Health Care Reform Preventative Drug List

Health Care Reform Preventative Drug list

At Capital Rx, we are driven to help our clients most effectively manage above. A plan decision is required for coverage under the pharmacy changes in the prescription drug environment. As part of the Patient benefit for each of the lists noted below. The content of the list will Protection and Affordable Care Act (PPACA), non-grandfathered plans be continually reviewed and updated to ensure compliance with are required to cover select FDA-approved drug products related to healthcare reform mandates. preventive health services for Adults, Children and Women without UPDATE: For plan years beginning on or after September 24, 2014 a member having to pay a copayment or co-insurance or meet a (January 1, 2015 for calendar year plans), non-grandfathered health deductible. As your pharmacy benefits manager, we will support plans are required to cover prescription medications designed to coverage of specific products at $0 copay as prescription benefit reduce the risk of breast cancer in women, without cost-sharing, plans become subject to the law. We will also routinely update subject to reasonable medical management. These required drugs FDA-approved product lists to comply with the Preventive Health have been added to the “Preventive Health for Adults, Children and mandates, and require prescriptions for product coverage. Women: Prescription and OTC Products” list below. To meet the needs and provide flexibility to our clients, we have created eight specific lists that address the preventive health requirements

1. Preventive Health for Adults, Children and Women: Prescription and OTC Products. Age edits may apply.

Generic Name Covered Label Name Rx or OTC Form

aspirin Various OTC ORAL ferrous sulfate Child Ferrous Sulfate 15 Mg/Ml OTC ORAL ferrous sulfate Children’S Iron 15 Mg/Ml Drops OTC ORAL folic acid Folic Acid 800 Mcg Tablet OTC ORAL folic acid Eql Folic Acid 400 Mcg Tab OTC ORAL folic acid Fa-8 Capsules OTC ORAL ferrous sulfate Fer-Iron 15 Mg/1 Ml Drops OTC ORAL ferrous sulfate Ferosul 220 Mg/5 Ml Elixir OTC ORAL ferrous sulfate Ferrous Sulf 15 Mg Iron/Ml Drp OTC ORAL ferrous sulfate Ferrous Sulf 220 Mg/5 Ml OTC ORAL ferrous sulfate Ferrous Sulf 300 Mg/5 Ml Liq OTC ORAL fluoride (sodium) Fluor-A-Day 2.5 Mg/Ml Drops RX ORAL fluoride (sodium) Fluoride 0.25 Mg Tablet Chew RX ORAL fluoride (sodium) Fluoride 0.5 Mg Tablet Chew RX ORAL fluoride (sodium) Fluoride 1 Mg Tablet Chewable RX ORAL fluoride (sodium) Fluoritab 0.125 Mg/Drp Drops RX ORAL

© Capital Rx, LLC. Portions © Magellan Health, Inc. All Rights Reserved. 1 Generic Name Covered Label Name Rx or OTC Form fluoride (sodium) Fluoritab 0.5 Mg Tablet Chew RX ORAL fluoride (sodium) Fluoritab 1 Mg Tablet Chew RX ORAL fluoride (sodium) Flura-Drops 0.25 Mg/Drop RX ORAL folic acid Folic Acid 0.4 Mg Tablet OTC ORAL folic acid Folic Acid 0.8 Mg Tablet OTC ORAL folic acid Folic Acid 20 Mg Capsule OTC ORAL folic acid Folic Acid 400 Mcg OTC ORAL sodium chloride/sodium bicarbonate/ Gavilyte-N Solution RX ORAL potassium ferrous sulfate Iron 15 Mg/Ml Drops OTC ORAL ferrous sulfate Iron 65 Mg Tablet OTC ORAL fluoride (sodium) Ludent Fluoride 0.25 Mg Tb Chw RX ORAL fluoride (sodium) Ludent Fluoride 0.5 Mg Tb Chew RX ORAL fluoride (sodium) Ludent Fluoride 1 Mg Tab Chew RX ORAL sodium chloride/sodium bicarbonate/ Peg 3350-Electrolyte Solution RX ORAL potassium folic acid Pv Folic Acid 400 Mcg Tablet OTC ORAL folic acid Pv Folic Acid 800 Mcg Tablet OTC ORAL folic acid Ra Folic Acid 0.4 Mg Tablet OTC ORAL folic acid Ra Folic Acid 800 Mcg Tablet OTC ORAL folic acid Sm Folic Acid 0.4 Mg Tablet OTC ORAL folic acid Sm Folic Acid 400 Mcg Tablet OTC ORAL fluoride (sodium) Sodium Fluoride 0.5 Mg(1.1 Mg) RX ORAL fluoride (sodium) Sodium Fluoride 0.5 Mg/Ml Drop RX ORAL fluoride (sodium) Sodium Fluoride 1 Mg (2.2 Mg) RX ORAL folic acid Sv Folic Acid 800 Mcg Tablet OTC ORAL sodium chloride/sodium bicarbonate/ Trilyte With Flavor Packets RX ORAL potassium

Generic Name Covered Label Name Rx or OTC Form

Bowel Prep Products: Quantity limit and age edits apply peg 3350/mannitol/sodium bicarbonate/citric Base, Pcca Rapid Dissolve Powd OTC MISCELL acid/sucrose peg 3350/sod sulf/sod bicarb/sod chloride/ Gavilyte-C Solution RX ORAL potassium chloride

Bowel Prep Products: Quantity limit and age edits apply peg 3350/sod sulf/sod bicarb/sod chloride/ Gavilyte-G Solution RX ORAL potassium chloride peg 3350/sod sulf/sod bicarb/sod chloride/ Golytely Packet RX ORAL potassium chloride peg 3350/sodium sulfate/sod chloride/ kcl/ Moviprep Powder Packet RX ORAL ascorbate sod/vit c peg 3350/sod sulf/sod bicarb/sod chloride/ Peg 3350 Electrolyte Soln RX ORAL potassium chloride peg 3350/sod sulf/sod bicarb/sod chloride/ Peg-3350 And Electrolytes Soln RX ORAL potassium chloride polyethylene glycol 3350 Polyethylene Glycol 3350 Powd RX/OTC ORAL

Generic Name Covered Label Name Rx or OTC Form

Risk-Reducing Drugs for Breast Cancer: Gender edits apply raloxifene hcl Raloxifene Hcl 60 Mg Tablet RX ORAL tamoxifen citrate Tamoxifen 10 Mg Tablet RX ORAL tamoxifen citrate Tamoxifen 20 Mg Tablet RX ORAL

Generic Name Covered Label Name Rx or OTC Form

Rx Statins Age Edits: Age edits apply atorvastatin calcium Atorvastatin 10 Mg Tablet RX ORAL atorvastatin calcium Atorvastatin 20 Mg Tablet RX ORAL lovastatin Lovastatin 10 Mg Tablet RX ORAL lovastatin Lovastatin 20 Mg Tablet RX ORAL lovastatin Lovastatin 40 Mg Tablet RX ORAL pravastatin sodium Pravastatin Sodium 10 Mg Tab RX ORAL pravastatin sodium Pravastatin Sodium 20 Mg Tab RX ORAL pravastatin sodium Pravastatin Sodium 40 Mg Tab RX ORAL pravastatin sodium Pravastatin Sodium 80 Mg Tab RX ORAL rosuvastatin calcium Rosuvastatin Calcium 10 Mg Tab RX ORAL rosuvastatin calcium Rosuvastatin Calcium 5 Mg Tab RX ORAL simvastatin Simvastatin 10 Mg Tablet RX ORAL simvastatin Simvastatin 20 Mg Tablet RX ORAL simvastatin Simvastatin 40 Mg Tablet RX ORAL simvastatin Simvastatin 5 Mg Tablet RX ORAL

© Capital Rx, LLC. Portions © Magellan Health, Inc. All Rights Reserved. 3 2. Preventive Health for Women: Contraceptives*— Prescription Contraceptive Products (*Required on or after August 1, 2012). Gender and Quantity Limits apply. Multi-source brands and select single source brands are not covered.

Generic Name Covered Label Name RX/OTC (FDB) Form

Hormonal Contraceptives levonorgestrel-ethinyl estradiol Altavera-28 RX ORAL norethindrone-ethinyl estradiol Alyacen RX ORAL levonorgestrel/ethinyl estradiol and ethinyl Amethia RX ORAL estradiol levonorgestrel/ethinyl estradiol and ethinyl Amethia Lo RX ORAL estradiol levonorgestrel-ethinyl estradiol Amethyst RX ORAL desogestrel-ethinyl estradiol Apri 28 RX ORAL norethindrone-ethinyl estradiol Aranelle 28 RX ORAL levonorgestrel/ethinyl estradiol and ethinyl Ashlyna RX ORAL estradiol levonorgestrel-ethinyl estradiol Aubra-28 RX ORAL levonorgestrel-ethinyl estradiol Aviane-28 RX ORAL desogestrel-ethinyl estradiol/ethinyl estradiol Azurette 28 RX ORAL norethindrone-ethinyl estradiol Balziva 28 RX ORAL desogestrel-ethinyl estradiol/ethinyl estradiol Bekyree 28 RX ORAL norethindrone acetate-ethinyl estradiol/ Blisovi 24 Fe RX ORAL ferrous fumarate norethindrone acetate-ethinyl estradiol/ Blisovi Fe RX ORAL ferrous fumarate norethindrone-ethinyl estradiol Briellyn RX ORAL norethindrone Camila RX ORAL levonorgestrel/ethinyl estradiol and ethinyl Camrese RX ORAL estradiol levonorgestrel/ethinyl estradiol and ethinyl Camrese Lo Tablet RX ORAL estradiol desogestrel-ethinyl estradiol Caziant RX ORAL levonorgestrel-ethinyl estradiol Chateal-28 RX ORAL norgestrel-ethinyl estradiol Cryselle-28 RX ORAL norethindrone-ethinyl estradiol Cyclafem RX ORAL desogestrel-ethinyl estradiol Cyred 28 Day RX ORAL norethindrone-ethinyl estradiol Dasetta RX ORAL

Hormonal Contraceptives levonorgestrel/ethinyl estradiol and ethinyl Daysee RX ORAL estradiol norethindrone Deblitane RX ORAL levonorgestrel-ethinyl estradiol Delyla-28 RX ORAL medroxyprogesterone acetate Depo-Subq Provera RX INJ desogestrel-ethinyl estradiol Desogest-Eth Estra RX ORAL desogestrel-ethinyl estradiol Desogestrel-Ethinyl Estrad RX ORAL desogestrel-ethinyl estradiol/ethinyl estradiol Desogestr-Eth Estrad Eth Estra RX ORAL drospirenone/ethinyl estradiol/levomefolate Drosp-Ee-Levomef RX ORAL calcium ethinyl estradiol/drospirenone Drospirenone-Ee RX ORAL norgestrel-ethinyl estradiol Elinest-28 RX ORAL ulipristal acetate Ella RX ORAL desogestrel-ethinyl estradiol Emoquette 28 RX ORAL levonorgestrel-ethinyl estradiol Enpresse-28 RX ORAL desogestrel-ethinyl estradiol Enskyce 28 RX ORAL norethindrone Errin RX ORAL norgestimate-ethinyl estradiol Estarylla RX ORAL ethynodiol diacetate-ethinyl estradiol Ethynodiol-Eth Estra RX ORAL levonorgestrel-ethinyl estradiol Falmina-28 RX ORAL levonorgestrel/ethinyl estradiol and ethinyl Fayosim RX ORAL estradiol norgestimate-ethinyl estradiol Femynor 28 RX ORAL ethinyl estradiol/drospirenone Gianvi RX ORAL norethindrone-ethinyl estradiol Gildagia RX ORAL norethindrone acetate-ethinyl estradiol Gildess RX ORAL norethindrone acetate-ethinyl estradiol/ Gildess 24 Fe RX ORAL ferrous fumarate norethindrone Heather RX ORAL levonorgestrel-ethinyl estradiol Introvale RX ORAL desogestrel-ethinyl estradiol Isibloom 28 RX ORAL norethindrone Jencycla RX ORAL norethindrone acetate-ethinyl estradiol Jinteli RX ORAL levonorgestrel-ethinyl estradiol Jolessa RX ORAL

Hormonal Contraceptives norethindrone Jolivette RX ORAL desogestrel-ethinyl estradiol Juleber 28 RX ORAL norethindrone acetate-ethinyl estradiol Junel RX ORAL norethindrone acetate-ethinyl estradiol/ Junel Fe RX ORAL ferrous fumarate norethindrone acetate-ethinyl estradiol/ Junel Fe 24 RX ORAL ferrous fumarate norethindrone-ethinyl estradiol/ferrous Kaitlib Fe Chewable RX ORAL fumarate desogestrel-ethinyl estradiol/ethinyl estradiol Kariva 28 RX ORAL ethynodiol diacetate-ethinyl estradiol Kelnor 28 RX ORAL desogestrel-ethinyl estradiol/ethinyl estradiol Kimidess 28 RX ORAL levonorgestrel-ethinyl estradiol Kurvelo RX ORAL norethindrone acetate-ethinyl estradiol Larin RX ORAL norethindrone acetate-ethinyl estradiol/ Larin 24 Fe RX ORAL ferrous fumarate levonorgestrel-ethinyl estradiol Larissia-28 RX ORAL norethindrone-ethinyl estradiol/ferrous Layolis Fe Chewable RX ORAL fumarate norethindrone-ethinyl estradiol Leena 28 RX ORAL levonorgestrel-ethinyl estradiol Lessina-28 RX ORAL levonorgestrel-ethinyl estradiol Levonest-28 RX ORAL levonorgestrel/ethinyl estradiol and ethinyl Levono-E Estrad RX ORAL estradiol levonorgestrel-ethinyl estradiol Levonor-Eth Estra RX ORAL levonorgestrel-ethinyl estradiol Levonor-Eth Estrad Triphasic RX ORAL levonorgestrel/ethinyl estradiol and ethinyl Levonorg RX ORAL estradiol levonorgestrel-ethinyl estradiol Levora-28 RX ORAL levonorgestrel-ethinyl estradiol Lillow-28 RX ORAL norethindrone acetate-ethinyl estradiol/ Lo Loestrin Fe RX ORAL ferrous fumarate norethindrone acetate-ethinyl estradiol/ Lomedia 24 Fe RX ORAL ferrous fumarate ethinyl estradiol/drospirenone Loryna RX ORAL norgestrel-ethinyl estradiol Low-Ogestrel-28 RX ORAL

Hormonal Contraceptives levonorgestrel-ethinyl estradiol Lutera-28 RX ORAL norethindrone Lyza RX ORAL levonorgestrel-ethinyl estradiol Marlissa-28 RX ORAL medroxyprogesterone acetate Medroxyprogesterone 150 Mg/Ml RX INJ norethindrone acetate-ethinyl estradiol/ Melodetta 24 Fe Chewable RX ORAL ferrous fumarate norethindrone acetate-ethinyl estradiol/ Mibelas 24 Fe Chewable RX ORAL ferrous fumarate norethindrone acetate-ethinyl estradiol Microgestin RX ORAL norethindrone acetate-ethinyl estradiol/ Microgestin 24 Fe RX ORAL ferrous fumarate norethindrone acetate-ethinyl estradiol/ Microgestin Fe RX ORAL ferrous fumarate norgestimate-ethinyl estradiol Mono-Linyah 28 RX ORAL norgestimate-ethinyl estradiol Mononessa 28 RX ORAL levonorgestrel-ethinyl estradiol Myzilra-28 RX ORAL norethindrone-ethinyl estradiol Necon RX ORAL ethinyl estradiol/drospirenone Nikki RX ORAL norethindrone Nora-Be RX ORAL norethindrone-ethinyl estradiol/ferrous Noret-Estr-Fe RX ORAL fumarate norethindrone acetate-ethinyl estradiol/ Noreth-Estrad-Fe RX ORAL ferrous fumarate norethindrone acetate-ethinyl estradiol/ Noreth-Estrad-Fe RX ORAL ferrous fumarate norethindrone acetate-ethinyl estradiol Norethind-Eth Estrad RX ORAL norethindrone Norethindrone RX ORAL norethindrone-ethinyl estradiol/ferrous Norethin-Estra-Fe RX ORAL fumarate norethindrone acetate-ethinyl estradiol Norethin-Eth Estrad RX ORAL norgestimate-ethinyl estradiol Norg-Ee RX ORAL norgestimate-ethinyl estradiol Norg-Ethin Estra RX ORAL norethindrone-mestranol Norinyl RX ORAL norethindrone Norlyda RX ORAL norethindrone Norlyroc RX ORAL

Hormonal Contraceptives norethindrone-ethinyl estradiol Nortrel RX ORAL ethinyl estradiol/drospirenone Ocella RX ORAL norgestrel-ethinyl estradiol Ogestrel RX ORAL levonorgestrel-ethinyl estradiol Orsythia-28 RX ORAL norethindrone-ethinyl estradiol Philith RX ORAL desogestrel-ethinyl estradiol/ethinyl estradiol Pimtrea 28 RX ORAL norethindrone-ethinyl estradiol Pirmella RX ORAL levonorgestrel-ethinyl estradiol Portia-28 RX ORAL norgestimate-ethinyl estradiol Previfem RX ORAL levonorgestrel-ethinyl estradiol Quasense RX ORAL drospirenone/ethinyl estradiol/levomefolate Rajani 28 RX ORAL calcium desogestrel-ethinyl estradiol Reclipsen 28 RX ORAL levonorgestrel/ethinyl estradiol and ethinyl Rivelsa RX ORAL estradiol levonorgestrel-ethinyl estradiol Setlakin RX ORAL norethindrone Sharobel RX ORAL norgestimate-ethinyl estradiol Sprintec 28 RX ORAL levonorgestrel-ethinyl estradiol Sronyx RX ORAL ethinyl estradiol/drospirenone Syeda 28 RX ORAL norethindrone acetate-ethinyl estradiol/ Tarina Fe RX ORAL ferrous fumarate norethindrone acetate-ethinyl estradiol/ Taytulla RX ORAL ferrous fumarate norethindrone acetate-ethinyl estradiol/ Tilia Fe 28 RX ORAL ferrous fumarate norgestimate-ethinyl estradiol Tri Femynor 28 RX ORAL norgestimate-ethinyl estradiol Tri-Estarylla RX ORAL norethindrone acetate-ethinyl estradiol/ Tri-Legest Fe-28 RX ORAL ferrous fumarate norgestimate-ethinyl estradiol Tri-Linyah RX ORAL norgestimate-ethinyl estradiol Tri-Lo-Estarylla RX ORAL norgestimate-ethinyl estradiol Tri-Lo-Marzia RX ORAL norgestimate-ethinyl estradiol Tri-Lo-Sprintec RX ORAL norgestimate-ethinyl estradiol Trinessa Lo RX ORAL

Hormonal Contraceptives norgestimate-ethinyl estradiol Trinessa RX ORAL norgestimate-ethinyl estradiol Tri-Previfem RX ORAL norgestimate-ethinyl estradiol Tri-Sprintec RX ORAL levonorgestrel-ethinyl estradiol Trivora-28 RX ORAL desogestrel-ethinyl estradiol Velivet 28 RX ORAL ethinyl estradiol/drospirenone Vestura RX ORAL levonorgestrel-ethinyl estradiol Vienva-28 RX ORAL desogestrel-ethinyl estradiol/ethinyl estradiol Viorele 28 RX ORAL norethindrone-ethinyl estradiol Vyfemla 28 RX ORAL norethindrone-ethinyl estradiol Wera RX ORAL norethindrone-ethinyl estradiol/ferrous Wymzya Fe Chewable RX ORAL fumarate ethinyl estradiol/drospirenone Zarah RX ORAL norethindrone-ethinyl estradiol Zenchent RX ORAL norethindrone-ethinyl estradiol/ferrous Zenchent Fe Chewable RX ORAL fumarate norethindrone-ethinyl estradiol/ferrous Zeosa Chewable RX ORAL fumarate ethynodiol diacetate-ethinyl estradiol Zovia RX ORAL

Generic Name Covered Label Name RX/OTC (FDB) Form

Cervical Caps cervical cap Femcap 22 Mm Cervical Cap RX VAGINAL

Generic Name Covered Label Name RX/OTC (FDB) Form

Diaphragms diaphragms, wide seal Wide Seal Diaphragm RX VAGINAL

Generic Name Covered Label Name RX/OTC (FDB) Form

Other etonogestrel/ethinyl estradiol Nuvaring Vaginal Ring RX RNG norelgestromin/ethinyl estradiol Xulane Patch RX TRANSDERM

Generic Name Covered Label Name RX/OTC (FDB) Form levonorgestrel Aftera 1.5 Mg Tablet OTC ORAL levonorgestrel Econtra Ez 1.5 Mg Tablet OTC ORAL levonorgestrel Fallback Solo 1.5 Mg Tablet OTC ORAL levonorgestrel Levonorgestrel 1.5 Mg Tablet RX/OTC ORAL levonorgestrel My Way 1.5 Mg Tablet OTC ORAL levonorgestrel Next Choice One Dose 1.5 Mg Tb OTC ORAL levonorgestrel Opcicon One-Step 1.5 Mg Tablet OTC ORAL levonorgestrel Option 2 1.5 Mg Tablet OTC ORAL levonorgestrel React 1.5 Mg Tablet OTC ORAL

Generic Name Covered Label Name RX/OTC (FDB) Form

Condoms condoms, latex, lubricated Aimsco Latex Condom OTC MISCELL condoms, latex, lubricated Condoms Lubricated OTC MISCELL condoms, non-latex, lubricated Durex Avanti Real Feel Condom OTC MISCELL condoms, latex, lubricated Fantasy Condom OTC MISCELL condoms, female Fc2 Female Condom OTC MISCELL nonoxynol 9 Gynol Ii 3% Gel OTC Insert condoms, latex, non-lubricated Kimono Condoms OTC MISCELL nonoxynol 9 Today Contraceptive Sponge OTC Insert condoms, latex, lubricated Trustex Condom OTC MISCELL

Generic Name Covered Label Name RX/OTC (FDB) Form

Spermicides nonoxynol 9 Vcf Contraceptive Film OTC Insert nonoxynol 9 Vcf Contraceptive Foam OTC Insert

© Capital Rx, LLC. Portions © Magellan Health, Inc. All Rights Reserved. 10 4. Preventive Health for Women: Contraceptives—Medical Drug Products: Implants and IUDs. Gender Edits and Quantity Limits apply.

Generic Name Covered Label Name RX/OTC (FDB) Form

IUDS levonorgestrel Kyleena 19.5 Mg System RX INTRAUTERI levonorgestrel Mirena System RX INTRAUTERI copper Paragard T 380-A Iud RX INTRAUTERI levonorgestrel Skyla System RX INTRAUTERI

Generic Name Covered Label Name RX/OTC (FDB) Form

Implants etonogestrel Nexplanon 68 Mg Implant RX INJ

5. Preventive Health for Adults, and Children: Vaccines. Gender Edits and Age Edits may apply.

Generic Name Covered Label Name RX/OTC (FDB) Form

diphtheria,pertussis(acellular),tetanus Adacel Tdap RX INTRAMUSC vaccine/pf influenza virus vaccine trivalent /pf Afluria RX INTRAMUSC influenza virus vaccine quadrivalent/pf Afluria Quad RX INTRAMUSC diphtheria,pertussis(acellular),tetanus Boostrix Tdap Vaccine RX INTRAMUSC vaccine human papillomavirus vaccine, bivalent/pf Cervarix Vaccine Syringe RX INTRAMUSC diphtheria, pertussis (acell), tetanus pediatric Daptacel Dtap Vaccine RX INTRAMUSC vaccine/pf hepatitis b virus vaccine recombinant/pf Engerix-B RX INTRAMUSC influenza virus vaccine quadrival /pf Ez Flu(Fluzon Quad Ped) RX INTRAMUSC influenza virus vaccine trivalent/pf Ez Flu (Afluria) RX INTRAMUSC influenza virus vaccine trival/pf Ez Flu (Fluvirin) RX INTRAMUSC influenza vaccine tvs /adjuvant mf59c.1/pf Fluad RX INTRAMUSC influenza virus vaccine quadval split/pf Fluarix Quad RX INTRAMUSC influenza virus vaccine tv rcmb/pf Flublok RX INTRAMUSC flu vaccine qs cell derived/pf Flucelvax Quad RX INTRAMUSC influenza virus vaccine qvalsplit Flulaval Quad RX INTRAMUSC

© Capital Rx, LLC. Portions © Magellan Health, Inc. All Rights Reserved. 11 Generic Name Covered Label Name RX/OTC (FDB) Form influenza virus vaccine trival/pf Fluvirin RX INTRAMUSC influenza virus vaccine trival split /pf Fluzone High-Dose RX INTRAMUSC influenza virus vaccine quadrivalent /pf Fluzone Intraderm Quad RX INTRAMUSC influenza virus vaccine quadval split /pf Fluzone Quad RX INTRAMUSC human papillomavirus vaccine, quadrivalent/pf Gardasil RX INTRAMUSC hepatitis a virus vaccine/pf Havrix RX INTRAMUSC meningococcalvaccine a,c,y,w-135,diphtheria Menactra Vial RX INTRAMUSC toxoid conj/pf meningococcal vac a,c,y,w-135 Menomune-A-C-Y-W-135 RX SUB-Q meningococcalvaccine a,c,y,w-135,diphtheria Menveo A-C-Y-W-135-Dip RX INTRAMUSC toxoid conj/pf measles, mumps, and rubella vaccine live/pf M-M-R Ii Vaccine RX SUB-Q pneumococcal 23-valent polysaccharide Pneumovax 23 RX INJECTION vaccine pneumococcal 13-valent conjugate vaccine Prevnar 13 RX INTRAMUSC (diphtheria crm)/pf tetanus and diphtheria toxoids, adsorbed, Tenivac RX INTRAMUSC adult/pf tetanus and diphtheria toxoids, adult Tetanus Diphtheria Toxoids RX INTRAMUSC hepatitis a virus and hepatitis b virus vaccine/pf Twinrix RX INTRAMUSC hepatitis a virus vaccine/pf Vaqta RX INTRAMUSC varicella-zoster virus glycoprotein e,rec/as01b Shingrix RX SUB-Q adjuvant/pf varicella virus vaccine live/pf Varivax RX SUB-Q zoster vaccine live/pf Zostavax RX SUB-Q

6. Preventive Health for Adults: Smoking Cessation (Prescription and OTC). Age Edits and Quantity Limits apply.

Generic Name Covered Label Name RX/OTC (FDB) Form bupropion hcl Buproban 150 Mg Tablet RX ORAL bupropion hcl Bupropion Hcl Sr 150 Mg Tablet RX ORAL varenicline tartrate Chantix 0.5 Mg Tablet RX ORAL varenicline tartrate Chantix 1 Mg Cont Month Box RX ORAL varenicline tartrate Chantix 1 Mg Tablet RX ORAL varenicline tartrate Chantix Starting Month Box RX ORAL

© Capital Rx, LLC. Portions © Magellan Health, Inc. All Rights Reserved. 12 Generic Name Covered Label Name RX/OTC (FDB) Form nicotine Nicotine Patch OTC PATCH nicotine polacrilex Nicotine Gum OTC ORAL nicotine polacrilex Nicotine Lozenge OTC ORAL nicotine polacrilex Nicotine Mini Lozenge OTC ORAL nicotine Nicotine Transdermal System OTC PATCH

7. Preventive Health for Adults: Smoking Cessation (Prescription Only). Age Edits and Quantity Limits apply.

8. Preventive Health for Adults: Smoking Cessation (OTC Only). Age Edits and Quantity Limits apply.

Generic Name Covered Label Name RX/OTC (FDB) Form nicotine Nicotine Patch OTC PATCH nicotine polacrilex Nicotine Gum OTC ORAL nicotine polacrilex Nicotine Lozenge OTC ORAL nicotine polacrilex Nicotine Mini Lozenge OTC ORAL nicotine Nicotine Transdermal System OTC PATCH nicotine Nicotine Patch OTC PATCH