol- 3 acetaminophen) ULTRAM ORAL TABLET 50 MG (tramadol hcl) 3 XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE- DETERRENT 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG 3 PA; QL (2 EA per 1 day) (oxycodone) OPIATE ANTAGONISTS - Drugs for Overdose or Poisoning BUNAVAIL BUCCAL FILM 4.2-0.7 MG (buprenorphine hcl- 3 PA naloxone hcl) buprenorphine hcl-naloxone hcl sublingual film 12-3 mg, 2- 1 PA 0.5 mg, 4-1 mg, 8-2 mg

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 230 Coverage Requirements & Prescription Drug Name Drug Tier Limits buprenorphine hcl-naloxone hcl sublingual tablet 1 PA sublingual 2-0.5 mg, 8-2 mg KLOXXADO NASAL LIQUID 8 MG/0.1ML (naloxone hcl) 3 PA LIFEMS NALOXONE INJECTION PREFILLED SYRINGE KIT 2 3 PA MG/2ML PA; QL (30 day supply per 1 naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml SI fill) naloxone hcl injection solution cartridge 0.4 mg/ml SI QL (30 day supply per 1 fill) PA; QL (30 day supply per 1 naloxone hcl injection solution prefilled syringe 2 mg/2ml SI fill) naltrexone hcl oral tablet 50 mg 1 NALTREXONE SUBCUTANEOUS IMPLANT 200-6.5 MG 3 NARCAN NASAL LIQUID 4 MG/0.1ML (naloxone hcl) 3 pentazocine-naloxone hcl oral tablet 50-0.5 mg 1 RELISTOR ORAL TABLET 150 MG (methylnaltrexone 3 PA bromide) RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, 8 PA; QL (30 day supply per 1 SI MG/0.4ML (methylnaltrexone bromide) fill) SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-1 MG, 3 PA 8-2 MG (buprenorphine hcl-naloxone hcl) VIVITROL INTRAMUSCULAR SUSPENSION OA QL (30 day supply per 1 fill) RECONSTITUTED 380 MG (naltrexone) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 3 PA MG (buprenorphine hcl-naloxone hcl) OPIATE PARTIAL AGONISTS - Drugs for Pain BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 3 MCG, 75 MCG, 750 MCG, 900 MCG (buprenorphine hcl) BUNAVAIL BUCCAL FILM 4.2-0.7 MG (buprenorphine hcl- 3 PA naloxone hcl)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 231 Coverage Requirements & Prescription Drug Name Drug Tier Limits BUPRENEX INJECTION SOLUTION 0.3 MG/ML OA (buprenorphine hcl) buprenorphine hcl injection solution 0.3 mg/ml OA buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg 1 buprenorphine hcl-naloxone hcl sublingual film 12-3 mg, 2- 1 PA 0.5 mg, 4-1 mg, 8-2 mg buprenorphine hcl-naloxone hcl sublingual tablet 1 PA sublingual 2-0.5 mg, 8-2 mg buprenorphine transdermal patch weekly 10 mcg/hr, 15 1 mcg/hr, 20 mcg/hr, 5 mcg/hr, 7.5 mcg/hr butorphanol tartrate injection solution 1 mg/ml, 2 mg/ml OA QL (10 ML per 30 days) butorphanol tartrate nasal solution 10 mg/ml 1 QL (10 ML per 30 days) BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR, 7.5 MCG/HR 3 (buprenorphine) nalbuphine hcl injection solution 10 mg/ml, 20 mg/ml OA pentazocine-naloxone hcl oral tablet 50-0.5 mg 1 SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 100 MG/0.5ML, 300 MG/1.5ML (buprenorphine) per 1 fill) SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-1 MG, 3 PA 8-2 MG (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 3 PA MG (buprenorphine hcl-naloxone hcl) OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS - Drugs for Pain ANJESO INTRAVENOUS INJECTABLE 30 MG/ML OA (meloxicam) ARTHROTEC ORAL TABLET DELAYED RELEASE 50-0.2 MG, 3 75-0.2 MG (diclofenac-misoprostol)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 232 Coverage Requirements & Prescription Drug Name Drug Tier Limits CALDOLOR INTRAVENOUS SOLUTION 800 MG/200ML, 800 OA MG/8ML (ibuprofen) CAMBIA ORAL PACKET 50 MG (diclofenac 3 PA potassium(migraine)) CATAFLAM ORAL TABLET 50 MG (diclofenac potassium) 3 DAYPRO ORAL TABLET 600 MG (oxaprozin) 3 DEXAMETH-MOXIFLOX-KETOROLAC INTRAOCULAR OA SOLUTION 1-0.5-0.4 MG/ML DICLOFENAC CAP ORAL CAPSULE 35 MG 3 PA DICLOFENAC PATCH EXTERNAL PATCH 1.3 % 3 PA diclofenac potassium oral tablet 50 mg 1 diclofenac sodium er oral tablet extended release 24 hour 1 100 mg diclofenac sodium oral tablet delayed release 25 mg, 50 1 mg, 75 mg diclofenac-misoprostol oral tablet delayed release 50-0.2 1 mg, 75-0.2 mg diflunisal oral tablet 500 mg 1 DUEXIS ORAL TABLET 800-26.6 MG (ibuprofen-famotidine) 3 PA EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG, 3 500 MG (naproxen) ec-naproxen oral tablet delayed release 375 mg, 500 mg 1 etodolac er oral tablet extended release 24 hour 400 mg, 1 500 mg, 600 mg etodolac oral capsule 200 mg, 300 mg 1 etodolac oral tablet 400 mg, 500 mg 1 FELDENE ORAL CAPSULE 10 MG, 20 MG (piroxicam) 3 fenoprofen calcium oral capsule 200 mg, 400 mg 3 PA fenoprofen calcium oral tablet 600 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 233 Coverage Requirements & Prescription Drug Name Drug Tier Limits fenortho oral capsule 200 mg 3 PA FLECTOR EXTERNAL PATCH 1.3 % (diclofenac epolamine) 3 PA flurbiprofen oral tablet 100 mg, 50 mg 1 hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 1 7.5-200 mg ibuprofen lysine intravenous solution 10 mg/ml OA ibuprofen oral suspension 100 mg/5ml 1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 ibuprofen-famotidine oral tablet 800-26.6 mg 1 PA INDOCIN ORAL SUSPENSION 25 MG/5ML (indomethacin) 2 INDOCIN RECTAL SUPPOSITORY 50 MG (indomethacin) 3 indomethacin er oral capsule extended release 75 mg 1 INDOMETHACIN ORAL CAPSULE 20 MG 3 PA indomethacin oral capsule 25 mg, 50 mg 1 indomethacin sodium intravenous solution reconstituted 1 OA mg ketoprofen er oral capsule extended release 24 hour 200 1 mg ketoprofen oral capsule 25 mg, 50 mg, 75 mg 1 PA; QL (30 day supply per 1 ketorolac tromethamine injection solution 15 mg/ml SI fill) PA; QL (30 day supply per 1 ketorolac tromethamine intramuscular solution 60 mg/2ml SI fill) KETOROLAC TROMETHAMINE NASAL SOLUTION 15.75 PA; QL (30 day supply per 1 3 MG/SPRAY fill) ketorolac tromethamine oral tablet 10 mg 1 ketorolac tromethamine solution 30 mg/ml injection 30 PA; QL (30 day supply per 1 SI mg/ml fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 234 Coverage Requirements & Prescription Drug Name Drug Tier Limits KETOROLAC TROMETHAMINE SOLUTION 30 MG/ML PA; QL (30 day supply per 1 3 INJECTION 30 MG/ML fill) KETOROLAC-BUPIV-KETAMINE INJECTION SOLUTION 3 PREFILLED SYRINGE 60-150-60 MG/50ML KETOROLAC-ROPIV-KETAMINE INJECTION SOLUTION 3 PREFILLED SYRINGE 15-100-30 MG/50ML LICART EXTERNAL PATCH 24 HOUR 1.3 % (diclofenac 3 PA epolamine) LODINE ORAL TABLET 400 MG (etodolac) 3 meclofenamate sodium oral capsule 100 mg, 50 mg 1 mefenamic acid oral capsule 250 mg 1 meloxicam oral capsule 10 mg, 5 mg 1 PA meloxicam oral tablet 15 mg, 7.5 mg 1 MOBIC ORAL TABLET 15 MG, 7.5 MG (meloxicam) 3 nabumetone oral tablet 500 mg, 750 mg 1 NALFON ORAL CAPSULE 400 MG (fenoprofen calcium) 3 PA NALFON ORAL TABLET 600 MG (fenoprofen calcium) 3 NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 3 PA 375 MG, 500 MG (naproxen sodium) NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 2 PA 750 MG (naproxen sodium) NAPROSYN ORAL SUSPENSION 125 MG/5ML (naproxen) 3 NAPROSYN ORAL TABLET 500 MG (naproxen) 3 naproxen oral suspension 125 mg/5ml 1 naproxen oral tablet 250 mg, 375 mg, 500 mg 1 naproxen oral tablet delayed release 375 mg, 500 mg 1 naproxen sodium er oral tablet extended release 24 hour 1 PA 375 mg, 500 mg

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 235 Coverage Requirements & Prescription Drug Name Drug Tier Limits NAPROXEN SODIUM ER ORAL TABLET EXTENDED 2 PA RELEASE 24 HOUR 750 MG naproxen sodium oral tablet 275 mg, 550 mg 1 naproxen-esomeprazole oral tablet delayed release 375-20 1 mg, 500-20 mg NEOPROFEN INTRAVENOUS SOLUTION 10 MG/ML OA (ibuprofen lysine) oxaprozin oral tablet 600 mg 1 piroxicam oral capsule 10 mg, 20 mg 1 RELAFEN DS ORAL TABLET 1000 MG (nabumetone) 3 RELAFEN ORAL TABLET 500 MG, 750 MG (nabumetone) 3 ROPIV-CLONIDINE-KETOROLAC SOLUTION PREFILLED 3 SYRINGE 123-0.04-15 MG/50ML SPRIX NASAL SOLUTION 15.75 MG/SPRAY (ketorolac PA; QL (30 day supply per 1 3 tromethamine) fill) sulindac oral tablet 150 mg, 200 mg 1 sumatriptan-naproxen sodium oral tablet 85-500 mg 1 QL (0.3 EA per 1 day) TIVORBEX ORAL CAPSULE 20 MG (indomethacin) 3 PA TREXIMET ORAL TABLET 85-500 MG (sumatriptan- 3 QL (0.3 EA per 1 day) naproxen sodium) VIMOVO ORAL TABLET DELAYED RELEASE 375-20 MG, 3 500-20 MG (naproxen-esomeprazole) VIVLODEX ORAL CAPSULE 10 MG, 5 MG (meloxicam) 3 PA ZIPSOR ORAL CAPSULE 25 MG (diclofenac potassium) 3 PA ZORVOLEX ORAL CAPSULE 18 MG, 35 MG (diclofenac) 3 PA ZYNRELEF INJECTION SOLUTION 200-6 MG/7ML, 400-12 OA PA MG/14ML (bupivacaine-meloxicam) PHENOTHIAZINES - Drugs for Depression & Psychosis chlorpromazine hcl injection solution 25 mg/ml, 50 mg/2ml OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 236 Coverage Requirements & Prescription Drug Name Drug Tier Limits chlorpromazine hcl oral concentrate 100 mg/ml, 30 mg/ml 1 chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 1 mg, 50 mg compro rectal suppository 25 mg 1 fluphenazine decanoate injection solution 25 mg/ml OA fluphenazine hcl injection solution 2.5 mg/ml OA fluphenazine hcl oral concentrate 5 mg/ml 1 fluphenazine hcl oral elixir 2.5 mg/5ml 1 fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg 1 perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 1 perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4- 1 10 mg, 4-25 mg, 4-50 mg prochlorperazine edisylate injection solution 10 mg/2ml, 50 OA mg/10ml prochlorperazine maleate oral tablet 10 mg, 5 mg 1 prochlorperazine rectal suppository 25 mg 1 thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1 trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg 1 RESPIRATORY AND CNS STIMULANTS - Drugs for the Nervous System ACTIVE INJECTION KL-3 COMBINATION KIT 40-1 MG/ML-% OA ADHANSIA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 25 MG, 35 MG, 45 MG, 55 MG, 70 MG, 85 MG 3 ST; AL (Min 6 Years) (methylphenidate hcl) apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg 1 apap-caff-dihydrocodeine oral tablet 325-30-16 mg 1 APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG 3 ST; AL (Min 6 Years) (methylphenidate hcl)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 237 Coverage Requirements & Prescription Drug Name Drug Tier Limits ascomp-codeine oral capsule 50-325-40-30 mg 1 PA AZSTARYS ORAL CAPSULE 26.1-5.2 MG, 39.2-7.8 MG, 52.3- 3 PA 10.4 MG (serdexmethylphen-dexmethylphen) bac oral tablet 50-325-40 mg 1 butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50- 1 325-40-30 mg butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325- 1 40 mg butalbital-apap-caffeine oral tablet 50-325-40 mg 1 butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 PA butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 CAFCIT INTRAVENOUS SOLUTION 60 MG/3ML (caffeine OA citrate) CAFERGOT ORAL TABLET 1-100 MG (ergotamine-caffeine) 3 caffeine citrate intravenous solution 60 mg/3ml OA caffeine citrate oral solution 20 mg/ml, 60 mg/3ml 1 CAFFEINE-SODIUM BENZOATE INJECTION SOLUTION 125- OA 125 MG/ML CONCERTA ORAL TABLET EXTENDED RELEASE 18 MG, 27 3 ST; AL (Min 6 Years) MG, 36 MG, 54 MG (methylphenidate hcl) COTEMPLA XR-ODT ORAL TABLET EXTENDED RELEASE 3 ST; AL (Min 6 Years) DISPERSIBLE 17.3 MG, 25.9 MG, 8.6 MG (methylphenidate) DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 3 ST; AL (Min 6 Years) MG/9HR, 20 MG/9HR, 30 MG/9HR (methylphenidate) dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 1 AL (Min 6 Years) 5 mg dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg 1 DOPRAM INTRAVENOUS SOLUTION 20 MG/ML (doxapram OA hcl) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 238 Coverage Requirements & Prescription Drug Name Drug Tier Limits ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 2 ergotamine-caffeine oral tablet 1-100 mg 1 ESGIC ORAL CAPSULE 50-325-40 MG (butalbital-apap- 3 caffeine) ESGIC ORAL TABLET 50-325-40 MG (butalbital-apap- 3 caffeine) FIORICET ORAL CAPSULE 50-300-40 MG (butalbital-apap- 3 caffeine) FIORICET/CODEINE ORAL CAPSULE 50-300-40-30 MG 3 (butalbital-apap-caff-cod) FOCALIN ORAL TABLET 10 MG, 2.5 MG, 5 MG 3 (dexmethylphenidate hcl) FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG, 3 ST; AL (Min 6 Years) 5 MG (dexmethylphenidate hcl) JORNAY PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 20 MG, 40 MG, 60 MG, 80 MG 3 ST; AL (Min 6 Years) (methylphenidate hcl) METHYLIN ORAL SOLUTION 10 MG/5ML, 5 MG/5ML 3 (methylphenidate hcl) methylphenidate hcl er (cd) oral capsule extended release 1 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule extended release 1 AL (Min 6 Years) 24 hour 10 mg, 20 mg, 30 mg, 40 mg, 60 mg methylphenidate hcl er (xr) oral capsule extended release 1 AL (Min 6 Years) 24 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er oral tablet extended release 10 mg, 1 AL (Min 6 Years) 18 mg, 20 mg, 27 mg, 36 mg, 54 mg, 72 mg methylphenidate hcl er oral tablet extended release 24 hour 1 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml 1 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 239 Coverage Requirements & Prescription Drug Name Drug Tier Limits methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg 1 methylphenidate hcl oral tablet chewable 10 mg, 2.5 mg, 5 1 mg MIGERGOT RECTAL SUPPOSITORY 2-100 MG (ergotamine- 3 caffeine) NORGESIC FORTE ORAL TABLET 50-770-60 MG 3 PA orphenadrine-asa-caffeine oral tablet 50-770-60 mg 1 PA ORPHENGESIC FORTE ORAL TABLET 50-770-60 MG 3 PA (orphenadrine-aspirin-caffeine) PHYSICIANS EZ USE JOINT/TUNNEL COMBINATION KIT 40- OA 1 MG/ML-% QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED 3 ST; AL (Min 6 Years) RELEASE 20 MG, 30 MG, 40 MG (methylphenidate hcl) QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED ER 3 ST; AL (Min 6 Years) 25 MG/5ML (methylphenidate hcl) relexxii oral tablet extended release 72 mg 1 AL (Min 6 Years) RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 3 ST; AL (Min 6 Years) HOUR 10 MG, 20 MG, 30 MG, 40 MG (methylphenidate hcl) RITALIN ORAL TABLET 10 MG, 20 MG, 5 MG 3 (methylphenidate hcl) THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 1 mg, 450 mg theophylline er oral tablet extended release 24 hour 400 1 mg, 600 mg theophylline oral solution 80 mg/15ml 1 TREZIX ORAL CAPSULE 320.5-30-16 MG (apap-caff- 3 dihydrocodeine)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 240 Coverage Requirements & Prescription Drug Name Drug Tier Limits VTOL LQ ORAL SOLUTION 50-325-40 MG/15ML (butalbital- 2 apap-caffeine) ZEBUTAL ORAL CAPSULE 50-325-40 MG (butalbital-apap- 3 caffeine) SALICYLATES - Drugs for Pain adult aspirin regimen oral tablet delayed release 81 mg 1 PV ascomp-codeine oral capsule 50-325-40-30 mg 1 PA aspirin adult low dose oral tablet delayed release 81 mg 1 PV aspirin adult low strength oral tablet delayed release 81 mg 1 PV aspirin childrens oral tablet chewable 81 mg 1 PV aspirin ec low dose oral tablet delayed release 81 mg 1 PV aspirin ec low strength oral tablet delayed release 81 mg 1 PV aspirin ec oral tablet delayed release 325 mg 1 PV aspirin low dose oral tablet chewable 81 mg 1 PV aspirin low dose oral tablet delayed release 81 mg 1 PV aspirin oral tablet 325 mg 1 PV aspirin oral tablet delayed release 325 mg, 81 mg 1 PV aspirin-dipyridamole er oral capsule extended release 12 1 hour 25-200 mg BAYER ASPIRIN EC LOW DOSE ORAL TABLET DELAYED 3 PV RELEASE 81 MG (aspirin) BAYER ASPIRIN ORAL TABLET 325 MG (aspirin) 3 PV BAYER ASPIRIN ORAL TABLET DELAYED RELEASE 325 MG 3 PV (aspirin) butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 PA butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 carisoprodol-aspirin-codeine oral tablet 200-325-16 mg 1 PA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 241 Coverage Requirements & Prescription Drug Name Drug Tier Limits DURLAZA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 PA 162.5 MG (aspirin) goodsense aspirin adults oral tablet 325 mg 1 PV goodsense aspirin low dose oral tablet delayed release 81 1 PV mg NORGESIC FORTE ORAL TABLET 50-770-60 MG 3 PA orphenadrine-asa-caffeine oral tablet 50-770-60 mg 1 PA ORPHENGESIC FORTE ORAL TABLET 50-770-60 MG 3 PA (orphenadrine-aspirin-caffeine) salsalate oral tablet 750 mg 1 ST JOSEPH LOW DOSE ORAL TABLET DELAYED RELEASE 3 PV 81 MG (aspirin) SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR - Drugs for Depression & Psychosis CYMBALTA ORAL CAPSULE DELAYED RELEASE 3 PARTICLES 20 MG, 30 MG, 60 MG (duloxetine hcl) DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 3 24 HOUR 100 MG, 50 MG desvenlafaxine succinate er oral tablet extended release 24 1 hour 100 mg, 25 mg, 50 mg DRIZALMA SPRINKLE ORAL CAPSULE DELAYED RELEASE 3 SPRINKLE 20 MG, 30 MG, 40 MG, 60 MG (duloxetine hcl) duloxetine hcl oral capsule delayed release particles 20 mg, 1 30 mg, 40 mg, 60 mg EFFEXOR XR ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 150 MG, 37.5 MG, 75 MG (venlafaxine hcl) FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 120 MG, 20 MG, 40 MG, 80 MG (levomilnacipran hcl) FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR 3 THERAPY PACK 20 & 40 MG (levomilnacipran hcl)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 242 Coverage Requirements & Prescription Drug Name Drug Tier Limits PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 100 3 MG, 25 MG, 50 MG (desvenlafaxine succinate) SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG 3 (milnacipran hcl) SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG 3 (milnacipran hcl) venlafaxine hcl er oral capsule extended release 24 hour 1 150 mg, 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 150 1 mg, 225 mg, 37.5 mg, 75 mg venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 1 75 mg SELECTIVE SEROTONIN AGONISTS - Migraine Treatment almotriptan malate oral tablet 12.5 mg, 6.25 mg 1 QL (0.4 EA per 1 day) AMERGE ORAL TABLET 1 MG, 2.5 MG (naratriptan hcl) 3 QL (0.3 EA per 1 day) eletriptan hydrobromide oral tablet 20 mg, 40 mg 1 QL (0.4 EA per 1 day) FROVA ORAL TABLET 2.5 MG (frovatriptan succinate) 3 QL (0.6 EA per 1 day) frovatriptan succinate oral tablet 2.5 mg 1 QL (0.6 EA per 1 day) IMITREX NASAL SOLUTION 20 MG/ACT, 5 MG/ACT 3 QL (12 EA per 30 days) (sumatriptan) IMITREX ORAL TABLET 100 MG, 25 MG, 50 MG (sumatriptan 3 QL (0.3 EA per 1 day) succinate) IMITREX STATDOSE REFILL SUBCUTANEOUS SOLUTION CARTRIDGE 4 MG/0.5ML, 6 MG/0.5ML (sumatriptan SI QL (30 day supply per 1 fill) succinate) IMITREX STATDOSE SYSTEM SUBCUTANEOUS SOLUTION AUTO-INJECTOR 4 MG/0.5ML, 6 MG/0.5ML (sumatriptan SI QL (0.17 ML per 1 day) succinate) IMITREX SUBCUTANEOUS SOLUTION 6 MG/0.5ML SI QL (30 day supply per 1 fill) (sumatriptan succinate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 243 Coverage Requirements & Prescription Drug Name Drug Tier Limits MAXALT ORAL TABLET 10 MG (rizatriptan benzoate) 3 QL (0.6 EA per 1 day) MAXALT-MLT ORAL TABLET DISPERSIBLE 10 MG 3 QL (0.6 EA per 1 day) (rizatriptan benzoate) naratriptan hcl oral tablet 1 mg, 2.5 mg 1 QL (0.3 EA per 1 day) ONZETRA XSAIL NASAL EXHALER POWDER 11 3 PA MG/NOSEPC (sumatriptan succinate) RELPAX ORAL TABLET 20 MG, 40 MG (eletriptan 3 QL (0.4 EA per 1 day) hydrobromide) REYVOW ORAL TABLET 100 MG, 50 MG (lasmiditan PA; QL (0.143 EA per 1 day); 3 succinate) AL (Min 18 Years) rizatriptan benzoate oral tablet 10 mg, 5 mg 1 QL (0.6 EA per 1 day) rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg 1 QL (0.6 EA per 1 day) sumatriptan nasal solution 20 mg/act, 5 mg/act 1 QL (12 EA per 30 days) sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg 1 QL (0.3 EA per 1 day) sumatriptan succinate refill subcutaneous solution SI QL (30 day supply per 1 fill) cartridge 4 mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution 6 mg/0.5ml SI QL (30 day supply per 1 fill) sumatriptan succinate subcutaneous solution auto-injector SI QL (0.17 ML per 1 day) 4 mg/0.5ml, 6 mg/0.5ml sumatriptan-naproxen sodium oral tablet 85-500 mg 1 QL (0.3 EA per 1 day) TOSYMRA NASAL SOLUTION 10 MG/ACT (sumatriptan) 3 QL (12 EA per 30 days) TREXIMET ORAL TABLET 85-500 MG (sumatriptan- 3 QL (0.3 EA per 1 day) naproxen sodium) ZEMBRACE SYMTOUCH SUBCUTANEOUS SOLUTION SI SP; QL (0.27 ML per 1 day) AUTO-INJECTOR 3 MG/0.5ML (sumatriptan succinate) ZOLMITRIPTAN NASAL SOLUTION 2.5 MG, 5 MG 2 QL (0.4 EA per 1 day) zolmitriptan oral tablet 2.5 mg, 5 mg 1 QL (0.4 EA per 1 day) zolmitriptan oral tablet dispersible 2.5 mg 1 QL (0.4 EA per 1 day) zolmitriptan oral tablet dispersible 5 mg 1 QL (0.3 EA per 1 day)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 244 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZOMIG NASAL SOLUTION 2.5 MG, 5 MG (zolmitriptan) 2 QL (0.4 EA per 1 day) ZOMIG ORAL TABLET 2.5 MG, 5 MG (zolmitriptan) 3 QL (0.4 EA per 1 day) SELECTIVE-SEROTONIN REUPTAKE INHIBITORS - Drugs for Depression & Psychosis BRISDELLE ORAL CAPSULE 7.5 MG (paroxetine mesylate) 3 CELEXA ORAL TABLET 10 MG, 20 MG, 40 MG (citalopram 3 hydrobromide) citalopram hydrobromide oral solution 10 mg/5ml 1 citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg 1 escitalopram oxalate oral solution 5 mg/5ml 1 escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg 1 fluoxetine hcl (pmdd) oral tablet 10 mg, 20 mg 1 PA fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg 1 fluoxetine hcl oral capsule delayed release 90 mg 1 fluoxetine hcl oral solution 20 mg/5ml 1 fluvoxamine maleate er oral capsule extended release 24 1 hour 100 mg, 150 mg fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg 1 LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG (escitalopram 3 oxalate) olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 1 3-25 mg, 6-25 mg, 6-50 mg paroxetine hcl er oral tablet extended release 24 hour 12.5 1 mg, 25 mg, 37.5 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg 1 paroxetine mesylate oral capsule 7.5 mg 1 PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 12.5 MG, 25 MG, 37.5 MG (paroxetine hcl) PAXIL ORAL SUSPENSION 10 MG/5ML (paroxetine hcl) 3 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 245 Coverage Requirements & Prescription Drug Name Drug Tier Limits PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG 3 (paroxetine hcl) PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG 3 (paroxetine mesylate) PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG (fluoxetine 3 hcl) sertraline hcl oral concentrate 20 mg/ml 1 sertraline hcl oral tablet 100 mg, 25 mg, 50 mg 1 SYMBYAX ORAL CAPSULE 3-25 MG, 6-25 MG (olanzapine- 3 fluoxetine hcl) ZOLOFT ORAL CONCENTRATE 20 MG/ML (sertraline hcl) 3 ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG (sertraline 3 hcl) SEROTONIN MODULATORS - Drugs for Depression & Psychosis nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 1 50 mg trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg 1 TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG 3 (vortioxetine hbr) VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG (vilazodone 3 hcl) VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG (vilazodone 3 hcl) SUCCINIMIDES - Drugs for Seizures CELONTIN ORAL CAPSULE 300 MG (methsuximide) 2 ethosuximide oral capsule 250 mg 1 ethosuximide oral solution 250 mg/5ml 1 ZARONTIN ORAL CAPSULE 250 MG (ethosuximide) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 246 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZARONTIN ORAL SOLUTION 250 MG/5ML (ethosuximide) 3 THIOXANTHENES - Drugs for Depression & Psychosis thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 TRICYCLICS, OTHER NOREPI-RU INHIBITORS - Drugs for Depression & Psychosis amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 1 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg 1 ANAFRANIL ORAL CAPSULE 25 MG, 50 MG, 75 MG 3 (clomipramine hcl) chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 1 mg clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg 1 desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 1 50 mg, 75 mg doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 1 mg, 75 mg doxepin hcl oral concentrate 10 mg/ml 1 doxepin hcl oral tablet 3 mg, 6 mg 1 imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 1 imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 1 75 mg NORPRAMIN ORAL TABLET 10 MG, 25 MG (desipramine 3 hcl) nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg 1 nortriptyline hcl oral solution 10 mg/5ml 1 PAMELOR ORAL CAPSULE 10 MG, 25 MG, 50 MG, 75 MG 3 (nortriptyline hcl)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 247 Coverage Requirements & Prescription Drug Name Drug Tier Limits perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4- 1 10 mg, 4-25 mg, 4-50 mg protriptyline hcl oral tablet 10 mg, 5 mg 1 SILENOR ORAL TABLET 3 MG, 6 MG (doxepin hcl) 3 trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg 1 VESICULAR MONOAMINE TRANSPORT2 INHIBITOR - Drugs for the Nervous System AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG PA; SP; QL (30 day supply 3 (deutetrabenazine) per 1 fill) INGREZZA ORAL CAPSULE 40 MG, 60 MG, 80 MG PA; SP; QL (30 day supply 3 (valbenazine tosylate) per 1 fill) INGREZZA ORAL CAPSULE THERAPY PACK 40 & 80 MG PA; SP; QL (30 day supply 3 (valbenazine tosylate) per 1 fill) PA; SP; QL (30 day supply tetrabenazine oral tablet 12.5 mg, 25 mg 1 per 1 fill) PA; SP; QL (30 day supply XENAZINE ORAL TABLET 12.5 MG, 25 MG (tetrabenazine) 3 per 1 fill) WAKEFULNESS-PROMOTING AGENTS - Drugs for the Nervous System armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg 1 modafinil oral tablet 100 mg, 200 mg 1 NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 MG 3 (armodafinil) PROVIGIL ORAL TABLET 100 MG, 200 MG (modafinil) 3 SUNOSI ORAL TABLET 150 MG, 75 MG (solriamfetol hcl) 3 PA PA; SP; QL (30 day supply WAKIX ORAL TABLET 17.8 MG, 4.45 MG (pitolisant hcl) 3 per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 248 Coverage Requirements & Prescription Drug Name Drug Tier Limits DENTAL AGENTS - Oral Care DENTAL AGENTS - Oral Care FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE 1.1-5 % 3 (sod fluoride-potassium nitrate) MI PASTE DENTAL PASTE (dentifrices) 3 MI PASTE PLUS DENTAL PASTE (dentifrices) 3 NAFRINSE DAILY ACIDULATED MOUTH/THROAT SOLUTION RECONSTITUTED 1 MG/5ML (sodium fluoride- 3 phosphoric acd) PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE 1.1-5 3 % (sod fluoride-potassium nitrate) PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 % (sod 3 fluoride-potassium nitrate) REMESENSE DENTAL 3 % (dental desensitizing product) 3 sodium fluoride 5000 enamel dental paste 1.1-5 % 1 sodium fluoride 5000 sensitive dental paste 1.1-5 % 1 DEVICES - Medical Supplies and Durable Medical Equipment DEVICES - Medical Supplies and Durable Medical Equipment ACCU-CHEK AVIVA IN VITRO SOLUTION (blood glucose 3 calibration) ACCU-CHEK COMPACT PLUS CONTROL IN VITRO 3 SOLUTION (blood glucose calibration) ACCU-CHEK GUIDE CONTROL IN VITRO LIQUID (blood 3 glucose calibration) ACCU-CHEK SMARTVIEW CONTROL IN VITRO LIQUID 3 (blood glucose calibration) AEROCHAMBER MINI CHAMBER DEVICE (spacer/aero- 2 holding chambers)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 249 Coverage Requirements & Prescription Drug Name Drug Tier Limits AEROCHAMBER MV (spacer/aero-holding chambers) 2 AEROCHAMBER PLUS FLO-VU (spacer/aero-holding 2 chambers) AEROCHAMBER PLUS FLOW VU (spacer/aero-holding 2 chambers) AEROCHAMBER W/FLOWSIGNAL (spacer/aero-holding 2 chambers) AGAMATRIX CONTROL LEVEL 2 IN VITRO SOLUTION 3 (blood glucose calibration) AGAMATRIX CONTROL LEVEL 4 IN VITRO SOLUTION 3 (blood glucose calibration) ALCOHOL PREP PADS PAD 3 ALCOHOL PREP PADS PAD 70 % 3 ALCOHOL PREP PADS SHEET 70 % 3 AMD FOAM DRESSING PAD 3-1/2"X3" , 6"X6" (gauze pads & 3 dressings) BD AUTOSHIELD DUO PEN NEEDLES 30G X 5 MM (insulin 2 pen needle) BD ULTRA-FINE INSULIN SYRINGES 27G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 31G X 15/64" 0.3 2 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe- needle u-100) BD ULTRA-FINE INSULIN SYRINGES 31G X 6MM 0.5 ML 2 (insulin syringe/needle u-500) BD ULTRA-FINE PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM (insulin pen 2 needle) BIOFREQUENCY INSOLES (foot care products) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 250 Coverage Requirements & Prescription Drug Name Drug Tier Limits BLULINK CONTROL HIGH & LOW IN VITRO LIQUID (blood 3 glucose calibration) BLULINK GLUCOSE MONITORING SYS DEVICE (blood 3 glucose monitoring suppl) BREATHE EASE LARGE DEVICE 2 BREATHE EASE MEDIUM DEVICE 2 BREATHE EASE SMALL DEVICE 2 CARETOUCH CONTROL SOL LEVEL 2 IN VITRO LIQUID 3 (blood glucose calibration) CEFALY KIT DEVICE (nerve stimulator) OA CEQUR SIMPLICITY 2U DEVICE (injection device for SI QL (30 day supply per 1 fill) insulin) CEQUR SIMPLICITY INSERTER (injection device for insulin) OA CHEMSTRIP BG LOG BOOK (blood glucose monitoring 3 suppl) CLEVER CHOICE HOLDING CHAMBER DEVICE 2 (spacer/aero-holding chambers) CLEVER CHOICE TENS UNIT DEVICE (nerve stimulator) OA COMPACT SPACE CHAMBER DEVICE (spacer/aero-holding 2 chambers) COMPACT SPACE CHAMBER/LG MASK DEVICE 2 (spacer/aero-holding chambers) COMPACT SPACE CHAMBER/MED MASK DEVICE 2 (spacer/aero-holding chambers) COMPACT SPACE CHAMBER/SM MASK DEVICE 2 (spacer/aero-holding chambers) CONTOUR CONTROL IN VITRO LIQUID HIGH , LOW , 3 NORMAL (blood glucose calibration) CONTOUR MONITOR DEVICE DEVICE (blood glucose 3 monitoring suppl)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 251 Coverage Requirements & Prescription Drug Name Drug Tier Limits CONTOUR NEXT CONTROL IN VITRO SOLUTION LOW , 3 NORMAL (blood glucose calibration) CURITY AMD ANTIMICROBIAL STRIP (gauze pads & 3 dressings) CURITY IODOFORM PACKING STRIP (gauze pads & 3 dressings) DIASCREEN 1B (urine glucose monitoring suppl) 3 DIASCREEN 1K STRIP (urine glucose monitoring suppl) 3 DIATHRIVE BLOOD GLUCOSE METER DEVICE (blood 3 glucose monitoring suppl) DIATHRIVE GLUCOSE CONTROL SOLN IN VITRO LIQUID 3 (blood glucose calibration) DIATHRIVE+ GLUCOSE MONITOR DEVICE (blood glucose 3 monitoring suppl) DROPLET MICRON 34G X 3.5 MM (insulin pen needle) 2 EASIVENT (spacer/aero-holding chambers) 2 EASY TRAK II BLOOD GLUCOSE SYS DEVICE 3 EASY TRAK II CONTROL IN VITRO LIQUID NORMAL 3 EASYMAX 15 LEVEL 2-3 CONTROL IN VITRO LIQUID (blood 3 glucose calibration) EASYMAX CONTROL IN VITRO SOLUTION NORMAL (blood 3 glucose calibration) EASYMAX CONTROL NORMAL/HIGH IN VITRO LIQUID 3 (blood glucose calibration) EMBRACE EVO GLUCOSE MONITOR DEVICE (blood 3 glucose monitoring suppl) EMBRACE TALK BLOOD GLUCOSE DEVICE (blood glucose 3 monitoring suppl) EMBRACE TALK GLUCOSE CONTROL IN VITRO SOLUTION 3 HIGH , LOW (blood glucose calibration)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 252 Coverage Requirements & Prescription Drug Name Drug Tier Limits EMJOI TENS DEVICE (nerve stimulator) OA FLEXICHAMBER ADULT MASK/SMALL (spacer/aero-hold 2 chamber mask) FLEXICHAMBER CHILD MASK/LARGE (spacer/aero-hold 2 chamber mask) FLEXICHAMBER CHILD MASK/SMALL (spacer/aero-hold 2 chamber mask) FLEXICHAMBER DEVICE (spacer/aero-holding chambers) 2 FORA D40G GLUCOSE/PRESSURE DEVICE (blood glucose- 3 bp monitor) FORA GTEL BLOOD GLUCOSE SYSTEM DEVICE (blood 3 glucose monitoring suppl) FORTISCARE CONTROL IN VITRO SOLUTION HIGH , LOW , 3 NORMAL (blood glucose calibration) FORTISCARE T1 GLUCOSE SYSTEM DEVICE (blood 3 glucose monitoring suppl) GAMMACORE DEVICE (nerve stimulator) OA GAMMACORE SAPPHIRE 31-DAY DEVICE (nerve OA stimulator) GAMMACORE SAPPHIRE D DEVICE (nerve stimulator) OA GAMMACORE SAPPHIRE DEVICE (nerve stimulator) OA GAMMACORE SAPPHIRE REFILL KIT (nerve stimulator) OA GOJJI CONTROL IN VITRO SOLUTION NORMAL (blood 3 glucose calibration) HUMATROPEN FOR 12MG DEVICE (injection device) SI QL (30 day supply per 1 fill) HUMATROPEN FOR 24MG DEVICE (injection device) SI QL (30 day supply per 1 fill) HUMATROPEN FOR 6MG DEVICE (injection device) SI QL (30 day supply per 1 fill) HW EMBRACE PRO GLUCOSE METER DEVICE (blood 3 glucose monitoring suppl)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 253 Coverage Requirements & Prescription Drug Name Drug Tier Limits HW EMBRACE TALK BLOOD GLUCOSE DEVICE (blood 3 glucose monitoring suppl) INPEN 100-BLUE-LILLY DEVICE (injection device for SI QL (30 day supply per 1 fill) insulin) INPEN 100-BLUE-NOVO DEVICE (injection device for SI QL (30 day supply per 1 fill) insulin) INPEN 100-GRAY-LILLY DEVICE (injection device for SI QL (30 day supply per 1 fill) insulin) INPEN 100-GREY-NOVO DEVICE (injection device for SI QL (30 day supply per 1 fill) insulin) INPEN 100-PINK-LILLY DEVICE (injection device for insulin) SI QL (30 day supply per 1 fill) INPEN 100-PINK-NOVO DEVICE (injection device for SI QL (30 day supply per 1 fill) insulin) INSPIREASE RESERVOIR BAGS (spacer/aero-hold chamber 3 bags) INSULIN PEN NEEDLES 29G X 12.7MM , 29G X 5MM , 29G X 8MM , 30G X 5 MM , 30G X 6 MM , 31G X 4 MM , 31G X 8 MM 2 , 32G X 4 MM , 32G X 6 MM , 33G X 4 MM (insulin pen needle) INSULIN PEN NEEDLES 29G X 12MM , 30G X 8 MM , 31G X 5 MM , 31G X 6 MM , 32G X 5 MM , 32G X 8 MM , 33G X 5 MM , 2 33G X 6 MM INSULIN SYRINGES 27G X 1/2" 0.5 ML, 27G X 1/2" 1 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 2 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) INSULIN SYRINGES 28G X 1/2" 0.5 ML, 30G X 5/16" 1 ML, 2 31G X 15/64" 1 ML, 32G X 5/16" 0.5 ML, 32G X 5/16" 1 ML KERLIX AMD ANTIMICROBIAL (gauze pads & dressings) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 254 Coverage Requirements & Prescription Drug Name Drug Tier Limits KERLIX AMD SUPER SPONGES PAD 6"X6-3/4" (gauze pads 3 & dressings) LANCETS (lancets misc.) 3 MICROCHAMBER DEVICE (spacer/aero-holding chambers) 2 MONARCH ETNS SYSTEM DEVICE OA NERIVIO DEVICE (nerve stimulator) OA NOVOFINE AUTOCOVER PEN NEEDLE 30G X 8 MM (insulin 2 pen needle) NOVOFINE PEN NEEDLE 32G X 6 MM (insulin pen needle) 2 NOVOFINE PLUS PEN NEEDLE 32G X 4 MM (insulin pen 2 needle) NOVOPEN ECHO DEVICE (injection device for insulin) SI QL (30 day supply per 1 fill) NOVOTWIST PEN NEEDLE 32G X 5 MM (insulin pen needle) 2 NOZIN NASAL SANITIZER POPSWAB NASAL SWAB 3 (alcohol) NS-2 ELECTRIC PATCH POUCH OA ONETOUCH VERIO IN VITRO SOLUTION HIGH (blood 3 glucose calibration) OPTICHAMBER DIAMOND (spacer/aero-holding chambers) 2 OPTICHAMBER DIAMOND-LG MASK DEVICE (spacer/aero- 2 holding chambers) OPTICHAMBER DIAMOND-MD MASK (spacer/aero-holding 2 chambers) OPTICHAMBER DIAMOND-SM MASK (spacer/aero-holding 2 chambers) PAIN RELIEF WITH TENS S2000 DEVICE OA PANDA MASK LARGE (spacer/aero-hold chamber mask) 2 PANDA MASK MEDIUM (spacer/aero-hold chamber mask) 2 PANDA MASK SMALL (spacer/aero-hold chamber mask) 2

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 255 Coverage Requirements & Prescription Drug Name Drug Tier Limits PEDIATRIC PANDA MASK (spacer/aero-hold chamber 2 mask) POCKET SPACER DEVICE (spacer/aero-holding chambers) 2 POGO AUTOMATIC BLOOD GLUCOSE DEVICE (blood 3 glucose monitoring suppl) PRECISION QID MONITOR DEVICE (blood glucose 3 monitoring suppl) PRECISION SOF-TACT MONITOR DEVICE (blood glucose 3 monitoring suppl) PRECISION XTRA DEVICE (blood glucose monitoring 3 suppl) PRECISION XTRA MONITOR DEVICE (blood glucose 3 monitoring suppl) PRO COMFORT TENS UNIT DEVICE OA PROCARE TENS & EMS DEVICE OA PROLIXUS OA RELION PREMIER CLASSIC DEVICE (blood glucose 3 monitoring suppl) RIGHTEST GT333 BLOOD GLUCOSE DEVICE (blood 3 glucose monitoring suppl) SPABUDDY SPORT ELITE DEVICE OA SURESTEP PRO HIGH GLUCOSE IN VITRO LIQUID (blood 3 glucose calibration) SURESTEP PRO LOW GLUCOSE IN VITRO LIQUID (blood 3 glucose calibration) SURESTEP PRO NORMAL GLUCOSE IN VITRO LIQUID 3 (blood glucose calibration) T: SLIM X2 INS PMP/CONTROL 7.4 DEVICE (insulin infusion 3 pump)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 256 Coverage Requirements & Prescription Drug Name Drug Tier Limits T:SLIM X2 INSULIN PMP BASAL6.4 DEVICE (insulin infusion 3 pump) TELFA AMD ISLAND DRESSING PAD 4"X8" (gauze pads & 3 dressings) TENS WIRED PAIN MANAGEMENT DEVICE OA TRUE FOCUS BLOOD GLUCOSE METER DEVICE (blood 3 glucose monitoring suppl) TRUE METRIX LEVEL 1 IN VITRO SOLUTION LOW (blood 3 glucose calibration) TRUE METRIX LEVEL 2 IN VITRO SOLUTION NORMAL 3 (blood glucose calibration) TRUE METRIX LEVEL 3 IN VITRO SOLUTION HIGH (blood 3 glucose calibration) ULTIGUARD SAFEPACK SYR/NEEDLE 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 31G X 5/16" 0.3 ML, 31G 2 X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u- 100) UNISTRIP CONTROL IN VITRO SOLUTION LOW (blood 3 glucose calibration) VIVAGUARD INO CONTROL SOLUTION IN VITRO LIQUID 3 (blood glucose calibration) VIVAGUARD INO GLUCOSE METER DEVICE (blood glucose 3 monitoring suppl) VORTEX VALVED HOLDING CHAMBER DEVICE 2 (spacer/aero-holding chambers) XEROFORM OIL EMULSION STRIP EXTERNAL (bismuth OA tribromoph-petrolatum) XEROFORM OIL ROLL 4"X9' EXTERNAL 3 % (bismuth OA tribromoph-petrolatum) XEROFORM PETROLAT GAUZE 1"X8" EXTERNAL (bismuth OA tribromoph-petrolatum)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 257 Coverage Requirements & Prescription Drug Name Drug Tier Limits XEROFORM PETROLAT GAUZE 5"X9" EXTERNAL (bismuth OA tribromoph-petrolatum) XEROFORM PETROLATUM ROLL 4"X9' EXTERNAL (bismuth OA tribromoph-petrolatum) ZEWA DIGITAL TENS UNIT DEVICE (nerve stimulator) OA ZEWA TENS/EMS COMBO UNIT DEVICE (nerve stimulator) OA DIAGNOSTIC AGENTS ADRENOCORTICAL INSUFFICIENCY PA; QL (30 day supply per 1 ACTHAR INJECTION GEL 80 UNIT/ML (corticotropin) OA fill) CORTROSYN INJECTION SOLUTION RECONSTITUTED 0.25 OA MG (cosyntropin) cosyntropin injection solution reconstituted 0.25 mg OA ALLERGENIC EXTRACTS (DIAGNOSTIC) ACACIA SUBCUTANEOUS SOLUTION 1:20 OA ACREMONIUM SUBCUTANEOUS SOLUTION 20000 PNU/ML OA ALDER SUBCUTANEOUS SOLUTION 1:20 OA ALTERNARIA SUBCUTANEOUS SOLUTION 20000 PNU/ML OA AMERICAN BEECH SUBCUTANEOUS SOLUTION 1:20 OA AMERICAN COCKROACH SUBCUTANEOUS SOLUTION 1:20 OA AMERICAN ELM SUBCUTANEOUS SOLUTION 1:20 OA AUREOBASIDIUM SUBCUTANEOUS SOLUTION 10000 OA PNU/ML, 20000 PNU/ML AUSTRALIAN PINE SUBCUTANEOUS SOLUTION 1:20 OA BAHIA SUBCUTANEOUS SOLUTION 1:20 OA BAYBERRY (WAX MYRTLE) SUBCUTANEOUS SOLUTION OA 1:20 BERMUDA GRASS INJECTION SOLUTION 10000 BAU/ML OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 258 Coverage Requirements & Prescription Drug Name Drug Tier Limits BERMUDA GRASS SUBCUTANEOUS SOLUTION 10000 OA BAU/ML BLACK WILLOW SUBCUTANEOUS SOLUTION 1:20 OA BOTRYTIS SUBCUTANEOUS SOLUTION 20000 PNU/ML OA BROME SUBCUTANEOUS SOLUTION 1:20 OA CANDIDA ALBICANS EXTRACT SUBCUTANEOUS OA SOLUTION 10000 PNU/ML CAT HAIR EXTRACT INJECTION SOLUTION 10000 BAU/ML, OA 5000 BAU/ML CAT HAIR EXTRACT SUBCUTANEOUS SOLUTION 10000 OA BAU/ML CATTLE EPITHELIUM SUBCUTANEOUS SOLUTION 1:20 OA CEDAR ELM SUBCUTANEOUS SOLUTION 1:20 OA CLADOSPORIUM CLADOSPORIOIDES INTRADERMAL OA SOLUTION 1:20 CLADOSPORIUM CLADOSPORIOIDES SUBCUTANEOUS OA SOLUTION 10000 PNU/ML, 20000 PNU/ML CLADOSPORIUM SPHAEROSPERMUM SUBCUTANEOUS OA SOLUTION 20000 PNU/ML COCKLEBUR SUBCUTANEOUS SOLUTION 1:20 OA CORN POLLEN SUBCUTANEOUS SOLUTION 1:20 OA CURVULARIA SUBCUTANEOUS SOLUTION 20000 PNU/ML OA DOG EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 1:20 OA DOG FENNEL SUBCUTANEOUS SOLUTION 1:20 OA DRECHSLERA SUBCUTANEOUS SOLUTION 10000 PNU/ML, OA 20000 PNU/ML DUST MITE MIXED ALLERGEN EXT INJECTION SOLUTION OA PA 10000 AU/ML, 15000-15000 AU/ML

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 259 Coverage Requirements & Prescription Drug Name Drug Tier Limits DUST MITE MIXED ALLERGEN EXT SUBCUTANEOUS OA PA SOLUTION 10000 AU/ML EASTERN COTTONWOOD SUBCUTANEOUS SOLUTION OA 1:20 EPICOCCUM SUBCUTANEOUS SOLUTION 20000 PNU/ML OA FUSARIUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, OA 20000 PNU/ML GOLDENROD SUBCUTANEOUS SOLUTION 1:20 OA GRASS POLLEN(K-O-R-T-SWT VERN) INJECTION OA SOLUTION 100000 BAU/ML HACKBERRY SUBCUTANEOUS SOLUTION 1:20 OA HONEY BEE VENOM PROTEIN INJECTION SOLUTION OA RECONSTITUTED 550 MCG (honey bee venom) HONEY BEE VENOM SUBCUTANEOUS SOLUTION OA RECONSTITUTED 1100 MCG, 120 MCG HORSE EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , OA 1:20 JOHNSON GRASS SUBCUTANEOUS SOLUTION 1:20 OA JUNE GRASS POLLEN STANDARDIZED SUBCUTANEOUS OA SOLUTION 100000 BAU/ML KAPOK SUBCUTANEOUS SOLUTION 1:20 OA KOCHIA SUBCUTANEOUS SOLUTION 1:20 OA MEADOW FESCUE GRASS POLLEN SUBCUTANEOUS OA SOLUTION 100000 BAU/ML MELALEUCA SUBCUTANEOUS SOLUTION 1:20 OA MESQUITE SUBCUTANEOUS SOLUTION 1:20 OA MITE (D. FARINAE) SUBCUTANEOUS SOLUTION 10000 OA AU/ML MITE (D. PTERONYSSINUS) SUBCUTANEOUS SOLUTION OA 10000 AU/ML Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 260 Coverage Requirements & Prescription Drug Name Drug Tier Limits MIXED ASPERGILLUS SUBCUTANEOUS SOLUTION 20000 OA PNU/ML MIXED FEATHERS SUBCUTANEOUS SOLUTION 1:20 OA MIXED RAGWEED SUBCUTANEOUS SOLUTION 1:20 OA MIXED VESPID VENOM PROTEIN INJECTION SOLUTION OA RECONSTITUTED 550-550-550 MCG mixed vespid venom protein subcutaneous solution OA reconstituted 1100-1100-1100 mcg MIXED VESPID VENOM PROTEIN SUBCUTANEOUS OA SOLUTION RECONSTITUTED 120-120-120 MCG MOUNTAIN CEDAR SUBCUTANEOUS SOLUTION 1:20 OA MOUSE EPITHELIUM SUBCUTANEOUS SOLUTION 1:20 OA MUGWORT SUBCUTANEOUS SOLUTION 1:20 OA ORCHARD GRASS POLLEN SUBCUTANEOUS SOLUTION OA 100000 BAU/ML PENICILLIUM NOTATUM SUBCUTANEOUS SOLUTION OA 10000 PNU/ML, 20000 PNU/ML PERENNIAL RYE GRASS POLLEN INJECTION SOLUTION OA 100000 BAU/ML PHOMA EXIGUA SUBCUTANEOUS SOLUTION 20000 OA PNU/ML PRIVET SUBCUTANEOUS SOLUTION 1:20 OA QUEEN PALM SUBCUTANEOUS SOLUTION 1:20 OA RABBIT EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , OA 1:20 RED MULBERRY SUBCUTANEOUS SOLUTION 1:20 OA RED TOP GRASS POLLEN SUBCUTANEOUS SOLUTION OA 100000 BAU/ML ROUGH MARSH ELDER SUBCUTANEOUS SOLUTION 1:20 OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 261 Coverage Requirements & Prescription Drug Name Drug Tier Limits RUSSIAN THISTLE SUBCUTANEOUS SOLUTION 1:20 OA SHAGBARK HICKORY SUBCUTANEOUS SOLUTION 1:20 OA SHORT RAGWEED POLLEN EXT SUBCUTANEOUS OA SOLUTION 1:20 SORREL/DOCK MIX SUBCUTANEOUS SOLUTION 1:20 OA SPINY PIGWEED SUBCUTANEOUS SOLUTION 1:20 OA SWEET VERNAL GRASS POLLEN SUBCUTANEOUS OA SOLUTION 100000 BAU/ML TALL RAGWEED SUBCUTANEOUS SOLUTION 1:20 OA TIMOTHY GRASS POLLEN ALLERGEN INJECTION OA SOLUTION 10000 BAU/ML, 100000 BAU/ML TIMOTHY GRASS POLLEN ALLERGEN SUBCUTANEOUS OA SOLUTION 10000 BAU/ML, 100000 BAU/ML TRICHOPHYTON SUBCUTANEOUS SOLUTION 20000 OA PNU/ML VENOMIL MIXED VESPID VENOM INJECTION SOLUTION OA RECONSTITUTED 550-550-550 MCG (mixed vespid venom) WASP VENOM PROTEIN INJECTION SOLUTION OA RECONSTITUTED 550 MCG WASP VENOM PROTEIN SUBCUTANEOUS SOLUTION OA RECONSTITUTED 1100 MCG, 120 MCG WESTERN JUNIPER SUBCUTANEOUS SOLUTION 1:20 OA WHITE FACED HORNET VENOM SUBCUTANEOUS OA SOLUTION RECONSTITUTED 1100 MCG, 120 MCG WHITE MULBERRY SUBCUTANEOUS SOLUTION 1:20 OA WHITE OAK SUBCUTANEOUS SOLUTION 1:20 OA WHITE PINE SUBCUTANEOUS SOLUTION 1:20 OA WHITE-FACED HORNET VENOM INJECTION SOLUTION OA RECONSTITUTED 550 MCG (white faced hornet venom)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 262 Coverage Requirements & Prescription Drug Name Drug Tier Limits YELLOW HORNET VENOM PROTEIN INJECTION SOLUTION OA RECONSTITUTED 550 MCG YELLOW HORNET VENOM PROTEIN SUBCUTANEOUS OA SOLUTION RECONSTITUTED 1100 MCG, 120 MCG YELLOW JACKET VENOM PROTEIN INJECTION SOLUTION OA RECONSTITUTED 550 MCG YELLOW JACKET VENOM PROTEIN SUBCUTANEOUS OA SOLUTION RECONSTITUTED 120 MCG CARDIAC FUNCTION adenosine (diagnostic) intravenous solution 3 mg/ml OA adenosine intravenous solution 3 mg/ml OA IC GREEN INTRAVENOUS SOLUTION RECONSTITUTED 25 OA MG (indocyanine green) indocyanine green intravenous solution reconstituted 25 OA mg LEXISCAN INTRAVENOUS SOLUTION 0.4 MG/5ML OA (regadenoson) DIABETES MELLITUS ACCU-CHEK AVIVA PLUS IN VITRO STRIP (glucose blood) 3 PA ACCU-CHEK COMPACT PLUS TEST STRIPS IN VITRO 3 PA STRIP (glucose blood) ACCU-CHEK GUIDE IN VITRO STRIP (glucose blood) 3 PA ACCU-CHEK SMARTVIEW TEST STRIPS IN VITRO STRIP 3 PA (glucose blood) AGAMATRIX PRESTO TEST IN VITRO STRIP (glucose 3 PA blood) ASSURE PLATINUM IN VITRO STRIP (glucose blood) 3 PA BLOOD GLUCOSE TEST IN VITRO STRIP 3 PA BLULINK GLUCOSE TEST IN VITRO STRIP (glucose blood) 3 PA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 263 Coverage Requirements & Prescription Drug Name Drug Tier Limits CARETOUCH TEST IN VITRO STRIP (glucose blood) 3 PA CONTOUR NEXT TEST IN VITRO STRIP (glucose blood) 3 PA CONTOUR TEST IN VITRO STRIP (glucose blood) 3 PA DIATHRIVE BLOOD GLUCOSE TEST IN VITRO STRIP 3 PA (glucose blood) DIATHRIVE GLUCOSE TEST IN VITRO STRIP (glucose 3 PA blood) DIATHRIVE+ GLUCOSE TEST IN VITRO STRIP (glucose 3 PA blood) EASY TOUCH HEALTHPRO GLUCOSE IN VITRO STRIP 3 PA (glucose blood) EASY TRAK II GLUCOSE TEST IN VITRO STRIP 3 PA EMBRACE TALK GLUCOSE TEST IN VITRO STRIP (glucose 3 PA blood) FORA 6 CONNECT IN VITRO STRIP (glucose blood) 3 PA FORA GTEL BLOOD GLUCOSE TEST IN VITRO STRIP 3 PA (glucose blood) FORA TN'G ADVANCE PRO IN VITRO STRIP (glucose 3 PA blood) FORTISCARE G1 TEST STRIP IN VITRO STRIP (glucose 3 PA blood) FREESTYLE INSULINX TEST IN VITRO STRIP (glucose 2 blood) FREESTYLE LITE TEST IN VITRO STRIP (glucose blood) 2 FREESTYLE PRECISION NEO TEST IN VITRO STRIP 2 (glucose blood) FREESTYLE TEST IN VITRO STRIP (glucose blood) 2 GLUCOCARD 01 SENSOR PLUS IN VITRO STRIP (glucose 3 PA blood)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 264 Coverage Requirements & Prescription Drug Name Drug Tier Limits GLUCOCARD EXPRESSION TEST IN VITRO STRIP (glucose 3 PA blood) GLUCOCARD SHINE TEST IN VITRO STRIP (glucose blood) 3 PA GLUCOCARD VITAL TEST IN VITRO STRIP (glucose blood) 3 PA GOJJI BLOOD GLUCOSE TEST IN VITRO STRIP (glucose 3 PA blood) HW EMBRACE PRO GLUCOSE TEST IN VITRO STRIP 3 PA (glucose blood) HW EMBRACE TALK GLUCOSE TEST IN VITRO STRIP 3 PA (glucose blood) INFINITY BLOOD GLUCOSE TEST IN VITRO STRIP (glucose 3 PA blood) KROGER HEALTHPRO GLUCOSE TEST IN VITRO STRIP 3 PA (glucose blood) LANCETS IN VITRO STRIP (glucose blood) 3 PA MICRODOT TEST IN VITRO STRIP (glucose blood) 3 PA ONE DROP TEST IN VITRO STRIP 3 PA ONETOUCH ULTRA IN VITRO STRIP (glucose blood) 2 ONETOUCH VERIO IN VITRO STRIP (glucose blood) 2 PRECISION PCX PLUS TEST IN VITRO STRIP (glucose 2 blood) PRECISION QID TEST IN VITRO STRIP (glucose blood) 2 PRECISION SOF-TACT TEST IN VITRO STRIP (glucose 2 blood) PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP 2 (glucose blood) RELION BLOOD GLUCOSE TEST IN VITRO STRIP (glucose 3 PA blood) RELION PREMIER TEST IN VITRO STRIP (glucose blood) 3 PA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 265 Coverage Requirements & Prescription Drug Name Drug Tier Limits RIGHTEST GT333 BLOOD GLUCOSE IN VITRO STRIP 3 PA (glucose blood) TRUE METRIX BLOOD GLUCOSE TEST IN VITRO STRIP 3 PA (glucose blood) TRUE METRIX PRO BLOOD GLUCOSE IN VITRO STRIP 3 PA (glucose blood) TRUETRACK TEST IN VITRO STRIP (glucose blood) 3 PA VIVAGUARD INO TEST STRIPS IN VITRO STRIP (glucose 3 PA blood) DIAGNOSTIC AGENTS CYSVIEW INTRAVESICAL SOLUTION RECONSTITUTED 100 OA MG (hexaminolevulinate hcl) isosulfan blue subcutaneous solution 1 % OA DRUG HYPERSENSITIVITY PRE-PEN INTRADERMAL SOLUTION 0.25 ML OA (benzylpenicilloyl polylysine) GALLBLADDER FUNCTION KINEVAC INJECTION SOLUTION RECONSTITUTED 5 MCG OA (sincalide) KIDNEY FUNCTION indigo carmine injection solution 8 mg/ml OA INULIN INTRAVENOUS SOLUTION 100-0.9 MG/ML-% OA LIVER FUNCTION IC GREEN INTRAVENOUS SOLUTION RECONSTITUTED 25 OA MG (indocyanine green) indocyanine green intravenous solution reconstituted 25 OA mg

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 266 Coverage Requirements & Prescription Drug Name Drug Tier Limits MYASTHENIA GRAVIS BLOXIVERZ INTRAVENOUS SOLUTION 10 MG/10ML, 5 OA MG/10ML (neostigmine methylsulfate) neostigmine methylsulfate intravenous solution 10 OA mg/10ml, 5 mg/10ml NEOSTIGMINE METHYLSULFATE INTRAVENOUS OA SOLUTION 3 MG/3ML, 5 MG/5ML NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 2 MG/2ML, 3 MG/3ML, 4 OA MG/4ML, 5 MG/5ML OCULAR DISORDERS ak-fluor intravenous solution 10 %, 25 % OA FLUORESCITE INTRAVENOUS SOLUTION 10 % (fluorescein OA sodium) MEMBRANEBLUE OPHTHALMIC SOLUTION 0.15 % (trypan 3 blue) TISSUEBLUE INTRAOCULAR SOLUTION PREFILLED OA SYRINGE 0.025 % (brilliant blue g) VISIONBLUE OPHTHALMIC SOLUTION 0.06 % (trypan blue) 3 PANCREATIC FUNCTION CHIRHOSTIM INTRAVENOUS SOLUTION RECONSTITUTED OA 16 MCG (secretin acetate (human)) SECREFLO INTRAVENOUS SOLUTION RECONSTITUTED OA 16 MCG (secretin acetate) tolbutamide oral tablet 500 mg 1 PHEOCHROMOCYTOMA HISTATROL INJECTION SOLUTION 2.75 MG/ML (histamine OA phosphate) HISTATROL INTRADERMAL SOLUTION 0.275 MG/ML OA (histamine phosphate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 267 Coverage Requirements & Prescription Drug Name Drug Tier Limits PITUITARY FUNCTION PA; QL (30 day supply per 1 MACRILEN ORAL PACKET 60 MG (macimorelin acetate) 3 fill) R-GENE 10 INTRAVENOUS SOLUTION 10 % (arginine hcl OA (diagnostic)) ROENTGENOGRAPHY AND OTHER IMAGING AGENTS NEURACEQ INTRAVENOUS SOLUTION 1.4-135 MCI/ML OA (florbetaben f 18) DISINFECTANTS (FOR NON-DERMATOLOGIC USE) - Disinfectants DISINFECTANTS (FOR NON-DERMATOLOGIC USE) - Disinfectants formaldehyde external solution 10 %, 37 % 1 glutaraldehyde external solution 25 % 1 ELECTROLYTIC, CALORIC, AND WATER BALANCE ACIDIFYING AGENTS K-PHOS NO 2 ORAL TABLET 305-700 MG (pot & sod ac 3 phosphates) ALKALINIZING AGENTS cytra k crystals oral packet 3300-1002 mg 1 LIDOCAINE-SODIUM BICARBONATE INJECTION SOLUTION OA PREFILLED SYRINGE 1-8.4 % ORACIT ORAL SOLUTION 490-640 MG/5ML (sod citrate- 2 citric acid) pot & sod cit-cit ac oral solution 550-500-334 mg/5ml 1 potassium citrate er oral tablet extended release 10 meq 1 (1080 mg), 15 meq (1620 mg), 5 meq (540 mg) potassium citrate-citric acid oral solution 1100-334 mg/5ml 1 sod citrate-citric acid oral solution 500-334 mg/5ml 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 268 Coverage Requirements & Prescription Drug Name Drug Tier Limits sodium acetate intravenous solution 2 meq/ml, 4 meq/ml OA sodium bicarbonate intravenous solution 4.2 %, 7.5 % OA sodium bicarbonate solution 8.4 % intravenous 8.4 % OA SODIUM BICARBONATE SOLUTION 8.4 % INTRAVENOUS OA 8.4 % SODIUM BICARBONATE-DEXTROSE INTRAVENOUS OA SOLUTION 150-5 MEQ/L-% THAM INTRAVENOUS SOLUTION 30 MEQ/100ML OA (tromethamine) tricitrates oral solution 550-500-334 mg/5ml 1 UROCIT-K 10 ORAL TABLET EXTENDED RELEASE 10 MEQ 3 (1080 MG) (potassium citrate) UROCIT-K 15 ORAL TABLET EXTENDED RELEASE 15 MEQ 3 (1620 MG) (potassium citrate) UROCIT-K 5 ORAL TABLET EXTENDED RELEASE 5 MEQ 3 (540 MG) (potassium citrate) AMMONIA DETOXICANTS AMMONUL INTRAVENOUS SOLUTION 10-10 % (sod benz- OA sod phenylacet) BUPHENYL ORAL POWDER 3 GM/TSP (sodium 3 phenylbutyrate) BUPHENYL ORAL TABLET 500 MG (sodium phenylbutyrate) 3 PA; SP; QL (30 day supply CARBAGLU ORAL TABLET 200 MG (carglumic acid) 3 per 1 fill) constulose oral solution 10 gm/15ml 1 enulose oral solution 10 gm/15ml 1 generlac oral solution 10 gm/15ml 1 KRISTALOSE ORAL PACKET 10 GM, 20 GM (lactulose) 2 lactulose encephalopathy oral solution 10 gm/15ml 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 269 Coverage Requirements & Prescription Drug Name Drug Tier Limits lactulose oral packet 10 gm 1 lactulose oral solution 10 gm/15ml, 20 gm/30ml 1 LITHOSTAT ORAL TABLET 250 MG (acetohydroxamic acid) 3 PA; SP; QL (30 day supply RAVICTI ORAL LIQUID 1.1 GM/ML (glycerol phenylbutyrate) 3 per 1 fill) sod benz-sod phenylacet intravenous solution 10-10 % OA sodium phenylbutyrate oral powder 3 gm/tsp 1 sodium phenylbutyrate oral tablet 500 mg 1 CALORIC AGENTS - Drugs for Nutrition AMINO ACID INTRAVENOUS SOLUTION 5 % OA aminoamrms oral capsule 1 AMINOPMRMS ORAL CAPSULE (nutritional supplements) 3 AMINOPROTECT INTRAVENOUS SOLUTION 5 % (amino OA acid infusion) aminoreliefrms oral capsule 1 AMINOSYN II INTRAVENOUS SOLUTION 10 %, 15 % (amino OA acid infusion) AMINOSYN-PF INTRAVENOUS SOLUTION 10 %, 7 % (amino OA acid infusion) AMIODARONE HCL IN DEXTROSE INTRAVENOUS OA SOLUTION 450-5 MG/250ML-%, 900-5 MG/500ML-% APP SLIM RMS ORAL CAPSULE (nutritional supp - diet 3 aids) ARGININE HCL INJECTION SOLUTION 6 GM/30ML 3 asilnasalrms oral capsule 1 bupivacaine in dextrose intrathecal solution 0.75-8.25 % OA bupivacaine spinal intrathecal solution 0.75-8.25 % OA cefazolin sodium-dextrose intravenous solution 1-4 OA gm/50ml-%, 2-4 gm/100ml-% Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 270 Coverage Requirements & Prescription Drug Name Drug Tier Limits CEFAZOLIN SODIUM-DEXTROSE INTRAVENOUS OA SOLUTION 2-5 GM/100ML-% cefazolin sodium-dextrose intravenous solution OA reconstituted 1-4 gm-%(50ml), 2-3 gm-%(50ml) cefepime-dextrose intravenous solution reconstituted 1-5 OA gm-%(50ml), 2-5 gm-%(50ml) ceftazidime and dextrose intravenous solution OA reconstituted 1-5 gm-%(50ml), 2-5 gm-%(50ml) ceftriaxone sodium in dextrose intravenous solution 20 OA mg/ml, 40 mg/ml ceftriaxone sodium-dextrose intravenous solution OA reconstituted 1-3.74 gm-%(50ml), 2-2.22 gm-%(50ml) clindamycin phosphate in d5w intravenous solution 300 OA mg/50ml, 600 mg/50ml, 900 mg/50ml CLINIMIX E/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION OA 2.75 % (amino ac elect-calc in d5w) CLINIMIX E/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION OA 4.25 % (amino ac elect-calc in d10w) CLINIMIX E/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION OA 4.25 % (amino ac elect-calc in d5w) CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 OA % (amino ac elect-calc in d15w) CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 OA % (amino ac elect-calc in d20w) CLINIMIX E/DEXTROSE (8/10) INTRAVENOUS SOLUTION 8 OA % CLINIMIX E/DEXTROSE (8/14) INTRAVENOUS SOLUTION 8 OA % CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION OA 4.25 % (amino acid infusion in d10w)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 271 Coverage Requirements & Prescription Drug Name Drug Tier Limits CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION OA 4.25 % (amino acid infusion in d5w) CLINIMIX/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 % OA (amino acid infusion in d15w) CLINIMIX/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 % OA (amino acid infusion in d20w) CLINIMIX/DEXTROSE (6/5) INTRAVENOUS SOLUTION 6 % OA CLINIMIX/DEXTROSE (8/10) INTRAVENOUS SOLUTION 8 % OA CLINIMIX/DEXTROSE (8/14) INTRAVENOUS SOLUTION 8 % OA CLINISOL SF INTRAVENOUS SOLUTION 15 % (amino acid OA infusion) CLINOLIPID INTRAVENOUS EMULSION 20 % (fat emulsion OA plant based) DEXTROSE 5%/ELECTROLYTE #48 INTRAVENOUS OA SOLUTION dextrose in lactated ringers intravenous solution 5 % OA dextrose intravenous solution 10 %, 20 %, 30 %, 40 %, 5 %, OA 70 % DEXTROSE SOLUTION 250 MG/ML INTRAVENOUS 250 OA MG/ML dextrose solution 250 mg/ml intravenous 250 mg/ml OA DEXTROSE SOLUTION 50 % INTRAVENOUS 50 % OA dextrose solution 50 % intravenous 50 % OA dextrose-nacl intravenous solution 10-0.2 %, 10-0.45 %, 2.5- OA 0.45 %, 5-0.2 %, 5-0.33 %, 5-0.45 %, 5-0.9 % dextrose-sodium chloride intravenous solution 2.5-0.45 %, OA 5-0.225 %, 5-0.3 %, 5-0.45 %, 5-0.9 % DILTIAZEM HCL-DEXTROSE INTRAVENOUS SOLUTION OA 125-5 MG/125ML-% DOJOLVI ORAL LIQUID 100 % (triheptanoin) 3 PA Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 272 Coverage Requirements & Prescription Drug Name Drug Tier Limits ELCYS INTRAVENOUS SOLUTION 50 MG/ML (cysteine hcl) OA ELLIOTTS B INTRATHECAL SOLUTION (intrathecal elec- OA dextrose) ENU PRO3 PLUS ORAL POWDER (nutritional supplements) 3 EPINEPHRINE HCL-DEXTROSE INTRAVENOUS SOLUTION OA 4-5 MG/250ML-% EPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION 2-5 OA MG/250ML-% EPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION OA PREFILLED SYRINGE 100-5 MCG/10ML-% EQUACARE JR ORAL POWDER 3 ESSENTIAL CARE JR ORAL POWDER (nutritional 3 supplements) FOLITE ORAL TABLET 3 FREAMINE III INTRAVENOUS SOLUTION 10 % (amino acid OA infusion) GLUTATHIONE INJECTION SOLUTION 200 MG/ML, 6 3 GM/30ML GLUTATHIONE INTRAVENOUS SOLUTION 6 GM/30ML OA GLYCINE INJECTION SOLUTION 50 MG/ML 3 heparin sod (porcine) in d5w intravenous solution 100 OA unit/ml, 25000-5 ut/500ml-%, 40-5 unit/ml-% INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % (fat OA emulsion plant based) IONOSOL-MB IN D5W INTRAVENOUS SOLUTION OA (electrolyte-mb in dextrose) ISOLYTE-P IN D5W INTRAVENOUS SOLUTION (electrolyte- OA p in dextrose) KABIVEN INTRAVENOUS EMULSION 3.3-9.8-3.9-0.7 % OA (amino ac-dext-lipid-electrolyt)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 273 Coverage Requirements & Prescription Drug Name Drug Tier Limits KATE FARMS PEPTIDE 1.5 ENTERAL LIQUID (nutritional 3 supplements) KATE FARMS STANDARD 1.4 ENTERAL LIQUID (nutritional 3 supplements) kcl in dextrose-nacl intravenous solution 10-5-0.45 meq/l- %-%, 20-5-0.2 meq/l-%-%, 20-5-0.225 meq/l-%-%, 20-5-0.45 OA meq/l-%-%, 20-5-0.9 meq/l-%-%, 30-5-0.45 meq/l-%-%, 40-5- 0.45 meq/l-%-%, 40-5-0.9 meq/l-%-% kcl-lactated ringers-d5w intravenous solution 20 meq/l OA LABETALOL HCL-DEXTROSE INTRAVENOUS SOLUTION OA 200-5 MG/200ML-% LABETALOL HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 100-0.72 MG/100ML-%, 200-0.72 MG/200ML-%, OA 300-0.72 MG/300ML-% LIDOCAINE IN D5W INTRAVENOUS SOLUTION 2-5 MG/ML- OA % lidocaine in d5w intravenous solution 4-5 mg/ml-%, 8-5 OA mg/ml-% LIDOCAINE IN DEXTROSE SOLUTION 5-7.5 % OA LMD IN D5W INTRAVENOUS SOLUTION 10-5 % (dextran 40 OA in d5w) LYSINE HCL INJECTION SOLUTION 100 MG/ML 3 magnesium sulfate in d5w intravenous solution 1-5 OA gm/100ml-% MARCAINE SPINAL INTRATHECAL SOLUTION 0.75-8.25 % OA (bupivacaine in dextrose) milrinone lactate in dextrose intravenous solution 20-5 OA mg/100ml-%, 40-5 mg/200ml-% NAFCILLIN SODIUM IN DEXTROSE INTRAVENOUS OA SOLUTION 1 GM/50ML, 2 GM/100ML NEOKE ALCAR ORAL POWDER (acetylcarnitine) 3 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 274 Coverage Requirements & Prescription Drug Name Drug Tier Limits NEXTERONE INTRAVENOUS SOLUTION 150-4.21 MG/100ML-%, 360-4.14 MG/200ML-% (amiodarone hcl in OA dextrose) nitroglycerin in d5w intravenous solution 100-5 mcg/ml-%, OA 200-5 mcg/ml-%, 400-5 mcg/ml-% NOREPINEPHRINE (BASE)-DEXTROSE INTRAVENOUS OA SOLUTION 4-5 MG/250ML-%, 8-5 MG/500ML-% NOREPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION OA 4-5 MG/250ML-%, 8-5 MG/250ML-% NOREPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION OA 8-5 MG/500ML-% NORMOSOL-M IN D5W INTRAVENOUS SOLUTION OA (electrolyte-m in dextrose) NORMOSOL-R IN D5W INTRAVENOUS SOLUTION OA (electrolyte-r in dextrose) nutrilipid intravenous emulsion 20 % OA OMEGAVEN INTRAVENOUS EMULSION 10 GM/100ML, 5 OA GM/50ML (fish oil triglyceride based) OXACILLIN SODIUM IN DEXTROSE INTRAVENOUS OA SOLUTION 1 GM/50ML, 2 GM/50ML PENICILLIN G POT IN DEXTROSE INTRAVENOUS OA SOLUTION 20000 UNIT/ML, 40000 UNIT/ML, 60000 UNIT/ML PERIKABIVEN INTRAVENOUS EMULSION 2.4-6.8-3.5-0.5 % OA (amino ac-dext-lipid-electrolyt) PLENAMINE INTRAVENOUS SOLUTION 15 % (amino acid OA infusion) potassium chloride in dextrose intravenous solution 20-5 OA meq/l-% PREMASOL INTRAVENOUS SOLUTION 10 % (amino acid OA infusion)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 275 Coverage Requirements & Prescription Drug Name Drug Tier Limits PROCALAMINE INTRAVENOUS SOLUTION 3 % (amino acd OA electrolyte infusion) PROSOL INTRAVENOUS SOLUTION 20 % (amino acid OA infusion) SMOFLIPID INTRAVENOUS EMULSION 20 % (fat emul fish OA oil/plant based) SODIUM BICARBONATE-DEXTROSE INTRAVENOUS OA SOLUTION 150-5 MEQ/L-% TAURINE INJECTION SOLUTION 50 MG/ML 3 TAZICEF INTRAVENOUS SOLUTION 1 GM/50ML OA (ceftazidime sodium in dextrose) TRAVASOL INTRAVENOUS SOLUTION 10 % (amino acid OA infusion) TRI-AMINO INJECTION SOLUTION 100-100-100 MG/ML 3 TROPHAMINE INTRAVENOUS SOLUTION 10 % (amino acid OA infusion) VANCOMYCIN HCL IN DEXTROSE INTRAVENOUS OA SOLUTION 1.25-5 GM/250ML-%, 1.5-5 GM/250ML-% vancomycin hcl in dextrose intravenous solution 1-5 OA gm/200ml-%, 500-5 mg/100ml-%, 750-5 mg/150ml-% VAPRISOL INTRAVENOUS SOLUTION 20-5 MG/100ML-% OA PA (conivaptan hcl in dextrose) ZOSYN INTRAVENOUS SOLUTION 2-0.25 GM/50ML, 3-0.375 OA GM/50ML, 4-0.5 GM/100ML (piperacillin-tazobactam in dex) CARBONIC ANHYDRASE INHIBITORS - Drugs for Water Balance acetazolamide er oral capsule extended release 12 hour 500 1 mg acetazolamide oral tablet 125 mg, 250 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 276 Coverage Requirements & Prescription Drug Name Drug Tier Limits acetazolamide sodium injection solution reconstituted 500 OA mg DIURETICS, MISCELLANEOUS - Drugs for Water Balance ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 2 THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 1 mg, 450 mg theophylline er oral tablet extended release 24 hour 400 1 mg, 600 mg theophylline oral solution 80 mg/15ml 1 ELECTROLYTIC,CALORIC,WATER BALANCE MISC, CRYSVITA SUBCUTANEOUS SOLUTION 10 MG/ML, 20 OA QL (30 day supply per 1 fill) MG/ML, 30 MG/ML (burosumab-twza) IRRIGATING SOLUTIONS acetic acid irrigation solution 0.25 % 1 argyle sterile saline irrigation solution 0.9 % 1 argyle sterile water irrigation solution OA curity sterile saline irrigation solution 0.9 % 1 DELFLEX-LC/1.5% DEXTROSE INTRAPERITONEAL OA SOLUTION 344 MOSM/L (peritoneal dialysis solutions) DELFLEX-LC/2.5% DEXTROSE INTRAPERITONEAL OA SOLUTION 394 MOSM/L (peritoneal dialysis solutions) DELFLEX-LC/4.25% DEXTROSE INTRAPERITONEAL OA SOLUTION 483 MOSM/L (peritoneal dialysis solutions) DELFLEX-SM/1.5% DEXTROSE INTRAPERITONEAL OA SOLUTION 347 MOSM/L (peritoneal dialysis solutions) DELFLEX-SM/2.5% DEXTROSE INTRAPERITONEAL OA SOLUTION 398 MOSM/L (peritoneal dialysis solutions)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 277 Coverage Requirements & Prescription Drug Name Drug Tier Limits DIANEAL LOW CALCIUM/1.5% DEX INTRAPERITONEAL OA SOLUTION 344 MOSM/L (peritoneal dialysis solutions) DIANEAL LOW CALCIUM/2.5% DEX INTRAPERITONEAL OA SOLUTION 395 MOSM/L (peritoneal dialysis solutions) DIANEAL LOW CALCIUM/4.25% DEX INTRAPERITONEAL OA SOLUTION 483 MOSM/L (peritoneal dialysis solutions) DIANEAL PD-2/1.5% DEXTROSE INTRAPERITONEAL OA SOLUTION 346 MOSM/L (peritoneal dialysis solutions) DIANEAL PD-2/2.5% DEXTROSE INTRAPERITONEAL OA SOLUTION 396 MOSM/L (peritoneal dialysis solutions) DIANEAL PD-2/4.25% DEXTROSE INTRAPERITONEAL OA SOLUTION 485 MOSM/L (peritoneal dialysis solutions) EXTRANEAL INTRAPERITONEAL SOLUTION 7.5 % OA (icodextrin-electrolytes) glycine irrigation solution 1.5 % 1 glycine urologic irrigation solution 1.5 % 1 lactated ringers irrigation solution 1 PHYSIOLYTE IRRIGATION SOLUTION (irrigation solns 3 physiological) PHYSIOSOL IRRIGATION IRRIGATION SOLUTION (irrigation 3 solns physiological) RENACIDIN IRRIGATION SOLUTION (citric ac-gluconolact- 3 mg carb) ringers irrigation irrigation solution 1 sodium chloride irrigation solution 0.9 % 1 SORBITOL IRRIGATION SOLUTION 3 % 3 sorbitol-mannitol irrigation solution 2.7-0.54 gm/100ml 1 sterile water for irrigation irrigation solution OA tis-u-sol irrigation solution 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 278 Coverage Requirements & Prescription Drug Name Drug Tier Limits ULTRABAG/DIANEAL PD-2/1.5% DEX INTRAPERITONEAL OA SOLUTION 346 MOSM/L (peritoneal dialysis solutions) ULTRABAG/DIANEAL PD-2/2.5% DEX INTRAPERITONEAL OA SOLUTION 396 MOSM/L (peritoneal dialysis solutions) ULTRABAG/DIANEAL PD-2/4.25%DEX INTRAPERITONEAL OA SOLUTION 485 MOSM/L (peritoneal dialysis solutions) ULTRABAG/DIANEAL/1.5% DEXTROSE INTRAPERITONEAL OA SOLUTION 344 MOSM/L (peritoneal dialysis solutions) ULTRABAG/DIANEAL/2.5% DEXTROSE INTRAPERITONEAL OA SOLUTION 395 MOSM/L (peritoneal dialysis solutions) ULTRABAG/DIANEAL/4.25% DEX INTRAPERITONEAL OA SOLUTION 483 MOSM/L (peritoneal dialysis solutions) water for irrigation, sterile irrigation solution OA LOOP DIURETICS - Drugs for Water Balance bumetanide injection solution 0.25 mg/ml OA bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1 BUMEX ORAL TABLET 0.5 MG (bumetanide) 3 EDECRIN ORAL TABLET 25 MG (ethacrynic acid) 3 ethacrynate sodium intravenous solution reconstituted 50 OA mg ethacrynic acid oral tablet 25 mg 1 FUROSEMIDE IN SODIUM CHLORIDE INTRAVENOUS OA SOLUTION 100-0.9 MG/100ML-% furosemide injection solution 10 mg/ml OA furosemide oral solution 10 mg/ml, 8 mg/ml 1 furosemide oral tablet 20 mg, 40 mg, 80 mg 1 LASIX ORAL TABLET 20 MG, 40 MG, 80 MG (furosemide) 3 SODIUM EDECRIN INTRAVENOUS SOLUTION OA RECONSTITUTED 50 MG (ethacrynate sodium)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 279 Coverage Requirements & Prescription Drug Name Drug Tier Limits torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1 OSMOTIC DIURETICS - Drugs for Water Balance mannitol intravenous solution 20 %, 25 % OA OSMITROL INTRAVENOUS SOLUTION 10 %, 15 %, 20 % OA (mannitol) OTHER ION-REMOVING AGENTS RADIOGARDASE ORAL CAPSULE 0.5 GM (prussian blue 3 PA insoluble) PHOSPHATE-REMOVING AGENTS AURYXIA ORAL TABLET 1 GM 210 MG(FE) (ferric citrate) 3 calcium acetate (phos binder) oral capsule 667 mg 1 calcium acetate (phos binder) oral tablet 667 mg 1 calcium acetate oral tablet 667 mg 1 FOSRENOL ORAL PACKET 1000 MG, 750 MG (lanthanum 3 carbonate) FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 MG, 3 750 MG (lanthanum carbonate) lanthanum carbonate oral tablet chewable 1000 mg, 500 1 mg, 750 mg PHOSLYRA ORAL SOLUTION 667 MG/5ML (calcium acetate 3 (phos binder)) RENAGEL ORAL TABLET 800 MG (sevelamer hcl) 3 RENVELA ORAL PACKET 0.8 GM, 2.4 GM (sevelamer 3 carbonate) RENVELA ORAL TABLET 800 MG (sevelamer carbonate) 3 sevelamer carbonate oral packet 0.8 gm, 2.4 gm 1 sevelamer carbonate oral tablet 800 mg 1 sevelamer hcl oral tablet 400 mg, 800 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 280 Coverage Requirements & Prescription Drug Name Drug Tier Limits VELPHORO ORAL TABLET CHEWABLE 500 MG (sucroferric 3 oxyhydroxide) POTASSIUM-REMOVING AGENTS LOKELMA ORAL PACKET 10 GM, 5 GM (sodium zirconium 2 cyclosilicate) sodium polystyrene sulfonate oral powder 1 sps oral suspension 15 gm/60ml 1 VELTASSA ORAL PACKET 16.8 GM, 25.2 GM, 8.4 GM 3 (patiromer sorbitex calcium) POTASSIUM-SPARING DIURETICS - Drugs for Water Balance ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG 3 (spironolactone) amiloride hcl oral tablet 5 mg 1 amiloride-hydrochlorothiazide oral tablet 5-50 mg 1 CAROSPIR ORAL SUSPENSION 25 MG/5ML 3 (spironolactone) DYRENIUM ORAL CAPSULE 100 MG, 50 MG (triamterene) 3 eplerenone oral tablet 25 mg, 50 mg 1 INSPRA ORAL TABLET 25 MG, 50 MG (eplerenone) 3 MAXZIDE ORAL TABLET 75-50 MG (triamterene-hctz) 3 MAXZIDE-25 ORAL TABLET 37.5-25 MG (triamterene-hctz) 3 spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 triamterene oral capsule 100 mg, 50 mg 1 triamterene-hctz oral capsule 37.5-25 mg 1 triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1 REPLACEMENT PREPARATIONS ADENOCAINE INTRAVENOUS SOLUTION PREFILLED OA SYRINGE (cardioplegic soln) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 281 Coverage Requirements & Prescription Drug Name Drug Tier Limits AGGRASTAT INTRAVENOUS SOLUTION 12.5-0.9 OA MG/250ML-%, 5-0.9 MG/100ML-% (tirofiban hcl in nacl) BIVALIRUDIN-SODIUM CHLORIDE INTRAVENOUS OA SOLUTION 500-0.9 MG/100ML-% BREVIBLOC IN NACL INTRAVENOUS SOLUTION 2000 OA MG/100ML, 2500 MG/250ML (esmolol hcl-sodium chloride) BREVIBLOC PREMIXED DS INTRAVENOUS SOLUTION 2000 OA MG/100ML (esmolol hcl-sodium chloride) BREVIBLOC PREMIXED INTRAVENOUS SOLUTION 2500 OA MG/250ML (esmolol hcl-sodium chloride) BUPIVACAINE HCL-NACL EPIDURAL SOLUTION 0.125-0.9 % OA BUPIVACAINE HCL-NACL EPIDURAL SOLUTION PREFILLED OA SYRINGE 0.25-0.9 % CALCIFOL ORAL WAFER 1342-1.6 MG (ca carb-fa-d-b6-b12- 3 boron-mg) calcium acetate (phos binder) oral capsule 667 mg 1 calcium acetate (phos binder) oral tablet 667 mg 1 calcium acetate oral tablet 667 mg 1 CALCIUM CHLORIDE SOLUTION 10 % INTRAVENOUS 10 % OA calcium chloride solution 10 % intravenous 10 % OA calcium gluconate intravenous solution 10 % OA CALCIUM GLUCONATE-NACL INTRAVENOUS SOLUTION 1- OA 0.675 GM/50ML-%, 2-0.675 GM/100ML-% CALCIUM GLUCONATE-NACL INTRAVENOUS SOLUTION 1- OA 0.9 GM/100ML-%, 2-0.9 GM/100ML-% calcium-folic acid plus d oral wafer 1342-1 mg 1 CARDIOPLEGIA DEL NIDO FORMULA PERFUSION OA SOLUTION CARDIOPLEGIA IND PLASMA HIGH K PERFUSION OA SOLUTION Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 282 Coverage Requirements & Prescription Drug Name Drug Tier Limits CARDIOPLEGIA IND PLASMA-TROMET PERFUSION OA SOLUTION CARDIOPLEGIA INDUCTION HIGH K PERFUSION OA SOLUTION CARDIOPLEGIA INDUCTION LOW DEX PERFUSION OA SOLUTION CARDIOPLEGIA INDUCTION NON-ENR PERFUSION OA SOLUTION CARDIOPLEGIA MAIN LOW DEXTROSE PERFUSION OA SOLUTION CARDIOPLEGIA MAIN LOW TROMETHA PERFUSION OA SOLUTION CARDIOPLEGIA MAIN PLASMA-TROME PERFUSION OA SOLUTION CARDIOPLEGIA MAINTENANCE PERFUSION SOLUTION OA CARDIOPLEGIA REPERFUSATE 4:1 PERFUSION SOLUTION OA CARDIOPLEGIC SOLUTION PERFUSION OA cardioplegic solution perfusion OA CEFAZOLIN IN SODIUM CHLORIDE INTRAVENOUS OA SOLUTION 2-0.9 GM/100ML-%, 3-0.9 GM/100ML-% chromic chloride intravenous solution 40 mcg/10ml OA CLINDAMYCIN PHOSPHATE IN NACL INTRAVENOUS SOLUTION 300-0.9 MG/50ML-%, 600-0.9 MG/50ML-%, 900- OA 0.9 MG/50ML-% CUPRIC CHLORIDE INTRAVENOUS SOLUTION 0.4 MG/ML OA DEXAMETHASONE SOD PHOS-NACL INTRAVENOUS OA SOLUTION 6-0.9 MG/25ML-% dexmedetomidine hcl in nacl intravenous solution 200 mcg/50ml, 200-0.9 mcg/50ml-%, 400 mcg/100ml, 80 OA mcg/20ml

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 283 Coverage Requirements & Prescription Drug Name Drug Tier Limits DEXMEDETOMIDINE HCL IN NACL INTRAVENOUS OA SOLUTION PREFILLED SYRINGE 20-0.9 MCG/5ML-% DEXMEDETOMIDINE HCL-DEXTROSE INTRAVENOUS OA SOLUTION 200MCG/50ML -5%, 400MCG/100ML -5% DEXTROSE 5%/ELECTROLYTE #48 INTRAVENOUS OA SOLUTION dextrose in lactated ringers intravenous solution 5 % OA dextrose-nacl intravenous solution 10-0.2 %, 10-0.45 %, 2.5- OA 0.45 %, 5-0.2 %, 5-0.33 %, 5-0.45 %, 5-0.9 % dextrose-sodium chloride intravenous solution 2.5-0.45 %, OA 5-0.225 %, 5-0.3 %, 5-0.45 %, 5-0.9 % DILTIAZEM HCL-SODIUM CHLORIDE INTRAVENOUS OA SOLUTION 125-0.7 MG/125ML-%, 125-0.9 MG/125ML-% DILUENT FOR LEFAMULIN INTRAVENOUS SOLUTION 0.9 % OA EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ 2 (potassium bicarb-citric acid) effer-k oral tablet effervescent 25 meq 1 ELLIOTTS B INTRATHECAL SOLUTION (intrathecal elec- OA dextrose) EPHEDRINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MG/ML-%, 100-0.9 MG/10ML-%, OA 25-0.9 MG/5ML-%, 50-0.9 MG/10ML-%, 50-0.9 MG/5ML-% EPINEPHRINE HCL-NACL INTRAVENOUS SOLUTION 8-0.9 OA MG/250ML-% EPINEPHRINE-NACL INTRAVENOUS SOLUTION 2-0.9 OA MG/250ML-%, 5-0.9 MG/250ML-% EPINEPHRINE-NACL INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 1-0.9 MG/10ML-% esmolol hcl-sodium chloride intravenous solution 2000 OA mg/100ml, 2500 mg/250ml

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 284 Coverage Requirements & Prescription Drug Name Drug Tier Limits FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION 1-0.9 MG/100ML-%, 1.25-0.9 MG/250ML-%, 2-0.9 MG/100ML-%, 2.5- OA 0.9 MG/250ML-% FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MCG/2ML-%, 10-0.9 MCG/ML- OA %, 100-0.9 MCG/10ML-%, 1000-0.9 MCG/50ML-%, 5-0.9 MCG/ML-%, 500-0.9 MCG/50ML-%, 550-0.9 MCG/55ML-% FENTANYL CIT-ROPIVACAINE-NACL EPIDURAL SOLUTION 0.2-0.2-0.9 MG/100ML-%, 0.3-0.2-0.9 MG/150ML-%, 0.4-0.1- OA 0.9 MG/200ML-%, 0.4-0.2-0.9 MG/200ML-%, 0.5-0.2-0.9 MG/250ML-% FENTANYL-BUPIVACAINE-NACL EPIDURAL SOLUTION 0.2- 0.1-0.9 MG/100ML-%, 0.2-0.125-0.9 MG/100ML-%, 0.5-0.0625- OA 0.9 MG/250ML-%, 0.5-0.1-0.9 MG/250ML-%, 0.5-0.125-0.9 MG/250ML-%, 0.8-0.1667-0.9 MG/200ML-% FENTANYL-BUPIVACAINE-NACL EPIDURAL SOLUTION OA PREFILLED SYRINGE 0.1-0.125-0.9 MG/50ML-% FENTANYL-BUPIVACAINE-NACL INJECTION SOLUTION 2- OA 0.125-0.9 MCG/ML-%-% FENTANYL-ROPIVACAINE-NACL EPIDURAL SOLUTION 0.2- OA 0.1-0.9 MG/100ML-% fluconazole in sodium chloride intravenous solution 200- OA 0.9 mg/100ml-%, 400-0.9 mg/200ml-% FOLITE ORAL TABLET 3 FUROSEMIDE IN SODIUM CHLORIDE INTRAVENOUS OA SOLUTION 100-0.9 MG/100ML-% GALZIN ORAL CAPSULE 25 MG, 50 MG (zinc acetate (oral)) 3 gentamicin in saline intravenous solution 0.8-0.9 mg/ml-%, 1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.6-0.9 mg/ml-%, 2-0.9 OA mg/ml-% GLYCOPHOS INTRAVENOUS SOLUTION 1 MMOLE/ML OA (sodium glycerophosphate) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 285 Coverage Requirements & Prescription Drug Name Drug Tier Limits heparin (porcine) in nacl intravenous solution 1000-0.9 ut/500ml-%, 12500-0.45 ut/250ml-%, 2000-0.9 unit/l-%, OA 25000-0.45 ut/500ml-% HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 2500-0.9 UT/500ML-%, 30000-0.9 UNIT/L-%, 4000-0.9 UNIT/L- OA %, 500-0.9 UT/500ML-%, 5000-0.9 UNIT/L-%, 5000-0.9 UT/500ML-% heparin (porcine) in nacl intravenous solution 25000-0.45 OA PA ut/250ml-% HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 20-0.9 UNT/20ML-%, 50-0.9 OA QL (30 day supply per 1 fill) UNT/50ML-% HESPAN INTRAVENOUS SOLUTION 6-0.9 % (hetastarch- OA nacl) hetastarch-nacl intravenous solution 6-0.9 % OA HEXTEND INTRAVENOUS SOLUTION 6 % (hetastarch in OA lact electrolyte) HYDROMORPHONE HCL-NACL INJECTION SOLUTION 20- OA 0.9 MG/100ML-% HYDROMORPHONE HCL-NACL INJECTION SOLUTION PREFILLED SYRINGE 10-0.9 MG/50ML-%, 30-0.9 MG/30ML- OA % HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION 10-0.9 MG/50ML-%, 100-0.9 MG/50ML-%, 20-0.9 MG/100ML- OA %, 25-0.9 MG/50ML-%, 30-0.9 MG/30ML-%, 50-0.9 MG/50ML- %, 6-0.9 MG/30ML-% HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.2-0.9 MG/0.2ML-%, 0.5-0.9 MG/0.5ML-%, 1-0.9 MG/5ML-%, 1-0.9 MG/ML-%, 10-0.9 OA MG/50ML-%, 15-0.9 MG/30ML-%, 2-0.9 MG/ML-%, 25-0.9 MG/50ML-%, 30-0.9 MG/30ML-%, 5-0.9 MG/25ML-%, 50-0.9 MG/50ML-%, 55-0.9 MG/55ML-%, 6-0.9 MG/30ML-%

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 286 Coverage Requirements & Prescription Drug Name Drug Tier Limits HYPERLYTE-CR INTRAVENOUS CONCENTRATE OA (parenteral electrolytes) INFASURF INTRATRACHEAL SUSPENSION 35-0.9 MG/ML-% 3 (calfactant in nacl) INFUGEM INTRAVENOUS SOLUTION 1200-0.9 MG/120ML- %, 1300-0.9 MG/130ML-%, 1400-0.9 MG/140ML-%, 1500-0.9 MG/150ML-%, 1600-0.9 MG/160ML-%, 1700-0.9 MG/170ML-%, OA 1800-0.9 MG/180ML-%, 1900-0.9 MG/190ML-%, 2000-0.9 MG/200ML-%, 2200-0.9 MG/220ML-% (gemcitabine hcl-nacl) IONOSOL-MB IN D5W INTRAVENOUS SOLUTION OA (electrolyte-mb in dextrose) ISOLYTE-P IN D5W INTRAVENOUS SOLUTION (electrolyte- OA p in dextrose) ISOLYTE-S INTRAVENOUS SOLUTION (electrolyte-s) OA ISOLYTE-S PH 7.4 INTRAVENOUS SOLUTION (electrolyte-s OA (ph 7.4)) ISOPROTERENOL-SODIUM CHLORIDE INTRAVENOUS OA SOLUTION 200-0.9 MCG/50ML-% JENLIVA PRENATAL/POSTNATAL ORAL CAPSULE 1 MG 3 PV KCL (IN NACL 0.9%) INTRAVENOUS SOLUTION 40 OA MEQ/500ML kcl in dextrose-nacl intravenous solution 10-5-0.45 meq/l- %-%, 20-5-0.2 meq/l-%-%, 20-5-0.225 meq/l-%-%, 20-5-0.45 OA meq/l-%-%, 20-5-0.9 meq/l-%-%, 30-5-0.45 meq/l-%-%, 40-5- 0.45 meq/l-%-%, 40-5-0.9 meq/l-%-% kcl-lactated ringers-d5w intravenous solution 20 meq/l OA KCL-LIDOCAINE-NACL INTRAVENOUS SOLUTION 10-10 OA MEQ-MG /100ML KETAMINE HCL-SODIUM CHLORIDE INJECTION SOLUTION OA PREFILLED SYRINGE 50-0.9 MG/5ML-%

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 287 Coverage Requirements & Prescription Drug Name Drug Tier Limits KETAMINE HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MG/ML-%, 100-0.9 OA MG/10ML-%, 20-0.9 MG/2ML-%, 50-0.9 MG/5ML-% klor-con 10 oral tablet extended release 10 meq 1 klor-con m10 oral tablet extended release 10 meq 1 klor-con m15 oral tablet extended release 15 meq 1 klor-con m20 oral tablet extended release 20 meq 1 klor-con oral packet 20 meq 1 klor-con oral tablet extended release 8 meq 1 klor-con/ef oral tablet effervescent 25 meq 1 K-PHOS ORAL TABLET 500 MG (potassium phosphate 3 monobasic) K-PHOS-NEUTRAL ORAL TABLET 155-852-130 MG (k phos 3 mono-sod phos di & mono) k-prime oral tablet effervescent 25 meq 1 K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ 2 (potassium chloride) K-TAB ORAL TABLET EXTENDED RELEASE 8 MEQ 1 (potassium chloride) lactated ringers intravenous solution OA levetiracetam in nacl intravenous solution 1000 mg/100ml, OA 1500 mg/100ml, 500 mg/100ml linezolid in sodium chloride intravenous solution 600-0.9 OA mg/300ml-% LMD IN D5W INTRAVENOUS SOLUTION 10-5 % (dextran 40 OA in d5w) LMD IN NACL INTRAVENOUS SOLUTION 10-0.9 % (dextran OA 40 in saline) magnesium chloride injection solution 200 mg/ml OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 288 Coverage Requirements & Prescription Drug Name Drug Tier Limits magnesium sulfate in d5w intravenous solution 1-5 OA gm/100ml-% MAGNESIUM SULFATE-NACL INTRAVENOUS SOLUTION 2- OA 0.9 GM/50ML-% MANGANESE CHLORIDE INTRAVENOUS SOLUTION 0.1 OA MG/ML METHADONE HCL-NACL INTRAVENOUS SOLUTION OA PREFILLED SYRINGE 1-0.9 MG/ML-% MICROPLEGIA MSA-MSG PERFUSION SOLUTION OA MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 100-0.8 MG/100ML-%, 100-0.9 MG/100ML-%, 50- OA 0.8 MG/50ML-%, 50-0.9 MG/50ML-% MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 2-0.9 MG/2ML-%, 5-0.9 OA MG/5ML-%, 55-0.9 MG/55ML-% MIDAZOLAM-SODIUM CHLORIDE INTRAVENOUS OA SOLUTION 100-0.9 MG/100ML-%, 50-0.9 MG/50ML-% MIDAZOLAM-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 30-0.9 MG/30ML-%, 50-0.9 OA MG/50ML-%, 55-0.9 MG/55ML-%, 60-0.9 MG/30ML-% monoject flush syringe intravenous solution 0.9 % OA monoject sodium chloride flush intravenous solution 0.9 % OA MORPHINE SULFATE-NACL INJECTION SOLUTION 3 PREFILLED SYRINGE 5-0.9 MG/5ML-% MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION 100- OA 0.9 MG/100ML-%, 50-0.9 MG/50ML-%, 500-0.9 MG/100ML-% MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 1-0.9 MG/ML-%, 150-0.9 MG/30ML-%, OA 2-0.9 MG/ML-%, 30-0.9 MG/30ML-%, 4-0.9 MG/ML-%, 50-0.9 MG/50ML-%, 55-0.9 MG/55ML-%

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 289 Coverage Requirements & Prescription Drug Name Drug Tier Limits multitrace-4 neonatal intravenous solution 100-25-1500 OA mcg/ml MULTITRACE-4 PEDIATRIC INTRAVENOUS SOLUTION 1- OA 100-25-1000 MCG/ML (trace minerals cr-cu-mn-zn) MULTRYS INTRAVENOUS SOLUTION 60-3-6-1000 MCG/ML OA (trace minerals cu-mn-se-zn) MYXREDLIN INTRAVENOUS SOLUTION 100-0.9 UT/100ML- OA % (insulin regular(human) in nacl) NICARDIPINE HCL IN NACL INTRAVENOUS SOLUTION OA PREFILLED SYRINGE 1-0.9 MG/10ML-% NIPRIDE RTU INTRAVENOUS SOLUTION 20-0.9 MG/100ML- OA %, 50-0.9 MG/100ML-% (nitroprusside sodium-nacl) NOREPINEPHRINE-SODIUM CHLORIDE INTRAVENOUS SOLUTION 16-0.9 MG/250ML-%, 4-0.9 MG/250ML-%, 8-0.9 OA MG/250ML-%, 8-0.9 MG/500ML-% normal saline flush intravenous solution 0.9 % OA NORMOSOL-M IN D5W INTRAVENOUS SOLUTION OA (electrolyte-m in dextrose) NORMOSOL-R IN D5W INTRAVENOUS SOLUTION OA (electrolyte-r in dextrose) NORMOSOL-R INTRAVENOUS SOLUTION (electrolyte-r) OA NORMOSOL-R PH 7.4 INTRAVENOUS SOLUTION OA (electrolyte-r (ph 7.4)) OXYTOCIN-LACTATED RINGERS INTRAVENOUS OA SOLUTION 20 UNIT/L, 30 UNIT/500ML OXYTOCIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION OA 15-0.9 UT/250ML-%, 20-0.9 UNIT/L-%, 30-0.9 UT/500ML-% oyster shell calcium/d oral tablet 500-200 mg-unit, 500-400 1 PV mg-unit, 500-5 mg-mcg oyster shell calcium/vit d3 oral tablet 250-3.12 mg-mcg 1 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 290 Coverage Requirements & Prescription Drug Name Drug Tier Limits oyster shell calcium/vitamin d oral tablet 500-200 mg-unit 1 PV PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION 10- 0.9 MG/250ML-%, 100-0.9 MG/250ML-%, 20-0.9 MG/250ML-%, OA 25-0.9 MG/250ML-%, 40-0.9 MG/250ML-%, 50-0.9 MG/250ML- %, 80-0.9 MG/250ML-% PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.4-0.9 MG/10ML-%, 0.5-0.9 MG/5ML- OA %, 0.8-0.9 MG/10ML-%, 1-0.9 MG/10ML-%, 100-0.9 MCG/10ML-%, 20-0.9 MG/50ML-%, 5-0.9 MG/50ML-% PHOSLYRA ORAL SOLUTION 667 MG/5ML (calcium acetate 3 (phos binder)) PHOSPHA 250 NEUTRAL ORAL TABLET 155-852-130 MG (k 3 phos mono-sod phos di & mono) phosphorous oral tablet 155-852-130 mg 1 phospho-trin 250 neutral oral tablet 155-852-130 mg 1 PHOXILLUM B22K4/0 INTRAVENOUS SOLUTION 22-4-1 OA MEQ-MMOL/L PHOXILLUM BK4/2.5 INTRAVENOUS SOLUTION 32-4-2.5-1 OA MEQ-MMOL/L PLASMA-LYTE 148 INTRAVENOUS SOLUTION (electrolyte- OA 148) PLASMA-LYTE A INTRAVENOUS SOLUTION (electrolyte-a) OA PLEGISOL PERFUSION SOLUTION (cardioplegic soln) OA potassium acetate intravenous solution 2 meq/ml OA potassium chloride crys er oral tablet extended release 10 1 meq, 15 meq, 20 meq potassium chloride er oral capsule extended release 10 1 meq, 8 meq potassium chloride er oral tablet extended release 10 meq, 1 8 meq

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 291 Coverage Requirements & Prescription Drug Name Drug Tier Limits potassium chloride in dextrose intravenous solution 20-5 OA meq/l-% potassium chloride in nacl intravenous solution 20-0.45 OA meq/l-%, 20-0.9 meq/l-%, 40-0.9 meq/l-% potassium chloride intravenous solution 10 meq/100ml, 10 meq/50ml, 2 meq/ml, 20 meq/100ml, 20 meq/50ml, 40 OA meq/100ml potassium chloride oral packet 20 meq 1 potassium chloride oral solution 10 %, 20 meq/15ml (10%), 1 40 meq/15ml (20%) potassium phosphates intravenous solution 15 mmole/5ml, OA 150 mmole/50ml, 45 mmole/15ml potassium phosphates(66 meq k) intravenous solution 45 OA mmole/15ml potassium phosphates(71 meq k) intravenous solution 45 OA mmole/15ml PRECEDEX INTRAVENOUS SOLUTION 1000 MCG/250ML, 200 MCG/50ML, 400 MCG/100ML, 80 MCG/20ML OA (dexmedetomidine hcl in nacl) prenatal multi +dha oral capsule 27-0.8-200 mg, 27-0.8-250 1 PV mg PRENATVITE RX ORAL TABLET 0.8 MG 3 PRISMASOL B22GK 4/0 INTRAVENOUS SOLUTION 22-4 OA MEQ/L (bicarb-dextrose-k (crrt)) PRISMASOL BGK 0/2.5 INTRAVENOUS SOLUTION 32-2.5 OA MEQ/L (bicarb-dextrose-ca (crrt)) PRISMASOL BGK 2/0 INTRAVENOUS SOLUTION 32-2 OA MEQ/L (bicarb-dextrose-k (crrt)) PRISMASOL BGK 2/3.5 INTRAVENOUS SOLUTION 32-2-3.5 OA MEQ/L (bicarb-dextrose-k-ca (crrt))

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 292 Coverage Requirements & Prescription Drug Name Drug Tier Limits PRISMASOL BGK 4/0/1.2 INTRAVENOUS SOLUTION 32-4- OA 1.2 MEQ/L (bicarb-dextose-k-mg (crrt)) PRISMASOL BGK 4/2.5 INTRAVENOUS SOLUTION 32-4-2.5 OA MEQ/L (bicarb-dextrose-k-ca (crrt)) PRISMASOL BK 0/0/1.2 INTRAVENOUS SOLUTION 32-1.2 OA MEQ/L (bicarb-mg (crrt)) QUFLORA FE ORAL TABLET CHEWABLE 0.25 MG (multi vit- 3 min-fluoride-fe-fa) ringers intravenous solution OA ROPIVACAINE HCL-NACL EPIDURAL SOLUTION 0.15-0.9 %, OA 0.2-0.9 % ROPIVACAINE HCL-NACL INJECTION SOLUTION 0.2-0.9 % 3 saline bacteriostatic injection solution 0.9 % OA SALINE-PHENOL INJECTION SOLUTION 0.4-0.9 % 3 SELENIOUS ACID INTRAVENOUS SOLUTION 60 MCG/ML OA sodium chloride (pf) injection solution 0.9 % OA sodium chloride bacteriostatic injection solution 0.9 % OA sodium chloride flush intravenous solution 0.9 % OA sodium chloride injection solution 2.5 meq/ml OA sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 4 OA meq/ml, 5 % sodium phosphates intravenous solution 15 mmole/5ml, 45 OA mmole/15ml THE LIQUILIFT TRACE INTRAVENOUS KIT 10-1000-500-60 OA MCG/ML (trace minerals cr-cu-mn-se-zn) TPN ELECTROLYTES INTRAVENOUS CONCENTRATE OA (parenteral electrolytes) TRACE ELEMENTS 4/PEDIATRIC INTRAVENOUS SOLUTION OA 1-100-30-500 MCG/ML (trace minerals cr-cu-mn-zn)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 293 Coverage Requirements & Prescription Drug Name Drug Tier Limits TRALEMENT INTRAVENOUS SOLUTION 300-55-60-3000 OA MCG/ML (trace minerals cu-mn-se-zn) TRISODIUM CITRATE/CRRT INTRAVENOUS SOLUTION OA vancomycin hcl in nacl intravenous solution 1-0.9 OA gm/200ml-%, 500-0.9 mg/100ml-% VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 1- 0.9 GM/250ML-%, 1.25-0.9 GM/250ML-%, 1.5-0.9 GM/250ML- OA %, 1.5-0.9 GM/500ML-%, 1.75-0.9 GM/250ML-%, 2-0.9 GM/500ML-% VANCOMYCIN HCL IN NACL SOLUTION 750-0.9 MG/150ML- OA % INTRAVENOUS 750-0.9 MG/150ML-% vancomycin hcl in nacl solution 750-0.9 mg/150ml-% OA intravenous 750-0.9 mg/150ml-% virt-phos 250 neutral oral tablet 155-852-130 mg 1 WILZIN ORAL CAPSULE 25 MG (zinc acetate (oral)) 3 ZINC CHLORIDE INTRAVENOUS SOLUTION 1 MG/ML OA ZINC SULFATE INTRAVENOUS SOLUTION 1 MG/ML, 3 OA MG/ML, 5 MG/ML SALT AND SUGAR SUBSTITUTES sodium saccharin powder 1 THIAZIDE DIURETICS - Drugs for Water Balance ACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 3 MG (quinapril-hydrochlorothiazide) ALDACTAZIDE ORAL TABLET 25-25 MG (spironolactone- 3 hctz) ALDACTAZIDE ORAL TABLET 50-50 MG (spironolactone- 2 hctz) amiloride-hydrochlorothiazide oral tablet 5-50 mg 1 amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10- 1 ST 160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 294 Coverage Requirements & Prescription Drug Name Drug Tier Limits ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 MG, 32- 3 ST 25 MG (candesartan cilexetil-hctz) AVALIDE ORAL TABLET 150-12.5 MG, 300-12.5 MG 3 ST (irbesartan-hydrochlorothiazide) benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- 1 12.5 mg, 20-25 mg, 5-6.25 mg BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, 40-25 3 ST MG (olmesartan medoxomil-hctz) bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5- 1 6.25 mg, 5-6.25 mg candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 1 ST mg, 32-25 mg chlorothiazide sodium intravenous solution reconstituted OA 500 mg DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320- 12.5 MG, 320-25 MG, 80-12.5 MG (valsartan- 3 ST hydrochlorothiazide) DIURIL ORAL SUSPENSION 250 MG/5ML (chlorothiazide) 2 DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG (metoprolol- 3 hydrochlorothiazide) EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG 3 ST (azilsartan-chlorthalidone) enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 1 mg EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG 3 ST (amlodipine-valsartan-hctz) fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg 1 hydrochlorothiazide oral capsule 12.5 mg 1 hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg 1 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 295 Coverage Requirements & Prescription Drug Name Drug Tier Limits HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 3 ST MG (losartan potassium-hctz) irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300- 1 12.5 mg lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- 1 * 12.5 mg, 20-25 mg losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 1 * 50-12.5 mg LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20- 3 25 MG (benazepril-hydrochlorothiazide) MAXZIDE ORAL TABLET 75-50 MG (triamterene-hctz) 3 MAXZIDE-25 ORAL TABLET 37.5-25 MG (triamterene-hctz) 3 metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100- 1 50 mg, 50-25 mg MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5 MG, 80- 3 ST 25 MG (telmisartan-hctz) olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 1 mg, 40-25 mg olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10- 1 ST 12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- 1 12.5 mg, 20-25 mg SODIUM DIURIL INTRAVENOUS SOLUTION OA RECONSTITUTED 500 MG (chlorothiazide sodium) spironolactone-hctz oral tablet 25-25 mg 1 TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 3 300-12.5 MG, 300-25 MG (aliskiren-hydrochlorothiazide) telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 1 mg triamterene-hctz oral capsule 37.5-25 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 296 Coverage Requirements & Prescription Drug Name Drug Tier Limits triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1 TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG (olmesartan- 3 ST amlodipine-hctz) valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160- 1 25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg VASERETIC ORAL TABLET 10-25 MG (enalapril- 3 hydrochlorothiazide) ZESTORETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 3 MG (lisinopril-hydrochlorothiazide) ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG 3 (bisoprolol-hydrochlorothiazide) THIAZIDE-LIKE DIURETICS - Drugs for Water Balance atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1 chlorthalidone oral tablet 25 mg, 50 mg 1 indapamide oral tablet 1.25 mg, 2.5 mg 1 metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1 TENORETIC 100 ORAL TABLET 100-25 MG (atenolol- 3 chlorthalidone) TENORETIC 50 ORAL TABLET 50-25 MG (atenolol- 3 chlorthalidone) URICOSURIC AGENTS colchicine-probenecid oral tablet 0.5-500 mg 1 probenecid oral tablet 500 mg 1 VASOPRESSIN ANTAGONISTS - Drugs for Water Balance PA; SP; QL (30 day supply JYNARQUE ORAL TABLET 15 MG, 30 MG (tolvaptan) 3 per 1 fill) JYNARQUE ORAL TABLET THERAPY PACK 15 MG, 30 & 15 PA; SP; QL (30 day supply 3 MG, 45 & 15 MG, 60 & 30 MG, 90 & 30 MG (tolvaptan) per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 297 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SP; QL (30 day supply SAMSCA ORAL TABLET 15 MG, 30 MG (tolvaptan) 3 per 1 fill) PA; SP; QL (30 day supply TOLVAPTAN ORAL TABLET 15 MG 3 per 1 fill) PA; SP; QL (30 day supply tolvaptan oral tablet 30 mg 1 per 1 fill) VAPRISOL INTRAVENOUS SOLUTION 20-5 MG/100ML-% OA PA (conivaptan hcl in dextrose) ENZYMES ENZYMES ACTIVASE INTRAVENOUS SOLUTION RECONSTITUTED OA 100 MG, 50 MG (alteplase) ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5ML OA QL (30 day supply per 1 fill) (laronidase) AMPHADASE INJECTION SOLUTION 150 UNIT/ML OA (hyaluronidase bovine) PA; QL (30 day supply per 1 BRINEURA KIT 2 X 150 MG/5ML (cerliponase alfa) OA fill) CATHFLO ACTIVASE INJECTION SOLUTION OA RECONSTITUTED 2 MG (alteplase) CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 400 UNIT (imiglucerase) CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000-38000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 2 36000-114000 UNIT, 6000-19000 UNIT (pancrelipase (lip- prot-amyl)) ELAPRASE INTRAVENOUS SOLUTION 6 MG/3ML OA QL (30 day supply per 1 fill) (idursulfase) ELELYSO INTRAVENOUS SOLUTION RECONSTITUTED 200 OA QL (30 day supply per 1 fill) UNIT (taliglucerase alfa)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 298 Coverage Requirements & Prescription Drug Name Drug Tier Limits ELITEK INTRAVENOUS SOLUTION RECONSTITUTED 1.5 OA MG, 7.5 MG (rasburicase) ERWINASE INJECTION SOLUTION RECONSTITUTED 10000 OA QL (30 day supply per 1 fill) UNIT (asparaginase erwinia chrysanth) FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 35 MG (agalsidase beta) FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED PA; QL (30 day supply per 1 OA 5 MG (agalsidase beta) fill) HYLENEX INJECTION SOLUTION 150 UNIT/ML OA (hyaluronidase human) HYQVIA SUBCUTANEOUS KIT 10 GM/100ML, 2.5 GM/25ML, PA; SP; QL (30 day supply 20 GM/200ML, 30 GM/300ML, 5 GM/50ML (immune globulin- SI per 1 fill) hyaluronidase) KANUMA INTRAVENOUS SOLUTION 20 MG/10ML OA QL (30 day supply per 1 fill) (sebelipase alfa) LUMIZYME INTRAVENOUS SOLUTION RECONSTITUTED 50 OA QL (30 day supply per 1 fill) MG (alglucosidase alfa) MEPSEVII INTRAVENOUS SOLUTION 10 MG/5ML OA QL (30 day supply per 1 fill) (vestronidase alfa-vjbk) NAGLAZYME INTRAVENOUS SOLUTION 1 MG/ML OA QL (30 day supply per 1 fill) (galsulfase) NEXVIAZYME INTRAVENOUS SOLUTION RECONSTITUTED OA PA; SP 100 MG (avalglucosidase alfa-ngpt) PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SYRINGE 10 MG/0.5ML, 2.5 MG/0.5ML, 20 MG/ML SI per 1 fill) (pegvaliase-pqpz) PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500-35500 UNIT, 16800-56800 UNIT, 21000- 2 54700 UNIT, 4200-14200 UNIT (pancrelipase (lip-prot-amyl))

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 299 Coverage Requirements & Prescription Drug Name Drug Tier Limits PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 2600-8800 UNIT, 37000-97300 UNIT 3 (pancrelipase (lip-prot-amyl)) PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000-57500 UNIT, 24000-86250 UNIT, 4000-14375 UNIT, 2 8000-28750 UNIT (pancrelipase (lip-prot-amyl)) PULMOZYME INHALATION SOLUTION 1 MG/ML (dornase PA; SP; QL (30 day supply 3 alfa) per 1 fill) RETAVASE HALF-KIT INTRAVENOUS KIT 1 X 10 UNIT OA (reteplase) RETAVASE INTRAVENOUS KIT 2 X 10 UNIT (reteplase) OA REVCOVI INTRAMUSCULAR SOLUTION 2.4 MG/1.5ML OA QL (30 day supply per 1 fill) (elapegademase-lvlr) SANTYL EXTERNAL OINTMENT 250 UNIT/GM (collagenase) 3 STRENSIQ SUBCUTANEOUS SOLUTION 18 MG/0.45ML, 28 PA; SP; QL (30 day supply SI MG/0.7ML, 40 MG/ML, 80 MG/0.8ML (asfotase alfa) per 1 fill) SP; QL (30 day supply per 1 SUCRAID ORAL SOLUTION 8500 UNIT/ML (sacrosidase) 3 fill) TNKASE INTRAVENOUS KIT 50 MG (tenecteplase) OA VIMIZIM INTRAVENOUS SOLUTION 5 MG/5ML (elosulfase OA QL (30 day supply per 1 fill) alfa) VIOKACE ORAL TABLET 10440-39150 UNIT, 20880-78300 2 UNIT (pancrelipase (lip-prot-amyl)) VITRASE INJECTION SOLUTION 200 UNIT/ML OA (hyaluronidase ovine) VORAXAZE INTRAVENOUS SOLUTION RECONSTITUTED OA 1000 UNIT (glucarpidase) VPRIV INTRAVENOUS SOLUTION RECONSTITUTED 400 OA QL (30 day supply per 1 fill) UNIT (velaglucerase alfa) XIAFLEX INJECTION SOLUTION RECONSTITUTED 0.9 MG PA; QL (30 day supply per 1 SI (collagenase clostrid histolyt) fill) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 300 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 2 25000-79000 UNIT, 3000-10000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT (pancrelipase (lip-prot-amyl)) EYE, EAR, NOSE AND THROAT (EENT) PREPS. ALPHA-ADRENERGIC AGONISTS (EENT) - Drugs for the Eye ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % (brimonidine 2 tartrate) ALPHAGAN P OPHTHALMIC SOLUTION 0.15 % (brimonidine 3 tartrate) brimonidine tartrate ophthalmic solution 0.15 %, 0.2 % 1 COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % 3 (brimonidine tartrate-timolol) SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 % 3 (brinzolamide-brimonidine) ANTIALLERGIC AGENTS - Drugs for Allergy ALOCRIL OPHTHALMIC SOLUTION 2 % (nedocromil 3 sodium) ALOMIDE OPHTHALMIC SOLUTION 0.1 % (lodoxamide 2 tromethamine) azelastine hcl nasal solution 0.1 %, 0.15 %, 137 mcg/spray 1 azelastine hcl ophthalmic solution 0.05 % 1 azelastine-fluticasone nasal suspension 137-50 mcg/act 1 bepotastine besilate ophthalmic solution 1.5 % 1 BEPREVE OPHTHALMIC SOLUTION 1.5 % (bepotastine 3 besilate) cromolyn sodium inhalation nebulization solution 20 1 mg/2ml cromolyn sodium ophthalmic solution 4 % 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 301 Coverage Requirements & Prescription Drug Name Drug Tier Limits DYMISTA NASAL SUSPENSION 137-50 MCG/ACT 3 (azelastine-fluticasone) epinastine hcl ophthalmic solution 0.05 % 1 LASTACAFT OPHTHALMIC SOLUTION 0.25 % (alcaftadine) 3 olopatadine hcl nasal solution 0.6 % 1 olopatadine hcl ophthalmic solution 0.1 %, 0.2 % 1 PATANASE NASAL SOLUTION 0.6 % (olopatadine hcl) 3 PA; QL (2 EA per 1 day); AL ZERVIATE OPHTHALMIC SOLUTION 0.24 % (cetirizine hcl) 3 (Max 2 Years) ANTIBACTERIALS (EENT) - Drugs for Infections ak-poly-bac ophthalmic ointment 500-10000 unit/gm 1 AZASITE OPHTHALMIC SOLUTION 1 % (azithromycin) 3 bacitracin ophthalmic ointment 500 unit/gm 1 bacitracin-polymyxin b ophthalmic ointment 500-10000 1 unit/gm bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % 1 BESIVANCE OPHTHALMIC SUSPENSION 0.6 % 3 (besifloxacin hcl) BLEPH-10 OPHTHALMIC SOLUTION 10 % (sulfacetamide 3 sodium) BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 % 3 (sulfacetamide-prednisolone) BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 % 3 (sulfacetamide-prednisolone) CETRAXAL OTIC SOLUTION 0.2 % (ciprofloxacin hcl) 3 CILOXAN OPHTHALMIC OINTMENT 0.3 % (ciprofloxacin 3 hcl) CILOXAN OPHTHALMIC SOLUTION 0.3 % (ciprofloxacin hcl) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 302 Coverage Requirements & Prescription Drug Name Drug Tier Limits CIPRO HC OTIC SUSPENSION 0.2-1 % (ciprofloxacin- 3 hydrocortisone) CIPRODEX OTIC SUSPENSION 0.3-0.1 % (ciprofloxacin- 3 dexamethasone) ciprofloxacin hcl ophthalmic solution 0.3 % 1 ciprofloxacin hcl otic solution 0.2 % 1 ciprofloxacin-dexamethasone otic suspension 0.3-0.1 % 1 CIPROFLOXACIN-FLUOCINOLONE PF OTIC SOLUTION 0.3- 2 0.025 % CORTISPORIN-TC OTIC SUSPENSION 3.3-3-10-0.5 MG/ML 3 (neomycin-colist-hc-thonzonium) erythromycin ophthalmic ointment 5 mg/gm 1 gatifloxacin ophthalmic solution 0.5 % 1 gentak ophthalmic ointment 0.3 % 1 gentamicin sulfate ophthalmic solution 0.3 % 1 KLARITY-A OPHTHALMIC SOLUTION 1 % (azithromycin) 3 levofloxacin ophthalmic solution 0.5 % 1 MAXITROL OPHTHALMIC OINTMENT 3.5-10000-0.1 3 (neomycin-polymyxin-dexameth) MAXITROL OPHTHALMIC SUSPENSION 3.5-10000-0.1 3 (neomycin-polymyxin-dexameth) MITOMYCIN INTRAOCULAR SOLUTION PREFILLED OA SYRINGE 0.02 %, 0.03 %, 0.04 % MOXEZA OPHTHALMIC SOLUTION 0.5 % (moxifloxacin hcl) 3 moxifloxacin hcl (2x day) ophthalmic solution 0.5 % 1 MOXIFLOXACIN HCL INTRAOCULAR SOLUTION PREFILLED OA SYRINGE 0.16 %, 0.3 MG/0.3ML moxifloxacin hcl ophthalmic solution 0.5 % 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 303 Coverage Requirements & Prescription Drug Name Drug Tier Limits MOXIFLOXACIN HCL OPHTHALMIC SOLUTION PREFILLED OA PA SYRINGE 0.5 % MOXIFLOXACIN HCL-BSS INTRAVITREAL SOLUTION 1 OA MG/ML neomycin-bacitracin zn-polymyx ophthalmic ointment 3.5- 1 400-10000 , 5-400-10000 neomycin-polymyxin-dexameth ophthalmic ointment 3.5- 1 10000-0.1 neomycin-polymyxin-dexameth ophthalmic suspension 3.5- 1 10000-0.1 neomycin-polymyxin-gramicidin ophthalmic solution 1.75- 1 10000-.025 neomycin-polymyxin-hc ophthalmic suspension 3.5-10000- 1 1 neomycin-polymyxin-hc otic solution 1 %, 3.5-10000-1 1 neomycin-polymyxin-hc otic suspension 3.5-10000-1 1 neo-polycin hc ophthalmic ointment 1 % 1 neo-polycin ophthalmic ointment 3.5-400-10000 1 OCUFLOX OPHTHALMIC SOLUTION 0.3 % (ofloxacin) 3 ofloxacin ophthalmic solution 0.3 % 1 ofloxacin otic solution 0.3 % 1 OTIPRIO INTRATYMPANIC SUSPENSION 6 % 3 (ciprofloxacin) OTOVEL OTIC SOLUTION 0.3-0.025 % (ciprofloxacin- 2 fluocinolone) polycin ophthalmic ointment 500-10000 unit/gm 1 polymyxin b-trimethoprim ophthalmic solution 10000-0.1 1 unit/ml-% POLYTRIM OPHTHALMIC SOLUTION 10000-0.1 UNIT/ML-% 3 (polymyxin b-trimethoprim) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 304 Coverage Requirements & Prescription Drug Name Drug Tier Limits PRED-G OPHTHALMIC SUSPENSION 0.3-1 % (gentamicin- 3 prednisolone acet) PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 % 3 (gentamicin-prednisolone acet) PREDNISOL ACE-MOXIFLOX-BROMFEN OPHTHALMIC 3 SUSPENSION 1-0.5-0.075 % PREDNISOLONE ACET-MOXIFLOXACIN OPHTHALMIC 3 SUSPENSION 1-0.5 % PREDNISOLONE-GATIFLOXACIN OPHTHALMIC 2 SUSPENSION 1-0.5 % PREDNISOLONE-MOXIFLOXACIN OPHTHALMIC SOLUTION 3 1-0.5 % PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC 3 SOLUTION 1-0.5-0.075 % PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC 3 SUSPENSION 1-0.5-0.075 % PREDNISOLON-MOXIFLOX-BROMFENAC OPHTHALMIC 3 SOLUTION 1-0.5-0.075 % PREDNISOLON-MOXIFLOX-NEPAFENAC OPHTHALMIC 3 SUSPENSION 1-0.5-0.1 % sulfacetamide sodium ophthalmic ointment 10 % 1 sulfacetamide sodium ophthalmic solution 10 % 1 sulfacetamide-prednisolone ophthalmic solution 10-0.23 % 1 TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % 2 (tobramycin-dexamethasone) TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 % 3 (tobramycin-dexamethasone) TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 % 2 (tobramycin-dexamethasone) tobramycin ophthalmic solution 0.3 % 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 305 Coverage Requirements & Prescription Drug Name Drug Tier Limits tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 1 % TOBREX OPHTHALMIC OINTMENT 0.3 % (tobramycin) 2 TOBREX OPHTHALMIC SOLUTION 0.3 % (tobramycin) 3 VANCOMYCIN HCL OPHTHALMIC SOLUTION PREFILLED OA SYRINGE 10 MG/ML VIGAMOX OPHTHALMIC SOLUTION 0.5 % (moxifloxacin 3 hcl) ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 % (loteprednol- 3 tobramycin) ZYMAXID OPHTHALMIC SOLUTION 0.5 % (gatifloxacin) 3 ANTIFUNGALS (EENT) - Drugs for Infections NATACYN OPHTHALMIC SUSPENSION 5 % (natamycin) 3 ANTIGLAUCOMA AGENTS, MISCELLANEOUS - Drugs for the Eye EPINEPHRINE HCL INTRAOCULAR SOLUTION PREFILLED OA SYRINGE 1 MG/ML ANTIVIRALS (EENT) - Drugs for Infections trifluridine ophthalmic solution 1 % 1 ZIRGAN OPHTHALMIC GEL 0.15 % (ganciclovir) 3 BETA-ADRENERGIC BLOCKING AGENTS (EENT) - Drugs for the Eye betaxolol hcl ophthalmic solution 0.5 % 1 BETIMOL OPHTHALMIC SOLUTION 0.25 %, 0.5 % (timolol 3 hemihydrate) BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 % (betaxolol 2 hcl) carteolol hcl ophthalmic solution 1 % 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 306 Coverage Requirements & Prescription Drug Name Drug Tier Limits COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % 3 (brimonidine tartrate-timolol) COSOPT OPHTHALMIC SOLUTION 22.3-6.8 MG/ML 3 (dorzolamide hcl-timolol mal) COSOPT PF OPHTHALMIC SOLUTION 2-0.5 % (dorzolamide 3 hcl-timolol mal) dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 1 mg/ml dorzolamide hcl-timolol mal pf ophthalmic solution 2-0.5 % 1 ISTALOL OPHTHALMIC SOLUTION 0.5 % (timolol maleate) 3 levobunolol hcl ophthalmic solution 0.5 % 1 timolol maleate ocudose ophthalmic solution 0.5 % 1 timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 1 % timolol maleate ophthalmic solution 0.25 %, 0.5 %, 0.5 % 1 (daily) timolol maleate pf ophthalmic solution 0.5 % 1 TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 % 2 (timolol maleate) TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.5 % 3 (timolol maleate) TIMOPTIC OPHTHALMIC SOLUTION 0.25 %, 0.5 % (timolol 3 maleate) TIMOPTIC-XE OPHTHALMIC GEL FORMING SOLUTION 0.25 3 %, 0.5 % (timolol maleate) CARBONIC ANHYDRASE INHIBITORS (EENT) - Drugs for the Eye acetazolamide er oral capsule extended release 12 hour 500 1 mg acetazolamide oral tablet 125 mg, 250 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 307 Coverage Requirements & Prescription Drug Name Drug Tier Limits acetazolamide sodium injection solution reconstituted 500 OA mg AZOPT OPHTHALMIC SUSPENSION 1 % (brinzolamide) 3 brinzolamide ophthalmic suspension 1 % 1 COSOPT OPHTHALMIC SOLUTION 22.3-6.8 MG/ML 3 (dorzolamide hcl-timolol mal) COSOPT PF OPHTHALMIC SOLUTION 2-0.5 % (dorzolamide 3 hcl-timolol mal) DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC 2 % 2 dorzolamide hcl solution 2 % ophthalmic 2 % 1 dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 1 mg/ml dorzolamide hcl-timolol mal pf ophthalmic solution 2-0.5 % 1 methazolamide oral tablet 25 mg, 50 mg 1 SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 % 3 (brinzolamide-brimonidine) TRUSOPT OPHTHALMIC SOLUTION 2 % (dorzolamide hcl) 3 CORTICOSTEROIDS (EENT) - Drugs for Inflammation ALREX OPHTHALMIC SUSPENSION 0.2 % (loteprednol 3 etabonate) azelastine-fluticasone nasal suspension 137-50 mcg/act 1 bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % 1 BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY 2 QL (1.7 GM per 1 day) (beclomethasone diprop monohyd) BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 % 3 (sulfacetamide-prednisolone) BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 % 3 (sulfacetamide-prednisolone)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 308 Coverage Requirements & Prescription Drug Name Drug Tier Limits CIPRO HC OTIC SUSPENSION 0.2-1 % (ciprofloxacin- 3 hydrocortisone) CIPRODEX OTIC SUSPENSION 0.3-0.1 % (ciprofloxacin- 3 dexamethasone) ciprofloxacin-dexamethasone otic suspension 0.3-0.1 % 1 CIPROFLOXACIN-FLUOCINOLONE PF OTIC SOLUTION 0.3- 2 0.025 % cortic-nd otic solution 10-10-1 mg/ml 1 CORTISPORIN-TC OTIC SUSPENSION 3.3-3-10-0.5 MG/ML 3 (neomycin-colist-hc-thonzonium) DERMOTIC OTIC OIL 0.01 % (fluocinolone acetonide) 3 dexamethasone sodium phosphate ophthalmic solution 0.1 1 % DEXAMETHASONE-MOXIFLOXACIN INTRAOCULAR OA SOLUTION 1-5 MG/ML DEXAMETH-MOXIFLOX-KETOROLAC INTRAOCULAR OA SOLUTION 1-0.5-0.4 MG/ML DEXTENZA OPHTHALMIC INSERT 0.4 MG (dexamethasone) 3 DEXYCU INTRAOCULAR SUSPENSION 9 % OA (dexamethasone) DUREZOL OPHTHALMIC EMULSION 0.05 % (difluprednate) 3 DYMISTA NASAL SUSPENSION 137-50 MCG/ACT 3 (azelastine-fluticasone) EYSUVIS OPHTHALMIC SUSPENSION 0.25 % (loteprednol 3 PA; QL (8.3 ML per 1 fill) etabonate) flac otic oil 0.01 % 1 FLAREX OPHTHALMIC SUSPENSION 0.1 % 3 (fluorometholone acetate) flunisolide nasal solution 25 mcg/act (0.025%) 1 QL (0.84 ML per 1 day) fluocinolone acetonide otic oil 0.01 % 1 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 309 Coverage Requirements & Prescription Drug Name Drug Tier Limits fluorometholone ophthalmic suspension 0.1 % 1 fluticasone propionate nasal suspension 50 mcg/act 1 FML FORTE OPHTHALMIC SUSPENSION 0.25 % 2 (fluorometholone) FML LIQUIFILM OPHTHALMIC SUSPENSION 0.1 % 3 (fluorometholone) FML OPHTHALMIC OINTMENT 0.1 % (fluorometholone) 2 hydrocortisone-acetic acid otic solution 1-2 % 1 ILUVIEN INTRAVITREAL IMPLANT 0.19 MG (fluocinolone OA QL (365 day supply per 1 fill) acetonide) INVELTYS OPHTHALMIC SUSPENSION 1 % (loteprednol 3 ST; QL (1 fill per 1 lifetime) etabonate) KLARITY-L OPHTHALMIC EMULSION 0.2 %, 0.5 % 3 (loteprednol etabonate) LOTEMAX OPHTHALMIC GEL 0.5 % (loteprednol etabonate) 3 LOTEMAX OPHTHALMIC OINTMENT 0.5 % (loteprednol 3 etabonate) LOTEMAX OPHTHALMIC SUSPENSION 0.5 % (loteprednol 3 etabonate) LOTEMAX SM OPHTHALMIC GEL 0.38 % (loteprednol 3 etabonate) loteprednol etabonate ophthalmic gel 0.5 % 1 loteprednol etabonate ophthalmic suspension 0.5 % 1 MAXIDEX OPHTHALMIC SUSPENSION 0.1 % 3 (dexamethasone) MAXITROL OPHTHALMIC OINTMENT 3.5-10000-0.1 3 (neomycin-polymyxin-dexameth) MAXITROL OPHTHALMIC SUSPENSION 3.5-10000-0.1 3 (neomycin-polymyxin-dexameth) mometasone furoate nasal suspension 50 mcg/act 1 QL (1.14 GM per 1 day) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 310 Coverage Requirements & Prescription Drug Name Drug Tier Limits NASONEX NASAL SUSPENSION 50 MCG/ACT (mometasone 3 QL (1.14 GM per 1 day) furoate) neomycin-polymyxin-dexameth ophthalmic ointment 3.5- 1 10000-0.1 neomycin-polymyxin-dexameth ophthalmic suspension 3.5- 1 10000-0.1 neomycin-polymyxin-hc ophthalmic suspension 3.5-10000- 1 1 neomycin-polymyxin-hc otic solution 1 %, 3.5-10000-1 1 neomycin-polymyxin-hc otic suspension 3.5-10000-1 1 neo-polycin hc ophthalmic ointment 1 % 1 OMNARIS NASAL SUSPENSION 50 MCG/ACT (ciclesonide) 3 QL (0.42 GM per 1 day) OTOVEL OTIC SOLUTION 0.3-0.025 % (ciprofloxacin- 2 fluocinolone) OZURDEX INTRAVITREAL IMPLANT 0.7 MG OA QL (90 day supply per 1 fill) (dexamethasone) PRED FORTE OPHTHALMIC SUSPENSION 1 % 3 (prednisolone acetate) PRED MILD OPHTHALMIC SUSPENSION 0.12 % 2 (prednisolone acetate) PRED-G OPHTHALMIC SUSPENSION 0.3-1 % (gentamicin- 3 prednisolone acet) PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 % 3 (gentamicin-prednisolone acet) PREDNISOL ACE-MOXIFLOX-BROMFEN OPHTHALMIC 3 SUSPENSION 1-0.5-0.075 % prednisolone acetate ophthalmic suspension 1 % 1 prednisolone acetate p-f ophthalmic suspension 1 % 1 PREDNISOLONE ACETATE-NEPAFENAC OPHTHALMIC 3 SUSPENSION 1-0.1 %

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 311 Coverage Requirements & Prescription Drug Name Drug Tier Limits PREDNISOLONE ACET-MOXIFLOXACIN OPHTHALMIC 3 SUSPENSION 1-0.5 % prednisolone sodium phosphate ophthalmic solution 1 % 1 PREDNISOLONE-BROMFENAC OPHTHALMIC SOLUTION 1- 3 0.075 % PREDNISOLONE-GATIFLOXACIN OPHTHALMIC 2 SUSPENSION 1-0.5 % PREDNISOLONE-MOXIFLOXACIN OPHTHALMIC SOLUTION 3 1-0.5 % PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC 3 SOLUTION 1-0.5-0.075 % PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC 3 SUSPENSION 1-0.5-0.075 % PREDNISOLON-MOXIFLOX-BROMFENAC OPHTHALMIC 3 SOLUTION 1-0.5-0.075 % PREDNISOLON-MOXIFLOX-NEPAFENAC OPHTHALMIC 3 SUSPENSION 1-0.5-0.1 % QNASL CHILDRENS NASAL AEROSOL SOLUTION 40 3 MCG/ACT (beclomethasone diprop (nasal)) QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT 3 (beclomethasone diprop (nasal)) RETISERT INTRAVITREAL IMPLANT 0.59 MG (fluocinolone OA QL (365 day supply per 1 fill) acetonide) SINUVA NASAL IMPLANT 1350 MCG (mometasone furoate) OA QL (30 day supply per 1 fill) sulfacetamide-prednisolone ophthalmic solution 10-0.23 % 1 TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % 2 (tobramycin-dexamethasone) TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 % 3 (tobramycin-dexamethasone)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 312 Coverage Requirements & Prescription Drug Name Drug Tier Limits TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 % 2 (tobramycin-dexamethasone) tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 1 % TRIAMCINOLONE-MOXIFLOXACIN INTRAOCULAR OA SUSPENSION 15-1 MG/ML TRIESENCE INTRAOCULAR SUSPENSION 40 MG/ML OA (triamcinolone acetonide) XHANCE NASAL EXHALER SUSPENSION 93 MCG/ACT 3 PA (fluticasone propionate) YUTIQ INTRAVITREAL IMPLANT 0.18 MG (fluocinolone OA QL (365 day supply per 1 fill) acetonide) ZETONNA NASAL AEROSOL SOLUTION 37 MCG/ACT 3 (ciclesonide) ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 % (loteprednol- 3 tobramycin) EENT ANTI-INFECTIVES, MISCELLANEOUS - Drugs for Infections ARZOL SILVER NIT APPLICATORS EXTERNAL 75-25 % 3 (silver nitrate-pot nitrate) BETADINE OPHTHALMIC PREP OPHTHALMIC SOLUTION 5 3 % (povidone-iodine) chlorhexidine gluconate mouth/throat solution 0.12 % 1 cortic-nd otic solution 10-10-1 mg/ml 1 PERIDEX MOUTH/THROAT SOLUTION 0.12 % 3 (chlorhexidine gluconate) periogard mouth/throat solution 0.12 % 1 POVIDONE-IODINE OPHTHALMIC SOLUTION 5 % 3 PRAMOTIC OTIC LIQUID 1-0.1 % (pramoxine-chloroxylenol) 3 silver nitrate external solution 0.5 %, 10 %, 25 %, 50 % 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 313 Coverage Requirements & Prescription Drug Name Drug Tier Limits EENT ANTI-INFLAMMATORY AGENTS, MISC. - Drugs for Inflammation CEQUA OPHTHALMIC SOLUTION 0.09 % (cyclosporine) 3 PA DISCOVISC INTRAOCULAR SOLUTION 40-17 MG/ML (na OA chondroit sulf-na hyaluron) DUOVISC INTRAOCULAR KIT 0.4-0.35 ML, 0.55-0.5 ML, 0.85- OA 0.5 ML (na hyalur & na chond-na hyalur) RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 % 3 (cyclosporine) RESTASIS OPHTHALMIC EMULSION 0.05 % (cyclosporine) 3 VISCOAT INTRAOCULAR SOLUTION 40-30 MG/ML (na OA chondroit sulf-na hyaluron) XIIDRA OPHTHALMIC SOLUTION 5 % (lifitegrast) 3 PA EENT DRUGS, MISCELLANEOUS acetic acid otic solution 2 % 1 AMVISC INTRAOCULAR SOLUTION 12 MG/ML (sodium OA hyaluronate) AMVISC PLUS INTRAOCULAR SOLUTION 16 MG/ML OA (sodium hyaluronate) apraclonidine hcl ophthalmic solution 0.5 % 1 balanced salt intraocular solution OA BEOVU INTRAVITREAL SOLUTION 6 MG/0.05ML OA (brolucizumab-dbll) BEVACIZUMAB INTRAOCULAR SOLUTION PREFILLED OA SYRINGE 2.75 MG/0.11ML, 3.75 MG/0.15ML BEVACIZUMAB INTRAVITREAL SOLUTION PREFILLED SYRINGE 2.5 MG/0.1ML, 3 MG/0.12ML, 3.25 MG/0.13ML, 3.75 OA MG/0.15ML BOCASAL MOUTH/THROAT PACKET (artificial saliva) 3 BSS INTRAOCULAR SOLUTION (ophth irr soln-intraocular) OA Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 314 Coverage Requirements & Prescription Drug Name Drug Tier Limits bss plus solution intraocular OA BSS PLUS SOLUTION INTRAOCULAR (ophth irr soln- OA intraocular) CELLUGEL INTRAOCULAR SOLUTION 2 % (hypromellose) OA CHONDROITIN SULFATE OPHTHALMIC SOLUTION 0.25 % 3 PA cromolyn sodium ophthalmic solution 4 % 1 cromolyn sodium oral concentrate 100 mg/5ml 1 CYSTADROPS OPHTHALMIC SOLUTION 0.37 % PA; SP; QL (30 day supply 3 (cysteamine hcl) per 1 fill) CYSTARAN OPHTHALMIC SOLUTION 0.44 % (cysteamine PA; SP; QL (30 day supply 3 hcl) per 1 fill) DEBACTEROL MOUTH/THROAT SOLUTION 30-50 % 3 (sulfuric acid-sulf phenolics) DISCOVISC INTRAOCULAR SOLUTION 40-17 MG/ML (na OA chondroit sulf-na hyaluron) DUOVISC INTRAOCULAR KIT 0.4-0.35 ML, 0.55-0.5 ML, 0.85- OA 0.5 ML (na hyalur & na chond-na hyalur) EYLEA INTRAVITREAL SOLUTION 2 MG/0.05ML (aflibercept) OA QL (30 day supply per 1 fill) EYLEA INTRAVITREAL SOLUTION PREFILLED SYRINGE 2 OA QL (30 day supply per 1 fill) MG/0.05ML (aflibercept) GASTROCROM ORAL CONCENTRATE 100 MG/5ML 3 (cromolyn sodium) HEALON DUET PRO INTRAOCULAR SOLUTION PREFILLED OA SYRINGE 1 & 3 % (sodium hyaluronate) HEALON GV INTRAOCULAR SOLUTION 14 MG/ML (sodium OA hyaluronate) HEALON GV PRO INTRAOCULAR SOLUTION 18 MG/ML OA (sodium hyaluronate) HEALON INTRAOCULAR SOLUTION 10 MG/ML (sodium OA hyaluronate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 315 Coverage Requirements & Prescription Drug Name Drug Tier Limits HEALON PRO INTRAOCULAR SOLUTION 10 MG/ML OA (sodium hyaluronate) HEALON5 INTRAOCULAR SOLUTION 23 MG/ML (sodium OA hyaluronate) HEALON5 PRO INTRAOCULAR SOLUTION 23 MG/ML OA (sodium hyaluronate) hydrocortisone-acetic acid otic solution 1-2 % 1 IOPIDINE OPHTHALMIC SOLUTION 1 % (apraclonidine hcl) 3 LACRISERT OPHTHALMIC INSERT 5 MG (artificial tear 3 insert) LIDOCAINE-PHENYLEPHRINE-BSS INTRAOCULAR OA SOLUTION PREFILLED SYRINGE 1-1.5 % (1ML) LUCENTIS INTRAVITREAL SOLUTION 0.3 MG/0.05ML, 0.5 OA QL (30 day supply per 1 fill) MG/0.05ML (ranibizumab) LUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINGE OA QL (30 day supply per 1 fill) 0.3 MG/0.05ML, 0.5 MG/0.05ML (ranibizumab) NUMOISYN MOUTH/THROAT LOZENGE (artificial saliva) 3 OCUCOAT VISCOADHERENT INTRAOCULAR SOLUTION 2 OA % (hypromellose) OXERVATE OPHTHALMIC SOLUTION 0.002 % (cenegermin- PA; SP; QL (30 day supply 3 bkbj) per 1 fill) PHOTREXA VISCOUS OPHTHALMIC SOLUTION PREFILLED 3 SYRINGE 0.146-20 % (riboflavin 5-phosphate-dextran) PROVISC INTRAOCULAR SOLUTION 10 MG/ML (sodium OA hyaluronate) TEPEZZA INTRAVENOUS SOLUTION RECONSTITUTED 500 OA MG (teprotumumab-trbw) VISCOAT INTRAOCULAR SOLUTION 40-30 MG/ML (na OA chondroit sulf-na hyaluron)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 316 Coverage Requirements & Prescription Drug Name Drug Tier Limits VISUDYNE INTRAVENOUS SOLUTION RECONSTITUTED 15 OA QL (90 day supply per 1 fill) MG (verteporfin) XEROSTOMIA RELIEF SPRAY MOUTH/THROAT SOLUTION 3 (artificial saliva) EENT NONSTEROIDAL ANTI-INFLAM. AGENTS - Drugs for Inflammation ACULAR LS OPHTHALMIC SOLUTION 0.4 % (ketorolac 3 tromethamine) ACULAR OPHTHALMIC SOLUTION 0.5 % (ketorolac 3 tromethamine) ACUVAIL OPHTHALMIC SOLUTION 0.45 % (ketorolac 2 tromethamine) bromfenac sodium (once-daily) ophthalmic solution 0.09 % 1 BROMSITE OPHTHALMIC SOLUTION 0.075 % (bromfenac 2 sodium) diclofenac sodium ophthalmic solution 0.1 % 1 flurbiprofen sodium ophthalmic solution 0.03 % 1 ILEVRO OPHTHALMIC SUSPENSION 0.3 % (nepafenac) 2 ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % 1 NEVANAC OPHTHALMIC SUSPENSION 0.1 % (nepafenac) 2 OMIDRIA INTRAOCULAR SOLUTION 1-0.3 % OA (phenylephrine-ketorolac) PREDNISOL ACE-MOXIFLOX-BROMFEN OPHTHALMIC 3 SUSPENSION 1-0.5-0.075 % PREDNISOLONE ACETATE-NEPAFENAC OPHTHALMIC 3 SUSPENSION 1-0.1 % PREDNISOLONE-BROMFENAC OPHTHALMIC SOLUTION 1- 3 0.075 % PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC 3 SOLUTION 1-0.5-0.075 %

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 317 Coverage Requirements & Prescription Drug Name Drug Tier Limits PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC 3 SUSPENSION 1-0.5-0.075 % PREDNISOLON-MOXIFLOX-BROMFENAC OPHTHALMIC 3 SOLUTION 1-0.5-0.075 % PREDNISOLON-MOXIFLOX-NEPAFENAC OPHTHALMIC 3 SUSPENSION 1-0.5-0.1 % PROLENSA OPHTHALMIC SOLUTION 0.07 % (bromfenac 2 sodium) TROPIC-PROPARACA-PE-KETOROLAC OPHTHALMIC 3 PA SOLUTION 1-0.5-2.5-0.5 % LOCAL ANESTHETICS (EENT) - Drugs for Numbing 1ST MEDX-PATCH/ LIDOCAINE EXTERNAL PATCH 4- 3 0.0375-5-20 % (lido-capsaicin-men-methyl sal) AKTEN OPHTHALMIC GEL 3.5 % (lidocaine hcl) 3 ALCAINE OPHTHALMIC SOLUTION 0.5 % (proparacaine hcl) 3 ALTACAINE OPHTHALMIC SOLUTION 0.5 % (tetracaine hcl) 3 ANACAINE EXTERNAL OINTMENT 10 % (benzocaine) 3 COCAINE HCL NASAL SOLUTION 40 MG/ML 3 cortic-nd otic solution 10-10-1 mg/ml 1 GOPRELTO NASAL SOLUTION 40 MG/ML 3 lidocaine hcl mouth/throat solution 4 % 1 lidocaine viscous hcl mouth/throat solution 2 % 1 LIDOCAINE-EPINEPHRINE INTRAOCULAR SOLUTION 7.5- OA 0.25 MG/ML LIDOCAINE-PHENYLEPHRINE INTRAOCULAR SOLUTION 1- OA 1.5 % LIDOCAINE-PHENYLEPHRINE-BSS INTRAOCULAR OA SOLUTION PREFILLED SYRINGE 1-1.5 % (1ML)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 318 Coverage Requirements & Prescription Drug Name Drug Tier Limits NUMBRINO NASAL SOLUTION 40 MG/ML (cocaine hcl 3 (nasal anesthetic)) PRAMOTIC OTIC LIQUID 1-0.1 % (pramoxine-chloroxylenol) 3 proparacaine hcl ophthalmic solution 0.5 % 1 SOOTHEE EXTERNAL PATCH 0.5-0.0375-5-2 % (lido- 3 capsaicin-men-methyl sal) tetracaine hcl ophthalmic solution 0.5 % 1 TROPIC-PROPARACA-PE-KETOROLAC OPHTHALMIC 3 PA SOLUTION 1-0.5-2.5-0.5 % MIOTICS - Drugs for the Eye ISOPTO CARPINE OPHTHALMIC SOLUTION 1 %, 2 %, 4 % 3 (pilocarpine hcl) MIOCHOL-E INTRAOCULAR SOLUTION RECONSTITUTED OA 20 MG (acetylcholine chloride) MIOSTAT INTRAOCULAR SOLUTION 0.01 % (carbachol) OA pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % 1 MYDRIATICS - Drugs for the Eye altafrin ophthalmic solution 10 %, 2.5 % 1 atropine sulfate ophthalmic ointment 1 % 1 ATROPINE SULFATE OPHTHALMIC SOLUTION 0.01 % 3 atropine sulfate ophthalmic solution 1 % 1 CYCLOGYL OPHTHALMIC SOLUTION 0.5 %, 2 % 3 (cyclopentolate hcl) CYCLOGYL OPHTHALMIC SOLUTION 1 % (cyclopentolate 2 hcl) CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 % 3 (cyclopentolate-phenylephrine) cyclopentolate hcl ophthalmic solution 0.5 %, 1 %, 2 % 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 319 Coverage Requirements & Prescription Drug Name Drug Tier Limits EPINEPHRINE HCL INTRAOCULAR SOLUTION PREFILLED OA SYRINGE 1 MG/ML homatropaire ophthalmic solution 5 % 1 ISOPTO ATROPINE OPHTHALMIC SOLUTION 1 % (atropine 3 sulfate) LIDOCAINE-EPINEPHRINE INTRAOCULAR SOLUTION 7.5- OA 0.25 MG/ML OMIDRIA INTRAOCULAR SOLUTION 1-0.3 % OA (phenylephrine-ketorolac) PHENYLEPHRINE HCL INTRAOCULAR SOLUTION OA PREFILLED SYRINGE 1.5 % phenylephrine hcl ophthalmic solution 10 %, 2.5 % 1 TROPICAMIDE-CYCLOPENTOLATE-PE OPHTHALMIC 3 PA SOLUTION 1-1-2.5 % TROPICAMIDE-PHENYLEPHRINE OPHTHALMIC SOLUTION 3 1-2.5 % TROPIC-PROPARACA-PE-KETOROLAC OPHTHALMIC 3 PA SOLUTION 1-0.5-2.5-0.5 % OSMOTIC AGENTS - Drugs for the Eye mannitol intravenous solution 20 %, 25 % OA OSMITROL INTRAVENOUS SOLUTION 10 %, 15 %, 20 % OA (mannitol) PROSTAGLANDIN ANALOGS - Drugs for the Eye bimatoprost ophthalmic solution 0.03 % 1 DURYSTA INTRAOCULAR IMPLANT 10 MCG (bimatoprost) OA latanoprost ophthalmic solution 0.005 % 1 LUMIGAN OPHTHALMIC SOLUTION 0.01 % (bimatoprost) 2 ROCKLATAN OPHTHALMIC SOLUTION 0.02-0.005 % 3 PA (netarsudil-latanoprost)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 320 Coverage Requirements & Prescription Drug Name Drug Tier Limits TRAVATAN Z OPHTHALMIC SOLUTION 0.004 % (travoprost) 3 travoprost (bak free) ophthalmic solution 0.004 % 1 VYZULTA OPHTHALMIC SOLUTION 0.024 % 3 PA (latanoprostene bunod) XALATAN OPHTHALMIC SOLUTION 0.005 % (latanoprost) 3 XELPROS OPHTHALMIC EMULSION 0.005 % (latanoprost) 3 ZIOPTAN OPHTHALMIC SOLUTION 0.0015 % (tafluprost) 3 RHO KINASE INHIBITORS - Drugs for the Eye RHOPRESSA OPHTHALMIC SOLUTION 0.02 % (netarsudil 3 PA dimesylate) ROCKLATAN OPHTHALMIC SOLUTION 0.02-0.005 % 3 PA (netarsudil-latanoprost) VASOCONSTRICTORS ADRENALIN NASAL SOLUTION 0.1 % (epinephrine hcl 3 (nasal)) altafrin ophthalmic solution 10 %, 2.5 % 1 CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 % 3 (cyclopentolate-phenylephrine) L.E.T. EXTERNAL GEL 4-0.05-0.5 % (lido-epinephrine- 3 tetracaine) LIDOCAINE-PHENYLEPHRINE INTRAOCULAR SOLUTION 1- OA 1.5 % LIDOCAINE-PHENYLEPHRINE-BSS INTRAOCULAR OA SOLUTION PREFILLED SYRINGE 1-1.5 % (1ML) PHENYLEPHRINE HCL INTRAOCULAR SOLUTION OA PREFILLED SYRINGE 1.5 % phenylephrine hcl ophthalmic solution 10 %, 2.5 % 1 STERILE TOPICAL L.E.T. GEL EXTERNAL GEL 0.18-4-0.5 % 3 (lido-epinephrine-tetracaine)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 321 Coverage Requirements & Prescription Drug Name Drug Tier Limits TROPICAMIDE-CYCLOPENTOLATE-PE OPHTHALMIC 3 PA SOLUTION 1-1-2.5 % TROPICAMIDE-PHENYLEPHRINE OPHTHALMIC SOLUTION 3 1-2.5 % TROPIC-PROPARACA-PE-KETOROLAC OPHTHALMIC 3 PA SOLUTION 1-0.5-2.5-0.5 % UPNEEQ OPHTHALMIC SOLUTION 0.1 % (oxymetazoline 3 PA hcl) GASTROINTESTINAL DRUGS ANTACIDS AND ADSORBENTS omeprazole-sodium bicarbonate oral capsule 20-1100 mg, 1 PA; QL (2 EA per 1 day) 40-1100 mg omeprazole-sodium bicarbonate oral packet 20-1680 mg, 1 PA; QL (2 EA per 1 day) 40-1680 mg sodium bicarbonate oral powder 1 ZEGERID ORAL CAPSULE 20-1100 MG, 40-1100 MG 3 PA; QL (2 EA per 1 day) (omeprazole-sodium bicarbonate) ZEGERID ORAL PACKET 20-1680 MG, 40-1680 MG 3 PA; QL (2 EA per 1 day) (omeprazole-sodium bicarbonate) GASTROINTESTINAL DRUGS - Drugs for the Stomach 5-HT3 RECEPTOR ANTAGONISTS - Drugs for Vomiting and Nausea AKYNZEO INTRAVENOUS SOLUTION 235-0.25 MG/20ML OA (fosnetupitant-palonosetron) AKYNZEO INTRAVENOUS SOLUTION RECONSTITUTED OA 235-0.25 MG (fosnetupitant-palonosetron) AKYNZEO ORAL CAPSULE 300-0.5 MG (netupitant- 3 palonosetron) ALOXI INTRAVENOUS SOLUTION 0.25 MG/5ML OA (palonosetron hcl)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 322 Coverage Requirements & Prescription Drug Name Drug Tier Limits granisetron hcl intravenous solution 1 mg/ml, 4 mg/4ml OA granisetron hcl oral tablet 1 mg 1 QL (0.47 EA per 1 day) ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml OA QL (30 ML per 1 day) ondansetron hcl oral solution 4 mg/5ml 1 QL (30 ML per 1 day) ondansetron hcl oral tablet 24 mg 1 QL (0.07 EA per 1 day) ondansetron hcl oral tablet 4 mg 1 QL (6 EA per 1 day) ondansetron hcl oral tablet 8 mg 1 QL (3 EA per 1 day) ondansetron odt oral tablet dispersible 4 mg 1 QL (6 EA per 1 day) ondansetron odt oral tablet dispersible 8 mg 1 QL (3 EA per 1 day) palonosetron hcl intravenous solution 0.25 mg/2ml, 0.25 OA mg/5ml palonosetron hcl intravenous solution prefilled syringe 0.25 OA mg/5ml SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR 3 QL (0.07 EA per 1 day) (granisetron) SUSTOL SUBCUTANEOUS PREFILLED SYRINGE 10 OA MG/0.4ML (granisetron) ZOFRAN ORAL TABLET 4 MG (ondansetron hcl) 3 QL (6 EA per 1 day) ZUPLENZ ORAL FILM 4 MG, 8 MG (ondansetron) 3 QL (0.34 EA per 1 day) ANTIDIARRHEA AGENTS - Drugs for Diarrhea diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml 1 diphenoxylate-atropine oral tablet 2.5-0.025 mg 1 HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) 3 LOMOTIL ORAL TABLET 2.5-0.025 MG (diphenoxylate- 3 atropine) loperamide hcl oral capsule 2 mg 1 MOTOFEN ORAL TABLET 1-0.025 MG (difenoxin-atropine) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 323 Coverage Requirements & Prescription Drug Name Drug Tier Limits MYTESI ORAL TABLET DELAYED RELEASE 125 MG 2 PA (crofelemer) PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- 3 metronid-tetracyc) PA; SP; QL (30 day supply XERMELO ORAL TABLET 250 MG (telotristat etiprate) 3 per 1 fill) ANTIEMETICS, MISCELLANEOUS - Drugs for Vomiting and Nausea BARHEMSYS INTRAVENOUS SOLUTION 10 MG/4ML OA (amisulpride (antiemetic)) BARHEMSYS INTRAVENOUS SOLUTION 5 MG/2ML OA PA (amisulpride (antiemetic)) dronabinol oral capsule 10 mg, 2.5 mg, 5 mg 1 MARINOL ORAL CAPSULE 10 MG, 2.5 MG, 5 MG 3 (dronabinol) PHENERGAN INJECTION SOLUTION 25 MG/ML, 50 MG/ML OA PA (promethazine hcl) promethazine hcl injection solution 25 mg/ml, 50 mg/ml OA PA promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1 promethazine hcl rectal suppository 12.5 mg, 25 mg 1 promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 1 scopolamine transdermal patch 72 hour 1 mg/3days 1 SYNDROS ORAL SOLUTION 5 MG/ML (dronabinol) 3 TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH 72 3 HOUR 1 MG/3DAYS (scopolamine base)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 324 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTIHISTAMINES (GI DRUGS) - Drugs for Vomiting and Nausea ANTIVERT ORAL TABLET 50 MG (meclizine hcl) 3 BONJESTA ORAL TABLET EXTENDED RELEASE 20-20 MG 3 (doxylamine-pyridoxine) compro rectal suppository 25 mg 1 DICLEGIS ORAL TABLET DELAYED RELEASE 10-10 MG 3 (doxylamine-pyridoxine) dimenhydrinate injection solution 50 mg/ml OA doxylamine-pyridoxine oral tablet delayed release 10-10 mg 1 meclizine hcl oral tablet 12.5 mg, 25 mg 1 prochlorperazine edisylate injection solution 10 mg/2ml, 50 OA mg/10ml prochlorperazine maleate oral tablet 10 mg, 5 mg 1 prochlorperazine rectal suppository 25 mg 1 TIGAN INTRAMUSCULAR SOLUTION 100 MG/ML OA (trimethobenzamide hcl) trimethobenzamide hcl oral capsule 300 mg 1 ANTI-INFLAMMATORY AGENTS (GI DRUGS) - Drugs for Inflammation alosetron hcl oral tablet 0.5 mg, 1 mg 1 APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 0.375 GM (mesalamine) ASACOL HD ORAL TABLET DELAYED RELEASE 800 MG 3 (mesalamine) AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 3 500 MG (sulfasalazine) AZULFIDINE ORAL TABLET 500 MG (sulfasalazine) 3 balsalazide disodium oral capsule 750 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 325 Coverage Requirements & Prescription Drug Name Drug Tier Limits CANASA RECTAL SUPPOSITORY 1000 MG (mesalamine) 3 COLAZAL ORAL CAPSULE 750 MG (balsalazide disodium) 3 DELZICOL ORAL CAPSULE DELAYED RELEASE 400 MG 3 (mesalamine) DIPENTUM ORAL CAPSULE 250 MG (olsalazine sodium) 2 LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM 3 (mesalamine) LOTRONEX ORAL TABLET 0.5 MG, 1 MG (alosetron hcl) 3 mesalamine er oral capsule extended release 24 hour 0.375 1 gm mesalamine oral capsule delayed release 400 mg 1 mesalamine oral tablet delayed release 1.2 gm, 800 mg 1 mesalamine rectal enema 4 gm 1 mesalamine rectal suppository 1000 mg 1 PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG, 2 500 MG (mesalamine) SFROWASA RECTAL ENEMA 4 GM/60ML (mesalamine) 3 sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1 ANTIULCER AGENTS AND ACID SUPPRESS.,MISC - Drugs for Ulcers and Stomach Acid HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) 3 PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- 3 metronid-tetracyc) TALICIA ORAL CAPSULE DELAYED RELEASE 250-12.5-10 3 MG (amoxicill-rifabutin-omeprazole) ANTIULCER AGENTS AND ACID SUPPRESSANTS - Drugs for Ulcers and Stomach Acid amoxicillin oral capsule 250 mg, 500 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 326 Coverage Requirements & Prescription Drug Name Drug Tier Limits amoxicillin oral suspension reconstituted 125 mg/5ml, 200 1 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg 1 amoxicillin oral tablet chewable 125 mg, 250 mg 1 clarithromycin er oral tablet extended release 24 hour 500 1 mg clarithromycin oral suspension reconstituted 125 mg/5ml, 1 250 mg/5ml clarithromycin oral tablet 250 mg, 500 mg 1 FLAGYL ORAL CAPSULE 375 MG (metronidazole) 3 metronidazole in nacl intravenous solution 5-0.79 mg/ml-%, OA 500-0.74 mg/100ml-%, 500-0.79 mg/100ml-% metronidazole oral capsule 375 mg 1 metronidazole oral tablet 250 mg, 500 mg 1 sodium bicarbonate oral powder 1 tetracycline hcl oral capsule 250 mg, 500 mg 1 CATHARTICS AND LAXATIVES - Drugs for Constipation bisacodyl ec oral tablet delayed release 5 mg 1 PV cascara sagrada oral fluid extract 1 gm/ml 1 citroma oral solution 1.745 gm/30ml 1 PV clearlax oral powder 17 gm/scoop 1 PV CLENPIQ ORAL SOLUTION 10-3.5-12 MG-GM -GM/160ML 3 (sod picosulfate-mag ox-cit acd) gavilax oral powder 17 gm/scoop 1 PV gavilyte-c oral solution reconstituted 240 gm 1 PV gavilyte-g oral solution reconstituted 236 gm 1 PV gavilyte-n with flavor pack oral solution reconstituted 420 1 PV gm

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 327 Coverage Requirements & Prescription Drug Name Drug Tier Limits gentle laxative oral tablet delayed release 5 mg 1 PV glycolax oral powder 17 gm/scoop 1 PV GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM 3 (peg 3350-kcl-nabcb-nacl-nasulf) healthylax oral packet 17 gm 1 PV magnesium citrate oral solution 1.745 gm/30ml 1 PV milk of magnesia concentrate oral suspension 2400 1 PV mg/10ml milk of magnesia oral suspension 1200 mg/15ml, 400 1 PV mg/5ml mineral oil heavy oral oil 1 MIRALAX MIX-IN PAX ORAL PACKET 17 GM (polyethylene 3 PV glycol 3350) mm clearlax oral powder 17 gm/scoop 1 PV MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM 3 QL (1 EA per 1 fill) (peg-kcl-nacl-nasulf-na asc-c) NULYTELY LEMON-LIME ORAL SOLUTION 3 RECONSTITUTED 420 GM (peg 3350-kcl-na bicarb-nacl) OSMOPREP ORAL TABLET 1.102-0.398 GM (sod phos 2 mono-sod phos dibasic) peg 3350 oral packet 17 gm 1 PV peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 1 PV gm peg-3350/electrolytes oral solution reconstituted 236 gm 1 PV peg-3350/electrolytes/ascorbat oral solution reconstituted 1 QL (1 EA per 1 fill) 100 gm peg-kcl-nacl-nasulf-na asc-c oral solution reconstituted 100 1 QL (1 EA per 1 fill) gm peg-prep oral kit 5-210 mg-gm 1 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 328 Coverage Requirements & Prescription Drug Name Drug Tier Limits PLENVU ORAL SOLUTION RECONSTITUTED 140 GM (peg- 3 kcl-nacl-nasulf-na asc-c) polyethylene glycol 3350 oral packet 17 gm 1 PV polyethylene glycol 3350 oral powder 17 gm/scoop 1 PV qc magnesium citrate oral solution 1.745 gm/30ml 1 PV SUPREP BOWEL PREP KIT ORAL SOLUTION 17.5-3.13-1.6 3 GM/177ML (na sulfate-k sulfate-mg sulf) SUTAB ORAL TABLET 1479-225-188 MG (sodium sulfate- 3 mag sulfate-kcl) CHOLELITHOLYTIC AGENTS - Drugs for the Stomach SP; QL (30 day supply per 1 CHENODAL ORAL TABLET 250 MG (chenodiol) 3 fill) RELTONE ORAL CAPSULE 200 MG, 400 MG (ursodiol) 3 PA URSO 250 ORAL TABLET 250 MG (ursodiol) 3 URSO FORTE ORAL TABLET 500 MG (ursodiol) 3 URSODIOL ORAL CAPSULE 200 MG, 400 MG 3 PA ursodiol oral capsule 300 mg 1 ursodiol oral tablet 250 mg, 500 mg 1 DIGESTANTS - Drugs for the Stomach CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000-38000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 2 36000-114000 UNIT, 6000-19000 UNIT (pancrelipase (lip- prot-amyl)) ENZADYNE ORAL CAPSULE 3 PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500-35500 UNIT, 16800-56800 UNIT, 21000- 2 54700 UNIT, 4200-14200 UNIT (pancrelipase (lip-prot-amyl)) PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 2600-8800 UNIT, 37000-97300 UNIT 3 (pancrelipase (lip-prot-amyl)) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 329 Coverage Requirements & Prescription Drug Name Drug Tier Limits PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000-57500 UNIT, 24000-86250 UNIT, 4000-14375 UNIT, 2 8000-28750 UNIT (pancrelipase (lip-prot-amyl)) VIOKACE ORAL TABLET 10440-39150 UNIT, 20880-78300 2 UNIT (pancrelipase (lip-prot-amyl)) ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 2 25000-79000 UNIT, 3000-10000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT (pancrelipase (lip-prot-amyl)) GI DRUGS, MISCELLANEOUS - Drugs for the Stomach alvimopan oral capsule 12 mg 1 AMITIZA ORAL CAPSULE 24 MCG, 8 MCG (lubiprostone) 3 PA AVSOLA INTRAVENOUS SOLUTION RECONSTITUTED 100 OA MG (infliximab-axxq) BYLVAY (PELLETS) ORAL CAPSULE SPRINKLE 200 MCG, PA; SP; QL (30 day supply 3 600 MCG (odevixibat) per 1 fill) PA; SP; QL (30 day supply BYLVAY ORAL CAPSULE 1200 MCG, 400 MCG (odevixibat) 3 per 1 fill) PA; SP; QL (30 day supply CHOLBAM ORAL CAPSULE 250 MG, 50 MG (cholic acid) 2 per 1 fill) CIMZIA PREFILLED KIT SUBCUTANEOUS KIT 2 X 200 PA; SP; QL (30 day supply SI MG/ML (certolizumab pegol) per 1 fill) CIMZIA STARTER KIT SUBCUTANEOUS KIT 6 X 200 MG/ML PA; SP; QL (30 day supply SI (certolizumab pegol) per 1 fill) CIMZIA SUBCUTANEOUS KIT 2 X 200 MG (certolizumab PA; SP; QL (30 day supply SI pegol) per 1 fill) ENTEREG ORAL CAPSULE 12 MG (alvimopan) 3 ENTYVIO INTRAVENOUS SOLUTION RECONSTITUTED 300 OA QL (30 day supply per 1 fill) MG (vedolizumab) PA; SP; QL (30 day supply GATTEX SUBCUTANEOUS KIT 5 MG (teduglutide (rdna)) SI per 1 fill) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 330 Coverage Requirements & Prescription Drug Name Drug Tier Limits HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PA; SP; QL (30 day supply PREFILLED SYRINGE KIT 80 MG/0.8ML, 80 MG/0.8ML & SI per 1 fill) 40MG/0.4ML (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 PA; SP; QL (30 day supply SI MG/0.4ML, 40 MG/0.8ML, 80 MG/0.8ML (adalimumab) per 1 fill) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- PA; SP; QL (30 day supply SI INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML (adalimumab) per 1 fill) HUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS PA; SP; QL (30 day supply SI PEN-INJECTOR KIT 80 MG/0.8ML (adalimumab) per 1 fill) HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PA; SP; QL (30 day supply SI PEN-INJECTOR KIT 40 MG/0.8ML (adalimumab) per 1 fill) HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PA; SP; QL (30 day supply PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML SI per 1 fill) (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 PA; SP; QL (30 day supply MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML SI per 1 fill) (adalimumab) INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED OA QL (56 day supply per 1 fill) 100 MG (infliximab-dyyb) LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG 2 (linaclotide) LUBIPROSTONE ORAL CAPSULE 24 MCG, 8 MCG 3 PA MOTEGRITY ORAL TABLET 1 MG, 2 MG (prucalopride 3 PA succinate) MOVANTIK ORAL TABLET 12.5 MG, 25 MG (naloxegol 2 oxalate) MYCAPSSA ORAL CAPSULE DELAYED RELEASE 20 MG PA; SP; QL (30 day supply 3 (octreotide acetate) per 1 fill) PA; SP; QL (30 day supply OCALIVA ORAL TABLET 10 MG, 5 MG (obeticholic acid) 3 per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 331 Coverage Requirements & Prescription Drug Name Drug Tier Limits octreotide acetate injection solution 100 mcg/ml, 1000 OA QL (30 day supply per 1 fill) mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml RELISTOR ORAL TABLET 150 MG (methylnaltrexone 3 PA bromide) RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, 8 PA; QL (30 day supply per 1 SI MG/0.4ML (methylnaltrexone bromide) fill) REMICADE INTRAVENOUS SOLUTION RECONSTITUTED OA QL (56 day supply per 1 fill) 100 MG (infliximab) RENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 100 MG (infliximab-abda) SANDOSTATIN INJECTION SOLUTION 100 MCG/ML, 50 OA QL (30 day supply per 1 fill) MCG/ML, 500 MCG/ML (octreotide acetate) SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, OA QL (30 day supply per 1 fill) 20 MG, 30 MG (octreotide acetate) SIMPONI ARIA INTRAVENOUS SOLUTION 50 MG/4ML PA; SP; QL (30 day supply OA (golimumab) per 1 fill) SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; SP; QL (30 day supply SI 100 MG/ML, 50 MG/0.5ML (golimumab) per 1 fill) SIMPONI SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 100 MG/ML, 50 MG/0.5ML (golimumab) per 1 fill) STELARA INTRAVENOUS SOLUTION 130 MG/26ML OA QL (90 day supply per 1 fill) (ustekinumab) SYMPROIC ORAL TABLET 0.2 MG (naldemedine tosylate) 2 TRULANCE ORAL TABLET 3 MG (plecanatide) 3 PA VIBERZI ORAL TABLET 100 MG, 75 MG (eluxadoline) 3 PA HISTAMINE H2-ANTAGONISTS - Drugs for Ulcers and Stomach Acid cimetidine hcl oral solution 300 mg/5ml, 400 mg/6.67ml 1 cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg 1 DUEXIS ORAL TABLET 800-26.6 MG (ibuprofen-famotidine) 3 PA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 332 Coverage Requirements & Prescription Drug Name Drug Tier Limits famotidine intravenous solution 20 mg/2ml, 200 mg/20ml, OA 40 mg/4ml famotidine oral suspension reconstituted 40 mg/5ml 1 famotidine oral tablet 20 mg, 40 mg 1 famotidine premixed intravenous solution 20-0.9 mg/50ml- OA % ibuprofen-famotidine oral tablet 800-26.6 mg 1 PA nizatidine oral capsule 150 mg, 300 mg 1 nizatidine oral solution 15 mg/ml 1 PEPCID ORAL TABLET 20 MG, 40 MG (famotidine) 3 LIPOTROPIC AGENTS - Drugs for the Stomach LIPO INTRAMUSCULAR SOLUTION 50-50-25 MG/ML 3 LIPO-C INTRAMUSCULAR SOLUTION 3 MIC-L-CARNITINE INJECTION SOLUTION 25-50-50-50 3 MG/ML NEUROKININ-1 RECEPTOR ANTAGONISTS - Drugs for Vomiting and Nausea AKYNZEO INTRAVENOUS SOLUTION 235-0.25 MG/20ML OA (fosnetupitant-palonosetron) AKYNZEO INTRAVENOUS SOLUTION RECONSTITUTED OA 235-0.25 MG (fosnetupitant-palonosetron) AKYNZEO ORAL CAPSULE 300-0.5 MG (netupitant- 3 palonosetron) aprepitant oral 80 & 125 mg 1 QL (6 EA per 30 days) aprepitant oral capsule 125 mg 1 QL (2 EA per 30 days) aprepitant oral capsule 40 mg 1 QL (1 EA per 30 days) aprepitant oral capsule 80 & 125 mg 1 QL (6 EA per 30 days) aprepitant oral capsule 80 mg 1 QL (8 EA per 30 days)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 333 Coverage Requirements & Prescription Drug Name Drug Tier Limits CINVANTI INTRAVENOUS EMULSION 130 MG/18ML OA (aprepitant) EMEND INTRAVENOUS SOLUTION RECONSTITUTED 150 OA MG (fosaprepitant dimeglumine) EMEND ORAL CAPSULE 80 MG (aprepitant) 3 QL (8 EA per 30 days) EMEND ORAL SUSPENSION RECONSTITUTED 125 MG/5ML 3 (aprepitant) EMEND TRI-PACK ORAL CAPSULE 80 & 125 MG 3 QL (6 EA per 30 days) (aprepitant) fosaprepitant dimeglumine intravenous solution OA reconstituted 150 mg VARUBI (180 MG DOSE) ORAL TABLET THERAPY PACK 2 X 3 PA 90 MG (rolapitant hcl) PROKINETIC AGENTS - Drugs for the Stomach GIMOTI NASAL SOLUTION 15 MG/ACT (metoclopramide 3 hcl) metoclopramide hcl injection solution 5 mg/ml OA metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml 1 metoclopramide hcl oral tablet 10 mg, 5 mg 1 metoclopramide hcl oral tablet dispersible 10 mg, 5 mg 1 REGLAN ORAL TABLET 10 MG, 5 MG (metoclopramide hcl) 3 ZELNORM ORAL TABLET 6 MG (tegaserod maleate) 3 PROSTAGLANDINS - Drugs for Ulcers and Stomach Acid ARTHROTEC ORAL TABLET DELAYED RELEASE 50-0.2 MG, 3 75-0.2 MG (diclofenac-misoprostol) CYTOTEC ORAL TABLET 100 MCG, 200 MCG (misoprostol) 3 diclofenac-misoprostol oral tablet delayed release 50-0.2 1 mg, 75-0.2 mg misoprostol oral tablet 100 mcg, 200 mcg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 334 Coverage Requirements & Prescription Drug Name Drug Tier Limits PROTECTANTS - Drugs for Ulcers and Stomach Acid CARAFATE ORAL SUSPENSION 1 GM/10ML (sucralfate) 3 CARAFATE ORAL TABLET 1 GM (sucralfate) 3 sucralfate oral suspension 1 gm/10ml 1 sucralfate oral tablet 1 gm 1 PROTON-PUMP INHIBITORS - Drugs for Ulcers and Stomach Acid ACIPHEX ORAL TABLET DELAYED RELEASE 20 MG 3 QL (1 EA per 1 day) (rabeprazole sodium) ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE 10 MG, 5 3 QL (1 EA per 1 day) MG (rabeprazole sodium) amoxicill-clarithro-lansopraz oral 1 ASPIRIN-OMEPRAZOLE ORAL TABLET DELAYED RELEASE 3 PA 325-40 MG, 81-40 MG DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG, 60 3 QL (1 EA per 1 day) MG (dexlansoprazole) esomeprazole magnesium oral capsule delayed release 20 1 QL (1 EA per 1 day) mg, 40 mg esomeprazole magnesium oral packet 10 mg, 20 mg, 40 mg 1 QL (1 EA per 1 day) esomeprazole sodium intravenous solution reconstituted OA 40 mg ESOMEPRAZOLE STRONTIUM ORAL CAPSULE DELAYED 3 RELEASE 49.3 MG FIRST-LANSOPRAZOLE ORAL SUSPENSION 3 MG/ML 3 (lansoprazole) FIRST-OMEPRAZOLE ORAL SUSPENSION 2 MG/ML 3 (omeprazole) lansoprazole oral capsule delayed release 15 mg, 30 mg 1 QL (1 EA per 1 day) lansoprazole oral tablet delayed release dispersible 15 mg, 1 QL (1 EA per 1 day) 30 mg Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 335 Coverage Requirements & Prescription Drug Name Drug Tier Limits naproxen-esomeprazole oral tablet delayed release 375-20 1 mg, 500-20 mg NEXIUM I.V. INTRAVENOUS SOLUTION RECONSTITUTED OA 40 MG (esomeprazole sodium) NEXIUM ORAL CAPSULE DELAYED RELEASE 20 MG, 40 3 QL (1 EA per 1 day) MG (esomeprazole magnesium) NEXIUM ORAL PACKET 10 MG, 20 MG, 40 MG 3 QL (1 EA per 1 day) (esomeprazole magnesium) NEXIUM ORAL PACKET 2.5 MG, 5 MG (esomeprazole 2 QL (1 EA per 1 day) magnesium) OMECLAMOX-PAK ORAL 500-500-20 MG (amoxicill- 3 clarithro-omeprazole) omeprazole oral capsule delayed release 10 mg, 40 mg 1 QL (1 EA per 1 day) omeprazole oral capsule delayed release 20 mg 1 QL (2 EA per 1 day) OMEPRAZOLE+SYRSPEND SF ALKA ORAL SUSPENSION 2 3 MG/ML (omeprazole) omeprazole-sodium bicarbonate oral capsule 20-1100 mg, 1 PA; QL (2 EA per 1 day) 40-1100 mg omeprazole-sodium bicarbonate oral packet 20-1680 mg, 1 PA; QL (2 EA per 1 day) 40-1680 mg pantoprazole sodium intravenous solution reconstituted 40 OA mg pantoprazole sodium oral packet 40 mg 1 QL (1 EA per 1 day) pantoprazole sodium oral tablet delayed release 20 mg, 40 1 QL (1 EA per 1 day) mg PREVACID ORAL CAPSULE DELAYED RELEASE 30 MG 3 QL (1 EA per 1 day) (lansoprazole) PREVACID SOLUTAB ORAL TABLET DELAYED RELEASE 3 QL (1 EA per 1 day) DISPERSIBLE 15 MG, 30 MG (lansoprazole)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 336 Coverage Requirements & Prescription Drug Name Drug Tier Limits PRILOSEC ORAL PACKET 10 MG, 2.5 MG (omeprazole 3 magnesium) PROTONIX INTRAVENOUS SOLUTION RECONSTITUTED 40 OA MG (pantoprazole sodium) PROTONIX ORAL PACKET 40 MG (pantoprazole sodium) 3 QL (1 EA per 1 day) PROTONIX ORAL TABLET DELAYED RELEASE 20 MG, 40 3 QL (1 EA per 1 day) MG (pantoprazole sodium) RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE 10 MG 3 QL (1 EA per 1 day) rabeprazole sodium oral tablet delayed release 20 mg 1 QL (1 EA per 1 day) VIMOVO ORAL TABLET DELAYED RELEASE 375-20 MG, 3 500-20 MG (naproxen-esomeprazole) YOSPRALA ORAL TABLET DELAYED RELEASE 325-40 MG, 3 PA 81-40 MG (aspirin-omeprazole) ZEGERID ORAL CAPSULE 20-1100 MG, 40-1100 MG 3 PA; QL (2 EA per 1 day) (omeprazole-sodium bicarbonate) ZEGERID ORAL PACKET 20-1680 MG, 40-1680 MG 3 PA; QL (2 EA per 1 day) (omeprazole-sodium bicarbonate) GOLD COMPOUNDS GOLD COMPOUNDS RIDAURA ORAL CAPSULE 3 MG (auranofin) 2 HEAVY METAL ANTAGONISTS - Drugs to Reduce Iron HEAVY METAL ANTAGONISTS - Drugs to Reduce Iron bal in oil intramuscular solution 100 mg/ml OA CALCIUM DISODIUM VERSENATE INJECTION SOLUTION 1 OA GM/5ML CHEMET ORAL CAPSULE 100 MG (succimer) 3 clovique oral capsule 250 mg 1 CUPRIMINE ORAL CAPSULE 250 MG (penicillamine) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 337 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SP; QL (30 day supply deferasirox granules oral packet 180 mg, 360 mg, 90 mg 1 per 1 fill) PA; SP; QL (30 day supply deferasirox oral packet 180 mg, 360 mg, 90 mg 1 per 1 fill) PA; SP; QL (30 day supply deferasirox oral tablet 180 mg, 360 mg, 90 mg 1 per 1 fill) PA; SP; QL (30 day supply deferasirox oral tablet soluble 125 mg, 250 mg, 500 mg 1 per 1 fill) PA; SP; QL (30 day supply deferiprone oral tablet 500 mg 1 per 1 fill) deferoxamine mesylate injection solution reconstituted 2 OA gm, 500 mg DEPEN TITRATABS ORAL TABLET 250 MG (penicillamine) 3 DESFERAL INJECTION SOLUTION RECONSTITUTED 500 OA MG (deferoxamine mesylate) DIMERCAPTOPROPANE-SULFONATE INJECTION OA SOLUTION 250 MG/5ML EDETATE DISODIUM INTRAVENOUS SOLUTION 150 MG/ML OA EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG PA; SP; QL (30 day supply 3 (deferasirox) per 1 fill) PA; SP; QL (30 day supply FERRIPROX ORAL SOLUTION 100 MG/ML (deferiprone) 3 per 1 fill) PA; SP; QL (30 day supply FERRIPROX ORAL TABLET 1000 MG, 500 MG (deferiprone) 3 per 1 fill) FERRIPROX TWICE-A-DAY ORAL TABLET 1000 MG PA; SP; QL (30 day supply 3 (deferiprone) per 1 fill) JADENU ORAL TABLET 180 MG, 360 MG, 90 MG PA; SP; QL (30 day supply 3 (deferasirox) per 1 fill) JADENU SPRINKLE ORAL PACKET 180 MG, 360 MG, 90 MG PA; SP; QL (30 day supply 3 (deferasirox) per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 338 Coverage Requirements & Prescription Drug Name Drug Tier Limits NITHIODOTE INTRAVENOUS KIT 300MG/10ML&12.5 OA GM/50ML (sodium nitrite-sod thiosulfate) penicillamine oral capsule 250 mg 1 penicillamine oral tablet 250 mg 1 PENTETATE CALCIUM TRISODIUM COMBINATION 3 SOLUTION 200 MG/ML PENTETATE ZINC TRISODIUM COMBINATION SOLUTION 3 200 MG/ML sodium nitrite intravenous solution 30 mg/ml OA SODIUM THIOSULFATE SOLUTION 25 % INTRAVENOUS 25 OA % sodium thiosulfate solution 25 % intravenous 25 % OA SYPRINE ORAL CAPSULE 250 MG (trientine hcl) 3 trientine hcl oral capsule 250 mg 1 HORMONES AND SYNTHETIC SUBSTITUTES - Hormones ADRENALS - Hormones ACTIVE INJECTION D INJECTION KIT 10 MG/ML OA ACTIVE INJECTION DL INJECTION KIT 10 & 1 MG/ML-% OA ACTIVE INJECTION KL-3 COMBINATION KIT 40-1 MG/ML-% OA ACTIVE INJECTION KM INJECTION KIT 40-0.5 MG/ML-% OA ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 3 QL (2 EA per 1 day) MCG/DOSE (fluticasone-salmeterol) ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230- 2 QL (0.4 GM per 1 day) 21 MCG/ACT, 45-21 MCG/ACT (fluticasone-salmeterol) AIRDUO DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 3 QL (2 EA per 1 day) 55-14 MCG/ACT (fluticasone-salmeterol)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 339 Coverage Requirements & Prescription Drug Name Drug Tier Limits AIRDUO RESPICLICK 113/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT 3 QL (2 EA per 1 day) (fluticasone-salmeterol) AIRDUO RESPICLICK 232/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 232-14 MCG/ACT 3 QL (2 EA per 1 day) (fluticasone-salmeterol) AIRDUO RESPICLICK 55/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 55-14 MCG/ACT 3 QL (2 EA per 1 day) (fluticasone-salmeterol) ALKINDI SPRINKLE ORAL CAPSULE SPRINKLE 0.5 MG, 1 3 PA MG, 2 MG, 5 MG (hydrocortisone) ALVESCO INHALATION AEROSOL SOLUTION 160 3 QL (0.41 GM per 1 day) MCG/ACT, 80 MCG/ACT (ciclesonide) ARMONAIR DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 113 MCG/ACT, 232 MCG/ACT, 55 3 PA MCG/ACT (fluticasone propionate (inhal)) ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 2 MCG/ACT (fluticasone furoate) ASMANEX (120 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH (mometasone 2 QL (0.04 EA per 1 day) furoate) ASMANEX (14 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH (mometasone 2 QL (0.04 EA per 1 day) furoate) ASMANEX (30 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH 2 QL (0.04 EA per 1 day) (mometasone furoate) ASMANEX (60 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH (mometasone 2 QL (0.04 EA per 1 day) furoate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 340 Coverage Requirements & Prescription Drug Name Drug Tier Limits ASMANEX (7 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH (mometasone 2 QL (0.04 EA per 1 day) furoate) ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 2 QL (0.46 GM per 1 day) MCG/ACT, 50 MCG/ACT (mometasone furoate) BETA 1 KIT INJECTION KIT 30 MG/5ML OA BETAMETHASONE COMBO INJECTION SUSPENSION 6 (3- OA 3) MG/ML, 7 (4-3) MG/ML BETAMETHASONE SOD PHOS & ACET INJECTION OA SUSPENSION 7 (4-3) MG/ML BETAMETHASONE SOD PHOS & ACET SUSPENSION 6 (3- OA 3) MG/ML INJECTION 6 (3-3) MG/ML betamethasone sod phos & acet suspension 6 (3-3) mg/ml OA injection 6 (3-3) mg/ml BETAMETHASONE SODIUM PHOSPHATE INJECTION OA SOLUTION 12 MG/2ML, 6 MG/ML BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH (fluticasone 2 furoate-vilanterol) BREZTRI AEROSPHERE INHALATION AEROSOL 160-9-4.8 3 PA MCG/ACT (budeson-glycopyrrol-formoterol) BSP 0820 INJECTION KIT 30 MG/5ML OA budesonide er oral tablet extended release 24 hour 9 mg 1 PA budesonide inhalation suspension 0.25 mg/2ml, 0.5 1 mg/2ml, 1 mg/2ml budesonide oral capsule delayed release particles 3 mg 1 BUDESONIDE-FORMOTEROL FUMARATE INHALATION 2 QL (0.34 GM per 1 day) AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT BUPIVILOG INJECTION KIT 40 & 0.5 MG/ML-% OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 341 Coverage Requirements & Prescription Drug Name Drug Tier Limits CELESTONE SOLUSPAN INJECTION SUSPENSION 6 (3-3) OA MG/ML (betamethasone sod phos & acet) CORTEF ORAL TABLET 10 MG, 20 MG, 5 MG 3 (hydrocortisone) DECADRON ORAL TABLET 0.5 MG, 0.75 MG, 4 MG, 6 MG 3 (dexamethasone) DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML, 40 OA MG/ML, 80 MG/ML (methylprednisolone acetate) DEXABLISS ORAL TABLET THERAPY PACK 1.5 MG (39) 2 DEXAMETH SOD PHOS-BUPIV-EPIN INJECTION SOLUTION 3 PREFILLED SYRINGE 0.01-0.375 %-1:200000 DEXAMETHASONE (LA) INJECTION SUSPENSION 16 OA MG/ML, 8 MG/ML DEXAMETHASONE ACE & SOD PHOS INJECTION OA SUSPENSION 8-4 MG/ML dexamethasone intensol oral concentrate 1 mg/ml 1 dexamethasone oral elixir 0.5 mg/5ml 1 dexamethasone oral solution 0.5 mg/5ml 1 dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 1 mg, 4 mg, 6 mg dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg 1 (35), 1.5 mg (51) DEXAMETHASONE SOD PHOS-NACL INTRAVENOUS OA SOLUTION 6-0.9 MG/25ML-% dexamethasone sod phosphate pf injection solution 10 OA mg/ml dexamethasone sod phosphate pf injection solution 1 prefilled syringe 10 mg/ml dexamethasone sodium phosphate injection solution 100 OA mg/10ml, 120 mg/30ml, 20 mg/5ml

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 342 Coverage Requirements & Prescription Drug Name Drug Tier Limits DEXAMETHASONE SODIUM PHOSPHATE SOLUTION 10 OA MG/ML INJECTION 10 MG/ML dexamethasone sodium phosphate solution 10 mg/ml OA injection 10 mg/ml DEXAMETHASONE SODIUM PHOSPHATE SOLUTION 4 OA MG/ML INJECTION 4 MG/ML dexamethasone sodium phosphate solution 4 mg/ml OA injection 4 mg/ml DEXLIDO INJECTION KIT 10 & 1 MG/ML-% (dexamethasone OA sod phos-lido) DEXONTO 0.4% IONTOPHORESIS SOLUTION 20 MG/5ML OA (dexamethasone sodium phosphate) DOUBLEDEX INJECTION KIT 10 MG/ML (dexamethasone OA sodium phosphate) DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT, 50-5 MCG/ACT (mometasone furo-formoterol 3 QL (0.44 GM per 1 day) fum) DXEVO 11-DAY ORAL TABLET THERAPY PACK 1.5 MG 2 (dexamethasone) PA; SP; QL (30 day supply EMFLAZA ORAL SUSPENSION 22.75 MG/ML (deflazacort) 3 per 1 fill) EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 MG, 6 MG PA; SP; QL (30 day supply 3 (deflazacort) per 1 fill) ENTOCORT EC ORAL CAPSULE DELAYED RELEASE 3 PARTICLES 3 MG (budesonide) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST (fluticasone 2 QL (4 EA per 1 day) propionate (inhal)) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250 MCG/BLIST (fluticasone 2 QL (8 EA per 1 day) propionate (inhal))

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 343 Coverage Requirements & Prescription Drug Name Drug Tier Limits FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/BLIST (fluticasone propionate 2 QL (2 EA per 1 day) (inhal)) FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 2 QL (0.8 GM per 1 day) MCG/ACT (fluticasone propionate hfa) FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT 2 QL (0.71 GM per 1 day) (fluticasone propionate hfa) fludrocortisone acetate oral tablet 0.1 mg 1 flunisolide nasal solution 25 mcg/act (0.025%) 1 QL (0.84 ML per 1 day) fluticasone propionate nasal suspension 50 mcg/act 1 fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 1 QL (2 EA per 1 day) mcg/dose FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 3 QL (2 EA per 1 day) MCG/ACT, 55-14 MCG/ACT HEMADY ORAL TABLET 20 MG (dexamethasone) 3 PA HIDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG (21) 2 (dexamethasone) hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1 INTRAROSA VAGINAL INSERT 6.5 MG (prasterone) 3 KENALOG INJECTION SUSPENSION 10 MG/ML, 40 MG/ML OA (triamcinolone acetonide) KENALOG-80 INJECTION SUSPENSION 80 MG/ML 3 (triamcinolone acetonide) LIDOCIDEX I INJECTION SOLUTION 5-10 MG/1.5ML OA lidolog injection kit 40 & 2 mg/ml-% OA MAS CARE-PAK INJECTION KIT 10 MG/ML (dexamethasone OA sodium phosphate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 344 Coverage Requirements & Prescription Drug Name Drug Tier Limits MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG 3 (methylprednisolone) MEDROL ORAL TABLET 2 MG (methylprednisolone) 2 MEDROL ORAL TABLET THERAPY PACK 4 MG 3 (methylprednisolone) METHYLPREDNISOLONE ACE-LIDO INJECTION 3 SUSPENSION 40-10 MG/ML, 80-10 MG/ML METHYLPREDNISOLONE ACETATE INJECTION OA SUSPENSION 50 MG/ML METHYLPREDNISOLONE ACETATE SUSPENSION 40 OA MG/ML INJECTION 40 MG/ML methylprednisolone acetate suspension 40 mg/ml injection OA 40 mg/ml METHYLPREDNISOLONE ACETATE SUSPENSION 80 OA MG/ML INJECTION 80 MG/ML methylprednisolone acetate suspension 80 mg/ml injection OA 80 mg/ml methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1 methylprednisolone oral tablet therapy pack 4 mg 1 methylprednisolone sodium succ injection solution OA reconstituted 1000 mg, 125 mg, 40 mg methylprednisolone sodium succ injection solution 1 reconstituted 500 mg METHYLPREDNISOLONE-BUPIVACAINE INJECTION OA SUSPENSION 40-5 MG/ML, 80-5 MG/ML MILLIPRED ORAL TABLET 5 MG (prednisolone) 3 mometasone furoate nasal suspension 50 mcg/act 1 QL (1.14 GM per 1 day) NALTREXONE SUBCUTANEOUS IMPLANT 200-6.5 MG 3 NASONEX NASAL SUSPENSION 50 MCG/ACT (mometasone 3 QL (1.14 GM per 1 day) furoate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 345 Coverage Requirements & Prescription Drug Name Drug Tier Limits ORAPRED ODT ORAL TABLET DISPERSIBLE 10 MG, 15 MG, 3 30 MG (prednisolone sodium phosphate) ORTIKOS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 PA 6 MG, 9 MG (budesonide) P-CARE K40 INJECTION KIT 40 MG/ML OA P-CARE K80 INJECTION KIT 2 X 40 MG/ML OA PEDIAPRED ORAL SOLUTION 6.7 (5 BASE) MG/5ML 2 (prednisolone sodium phosphate) PHYSICIANS EZ USE JOINT/TUNNEL COMBINATION KIT 40- OA 1 MG/ML-% PHYSICIANS EZ USE M-PRED INJECTION KIT 40-0.5 OA MG/ML-% POD-CARE 100K INJECTION KIT 40 MG/ML OA POINT OF CARE KM INJECTION KIT 40 & 0.5 MG/ML-% OA (triamcinolone-bupivacaine) prednisolone oral solution 15 mg/5ml 1 prednisolone sodium phosphate oral solution 10 mg/5ml, 1 15 mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml prednisolone sodium phosphate oral tablet dispersible 10 1 mg, 15 mg, 30 mg prednisone intensol oral concentrate 5 mg/ml 1 prednisone oral solution 5 mg/5ml 1 prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 1 mg prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 1 5 mg (21), 5 mg (48) PRO-C-DURE 5 INJECTION KIT 2 X 40 MG/ML OA (triamcinolone acetonide) PRO-C-DURE 6 INJECTION KIT 3 X 40 MG/ML OA (triamcinolone acetonide)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 346 Coverage Requirements & Prescription Drug Name Drug Tier Limits PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT 2 QL (0.07 EA per 1 day) (budesonide) PULMICORT SUSPENSION INHALATION SUSPENSION 0.25 3 MG/2ML, 0.5 MG/2ML, 1 MG/2ML (budesonide) QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT (beclomethasone 2 diprop hfa) RAYOS ORAL TABLET DELAYED RELEASE 1 MG, 2 MG, 5 3 PA MG (prednisone) READYSHARP BETAMETHASONE INJECTION KIT 30 OA MG/5ML (betamethasone sod phos & acet) READYSHARP DEXAMETHASONE INJECTION KIT 10 OA MG/ML (dexamethasone sodium phosphate) SINUVA NASAL IMPLANT 1350 MCG (mometasone furoate) OA QL (30 day supply per 1 fill) SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED PA; QL (30 day supply per 1 100 MG, 1000 MG, 250 MG, 500 MG (hydrocortisone sod SI fill) succinate) SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 1000 MG, 125 MG, 2 GM, 40 MG (methylprednisolone OA sodium succ) SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 3 500 MG (methylprednisolone sodium succ) SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80- 2 QL (0.34 GM per 1 day) 4.5 MCG/ACT (budesonide-formoterol fumarate) TAPERDEX 12-DAY ORAL TABLET THERAPY PACK 1.5 MG 2 (49) (dexamethasone) TAPERDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG, 2 1.5 MG (21) (dexamethasone) TAPERDEX 7-DAY ORAL TABLET THERAPY PACK 1.5 MG 2 (27) (dexamethasone)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 347 Coverage Requirements & Prescription Drug Name Drug Tier Limits TOPIDEX INJECTION KIT 10 MG/ML OA TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH, 200-62.5-25 2 MCG/INH (fluticasone-umeclidin-vilant) TRIAMCINOLONE ACETONIDE INJECTION SUSPENSION 50 OA MG/ML triamcinolone acetonide suspension 40 mg/ml injection 40 OA mg/ml TRIAMCINOLONE ACETONIDE SUSPENSION 40 MG/ML OA INJECTION 40 MG/ML TRIAMCINOLONE DIACETATE INJECTION SUSPENSION 40 OA MG/ML, 80 MG/ML TRIAMCINOLONE-BUPIVACAINE INJECTION SUSPENSION OA 40-5 MG/ML UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR 9 3 PA MG (budesonide) wixela inhub inhalation aerosol powder breath activated 1 QL (2 EA per 1 day) 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose XHANCE NASAL EXHALER SUSPENSION 93 MCG/ACT 3 PA (fluticasone propionate) ZCORT 7-DAY ORAL TABLET THERAPY PACK 1.5 MG (25) 3 ZILRETTA INTRA-ARTICULAR SUSPENSION OA RECONSTITUTED ER 32 MG (triamcinolone acetonide) ALPHA-GLUCOSIDASE INHIBITORS - Drugs for Diabetes acarbose oral tablet 100 mg, 25 mg, 50 mg 1 miglitol oral tablet 100 mg, 25 mg, 50 mg 1 PRECOSE ORAL TABLET 100 MG, 25 MG, 50 MG (acarbose) 3 AMYLINOMIMETICS - Drugs for Diabetes SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN- PA; QL (30 day supply per 1 SI INJECTOR 2700 MCG/2.7ML (pramlintide acetate) fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 348 Coverage Requirements & Prescription Drug Name Drug Tier Limits SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN- PA; QL (30 day supply per 1 SI INJECTOR 1500 MCG/1.5ML (pramlintide acetate) fill) ANDROGENS - Hormones ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 3 QL (1 EA per 1 day) MG/24HR, 4 MG/24HR (testosterone) ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT 3 QL (5 GM per 1 day) (1.62%) (testosterone) ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 3 QL (5 GM per 1 day) 40.5 MG/2.5GM (1.62%) (testosterone) ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM (1%) 3 QL (7.5 GM per 1 day) (testosterone) ANDROGEL TRANSDERMAL GEL 50 MG/5GM (1%) 3 QL (10 GM per 1 day) (testosterone) AVEED INTRAMUSCULAR SOLUTION 750 MG/3ML PA; SP; QL (90 day supply 3 (testosterone undecanoate) per 1 fill) danazol oral capsule 100 mg, 200 mg, 50 mg 1 DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 PA; QL (30 day supply per 1 SI MG/ML (testosterone cypionate) fill) DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 200 SI QL (4 ML per 28 days) MG/ML (testosterone cypionate) FORTESTA TRANSDERMAL GEL 10 MG/ACT (2%) 3 QL (4 GM per 1 day) (testosterone) JATENZO ORAL CAPSULE 158 MG, 198 MG, 237 MG 3 PA (testosterone undecanoate) METHITEST ORAL TABLET 10 MG 3 methyltestosterone oral capsule 10 mg 1 NATESTO NASAL GEL 5.5 MG/ACT (testosterone) 3 QL (1.5 GM per 1 day) oxandrolone oral tablet 10 mg, 2.5 mg 1 TESTIM TRANSDERMAL GEL 50 MG/5GM (1%) 3 QL (10 GM per 1 day) (testosterone)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 349 Coverage Requirements & Prescription Drug Name Drug Tier Limits TESTOPEL IMPLANT PELLET 75 MG (testosterone) OA QL (30 day supply per 1 fill) TESTOSTERONE CYPIONATE INJECTION SOLUTION 200 SI PA MG/ML PA; QL (30 day supply per 1 testosterone cypionate intramuscular solution 100 mg/ml SI fill) testosterone cypionate intramuscular solution 200 mg/ml SI QL (4 ML per 28 days) PA; QL (30 day supply per 1 testosterone enanthate intramuscular solution 200 mg/ml SI fill) TESTOSTERONE IMPLANT PELLET 100 MG, 200 MG, 25 OA MG, 50 MG testosterone transdermal gel 1.62 %, 20.25 mg/1.25gm 1 QL (5 GM per 1 day) (1.62%), 20.25 mg/act (1.62%), 40.5 mg/2.5gm (1.62%) testosterone transdermal gel 10 mg/act (2%) 1 QL (4 GM per 1 day) testosterone transdermal gel 12.5 mg/act (1%), 50 mg/5gm 1 QL (10 GM per 1 day) (1%) testosterone transdermal gel 25 mg/2.5gm (1%) 1 QL (7.5 GM per 1 day) testosterone transdermal solution 30 mg/act 1 VOGELXO PUMP TRANSDERMAL GEL 12.5 MG/ACT (1%) 3 QL (10 GM per 1 day) (testosterone) VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%) 3 QL (10 GM per 1 day) (testosterone) XYOSTED SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; QL (30 day supply per 1 100 MG/0.5ML, 50 MG/0.5ML, 75 MG/0.5ML (testosterone SI fill) enanthate) ANTIDIABETIC AGENTS, MISCELLANEOUS - Drugs for Diabetes colesevelam hcl oral packet 3.75 gm 1 colesevelam hcl oral tablet 625 mg 1 CYCLOSET ORAL TABLET 0.8 MG (bromocriptine mesylate) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 350 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SP; QL (30 day supply KORLYM ORAL TABLET 300 MG (mifepristone) 3 per 1 fill) WELCHOL ORAL PACKET 3.75 GM (colesevelam hcl) 3 WELCHOL ORAL TABLET 625 MG (colesevelam hcl) 3 ANTIESTROGENS - Drugs for Women anastrozole oral tablet 1 mg 1 AC ARIMIDEX ORAL TABLET 1 MG (anastrozole) 3 AC AROMASIN ORAL TABLET 25 MG (exemestane) 3 AC exemestane oral tablet 25 mg 1 AC FEMARA ORAL TABLET 2.5 MG (letrozole) 3 AC KISQALI FEMARA ORAL TABLET THERAPY PACK 200 & 2.5 PA; SP; AC; QL (30 day 3 MG (ribociclib-letrozole) supply per 1 fill) letrozole oral tablet 2.5 mg 1 AC ANTIGONADTROPINS - Hormones CETROTIDE SUBCUTANEOUS KIT 0.25 MG (cetrorelix PA; QL (30 day supply per 1 INF acetate) fill) FIRMAGON (240 MG DOSE) SUBCUTANEOUS SOLUTION OA QL (30 day supply per 1 fill) RECONSTITUTED 120 MG/VIAL (degarelix acetate) FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 80 MG (degarelix acetate) ganirelix acetate subcutaneous solution prefilled syringe PA; QL (30 day supply per 1 INF 250 mcg/0.5ml fill) MYFEMBREE ORAL TABLET 40-1-0.5 MG (relugolix- 3 PA estradiol-norethind) PA; SP; AC; QL (30 day ORGOVYX ORAL TABLET 120 MG (relugolix) 3 supply per 1 fill) ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 & 300 3 PA MG (elagolix-estradiol-norethind) ORILISSA ORAL TABLET 150 MG, 200 MG (elagolix sodium) 3 PA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 351 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS - Hormones diazoxide oral suspension 50 mg/ml 1 PROGLYCEM ORAL SUSPENSION 50 MG/ML (diazoxide) 3 ANTIPARATHYROID AGENTS - Drugs for Bones calcitonin (salmon) injection solution 200 unit/ml OA PA calcitonin (salmon) nasal solution 200 unit/act 1 PA cinacalcet hcl oral tablet 30 mg, 60 mg, 90 mg 1 MIACALCIN INJECTION SOLUTION 200 UNIT/ML (calcitonin OA PA (salmon)) PARSABIV INTRAVENOUS SOLUTION 10 MG/2ML, 2.5 OA MG/0.5ML, 5 MG/ML (etelcalcetide hcl) SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG (cinacalcet 3 hcl) ANTITHYROID AGENTS - Drugs for the Thyroid methimazole oral tablet 10 mg, 5 mg 1 propylthiouracil oral tablet 50 mg 1 SODIUM IODIDE I-131 ORAL SOLUTION 1000 MCI/ML OA TAPAZOLE ORAL TABLET 10 MG, 5 MG (methimazole) 3 BIGUANIDES - Drugs for Diabetes ACTOPLUS MET ORAL TABLET 15-500 MG, 15-850 MG 3 (pioglitazone hcl-metformin hcl) ALOGLIPTIN-METFORMIN HCL ORAL TABLET 12.5-1000 3 ST MG, 12.5-500 MG glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 1 5-500 mg GLUMETZA ORAL TABLET EXTENDED RELEASE 24 HOUR 3 PA 1000 MG, 500 MG (metformin hcl)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 352 Coverage Requirements & Prescription Drug Name Drug Tier Limits glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5- 1 500 mg INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50- 2 1000 MG, 50-500 MG (canagliflozin-metformin hcl) INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG 2 (canagliflozin-metformin hcl) JANUMET ORAL TABLET 50-1000 MG, 50-500 MG 2 (sitagliptin-metformin hcl) JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG (sitagliptin- 2 metformin hcl) JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5- 2 QL (2 EA per 1 day) 850 MG (linagliptin-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 2 QL (2 EA per 1 day) HOUR 2.5-1000 MG (linagliptin-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 2 QL (1 EA per 1 day) HOUR 5-1000 MG (linagliptin-metformin hcl) KAZANO ORAL TABLET 12.5-1000 MG, 12.5-500 MG 3 ST (alogliptin-metformin hcl) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG, 5-500 MG (saxagliptin- 3 ST metformin) metformin hcl er (mod) oral tablet extended release 24 hour 1 PA 1000 mg, 500 mg metformin hcl er (osm) oral tablet extended release 24 hour 1 PA 1000 mg, 500 mg metformin hcl er oral tablet extended release 24 hour 500 1 * mg, 750 mg metformin hcl oral solution 500 mg/5ml 1 metformin hcl oral tablet 1000 mg, 500 mg, 850 mg 1 *

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 353 Coverage Requirements & Prescription Drug Name Drug Tier Limits pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 1 mg RIOMET ORAL SOLUTION 500 MG/5ML (metformin hcl) 3 SEGLUROMET ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 7.5- 3 ST 1000 MG, 7.5-500 MG (ertugliflozin-metformin hcl) SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5- 2 1000 MG, 5-500 MG (empagliflozin-metformin hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5-1000 MG 2 (empagliflozin-metformin hcl) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 12.5-2.5-1000 MG, 25-5-1000 MG, 5- 3 PA 2.5-1000 MG (empagliflozin-linaglip-metform) XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 2.5-1000 MG, 5-1000 MG, 5-500 MG 3 ST (dapagliflozin-metformin hcl) CONTRACEPTIVES - Drugs for Women afirmelle oral tablet 0.1-20 mg-mcg 1 PV altavera oral tablet 0.15-30 mg-mcg 1 PV alyacen 1/35 oral tablet 1-35 mg-mcg 1 PV alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 PV PV; QL (91 day supply per 1 amethia oral tablet 0.15-0.03 &0.01 mg 1 fill) amethyst oral tablet 90-20 mcg 1 PV ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR PA; PV; QL (1 EA per 365 3 (segesterone-ethinyl estradiol) days) apri oral tablet 0.15-30 mg-mcg 1 PV aranelle oral tablet 0.5/1/0.5-35 mg-mcg 1 PV PV; QL (91 day supply per 1 ashlyna oral tablet 0.15-0.03 &0.01 mg 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 354 Coverage Requirements & Prescription Drug Name Drug Tier Limits aubra eq oral tablet 0.1-20 mg-mcg 1 PV aubra oral tablet 0.1-20 mg-mcg 1 PV aurovela 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV aurovela 1/20 oral tablet 1-20 mg-mcg 1 PV aurovela 24 fe oral tablet 1-20 mg-mcg(24) 1 PV aurovela fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV aurovela fe 1/20 oral tablet 1-20 mg-mcg 1 PV aviane oral tablet 0.1-20 mg-mcg 1 PV ayuna oral tablet 0.15-30 mg-mcg 1 PV azurette oral tablet 0.15-0.02/0.01 mg (21/5) 1 PV BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) 3 PA (levonorgest-eth estrad-fe bisg) balziva oral tablet 0.4-35 mg-mcg 1 PV BEYAZ ORAL TABLET 3-0.02-0.451 MG (drospiren-eth 3 estrad-levomefol) blisovi 24 fe oral tablet 1-20 mg-mcg(24) 1 PV blisovi fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV blisovi fe 1/20 oral tablet 1-20 mg-mcg 1 PV briellyn oral tablet 0.4-35 mg-mcg 1 PV camila oral tablet 0.35 mg 1 PV PV; QL (91 day supply per 1 camrese lo oral tablet 0.1-0.02 & 0.01 mg 1 fill) PV; QL (91 day supply per 1 camrese oral tablet 0.15-0.03 &0.01 mg 1 fill) caziant oral tablet 0.1/0.125/0.15 -0.025 mg 1 PV charlotte 24 fe oral tablet chewable 1-20 mg-mcg(24) 1 PV chateal eq oral tablet 0.15-30 mg-mcg 1 PV chateal oral tablet 0.15-30 mg-mcg 1 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 355 Coverage Requirements & Prescription Drug Name Drug Tier Limits cryselle-28 oral tablet 0.3-30 mg-mcg 1 PV cyclafem 1/35 oral tablet 1-35 mg-mcg 1 PV cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 PV cyred eq oral tablet 0.15-30 mg-mcg 1 PV cyred oral tablet 0.15-30 mg-mcg 1 PV dasetta 1/35 oral tablet 1-35 mg-mcg 1 PV dasetta 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 PV PV; QL (91 day supply per 1 daysee oral tablet 0.15-0.03 &0.01 mg 1 fill) deblitane oral tablet 0.35 mg 1 PV delyla oral tablet 0.1-20 mg-mcg 1 PV DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 OA MG/ML (medroxyprogesterone acetate) DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 150 MG/ML (medroxyprogesterone OA acetate) DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML OA (medroxyprogesterone acetate) desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg 1 PV (21/5), 0.15-30 mg-mcg dolishale oral tablet 90-20 mcg 1 PV drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 1 PV 3-0.03-0.451 mg drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 1 PV mg elinest oral tablet 0.3-30 mg-mcg 1 PV ELLA ORAL TABLET 30 MG (ulipristal acetate) 3 PV eluryng vaginal ring 0.12-0.015 mg/24hr 1 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 356 Coverage Requirements & Prescription Drug Name Drug Tier Limits emoquette oral tablet 0.15-30 mg-mcg 1 PV enpresse-28 oral tablet 50-30/75-40/ 125-30 mcg 1 PV enskyce oral tablet 0.15-30 mg-mcg 1 PV errin oral tablet 0.35 mg 1 PV estarylla oral tablet 0.25-35 mg-mcg 1 PV ESTROSTEP FE ORAL TABLET 1-20/1-30/1-35 MG-MCG 3 (norethindron-ethinyl estrad-fe) ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 1 PV mg-mcg etonogestrel-ethinyl estradiol vaginal ring 0.12-0.015 1 PV mg/24hr falmina oral tablet 0.1-20 mg-mcg 1 PV PV; QL (91 day supply per 1 fayosim oral tablet 42-21-21-7 days 1 fill) femynor oral tablet 0.25-35 mg-mcg 1 PV gemmily oral capsule 1-20 mg-mcg(24) 1 PV GENERESS FE ORAL TABLET CHEWABLE 0.8-25 MG-MCG 3 (norethin-eth estradiol-fe) hailey 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV hailey 24 fe oral tablet 1-20 mg-mcg(24) 1 PV hailey fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV hailey fe 1/20 oral tablet 1-20 mg-mcg 1 PV heather oral tablet 0.35 mg 1 PV PV; QL (91 day supply per 1 iclevia oral tablet 0.15-0.03 mg 1 fill) incassia oral tablet 0.35 mg 1 PV PV; QL (91 day supply per 1 introvale oral tablet 0.15-0.03 mg 1 fill) isibloom oral tablet 0.15-30 mg-mcg 1 PV Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 357 Coverage Requirements & Prescription Drug Name Drug Tier Limits PV; QL (91 day supply per 1 jaimiess oral tablet 0.15-0.03 &0.01 mg 1 fill) jasmiel oral tablet 3-0.02 mg 1 PV jencycla oral tablet 0.35 mg 1 PV PV; QL (91 day supply per 1 jolessa oral tablet 0.15-0.03 mg 1 fill) juleber oral tablet 0.15-30 mg-mcg 1 PV junel 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV junel 1/20 oral tablet 1-20 mg-mcg 1 PV junel fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV junel fe 1/20 oral tablet 1-20 mg-mcg 1 PV junel fe 24 oral tablet 1-20 mg-mcg(24) 1 PV kaitlib fe oral tablet chewable 0.8-25 mg-mcg 1 PV kalliga oral tablet 0.15-30 mg-mcg 1 PV kariva oral tablet 0.15-0.02/0.01 mg (21/5) 1 PV kelnor 1/35 oral tablet 1-35 mg-mcg 1 PV kelnor 1/50 oral tablet 1-50 mg-mcg 1 PV kurvelo oral tablet 0.15-30 mg-mcg 1 PV KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 19.5 MG OA QL (365 day supply per 1 fill) (levonorgestrel) larin 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV larin 1/20 oral tablet 1-20 mg-mcg 1 PV larin 24 fe oral tablet 1-20 mg-mcg(24) 1 PV larin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV larin fe 1/20 oral tablet 1-20 mg-mcg 1 PV larissia oral tablet 0.1-20 mg-mcg 1 PV layolis fe oral tablet chewable 0.8-25 mg-mcg 1 PV leena oral tablet 0.5/1/0.5-35 mg-mcg 1 PV Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 358 Coverage Requirements & Prescription Drug Name Drug Tier Limits lessina oral tablet 0.1-20 mg-mcg 1 PV levonest oral tablet 50-30/75-40/ 125-30 mcg 1 PV PV; QL (91 day supply per 1 levonorgest-eth est & eth est oral tablet 42-21-21-7 days 1 fill) levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 PV; QL (91 day supply per 1 1 mg, 0.15-0.03 &0.01 mg, 0.15-0.03 mg fill) levonorgestrel oral tablet 1.5 mg 1 PV levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 1 PV 0.15-30 mg-mcg, 90-20 mcg levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125-30 1 PV mcg levora 0.15/30 (28) oral tablet 0.15-30 mg-mcg 1 PV LILETTA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE OA QL (365 day supply per 1 fill) 19.5 MCG/DAY (levonorgestrel) lillow oral tablet 0.15-30 mg-mcg 1 PV LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG 2 PV (norethin-eth estrad-fe biphas) LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG 3 (norethindrone acet-ethinyl est) LOESTRIN 1/20 (21) ORAL TABLET 1-20 MG-MCG 3 (norethindrone acet-ethinyl est) LOESTRIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG 3 (norethin ace-eth estrad-fe) LOESTRIN FE 1/20 ORAL TABLET 1-20 MG-MCG (norethin 3 ace-eth estrad-fe) PV; QL (91 day supply per 1 lojaimiess oral tablet 0.1-0.02 & 0.01 mg 1 fill) loryna oral tablet 3-0.02 mg 1 PV LOSEASONIQUE ORAL TABLET 0.1-0.02 & 0.01 MG 3 QL (91 day supply per 1 fill) (levonorgest-eth estrad 91-day)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 359 Coverage Requirements & Prescription Drug Name Drug Tier Limits low-ogestrel oral tablet 0.3-30 mg-mcg 1 PV lo-zumandimine oral tablet 3-0.02 mg 1 PV lutera oral tablet 0.1-20 mg-mcg 1 PV lyleq oral tablet 0.35 mg 1 PV lyza oral tablet 0.35 mg 1 PV marlissa oral tablet 0.15-30 mg-mcg 1 PV medroxyprogesterone acetate intramuscular suspension OA PV 150 mg/ml medroxyprogesterone acetate intramuscular suspension OA PV prefilled syringe 150 mg/ml merzee oral capsule 1-20 mg-mcg(24) 1 PV mibelas 24 fe oral tablet chewable 1-20 mg-mcg(24) 1 PV microgestin 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV microgestin 1/20 oral tablet 1-20 mg-mcg 1 PV microgestin 24 fe oral tablet 1-20 mg-mcg 1 PV microgestin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV microgestin fe 1/20 oral tablet 1-20 mg-mcg 1 PV mili oral tablet 0.25-35 mg-mcg 1 PV MINASTRIN 24 FE ORAL TABLET CHEWABLE 1-20 MG- 3 MCG(24) (norethin ace-eth estrad-fe) MIRCETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) 3 (desogestrel-ethinyl estradiol) MIRENA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE OA QL (365 day supply per 1 fill) 20 MCG/24HR (levonorgestrel) mono-linyah oral tablet 0.25-35 mg-mcg 1 PV NATAZIA ORAL TABLET 3/2-2/2-3/1 MG (estradiol valerate- 3 PV dienogest) necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 360 Coverage Requirements & Prescription Drug Name Drug Tier Limits NEXPLANON SUBCUTANEOUS IMPLANT 68 MG OA QL (365 day supply per 1 fill) (etonogestrel) NEXTSTELLIS ORAL TABLET 3-14.2 MG (drospirenone- 3 PA estetrol) nikki oral tablet 3-0.02 mg 1 PV nora-be oral tablet 0.35 mg 1 PV norethin ace-eth estrad-fe oral capsule 1-20 mg-mcg(24) 1 PV norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1.5-30 1 PV mg-mcg norethin ace-eth estrad-fe oral tablet chewable 1-20 mg- 1 PV mcg(24) norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg, 1.5- 1 PV 30 mg-mcg norethindrone oral tablet 0.35 mg 1 PV norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg- 1 PV mcg, 0.8-25 mg-mcg norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg 1 PV norgestimate-ethinyl estradiol triphasic oral tablet 1 PV 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg norlyda oral tablet 0.35 mg 1 PV norlyroc oral tablet 0.35 mg 1 PV nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 PV nortrel 1/35 (21) oral tablet 1-35 mg-mcg 1 PV nortrel 1/35 (28) oral tablet 1-35 mg-mcg 1 PV nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 PV NUVARING VAGINAL RING 0.12-0.015 MG/24HR 3 (etonogestrel-ethinyl estradiol) nylia 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 PV nymyo oral tablet 0.25-35 mg-mcg 1 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 361 Coverage Requirements & Prescription Drug Name Drug Tier Limits ocella oral tablet 3-0.03 mg 1 PV orsythia oral tablet 0.1-20 mg-mcg 1 PV philith oral tablet 0.4-35 mg-mcg 1 PV pimtrea oral tablet 0.15-0.02/0.01 mg (21/5) 1 PV pirmella 1/35 oral tablet 1-35 mg-mcg 1 PV pirmella 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 PV portia-28 oral tablet 0.15-30 mg-mcg 1 PV preventeza oral tablet 1.5 mg 1 PV previfem oral tablet 0.25-35 mg-mcg 1 PV QUARTETTE ORAL TABLET 42-21-21-7 DAYS (levonorgest- 3 QL (91 day supply per 1 fill) eth estrad 91-day) reclipsen oral tablet 0.15-30 mg-mcg 1 PV PV; QL (91 day supply per 1 rivelsa oral tablet 42-21-21-7 days 1 fill) SAFYRAL ORAL TABLET 3-0.03-0.451 MG (drospiren-eth 3 estrad-levomefol) SEASONIQUE ORAL TABLET 0.15-0.03 &0.01 MG 3 QL (91 day supply per 1 fill) (levonorgest-eth estrad 91-day) PV; QL (91 day supply per 1 setlakin oral tablet 0.15-0.03 mg 1 fill) sharobel oral tablet 0.35 mg 1 PV simliya oral tablet 0.15-0.02/0.01 mg (21/5) 1 PV PV; QL (91 day supply per 1 simpesse oral tablet 0.15-0.03 &0.01 mg 1 fill) SKYLA INTRAUTERINE INTRAUTERINE DEVICE 13.5 MG OA QL (365 day supply per 1 fill) (levonorgestrel) SLYND ORAL TABLET 4 MG (drospirenone) 3 PV sprintec 28 oral tablet 0.25-35 mg-mcg 1 PV sronyx oral tablet 0.1-20 mg-mcg 1 PV Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 362 Coverage Requirements & Prescription Drug Name Drug Tier Limits syeda oral tablet 3-0.03 mg 1 PV tarina 24 fe oral tablet 1-20 mg-mcg(24) 1 PV tarina fe 1/20 eq oral tablet 1-20 mg-mcg 1 PV tarina fe 1/20 oral tablet 1-20 mg-mcg 1 PV taysofy oral capsule 1-20 mg-mcg(24) 1 PV TAYTULLA ORAL CAPSULE 1-20 MG-MCG(24) (norethin 3 ace-eth estrad-fe) tilia fe oral tablet 1-20/1-30/1-35 mg-mcg 1 PV tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg 1 PV tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg 1 PV tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg 1 PV tri-lo-mili oral tablet 0.18/0.215/0.25 mg-25 mcg 1 PV tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg 1 PV tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV tri-nymyo oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV trivora (28) oral tablet 50-30/75-40/ 125-30 mcg 1 PV tri-vylibra lo oral tablet 0.18/0.215/0.25 mg-25 mcg 1 PV tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV tulana oral tablet 0.35 mg 1 PV TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 3 ST MCG/24HR (levonorgestrel-eth estradiol) tyblume oral tablet chewable 0.1-20 mg-mcg 1 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 363 Coverage Requirements & Prescription Drug Name Drug Tier Limits tydemy oral tablet 3-0.03-0.451 mg 1 PV velivet oral tablet 0.1/0.125/0.15 -0.025 mg 1 PV vestura oral tablet 3-0.02 mg 1 PV vienva oral tablet 0.1-20 mg-mcg 1 PV viorele oral tablet 0.15-0.02/0.01 mg (21/5) 1 PV volnea oral tablet 0.15-0.02/0.01 mg (21/5) 1 PV vyfemla oral tablet 0.4-35 mg-mcg 1 PV vylibra oral tablet 0.25-35 mg-mcg 1 PV wera oral tablet 0.5-35 mg-mcg 1 PV wymzya fe oral tablet chewable 0.4-35 mg-mcg 1 PV xulane transdermal patch weekly 150-35 mcg/24hr 1 PV YASMIN 28 ORAL TABLET 3-0.03 MG (drospirenone-ethinyl 3 estradiol) YAZ ORAL TABLET 3-0.02 MG (drospirenone-ethinyl 3 estradiol) zafemy transdermal patch weekly 150-35 mcg/24hr 1 PV zarah oral tablet 3-0.03 mg 1 PV zovia 1/35 (28) oral tablet 1-35 mg-mcg 1 PV zovia 1/35e (28) oral tablet 1-35 mg-mcg 1 PV zumandimine oral tablet 3-0.03 mg 1 PV DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS - Drugs for Diabetes ALOGLIPTIN BENZOATE ORAL TABLET 12.5 MG, 25 MG, 3 ST 6.25 MG ALOGLIPTIN-METFORMIN HCL ORAL TABLET 12.5-1000 3 ST MG, 12.5-500 MG ALOGLIPTIN-PIOGLITAZONE ORAL TABLET 12.5-15 MG, 3 ST 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 364 Coverage Requirements & Prescription Drug Name Drug Tier Limits GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG (empagliflozin- 3 PA linagliptin) JANUMET ORAL TABLET 50-1000 MG, 50-500 MG 2 (sitagliptin-metformin hcl) JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG (sitagliptin- 2 metformin hcl) JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG (sitagliptin 2 phosphate) JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5- 2 QL (2 EA per 1 day) 850 MG (linagliptin-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 2 QL (2 EA per 1 day) HOUR 2.5-1000 MG (linagliptin-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 2 QL (1 EA per 1 day) HOUR 5-1000 MG (linagliptin-metformin hcl) KAZANO ORAL TABLET 12.5-1000 MG, 12.5-500 MG 3 ST (alogliptin-metformin hcl) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG, 5-500 MG (saxagliptin- 3 ST metformin) NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG (alogliptin 3 ST benzoate) ONGLYZA ORAL TABLET 2.5 MG, 5 MG (saxagliptin hcl) 3 ST OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 3 ST 25-15 MG, 25-30 MG, 25-45 MG (alogliptin-pioglitazone) QTERN ORAL TABLET 10-5 MG, 5-5 MG (dapagliflozin- 3 PA saxagliptin) STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG 3 PA (ertugliflozin-sitagliptin) TRADJENTA ORAL TABLET 5 MG (linagliptin) 2

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 365 Coverage Requirements & Prescription Drug Name Drug Tier Limits TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 12.5-2.5-1000 MG, 25-5-1000 MG, 5- 3 PA 2.5-1000 MG (empagliflozin-linaglip-metform) ESTROGEN AGONIST-ANTAGONISTS - Drugs for Women clomiphene citrate oral tablet 50 mg INF PA DUAVEE ORAL TABLET 0.45-20 MG (conj estrogens- 3 bazedoxifene) EVISTA ORAL TABLET 60 MG (raloxifene hcl) 3 FARESTON ORAL TABLET 60 MG (toremifene citrate) 3 AC OSPHENA ORAL TABLET 60 MG (ospemifene) 3 raloxifene hcl oral tablet 60 mg 1 PV SOLTAMOX ORAL SOLUTION 10 MG/5ML (tamoxifen citrate) 3 PV; AC tamoxifen citrate oral tablet 10 mg, 20 mg 1 PV; AC toremifene citrate oral tablet 60 mg 1 AC ESTROGENS - Drugs for Women ACTIVELLA ORAL TABLET 1-0.5 MG (estradiol- 3 norethindrone acet) afirmelle oral tablet 0.1-20 mg-mcg 1 PV ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR 2 QL (0.3 EA per 1 day) (estradiol) altavera oral tablet 0.15-30 mg-mcg 1 PV alyacen 1/35 oral tablet 1-35 mg-mcg 1 PV alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 PV amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg 1 PV; QL (91 day supply per 1 amethia oral tablet 0.15-0.03 &0.01 mg 1 fill) amethyst oral tablet 90-20 mcg 1 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 366 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG 3 (drospirenone-estradiol) ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR PA; PV; QL (1 EA per 365 3 (segesterone-ethinyl estradiol) days) apri oral tablet 0.15-30 mg-mcg 1 PV aranelle oral tablet 0.5/1/0.5-35 mg-mcg 1 PV PV; QL (91 day supply per 1 ashlyna oral tablet 0.15-0.03 &0.01 mg 1 fill) aubra eq oral tablet 0.1-20 mg-mcg 1 PV aubra oral tablet 0.1-20 mg-mcg 1 PV aurovela 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV aurovela 1/20 oral tablet 1-20 mg-mcg 1 PV aurovela 24 fe oral tablet 1-20 mg-mcg(24) 1 PV aurovela fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV aurovela fe 1/20 oral tablet 1-20 mg-mcg 1 PV aviane oral tablet 0.1-20 mg-mcg 1 PV ayuna oral tablet 0.15-30 mg-mcg 1 PV azurette oral tablet 0.15-0.02/0.01 mg (21/5) 1 PV BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) 3 PA (levonorgest-eth estrad-fe bisg) balziva oral tablet 0.4-35 mg-mcg 1 PV BEYAZ ORAL TABLET 3-0.02-0.451 MG (drospiren-eth 3 estrad-levomefol) BIJUVA ORAL CAPSULE 1-100 MG (estradiol-progesterone) 3 PA blisovi 24 fe oral tablet 1-20 mg-mcg(24) 1 PV blisovi fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV blisovi fe 1/20 oral tablet 1-20 mg-mcg 1 PV briellyn oral tablet 0.4-35 mg-mcg 1 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 367 Coverage Requirements & Prescription Drug Name Drug Tier Limits PV; QL (91 day supply per 1 camrese lo oral tablet 0.1-0.02 & 0.01 mg 1 fill) PV; QL (91 day supply per 1 camrese oral tablet 0.15-0.03 &0.01 mg 1 fill) caziant oral tablet 0.1/0.125/0.15 -0.025 mg 1 PV charlotte 24 fe oral tablet chewable 1-20 mg-mcg(24) 1 PV chateal eq oral tablet 0.15-30 mg-mcg 1 PV chateal oral tablet 0.15-30 mg-mcg 1 PV CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045- 2 QL (0.15 EA per 1 day) 0.015 MG/DAY (estradiol-levonorgestrel) CLIMARA TRANSDERMAL PATCH WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.06 MG/24HR, 0.075 3 QL (0.2 EA per 1 day) MG/24HR, 0.1 MG/24HR (estradiol) COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY (estradiol- 3 QL (0.3 EA per 1 day) norethindrone acet) cryselle-28 oral tablet 0.3-30 mg-mcg 1 PV cyclafem 1/35 oral tablet 1-35 mg-mcg 1 PV cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 PV cyred eq oral tablet 0.15-30 mg-mcg 1 PV cyred oral tablet 0.15-30 mg-mcg 1 PV dasetta 1/35 oral tablet 1-35 mg-mcg 1 PV dasetta 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 PV PV; QL (91 day supply per 1 daysee oral tablet 0.15-0.03 &0.01 mg 1 fill) DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML, 20 PA; QL (30 day supply per 1 SI MG/ML, 40 MG/ML (estradiol valerate) fill) delyla oral tablet 0.1-20 mg-mcg 1 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 368 Coverage Requirements & Prescription Drug Name Drug Tier Limits DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML PA; QL (30 day supply per 1 SI (estradiol cypionate) fill) desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg 1 PV (21/5), 0.15-30 mg-mcg DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 3 QL (1 EA per 1 day) MG/0.5GM, 0.75 MG/0.75GM (estradiol) DIVIGEL TRANSDERMAL GEL 1 MG/GM (estradiol) 3 QL (1 GM per 1 day) DIVIGEL TRANSDERMAL GEL 1.25 MG/1.25GM (estradiol) 3 dolishale oral tablet 90-20 mcg 1 PV dotti transdermal patch twice weekly 0.025 mg/24hr, 0.0375 1 QL (0.3 EA per 1 day) mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 1 PV 3-0.03-0.451 mg drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 1 PV mg DUAVEE ORAL TABLET 0.45-20 MG (conj estrogens- 3 bazedoxifene) ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM (0.06%) 3 QL (1.74 GM per 1 day) (estradiol) elinest oral tablet 0.3-30 mg-mcg 1 PV eluryng vaginal ring 0.12-0.015 mg/24hr 1 PV emoquette oral tablet 0.15-30 mg-mcg 1 PV enpresse-28 oral tablet 50-30/75-40/ 125-30 mcg 1 PV enskyce oral tablet 0.15-30 mg-mcg 1 PV estarylla oral tablet 0.25-35 mg-mcg 1 PV ESTRACE ORAL TABLET 0.5 MG, 1 MG, 2 MG (estradiol) 3 ESTRACE VAGINAL CREAM 0.1 MG/GM (estradiol) 3 ESTRADIOL IMPLANT PELLET 6 MG OA estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 369 Coverage Requirements & Prescription Drug Name Drug Tier Limits estradiol transdermal patch twice weekly 0.025 mg/24hr, 1 QL (0.3 EA per 1 day) 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 1 QL (0.2 EA per 1 day) mg/24hr estradiol vaginal cream 0.1 mg/gm 1 estradiol vaginal tablet 10 mcg 1 PA; QL (30 day supply per 1 estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml SI fill) estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg 1 ESTRING VAGINAL RING 2 MG (estradiol) 3 ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM (0.06%) 3 QL (1.67 GM per 1 day) (estradiol) ESTROSTEP FE ORAL TABLET 1-20/1-30/1-35 MG-MCG 3 (norethindron-ethinyl estrad-fe) ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 1 PV mg-mcg etonogestrel-ethinyl estradiol vaginal ring 0.12-0.015 1 PV mg/24hr EVAMIST TRANSDERMAL SOLUTION 1.53 MG/SPRAY 3 QL (0.55 ML per 1 day) (estradiol) falmina oral tablet 0.1-20 mg-mcg 1 PV PV; QL (91 day supply per 1 fayosim oral tablet 42-21-21-7 days 1 fill) FEMHRT ORAL TABLET 0.5-2.5 MG-MCG (norethindrone-eth 3 estradiol) FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR 3 (estradiol acetate) femynor oral tablet 0.25-35 mg-mcg 1 PV fyavolv oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 370 Coverage Requirements & Prescription Drug Name Drug Tier Limits gemmily oral capsule 1-20 mg-mcg(24) 1 PV GENERESS FE ORAL TABLET CHEWABLE 0.8-25 MG-MCG 3 (norethin-eth estradiol-fe) hailey 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV hailey 24 fe oral tablet 1-20 mg-mcg(24) 1 PV hailey fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV hailey fe 1/20 oral tablet 1-20 mg-mcg 1 PV PV; QL (91 day supply per 1 iclevia oral tablet 0.15-0.03 mg 1 fill) IMVEXXY MAINTENANCE PACK VAGINAL INSERT 10 MCG, 2 4 MCG (estradiol) IMVEXXY STARTER PACK VAGINAL INSERT 10 MCG, 4 2 MCG (estradiol) PV; QL (91 day supply per 1 introvale oral tablet 0.15-0.03 mg 1 fill) isibloom oral tablet 0.15-30 mg-mcg 1 PV PV; QL (91 day supply per 1 jaimiess oral tablet 0.15-0.03 &0.01 mg 1 fill) jasmiel oral tablet 3-0.02 mg 1 PV jinteli oral tablet 1-5 mg-mcg 1 PV; QL (91 day supply per 1 jolessa oral tablet 0.15-0.03 mg 1 fill) juleber oral tablet 0.15-30 mg-mcg 1 PV junel 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV junel 1/20 oral tablet 1-20 mg-mcg 1 PV junel fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV junel fe 1/20 oral tablet 1-20 mg-mcg 1 PV junel fe 24 oral tablet 1-20 mg-mcg(24) 1 PV kaitlib fe oral tablet chewable 0.8-25 mg-mcg 1 PV Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 371 Coverage Requirements & Prescription Drug Name Drug Tier Limits kalliga oral tablet 0.15-30 mg-mcg 1 PV kariva oral tablet 0.15-0.02/0.01 mg (21/5) 1 PV kelnor 1/35 oral tablet 1-35 mg-mcg 1 PV kelnor 1/50 oral tablet 1-50 mg-mcg 1 PV kurvelo oral tablet 0.15-30 mg-mcg 1 PV larin 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV larin 1/20 oral tablet 1-20 mg-mcg 1 PV larin 24 fe oral tablet 1-20 mg-mcg(24) 1 PV larin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV larin fe 1/20 oral tablet 1-20 mg-mcg 1 PV larissia oral tablet 0.1-20 mg-mcg 1 PV layolis fe oral tablet chewable 0.8-25 mg-mcg 1 PV leena oral tablet 0.5/1/0.5-35 mg-mcg 1 PV lessina oral tablet 0.1-20 mg-mcg 1 PV levonest oral tablet 50-30/75-40/ 125-30 mcg 1 PV PV; QL (91 day supply per 1 levonorgest-eth est & eth est oral tablet 42-21-21-7 days 1 fill) levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 PV; QL (91 day supply per 1 1 mg, 0.15-0.03 &0.01 mg, 0.15-0.03 mg fill) levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 1 PV 0.15-30 mg-mcg, 90-20 mcg levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125-30 1 PV mcg levora 0.15/30 (28) oral tablet 0.15-30 mg-mcg 1 PV lillow oral tablet 0.15-30 mg-mcg 1 PV LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG 2 PV (norethin-eth estrad-fe biphas)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 372 Coverage Requirements & Prescription Drug Name Drug Tier Limits LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG 3 (norethindrone acet-ethinyl est) LOESTRIN 1/20 (21) ORAL TABLET 1-20 MG-MCG 3 (norethindrone acet-ethinyl est) LOESTRIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG 3 (norethin ace-eth estrad-fe) LOESTRIN FE 1/20 ORAL TABLET 1-20 MG-MCG (norethin 3 ace-eth estrad-fe) PV; QL (91 day supply per 1 lojaimiess oral tablet 0.1-0.02 & 0.01 mg 1 fill) loryna oral tablet 3-0.02 mg 1 PV LOSEASONIQUE ORAL TABLET 0.1-0.02 & 0.01 MG 3 QL (91 day supply per 1 fill) (levonorgest-eth estrad 91-day) low-ogestrel oral tablet 0.3-30 mg-mcg 1 PV lo-zumandimine oral tablet 3-0.02 mg 1 PV lutera oral tablet 0.1-20 mg-mcg 1 PV lyllana transdermal patch twice weekly 0.025 mg/24hr, 1 QL (0.3 EA per 1 day) 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr marlissa oral tablet 0.15-30 mg-mcg 1 PV MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG 3 (esterified estrogens) MENOSTAR TRANSDERMAL PATCH WEEKLY 14 3 QL (0.2 EA per 1 day) MCG/24HR (estradiol) merzee oral capsule 1-20 mg-mcg(24) 1 PV mibelas 24 fe oral tablet chewable 1-20 mg-mcg(24) 1 PV microgestin 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV microgestin 1/20 oral tablet 1-20 mg-mcg 1 PV microgestin 24 fe oral tablet 1-20 mg-mcg 1 PV microgestin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 373 Coverage Requirements & Prescription Drug Name Drug Tier Limits microgestin fe 1/20 oral tablet 1-20 mg-mcg 1 PV mili oral tablet 0.25-35 mg-mcg 1 PV mimvey oral tablet 1-0.5 mg 1 MINASTRIN 24 FE ORAL TABLET CHEWABLE 1-20 MG- 3 MCG(24) (norethin ace-eth estrad-fe) MINIVELLE TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 3 QL (0.3 EA per 1 day) 0.1 MG/24HR (estradiol) MIRCETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) 3 (desogestrel-ethinyl estradiol) mono-linyah oral tablet 0.25-35 mg-mcg 1 PV MYFEMBREE ORAL TABLET 40-1-0.5 MG (relugolix- 3 PA estradiol-norethind) NATAZIA ORAL TABLET 3/2-2/2-3/1 MG (estradiol valerate- 3 PV dienogest) necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 PV NEXTSTELLIS ORAL TABLET 3-14.2 MG (drospirenone- 3 PA estetrol) nikki oral tablet 3-0.02 mg 1 PV norethin ace-eth estrad-fe oral capsule 1-20 mg-mcg(24) 1 PV norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1.5-30 1 PV mg-mcg norethin ace-eth estrad-fe oral tablet chewable 1-20 mg- 1 PV mcg(24) norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg, 1.5- 1 PV 30 mg-mcg norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 1 mg-mcg norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg- 1 PV mcg, 0.8-25 mg-mcg

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 374 Coverage Requirements & Prescription Drug Name Drug Tier Limits norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg 1 PV norgestimate-ethinyl estradiol triphasic oral tablet 1 PV 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 PV nortrel 1/35 (21) oral tablet 1-35 mg-mcg 1 PV nortrel 1/35 (28) oral tablet 1-35 mg-mcg 1 PV nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 PV NUVARING VAGINAL RING 0.12-0.015 MG/24HR 3 (etonogestrel-ethinyl estradiol) nylia 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 PV nymyo oral tablet 0.25-35 mg-mcg 1 PV ocella oral tablet 3-0.03 mg 1 PV ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 & 300 3 PA MG (elagolix-estradiol-norethind) orsythia oral tablet 0.1-20 mg-mcg 1 PV philith oral tablet 0.4-35 mg-mcg 1 PV pimtrea oral tablet 0.15-0.02/0.01 mg (21/5) 1 PV pirmella 1/35 oral tablet 1-35 mg-mcg 1 PV pirmella 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 PV portia-28 oral tablet 0.15-30 mg-mcg 1 PV PREFEST ORAL TABLET 1/1-0.09 MG (15/15) (estradiol- 2 norgestimate) PREMARIN INJECTION SOLUTION RECONSTITUTED 25 MG OA (estrogens conjugated) PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 2 MG, 1.25 MG (estrogens conjugated) PREMARIN VAGINAL CREAM 0.625 MG/GM (estrogens, 2 conjugated)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 375 Coverage Requirements & Prescription Drug Name Drug Tier Limits PREMPHASE ORAL TABLET 0.625-5 MG (conj estrog- 2 medroxyprogest ace) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 2 MG, 0.625-5 MG (conj estrog-medroxyprogest ace) previfem oral tablet 0.25-35 mg-mcg 1 PV QUARTETTE ORAL TABLET 42-21-21-7 DAYS (levonorgest- 3 QL (91 day supply per 1 fill) eth estrad 91-day) reclipsen oral tablet 0.15-30 mg-mcg 1 PV PV; QL (91 day supply per 1 rivelsa oral tablet 42-21-21-7 days 1 fill) SAFYRAL ORAL TABLET 3-0.03-0.451 MG (drospiren-eth 3 estrad-levomefol) SEASONIQUE ORAL TABLET 0.15-0.03 &0.01 MG 3 QL (91 day supply per 1 fill) (levonorgest-eth estrad 91-day) PV; QL (91 day supply per 1 setlakin oral tablet 0.15-0.03 mg 1 fill) simliya oral tablet 0.15-0.02/0.01 mg (21/5) 1 PV PV; QL (91 day supply per 1 simpesse oral tablet 0.15-0.03 &0.01 mg 1 fill) sprintec 28 oral tablet 0.25-35 mg-mcg 1 PV sronyx oral tablet 0.1-20 mg-mcg 1 PV syeda oral tablet 3-0.03 mg 1 PV tarina 24 fe oral tablet 1-20 mg-mcg(24) 1 PV tarina fe 1/20 eq oral tablet 1-20 mg-mcg 1 PV tarina fe 1/20 oral tablet 1-20 mg-mcg 1 PV taysofy oral capsule 1-20 mg-mcg(24) 1 PV TAYTULLA ORAL CAPSULE 1-20 MG-MCG(24) (norethin 3 ace-eth estrad-fe) tilia fe oral tablet 1-20/1-30/1-35 mg-mcg 1 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 376 Coverage Requirements & Prescription Drug Name Drug Tier Limits tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg 1 PV tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg 1 PV tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg 1 PV tri-lo-mili oral tablet 0.18/0.215/0.25 mg-25 mcg 1 PV tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg 1 PV tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV tri-nymyo oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV trivora (28) oral tablet 50-30/75-40/ 125-30 mcg 1 PV tri-vylibra lo oral tablet 0.18/0.215/0.25 mg-25 mcg 1 PV tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 3 ST MCG/24HR (levonorgestrel-eth estradiol) tyblume oral tablet chewable 0.1-20 mg-mcg 1 PV tydemy oral tablet 3-0.03-0.451 mg 1 PV VAGIFEM VAGINAL TABLET 10 MCG (estradiol) 3 velivet oral tablet 0.1/0.125/0.15 -0.025 mg 1 PV vestura oral tablet 3-0.02 mg 1 PV vienva oral tablet 0.1-20 mg-mcg 1 PV viorele oral tablet 0.15-0.02/0.01 mg (21/5) 1 PV VIVELLE-DOT TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 3 QL (0.3 EA per 1 day) MG/24HR, 0.1 MG/24HR (estradiol) volnea oral tablet 0.15-0.02/0.01 mg (21/5) 1 PV Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 377 Coverage Requirements & Prescription Drug Name Drug Tier Limits vyfemla oral tablet 0.4-35 mg-mcg 1 PV vylibra oral tablet 0.25-35 mg-mcg 1 PV wera oral tablet 0.5-35 mg-mcg 1 PV wymzya fe oral tablet chewable 0.4-35 mg-mcg 1 PV xulane transdermal patch weekly 150-35 mcg/24hr 1 PV YASMIN 28 ORAL TABLET 3-0.03 MG (drospirenone-ethinyl 3 estradiol) YAZ ORAL TABLET 3-0.02 MG (drospirenone-ethinyl 3 estradiol) yuvafem vaginal tablet 10 mcg 1 zafemy transdermal patch weekly 150-35 mcg/24hr 1 PV zarah oral tablet 3-0.03 mg 1 PV zovia 1/35 (28) oral tablet 1-35 mg-mcg 1 PV zovia 1/35e (28) oral tablet 1-35 mg-mcg 1 PV zumandimine oral tablet 3-0.03 mg 1 PV GLYCOGENOLYTIC AGENTS - Hormones BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE 3 (glucagon) BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE 3 (glucagon) GLUCAGEN DIAGNOSTIC INJECTION SOLUTION OA RECONSTITUTED 1 MG (glucagon hcl rdna (diagnostic)) GLUCAGEN HYPOKIT INJECTION SOLUTION SI QL (30 day supply per 1 fill) RECONSTITUTED 1 MG (glucagon hcl (rdna)) glucagon emergency kit 1 mg injection 1 mg 1 GLUCAGON EMERGENCY KIT 1 MG INJECTION 1 MG 3 GLUCAGON EMERGENCY KIT INJECTION SOLUTION 3 RECONSTITUTED 1 MG/ML

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 378 Coverage Requirements & Prescription Drug Name Drug Tier Limits GLUCAGON HCL (DIAGNOSTIC) INJECTION SOLUTION OA RECONSTITUTED 1 MG GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION 3 AUTO-INJECTOR 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION 3 AUTO-INJECTOR 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED 3 SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) ZEGALOGUE SUBCUTANEOUS SOLUTION AUTO- 3 PA INJECTOR 0.6 MG/0.6ML (dasiglucagon hcl) ZEGALOGUE SUBCUTANEOUS SOLUTION PREFILLED 3 PA SYRINGE 0.6 MG/0.6ML (dasiglucagon hcl) GONADOTROPINS - Hormones chorionic gonadotropin intramuscular solution PA; QL (30 day supply per 1 INF reconstituted 10000 unit fill) ELIGARD SUBCUTANEOUS KIT 22.5 MG (leuprolide acetate OA QL (30 day supply per 1 fill) (3 month)) ELIGARD SUBCUTANEOUS KIT 30 MG (leuprolide acetate (4 OA QL (30 day supply per 1 fill) month)) ELIGARD SUBCUTANEOUS KIT 45 MG (leuprolide acetate (6 OA QL (30 day supply per 1 fill) month)) PA; QL (30 day supply per 1 ELIGARD SUBCUTANEOUS KIT 7.5 MG (leuprolide acetate) OA fill) FENSOLVI (6 MONTH) SUBCUTANEOUS KIT 45 MG (PED) OA QL (30 day supply per 1 fill) (leuprolide acetate (6 month)) FOLLISTIM AQ SUBCUTANEOUS SOLUTION 300 PA; QL (30 day supply per 1 UNT/0.36ML, 600 UNT/0.72ML, 900 UNT/1.08ML (follitropin INF fill) beta) GONAL-F INJECTION SOLUTION RECONSTITUTED 1050 PA; QL (30 day supply per 1 INF UNIT, 450 UNIT (follitropin alfa) fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 379 Coverage Requirements & Prescription Drug Name Drug Tier Limits GONAL-F RFF REDIJECT SUBCUTANEOUS SOLUTION 300 PA; QL (30 day supply per 1 UNIT/0.5ML, 450 UNT/0.75ML, 900 UNIT/1.5ML (follitropin INF fill) alfa) GONAL-F RFF SUBCUTANEOUS SOLUTION PA; QL (30 day supply per 1 INF RECONSTITUTED 75 UNIT (follitropin alfa) fill) LEUPROLIDE ACETATE-BUPIVACAINE INTRAMUSCULAR 3 SOLUTION 25-5 MG/ML LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 PA; QL (30 day supply per 1 OA MG, 7.5 MG (leuprolide acetate) fill) LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 OA QL (30 day supply per 1 fill) MG, 22.5 MG (leuprolide acetate (3 month)) LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG OA QL (30 day supply per 1 fill) INTRAMUSCULAR KIT 30 MG (leuprolide acetate (4 month)) LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG OA QL (30 day supply per 1 fill) INTRAMUSCULAR KIT 45 MG (leuprolide acetate (6 month)) LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT OA QL (30 day supply per 1 fill) 11.25 MG, 15 MG, 7.5 MG (leuprolide acetate) LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT OA QL (30 day supply per 1 fill) 11.25 MG (PED), 30 MG (PED) (leuprolide acetate (3 month)) MENOPUR SUBCUTANEOUS SOLUTION RECONSTITUTED PA; QL (30 day supply per 1 INF 75 UNIT (menotropins) fill) PA; QL (30 day supply per 1 novarel intramuscular solution reconstituted 10000 unit INF fill) NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED PA; QL (30 day supply per 1 INF 5000 UNIT (chorionic gonadotropin) fill) OVIDREL SUBCUTANEOUS INJECTABLE 250 MCG/0.5ML PA; QL (30 day supply per 1 INF (choriogonadotropin alfa) fill) PA; QL (30 day supply per 1 pregnyl intramuscular solution reconstituted 10000 unit INF fill) SUPPRELIN LA SUBCUTANEOUS KIT 50 MG (histrelin PA; QL (365 day supply per OA acetate (cpp)) 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 380 Coverage Requirements & Prescription Drug Name Drug Tier Limits SYNAREL NASAL SOLUTION 2 MG/ML (nafarelin acetate) 2 TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG, 22.5 MG, 3.75 MG (triptorelin OA pamoate) TRIPTODUR INTRAMUSCULAR SUSPENSION OA QL (30 day supply per 1 fill) RECONSTITUTED ER 22.5 MG (triptorelin pamoate) PA; QL (365 day supply per VANTAS SUBCUTANEOUS KIT 50 MG (histrelin acetate) OA 1 fill) ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG (goserelin OA QL (90 day supply per 1 fill) acetate) ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG (goserelin OA QL (30 day supply per 1 fill) acetate) INCRETIN MIMETICS - Drugs for Diabetes ADLYXIN STARTER PACK SUBCUTANEOUS PEN- PA; QL (30 day supply per 1 SI INJECTOR KIT 10 & 20 MCG/0.2ML (lixisenatide) fill) ADLYXIN SUBCUTANEOUS SOLUTION PEN-INJECTOR 20 PA; QL (30 day supply per 1 SI MCG/0.2ML (lixisenatide) fill) BYDUREON BCISE AUTOINJECTOR SUBCUTANEOUS PA; QL (30 day supply per 1 SI AUTO-INJECTOR 2 MG/0.85ML (exenatide) fill) BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN- PA; QL (30 day supply per 1 SI INJECTOR 10 MCG/0.04ML (exenatide) fill) BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN- PA; QL (30 day supply per 1 SI INJECTOR 5 MCG/0.02ML (exenatide) fill) OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 PA; QL (30 day supply per 1 SI MG/1.5ML, 4 MG/3ML (semaglutide) fill) RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG 2 PA (semaglutide) SAXENDA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 SI PA; QL (0.5 ML per 1 day) MG/3ML (liraglutide -weight management) SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100- PA; QL (30 day supply per 1 SI 33 UNT-MCG/ML (insulin glargine-lixisenatide) fill) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 381 Coverage Requirements & Prescription Drug Name Drug Tier Limits TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; QL (30 day supply per 1 0.75 MG/0.5ML, 1.5 MG/0.5ML, 3 MG/0.5ML, 4.5 MG/0.5ML SI fill) (dulaglutide) VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 PA; QL (30 day supply per 1 SI MG/3ML (liraglutide) fill) WEGOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.25 MG/0.5ML, 0.5 MG/0.5ML, 1 MG/0.5ML, 1.7 MG/0.75ML, SI PA; QL (0.11 ML per 1 day) 2.4 MG/0.75ML (semaglutide-weight management) XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; QL (30 day supply per 1 SI 100-3.6 UNIT-MG/ML (insulin degludec-liraglutide) fill) INTERMEDIATE-ACTING INSULINS - Drugs for Diabetes HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin nph isophane 2 & regular) HUMULIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70- 2 30) 100 UNIT/ML (insulin nph isophane & regular) HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph human 2 (isophane)) HUMULIN N VIAL SUBCUTANEOUS SUSPENSION 100 2 UNIT/ML (insulin nph human (isophane)) NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin 2 nph isophane & regular) NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin nph isophane 2 & regular) NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION 2 (70-30) 100 UNIT/ML (insulin nph isophane & regular) NOVOLIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70- 2 30) 100 UNIT/ML (insulin nph isophane & regular)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 382 Coverage Requirements & Prescription Drug Name Drug Tier Limits NOVOLIN N FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph 2 human (isophane)) NOVOLIN N FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph human 2 (isophane)) NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 2 UNIT/ML (insulin nph human (isophane)) NOVOLIN N VIAL SUBCUTANEOUS SUSPENSION 100 2 UNIT/ML (insulin nph human (isophane)) LEPTINS - Hormones MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED PA; SP; QL (30 day supply SI 11.3 MG (metreleptin) per 1 fill) LONG-ACTING INSULINS - Drugs for Diabetes BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN- 3 ST INJECTOR 100 UNIT/ML (insulin glargine) LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML (insulin glargine) LANTUS U-100 VIAL SUBCUTANEOUS SOLUTION 100 2 UNIT/ML (insulin glargine) LEVEMIR U-100 FLEXTOUCH SUBCUTANEOUS SOLUTION 2 PEN-INJECTOR 100 UNIT/ML (insulin detemir) LEVEMIR U-100 VIAL SUBCUTANEOUS SOLUTION 100 2 UNIT/ML (insulin detemir) SEMGLEE SUBCUTANEOUS SOLUTION 100 UNIT/ML 2 (insulin glargine) SEMGLEE SUBCUTANEOUS SOLUTION PEN-INJECTOR 3 PA 100 UNIT/ML (insulin glargine) SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100- PA; QL (30 day supply per 1 SI 33 UNT-MCG/ML (insulin glargine-lixisenatide) fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 383 Coverage Requirements & Prescription Drug Name Drug Tier Limits TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION 2 PEN-INJECTOR 300 UNIT/ML (insulin glargine) TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 300 UNIT/ML (insulin glargine) TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin degludec) TRESIBA SUBCUTANEOUS SOLUTION 100 UNIT/ML (insulin 2 degludec) XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; QL (30 day supply per 1 SI 100-3.6 UNIT-MG/ML (insulin degludec-liraglutide) fill) MEGLITINIDES - Drugs for Diabetes nateglinide oral tablet 120 mg, 60 mg 1 repaglinide oral tablet 0.5 mg, 1 mg, 2 mg 1 PARATHYROID AGENTS - Drugs for Bones FORTEO SUBCUTANEOUS SOLUTION PEN-INJECTOR 620 PA; SP; QL (30 day supply SI MCG/2.48ML (teriparatide (recombinant)) per 1 fill) NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, 25 PA; SP; QL (30 day supply SI MCG, 50 MCG, 75 MCG (parathyroid hormone (recomb)) per 1 fill) TERIPARATIDE (RECOMBINANT) SUBCUTANEOUS PA; SP; QL (30 day supply SI SOLUTION PEN-INJECTOR 620 MCG/2.48ML per 1 fill) TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 PA; SP; QL (30 day supply SI MCG/1.56ML (abaloparatide) per 1 fill) PITUITARY - Hormones PA; QL (30 day supply per 1 ACTHAR INJECTION GEL 80 UNIT/ML (corticotropin) OA fill) DDAVP INJECTION SOLUTION 4 MCG/ML (desmopressin OA acetate) DDAVP ORAL TABLET 0.1 MG, 0.2 MG (desmopressin 3 acetate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 384 Coverage Requirements & Prescription Drug Name Drug Tier Limits DDAVP PF INJECTION SOLUTION 4 MCG/ML OA (desmopressin acetate) desmopressin ace spray refrig nasal solution 0.01 % 1 desmopressin acetate injection solution 4 mcg/ml OA SP; QL (30 day supply per 1 DESMOPRESSIN ACETATE NASAL SOLUTION 1.5 MG/ML 3 fill) desmopressin acetate oral tablet 0.1 mg, 0.2 mg 1 desmopressin acetate pf injection solution 4 mcg/ml OA desmopressin acetate spray nasal solution 0.01 % 1 GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply RECONSTITUTED 0.2 MG, 0.4 MG, 0.6 MG, 0.8 MG, 1 MG, SI per 1 fill) 1.2 MG, 1.4 MG, 1.6 MG, 1.8 MG, 2 MG (somatropin) GENOTROPIN SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply SI RECONSTITUTED 12 MG, 5 MG (somatropin) per 1 fill) HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 PA; SP; QL (30 day supply SI MG, 24 MG, 6 MG (somatropin) per 1 fill) NOCDURNA SUBLINGUAL TABLET SUBLINGUAL 27.7 MCG, 3 PA 55.3 MCG (desmopressin acetate) NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply PEN-INJECTOR 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 SI per 1 fill) MG/1.5ML (somatropin) NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply SI PEN-INJECTOR 10 MG/2ML (somatropin) per 1 fill) NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply SI PEN-INJECTOR 20 MG/2ML (somatropin) per 1 fill) NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply SI PEN-INJECTOR 5 MG/2ML (somatropin) per 1 fill) OMNITROPE SUBCUTANEOUS SOLUTION CARTRIDGE 10 PA; SP; QL (30 day supply SI MG/1.5ML, 5 MG/1.5ML (somatropin) per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 385 Coverage Requirements & Prescription Drug Name Drug Tier Limits OMNITROPE SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply SI RECONSTITUTED 5.8 MG (somatropin) per 1 fill) SAIZEN INJECTION SOLUTION RECONSTITUTED 5 MG, 8.8 PA; SP; QL (30 day supply SI MG (somatropin (non-refrigerated)) per 1 fill) SAIZENPREP INJECTION SOLUTION RECONSTITUTED 8.8 PA; SP; QL (30 day supply SI MG (somatropin (non-refrigerated)) per 1 fill) SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED PA; SP; QL (30 day supply SI 4 MG, 5 MG, 6 MG (somatropin (non-refrigerated)) per 1 fill) STIMATE NASAL SOLUTION 1.5 MG/ML (desmopressin SP; QL (30 day supply per 1 3 acetate) fill) VASOSTRICT INTRAVENOUS SOLUTION 20 UNIT/ML OA (vasopressin) ZOMACTON (FOR ZOMA-JET 10) SUBCUTANEOUS PA; SP; QL (30 day supply SI SOLUTION RECONSTITUTED 10 MG (somatropin) per 1 fill) ZOMACTON SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply SI RECONSTITUTED 10 MG, 5 MG (somatropin) per 1 fill) ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED PA; SP; QL (30 day supply SI 8.8 MG (somatropin (non-refrigerated)) per 1 fill) PROGESTINS - Drugs for Women ACTIVELLA ORAL TABLET 1-0.5 MG (estradiol- 3 norethindrone acet) afirmelle oral tablet 0.1-20 mg-mcg 1 PV altavera oral tablet 0.15-30 mg-mcg 1 PV alyacen 1/35 oral tablet 1-35 mg-mcg 1 PV alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 PV amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg 1 PV; QL (91 day supply per 1 amethia oral tablet 0.15-0.03 &0.01 mg 1 fill) amethyst oral tablet 90-20 mcg 1 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 386 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG 3 (drospirenone-estradiol) ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR PA; PV; QL (1 EA per 365 3 (segesterone-ethinyl estradiol) days) apri oral tablet 0.15-30 mg-mcg 1 PV aranelle oral tablet 0.5/1/0.5-35 mg-mcg 1 PV PV; QL (91 day supply per 1 ashlyna oral tablet 0.15-0.03 &0.01 mg 1 fill) aubra eq oral tablet 0.1-20 mg-mcg 1 PV aubra oral tablet 0.1-20 mg-mcg 1 PV aurovela 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV aurovela 1/20 oral tablet 1-20 mg-mcg 1 PV aurovela 24 fe oral tablet 1-20 mg-mcg(24) 1 PV aurovela fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV aurovela fe 1/20 oral tablet 1-20 mg-mcg 1 PV aviane oral tablet 0.1-20 mg-mcg 1 PV AYGESTIN ORAL TABLET 5 MG (norethindrone acetate) 3 ayuna oral tablet 0.15-30 mg-mcg 1 PV azurette oral tablet 0.15-0.02/0.01 mg (21/5) 1 PV BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) 3 PA (levonorgest-eth estrad-fe bisg) balziva oral tablet 0.4-35 mg-mcg 1 PV BEYAZ ORAL TABLET 3-0.02-0.451 MG (drospiren-eth 3 estrad-levomefol) BIJUVA ORAL CAPSULE 1-100 MG (estradiol-progesterone) 3 PA blisovi 24 fe oral tablet 1-20 mg-mcg(24) 1 PV blisovi fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV blisovi fe 1/20 oral tablet 1-20 mg-mcg 1 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 387 Coverage Requirements & Prescription Drug Name Drug Tier Limits briellyn oral tablet 0.4-35 mg-mcg 1 PV camila oral tablet 0.35 mg 1 PV PV; QL (91 day supply per 1 camrese lo oral tablet 0.1-0.02 & 0.01 mg 1 fill) PV; QL (91 day supply per 1 camrese oral tablet 0.15-0.03 &0.01 mg 1 fill) caziant oral tablet 0.1/0.125/0.15 -0.025 mg 1 PV charlotte 24 fe oral tablet chewable 1-20 mg-mcg(24) 1 PV chateal eq oral tablet 0.15-30 mg-mcg 1 PV chateal oral tablet 0.15-30 mg-mcg 1 PV CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045- 2 QL (0.15 EA per 1 day) 0.015 MG/DAY (estradiol-levonorgestrel) COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY (estradiol- 3 QL (0.3 EA per 1 day) norethindrone acet) CRINONE VAGINAL GEL 4 % (progesterone) 3 PA PA; SP; QL (30 day supply CRINONE VAGINAL GEL 8 % (progesterone) 3 per 1 fill) cryselle-28 oral tablet 0.3-30 mg-mcg 1 PV cyclafem 1/35 oral tablet 1-35 mg-mcg 1 PV cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 PV cyred eq oral tablet 0.15-30 mg-mcg 1 PV cyred oral tablet 0.15-30 mg-mcg 1 PV dasetta 1/35 oral tablet 1-35 mg-mcg 1 PV dasetta 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 PV PV; QL (91 day supply per 1 daysee oral tablet 0.15-0.03 &0.01 mg 1 fill) deblitane oral tablet 0.35 mg 1 PV delyla oral tablet 0.1-20 mg-mcg 1 PV Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 388 Coverage Requirements & Prescription Drug Name Drug Tier Limits DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 OA MG/ML (medroxyprogesterone acetate) DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 150 MG/ML (medroxyprogesterone OA acetate) DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML OA (medroxyprogesterone acetate) desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg 1 PV (21/5), 0.15-30 mg-mcg dolishale oral tablet 90-20 mcg 1 PV drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 1 PV 3-0.03-0.451 mg drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 1 PV mg elinest oral tablet 0.3-30 mg-mcg 1 PV ELLA ORAL TABLET 30 MG (ulipristal acetate) 3 PV eluryng vaginal ring 0.12-0.015 mg/24hr 1 PV emoquette oral tablet 0.15-30 mg-mcg 1 PV PA; SP; QL (30 day supply ENDOMETRIN VAGINAL INSERT 100 MG (progesterone) 3 per 1 fill) enpresse-28 oral tablet 50-30/75-40/ 125-30 mcg 1 PV enskyce oral tablet 0.15-30 mg-mcg 1 PV errin oral tablet 0.35 mg 1 PV estarylla oral tablet 0.25-35 mg-mcg 1 PV estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg 1 ESTROSTEP FE ORAL TABLET 1-20/1-30/1-35 MG-MCG 3 (norethindron-ethinyl estrad-fe) ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 1 PV mg-mcg Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 389 Coverage Requirements & Prescription Drug Name Drug Tier Limits etonogestrel-ethinyl estradiol vaginal ring 0.12-0.015 1 PV mg/24hr falmina oral tablet 0.1-20 mg-mcg 1 PV PV; QL (91 day supply per 1 fayosim oral tablet 42-21-21-7 days 1 fill) FEMHRT ORAL TABLET 0.5-2.5 MG-MCG (norethindrone-eth 3 estradiol) femynor oral tablet 0.25-35 mg-mcg 1 PV fyavolv oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg 1 gemmily oral capsule 1-20 mg-mcg(24) 1 PV GENERESS FE ORAL TABLET CHEWABLE 0.8-25 MG-MCG 3 (norethin-eth estradiol-fe) hailey 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV hailey 24 fe oral tablet 1-20 mg-mcg(24) 1 PV hailey fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV hailey fe 1/20 oral tablet 1-20 mg-mcg 1 PV heather oral tablet 0.35 mg 1 PV PA; QL (30 day supply per 1 hydroxyprogesterone caproate intramuscular oil 250 mg/ml OA fill) hydroxyprogesterone caproate intramuscular solution 1.25 SI QL (30 day supply per 1 fill) gm/5ml PV; QL (91 day supply per 1 iclevia oral tablet 0.15-0.03 mg 1 fill) incassia oral tablet 0.35 mg 1 PV PV; QL (91 day supply per 1 introvale oral tablet 0.15-0.03 mg 1 fill) isibloom oral tablet 0.15-30 mg-mcg 1 PV PV; QL (91 day supply per 1 jaimiess oral tablet 0.15-0.03 &0.01 mg 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 390 Coverage Requirements & Prescription Drug Name Drug Tier Limits jasmiel oral tablet 3-0.02 mg 1 PV jencycla oral tablet 0.35 mg 1 PV jinteli oral tablet 1-5 mg-mcg 1 PV; QL (91 day supply per 1 jolessa oral tablet 0.15-0.03 mg 1 fill) juleber oral tablet 0.15-30 mg-mcg 1 PV junel 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV junel 1/20 oral tablet 1-20 mg-mcg 1 PV junel fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV junel fe 1/20 oral tablet 1-20 mg-mcg 1 PV junel fe 24 oral tablet 1-20 mg-mcg(24) 1 PV kaitlib fe oral tablet chewable 0.8-25 mg-mcg 1 PV kalliga oral tablet 0.15-30 mg-mcg 1 PV kariva oral tablet 0.15-0.02/0.01 mg (21/5) 1 PV kelnor 1/35 oral tablet 1-35 mg-mcg 1 PV kelnor 1/50 oral tablet 1-50 mg-mcg 1 PV kurvelo oral tablet 0.15-30 mg-mcg 1 PV KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 19.5 MG OA QL (365 day supply per 1 fill) (levonorgestrel) larin 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV larin 1/20 oral tablet 1-20 mg-mcg 1 PV larin 24 fe oral tablet 1-20 mg-mcg(24) 1 PV larin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV larin fe 1/20 oral tablet 1-20 mg-mcg 1 PV larissia oral tablet 0.1-20 mg-mcg 1 PV layolis fe oral tablet chewable 0.8-25 mg-mcg 1 PV leena oral tablet 0.5/1/0.5-35 mg-mcg 1 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 391 Coverage Requirements & Prescription Drug Name Drug Tier Limits lessina oral tablet 0.1-20 mg-mcg 1 PV levonest oral tablet 50-30/75-40/ 125-30 mcg 1 PV PV; QL (91 day supply per 1 levonorgest-eth est & eth est oral tablet 42-21-21-7 days 1 fill) levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 PV; QL (91 day supply per 1 1 mg, 0.15-0.03 &0.01 mg, 0.15-0.03 mg fill) levonorgestrel oral tablet 1.5 mg 1 PV levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 1 PV 0.15-30 mg-mcg, 90-20 mcg levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125-30 1 PV mcg levora 0.15/30 (28) oral tablet 0.15-30 mg-mcg 1 PV LILETTA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE OA QL (365 day supply per 1 fill) 19.5 MCG/DAY (levonorgestrel) lillow oral tablet 0.15-30 mg-mcg 1 PV LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG 2 PV (norethin-eth estrad-fe biphas) LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG 3 (norethindrone acet-ethinyl est) LOESTRIN 1/20 (21) ORAL TABLET 1-20 MG-MCG 3 (norethindrone acet-ethinyl est) LOESTRIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG 3 (norethin ace-eth estrad-fe) LOESTRIN FE 1/20 ORAL TABLET 1-20 MG-MCG (norethin 3 ace-eth estrad-fe) PV; QL (91 day supply per 1 lojaimiess oral tablet 0.1-0.02 & 0.01 mg 1 fill) loryna oral tablet 3-0.02 mg 1 PV LOSEASONIQUE ORAL TABLET 0.1-0.02 & 0.01 MG 3 QL (91 day supply per 1 fill) (levonorgest-eth estrad 91-day)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 392 Coverage Requirements & Prescription Drug Name Drug Tier Limits low-ogestrel oral tablet 0.3-30 mg-mcg 1 PV lo-zumandimine oral tablet 3-0.02 mg 1 PV lutera oral tablet 0.1-20 mg-mcg 1 PV lyleq oral tablet 0.35 mg 1 PV lyza oral tablet 0.35 mg 1 PV MAKENA INTRAMUSCULAR OIL 250 MG/ML PA; QL (30 day supply per 1 OA (hydroxyprogesterone caproate) fill) MAKENA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; QL (30 day supply per 1 OA 275 MG/1.1ML (hydroxyprogesterone caproate) fill) marlissa oral tablet 0.15-30 mg-mcg 1 PV medroxyprogesterone acetate intramuscular suspension OA PV 150 mg/ml medroxyprogesterone acetate intramuscular suspension OA PV prefilled syringe 150 mg/ml medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 1 mg megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml 1 AC megestrol acetate oral suspension 625 mg/5ml 1 megestrol acetate oral tablet 20 mg, 40 mg 1 AC merzee oral capsule 1-20 mg-mcg(24) 1 PV mibelas 24 fe oral tablet chewable 1-20 mg-mcg(24) 1 PV microgestin 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV microgestin 1/20 oral tablet 1-20 mg-mcg 1 PV microgestin 24 fe oral tablet 1-20 mg-mcg 1 PV microgestin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 PV microgestin fe 1/20 oral tablet 1-20 mg-mcg 1 PV mili oral tablet 0.25-35 mg-mcg 1 PV mimvey oral tablet 1-0.5 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 393 Coverage Requirements & Prescription Drug Name Drug Tier Limits MINASTRIN 24 FE ORAL TABLET CHEWABLE 1-20 MG- 3 MCG(24) (norethin ace-eth estrad-fe) MIRCETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) 3 (desogestrel-ethinyl estradiol) MIRENA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE OA QL (365 day supply per 1 fill) 20 MCG/24HR (levonorgestrel) mono-linyah oral tablet 0.25-35 mg-mcg 1 PV MYFEMBREE ORAL TABLET 40-1-0.5 MG (relugolix- 3 PA estradiol-norethind) NATAZIA ORAL TABLET 3/2-2/2-3/1 MG (estradiol valerate- 3 PV dienogest) necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 PV NEXPLANON SUBCUTANEOUS IMPLANT 68 MG OA QL (365 day supply per 1 fill) (etonogestrel) NEXTSTELLIS ORAL TABLET 3-14.2 MG (drospirenone- 3 PA estetrol) nikki oral tablet 3-0.02 mg 1 PV nora-be oral tablet 0.35 mg 1 PV norethin ace-eth estrad-fe oral capsule 1-20 mg-mcg(24) 1 PV norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1.5-30 1 PV mg-mcg norethin ace-eth estrad-fe oral tablet chewable 1-20 mg- 1 PV mcg(24) norethindrone acetate oral tablet 5 mg 1 norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg, 1.5- 1 PV 30 mg-mcg norethindrone oral tablet 0.35 mg 1 PV norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 1 mg-mcg

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 394 Coverage Requirements & Prescription Drug Name Drug Tier Limits norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg- 1 PV mcg, 0.8-25 mg-mcg norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg 1 PV norgestimate-ethinyl estradiol triphasic oral tablet 1 PV 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg norlyda oral tablet 0.35 mg 1 PV norlyroc oral tablet 0.35 mg 1 PV nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 PV nortrel 1/35 (21) oral tablet 1-35 mg-mcg 1 PV nortrel 1/35 (28) oral tablet 1-35 mg-mcg 1 PV nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 PV NUVARING VAGINAL RING 0.12-0.015 MG/24HR 3 (etonogestrel-ethinyl estradiol) nylia 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 PV nymyo oral tablet 0.25-35 mg-mcg 1 PV ocella oral tablet 3-0.03 mg 1 PV ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 & 300 3 PA MG (elagolix-estradiol-norethind) orsythia oral tablet 0.1-20 mg-mcg 1 PV philith oral tablet 0.4-35 mg-mcg 1 PV pimtrea oral tablet 0.15-0.02/0.01 mg (21/5) 1 PV pirmella 1/35 oral tablet 1-35 mg-mcg 1 PV pirmella 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 PV PODPROG EXTERNAL SOLUTION 0.1-7 % 3 portia-28 oral tablet 0.15-30 mg-mcg 1 PV PREFEST ORAL TABLET 1/1-0.09 MG (15/15) (estradiol- 2 norgestimate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 395 Coverage Requirements & Prescription Drug Name Drug Tier Limits PREMPHASE ORAL TABLET 0.625-5 MG (conj estrog- 2 medroxyprogest ace) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 2 MG, 0.625-5 MG (conj estrog-medroxyprogest ace) preventeza oral tablet 1.5 mg 1 PV previfem oral tablet 0.25-35 mg-mcg 1 PV PA; SP; QL (30 day supply progesterone intramuscular oil 50 mg/ml SI per 1 fill) progesterone oral capsule 100 mg, 200 mg 1 PROMETRIUM ORAL CAPSULE 100 MG, 200 MG 3 (progesterone) PROVERA ORAL TABLET 10 MG, 2.5 MG, 5 MG 3 (medroxyprogesterone acetate) QUARTETTE ORAL TABLET 42-21-21-7 DAYS (levonorgest- 3 QL (91 day supply per 1 fill) eth estrad 91-day) reclipsen oral tablet 0.15-30 mg-mcg 1 PV PV; QL (91 day supply per 1 rivelsa oral tablet 42-21-21-7 days 1 fill) SAFYRAL ORAL TABLET 3-0.03-0.451 MG (drospiren-eth 3 estrad-levomefol) SEASONIQUE ORAL TABLET 0.15-0.03 &0.01 MG 3 QL (91 day supply per 1 fill) (levonorgest-eth estrad 91-day) PV; QL (91 day supply per 1 setlakin oral tablet 0.15-0.03 mg 1 fill) sharobel oral tablet 0.35 mg 1 PV simliya oral tablet 0.15-0.02/0.01 mg (21/5) 1 PV PV; QL (91 day supply per 1 simpesse oral tablet 0.15-0.03 &0.01 mg 1 fill) SKYLA INTRAUTERINE INTRAUTERINE DEVICE 13.5 MG OA QL (365 day supply per 1 fill) (levonorgestrel)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 396 Coverage Requirements & Prescription Drug Name Drug Tier Limits SLYND ORAL TABLET 4 MG (drospirenone) 3 PV sprintec 28 oral tablet 0.25-35 mg-mcg 1 PV sronyx oral tablet 0.1-20 mg-mcg 1 PV syeda oral tablet 3-0.03 mg 1 PV tarina 24 fe oral tablet 1-20 mg-mcg(24) 1 PV tarina fe 1/20 eq oral tablet 1-20 mg-mcg 1 PV tarina fe 1/20 oral tablet 1-20 mg-mcg 1 PV taysofy oral capsule 1-20 mg-mcg(24) 1 PV TAYTULLA ORAL CAPSULE 1-20 MG-MCG(24) (norethin 3 ace-eth estrad-fe) tilia fe oral tablet 1-20/1-30/1-35 mg-mcg 1 PV tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg 1 PV tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg 1 PV tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg 1 PV tri-lo-mili oral tablet 0.18/0.215/0.25 mg-25 mcg 1 PV tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg 1 PV tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV tri-nymyo oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV trivora (28) oral tablet 50-30/75-40/ 125-30 mcg 1 PV tri-vylibra lo oral tablet 0.18/0.215/0.25 mg-25 mcg 1 PV tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg 1 PV tulana oral tablet 0.35 mg 1 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 397 Coverage Requirements & Prescription Drug Name Drug Tier Limits TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 3 ST MCG/24HR (levonorgestrel-eth estradiol) tyblume oral tablet chewable 0.1-20 mg-mcg 1 PV tydemy oral tablet 3-0.03-0.451 mg 1 PV velivet oral tablet 0.1/0.125/0.15 -0.025 mg 1 PV vestura oral tablet 3-0.02 mg 1 PV vienva oral tablet 0.1-20 mg-mcg 1 PV viorele oral tablet 0.15-0.02/0.01 mg (21/5) 1 PV volnea oral tablet 0.15-0.02/0.01 mg (21/5) 1 PV vyfemla oral tablet 0.4-35 mg-mcg 1 PV vylibra oral tablet 0.25-35 mg-mcg 1 PV wera oral tablet 0.5-35 mg-mcg 1 PV wymzya fe oral tablet chewable 0.4-35 mg-mcg 1 PV xulane transdermal patch weekly 150-35 mcg/24hr 1 PV YASMIN 28 ORAL TABLET 3-0.03 MG (drospirenone-ethinyl 3 estradiol) YAZ ORAL TABLET 3-0.02 MG (drospirenone-ethinyl 3 estradiol) zafemy transdermal patch weekly 150-35 mcg/24hr 1 PV zarah oral tablet 3-0.03 mg 1 PV zovia 1/35 (28) oral tablet 1-35 mg-mcg 1 PV zovia 1/35e (28) oral tablet 1-35 mg-mcg 1 PV zumandimine oral tablet 3-0.03 mg 1 PV RAPID-ACTING INSULINS - Drugs for Diabetes ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 3 ST INJECTOR 100 UNIT/ML (insulin lispro) ADMELOG SUBCUTANEOUS SOLUTION 100 UNIT/ML 3 ST (insulin lispro)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 398 Coverage Requirements & Prescription Drug Name Drug Tier Limits AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 4 UNIT, 8 UNIT, 90 X 4 UNIT & 90X8 UNIT, 90 X 8 UNIT & 3 90X12 UNIT (insulin regular human) APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 3 ST INJECTOR 100 UNIT/ML (insulin glulisine) APIDRA VIAL INJECTION SOLUTION 100 UNIT/ML (insulin 3 ST glulisine) FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- 3 ST INJECTOR 100 UNIT/ML (insulin aspart (w/niacinamide)) FIASP PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 3 ST 100 UNIT/ML (insulin aspart (w/niacinamide)) FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML (insulin 3 ST aspart (w/niacinamide)) HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin lispro) HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML (insulin 2 lispro prot & lispro) HUMALOG MIX 50/50 VIAL SUBCUTANEOUS SUSPENSION 2 (50-50) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML (insulin 2 lispro prot & lispro) HUMALOG MIX 75/25 VIAL SUBCUTANEOUS SUSPENSION 2 (75-25) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML 2 (insulin lispro) HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 2 UNIT/ML (insulin lispro) HUMALOG U-100 JUNIOR KWIKPEN SUBCUTANEOUS 2 SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin lispro)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 399 Coverage Requirements & Prescription Drug Name Drug Tier Limits INSULIN ASP PROT & ASP FLEXPEN SUBCUTANEOUS 3 ST SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML INSULIN ASPART FLEXPEN SUBCUTANEOUS SOLUTION 3 ST PEN-INJECTOR 100 UNIT/ML INSULIN ASPART PENFILL SUBCUTANEOUS SOLUTION 3 ST CARTRIDGE 100 UNIT/ML INSULIN ASPART PROT & ASPART SUBCUTANEOUS 3 ST SUSPENSION (70-30) 100 UNIT/ML INSULIN ASPART SUBCUTANEOUS SOLUTION 100 3 ST UNIT/ML INSULIN LISPRO (1 UNIT DIAL) SUBCUTANEOUS 3 ST SOLUTION PEN-INJECTOR 100 UNIT/ML INSULIN LISPRO JUNIOR KWIKPEN SUBCUTANEOUS 3 SOLUTION PEN-INJECTOR 100 UNIT/ML INSULIN LISPRO PROT & LISPRO SUBCUTANEOUS 3 SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML INSULIN LISPRO SUBCUTANEOUS SOLUTION 100 UNIT/ML 3 ST LYUMJEV KWIKPEN SUBCUTANEOUS SOLUTION PEN- 3 ST INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin lispro-aabc) LYUMJEV VIAL INJECTION SOLUTION 100 UNIT/ML (insulin 3 ST lispro-aabc) NOVOLOG 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin 2 aspart prot & aspart) NOVOLOG FLEXPEN RELION SUBCUTANEOUS SOLUTION 2 PEN-INJECTOR 100 UNIT/ML (insulin aspart) NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML (insulin aspart) NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin 2 aspart prot & aspart)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 400 Coverage Requirements & Prescription Drug Name Drug Tier Limits NOVOLOG MIX 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML (insulin aspart prot & 3 ST aspart) NOVOLOG MIX 70/30 VIAL SUBCUTANEOUS SUSPENSION 2 (70-30) 100 UNIT/ML (insulin aspart prot & aspart) NOVOLOG PENFILL SUBCUTANEOUS SOLUTION 2 CARTRIDGE 100 UNIT/ML (insulin aspart) NOVOLOG RELION SUBCUTANEOUS SOLUTION 100 2 UNIT/ML (insulin aspart) NOVOLOG U-100 VIAL SUBCUTANEOUS SOLUTION 100 2 UNIT/ML (insulin aspart) RENIN-ANGIOTENSIN-ALDOSTERONE SYST(RAAS) - Hormones GIAPREZA INTRAVENOUS SOLUTION 2.5 MG/ML OA (angiotensin ii acetate) SHORT-ACTING INSULINS - Drugs for Diabetes HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin nph isophane 2 & regular) HUMULIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70- 2 30) 100 UNIT/ML (insulin nph isophane & regular) HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION 2 PEN-INJECTOR 500 UNIT/ML (insulin regular human) HUMULIN R U-500 VIAL SUBCUTANEOUS SOLUTION 500 2 UNIT/ML (insulin regular human) HUMULIN R VIAL INJECTION SOLUTION 100 UNIT/ML 2 (insulin regular human) MYXREDLIN INTRAVENOUS SOLUTION 100-0.9 UT/100ML- OA % (insulin regular(human) in nacl)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 401 Coverage Requirements & Prescription Drug Name Drug Tier Limits NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin 2 nph isophane & regular) NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin nph isophane 2 & regular) NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION 2 (70-30) 100 UNIT/ML (insulin nph isophane & regular) NOVOLIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70- 2 30) 100 UNIT/ML (insulin nph isophane & regular) NOVOLIN R FLEXPEN INJECTION SOLUTION PEN- 2 INJECTOR 100 UNIT/ML (insulin regular human) NOVOLIN R FLEXPEN RELION INJECTION SOLUTION PEN- 2 INJECTOR 100 UNIT/ML (insulin regular human) NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML 2 (insulin regular human) NOVOLIN R VIAL INJECTION SOLUTION 100 UNIT/ML 2 (insulin regular human) SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB - Drugs for Diabetes FARXIGA ORAL TABLET 10 MG, 5 MG (dapagliflozin 3 ST propanediol) GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG (empagliflozin- 3 PA linagliptin) INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50- 2 1000 MG, 50-500 MG (canagliflozin-metformin hcl) INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG 2 (canagliflozin-metformin hcl) INVOKANA ORAL TABLET 100 MG, 300 MG (canagliflozin) 2 JARDIANCE ORAL TABLET 10 MG, 25 MG (empagliflozin) 2

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 402 Coverage Requirements & Prescription Drug Name Drug Tier Limits QTERN ORAL TABLET 10-5 MG, 5-5 MG (dapagliflozin- 3 PA saxagliptin) SEGLUROMET ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 7.5- 3 ST 1000 MG, 7.5-500 MG (ertugliflozin-metformin hcl) STEGLATRO ORAL TABLET 15 MG, 5 MG (ertugliflozin l- 3 ST pyroglutamicac) STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG 3 PA (ertugliflozin-sitagliptin) SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5- 2 1000 MG, 5-500 MG (empagliflozin-metformin hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5-1000 MG 2 (empagliflozin-metformin hcl) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 12.5-2.5-1000 MG, 25-5-1000 MG, 5- 3 PA 2.5-1000 MG (empagliflozin-linaglip-metform) XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 2.5-1000 MG, 5-1000 MG, 5-500 MG 3 ST (dapagliflozin-metformin hcl) SOMATOSTATIN AGONISTS - Hormones MYCAPSSA ORAL CAPSULE DELAYED RELEASE 20 MG PA; SP; QL (30 day supply 3 (octreotide acetate) per 1 fill) octreotide acetate injection solution 100 mcg/ml, 1000 OA QL (30 day supply per 1 fill) mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml SANDOSTATIN INJECTION SOLUTION 100 MCG/ML, 50 OA QL (30 day supply per 1 fill) MCG/ML, 500 MCG/ML (octreotide acetate) SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, OA QL (30 day supply per 1 fill) 20 MG, 30 MG (octreotide acetate) SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 10 MG, 20 MG, 30 MG, 40 MG, 60 MG OA QL (30 day supply per 1 fill) (pasireotide pamoate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 403 Coverage Requirements & Prescription Drug Name Drug Tier Limits SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, 0.6 PA; SP; QL (30 day supply SI MG/ML, 0.9 MG/ML (pasireotide diaspartate) per 1 fill) SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 PA; QL (30 day supply per 1 OA MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML (lanreotide acetate) fill) SOMATOTROPIN AGONISTS - Hormones EGRIFTA SV SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply SI RECONSTITUTED 2 MG (tesamorelin acetate) per 1 fill) GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply RECONSTITUTED 0.2 MG, 0.4 MG, 0.6 MG, 0.8 MG, 1 MG, SI per 1 fill) 1.2 MG, 1.4 MG, 1.6 MG, 1.8 MG, 2 MG (somatropin) GENOTROPIN SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply SI RECONSTITUTED 12 MG, 5 MG (somatropin) per 1 fill) HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 PA; SP; QL (30 day supply SI MG, 24 MG, 6 MG (somatropin) per 1 fill) INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML PA; SP; QL (30 day supply SI (mecasermin) per 1 fill) NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply PEN-INJECTOR 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 SI per 1 fill) MG/1.5ML (somatropin) NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply SI PEN-INJECTOR 10 MG/2ML (somatropin) per 1 fill) NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply SI PEN-INJECTOR 20 MG/2ML (somatropin) per 1 fill) NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply SI PEN-INJECTOR 5 MG/2ML (somatropin) per 1 fill) OMNITROPE SUBCUTANEOUS SOLUTION CARTRIDGE 10 PA; SP; QL (30 day supply SI MG/1.5ML, 5 MG/1.5ML (somatropin) per 1 fill) OMNITROPE SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply SI RECONSTITUTED 5.8 MG (somatropin) per 1 fill) SAIZEN INJECTION SOLUTION RECONSTITUTED 5 MG, 8.8 PA; SP; QL (30 day supply SI MG (somatropin (non-refrigerated)) per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 404 Coverage Requirements & Prescription Drug Name Drug Tier Limits SAIZENPREP INJECTION SOLUTION RECONSTITUTED 8.8 PA; SP; QL (30 day supply SI MG (somatropin (non-refrigerated)) per 1 fill) SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED PA; SP; QL (30 day supply SI 4 MG, 5 MG, 6 MG (somatropin (non-refrigerated)) per 1 fill) ZOMACTON (FOR ZOMA-JET 10) SUBCUTANEOUS PA; SP; QL (30 day supply SI SOLUTION RECONSTITUTED 10 MG (somatropin) per 1 fill) ZOMACTON SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply SI RECONSTITUTED 10 MG, 5 MG (somatropin) per 1 fill) ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED PA; SP; QL (30 day supply SI 8.8 MG (somatropin (non-refrigerated)) per 1 fill) SOMATOTROPIN ANTAGONISTS - Hormones SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED PA; SP; QL (30 day supply SI 10 MG, 15 MG, 20 MG, 25 MG, 30 MG (pegvisomant) per 1 fill) SULFONYLUREAS - Drugs for Diabetes AMARYL ORAL TABLET 1 MG, 2 MG, 4 MG (glimepiride) 3 DUETACT ORAL TABLET 30-2 MG, 30-4 MG (pioglitazone 3 hcl-glimepiride) glimepiride oral tablet 1 mg, 2 mg, 4 mg 1 glipizide er oral tablet extended release 24 hour 10 mg, 2.5 1 mg, 5 mg glipizide oral tablet 10 mg, 5 mg 1 glipizide xl oral tablet extended release 24 hour 10 mg, 2.5 1 mg, 5 mg glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 1 5-500 mg GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 10 MG, 2.5 MG, 5 MG (glipizide) glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg 1 glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 405 Coverage Requirements & Prescription Drug Name Drug Tier Limits glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5- 1 500 mg GLYNASE ORAL TABLET 1.5 MG, 3 MG, 6 MG (glyburide 3 micronized) pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg 1 tolbutamide oral tablet 500 mg 1 THIAZOLIDINEDIONES - Drugs for Diabetes ACTOPLUS MET ORAL TABLET 15-500 MG, 15-850 MG 3 (pioglitazone hcl-metformin hcl) ACTOS ORAL TABLET 15 MG, 30 MG, 45 MG (pioglitazone 3 hcl) ALOGLIPTIN-PIOGLITAZONE ORAL TABLET 12.5-15 MG, 3 ST 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG DUETACT ORAL TABLET 30-2 MG, 30-4 MG (pioglitazone 3 hcl-glimepiride) OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 3 ST 25-15 MG, 25-30 MG, 25-45 MG (alogliptin-pioglitazone) pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg 1 pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg 1 pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 1 mg THYROID AGENTS - Drugs for the Thyroid ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 2 240 MG, 30 MG, 300 MG, 60 MG, 90 MG (thyroid) CYTOMEL ORAL TABLET 25 MCG, 5 MCG, 50 MCG 3 (liothyronine sodium) euthyrox oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 1 mcg

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 406 Coverage Requirements & Prescription Drug Name Drug Tier Limits levo-t oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 1 88 mcg levothyroxine sodium intravenous solution 100 mcg/5ml, OA 200 mcg/5ml, 500 mcg/5ml levothyroxine sodium intravenous solution reconstituted OA 100 mcg, 200 mcg, 500 mcg LEVOTHYROXINE SODIUM ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 175 MCG, 200 3 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 1 mcg, 50 mcg, 75 mcg, 88 mcg levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 1 mcg liothyronine sodium intravenous solution 10 mcg/ml OA liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg 1 NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 1 MG, 65 MG, 81.25 MG, 97.5 MG (thyroid) NATURE-THROID ORAL TABLET 162.5 MG (thyroid) 3 np thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg 1 SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 3 50 MCG, 75 MCG, 88 MCG (levothyroxine sodium) TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 3 50 MCG, 75 MCG, 88 MCG (levothyroxine sodium)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 407 Coverage Requirements & Prescription Drug Name Drug Tier Limits TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 MCG/ML, 200 MCG/ML, 25 MCG/ML, 37.5 MCG/ML, 44 3 MCG/ML, 50 MCG/ML, 62.5 MCG/ML, 75 MCG/ML, 88 MCG/ML (levothyroxine sodium) TRIOSTAT INTRAVENOUS SOLUTION 10 MCG/ML OA (liothyronine sodium) unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 1 mcg, 88 mcg WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 65 1 MG, 97.5 MG (thyroid) WP THYROID ORAL TABLET 113.75 MG, 130 MG, 16.25 MG, 3 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG (thyroid) LOCAL ANESTHETICS (PARENTERAL) - Drugs for Numbing LOCAL ANESTHETICS (PARENTERAL) - Drugs for Numbing ACTIVE INJECTION DL INJECTION KIT 10 & 1 MG/ML-% OA ACTIVE INJECTION KL-3 COMBINATION KIT 40-1 MG/ML-% OA ACTIVE INJECTION KM INJECTION KIT 40-0.5 MG/ML-% OA ARTICADENT DENTAL INJECTION SOLUTION CARTRIDGE OA 4 %-1:100000 (articaine-epinephrine) bupivacaine fisiopharma injection solution 2.5 mg/ml, 5 OA mg/ml bupivacaine hcl (pf) injection solution 0.25 %, 0.5 %, 0.75 % OA bupivacaine hcl injection solution 0.25 %, 0.5 % OA BUPIVACAINE HCL INJECTION SOLUTION PREFILLED 3 SYRINGE 0.125 % (50 ML) BUPIVACAINE HCL-NACL EPIDURAL SOLUTION 0.125-0.9 % OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 408 Coverage Requirements & Prescription Drug Name Drug Tier Limits BUPIVACAINE HCL-NACL EPIDURAL SOLUTION PREFILLED OA SYRINGE 0.25-0.9 % bupivacaine in dextrose intrathecal solution 0.75-8.25 % OA bupivacaine spinal intrathecal solution 0.75-8.25 % OA bupivacaine-epinephrine (pf) injection solution 0.25% - OA 1:200000, 0.5% -1:200000 bupivacaine-epinephrine injection solution 0.25% - OA 1:200000, 0.5% -1:200000 BUPIVILOG INJECTION KIT 40 & 0.5 MG/ML-% OA CARBOCAINE INJECTION SOLUTION 1 % (mepivacaine hcl) OA CARBOCAINE PRESERVATIVE-FREE INJECTION OA SOLUTION 1 %, 1.5 %, 2 % (mepivacaine hcl) chloroprocaine hcl (pf) injection solution 2 %, 3 % OA CLOROTEKAL INTRATHECAL SOLUTION 50 MG/5ML OA (chloroprocaine hcl) DEXAMETH SOD PHOS-BUPIV-EPIN INJECTION SOLUTION 3 PREFILLED SYRINGE 0.01-0.375 %-1:200000 DEXLIDO INJECTION KIT 10 & 1 MG/ML-% (dexamethasone OA sod phos-lido) EXPAREL INJECTION SUSPENSION 1.3 % (bupivacaine OA liposome) FENTANYL CIT-ROPIVACAINE-NACL EPIDURAL SOLUTION 0.2-0.2-0.9 MG/100ML-%, 0.3-0.2-0.9 MG/150ML-%, 0.4-0.1- OA 0.9 MG/200ML-%, 0.4-0.2-0.9 MG/200ML-%, 0.5-0.2-0.9 MG/250ML-% FENTANYL-BUPIVACAINE-NACL EPIDURAL SOLUTION 0.2- 0.1-0.9 MG/100ML-%, 0.2-0.125-0.9 MG/100ML-%, 0.5-0.0625- OA 0.9 MG/250ML-%, 0.5-0.1-0.9 MG/250ML-%, 0.5-0.125-0.9 MG/250ML-%, 0.8-0.1667-0.9 MG/200ML-% FENTANYL-BUPIVACAINE-NACL EPIDURAL SOLUTION OA PREFILLED SYRINGE 0.1-0.125-0.9 MG/50ML-% Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 409 Coverage Requirements & Prescription Drug Name Drug Tier Limits FENTANYL-BUPIVACAINE-NACL INJECTION SOLUTION 2- OA 0.125-0.9 MCG/ML-%-% FENTANYL-ROPIVACAINE-NACL EPIDURAL SOLUTION 0.2- OA 0.1-0.9 MG/100ML-% KCL-LIDOCAINE-NACL INTRAVENOUS SOLUTION 10-10 OA MEQ-MG /100ML KETOROLAC-BUPIV-KETAMINE INJECTION SOLUTION 3 PREFILLED SYRINGE 60-150-60 MG/50ML KETOROLAC-ROPIV-KETAMINE INJECTION SOLUTION 3 PREFILLED SYRINGE 15-100-30 MG/50ML LEUPROLIDE ACETATE-BUPIVACAINE INTRAMUSCULAR 3 SOLUTION 25-5 MG/ML lidocaine hcl (pf) injection solution 0.5 %, 1 %, 1.5 %, 2 %, 4 OA % lidocaine hcl injection solution 0.5 % OA LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 10 MG/ML, 100 MG/10ML, 100 MG/5ML, 200 OA MG/10ML, 60 MG/3ML LIDOCAINE HCL INJECTION SOLUTION PREFILLED 3 SYRINGE 9 MG/ML LIDOCAINE HCL INTRADERMAL JET-INJECTOR 0.5 MG OA LIDOCAINE HCL SOLUTION 1 % INJECTION 1 % OA lidocaine hcl solution 1 % injection 1 % OA LIDOCAINE HCL SOLUTION 2 % INJECTION 2 % OA lidocaine hcl solution 2 % injection 2 % OA LIDOCAINE IN DEXTROSE SOLUTION 5-7.5 % OA lidocaine-epinephrine injection solution 0.5 %-1:200000, 1 %-1:100000, 1.5 %-1:200000, 2 %-1:100000, 2 %-1:200000, 2 OA %-1:50000

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 410 Coverage Requirements & Prescription Drug Name Drug Tier Limits LIDOCAINE-SODIUM BICARBONATE INJECTION SOLUTION OA PREFILLED SYRINGE 1-8.4 % LIDOCIDEX I INJECTION SOLUTION 5-10 MG/1.5ML OA lidolog injection kit 40 & 2 mg/ml-% OA LIDOMAR INJECTION SOLUTION 50-18.75 MG/5ML OA (lidocaine hcl-bupivacaine hcl) MARCAINE INJECTION SOLUTION 0.25 %, 0.5 %, 0.75 % OA (bupivacaine hcl) MARCAINE PRESERVATIVE FREE INJECTION SOLUTION OA 0.25 %, 0.5 % (bupivacaine hcl) MARCAINE SPINAL INTRATHECAL SOLUTION 0.75-8.25 % OA (bupivacaine in dextrose) MARCAINE/EPINEPHRINE INJECTION SOLUTION 0.25% - OA 1:200000, 0.5% -1:200000 (bupivacaine-epinephrine) MARCAINE/EPINEPHRINE PF INJECTION SOLUTION 0.25% OA -1:200000, 0.5% -1:200000 (bupivacaine-epinephrine) METHYLPREDNISOLONE ACE-LIDO INJECTION 3 SUSPENSION 40-10 MG/ML, 80-10 MG/ML METHYLPREDNISOLONE-BUPIVACAINE INJECTION OA SUSPENSION 40-5 MG/ML, 80-5 MG/ML NAROPIN INJECTION SOLUTION 10 MG/ML, 2 MG/ML, 5 OA MG/ML, 7.5 MG/ML (ropivacaine hcl) NESACAINE INJECTION SOLUTION 1 %, 2 % OA (chloroprocaine hcl) NESACAINE-MPF INJECTION SOLUTION 2 %, 3 % OA (chloroprocaine hcl) ORABLOC INJECTION SOLUTION CARTRIDGE 4 %- OA 1:100000, 4 %-1:200000 (articaine-epinephrine) PHYSICIANS EZ USE JOINT/TUNNEL COMBINATION KIT 40- OA 1 MG/ML-%

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 411 Coverage Requirements & Prescription Drug Name Drug Tier Limits PHYSICIANS EZ USE M-PRED INJECTION KIT 40-0.5 OA MG/ML-% POINT OF CARE KM INJECTION KIT 40 & 0.5 MG/ML-% OA (triamcinolone-bupivacaine) polocaine injection solution 1 %, 2 % OA polocaine-mpf injection solution 1 %, 1.5 %, 2 % OA ROPIVACAINE HCL EPIDURAL SOLUTION 0.2 % OA ropivacaine hcl injection solution 10 mg/ml, 5 mg/ml, 7.5 OA mg/ml ROPIVACAINE HCL INJECTION SOLUTION PREFILLED 3 SYRINGE 0.2 % ropivacaine hcl solution 2 mg/ml injection 2 mg/ml OA ROPIVACAINE HCL SOLUTION 2 MG/ML INJECTION 2 OA MG/ML ROPIVACAINE HCL-NACL EPIDURAL SOLUTION 0.15-0.9 %, OA 0.2-0.9 % ROPIVACAINE HCL-NACL INJECTION SOLUTION 0.2-0.9 % 3 ROPIV-CLONIDINE-KETOROLAC SOLUTION PREFILLED 3 SYRINGE 123-0.04-15 MG/50ML SENSORCAINE INJECTION SOLUTION 0.25 %, 0.5 % OA (bupivacaine hcl) SENSORCAINE/EPINEPHRINE INJECTION SOLUTION 0.25% OA -1:200000, 0.5% -1:200000 (bupivacaine-epinephrine) SENSORCAINE-MPF INJECTION SOLUTION 0.75 % OA (bupivacaine hcl) SENSORCAINE-MPF SOLUTION 0.25 % INJECTION 0.25 % OA (bupivacaine hcl) sensorcaine-mpf solution 0.25 % injection 0.25 % OA sensorcaine-mpf solution 0.5 % injection 0.5 % OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 412 Coverage Requirements & Prescription Drug Name Drug Tier Limits SENSORCAINE-MPF SOLUTION 0.5 % INJECTION 0.5 % OA (bupivacaine hcl) SENSORCAINE-MPF/EPINEPHRINE INJECTION SOLUTION OA 0.25% -1:200000, 0.5% -1:200000 (bupivacaine-epinephrine) SENSORCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 3 0.75-1:200000 % (bupivacaine-epinephrine) TRIAMCINOLONE-BUPIVACAINE INJECTION SUSPENSION OA 40-5 MG/ML XARACOLL IMPLANT IMPLANT 3 X 100 MG (bupivacaine OA hcl) XYLOCAINE INJECTION SOLUTION 0.5 %, 1 %, 2 % OA (lidocaine hcl) XYLOCAINE/EPINEPHRINE INJECTION SOLUTION 0.5 %- 1:200000, 1 %-1:100000, 2 %-1:100000 (lidocaine- OA epinephrine) XYLOCAINE-MPF INJECTION SOLUTION 0.5 %, 1 %, 1.5 %, OA 2 % (lidocaine hcl) XYLOCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 1 %-1:200000, 1.5 %-1:200000, 2 %-1:200000 (lidocaine- OA epinephrine) ZINGO INTRADERMAL JET-INJECTOR 0.5 MG (lidocaine OA hcl) ZTLIDO EXTERNAL PATCH 1.8 % (lidocaine) 3 ZYNRELEF INJECTION SOLUTION 200-6 MG/7ML, 400-12 OA PA MG/14ML (bupivacaine-meloxicam) MISCELLANEOUS THERAPEUTIC AGENTS 5-ALPHA-REDUCTASE INHIBITORS AVODART ORAL CAPSULE 0.5 MG (dutasteride) 3 dutasteride oral capsule 0.5 mg 1 dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 413 Coverage Requirements & Prescription Drug Name Drug Tier Limits FINAPOD EXTERNAL SOLUTION 0.1-7 % 3 finasteride oral tablet 5 mg 1 JALYN ORAL CAPSULE 0.5-0.4 MG (dutasteride-tamsulosin 3 hcl) PROSCAR ORAL TABLET 5 MG (finasteride) 3 ALCOHOL DETERRENTS - Drugs for Alcohol Dependence disulfiram oral tablet 250 mg, 500 mg 1 naltrexone hcl oral tablet 50 mg 1 NALTREXONE SUBCUTANEOUS IMPLANT 200-6.5 MG 3 VIVITROL INTRAMUSCULAR SUSPENSION OA QL (30 day supply per 1 fill) RECONSTITUTED 380 MG (naltrexone) ANTIDOTES - Drugs for Overdose or Poisoning ACETADOTE INTRAVENOUS SOLUTION 200 MG/ML OA (acetylcysteine) acetylcysteine inhalation solution 10 %, 20 % 1 acetylcysteine intravenous solution 200 mg/ml OA ANAVIP INTRAVENOUS SOLUTION RECONSTITUTED OA (crotalidae immune fab (equine)) ANTIVENIN LATRODECTUS MACTANS INJECTION KIT OA ANTIVENIN MICRURUS FULVIUS INTRAVENOUS SOLUTION OA RECONSTITUTED ATROPEN INTRAMUSCULAR SOLUTION AUTO-INJECTOR 0.25 MG/0.3ML, 0.5 MG/0.7ML, 1 MG/0.7ML, 2 MG/0.7ML OA (atropine sulfate) atropine sulfate injection solution 0.4 mg/ml, 1 mg/ml, 8 OA mg/20ml atropine sulfate injection solution prefilled syringe 0.25 OA mg/5ml, 0.5 mg/5ml, 1 mg/10ml atropine sulfate intravenous solution 0.4 mg/ml, 1 mg/ml OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 414 Coverage Requirements & Prescription Drug Name Drug Tier Limits ATROPINE SULFATE INTRAVENOUS SOLUTION OA PREFILLED SYRINGE 0.8 MG/2ML, 1 MG/2.5ML, 1.2 MG/3ML bal in oil intramuscular solution 100 mg/ml OA BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE 3 (glucagon) BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE 3 (glucagon) BRIDION INTRAVENOUS SOLUTION 200 MG/2ML, 500 OA MG/5ML (sugammadex sodium) CALCIUM DISODIUM VERSENATE INJECTION SOLUTION 1 OA GM/5ML CHEMET ORAL CAPSULE 100 MG (succimer) 3 CROFAB INTRAVENOUS SOLUTION RECONSTITUTED OA (crotalidae polyval immune fab) CYANOKIT INTRAVENOUS SOLUTION RECONSTITUTED 5 OA GM (hydroxocobalamin) deferoxamine mesylate injection solution reconstituted 2 OA gm, 500 mg DESFERAL INJECTION SOLUTION RECONSTITUTED 500 OA MG (deferoxamine mesylate) DIGIFAB INTRAVENOUS SOLUTION RECONSTITUTED 40 OA MG (digoxin immune fab) DUODOTE INTRAMUSCULAR SOLUTION AUTO-INJECTOR OA 2.1-600 MG (atropine-pralidoxime chloride) EDETATE DISODIUM INTRAVENOUS SOLUTION 150 MG/ML OA flumazenil intravenous solution 0.5 mg/5ml, 1 mg/10ml OA fomepizole intravenous solution 1.5 gm/1.5ml OA FOSRENOL ORAL PACKET 1000 MG, 750 MG (lanthanum 3 carbonate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 415 Coverage Requirements & Prescription Drug Name Drug Tier Limits FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 MG, 3 750 MG (lanthanum carbonate) GLUCAGEN DIAGNOSTIC INJECTION SOLUTION OA RECONSTITUTED 1 MG (glucagon hcl rdna (diagnostic)) GLUCAGEN HYPOKIT INJECTION SOLUTION SI QL (30 day supply per 1 fill) RECONSTITUTED 1 MG (glucagon hcl (rdna)) glucagon emergency kit 1 mg injection 1 mg 1 GLUCAGON EMERGENCY KIT 1 MG INJECTION 1 MG 3 GLUCAGON EMERGENCY KIT INJECTION SOLUTION 3 RECONSTITUTED 1 MG/ML GLUCAGON HCL (DIAGNOSTIC) INJECTION SOLUTION OA RECONSTITUTED 1 MG GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION 3 AUTO-INJECTOR 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION 3 AUTO-INJECTOR 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED 3 SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) KHAPZORY INTRAVENOUS SOLUTION RECONSTITUTED OA 175 MG, 300 MG (levoleucovorin) lanthanum carbonate oral tablet chewable 1000 mg, 500 1 mg, 750 mg leucovorin calcium injection solution 100 mg/10ml, 500 OA mg/50ml leucovorin calcium injection solution reconstituted 100 mg, OA 200 mg, 350 mg, 50 mg, 500 mg leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg 1 AC levoleucovorin calcium intravenous solution reconstituted OA 50 mg

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 416 Coverage Requirements & Prescription Drug Name Drug Tier Limits levoleucovorin calcium pf intravenous solution 175 OA mg/17.5ml, 250 mg/25ml LIFEMS NALOXONE INJECTION PREFILLED SYRINGE KIT 2 3 PA MG/2ML magnesium sulfate in d5w intravenous solution 1-5 OA gm/100ml-% magnesium sulfate intravenous solution 2 gm/50ml, 20 OA gm/500ml, 4 gm/100ml, 4 gm/50ml, 40 gm/1000ml MAGNESIUM SULFATE SOLUTION 50 % INJECTION 50 % OA magnesium sulfate solution 50 % injection 50 % OA MAGNESIUM SULFATE-NACL INTRAVENOUS SOLUTION 2- OA 0.9 GM/50ML-% MEPHYTON ORAL TABLET 5 MG (phytonadione) 3 methylene blue injection solution 1 % OA PA; QL (30 day supply per 1 naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml SI fill) naloxone hcl injection solution cartridge 0.4 mg/ml SI QL (30 day supply per 1 fill) PA; QL (30 day supply per 1 naloxone hcl injection solution prefilled syringe 2 mg/2ml SI fill) naltrexone hcl oral tablet 50 mg 1 NALTREXONE SUBCUTANEOUS IMPLANT 200-6.5 MG 3 PHYSOSTIGMINE SALICYLATE INJECTION SOLUTION 1 OA MG/ML phytonadione injection solution 1 mg/0.5ml, 10 mg/ml OA phytonadione oral tablet 5 mg 1 protamine sulfate intravenous solution 10 mg/ml OA PROTOPAM CHLORIDE INTRAVENOUS SOLUTION OA RECONSTITUTED 1 GM (pralidoxime chloride)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 417 Coverage Requirements & Prescription Drug Name Drug Tier Limits PROVAYBLUE INTRAVENOUS SOLUTION 50 MG/10ML OA (methylene blue (antidote)) RADIOGARDASE ORAL CAPSULE 0.5 GM (prussian blue 3 PA insoluble) RENAGEL ORAL TABLET 800 MG (sevelamer hcl) 3 RENVELA ORAL PACKET 0.8 GM, 2.4 GM (sevelamer 3 carbonate) RENVELA ORAL TABLET 800 MG (sevelamer carbonate) 3 sevelamer carbonate oral packet 0.8 gm, 2.4 gm 1 sevelamer carbonate oral tablet 800 mg 1 sevelamer hcl oral tablet 400 mg, 800 mg 1 sodium polystyrene sulfonate oral powder 1 sps oral suspension 15 gm/60ml 1 PA; QL (30 day supply per 1 VISTOGARD ORAL PACKET 10 GM (uridine triacetate) OA fill) vitamin k1 injection solution 1 mg/0.5ml, 10 mg/ml OA VIVITROL INTRAMUSCULAR SUSPENSION OA QL (30 day supply per 1 fill) RECONSTITUTED 380 MG (naltrexone) VORAXAZE INTRAVENOUS SOLUTION RECONSTITUTED OA 1000 UNIT (glucarpidase) ZEGALOGUE SUBCUTANEOUS SOLUTION AUTO- 3 PA INJECTOR 0.6 MG/0.6ML (dasiglucagon hcl) ZEGALOGUE SUBCUTANEOUS SOLUTION PREFILLED 3 PA SYRINGE 0.6 MG/0.6ML (dasiglucagon hcl) ANTIGOUT AGENTS - Drugs for Gout allopurinol oral tablet 100 mg, 300 mg 1 allopurinol sodium intravenous solution reconstituted 500 OA mg

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 418 Coverage Requirements & Prescription Drug Name Drug Tier Limits ALOPRIM INTRAVENOUS SOLUTION RECONSTITUTED 500 OA MG (allopurinol sodium) COLCHICINE ORAL CAPSULE 0.6 MG 2 colchicine oral tablet 0.6 mg 1 colchicine-probenecid oral tablet 0.5-500 mg 1 COLCRYS ORAL TABLET 0.6 MG (colchicine) 3 EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG, 3 500 MG (naproxen) ec-naproxen oral tablet delayed release 375 mg, 500 mg 1 febuxostat oral tablet 40 mg, 80 mg 1 ST GLOPERBA ORAL SOLUTION 0.6 MG/5ML (colchicine) 3 INDOCIN ORAL SUSPENSION 25 MG/5ML (indomethacin) 2 INDOCIN RECTAL SUPPOSITORY 50 MG (indomethacin) 3 indomethacin er oral capsule extended release 75 mg 1 indomethacin oral capsule 25 mg, 50 mg 1 indomethacin sodium intravenous solution reconstituted 1 OA mg KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML OA QL (30 day supply per 1 fill) (pegloticase) MITIGARE ORAL CAPSULE 0.6 MG (colchicine) 2 NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 3 PA 375 MG, 500 MG (naproxen sodium) NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 2 PA 750 MG (naproxen sodium) NAPROSYN ORAL SUSPENSION 125 MG/5ML (naproxen) 3 NAPROSYN ORAL TABLET 500 MG (naproxen) 3 naproxen oral suspension 125 mg/5ml 1 naproxen oral tablet 250 mg, 375 mg, 500 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 419 Coverage Requirements & Prescription Drug Name Drug Tier Limits naproxen oral tablet delayed release 375 mg, 500 mg 1 naproxen sodium er oral tablet extended release 24 hour 1 PA 375 mg, 500 mg NAPROXEN SODIUM ER ORAL TABLET EXTENDED 2 PA RELEASE 24 HOUR 750 MG naproxen sodium oral tablet 275 mg, 550 mg 1 probenecid oral tablet 500 mg 1 ULORIC ORAL TABLET 40 MG, 80 MG (febuxostat) 3 ST ZYLOPRIM ORAL TABLET 100 MG, 300 MG (allopurinol) 3 ANTISENSE OLIGONUCLEOTIDES PA; SP; QL (30 day supply AMONDYS 45 INTRAVENOUS SOLUTION 100 MG/2ML OA per 1 fill) EXONDYS 51 INTRAVENOUS SOLUTION 100 MG/2ML, 500 PA; SP; QL (30 day supply OA MG/10ML (eteplirsen) per 1 fill) SPINRAZA INTRATHECAL SOLUTION 12 MG/5ML OA (nusinersen) TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 284 MG/1.5ML (inotersen sodium) per 1 fill) VILTEPSO INTRAVENOUS SOLUTION 250 MG/5ML OA PA; SP (viltolarsen) VYONDYS 53 INTRAVENOUS SOLUTION 100 MG/2ML OA PA; SP (golodirsen) BONE ANABOLIC AGENTS EVENITY SUBCUTANEOUS SOLUTION PREFILLED 3 PA SYRINGE 105 MG/1.17ML (romosozumab-aqqg) FORTEO SUBCUTANEOUS SOLUTION PEN-INJECTOR 620 PA; SP; QL (30 day supply SI MCG/2.48ML (teriparatide (recombinant)) per 1 fill) NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, 25 PA; SP; QL (30 day supply SI MCG, 50 MCG, 75 MCG (parathyroid hormone (recomb)) per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 420 Coverage Requirements & Prescription Drug Name Drug Tier Limits TERIPARATIDE (RECOMBINANT) SUBCUTANEOUS PA; SP; QL (30 day supply SI SOLUTION PEN-INJECTOR 620 MCG/2.48ML per 1 fill) TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 PA; SP; QL (30 day supply SI MCG/1.56ML (abaloparatide) per 1 fill) BONE RESORPTION INHIBITORS - Drugs for Bone Loss ACTONEL ORAL TABLET 150 MG, 35 MG (risedronate 3 sodium) alendronate sodium oral solution 70 mg/75ml 1 alendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 70 mg 1 ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR 2 QL (0.3 EA per 1 day) (estradiol) ATELVIA ORAL TABLET DELAYED RELEASE 35 MG 3 (risedronate sodium) BINOSTO ORAL TABLET EFFERVESCENT 70 MG 3 (alendronate sodium) BONIVA ORAL TABLET 150 MG (ibandronate sodium) 3 calcitonin (salmon) injection solution 200 unit/ml OA PA calcitonin (salmon) nasal solution 200 unit/act 1 PA CLIMARA TRANSDERMAL PATCH WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.06 MG/24HR, 0.075 3 QL (0.2 EA per 1 day) MG/24HR, 0.1 MG/24HR (estradiol) DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML, 20 PA; QL (30 day supply per 1 SI MG/ML, 40 MG/ML (estradiol valerate) fill) DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML PA; QL (30 day supply per 1 SI (estradiol cypionate) fill) DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 3 QL (1 EA per 1 day) MG/0.5GM, 0.75 MG/0.75GM (estradiol) DIVIGEL TRANSDERMAL GEL 1 MG/GM (estradiol) 3 QL (1 GM per 1 day) DIVIGEL TRANSDERMAL GEL 1.25 MG/1.25GM (estradiol) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 421 Coverage Requirements & Prescription Drug Name Drug Tier Limits dotti transdermal patch twice weekly 0.025 mg/24hr, 0.0375 1 QL (0.3 EA per 1 day) mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM (0.06%) 3 QL (1.74 GM per 1 day) (estradiol) ESTRACE ORAL TABLET 0.5 MG, 1 MG, 2 MG (estradiol) 3 ESTRACE VAGINAL CREAM 0.1 MG/GM (estradiol) 3 ESTRADIOL IMPLANT PELLET 6 MG OA estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1 estradiol transdermal patch twice weekly 0.025 mg/24hr, 1 QL (0.3 EA per 1 day) 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 1 QL (0.2 EA per 1 day) mg/24hr estradiol vaginal cream 0.1 mg/gm 1 estradiol vaginal tablet 10 mcg 1 PA; QL (30 day supply per 1 estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml SI fill) ESTRING VAGINAL RING 2 MG (estradiol) 3 ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM (0.06%) 3 QL (1.67 GM per 1 day) (estradiol) EVAMIST TRANSDERMAL SOLUTION 1.53 MG/SPRAY 3 QL (0.55 ML per 1 day) (estradiol) EVISTA ORAL TABLET 60 MG (raloxifene hcl) 3 FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR 3 (estradiol acetate) FOSAMAX ORAL TABLET 70 MG (alendronate sodium) 3 FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, 70- 2 5600 MG-UNIT (alendronate-cholecalciferol) ibandronate sodium intravenous solution 3 mg/3ml OA QL (90 day supply per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 422 Coverage Requirements & Prescription Drug Name Drug Tier Limits ibandronate sodium oral tablet 150 mg 1 lyllana transdermal patch twice weekly 0.025 mg/24hr, 1 QL (0.3 EA per 1 day) 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG 3 (esterified estrogens) MENOSTAR TRANSDERMAL PATCH WEEKLY 14 3 QL (0.2 EA per 1 day) MCG/24HR (estradiol) MIACALCIN INJECTION SOLUTION 200 UNIT/ML (calcitonin OA PA (salmon)) MINIVELLE TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 3 QL (0.3 EA per 1 day) 0.1 MG/24HR (estradiol) pamidronate disodium intravenous solution 30 mg/10ml, 6 OA mg/ml, 90 mg/10ml PREMARIN INJECTION SOLUTION RECONSTITUTED 25 MG OA (estrogens conjugated) PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 2 MG, 1.25 MG (estrogens conjugated) PREMARIN VAGINAL CREAM 0.625 MG/GM (estrogens, 2 conjugated) PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE OA QL (180 day supply per 1 fill) 60 MG/ML (denosumab) raloxifene hcl oral tablet 60 mg 1 PV RECLAST INTRAVENOUS SOLUTION 5 MG/100ML PA; QL (365 day supply per OA (zoledronic acid) 1 fill) risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg 1 risedronate sodium oral tablet delayed release 35 mg 1 VAGIFEM VAGINAL TABLET 10 MCG (estradiol) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 423 Coverage Requirements & Prescription Drug Name Drug Tier Limits VIVELLE-DOT TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 3 QL (0.3 EA per 1 day) MG/24HR, 0.1 MG/24HR (estradiol) XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7ML PA; SP; QL (30 day supply SI (denosumab) per 1 fill) yuvafem vaginal tablet 10 mcg 1 zoledronic acid intravenous concentrate 4 mg/5ml OA QL (30 day supply per 1 fill) zoledronic acid intravenous solution 4 mg/100ml OA QL (30 day supply per 1 fill) PA; QL (365 day supply per zoledronic acid intravenous solution 5 mg/100ml OA 1 fill) CARBONIC ANHYDRASE INHIBITORS (MISC.) SP; QL (30 day supply per 1 KEVEYIS ORAL TABLET 50 MG (dichlorphenamide) 3 fill) CARIOSTATIC AGENTS - Vitamins and Fluoride adc/f (0.5mg/ml) oral solution 0.5 mg/ml 1 PV cavarest dental gel 1.1 % 1 CLINPRO 5000 DENTAL PASTE 1.1 % (sodium fluoride) 3 DENTA 5000 PLUS DENTAL CREAM 1.1 % (sodium fluoride) 3 DENTAGEL DENTAL GEL 1.1 % (sodium fluoride) 3 easygel dental gel 0.4 % 1 fluoridex daily renewal mouth/throat concentrate 0.63 % 1 FLUORIDEX DENTAL PASTE 1.1 % (sodium fluoride) 3 FLUORIDEX ENHANCED WHITENING DENTAL PASTE 1.1 % 3 (sodium fluoride) FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE 1.1-5 % 3 (sod fluoride-potassium nitrate) fluoritab oral solution 0.275 (0.125 f) mg/drop 1 PV multi-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 424 Coverage Requirements & Prescription Drug Name Drug Tier Limits multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 PV 1 mg multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml 1 NAFRINSE DAILY ACIDULATED MOUTH/THROAT SOLUTION RECONSTITUTED 1 MG/5ML (sodium fluoride- 3 phosphoric acd) NAFRINSE DAILY/NEUTRAL MOUTH/THROAT SOLUTION 3 RECONSTITUTED 0.05 % (sodium fluoride) nafrinse drops oral solution 0.275 (0.125 f) mg/drop 1 PV nafrinse oral tablet chewable 2.2 (1 f) mg 1 PV NAFRINSE WEEKLY MOUTH/THROAT SOLUTION 3 RECONSTITUTED 0.2 % (sodium fluoride) PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE 1.1 % 3 (sodium fluoride) PREVIDENT 5000 DRY MOUTH DENTAL GEL 1.1 % (sodium 3 fluoride) PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE 1.1-5 3 % (sod fluoride-potassium nitrate) PREVIDENT 5000 ORTHO DEFENSE DENTAL PASTE 1.1 % 3 (sodium fluoride) PREVIDENT 5000 PLUS DENTAL CREAM 1.1 % (sodium 3 fluoride) PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 % (sod 3 fluoride-potassium nitrate) PREVIDENT DENTAL GEL 1.1 % (sodium fluoride) 3 prevident mouth/throat solution 0.2 % 1 QUFLORA FE ORAL TABLET CHEWABLE 0.25 MG (multi vit- 3 min-fluoride-fe-fa) sf 5000 plus dental cream 1.1 % 1 sf dental gel 1.1 % 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 425 Coverage Requirements & Prescription Drug Name Drug Tier Limits sodium fluoride 5000 enamel dental paste 1.1-5 % 1 sodium fluoride 5000 plus dental cream 1.1 % 1 sodium fluoride 5000 ppm dental cream 1.1 % 1 sodium fluoride 5000 ppm dental paste 1.1 % 1 sodium fluoride 5000 sensitive dental paste 1.1-5 % 1 sodium fluoride dental cream 1.1 % 1 sodium fluoride dental gel 1.1 % 1 sodium fluoride mouth/throat solution 0.2 % 1 sodium fluoride oral solution 0.5 mg/ml 1 sodium fluoride oral solution 1.1 (0.5 f) mg/ml 1 PV sodium fluoride oral tablet 1.1 (0.5 f) mg, 2.2 (1 f) mg 1 PV sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 1 PV (0.5 f) mg, 2.2 (1 f) mg tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 PV vitamins acd-fluoride oral solution 0.25 mg/ml 1 PV COMPLEMENT INHIBITORS BERINERT INTRAVENOUS KIT 500 UNIT (c1 esterase OA QL (30 day supply per 1 fill) inhibitor (human)) CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 PA; QL (30 day supply per 1 OA UNIT (c1 esterase inhibitor (human)) fill) EMPAVELI SUBCUTANEOUS SOLUTION 1080 MG/20ML PA; SP; QL (30 day supply SI (pegcetacoplan) per 1 fill) FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML PA; SP; QL (30 day supply SI (icatibant acetate) per 1 fill) HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED PA; SP; QL (30 day supply SI 2000 UNIT, 3000 UNIT (c1 esterase inhibitor (human)) per 1 fill) PA; SP; QL (30 day supply icatibant acetate subcutaneous solution 30 mg/3ml SI per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 426 Coverage Requirements & Prescription Drug Name Drug Tier Limits KALBITOR SUBCUTANEOUS SOLUTION 10 MG/ML PA; SP; QL (30 day supply SI (ecallantide) per 1 fill) ORLADEYO ORAL CAPSULE 110 MG, 150 MG (berotralstat PA; SP; QL (30 day supply 3 hcl) per 1 fill) RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 2100 UNIT (c1 esterase inhibitor (recomb)) PA; SP; QL (30 day supply sajazir subcutaneous solution 30 mg/3ml SI per 1 fill) SOLIRIS INTRAVENOUS SOLUTION 300 MG/30ML OA QL (30 day supply per 1 fill) (eculizumab) TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG/2ML PA; SP; QL (30 day supply SI (lanadelumab-flyo) per 1 fill) ULTOMIRIS INTRAVENOUS SOLUTION 1100 MG/11ML, 300 PA; QL (56 day supply per 1 OA MG/3ML (ravulizumab-cwvz) fill) DISEASE-MODIFYING ANTIRHEUMATIC AGENTS - Drugs for Arthritis ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION AUTO- PA; SP; QL (30 day supply SI INJECTOR 162 MG/0.9ML (tocilizumab) per 1 fill) ACTEMRA INTRAVENOUS SOLUTION 200 MG/10ML, 400 PA; SP; QL (30 day supply OA MG/20ML, 80 MG/4ML (tocilizumab) per 1 fill) ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 162 MG/0.9ML (tocilizumab) per 1 fill) ARAVA ORAL TABLET 10 MG, 20 MG (leflunomide) 3 AVSOLA INTRAVENOUS SOLUTION RECONSTITUTED 100 OA MG (infliximab-axxq) AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) 3 azathioprine oral tablet 50 mg 1 azathioprine sodium injection solution reconstituted 100 OA mg

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 427 Coverage Requirements & Prescription Drug Name Drug Tier Limits AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 3 500 MG (sulfasalazine) AZULFIDINE ORAL TABLET 500 MG (sulfasalazine) 3 CIMZIA PREFILLED KIT SUBCUTANEOUS KIT 2 X 200 PA; SP; QL (30 day supply SI MG/ML (certolizumab pegol) per 1 fill) CIMZIA STARTER KIT SUBCUTANEOUS KIT 6 X 200 MG/ML PA; SP; QL (30 day supply SI (certolizumab pegol) per 1 fill) CIMZIA SUBCUTANEOUS KIT 2 X 200 MG (certolizumab PA; SP; QL (30 day supply SI pegol) per 1 fill) CUPRIMINE ORAL CAPSULE 250 MG (penicillamine) 3 cyclosporine intravenous solution 50 mg/ml OA cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 1 cyclosporine modified oral solution 100 mg/ml 1 cyclosporine oral capsule 100 mg, 25 mg 1 DEPEN TITRATABS ORAL TABLET 250 MG (penicillamine) 3 ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 PA; SP; QL (30 day supply SI MG/ML (etanercept) per 1 fill) ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML PA; SP; QL (30 day supply SI (etanercept) per 1 fill) ENBREL SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 25 MG/0.5ML, 50 MG/ML (etanercept) per 1 fill) ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 PA; SP; QL (30 day supply SI MG (etanercept) per 1 fill) ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- PA; SP; QL (30 day supply SI INJECTOR 50 MG/ML (etanercept) per 1 fill) gengraf oral capsule 100 mg, 25 mg 1 gengraf oral solution 100 mg/ml 1 HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PA; SP; QL (30 day supply PREFILLED SYRINGE KIT 80 MG/0.8ML, 80 MG/0.8ML & SI per 1 fill) 40MG/0.4ML (adalimumab) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 428 Coverage Requirements & Prescription Drug Name Drug Tier Limits HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 PA; SP; QL (30 day supply SI MG/0.4ML, 40 MG/0.8ML, 80 MG/0.8ML (adalimumab) per 1 fill) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- PA; SP; QL (30 day supply SI INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML (adalimumab) per 1 fill) HUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS PA; SP; QL (30 day supply SI PEN-INJECTOR KIT 80 MG/0.8ML (adalimumab) per 1 fill) HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PA; SP; QL (30 day supply SI PEN-INJECTOR KIT 40 MG/0.8ML (adalimumab) per 1 fill) HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PA; SP; QL (30 day supply PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML SI per 1 fill) (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 PA; SP; QL (30 day supply MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML SI per 1 fill) (adalimumab) hydroxychloroquine sulfate oral tablet 100 mg, 200 mg, 300 1 mg, 400 mg IMURAN ORAL TABLET 50 MG (azathioprine) 3 INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED OA QL (56 day supply per 1 fill) 100 MG (infliximab-dyyb) KEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; SP; QL (30 day supply SI 150 MG/1.14ML, 200 MG/1.14ML (sarilumab) per 1 fill) KEVZARA SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 150 MG/1.14ML, 200 MG/1.14ML (sarilumab) per 1 fill) KINERET SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 100 MG/0.67ML (anakinra) per 1 fill) leflunomide oral tablet 10 mg, 20 mg 1 methotrexate oral tablet 2.5 mg 1 AC methotrexate sodium (pf) injection solution 1 gm/40ml, 250 PA; QL (30 day supply per 1 SI mg/10ml, 50 mg/2ml fill) methotrexate sodium injection solution 250 mg/10ml, 50 PA; QL (30 day supply per 1 SI mg/2ml fill) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 429 Coverage Requirements & Prescription Drug Name Drug Tier Limits methotrexate sodium injection solution reconstituted 1 gm OA methotrexate sodium oral tablet 2.5 mg 1 AC NEORAL ORAL CAPSULE 100 MG, 25 MG (cyclosporine 3 modified) NEORAL ORAL SOLUTION 100 MG/ML (cyclosporine 3 modified) OLUMIANT ORAL TABLET 1 MG (baricitinib) 3 PA PA; SP; QL (30 day supply OLUMIANT ORAL TABLET 2 MG (baricitinib) 3 per 1 fill) ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO- PA; SP; QL (30 day supply SI INJECTOR 125 MG/ML (abatacept) per 1 fill) ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED 250 PA; QL (30 day supply per 1 OA MG (abatacept) fill) ORENCIA SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML SI per 1 fill) (abatacept) PA; SP; QL (30 day supply OTEZLA ORAL TABLET 30 MG (apremilast) 2 per 1 fill) OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG PA; SP; QL (30 day supply 2 (apremilast) per 1 fill) OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.4ML, 12.5 MG/0.4ML, 15 MG/0.4ML, 17.5 MG/0.4ML, PA; QL (30 day supply per 1 SI 20 MG/0.4ML, 22.5 MG/0.4ML, 25 MG/0.4ML (methotrexate fill) (anti-rheumatic)) penicillamine oral capsule 250 mg 1 penicillamine oral tablet 250 mg 1 PLAQUENIL ORAL TABLET 200 MG (hydroxychloroquine 3 sulfate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 430 Coverage Requirements & Prescription Drug Name Drug Tier Limits RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, PA; QL (30 day supply per 1 SI 20 MG/0.4ML, 22.5 MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, fill) 7.5 MG/0.15ML (methotrexate (anti-rheumatic)) REDITREX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10 MG/0.4ML, 12.5 MG/0.5ML, 15 MG/0.6ML, 17.5 PA; QL (30 day supply per 1 3 MG/0.7ML, 20 MG/0.8ML, 22.5 MG/0.9ML, 25 MG/ML, 7.5 fill) MG/0.3ML (methotrexate (anti-rheumatic)) REMICADE INTRAVENOUS SOLUTION RECONSTITUTED OA QL (56 day supply per 1 fill) 100 MG (infliximab) RENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 100 MG (infliximab-abda) RIDAURA ORAL CAPSULE 3 MG (auranofin) 2 RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR 15 PA; SP; QL (30 day supply 2 MG (upadacitinib) per 1 fill) SANDIMMUNE INTRAVENOUS SOLUTION 50 MG/ML OA (cyclosporine) SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG 3 (cyclosporine) SANDIMMUNE ORAL SOLUTION 100 MG/ML (cyclosporine) 2 SIMPONI ARIA INTRAVENOUS SOLUTION 50 MG/4ML PA; SP; QL (30 day supply OA (golimumab) per 1 fill) SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; SP; QL (30 day supply SI 100 MG/ML, 50 MG/0.5ML (golimumab) per 1 fill) SIMPONI SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 100 MG/ML, 50 MG/0.5ML (golimumab) per 1 fill) sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1 TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 2 AC (methotrexate sodium) XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) 3 AC Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 431 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SP; QL (30 day supply XELJANZ ORAL SOLUTION 1 MG/ML (tofacitinib citrate) 2 per 1 fill) PA; SP; QL (30 day supply XELJANZ ORAL TABLET 10 MG, 5 MG (tofacitinib citrate) 2 per 1 fill) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR PA; SP; QL (30 day supply 2 11 MG (tofacitinib citrate) per 1 fill) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR PA; QL (30 day supply per 1 2 22 MG (tofacitinib citrate) fill) IMMUNOMODULATORY AGENTS - DRUGS FOR THE IMMUNE SYSTEM ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION AUTO- PA; SP; QL (30 day supply SI INJECTOR 162 MG/0.9ML (tocilizumab) per 1 fill) ACTEMRA INTRAVENOUS SOLUTION 200 MG/10ML, 400 PA; SP; QL (30 day supply OA MG/20ML, 80 MG/4ML (tocilizumab) per 1 fill) ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 162 MG/0.9ML (tocilizumab) per 1 fill) ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 PA; SP; QL (30 day supply SI UNIT/0.5ML (interferon gamma-1b) per 1 fill) ALFERON N INJECTION SOLUTION 5000000 UNIT/ML OA (interferon alfa-n3) ARAVA ORAL TABLET 10 MG, 20 MG (leflunomide) 3 PA; SP; QL (30 day supply AUBAGIO ORAL TABLET 14 MG, 7 MG (teriflunomide) 3 per 1 fill) AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT 30 PA; SP; QL (30 day supply SI MCG/0.5ML (interferon beta-1a) per 1 fill) AVONEX PREFILLED INTRAMUSCULAR PREFILLED PA; SP; QL (30 day supply SI SYRINGE KIT 30 MCG/0.5ML (interferon beta-1a) per 1 fill) AVSOLA INTRAVENOUS SOLUTION RECONSTITUTED 100 OA MG (infliximab-axxq) AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 432 Coverage Requirements & Prescription Drug Name Drug Tier Limits azathioprine oral tablet 50 mg 1 azathioprine sodium injection solution reconstituted 100 OA mg AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 3 500 MG (sulfasalazine) AZULFIDINE ORAL TABLET 500 MG (sulfasalazine) 3 BAFIERTAM ORAL CAPSULE DELAYED RELEASE 95 MG 3 PA; SP; QL (4 EA per 1 day) (monomethyl fumarate) BETASERON SUBCUTANEOUS KIT 0.3 MG (interferon beta- PA; SP; QL (30 day supply SI 1b) per 1 fill) CIMZIA PREFILLED KIT SUBCUTANEOUS KIT 2 X 200 PA; SP; QL (30 day supply SI MG/ML (certolizumab pegol) per 1 fill) CIMZIA STARTER KIT SUBCUTANEOUS KIT 6 X 200 MG/ML PA; SP; QL (30 day supply SI (certolizumab pegol) per 1 fill) CIMZIA SUBCUTANEOUS KIT 2 X 200 MG (certolizumab PA; SP; QL (30 day supply SI pegol) per 1 fill) COPAXONE SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 20 MG/ML, 40 MG/ML (glatiramer acetate) per 1 fill) cyclosporine intravenous solution 50 mg/ml OA cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 1 cyclosporine modified oral solution 100 mg/ml 1 cyclosporine oral capsule 100 mg, 25 mg 1 dimethyl fumarate oral capsule delayed release 120 mg, 240 PA; SP; QL (30 day supply 2 mg per 1 fill) PA; SP; QL (30 day supply dimethyl fumarate starter pack oral 120 & 240 mg 2 per 1 fill) ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 PA; SP; QL (30 day supply SI MG/ML (etanercept) per 1 fill) ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML PA; SP; QL (30 day supply SI (etanercept) per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 433 Coverage Requirements & Prescription Drug Name Drug Tier Limits ENBREL SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 25 MG/0.5ML, 50 MG/ML (etanercept) per 1 fill) ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 PA; SP; QL (30 day supply SI MG (etanercept) per 1 fill) ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- PA; SP; QL (30 day supply SI INJECTOR 50 MG/ML (etanercept) per 1 fill) ENSPRYNG SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply 3 SYRINGE 120 MG/ML (satralizumab-mwge) per 1 fill) PA; SP; QL (30 day supply EXTAVIA SUBCUTANEOUS KIT 0.3 MG (interferon beta-1b) SI per 1 fill) gengraf oral capsule 100 mg, 25 mg 1 gengraf oral solution 100 mg/ml 1 PA; SP; QL (30 day supply GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG (fingolimod hcl) 2 per 1 fill) glatiramer acetate subcutaneous solution prefilled syringe PA; SP; QL (30 day supply SI 20 mg/ml, 40 mg/ml per 1 fill) glatopa subcutaneous solution prefilled syringe 20 mg/ml, PA; SP; QL (30 day supply SI 40 mg/ml per 1 fill) HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PA; SP; QL (30 day supply PREFILLED SYRINGE KIT 80 MG/0.8ML, 80 MG/0.8ML & SI per 1 fill) 40MG/0.4ML (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 PA; SP; QL (30 day supply SI MG/0.4ML, 40 MG/0.8ML, 80 MG/0.8ML (adalimumab) per 1 fill) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- PA; SP; QL (30 day supply SI INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML (adalimumab) per 1 fill) HUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS PA; SP; QL (30 day supply SI PEN-INJECTOR KIT 80 MG/0.8ML (adalimumab) per 1 fill) HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PA; SP; QL (30 day supply SI PEN-INJECTOR KIT 40 MG/0.8ML (adalimumab) per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 434 Coverage Requirements & Prescription Drug Name Drug Tier Limits HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PA; SP; QL (30 day supply PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML SI per 1 fill) (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 PA; SP; QL (30 day supply MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML SI per 1 fill) (adalimumab) hydroxychloroquine sulfate oral tablet 100 mg, 200 mg, 300 1 mg, 400 mg IMURAN ORAL TABLET 50 MG (azathioprine) 3 INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED OA QL (56 day supply per 1 fill) 100 MG (infliximab-dyyb) INTRON A INJECTION SOLUTION 10000000 UNIT/ML, PA; SP; QL (30 day supply SI 6000000 UNIT/ML (interferon alfa-2b) per 1 fill) INTRON A INJECTION SOLUTION RECONSTITUTED PA; SP; QL (30 day supply 10000000 UNIT, 18000000 UNIT, 50000000 UNIT (interferon SI per 1 fill) alfa-2b) KESIMPTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; SP; QL (30 day supply 3 20 MG/0.4ML (ofatumumab) per 1 fill) KINERET SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 100 MG/0.67ML (anakinra) per 1 fill) leflunomide oral tablet 10 mg, 20 mg 1 LEMTRADA INTRAVENOUS SOLUTION 12 MG/1.2ML OA QL (365 day supply per 1 fill) (alemtuzumab) MAYZENT ORAL TABLET 0.25 MG, 2 MG (siponimod 3 PA fumarate) MAYZENT STARTER PACK ORAL TABLET THERAPY PACK 3 12 X 0.25 MG (siponimod fumarate) methotrexate oral tablet 2.5 mg 1 AC methotrexate sodium (pf) injection solution 1 gm/40ml, 250 PA; QL (30 day supply per 1 SI mg/10ml, 50 mg/2ml fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 435 Coverage Requirements & Prescription Drug Name Drug Tier Limits methotrexate sodium injection solution 250 mg/10ml, 50 PA; QL (30 day supply per 1 SI mg/2ml fill) methotrexate sodium injection solution reconstituted 1 gm OA methotrexate sodium oral tablet 2.5 mg 1 AC NEORAL ORAL CAPSULE 100 MG, 25 MG (cyclosporine 3 modified) NEORAL ORAL SOLUTION 100 MG/ML (cyclosporine 3 modified) OCREVUS INTRAVENOUS SOLUTION 300 MG/10ML OA QL (365 day supply per 1 fill) (ocrelizumab) ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO- PA; SP; QL (30 day supply SI INJECTOR 125 MG/ML (abatacept) per 1 fill) ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED 250 PA; QL (30 day supply per 1 OA MG (abatacept) fill) ORENCIA SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML SI per 1 fill) (abatacept) PA; SP; QL (30 day supply OTEZLA ORAL TABLET 30 MG (apremilast) 2 per 1 fill) OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG PA; SP; QL (30 day supply 2 (apremilast) per 1 fill) PLAQUENIL ORAL TABLET 200 MG (hydroxychloroquine 3 sulfate) PLEGRIDY INTRAMUSCULAR SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 125 MCG/0.5ML (peginterferon beta-1a) per 1 fill) PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply SI PEN-INJECTOR 63 & 94 MCG/0.5ML (peginterferon beta-1a) per 1 fill) PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply PREFILLED SYRINGE 63 & 94 MCG/0.5ML (peginterferon SI per 1 fill) beta-1a)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 436 Coverage Requirements & Prescription Drug Name Drug Tier Limits PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; SP; QL (30 day supply SI 125 MCG/0.5ML (peginterferon beta-1a) per 1 fill) PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 125 MCG/0.5ML (peginterferon beta-1a) per 1 fill) POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PA; SP; AC; QL (30 day 3 (pomalidomide) supply per 1 fill) PA; SP; QL (30 day supply PONVORY ORAL TABLET 20 MG (ponesimod) 3 per 1 fill) PONVORY STARTER PACK ORAL TABLET THERAPY PACK PA; SP; QL (30 day supply 3 2-3-4-5-6-7-8-9 & 10 MG (ponesimod) per 1 fill) PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 22000000 UNIT (aldesleukin) REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO- PA; SP; QL (30 day supply INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML (interferon beta- SI per 1 fill) 1a) REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS PA; SP; QL (30 day supply SOLUTION AUTO-INJECTOR 6X8.8 & 6X22 MCG (interferon SI per 1 fill) beta-1a) REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP; QL (30 day supply SI 22 MCG/0.5ML, 44 MCG/0.5ML (interferon beta-1a) per 1 fill) REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply PREFILLED SYRINGE 6X8.8 & 6X22 MCG (interferon beta- SI per 1 fill) 1a) REMICADE INTRAVENOUS SOLUTION RECONSTITUTED OA QL (56 day supply per 1 fill) 100 MG (infliximab) RENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 100 MG (infliximab-abda) REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, PA; SP; AC; QL (30 day 3 25 MG, 5 MG (lenalidomide) supply per 1 fill) RIDAURA ORAL CAPSULE 3 MG (auranofin) 2

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 437 Coverage Requirements & Prescription Drug Name Drug Tier Limits SANDIMMUNE INTRAVENOUS SOLUTION 50 MG/ML OA (cyclosporine) SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG 3 (cyclosporine) SANDIMMUNE ORAL SOLUTION 100 MG/ML (cyclosporine) 2 SIMPONI ARIA INTRAVENOUS SOLUTION 50 MG/4ML PA; SP; QL (30 day supply OA (golimumab) per 1 fill) SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; SP; QL (30 day supply SI 100 MG/ML, 50 MG/0.5ML (golimumab) per 1 fill) SIMPONI SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 100 MG/ML, 50 MG/0.5ML (golimumab) per 1 fill) sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1 PA; SP; QL (30 day supply TECFIDERA ORAL 120 & 240 MG (dimethyl fumarate) 2 per 1 fill) TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG, PA; SP; QL (30 day supply 2 240 MG (dimethyl fumarate) per 1 fill) THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 PA; SP; AC; QL (30 day 3 MG (thalidomide) supply per 1 fill) TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 2 AC (methotrexate sodium) TYSABRI INTRAVENOUS CONCENTRATE 300 MG/15ML OA QL (30 day supply per 1 fill) (natalizumab) UPLIZNA INTRAVENOUS SOLUTION 100 MG/10ML OA (inebilizumab-cdon) VUMERITY ORAL CAPSULE DELAYED RELEASE 231 MG 2 PA; SP; QL (1 EA per 1 day) (diroximel fumarate) XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) 3 AC ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE PA; SP; QL (30 day supply 3 THERAPY PACK 4 X 0.23MG & 3 X 0.46MG (ozanimod hcl) per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 438 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SP; QL (30 day supply ZEPOSIA ORAL CAPSULE 0.92 MG (ozanimod hcl) 3 per 1 fill) ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY PACK PA; SP; QL (30 day supply 3 0.23MG & 0.46MG & 0.92MG (ozanimod hcl) per 1 fill) IMMUNOSUPPRESSIVE AGENTS - Drugs for Transplant ARAVA ORAL TABLET 10 MG, 20 MG (leflunomide) 3 ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 0.5 MG, 1 MG, 5 MG (tacrolimus) ATGAM INTRAVENOUS INJECTABLE 50 MG/ML OA (lymphocyte,anti-thymo imm glob) AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) 3 azathioprine oral tablet 50 mg 1 azathioprine sodium injection solution reconstituted 100 OA mg BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 120 MG, 400 MG (belimumab) BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; SP; QL (30 day supply SI 200 MG/ML (belimumab) per 1 fill) BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 200 MG/ML (belimumab) per 1 fill) CELLCEPT INTRAVENOUS INTRAVENOUS SOLUTION OA RECONSTITUTED 500 MG (mycophenolate mofetil hcl) CELLCEPT ORAL CAPSULE 250 MG (mycophenolate 3 mofetil) CELLCEPT ORAL SUSPENSION RECONSTITUTED 200 3 MG/ML (mycophenolate mofetil) CELLCEPT ORAL TABLET 500 MG (mycophenolate mofetil) 3 cyclophosphamide injection solution reconstituted 1 gm, 2 OA gm, 500 mg

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 439 Coverage Requirements & Prescription Drug Name Drug Tier Limits CYCLOPHOSPHAMIDE INTRAVENOUS SOLUTION 1 OA PA; SP GM/5ML, 500 MG/2.5ML cyclophosphamide oral capsule 25 mg, 50 mg 1 AC CYCLOPHOSPHAMIDE ORAL TABLET 25 MG, 50 MG 3 AC cyclosporine intravenous solution 50 mg/ml OA cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 1 cyclosporine modified oral solution 100 mg/ml 1 cyclosporine oral capsule 100 mg, 25 mg 1 ELIDEL EXTERNAL CREAM 1 % (pimecrolimus) 3 ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 3 HOUR 0.75 MG, 1 MG, 4 MG (tacrolimus) everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg 1 GAMIFANT INTRAVENOUS SOLUTION 10 MG/2ML, 50 OA QL (30 day supply per 1 fill) MG/10ML (emapalumab-lzsg) GAMIFANT INTRAVENOUS SOLUTION 100 MG/20ML OA (emapalumab-lzsg) gengraf oral capsule 100 mg, 25 mg 1 gengraf oral solution 100 mg/ml 1 IMURAN ORAL TABLET 50 MG (azathioprine) 3 leflunomide oral tablet 10 mg, 20 mg 1 PA; SP; QL (30 day supply LUPKYNIS ORAL CAPSULE 7.9 MG (voclosporin) 3 per 1 fill) MAVENCLAD ORAL TABLET THERAPY PACK 10 MG PA; SP; QL (30 day supply 3 (cladribine) per 1 fill) mercaptopurine oral tablet 50 mg 1 AC methotrexate oral tablet 2.5 mg 1 AC methotrexate sodium (pf) injection solution 1 gm/40ml, 250 PA; QL (30 day supply per 1 SI mg/10ml, 50 mg/2ml fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 440 Coverage Requirements & Prescription Drug Name Drug Tier Limits methotrexate sodium injection solution 250 mg/10ml, 50 PA; QL (30 day supply per 1 SI mg/2ml fill) methotrexate sodium injection solution reconstituted 1 gm OA methotrexate sodium oral tablet 2.5 mg 1 AC mycophenolate mofetil hcl intravenous solution OA reconstituted 500 mg mycophenolate mofetil intravenous solution reconstituted OA 500 mg mycophenolate mofetil oral capsule 250 mg 1 mycophenolate mofetil oral suspension reconstituted 200 1 mg/ml mycophenolate mofetil oral tablet 500 mg 1 mycophenolate sodium oral tablet delayed release 180 mg, 1 360 mg MYFORTIC ORAL TABLET DELAYED RELEASE 180 MG, 360 3 MG (mycophenolate sodium) NEORAL ORAL CAPSULE 100 MG, 25 MG (cyclosporine 3 modified) NEORAL ORAL SOLUTION 100 MG/ML (cyclosporine 3 modified) NULOJIX INTRAVENOUS SOLUTION RECONSTITUTED 250 OA MG (belatacept) OXIANUJO EXTERNAL OINTMENT 4-0.1 % 3 pimecrolimus external cream 1 % 1 PROGRAF INTRAVENOUS SOLUTION 5 MG/ML (tacrolimus) OA PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5 MG 3 (tacrolimus) PROGRAF ORAL PACKET 0.2 MG, 1 MG (tacrolimus) 3 PROTOPIC EXTERNAL OINTMENT 0.03 %, 0.1 % 3 (tacrolimus) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 441 Coverage Requirements & Prescription Drug Name Drug Tier Limits PURIXAN ORAL SUSPENSION 2000 MG/100ML SP; AC; QL (30 day supply 3 (mercaptopurine) per 1 fill) RAPAMUNE ORAL SOLUTION 1 MG/ML (sirolimus) 3 RAPAMUNE ORAL TABLET 0.5 MG, 1 MG, 2 MG (sirolimus) 3 SANDIMMUNE INTRAVENOUS SOLUTION 50 MG/ML OA (cyclosporine) SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG 3 (cyclosporine) SANDIMMUNE ORAL SOLUTION 100 MG/ML (cyclosporine) 2 SAPHNELO INTRAVENOUS SOLUTION 300 MG/2ML OA PA; SP (anifrolumab-fnia) SIMULECT INTRAVENOUS SOLUTION RECONSTITUTED 10 OA MG, 20 MG (basiliximab) sirolimus oral solution 1 mg/ml 1 sirolimus oral tablet 0.5 mg, 1 mg, 2 mg 1 tacrolimus external ointment 0.03 %, 0.1 % 1 tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 1 THYMOGLOBULIN INTRAVENOUS SOLUTION OA RECONSTITUTED 25 MG (anti-thymocyte glob (rabbit)) TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 2 AC (methotrexate sodium) XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) 3 AC ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG, 1 MG 3 (everolimus) OTHER MISCELLANEOUS THERAPEUTIC AGENTS ALPHA-LIPOIC ACID INJECTION SOLUTION 25 MG/ML 3 AMPYRA ORAL TABLET EXTENDED RELEASE 12 HOUR 10 PA; SP; QL (30 day supply 3 MG (dalfampridine) per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 442 Coverage Requirements & Prescription Drug Name Drug Tier Limits ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED PA; SP; QL (30 day supply SI 220 MG (rilonacept) per 1 fill) BOTOX COSMETIC INTRAMUSCULAR SOLUTION RECONSTITUTED 100 UNIT, 50 UNIT (onabotulinumtoxina OA (cosmetic)) BOTOX INJECTION SOLUTION RECONSTITUTED 100 UNIT, OA QL (168 day supply per 1 fill) 200 UNIT (onabotulinumtoxina) CARNITOR INTRAVENOUS SOLUTION 200 MG/ML OA PA (levocarnitine) CARNITOR ORAL SOLUTION 1 GM/10ML (levocarnitine) 3 CARNITOR ORAL TABLET 330 MG (levocarnitine) 3 CARNITOR SF ORAL SOLUTION 1 GM/10ML (levocarnitine) 3 CARTICEL INTRA-ARTICULAR IMPLANT (autologous OA culture chondrocyte) PA; SP; QL (30 day supply CERDELGA ORAL CAPSULE 84 MG (eliglustat tartrate) 3 per 1 fill) COENZYME Q-10 INJECTION SOLUTION 20 MG/ML 3 SP; QL (30 day supply per 1 CYSTADANE ORAL POWDER (betaine) 3 fill) CYSTAGON ORAL CAPSULE 150 MG, 50 MG (cysteamine SP; QL (30 day supply per 1 3 bitartrate) fill) CYTOTINE ORAL POWDER (creatine monohydrate) 3 PA; SP; QL (30 day supply dalfampridine er oral tablet extended release 12 hour 10 mg 1 per 1 fill) DEMSER ORAL CAPSULE 250 MG (metyrosine) 3 DUROLANE INTRA-ARTICULAR PREFILLED SYRINGE 60 OA MG/3ML (sodium hyaluronate (viscosup)) DYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED OA QL (90 day supply per 1 fill) 300 UNIT, 500 UNIT (abobotulinumtoxina)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 443 Coverage Requirements & Prescription Drug Name Drug Tier Limits ELMIRON ORAL CAPSULE 100 MG (pentosan polysulfate 3 sodium) PA; SP; QL (30 day supply ENDARI ORAL PACKET 5 GM (glutamine (sickle cell)) 3 per 1 fill) ENDEAVORRX (digital therapy) 3 EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED OA QL (30 day supply per 1 fill) SYRINGE 20 MG/2ML (sodium hyaluronate (viscosup)) EVOTAZ ORAL TABLET 300-150 MG (atazanavir-cobicistat) 3 PA EVRYSDI ORAL SOLUTION RECONSTITUTED 0.75 MG/ML PA; SP; QL (30 day supply 3 (risdiplam) per 1 fill) FIRDAPSE ORAL TABLET 10 MG (amifampridine PA; SP; QL (30 day supply 3 phosphate) per 1 fill) PA; SP; QL (30 day supply GALAFOLD ORAL CAPSULE 123 MG (migalastat hcl) 3 per 1 fill) GEL-ONE INTRA-ARTICULAR PREFILLED SYRINGE 30 OA MG/3ML (cross-linked hyaluronate) GELSYN-3 INTRA-ARTICULAR SOLUTION PREFILLED OA SYRINGE 16.8 MG/2ML (sodium hyaluronate (viscosup)) GENVISC 850 INTRA-ARTICULAR SOLUTION PREFILLED OA SYRINGE 25 MG/2.5ML (sodium hyaluronate (viscosup)) GIVLAARI SUBCUTANEOUS SOLUTION 189 MG/ML OA (givosiran sodium) HYALGAN INTRA-ARTICULAR SOLUTION 20 MG/2ML OA (sodium hyaluronate (viscosup)) HYALGAN INTRA-ARTICULAR SOLUTION PREFILLED OA QL (30 day supply per 1 fill) SYRINGE 20 MG/2ML (sodium hyaluronate (viscosup)) HYMOVIS INTRA-ARTICULAR SOLUTION PREFILLED OA SYRINGE 24 MG/3ML (hyaluronan) ISTURISA ORAL TABLET 1 MG, 10 MG, 5 MG (osilodrostat PA; SP; QL (30 day supply 3 phosphate) per 1 fill); AL (Max 18 Years)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 444 Coverage Requirements & Prescription Drug Name Drug Tier Limits KUVAN ORAL PACKET 100 MG, 500 MG (sapropterin SP; QL (30 day supply per 1 3 dihydrochloride) fill) KUVAN ORAL TABLET 100 MG (sapropterin SP; QL (30 day supply per 1 3 dihydrochloride) fill) LEVOCARNITINE INJECTION SOLUTION 500 MG/ML OA levocarnitine oral solution 1 gm/10ml 1 levocarnitine oral tablet 330 mg 1 levocarnitine sf oral solution 1 gm/10ml 1 MACI INTRA-ARTICULAR SHEET (autolog cult chond coll OA membr) MAHANA IBS (digital therapy) 3 me/naphos/mb/hyo1 oral tablet 81.6 mg 1 metyrosine oral capsule 250 mg 1 PA; SP; QL (30 day supply miglustat oral capsule 100 mg 1 per 1 fill) MONOVISC INTRA-ARTICULAR SOLUTION PREFILLED OA SYRINGE 88 MG/4ML (hyaluronan) MYOBLOC INTRAMUSCULAR SOLUTION 10000 UNIT/2ML, OA QL (30 day supply per 1 fill) 2500 UNIT/0.5ML, 5000 UNIT/ML (rimabotulinumtoxinb) NEXAVIR INJECTION SOLUTION 25.5 MG/ML (liver OA derivative complex) SP; QL (30 day supply per 1 nitisinone oral capsule 10 mg, 2 mg, 5 mg 1 fill) SP; QL (30 day supply per 1 NITYR ORAL TABLET 10 MG, 2 MG, 5 MG (nitisinone) 3 fill) NULIBRY INTRAVENOUS SOLUTION RECONSTITUTED 9.5 PA; SP; QL (30 day supply OA MG (fosdenopterin hydrobromide) per 1 fill) ONE-A-DAY WOMENS PRENATAL 1 ORAL CAPSULE 28-0.8- 3 PV 235 MG (prenat-fe carbonyl-fa-omega 3)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 445 Coverage Requirements & Prescription Drug Name Drug Tier Limits ONPATTRO INTRAVENOUS SOLUTION 10 MG/5ML OA QL (30 day supply per 1 fill) (patisiran sodium) ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG SP; QL (30 day supply per 1 3 (nitisinone) fill) SP; QL (30 day supply per 1 ORFADIN ORAL SUSPENSION 4 MG/ML (nitisinone) 3 fill) ORTHOVISC INTRA-ARTICULAR SOLUTION PREFILLED OA SYRINGE 30 MG/2ML (hyaluronan) OXLUMO SUBCUTANEOUS SOLUTION 94.5 MG/0.5ML OA PA; SP (lumasiran sodium) PENTOSAN POLYSULFATE SODIUM ORAL CAPSULE 3 DELAYED RELEASE 150 MG, 200 MG PHENOL INJECTION SOLUTION 6 % OA PHOSPHASAL ORAL TABLET 81.6 MG (meth-hyo-m bl-na 3 phos-ph sal) prenatal multi +dha oral capsule 27-0.8-200 mg, 27-0.8-228 1 PV mg, 27-0.8-250 mg PREZCOBIX ORAL TABLET 800-150 MG (darunavir- 2 cobicistat) PROCYSBI ORAL CAPSULE DELAYED RELEASE 25 MG, 75 PA; SP; QL (30 day supply 3 MG (cysteamine bitartrate) per 1 fill) PROCYSBI ORAL PACKET 300 MG, 75 MG (cysteamine PA; SP; QL (30 day supply 3 bitartrate) per 1 fill) RELNATE DHA ORAL CAPSULE 28-1-200 MG 3 PV RESET FOR IOS OR ANDROID APP (digital therapy) 3 RESET-O FOR IOS OR ANDROID APP (digital therapy) 3 PA; SP; QL (30 day supply REZUROCK ORAL TABLET 200 MG (belumosudil mesylate) 3 per 1 fill) RIMSO-50 INTRAVESICAL SOLUTION 50 % (dimethyl OA sulfoxide)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 446 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SP; QL (30 day supply RUZURGI ORAL TABLET 10 MG (amifampridine) 3 per 1 fill) SP; QL (30 day supply per 1 sapropterin dihydrochloride oral packet 100 mg, 500 mg 1 fill) SP; QL (30 day supply per 1 sapropterin dihydrochloride oral tablet 100 mg 1 fill) SOLESTA INJECTION GEL 50-15 MG/ML (dextranomer- OA QL (30 day supply per 1 fill) sodium hyaluronate) SOMRYST (digital therapy) 3 STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg- 3 cobic-emtricit-tenofdf) SUPARTZ FX INTRA-ARTICULAR SOLUTION PREFILLED OA SYRINGE 25 MG/2.5ML (sodium hyaluronate (viscosup)) SYMTUZA ORAL TABLET 800-150-200-10 MG (darun-cobic- 2 ST emtricit-tenofaf) SYNVISC INTRA-ARTICULAR SOLUTION PREFILLED OA SYRINGE 16 MG/2ML (hylan) SYNVISC ONE INTRA-ARTICULAR SOLUTION PREFILLED OA SYRINGE 48 MG/6ML (hylan) THIOLA EC ORAL TABLET DELAYED RELEASE 100 MG, 300 3 MG (tiopronin) SP; QL (30 day supply per 1 THIOLA ORAL TABLET 100 MG (tiopronin) 3 fill) SP; QL (30 day supply per 1 tiopronin oral tablet 100 mg 1 fill) TRI-CHLOR EXTERNAL LIQUID 80 % (trichloroacetic acid) 3 TRILURON INTRA-ARTICULAR SOLUTION PREFILLED OA QL (30 day supply per 1 fill) SYRINGE 20 MG/2ML (sodium hyaluronate (viscosup)) TRIVISC INTRA-ARTICULAR SOLUTION PREFILLED OA SYRINGE 25 MG/2.5ML (sodium hyaluronate (viscosup))

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 447 Coverage Requirements & Prescription Drug Name Drug Tier Limits TYBOST ORAL TABLET 150 MG (cobicistat) 2 URIMAR-T ORAL TABLET 120 MG (meth-hyo-m bl-na phos- 3 ph sal) urin ds oral tablet 81.6 mg 1 UROGESIC-BLUE ORAL TABLET 81.6 MG (methen-hyosc- 3 meth blue-na phos) USTELL ORAL CAPSULE 120 MG (meth-hyo-m bl-na phos- 3 ph sal) UTIRA-C ORAL TABLET 81.6 MG (meth-hyo-m bl-na phos- 3 ph sal) VISCO-3 INTRA-ARTICULAR SOLUTION PREFILLED OA SYRINGE 25 MG/2.5ML (sodium hyaluronate (viscosup)) XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED OA QL (90 day supply per 1 fill) 100 UNIT, 200 UNIT, 50 UNIT (incobotulinumtoxina) PA; SP; QL (30 day supply XURIDEN ORAL PACKET 2 GM (uridine triacetate) 3 per 1 fill) PA; SP; QL (30 day supply ZAVESCA ORAL CAPSULE 100 MG (miglustat) 3 per 1 fill) PA; SP; QL (30 day supply ZOKINVY ORAL CAPSULE 50 MG, 75 MG (lonafarnib) 3 per 1 fill) PROTECTIVE AGENTS COSELA INTRAVENOUS SOLUTION RECONSTITUTED 300 OA PA; SP MG (trilaciclib dihydrochloride) dexrazoxane hcl intravenous solution reconstituted 250 OA mg, 500 mg ETHYOL INTRAVENOUS SOLUTION RECONSTITUTED 500 OA MG (amifostine) mesna intravenous solution 100 mg/ml OA MESNEX INTRAVENOUS SOLUTION 100 MG/ML (mesna) OA MESNEX ORAL TABLET 400 MG (mesna) 3 AC

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 448 Coverage Requirements & Prescription Drug Name Drug Tier Limits TOTECT INTRAVENOUS SOLUTION RECONSTITUTED 500 OA MG (dexrazoxane hcl) NONHORMONAL CONTRACEPTIVES - Drugs for Women NONHORMONAL CONTRACEPTIVES - Drugs for Women CAYA VAGINAL DIAPHRAGM (diaphragm arc-spring) 3 PV; QL (1 EA per 365 days) ENCARE VAGINAL SUPPOSITORY 100 MG (nonoxynol-9) 3 PV; QL (12 EA per 30 days) FC FEMALE CONDOM (condoms - female) 3 PV; QL (12 EA per 30 days) FC2 FEMALE CONDOM (condoms - female) 3 PV; QL (12 EA per 30 days) FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM (cervical 3 PV; QL (1 EA per 365 days) caps) OPTIONS GYNOL II CONTRACEPTIVE VAGINAL GEL 3 % 3 PV; QL (85 GM per 30 days) (nonoxynol-9) PARAGARD INTRAUTERINE COPPER INTRAUTERINE OA QL (30 day supply per 1 fill) INTRAUTERINE DEVICE (copper) PHEXXI VAGINAL GEL 1.8-1-0.4 % (lactic ac-citric ac-pot 3 PA; QL (12 GM per 30 days) bitart) TODAY SPONGE VAGINAL 1000 MG (nonoxynol-9) 3 PV; QL (12 EA per 30 days) VCF VAGINAL CONTRACEPTIVE VAGINAL FILM 28 % 3 PV; QL (12 EA per 30 days) (nonoxynol-9) VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM 12.5 % 3 PV; QL (17 GM per 30 days) (nonoxynol-9) vcf vaginal contraceptive vaginal gel 4 % 1 PV; QL (2.7 GM per 30 days) WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 2 % 3 PV; QL (1 EA per 365 days) (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM 2 % 3 PV; QL (1 EA per 365 days) (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM 2 % 3 PV; QL (1 EA per 365 days) (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM 2 % 3 PV; QL (1 EA per 365 days) (diaphragm wide seal) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 449 Coverage Requirements & Prescription Drug Name Drug Tier Limits WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM 2 % 3 PV; QL (1 EA per 365 days) (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM 2 % 3 PV; QL (1 EA per 365 days) (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM 2 % 3 PV; QL (1 EA per 365 days) (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM 2 % 3 PV; QL (1 EA per 365 days) (diaphragm wide seal) OXYTOCICS - Drugs for Women OXYTOCICS - Drugs for Women carboprost tromethamine intramuscular solution 250 OA mcg/ml CERVIDIL VAGINAL INSERT 10 MG (dinoprostone) 3 HEMABATE INTRAMUSCULAR SOLUTION 250 MCG/ML OA (carboprost tromethamine) methergine oral tablet 0.2 mg 1 methylergonovine maleate injection solution 0.2 mg/ml OA methylergonovine maleate oral tablet 0.2 mg 1 MIFEPREX ORAL TABLET 200 MG (mifepristone) 3 mifepristone oral tablet 200 mg 1 oxytocin injection solution 10 unit/ml OA OXYTOCIN-LACTATED RINGERS INTRAVENOUS OA SOLUTION 20 UNIT/L, 30 UNIT/500ML OXYTOCIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION OA 15-0.9 UT/250ML-%, 20-0.9 UNIT/L-%, 30-0.9 UT/500ML-% PITOCIN INJECTION SOLUTION 10 UNIT/ML (oxytocin) OA PREPIDIL VAGINAL GEL 0.5 MG/3GM (dinoprostone) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 450 Coverage Requirements & Prescription Drug Name Drug Tier Limits PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS BACTERIOSTATIC WATER(BENZ ALC) INJECTION 3 SOLUTION diluent for treprostinil intravenous solution OA IV STABILIZER FOR LUMOXITI INTRAVENOUS SOLUTION OA 0.7-6.5-6.4 MG/ML (citric acid-polysorbate 80) PYROGALLIC ACID EXTERNAL OINTMENT 25-2 % 3 STERILE DILUENT FLOLAN PH 12 INTRAVENOUS OA SOLUTION (glycine diluent) sterile diluent/epoprostenol intravenous solution OA sterile water for injection injection solution OA sterile water for injection intravenous solution OA RADIOACTIVE AGENTS RADIOACTIVE AGENTS LUTATHERA INTRAVENOUS SOLUTION 370 MBQ/ML OA (lutetium lu 177 dotatate) PYLARIFY INTRAVENOUS SOLUTION PREFILLED SYRINGE OA 9 MCI (piflufolastat f 18) QUADRAMET INTRAVENOUS SOLUTION 1850 MBQ/ML OA (samarium sm 153 lexidronam) STRONTIUM CHLORIDE SR-89 INTRAVENOUS SOLUTION 1 OA MCI/ML XOFIGO INTRAVENOUS SOLUTION 30 MCCI/ML (radium ra OA 223 dichloride)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 451 Coverage Requirements & Prescription Drug Name Drug Tier Limits RESPIRATORY TRACT AGENTS - Drugs for the Lungs ALPHA AND BETA ADRENERGIC AGONIST(RESPR) - Drugs for Asthma/COPD ADRENALIN INJECTION SOLUTION 1 MG/ML, 30 MG/30ML OA (epinephrine) ADRENALIN NASAL SOLUTION 0.1 % (epinephrine hcl 3 (nasal)) AKOVAZ INTRAVENOUS SOLUTION 50 MG/ML (ephedrine OA sulfate (pressors)) AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1 PA; QL (30 day supply per 1 SI MG/0.1ML, 0.15 MG/0.15ML, 0.3 MG/0.3ML (epinephrine) fill) EMERPHED INTRAVENOUS SOLUTION 5 MG/ML (ephedrine OA sulfate (pressors)) EPHEDRINE SULFATE (PRESSORS) INJECTION SOLUTION 3 PREFILLED SYRINGE 25 MG/5ML, 50 MG/10ML, 50 MG/5ML ephedrine sulfate injection solution 50 mg/ml OA ephedrine sulfate intravenous solution 50 mg/ml OA EPHEDRINE SULFATE INTRAVENOUS SOLUTION OA PREFILLED SYRINGE 25 MG/5ML EPHEDRINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MG/ML-%, 100-0.9 MG/10ML-%, OA 25-0.9 MG/5ML-%, 50-0.9 MG/10ML-%, 50-0.9 MG/5ML-% epinephrine (anaphylaxis) injection solution 30 mg/30ml OA EPINEPHRINE HCL-DEXTROSE INTRAVENOUS SOLUTION OA 4-5 MG/250ML-% EPINEPHRINE HCL-NACL INTRAVENOUS SOLUTION 8-0.9 OA MG/250ML-% epinephrine injection solution auto-injector 0.15 mg/0.15ml, SI QL (30 day supply per 1 fill) 0.15 mg/0.3ml, 0.3 mg/0.3ml EPINEPHRINE INTRAVENOUS SOLUTION 1 MG/10ML OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 452 Coverage Requirements & Prescription Drug Name Drug Tier Limits EPINEPHRINE INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 0.1 MG/10ML epinephrine intravenous solution prefilled syringe 1 OA mg/10ml epinephrine pf injection solution 1 mg/ml OA epinephrine solution prefilled syringe 1 mg/10ml injection 1 OA mg/10ml EPINEPHRINE SOLUTION PREFILLED SYRINGE 1 MG/10ML OA INJECTION 1 MG/10ML EPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION 2-5 OA MG/250ML-% EPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION OA PREFILLED SYRINGE 100-5 MCG/10ML-% EPINEPHRINE-NACL INTRAVENOUS SOLUTION 2-0.9 OA MG/250ML-%, 5-0.9 MG/250ML-% EPINEPHRINE-NACL INTRAVENOUS SOLUTION PREFILLED OA SYRINGE 1-0.9 MG/10ML-% EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.3 SI QL (30 day supply per 1 fill) MG/0.3ML (epinephrine) EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR SI QL (30 day supply per 1 fill) 0.15 MG/0.3ML (epinephrine) SYMJEPI INJECTION SOLUTION PREFILLED SYRINGE 0.15 3 MG/0.3ML (epinephrine) SYMJEPI INJECTION SOLUTION PREFILLED SYRINGE 0.3 SI QL (30 day supply per 1 fill) MG/0.3ML (epinephrine) ANTICHOLINERGIC AGENTS (RESPIR.TRACT) - Drugs for Asthma/COPD ATROPEN INTRAMUSCULAR SOLUTION AUTO-INJECTOR 0.25 MG/0.3ML, 0.5 MG/0.7ML, 1 MG/0.7ML, 2 MG/0.7ML OA (atropine sulfate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 453 Coverage Requirements & Prescription Drug Name Drug Tier Limits atropine sulfate injection solution 0.4 mg/ml, 1 mg/ml, 8 OA mg/20ml atropine sulfate injection solution prefilled syringe 0.25 OA mg/5ml, 0.5 mg/5ml, 1 mg/10ml atropine sulfate intravenous solution 0.4 mg/ml, 1 mg/ml OA ATROPINE SULFATE INTRAVENOUS SOLUTION OA PREFILLED SYRINGE 0.8 MG/2ML, 1 MG/2.5ML, 1.2 MG/3ML ATROVENT HFA INHALATION AEROSOL SOLUTION 17 2 MCG/ACT (ipratropium bromide hfa) COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 3 20-100 MCG/ACT (ipratropium-albuterol) ipratropium bromide inhalation solution 0.02 % 1 ipratropium bromide nasal solution 0.03 %, 0.06 % 1 ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 LONHALA MAGNAIR REFILL KIT INHALATION SOLUTION 25 3 ST MCG/ML (glycopyrrolate) LONHALA MAGNAIR STARTER KIT INHALATION SOLUTION 3 ST 25 MCG/ML (glycopyrrolate) QUAD-MIX INTRACAVERNOSAL SOLUTION ED RECONSTITUTED 150-10-0.1-1 MG SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG 2 (tiotropium bromide monohydrate) SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 3 MCG/ACT, 2.5 MCG/ACT (tiotropium bromide monohydrate) SUPER QUAD-MIX INTRACAVERNOSAL SOLUTION ED RECONSTITUTED 150-20-0.2-2 MG ANTIFIBROTIC AGENTS - Drugs for the Lungs PA; SP; QL (30 day supply ESBRIET ORAL CAPSULE 267 MG (pirfenidone) 3 per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 454 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SP; QL (30 day supply ESBRIET ORAL TABLET 267 MG, 801 MG (pirfenidone) 3 per 1 fill) PA; SP; QL (30 day supply OFEV ORAL CAPSULE 100 MG, 150 MG (nintedanib esylate) 3 per 1 fill) ANTI-INFLAMMATORY AGENTS (RESPIRATORY) - Drugs for Inflammation NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 3 MG/ML (mepolizumab) NUCALA SUBCUTANEOUS SOLUTION PREFILLED 3 SYRINGE 100 MG/ML (mepolizumab) NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 100 MG (mepolizumab) ANTITUSSIVES - Drugs for Cough and Cold benzonatate oral capsule 100 mg, 150 mg, 200 mg 1 codeine sulfate oral tablet 15 mg, 30 mg, 60 mg 1 diphen oral elixir 12.5 mg/5ml 1 di-phen oral elixir 12.5 mg/5ml 1 diphenhydramine hcl injection solution 50 mg/ml 1 PA diphenhydramine hcl oral elixir 12.5 mg/5ml 1 guaiatussin ac oral syrup 100-10 mg/5ml 1 guaifenesin ac oral syrup 100-10 mg/5ml 1 HYCODAN ORAL SYRUP 5-1.5 MG/5ML (hydrocodone- 3 homatropine) hydrocodone polst-chlorphen polst er susp oral 1 suspension extended release 10-8 mg/5ml hydrocodone-homatropine oral syrup 5-1.5 mg/5ml 1 hydrocodone-homatropine oral tablet 5-1.5 mg 1 hydromet oral syrup 5-1.5 mg/5ml 1 maxi-tuss ac oral solution 100-10 mg/5ml 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 455 Coverage Requirements & Prescription Drug Name Drug Tier Limits promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml 1 promethazine-codeine oral solution 6.25-10 mg/5ml 1 promethazine-codeine oral syrup 6.25-10 mg/5ml 1 promethazine-dm oral syrup 6.25-15 mg/5ml 1 promethazine-phenyleph-codeine oral syrup 6.25-5-10 1 mg/5ml pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml 1 TESSALON PERLES ORAL CAPSULE 100 MG (benzonatate) 3 TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 3 HOUR 10-8 MG (hydrocod polst-chlorphen polst) TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 HOUR 3 54.3-8 MG (chlorpheniramine-codeine) TUZISTRA XR ORAL SUSPENSION EXTENDED RELEASE 3 PA 14.7-2.8 MG/5ML (codeine polst-chlorphen polst) virtussin ac w/alc oral liquid 100-10 mg/5ml 1 CYSTIC FIBROSIS (CFTR) CORRECTORS - Drugs for the Lungs ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG PA; SP; QL (30 day supply 3 (lumacaftor-ivacaftor) per 1 fill) ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG PA; SP; QL (30 day supply 3 (lumacaftor-ivacaftor) per 1 fill) SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 PA; SP; QL (30 day supply 3 MG, 50-75 & 75 MG (tezacaftor-ivacaftor) per 1 fill) TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75 & 150 PA; SP; QL (30 day supply 3 MG, 50-25-37.5 & 75 MG (elexacaftor-tezacaftor-ivacaft) per 1 fill); AL (Min 6 Years) CYSTIC FIBROSIS (CFTR) POTENTIATORS - Drugs for the Lungs PA; SP; QL (30 day supply KALYDECO ORAL PACKET 25 MG, 50 MG, 75 MG (ivacaftor) 3 per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 456 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SP; QL (30 day supply KALYDECO ORAL TABLET 150 MG (ivacaftor) 3 per 1 fill) ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG PA; SP; QL (30 day supply 3 (lumacaftor-ivacaftor) per 1 fill) ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG PA; SP; QL (30 day supply 3 (lumacaftor-ivacaftor) per 1 fill) SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 PA; SP; QL (30 day supply 3 MG, 50-75 & 75 MG (tezacaftor-ivacaftor) per 1 fill) TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75 & 150 PA; SP; QL (30 day supply 3 MG, 50-25-37.5 & 75 MG (elexacaftor-tezacaftor-ivacaft) per 1 fill); AL (Min 6 Years) EXPECTORANTS - Drugs for the Lungs GILPHEX TR ORAL TABLET 10-388 MG (phenylephrine- 3 guaifenesin) guaiatussin ac oral syrup 100-10 mg/5ml 1 guaifenesin ac oral syrup 100-10 mg/5ml 1 iodine strong oral solution 5 % 1 maxi-tuss ac oral solution 100-10 mg/5ml 1 SSKI ORAL SOLUTION 1 GM/ML (potassium iodide 3 (expectorant)) virtussin ac w/alc oral liquid 100-10 mg/5ml 1 FIRST GENERATION ANTIHIST.(RESPIR TRACT) - Drugs for Allergy BROMPHENIRAMINE MALEATE INTRAMUSCULAR 3 SOLUTION 10 MG/ML carbinoxamine maleate oral solution 4 mg/5ml 1 carbinoxamine maleate oral tablet 4 mg, 6 mg 1 clemastine fumarate oral syrup 0.67 mg/5ml 1 clemastine fumarate oral tablet 2.68 mg 1 cyproheptadine hcl oral syrup 2 mg/5ml 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 457 Coverage Requirements & Prescription Drug Name Drug Tier Limits cyproheptadine hcl oral tablet 4 mg 1 diphen oral elixir 12.5 mg/5ml 1 di-phen oral elixir 12.5 mg/5ml 1 diphenhydramine hcl injection solution 50 mg/ml 1 PA diphenhydramine hcl oral elixir 12.5 mg/5ml 1 KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE 4 3 MG/5ML (carbinoxamine maleate) PHENERGAN INJECTION SOLUTION 25 MG/ML, 50 MG/ML OA PA (promethazine hcl) promethazine hcl injection solution 25 mg/ml, 50 mg/ml OA PA promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1 promethazine hcl rectal suppository 12.5 mg, 25 mg 1 promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 1 ryvent oral tablet 6 mg 1 INTERLEUKIN ANTAGONISTS - Drugs for Inflammation CINQAIR INTRAVENOUS SOLUTION 100 MG/10ML OA QL (30 day supply per 1 fill) (reslizumab) DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 200 MG/1.14ML (dupilumab) per 1 fill) FASENRA PEN SUBCUTANEOUS SOLUTION AUTO- PA; QL (30 day supply per 1 3 INJECTOR 30 MG/ML (benralizumab) fill) FASENRA SUBCUTANEOUS SOLUTION PREFILLED OA QL (30 day supply per 1 fill) SYRINGE 30 MG/ML (benralizumab) LEUKOTRIENE MODIFIERS - Drugs for Inflammation ACCOLATE ORAL TABLET 10 MG, 20 MG (zafirlukast) 3 montelukast sodium oral packet 4 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 458 Coverage Requirements & Prescription Drug Name Drug Tier Limits montelukast sodium oral tablet 10 mg 1 montelukast sodium oral tablet chewable 4 mg, 5 mg 1 SINGULAIR ORAL PACKET 4 MG (montelukast sodium) 3 SINGULAIR ORAL TABLET 10 MG (montelukast sodium) 3 SINGULAIR ORAL TABLET CHEWABLE 4 MG, 5 MG 3 (montelukast sodium) zafirlukast oral tablet 10 mg, 20 mg 1 zileuton er oral tablet extended release 12 hour 600 mg 1 PA ZYFLO ORAL TABLET 600 MG (zileuton) 3 PA MAST-CELL STABILIZERS - Drugs for Inflammation ALOCRIL OPHTHALMIC SOLUTION 2 % (nedocromil 3 sodium) cromolyn sodium inhalation nebulization solution 20 1 mg/2ml cromolyn sodium ophthalmic solution 4 % 1 cromolyn sodium oral concentrate 100 mg/5ml 1 GASTROCROM ORAL CONCENTRATE 100 MG/5ML 3 (cromolyn sodium) MUCOLYTIC AGENTS - Drugs for the Lungs acetylcysteine inhalation solution 10 %, 20 % 1 HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 %, 3 7 % (sodium chloride) PULMOZYME INHALATION SOLUTION 1 MG/ML (dornase PA; SP; QL (30 day supply 3 alfa) per 1 fill) sodium chloride inhalation nebulization solution 0.9 %, 10 1 %, 3 %, 7 % NASAL PREPARATIONS (STEROIDS) - Drugs for Inflammation azelastine-fluticasone nasal suspension 137-50 mcg/act 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 459 Coverage Requirements & Prescription Drug Name Drug Tier Limits BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY 2 QL (1.7 GM per 1 day) (beclomethasone diprop monohyd) DYMISTA NASAL SUSPENSION 137-50 MCG/ACT 3 (azelastine-fluticasone) flunisolide nasal solution 25 mcg/act (0.025%) 1 QL (0.84 ML per 1 day) fluticasone propionate nasal suspension 50 mcg/act 1 mometasone furoate nasal suspension 50 mcg/act 1 QL (1.14 GM per 1 day) NASONEX NASAL SUSPENSION 50 MCG/ACT (mometasone 3 QL (1.14 GM per 1 day) furoate) QNASL CHILDRENS NASAL AEROSOL SOLUTION 40 3 MCG/ACT (beclomethasone diprop (nasal)) QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT 3 (beclomethasone diprop (nasal)) SINUVA NASAL IMPLANT 1350 MCG (mometasone furoate) OA QL (30 day supply per 1 fill) XHANCE NASAL EXHALER SUSPENSION 93 MCG/ACT 3 PA (fluticasone propionate) NON-SELECT.BETA-ADRENERGIC AGONT(RESPIR) - Drugs for Asthma/COPD isoproterenol hcl injection solution 0.2 mg/ml OA ISUPREL INJECTION SOLUTION 0.2 MG/ML (isoproterenol OA hcl) ORALLY INHALED PREPARATIONS (STEROIDS) - Drugs for Inflammation ARMONAIR DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 113 MCG/ACT, 232 MCG/ACT, 55 3 PA MCG/ACT (fluticasone propionate (inhal)) ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 2 MCG/ACT (fluticasone furoate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 460 Coverage Requirements & Prescription Drug Name Drug Tier Limits budesonide inhalation suspension 0.25 mg/2ml, 0.5 1 mg/2ml, 1 mg/2ml FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST (fluticasone 2 QL (4 EA per 1 day) propionate (inhal)) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250 MCG/BLIST (fluticasone 2 QL (8 EA per 1 day) propionate (inhal)) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/BLIST (fluticasone propionate 2 QL (2 EA per 1 day) (inhal)) FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 2 QL (0.8 GM per 1 day) MCG/ACT (fluticasone propionate hfa) FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT 2 QL (0.71 GM per 1 day) (fluticasone propionate hfa) PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT 2 QL (0.07 EA per 1 day) (budesonide) PULMICORT SUSPENSION INHALATION SUSPENSION 0.25 3 MG/2ML, 0.5 MG/2ML, 1 MG/2ML (budesonide) QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT (beclomethasone 2 diprop hfa) PHOSPHODIESTERASE TYPE 4 INHIBITORS - Drugs for the Lungs DALIRESP ORAL TABLET 250 MCG, 500 MCG (roflumilast) 3 PULMONARY SURFACTANTS - Drugs for the Lungs CUROSURF INTRATRACHEAL SUSPENSION 120 MG/1.5ML, 3 240 MG/3ML (poractant alfa) INFASURF INTRATRACHEAL SUSPENSION 35-0.9 MG/ML-% 3 (calfactant in nacl)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 461 Coverage Requirements & Prescription Drug Name Drug Tier Limits SURVANTA INTRATRACHEAL SUSPENSION 25-0.9 MG/ML- 3 % (beractant in nacl) RESPIRATORY TRACT AGENTS, MISCELLANEOUS - Drugs for the Lungs ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 1000 MG, 500 MG (alpha1-proteinase inhibitor) BRONCHITOL INHALATION CAPSULE 40 MG (mannitol PA; SP; QL (30 day supply 3 (cystic fibrosis)) per 1 fill) BRONCHITOL TOLERANCE TEST INHALATION CAPSULE 40 PA; SP; QL (30 day supply 3 MG (mannitol (cystic fibrosis)) per 1 fill) GLASSIA INTRAVENOUS SOLUTION 1000 MG/50ML OA QL (30 day supply per 1 fill) (alpha1-proteinase inhibitor) PROLASTIN-C INTRAVENOUS SOLUTION 1000 MG/20ML OA QL (30 day supply per 1 fill) (alpha1-proteinase inhibitor) PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 1000 MG (alpha1-proteinase inhibitor) XOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGE OA QL (30 day supply per 1 fill) 150 MG/ML, 75 MG/0.5ML (omalizumab) XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 OA QL (30 day supply per 1 fill) MG (omalizumab) ZEMAIRA INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 1000 MG (alpha1-proteinase inhibitor) SECOND GENERATION ANTIHIST(RESPIR TRACT) - Drugs for Allergy azelastine hcl nasal solution 0.1 %, 0.15 %, 137 mcg/spray 1 azelastine hcl ophthalmic solution 0.05 % 1 azelastine-fluticasone nasal suspension 137-50 mcg/act 1 cetirizine hcl oral solution 1 mg/ml, 5 mg/5ml 1 CLARINEX ORAL TABLET 5 MG (desloratadine) 3 desloratadine oral tablet 5 mg 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 462 Coverage Requirements & Prescription Drug Name Drug Tier Limits desloratadine oral tablet dispersible 2.5 mg, 5 mg 1 DYMISTA NASAL SUSPENSION 137-50 MCG/ACT 3 (azelastine-fluticasone) QUZYTTIR INTRAVENOUS SOLUTION 10 MG/ML (cetirizine OA hcl) PA; QL (2 EA per 1 day); AL ZERVIATE OPHTHALMIC SOLUTION 0.24 % (cetirizine hcl) 3 (Max 2 Years) SELECT.BETA-2-ADRENERGIC AGONIST(RESPIR) - Drugs for Asthma/COPD albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act 1 inhalation 108 (90 base) mcg/act albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act 1 QL (1.2 GM per 1 day) inhalation 108 (90 base) mcg/act ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 2 QL (1.2 GM per 1 day) BASE) MCG/ACT INHALATION 108 (90 BASE) MCG/ACT albuterol sulfate inhalation nebulization solution (2.5 1 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 3 MG/ML) 0.5% INHALATION (5 MG/ML) 0.5% albuterol sulfate nebulization solution (5 mg/ml) 0.5% 1 inhalation (5 mg/ml) 0.5% albuterol sulfate oral syrup 2 mg/5ml 1 albuterol sulfate oral tablet 2 mg, 4 mg 1 formoterol fumarate inhalation nebulization solution 20 1 QL (4 ML per 1 day) mcg/2ml levalbuterol hcl inhalation nebulization solution 0.31 1 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT 3 PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 3 QL (4 ML per 1 day) MCG/2ML (formoterol fumarate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 463 Coverage Requirements & Prescription Drug Name Drug Tier Limits PROAIR DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT (albuterol 3 sulfate) PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 2 QL (0.6 GM per 1 day) BASE) MCG/ACT (albuterol sulfate) PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT (albuterol 2 QL (2 EA per 25 days) sulfate) PROVENTIL HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION 108 (90 BASE) MCG/ACT (albuterol 2 sulfate) PROVENTIL HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION 108 (90 BASE) MCG/ACT (albuterol 2 QL (0.5 GM per 1 day) sulfate) SEREVENT DISKUS INHALATION AEROSOL POWDER 2 QL (2 EA per 1 day) BREATH ACTIVATED 50 MCG/DOSE (salmeterol xinafoate) STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 3 2.5 MCG/ACT (olodaterol hcl) terbutaline sulfate injection solution 1 mg/ml OA terbutaline sulfate oral tablet 2.5 mg, 5 mg 1 VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 2 QL (1.2 GM per 1 day) BASE) MCG/ACT (albuterol sulfate) XOPENEX CONCENTRATE INHALATION NEBULIZATION 3 SOLUTION 1.25 MG/0.5ML (levalbuterol hcl) XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT 3 (levalbuterol tartrate) XOPENEX INHALATION NEBULIZATION SOLUTION 0.31 3 MG/3ML, 0.63 MG/3ML, 1.25 MG/3ML (levalbuterol hcl)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 464 Coverage Requirements & Prescription Drug Name Drug Tier Limits VASODILATING AGENTS (RESPIRATORY TRACT) - Drugs for the Lungs PA; SP; QL (30 day supply ADCIRCA ORAL TABLET 20 MG (tadalafil (pah)) 3 per 1 fill) ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 PA; SP; QL (30 day supply 3 MG (riociguat) per 1 fill) PA; SP; QL (30 day supply alyq oral tablet 20 mg 1 per 1 fill) PA; SP; QL (30 day supply ambrisentan oral tablet 10 mg, 5 mg 1 per 1 fill) PA; SP; QL (30 day supply bosentan oral tablet 125 mg, 62.5 mg 1 per 1 fill) epoprostenol sodium intravenous solution reconstituted OA QL (30 day supply per 1 fill) 0.5 mg, 1.5 mg FLOLAN INTRAVENOUS SOLUTION RECONSTITUTED 0.5 OA QL (30 day supply per 1 fill) MG, 1.5 MG (epoprostenol sodium) PA; SP; QL (30 day supply LETAIRIS ORAL TABLET 10 MG, 5 MG (ambrisentan) 3 per 1 fill) PA; SP; QL (30 day supply OPSUMIT ORAL TABLET 10 MG (macitentan) 3 per 1 fill) ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 PA; SP; QL (30 day supply 3 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG (treprostinil diolamine) per 1 fill) REMODULIN INJECTION SOLUTION 100 MG/20ML, 20 OA QL (30 day supply per 1 fill) MG/20ML, 200 MG/20ML, 50 MG/20ML (treprostinil) REVATIO INTRAVENOUS SOLUTION 10 MG/12.5ML OA QL (30 day supply per 1 fill) (sildenafil citrate) REVATIO ORAL SUSPENSION RECONSTITUTED 10 MG/ML PA; SP; QL (30 day supply 3 (sildenafil citrate) per 1 fill) PA; SP; QL (30 day supply REVATIO ORAL TABLET 20 MG (sildenafil citrate) 3 per 1 fill) sildenafil citrate intravenous solution 10 mg/12.5ml OA QL (30 day supply per 1 fill) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 465 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SP; QL (30 day supply sildenafil citrate oral suspension reconstituted 10 mg/ml 1 per 1 fill) sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg ED QL (0.27 EA per 1 day) PA; SP; QL (30 day supply sildenafil citrate oral tablet 20 mg 1 per 1 fill) PA; SP; QL (30 day supply tadalafil (pah) oral tablet 20 mg 1 per 1 fill) PA; SP; QL (30 day supply TRACLEER ORAL TABLET 125 MG, 62.5 MG (bosentan) 3 per 1 fill) PA; SP; QL (30 day supply TRACLEER ORAL TABLET SOLUBLE 32 MG (bosentan) 3 per 1 fill) treprostinil injection solution 100 mg/20ml, 20 mg/20ml, 200 OA QL (30 day supply per 1 fill) mg/20ml, 50 mg/20ml PA; SP; QL (30 day supply TYVASO INHALATION SOLUTION 0.6 MG/ML (treprostinil) 3 per 1 fill) TYVASO REFILL INHALATION SOLUTION 0.6 MG/ML PA; SP; QL (30 day supply 3 (treprostinil) per 1 fill) TYVASO STARTER INHALATION SOLUTION 0.6 MG/ML PA; SP; QL (30 day supply 3 (treprostinil) per 1 fill) UPTRAVI INTRAVENOUS SOLUTION RECONSTITUTED OA PA; SP 1800 MCG (selexipag) UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, PA; SP; QL (30 day supply 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG 3 per 1 fill) (selexipag) UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCG PA; SP; QL (30 day supply 3 (selexipag) per 1 fill) VELETRI INTRAVENOUS SOLUTION RECONSTITUTED 0.5 OA QL (30 day supply per 1 fill) MG, 1.5 MG (epoprostenol sodium) VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML PA; SP; QL (30 day supply 3 (iloprost) per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 466 Coverage Requirements & Prescription Drug Name Drug Tier Limits VIAGRA ORAL TABLET 100 MG, 25 MG, 50 MG (sildenafil ED QL (0.27 EA per 1 day) citrate) XANTHINE DERIVATIVES - Drugs for Asthma/COPD ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 2 THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 1 mg, 450 mg theophylline er oral tablet extended release 24 hour 400 1 mg, 600 mg theophylline oral solution 80 mg/15ml 1 SKIN AND MUCOUS MEMBRANE AGENTS - Drugs for the Skin ALLYLAMINES (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin DIFMETIOXRIME EXTERNAL SOLUTION 4-2-1-4 % 3 naftifine hcl external cream 1 %, 2 % 1 naftifine hcl external gel 1 % 1 NAFTIN EXTERNAL GEL 1 %, 2 % (naftifine hcl) 3 ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) - Drugs for the Skin ACANYA EXTERNAL GEL 1.2-2.5 % (clindamycin phos- 3 benzoyl perox) ACZONE EXTERNAL GEL 5 %, 7.5 % (dapsone) 3 PA ALTABAX EXTERNAL OINTMENT 1 % (retapamulin) 3 AMZEEQ EXTERNAL FOAM 4 % (minocycline hcl PA; QL (30 GM per 1 fill); AL 3 micronized) (Min 9 Years) BENZACLIN EXTERNAL GEL 1-5 % (clindamycin phos- 3 benzoyl perox)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 467 Coverage Requirements & Prescription Drug Name Drug Tier Limits BENZACLIN WITH PUMP EXTERNAL GEL 1-5 % 3 (clindamycin phos-benzoyl perox) BENZAMYCIN EXTERNAL GEL 5-3 % (benzoyl peroxide- 3 erythromycin) benzoyl peroxide-erythromycin external gel 5-3 % 1 bp cleansing wash external emulsion 10-4 % 1 CENTANY EXTERNAL OINTMENT 2 % (mupirocin) 3 CLEOCIN VAGINAL CREAM 2 % (clindamycin phosphate) 3 CLEOCIN VAGINAL SUPPOSITORY 100 MG (clindamycin 2 phosphate) CLEOCIN-T EXTERNAL LOTION 1 % (clindamycin 3 phosphate) clindacin etz external swab 1 % 1 clindacin-p external swab 1 % 1 CLINDAGEL EXTERNAL GEL 1 % (clindamycin phosphate) 3 clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 1 %, 1.2-5 % clindamycin phosphate external foam 1 % 1 clindamycin phosphate external lotion 1 % 1 clindamycin phosphate external solution 1 % 1 clindamycin phosphate external swab 1 % 1 CLINDAMYCIN PHOSPHATE GEL 1 % EXTERNAL 1 % 3 clindamycin phosphate gel 1 % external 1 % 1 clindamycin phosphate vaginal cream 2 % 1 clindamycin-tretinoin external gel 1.2-0.025 % 1 AL (Max 29 Years) CLINDESSE VAGINAL CREAM 2 % (clindamycin phosphate 2 (1 dose)) dapsone external gel 5 % 1 PA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 468 Coverage Requirements & Prescription Drug Name Drug Tier Limits DAPSONE EXTERNAL GEL 7.5 % 3 PA DEOXIA EXTERNAL LOTION 1-4 % 3 DRAXACE EXTERNAL SUSPENSION 2-8 % 3 DRAXACE LOTION CLEANSER EXTERNAL SUSPENSION 2- 3 8 % DRIXECE EXTERNAL SUSPENSION 5-10 % 3 ECEOXIA EXTERNAL CREAM 4-10 % 3 ery external pad 2 % 1 ERYGEL EXTERNAL GEL 2 % (erythromycin) 3 erythromycin external gel 2 % 1 erythromycin external solution 2 % 1 EVOCLIN EXTERNAL FOAM 1 % (clindamycin phosphate) 3 gentamicin sulfate external cream 0.1 % 1 gentamicin sulfate external ointment 0.1 % 1 KLARON EXTERNAL LOTION 10 % (sulfacetamide sodium 3 (acne)) METROCREAM EXTERNAL CREAM 0.75 % (metronidazole) 3 METROGEL EXTERNAL GEL 1 % (metronidazole) 3 METROLOTION EXTERNAL LOTION 0.75 % (metronidazole) 3 metronidazole external cream 0.75 % 1 metronidazole external gel 0.75 %, 1 % 1 metronidazole external lotion 0.75 % 1 metronidazole vaginal gel 0.75 % 1 mupirocin calcium external cream 2 % 1 mupirocin external ointment 2 % 1 neomycin-polymyxin b gu irrigation solution 40-200000 1 NEO-SYNALAR EXTERNAL CREAM 0.5-0.025 % (neomycin- 3 PA fluocinolone) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 469 Coverage Requirements & Prescription Drug Name Drug Tier Limits neuac external gel 1.2-5 % 1 NORITATE EXTERNAL CREAM 1 % (metronidazole) 2 NUVESSA VAGINAL GEL 1.3 % (metronidazole) 2 ONEXTON EXTERNAL GEL 1.2-3.75 % (clindamycin phos- 2 benzoyl perox) OVACE PLUS EXTERNAL CREAM 10 % (sulfacetamide 3 sodium) OVACE PLUS EXTERNAL FOAM 9.8 % (sulfacetamide 3 sodium) OVACE PLUS EXTERNAL LOTION 9.8 % (sulfacetamide 3 sodium) OVACE PLUS EXTERNAL SHAMPOO 10 % (sulfacetamide 3 sodium) OVACE PLUS WASH EXTERNAL GEL 10 % (sulfacetamide 3 sodium) OVACE PLUS WASH EXTERNAL LIQUID 10 % 3 (sulfacetamide sodium) OVACE WASH EXTERNAL LIQUID 10 % (sulfacetamide 3 sodium) PLEXION CLEANSING CLOTH EXTERNAL PAD 9.8-4.8 % 3 (sulfacetamide sodium-sulfur) PLEXION EXTERNAL CREAM 9.8-4.8 % (sulfacetamide 3 sodium-sulfur) PLEXION EXTERNAL LOTION 9.8-4.8 % (sulfacetamide 3 sodium-sulfur) polymyxin b sulfate injection solution reconstituted 500000 OA unit rosadan external cream 0.75 % 1 rosadan external gel 0.75 % 1 sodium sulfacetamide external shampoo 10 % 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 470 Coverage Requirements & Prescription Drug Name Drug Tier Limits sodium sulfacetamide wash external liquid 10 % 1 sulfacetamide sodium (acne) external lotion 10 % 1 sulfacetamide sodium external gel 10 % (cleans) 1 sulfacetamide sodium external liquid 10 % 1 sulfacetamide sodium-sulfur external cream 9.8-4.8 % 1 sulfacetamide sodium-sulfur external lotion 9.8-4.8 % 1 sulfacetamide sodium-sulfur external pad 10-4 %, 9.8-4.8 % 1 sulfacetamide sodium-sulfur external suspension 10-5 % 1 SUMAXIN EXTERNAL PAD 10-4 % (sulfacetamide sodium- 3 sulfur) TARDEOXIA EXTERNAL CREAM 1-4-0.025 % 3 vandazole vaginal gel 0.75 % 1 VELTIN EXTERNAL GEL 1.2-0.025 % (clindamycin-tretinoin) 3 AL (Max 29 Years) XEPI EXTERNAL CREAM 1 % (ozenoxacin) 3 PA ZIANA EXTERNAL GEL 1.2-0.025 % (clindamycin-tretinoin) 3 AL (Max 29 Years) ZILXI EXTERNAL FOAM 1.5 % (minocycline hcl micronized) 3 PA; QL (1 GM per 1 day) ANTIFULGALS (SKIN, MUCOUS MEMBRANE),MISC - Drugs for the Skin ALA-QUIN EXTERNAL CREAM 3-0.5 % (clioquinol-hc) 3 FUNGIMEZ EXTERNAL SOLUTION 3 RECURA EXTERNAL CREAM (misc antifungal combo 3 PA products) ANTI-INFLAMMATORY AGENTS, MISC (SKIN) - Drugs for the Skin EUCRISA EXTERNAL OINTMENT 2 % (crisaborole) 3 PA ANTIPRURITICS AND LOCAL ANESTHETICS - Drugs for the Skin 7T LIDO EXTERNAL GEL 2 % (lidocaine hcl) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 471 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANACAINE EXTERNAL OINTMENT 10 % (benzocaine) 3 ANALPRAM HC EXTERNAL CREAM 2.5-1 % (hydrocortisone 3 ace-pramoxine) ANALPRAM HC SINGLES EXTERNAL CREAM 2.5-1 % 3 (hydrocortisone ace-pramoxine) ANALPRAM-HC EXTERNAL CREAM 1-1 % (hydrocortisone 3 ace-pramoxine) ASTERO EXTERNAL GEL 4 % (lidocaine hcl) 3 PA CORTANE-B EXTERNAL LOTION 10-10-1 MG/ML (hc- 3 pramoxine-chloroxylenol) CRYODOSE TA EXTERNAL AEROSOL (pentafluoroprop- 3 tetrafluoroeth) DERMACINRX LIDOGEL EXTERNAL GEL 2.8 % (lidocaine 3 hcl) doxepin hcl external cream 5 % 1 EHA EXTERNAL LOTION 4 % 3 EPIFOAM EXTERNAL FOAM 1-1 % (pramoxine-hc) 3 ethyl chloride external aerosol 1 FLEXIN EXTERNAL PATCH 0.0375-5 % 3 GEBAUERS PAIN EASE EXTERNAL AEROSOL 3 (pentafluoroprop-tetrafluoroeth) GEBAUERS SPRAY AND STRETCH EXTERNAL AEROSOL 3 (pentafluoroprop-tetrafluoroeth) GEN7T EXTERNAL LOTION 3.5 % 3 GEN7T EXTERNAL PATCH 3.5 % 3 GEN7T PLUS EXTERNAL LOTION 3.5-7 % 3 GEN7T PLUS EXTERNAL PATCH 3.5-7 % 3 glydo external prefilled syringe 2 % 1 GUANENDRUX EXTERNAL CREAM 10-5-40 % 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 472 Coverage Requirements & Prescription Drug Name Drug Tier Limits hydrocortisone ace-pramoxine external cream 1-1 %, 2.5-1 1 % hydrocort-pramoxine (perianal) external cream 2.5-1 % 1 L.E.T. EXTERNAL GEL 4-0.05-0.5 % (lido-epinephrine- 3 tetracaine) LDO PLUS EXTERNAL GEL 4 % (lidocaine hcl) 3 PA LEVATIO EXTERNAL PATCH 0.03-5 % 3 lidocaine external ointment 5 % 1 QL (2 GM per 1 day) lidocaine external patch 5 % 1 lidocaine hcl external cream 3 % 1 PA LIDOCAINE HCL EXTERNAL CREAM 4.12 % 3 lidocaine hcl external solution 4 % 1 lidocaine hcl urethral/mucosal external gel 2 % 1 lidocaine hcl urethral/mucosal external prefilled syringe 2 1 % lidocaine-hydrocort (perianal) external cream 3-0.5 % 1 LIDOCAINE-HYDROCORTISONE ACE EXTERNAL CREAM 1- 3 1 % LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL 2.8-0.55 3 % lidocaine-prilocaine external cream 2.5-2.5 % 1 LIDOCANNA EXTERNAL PATCH 4 % 3 LIDOCORT EXTERNAL CREAM 3-0.5 % (lidocaine- 3 hydrocortisone ace) LIDODERM EXTERNAL PATCH 5 % (lidocaine) 3 lidopin external cream 3 % 1 PA LIDOPIN EXTERNAL CREAM 3.25 % 3 LIDOTHOL EXTERNAL GEL 4.5-5 % (lidocaine-menthol) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 473 Coverage Requirements & Prescription Drug Name Drug Tier Limits LIDOTHOL EXTERNAL PATCH 4.5-5 % (lidocaine-menthol) 3 LIDOTRAL EXTERNAL CREAM 3.88 % (lidocaine hcl) 3 PA LYDEXA EXTERNAL CREAM 4.12 % (lidocaine hcl) 3 phenazo oral tablet 200 mg 1 phenazopyridine hcl oral tablet 100 mg, 200 mg 1 PRAMOSONE EXTERNAL CREAM 1-1 %, 1-2.5 % 3 (pramoxine-hc) PRAMOSONE EXTERNAL LOTION 1-1 %, 1-2.5 % 3 (pramoxine-hc) PRAMOSONE EXTERNAL OINTMENT 1-1 %, 1-2.5 % 3 (pramoxine-hc) pramox external gel 1 % 1 premium lidocaine external ointment 5 % 1 QL (2 GM per 1 day) PREMIUM SCAR EXTERNAL PATCH 2-4-30 % 3 PROCORT EXTERNAL CREAM 1.85-1.15 % (hydrocortisone 3 ace-pramoxine) PROCTOFOAM HC EXTERNAL FOAM 1-1 % (hydrocortisone 2 ace-pramoxine) PRUDOXIN EXTERNAL CREAM 5 % (doxepin hcl 3 (antipruritic)) PYRIDIUM ORAL TABLET 100 MG, 200 MG 3 (phenazopyridine hcl) STERILE TOPICAL L.E.T. GEL EXTERNAL GEL 0.18-4-0.5 % 3 (lido-epinephrine-tetracaine) SYNERA EXTERNAL PATCH 70-70 MG (lidocaine-tetracaine) 3 ZERUVIA EXTERNAL PATCH 4-1 % 3 ZONALON EXTERNAL CREAM 5 % (doxepin hcl 3 (antipruritic))

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 474 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTIVIRALS (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin acyclovir external cream 5 % 1 acyclovir external ointment 5 % 1 DENAVIR EXTERNAL CREAM 1 % (penciclovir) 3 XERESE EXTERNAL CREAM 5-1 % (acyclovir- 3 hydrocortisone) ZOVIRAX EXTERNAL CREAM 5 % (acyclovir) 3 ZOVIRAX EXTERNAL OINTMENT 5 % (acyclovir) 3 ASTRINGENTS - Drugs for the Skin DRYSOL EXTERNAL SOLUTION 20 % (aluminum chloride) 3 MICONAZOLE-ZINC OXIDE-PETROLAT EXTERNAL 3 OINTMENT 0.25-15-81.35 % PREMIUM SCAR EXTERNAL PATCH 2-4-30 % 3 VUSION EXTERNAL OINTMENT 0.25-15-81.35 % 3 (miconazole-zinc oxide-petrolat) XERAC AC EXTERNAL SOLUTION 6.25 % (aluminum 3 chloride in alcohol) AZOLES (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin clotrimazole external cream 1 % 1 clotrimazole external solution 1 % 1 clotrimazole mouth/throat troche 10 mg 1 clotrimazole-betamethasone external cream 1-0.05 % 1 clotrimazole-betamethasone external lotion 1-0.05 % 1 DIFMETIOXRIME EXTERNAL SOLUTION 4-2-1-4 % 3 econazole nitrate external cream 1 % 1 ECOZA EXTERNAL FOAM 1 % (econazole nitrate) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 475 Coverage Requirements & Prescription Drug Name Drug Tier Limits ERTACZO EXTERNAL CREAM 2 % (sertaconazole nitrate) 3 EXELDERM EXTERNAL CREAM 1 % (sulconazole nitrate) 2 EXELDERM EXTERNAL SOLUTION 1 % (sulconazole 2 nitrate) EXTINA EXTERNAL FOAM 2 % (ketoconazole) 3 GYNAZOLE-1 VAGINAL CREAM 2 % (butoconazole nitrate (1 3 dose)) IMIOXIA EXTERNAL CREAM 1-4 % 3 JUBLIA EXTERNAL SOLUTION 10 % (efinaconazole) 3 PA ketoconazole external cream 2 % 1 ketoconazole external foam 2 % 1 ketoconazole external shampoo 2 % 1 ketodan external foam 2 % 1 LULICONAZOLE EXTERNAL CREAM 1 % 2 LUZU EXTERNAL CREAM 1 % (luliconazole) 3 miconazole 3 vaginal suppository 200 mg 1 MICONAZOLE-ZINC OXIDE-PETROLAT EXTERNAL 3 OINTMENT 0.25-15-81.35 % ORAVIG BUCCAL TABLET 50 MG (miconazole) 3 oxiconazole nitrate external cream 1 % 1 OXISTAT EXTERNAL CREAM 1 % (oxiconazole nitrate) 3 OXISTAT EXTERNAL LOTION 1 % (oxiconazole nitrate) 3 PHEODOYO EXTERNAL CREAM 1-2.5-2 % 3 PHEYO EXTERNAL CREAM 2.5-2 % 3 SULCONAZOLE NITRATE EXTERNAL CREAM 1 % 2 SULCONAZOLE NITRATE EXTERNAL SOLUTION 1 % 2 terconazole vaginal cream 0.4 %, 0.8 % 1 terconazole vaginal suppository 80 mg 1 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 476 Coverage Requirements & Prescription Drug Name Drug Tier Limits VUSION EXTERNAL OINTMENT 0.25-15-81.35 % 3 (miconazole-zinc oxide-petrolat) XOLEGEL EXTERNAL GEL 2 % (ketoconazole) 3 BASIC LOTIONS AND LINIMENTS - Drugs for the Skin 1ST MEDX-PATCH/ LIDOCAINE EXTERNAL PATCH 4- 3 0.0375-5-20 % (lido-capsaicin-men-methyl sal) ammonium lactate external cream 12 % 1 ammonium lactate external lotion 12 % 1 GORDOFILM EXTERNAL SOLUTION 16.7-16.7 % (salicylic 3 acid-lactic acid) lactic acid external lotion 10 % 1 methyl salicylate external liquid 1 SOOTHEE EXTERNAL PATCH 0.5-0.0375-5-2 % (lido- 3 capsaicin-men-methyl sal) turpentine external spirit 1 urea hydrating external foam 35 % 1 BASIC OILS AND OTHER SOLVENTS - Drugs for the Skin lactic acid e external cream 10-3500 %-unt/30gm 1 BASIC OINTMENTS AND PROTECTANTS - Drugs for the Skin iodoquinol-hc-aloe polysacch external gel 1-2-1 % 1 lactic acid e external cream 10-3500 %-unt/30gm 1 PROSILK EXTERNAL GEL (silicone) 3 BENZYLAMINES (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin MENTAX EXTERNAL CREAM 1 % (butenafine hcl) 3 CELL STIMULANTS AND PROLIFERANTS - Drugs for the Skin ALTRENO EXTERNAL LOTION 0.05 % (tretinoin) 3 AL (Max 29 Years) Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 477 Coverage Requirements & Prescription Drug Name Drug Tier Limits ATRALIN EXTERNAL GEL 0.05 % (tretinoin) 3 AL (Max 29 Years) AVITA EXTERNAL CREAM 0.025 % (tretinoin) 3 AL (Max 29 Years) AVITA EXTERNAL GEL 0.025 % (tretinoin) 3 AL (Max 29 Years) clindamycin-tretinoin external gel 1.2-0.025 % 1 AL (Max 29 Years) KEPIVANCE INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 6.25 MG (palifermin) OXIATAR EXTERNAL CREAM 4-0.025 % 3 OXIAVARRY EXTERNAL CREAM 4-0.05 % 3 RETIN-A EXTERNAL CREAM 0.025 %, 0.05 %, 0.1 % 3 AL (Max 29 Years) (tretinoin) RETIN-A EXTERNAL GEL 0.01 %, 0.025 % (tretinoin) 3 AL (Max 29 Years) RETIN-A MICRO EXTERNAL GEL 0.04 %, 0.1 % (tretinoin 3 AL (Max 29 Years) microsphere) RETIN-A MICRO PUMP EXTERNAL GEL 0.04 %, 0.1 % 3 AL (Max 29 Years) (tretinoin microsphere) RETIN-A MICRO PUMP EXTERNAL GEL 0.06 %, 0.08 % 2 AL (Max 29 Years) (tretinoin microsphere) TARDEOXIA EXTERNAL CREAM 1-4-0.025 % 3 TAROXIA EXTERNAL CREAM 4-0.025 % 3 TAROXIA EXTERNAL GEL 4-0.025 % 3 tretinoin external cream 0.025 %, 0.05 %, 0.1 % 1 AL (Max 29 Years) tretinoin external gel 0.01 %, 0.025 %, 0.05 % 1 AL (Max 29 Years) tretinoin microsphere external gel 0.04 %, 0.1 % 1 AL (Max 29 Years) tretinoin microsphere pump external gel 0.04 %, 0.1 % 1 AL (Max 29 Years) VARDIMAXIA EXTERNAL GEL 2-5-0.05 % 3 VAROXIA EXTERNAL CREAM 4-0.05 % 3 VAROXIA EXTERNAL GEL 4-0.05 % 3 VELTIN EXTERNAL GEL 1.2-0.025 % (clindamycin-tretinoin) 3 AL (Max 29 Years)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 478 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZIANA EXTERNAL GEL 1.2-0.025 % (clindamycin-tretinoin) 3 AL (Max 29 Years) CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) - Drugs for the Skin ALA SCALP EXTERNAL LOTION 2 % (hydrocortisone) 3 ala-cort external cream 1 %, 2.5 % 1 ALA-QUIN EXTERNAL CREAM 3-0.5 % (clioquinol-hc) 3 alclometasone dipropionate external cream 0.05 % 1 alclometasone dipropionate external ointment 0.05 % 1 amcinonide external cream 0.1 % 1 amcinonide external lotion 0.1 % 1 amcinonide external ointment 0.1 % 1 ANALPRAM HC EXTERNAL CREAM 2.5-1 % (hydrocortisone 3 ace-pramoxine) ANALPRAM HC SINGLES EXTERNAL CREAM 2.5-1 % 3 (hydrocortisone ace-pramoxine) ANALPRAM-HC EXTERNAL CREAM 1-1 % (hydrocortisone 3 ace-pramoxine) ANUSOL-HC EXTERNAL CREAM 2.5 % (hydrocortisone) 3 APEXICON E EXTERNAL CREAM 0.05 % (diflorasone diacet 3 emoll base) BENZOYL PEROX-HYDROCORTISONE EXTERNAL LOTION 3 5-0.5 % BENZOYL PEROXIDE FORTE- HC EXTERNAL LOTION 7.5-1 3 % beser external lotion 0.05 % 1 betamethasone dipropionate aug external cream 0.05 % 1 betamethasone dipropionate aug external gel 0.05 % 1 betamethasone dipropionate aug external lotion 0.05 % 1 betamethasone dipropionate aug external ointment 0.05 % 1 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 479 Coverage Requirements & Prescription Drug Name Drug Tier Limits betamethasone dipropionate external cream 0.05 % 1 betamethasone dipropionate external lotion 0.05 % 1 betamethasone dipropionate external ointment 0.05 % 1 betamethasone valerate external cream 0.1 % 1 betamethasone valerate external foam 0.12 % 1 betamethasone valerate external lotion 0.1 % 1 betamethasone valerate external ointment 0.1 % 1 BRYHALI EXTERNAL LOTION 0.01 % (halobetasol 3 propionate) calcipotriene-betameth diprop external ointment 0.005- 1 0.064 % calcipotriene-betameth diprop external suspension 0.005- 1 0.064 % CAPEX EXTERNAL SHAMPOO 0.01 % (fluocinolone 3 QL (30 day supply per 1 fill) acetonide) CHLOOXIA EXTERNAL CREAM 0.05-4 % 3 CHLOOXIA EXTERNAL OINTMENT 0.05-4 % 3 CHLOOXIA EXTERNAL SOLUTION 0.05-4 % 3 clobetasol prop emollient base external cream 0.05 % 1 clobetasol propionate e external cream 0.05 % 1 clobetasol propionate emulsion external foam 0.05 % 1 clobetasol propionate external cream 0.05 % 1 clobetasol propionate external foam 0.05 % 1 clobetasol propionate external gel 0.05 % 1 clobetasol propionate external liquid 0.05 % 1 clobetasol propionate external lotion 0.05 % 1 clobetasol propionate external ointment 0.05 % 1 clobetasol propionate external shampoo 0.05 % 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 480 Coverage Requirements & Prescription Drug Name Drug Tier Limits clobetasol propionate external solution 0.05 % 1 CLOBEX EXTERNAL LOTION 0.05 % (clobetasol propionate) 3 CLOBEX EXTERNAL SHAMPOO 0.05 % (clobetasol 3 propionate) CLOBEX SPRAY EXTERNAL LIQUID 0.05 % (clobetasol 3 propionate) clocortolone pivalate external cream 0.1 % 1 clodan external shampoo 0.05 % 1 CLODERM EXTERNAL CREAM 0.1 % (clocortolone pivalate) 3 clotrimazole-betamethasone external cream 1-0.05 % 1 clotrimazole-betamethasone external lotion 1-0.05 % 1 CORDRAN EXTERNAL CREAM 0.025 % (flurandrenolide) 2 CORDRAN EXTERNAL CREAM 0.05 % (flurandrenolide) 3 CORDRAN EXTERNAL LOTION 0.05 % (flurandrenolide) 3 CORDRAN EXTERNAL OINTMENT 0.05 % (flurandrenolide) 3 CORTANE-B EXTERNAL LOTION 10-10-1 MG/ML (hc- 3 pramoxine-chloroxylenol) CORTENEMA RECTAL ENEMA 100 MG/60ML 3 (hydrocortisone) CORTIFOAM EXTERNAL FOAM 10 % (hydrocortisone 2 acetate) CORTI-SAV EXTERNAL CREAM 1-1 % 3 CUTIVATE EXTERNAL LOTION 0.05 % (fluticasone 3 propionate) DERMA-SMOOTHE/FS BODY EXTERNAL OIL 0.01 % 3 QL (30 day supply per 1 fill) (fluocinolone acetonide) DERMA-SMOOTHE/FS SCALP EXTERNAL OIL 0.01 % 3 (fluocinolone acetonide)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 481 Coverage Requirements & Prescription Drug Name Drug Tier Limits DERMAZENE EXTERNAL CREAM 1-1 % (hydrocortisone- 3 iodoquinol) DESONATE EXTERNAL GEL 0.05 % (desonide) 3 desonide external cream 0.05 % 1 desonide external gel 0.05 % 1 desonide external lotion 0.05 % 1 desonide external ointment 0.05 % 1 DESOWEN EXTERNAL CREAM 0.05 % (desonide) 3 desoximetasone external cream 0.05 %, 0.25 % 1 desoximetasone external gel 0.05 % 1 desoximetasone external liquid 0.25 % 1 desoximetasone external ointment 0.05 %, 0.25 % 1 desrx external gel 0.05 % 1 diflorasone diacetate external cream 0.05 % 1 diflorasone diacetate external ointment 0.05 % 1 DIOCHLOY EXTERNAL SOLUTION 0.005-0.05 % 3 DIPROLENE AF EXTERNAL CREAM 0.05 % (betamethasone 2 dipropionate aug) DIPROLENE EXTERNAL OINTMENT 0.05 % (betamethasone 3 dipropionate aug) DUOBRII EXTERNAL LOTION 0.01-0.045 % (halobetasol 3 PA prop-tazarotene) ENSTILAR EXTERNAL FOAM 0.005-0.064 % (calcipotriene- 3 betameth diprop) EPIFOAM EXTERNAL FOAM 1-1 % (pramoxine-hc) 3 fluocinolone acetonide body external oil 0.01 % 1 QL (30 day supply per 1 fill) fluocinolone acetonide external cream 0.01 %, 0.025 % 1 QL (30 day supply per 1 fill) fluocinolone acetonide external ointment 0.025 % 1 QL (30 day supply per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 482 Coverage Requirements & Prescription Drug Name Drug Tier Limits fluocinolone acetonide external solution 0.01 % 1 QL (30 day supply per 1 fill) fluocinolone acetonide scalp external oil 0.01 % 1 fluocinonide emulsified base external cream 0.05 % 1 fluocinonide external cream 0.05 %, 0.1 % 1 fluocinonide external gel 0.05 % 1 fluocinonide external ointment 0.05 % 1 fluocinonide external solution 0.05 % 1 flurandrenolide external cream 0.05 % 1 flurandrenolide external lotion 0.05 % 1 flurandrenolide external ointment 0.05 % 1 fluticasone propionate external cream 0.05 % 1 fluticasone propionate external lotion 0.05 % 1 fluticasone propionate external ointment 0.005 % 1 halcinonide external cream 0.1 % 1 halobetasol propionate external cream 0.05 % 1 HALOBETASOL PROPIONATE EXTERNAL FOAM 0.05 % 2 halobetasol propionate external ointment 0.05 % 1 HALOG EXTERNAL CREAM 0.1 % (halcinonide) 3 HALOG EXTERNAL OINTMENT 0.1 % (halcinonide) 3 HALOG EXTERNAL SOLUTION 0.1 % (halcinonide) 3 HAXCHLO EXTERNAL SHAMPOO 0.77-0.05 % 3 hydrocortisone (perianal) external cream 1 %, 2.5 % 1 hydrocortisone ace-pramoxine external cream 1-1 %, 2.5-1 1 % hydrocortisone butyr lipo base external cream 0.1 % 1 hydrocortisone butyrate external cream 0.1 % 1 hydrocortisone butyrate external lotion 0.1 % 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 483 Coverage Requirements & Prescription Drug Name Drug Tier Limits hydrocortisone butyrate external ointment 0.1 % 1 hydrocortisone butyrate external solution 0.1 % 1 hydrocortisone external cream 1 %, 2.5 % 1 hydrocortisone external lotion 2.5 % 1 hydrocortisone external ointment 1 %, 2.5 % 1 hydrocortisone rectal enema 100 mg/60ml 1 hydrocortisone valerate external cream 0.2 % 1 hydrocortisone valerate external ointment 0.2 % 1 hydrocortisone-iodoquinol external cream 1-1 % 1 hydrocort-pramoxine (perianal) external cream 2.5-1 % 1 IMPEKLO EXTERNAL LOTION 0.15 MG/ACT (0.05%) 3 PA (clobetasol propionate) IMPOYZ EXTERNAL CREAM 0.025 % (clobetasol 2 propionate) iodoquinol-hc-aloe polysacch external gel 1-2-1 % 1 KENALOG EXTERNAL AEROSOL SOLUTION 0.147 MG/GM 3 (triamcinolone acetonide) LEXETTE EXTERNAL FOAM 0.05 % (halobetasol 3 propionate) lidocaine-hydrocort (perianal) external cream 3-0.5 % 1 LIDOCAINE-HYDROCORTISONE ACE EXTERNAL CREAM 1- 3 1 % LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL 2.8-0.55 3 % LIDOCORT EXTERNAL CREAM 3-0.5 % (lidocaine- 3 hydrocortisone ace) LOCOID EXTERNAL LOTION 0.1 % (hydrocortisone 3 butyrate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 484 Coverage Requirements & Prescription Drug Name Drug Tier Limits LOCOID LIPOCREAM EXTERNAL CREAM 0.1 % 3 (hydrocortisone butyr lipo base) LUXIQ EXTERNAL FOAM 0.12 % (betamethasone valerate) 3 mometasone furoate external cream 0.1 % 1 mometasone furoate external ointment 0.1 % 1 mometasone furoate external solution 0.1 % 1 NEO-SYNALAR EXTERNAL CREAM 0.5-0.025 % (neomycin- 3 PA fluocinolone) nolix external cream 0.05 % 1 nolix external lotion 0.05 % 1 NUCORT EXTERNAL LOTION 2 % (hydrocortisone acetate) 3 nystatin-triamcinolone external cream 100000-0.1 unit/gm- 1 % nystatin-triamcinolone external ointment 100000-0.1 1 unit/gm-% OLUX EXTERNAL FOAM 0.05 % (clobetasol propionate) 3 OLUX-E EXTERNAL FOAM 0.05 % (clobetasol propionate 3 emulsion) oralone mouth/throat paste 0.1 % 1 PANDEL EXTERNAL CREAM 0.1 % (hydrocortisone 3 probutate) PHEODOYO EXTERNAL CREAM 1-2.5-2 % 3 PHEYO EXTERNAL CREAM 2.5-2 % 3 PRAMOSONE EXTERNAL CREAM 1-1 %, 1-2.5 % 3 (pramoxine-hc) PRAMOSONE EXTERNAL LOTION 1-1 %, 1-2.5 % 3 (pramoxine-hc) PRAMOSONE EXTERNAL OINTMENT 1-1 %, 1-2.5 % 3 (pramoxine-hc)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 485 Coverage Requirements & Prescription Drug Name Drug Tier Limits prednicarbate external ointment 0.1 % 1 PROCORT EXTERNAL CREAM 1.85-1.15 % (hydrocortisone 3 ace-pramoxine) PROCTOCORT EXTERNAL CREAM 1 % (hydrocortisone) 3 PROCTOFOAM HC EXTERNAL FOAM 1-1 % (hydrocortisone 2 ace-pramoxine) procto-med hc external cream 2.5 % 1 procto-pak external cream 1 % 1 proctozone-hc external cream 2.5 % 1 PSORCON EXTERNAL CREAM 0.05 % 3 SERNIVO EXTERNAL EMULSION 0.05 % (betamethasone 3 dipropionate) SYNALAR EXTERNAL CREAM 0.025 % (fluocinolone 3 QL (30 day supply per 1 fill) acetonide) SYNALAR EXTERNAL OINTMENT 0.025 % (fluocinolone 3 QL (30 day supply per 1 fill) acetonide) SYNALAR EXTERNAL SOLUTION 0.01 % (fluocinolone 3 QL (30 day supply per 1 fill) acetonide) TACLONEX EXTERNAL OINTMENT 0.005-0.064 % 3 (calcipotriene-betameth diprop) TACLONEX EXTERNAL SUSPENSION 0.005-0.064 % 3 (calcipotriene-betameth diprop) TEMOVATE EXTERNAL CREAM 0.05 % (clobetasol 3 propionate) TEMOVATE EXTERNAL OINTMENT 0.05 % (clobetasol 3 propionate) TEXACORT EXTERNAL SOLUTION 2.5 % (hydrocortisone) 3 TOPICORT EXTERNAL CREAM 0.05 %, 0.25 % 3 (desoximetasone) TOPICORT EXTERNAL GEL 0.05 % (desoximetasone) 3 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 486 Coverage Requirements & Prescription Drug Name Drug Tier Limits TOPICORT EXTERNAL OINTMENT 0.05 %, 0.25 % 3 (desoximetasone) TOPICORT SPRAY EXTERNAL LIQUID 0.25 % 3 (desoximetasone) tovet external foam 0.05 % 1 triamcinolone acetonide external aerosol solution 0.147 1 mg/gm triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 1 % triamcinolone acetonide external lotion 0.025 %, 0.1 % 1 triamcinolone acetonide external ointment 0.025 %, 0.05 %, 1 0.1 %, 0.5 % triamcinolone acetonide mouth/throat paste 0.1 % 1 triamcinolone in absorbase external ointment 0.05 % 1 TRIANEX EXTERNAL OINTMENT 0.05 % (triamcinolone 3 acetonide) triderm external cream 0.1 %, 0.5 % 1 TRIDESILON EXTERNAL CREAM 0.05 % (desonide) 3 tritocin external ointment 0.05 % 1 UCERIS RECTAL FOAM 2 MG/ACT (budesonide) 3 ULTRAVATE EXTERNAL LOTION 0.05 % (halobetasol 3 PA propionate) VANOS EXTERNAL CREAM 0.1 % (fluocinonide) 3 VANOXIDE-HC EXTERNAL LOTION 5-0.5 % (benzoyl perox- 3 hydrocortisone) VERDESO EXTERNAL FOAM 0.05 % (desonide) 2 WYNZORA EXTERNAL CREAM 0.005-0.064 % 3 (calcipotriene-betameth diprop)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 487 Coverage Requirements & Prescription Drug Name Drug Tier Limits XERESE EXTERNAL CREAM 5-1 % (acyclovir- 3 hydrocortisone) EMOLLIENTS, DEMULCENTS, AND PROTECTANTS - Drugs for the Skin INOVA EXTERNAL KIT 4 & 5 % (benzoyl peroxide-vitamin e) 2 MICONAZOLE-ZINC OXIDE-PETROLAT EXTERNAL 3 OINTMENT 0.25-15-81.35 % PREMIUM SCAR EXTERNAL PATCH 2-4-30 % 3 VUSION EXTERNAL OINTMENT 0.25-15-81.35 % 3 (miconazole-zinc oxide-petrolat) XEROFORM OIL EMULSION STRIP EXTERNAL (bismuth OA tribromoph-petrolatum) XEROFORM OIL ROLL 4"X9' EXTERNAL 3 % (bismuth OA tribromoph-petrolatum) XEROFORM PETROLAT GAUZE 1"X8" EXTERNAL (bismuth OA tribromoph-petrolatum) XEROFORM PETROLAT GAUZE 5"X9" EXTERNAL (bismuth OA tribromoph-petrolatum) XEROFORM PETROLATUM ROLL 4"X9' EXTERNAL (bismuth OA tribromoph-petrolatum) HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE) - Drugs for the Skin ciclodan external solution 8 % 1 ciclopirox external gel 0.77 % 1 ciclopirox external shampoo 1 % 1 ciclopirox external solution 8 % 1 ciclopirox olamine external cream 0.77 % 1 ciclopirox olamine external suspension 0.77 % 1 HAXCHLO EXTERNAL SHAMPOO 0.77-0.05 % 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 488 Coverage Requirements & Prescription Drug Name Drug Tier Limits LOPROX EXTERNAL CREAM 0.77 % (ciclopirox olamine) 3 LOPROX EXTERNAL SHAMPOO 1 % (ciclopirox) 3 LOPROX EXTERNAL SUSPENSION 0.77 % (ciclopirox 3 olamine) KERATOLYTIC AGENTS - Drugs for the Skin ACNESIC EXTERNAL GEL 0.5 % (salicylic acid) 3 bp cleansing wash external emulsion 10-4 % 1 CANTHARIDIN EXTERNAL SOLUTION 0.7 % 3 CEM-UREA EXTERNAL SOLUTION 45 % (urea) 3 cerovel external lotion 40 % 1 DRAXACE EXTERNAL SUSPENSION 2-8 % 3 DRAXACE LOTION CLEANSER EXTERNAL SUSPENSION 2- 3 8 % DRIXECE EXTERNAL SUSPENSION 5-10 % 3 GORDOFILM EXTERNAL SOLUTION 16.7-16.7 % (salicylic 3 acid-lactic acid) GUANENDRUX EXTERNAL CREAM 10-5-40 % 3 HYDRO 40 EXTERNAL FOAM 40 % (urea) 3 KERALYT EXTERNAL GEL 6 % (salicylic acid) 3 PLEXION CLEANSING CLOTH EXTERNAL PAD 9.8-4.8 % 3 (sulfacetamide sodium-sulfur) PLEXION EXTERNAL CREAM 9.8-4.8 % (sulfacetamide 3 sodium-sulfur) PLEXION EXTERNAL LOTION 9.8-4.8 % (sulfacetamide 3 sodium-sulfur) PROMISEB EXTERNAL CREAM (antiseborrheic products, 3 misc.) PYROGALLIC ACID EXTERNAL OINTMENT 25-2 % 3 RESORCINOL-SULFUR EXTERNAL LOTION 2-5 % 3 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 489 Coverage Requirements & Prescription Drug Name Drug Tier Limits salicylic acid er external solution 28.5 % 1 salicylic acid external foam 6 % 1 salicylic acid external gel 6 % 1 salicylic acid external shampoo 6 % 1 salicylic acid external solution 26 % 1 salicylic acid wart remover external liquid 27.5 % 1 salimez external cream 6 % 1 SALIMEZ FORTE EXTERNAL CREAM 10 % 3 SALVAX EXTERNAL FOAM 6 % (salicylic acid) 3 selenium sulfide external shampoo 2.25 %, 2.3 % 1 SELRX EXTERNAL SHAMPOO 2.3 % (selenium sulfide) 3 sulfacetamide sodium-sulfur external cream 9.8-4.8 % 1 sulfacetamide sodium-sulfur external lotion 9.8-4.8 % 1 sulfacetamide sodium-sulfur external pad 10-4 %, 9.8-4.8 % 1 sulfacetamide sodium-sulfur external suspension 10-5 % 1 SUMAXIN EXTERNAL PAD 10-4 % (sulfacetamide sodium- 3 sulfur) ULTRASAL-ER EXTERNAL SOLUTION 28.5 % (salicylic acid) 3 UMECTA MOUSSE EXTERNAL FOAM 40 % (urea) 3 URAMAXIN EXTERNAL GEL 45 % (urea) 3 UREA EXTERNAL FOAM 35 % 3 urea external lotion 40 % 1 urea hydrating external foam 35 % 1 urea nail external gel 45 % 1 VIRASAL EXTERNAL LIQUID 27.5 % (salicylic acid) 3 XALIX EXTERNAL SOLUTION 28 % (salicylic acid) 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 490 Coverage Requirements & Prescription Drug Name Drug Tier Limits KERATOPLASTIC AGENTS - Drugs for the Skin coal tar external solution 20 % 1 LOCAL ANTI-INFECTIVES, MISCELLANEOUS - Drugs for the Skin ACANYA EXTERNAL GEL 1.2-2.5 % (clindamycin phos- 3 benzoyl perox) adapalene-benzoyl peroxide external gel 0.1-2.5 % 1 BENZACLIN EXTERNAL GEL 1-5 % (clindamycin phos- 3 benzoyl perox) BENZACLIN WITH PUMP EXTERNAL GEL 1-5 % 3 (clindamycin phos-benzoyl perox) benzalkonium chloride external solution , 50 % 1 BENZAMYCIN EXTERNAL GEL 5-3 % (benzoyl peroxide- 3 erythromycin) BENZEPRO EXTERNAL FOAM 5.2 %, 9.7 % (benzoyl 3 peroxide) benzepro external foam 5.3 % 1 BENZEPRO SHORT CONTACT EXTERNAL FOAM 9.8 % 2 (benzoyl peroxide) BENZOYL PEROX-HYDROCORTISONE EXTERNAL LOTION 3 5-0.5 % benzoyl peroxide external foam 9.8 % 1 BENZOYL PEROXIDE EXTERNAL GEL 6.5 %, 8 % 3 BENZOYL PEROXIDE FORTE- HC EXTERNAL LOTION 7.5-1 3 % benzoyl peroxide-erythromycin external gel 5-3 % 1 chlorhexidine gluconate mouth/throat solution 0.12 % 1 CHLORHEXIDINE GLUCONATE SOLUTION 20 % 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 491 Coverage Requirements & Prescription Drug Name Drug Tier Limits clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 1 %, 1.2-5 % CORTANE-B EXTERNAL LOTION 10-10-1 MG/ML (hc- 3 pramoxine-chloroxylenol) CORTI-SAV EXTERNAL CREAM 1-1 % 3 DEBACTEROL MOUTH/THROAT SOLUTION 30-50 % 3 (sulfuric acid-sulf phenolics) DERMAZENE EXTERNAL CREAM 1-1 % (hydrocortisone- 3 iodoquinol) ENZOCLEAR EXTERNAL FOAM 9.8 % (benzoyl peroxide) 2 EPIDUO EXTERNAL GEL 0.1-2.5 % (adapalene-benzoyl 3 peroxide) EPIDUO FORTE EXTERNAL GEL 0.3-2.5 % (adapalene- 3 benzoyl peroxide) FEM PH VAGINAL GEL 0.9-0.025 % (acetic acid- 3 oxyquinoline) hydrocortisone-iodoquinol external cream 1-1 % 1 hydrogen peroxide solution 30 % 1 INOVA EXTERNAL KIT 4 & 5 % (benzoyl peroxide-vitamin e) 2 iodoquinol-hc-aloe polysacch external gel 1-2-1 % 1 LUGOLS STRONG IODINE EXTERNAL SOLUTION 5-10 % 3 mafenide acetate external packet 5 % 1 neuac external gel 1.2-5 % 1 ONEXTON EXTERNAL GEL 1.2-3.75 % (clindamycin phos- 2 benzoyl perox) PERIDEX MOUTH/THROAT SOLUTION 0.12 % 3 (chlorhexidine gluconate) periogard mouth/throat solution 0.12 % 1 PHEODOYO EXTERNAL CREAM 1-2.5-2 % 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 492 Coverage Requirements & Prescription Drug Name Drug Tier Limits selenium sulfide external lotion 2.5 % 1 selenium sulfide external shampoo 2.25 %, 2.3 % 1 SELRX EXTERNAL SHAMPOO 2.3 % (selenium sulfide) 3 SILVADENE EXTERNAL CREAM 1 % (silver sulfadiazine) 3 silver sulfadiazine external cream 1 % 1 ssd external cream 1 % 1 SULFAMYLON EXTERNAL CREAM 85 MG/GM (mafenide 3 acetate) SULFAMYLON EXTERNAL PACKET 5 % (mafenide acetate) 3 VANOXIDE-HC EXTERNAL LOTION 5-0.5 % (benzoyl perox- 3 hydrocortisone) zaclir cleansing external lotion 8 % 1 NONSTEROIDAL ANTI-INFLAMMAT.AGENTS(SKIN) - Drugs for the Skin diclofenac sodium external gel 1 % 1 diclofenac sodium external gel 3 % 1 PA diclofenac sodium external solution 1.5 % 1 PA; QL (1 ML per 30 days) DICLOFONO EXTERNAL GEL 1.6 % (diclofenac sodium) 3 DIFMETIOXRIME EXTERNAL SOLUTION 4-2-1-4 % 3 PENNSAID EXTERNAL SOLUTION 2 % (diclofenac sodium) 3 PA; QL (1 GM per 30 days) OXABOROLES - Drugs for the Skin KERYDIN EXTERNAL SOLUTION 5 % (tavaborole) 3 PA tavaborole external solution 5 % 1 PA PIGMENTING AGENTS - Drugs for the Skin methoxsalen rapid oral capsule 10 mg 1 UVADEX INJECTION SOLUTION 20 MCG/ML (methoxsalen OA (photopheresis))

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 493 Coverage Requirements & Prescription Drug Name Drug Tier Limits POLYENES (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin nyamyc external powder 100000 unit/gm 1 nystatin external cream 100000 unit/gm 1 nystatin external ointment 100000 unit/gm 1 nystatin external powder 100000 unit/gm 1 nystatin-triamcinolone external cream 100000-0.1 unit/gm- 1 % nystatin-triamcinolone external ointment 100000-0.1 1 unit/gm-% nystop external powder 100000 unit/gm 1 SCABICIDES AND PEDICULICIDES - Drugs for the Skin crotan external lotion 10 % 1 ivermectin external cream 1 % 1 ivermectin external lotion 0.5 % 1 lindane external shampoo 1 % 1 malathion external lotion 0.5 % 1 NATROBA EXTERNAL SUSPENSION 0.9 % (spinosad) 3 OVIDE EXTERNAL LOTION 0.5 % (malathion) 3 permethrin external cream 5 % 1 SOOLANTRA EXTERNAL CREAM 1 % (ivermectin) 3 spinosad external suspension 0.9 % 1 sulfurated lime external solution 1 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. - Drugs for the Skin 1ST MEDX-PATCH/ LIDOCAINE EXTERNAL PATCH 4- 3 0.0375-5-20 % (lido-capsaicin-men-methyl sal)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 494 Coverage Requirements & Prescription Drug Name Drug Tier Limits ABSORICA LD ORAL CAPSULE 16 MG, 24 MG, 32 MG, 8 MG 3 (isotretinoin micronized) ABSORICA ORAL CAPSULE 10 MG, 20 MG, 25 MG, 30 MG, 3 PA 35 MG, 40 MG (isotretinoin) accutane oral capsule 20 mg, 30 mg, 40 mg 1 PA ACIOXIAY EXTERNAL CREAM 15-4 % 3 acitretin oral capsule 10 mg, 17.5 mg, 25 mg 1 ACZONE EXTERNAL GEL 5 %, 7.5 % (dapsone) 3 PA adapalene external cream 0.1 % 1 PA adapalene external gel 0.1 % 1 PA adapalene external gel 0.3 % 1 AL (Max 29 Years) ADAPALENE EXTERNAL PAD 0.1 % 3 PA ADAPALENE EXTERNAL SOLUTION 0.1 % 3 PA adapalene-benzoyl peroxide external gel 0.1-2.5 % 1 AKLIEF EXTERNAL CREAM 0.005 % (trifarotene) 3 PA; AL (Min 9 Years) ALDARA EXTERNAL CREAM 5 % (imiquimod) 3 AMELUZ EXTERNAL GEL 10 % (aminolevulinic acid hcl) 3 amnesteem oral capsule 10 mg, 20 mg, 40 mg 1 PA ARAZLO EXTERNAL LOTION 0.045 % (tazarotene) 3 PA ARTISS EXTERNAL SOLUTION (fibrin sealant component) 3 AVSOLA INTRAVENOUS SOLUTION RECONSTITUTED 100 OA MG (infliximab-axxq) azelaic acid external gel 15 % 1 AZELEX EXTERNAL CREAM 20 % (azelaic acid) 3 calcipotriene external cream 0.005 % 1 CALCIPOTRIENE EXTERNAL FOAM 0.005 % 3 calcipotriene external ointment 0.005 % 1 calcipotriene external solution 0.005 % 1 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 495 Coverage Requirements & Prescription Drug Name Drug Tier Limits calcipotriene-betameth diprop external ointment 0.005- 1 0.064 % calcipotriene-betameth diprop external suspension 0.005- 1 0.064 % CALCITRENE EXTERNAL OINTMENT 0.005 % 3 (calcipotriene) calcitriol external ointment 3 mcg/gm 1 CARAC EXTERNAL CREAM 0.5 % (fluorouracil) 2 CHLOOXIA EXTERNAL CREAM 0.05-4 % 3 CHLOOXIA EXTERNAL OINTMENT 0.05-4 % 3 CHLOOXIA EXTERNAL SOLUTION 0.05-4 % 3 claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1 PA clindamycin-tretinoin external gel 1.2-0.025 % 1 AL (Max 29 Years) CONDYLOX EXTERNAL GEL 0.5 % (podofilox) 2 coremino oral tablet extended release 24 hour 135 mg, 45 1 PA mg, 90 mg COSENTYX (300 MG DOSE) SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply SI PREFILLED SYRINGE 150 MG/ML (secukinumab) per 1 fill) COSENTYX 150 MG/ML SUBCUTANEOUS SOLUTION PA; SP; QL (30 day supply PREFILLED SYRINGE 150 MG/ML, 75 MG/0.5ML SI per 1 fill) (secukinumab) COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS PA; SP; QL (30 day supply SI SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab) per 1 fill) COSENTYX SENSOREADY PEN SUBCUTANEOUS PA; SP; QL (30 day supply SI SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab) per 1 fill) dapsone external gel 5 % 1 PA DAPSONE EXTERNAL GEL 7.5 % 3 PA DEOXIA EXTERNAL LOTION 1-4 % 3 diclofenac sodium external gel 1 % 1

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 496 Coverage Requirements & Prescription Drug Name Drug Tier Limits diclofenac sodium external solution 1.5 % 1 PA; QL (1 ML per 30 days) DICLOFONO EXTERNAL GEL 1.6 % (diclofenac sodium) 3 DIFFERIN EXTERNAL CREAM 0.1 % (adapalene) 3 PA DIFFERIN EXTERNAL GEL 0.3 % (adapalene) 3 AL (Max 29 Years) DIFFERIN EXTERNAL LOTION 0.1 % (adapalene) 3 PA DIMOXIA EXTERNAL GEL 4-5 % 3 DIOCHLOY EXTERNAL SOLUTION 0.005-0.05 % 3 DOVONEX EXTERNAL CREAM 0.005 % (calcipotriene) 3 doxycycline oral capsule delayed release 40 mg 1 PA DRITHO-CREME HP EXTERNAL CREAM 1 % (anthralin) 3 DUOBRII EXTERNAL LOTION 0.01-0.045 % (halobetasol 3 PA prop-tazarotene) DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; SP; QL (30 day supply SI 200 MG/1.14ML, 300 MG/2ML (dupilumab) per 1 fill) DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 300 MG/2ML (dupilumab) per 1 fill) ECEOXIA EXTERNAL CREAM 4-10 % 3 EFUDEX EXTERNAL CREAM 5 % (fluorouracil) 3 ELIDEL EXTERNAL CREAM 1 % (pimecrolimus) 3 ENSTILAR EXTERNAL FOAM 0.005-0.064 % (calcipotriene- 3 betameth diprop) EPIDUO EXTERNAL GEL 0.1-2.5 % (adapalene-benzoyl 3 peroxide) EPIDUO FORTE EXTERNAL GEL 0.3-2.5 % (adapalene- 3 benzoyl peroxide) ESKATA EXTERNAL SOLUTION 40 % (hydrogen peroxide) 2 ETHOXIA EXTERNAL CREAM 4-0.05 % 3 FABIOR EXTERNAL FOAM 0.1 % (tazarotene) 3 PA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 497 Coverage Requirements & Prescription Drug Name Drug Tier Limits FEM PH VAGINAL GEL 0.9-0.025 % (acetic acid- 3 oxyquinoline) FINACEA EXTERNAL FOAM 15 % (azelaic acid) 3 FINACEA EXTERNAL GEL 15 % (azelaic acid) 3 FINAPOD EXTERNAL SOLUTION 0.1-7 % 3 FLEXIN EXTERNAL PATCH 0.0375-5 % 3 FLUOROPLEX EXTERNAL CREAM 1 % (fluorouracil) 2 FLUOROURACIL EXTERNAL CREAM 0.5 % 2 fluorouracil external cream 5 % 1 fluorouracil external solution 2 %, 5 % 1 GELCLAIR MOUTH/THROAT GEL (povidone-nahyaluron- 3 glycyrrhet) GEN7T PLUS EXTERNAL LOTION 3.5-7 % 3 GEN7T PLUS EXTERNAL PATCH 3.5-7 % 3 GENADUR EXTERNAL LIQUID (dermatological products, 3 misc.) glycolic acid solution 70 % 1 HPR PLUS EXTERNAL FOAM (dermatological products, 3 misc.) HYLATOPIC PLUS EXTERNAL LOTION (dermatological 3 products, misc.) ILUMYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP; QL (30 day supply SI 100 MG/ML (tildrakizumab-asmn) per 1 fill) IMIOXIA EXTERNAL CREAM 1-4 % 3 imiquimod external cream 3.75 %, 5 % 1 IMIQUIMOD PUMP EXTERNAL CREAM 3.75 % 3 INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED OA QL (56 day supply per 1 fill) 100 MG (infliximab-dyyb)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 498 Coverage Requirements & Prescription Drug Name Drug Tier Limits isotretinoin oral capsule 10 mg, 20 mg, 25 mg, 30 mg, 35 1 PA mg, 40 mg ITHOXIA EXTERNAL CREAM 4-0.1 % 3 KLISYRI EXTERNAL OINTMENT 1 % (tirbanibulin) 3 PA; QL (1 EA per 5 days) LEVATIO EXTERNAL PATCH 0.03-5 % 3 LEVULAN KERASTICK EXTERNAL SOLUTION 3 RECONSTITUTED 20 % (aminolevulinic acid hcl) LIDOTHOL EXTERNAL GEL 4.5-5 % (lidocaine-menthol) 3 LIDOTHOL EXTERNAL PATCH 4.5-5 % (lidocaine-menthol) 3 MINOCYCLINE HCL ER ORAL CAPSULE EXTENDED 3 PA RELEASE 24 HOUR 135 MG, 45 MG, 90 MG minocycline hcl er oral tablet extended release 24 hour 105 1 PA mg, 115 mg, 135 mg, 45 mg, 55 mg, 65 mg, 80 mg, 90 mg MINOLIRA ORAL TABLET EXTENDED RELEASE 24 HOUR 3 PA 105 MG, 135 MG (minocycline hcl) MIRVASO EXTERNAL GEL 0.33 % (brimonidine tartrate) 3 myorisan oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1 PA NEOSALUS EXTERNAL FOAM (dermatological products, 3 misc.) NEOSALUS EXTERNAL LOTION (dermatological products, 3 misc.) ORACEA ORAL CAPSULE DELAYED RELEASE 40 MG 3 PA (doxycycline) PA; SP; QL (30 day supply OTEZLA ORAL TABLET 30 MG (apremilast) 2 per 1 fill) OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG PA; SP; QL (30 day supply 2 (apremilast) per 1 fill) OXIANUJO EXTERNAL OINTMENT 4-0.1 % 3 OXIATAR EXTERNAL CREAM 4-0.025 % 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 499 Coverage Requirements & Prescription Drug Name Drug Tier Limits OXIAVARRY EXTERNAL CREAM 4-0.05 % 3 PANRETIN EXTERNAL GEL 0.1 % (alitretinoin) 2 PA PENNSAID EXTERNAL SOLUTION 2 % (diclofenac sodium) 3 PA; QL (1 GM per 30 days) pimecrolimus external cream 1 % 1 podocon external solution 25 % 1 podofilox external solution 0.5 % 1 PODPROG EXTERNAL SOLUTION 0.1-7 % 3 PRESERA EXTERNAL FOAM (dermatological products, 3 misc.) PROTOPIC EXTERNAL OINTMENT 0.03 %, 0.1 % 3 (tacrolimus) PYROGALLIC ACID EXTERNAL OINTMENT 25-2 % 3 QBREXZA EXTERNAL PAD 2.4 % (glycopyrronium tosylate) 3 PA RECTIV RECTAL OINTMENT 0.4 % (nitroglycerin) 3 REMICADE INTRAVENOUS SOLUTION RECONSTITUTED OA QL (56 day supply per 1 fill) 100 MG (infliximab) RENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED OA QL (30 day supply per 1 fill) 100 MG (infliximab-abda) RHOFADE EXTERNAL CREAM 1 % (oxymetazoline hcl) 3 PA SANTYL EXTERNAL OINTMENT 250 UNIT/GM (collagenase) 3 SCENESSE SUBCUTANEOUS IMPLANT 16 MG OA (afamelanotide acetate) SILATRIX MOUTH/THROAT GEL 10 % 3 SILIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP; QL (30 day supply SI 210 MG/1.5ML (brodalumab) per 1 fill) SKYRIZI (150 MG DOSE) SUBCUTANEOUS PREFILLED PA; SP; QL (30 day supply SI SYRINGE KIT 75 MG/0.83ML (risankizumab-rzaa) per 1 fill) SKYRIZI PEN SUBCUTANEOUS SOLUTION AUTO- PA; SP; QL (30 day supply SI INJECTOR 150 MG/ML (risankizumab-rzaa) per 1 fill)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 500 Coverage Requirements & Prescription Drug Name Drug Tier Limits SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP; QL (30 day supply SI 150 MG/ML (risankizumab-rzaa) per 1 fill) SOLODYN ORAL TABLET EXTENDED RELEASE 24 HOUR 3 PA 105 MG, 115 MG, 55 MG, 65 MG, 80 MG (minocycline hcl) SOOTHEE EXTERNAL PATCH 0.5-0.0375-5-2 % (lido- 3 capsaicin-men-methyl sal) SORIATANE ORAL CAPSULE 10 MG, 25 MG (acitretin) 3 SORILUX EXTERNAL FOAM 0.005 % (calcipotriene) 3 STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML PA; SP; QL (30 day supply SI (ustekinumab) per 1 fill) STELARA SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 45 MG/0.5ML, 90 MG/ML (ustekinumab) per 1 fill) TACHOSIL EXTERNAL PATCH 4.8 X 4.8 CM, 9.5 X 4.8 CM 3 (absorbable fibrin sealant) TACLONEX EXTERNAL OINTMENT 0.005-0.064 % 3 (calcipotriene-betameth diprop) TACLONEX EXTERNAL SUSPENSION 0.005-0.064 % 3 (calcipotriene-betameth diprop) tacrolimus external ointment 0.03 %, 0.1 % 1 TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR 80 PA; SP; QL (30 day supply SI MG/ML (ixekizumab) per 1 fill) TALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP; QL (30 day supply SI 80 MG/ML (ixekizumab) per 1 fill) TARDEOXIA EXTERNAL CREAM 1-4-0.025 % 3 SP; QL (30 day supply per 1 TARGRETIN EXTERNAL GEL 1 % (bexarotene) 3 fill) TAROXIA EXTERNAL CREAM 4-0.025 % 3 TAROXIA EXTERNAL GEL 4-0.025 % 3 tazarotene external cream 0.1 % 1 PA TAZAROTENE EXTERNAL FOAM 0.1 % 3 PA Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 501 Coverage Requirements & Prescription Drug Name Drug Tier Limits TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % (tazarotene) 3 PA TAZORAC EXTERNAL GEL 0.05 %, 0.1 % (tazarotene) 3 PA TISSEEL EXTERNAL SOLUTION (fibrin sealant component) 3 TREMFYA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 PA; SP; QL (30 day supply SI MG/ML (guselkumab) per 1 fill) TREMFYA SUBCUTANEOUS SOLUTION PREFILLED PA; SP; QL (30 day supply SI SYRINGE 100 MG/ML (guselkumab) per 1 fill) VALCHLOR EXTERNAL GEL 0.016 % (mechlorethamine hcl SP; QL (30 day supply per 1 3 (topical)) fill) VARDIMAXIA EXTERNAL GEL 2-5-0.05 % 3 VAROXIA EXTERNAL CREAM 4-0.05 % 3 VAROXIA EXTERNAL GEL 4-0.05 % 3 VECTICAL EXTERNAL OINTMENT 3 MCG/GM (calcitriol) 3 VELTIN EXTERNAL GEL 1.2-0.025 % (clindamycin-tretinoin) 3 AL (Max 29 Years) VEREGEN EXTERNAL OINTMENT 15 % (sinecatechins) 3 WINLEVI EXTERNAL CREAM 1 % (clascoterone) 3 PA; QL (2 GM per 1 day) WYNZORA EXTERNAL CREAM 0.005-0.064 % 3 (calcipotriene-betameth diprop) XIMINO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 PA 135 MG, 45 MG, 90 MG (minocycline hcl) zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1 PA ZERUVIA EXTERNAL PATCH 4-1 % 3 ZIANA EXTERNAL GEL 1.2-0.025 % (clindamycin-tretinoin) 3 AL (Max 29 Years) ZITHRANOL EXTERNAL SHAMPOO 1 % (anthralin) 3 ZYCLARA EXTERNAL CREAM 3.75 % (imiquimod) 3 ZYCLARA PUMP EXTERNAL CREAM 2.5 %, 3.75 % 3 (imiquimod)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 502 Coverage Requirements & Prescription Drug Name Drug Tier Limits SMOOTH MUSCLE RELAXANTS - Drugs to Relax Muscles ANTIMUSCARINICS - Drugs for the Urinary System darifenacin hydrobromide er oral tablet extended release 24 1 hour 15 mg, 7.5 mg DETROL LA ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 2 MG, 4 MG (tolterodine tartrate) DETROL ORAL TABLET 1 MG, 2 MG (tolterodine tartrate) 3 DITROPAN XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 10 MG, 5 MG (oxybutynin chloride) flavoxate hcl oral tablet 100 mg 1 GELNIQUE TRANSDERMAL GEL 10 % (oxybutynin chloride) 3 oxybutynin chloride er oral tablet extended release 24 hour 1 10 mg, 15 mg, 5 mg oxybutynin chloride oral syrup 5 mg/5ml 1 oxybutynin chloride oral tablet 5 mg 1 OXYTROL TRANSDERMAL PATCH TWICE WEEKLY 3.9 3 MG/24HR (oxybutynin) solifenacin succinate oral tablet 10 mg, 5 mg 1 tolterodine tartrate er oral capsule extended release 24 1 hour 2 mg, 4 mg tolterodine tartrate oral tablet 1 mg, 2 mg 1 TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR 4 3 MG, 8 MG (fesoterodine fumarate) trospium chloride er oral capsule extended release 24 hour 1 60 mg trospium chloride oral tablet 20 mg 1 VESICARE LS ORAL SUSPENSION 5 MG/5ML (solifenacin 3 PA succinate)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 503 Coverage Requirements & Prescription Drug Name Drug Tier Limits VESICARE ORAL TABLET 10 MG, 5 MG (solifenacin 3 succinate) RESPIRATORY SMOOTH MUSCLE RELAXANTS - Drugs for Lungs aminophylline intravenous solution 25 mg/ml OA ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 2 REVATIO INTRAVENOUS SOLUTION 10 MG/12.5ML OA QL (30 day supply per 1 fill) (sildenafil citrate) REVATIO ORAL SUSPENSION RECONSTITUTED 10 MG/ML PA; SP; QL (30 day supply 3 (sildenafil citrate) per 1 fill) PA; SP; QL (30 day supply REVATIO ORAL TABLET 20 MG (sildenafil citrate) 3 per 1 fill) sildenafil citrate intravenous solution 10 mg/12.5ml OA QL (30 day supply per 1 fill) PA; SP; QL (30 day supply sildenafil citrate oral suspension reconstituted 10 mg/ml 1 per 1 fill) PA; SP; QL (30 day supply sildenafil citrate oral tablet 20 mg 1 per 1 fill) THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 1 mg, 450 mg theophylline er oral tablet extended release 24 hour 400 1 mg, 600 mg theophylline oral solution 80 mg/15ml 1 SELECTIVE BETA-3-ADRENERGIC AGONISTS - Drugs for the Urinary System GEMTESA ORAL TABLET 75 MG (vibegron) 3 QL (1 EA per 1 day) MYRBETRIQ ORAL SUSPENSION RECONSTITUTED ER 8 3 PA MG/ML (mirabegron)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 504 Coverage Requirements & Prescription Drug Name Drug Tier Limits MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 3 25 MG, 50 MG (mirabegron) VITAMINS MULTIVITAMIN PREPARATIONS adc/f (0.5mg/ml) oral solution 0.5 mg/ml 1 PV INFUVITE ADULT INTRAVENOUS INJECTABLE (multiple OA vitamin) INFUVITE PEDIATRIC INTRAVENOUS SOLUTION (pediatric OA multiple vitamins) JENLIVA PRENATAL/POSTNATAL ORAL CAPSULE 1 MG 3 PV M.V.I. ADULT INTRAVENOUS INJECTABLE (multiple OA vitamin) M.V.I. PEDIATRIC INTRAVENOUS SOLUTION OA RECONSTITUTED (pediatric multiple vitamins) multi-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 PV multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 PV 1 mg multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml 1 NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o 3 PV vit a) ONE VITE WOMENS ORAL TABLET 27-0.8 MG 3 PV ONE-A-DAY WOMENS PRENATAL 1 ORAL CAPSULE 28-0.8- 3 PV 235 MG (prenat-fe carbonyl-fa-omega 3) prenatal multi +dha oral capsule 27-0.8-200 mg, 27-0.8-228 1 PV mg, 27-0.8-250 mg prenatal oral tablet 27-0.8 mg 1 PV PRENATVITE RX ORAL TABLET 0.8 MG 3 QUFLORA FE ORAL TABLET CHEWABLE 0.25 MG (multi vit- 3 min-fluoride-fe-fa)

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 505 Coverage Requirements & Prescription Drug Name Drug Tier Limits RELNATE DHA ORAL CAPSULE 28-1-200 MG 3 PV tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 PV vitamins acd-fluoride oral solution 0.25 mg/ml 1 PV VITAMIN A adc/f (0.5mg/ml) oral solution 0.5 mg/ml 1 PV AQUASOL A INTRAMUSCULAR SOLUTION 50000 UNIT/ML OA (vitamin a) tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 PV vitamins acd-fluoride oral solution 0.25 mg/ml 1 PV VITAMIN B COMPLEX B-COMPLEX INJECTION INJECTABLE OA BEYAZ ORAL TABLET 3-0.02-0.451 MG (drospiren-eth 3 estrad-levomefol) CALCIFOL ORAL WAFER 1342-1.6 MG (ca carb-fa-d-b6-b12- 3 boron-mg) calcium-folic acid plus d oral wafer 1342-1 mg 1 cyanocobalamin injection solution 1000 mcg/ml SI QL (0.04 ML per 1 day) CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML 3 DEXPANTHENOL INJECTION SOLUTION 250 MG/ML 3 drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 1 PV 3-0.03-0.451 mg folate oral tablet 400 mcg 1 PV FOLDITAM ORAL TABLET 1-10000 MG-UNIT (folic acid- 3 cholecalciferol) folic acid injection solution 5 mg/ml OA folic acid oral tablet 1 mg, 400 mcg, 800 mcg 1 PV FOLIC D3 ORAL CAPSULE 1-3775 MG-UNIT 3

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 506 Coverage Requirements & Prescription Drug Name Drug Tier Limits FOLI-D ORAL TABLET 1-2000 MG-UNIT (folic acid- 3 cholecalciferol) FOLITE ORAL TABLET 3 FOLVITE-D ORAL TABLET 1-3775 MG-UNIT (folic acid- 3 cholecalciferol) hematinic/folic acid oral tablet 324-1 mg 1 hemocyte-f oral tablet 324-1 mg 1 hydroxocobalamin acetate intramuscular solution 1000 OA mcg/ml JENLIVA PRENATAL/POSTNATAL ORAL CAPSULE 1 MG 3 PV KHAPZORY INTRAVENOUS SOLUTION RECONSTITUTED OA 175 MG, 300 MG (levoleucovorin) leucovorin calcium injection solution 100 mg/10ml, 500 OA mg/50ml leucovorin calcium injection solution reconstituted 100 mg, OA 200 mg, 350 mg, 50 mg, 500 mg leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg 1 AC levoleucovorin calcium intravenous solution reconstituted OA 50 mg levoleucovorin calcium pf intravenous solution 175 OA mg/17.5ml, 250 mg/25ml LIPO-C INTRAMUSCULAR SOLUTION 3 METHYLCOBALAMIN INJECTION SOLUTION 3 RECONSTITUTED 10000 MCG, 50000 MCG NASCOBAL NASAL SOLUTION 500 MCG/0.1ML 3 (cyanocobalamin) NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o 3 PV vit a) niacin (antihyperlipidemic) oral tablet 500 mg 1 niacor oral tablet 500 mg 1 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 507 Coverage Requirements & Prescription Drug Name Drug Tier Limits ONE VITE WOMENS ORAL TABLET 27-0.8 MG 3 PV ONE-A-DAY WOMENS PRENATAL 1 ORAL CAPSULE 28-0.8- 3 PV 235 MG (prenat-fe carbonyl-fa-omega 3) POTABA ORAL CAPSULE 500 MG (potassium 3 aminobenzoate) prenatal multi +dha oral capsule 27-0.8-200 mg, 27-0.8-228 1 PV mg, 27-0.8-250 mg prenatal oral tablet 27-0.8 mg 1 PV PRENATVITE RX ORAL TABLET 0.8 MG 3 QUFLORA FE ORAL TABLET CHEWABLE 0.25 MG (multi vit- 3 min-fluoride-fe-fa) RELNATE DHA ORAL CAPSULE 28-1-200 MG 3 PV SAFYRAL ORAL TABLET 3-0.03-0.451 MG (drospiren-eth 3 estrad-levomefol) thiamine hcl injection solution 100 mg/ml 1 tydemy oral tablet 3-0.03-0.451 mg 1 PV vitamin b complex 100 injection injectable OA VITAMIN B COMPLEX-HYDROXOCOBAL INJECTION OA INJECTABLE vitamin b-complex 100 injection injectable OA yl folic acid oral tablet 400 mcg 1 PV VITAMIN C adc/f (0.5mg/ml) oral solution 0.5 mg/ml 1 PV ASCOR INTRAVENOUS SOLUTION 25000 MG/50ML OA (ascorbic acid) ASCORBIC ACID INTRAVENOUS SOLUTION 15000 OA MG/30ML ASCORBIC ACID SOLUTION 500 MG/ML INJECTION 500 OA MG/ML

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 508 Coverage Requirements & Prescription Drug Name Drug Tier Limits ascorbic acid solution 500 mg/ml injection 500 mg/ml OA MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM 3 QL (1 EA per 1 fill) (peg-kcl-nacl-nasulf-na asc-c) peg-3350/electrolytes/ascorbat oral solution reconstituted 1 QL (1 EA per 1 fill) 100 gm peg-kcl-nacl-nasulf-na asc-c oral solution reconstituted 100 1 QL (1 EA per 1 fill) gm PLENVU ORAL SOLUTION RECONSTITUTED 140 GM (peg- 3 kcl-nacl-nasulf-na asc-c) tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 PV vitamins acd-fluoride oral solution 0.25 mg/ml 1 PV VITAMIN D adc/f (0.5mg/ml) oral solution 0.5 mg/ml 1 PV CALCIFOL ORAL WAFER 1342-1.6 MG (ca carb-fa-d-b6-b12- 3 boron-mg) calcitriol intravenous solution 1 mcg/ml OA calcitriol oral capsule 0.25 mcg, 0.5 mcg 1 calcitriol oral solution 1 mcg/ml 1 calcium-folic acid plus d oral wafer 1342-1 mg 1 d3 high potency oral capsule 25 mcg (1000 ut) 1 PV DECARA K ORAL CAPSULE 1250-200 MCG (vitamin d- 3 vitamin k) doxercalciferol intravenous solution 4 mcg/2ml OA doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg 1 DRISDOL ORAL CAPSULE 1.25 MG (50000 UT) 3 (ergocalciferol) d-vite pediatric oral liquid 10 mcg/ml 1 PV ERGOCAL ORAL CAPSULE 62.5 MCG (2500 UT) 3 ergocalciferol oral capsule 1.25 mg (50000 ut) 1 Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 509 Coverage Requirements & Prescription Drug Name Drug Tier Limits FOLDITAM ORAL TABLET 1-10000 MG-UNIT (folic acid- 3 cholecalciferol) FOLIC D3 ORAL CAPSULE 1-3775 MG-UNIT 3 FOLI-D ORAL TABLET 1-2000 MG-UNIT (folic acid- 3 cholecalciferol) FOLITE ORAL TABLET 3 FOLVITE-D ORAL TABLET 1-3775 MG-UNIT (folic acid- 3 cholecalciferol) FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, 70- 2 5600 MG-UNIT (alendronate-cholecalciferol) HECTOROL INTRAVENOUS SOLUTION 4 MCG/2ML OA (doxercalciferol) kids first vitamin d3 gummies oral tablet chewable 25 mcg 1 PV (1000 ut) oyster shell calcium/d oral tablet 500-200 mg-unit, 500-400 1 PV mg-unit, 500-5 mg-mcg oyster shell calcium/vit d3 oral tablet 250-3.12 mg-mcg 1 PV oyster shell calcium/vitamin d oral tablet 500-200 mg-unit 1 PV paricalcitol intravenous solution 2 mcg/ml, 5 mcg/ml OA paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 1 pharmacist choice d-vitamin oral liquid 400 unit/ml 1 PV RAYALDEE ORAL CAPSULE EXTENDED RELEASE 30 MCG 3 (calcifediol) ROCALTROL ORAL CAPSULE 0.25 MCG, 0.5 MCG 3 (calcitriol) ROCALTROL ORAL SOLUTION 1 MCG/ML (calcitriol) 3 tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 PV vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) 1 vitamins acd-fluoride oral solution 0.25 mg/ml 1 PV

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 510 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZEMPLAR INTRAVENOUS SOLUTION 2 MCG/ML, 5 MCG/ML OA (paricalcitol) ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG (paricalcitol) 3 VITAMIN E wheat germ oil oral oil 1 VITAMIN K ACTIVITY DECARA K ORAL CAPSULE 1250-200 MCG (vitamin d- 3 vitamin k) MEPHYTON ORAL TABLET 5 MG (phytonadione) 3 phytonadione injection solution 1 mg/0.5ml, 10 mg/ml OA phytonadione oral tablet 5 mg 1 vitamin k1 injection solution 1 mg/0.5ml, 10 mg/ml OA

Tier 1: Preferred generic and certain preferred brand-name medications; Tier 2: Preferred brand name and certain non-preferred generic medications; Tier 3: Non-preferred (generic or brand) medications; SI: Self- injectable medications; ED: Erectile dysfunction medications; INF: Infertility medications; OA: Office administered medications; AL: Age Limit – These medications may require prior authorization if your age does not fall within the drug manufacturer, Food and Drug Administration (FDA) or treatment guideline recommendations; AC: Anti-Cancer – These oral anti-cancer drugs are subject to a maximum copayment for up to each 30-day supply, after any deductible has been met (per California State Law). This amount is listed in your WHA Copayment Summary; PA: Prior Authorization – Your doctor is required to give Western Health Advantage more information to determine coverage; QL: Quantity Limit – Medication may be limited to a certain quantity ; ST: Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered; PV: Due to Health Care Reform this product may be available at zero copay through your pharmacy benefit; SP: Specialty Medication – May require PA, limited to 30-day supply. Up to 2 initial fills allowed at local retail pharmacies. Exceptions may be allowed when manufacturer or FDA limits supply to select specialty pharmacies only; *: Copayments waived for this medication; any plan deductible still applies Effective Date 10/01/2021 511 Index of Drugs 1ST MEDX-PATCH/ acetaminophen-codeine #2 ADDERALL...... 179 LIDOCAINE...... 318, 477, 494 ...... 180, 222 ADDERALL XR...... 179 7T LIDO...... 471 acetaminophen-codeine #3 ADDYI...... 215 abacavir sulfate...... 36 ...... 180, 222 adefovir dipivoxil...... 43 abacavir sulfate-lamivudine...36 acetaminophen-codeine #4 ADEMPAS...... 465 abacavir-lamivudine- ...... 180, 222 ADENOCAINE...... 281 zidovudine...... 36 acetazolamide151, 184, 276, 307 adenosine...... 159, 263 ABECMA...... 177 acetazolamide er adenosine (diagnostic)...... 263 ABELCET...... 46 ...... 151, 184, 276, 307 ADHANSIA XR...... 237 ABILIFY...... 192, 203 acetazolamide sodium ADIPEX-P...... 178 ABILIFY MAINTENA...... 191, 203 ...... 151, 184, 277, 308 ADLYXIN...... 381 ABILIFY MYCITE...... 192, 203 acetic acid...... 277, 314 ADLYXIN STARTER PACK.... 381 ABILIFY MYCITE acetylcysteine...... 414, 459 ADMELOG...... 398 MAINTENANCE KIT...... 192, 203 ACIOXIAY...... 495 ADMELOG SOLOSTAR...... 398 ABILIFY MYCITE STARTER ACIPHEX...... 335 ADRENALIN...... 89, 321, 452 KIT...... 192, 203 ACIPHEX SPRINKLE...... 335 adriamycin...... 53 abiraterone acetate...... 53 acitretin...... 495 ADUHELM...... 215 ABLYSINOL...... 172 ACNESIC...... 489 adult aspirin regimen ABRAXANE...... 53 ACREMONIUM...... 75, 258 ...... 129, 131, 196, 241 ABSORICA...... 495 ACTEMRA...... 427, 432 ADVAIR DISKUS...... 109, 339 ABSORICA LD...... 495 ACTEMRA ACTPEN...... 427, 432 ADVAIR HFA...... 109, 339 ACACIA...... 75, 258 ACTHAR...... 258, 384 ADVATE...... 121 acamprosate calcium...... 215 ACTHIB...... 85 ADYNOVATE...... 121 ACANYA...... 467, 491 ACTICLATE...... 21, 49 ADZENYS ER...... 179 acarbose...... 348 ACTIMMUNE...... 432 ADZENYS XR-ODT...... 179 ACCOLATE...... 458 ACTIQ...... 222 AEMCOLO...... 48 ACCRUFER...... 127 ACTIVASE...... 131, 298 AEROCHAMBER MINI ACCU-CHEK AVIVA...... 249 ACTIVE INJECTION D...... 339 CHAMBER...... 249 ACCU-CHEK AVIVA PLUS.....263 ACTIVE INJECTION DL. 339, 408 AEROCHAMBER MV...... 250 ACCU-CHEK COMPACT ACTIVE INJECTION KL-3 AEROCHAMBER PLUS FLO- PLUS CONTROL...... 249 ...... 237, 339, 408 VU...... 250 ACCU-CHEK COMPACT ACTIVE INJECTION KM.339, 408 AEROCHAMBER PLUS PLUS TEST STRIPS...... 263 ACTIVELLA...... 366, 386 FLOW VU...... 250 ACCU-CHEK GUIDE...... 263 ACTONEL...... 421 AEROCHAMBER ACCU-CHEK GUIDE ACTOPLUS MET...... 352, 406 W/FLOWSIGNAL...... 250 CONTROL...... 249 ACTOS...... 406 AFINITOR...... 53 ACCU-CHEK SMARTVIEW ACULAR...... 317 AFINITOR DISPERZ...... 53 CONTROL...... 249 ACULAR LS...... 317 afirmelle...... 354, 366, 386 ACCU-CHEK SMARTVIEW ACUVAIL...... 317 AFLURIA QUADRIVALENT...... 85 TEST STRIPS...... 263 acyclovir...... 43, 475 AFREZZA...... 399 ACCUPRIL...... 137, 138 acyclovir sodium...... 43 AFSTYLA...... 121 ACCURETIC...... 138, 294 ACZONE...... 467, 495 AGAMATRIX CONTROL accutane...... 495 ADACEL...... 84, 85 LEVEL 2...... 250 ACD FORMULA A...... 116 ADAKVEO...... 117 AGAMATRIX CONTROL ACD-A NOCLOT-50...... 116 adapalene...... 495 LEVEL 4...... 250 acebutolol hcl 112, 141, 144, 155 ADAPALENE...... 495 AGAMATRIX PRESTO TEST.263 ACETADOTE...... 414 adapalene-benzoyl peroxide AGGRASTAT...... 129, 282 acetaminophen...... 180, 196 ...... 491, 495 AGRYLIN...... 130 ACETAMINOPHEN...... 180, 196 adc/f (0.5mg/ml) AIMOVIG...... 213 acetaminophen-codeine ...... 424, 505, 506, 508, 509 AIRDUO DIGIHALER...... 109, 339 ...... 180, 222 ADCETRIS...... 53 ADCIRCA...... 171, 465

512 AIRDUO RESPICLICK 113/14 ALOCRIL...... 301, 459 AMICAR...... 122 ...... 109, 340 ALOGLIPTIN BENZOATE...... 364 AMIDATE...... 218 AIRDUO RESPICLICK 232/14 ALOGLIPTIN-METFORMIN amikacin sulfate...... 17 ...... 109, 340 HCL...... 352, 364 amiloride hcl...... 172, 281 AIRDUO RESPICLICK 55/14 ALOGLIPTIN-PIOGLITAZONE amiloride- ...... 109, 340 ...... 364, 406 hydrochlorothiazide...... 281, 294 AJOVY...... 213 ALOMIDE...... 12, 301 AMINO ACID...... 270 ak-fluor...... 267 ALOPRIM...... 419 aminoamrms...... 270 AKLIEF...... 495 ALORA...... 366, 421 aminocaproic acid...... 122 AKOVAZ...... 89, 452 alosetron hcl...... 325 aminophylline...... 504 ak-poly-bac...... 302 ALOXI...... 322 AMINOPMRMS...... 270 AKTEN...... 318 ALPHAGAN P...... 301 AMINOPROTECT...... 270 AKYNZEO...... 322, 333 ALPHA-LIPOIC ACID...... 442 aminoreliefrms...... 270 ALA SCALP...... 479 ALPHANATE...... 121 AMINOSYN II...... 270 ala-cort...... 479 ALPHANINE SD...... 121 AMINOSYN-PF...... 270 ALA-QUIN...... 471, 479 alprazolam...... 210 amiodarone hcl...... 158 albendazole...... 20 alprazolam er...... 210 AMIODARONE HCL IN ALBENZA...... 20 alprazolam intensol...... 210 DEXTROSE...... 158, 270 ALBUKED 25...... 114 alprazolam xr...... 210 AMITIZA...... 330 ALBUKED 5...... 114 ALPROLIX...... 121 amitriptyline hcl...... 247 albumin human...... 114 alprostadil...... 174 amlodipine besylate ALBUMINEX...... 114 ALREX...... 308 ...... 161, 163, 174 albumin-zlb...... 114 ALTABAX...... 467 amlodipine besylate- alburx...... 115 ALTACAINE...... 318 benazepril hcl...... 138, 161 ALBUTEIN...... 115 ALTACE...... 137, 138 amlodipine besylate- albuterol sulfate...... 110, 463 altafrin...... 319, 321 valsartan...... 134, 161 ALBUTEROL SULFATE. 110, 463 altavera...... 354, 366, 386 amlodipine-atorvastatin161, 166 albuterol sulfate hfa...... 109, 463 ALTERNARIA...... 75, 258 amlodipine-olmesartan.134, 161 ALBUTEROL SULFATE HFA ALTOPREV...... 166 amlodipine-valsartan-hctz ...... 110, 463 ALTRENO...... 477 ...... 134, 161, 294 ALCAINE...... 318 ALUNBRIG...... 53 ammonium lactate...... 477 alclometasone dipropionate 479 ALVESCO...... 340 AMMONUL...... 269 ALCOHOL PREP PADS...... 250 alvimopan...... 330 amnesteem...... 495 ALDACTAZIDE...... 168, 294 alyacen 1/35...... 354, 366, 386 AMONDYS 45...... 420 ALDACTONE.. 168, 169, 172, 281 alyacen 7/7/7...... 354, 366, 386 amoxapine...... 247 ALDARA...... 495 alyq...... 171, 465 amoxicill-clarithro-lansopraz ALDER...... 75, 258 amabelz...... 366, 386 ...... 19, 44, 335 ALDURAZYME...... 298 amantadine hcl...... 16, 178 amoxicillin...... 19, 326, 327 ALECENSA...... 53 AMARYL...... 405 amoxicillin-potassium alendronate sodium...... 421 AMBIEN...... 200 clavulanate...... 19 alfentanil hcl...... 222 AMBIEN CR...... 200 amoxicillin-potassium ALFERON N...... 40, 53, 432 AMBISOME...... 46 clavulanate er...... 19 alfuzosin hcl er...... 108 ambrisentan...... 465 AMPHADASE...... 298 ALIMTA...... 53 amcinonide...... 479 AMPHETAMINE ER...... 179 ALINIA...... 23 AMD FOAM DRESSING...... 250 amphetamine- ALIQOPA...... 53 AMELUZ...... 495 dextroamphetamine...... 179 aliskiren fumarate...... 172 AMERGE...... 243 amphetamine- ALKERAN...... 53 AMERICAN BEECH...... 75, 258 dextroamphetamine er...... 179 ALKINDI SPRINKLE...... 340 AMERICAN COCKROACH amphotericin b...... 47 allopurinol...... 418 ...... 75, 258 ampicillin...... 19 allopurinol sodium...... 418 AMERICAN ELM...... 75, 258 ampicillin sodium...... 19 ALLZITAL...... 180, 207 amethia...... 354, 366, 386 ampicillin-sulbactam sodium.19 almotriptan malate...... 243 amethyst...... 354, 366, 386 AMPYRA...... 442

513 AMRIX...... 100 APTIVUS...... 39 ASMANEX (30 METERED AMVISC...... 314 AQUASOL A...... 506 DOSES)...... 340 AMVISC PLUS...... 314 ARAKODA...... 21 ASMANEX (60 METERED AMYTAL SODIUM...... 207 ARALAST NP...... 462 DOSES)...... 340 AMZEEQ...... 467 aranelle...... 354, 367, 387 ASMANEX (7 METERED ANACAINE...... 318, 472 ARANESP (ALBUMIN FREE) DOSES)...... 341 ANAFRANIL...... 247 ...... 115, 116, 119 ASMANEX HFA...... 341 anagrelide hcl...... 130 ARAVA...... 427, 432, 439 ASPARLAS...... 54 ANALPRAM HC...... 472, 479 ARAZLO...... 495 aspirin.... 129, 131, 196, 197, 241 ANALPRAM HC SINGLES ARCALYST...... 443 aspirin adult low dose ...... 472, 479 arformoterol tartrate...... 110 ...... 129, 131, 196, 241 ANALPRAM-HC...... 472, 479 argatroban...... 118 aspirin adult low strength ANASCORP...... 81 argatroban in sodium ...... 129, 131, 196, 241 ANASPAZ...... 94 chloride...... 118 aspirin childrens anastrozole...... 54, 351 ARGININE HCL...... 270 ...... 129, 131, 196, 241 ANAVIP...... 81, 414 argyle sterile saline...... 277 aspirin ec...... 129, 131, 196, 241 ANCOBON...... 47 argyle sterile water...... 277 aspirin ec low dose ANDEXXA...... 117 ARICEPT...... 106 ...... 129, 131, 196, 241 ANDRODERM...... 349 ARIKAYCE...... 17 aspirin ec low strength ANDROGEL...... 349 ARIMIDEX...... 54, 351 ...... 129, 131, 196, 241 ANDROGEL PUMP...... 349 aripiprazole...... 192, 203 aspirin low dose ANESTHESIA S/I-40A.... 200, 218 ARIXTRA...... 116 ...... 129, 131, 196, 241 ANESTHESIA S/I-40H.... 200, 218 ARIZONA CYPRESS...... 75 aspirin-dipyridamole er 129, 241 ANESTHESIA S/I-40S.... 200, 218 armodafinil...... 248 ASPIRIN-OMEPRAZOLE129, 335 ANGELIQ...... 367, 387 ARMONAIR DIGIHALER 340, 460 ASSURE PLATINUM...... 263 ANGIOMAX...... 118 ARMOUR THYROID...... 406 ASTAGRAF XL...... 439 ANJESO...... 232 ARNUITY ELLIPTA...... 340, 460 ASTERO...... 472 ANNOVERA...... 354, 367, 387 AROMASIN...... 54, 351 ASTRINGYN...... 122 ANORO ELLIPTA...... 94, 110 ARRANON...... 54 ATACAND...... 134, 135 ANTARA...... 165 arsenic trioxide...... 54 ATACAND HCT...... 135, 295 ANTICOAGULANT SODIUM ARTESUNATE...... 21 atazanavir sulfate...... 39 CITRATE...... 116 ARTHROTEC...... 232, 334 ATELVIA...... 421 ANTIVENIN LATRODECTUS ARTICADENT DENTAL....89, 408 atenolol...... 112, 141, 144, 155 MACTANS...... 81, 414 ARTISS...... 495 atenolol-chlorthalidone 141, 297 ANTIVENIN MICRURUS ARZERRA...... 54 ATGAM...... 439 FULVIUS...... 81, 414 ARZOL SILVER NIT ATIVAN...... 209, 210 ANTIVERT...... 9, 325 APPLICATORS...... 313 atomoxetine hcl...... 215 ANUSOL-HC...... 479 ASACOL HD...... 325 atorvastatin calcium...... 166 apap-caff-dihydrocodeine ASCENIV...... 81 atovaquone...... 23 ...... 180, 222, 223, 237 ASCLERA...... 172 atovaquone-proguanil hcl...... 21 APEXICON E...... 479 ascomp-codeine atracurium besylate...... 102 APIDRA SOLOSTAR...... 399 ...... 207, 223, 238, 241 ATRALIN...... 478 APIDRA VIAL...... 399 ASCOR...... 508 ATRIPLA...... 35, 36 APLENZIN...... 190 ASCORBIC ACID...... 508 ATROPEN...... 94, 414, 453 APOKYN...... 221 ascorbic acid...... 509 atropine sulfate94, 319, 414, 454 APO-VARENICLINE...... 99 asenapine maleate...... 192, 203 ATROPINE SULFATE APP SLIM RMS...... 270 ashlyna...... 354, 367, 387 ...... 94, 319, 415, 454 apraclonidine hcl...... 314 asilnasalrms...... 270 ATROVENT HFA...... 94, 454 aprepitant...... 333 ASMANEX (120 METERED AUBAGIO...... 432 apri...... 354, 367, 387 DOSES)...... 340 aubra...... 355, 367, 387 APRISO...... 325 ASMANEX (14 METERED aubra eq...... 355, 367, 387 APTENSIO XR...... 237 DOSES)...... 340 AUGMENTIN...... 19, 20 APTIOM...... 184 AUGMENTIN ES-600...... 19

514 AUREOBASIDIUM...... 75, 258 bacitra-neomycin- BENZACLIN...... 467, 491 aurovela 1.5/30...... 355, 367, 387 polymyxin-hc...... 302, 308 BENZACLIN WITH PUMP aurovela 1/20...... 355, 367, 387 baclofen...... 101 ...... 468, 491 aurovela 24 fe...... 355, 367, 387 BACTERIOSTATIC benzalkonium chloride...... 491 aurovela fe 1.5/30.. 355, 367, 387 WATER(BENZ ALC)...... 451 BENZAMYCIN...... 468, 491 aurovela fe 1/20..... 355, 367, 387 BACTRIM...... 23, 49, 51 BENZEPRO...... 491 AURYXIA...... 280 BACTRIM DS...... 23, 49, 51 benzepro...... 491 AUSTEDO...... 248 BAFIERTAM...... 433 BENZEPRO SHORT AUSTRALIAN PINE...... 76, 258 BAHIA...... 76, 258 CONTACT...... 491 AUVI-Q...... 89, 452 bal in oil...... 337, 415 BENZNIDAZOLE...... 23 AVALIDE...... 135, 295 balanced salt...... 314 benzonatate...... 455 AVAPRO...... 134, 135 BALCOLTRA...... 355, 367, 387 BENZOYL PEROX- AVASTIN...... 54 BALD CYPRESS...... 76 HYDROCORTISONE...... 479, 491 AVEED...... 349 balsalazide disodium...... 325 benzoyl peroxide...... 491 aviane...... 355, 367, 387 BALVERSA...... 54 BENZOYL PEROXIDE...... 491 avidoxy...... 21, 49 balziva...... 355, 367, 387 BENZOYL PEROXIDE AVITA...... 478 BAMLANIVIMAB...... 41 FORTE- HC...... 479, 491 AVODART...... 413 BANZEL...... 184 benzoyl peroxide- AVONEX PEN...... 432 BAQSIMI ONE PACK..... 378, 415 erythromycin...... 468, 491 AVONEX PREFILLED...... 432 BAQSIMI TWO PACK.....378, 415 benztropine mesylate..... 98, 184 AVSOLA...... 330, 427, 432, 495 BARACLUDE...... 43 BEOVU...... 314 AVYCAZ...... 15 BARHEMSYS...... 324 bepotastine besilate...... 301 AYGESTIN...... 387 BASAGLAR KWIKPEN...... 383 BEPREVE...... 301 ayuna...... 355, 367, 387 BAVENCIO...... 54 BERINERT...... 426 AYVAKIT...... 54 BAXDELA...... 47 BERMUDA GRASS.. 76, 258, 259 azacitidine...... 54 BAYBERRY (WAX MYRTLE) beser...... 479 AZACTAM...... 41 ...... 76, 258 BESIVANCE...... 302 AZASAN...... 427, 432, 439 BAYER ASPIRIN BESPONSA...... 55 AZASITE...... 302 ...... 129, 130, 131, 197, 241 BETA 1 KIT...... 341 azathioprine...... 427, 433, 439 BAYER ASPIRIN EC LOW BETADINE OPHTHALMIC azathioprine sodium DOSE...... 129, 131, 197, 241 PREP...... 313 ...... 427, 433, 439 BCG VACCINE...... 85 BETAMETHASONE COMBO. 341 AZEDRA DOSIMETRIC...... 54 B-COMPLEX...... 506 betamethasone dipropionate AZEDRA THERAPEUTIC...... 54 BD AUTOSHIELD DUO PEN ...... 480 azelaic acid...... 495 NEEDLES...... 250 betamethasone dipropionate azelastine hcl...... 301, 462 BD ULTRA-FINE INSULIN aug...... 479 azelastine-fluticasone SYRINGES...... 250 BETAMETHASONE SOD ...... 301, 308, 459, 462 BD ULTRA-FINE PEN PHOS & ACET...... 341 AZELEX...... 495 NEEDLES...... 250 betamethasone sod phos & AZILECT...... 220, 221 BECONASE AQ...... 308, 460 acet...... 341 azithromycin...... 45 BELBUCA...... 231 BETAMETHASONE SODIUM AZOPT...... 308 BELEODAQ...... 54 PHOSPHATE...... 341 AZOR...... 135, 161 BELRAPZO...... 54 betamethasone valerate...... 480 AZSTARYS...... 238 BELSOMRA...... 200 BETAPACE aztreonam...... 41 benazepril hcl...... 137, 138 ...... 102, 141, 144, 156, 158 AZULFIDINE..... 49, 325, 428, 433 benazepril- BETAPACE AF AZULFIDINE EN-TABS hydrochlorothiazide...... 138, 295 ...... 102, 141, 144, 155, 158 ...... 49, 325, 428, 433 BENDEKA...... 54 BETASERON...... 433 azurette...... 355, 367, 387 BENEFIX...... 122 betaxolol hcl bac...... 180, 207, 238 BENICAR...... 134, 135 ...... 112, 141, 144, 156, 306 bacitracin...... 28, 302 BENICAR HCT...... 135, 295 bethanechol chloride...... 106 bacitracin-polymyxin b...... 302 BENLYSTA...... 439 BETHKIS...... 17 BENTYL...... 94 BETIMOL...... 306

515 BETOPTIC-S...... 306 bosentan...... 465 BUDESONIDE- BEVACIZUMAB...... 314 BOSULIF...... 55 FORMOTEROL FUMARATE BEVESPI AEROSPHERE.94, 110 BOTOX...... 114, 443 ...... 110, 341 bexarotene...... 55 BOTOX COSMETIC...... 114, 443 bumetanide...... 168, 279 BEXSERO...... 85 BOTRYTIS...... 76, 259 BUMEX...... 168, 279 BEYAZ...... 355, 367, 387, 506 bp cleansing wash...... 468, 489 BUNAVAIL...... 230, 231 bicalutamide...... 55 BRAFTOVI...... 55 BUPAP...... 181, 207 BICILLIN C-R...... 42 BREATHE EASE LARGE...... 251 BUPHENYL...... 269 BICILLIN C-R 900/300...... 42 BREATHE EASE MEDIUM.....251 bupivacaine fisiopharma...... 408 BICILLIN L-A...... 42 BREATHE EASE SMALL...... 251 bupivacaine hcl...... 408 BICNU...... 55 BREO ELLIPTA...... 110, 341 BUPIVACAINE HCL...... 408 BIDIL...... 164, 169 BRETYLIUM TOSYLATE...... 158 bupivacaine hcl (pf)...... 408 BIJUVA...... 367, 387 BREVIBLOC... 113, 141, 144, 156 BUPIVACAINE HCL-NACL BIKTARVY...... 34, 35, 37 BREVIBLOC IN NACL ...... 282, 408, 409 BILTRICIDE...... 20 ...... 113, 141, 144, 156, 282 bupivacaine in dextrose bimatoprost...... 320 BREVIBLOC PREMIXED ...... 270, 409 BI-MIX...... 104, 174 ...... 113, 141, 144, 156, 282 bupivacaine spinal...... 270, 409 BINOSTO...... 421 BREVIBLOC PREMIXED DS bupivacaine-epinephrine 89, 409 BIOFREQUENCY INSOLES...250 ...... 113, 141, 144, 156, 282 bupivacaine-epinephrine (pf) BIORPHEN...... 92 BREVITAL SODIUM...... 206, 208 ...... 89, 409 BIOTHRAX...... 85 BREXAFEMME...... 20 BUPIVILOG...... 341, 409 bisacodyl ec...... 327 BREYANZI...... 55, 177 BUPRENEX...... 232 bisoprolol fumarate BREZTRI AEROSPHERE buprenorphine...... 232 ...... 112, 141, 144, 156 ...... 95, 110, 341 buprenorphine hcl...... 232 bisoprolol- BRIDION...... 415 buprenorphine hcl-naloxone hydrochlorothiazide...... 141, 295 briellyn...... 355, 367, 388 hcl...... 230, 231, 232 BIVALIRUDIN RTU...... 118 BRILINTA...... 130 bupropion hcl...... 191 bivalirudin trifluoroacetate...118 brimonidine tartrate...... 301 bupropion hcl er (smoking BIVALIRUDIN-SODIUM BRINEURA...... 298 det)...... 190 CHLORIDE...... 118, 282 brinzolamide...... 308 bupropion hcl er (sr)...... 191 BIVIGAM...... 81 BRISDELLE...... 245 bupropion hcl er (xl)...... 191 BLACK WILLOW...... 76, 259 BRIVIACT...... 184, 185 BUPROPION HCL ER (XL).... 191 BLENREP...... 55 BROME...... 76, 259 buspirone hcl...... 200 bleomycin sulfate...... 55 bromfenac sodium (once- busulfan...... 55 BLEPH-10...... 302 daily)...... 317 BUSULFEX...... 55 BLEPHAMIDE...... 302, 308 bromocriptine mesylate...... 218 butalbital-acetaminophen BLEPHAMIDE S.O.P...... 302, 308 BROMPHENIRAMINE ...... 181, 207 BLINCYTO...... 55 MALEATE...... 9, 12, 457 BUTALBITAL- blisovi 24 fe...... 355, 367, 387 BROMSITE...... 317 ACETAMINOPHEN...... 181, 207 blisovi fe 1.5/30..... 355, 367, 387 BRONCHITOL...... 462 butalbital-apap-caff-cod blisovi fe 1/20...... 355, 367, 387 BRONCHITOL TOLERANCE ...... 181, 207, 223, 238 BLOOD GLUCOSE TEST...... 263 TEST...... 462 butalbital-apap-caffeine BLOXIVERZ...... 106, 267 BROVANA...... 110 ...... 181, 207, 238 BLULINK CONTROL HIGH & BRUKINSA...... 55 butalbital-asa-caff-codeine LOW...... 251 BRYHALI...... 480 ...... 208, 223, 238, 241 BLULINK GLUCOSE BSP 0820...... 341 butalbital-aspirin-caffeine MONITORING SYS...... 251 BSS...... 314 ...... 208, 238, 241 BLULINK GLUCOSE TEST.... 263 bss plus...... 315 butorphanol tartrate...... 197, 232 BOCASAL...... 314 BSS PLUS...... 315 BUTRANS...... 232 BONIVA...... 421 budesonide...... 341, 461 BYDUREON BCISE BONJESTA...... 325 budesonide er...... 341 AUTOINJECTOR...... 381 BOOSTRIX...... 84, 85 BYETTA 10 MCG PEN...... 381 BORTEZOMIB...... 55 BYETTA 5 MCG PEN...... 381

516 BYFAVO...... 210 CAPEX...... 480 CARETOUCH CONTROL SOL BYLVAY...... 330 CAPLYTA...... 203 LEVEL 2...... 251 BYLVAY (PELLETS)...... 330 CAPRELSA...... 56 CARETOUCH TEST...... 264 BYSTOLIC...... 103, 141 captopril...... 137, 138 carisoprodol...... 100 CABENUVA...... 34, 35 CARAC...... 496 carisoprodol-aspirin-codeine cabergoline...... 218 CARAFATE...... 335 ...... 100, 223, 241 CABLIVI...... 117 CARBAGLU...... 269 carmustine...... 56 CABOMETYX...... 55 carbamazepine...... 185, 192 CARNITOR...... 443 CADUET...... 161, 166 carbamazepine er...... 185, 192 CARNITOR SF...... 443 CAFCIT...... 197, 238 CARBATROL...... 185, 192 CAROSPIR..... 168, 169, 172, 281 CAFERGOT...... 105, 197, 238 carbidopa...... 217 carteolol hcl...... 306 caffeine citrate...... 197, 238 carbidopa-levodopa...... 217 cartia xt...... 148, 150, 159, 174 CAFFEINE-SODIUM carbidopa-levodopa er...... 217 CARTICEL...... 443 BENZOATE...... 197, 238 carbidopa-levodopa- carvedilol CALAN SR...... 148, 149, 159, 174 entacapone...... 214, 217 103, 108, 132, 133, 141, 145, 156 CALCIFOL...... 282, 506, 509 carbinoxamine maleate.... 9, 457 carvedilol phosphate er calcipotriene...... 495 CARBOCAINE...... 409 103, 108, 132, 133, 142, 145, 156 CALCIPOTRIENE...... 495 CARBOCAINE cascara sagrada...... 327 calcipotriene-betameth PRESERVATIVE-FREE...... 409 CASIRIVIMAB...... 41 diprop...... 480, 496 carboplatin...... 56 CASODEX...... 56 calcitonin (salmon)...... 352, 421 carboprost tromethamine.... 450 caspofungin acetate...... 29 CALCITRENE...... 496 CARDENE IV...... 161, 163, 174 CAT HAIR EXTRACT...... 76, 259 calcitriol...... 496, 509 CARDIOPLEGIA DEL NIDO CATAFLAM...... 233 calcium acetate...... 280, 282 FORMULA...... 282 CATAPRES-TTS-1...... 92, 153 calcium acetate (phos CARDIOPLEGIA IND PLASMA CATAPRES-TTS-2...... 92, 153 binder)...... 280, 282 HIGH K...... 282 CATAPRES-TTS-3...... 92, 153 CALCIUM CHLORIDE...... 282 CARDIOPLEGIA IND CATHFLO ACTIVASE.... 131, 298 calcium chloride...... 282 PLASMA-TROMET...... 283 CATTLE EPITHELIUM...... 76, 259 CALCIUM DISODIUM CARDIOPLEGIA INDUCTION cavarest...... 424 VERSENATE...... 337, 415 HIGH K...... 283 CAVERJECT...... 174 calcium gluconate...... 282 CARDIOPLEGIA INDUCTION CAVERJECT IMPULSE...... 174 CALCIUM GLUCONATE- LOW DEX...... 283 CAYA...... 449 NACL...... 282 CARDIOPLEGIA INDUCTION CAYSTON...... 41 calcium-folic acid plus d NON-ENR...... 283 caziant...... 355, 368, 388 ...... 282, 506, 509 CARDIOPLEGIA MAIN LOW CEDAR ELM...... 76, 259 CALDOLOR...... 233 DEXTROSE...... 283 cefaclor...... 14 CALIFORNIA PEPPER TREE.. 76 CARDIOPLEGIA MAIN LOW cefaclor er...... 14 CALQUENCE...... 55 TROMETHA...... 283 cefadroxil...... 13 CAMBIA...... 197, 233 CARDIOPLEGIA MAIN CEFALY KIT...... 251 camila...... 355, 388 PLASMA-TROME...... 283 CEFAZOLIN IN SODIUM CAMPTOSAR...... 56 CARDIOPLEGIA CHLORIDE...... 13, 283 camrese...... 355, 368, 388 MAINTENANCE...... 283 cefazolin sodium...... 13 camrese lo...... 355, 368, 388 CARDIOPLEGIA CEFAZOLIN SODIUM...... 13 CANASA...... 326 REPERFUSATE 4:1...... 283 cefazolin sodium-dextrose CANCIDAS...... 29 CARDIOPLEGIC...... 283 ...... 13, 270, 271 candesartan cilexetil.....134, 135 cardioplegic...... 283 CEFAZOLIN SODIUM- candesartan cilexetil-hctz CARDIZEM..... 148, 150, 159, 174 DEXTROSE...... 13, 271 ...... 135, 295 CARDIZEM CD cefdinir...... 15 CANDIDA ALBICANS ...... 148, 149, 159, 174 cefepime hcl...... 16 EXTRACT...... 76, 259 CARDIZEM LA 148, 150, 159, 174 cefepime-dextrose...... 16, 271 CANTHARIDIN...... 489 CARDURA...... 104, 132, 133 cefixime...... 15 CAPASTAT SULFATE...... 24 CARDURA XL...... 104, 132, 133 CEFOTAN...... 14, 28 capecitabine...... 56 cefotaxime sodium...... 15

517 cefotetan disodium...... 14, 28 CHENODAL...... 329 CIPROFLOXACIN- cefotetan disodium-dextrose CHIRHOSTIM...... 267 FLUOCINOLONE PF...... 303, 309 ...... 14, 28 CHLOOXIA...... 480, 496 cisatracurium besylate...... 102 cefoxitin sodium...... 14, 29 chloramphenicol sod cisatracurium besylate (pf).. 102 CEFOXITIN SODIUM- succinate...... 29 cisplatin...... 56 DEXTROSE...... 14, 29 chlordiazepoxide hcl...... 210 CISPLATIN...... 56 cefpodoxime proxetil...... 15 chlordiazepoxide- citalopram hydrobromide.....245 cefprozil...... 14 amitriptyline...... 211, 247 citroma...... 327 ceftazidime...... 15 chlordiazepoxide-clidinium CLADOSPORIUM ceftazidime and dextrose ...... 95, 211 CLADOSPORIOIDES...... 76, 259 ...... 15, 271 chlorhexidine gluconate CLADOSPORIUM ceftriaxone sodium...... 15 ...... 313, 491 SPHAEROSPERMUM...... 76, 259 ceftriaxone sodium in CHLORHEXIDINE cladribine...... 56 dextrose...... 15, 271 GLUCONATE...... 491 claravis...... 496 ceftriaxone sodium-dextrose chloroprocaine hcl (pf)...... 409 CLARINEX...... 12, 462 ...... 15, 271 chloroquine phosphate...... 21 CLARINEX-D 12 HOUR...... 13, 89 cefuroxime axetil...... 14 chlorothiazide sodium..173, 295 clarithromycin...... 25, 45, 327 cefuroxime sodium...... 14 chlorpromazine hcl...... 236, 237 clarithromycin er...... 25, 45, 327 CELEBREX...... 216 chlorthalidone...... 173, 297 clearlax...... 327 celecoxib...... 216 chlorzoxazone...... 100 clemastine fumarate...... 9, 457 CELESTONE SOLUSPAN...... 342 CHOLBAM...... 330 CLENPIQ...... 327 CELEXA...... 245 cholestyramine...... 147 CLEOCIN...... 40, 468 CELLCEPT...... 439 cholestyramine light...... 147 CLEOCIN PHOSPHATE...... 41 CELLCEPT INTRAVENOUS.. 439 CHONDROITIN SULFATE..... 315 CLEOCIN-T...... 468 CELLUGEL...... 315 chorionic gonadotropin...... 379 CLEVER CHOICE HOLDING CELONTIN...... 246 chromic chloride...... 283 CHAMBER...... 251 CEM-UREA...... 489 CIALIS...... 171 CLEVER CHOICE TENS UNIT CENTANY...... 468 ciclodan...... 488 ...... 251 cephalexin...... 13, 14 ciclopirox...... 488 CLEVIPREX...... 161, 163 CEPROTIN...... 116 ciclopirox olamine...... 488 CLIMARA...... 368, 421 CEQUA...... 314 cidofovir...... 43 CLIMARA PRO...... 368, 388 CEQUR SIMPLICITY 2U...... 251 cilostazol...... 130, 171 clindacin etz...... 468 CEQUR SIMPLICITY CILOXAN...... 302 clindacin-p...... 468 INSERTER...... 251 CIMDUO...... 37 CLINDAGEL...... 468 CERDELGA...... 443 cimetidine...... 10, 332 clindamycin hcl...... 41 CEREBYX...... 220 cimetidine hcl...... 10, 332 clindamycin palmitate hcl...... 41 CEREZYME...... 298 CIMZIA...... 330, 428, 433 clindamycin phos-benzoyl cerovel...... 489 CIMZIA PREFILLED KIT perox...... 468, 492 CERVIDIL...... 450 ...... 330, 428, 433 clindamycin phosphate.. 41, 468 cetirizine hcl...... 12, 462 CIMZIA STARTER KIT CLINDAMYCIN PHOSPHATE 468 CETRAXAL...... 302 ...... 330, 428, 433 clindamycin phosphate in CETROTIDE...... 351 cinacalcet hcl...... 352 d5w...... 41, 271 cevimeline hcl...... 106 CINQAIR...... 458 CLINDAMYCIN PHOSPHATE CHANTIX...... 99 CINRYZE...... 426 IN NACL...... 41, 283 CHANTIX CONTINUING CINVANTI...... 334 clindamycin-tretinoin MONTH PAK...... 99 CIPRO...... 24, 47 ...... 468, 478, 496 CHANTIX STARTING MONTH CIPRO HC...... 303, 309 CLINDESSE...... 468 PAK...... 99 CIPRODEX...... 303, 309 CLINIMIX E/DEXTROSE charlotte 24 fe...... 355, 368, 388 ciprofloxacin hcl...... 24, 47, 303 (2.75/5)...... 271 chateal...... 355, 368, 388 ciprofloxacin in d5w...... 24, 47 CLINIMIX E/DEXTROSE chateal eq...... 355, 368, 388 ciprofloxacin- (4.25/10)...... 271 CHEMET...... 337, 415 dexamethasone...... 303, 309 CLINIMIX E/DEXTROSE CHEMSTRIP BG LOG BOOK.251 (4.25/5)...... 271

518 CLINIMIX E/DEXTROSE COARTEM...... 21 COREG CR (5/15)...... 271 COCAINE HCL...... 318 103, 108, 132, 133, 142, 145, 156 CLINIMIX E/DEXTROSE COCKLEBUR...... 76, 259 coremino...... 49, 496 (5/20)...... 271 codeine sulfate...... 223, 455 CORGARD...... 103, 142, 145 CLINIMIX E/DEXTROSE COENZYME Q-10...... 443 CORIFACT...... 122 (8/10)...... 271 COGENTIN...... 98, 184 CORLANOR...... 151, 174 CLINIMIX E/DEXTROSE COLAZAL...... 326 CORLOPAM...... 164 (8/14)...... 271 COLCHICINE...... 419 CORN POLLEN...... 76, 259 CLINIMIX/DEXTROSE colchicine...... 419 CORTANE-B...... 472, 481, 492 (4.25/10)...... 271 colchicine-probenecid..297, 419 CORTEF...... 342 CLINIMIX/DEXTROSE (4.25/5) COLCRYS...... 419 CORTENEMA...... 481 ...... 272 colesevelam hcl...... 147, 350 cortic-nd...... 309, 313, 318 CLINIMIX/DEXTROSE (5/15). 272 COLESTID...... 147 CORTIFOAM...... 481 CLINIMIX/DEXTROSE (5/20). 272 COLESTID FLAVORED...... 147 CORTI-SAV...... 481, 492 CLINIMIX/DEXTROSE (6/5)... 272 colestipol hcl...... 147 CORTISPORIN-TC...... 303, 309 CLINIMIX/DEXTROSE (8/10). 272 colistimethate sodium (cba).. 47 CORTROSYN...... 258 CLINIMIX/DEXTROSE (8/14). 272 COLY-MYCIN M...... 47 CORVERT...... 158 CLINISOL SF...... 272 COMBIGAN...... 301, 307 COSELA...... 448 CLINOLIPID...... 272 COMBIPATCH...... 368, 388 COSENTYX (300 MG DOSE).496 CLINPRO 5000...... 424 COMBIVENT RESPIMAT COSENTYX 150 MG/ML...... 496 clobazam...... 209, 211 ...... 95, 110, 454 COSENTYX SENSOREADY clobetasol prop emollient COMBIVIR...... 37 (300 MG)...... 496 base...... 480 COMETRIQ...... 56 COSENTYX SENSOREADY clobetasol propionate...480, 481 COMPACT SPACE PEN...... 496 clobetasol propionate e...... 480 CHAMBER...... 251 COSMEGEN...... 56 clobetasol propionate COMPACT SPACE COSOPT...... 307, 308 emulsion...... 480 CHAMBER/LG MASK...... 251 COSOPT PF...... 307, 308 CLOBEX...... 481 COMPACT SPACE cosyntropin...... 258 CLOBEX SPRAY...... 481 CHAMBER/MED MASK...... 251 COTELLIC...... 56 clocortolone pivalate...... 481 COMPACT SPACE COTEMPLA XR-ODT...... 238 clodan...... 481 CHAMBER/SM MASK...... 251 COZAAR...... 134, 135 CLODERM...... 481 COMPLERA...... 35, 37 CREON...... 298, 329 clofarabine...... 56 compro...... 237, 325 CRESEMBA...... 26, 27 CLOLAR...... 56 COMTAN...... 214 CRESTOR...... 166 clomiphene citrate...... 366 CONCERTA...... 238 CRINONE...... 388 clomipramine hcl...... 247 CONDYLOX...... 496 CRIXIVAN...... 39 clonazepam...... 209, 211 CONJUPRI...... 162, 163, 174 CROFAB...... 81, 415 clonidine...... 92, 153 CONSENSI...... 162, 216 cromolyn sodium.. 301, 315, 459 clonidine hcl...... 92, 153 constulose...... 269 crotan...... 494 clonidine hcl (analgesia) 92, 153 CONTOUR CONTROL...... 251 CRYODOSE TA...... 472 clonidine hcl er...... 92, 153 CONTOUR MONITOR cryselle-28...... 356, 368, 388 clopidogrel bisulfate...... 130 DEVICE...... 251 CRYSVITA...... 277 clorazepate dipotassium CONTOUR NEXT CONTROL.252 CUBICIN...... 29 ...... 209, 211 CONTOUR NEXT TEST...... 264 CUBICIN RF...... 29 CLOROTEKAL...... 409 CONTOUR TEST...... 264 CUPRIC CHLORIDE...... 283 clotrimazole...... 475 CONTRAVE...... 183 CUPRIMINE...... 337, 428 clotrimazole-betamethasone CONZIP...... 223 CURITY AMD ...... 475, 481 COPAXONE...... 433 ANTIMICROBIAL STRIP...... 252 clovique...... 337 COPIKTRA...... 56 CURITY IODOFORM clozapine...... 203, 204 CORDRAN...... 481 PACKING STRIP...... 252 CLOZARIL...... 204 COREG curity sterile saline...... 277 COAGADEX...... 122 103, 108, 132, 133, 142, 145, 156 CUROSURF...... 461 coal tar...... 491 CURVULARIA...... 77, 259

519 CUTAQUIG...... 81 DAPSONE...... 469, 496 DEPO-ESTRADIOL...... 369, 421 CUTIVATE...... 481 DAPTACEL...... 84, 85 DEPO-MEDROL...... 342 CUVPOSA...... 95 daptomycin...... 29 DEPO-PROVERA...... 356, 389 cyanocobalamin...... 128, 506 DARAPRIM...... 21 DEPO-SUBQ PROVERA 104 CYANOCOBALAMIN...... 128, 506 darifenacin hydrobromide er503 ...... 356, 389 CYANOKIT...... 415 DARZALEX...... 57 DEPO-TESTOSTERONE...... 349 cyclafem 1/35...... 356, 368, 388 DARZALEX FASPRO...... 57 DERMACINRX LIDOGEL...... 472 cyclafem 7/7/7...... 356, 368, 388 dasetta 1/35...... 356, 368, 388 DERMA-SMOOTHE/FS BODY cyclobenzaprine hcl...... 100 dasetta 7/7/7...... 356, 368, 388 ...... 481 cyclobenzaprine hcl er...... 100 daunorubicin hcl...... 57 DERMA-SMOOTHE/FS CYCLOGYL...... 319 DAURISMO...... 57 SCALP...... 481 CYCLOMYDRIL...... 319, 321 DAYPRO...... 233 DERMAZENE...... 482, 492 cyclopentolate hcl...... 319 daysee...... 356, 368, 388 DERMOTIC...... 309 cyclophosphamide. 56, 439, 440 DAYTRANA...... 238 DESCOVY...... 37 CYCLOPHOSPHAMIDE DAYVIGO...... 200 DESFERAL...... 338, 415 ...... 56, 57, 440 DDAVP...... 122, 384 desipramine hcl...... 247 cycloserine...... 25 DDAVP PF...... 122, 385 desloratadine...... 13, 462, 463 CYCLOSET...... 350 DEBACTEROL...... 315, 492 desmopressin ace spray cyclosporine...... 428, 433, 440 deblitane...... 356, 388 refrig...... 122, 385 cyclosporine modified DECADRON...... 342 desmopressin acetate.. 122, 385 ...... 428, 433, 440 DECARA K...... 509, 511 DESMOPRESSIN ACETATE CYKLOKAPRON...... 122 decitabine...... 57 ...... 122, 385 CYMBALTA...... 218, 242 deferasirox...... 338 desmopressin acetate pf cyproheptadine hcl deferasirox granules...... 338 ...... 122, 385 ...... 9, 10, 457, 458 deferiprone...... 338 desmopressin acetate spray CYRAMZA...... 57 deferoxamine mesylate 338, 415 ...... 122, 385 cyred...... 356, 368, 388 DEFITELIO...... 117 desogestrel-ethinyl estradiol cyred eq...... 356, 368, 388 DELESTROGEN...... 368, 421 ...... 356, 369, 389 CYSTADANE...... 443 DELFLEX-LC/1.5% DESONATE...... 482 CYSTADROPS...... 315 DEXTROSE...... 277 desonide...... 482 CYSTAGON...... 443 DELFLEX-LC/2.5% DESOWEN...... 482 CYSTARAN...... 315 DEXTROSE...... 277 desoximetasone...... 482 CYSVIEW...... 266 DELFLEX-LC/4.25% DESOXYN...... 179 cytarabine...... 57 DEXTROSE...... 277 desrx...... 482 cytarabine (pf)...... 57 DELFLEX-SM/1.5% DESVENLAFAXINE ER...... 242 CYTOGAM...... 82 DEXTROSE...... 277 desvenlafaxine succinate er 242 CYTOMEL...... 406 DELFLEX-SM/2.5% DETROL...... 503 CYTOTEC...... 334 DEXTROSE...... 277 DETROL LA...... 503 CYTOTINE...... 443 DELSTRIGO...... 35, 37 DEXABLISS...... 342 cytra k crystals...... 268 delyla...... 356, 368, 388 DEXAMETH SOD PHOS- D.H.E. 45...... 105, 197 DELZICOL...... 326 BUPIV-EPIN...... 89, 342, 409 d3 high potency...... 509 demeclocycline hcl...... 49 dexamethasone...... 342 dacarbazine...... 57 DEMEROL...... 223 DEXAMETHASONE (LA)...... 342 DACOGEN...... 57 DEMSER...... 443 DEXAMETHASONE ACE & dactinomycin...... 57 DENAVIR...... 475 SOD PHOS...... 342 dalfampridine er...... 443 DENTA 5000 PLUS...... 424 dexamethasone intensol...... 342 DALIRESP...... 461 DENTAGEL...... 424 DEXAMETHASONE SOD DALVANCE...... 31 DEOXIA...... 469, 496 PHOS-NACL...... 283, 342 danazol...... 349 DEPAKOTE...... 185, 192, 197 dexamethasone sod DANTRIUM...... 101 DEPAKOTE ER...... 185, 192, 197 phosphate pf...... 342 dantrolene sodium...... 101 DEPAKOTE SPRINKLES dexamethasone sodium DANYELZA...... 57 ...... 185, 192, 197 phosphate...... 309, 342, 343 dapsone...... 23, 468, 496 DEPEN TITRATABS...... 338, 428

520 DEXAMETHASONE SODIUM DIATHRIVE BLOOD DILTIAZEM HCL-SODIUM PHOSPHATE...... 343 GLUCOSE METER...... 252 CHLORIDE DEXAMETHASONE- DIATHRIVE BLOOD ...... 149, 150, 160, 175, 284 MOXIFLOXACIN...... 25, 47, 309 GLUCOSE TEST...... 264 dilt-xr...... 149, 150, 160, 175 DEXAMETH-MOXIFLOX- DIATHRIVE GLUCOSE DILUENT FOR LEFAMULIN...284 KETOROLAC...... 25, 47, 233, 309 CONTROL SOLN...... 252 diluent for treprostinil...... 451 DEXEDRINE...... 179 DIATHRIVE GLUCOSE TEST 264 dimenhydrinate...... 10, 325 DEXILANT...... 335 DIATHRIVE+ GLUCOSE DIMERCAPTOPROPANE- DEXLIDO...... 343, 409 MONITOR...... 252 SULFONATE...... 338 DEXMEDETOMIDINE HCL.... 201 DIATHRIVE+ GLUCOSE dimethyl fumarate...... 433 dexmedetomidine hcl...... 201 TEST...... 264 dimethyl fumarate starter dexmedetomidine hcl in nacl diazepam...... 209, 211 pack...... 433 ...... 201, 283 DIAZEPAM...... 209, 211 DIMOXIA...... 497 DEXMEDETOMIDINE HCL IN diazepam intensol...... 209, 211 DIOCHLOY...... 482, 497 NACL...... 201, 284 diazoxide...... 352 DIOVAN...... 134, 135 DEXMEDETOMIDINE HCL- DIBENZYLINE...... 105, 167 DIOVAN HCT...... 135, 295 DEXTROSE...... 201, 284 DICLEGIS...... 325 DIPENTUM...... 326 dexmethylphenidate hcl...... 238 DICLOFENAC CAP...... 233 diphen dexmethylphenidate hcl er...238 DICLOFENAC PATCH...... 233 ...... 9, 10, 98, 184, 201, 455, 458 DEXONTO 0.4%...... 343 diclofenac potassium...... 233 di-phen DEXPANTHENOL...... 506 diclofenac sodium ...... 9, 10, 98, 184, 201, 455, 458 dexrazoxane hcl...... 448 ...... 233, 317, 493, 496, 497 diphenhydramine hcl DEXTENZA...... 309 diclofenac sodium er...... 233 ...... 9, 10, 98, 184, 201, 455, 458 dextroamphetamine sulfate. 179 diclofenac-misoprostol 233, 334 diphenoxylate-atropine.. 95, 323 dextroamphetamine sulfate DICLOFONO...... 493, 497 DIPHTHERIA-TETANUS er...... 179 dicloxacillin sodium...... 46 TOXOIDS DT...... 84 dextrose...... 272 dicyclomine hcl...... 95 DIPRIVAN...... 201, 219 DEXTROSE...... 272 DIFFERIN...... 497 DIPROLENE...... 482 DEXTROSE DIFICID...... 45 DIPROLENE AF...... 482 5%/ELECTROLYTE #48.272, 284 diflorasone diacetate...... 482 dipyridamole...... 130, 175 dextrose in lactated ringers DIFLUCAN...... 27 DISCOVISC...... 314, 315 ...... 272, 284 diflunisal...... 233 disopyramide phosphate..... 154 dextrose-nacl...... 272, 284 DIFMETIOXRIME... 467, 475, 493 disulfiram...... 414 dextrose-sodium chloride DIGIFAB...... 82, 415 DITROPAN XL...... 503 ...... 272, 284 digitek...... 139, 152 DIURIL...... 173, 295 DEXYCU...... 309 digox...... 140, 152 divalproex sodium 185, 193, 198 DIACOMIT...... 185 digoxin...... 140, 152 divalproex sodium er DIANEAL LOW dihydroergotamine mesylate ...... 185, 193, 197 CALCIUM/1.5% DEX...... 278 ...... 105, 197 DIVIGEL...... 369, 421 DIANEAL LOW DILANTIN...... 154, 220 dobutamine hcl...... 109, 152 CALCIUM/2.5% DEX...... 278 DILANTIN INFATABS..... 154, 220 dobutamine in d5w...... 109, 152 DIANEAL LOW DILAUDID...... 223 docetaxel...... 57 CALCIUM/4.25% DEX...... 278 diltiazem hcl.. 148, 150, 160, 175 dofetilide...... 158 DIANEAL PD-2/1.5% diltiazem hcl er DOG EPITHELIUM...... 77, 259 DEXTROSE...... 278 ...... 148, 150, 160, 175 DOG FENNEL...... 77, 259 DIANEAL PD-2/2.5% diltiazem hcl er beads DOJOLVI...... 272 DEXTROSE...... 278 ...... 148, 150, 159, 175 dolishale...... 356, 369, 389 DIANEAL PD-2/4.25% diltiazem hcl er coated donepezil hcl...... 106 DEXTROSE...... 278 beads...... 148, 150, 159, 160, 175 dopamine hcl...... 109, 152 DIASCREEN 1B...... 252 DILTIAZEM HCL-DEXTROSE dopamine in d5w...... 109, 152 DIASCREEN 1K...... 252 ...... 148, 150, 160, 175, 272 DOPRAM...... 238 DIASTAT ACUDIAL...... 209, 211 DOPTELET...... 119 DIASTAT PEDIATRIC.....209, 211 DORAL...... 211

521 DORYX...... 21, 50 DUODOTE...... 95, 415 efavirenz...... 35 DORYX MPC...... 21, 50 DUOPA...... 217 efavirenz-emtricitab- DORZOLAMIDE HCL...... 308 DUOVISC...... 314, 315 tenofovir...... 35, 37 dorzolamide hcl...... 308 DUPIXENT...... 458, 497 efavirenz-lamivudine- dorzolamide hcl-timolol mal DURACLON...... 93, 153 tenofovir...... 35, 37 ...... 307, 308 duramorph...... 223 EFFER-K...... 284 dorzolamide hcl-timolol mal DUREZOL...... 309 effer-k...... 284 pf...... 307, 308 DURLAZA...... 130, 242 EFFEXOR XR...... 242 dotti...... 369, 422 DUROLANE...... 443 EFFIENT...... 130 DOUBLEDEX...... 343 DURYSTA...... 320 EFUDEX...... 497 DOVATO...... 34, 37 DUST MITE MIXED EGATEN...... 20 DOVONEX...... 497 ALLERGEN EXT...... 77, 259, 260 EGRIFTA SV...... 404 doxazosin mesylate dutasteride...... 413 EHA...... 472 ...... 104, 132, 133 dutasteride-tamsulosin hcl ELAPRASE...... 298 doxepin hcl...... 247, 472 ...... 108, 413 ELCYS...... 273 doxercalciferol...... 509 DUTOPROL...... 142, 295 ELELYSO...... 298 DOXIL...... 57 d-vite pediatric...... 509 ELEPSIA XR...... 185 doxorubicin hcl...... 57 DXEVO 11-DAY...... 343 ELESTRIN...... 369, 422 doxorubicin hcl liposomal..... 57 DYANAVEL XR...... 179 eletriptan hydrobromide...... 243 doxy 100...... 21, 50 DYMISTA...... 302, 309, 460, 463 ELIDEL...... 440, 497 doxycycline...... 50, 497 DYRENIUM...... 172, 281 ELIGARD...... 58, 379 doxycycline hyclate...... 21, 50 DYSPORT...... 114, 443 elinest...... 356, 369, 389 DOXYCYCLINE HYCLATE.21, 50 E.E.S. 400...... 29 ELIQUIS...... 118 doxycycline monohydrate E.E.S. GRANULES...... 30 ELIQUIS DVT/PE STARTER ...... 21, 22, 50 EASIVENT...... 252 PACK...... 118 doxylamine-pyridoxine...... 325 EASTERN COTTONWOOD ELITEK...... 299 DRAXACE...... 469, 489 ...... 77, 260 ELIXOPHYLLIN DRAXACE LOTION EASY TOUCH HEALTHPRO ...... 165, 239, 277, 467, 504 CLEANSER...... 469, 489 GLUCOSE...... 264 ELLA...... 356, 389 DRECHSLERA...... 77, 259 EASY TRAK II BLOOD ELLENCE...... 58 DRISDOL...... 509 GLUCOSE SYS...... 252 ELLIOTTS B...... 273, 284 DRITHO-CREME HP...... 497 EASY TRAK II CONTROL...... 252 ELMIRON...... 444 DRIXECE...... 469, 489 EASY TRAK II GLUCOSE ELOCTATE...... 123 DRIZALMA SPRINKLE...... 242 TEST...... 264 eluryng...... 356, 369, 389 dronabinol...... 324 easygel...... 424 ELZONRIS...... 58 droperidol...... 201 EASYMAX 15 LEVEL 2-3 EMBRACE EVO GLUCOSE DROPERIDOL...... 201 CONTROL...... 252 MONITOR...... 252 DROPLET MICRON...... 252 EASYMAX CONTROL...... 252 EMBRACE TALK BLOOD drospiren-eth estrad- EASYMAX CONTROL GLUCOSE...... 252 levomefol...... 356, 369, 389, 506 NORMAL/HIGH...... 252 EMBRACE TALK GLUCOSE drospirenone-ethinyl ECEOXIA...... 469, 497 CONTROL...... 252 estradiol...... 356, 369, 389 EC-NAPROSYN...... 198, 233, 419 EMBRACE TALK GLUCOSE DROXIA...... 58 ec-naproxen...... 198, 233, 419 TEST...... 264 droxidopa...... 89 econazole nitrate...... 475 EMCYT...... 58 DRYSOL...... 475 ECOZA...... 475 EMEND...... 334 DSUVIA...... 223 EDARBI...... 134, 135 EMEND TRI-PACK...... 334 DUAKLIR PRESSAIR...... 95, 110 EDARBYCLOR...... 135, 295 EMERPHED...... 89, 452 DUAVEE...... 366, 369 EDECRIN...... 168, 279 EMFLAZA...... 343 DUETACT...... 405, 406 EDETATE DISODIUM.... 338, 415 EMGALITY...... 214 DUEXIS...... 233, 332 EDEX...... 175 EMGALITY (300 MG DOSE).. 213 DULERA...... 111, 343 EDLUAR...... 201 EMJOI TENS...... 253 duloxetine hcl...... 218, 242 ED-SPAZ...... 95 emoquette...... 357, 369, 389 DUOBRII...... 482, 497 EDURANT...... 35 EMPAVELI...... 426

522 EMPLICITI...... 58 epinephrine (anaphylaxis) ESGIC...... 181, 208, 239 EMSAM...... 220, 221 ...... 90, 452 ESKATA...... 497 emtricitabine...... 37 EPINEPHRINE HCL...... 306, 320 esmolol hcl.... 113, 142, 145, 156 emtricitabine-tenofovir df...... 37 EPINEPHRINE HCL- ESMOLOL HCL EMTRIVA...... 37 DEXTROSE...... 90, 273, 452 ...... 113, 142, 145, 156 EMVERM...... 20 EPINEPHRINE HCL-NACL esmolol hcl-sodium chloride enalapril maleate...... 137, 138 ...... 90, 284, 452 ...... 113, 142, 145, 156, 284 enalaprilat...... 137, 138 epinephrine pf...... 90, 453 esomeprazole magnesium... 335 enalapril- EPINEPHRINE-DEXTROSE esomeprazole sodium...... 335 hydrochlorothiazide...... 138, 295 ...... 90, 273, 453 ESOMEPRAZOLE ENBREL...... 428, 433, 434 EPINEPHRINE-NACL STRONTIUM...... 335 ENBREL MINI...... 428, 433 ...... 90, 284, 453 ESPEROCT...... 123 ENBREL SURECLICK.... 428, 434 EPIPEN 2-PAK...... 91, 453 ESSENTIAL CARE JR...... 273 ENCARE...... 449 EPIPEN JR 2-PAK...... 91, 453 estarylla...... 357, 369, 389 ENDARI...... 444 epirubicin hcl...... 58 estazolam...... 211 ENDEAVORRX...... 444 epitol...... 186, 193 ESTRACE...... 369, 422 endocet...... 181, 223 EPIVIR...... 37 ESTRADIOL...... 369, 422 ENDOMETRIN...... 389 EPIVIR HBV...... 37 estradiol...... 369, 370, 422 ENGERIX-B...... 86 eplerenone.....168, 169, 172, 281 estradiol valerate...... 370, 422 ENHERTU...... 58 EPOGEN...... 116, 119 estradiol-norethindrone acet enoxaparin sodium...... 126 epoprostenol sodium...... 465 ...... 370, 389 enpresse-28...... 357, 369, 389 eptifibatide...... 130 ESTRING...... 370, 422 enskyce...... 357, 369, 389 EPZICOM...... 37 ESTROGEL...... 370, 422 ENSPRYNG...... 434 EQUACARE JR...... 273 ESTROSTEP FE.....357, 370, 389 ENSTILAR...... 482, 497 EQUETRO...... 186, 193 eszopiclone...... 201 entacapone...... 214 ERAXIS...... 29 ethacrynate sodium...... 168, 279 entecavir...... 43 ERBITUX...... 58 ethacrynic acid...... 168, 279 ENTEREG...... 330 ERGOCAL...... 509 ethambutol hcl...... 25 ENTOCORT EC...... 343 ergocalciferol...... 509 ETHAMOLIN...... 173 ENTRESTO...... 135, 172 ergoloid mesylates...... 105 ethosuximide...... 246 ENTYVIO...... 330 ERGOMAR...... 105, 198 ETHOXIA...... 497 ENU PRO3 PLUS...... 273 ergotamine-caffeine ethyl chloride...... 472 enulose...... 269 ...... 105, 198, 239 ethynodiol diac-eth estradiol ENVARSUS XR...... 440 ERIVEDGE...... 58 ...... 357, 370, 389 ENZADYNE...... 329 ERLEADA...... 58 ETHYOL...... 448 ENZOCLEAR...... 492 erlotinib hcl...... 58 etodolac...... 233 EPANED...... 137, 138 errin...... 357, 389 etodolac er...... 233 EPCLUSA...... 32, 33 ERTACZO...... 476 etomidate...... 219 ephedrine sulfate...... 89, 452 ertapenem sodium...... 28 etonogestrel-ethinyl EPHEDRINE SULFATE....90, 452 ERWINASE...... 59, 299 estradiol...... 357, 370, 390 EPHEDRINE SULFATE ery...... 469 ETOPOPHOS...... 59 (PRESSORS)...... 89, 452 ERYGEL...... 469 etoposide...... 59 EPHEDRINE SULFATE-NACL ERYPED 200...... 30 etravirine...... 36 ...... 90, 284, 452 ERYPED 400...... 30 EUCRISA...... 471 EPICOCCUM...... 77, 260 ERY-TAB...... 30 EUFLEXXA...... 444 EPIDIOLEX...... 185 ERYTHROCIN euthyrox...... 406 EPIDUO...... 492, 497 LACTOBIONATE...... 30 EVAMIST...... 370, 422 EPIDUO FORTE...... 492, 497 ERYTHROCIN STEARATE...... 30 EVEKEO...... 179 EPIFOAM...... 472, 482 erythromycin...... 30, 303, 469 EVEKEO ODT...... 179 epinastine hcl...... 302 erythromycin base...... 30 EVENITY...... 420 epinephrine...... 90, 452, 453 erythromycin ethylsuccinate. 30 everolimus...... 59, 440 EPINEPHRINE...... 90, 452, 453 ESBRIET...... 454, 455 EVISTA...... 366, 422 escitalopram oxalate...... 245 EVKEEZA...... 140

523 EVOCLIN...... 469 fenofibric acid...... 165 FLAREX...... 309 EVOMELA...... 59 FENOGLIDE...... 165 flavoxate hcl...... 503 EVOTAZ...... 39, 444 fenoprofen calcium...... 233 FLEBOGAMMA DIF...... 82 EVOXAC...... 106 fenortho...... 234 flecainide acetate...... 155 EVRYSDI...... 444 FENSOLVI (6 MONTH)...... 379 FLECTOR...... 234 EXELDERM...... 476 fentanyl...... 224 FLEXBUMIN...... 115 EXELON...... 106 fentanyl citrate...... 223 FLEXICHAMBER...... 253 exemestane...... 59, 351 FENTANYL CITRATE.....223, 224 FLEXICHAMBER ADULT EXFORGE...... 136, 162 fentanyl citrate (pf)...... 223 MASK/SMALL...... 253 EXFORGE HCT...... 136, 162, 295 fentanyl citrate pf...... 224 FLEXICHAMBER CHILD EXJADE...... 338 FENTANYL CITRATE-NACL MASK/LARGE...... 253 EXONDYS 51...... 420 ...... 224, 285 FLEXICHAMBER CHILD EXPAREL...... 409 FENTANYL CIT- MASK/SMALL...... 253 EXSERVAN...... 215 ROPIVACAINE-NACL FLEXIN...... 472, 498 EXTAVIA...... 434 ...... 224, 285, 409 FLOLAN...... 465 EXTINA...... 476 FENTANYL-BUPIVACAINE- FLOLIPID...... 166 EXTRANEAL...... 278 NACL...... 224, 285, 409, 410 FLOMAX...... 108 EYLEA...... 315 FENTANYL-ROPIVACAINE- FLOVENT DISKUS. 343, 344, 461 EYSUVIS...... 309 NACL...... 225, 285, 410 FLOVENT HFA...... 344, 461 EZALLOR SPRINKLE...... 166 FENTORA...... 225 floxuridine...... 59 ezetimibe...... 153 FERAHEME...... 127 FLUARIX QUADRIVALENT...... 86 ezetimibe-simvastatin...153, 166 FERRIPROX...... 338 FLUBLOK QUADRIVALENT.....86 FABIOR...... 497 FERRIPROX TWICE-A-DAY.. 338 FLUCELVAX FABRAZYME...... 299 FERRLECIT...... 127 QUADRIVALENT...... 86 falmina...... 357, 370, 390 ferrous sulfate...... 127 fluconazole...... 27 famciclovir...... 43 ferumoxytol...... 127 fluconazole in sodium famotidine...... 11, 333 FETROJA...... 48 chloride...... 27, 285 famotidine premixed...... 11, 333 FETZIMA...... 242 flucytosine...... 47 FANAPT...... 204 FETZIMA TITRATION...... 242 fludarabine phosphate...... 59 FANAPT TITRATION PACK... 204 FEXMID...... 100 fludrocortisone acetate...... 344 FARESTON...... 59, 366 FIASP...... 399 FLULAVAL QUADRIVALENT... 86 FARXIGA...... 402 FIASP FLEXTOUCH...... 399 flumazenil...... 215, 415 FARYDAK...... 59 FIASP PENFILL...... 399 FLUMIST QUADRIVALENT...... 86 FASENRA...... 458 FIBRICOR...... 166 flunisolide...... 309, 344, 460 FASENRA PEN...... 458 FIBRYGA...... 123 fluocinolone acetonide FASLODEX...... 59 FINACEA...... 498 ...... 309, 482, 483 fayosim...... 357, 370, 390 FINAPOD...... 414, 498 fluocinolone acetonide body482 FC FEMALE CONDOM...... 449 finasteride...... 414 fluocinolone acetonide scalp FC2 FEMALE CONDOM...... 449 FINTEPLA...... 186 ...... 483 febuxostat...... 419 FIORICET...... 181, 208, 239 fluocinonide...... 483 FEIBA...... 123 FIORICET/CODEINE fluocinonide emulsified base felbamate...... 186 ...... 181, 208, 225, 239 ...... 483 FELBATOL...... 186 FIRAZYR...... 426 FLUORESCITE...... 267 FELDENE...... 233 FIRDAPSE...... 444 FLUORIDEX...... 424 felodipine er...... 162, 163 FIRE ANT...... 77 fluoridex daily renewal...... 424 FEM PH...... 492, 498 FIRMAGON...... 59, 351 FLUORIDEX ENHANCED FEMARA...... 59, 351 FIRMAGON (240 MG DOSE) WHITENING...... 424 FEMCAP...... 449 ...... 59, 351 FLUORIDEX SENSITIVITY FEMHRT...... 370, 390 FIRST-LANSOPRAZOLE...... 335 RELIEF...... 249, 424 FEMRING...... 370, 422 FIRST-OMEPRAZOLE...... 335 fluoritab...... 424 femynor...... 357, 370, 390 FIRVANQ...... 31 fluorometholone...... 310 fenofibrate...... 165 flac...... 309 FLUOROPLEX...... 498 fenofibrate micronized...... 165 FLAGYL...... 17, 23, 327 fluorouracil...... 59, 498

524 FLUOROURACIL...... 498 FORTISCARE G1 TEST GAMMACORE SAPPHIRE fluoxetine hcl...... 245 STRIP...... 264 REFILL KIT...... 253 fluoxetine hcl (pmdd)...... 245 FORTISCARE T1 GLUCOSE GAMMAGARD...... 82 fluphenazine decanoate...... 237 SYSTEM...... 253 GAMMAGARD S/D LESS IGA..82 fluphenazine hcl...... 237 FOSAMAX...... 422 GAMMAKED...... 82 flurandrenolide...... 483 FOSAMAX PLUS D...... 422, 510 GAMMAPLEX...... 82 flurazepam hcl...... 211 fosamprenavir calcium...... 39 GAMUNEX-C...... 82 flurbiprofen...... 234 fosaprepitant dimeglumine.. 334 GANCICLOVIR...... 43 flurbiprofen sodium...... 317 foscarnet sodium...... 26 ganciclovir sodium...... 43 flutamide...... 59 FOSCAVIR...... 26 ganirelix acetate...... 351 fluticasone propionate fosfomycin tromethamine...... 51 GARDASIL 9...... 86 ...... 310, 344, 460, 483 fosinopril sodium...... 137, 138 GASTROCROM...... 315, 459 fluticasone-salmeterol..111, 344 fosinopril sodium-hctz. 138, 295 gatifloxacin...... 303 FLUTICASONE- fosphenytoin sodium...... 220 GATTEX...... 330 SALMETEROL...... 111, 344 FOSRENOL...... 280, 415, 416 gavilax...... 327 fluvastatin sodium...... 166 FOTIVDA...... 60 gavilyte-c...... 327 fluvastatin sodium er...... 166 FRAGMIN...... 126 gavilyte-g...... 327 fluvoxamine maleate...... 245 FREAMINE III...... 273 gavilyte-n with flavor pack... 327 fluvoxamine maleate er...... 245 FREESTYLE INSULINX TEST264 GAVRETO...... 60 FLUZONE HIGH-DOSE FREESTYLE LITE TEST...... 264 GAZYVA...... 60 QUADRIVALENT...... 86 FREESTYLE PRECISION GEBAUERS PAIN EASE...... 472 FLUZONE QUADRIVALENT.... 86 NEO TEST...... 264 GEBAUERS SPRAY AND FML...... 310 FREESTYLE TEST...... 264 STRETCH...... 472 FML FORTE...... 310 fresenius propoven...... 201, 219 GELCLAIR...... 498 FML LIQUIFILM...... 310 FRESENIUS PROPOVEN GELFILM...... 123 FOCALIN...... 239 ...... 201, 219 GELNIQUE...... 503 FOCALIN XR...... 239 FROVA...... 243 GEL-ONE...... 444 folate...... 506 frovatriptan succinate...... 243 GELSYN-3...... 444 FOLDITAM...... 506, 510 FULPHILA...... 119 gemcitabine hcl...... 60 folic acid...... 506 fulvestrant...... 60 gemfibrozil...... 166 FOLIC D3...... 506, 510 FUNGIMEZ...... 471 gemmily...... 357, 371, 390 FOLI-D...... 507, 510 furosemide...... 168, 279 GEMTESA...... 504 FOLITE...... 273, 285, 507, 510 FUROSEMIDE IN SODIUM GEN7T...... 472 FOLLISTIM AQ...... 379 CHLORIDE...... 168, 279, 285 GEN7T PLUS...... 472, 498 FOLOTYN...... 60 FUSARIUM...... 77, 260 GENADUR...... 498 FOLVITE-D...... 507, 510 FUZEON...... 34 GENERESS FE...... 357, 371, 390 fomepizole...... 415 fyavolv...... 370, 390 generlac...... 269 fondaparinux sodium...... 116 FYCOMPA...... 186 gengraf...... 428, 434, 440 FORA 6 CONNECT...... 264 gabapentin...... 181, 186 GENOTROPIN...... 385, 404 FORA D40G GABITRIL...... 186 GENOTROPIN MINIQUICK GLUCOSE/PRESSURE...... 253 GABLOFEN...... 101 ...... 385, 404 FORA GTEL BLOOD GALAFOLD...... 444 gentak...... 303 GLUCOSE SYSTEM...... 253 galantamine hydrobromide..106 gentamicin in saline...... 17, 285 FORA GTEL BLOOD galantamine hydrobromide gentamicin sulfate.. 18, 303, 469 GLUCOSE TEST...... 264 er...... 106 gentle laxative...... 328 FORA TN'G ADVANCE PRO..264 GALZIN...... 285 GENVISC 850...... 444 FORFIVO XL...... 191 GAMASTAN...... 82 GENVOYA...... 34, 37 formaldehyde...... 268 GAMIFANT...... 440 GEODON...... 193, 204 formoterol fumarate...... 111, 463 GAMMACORE...... 253 GERMAN COCKROACH...... 77 FORTAZ...... 15, 16 GAMMACORE SAPPHIRE.....253 GIAPREZA...... 401 FORTEO...... 384, 420 GAMMACORE SAPPHIRE 31- GILENYA...... 434 FORTESTA...... 349 DAY...... 253 GILOTRIF...... 60 FORTISCARE CONTROL...... 253 GAMMACORE SAPPHIRE D. 253 GILPHEX TR...... 93, 457

525 GIMOTI...... 334 GOLDENROD...... 77, 260 HEALON...... 315 GIVLAARI...... 444 GOLYTELY...... 328 HEALON DUET PRO...... 315 GLASSIA...... 462 GONAL-F...... 379 HEALON GV...... 315 glatiramer acetate...... 434 GONAL-F RFF...... 380 HEALON GV PRO...... 315 glatopa...... 434 GONAL-F RFF REDIJECT..... 380 HEALON PRO...... 316 GLEEVEC...... 60 GONITRO...... 169 HEALON5...... 316 GLEOSTINE...... 60 goodsense aspirin adults HEALON5 PRO...... 316 GLIADEL WAFER...... 60 ...... 130, 131, 198, 242 healthylax...... 328 glimepiride...... 405 goodsense aspirin low dose heather...... 357, 390 glipizide...... 405 ...... 130, 131, 198, 242 HECTOROL...... 510 glipizide er...... 405 goodsense nicotine...... 99 HELIDAC THERAPY glipizide xl...... 405 GOPRELTO...... 318 ...... 20, 23, 50, 323, 326 glipizide-metformin hcl.352, 405 GORDOFILM...... 477, 489 HEMABATE...... 450 GLOPERBA...... 419 GRALISE...... 181, 186 HEMADY...... 344 GLUCAGEN DIAGNOSTIC granisetron hcl...... 323 HEMANGEOL ...... 378, 416 GRANIX...... 119 ...... 103, 142, 145, 156, 198 GLUCAGEN HYPOKIT... 378, 416 GRASS POLLEN(K-O-R-T- hematinic/folic acid...... 127, 507 glucagon emergency kit SWT VERN)...... 77, 260 HEMLIBRA...... 123 ...... 378, 416 GRASTEK...... 77 hemocyte-f...... 127, 507 GLUCAGON EMERGENCY griseofulvin microsize...... 20 HEMOFIL M...... 123 KIT...... 378, 416 griseofulvin ultramicrosize.... 20 HEPAGAM B...... 82 GLUCAGON HCL guaiatussin ac...... 455, 457 heparin (porcine) in nacl (DIAGNOSTIC)...... 379, 416 guaifenesin ac...... 455, 457 ...... 126, 286 GLUCOCARD 01 SENSOR GUANENDRUX...... 472, 489 HEPARIN (PORCINE) IN PLUS...... 264 guanfacine hcl...... 153, 215 NACL...... 126, 286 GLUCOCARD EXPRESSION guanfacine hcl er...... 215 heparin lock flush...... 126 TEST...... 265 GVOKE HYPOPEN 1-PACK heparin sod (porcine) in d5w GLUCOCARD SHINE TEST...265 ...... 379, 416 ...... 127, 273 GLUCOCARD VITAL TEST....265 GVOKE HYPOPEN 2-PACK heparin sodium (porcine).....127 GLUCOTROL XL...... 405 ...... 379, 416 heparin sodium (porcine) pf 127 GLUMETZA...... 352 GVOKE PFS...... 379, 416 heparin sodium lock flush... 127 glutaraldehyde...... 268 GYNAZOLE-1...... 476 HEPLISAV-B...... 87 GLUTATHIONE...... 273 habitrol...... 99 HEPSERA...... 43 glyburide...... 405 HACKBERRY...... 77, 260 HERCEPTIN...... 60 glyburide micronized...... 405 HAEGARDA...... 426 HERCEPTIN HYLECTA...... 60 glyburide-metformin..... 353, 406 hailey 1.5/30...... 357, 371, 390 HERZUMA...... 60 GLYCINE...... 273 hailey 24 fe...... 357, 371, 390 HESPAN...... 286 glycine...... 278 hailey fe 1.5/30...... 357, 371, 390 hetastarch-nacl...... 286 glycine urologic...... 278 hailey fe 1/20...... 357, 371, 390 HETLIOZ...... 201 glycolax...... 328 HALAVEN...... 60 HETLIOZ LQ...... 201 glycolic acid...... 498 halcinonide...... 483 HEXTEND...... 286 GLYCOPHOS...... 285 HALCION...... 211 HIBERIX...... 87 glycopyrrolate...... 95 HALDOL DECANOATE...... 213 HIDEX 6-DAY...... 344 GLYCOPYRROLATE...... 95 halobetasol propionate...... 483 HIPREX...... 51 glycopyrrolate pf...... 95 HALOBETASOL HISTATROL...... 267 glydo...... 472 PROPIONATE...... 483 HIZENTRA...... 82 GLYNASE...... 406 HALOG...... 483 homatropaire...... 320 GLYRX-PF...... 95, 96 haloperidol...... 213 HONEY BEE VENOM...... 77, 260 GLYXAMBI...... 365, 402 haloperidol decanoate...... 213 HONEY BEE VENOM GOCOVRI...... 17, 178 haloperidol lactate...... 213 PROTEIN...... 77, 260 GOJJI BLOOD GLUCOSE HARVONI...... 32, 33 HORIZANT...... 186 TEST...... 265 HAVRIX...... 86 HORSE EPITHELIUM...... 77, 260 GOJJI CONTROL...... 253 HAXCHLO...... 483, 488 HPR PLUS...... 498

526 HUMALOG...... 399 hydrocodone polst- HYZAAR...... 136, 296 HUMALOG KWIKPEN...... 399 chlorphen polst er susp. 12, 455 ibandronate sodium...... 422, 423 HUMALOG MIX 50/50 hydrocodone- IBRANCE...... 61 KWIKPEN...... 399 acetaminophen...... 182, 225 ibuprofen...... 198, 234 HUMALOG MIX 50/50 VIAL....399 hydrocodone-homatropine ibuprofen lysine...... 198, 234 HUMALOG MIX 75/25 ...... 96, 455 ibuprofen-famotidine.... 234, 333 KWIKPEN...... 399 hydrocodone-ibuprofen225, 234 ibutilide fumarate...... 158 HUMALOG MIX 75/25 VIAL....399 hydrocortisone...... 344, 484 IC GREEN...... 263, 266 HUMALOG U-100 JUNIOR hydrocortisone (perianal).....483 icatibant acetate...... 426 KWIKPEN...... 399 hydrocortisone ace- iclevia...... 357, 371, 390 HUMAN ALBUMIN GRIFOLS. 115 pramoxine...... 473, 483 ICLUSIG...... 61 HUMATE-P...... 123 hydrocortisone butyr lipo icosapent ethyl...... 140 HUMATIN...... 17, 18 base...... 483 IDAMYCIN PFS...... 61 HUMATROPE...... 385, 404 hydrocortisone butyrate idarubicin hcl...... 61 HUMATROPEN FOR 12MG... 253 ...... 483, 484 IDELVION...... 123 HUMATROPEN FOR 24MG... 253 hydrocortisone valerate...... 484 IDHIFA...... 61 HUMATROPEN FOR 6MG..... 253 hydrocortisone-acetic acid IFEX...... 61 HUMIRA...... 331, 429, 435 ...... 310, 316 ifosfamide...... 61 HUMIRA PEDIATRIC hydrocortisone-iodoquinol ILARIS...... 182 CROHNS START....331, 428, 434 ...... 484, 492 ILEVRO...... 317 HUMIRA PEN...... 331, 429, 434 hydrocort-pramoxine ILUMYA...... 498 HUMIRA PEN-CD/UC/HS (perianal)...... 473, 484 ILUVIEN...... 310 STARTER...... 331, 429, 434 hydrogen peroxide...... 492 imatinib mesylate...... 61 HUMIRA PEN-PEDIATRIC UC hydromet...... 96, 455 IMBRUVICA...... 61 START...... 331, 429, 434 HYDROMORPHONE HCL...... 225 IMCIVREE...... 184 HUMIRA PEN-PS/UV/ADOL hydromorphone hcl...... 225, 226 IMDEVIMAB...... 41 HS START...... 331, 429, 434 hydromorphone hcl er...... 225 IMFINZI...... 62 HUMIRA PEN-PSOR/UVEIT hydromorphone hcl pf...... 225 IMIOXIA...... 476, 498 STARTER...... 331, 429, 435 HYDROMORPHONE HCL- imipenem-cilastatin...... 28 HUMULIN 70/30 KWIKPEN NACL...... 226, 286 imipramine hcl...... 247 ...... 382, 401 hydroxocobalamin acetate imipramine pamoate...... 247 HUMULIN 70/30 VIAL.....382, 401 ...... 128, 507 imiquimod...... 498 HUMULIN N KWIKPEN...... 382 hydroxychloroquine sulfate IMIQUIMOD PUMP...... 498 HUMULIN N VIAL...... 382 ...... 22, 429, 435 IMITREX...... 243 HUMULIN R U-500 KWIKPEN 401 hydroxyprogesterone IMITREX STATDOSE REFILL 243 HUMULIN R U-500 VIAL...... 401 caproate...... 61, 390 IMITREX STATDOSE HUMULIN R VIAL...... 401 hydroxyurea...... 61 SYSTEM...... 243 HW EMBRACE PRO hydroxyzine hcl...... 10, 11, 202 IMLYGIC...... 62 GLUCOSE METER...... 253 hydroxyzine pamoate10, 11, 202 IMOGAM RABIES-HT...... 83 HW EMBRACE PRO HYLATOPIC PLUS...... 498 IMOVAX RABIES...... 87 GLUCOSE TEST...... 265 HYLENEX...... 299 IMPAVIDO...... 23 HW EMBRACE TALK BLOOD HYMOVIS...... 444 IMPEKLO...... 484 GLUCOSE...... 254 hyoscyamine sulfate...... 96 IMPOYZ...... 484 HW EMBRACE TALK hyoscyamine sulfate sl...... 96 IMURAN...... 429, 435, 440 GLUCOSE TEST...... 265 hyosyne...... 96 IMVEXXY MAINTENANCE HYALGAN...... 444 HYPERHEP B...... 83 PACK...... 371 HYCAMTIN...... 61 HYPERLYTE-CR...... 287 IMVEXXY STARTER PACK... 371 HYCODAN...... 96, 455 HYPERRAB...... 83 INBRIJA...... 217 hydralazine hcl...... 165 HYPERRHO S/D...... 83 incassia...... 357, 390 HYDREA...... 61 HYPERSAL...... 459 INCRELEX...... 404 HYDRO 40...... 489 HYPERTET S/D...... 83 INCRUSE ELLIPTA...... 96 hydrochlorothiazide...... 173, 295 HYQVIA...... 83, 299 indapamide...... 173, 297 hydrocodone bitartrate er.... 225 HYSINGLA ER...... 226

527 INDERAL LA INSULIN PEN NEEDLES...... 254 ISTALOL...... 307 ...... 103, 142, 145, 156, 198 INSULIN SYRINGES...... 254 ISTODAX (OVERFILL)...... 62 INDERAL XL INTELENCE...... 36 ISTURISA...... 444 ...... 103, 142, 145, 157, 198 INTRALIPID...... 273 ISUPREL...... 106, 460 indigo carmine...... 266 INTRAROSA...... 344 ITHOXIA...... 499 INDOCIN...... 234, 419 INTRON A...... 40, 62, 435 itraconazole...... 27 indocyanine green...... 263, 266 introvale...... 357, 371, 390 IV STABILIZER FOR INDOMETHACIN...... 234 INTUNIV...... 215 LUMOXITI...... 451 indomethacin...... 234, 419 INULIN...... 266 ivermectin...... 20, 494 indomethacin er...... 234, 419 INVANZ...... 28 IXEMPRA KIT...... 62 indomethacin sodium...234, 419 INVEGA...... 204 IXIARO...... 87 INFANRIX...... 84, 87 INVEGA HAFYERA...... 204 IXINITY...... 123 INFASURF...... 287, 461 INVEGA SUSTENNA...... 204 JADENU...... 338 INFED...... 127 INVEGA TRINZA...... 204 JADENU SPRINKLE...... 338 INFINITY BLOOD GLUCOSE INVELTYS...... 310 jaimiess...... 358, 371, 390 TEST...... 265 INVIRASE...... 39 JAKAFI...... 62 INFLECTRA.... 331, 429, 435, 498 INVOKAMET...... 353, 402 JALYN...... 108, 414 INFUGEM...... 62, 287 INVOKAMET XR...... 353, 402 jantoven...... 118 INFUMORPH 200...... 226 INVOKANA...... 402 JANUMET...... 353, 365 INFUMORPH 500...... 226 iodine strong...... 457 JANUMET XR...... 353, 365 INFUVITE ADULT...... 505 iodoquinol-hc-aloe JANUVIA...... 365 INFUVITE PEDIATRIC...... 505 polysacch...... 477, 484, 492 JARDIANCE...... 402 INGREZZA...... 248 IONOSOL-MB IN D5W... 273, 287 jasmiel...... 358, 371, 391 INJECTAFER...... 127 IOPIDINE...... 316 JATENZO...... 349 INLYTA...... 62 IPOL...... 87 JELMYTO...... 63 INNOPRAN XL ipratropium bromide...... 96, 454 JEMPERLI...... 63 ...... 103, 142, 145, 157, 198 ipratropium-albuterol jencycla...... 358, 391 INOVA...... 488, 492 ...... 96, 111, 454 JENLIVA INPEN 100-BLUE-LILLY...... 254 irbesartan...... 134, 136 PRENATAL/POSTNATAL INPEN 100-BLUE-NOVO...... 254 irbesartan- ...... 127, 287, 505, 507 INPEN 100-GRAY-LILLY...... 254 hydrochlorothiazide...... 136, 296 JENTADUETO...... 353, 365 INPEN 100-GREY-NOVO...... 254 IRESSA...... 62 JENTADUETO XR...... 353, 365 INPEN 100-PINK-LILLY...... 254 irinotecan hcl...... 62 JEVTANA...... 63 INPEN 100-PINK-NOVO...... 254 ISENTRESS...... 34, 35 jinteli...... 371, 391 INQOVI...... 62 ISENTRESS HD...... 34 JIVI...... 123 INREBIC...... 62 isibloom...... 357, 371, 390 JOHNSON GRASS...... 77, 260 INSPIREASE RESERVOIR ISOLYTE-P IN D5W...... 273, 287 jolessa...... 358, 371, 391 BAGS...... 254 ISOLYTE-S...... 287 JORNAY PM...... 239 INSPRA...... 169, 172, 281 ISOLYTE-S PH 7.4...... 287 JUBLIA...... 476 INSULIN ASP PROT & ASP isoniazid...... 25 juleber...... 358, 371, 391 FLEXPEN...... 400 isoproterenol hcl...... 106, 460 JULUCA...... 35, 36 INSULIN ASPART...... 400 ISOPROTERENOL-SODIUM JUNE GRASS POLLEN INSULIN ASPART FLEXPEN. 400 CHLORIDE...... 106, 287 STANDARDIZED...... 78, 260 INSULIN ASPART PENFILL...400 ISOPTO ATROPINE...... 320 junel 1.5/30...... 358, 371, 391 INSULIN ASPART PROT & ISOPTO CARPINE...... 319 junel 1/20...... 358, 371, 391 ASPART...... 400 ISORDIL TITRADOSE...... 169 junel fe 1.5/30...... 358, 371, 391 INSULIN LISPRO...... 400 isosorbide dinitrate...... 169 junel fe 1/20...... 358, 371, 391 INSULIN LISPRO (1 UNIT isosorbide mononitrate...... 169 junel fe 24...... 358, 371, 391 DIAL)...... 400 isosorbide mononitrate er....169 JUXTAPID...... 140 INSULIN LISPRO JUNIOR isosulfan blue...... 266 JYNARQUE...... 297 KWIKPEN...... 400 isotretinoin...... 499 KABIVEN...... 273 INSULIN LISPRO PROT & isoxsuprine hcl...... 175 KADCYLA...... 63 LISPRO...... 400 isradipine...... 162, 164 kaitlib fe...... 358, 371, 391

528 KALBITOR...... 427 KETOROLAC KYNMOBI TITRATION KIT.....221 KALETRA...... 39 TROMETHAMINE...... 234, 235 KYPROLIS...... 63 kalliga...... 358, 372, 391 KETOROLAC-BUPIV- L.E.T...... 321, 473 KALYDECO...... 456, 457 KETAMINE...... 219, 235, 410 LABETALOL HCL KANJINTI...... 63 KETOROLAC-ROPIV- 103, 108, 132, 133, 142, 143, 145, KANUMA...... 299 KETAMINE...... 219, 235, 410 146, 157 KAPOK...... 78, 260 KEVEYIS...... 424 labetalol hcl KAPSPARGO SPRINKLE KEVZARA...... 429 103, 108, 132, 133, 142, 143, 145, ...... 113, 142, 145, 157 KEYTRUDA...... 63 157 KAPVAY...... 93, 153 KHAPZORY...... 416, 507 LABETALOL HCL-DEXTROSE KARBINAL ER...... 9, 10, 458 kids first vitamin d3 103, 108, 132, 133, 143, 146, 157, kariva...... 358, 372, 391 gummies...... 510 274 KATE FARMS PEPTIDE 1.5...274 KIMYRSA...... 31 LABETALOL HCL-SODIUM KATE FARMS STANDARD 1.4 KINERET...... 429, 435 CHLORIDE ...... 274 KINEVAC...... 266 103, 108, 132, 133, 143, 146, 157, KATERZIA...... 162, 164, 175 KINRIX...... 84, 87 274 KAZANO...... 353, 365 KISQALI...... 63 LACRISERT...... 316 KCENTRA...... 123 KISQALI FEMARA...... 63, 351 lactated ringers...... 278, 288 KCL (IN NACL 0.9%)...... 287 KLARITY-A...... 303 lactic acid...... 477 kcl in dextrose-nacl...... 274, 287 KLARITY-L...... 310 lactic acid e...... 477 kcl-lactated ringers-d5w KLARON...... 469 lactulose...... 270 ...... 274, 287 KLISYRI...... 499 lactulose encephalopathy.... 269 KCL-LIDOCAINE-NACL..287, 410 KLONOPIN...... 209, 211 LAMICTAL...... 187, 193 kedbumin...... 115 klor-con...... 288 LAMICTAL ODT...... 187, 193 KEDRAB...... 83 klor-con 10...... 288 LAMICTAL STARTER.....187, 193 KEFLEX...... 14 klor-con m10...... 288 LAMICTAL XR...... 187, 193 kelnor 1/35...... 358, 372, 391 klor-con m15...... 288 lamivudine...... 38 kelnor 1/50...... 358, 372, 391 klor-con m20...... 288 lamivudine-zidovudine...... 38 KENALOG...... 344, 484 klor-con/ef...... 288 lamotrigine...... 187, 193, 194 KENALOG-80...... 344 KLOXXADO...... 231 lamotrigine er...... 187, 193 KENGREAL...... 130 KOATE...... 124 lamotrigine starter kit-blue KEPIVANCE...... 478 KOATE-DVI...... 124 ...... 187, 194 KEPPRA...... 186 KOCHIA...... 78, 260 lamotrigine starter kit-green KEPPRA XR...... 187 KOGENATE FS...... 124 ...... 187, 194 KERALYT...... 489 KOMBIGLYZE XR...... 353, 365 lamotrigine starter kit- KERENDIA...... 169 KORLYM...... 351 orange...... 187, 194 KERLIX AMD KOSELUGO...... 63 LAMPIT...... 23 ANTIMICROBIAL...... 254 KOVALTRY...... 124 LANCETS...... 255, 265 KERLIX AMD SUPER K-PHOS...... 288 LANOXIN...... 140, 152 SPONGES...... 255 K-PHOS NO 2...... 268 LANOXIN PEDIATRIC.... 140, 152 KERYDIN...... 493 K-PHOS-NEUTRAL...... 288 lansoprazole...... 335 KESIMPTA...... 435 k-prime...... 288 lanthanum carbonate....280, 416 KETALAR...... 219 KRINTAFEL...... 22 LANTUS SOLOSTAR...... 383 KETAMINE HCL...... 219 KRISTALOSE...... 269 LANTUS U-100 VIAL...... 383 ketamine hcl...... 219 KROGER HEALTHPRO lapatinib ditosylate...... 63 KETAMINE HCL-SODIUM GLUCOSE TEST...... 265 larin 1.5/30...... 358, 372, 391 CHLORIDE...... 219, 287, 288 KRYSTEXXA...... 419 larin 1/20...... 358, 372, 391 ketoconazole...... 27, 476 K-TAB...... 288 larin 24 fe...... 358, 372, 391 ketodan...... 476 kurvelo...... 358, 372, 391 larin fe 1.5/30...... 358, 372, 391 ketoprofen...... 198, 234 KUVAN...... 445 larin fe 1/20...... 358, 372, 391 ketoprofen er...... 198, 234 KYLEENA...... 358, 391 larissia...... 358, 372, 391 ketorolac tromethamine234, 317 KYMRIAH...... 177 LASIX...... 168, 279 KYNMOBI...... 221 LASTACAFT...... 11, 302

529 latanoprost...... 320 levo-t...... 407 LIDOPIN...... 473 LATUDA...... 204 levothyroxine sodium...... 407 LIDOTHOL...... 473, 474, 499 layolis fe...... 358, 372, 391 LEVOTHYROXINE SODIUM.. 407 LIDOTRAL...... 474 LAZANDA...... 226 levoxyl...... 407 LIFEMS NALOXONE...... 231, 417 LDO PLUS...... 473 LEVSIN...... 96 LILETTA (52 MG)...... 359, 392 LEDIPASVIR-SOFOSBUVIR LEVSIN/SL...... 96 lillow...... 359, 372, 392 ...... 32, 33 LEVULAN KERASTICK...... 499 LINCOCIN...... 41 leena...... 358, 372, 391 LEXAPRO...... 245 lincomycin hcl...... 41 leflunomide...... 429, 435, 440 LEXETTE...... 484 lindane...... 494 LEMTRADA...... 435 LEXISCAN...... 263 linezolid...... 45 LENVIMA...... 63 LEXIVA...... 39 linezolid in sodium chloride LESCOL XL...... 167 LIALDA...... 326 ...... 45, 288 lessina...... 359, 372, 392 LIBRAX...... 96, 211 LINZESS...... 331 LETAIRIS...... 465 LIBTAYO...... 63 LIORESAL...... 101 letrozole...... 63, 351 LICART...... 235 liothyronine sodium...... 407 leucovorin calcium...... 416, 507 lidocaine...... 473 LIPITOR...... 167 LEUKERAN...... 63 lidocaine hcl...... 318, 410, 473 LIPO...... 333 LEUKINE...... 119 LIDOCAINE HCL...... 410, 473 LIPO-C...... 333, 507 LEUPROLIDE ACETATE- LIDOCAINE HCL (CARDIAC) LIPOFEN...... 166 BUPIVACAINE...... 380, 410 ...... 154, 155 lisinopril...... 137, 138 levalbuterol hcl...... 111, 463 lidocaine hcl (cardiac).. 154, 155 lisinopril- LEVALBUTEROL HFA....111, 463 lidocaine hcl (cardiac) pf...... 154 hydrochlorothiazide...... 139, 296 LEVATIO...... 473, 499 lidocaine hcl (pf)...... 410 lithium carbonate...... 194 LEVEMIR U-100 FLEXTOUCH lidocaine hcl lithium carbonate er...... 194 ...... 383 urethral/mucosal...... 473 LITHOBID...... 194 LEVEMIR U-100 VIAL...... 383 LIDOCAINE IN D5W...... 155, 274 LITHOSTAT...... 270 levetiracetam...... 188 lidocaine in d5w...... 155, 274 LIVALO...... 167 levetiracetam er...... 188 LIDOCAINE IN DEXTROSE LMD IN D5W...... 121, 274, 288 levetiracetam in nacl.....188, 288 ...... 274, 410 LMD IN NACL...... 121, 288 levobunolol hcl...... 307 lidocaine viscous hcl...... 318 LO LOESTRIN FE...359, 372, 392 LEVOCARNITINE...... 445 lidocaine-epinephrine.....91, 410 LOCOID...... 484 levocarnitine...... 445 LIDOCAINE-EPINEPHRINE LOCOID LIPOCREAM...... 485 levocarnitine sf...... 445 ...... 318, 320 LODINE...... 235 levocetirizine lidocaine-hydrocort LODOSYN...... 217 dihydrochloride...... 13 (perianal)...... 473, 484 LOESTRIN 1.5/30 (21) levofloxacin...... 25, 48, 303 LIDOCAINE- ...... 359, 373, 392 levofloxacin in d5w...... 25, 48 HYDROCORTISONE ACE LOESTRIN 1/20 (21) levoleucovorin calcium 416, 507 ...... 473, 484 ...... 359, 373, 392 levoleucovorin calcium pf LIDOCAINE- LOESTRIN FE 1.5/30 ...... 417, 507 PHENYLEPHRINE...... 318, 321 ...... 359, 373, 392 levonest...... 359, 372, 392 LIDOCAINE- LOESTRIN FE 1/20 359, 373, 392 levonorgest-eth est & eth est PHENYLEPHRINE-BSS lojaimiess...... 359, 373, 392 ...... 359, 372, 392 ...... 316, 318, 321 LOKELMA...... 281 levonorgest-eth estrad 91- lidocaine-prilocaine...... 473 LOMOTIL...... 97, 323 day...... 359, 372, 392 LIDOCAINE-SODIUM LONHALA MAGNAIR REFILL levonorgestrel...... 359, 392 BICARBONATE...... 268, 411 KIT...... 97, 454 levonorgestrel-ethinyl estrad LIDOCANNA...... 473 LONHALA MAGNAIR ...... 359, 372, 392 LIDOCIDEX I...... 344, 411 STARTER KIT...... 97, 454 levonorg-eth estrad triphasic LIDOCORT...... 473, 484 LONSURF...... 63 ...... 359, 372, 392 LIDODERM...... 473 loperamide hcl...... 323 LEVOPHED...... 91 lidolog...... 344, 411 LOPID...... 166 levora 0.15/30 (28). 359, 372, 392 LIDOMAR...... 411 lopinavir-ritonavir...... 39 levorphanol tartrate...... 226 lidopin...... 473 LOPRESSOR..113, 143, 146, 157

530 LOPROX...... 489 LUXTURNA...... 178 MAVYRET...... 33 lorazepam...... 209, 211, 212 LUZU...... 476 MAXALT...... 244 lorazepam intensol...... 209, 212 LYDEXA...... 474 MAXALT-MLT...... 244 LORBRENA...... 64 lyleq...... 360, 393 MAXIDEX...... 310 LOREEV XR...... 210, 212 lyllana...... 373, 423 MAXITROL...... 303, 310 LORTAB...... 182, 226 LYNPARZA...... 64 maxi-tuss ac...... 455, 457 loryna...... 359, 373, 392 LYRICA...... 188, 218 MAXZIDE...... 281, 296 LORZONE...... 100 LYRICA CR...... 182 MAXZIDE-25...... 281, 296 losartan potassium...... 134, 136 LYSINE HCL...... 274 MAYZENT...... 435 losartan potassium-hctz LYSODREN...... 64 MAYZENT STARTER PACK.. 435 ...... 136, 296 LYSTEDA...... 124 me/naphos/mb/hyo1. 52, 97, 445 LOSEASONIQUE... 359, 373, 392 LYUMJEV KWIKPEN...... 400 MEADOW FESCUE GRASS LOTEMAX...... 310 LYUMJEV VIAL...... 400 POLLEN...... 78, 260 LOTEMAX SM...... 310 lyza...... 360, 393 meclizine hcl...... 10, 325 LOTENSIN...... 137, 139 M.V.I. ADULT...... 505 meclofenamate sodium...... 235 LOTENSIN HCT...... 139, 296 M.V.I. PEDIATRIC...... 505 MEDROL...... 345 loteprednol etabonate...... 310 MACI...... 445 medroxyprogesterone LOTREL...... 139, 162 MACRILEN...... 268 acetate...... 360, 393 LOTRONEX...... 326 MACROBID...... 51 mefenamic acid...... 235 lovastatin...... 167 MACRODANTIN...... 52 mefloquine hcl...... 22 LOVAZA...... 140 mafenide acetate...... 492 megestrol acetate...... 64, 393 LOVENOX...... 127 magnesium chloride...... 288 MEKINIST...... 64 low-ogestrel...... 360, 373, 393 magnesium citrate...... 328 MEKTOVI...... 65 loxapine succinate...... 200 magnesium sulfate140, 188, 417 MELALEUCA...... 78, 260 lo-zumandimine.....360, 373, 393 MAGNESIUM SULFATE meloxicam...... 235 LUBIPROSTONE...... 331 ...... 140, 188, 417 melphalan...... 65 LUCEMYRA...... 93 magnesium sulfate in d5w melphalan hcl...... 65 LUCENTIS...... 316 ...... 140, 274, 289, 417 memantine hcl...... 215 LUGOLS STRONG IODINE....492 MAGNESIUM SULFATE- memantine hcl er...... 215 LULICONAZOLE...... 476 NACL...... 140, 289, 417 MEMBRANEBLUE...... 267 LUMAKRAS...... 64 MAHANA IBS...... 445 MENACTRA...... 87 LUMIGAN...... 320 MAKENA...... 393 MENEST...... 373, 423 LUMIZYME...... 299 MALARONE...... 22 MENOPUR...... 380 LUMOXITI...... 64 malathion...... 494 MENOSTAR...... 373, 423 LUNESTA...... 202 MANGANESE CHLORIDE..... 289 MENQUADFI...... 87 LUPKYNIS...... 440 mannitol...... 170, 280, 320 MENTAX...... 477 LUPRON DEPOT (1-MONTH) MARCAINE...... 411 MENVEO...... 87 ...... 64, 380 MARCAINE PRESERVATIVE meperidine hcl...... 226, 227 LUPRON DEPOT (3-MONTH) FREE...... 411 MEPHYTON...... 417, 511 ...... 64, 380 MARCAINE SPINAL...... 274, 411 meprobamate...... 202 LUPRON DEPOT (4-MONTH) MARCAINE/EPINEPHRINE MEPRON...... 23 INTRAMUSCULAR KIT 30MG ...... 91, 411 MEPSEVII...... 299 ...... 64, 380 MARCAINE/EPINEPHRINE mercaptopurine...... 65, 440 LUPRON DEPOT (6-MONTH) PF...... 91, 411 meropenem...... 28 INTRAMUSCULAR KIT 45MG MARGENZA...... 64 MEROPENEM-SODIUM ...... 64, 380 MARINOL...... 324 CHLORIDE...... 28 LUPRON DEPOT-PED (1- marlissa...... 360, 373, 393 merzee...... 360, 373, 393 MONTH)...... 380 MARPLAN...... 221 mesalamine...... 326 LUPRON DEPOT-PED (3- MARQIBO...... 64 mesalamine er...... 326 MONTH)...... 380 MAS CARE-PAK...... 344 mesna...... 448 LUTATHERA...... 64, 451 MATULANE...... 64 MESNEX...... 448 lutera...... 360, 373, 393 matzim la...... 149, 150, 160, 175 MESQUITE...... 78, 260 LUXIQ...... 485 MAVENCLAD...... 440 MESTINON...... 106

531 metaxalone...... 100 metoprolol succinate er milk of magnesia metformin hcl...... 353 ...... 113, 143, 146, 157 concentrate...... 328 metformin hcl er...... 353 metoprolol tartrate MILLIPRED...... 345 metformin hcl er (mod)...... 353 ...... 113, 143, 146, 157 milrinone lactate...... 152 metformin hcl er (osm)...... 353 metoprolol- milrinone lactate in dextrose methadone hcl...... 227 hydrochlorothiazide...... 143, 296 ...... 152, 274 methadone hcl intensol...... 227 METROCREAM...... 469 mimvey...... 374, 393 METHADONE HCL-NACL METROGEL...... 469 MINASTRIN 24 FE..360, 374, 394 ...... 227, 289 METROLOTION...... 469 mineral oil heavy...... 328 methadose...... 227 metronidazole....17, 23, 327, 469 MINIPRESS...... 104, 132, 133 methadose sugar-free...... 227 metronidazole in nacl17, 23, 327 minitran...... 169 methamphetamine hcl...... 180 metyrosine...... 445 MINIVELLE...... 374, 423 methazolamide...... 151, 308 mexiletine hcl...... 155 MINOCIN...... 22, 50 methenamine hippurate...... 52 MI PASTE...... 249 minocycline hcl...... 22, 50 methergine...... 450 MI PASTE PLUS...... 249 MINOCYCLINE HCL ER...50, 499 methimazole...... 352 MIACALCIN...... 352, 423 minocycline hcl er...... 50, 499 METHITEST...... 349 mibelas 24 fe...... 360, 373, 393 MINOLIRA...... 51, 499 methocarbamol...... 36, 100 micafungin sodium...... 29 minoxidil...... 165 METHOHEXITAL SODIUM MICARDIS...... 134, 136 MIOCHOL-E...... 319 ...... 207, 208 MICARDIS HCT...... 136, 296 MIOSTAT...... 319 methotrexate... 65, 429, 435, 440 MIC-L-CARNITINE...... 333 MIRALAX MIX-IN PAX...... 328 methotrexate sodium miconazole 3...... 476 MIRAPEX...... 222 ...... 65, 429, 430, 436, 441 MICONAZOLE-ZINC OXIDE- MIRAPEX ER...... 222 methotrexate sodium (pf) PETROLAT...... 475, 476, 488 MIRCERA...... 119 ...... 65, 429, 435, 440 MICRHOGAM ULTRA- MIRCETTE...... 360, 374, 394 methoxsalen rapid...... 493 FILTERED PLUS...... 83 MIRENA (52 MG)...... 360, 394 methscopolamine bromide.... 97 MICROCHAMBER...... 255 mirtazapine...... 191 methyl salicylate...... 477 MICRODOT TEST...... 265 MIRVASO...... 499 METHYLCOBALAMIN.... 129, 507 microgestin 1.5/30.360, 373, 393 misoprostol...... 334 methyldopa...... 93, 153 microgestin 1/20....360, 373, 393 MITE (D. FARINAE)...... 78, 260 methylene blue...... 417 microgestin 24 fe.. 360, 373, 393 MITE (D. PTERONYSSINUS) methylergonovine maleate...450 microgestin fe 1.5/30 ...... 78, 260 METHYLIN...... 239 ...... 360, 373, 393 MITIGARE...... 419 methylphenidate hcl..... 239, 240 microgestin fe 1/20360, 374, 393 mitigo...... 227 methylphenidate hcl er...... 239 MICROPLEGIA MSA-MSG.....289 mitomycin...... 65 methylphenidate hcl er (cd). 239 MIDAZOLAM...... 212 MITOMYCIN...... 65, 303 methylphenidate hcl er (la).. 239 midazolam hcl...... 212 mitoxantrone hcl...... 65 methylphenidate hcl er (xr).. 239 MIDAZOLAM HCL...... 212 MIXED ASPERGILLUS.....78, 261 methylprednisolone...... 345 midazolam hcl (pf)...... 212 MIXED FEATHERS...... 78, 261 METHYLPREDNISOLONE MIDAZOLAM HCL-SODIUM MIXED RAGWEED...... 78, 261 ACE-LIDO...... 345, 411 CHLORIDE...... 212, 289 MIXED VESPID VENOM METHYLPREDNISOLONE MIDAZOLAM-SODIUM PROTEIN...... 78, 261 ACETATE...... 345 CHLORIDE...... 212, 289 mixed vespid venom protein methylprednisolone acetate 345 midodrine hcl...... 93 ...... 78, 261 methylprednisolone sodium MIFEPREX...... 450 mm clearlax...... 328 succ...... 345 mifepristone...... 450 M-M-R II...... 87 METHYLPREDNISOLONE- MIGERGOT...... 105, 198, 240 MOBIC...... 235 BUPIVACAINE...... 345, 411 miglitol...... 348 modafinil...... 248 methyltestosterone...... 349 miglustat...... 445 moexipril hcl...... 137, 139 metoclopramide hcl...... 334 MIGRANAL...... 105, 199 molindone hcl...... 200 metolazone...... 173, 297 mili...... 360, 374, 393 mometasone furoate milk of magnesia...... 328 ...... 310, 345, 460, 485 MONARCH ETNS SYSTEM... 255

532 mondoxyne nl...... 22, 51 MVASI...... 65 NAPROXEN SODIUM ER MONJUVI...... 65 MYALEPT...... 383 ...... 199, 236, 420 MONOFERRIC...... 128 MYAMBUTOL...... 25 naproxen-esomeprazole monoject flush syringe...... 289 MYCAMINE...... 29 ...... 236, 336 monoject sodium chloride MYCAPSSA...... 331, 403 naratriptan hcl...... 244 flush...... 289 MYCOBUTIN...... 25, 48 NARCAN...... 231 mono-linyah...... 360, 374, 394 mycophenolate mofetil...... 441 NARDIL...... 221 MONONINE...... 124 mycophenolate mofetil hcl...441 NAROPIN...... 411 MONOVISC...... 445 mycophenolate sodium...... 441 NASCOBAL...... 129, 507 MONSELS FERRIC MYDAYIS...... 180 NASONEX...... 311, 345, 460 SUBSULFATE...... 124 MYFEMBREE...... 351, 374, 394 NATACYN...... 306 montelukast sodium..... 458, 459 MYFORTIC...... 441 NATAZIA...... 360, 374, 394 MONUROL...... 52 MYLERAN...... 65 nateglinide...... 384 morgidox...... 22, 51 MYLOTARG...... 65 NATESTO...... 349 MORPHINE SULFATE... 227, 228 MYOBLOC...... 114, 445 NATPARA...... 384, 420 morphine sulfate...... 227, 228 myorisan...... 499 NATROBA...... 494 morphine sulfate MYRBETRIQ...... 504, 505 NATURE-THROID...... 407 (concentrate)...... 227 MYSOLINE...... 207 NAVELBINE...... 65 morphine sulfate (pf)...... 227 MYTESI...... 324 NAYZILAM...... 210 morphine sulfate er...... 227 MYXREDLIN...... 290, 401 nebivolol hcl...... 104, 143 morphine sulfate er beads... 227 na ferric gluc cplx in sucrose NEBUPENT...... 24 MORPHINE SULFATE-NACL ...... 128 necon 0.5/35 (28)... 360, 374, 394 ...... 228, 289 NABI-HB...... 83 nefazodone hcl...... 246 MOTEGRITY...... 331 nabumetone...... 235 NEMBUTAL...... 208 MOTOFEN...... 97, 323 nadolol...... 103, 143, 146 NEOKE ALCAR...... 274 MOUNTAIN CEDAR...... 78, 261 nafcillin sodium...... 46 neomycin sulfate...... 18 MOUSE EPITHELIUM...... 78, 261 NAFCILLIN SODIUM IN neomycin-bacitracin zn- MOVANTIK...... 331 DEXTROSE...... 46, 274 polymyx...... 304 MOVIPREP...... 328, 509 nafrinse...... 425 neomycin-polymyxin b gu....469 MOXEZA...... 303 NAFRINSE DAILY neomycin-polymyxin- MOXIFLOXACIN HCL ACIDULATED...... 249, 425 dexameth...... 304, 311 ...... 25, 48, 303, 304 NAFRINSE DAILY/NEUTRAL.425 neomycin-polymyxin- moxifloxacin hcl...... 25, 48, 303 nafrinse drops...... 425 gramicidin...... 304 moxifloxacin hcl (2x day)..... 303 NAFRINSE WEEKLY...... 425 neomycin-polymyxin-hc moxifloxacin hcl in nacl... 25, 48 naftifine hcl...... 467 ...... 304, 311 MOXIFLOXACIN HCL-BSS.... 304 NAFTIN...... 467 neo-polycin...... 304 MOZOBIL...... 119 NAGLAZYME...... 299 neo-polycin hc...... 304, 311 MS CONTIN...... 228 nalbuphine hcl...... 232 NEOPROFEN...... 199, 236 MUCOR...... 78 NALFON...... 235 NEORAL...... 430, 436, 441 MUGWORT...... 78, 261 NALOCET...... 182, 228 NEOSALUS...... 499 MULPLETA...... 119 naloxone hcl...... 231, 417 neostigmine methylsulfate MULTAQ...... 158 NALTREXONE231, 345, 414, 417 ...... 107, 267 multitrace-4 neonatal...... 290 naltrexone hcl...... 231, 414, 417 NEOSTIGMINE MULTITRACE-4 PEDIATRIC..290 NAMENDA TITRATION PAK..215 METHYLSULFATE...... 107, 267 multivitamin/fluoride.....425, 505 NAMENDA XR...... 215 NEO-SYNALAR...... 469, 485 multi-vitamin/fluoride... 424, 505 NAMZARIC...... 107, 215, 216 NERIVIO...... 255 multi-vitamin/fluoride/iron NAPRELAN...... 199, 235, 419 NERLYNX...... 66 ...... 128, 425, 505 NAPROSYN...... 199, 235, 419 NESACAINE...... 411 MULTRYS...... 290 naproxen...... 199, 235, 419, 420 NESACAINE-MPF...... 411 mupirocin...... 469 naproxen sodium.. 199, 236, 420 NESINA...... 365 mupirocin calcium...... 469 naproxen sodium er NESTABS...... 128, 505, 507 MUSE...... 176 ...... 199, 235, 420 neuac...... 470, 492 mutamycin...... 65 NEULASTA...... 120

533 NEULASTA ONPRO...... 120 nitrofurantoin...... 52 nortrel 0.5/35 (28).. 361, 375, 395 NEUPOGEN...... 120 nitrofurantoin macrocrystal... 52 nortrel 1/35 (21)..... 361, 375, 395 NEUPRO...... 222 nitrofurantoin monohydrate nortrel 1/35 (28)..... 361, 375, 395 NEURACEQ...... 268 macrocrystals...... 52 nortrel 7/7/7...... 361, 375, 395 NEURONTIN...... 182, 188 nitroglycerin...... 170 nortriptyline hcl...... 247 NEVANAC...... 317 nitroglycerin in d5w...... 170, 275 NORVASC...... 163, 164, 176 nevirapine...... 36 NITROLINGUAL...... 170 NORVIR...... 39 nevirapine er...... 36 NITROMIST...... 170 NOURIANZ...... 216 NEXAVAR...... 66 nitroprusside sodium...... 165 novarel...... 380 NEXAVIR...... 445 NITROSTAT...... 170 NOVAREL...... 380 NEXIUM...... 336 NITRO-TIME...... 170 NOVOEIGHT...... 124 NEXIUM I.V...... 336 NITYR...... 445 NOVOFINE AUTOCOVER NEXLETOL...... 140 NIVESTYM...... 120 PEN NEEDLE...... 255 NEXLIZET...... 140, 153 nizatidine...... 11, 333 NOVOFINE PEN NEEDLE..... 255 NEXPLANON...... 361, 394 NOCDURNA...... 124, 385 NOVOFINE PLUS PEN NEXTERONE...... 159, 275 nolix...... 485 NEEDLE...... 255 NEXTSTELLIS...... 361, 374, 394 nora-be...... 361, 394 NOVOLIN 70/30 FLEXPEN NEXVIAZYME...... 299 NORDITROPIN FLEXPRO ...... 382, 402 niacin (antihyperlipidemic).. 507 ...... 385, 404 NOVOLIN 70/30 FLEXPEN niacin er NOREPINEPHRINE (BASE)- RELION...... 382, 402 (antihyperlipidemic)...... 141 DEXTROSE...... 91, 275 NOVOLIN 70/30 RELION382, 402 niacor...... 507 norepinephrine bitartrate...... 91 NOVOLIN 70/30 VIAL..... 382, 402 NIASPAN...... 141 NOREPINEPHRINE- NOVOLIN N FLEXPEN...... 383 nicardipine hcl...... 162, 164, 176 DEXTROSE...... 91, 275 NOVOLIN N FLEXPEN NICARDIPINE HCL IN NACL NOREPINEPHRINE-SODIUM RELION...... 383 ...... 162, 164, 176, 290 CHLORIDE...... 91, 290 NOVOLIN N RELION...... 383 NICORETTE...... 99 norethin ace-eth estrad-fe NOVOLIN N VIAL...... 383 nicotine...... 100 ...... 361, 374, 394 NOVOLIN R FLEXPEN...... 402 nicotine polacrilex...... 99 norethindrone...... 361, 394 NOVOLIN R FLEXPEN nicotine polacrilex mini...... 99 norethindrone acetate...... 394 RELION...... 402 nicotine step 1...... 99 norethindrone acet-ethinyl NOVOLIN R RELION...... 402 nicotine step 2...... 99 est...... 361, 374, 394 NOVOLIN R VIAL...... 402 nicotine step 3...... 99 norethindrone-eth estradiol NOVOLOG 70/30 FLEXPEN NICOTROL...... 100 ...... 374, 394 RELION...... 400 NICOTROL NS...... 100 norethin-eth estradiol-fe NOVOLOG FLEXPEN...... 400 nifedipine...... 162, 164, 176 ...... 361, 374, 395 NOVOLOG FLEXPEN nifedipine er...... 162, 164, 176 NORGESIC FORTE 114, 240, 242 RELION...... 400 nifedipine er osmotic release norgestimate-eth estradiol NOVOLOG MIX 70/30 ...... 162, 164, 176 ...... 361, 375, 395 FLEXPEN...... 400 nikki...... 361, 374, 394 norgestimate-ethinyl NOVOLOG MIX 70/30 NILANDRON...... 66 estradiol triphasic. 361, 375, 395 RELION...... 401 nilutamide...... 66 NORITATE...... 470 NOVOLOG MIX 70/30 VIAL....401 NIMBEX...... 102 norlyda...... 361, 395 NOVOLOG PENFILL...... 401 nimodipine...... 162, 164, 176 norlyroc...... 361, 395 NOVOLOG RELION...... 401 NINLARO...... 66 normal saline flush...... 290 NOVOLOG U-100 VIAL...... 401 NIPENT...... 66 NORMOSOL-M IN D5W. 275, 290 NOVOPEN ECHO...... 255 NIPRIDE RTU...... 165, 290 NORMOSOL-R...... 290 NOVOSEVEN RT...... 124 nisoldipine er...... 162, 164 NORMOSOL-R IN D5W..275, 290 NOVOTWIST PEN NEEDLE.. 255 nitazoxanide...... 24 NORMOSOL-R PH 7.4...... 290 NOXAFIL...... 27 NITHIODOTE...... 339 NORPACE...... 154 NOZIN NASAL SANITIZER nitisinone...... 445 NORPACE CR...... 154 POPSWAB...... 255 NITRO-BID...... 169 NORPRAMIN...... 247 np thyroid...... 407 NITRO-DUR...... 169, 170 NORTHERA...... 91 NPLATE...... 120

534 NS-2 ELECTRIC PATCH ODACTRA...... 79 OPTICHAMBER DIAMOND- POUCH...... 255 ODEFSEY...... 36, 38 LG MASK...... 255 NUBEQA...... 66 ODOMZO...... 66 OPTICHAMBER DIAMOND- NUCALA...... 455 OFEV...... 455 MD MASK...... 255 NUCORT...... 485 ofloxacin...... 48, 304 OPTICHAMBER DIAMOND- NUCYNTA...... 228 OGIVRI...... 66 SM MASK...... 255 NUCYNTA ER...... 228 olanzapine...... 194, 205 OPTIONS GYNOL II NUEDEXTA...... 216 olanzapine-fluoxetine hcl CONTRACEPTIVE...... 449 NULEV...... 97 ...... 205, 245 ORABLOC...... 91, 411 NULIBRY...... 445 OLINVYK...... 228 ORACEA...... 51, 499 NULOJIX...... 441 OLIVE TREE...... 79 ORACIT...... 268 NULYTELY LEMON-LIME...... 328 olmesartan medoxomil.134, 136 oralone...... 485 NUMBRINO...... 319 olmesartan medoxomil-hctz ORAPRED ODT...... 346 NUMOISYN...... 316 ...... 136, 296 ORAVIG...... 476 NUPLAZID...... 204 olmesartan-amlodipine-hctz ORBACTIV...... 31 NURTEC...... 214 ...... 136, 163, 296 ORCHARD GRASS POLLEN nutrilipid...... 275 olopatadine hcl...... 11, 302 ...... 79, 261 NUTROPIN AQ NUSPIN 10 OLUMIANT...... 430 ORENCIA...... 430, 436 ...... 385, 404 OLUX...... 485 ORENCIA CLICKJECT... 430, 436 NUTROPIN AQ NUSPIN 20 OLUX-E...... 485 ORENITRAM...... 465 ...... 385, 404 OMECLAMOX-PAK.... 20, 45, 336 ORFADIN...... 446 NUTROPIN AQ NUSPIN 5 omega-3-acid ethyl esters....141 ORGOVYX...... 66, 351 ...... 385, 404 OMEGAVEN...... 275 ORIAHNN...... 351, 375, 395 NUVARING...... 361, 375, 395 omeprazole...... 336 ORILISSA...... 351 NUVESSA...... 17, 470 OMEPRAZOLE+SYRSPEND ORKAMBI...... 456, 457 NUVIGIL...... 248 SF ALKA...... 336 ORLADEYO...... 427 NUWIQ...... 124 omeprazole-sodium orphenadrine citrate..... 114, 184 NUZYRA...... 18 bicarbonate...... 322, 336 orphenadrine citrate er.114, 184 nyamyc...... 494 OMIDRIA...... 317, 320 orphenadrine-asa-caffeine nylia 7/7/7...... 361, 375, 395 OMNARIS...... 311 ...... 114, 240, 242 NYMALIZE...... 163, 164, 176 OMNITROPE...... 385, 386, 404 ORPHENGESIC FORTE nymyo...... 361, 375, 395 ONCASPAR...... 66 ...... 114, 240, 242 nystatin...... 47, 494 ondansetron hcl...... 323 orsythia...... 362, 375, 395 nystatin-triamcinolone. 485, 494 ondansetron odt...... 323 ORTHOVISC...... 446 nystop...... 494 ONE DROP TEST...... 265 ORTIKOS...... 346 NYVEPRIA...... 120 ONE VITE WOMENS oscimin...... 97 OBIZUR...... 124 ...... 128, 505, 508 oseltamivir phosphate...... 42, 43 OCALIVA...... 331 ONE-A-DAY WOMENS OSENI...... 365, 406 ocella...... 362, 375, 395 PRENATAL 1.. 128, 445, 505, 508 OSMITROL...... 170, 280, 320 OCREVUS...... 436 ONETOUCH ULTRA...... 265 OSMOLEX ER...... 17, 178 OCTAGAM...... 83 ONETOUCH VERIO...... 255, 265 OSMOPREP...... 328 OCTAPLAS BLOOD GROUP ONEXTON...... 470, 492 OSPHENA...... 366 A...... 115 ONFI...... 210, 212 OTEZLA...... 430, 436, 499 OCTAPLAS BLOOD GROUP ONGENTYS...... 214 OTIPRIO...... 304 AB...... 115 ONGLYZA...... 365 OTOVEL...... 304, 311 OCTAPLAS BLOOD GROUP ONIVYDE...... 66 OTREXUP...... 430 B...... 115 ONPATTRO...... 446 OVACE PLUS...... 470 OCTAPLAS BLOOD GROUP ONTRUZANT...... 66 OVACE PLUS WASH...... 470 O...... 115 ONUREG...... 66 OVACE WASH...... 470 octreotide acetate...... 332, 403 ONZETRA XSAIL...... 244 OVIDE...... 494 OCUCOAT OPDIVO...... 66 OVIDREL...... 380 VISCOADHERENT...... 316 OPSUMIT...... 465 oxacillin sodium...... 46 OCUFLOX...... 304 OPTICHAMBER DIAMOND....255

535 OXACILLIN SODIUM IN PANCREAZE...... 299, 300, 329 pentamidine isethionate...... 24 DEXTROSE...... 46, 275 pancuronium bromide...... 102 PENTASA...... 326 oxaliplatin...... 67 PANDA MASK LARGE...... 255 pentazocine-naloxone hcl oxandrolone...... 349 PANDA MASK MEDIUM...... 255 ...... 231, 232 oxaprozin...... 236 PANDA MASK SMALL...... 255 PENTETATE CALCIUM OXAYDO...... 228 PANDEL...... 485 TRISODIUM...... 339 oxazepam...... 212 PANHEMATIN...... 115 PENTETATE ZINC OXBRYTA...... 117 PANRETIN...... 500 TRISODIUM...... 339 oxcarbazepine...... 188 pantoprazole sodium...... 336 pentobarbital sodium...... 208 OXERVATE...... 316 PANZYGA...... 83 PENTOSAN POLYSULFATE OXIANUJO...... 441, 499 papaverine hcl...... 176 SODIUM...... 446 OXIATAR...... 478, 499 PARAGARD INTRAUTERINE pentoxifylline er...... 121 OXIAVARRY...... 478, 500 COPPER...... 449 PEPAXTO...... 67 oxiconazole nitrate...... 476 paraplatin...... 67 PEPCID...... 11, 333 OXISTAT...... 476 paricalcitol...... 510 PERCOCET...... 182, 229 OXLUMO...... 446 PARLODEL...... 218 PERENNIAL RYE GRASS OXTELLAR XR...... 188 PARNATE...... 221 POLLEN...... 79, 261 oxybutynin chloride...... 503 paromomycin sulfate...... 17, 18 PERFOROMIST...... 111, 463 oxybutynin chloride er...... 503 paroxetine hcl...... 245 PERIDEX...... 313, 492 oxycodone hcl...... 229 paroxetine hcl er...... 245 PERIKABIVEN...... 275 OXYCODONE HCL ER...... 229 paroxetine mesylate...... 245 perindopril erbumine.... 137, 139 OXYCODONE- PARSABIV...... 352 periogard...... 313, 492 ACETAMINOPHEN...... 182, 229 PATANASE...... 11, 302 PERJETA...... 67 oxycodone-acetaminophen PAXIL...... 245, 246 permethrin...... 494 ...... 182, 229 PAXIL CR...... 245 perphenazine...... 237 OXYCONTIN...... 229 P-CARE K40...... 346 perphenazine-amitriptyline oxymorphone hcl...... 229 P-CARE K80...... 346 ...... 237, 248 oxymorphone hcl er...... 229 PEDIAPRED...... 346 PERSERIS...... 194, 205 oxytocin...... 450 PEDIARIX...... 85, 87 PERTZYE...... 300, 330 OXYTOCIN-LACTATED PEDIATRIC PANDA MASK.... 256 PEXEVA...... 246 RINGERS...... 290, 450 PEDVAX HIB...... 87 PFIZERPEN...... 42 OXYTOCIN-SODIUM peg 3350...... 328 pharmacist choice d-vitamin510 CHLORIDE...... 290, 450 peg 3350-kcl-na bicarb-nacl.328 phenazo...... 474 OXYTROL...... 503 peg-3350/electrolytes...... 328 phenazopyridine hcl...... 474 oyster shell calcium/d.. 290, 510 peg- phenelzine sulfate...... 221 oyster shell calcium/vit d3 3350/electrolytes/ascorbat PHENERGAN ...... 290, 510 ...... 328, 509 ...... 10, 11, 202, 324, 458 oyster shell calcium/vitamin PEGASYS...... 40 phenobarbital...... 207, 208 d...... 291, 510 peg-kcl-nacl-nasulf-na asc-c phenobarbital sodium.. 207, 208 OZEMPIC...... 381 ...... 328, 509 PHENOL...... 446 OZOBAX...... 101 peg-prep...... 328 phenoxybenzamine hcl 105, 167 OZURDEX...... 311 PEMAZYRE...... 67 phentermine hcl...... 178 PACERONE...... 159 penicillamine...... 339, 430 phentolamine mesylate 105, 167 paclitaxel...... 67 PENICILLIN G POT IN PHENYLEPHRINE HCL PADCEV...... 67 DEXTROSE...... 42, 275 ...... 93, 320, 321 PAIN RELIEF WITH TENS penicillin g potassium...... 42 phenylephrine hcl... 93, 320, 321 S2000...... 255 penicillin g procaine...... 42 PHENYLEPHRINE HCL PALFORZIA...... 79 penicillin g sodium...... 42 (PRESSORS)...... 93 paliperidone er...... 205 penicillin v potassium...... 42 PHENYLEPHRINE HCL-NACL palonosetron hcl...... 323 PENICILLIUM NOTATUM.79, 261 ...... 93, 291 PALYNZIQ...... 299 PENNSAID...... 493, 500 PHENYTEK...... 155, 220 PAMELOR...... 247 PENTACEL...... 85, 87 phenytoin...... 155, 220 pamidronate disodium...... 423 PENTAM...... 24 phenytoin infatabs...... 155, 220

536 phenytoin sodium...... 155, 220 PLEGRIDY STARTER PACK. 436 pramipexole dihydrochloride phenytoin sodium extended PLENAMINE...... 275 er...... 222 ...... 155, 220 PLENVU...... 329, 509 PRAMOSONE...... 474, 485 PHEODOYO...... 476, 485, 492 PLEXION...... 470, 489 PRAMOTIC...... 313, 319 PHESGO...... 67 PLEXION CLEANSING pramox...... 474 PHEXXI...... 449 CLOTH...... 470, 489 prasugrel hcl...... 130 PHEYO...... 476, 485 PNEUMOVAX 23...... 87 pravastatin sodium...... 167 philith...... 362, 375, 395 POCKET SPACER...... 256 PRAXBIND...... 117 PHOMA EXIGUA...... 79, 261 POD-CARE 100K...... 346 praziquantel...... 20 PHOSLYRA...... 280, 291 podocon...... 500 prazosin hcl...... 104, 132, 133 PHOSPHA 250 NEUTRAL...... 291 podofilox...... 500 PRECEDEX...... 202, 292 PHOSPHASAL....52, 97, 182, 446 PODPROG...... 395, 500 PRECISION PCX PLUS TEST265 phosphorous...... 291 POGO AUTOMATIC BLOOD PRECISION QID MONITOR...256 phospho-trin 250 neutral...... 291 GLUCOSE...... 256 PRECISION QID TEST...... 265 PHOTOFRIN...... 67 POINT OF CARE KM...... 346, 412 PRECISION SOF-TACT PHOTREXA VISCOUS...... 316 POLIDOCANOL...... 173 MONITOR...... 256 PHOXILLUM B22K4/0...... 291 POLIVY...... 67 PRECISION SOF-TACT TEST PHOXILLUM BK4/2.5...... 291 polocaine...... 412 ...... 265 PHYSICIANS EZ USE polocaine-mpf...... 412 PRECISION XTRA...... 256 JOINT/TUNNEL...... 240, 346, 411 polycin...... 304 PRECISION XTRA BLOOD PHYSICIANS EZ USE M- polyethylene glycol 3350...... 329 GLUCOSE...... 265 PRED...... 346, 412 polymyxin b sulfate...... 47, 470 PRECISION XTRA MONITOR 256 PHYSIOLYTE...... 278 polymyxin b-trimethoprim....304 PRECOSE...... 348 PHYSIOSOL IRRIGATION..... 278 POLYTRIM...... 304 PRED FORTE...... 311 PHYSOSTIGMINE POMALYST...... 67, 437 PRED MILD...... 311 SALICYLATE...... 107, 417 PONVORY...... 437 PRED-G...... 305, 311 phytonadione...... 417, 511 PONVORY STARTER PACK. 437 PRED-G S.O.P...... 305, 311 PIFELTRO...... 36 portia-28...... 362, 375, 395 prednicarbate...... 486 pilocarpine hcl...... 107, 319 PORTRAZZA...... 67 PREDNISOL ACE- pimecrolimus...... 441, 500 posaconazole...... 27 MOXIFLOX-BROMFEN pimozide...... 200 pot & sod cit-cit ac...... 268 ...... 305, 311, 317 pimtrea...... 362, 375, 395 POTABA...... 508 prednisolone...... 346 pindolol...... 104, 143, 146, 157 potassium acetate...... 291 prednisolone acetate...... 311 pioglitazone hcl...... 406 potassium chloride...... 292 prednisolone acetate p-f...... 311 pioglitazone hcl-glimepiride 406 potassium chloride crys er.. 291 PREDNISOLONE ACETATE- pioglitazone hcl-metformin potassium chloride er...... 291 NEPAFENAC...... 311, 317 hcl...... 354, 406 potassium chloride in PREDNISOLONE ACET- piperacillin sod-tazobactam dextrose...... 275, 292 MOXIFLOXACIN...... 305, 312 so...... 30 potassium chloride in nacl...292 prednisolone sodium PIQRAY...... 67 potassium citrate er...... 268 phosphate...... 312, 346 pirmella 1/35...... 362, 375, 395 potassium citrate-citric acid 268 PREDNISOLONE- pirmella 7/7/7...... 362, 375, 395 potassium phosphates...... 292 BROMFENAC...... 312, 317 piroxicam...... 236 potassium phosphates(66 PREDNISOLONE- PITOCIN...... 450 meq k)...... 292 GATIFLOXACIN...... 305, 312 PLAQUENIL...... 22, 430, 436 potassium phosphates(71 PREDNISOLONE- PLASBUMIN-25...... 115 meq k)...... 292 MOXIFLOXACIN...... 305, 312 PLASBUMIN-5...... 115 POTELIGEO...... 67 PREDNISOLON-GATIFLOX- PLASMA-LYTE 148...... 291 POVIDONE-IODINE...... 313 BROMFENAC. 305, 312, 317, 318 PLASMA-LYTE A...... 291 PRADAXA...... 119 PREDNISOLON-MOXIFLOX- PLASMANATE...... 115 PRALUENT...... 170 BROMFENAC...... 305, 312, 318 PLAVIX...... 130 pramipexole dihydrochloride PREDNISOLON-MOXIFLOX- PLEGISOL...... 291 ...... 222 NEPAFENAC...... 305, 312, 318 PLEGRIDY...... 436, 437 prednisone...... 346

537 prednisone intensol...... 346 PRISMASOL BGK 0/2.5...... 292 promethazine-phenyleph- PREFEST...... 375, 395 PRISMASOL BGK 2/0...... 292 codeine...... 12, 94, 456 pregabalin...... 188, 218 PRISMASOL BGK 2/3.5...... 292 promethazine-phenylephrine pregabalin er...... 182 PRISMASOL BGK 4/0/1.2...... 293 ...... 12, 94 pregnyl...... 380 PRISMASOL BGK 4/2.5...... 293 promethegan PREMARIN...... 375, 423 PRISMASOL BK 0/0/1.2...... 293 ...... 10, 12, 202, 324, 458 PREMASOL...... 275 PRISTIQ...... 243 PROMETRIUM...... 396 premium lidocaine...... 474 PRIVET...... 79, 261 PROMISEB...... 489 PREMIUM SCAR.... 474, 475, 488 PRIVIGEN...... 84 propafenone hcl...... 155 PREMPHASE...... 376, 396 PRO COMFORT TENS UNIT. 256 propafenone hcl er...... 155 PREMPRO...... 376, 396 PROAIR DIGIHALER...... 111, 464 proparacaine hcl...... 319 prenatal...... 128, 505, 508 PROAIR HFA...... 111, 464 propofol...... 202, 219 prenatal multi +dha PROAIR RESPICLICK....111, 464 propofol-lipuro...... 202, 219 ...... 128, 292, 446, 505, 508 probenecid...... 297, 420 propranolol hcl PRENATVITE RX procainamide hcl...... 154 ...... 104, 143, 146, 157, 158, 199 ...... 128, 292, 505, 508 PROCALAMINE...... 276 propranolol hcl er PRE-PEN...... 266 PROCARDIA XL..... 163, 164, 176 ...... 104, 143, 146, 157, 199 PREPIDIL...... 450 PROCARE TENS & EMS...... 256 propylthiouracil...... 352 PRESERA...... 500 PRO-C-DURE 5...... 346 PROQUAD...... 88 PRESTALIA...... 137, 163 PRO-C-DURE 6...... 346 PROSCAR...... 414 PRETOMANID...... 25 PROCENTRA...... 180 PROSILK...... 477 PREVACID...... 336 prochlorperazine...... 237, 325 PROSOL...... 276 PREVACID SOLUTAB...... 336 prochlorperazine edisylate PROSTIN VR...... 176 prevalite...... 147 ...... 237, 325 protamine sulfate...... 117, 417 preventeza...... 362, 396 prochlorperazine maleate PROTONIX...... 337 PREVIDENT...... 425 ...... 237, 325 PROTOPAM CHLORIDE...... 417 prevident...... 425 PROCORT...... 474, 486 PROTOPIC...... 441, 500 PREVIDENT 5000 BOOSTER PROCRIT...... 116, 120 protriptyline hcl...... 248 PLUS...... 425 PROCTOCORT...... 486 PROVAYBLUE...... 418 PREVIDENT 5000 DRY PROCTOFOAM HC...... 474, 486 PROVENGE...... 177 MOUTH...... 425 procto-med hc...... 486 PROVENTIL HFA...... 111, 464 PREVIDENT 5000 ENAMEL procto-pak...... 486 PROVERA...... 396 PROTECT...... 249, 425 proctozone-hc...... 486 PROVIGIL...... 248 PREVIDENT 5000 ORTHO PROCYSBI...... 446 PROVISC...... 316 DEFENSE...... 425 PROFILNINE...... 125 PROZAC...... 246 PREVIDENT 5000 PLUS...... 425 progesterone...... 396 PRUDOXIN...... 474 PREVIDENT 5000 SENSITIVE PROGLYCEM...... 352 pseudoephedrine- ...... 249, 425 PROGRAF...... 441 bromphen-dm...... 12, 91, 456 previfem...... 362, 376, 396 PROLASTIN-C...... 462 PSORCON...... 486 PREVNAR 13...... 87 PROLATE...... 183, 229 PULMICORT FLEXHALER PREVNAR 20...... 88 PROLENSA...... 318 ...... 347, 461 PREVYMIS...... 26 PROLEUKIN...... 68, 437 PULMICORT SUSPENSION PREZCOBIX...... 40, 446 PROLIA...... 423 ...... 347, 461 PREZISTA...... 40 PROLIXUS...... 256 PULMOZYME...... 300, 459 PRIALT...... 182 PROMACTA...... 120 PURIXAN...... 68, 442 PRIFTIN...... 26, 48 promethazine hcl PYLARIFY...... 451 PRILOSEC...... 337 ...... 9, 10, 11, 202, 324, 458 PYLERA...... 20, 24, 51, 324, 326 primaquine phosphate...... 22 promethazine vc...... 11, 93 pyrazinamide...... 26 PRIMAXIN IV...... 28 promethazine vc/codeine PYRIDIUM...... 474 primidone...... 207 ...... 12, 93, 456 pyridostigmine bromide...... 107 PRIMSOL...... 52 promethazine-codeine....12, 456 pyridostigmine bromide er...107 PRINIVIL...... 137, 139 promethazine-dm...... 12, 456 pyrimethamine...... 22 PRISMASOL B22GK 4/0...... 292 PYROGALLIC ACID451, 489, 500

538 QBRELIS...... 139 RAZADYNE ER...... 107 repaglinide...... 384 QBREXZA...... 97, 500 READYSHARP REPATHA...... 170 qc magnesium citrate...... 329 BETAMETHASONE...... 347 REPATHA PUSHTRONEX QDOLO...... 229 READYSHARP SYSTEM...... 170 QELBREE...... 216 DEXAMETHASONE...... 347 REPATHA SURECLICK...... 171 QINLOCK...... 68 REBIF...... 437 RESET FOR IOS OR QNASL...... 312, 460 REBIF REBIDOSE...... 437 ANDROID APP...... 446 QNASL CHILDRENS...... 312, 460 REBIF REBIDOSE RESET-O FOR IOS OR QSYMIA...... 183 TITRATION PACK...... 437 ANDROID APP...... 446 QTERN...... 365, 403 REBIF TITRATION PACK...... 437 RESORCINOL-SULFUR...... 489 QUAD-MIX...... 97, 105, 176, 454 REBINYN...... 125 RESTASIS...... 314 QUADRACEL...... 85, 88 REBLOZYL...... 120 RESTASIS MULTIDOSE...... 314 QUADRAMET...... 68, 451 RECARBRIO...... 28 RESTORIL...... 212 QUALAQUIN...... 22 RECLAST...... 423 RETACRIT...... 116, 120 QUARTETTE...... 362, 376, 396 reclipsen...... 362, 376, 396 RETAVASE...... 131, 300 quazepam...... 212 RECOMBINATE...... 125 RETAVASE HALF-KIT....131, 300 QUDEXY XR...... 188 RECOMBIVAX HB...... 88 RETEVMO...... 68 QUEEN PALM...... 79, 261 RECOTHROM...... 125 RETIN-A...... 478 QUESTRAN...... 147 RECOTHROM SPRAY KIT.....125 RETIN-A MICRO...... 478 QUESTRAN LIGHT...... 147 RECTIV...... 500 RETIN-A MICRO PUMP...... 478 quetiapine fumarate...... 194, 205 RECURA...... 471 RETISERT...... 312 quetiapine fumarate er. 194, 205 RED MAPLE...... 79 RETROVIR...... 38 QUFLORA FE RED MULBERRY...... 79, 261 REVATIO...... 171, 465, 504 ...... 128, 293, 425, 505, 508 RED TOP GRASS POLLEN REVCOVI...... 300 QUILLICHEW ER...... 240 ...... 79, 261 REVLIMID...... 68, 437 QUILLIVANT XR...... 240 REDITREX...... 431 revonto...... 101 quinapril hcl...... 137, 139 REGEN-COV...... 42 REXULTI...... 205 quinapril- REGLAN...... 334 REYATAZ...... 40 hydrochlorothiazide...... 139, 296 REGONOL...... 107 REYVOW...... 244 quinidine gluconate er....22, 154 RELAFEN...... 236 REZUROCK...... 446 quinidine sulfate...... 22, 154 RELAFEN DS...... 236 R-GENE 10...... 268 quinine sulfate...... 22 RELENZA DISKHALER...... 43 RHIZOPUS...... 79 QUZYTTIR...... 13, 463 relexxii...... 240 RHOFADE...... 500 QVAR REDIHALER...... 347, 461 RELION BLOOD GLUCOSE RHOGAM ULTRA-FILTERED RABAVERT...... 88 TEST...... 265 PLUS...... 84 RABBIT EPITHELIUM...... 79, 261 RELION PREMIER CLASSIC.256 RHOPHYLAC...... 84 RABEPRAZOLE SODIUM...... 337 RELION PREMIER TEST...... 265 RHOPRESSA...... 321 rabeprazole sodium...... 337 RELISTOR...... 231, 332 RIABNI...... 68 RADICAVA...... 216 RELNATE DHA RIASTAP...... 125 RADIOGARDASE...... 280, 418 ...... 128, 446, 506, 508 ribavirin...... 44 raloxifene hcl...... 366, 423 RELPAX...... 244 RIDAURA...... 337, 431, 437 ramelteon...... 202 RELTONE...... 329 rifabutin...... 26, 48 ramipril...... 137, 139 REMDESIVIR...... 44 RIFADIN...... 26, 48 RANEXA...... 151 REMERON...... 191 rifampin...... 26, 48 ranolazine er...... 152 REMERON SOLTAB...... 191 RIGHTEST GT333 BLOOD RAPAFLO...... 108 REMESENSE...... 249 GLUCOSE...... 256, 266 RAPAMUNE...... 442 REMICADE..... 332, 431, 437, 500 RILUTEK...... 216 RAPIVAB...... 43 remifentanil hcl...... 229 riluzole...... 216 rasagiline mesylate...... 220, 221 REMODULIN...... 465 rimantadine hcl...... 17 RASUVO...... 431 RENACIDIN...... 278 RIMSO-50...... 446 RAVICTI...... 270 RENAGEL...... 280, 418 ringers...... 293 RAYALDEE...... 510 RENFLEXIS.... 332, 431, 437, 500 ringers irrigation...... 278 RAYOS...... 347 RENVELA...... 280, 418 RINVOQ...... 431

539 RIOMET...... 354 SABRIL...... 189 SENSORCAINE- risedronate sodium...... 423 SACCHAROMYCES MPF/EPINEPHRINE...... 92, 413 RISPERDAL...... 195, 205 CEREVISIAE...... 80 SEREVENT DISKUS...... 112, 464 RISPERDAL CONSTA....194, 205 SAFYRAL...... 362, 376, 396, 508 SERNIVO...... 486 risperidone...... 195, 205 SAIZEN...... 386, 404 SEROQUEL...... 195, 206 RITALIN...... 240 SAIZENPREP...... 386, 405 SEROQUEL XR...... 195, 206 RITALIN LA...... 240 sajazir...... 427 SEROSTIM...... 386, 405 ritonavir...... 40 SALAGEN...... 107 sertraline hcl...... 246 RITUXAN...... 68 salicylic acid...... 490 setlakin...... 362, 376, 396 RITUXAN HYCELA...... 68 salicylic acid er...... 490 sevelamer carbonate.... 280, 418 rivastigmine...... 107 salicylic acid wart remover.. 490 sevelamer hcl...... 280, 418 rivastigmine tartrate...... 107 salimez...... 490 SEVENFACT...... 125 rivelsa...... 362, 376, 396 SALIMEZ FORTE...... 490 SEYSARA...... 18 RIXUBIS...... 125 saline bacteriostatic...... 293 sf...... 425 rizatriptan benzoate...... 244 SALINE-PHENOL...... 293 sf 5000 plus...... 425 ROBAXIN...... 100 salsalate...... 242 SFROWASA...... 326 ROCALTROL...... 510 SALVAX...... 490 SHAGBARK HICKORY.....80, 262 ROCKLATAN...... 320, 321 SAMSCA...... 298 sharobel...... 362, 396 rocuronium bromide...... 102 SANCUSO...... 323 SHEEP SORREL...... 80 ROCURONIUM BROMIDE..... 102 SANDIMMUNE...... 431, 438, 442 SHINGRIX...... 88 ROMIDEPSIN...... 68 SANDOSTATIN...... 332, 403 SHORT RAGWEED POLLEN ropinirole hcl...... 222 SANDOSTATIN LAR DEPOT EXT...... 80, 262 ropinirole hcl er...... 222 ...... 332, 403 SIGNIFOR...... 404 ROPIVACAINE HCL...... 412 SANTYL...... 300, 500 SIGNIFOR LAR...... 403 ropivacaine hcl...... 412 SAPHNELO...... 442 SIKLOS...... 69 ROPIVACAINE HCL-NACL SAPHRIS...... 195, 205 SILATRIX...... 500 ...... 293, 412 sapropterin dihydrochloride 447 sildenafil citrate ROPIV-CLONIDINE- SARCLISA...... 69 ...... 171, 465, 466, 504 KETOROLAC....94, 153, 236, 412 SAVAYSA...... 118 SILENOR...... 248 rosadan...... 470 SAVELLA...... 218, 243 SILIQ...... 500 rosuvastatin calcium...... 167 SAVELLA TITRATION PACK silodosin...... 108 ROSZET...... 154, 167 ...... 218, 243 SILVADENE...... 493 ROUGH MARSH ELDER..79, 261 SAXENDA...... 381 silver nitrate...... 313 roweepra...... 188 SCENESSE...... 500 silver sulfadiazine...... 493 ROXICODONE...... 230 SCLEROSOL SIMBRINZA...... 301, 308 ROZEREM...... 202 INTRAPLEURAL...... 173 simliya...... 362, 376, 396 ROZLYTREK...... 68 scopolamine...... 97, 324 simpesse...... 362, 376, 396 RUBRACA...... 68 SEASONIQUE...... 362, 376, 396 SIMPONI...... 332, 431, 438 RUCONEST...... 427 SECREFLO...... 267 SIMPONI ARIA...... 332, 431, 438 rufinamide...... 188, 189 SECUADO...... 195, 206 SIMULECT...... 442 RUKOBIA...... 34 SEGLUROMET...... 354, 403 simvastatin...... 167 RUSSIAN THISTLE...... 79, 262 selegiline hcl...... 220, 221 SINEMET...... 217 RUXIENCE...... 68 SELENIOUS ACID...... 293 SINGULAIR...... 459 RUZURGI...... 447 selenium sulfide...... 490, 493 SINUVA...... 312, 347, 460 RYANODEX...... 101 SELRX...... 490, 493 sirolimus...... 442 RYBELSUS...... 381 SELZENTRY...... 34 SIRTURO...... 26 RYBREVANT...... 68 SEMGLEE...... 383 SITAVIG...... 44 RYCLORA...... 12 SENSIPAR...... 352 SIVEXTRO...... 46 RYDAPT...... 68 SENSORCAINE...... 412 SKELAXIN...... 100 RYLAZE...... 69 SENSORCAINE/EPINEPHRIN SKYLA...... 362, 396 RYTARY...... 217 E...... 91, 412 SKYRIZI...... 501 RYTHMOL SR...... 155 SENSORCAINE-MPF..... 412, 413 SKYRIZI (150 MG DOSE)...... 500 ryvent...... 9, 10, 458 sensorcaine-mpf...... 412 SKYRIZI PEN...... 500

540 SLYND...... 362, 397 SOMA...... 100 STEGLATRO...... 403 SMOFLIPID...... 276 SOMATULINE DEPOT...... 404 STEGLUJAN...... 365, 403 sod benz-sod phenylacet..... 270 SOMAVERT...... 405 STELARA...... 332, 501 sod citrate-citric acid...... 268 SOMRYST...... 447 STENDRA...... 171 sodium acetate...... 269 SOOLANTRA...... 494 STERILE DILUENT FLOLAN sodium bicarbonate SOOTHEE...... 319, 477, 501 PH 12...... 451 ...... 269, 322, 327 SORBITOL...... 278 sterile diluent/epoprostenol.451 SODIUM BICARBONATE...... 269 sorbitol-mannitol...... 278 STERILE TALC POWDER...... 173 SODIUM BICARBONATE- SORIATANE...... 501 STERILE TOPICAL L.E.T. DEXTROSE...... 269, 276 SORILUX...... 501 GEL...... 321, 474 sodium chloride.... 278, 293, 459 sorine..... 104, 143, 146, 158, 159 sterile water for injection..... 451 sodium chloride (pf)...... 293 SORREL/DOCK MIX...... 80, 262 sterile water for irrigation.....278 sodium chloride SOTALOL HCL STERITALC...... 173 bacteriostatic...... 293 ...... 104, 143, 146, 158, 159 STIMATE...... 125, 386 sodium chloride flush...... 293 sotalol hcl STIOLTO RESPIMAT...... 97, 112 SODIUM CITRATE...... 116 ...... 104, 144, 146, 158, 159 STIVARGA...... 69 SODIUM CITRATE LOCK sotalol hcl (af) STRATTERA...... 216 FLUSH...... 117 ...... 104, 143, 146, 158, 159 STRENSIQ...... 300 SODIUM CITRATE- SOTRADECOL...... 173 streptomycin sulfate...... 18, 26 GENTAMICIN SULF...... 18, 117 SOTROVIMAB...... 42 STRIBILD...... 35, 38, 447 SODIUM DIURIL...... 173, 296 SOTYLIZE STRIVERDI RESPIMAT. 112, 464 SODIUM EDECRIN...... 168, 279 ...... 104, 144, 146, 158, 159 STROMECTOL...... 20 sodium fluoride...... 426 SOVALDI...... 32 STRONTIUM CHLORIDE SR- sodium fluoride 5000 enamel SPABUDDY SPORT ELITE....256 89...... 69, 451 ...... 249, 426 spinosad...... 494 SUBLOCADE...... 232 sodium fluoride 5000 plus....426 SPINRAZA...... 420 SUBOXONE...... 231, 232 sodium fluoride 5000 ppm... 426 SPINY PIGWEED...... 80, 262 SUBSYS...... 230 sodium fluoride 5000 SPIRIVA HANDIHALER....97, 454 subvenite...... 189, 195 sensitive...... 249, 426 SPIRIVA RESPIMAT...... 97, 454 subvenite starter kit-blue SODIUM IODIDE I-131...... 352 spironolactone...... 169, 172, 281 ...... 189, 195 sodium nitrite...... 339 spironolactone-hctz...... 169, 296 subvenite starter kit-green sodium nitroprusside...... 165 SPORANOX...... 27 ...... 189, 195 sodium phenylbutyrate...... 270 SPORANOX PULSEPAK...... 27 subvenite starter kit-orange sodium phosphates...... 293 SPRAVATO (56 MG DOSE)... 191 ...... 189, 195 sodium polystyrene SPRAVATO (84 MG DOSE)... 191 SUCCINYLCHOLINE sulfonate...... 281, 418 sprintec 28...... 362, 376, 397 CHLORIDE...... 102 sodium saccharin...... 294 SPRITAM...... 189 SUCRAID...... 300 sodium sulfacetamide...... 470 SPRIX...... 236 sucralfate...... 335 sodium sulfacetamide wash 471 SPRYCEL...... 69 sufentanil citrate...... 230 sodium tetradecyl sulfate.....173 sps...... 281, 418 SULAR...... 163, 164 SODIUM THIOSULFATE...... 339 sronyx...... 362, 376, 397 SULCONAZOLE NITRATE.....476 sodium thiosulfate...... 339 ssd...... 493 sulfacetamide sodium.. 305, 471 SOFOSBUVIR-VELPATASVIR SSKI...... 457 sulfacetamide sodium (acne) ...... 32, 33 ST JOSEPH LOW DOSE ...... 471 SOLESTA...... 447 ...... 130, 131, 199, 242 sulfacetamide sodium-sulfur solifenacin succinate...... 503 STALEVO 100...... 214, 217 ...... 471, 490 SOLIQUA...... 381, 383 STALEVO 125...... 214, 217 sulfacetamide-prednisolone SOLIRIS...... 427 STALEVO 150...... 214, 217 ...... 305, 312 SOLODYN...... 51, 501 STALEVO 200...... 214, 217 sulfadiazine...... 49 SOLOSEC...... 24 STALEVO 50...... 214, 217 sulfamethoxazole- SOLTAMOX...... 69, 366 STALEVO 75...... 214, 218 trimethoprim...... 24, 49, 52 SOLU-CORTEF...... 347 STAMARIL...... 88 SULFAMYLON...... 493 SOLU-MEDROL...... 347 stavudine...... 38 sulfasalazine....49, 326, 431, 438

541 sulfatrim pediatric...... 24, 49, 52 SYNERCID...... 49 taztia xt...... 149, 150, 160, 177 sulfurated lime...... 494 SYNJARDY...... 354, 403 TAZVERIK...... 70 sulindac...... 236 SYNJARDY XR...... 354, 403 TDVAX...... 85 sumatriptan...... 244 SYNRIBO...... 69 TECARTUS...... 70, 178 sumatriptan succinate...... 244 SYNTHROID...... 407 TECENTRIQ...... 70 sumatriptan succinate refill. 244 SYNVISC...... 447 TECFIDERA...... 438 sumatriptan-naproxen SYNVISC ONE...... 447 TEFLARO...... 16 sodium...... 236, 244 SYPRINE...... 339 TEGRETOL...... 189, 195 SUMAXIN...... 471, 490 T: SLIM X2 INS TEGRETOL-XR...... 189, 195 sunitinib malate...... 69 PMP/CONTROL 7.4...... 256 TEGSEDI...... 420 SUNOSI...... 248 T:SLIM X2 INSULIN PMP TEKTURNA...... 172 SUPARTZ FX...... 447 BASAL6.4...... 257 TEKTURNA HCT...... 172, 296 SUPER BI-MIX...... 105, 176 TABLOID...... 69 TELFA AMD ISLAND SUPER QUAD-MIX TABRECTA...... 69 DRESSING...... 257 ...... 97, 105, 176, 454 TACHOSIL...... 501 telmisartan...... 134, 136 SUPER TRI-MIX...... 105, 176 TACLONEX...... 486, 501 telmisartan-amlodipine.136, 163 SUPPRELIN LA...... 380 tacrolimus...... 442, 501 telmisartan-hctz...... 136, 296 SUPRAX...... 16 tadalafil...... 171 temazepam...... 213 SUPREP BOWEL PREP KIT..329 tadalafil (pah)...... 171, 466 TEMIXYS...... 38 SURESTEP PRO HIGH TAFINLAR...... 69 TEMODAR...... 70 GLUCOSE...... 256 TAGRISSO...... 69 TEMOVATE...... 486 SURESTEP PRO LOW TAKHZYRO...... 427 temozolomide...... 70 GLUCOSE...... 256 TALICIA...... 326 temsirolimus...... 70 SURESTEP PRO NORMAL TALL RAGWEED...... 80, 262 TENCON...... 183, 208 GLUCOSE...... 256 TALTZ...... 501 TENIVAC...... 85 SURVANTA...... 462 TALZENNA...... 69 tenofovir disoproxil fumarate 38 SUSTIVA...... 36 TAMIFLU...... 43 TENORETIC 100...... 144, 297 SUSTOL...... 323 tamoxifen citrate...... 69, 366 TENORETIC 50...... 144, 297 SUTAB...... 329 tamsulosin hcl...... 108 TENORMIN.....113, 144, 146, 158 SUTENT...... 69 TAPAZOLE...... 352 TENS WIRED PAIN SWEET GUM...... 80 TAPERDEX 12-DAY...... 347 MANAGEMENT...... 257 SWEET VERNAL GRASS TAPERDEX 6-DAY...... 347 TEPADINA...... 70 POLLEN...... 80, 262 TAPERDEX 7-DAY...... 347 TEPEZZA...... 316 syeda...... 363, 376, 397 TARCEVA...... 70 TEPMETKO...... 70 SYLVANT...... 69 TARDEOXIA...... 471, 478, 501 terazosin hcl...... 104, 133 SYMAX DUOTAB...... 97 TARGADOX...... 22, 51 terbinafine hcl...... 17 SYMAX-SL...... 98 TARGRETIN...... 70, 501 terbutaline sulfate...... 112, 464 SYMBICORT...... 112, 347 tarina 24 fe...... 363, 376, 397 terconazole...... 476 SYMBYAX...... 206, 246 tarina fe 1/20...... 363, 376, 397 TERIPARATIDE SYMDEKO...... 456, 457 tarina fe 1/20 eq.....363, 376, 397 (RECOMBINANT)...... 384, 421 SYMFI...... 36, 38 TAROXIA...... 478, 501 TESSALON PERLES...... 456 SYMFI LO...... 36, 38 TASIGNA...... 70 TESTIM...... 349 SYMJEPI...... 92, 453 TASMAR...... 215 TESTOPEL...... 350 SYMLINPEN 120...... 348 TAURINE...... 276 TESTOSTERONE...... 350 SYMLINPEN 60...... 349 tavaborole...... 493 testosterone...... 350 SYMPAZAN...... 210, 213 TAVALISSE...... 118 TESTOSTERONE SYMPROIC...... 332 taysofy...... 363, 376, 397 CYPIONATE...... 350 SYMTUZA...... 38, 40, 447 TAYTULLA...... 363, 376, 397 testosterone cypionate...... 350 SYNAGIS...... 42 tazarotene...... 501 testosterone enanthate...... 350 SYNALAR...... 486 TAZAROTENE...... 501 TETANUS-DIPHTHERIA SYNAREL...... 381 tazicef...... 16 TOXOIDS TD...... 85 SYNDROS...... 324 TAZICEF...... 16, 276 tetrabenazine...... 248 SYNERA...... 474 TAZORAC...... 502 tetracaine hcl...... 319

542 tetracycline hcl...... 22, 51, 327 TOBRADEX...... 305, 312 TRANSDERM-SCOP (1.5 MG) TEXACORT...... 486 TOBRADEX ST...... 305, 313 ...... 98, 324 THALOMID...... 438 tobramycin...... 18, 305 TRANXENE-T...... 210, 213 THAM...... 269 TOBRAMYCIN...... 18 tranylcypromine sulfate...... 221 THE LIQUILIFT TRACE...... 293 tobramycin sulfate...... 18 TRAVASOL...... 276 THEO-24.165, 240, 277, 467, 504 tobramycin-dexamethasone TRAVATAN Z...... 321 theophylline ...... 306, 313 travoprost (bak free)...... 321 ...... 165, 240, 277, 467, 504 TOBREX...... 306 TRAZIMERA...... 71 theophylline er TODAY SPONGE...... 449 trazodone hcl...... 246 ...... 165, 240, 277, 467, 504 tolbutamide...... 267, 406 TREANDA...... 71 thiamine hcl...... 508 tolcapone...... 215 TRECATOR...... 26 THIOLA...... 447 TOLSURA...... 27 TRELEGY ELLIPTA..98, 112, 348 THIOLA EC...... 447 tolterodine tartrate...... 503 TRELSTAR MIXJECT...... 71, 381 thioridazine hcl...... 237 tolterodine tartrate er...... 503 TREMFYA...... 502 thiotepa...... 70 TOLVAPTAN...... 298 treprostinil...... 466 thiothixene...... 247 tolvaptan...... 298 TRESIBA...... 384 THROMBATE III...... 117 TOPAMAX...... 189, 199 TRESIBA FLEXTOUCH...... 384 THROMBIN-JMI...... 125 TOPAMAX SPRINKLE....189, 200 tretinoin...... 71, 478 THROMBOGEN...... 125 TOPICORT...... 486, 487 tretinoin microsphere...... 478 THYMOGLOBULIN...... 442 TOPICORT SPRAY...... 487 tretinoin microsphere pump 478 tiadylt er...... 149, 151, 160, 177 TOPIDEX...... 348 TRETTEN...... 125 tiagabine hcl...... 189 topiramate...... 189, 200 TREXALL...... 71, 431, 438, 442 TIAZAC...... 149, 151, 160, 177 topiramate er...... 189 TREXIMET...... 236, 244 TIBSOVO...... 70 toposar...... 70 TREZIX...... 183, 230, 240 TICE BCG...... 70, 88 topotecan hcl...... 71 tri femynor...... 363, 377, 397 TIGAN...... 325 TOPROL XL....113, 144, 147, 158 TRIAMCINOLONE tigecycline...... 32 toremifene citrate...... 71, 366 ACETONIDE...... 348 TIGLUTIK...... 216 TORISEL...... 71 triamcinolone acetonide TIKOSYN...... 159 torsemide...... 168, 280 ...... 348, 487 tilia fe...... 363, 376, 397 TOSYMRA...... 244 TRIAMCINOLONE timolol maleate TOTECT...... 449 DIACETATE...... 348 ...... 104, 144, 146, 158, 199, 307 TOUJEO MAX SOLOSTAR.... 384 triamcinolone in absorbase. 487 timolol maleate ocudose...... 307 TOUJEO SOLOSTAR...... 384 TRIAMCINOLONE- timolol maleate pf...... 307 tovet...... 487 BUPIVACAINE...... 348, 413 TIMOPTIC...... 307 TOVIAZ...... 503 TRIAMCINOLONE- TIMOPTIC OCUDOSE...... 307 TPN ELECTROLYTES...... 293 MOXIFLOXACIN...... 26, 48, 313 TIMOPTIC-XE...... 307 TRACE ELEMENTS TRI-AMINO...... 276 TIMOTHY GRASS POLLEN 4/PEDIATRIC...... 293 triamterene...... 172, 281 ALLERGEN...... 80, 262 TRACLEER...... 466 triamterene-hctz.... 281, 296, 297 tinidazole...... 24 TRADJENTA...... 365 TRIANEX...... 487 tiopronin...... 447 TRALEMENT...... 294 triazolam...... 213 TIROSINT...... 407 tramadol hcl...... 230 TRIBENZOR...... 136, 163, 297 TIROSINT-SOL...... 408 TRAMADOL HCL ER...... 230 TRI-CHLOR...... 447 TISSEEL...... 502 tramadol hcl er...... 230 TRICHOPHYTON...... 80, 262 TISSUEBLUE...... 267 tramadol hcl er (biphasic).... 230 TRICITRASOL...... 117 tis-u-sol...... 278 tramadol-acetaminophen tricitrates...... 269 TIVICAY...... 35 ...... 183, 230 TRICOR...... 166 TIVICAY PD...... 35 trandolapril...... 138, 139 triderm...... 487 TIVORBEX...... 236 trandolapril-verapamil hcl er TRIDESILON...... 487 tizanidine hcl...... 100 ...... 139, 151 trientine hcl...... 339 TNKASE...... 132, 300 tranexamic acid...... 125 TRIESENCE...... 313 TOBI NEBULIZER...... 18 TRANEXAMIC ACID-NACL.... 125 tri-estarylla...... 363, 377, 397 TOBI PODHALER...... 18 TRIFERIC...... 128

543 trifluoperazine hcl...... 237 TRUE METRIX LEVEL 2...... 257 ULTRABAG/DIANEAL PD- trifluridine...... 306 TRUE METRIX LEVEL 3...... 257 2/2.5% DEX...... 279 trihexyphenidyl hcl... 98, 99, 184 TRUE METRIX PRO BLOOD ULTRABAG/DIANEAL PD- TRIJARDY XR...... 354, 366, 403 GLUCOSE...... 266 2/4.25%DEX...... 279 TRIKAFTA...... 456, 457 TRUETRACK TEST...... 266 ULTRABAG/DIANEAL/1.5% tri-legest fe...... 363, 377, 397 TRULANCE...... 332 DEXTROSE...... 279 TRILEPTAL...... 189 TRULICITY...... 382 ULTRABAG/DIANEAL/2.5% tri-linyah...... 363, 377, 397 TRUMENBA...... 88 DEXTROSE...... 279 TRILIPIX...... 166 TRUSELTIQ (100MG DAILY ULTRABAG/DIANEAL/4.25% tri-lo-estarylla...... 363, 377, 397 DOSE)...... 71 DEX...... 279 tri-lo-marzia...... 363, 377, 397 TRUSELTIQ (125MG DAILY ULTRACET...... 183, 230 tri-lo-mili...... 363, 377, 397 DOSE)...... 71 ULTRAM...... 230 tri-lo-sprintec...... 363, 377, 397 TRUSELTIQ (50MG DAILY ULTRASAL-ER...... 490 TRILURON...... 447 DOSE)...... 71 ULTRAVATE...... 487 trimethobenzamide hcl...... 325 TRUSELTIQ (75MG DAILY UMECTA MOUSSE...... 490 trimethoprim...... 52 DOSE)...... 71 UNASYN...... 20 tri-mili...... 363, 377, 397 TRUSOPT...... 308 UNISTRIP CONTROL...... 257 trimipramine maleate...... 248 TRUVADA...... 38 unithroid...... 408 TRI-MIX...... 105, 177 TRUXIMA...... 72 UNITUXIN...... 72 TRINTELLIX...... 246 TUDORZA PRESSAIR...... 98 UPLIZNA...... 438 tri-nymyo...... 363, 377, 397 TUKYSA...... 72 UPNEEQ...... 322 TRIOSTAT...... 408 tulana...... 363, 397 UPTRAVI...... 466 tri-previfem...... 363, 377, 397 TURALIO...... 72 URAMAXIN...... 490 TRIPTODUR...... 381 turpentine...... 477 UREA...... 490 TRISENOX...... 71 TUSSICAPS...... 12, 456 urea...... 490 TRISODIUM CITRATE/CRRT 294 TUXARIN ER...... 12, 456 urea hydrating...... 477, 490 tri-sprintec...... 363, 377, 397 TUZISTRA XR...... 12, 456 urea nail...... 490 tritocin...... 487 TWINRIX...... 88 URIMAR-T...... 52, 98, 183, 448 TRIUMEQ...... 35, 38 TWIRLA...... 363, 377, 398 urin ds...... 52, 98, 183, 448 TRIVISC...... 447 TWYNSTA...... 137, 163 UROCIT-K 10...... 269 tri-vite/fluoride tyblume...... 363, 377, 398 UROCIT-K 15...... 269 ...... 426, 506, 509, 510 TYBOST...... 448 UROCIT-K 5...... 269 trivora (28)...... 363, 377, 397 tydemy...... 364, 377, 398, 508 UROGESIC-BLUE...... 52, 98, 448 tri-vylibra...... 363, 377, 397 TYGACIL...... 32 UROXATRAL...... 108 tri-vylibra lo...... 363, 377, 397 TYKERB...... 72 URSO 250...... 329 TRIZIVIR...... 38 TYMLOS...... 384, 421 URSO FORTE...... 329 TRODELVY...... 71 TYPHIM VI...... 88 URSODIOL...... 329 TROGARZO...... 34 TYSABRI...... 438 ursodiol...... 329 TROKENDI XR...... 190, 200 TYVASO...... 466 USTELL...... 52, 98, 183, 448 TROPHAMINE...... 276 TYVASO REFILL...... 466 UTIRA-C...... 52, 98, 183, 448 TROPICAMIDE- TYVASO STARTER...... 466 UVADEX...... 493 CYCLOPENTOLATE-PE 320, 322 UBRELVY...... 214 VABOMERE...... 28 TROPICAMIDE- UCERIS...... 348, 487 VAGIFEM...... 377, 423 PHENYLEPHRINE...... 320, 322 UDENYCA...... 121 valacyclovir hcl...... 44 TROPIC-PROPARACA-PE- UKONIQ...... 72 VALCHLOR...... 502 KETOROLAC..318, 319, 320, 322 ULORIC...... 420 VALCYTE...... 44 trospium chloride...... 503 ULTIGUARD SAFEPACK valganciclovir hcl...... 44 trospium chloride er...... 503 SYR/NEEDLE...... 257 VALIUM...... 210, 213 TRUE FOCUS BLOOD ULTIVA...... 230 valproate sodium.. 190, 195, 200 GLUCOSE METER...... 257 ULTOMIRIS...... 427 valproic acid.. 190, 195, 196, 200 TRUE METRIX BLOOD ULTRABAG/DIANEAL PD- valrubicin...... 72 GLUCOSE TEST...... 266 2/1.5% DEX...... 279 valsartan...... 134, 137 TRUE METRIX LEVEL 1...... 257

544 valsartan- VENCLEXTA STARTING virt-phos 250 neutral...... 294 hydrochlorothiazide...... 137, 297 PACK...... 72 virtussin ac w/alc...... 456, 457 VALSTAR...... 72 venlafaxine hcl...... 243 VISCO-3...... 448 VALTOCO...... 210 venlafaxine hcl er...... 243 VISCOAT...... 314, 316 VALTREX...... 44 VENOFER...... 128 VISIONBLUE...... 267 VANADOM...... 100 VENOMIL MIXED VESPID VISTARIL...... 10, 11, 202 VANCOCIN...... 31 VENOM...... 80, 262 VISTOGARD...... 418 VANCOCIN HCL...... 31 VENTAVIS...... 466 VISUDYNE...... 317 vancomycin hcl...... 31, 32 VENTOLIN HFA...... 112, 464 vitamin b complex 100...... 508 VANCOMYCIN HCL...... 306 verapamil hcl VITAMIN B COMPLEX- VANCOMYCIN HCL IN ...... 149, 151, 160, 161, 177 HYDROXOCOBAL...... 508 DEXTROSE...... 31, 276 verapamil hcl er vitamin b-complex 100...... 508 vancomycin hcl in dextrose ...... 149, 151, 160, 177 vitamin d (ergocalciferol)..... 510 ...... 31, 276 VERDESO...... 487 vitamin k1...... 418, 511 vancomycin hcl in nacl...31, 294 VEREGEN...... 502 vitamins acd-fluoride VANCOMYCIN HCL IN NACL VERELAN...... 149, 151, 161, 177 ...... 426, 506, 509, 510 ...... 31, 294 VERELAN PM.149, 151, 161, 177 VITRAKVI...... 73 vandazole...... 17, 471 VERQUVO...... 177 VITRASE...... 300 VANOS...... 487 VERSACLOZ...... 206 VIVAGUARD INO CONTROL VANOXIDE-HC...... 487, 493 VERZENIO...... 72 SOLUTION...... 257 VANTAS...... 72, 381 VESICARE...... 504 VIVAGUARD INO GLUCOSE VAPRISOL...... 276, 298 VESICARE LS...... 503 METER...... 257 VAQTA...... 88 vestura...... 364, 377, 398 VIVAGUARD INO TEST vardenafil hcl...... 171 VFEND...... 27, 28 STRIPS...... 266 VARDIMAXIA...... 478, 502 VFEND IV...... 27 VIVELLE-DOT...... 377, 424 VARITHENA...... 173 VIAGRA...... 172, 467 VIVITROL...... 231, 414, 418 VARIVAX...... 88 VIBATIV...... 32 VIVLODEX...... 236 VARIZIG...... 84 VIBERZI...... 332 VIZIMPRO...... 73 VAROXIA...... 478, 502 VIBRAMYCIN...... 22, 23, 51 VOCABRIA...... 35 VARUBI (180 MG DOSE)...... 334 VICTOZA...... 382 VOGELXO...... 350 VASCEPA...... 141 VIDAZA...... 72 VOGELXO PUMP...... 350 VASERETIC...... 139, 297 VIEKIRA PAK...... 33 volnea...... 364, 377, 398 VASOSTRICT...... 386 vienva...... 364, 377, 398 VONVENDI...... 126 VASOTEC...... 138, 139 vigabatrin...... 190 VORAXAZE...... 300, 418 VAZCULEP...... 94 vigadrone...... 190 voriconazole...... 28 VCF VAGINAL VIGAMOX...... 306 VORTEX VALVED HOLDING CONTRACEPTIVE...... 449 VIIBRYD...... 246 CHAMBER...... 257 vcf vaginal contraceptive..... 449 VIIBRYD STARTER PACK..... 246 VOSEVI...... 33, 34 VECAMYL...... 167 VILTEPSO...... 420 VOTRIENT...... 73 VECTIBIX...... 72 VIMIZIM...... 300 VPRIV...... 300 VECTICAL...... 502 VIMOVO...... 236, 337 VRAYLAR...... 206 VECURONIUM BROMIDE...... 102 VIMPAT...... 190 VTOL LQ...... 183, 208, 241 vecuronium bromide...... 102 vinblastine sulfate...... 73 VUMERITY...... 438 VEKLURY...... 44 vincristine sulfate...... 73 VUSION...... 475, 477, 488 VELCADE...... 72 vinorelbine tartrate...... 73 VYEPTI...... 214 VELETRI...... 466 VIOKACE...... 300, 330 vyfemla...... 364, 378, 398 velivet...... 364, 377, 398 viorele...... 364, 377, 398 VYLEESI...... 216 VELPHORO...... 281 VIRACEPT...... 40 vylibra...... 364, 378, 398 VELTASSA...... 281 VIRAMUNE...... 36 VYNDAMAX...... 152, 216 VELTIN...... 471, 478, 502 VIRAMUNE XR...... 36 VYNDAQEL...... 152 VEMLIDY...... 44 VIRASAL...... 490 VYONDYS 53...... 420 VENCLEXTA...... 72 VIRAZOLE...... 44 VYTORIN...... 154, 167 VIREAD...... 38, 39 VYVANSE...... 180

545 VYXEOS...... 73 XELPROS...... 321 XTAMPZA ER...... 230 VYZULTA...... 321 XEMBIFY...... 84 XTANDI...... 74 WAKIX...... 248 XENAZINE...... 248 xulane...... 364, 378, 398 warfarin sodium...... 118 XENLETA...... 46 XULTOPHY...... 382, 384 WASP VENOM PROTEIN 80, 262 XEOMIN...... 114, 448 XURIDEN...... 448 water for irrigation, sterile....279 XEPI...... 471 XYLOCAINE...... 413 WEGOVY...... 382 XERAC AC...... 475 XYLOCAINE/EPINEPHRINE WELCHOL...... 147, 351 XERAVA...... 31 ...... 92, 413 WELIREG...... 73 XERESE...... 475, 488 XYLOCAINE-MPF...... 413 WELLBUTRIN SR...... 191 XERMELO...... 324 XYLOCAINE- WELLBUTRIN XL...... 191 XEROFORM OIL EMULSION MPF/EPINEPHRINE...... 92, 413 wera...... 364, 378, 398 STRIP...... 257, 488 XYNTHA...... 126 WESTERN JUNIPER...... 80, 262 XEROFORM OIL ROLL 4"X9' XYNTHA SOLOFUSE...... 126 WESTHROID...... 408 ...... 257, 488 XYOSTED...... 350 wheat germ oil...... 511 XEROFORM PETROLAT XYREM...... 216 WHITE BIRCH...... 80 GAUZE 1"X8"...... 257, 488 XYWAV...... 216 WHITE FACED HORNET XEROFORM PETROLAT YASMIN 28...... 364, 378, 398 VENOM...... 80, 262 GAUZE 5"X9"...... 258, 488 YAZ...... 364, 378, 398 WHITE MULBERRY...... 80, 262 XEROFORM PETROLATUM YELLOW DOCK...... 81 WHITE OAK...... 81, 262 ROLL 4"X9'...... 258, 488 YELLOW HORNET VENOM WHITE PINE...... 81, 262 XEROSTOMIA RELIEF PROTEIN...... 81, 263 WHITE-FACED HORNET SPRAY...... 317 YELLOW JACKET VENOM VENOM...... 81, 262 XGEVA...... 424 PROTEIN...... 81, 263 WIDE-SEAL DIAPHRAGM 60 449 XHANCE...... 313, 348, 460 YERVOY...... 74 WIDE-SEAL DIAPHRAGM 65 449 XIAFLEX...... 300 YESCARTA...... 74, 178 WIDE-SEAL DIAPHRAGM 70 449 XIFAXAN...... 48 YF-VAX...... 88 WIDE-SEAL DIAPHRAGM 75 449 XIGDUO XR...... 354, 403 yl folic acid...... 508 WIDE-SEAL DIAPHRAGM 80 450 XIIDRA...... 314 YONDELIS...... 74 WIDE-SEAL DIAPHRAGM 85 450 XIMINO...... 51, 502 YONSA...... 74 WIDE-SEAL DIAPHRAGM 90 450 XOFIGO...... 451 YOSPRALA...... 130, 337 WIDE-SEAL DIAPHRAGM 95 450 XOFLUZA (40 MG DOSE)...... 26 YUPELRI...... 98 WILATE...... 126 XOFLUZA (80 MG DOSE)...... 26 YUTIQ...... 313 WILZIN...... 294 XOLAIR...... 462 yuvafem...... 378, 424 WINLEVI...... 502 XOLEGEL...... 477 zaclir cleansing...... 493 WINRHO SDF...... 84 XOPENEX...... 112, 464 zafemy...... 364, 378, 398 wixela inhub...... 112, 348 XOPENEX CONCENTRATE zafirlukast...... 459 WP THYROID...... 408 ...... 112, 464 zaleplon...... 202 wymzya fe...... 364, 378, 398 XOPENEX HFA...... 112, 464 ZALTRAP...... 74 WYNZORA...... 487, 502 XOSPATA...... 73 ZANAFLEX...... 101 XADAGO...... 221 XPOVIO (100 MG ONCE ZANOSAR...... 74 XALATAN...... 321 WEEKLY)...... 73 zarah...... 364, 378, 398 XALIX...... 490 XPOVIO (40 MG ONCE ZARONTIN...... 246, 247 XALKORI...... 73 WEEKLY)...... 73 ZARXIO...... 121 XANAX...... 213 XPOVIO (40 MG TWICE ZAVESCA...... 448 XANAX XR...... 213 WEEKLY)...... 73 ZCORT 7-DAY...... 348 XARACOLL...... 413 XPOVIO (60 MG ONCE ZEBUTAL...... 183, 208, 241 XARELTO...... 118 WEEKLY)...... 73 ZEGALOGUE...... 379, 418 XARELTO STARTER PACK...118 XPOVIO (60 MG TWICE ZEGERID...... 322, 337 XATMEP...... 73, 431, 438, 442 WEEKLY)...... 74 ZEJULA...... 74 XCOPRI...... 190 XPOVIO (80 MG ONCE ZELAPAR...... 221 XELJANZ...... 432 WEEKLY)...... 74 ZELBORAF...... 74 XELJANZ XR...... 432 XPOVIO (80 MG TWICE ZELNORM...... 334 XELODA...... 73 WEEKLY)...... 74 ZEMAIRA...... 462

546 ZEMBRACE SYMTOUCH...... 244 zolmitriptan...... 244 ZEMDRI...... 18 ZOLOFT...... 246 ZEMPLAR...... 511 zolpidem tartrate...... 203 zenatane...... 502 zolpidem tartrate er...... 203 ZENPEP...... 301, 330 ZOLPIMIST...... 203 ZENZEDI...... 180 ZOMACTON...... 386, 405 ZEPATIER...... 33, 34 ZOMACTON (FOR ZOMA-JET ZEPOSIA...... 439 10)...... 386, 405 ZEPOSIA 7-DAY STARTER ZOMIG...... 245 PACK...... 438 ZONALON...... 474 ZEPOSIA STARTER KIT...... 439 ZONEGRAN...... 190 ZEPZELCA...... 74 zonisamide...... 190 ZERBAXA...... 16 ZONTIVITY...... 130 ZERUVIA...... 474, 502 ZORBTIVE...... 386, 405 ZERVIATE...... 302, 463 ZORTRESS...... 442 ZESTORETIC...... 139, 297 ZORVOLEX...... 236 ZESTRIL...... 138, 139 ZOSYN...... 30, 276 ZETIA...... 154 zovia 1/35 (28)...... 364, 378, 398 ZETONNA...... 313 zovia 1/35e (28)...... 364, 378, 398 ZEVALIN Y-90...... 74 ZOVIRAX...... 44, 475 ZEWA DIGITAL TENS UNIT...258 ZTLIDO...... 413 ZEWA TENS/EMS COMBO ZUBSOLV...... 231, 232 UNIT...... 258 ZULRESSO...... 191 ZIAC...... 144, 297 zumandimine...... 364, 378, 398 ZIAGEN...... 39 ZUPLENZ...... 323 ZIANA...... 471, 479, 502 ZYCLARA...... 502 zidovudine...... 39 ZYCLARA PUMP...... 502 ZIEXTENZO...... 121 ZYDELIG...... 75 zileuton er...... 459 ZYFLO...... 459 ZILRETTA...... 348 ZYKADIA...... 75 ZILXI...... 471 ZYLET...... 306, 313 ZINC CHLORIDE...... 294 ZYLOPRIM...... 420 ZINC SULFATE...... 294 ZYMAXID...... 306 ZINGO...... 413 ZYNLONTA...... 75 ZINPLAVA...... 84 ZYNRELEF...... 236, 413 ZIOPTAN...... 321 ZYPITAMAG...... 167 ziprasidone hcl...... 196, 206 ZYPREXA...... 196, 206 ziprasidone mesylate....196, 206 ZYPREXA RELPREVV... 196, 206 ZIPSOR...... 236 ZYPREXA ZYDIS...... 196, 206 ZIRABEV...... 75 ZYTIGA...... 75 ZIRGAN...... 306 ZYVOX...... 46 ZITHRANOL...... 502 ZITHROMAX...... 45 ZITHROMAX TRI-PAK...... 45 ZITHROMAX Z-PAK...... 45 ZOCOR...... 167 ZOFRAN...... 323 ZOKINVY...... 448 ZOLADEX...... 75, 381 zoledronic acid...... 424 ZOLGENSMA...... 178 ZOLINZA...... 75 ZOLMITRIPTAN...... 244

547 Nondiscrimination notice and access to communication services

OptumRx and its family of affiliated Optum companies does not discriminate on the basis of race, color, national origin, age, disability, or sex in its health programs or activities.

We provide assistance free of charge to people with disabilities or whose primary language is not English. To request a document in another format such as large print or to get language assistance such as a qualified interpreter, please call the number located on the back of your prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week.

If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can send a complaint to:

OptumRx Civil Rights Coordinator 11000 Optum Circle Eden Prairie, MN 55344

Phone: 1-800-562-6223, TTY 711 Fax: 855-351-5495 Email: [email protected]

If you need help filing a complaint, please call the number located on the back of your prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week. You can also file a complaint directly with the U.S. Dept. of Health and Human Services online, by phone, or by mail:

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

This information is available in other formats like large print. To ask for another format, please call the telephone number listed on your health plan ID card. Multi-language interpreter services

All Optum trademarks and logos are owned by Optum, Inc. in the U.S. and other jurisdictions. All other trademarks are the property of their respective owners. WF5235209-A 09102021 3-Tier Plan