Your Pharmacy Benefits Your Pharmacy Benefits

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2300 Main Street, Irvine, CA 92614 The information in this educational tool does not substitute for the medical advice, diagnosis or treatment of your physician. Always seek the help of your physician or qualified health provider for any questions you may have regarding your medical condition. OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an OptumTM company — a leading provider of integrated health services. Learn more at www.optum.com. All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. ORX2333_120629 ©2012 OptumRx, Inc. Your 2018 Formulary

Effective January 1, 2018

Please read: This document contains information about the drugs covered under your pharmacy benefit plan.

For a complete list of covered drugs or if you have questions:

Call the toll-free member phone number on your ID card.

Visit your plan’s member website listed on your ID card. • Locate a participating retail pharmacy by zip code. • Look up possible lower-cost medication alternatives. • Compare medication pricing and options.

OptumRx Innoviant Select 1 Your Formulary This Formulary outlines the most commonly prescribed medications from your plan’s complete pharmacy benefit coverage list, also known as a Prescription Drug List (PDL). A formulary identifies the drugs available for certain conditions and organizes them into cost levels, also known as tiers. An important part of the Formulary is giving you choices so you and your doctor can choose the best course of treatment for you.

Go to your plan’s member website for complete and up-to-date drug information Since the Formulary may change, we encourage you to your plan’s member website, which should be listed on your ID card. This website is the best source for up-to-date information about all of the medications your pharmacy benefit covers, possible lower- cost options and cost comparisons.

2 Table of Contents

Drug tiers and cost ...... 5 Gastrointestinal Acid Suppression ...... 16 Programs and limits ...... 6 Nausea/Vomiting ...... 17 Drugs by category ...... 9 Other ...... 17

Anti-Infectives HIV/AIDS ...... 17 Antibiotics ...... 9 Infertility ...... 17 Antifungals ...... 9 Antivirals ...... 9 Inflammatory Conditions ...... 17

Cancer ...... 9 Men’s Health Erectile Dysfunction ...... 18 Cardiovascular/Heart Disease Prostate ...... 18 Anticoagulants ...... 10 Testosterone Therapy ...... 18 High Blood Pressure ...... 10 High Cholesterol ...... 10 Miscellaneous ...... 18 Other ...... 11 Musculoskeletal Pulmonary Arterial Hypertension . . . . . 11 Osteoporosis ...... 19 Central Nervous System Other ...... 19 Attention Deficit Disorder ...... 11 Pain Relief ...... 19 Depression ...... 11 Overactive Bladder ...... 19 Migraine ...... 12 Multiple Sclerosis ...... 12 Respiratory Other ...... 12 Asthma/COPD ...... 20 Sedatives/Hypnotics ...... 12 Nasal Allergies ...... 20 Seizure Disorders ...... 12 Oral Allergies ...... 20

Dermatology ...... 13 Transplant ...... 20

Diabetes/Endocrine Vitamins/Electrolytes ...... 21 Blood Glucose Monitoring ...... 13 Insulin ...... 15 Women’s Health Non-Insulin ...... 15 Birth Control ...... 21 Hormone Replacement ...... 22 Endocrine Vaginal Anti-Infectives ...... 22 Growth Hormone ...... 15 Other ...... 15 Index ...... 23 Thyroid Hormone Replacement ...... 16

Eye Conditions Allergies ...... 16 Antibiotics ...... 16 Glaucoma ...... 16 Other ...... 16 3 At OptumRx, we want to help you better understand your medication options. Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we’ve included some of the most commonly asked questions about the Formulary.

What is a Formulary? This document is a list of commonly prescribed medications preferred by your plan sponsor for their safety, cost and effectiveness. Drugs are listed by common categories or class. They are placed into cost levels known as tiers. It includes both brand and generic prescription medications approved by the U.S. Food and Drug Administration (FDA). Please note: Where differences are noted between this Formulary and your benefit plan documents, the benefit plan documents will rule. It is not intended to be a complete list of medications, and not all medications listed may be covered under your plan. Please look at your benefit plan documents provided by your employer or plan sponsor to see what medications are covered under your plan. You may also log on to your plan’s member website or call the toll-free member phone number on your ID card for more information.

How do I use my Formulary? When choosing a medication, you and your doctor should consult the Formulary. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. It is organized by common medical conditions. Medications are then listed alphabetically. If your medication is not listed in this document, please visit your plan’s member website or call the toll-free member phone number on your ID card.

4 What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or plan sponsor. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor. Drug names shown in orange are preferred for their cost and effectiveness. If there is a  symbol in the Drug Tier column, check your benefit plan documents to find out your specific pharmacy plan costs.

$ Drug Tier Includes Helpful Tips

Tier 1 Lower-cost, commonly Use Tier 1 drugs for $ Lowest Cost used generic drugs. the lowest out-of- Some low-cost brands pocket costs. may be included. $$$ $ Tier 2 Many common brand- Use Tier 2 drugs, instead $$$$$ Mid-range name drugs, called of Tier 3, to help reduce Cost preferred brands. your out-of-pocket costs. $$ $$$ $$$$ Tier 3 Mostly higher-cost Many Tier 3 drugs have $$$ Highest Cost brand drugs, also lower-cost options in Tier $$$$ known as non- 1 or 2. Ask your doctor if $$$$$ preferred brands. they could work for you. $$$$ $$$$$ Please$$$$$ note: Some plans may have two or four tiers, while others may not have any. If you have a high deductible plan, the tier cost levels will apply once you hit your deductible. Refer to your enrollment and plan materials on your plan’s member website or call the toll-free member phone number on your ID card for more information about your benefit plan.

When does the Formulary change? • Medications may move to a lower tier at any time. • Medications may move to a higher tier when its generic becomes available. • Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year. When a medication changes tiers, you may have to pay a different amount for that medication. For the most up-to-date list, call customer service at the toll-free member phone number on your ID card. 5 Programs and Limits Some medications are noted with letters or symbols next to them. The letters and symbols refer to our pharmacy benefit programs and are provided to help you check which medications may have a program or limit. Your benefit plan determines how these medications may be covered for you.

AR Age Restrictions – Some restrictions may apply based on patient age.

Prior Authorization – Your doctor is required to provide additional PA information to determine coverage.

Step Therapy – Trial of lower cost medication(s) is required before ST a higher-cost medication is covered.

Quantity Limits – Amount of medication covered per copayment QL or in a specific time period.

Specialty Medication – Medication is designated as a specialty SP pharmacy drug.

++ Coverage is determined by the consumer’s prescription drug benefit plan.

To learn more about a pharmacy program or to find out if it applies to you, please visit your plan’s member website or call the toll-free member phone number on your ID card.

6 Why are some medications excluded from coverage? Medications may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription medication or an over-the-counter (OTC) medication. There may be other medication options available.

What if I don’t agree with a decision about an excluded medication? You (or your authorized representative) and your doctor can ask for an initial coverage decision by calling the toll-free member phone number on the back of your ID card.

Should I talk to my doctor about OTC medications? An OTC medication may be the right treatment option for some conditions. Talk to your doctor about available OTC options. Even though these medications may not be covered under your pharmacy benefit, they may cost less than your out-of-pocket expense for prescription medications.

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 of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes the same company that makes a brand-name medication also makes the generic version.

Is it a generic or brand-name drug? The drug list shows brand-name drugs in bold type (for example, Clobex) and generic drugs in plain type (for example, clobetasol).

What if my doctor writes a brand-name prescription? The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. Visit your plan’s member website to make sure.

7 Are you taking a specialty medication? Specialty medications treat rare or complex conditions and are typically higher cost medications. Please note, not all specialty medications are listed in the Formulary. BriovaRx, the OptumRx specialty pharmacy, can provide most of your specialty medications along with helpful programs and services. Call BriovaRx and have your prescriptions delivered right to your home or office.

How do I get updated information about my pharmacy benefit? Since the Formulary may change during your plan year, we encourage you to visit your plan’s member website or call the toll-free member phone number on the back of your ID card for more current information. When you register on our website and open an account, you can use the website’s helpful tools and features to: • Look up the price of drugs covered by your plan • Find lower-cost options • Refill and renew home delivery prescriptions • View your order status and claims history • View your benefits in real time

More information If you have additional questions please call customer service, 24 hours a day, 7 days a week using the toll-free member phone number on your ID card. Or visit your plan’s member website.

8 Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Sulfamethoxazole- Anti-Infectives: Antibiotics 1 Trimethoprim DS Amoxicillin 1 Anti-Infectives: Antifungals Amoxicillin/Clavulanate 1 Azasite 3 Fluconazole 1 Azithromycin 1 Nystatin Suspension 1 Bethkis 2 SP Terbinafine Tab 1 QL Cefdinir 1 Anti-Infectives: Antivirals Cefuroxime Tab 1 Acyclovir Cap, Tab, Cephalexin 1 1 Ciprodex Otic Suspension 2 Suspension Entecavir 1 QL, SP Ciprofloxacin Tab 1 Epclusa 2 PA, QL, SP Clarithromycin 1 Famciclovir Tab 1 Clindamycin Cap 1 Harvoni 2 PA, QL, SP Doryx MPC 3 Mavyret 2 PA, QL, SP Doxycycline Hyclate Cap 1 Oseltamivir 1 QL Doxycycline Hyclate Tab Odefsey 2 SP 1 (Immediate Release) Tamiflu 3 QL Doxycycline Valacyclovir 1 QL 1 Monohydrate Cap Zepatier 3 PA, QL, SP Doxycycline Cancer Monohydrate Oral 1 Akynzeo 3 QL Suspension, Tab Anastrozole Tab 1 Erythromycin 1 Cabometyx 2 PA, SP Levofloxacin Tab 1 Capecitabine 1 PA, SP Metronidazole Tab 1 Letrozole 1 Minocycline Cap 1 Mercaptopurine 1 SP Nitrofurantoin 1 Revlimid 2 PA, SP Macrocrystalline Sprycel 2 PA, SP Nitrofurantoin Tamoxifen Tab 1 Monohydrate 1 Zytiga 3 PA, SP Macrocrystalline Ofloxacin Otic Solution 1 Oracea 3 Penicillin VK 1 Solodyn 3 Sulfamethoxazole- 1 Trimethoprim

Bold type = Brand-name drug AR Age Restrictions SP Specialty Program [Plain type = Generic drug] PA Prior Authorization ++ Coverage is determined  Call customer service for pricing ST Step Therapy by the consumer’s 9 QL Quantity Limits prescription benefit plan Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Cardiovascular/Heart Disease: Labetalol 1 Anticoagulants Lisinopril 1 Brilinta 2 Lisinopril/HCTZ 1 Clopidogrel 1 Losartan 1 Effient 3 Losartan/HCTZ 1 Eliquis 3 QL Metoprolol Succinate 1 Enoxaparin  QL, SP Metoprolol Tartrate 1 Pradaxa 2 QL Nadolol 1 Savaysa 3 QL Nifedipine ER 1 Warfarin 1 Olmesartan 1 Xarelto 2 QL Olmesartan/HCTZ 1 Zontivity 3 Prazosin 1 Cardiovascular/Heart Disease: Propranolol 1 High Blood Pressure Propranolol ER 1 Amlodipine 1 Quinapril 1 Amlodipine/Benazepril 1 Ramipril 1 Amlodipine/Valsartan 1 Spironolactone 1 Atenolol 1 Tekturna 2 ST Atenolol/Chlorthalidone 1 Tekturna HCT 2 ST Benazepril 1 Telmisartan 1 Benazepril/HCTZ 1 Terazosin 1 Bisoprolol/HCTZ 1 Torsemide Tab 1 Bumetanide 1 Triamterene/HCTZ 1 Bystolic 2 Valsartan 1 Byvalson 2 Valsartan/HCTZ 1 Cartia XT 1 Verapamil ER 1 Carvedilol 1 Cardiovascular/Heart Disease: Chlorthalidone 1 High Cholesterol Clonidine Tab 1 Atorvastatin 1 Diltiazem ER Cap 1 Choline Fenofibrate ER 1 Doxazosin 1 Crestor 3 Dutasteride 1 Fenofibrate 40 mg, Edarbi 3 ST 43 mg, 48 mg, Edarbyclor 3 ST 50 mg, 54 mg, Enalapril 1 67 mg, 120 mg, 1 Furosemide 1 130 mg, 134 mg, Guanfacine Tab 145 mg, 150 mg, 1 (Immediate Release) 160 mg, 200 mg Hydralazine 1 Gemfibrozil 1 Hydrochlorothiazide 1 Livalo 3 ST Irbesartan 1 Lovastatin 1 Niacin ER Tab 1 Omega-3 Acid Cap 1 1 gm

Bold type = Brand-name drug AR Age Restrictions SP Specialty Program [Plain type = Generic drug] PA Prior Authorization ++ Coverage is determined  Call customer service for pricing ST Step Therapy by the consumer’s 10 QL Quantity Limits prescription benefit plan Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Praluent  PA, QL, SP Amphetamine- Pravastatin 1 Dextroamphetamine 1 QL Rosuvastatin 1 SR 24Hr Cap Simvastatin 5 mg, 10 Dexmethylphenidate ER 1 1 QL mg, 20 mg, 40 mg Cap Simvastatin 80 mg 1 PA Guanfacine ER Tab 1 Vascepa 2 Methylphenidate 1 QL Vytorin 10-10 mg, ER Cap 10-20 mg, 3 Methylphenidate ER Tab 1 QL 10-40 mg Methylphenidate SA 1 QL Vytorin 10-80 mg 3 PA Osmotic ER Tab Welchol 2 Methylphenidate Tab 1 QL Cardiovascular/Heart Disease: Other Strattera 3 QL Vyvanse 2 QL Corlanor 3 PA, QL Central Nervous System: Depression Digoxin 1 Flecainide 1 Amitriptyline 1 Isosorbide Mononitrate 1 Bupropion 1 Isosorbide Mononitrate Bupropion ER 1 QL 1 ER Bupropion SR 1 QL Multaq 3 Bupropion XL 1 QL Nitroglycerin SL Tab 1 Citalopram 1 Ranexa 2 ST Doxepin 1 Duloxetine Cap 20 mg, Sotalol 1 1 QL Cardiovascular/Heart Disease: 30 mg, 60 mg Pulmonary Arterial Hypertension Escitalopram Tab 1 Fluoxetine Cap Adcirca 3 PA, QL, SP 1 Adempas 2 PA, QL, SP (not PMDD) Letairis 2 PA, QL, SP Forfivo XL 2 QL Opsumit 2 PA, QL, SP Mirtazapine 1 Orenitram 3 PA, SP Nortriptyline 1 Sildenafil Tab 20 mg 1 PA, QL, SP Paroxetine Tab 1 Tracleer 2 PA, QL, SP Pristiq 3 QL Central Nervous System: Rexulti 3 QL Attention Deficit Disorder Risperidone Tab 1 QL Adderall XR Cap 3 QL, ST Sertraline 1 Amphetamine- Trazodone 1 Dextroamphetamine 1 QL Trintellix 3 QL, ST Venlafaxine Tab 1 Tab Venlafaxine ER Cap 1 Venlafaxine ER Tab 1 Viibryd 3 QL

Bold type = Brand-name drug AR Age Restrictions SP Specialty Program [Plain type = Generic drug] PA Prior Authorization ++ Coverage is determined  Call customer service for pricing ST Step Therapy by the consumer’s 11 QL Quantity Limits prescription benefit plan Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Central Nervous System: Migraine Risperidone Tab 1 QL Ropinirole 1 Butalbital- (Immediate Release) Acetaminophen- 1 Saphris 2 QL Caffeine Cap, Tab Central Nervous System: 50-325-40 mg Sedatives/Hypnotics Migranal 3 QL Eszopiclone Tab 1 QL Relpax 3 QL Silenor 3 QL Rizatriptan Tab, ODT 1 QL Temazepam 1 QL Sumatriptan Tab Triazolam Tab 1 QL 1 QL and Spray Xyrem 3 PA, QL, SP Sumavel Dose 3 QL Zaleplon 1 QL Central Nervous System: Zolpidem 1 QL Multiple Sclerosis Zolpidem ER 1 QL Ampyra 2 PA, QL, SP Central Nervous System: Aubagio 3 PA, QL, ST, SP Seizure Disorders Avonex Kit  PA, QL, SP Clonazepam 1 QL Avonex Pen Kit  PA, QL, SP Divalproex DR 1 Avonex Prefill Kit  PA, QL, SP Divalproex ER 1 Betaseron  PA, QL, SP Gabapentin 1 Copaxone 20 mg/mL Lamotrigine  PA, QL, SP 1 & 40 mg/mL (Immediate Release) Gilenya* 3 PA, QL, ST, SP Levetiracetam 1 Tecfidera 2 PA, QL, SP Lyrica Cap 2 QL Oxcarbazepine 1 Central Nervous System: Other Topiramate Tab 1 Alprazolam Tab 1 QL Vimpat 3 Aripiprazole 1 QL Zonisamide 1 Buspirone 1 Diazepam Tab 1 Hydroxyzine HCL 1 Hydroxyzine Pamoate 1 Latuda 3 QL, ST Lorazepam Tab 1 QL Modafinil 1 PA, QL Namenda XR 2 QL Namzaric 2 QL Olanzapine Tab 1 QL Pramipexole 1 Quetiapine 1 QL

* Tier 3 Preferred

Bold type = Brand-name drug AR Age Restrictions SP Specialty Program [Plain type = Generic drug] PA Prior Authorization ++ Coverage is determined  Call customer service for pricing ST Step Therapy by the consumer’s 12 QL Quantity Limits prescription benefit plan Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Nystatin Cream, Dermatology 1 Ointment, Powder Absorica 3 PA Onexton 3 Aczone Gel 3 Oxsoralen-UL 2 Atralin 3 PA Permethrin Cream 5% 1 Claravis 1 PA Proctofoam HC 2 Clindamycin Gel, Retin-A Micro gel 1 3 PA, ++ Lotion, Solution 0.1%, 0.04% Clindamycin/ Soolantra 2 Benzoyl Peroxide 1 Taclonex 3 QL Gel 1-5% Tazorac 3 PA, ++ Clindamycin/Benzoyl Tretinoin Cream 1 PA, ++ Tretinoin Microsphere Peroxide Gel 1 1 PA, ++ 1.2-5% Gel Clobetasol Cream, Triamcinolone 1 1 Ointment, Solution Vectical 3 Clobex 3 Zovirax Cream 2 Clotrimazole/ Zovirax Ointment 3 Betamethasone 1 Zyclara 3 Cream, Lotion Diabetes/Endocrine Blood: Dupixent  PA, QL, SP Glucose Monitoring Econazole Cream 1 Accu-Chek Active Elidel 2 ST Glucose Control 2 ++ Epiduo & Epiduo Liquid 3 Accu-Chek Active Test Forte 2 QL, ++ Eucrisa 2 ST Strips Fluocinonide Cream, Accu-Chek Aviva 1 2 ++ 0.1% Connect Kit Accu-Chek Aviva Plus Fluocinonide Cream, 2 ++ Gel, Ointment, 1 Control Liquid Accu-Chek Aviva Plus Solution 0.05% 2 ++ Hydrocortisone Cream, Kit 1 Accu-Chek Aviva Plus Ointment 2.5% 2 QL, ++ Lidocaine Topical Test Strips 1 Accu-Chek Compact Ointment, Solution 2 ++ Ketoconazole Cream/ Plus Control Liquid 1 Accu-Chek Compact Shampoo 2 QL, ++ Metrogel 3 Plus Test Strips Metronidazole Gel Accu-Chek Compact 1 2 ++ 0.75% Plus Kit Mirvaso Gel 2 Mupirocin Ointment 1 Myorisan 1 PA

Bold type = Brand-name drug AR Age Restrictions SP Specialty Program [Plain type = Generic drug] PA Prior Authorization ++ Coverage is determined  Call customer service for pricing ST Step Therapy by the consumer’s 13 QL Quantity Limits prescription benefit plan Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Accu-Chek FastClix Dexcom G5 2 ++ 3 ++ Kit Transmitter Kit Accu-Chek FastClix Freestyle Test Strips 3 QL, ST, ++ 2 ++ Lancets Insulin Pen Needle 2 ++ Accu-Chek Guide Insulin Syringe/ 2 ++ 2 ++ Control Liquid Needle Accu-Chek Guide Kit 2 ++ Novofine Pen Needle 2 ++ Accu-Chek Guide Test Novofine Autocover 2 QL, ++ 2 ++ Strips Pen Needle Accu-Chek Multiclix Novotwist Pen 2 ++ 2 ++ Kit Needle Accu-Chek Multiclix OneTouch Ultra 2 2 ++ 2 ++ Lancets System Accu-Chek Nano OneTouch UltraMini 2 ++ 2 ++ SmartView Kit System Kit Accu-Chek SmartView OneTouch Ultra Test 2 ++ 2 QL, ++ Control Liquid Strips Accu-Chek SmartView OneTouch Verio Flex 2 QL, ++ 2 ++ Test Strips System Kit Accu-Chek Soft Touch OneTouch Verio IQ 2 ++ 2 ++ Lancets System Kit OneTouch Verio Sync Accu-Chek Softclix Kit 2 ++ 2 ++ Accu-Chek Softclix System Kit 2 ++ OneTouch Verio Lancets 2 ++ Bayer Contour Test System Kit 3 QL, ST, ++ OneTouch Verio Strips 2 QL, ++ Dexcom G4 Platinum Test Strips 3 ++ Kit Precision Test Strips 3 QL, ST, ++ Dexcom G4 Platinum 3 ++ Sensor Kit Dexcom G4 Platinum 3 ++ Transmitter Kit Dexcom G5 Kit 3 ++ Dexcom G5 Sensor 3 ++ Kit

Bold type = Brand-name drug AR Age Restrictions SP Specialty Program [Plain type = Generic drug] PA Prior Authorization ++ Coverage is determined  Call customer service for pricing ST Step Therapy by the consumer’s 14 QL Quantity Limits prescription benefit plan Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Glumetza 3 PA Diabetes/Endocrine: Insulin Glyburide 1 Humalog Mix 50/50 Invokamet 2 ST 2 ++ Vial and KwikPen Invokamet XR 2 ST Humalog Mix 75-25 Invokana 2 ST 2 ++ Vial and KwikPen Janumet 2 ST Humalog U-100 Vial Janumet XR 2 ST 2 ++ and KwikPen Januvia 2 ST Humalog U-200 Jardiance 2 ST 2 ++ KwikPen Jentadueto 2 ST Humulin 70-30 Vial Jentadueto XR 2 ST 2 ++ and KwikPen Metformin 1 Humulin N Vial and Metformin ER 1 2 ++ Pioglitazone 1 KwikPen Humulin R U-500 Vial Synjardy 2 ST 2 ++ Tradjenta 2 ST and KwikPen Humulin R Vial 2 ++ Trulicity 2 QL, ST Lantus SoloStar 2 ++ Victoza 2 QL, ST Lantus Vial 2 ++ Endocrine: Growth Hormone Levemir FlexTouch 2 ++ Levemir Vial 2 ++ Norditropin  PA, SP, ++ Novolin 70/30 Vial 2 ++ Nutropin AQ  PA, SP, ++ Novolin N Vial 2 ++ Omnitrope  PA, SP, ++ Novolin R Vial 2 ++ Endocrine: Other Novolog Flexpen 2 ++ Novolog Mix 70/30 Calcitriol Cap 1 2 ++ Vial and Flexpen Clomiphene 1 Novolog Penfill 2 ++ Dexamethasone Tab 1 Novolog Vial 2 ++ H.P. Acthar  PA, SP Soliqua 2 QL, ST, ++ Hydrocortisone Tab 1 Toujeo SoloStar 2 ++ Lupron Depot  PA, SP Tresiba 3 ++ 3.75 mg, 11.25 mg Diabetes/Endocrine: Non-Insulin Lupron Depot 7.5 mg, 22.5 mg,  PA, SP Bydureon 2 QL, ST 30 mg, 45 mg Byetta 2 QL, ST Methylprednisolone Tab 1 Farxiga 3 ST Prednisone 1 Glimepiride 1 Prednisolone Solution 1 Glipizide 1 25 mg/5 ml Glipizide ER 1 Prednisolone Syrup, 1 Glipizide XL 1 Solution 15 mg/5 ml

Bold type = Brand-name drug AR Age Restrictions SP Specialty Program [Plain type = Generic drug] PA Prior Authorization ++ Coverage is determined  Call customer service for pricing ST Step Therapy by the consumer’s 15 QL Quantity Limits prescription benefit plan Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Endocrine: Eye Conditions: Glaucoma Thyroid Hormone Replacement Armour Thyroid 3 Alphagan P 2 Levothyroxine 1 Azopt 2 Liothyronine 1 Betimol 3 Methimazole 1 Combigan 2 Synthroid 3 Cosopt PF 3 Tirosint 3 Latanoprost 1 QL Lumigan 2 QL Eye Conditions: Allergies Simbrinza 2 Azelastine Ophthalmic Travatan Z 2 QL 1 Solution Eye Conditions: Other Pataday 3 Ketorolac Ophthalmic Pazeo 2 1 Solution Eye Conditions: Antibiotics Prednisolone Besivance 3 Ophthalmic 1 Ciprofloxacin Suspension 1 Ophthalmic Solution Restasis 2 PA Erythromycin Ointment 1 Restasis Multidose 2 PA Moxeza 2 Xiidra 2 PA Ofloxacin Ophthalmic 1 Gastrointestinal: Acid Suppression Solution Polymyxin B/ Dexilant 2 QL Trimethoprim 1 Esomeprazole Solution Magnesium 40 mg 1 QL Tobramycin 1 (Rx only) Tobramycin/ Famotidine Tab 40 mg 1 1 Dexamethasone (Rx only) Vigamox 3 Lansoprazole 30 mg 1 QL (Rx only) Misoprostol 1 Omeprazole (Rx only) 1 QL Pantoprazole 1 QL Rabeprazole 1 QL Ranitidine Tab, Cap, 1 Syrup (Rx only) Sucralfate Tab 1

Bold type = Brand-name drug AR Age Restrictions SP Specialty Program [Plain type = Generic drug] PA Prior Authorization ++ Coverage is determined  Call customer service for pricing ST Step Therapy by the consumer’s 16 QL Quantity Limits prescription benefit plan Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Gastrointestinal: Nausea/Vomiting Infertility Metoclopramide 1 Cetrotide  PA, SP, ++ Ondansetron ODT 1 QL Gonal-f  PA, SP, ++ Ondansetron Tab 1 Gonal-f RFF  PA, SP, ++ Varubi 3 QL Ovidrel  SP, ++ Gastrointestinal: Other Inflammatory Conditions Amitiza 2 QL, ST Cimzia Kit  PA, SP Apriso 2 Cosentyx*  PA, SP Canasa 2 Depen 2 SP Creon 2 Enbrel  PA, SP, ST Delzicol 3 ST Humira Kit  PA, SP Dicyclomine 1 Humira Pen Kit  PA, SP Dipentum 3 Humira Pen Kit Diphenoxylate/Atropine 1  PA, SP Crohns Gavilyte Solution 1 Humira Pen Kit Lialda 2 ST  PA, SP Psoriasis Linzess 2 QL, ST Hydroxychloroquine 1 Pentasa 3 Leflunomide 1 Prepopik 3 Methotrexate Tab 1 Pylera 2 Suprep Bowel Prep 3 Orencia SC  PA, SP, ST Uceris Foam 3 Otezla 2 PA, SP Zenpep 2 Rasuvo 2 PA, QL Remicade  PA, SP HIV/AIDS Simponi Aria  PA, SP Atripla 2 SP Simponi  PA, SP Complera 2 SP Stelara  PA, SP Descovy 2 SP Xeljanz 3 PA, SP, ST Genvoya 2 SP Isentress 2 SP Norvir 2 SP Prezcobix 2 SP Prezista 2 SP Reyataz 2 SP Stribild 2 SP Tivicay 2 SP Triumeq 2 SP Truvada 2 SP Viread 2 SP

* Tier 3 Preferred

Bold type = Brand-name drug AR Age Restrictions SP Specialty Program [Plain type = Generic drug] PA Prior Authorization ++ Coverage is determined  Call customer service for pricing ST Step Therapy by the consumer’s 17 QL Quantity Limits prescription benefit plan Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Euflexxa  PA, SP Men’s Health: Erectile Dysfunction Fosrenol 3 Cialis 2 QL, ++ Granix  PA, SP Levitra 3 QL, ++ Guaifenesin/Codeine 1 Stendra 3 QL, ++ Syrup Viagra 2 QL, ++ Hydrocodone/ Men’s Health: Prostate Chlorpheniramine 1 Liquid Cialis 2.5 mg & 5 mg 2 QL Hydrocodone Polistirex/ Doxazosin 1 Chlorpheniramine 1 Finasteride 5 mg 1 ER Suspension Rapaflo 2 Lidocaine Viscous 1 Tamsulosin 1 Solution 2% Terazosin 1 Makena  PA, SP Men’s Health: Testosterone Therapy Narcan 2 Neupogen  PA, SP Androderm 2 PA Phenazopyridine Androgel 1.62% 2 PA 1 (Rx only) Androgel 1% 3 PA, ST Phentermine Tab 1 PA Testosterone Cypionate 1 PA Procrit  PA, SP IM Injection Promethazine 1 Miscellaneous Promethazine DM Syrup 1 Promethazine/Codeine Allopurinol 1 1 Syrup Aranesp  PA, SP Renvela Tab 2 Armodafinil 1 PA, QL Rezira 3 Auryxia 3 Suboxone Film 2 QL Benzonatate 1 Synvisc  PA, SP Botox 100, 200 unit Synvisc One  PA, SP Injection  PA, SP Uloric 2 ST (non-cosmetic) Velphoro 3 Bunavail 3 QL Zarxio  PA, SP Cerdelga 3 PA, SP Zubsolv 2 QL Cheratussin 1 Zurampic 3 Chlorhexidine 1 Zutripro 3 Colcrys 2 Contrave 2 PA Epinephrine Auto-Injector (Authorized 2 Generic of EpiPen made by Mylan) EpiPen & EpiPen Jr 3 ST

Bold type = Brand-name drug AR Age Restrictions SP Specialty Program [Plain type = Generic drug] PA Prior Authorization ++ Coverage is determined  Call customer service for pricing ST Step Therapy by the consumer’s 18 QL Quantity Limits prescription benefit plan Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Hydrocodone/ Musculoskeletal: Osteoporosis Acetaminophen 1 QL Alendronate Tab 35 mg 5, 7.5, 10/325 mg 1 QL & 70 mg Hydromorphone Tab 1 QL Binosto 3 QL Hysingla ER 2 PA, QL Forteo  PA, SP Ibuprofen Tab 400, 600, 1 Tymlos  PA, SP 800 mg (Rx only) Indomethacin Cap 1 Musculoskeletal: Other Ketorolac Tab 1 QL Baclofen Tab 1 Lidocaine Patch 5% 1 Carisoprodol 350 mg 1 Meloxicam 1 Cyclobenzaprine Tab Methadone Tab 1 PA 1 5, 10 mg Morphine Sulfate ER 1 PA, QL Lorzone 3 Morphine Sulfate Tab 1 PA, QL Metaxalone 1 Nabumetone 1 Methocarbamol 1 Naproxen (Rx only) 1 Tizanidine Cap 1 Oxycodone Tab 5, Tizanidine Tab 1 10, 15, 30 mg 1 QL (Immediate Release) Musculoskeletal: Pain Relief Oxycodone 1 QL Acetaminophen w/ Acetaminophen 1 QL w/ Codeine Oxycontin 2 PA, QL Celecoxib 1 QL Tramadol Tab 50 mg 1 Tramadol Diclofenac Gel 1 QL 1 Diclofenac Tab 1 w/ Acetaminophen Embeda 2 PA, QL Zohydro ER 3 PA, QL Etodolac 1 Zorvolex 3 Flector patch 3 QL Overactive Bladder Fentanyl Patch 25 mcg/hr, Myrbetriq 2 50 mcg/hr, 1 PA, QL Oxybutynin 1 Oxybutynin ER 1 75 mcg/hr, Toviaz 3 100 mcg/hr Vesicare 2 Fentanyl Patch 37.5 mcg/hr, 1 PA, QL 62.5 mcg/hr, 87.5 mcg/hr Gralise 3 QL, ST

Respiratory: Asthma/COPD Respiratory: Nasal Allergies Advair Diskus 2 QL Astepro 3 QL Advair HFA 2 QL Azelastine Spray 1 QL Aerospan 3 QL Dymista Spray 2 QL Albuterol Ipratropium Spray 1 QL 1 QL Nebulizer Solution Mometasone 1 QL Anoro Ellipta 2 QL Omnaris 3 QL Arnuity Ellipta 2 QL QNasl 3 QL Breo Ellipta 2 QL Zetonna 3 QL Budesonide Inhalation 1 QL Respiratory: Oral Allergies Suspension Combivent Respimat 2 QL Promethazine Tab 1 Dulera 3 QL, ST Transplant Flovent Diskus 2 QL Flovent HFA 2 QL Azathioprine Tab 1 Incruse Ellipta 2 QL Mycophenolate Mofetil Ipratropium/Albuterol 250 mg Cap/ 1 SP 1 QL Nebulizer Solution 500 mg Tab Montelukast 1 Mycophenolate Sodium Proair HFA, RespiClick 2 QL 180 mg, 360 mg 1 SP Pulmicort Flexhaler 2 QL Tab Qvar 2 QL Prograf Cap 3 SP Serevent Diskus 2 QL Tacrolimus Cap 1 SP Spiriva Handihaler 2 QL Spiriva Respimat 2 QL Stiolto 2 QL Symbicort 2 QL Ventolin HFA 2 QL Xolair  PA, SP

Bold type = Brand-name drug AR Age Restrictions SP Specialty Program [Plain type = Generic drug] PA Prior Authorization ++ Coverage is determined  Call customer service for pricing ST Step Therapy by the consumer’s 20 QL Quantity Limits prescription benefit plan Drug Programs Drug Programs Drug Name Drug Name Tier and Limits Tier and Limits Loryna 1 ++ Vitamins/Electrolytes Low-Ogestrel 1 ++ Cyanocobalamine Lutera 1 ++ 1 ++ Medroxyprogesterone Injection 1 QL, ++ Folic Acid 1 mg Acetate Injection 1 (Rx only) Microgestin 1 ++ Klor-Con 8 and 10 MEQ 1 Microgestin Fe 1 ++ Klor-Con M10 and M20 1 Mono-Linyah 1 ++ Ludent 1 ++ Mononessa 1 ++ Potassium Chloride ER Natazia 2 ++ 1 Tab, Cap Necon 1 ++ Potassium Chloride Nora-Be 1 ++ 1 Micro ER Tab Norgest/Ethi Estradio 1 ++ Vitamin D 50,000 units Nortrel 1 ++ 1 ++ (Rx only) Nuvaring 2 ++ Ocella 1 ++ Women’s Health: Birth Control Orsythia 1 ++ Ortho Tri-Cyclen Lo 3 ++ Apri 1 ++ Previfem 1 ++ Aviane 1 ++ Reclipsen 1 ++ Azurette 1 ++ Sprintec 28 1 ++ Cryselle-28 1 ++ Tri-Linyah 1 ++ Falmina 1 ++ Tri-Lo Sprintec 1 ++ Generess Fe 3 ++ Tri-Previfem 1 ++ Chewable Trinessa 1 ++ Gianvi 1 ++ Tri-Sprintec 1 ++ Gildess 1 ++ Vestura 1 ++ Jolivette 1 ++ Viorele 1 ++ Junel 1 ++ Xulane 1 ++ Kariva 1 ++ Zarah 1 ++ Levora 28 1 ++ Lo Loestrin 3 ++ Lomedia Fe 1 ++

A Albuterol Nebulizer Solution . . 20 Azopt ...... 16 Alendronate Tab . . . . 19 Azurette ...... 21 Absorica ...... 13 Allopurinol ...... 18 Accu-Chek Active Glucose Alphagan P ...... 16 B Control Liquid . . . .13 Alprazolam Tab . . . . . 12 Accu-Chek Active Amitiza 17 Baclofen Tab ...... 19 Test Strips . . . . . 13 Amitriptyline ...... 11 Bayer Contour Test Strips 14 Accu-Chek Aviva Amlodipine ...... 10 Benazepril 10 Connect Kit . . . . 13 Amlodipine/Benazepril . . 10 Benazepril/HCTZ . . . . 10 Accu-Chek Aviva Amlodipine/Valsartan . . . 10 Benzonatate ...... 18 Plus Control Liquid . .13 Amoxicillin ...... 9 Besivance ...... 16 Accu-Chek Aviva Plus Kit . 13 Amoxicillin/Clavulanate . . . 9 Betaseron ...... 12 Accu-Chek Aviva Plus Amphetamine- Bethkis 9 Test Strips . . . . . 13 Dextroamphetamine Betimol 16 Accu-Chek Compact SR 24Hr Cap . . . . 11 Binosto 19 Plus Control Liquid . .13 Amphetamine- Bisoprolol/HCTZ 10 Accu-Chek Compact Dextroamphetamine Tab . 11 Botox 18 Plus Kit 13 Ampyra ...... 12 Breo Ellipta ...... 20 Accu-Chek Compact Anastrozole Tab 9 Brilinta 10 Plus Test Strips 13 Androderm ...... 18 Budesonide Inhalation Accu-Chek FastClix Kit . .14 Androgel 18 Suspension . . . . . 20 Accu-Chek FastClix Lancets . 14 Anoro Ellipta . . . . . 20 Bumetanide 10 Accu-Chek Guide Control Apri 21 Bunavail ...... 18 Liquid 14 Apriso ...... 17 Bupropion 11 Accu-Chek Guide Kit . . 14 Aranesp ...... 18 Bupropion ER ...... 11 Accu-Chek Guide Test Strips 14 Aripiprazole 12 Bupropion SR ...... 11 Accu-Chek Multiclix Kit . . 14 Armodafinil ...... 18 Bupropion XL ...... 11 Accu-Chek Multiclix Lancets 14 Armour Thyroid . . . . 16 Buspirone 12 Accu-Chek Nano Arnuity Ellipta 20 Butalbital-Acetaminophen- SmartView Kit 14 Astepro ...... 20 Caffeine 12 Accu-Chek SmartView Atenolol 10 Bydureon ...... 15 Control Liquid . . . .14 Atenolol/Chlorthalidone 10 Byetta ...... 15 Accu-Chek SmartView Atorvastatin ...... 10 Bystolic 10 Test Strips . . . . . 14 Atralin ...... 13 Byvalson 10 Accu-Chek Softclix Kit 14 Atripla ...... 17 Accu-Chek Softclix Lancets . 14 Aubagio ...... 12 C Accu-Chek Soft Touch Auryxia ...... 18 Cabometyx ...... 9 Lancets 14 Aviane ...... 21 Calcitriol Cap ...... 15 Acetaminophen w/ Codeine 19 Avonex Kit 12 Canasa ...... 17 Acyclovir Cap, Tab, Suspension 9 Avonex Pen Kit . . . . 12 Capecitabine ...... 9 Aczone Gel 13 Avonex Prefill Kit . . . .12 Carisoprodol 350 mg . . . 19 Adcirca 11 Azasite 9 Cartia XT ...... 10 Adderall XR Cap 11 Azathioprine Tab . . . . 20 Carvedilol 10 Adempas 11 Azelastine Ophthalmic Cefdinir 9 Advair Diskus . . . . . 20 Solution 16 Cefuroxime Tab . . . . . 9 Advair HFA ...... 20 Azelastine Spray 20 Celecoxib ...... 19 Aerospan ...... 20 Azithromycin ...... 9 Akynzeo ...... 9 Cephalexin ...... 9

Bold type = Brand-name drug [Plain type = Generic drug] 23 Index of Covered Drugs

Cerdelga ...... 18 Dexcom G4 Platinum Kit . 14 Enbrel ...... 17 Cetrotide 17 Dexcom G4 Platinum Enoxaparin ...... 10 Cheratussin ...... 18 Sensor Kit . . . . . 14 Entecavir ...... 9 Chlorhexidine 18 Dexcom G4 Platinum Epclusa 9 Chlorthalidone . . . . . 10 Transmitter Kit 14 Epiduo & Epiduo Forte . .13 Choline Fenofibrate ER . . 10 Dexcom G5 Kit 14 Epinephrine Auto-Injector 18 Cialis ...... 18 Dexcom G5 Sensor Kit . .14 EpiPen & EpiPen Jr . . . 18 Cimzia Kit ...... 17 Dexcom G5 Transmitter Kit 14 Erythromycin ...... 9 Ciprodex Otic Suspension . 9 Dexilant ...... 16 Erythromycin Ointment . . 16 Ciprofloxacin Ophthalmic Dexmethylphenidate ER Cap 11 Escitalopram Tab . . . . 11 Solution 16 Diazepam Tab 12 Esomeprazole Magnesium . 16 Ciprofloxacin Tab . . . . . 9 Diclofenac Gel . . . . . 19 Estrace Vaginal Cream . .22 Citalopram ...... 11 Diclofenac Tab . . . . . 19 Estradiol/Norethindrone Tab 22 Claravis ...... 13 Dicyclomine 17 Estradiol Patch, Tab . . . .22 Clarithromycin . . . . . 9 Digoxin ...... 11 Eszopiclone Tab . . . . . 12 Climara Pro ...... 22 Diltiazem ER Cap . . . . 10 Etodolac ...... 19 Clindamycin/Benzoyl Peroxide 13 Dipentum ...... 17 Eucrisa ...... 13 Clindamycin Cap . . . . . 9 Diphenoxylate/Atropine 17 Euflexxa ...... 18 Clindamycin 13 Divalproex DR 12 Clobetasol Cream, Ointment, Divalproex ER ...... 12 F Solution 13 Divigel ...... 22 Clobex ...... 13 Doryx MPC 9 Falmina ...... 21 Clomiphene 15 Doxazosin 10 Famciclovir Tab . . . . . 9 Clonazepam ...... 12 Doxazosin 18 Famotidine Tab Clonidine Tab ...... 10 Doxepin 11 Farxiga 15 Clopidogrel ...... 10 Doxycycline Hyclate . . . . 9 Fenofibrate 10 Clotrimazole/Betamethasone 13 Doxycycline Monohydrate Cap 9 Fentanyl Patch . . . . . 19 Colcrys ...... 18 Doxycycline Monohydrate Finasteride ...... 18 Combigan ...... 16 Oral Suspension 9 Flecainide ...... 11 Combivent Respimat . . 20 Duavee 22 Flector patch 19 Complera ...... 17 Dulera ...... 20 Flovent Diskus 20 Contrave ...... 18 Duloxetine Cap . . . . . 11 Flovent HFA ...... 20 Copaxone ...... 12 Dupixent 13 Fluconazole ...... 9 Corlanor ...... 11 Dutasteride ...... 10 Fluocinonide Cream 13 Cosentyx 17 Dymista Spray 20 Fluoxetine Cap . . . . . 11 Cosopt PF ...... 16 Folic Acid 21 Creon 17 E Forfivo XL ...... 11 Crestor 10 Forteo ...... 19 Cryselle-28 ...... 21 Econazole Cream . . . . 13 Fosrenol ...... 18 Cyanocobalamine Injection . 21 Edarbi ...... 10 Freestyle Test Strips 14 Cyclobenzaprine Tab . . . 19 Edarbyclor ...... 10 Furosemide ...... 10 Effient ...... 10 D Elestrin Gel ...... 22 G Elidel 13 Delzicol ...... 17 Eliquis ...... 10 Gabapentin ...... 12 Depen ...... 17 Embeda ...... 19 Gavilyte Solution . . . . 17 Descovy ...... 17 Enalapril 10 Dexamethasone Tab . . . 15

Bold type = Brand-name drug [Plain type = Generic drug] 24 Index of Covered Drugs

Gemfibrozil ...... 10 Hydrocodone Polistirex/ Ketorolac Tab ...... 19 Generess Fe Chewable . .21 Chlorpheniramine ER Klor-Con 8 and 10 MEQ 21 Genvoya ...... 17 Suspension . . . . . 18 Klor-Con M10 and M20 21 Gianvi 21 Hydrocortisone . . . . . 13 Gildess ...... 21 Hydrocortisone Tab . . . .15 L Gilenya 12 Hydromorphone Tab . . . 19 Glimepiride ...... 15 Hydroxychloroquine 17 Labetalol ...... 10 Glipizide ...... 15 Hydroxyzine HCL . . . . 12 Lamotrigine 12 Glipizide ER ...... 15 Hydroxyzine Pamoate . . . 12 Lansoprazole 30 mg 16 Glipizide XL ...... 15 Hysingla ER ...... 19 Lantus SoloStar . . . . 15 Glumetza ...... 15 Lantus Vial 15 Glyburide ...... 15 I Latanoprost 16 Gonal-f 17 Latuda ...... 12 Gonal-f RFF ...... 17 Ibuprofen ...... 19 Leflunomide 17 Gralise ...... 19 Incruse Ellipta . . . . . 20 Letairis 11 Granix ...... 18 Indomethacin Cap . . . .19 Letrozole ...... 9 Guaifenesin/Codeine Syrup . 18 Insulin Pen Needle . . . 14 Levemir FlexTouch 15 Guanfacine ER Tab . . . .11 Insulin Syringe/Needle 14 Levemir Vial ...... 15 Guanfacine Tab . . . . . 10 Invokamet ...... 15 Levetiracetam 12 Gynazole-1 Vaginal Cream . 22 Invokamet XR . . . . . 15 Levitra ...... 18 Invokana 15 Levofloxacin Tab 9 H Ipratropium/Albuterol Levora 28 ...... 21 Nebulizer Solution 20 Levothyroxine 16 Harvoni ...... 9 Ipratropium Spray 20 Lialda 17 H.P. Acthar 15 Irbesartan 10 Lidocaine Patch 5% 19 Humalog Mix 50/50 Isentress ...... 17 Lidocaine Topical Ointment, Vial and KwikPen . . 15 Isosorbide Mononitrate . . 11 Solution 13 Humalog Mix 75-25 Isosorbide Mononitrate ER . 11 Lidocaine Viscous Vial and KwikPen . . 15 Solution 2% 18 Humalog U-100 Vial J Linzess ...... 17 and KwikPen 15 Liothyronine ...... 16 Humalog U-200 KwikPen . 15 Janumet ...... 15 Lisinopril ...... 10 Humira Kit 17 Janumet XR ...... 15 Lisinopril/HCTZ . . . . . 10 Humira Pen Kit . . . . 17 Januvia 15 Livalo 10 Humira Pen Kit Crohns . . 17 Jardiance 15 Lo Loestrin 21 Humira Pen Kit Psoriasis . 17 Jentadueto 15 Lomedia Fe ...... 21 Humulin 70-30 Vial Jentadueto XR 15 Lorazepam Tab . . . . . 12 and KwikPen 15 Jolivette 21 Loryna ...... 21 Humulin N Vial Junel ...... 21 Lorzone ...... 19 and KwikPen 15 Losartan 10 Humulin R U-500 Vial and K Losartan/HCTZ . . . . . 10 KwikPen ...... 15 Lovastatin ...... 10 Humulin R Vial 15 Kariva 21 Low-Ogestrel ...... 21 Hydralazine ...... 10 Ketoconazole Ludent ...... 21 Hydrochlorothiazide 10 Cream/Shampoo . . . 13 Lumigan ...... 16 Hydrocodone/Acetaminophen 19 Ketorolac Lupron Depot 15 Hydrocodone/ Ophthalmic Solution 16 Chlorpheniramine Liquid 18

Bold type = Brand-name drug [Plain type = Generic drug] 25 Index of Covered Drugs

Lutera 21 Morphine Sulfate Tab . . . 19 Nutropin AQ 15 Lyrica Cap ...... 12 Moxeza ...... 16 Nuvaring 21 Multaq 11 Nystatin Cream, M Mupirocin Ointment . . . 13 Ointment, Powder 13 Mycophenolate Nystatin Suspension 9 Makena ...... 18 Mofetil 250 mg Cap/ Mavyret 9 500 mg Tab . . . . . 20 O Medroxyprogesterone Mycophenolate Acetate Injection . . . 21 Sodium 180 mg, Ocella 21 Medroxyprogesterone 360 mg Tab . . . . . 20 Odefsey ...... 9 Acetate Tab . . . . . 22 Myorisan ...... 13 Ofloxacin Ophthalmic Solution 16 Meloxicam ...... 19 Myrbetriq ...... 19 Ofloxacin Otic Solution . . . 9 Mercaptopurine 9 Olanzapine Tab . . . . . 12 Metaxalone ...... 19 N Olmesartan ...... 10 Metformin ...... 15 Olmesartan/HCTZ . . . . 10 Metformin ER 15 Nabumetone ...... 19 Omega-3 Acid Cap . . . .10 Methadone Tab . . . . . 19 Nadolol ...... 10 Omeprazole 16 Methimazole ...... 16 Namenda XR 12 Omnaris ...... 20 Methocarbamol 19 Namzaric 12 Omnitrope 15 Methotrexate Tab . . . . 17 Naproxen ...... 19 Ondansetron ODT 17 Methylphenidate ER Cap . .11 Narcan ...... 18 Ondansetron Tab . . . . 17 Methylphenidate ER Tab 11 Natazia 21 OneTouch Ultra 2 System 14 Methylphenidate SA Necon 21 OneTouch UltraMini Osmotic ER Tab . . . .11 Neupogen ...... 18 System Kit . . . . . 14 Methylphenidate Tab . . . 11 Niacin ER Tab ...... 10 OneTouch Ultra Test Strips . 14 Methylprednisolone Tab 15 Nifedipine ER ...... 10 OneTouch Verio Metoclopramide . . . . 17 Nitrofurantoin Macrocrystalline .9 Flex System Kit . . . 14 Metoprolol Succinate . . . 10 Nitrofurantoin Monohydrate OneTouch Verio IQ Metoprolol Tartrate . . . .10 Macrocrystalline 9 System Kit . . . . . 14 Metrogel 13 Nitroglycerin SL Tab . . . .11 OneTouch Verio Metronidazole Gel 0.75% 13 Nora-Be 21 Sync System Kit . . . 14 Metronidazole Tab . . . . 9 Norditropin ...... 15 OneTouch Verio System Kit . 14 Metronidazole Vaginal Gel . 22 Norgest/Ethi Estradio . . . 21 OneTouch Verio Test Strips . 14 Microgestin ...... 21 Nortrel ...... 21 Onexton ...... 13 Microgestin Fe . . . . . 21 Nortriptyline 11 Opsumit ...... 11 Migranal 12 Norvir ...... 17 Oracea ...... 9 Minivelle 22 Novofine Autocover Orencia SC 17 Minocycline Cap . . . . . 9 Pen Needle 14 Orenitram ...... 11 Mirtazapine 11 Novofine Pen Needle . . 14 Orsythia 21 Mirvaso Gel ...... 13 Novolin 70/30 Vial 15 Ortho Tri-Cyclen Lo . . . 21 Misoprostol ...... 16 Novolin N Vial 15 Oseltamivir ...... 9 Modafinil ...... 12 Novolin R Vial . . . . . 15 Osphena ...... 22 Mometasone ...... 20 Novolog Flexpen . . . .15 Otezla ...... 17 Mono-Linyah ...... 21 Novolog Mix 70/30 Ovidrel 17 Mononessa ...... 21 Vial and Flexpen 15 Oxcarbazepine . . . . . 12 Montelukast ...... 20 Novolog Penfill . . . . 15 Oxsoralen-UL . . . . . 13 Morphine Sulfate ER . . . 19 Novolog Vial 15 Oxybutynin 19 Novotwist Pen Needle . .14 Oxybutynin ER . . . . . 19

Bold type = Brand-name drug [Plain type = Generic drug] 26 Index of Covered Drugs

Oxycodone Tab . . . . . 19 Promethazine DM Syrup . .18 Simponi Aria 17 Oxycodone w/Acetaminophen 19 Promethazine Tab 20 Simvastatin ...... 11 Oxycontin ...... 19 Propranolol ...... 10 Soliqua 15 Propranolol ER . . . . . 10 Solodyn ...... 9 P Pulmicort Flexhaler . . . 20 Soolantra ...... 13 Pylera ...... 17 Sotalol ...... 11 Pantoprazole ...... 16 Spiriva Handihaler . . . 20 Paroxetine Tab . . . . . 11 Q Spiriva Respimat . . . .20 Pataday ...... 16 Spironolactone . . . . . 10 Pazeo 16 QNasl 20 Sprintec 28 ...... 21 Penicillin VK 9 Quetiapine ...... 12 Sprycel 9 Pentasa ...... 17 Quinapril ...... 10 Stelara ...... 17 Permethrin Cream 5% . . 13 Qvar ...... 20 Stendra ...... 18 Phenazopyridine . . . . 18 Stiolto ...... 20 Phentermine Tab . . . . 18 R Strattera ...... 11 Pioglitazone 15 Stribild 17 Rabeprazole 16 Polymyxin B/Trimethoprim Suboxone Film 18 Ramipril 10 Solution 16 Sucralfate Tab 16 Ranexa 11 Potassium Chloride ER . . 21 Sulfamethoxazole-Trimethoprim .9 Ranitidine 16 Potassium Chloride Sulfamethoxazole-Trimethoprim Rapaflo 18 Micro ER Tab . . . . 21 DS 9 Rasuvo 17 Pradaxa ...... 10 Sumatriptan Tab and Spray . 12 Reclipsen ...... 21 Praluent ...... 11 Sumavel Dose . . . . . 12 Relpax ...... 12 Pramipexole 12 Suprep Bowel Prep . . . 17 Remicade ...... 17 Pravastatin ...... 11 Symbicort ...... 20 Renvela Tab ...... 18 Prazosin 10 Synjardy ...... 15 Restasis ...... 16 Precision Test Strips 14 Synthroid ...... 16 Restasis Multidose . . . 16 Prednisolone Ophthalmic Synvisc 18 Retin-A Micro gel . . . .13 Suspension . . . . . 16 Synvisc One ...... 18 Prednisolone Solution 15 Revlimid ...... 9 Rexulti ...... 11 Prednisolone Syrup . . . .15 T Prednisone ...... 15 Reyataz ...... 17 Premarin Tab 22 Rezira ...... 18 Taclonex ...... 13 Premarin Vaginal Cream . 22 Risperidone Tab . . . .11, 12 Tacrolimus Cap . . . . . 20 Premphase 22 Rizatriptan Tab, ODT . . . 12 Tamiflu 9 Prempro ...... 22 Ropinirole 12 Tamoxifen Tab 9 Prepopik ...... 17 Rosuvastatin ...... 11 Tamsulosin ...... 18 Previfem ...... 21 Tazorac 13 Prezcobix ...... 17 S Tecfidera 12 Prezista ...... 17 Tekturna ...... 10 Saphris 12 Pristiq ...... 11 Tekturna HCT ...... 10 Savaysa ...... 10 Proair HFA, RespiClick 20 Telmisartan ...... 10 Serevent Diskus . . . . 20 Procrit ...... 18 Temazepam 12 Sertraline ...... 11 Proctofoam HC . . . . 13 Terazosin ...... 10, 18 Sildenafil Tab 20 mg 11 Progesterone Cap 22 Terbinafine Tab . . . . . 9 Silenor ...... 12 Prograf Cap ...... 20 Terconazole Vaginal Cream . 22 Simbrinza ...... 16 Promethazine ...... 18 Testosterone Cypionate IM Simponi ...... 17 Promethazine/Codeine Syrup 18 Injection 18

Bold type = Brand-name drug [Plain type = Generic drug] 27 Index of Covered Drugs

Tirosint 16 Venlafaxine ER Cap . . . .11 Zontivity 10 Tivicay ...... 17 Venlafaxine ER Tab . . . .11 Zorvolex ...... 19 Tizanidine Cap . . . . . 19 Venlafaxine Tab . . . . . 11 Zovirax Cream 13 Tizanidine Tab 19 Ventolin HFA . . . . . 20 Zovirax Ointment . . . .13 Tobramycin ...... 16 Verapamil ER ...... 10 Zubsolv ...... 18 Tobramycin/Dexamethasone 16 Vesicare ...... 19 Zurampic 18 Topiramate Tab . . . . . 12 Vestura ...... 21 Zutripro ...... 18 Torsemide Tab 10 Viagra ...... 18 Zyclara ...... 13 Toujeo SoloStar . . . . 15 Victoza 15 Zytiga ...... 9 Toviaz ...... 19 Vigamox ...... 16 Tracleer ...... 11 Viibryd 11 Tradjenta 15 Vimpat 12 Tramadol Tab 50 mg . . . 19 Viorele ...... 21 Tramadol w/ Acetaminophen . 19 Viread ...... 17 Travatan Z ...... 16 Vitamin D Trazodone 11 Vytorin 11 Tresiba ...... 15 Vyvanse ...... 11 Tretinoin Cream 13 Tretinoin Microsphere Gel 13 W Triamcinolone 13 Triamterene/HCTZ 10 Warfarin ...... 10 Triazolam Tab ...... 12 Welchol ...... 11 Tri-Linyah ...... 21 Tri-Lo Sprintec 21 X Trinessa ...... 21 Xarelto 10 Trintellix ...... 11 Xeljanz 17 Tri-Previfem ...... 21 Xiidra 16 Tri-Sprintec ...... 21 Xolair 20 Triumeq ...... 17 Xulane ...... 21 Trulicity ...... 15 Xyrem ...... 12 Truvada ...... 17 Tymlos ...... 19 Y U Yuvafem ...... 22 Uceris Foam ...... 17 Uloric 18 Z Zaleplon 12 V Zarah ...... 21 Zarxio ...... 18 Valacyclovir ...... 9 Zenpep ...... 17 Valsartan ...... 10 Zepatier ...... 9 Valsartan/HCTZ . . . . . 10 Zetonna ...... 20 Varubi ...... 17 Zohydro ER ...... 19 Vascepa ...... 11 Zolpidem ...... 12 Vectical 13 Zolpidem ER 12 Velphoro 18 Zonisamide ...... 12

Bold type = Brand-name drug [Plain type = Generic drug] 28 “My Medications” worksheet Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well.

Name of Medicine Drug I Take This Directions Doctor and Strength Tier Medicine For

Example: Lisinopril, 20 mg Tier 1 High blood pressure One tablet daily Dr. Johnson

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نفلت هرامش اب افطل .دشاب یم امش رایتخا رد ناگیار روط هب ینابز دادما تامدخ ،تسا (Farsi) یسراف امش نابز رگا :هجوت .ديريگب سامت هدش دیق امش یياسانش تراک یور هک یناگیار

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Your pharmacy benefit plan’s quantity limits program protects you and can help you get the best results from your medication therapy. Along with supporting safe and appropriate dosing, quantity limits can also keep prescription drug costs lower for you and your benefit plan sponsor.

Determining quantity limits Quantity limits are meant to minimize the risk of over-dosing and unwanted drug interactions. Quantity limit rules are based on: • Food and Drug Administration (FDA) approved indications • Manufacturer’s package labeling instructions • Well-accepted or published clinical recommendations

Establishing guidelines for use Our review committee of independent doctors and pharmacists meets regularly to review medications and consider how they should be covered by pharmacy benefit plans. They also recommend quantity limit guidelines. Core and Select Non-Specialty Quantity Limit THERAPY CLASS MEDICATION NAME LIMIT Anti-infectives Antibiotics SIVEXTRO (tedizolid) Soln 6 vials/30 days SIVEXTRO (tedizolid) Tabs 6 tabs/30 days ZYVOX (linezolid) 28 tabs/30 days ZYVOX (linezolid) Suspension 6 bottles (900 mL)/28 days Antifungals LAMISIL (terbinafine) 250 mg 84 days supply/180 days Antivirals, Herpetic SITAVIG (acyclovir) 50 mg 2 tabs/30 days VALTREX (valacyclovir) 4 tabs/day Antivirals, Influenza RELENZA (zanamivir) 40 inh/365 days TAMIFLU (oseltamivir) 30 mg 40 caps/365 days TAMIFLU (oseltamivir) 45 mg, 75 mg 20 caps/365 days TAMIFLU (oseltamivir) Suspension 360 mL/365 days Cardiology Anticoagulants ELIQUIS (apixiban) 2 tabs/day ELIQUIS (apixiban) 5 mg 3 tabs/day PRADAXA (dabigatran) 2 caps/day SAVAYSA (edoxaban) 1 tab/day XARELTO (rivaroxaban) 1 tab/day XARELTO (rivaroxaban) 15 mg 2 tabs/day XARELTO (rivaroxaban) Starter Pack 1 pack/30 days Heart Failure CORLANOR (ivabradine) 2 tabs/day ENTRESTO (sacubitril/valsartan) 2 tabs/day Platelet Inhibitors YOSPRALA (aspirin-omeprazole) 1 tab/day Central Nervous System ADHD Agents ADDERALL (amphetamine/ 3 tabs/day dextroamphetamine) ADDERALL XR (amphetamine/ 1 cap/day dextroamphetamine mixed salts) ADZENYS XR-ODT (amphetamine) 1 tab/day APTENSIO XR (methylphenidate) 1 cap/day CONCERTA (methylphenidate) 36 mg 2 tabs/day CONCERTA (methylphenidate) 1 tab/day COTEMPLA XR-ODT (methylphenidate) 6 tabs/day 8.6 mg COTEMPLA XR-ODT (methylphenidate) 3 tabs/day 17.3 mg COTEMPLA XR-ODT (methylphenidate) 2 tabs/day 25.9 mg

2 OptumRx | optumrx.com THERAPY CLASS MEDICATION NAME LIMIT ADHD Agents (cont.) DAYTRANA (methylphenidate 1 patch/day transdermal) DESOXYN (methamphetamine) 5 tabs/day DEXEDRINE (dextroamphetamine) 5 mg 3 caps/day DEXEDRINE (dextroamphetamine) 15 mg 4 caps/day DEXEDRINE (dextroamphetamine) 10 mg 6 caps/day DYANAVEL XR (amphetamine) 8 mL/day EVEKEO (amphetamine) 6 tabs/day FOCALIN (dexmethylphenidate) 2 tabs/day FOCALIN XR (dexmethylphenidate) 20 mg 2 caps/day FOCALIN XR (dexmethylphenidate) 1 cap/day METADATE CD (methylphenidate) 1 cap/day METADATE ER (methylphenidate) 20 mg 3 tabs/day METHYLIN (methylphenidate) 3 tabs/day METHYLIN 10 mg/5 mL 30 mL/day (methylphenidate) Soln METHYLIN 5 mg/5 mL (methylphenidate) 60 mL/day Soln METHYLIN CHEW TAB (methylphenidate) 3 tabs/day METHYLIN CHEW TAB (methylphenidate) 6 tabs/day 10 mg METHYLPHENIDATE ER 10 mg 2 tabs/day MYDAYIS (amphetamine/ 1 cap/day dextroamphetamine) PROCENTRA (dextroamphetamine) Sol 60 mL/day QUILLICHEW ER (methylphenidate) 2 tabs/day 30 mg QUILLICHEW ER (methylphenidate) 1 tab/day QUILLIVANT XR (methylphenidate) 12 mL/day RITALIN (methylphenidate) 3 tabs/day RITALIN LA (methylphenidate) 1 cap/day RITALIN SR (methylphenidate) 20 mg 3 tabs/day STRATTERA (atomoxetine) 1 cap/day STRATTERA (atomoxetine) 10 mg, 40 mg 2 caps/day VYVANSE (lisdexamfetamine) 1 cap/day VYVANSE CHEW TAB (lisdexamfetamine) 1 tab/day ZENZEDI (dextroamphetamine) 10 mg 6 tabs/day ZENZEDI (dextroamphetamine) 3 tabs/day ZENZEDI (dextroamphetamine) 30 mg 2 tabs/day

3 THERAPY CLASS MEDICATION NAME LIMIT Alzheimers Agents NAMENDA XR (memantine hcl) caps 1 cap/day NAMENDA XR TITRATION PACK 1 cap/day (memantine hcl) caps NAMZARIC (memantine hcl) caps 1 cap/ day NAMZARIC TITRATION PACK 2 packs/365 days (memantine hcl) Analgesics (non-opioid) CELEBREX (celecoxib) 2 caps/day DUEXIS (naproxen/esomeprazole) 3 tabs/day FLECTOR (diclofenac epolamine) 2 patches/day up to 15 days Ketorolac (ketorolac) 20 tabs or 5 days supply/30 days QUTENZA (capsaicin) 4 patches/3 months SPRIX (ketorolac) 5 bottles or 5 days supply/30 days VIMOVO (naproxen/esomeprazole) 2 tabs/day VOLTAREN (diclofenac) Gel 10 tubes/month Analgesics (opioid) ABSTRAL (fentanyl citrate) 4 tabs/day acetaminophen/codeine soln 120-12 136 mL/day up to 7 days for mg/5 mL treatment naive, 166.5 mL/day for treatment experienced acetaminophen/codeine tab 300-15 13 tabs/day up to 7 days for treatment naïve, 13 tabs/day for treatment experienced ACTIQ (fentanyl citrate) 4 lozenges/day ARYMO ER (morphine sulfate) 3 tabs/day AVINZA (morphine ext-release) 1 cap/day AVINZA (morphine ext-release) 120 mg 2 caps/day BELBUCA (buprenorphine) film 2 films/day BUNAVAIL (buprenorphrine/naloxone) 6 films/day 2.1-0.3 mg BUNAVAIL (buprenorphrine/naloxone) 2 films/day 6.3-1 mg BUNAVAIL (buprenorphrine/naloxone) 3 films/day 4.2-0.7 mg BUTRANS (buprenorphine) 4 patches/28 days CAPITAL/codeine susp 120-12mg /5 mL 136 mL/day up to 7 days for treatment naive, 166.5 mL/day for treatment experienced codeine tab 15 mg 21 tabs/day up to 7 days for treatment naïve, 40 tabs/day for treatment experienced

4 OptumRx | optumrx.com THERAPY CLASS MEDICATION NAME LIMIT Analgesics (opioid) codeine tab 30 mg 10 tabs/day up to 7 days for (cont.) treatment naïve, 20 tabs/day for treatment experienced codeine tab 60 mg 5 tabs/day up to 7 days for treatment naïve, 10 tabs/day for treatment experienced CONZIP (tramadol SR) 1 cap/day DEMEROL (meperidine) tab 100 mg 4 tabs/day up to 7 days for treatment naïve, 9 tabs/day for treatment experienced DEMEROL (meperidine) tab 50 mg 9 tabs/day up to 7 days for treatment naïve, 18 tabs/day for treatment experienced DILAUDID (hydromorphone) liq 1 mg/mL 12.25 mL/day up to 7 days for treatment naive, 22.5 mL/day for treatment experienced DILAUDID (hydromorphone) tab 2 mg 6 tabs/day up to 7 days for treatment naïve, 11 tabs/day for treatment experienced DILAUDID (hydromorphone) tab 4 mg 3 tabs/day up to 7 days for treatment naïve, 5 tabs/day for treatment experienced DILAUDID (hydromorphone) tab 8 mg 1 tabs/day up to 7 days for treatment naïve, 2 tabs/day for treatment experienced DURAGESIC (fentanyl transdermal) 15 patches/30 days DURAGESIC (fentanyl transdermal) 75 30 patches/30 days mcg/hr, 100 mcg/hr EMBEDA (morphine/naltrexone) 2 caps/day EXALGO (hydromorphone) 2 tabs/day FENTORA (fentanyl citrate) 4 tabs/day HYCET (hydrocodone/acetaminophen) sol 98 mL/day up to 7 days for 7.5-325 mg/15 mL treatment naive, 180 mL/day for treatment experienced hydromorphone supp 3 mg 4 supps/day up to 7 days for treatment naïve, 7 supps/day for treatment experienced HYSINGLA ER (hydrocodone bitartrate) 1 tab/day KADIAN (morphine ext-release) 2 caps/day LAZANDA (fentanyl citrate) 1 bottle/day

5 THERAPY CLASS MEDICATION NAME LIMIT Analgesics (opioid) LORTAB (hydrocodone/acetaminophen) 73.5 mL/day up to 7 days for (cont.) elx 10-300 mg/15 mL treatment naïve, 135 mL/day for treatment experienced meperidine/promethazine cap 50-25 mg 9 caps/day up to 7 days for treatment naïve, 18 caps/day for treatment experienced mepridine sol 50 mg/5 mL 49 mL/day up to 7 days for treatment naïve, 90 mL/day for treatment experienced MORPHABOND ER (morphine ext-release) 2 tabs/day morphine sol 10 mg/5 mL 24.5 mL/day up to 7 days for treatment naïve, 45 mL/day for treatment experienced morphine sol 20 mg/5 mL 12.25 mL/day up to 7 days for treatment naïve, 22.5 mL/day for treatment experienced morphine sol 20 mg/mL 2.4 mL/day up to 7 days for treatment naïve, 4.5 mL/day for treatment experienced morphine supp 10 mg 4 supps/day up to 7 days for treatment naïve, 9 supps/day for treatment experienced morphine supp 20 mg 2 supps/day up to 7 days for treatment naïve, 4 supps/day for treatment experienced morphine supp 30 mg 1 supps/day up to 7 days for treatment naïve, 3 supps/day for treatment experienced morphine supp 5 mg 9 supps/day up to 7 days for treatment naïve, 18 supps/day for treatment experienced morphine tab 15 mg 3 tabs/day up to 7 days for treatment naïve, 6 tabs/day for treatment experienced morphine tab 30 mg 1 tab/day up to 7 days for treatment naïve, 3 tabs/day for treatment experienced MS CONTIN (morphine ext-release) 3 tabs/day NORCO (hydrocodone/acetaminophen) 4 tabs/day up to 7 days for tab 10-325 mg treatment naïve, 9 tabs/day for treatment experienced

6 OptumRx | optumrx.com THERAPY CLASS MEDICATION NAME LIMIT Analgesics (opioid) NORCO (hydrocodone/acetaminophen) 9 tabs/day up to 7 days for (cont.) tab 5-325 mg treatment naïve, 12 tabs/day for treatment experienced NORCO (hydrocodone/acetaminophen) 6 tabs/day up to 7 days for tab 7.5-325 mg treatment naïve, 12 tabs/day for treatment experienced NUCYNTA (tapentadol) tab 100 mg 1 tab/day up to 7 days for treatment naïve, 2 tabs/day for treatment experienced NUCYNTA (tapentadol) tab 50 mg 2 tabs/day up to 7 days for treatment naïve, 4 tabs/day for treatment experienced NUCYNTA (tapentadol) tab 75 mg 1 tab/day up to 7 days for treatment naïve, 3 tabs/day for treatment experienced NUCYNTA ER (tapentadol) 2 tabs/day OPANA (oxymorphone) tab 10 mg 1 tab/day up to 7 days for treatment naïve, 3 tabs/day for treatment experienced OPANA (oxymorphone) tab 5 mg 3 tabs/day up to 7 days for treatment naïve, 6 tabs/day for treatment experienced OPANA ER (oxymorphone ext-release) 4 tabs/day OXAYDO (oxycodone) tab 5 mg 6 tabs/day up to 7 days for treatment naïve, 12 tabs/day for treatment experienced OXAYDO (oxycodone) tab 7.5 mg 4 tabs/day up to 7 days for treatment naïve, 8 tabs/day for treatment experienced oxycodone/aspirin tab 6 tabs/day up to 7 days for treatment naïve, 12 tabs/day for treatment experienced oxycodone/ibuprofen tab 5-400 mg 6 tabs/day up to 7 days for treatment naïve, 8 tabs/day for treatment experienced oxycodone cap 5 mg 6 caps/day up to 7 days for treatment naïve, 12 caps/day for treatment experienced oxycodone conc 20 mg/mL 1.6 mL/day up to 7 days for treatment naïve, 3 mL/day for treatment experienced

7 THERAPY CLASS MEDICATION NAME LIMIT Analgesics (opioid) oxycodone sol 5 mg/5 mL 32.6 mL/day up to 7 days for (cont.) treatment naïve, 60 mL/day for treatment experienced oxycodone tab 10 mg 3 tabs/day up to 7 days for treatment naïve, 6 tabs/day for treatment experienced oxycodone tab 20 mg 1 tab/day up to 7 days for treatment naïve, 3 tabs/day for treatment experienced oxycodone/acetaminophen sol 5-325 32.6 mL/day up to 7 days for mg/5 mL treatment naïve, 60 mL/day for treatment experienced OXYCONTIN (oxycodone ext-release) 4 tabs/day pentazocine/naloxone tab 50-0.5 mg 5 tabs/day up to 7 days for treatment naïve, 10 tabs/day for treatment experienced PERCOCET (oxycodone/acetaminophen) 3 tabs/day up to 7 days for tab 10-325 mg treatment naïve, 6 tabs/day for treatment experienced PERCOCET (oxycodone/acetaminophen) 12 tabs/day up to 7 days for tab 2.5-325 mg treatment naïve, 12 tabs/day for treatment experienced PERCOCET (oxycodone/acetaminophen) 6 tabs/day up to 7 days for tab 5-325 mg treatment naïve, 12 tabs/day for treatment experienced PERCOCET (oxycodone/acetaminophen) 4 tabs/day up to 7 days for tab 7.5-325 mg treatment naïve, 8 tabs/day for treatment experienced PRIMLEV (oxycodone/acetaminophen) tab 3 tabs/day up to 7 days for 10-300 mg treatment naïve, 6 tabs/day for treatment experienced PRIMLEV (oxycodone/acetaminophen) tab 6 tabs/day up to 7 days for 5-300 mg treatment naïve, 12 tabs/day for treatment experienced PRIMLEV (oxycodone/acetaminophen) tab 4 tabs/day up to 7 days for 7.5-300 mg treatment naïve, 8 tabs/day for treatment experienced REPREXAIN (hydrocodone/ibuprofen) tab 4 tabs/day up to 7 days for 10-200 mg treatment naïve, 9 tabs/day for treatment experienced

8 OptumRx | optumrx.com THERAPY CLASS MEDICATION NAME LIMIT Analgesics (opioid) REPREXAIN (hydrocodone/ibuprofen) tab 9 tabs/day up to 7 days for (cont.) 5-200 mg treatment naïve, 16 tabs/day for treatment experienced ROXICODONE (oxycodone) tab 15 mg 2 tabs/day up to 7 days for treatment naïve, 4 tabs/day for treatment experienced ROXICODONE (oxycodone) tab 30 mg 1 tab/day up to 7 days for treatment naïve, 2 tabs/day for treatment experienced ROXICODONE (oxycodone) tab 5 mg 6 tabs/day up to 7 days for treatment naïve, 12 tabs/day for treatment experienced SUBOXONE (buprenorphrine/naloxone) 3 tabs or films/day 8-2 mg SUBOXONE (buprenorphrine/naloxone) 2 films/day 12-3 mg SUBOXONE (buprenorphrine/naloxone) 6 films/day 4-1 mg SUBOXONE (buprenorphrine/naloxone) 12 tabs or films/day 2-0.5 mg SUBSYS (fentanyl) 16 sprays/day SUBUTEX (buprenorphrine) 8 mg 3 tabs/day SUBUTEX (buprenorphrine) 2 mg 12 tabs/day SYNALGOS-DC (aspirin/caffeine/ 11 caps/day up to 7 days for dihydrocodeine) cap treatment naïve, 11 caps/day for treatment experienced TREZIX (acetaminophen/caffeine/ 12 caps/day up to 7 days for dihydrocodeine) cap treatment naïve, 12 caps/day for treatment experienced TYLENOL (acetaminophen)/codeine #3 10 tabs/day up to 7 days for treatment naïve, 13 tabs/day for treatment experienced TYLENOL (acetaminophen)/codeine #4 5 tabs/day up to 7 days for treatment naïve, 10 tabs/day for treatment experienced ULTRAM ER (tramadol ext-release) 1 tab/day VERDROCET (hydrocodone/ 12 tabs/day up to 7 days for acetaminophen) tab 2.5-325 mg treatment naïve, 12 tabs/day for treatment experienced

9 THERAPY CLASS MEDICATION NAME LIMIT Analgesics (opioid) VICODIN (hydrocodone/acetaminophen) 9 tabs/day up to 7 days for (cont.) tab 5-300 mg treatment naïve, 13 tabs/day for treatment experienced VICODIN ES (hydrocodone/ 6 tabs/day up to 7 days for acetaminophen) tab 7.5-300 mg treatment naïve, 12 tabs/day for treatment experienced VICODIN HP (hydrocodone/ 4 tabs/day up to 7 days for acetaminophen) tab 10-300 mg treatment naïve, 9 tabs/day for treatment experienced VICOPROFEN (hydrocodone/ibuprofen) 6 tabs/day up to 7 days for tab 7.5-200 mg treatment naïve, 12 tabs/day for treatment experienced XTAMPZA ER (oxycodone) 4 caps/day ZAMICET (hydrocodone/acetaminophen) 73.5 mL/day up to 7 days for sol 10-325 mg/15 mL treatment naïve, 135 mL/day for treatment experienced ZOHYDRO ER (hydrocodone) 2 caps/day ZOHYDRO ER (hydrocodone) 50 mg 4 caps/day ZUBSOLV (buprenorphine/naloxone) SL 3 tabs/day Tab 0.7-0.18 MG ZUBSOLV (buprenorphine/naloxone) SL 3 tabs/day Tab 5.7-1.4 MG ZUBSOLV (buprenorphine/naloxone) SL 2 tabs/day Tab 8.6/2.1 MG ZUBSOLV (buprenorphine/naloxone) SL 1 tab/day Tab 11.4/2.9 MG ZUBSOLV (buprenorphine/naloxone) SL 6 tabs/day Tab 2.9/0.71 MG ZUBSOLV (buprenorphine/naloxone) SL 12 tabs/day Tab 1.4-0.36 MG Anticonvulsants DIASTAT GEL (diazepam) 2 boxes/fill GRALISE (gabapentin) 300 mg 6 tabs/day GRALISE (gabapentin) 600 mg 3 tabs/day GRALISE (gabapentin) Pack 1 kit/fill (78 tabs per fill) HORIZANT (gabapentin enacarbil) 2 tabs/day LYRICA (pregabalin) 300 mg 2 caps/day LYRICA (pregabalin) caps 3 caps/day LYRICA (pregabalin) Soln 900 mL/30 days Antidepressants APLENZIN (bupropion) 1 tab/day CYMBALTA (duloxetine) 2 caps/day

10 OptumRx | optumrx.com THERAPY CLASS MEDICATION NAME LIMIT Antidepressants (cont.) CYMBALTA (duloxetine) 30 mg 3 caps/day desvenlafaxine fumarate 1 tab/day EMSAM (selegiline) 1 patch/day FETZIMA (levomilnacipran) 1 cap/day FETZIMA (levomilnacipran) Pack 1 pack (28 caps)/year FORFIVO XL (bupropion) 450 mg 1 tab/day IRENKA (duloxetine) 2 caps/day KHEDEZLA (desvenlafaxine ER) 1 tab/day KHEDEZLA (desvenlafaxine ER) 100 mg 4 tabs/day LUVOX CR (fluvoxamine) 2 caps/day OLEPTRO (trazodone) 1 tab/day PEXEVA (paroxetine) 1 tab/day PEXEVA (paroxetine) 30 mg 2 tabs/day PRISTIQ (desvenlafaxine) 1 tab/day PRISTIQ (desvenlafaxine) 100 mg 4 tabs/day PROZAC WEEKLY (fluoxetine) 4 caps/28 days TRINTELLIX (vortioxetine) 1 tab/day VIIBRYD (vilazodone) 1 tab/day VIIBRYD (vilazodone) Kit 1 kit (30 tabs)/ fill WELLBUTRIN SR (bupropion) 3 tabs/day WELLBUTRIN XL (bupropion) 1 tab/day WELLBUTRIN XL (bupropion) 150 mg 3 tabs/day Antipsychotics ABILIFY (aripiprazole) tabs 1 tab/day ABILIFY DISCMELT (aripiprazole) 2 tabs/day ABILIFY SOLN (aripiprazole) 1 mg/mL 25 mL/day CLOZARIL (clozapine) 100 mg 9 tabs/day CLOZARIL (clozapine) 200 mg 4 tabs/day CLOZARIL (clozapine) 25 mg 9 tabs/day CLOZARIL (clozapine) 50 mg 6 tabs/day FANAPT (iloperidone) 2 tabs/day FANAPT PAK (iloperidone) 1 pack/180 days FAZACLO (clozapine) 100 mg 9 tabs/day FAZACLO (clozapine) 12.5 mg 3 tabs/day FAZACLO (clozapine) 150 mg 6 tabs/day FAZACLO (clozapine) 200 mg 4 tabs/day FAZACLO (clozapine) 25 mg 9 tabs/day GEODON (ziprasidone) 2 caps/day INVEGA (paliperidone) 1 tab/day INVEGA (paliperidone) 6 mg 2 tabs/day

11 THERAPY CLASS MEDICATION NAME LIMIT Antipsychotics (cont.) LATUDA (lurasidone) 20 mg, 40 mg, 1 tab/day 60mg, 120 mg LATUDA (lurasidone) 80 mg 2 tabs/day REXULTI (brexpiprazole) 1 tab/day RISPERDAL (risperidone) 2 tabs/day RISPERDAL M (risperidone) 2 tabs/day RISPERDAL SOLN (risperidone) 8 mL/day SAPHRIS (asenapine) 2 tabs/day SEROQUEL (quetiapine) 300 mg, 400 mg 2 tabs/day SEROQUEL (quetiapine) 25 mg, 50 mg, 3 tabs/day 100 mg, 200 mg SEROQUEL XR (quetiapine) 2 tabs/day SEROQUEL XR (quetiapine) 200 mg 3 tabs/day SYMBYAX (olanzapine/fluoxetine) 1 cap/day SYMBYAX (olanzapine/fluoxetine) 3-25 3 caps/day mg SYMBYAX (olanzapine/fluoxetine) 6-25 3 caps/day mg VERSACLOZ (clozapine) 18 mL/day VRAYLAR (cariprazine) 1 cap/day VRAYLAR (cariprazine) pack 2 packs/365 days ZYPREXA (olanzapine) 1 tab/day ZYPREXA ZYDIS (olanzapine) 1 tab/day Benzodiazepines ALPRAZOLAM INTENSOL (alprazolam) 10 mL/day ALPRAZOLAM ODT (alprazolam) 4 tabs/day ALPRAZOLAM ODT (alprazolam) 2 mg 5 tabs/day ATIVAN (lorazepam) 3 tabs/day ATIVAN (lorazepam) 2 mg 5 tabs/day CHLORDIAZEP (chlordiazepoxide) 10 mg 30 caps/day CHLORDIAZEP (chlordiazepoxide) 25 mg 12 caps/day CHLORDIAZEP (chlordiazepoxide) 5 mg 4 caps/day CLONAZEP ODT (clonazepam) 3 tabs/day CLONAZEP ODT (clonazepam) 2 mg 10 tabs/day KLONOPIN (clonazepam) 3 tabs/day LORAZEPAM INTENSOL (lorazepam) 5 mL/day OXAZEPAM (oxazepam) 4 caps/day TRANXENE T (clorazepate) 15 mg 6 tabs/day TRANXENE T (clorazepate) 3.75 mg 24 tabs/day

12 OptumRx | optumrx.com THERAPY CLASS MEDICATION NAME LIMIT Benzodiazepines (cont.) TRANXENE T (clorazepate) 7.5 mg 12 tabs/day XANAX (alprazolam) 4 tabs/day XANAX (alprazolam) 2 mg 5 tabs/day XANAX XR (alprazolam) 1 tab/day XANAX XR (alprazolam) 2 mg 5 tabs/day XANAX XR (alprazolam) 3 mg 3 tabs/day Fibromyalgia SAVELLA (milnacipran) 2 tabs/day SAVELLA (milnacipran) Pack 1 pack (55 tabs)/year Hypoactive Sexual Desire ADDYI (flibanserin) 1 tab/day Disorder Migraine ALSUMA (sumatriptan) 5 packages (10 syringes)/30 days AMERGE (naratriptan) 9 tabs/30 days AXERT (almotriptan) 12 tabs/30 days FROVA (frovatriptan) 9 tabs/30 days IMITREX (sumatriptan) 9 tabs/30 days IMITREX (sumatriptan) AUTO-INJECTOR 4 5 kits (10 units)/30 days mg/0.5 mL & 6 mg/0.5 mL IMITREX (sumatriptan) CARTRIDGE 4 5 kits (10 units)/30 days mg/0.5 mL & 6 mg/0.5 mL IMITREX (sumatriptan) Nasal 12 spray unit devices/30 days IMITREX (sumatriptan) SYRINGE 4 mg/0.5 5 kits (10 units)/30 days mL & 6 mg/0.5 mL MAXALT (rizatriptan) 18 tabs/30 days MAXALT-MLT (rizatriptan) 18 tabs/30 days MIGRANAL (dihydroergotamine) 1 package (8 vials)/30 days ONZETRA XSAIL (sumatriptan) 1 kit (8 doses)/30 days RELPAX (eletriptan) 12 tabs/30 days SUMAVEL DOSEPRO (sumatriptan) 12 prefilled syringes/30 days TREXIMET (sumatriptan/naproxen) 9 tabs/30 days ZECUITY (sumatriptan) 4 systems (1 carton)/30 days ZEMBRACE SYMTOUCH (sumatriptan) 4 cartons (16 doses)/30 days ZOMIG (zolmitriptan) 9 tabs/30 days ZOMIG (zolmitriptan) 2.5 mg 12 tabs/30 days ZOMIG (zolmitriptan) Nasal 2 packages (12 spray units) /30 days ZOMIG ZMT (zolmitriptan) 9 tabs/30 days ZOMIG ZMT (zolmitriptan) 2.5 mg 12 tabs/30 days Miscellaneous RILUTEK (riluzole) 2 tabs/day Parkinson’s XADAGO (safinamide) 1 tab/day

13 THERAPY CLASS MEDICATION NAME LIMIT Sedative Hypnotics AMBIEN (zolpidem) 1 tab/day AMBIEN CR (zolpidem) 1 tab/day BELSOMRA (suvorexant) 1 tab/day DORAL (quazepam) 1 tab/day EDLUAR (zolpidem) 1 tab/day ESTAZOLAM (estazolam) 1 tab/day FLURAZEPAM (flurazepam) 1 cap/day HALCION (triazolam) 2 tabs/day INTERMEZZO (zolpidem) 1 tab/day LUNESTA (eszopiclone) 1 tab/day RESTORIL (temazepam) 1 cap/day ROZEREM (ramelteon) 1 tab/day SILENOR (doxepin) 1 tab/day SONATA (zaleplon) 10 mg 2 cap/day SONATA (zaleplon) 5 mg 1 cap/day ZOLPIMIST (zolpidem) 1 bottle (7.7 g)/30 days Stimulants NUVIGIL (armodafinil) 1 tab/day NUVIGIL (armodafinil) 50 mg 2 tabs/day PROVIGIL (modafinil) 1 tab/day Dermatology Anti-Inflammatory SOLARAZE (diclofenac) GEL 300 gm/30 days Miscellaneous ENSTILAR (calcipotriene/betamethasone 420 g/28 days dipropionate) TACLONEX (calcipotriene/betamethasone) 400 g/30 days TACLONEX SCALP (calcipotriene/ 120 g/30 days betamethasone) Endocrinology & Metabolism Androgens, Anabolic OXANDRIN (oxandrolone) 10 mg 2 tabs/day Steroids OXANDRIN (oxandrolone) 2.5 mg 8 tabs/day Antidiabetic Agents ADLYXIN (lixisenatide) 2 pens (6 mL)/28 days ADLYXIN (lixisenatide) Starter Pack 2 starter kits (12 mL)/365 days BYDUREON (exenatide) 4 vials/pen-inj/28 days BYETTA (exenatide) 1 syringe/30 days SOLIQUA (insulin glargine/lixisenatide) 6 pens (18 mL)/30 days TANZEUM (albiglutide) 4 pen-inj/28 days TRULICITY (dulaglutide) 4 pen-inj/28 days VICTOZA (liraglutide) 3 pen-inj/ 30 days XULTOPHY (insulin degludec/liraglutide) 5 pens (15 mL)/30 days

14 OptumRx | optumrx.com THERAPY CLASS MEDICATION NAME LIMIT Osteoporosis ACTONEL (risedronate) tab 150 mg 1 tab/28 days ACTONEL (risedronate) tab 35 mg 4 tabs/28 days ATELVIA (risedronate) 4 tabs/28 days BINOSTO (alendronate) 4 tabs/28 days BONIVA (ibandronate) 1 tab/28 days BONIVA (ibandronate) inj 1 syringe/90 days FORTICAL (calcitonin) 1 bottle (3.7mL)/30 days FOSAMAX (alendronate) 35 mg & 70 mg 4 tabs/28 days FOSAMAX PLUS D (alendronate/ 4 tabs/28 days cholecalciferol) MIACALCIN (calcitonin) 1 bottle (3.7mL)/30 days Gastroenterology Antiemetics AKYNZEO (netupitant-palonosetron) 2 caps/30 days ANZEMET (dolasetron) 2 tabs/30 days CESAMET (nabilone) 20 tabs/fill or 3 max days DICLEGIS (doxylamine-pyridoxine) 4 tabs/day EMEND (aprepitant) caps 125 mg 2 caps/30 days EMEND (aprepitant) 125 mg/80 mg 2 packs (6 caps)/30 days EMEND (aprepitant) 40 mg 1 cap/30 days EMEND (aprepitant) 80 mg 4 caps/30 days EMEND (aprepitant) Susp 125 mg 3 packets/30 days GRANISOL (granisetron) 1 bottole (30 mL)/30 days KYTRIL (granisetron) 4 tabs/30 days MARINOL (dronabinol) 2 caps/day SANCUSO (granisetron) 2 patches/30 days SUSTOL (ganisetron) 3 syringes/30 days SYNDROS (dronabinol) 4 mL/day VARUBI (rolapitant) 4 tabs/30 days ZOFRAN (ondansetron) 120 mL/30 days ZOFRAN (ondansetron) 24 mg 2 tabs/30 days ZOFRAN ODT (ondansetron) 4 mg, 8 mg 15 tabs/30 days ZUPLENZ (ondansetron) 10 films/30 days Constipation AMITIZA (lubiprostone) 2 caps/day LINZESS (linaclotide) 1 cap/day Diarrhea FULYZAQ (crofelemer) 2 tabs/day MYTESI (crofelemer) 2 tabs/day Irritable Bowel Syndrome VIBERZI (eluxadoline) 2 tabs/day

15 THERAPY CLASS MEDICATION NAME LIMIT Opioid-induced MOVANTIK (naloxegol) 1 tab/day Constipation RELISTOR (methylnaltrexone) 1 syringe/day RELISTOR (methylnaltrexone) Kit 1 vial/day RELISTOR (methylnaltrexone) tab 3 tabs/day TRULANCE (plecanatide) 1 tab/day Proton Pump Inhibitors ACIPHEX (rabeprazole) 1 tab/day ACIPHEX SPRINKLE (rabeprazole) SPR 1 cap/day DEXILANT (dexlansoprazole) 1 cap/day esomeprazole strontium 1 cap/day NEXIUM (esomeprazole) Caps 1 cap/day NEXIUM (esomeprazole) Packs 1 packet/day PREVACID (lansoprazole) 1 cap/day PREVACID (lansoprazole) Solutab 1 tab/day PRILOSEC (omeprazole) 1 cap/day PRILOSEC PACKETS (omeprazole) 2 packets/day PROTONIX (pantoprazole) packets 1 packet/day PROTONIX (pantoprazole) tab 1 tab/day ZEGERID (omeprazole) caps 2 caps/day ZEGERID (omeprazole) packets 2 packets/day Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tab/day ORALAIR (mixed grass pollens allergen) 1 tab/day 300 IR ORALAIR ADULT SAMPLE KIT (mixed 1 kit/year grass pollens allergen) Kit ORALAIR ADULT STARTER PACK (mixed 1 pack/year grass pollens allergen) ORALAIR CHILDREN/ADOLESCENTS 2 packs/year (mixed grass pollens allergen) Starter Pack ORALAIR CHILDREN/ADOLESCENTS 2 kits/year (mixed grass pollens allergen) Sample Kit, RAGWITEK (short ragweed 1 tab/day pollen allergen) Miscellaneous Diabetic Supplies Glucose Test Strips 300/30 days Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors/28 days Injectors RASUVO (methotrexate) 4 auto-injectors/28 days

16 OptumRx | optumrx.com THERAPY CLASS MEDICATION NAME LIMIT Movement Disorder INGREZZA (valbenazine tosylate) 2 caps/day Agents Smoking Cessation CHANTIX (varenicline) 180 days supply/year Products COMMIT (nicotine lozenges) 180 days supply/year NICODERM (nicotine transdermal) 180 days supply/year NICORETTE (nicotine gum) 180 days supply/year NICOTROL Inhaler (nicotine) 180 days supply/year NICOTROL NS (nicotine) 180 days supply/year ZYBAN (bupropion) 180 days supply/year Obstetrics & Gynecology Contraceptives AMETHIA (levonorg-eth est) 1/91 days AMETHIA LO (levonorg-eth est) 1/91 days ASHLYNA (levonorg-eth est) 1/91 days CAMRESE (levonorg-eth est) 1/91 days CAMRESE LO (levonorg-eth est) 1/91 days DAYSEE (levonorg-eth est) 1/91 days DEPO/DEPO-SUBQ PROVERA 1/90 days (medroxyprogesterone) INTROVALE (levonorg-eth est) 1/91 days JOLESSA (levonorg-eth est) 1/91 days LOSEASONIQUE (ethinyl estradiol/ 1/91 days levonorgestrel) QUARTETTE (levonorg-eth est) 1/91 days QUASENSE (levonorg-eth est) 1/91 days SEASONIQUE (ethinyl estradiol/ 1/91 days levonorgestrel) SETLAKIN (levonorg-eth est) 1/91 days Hormone Replacement CRINONE (progesterone) 15 applicators/30 days ESTRING (estradiol) 1 package/90 days FEMRING (estradiol acetate) 1 package/90 days Miscellaneous BRISDELLE (paroxetine) 1 cap/day Ophthalmology Anti-inflammatory BROMDAY (bromfenac) 4 bottles/year BROMSITE (bromfenac) 4 bottles/year ILEVRO (nepafenac) 0.3% 2 bottles/30 days LOTEMAX (loteprednol) gel, oint 4 bottles/year NEVANAC (nepafenac) 0.1% 2 bottles/30 days PROLENSA (bromfenac sodium) 4 bottles/year

17 THERAPY CLASS MEDICATION NAME LIMIT Prostaglandins LUMIGAN (bimatoprost) 1 bottle (2.5 mL)/25 days RESCULA (unoprostone) 1 bottle (5 mL)/25 days TRAVATAN (travoprost) 1 bottle (2.5 mL)/25 days TRAVATAN Z (travoprost) 1 bottle (2.5 mL)/25 days XALATAN (latanoprost) 1 bottle (2.5 mL)/25 days ZIOPTAN (tafluprost) 1 container/day Respiratory Allergy (intranasal) ASTELIN 2 bottles (60 mL)/30 days ASTEPRO (azelastine) 2 bottles (60 mL)/30 days BECONASE AQ (beclomethasone) 1 inhaler (25 g)/25 days DYMISTA (fluticasone/azelastine) 1 inhaler (23 g)/30 days FLUNISOLIDE (flunisolide) 1 bottle (25 mL)/30 days NASONEX (mometasone) 2 inhalers/30 days OMNARIS (ciclesonide) 1 inhaler (12.5 g)/30 days PATANASE (olopatadine) 1 bottle (30.5 g)/30 days QNASL (beclomethasone) 1 inhaler (8.7 g)/30 days QNASL CHILDRENS (beclomethasone) 1 inhaler (4.9 g)/30 days RHINOCORT AQUA (budesonide) 2 bottles/30 days VERAMYST (fluticasone furoate) 1 bottle (10 g)/30 days ZETONNA (ciclesonide nasal) 1 inhaler (6.1 g)/30 days Asthma/COPD (inhaled) ADVAIR DISKUS (fluticasone/salmeterol) 1 diskus (60 doses)/30 days ADVAIR HFA (fluticasone/salmeterol) 1 inhaler/30 days AEROSPAN (flunisolide) 2 inhalers (8.9 g each)/30 days AIRDUO RESPICLICK 1 inhaler/30 days (fluticasone/salmeterol) ALVESCO (ciclesonide) 2 inhalers (6.1 g each)/30 days ANORO ELLIPTA (umeclidinium-vilanterol) 1 package (60 blisters)/30 days ARCAPTA (indacaterol) 4 caps/day ARMONAIR RESPICLICK (fluticacone) 1 inhaler/30 days ARNUITY ELLIPTA (fluticasone furoate) 1 inhaler/30 days ASMANEX HFA (mometasone) 1 inhaler/30 days ASMANEX TWISTHALER (mometasone) 1 inhaler/30 days ATROVENT HFA (ipratropium) 2 inhalers (12.9 g each)/30 days BREO ELLIPTA 1 package (60 blisters)/30 days (fluticasone furoate-vilanterol) BEVESPI AEROSPHERE (glycopyrrolate- 1 inhaler/30 days formoterol)

18 OptumRx | optumrx.com THERAPY CLASS MEDICATION NAME LIMIT Asthma/COPD (inhaled) COMBIVENT RESPIMAT 2 inhalers (4 g each)/30 days (cont.) (ipratropium/albuterol) DULERA (mometasone/formoterol) 1 inhaler/30 days FLOVENT (fluticasone) 110 mcg, 220 mcg 2 inhalers (12 g each)/30 days FLOVENT (fluticasone) 44 mcg 2 inhalers/30 days FLOVENT DISKUS (fluticasone) 250 mcg 240 blisters/30 days FLOVENT DISKUS (fluticasone) 50 mcg, 60 blisters/30 days 100 mcg FORADIL (formoterol) 1 package (60 doses)/30 days INCRUSE ELLIPTA (umeclidnium) 1 inhaler/30 days PROAIR HFA (albuterol) 2 inhalers/30 days PROAIR RESPICLICK (albuterol) 2 inhalers/30 days PROVENTIL HFA (albuterol) 2 inhalers/30 days PULMICORT FLEXHALER (budesonide) 2 packages/30 days QVAR (beclomethasone) 40 mcg 2 inhalers/30 days QVAR (beclomethasone) 80 mcg 3 inhalers/30 days SEEBRI NEOHALER (glycopyrolate) 2 caps/day SEREVENT DISKUS (salmeterol) 50 mcg 1 package (60 doses)/30 days SPIRIVA HANDIHALER (tiotropium) 1 package (30 caps)/30 days SPIRIVA RESPIMAT (tiotropium) 1 inhaler/30 days STIOLTO RESPIMAT 1 inhaler/30 days (tiotropium br-olodaterol) STRIVERDI RESPIMAT (olodaterol) 1 inhaler/30 days SYMBICORT (budesonide/formoterol) 1 inhaler/30 days TUDORZA (aclidinium bromide) 1 pouch (60 doses)/30 days UTIBRON NEOHALER (indacaterol 2 caps/day maleate-glycopyrrolate) VENTOLIN HFA (albuterol) 2 inhalers/30 days XOPENEX HFA (levalbuterol) 2 inhalers (15 g)/30 days Asthma/COPD (nebulized) ACCUNEB (albuterol) 5 packages (125 vials or 375 mL)/30 days Albuterol (albuterol) 2.5 mg/3 mL 180 vials (540 mL)/30 days (0.083%) Albuterol (albuterol) 5 mg/mL (0.5%) 150 mL/30 days ATROVENT (ipratropium) 125 vials (312.5 mL)/30 days BROVANA (arformoterol) 60 vials (120 mL)/30 days DUONEB (ipratropium/albuterol) 180 vials (540 mL)/30 days PERFOROMIST (formoterol) 60 vials (120 mL)/30 days PROVENTIL (albuterol) 2.5 mg/3mL 180 vials (540 mL)/30 days (0.083%)

19 THERAPY CLASS MEDICATION NAME LIMIT Asthma/COPD (nebulized) PULMICORT RESPULES (budesonide) 2 packages (120 mL)/30 days XOPENEX (levalbuterol) 180 vials (540 mL)/30 days XOPENEX (levalbuterol) 1.25 mg/0.5 mL 90 vials (45 mL)/30 days XOPENEX (levalbuterol) 1.25 mg/3 mL 90 vials (270 mL)/30 days Urology Erectile Dysfunction CAVERJECT (alprostadil) 6 units/30 days CIALIS (tadalafil) 10 mg 6 tabs/30 days CIALIS (tadalafil) 2.5 mg 1 tab/day CIALIS (tadalafil) 20 mg 6 tabs/30 days CIALIS (tadalafil) 5 mg 1 tab/day EDEX (alprostadil) 6 units/30 days LEVITRA (vardenafil) 6 tabs/30 days MUSE (alprostadil) 6 units/30 days STAXYN (vardenafil) 6 tabs/30 days STENDRA (avanafil) 6 tabs/30 days VIAGRA (sildenafil) 6 tabs/30 days Overactive Bladder OXYTROL (oxybutynin) 8 patches/28 days Antispasmodics

20 OptumRx | optumrx.com Core and Select Specialty Quantity Limit THERAPY CLASS MEDICATION NAME LIMIT Anti-Infectives Antiretrovirals, Hepatitis B BARACLUDE (entecavir) 1 tab/day BARACLUDE (entecavir) Soln 630 mL/30 days Antiretrovirals, HIV FUZEON (enfuvirtide) 60 vials or 1 kit/30 days Cardiology Anticoagulants, LMWH ARIXTRA (fondaparinux) 35 days supply/180 days FRAGMIN (dalteparin) 35 days supply/180 days LOVENOX (enoxaparin) 35 days supply/180 days Antilipemic JUXTAPID (lomitapide) 1 tab/day KYNAMRO (mipomersen) 4 syringes/28 days PRALUENT (alirocumab) 2 syringes/28 days REPATHA (evolocumab) 3 syringes/28 days REPATHA PUSH (evolocumab) 1 cartridge/28 days Pulmonary Arterial ADCIRCA (tadalafil) 2 tabs/day Hypertension ADEMPAS (riociguat) 3 tabs/day LETAIRIS (ambrisentan) 1 tab/day OPSUMIT (macitentan) 1 tab/day REVATIO (sildenafil) Susp 2 bottles/30 days REVATIO (sildenafil) Tabs 3 tabs/day TRACLEER (bosentan) 2 tabs/day TYVASO (treprostinil) 1 ampule/day UPTRAVI (selexipag) 2 tabs/day UPTRAVI (selexipag) Pack 2 packs/year VENTAVIS (iloprost) 9 ampules/day Central Nervous System Depressant XYREM (sodium oxybate) 3 bottles (540 mL)/30 days Parkinson’s APOKYN (apomorphine) 30 cartridges/30 days Sleep Disorder HETLIOZ (tasimelteon) 1 cap/day Dermatology Atopic Dermatitis DUPIXENT (dupilumab) 4 syringes (8mL)/28 days Electrolyte & Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabs/day Endocrinology & Metabolism Gonadotropins ELIGARD (leuprolide) 22.5 mg (3-month) 1 injection/84 days ELIGARD (leuprolide) 30 mg (4-month) 1 injection/112 days ELIGARD (leuprolide) 45 mg (6-month) 1 injection/168 days ELIGARD (leuprolide) 7.5 mg (1-month) 1 injection/28 days

21 THERAPY CLASS MEDICATION NAME LIMIT Gonadotropins (cont.) FIRMAGON (degarelix) 120 mg 2 vials/year FIRMAGON (degarelix) 80 mg 1 vial/28 days LUPANETA PACK (leuprolide) 1 pack/84 days 11.25 mg (3 mon) LUPANETA PACK (leuprolide) 1 pack/28 days 3.75 mg (1 mon) SUPPRELIN LA (histrelin acetate) 1 kit/365 days TRELSTAR (triptorelin) 22.5 mg (6-month) 1 injection/168 days TRELSTAR DEPOT (triptorelin) 1 injection/28 days 3.75 mg (1-month) TRELSTAR LA (triptorelin) 11.25 mg 1 injection/84 days (3-month) VANTAS (histrelin) 1 implant/year ZOLADEX (goserelin) 10.8 mg 1 injection/84 days ZOLADEX (goserelin) 3.6 mg 1 injection/28 days Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)/day Related Therapy EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)/day Hormone Modifiers NATPARA (parathyroid hormone) 2 cartridges/28 days Miscellaneous KORLYM (mifepristone) 4 tabs/day Osteoporosis PROLIA (denosumab) 2 syringes/year Somatostatins SIGNIFOR (pasireotide) 2 ampules/day SIGNIFOR LAR (pasireotide) 1 vial/28 days Vasopressin Antagonist SAMSCA (tolvaptan) 30 days supply/60 days Enzyme-Related Cystine-depleting Agents CYSTARAN (cysteamine) 4 bottles/28 days Enzyme Replacement XURIDEN (uridine triacetate) 4 packets/day Gastroenterology Diarrhea XERMELO (telotristat ethyl) 3 tabs/day Hepatic Agents OCALIVA (obeticholic acid) 1 tab/day Immunology Hematopoietic Agents MOZOBIL (plerixafor) 8 vials (9.6 mL)/transplant Hepatitis C Agents DAKLINZA (daclatasvir dihydrochloride) 1 tab/day EPCLUSA (sofosbuvir-velpatasvir) 1 tab/day HARVONI (ledipasvir-sofosbuvir) 1 tab/day MAVYRET (glecaprevir-pibrentasvir) 3 tabs/day OLYSIO (simeprevir) 1 cap/day SOVALDI (sofosbuvir) 1 tab/day TECHNIVIE 2 tabs/day (ombitasvir-paritaprevir-ritonavir)

22 OptumRx | optumrx.com THERAPY CLASS MEDICATION NAME LIMIT Hepatitis C Agents VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabs/day (cont.) paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabs/day paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasvir) 1 tab/day ZEPATIER (elbasvir-grazoprevir) 1 tab/day Interleukins ILARIS (canakinumab) 2 vials/4 weeks Multiple Sclerosis AMPYRA (dalfampridine) 2 tabs/day AUBAGIO (teriflunomide) 1 tab/day AVONEX (interferon beta-1a) 1 kit (4 syringes)/28 days BETASERON (interferon beta-1b) 1 package/28 days COPAXONE (glatiramer) SOSY 20 mg/ml 1 kit/30 days COPAXONE (glatiramer) SOSY 40 mg/ml 1 kit/28 days EXTAVIA (interferon beta-1b) 1 package/28 days GILENYA (fingolimod) 1 cap/day GLATOPA (glatiramer) SOSY 20 mg/ml 1 kit/30 days OCREVUS (ocrelizumab) Soln 40mL (4 vials)/365 days PLEGRIDY (peginterferon beta) 2 pens/syringes/28 days PLEGRIDY (peginterferon beta) 1 starter pack/30 days Starter Pack REBIF (interferon beta-1a) 12 syringes/28 days REBIF (interferon beta-1a) Starter Pack 1 starter pack/year TECFIDERA (dimethyl fumarate) 2 caps/day TECFIDERA (dimethyl fumarate) 1 starter pack/year Starter Pack TYSABRI (natalizumab) 1 injection/28 days Movement Disorder AUSTEDO (deutetrabenazine) 4 tabs/day Agents Oncology Kinase and Molecular AFINITOR (everolimus) 1 tab/day Target Inhibitors ALECENSA (alectinib) 8 caps/day ALUNBRIG (brigatinib) 6 tabs/day CAPRELSA (vandetanib) 100 mg 2 tabs/day COTELLIC (cobimetnib) 63 tabs/28 days FARYDAK (panobinostat) 6 caps/21 days GILOTRIF (afatinib) 1 tab/day ICLUSIG (ponatinib) 15 mg 2 tabs/day JAKAFI (ruxolitinib) 10 mg 2 tabs/day NINLARO (ixazomib) 3 caps/28 days

23 THERAPY CLASS MEDICATION NAME LIMIT Kinase and Molecular PORTRAZZA (necitumumab) Soln 2 vials/21 days Target Inhibitors (cont.) RYDAPT (midostaurin) 8 tabs/day TAGRISSO (osimertinib) 1 tab/day TARCEVA (erlotinib) 100 mg, 150 mg 1 tab/day TARCEVA (erlotinib) 25 mg 3 tabs/day ZEJULA (niraparib tosylate) caps 3 caps/day Miscellaneous KISQALI (ribociclib) Tabs 63 tabs/28 days KISQALI FEMARA DOSE (ribociclib 91 tabs/28 days succinate-letrozole) Pack LONSURF (trifluridine-tipiracil) 100 tabs/28 days 15-6.14 MG LONSURF (trifluridine-tipiracil) 80 tabs/28 days 20-8.19 MG RUBRACA (rucaparib camsylate) 4 tabs/day Respiratory Asthma/COPD NUCALA (mepolizumab) 1 vial/28 days Cystic Fibrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabs/day TOBI PODHALER (tobramycin) 1 package (224 tabs)/56 days

Quantity Limits effective as of January 1, 2018. PLEASE NOTE: This drug list is subject to periodic updates and may not be all inclusive. Drugs affected included both brand and generic where applicable and includes all strengths unless otherwise specifically noted. If a targeted drug has a new strength, it will automatically be added to the list.

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OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum® company — a leading provider of integrated health services. Learn more at optum.com.

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Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment you need, usually at a lower cost.

Here’s how it works:

Before a Step 2 medication is covered You get a Try a Step 1 prescription medication first

With this program, you need to try a Step 1 medication first, before a Step 2 medication may be covered. When you bring a prescription to the pharmacy, our system will automatically screen the medication for step therapy requirements. If your prior pharmacy claims show you have tried a Step 1 medication in the recent past, the Step 2 medication may be processed. If not, the pharmacist will contact your doctor for further explanation. We encourage you to discuss your treatment and medication options with your doctor. If you have questions about the Step Therapy program, call the toll-free member phone number on your ID card. Step Therapy Program

Step Therapy Medications If you have a prescription for any of the following Step 2 medications, you will be required to first try a Step 1 medication(s) for benefit coverage.

Condition Step 1 Step 2 Anti-infectives Oral Brand Any one of the following generics: Acticlate, Adoxa, Doryx, Monodox, Tetracyclines doxycycline Targadox AND any one of the following preferred brands: Doryx MPC Otic Agents ofloxacin Cetraxal, Ciprofloxacin Cardiovascular Beta Blockers carvedilol Coreg CR Calcium Channel Any one of the following generics: Prestalia Blockers amlodipine, perindopril Renin- Any one of the following generics: Edarbi, Edarbyclor, Tekturna, Angiotensin amlodipine-benazepril, amlodipine- Tekturna HCT System Agents olmesartan, benazepril, benazepril-HCTZ, candesartan, candesartan-HCTZ, captopril, captopril-HCTZ, enalapril, enalapril-HCTZ, fosinopril, fosinopril-HCTZ, irbesartan, irbesartan-HCTZ, lisinopril, lisinopril- HCTZ, losartan, losartan-HCTZ, moexipril, moexipril-HCTZ, olmesartan, olmesartan- HCTZ, olmesartan-amlodipine-HCTZ, perindopril, quinapril, quinapril-HCTZ, ramipril, telmisartan, telmisartan-HCTZ, trandolapril, trandolapril-verapamil Statins Any one of the following generics: Altoprev, Flolipid, Lipitor, Livalo, atorvastatin, fluvastatin, fluvastatin ER, Nikita, Zypitamag lovastatin, pravastatin, rosuvastatin, simvastatin Bold type = Brand-name drug Plain type = Generic drug

OptumRx | optumrx.com Step Therapy Medications Continued Condition Step 1 Step 2 Fibric Acid Any one of the following generics: Fenoglide, Fibricor, Lofibra, Derivatives fenofibric cap, fenofibrate tab, Triglide fenofibrate micronized cap, fenofibric acid tab AND any one of the following preferred brands: Lipofen Antianginals Any one of the following generics or Ranexa preferred brands: acebutolol, amlodipine, amlodipine- benazepril, amlodipine-telmisartan, amlodipine-valsartan, atenolol, bextaxolol, bisoprolol, carvedilol, diltiazem, diltiazem ER, felodipine ER, isosorbide dinitrate ER, isosorbide mononitrate ER, isradipine, metoprolol, metoprolol ER, nadolol, nicardipine, nifedipine, nisoldipine SR, nitroglycerin ER, pindolol, propranolol, propranolol SR, timolol, trandolapril-verapamil, verapamil, verapamil ER Bystolic, Dilatrate SR, Inderal XL, Innopran XL Central Nervous System ADHD Agents Any two of the following generics or Adderall XR#, Adzenys XR preferred brands: ODT#, Aptensio XR#, Concerta#, amphetamine-dextroamphetamine Cotempla XR-ODT#, Daytrana#, IR or ER, dexmethylphenidate IR or Desoxyn#, Dyanavel XR#, Evekeo#, ER, dextroamphetamine IR or SR, Focalin XR#, Kapvay, Metadate methylphenidate IR or ER, CD#, Methylin# solution, Methylin Vyvanse Chew#, Mydayis#, Procentra#, Quillichew ER#, Quillivant#, Ritalin LA#, Zenzedi# Anticonvulsants* topiramate Trokendi XR

Bold type = Brand-name drug Plain type = Generic drug

3 Step Therapy Program

Step Therapy Medications Continued Condition Step 1 Step 2 Antidepressants* Any two of the following generics: Trintellix# bupropion, citalopram, desvenlafaxine succinate ER, duloxetine, escitalopram, fluoxetine, mirtazapine, paroxetine, paroxetine ER, sertraline, venlafaxine, venlafaxine ER Any two of the following generics: Fetzima# desvenlafaxine succinate ER, duloxetine, venlafaxine, venlafaxine ER bupropion XL Alpenzin# Antipsychotics* Any two of the following generics or Fanapt#, Latuda#, Vraylar# preferred brands: aripiprazole, olanzapine, quetiapine, risperidone Saphris, Seroquel XR Insomnia Agents Any one of the following generics: Belsomra# eszopiclone, temazepam, zaleplon, zolpidem, zolpidem CR Any one of the following generics: Edluar#, Zolpimist# zolpidem, zolpidem CR Migraine Agents Any one of the following generics: Treximet#, Zecuity# rizatriptan, sumatriptan, zolmitriptan Any two of the following generics: Onzetra Xsail# rizatriptan, sumatriptan, zolmitriptan Neurologic gabapentin Gralise# Agents Any one of the following generics or Savella# preferred brands: amitriptyline, cyclobenzaprine, duloxetine Lyrica Bold type = Brand-name drug Plain type = Generic drug

OptumRx | optumrx.com Step Therapy Medications Continued Condition Step 1 Step 2 Non-Narcotic Any two of the following generics: Cambia, Tivorbex Analgesics diclofenac, diclofenac CR, diflunisal, etodolac, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meclofenamate, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin Opioid Narcan Nasal Spray Evzio Antagonists Parkinson’s Any one of the following generics: Rytary Disease carbidopa-levodopa, carbidopa-levodopa CR Both of the following generics: Xadago# rasagiline, selegiline Women’s Health Any one of the following generics: Brisdelle# esterified estrogens-methyltestosterone, estradiol, estradiol-norethindrone, estropipate, paroxetine, fluoxetine Dermatology Rosacea Soolantra Finacea Mirvaso Rhofade Skin Cancer Any one of the following generics: diclofenac gel 3%#, Picato, Agents fluorouracil, imiquimod Solaraze#, Tolak Topical Acne Any one of the following preferred Acanya, Aktipak, Benzaclin, Treatments brands: Benzamycin, Duac, Veltin, Ziana Epiduo/Epiduo Forte, Onexton Bold type = Brand-name drug Plain type = Generic drug

5 Step Therapy Program

Step Therapy Medications Continued Condition Step 1 Step 2 Topical Immuno- Any one of the following generics: Elidel, Eucrisa modulators alclometasone, amcinonide, betamethasone, calcipotriene- betamethasone, clobetasol, clocortolone, desonide, desoximetasone, diflorasone, fluocinolone, fluocinonide, fluticasone, halobetasol, hydrocortisone, mometasone, pramoxine-HC, prednicarbate, triamcinolone Endocrinology Basal Insulin All of the following preferred brands: Basaglar Lantus, Levemir, and Toujeo Diabetic Agents Any one of the following generics: Actoplus Met XR metformin, metformin ER, glipizide-metformin, glyburide-metformin, pioglitazone-metformin Any one of the following generics: Avandia, Cycloset metformin, metformin ER, glipizide-metformin, glyburide-metformin, pioglitazone-metformin Blood Glucose Both of the following Abbott#, Acon#, At Last#, Bayer#, Meters and preferred brands: Embrace#, EPS#, Fora Care#, Strips Accu-Check, Onetouch Glucocard#, Gmate#, Liberty#, Neutek#, Quintet#, Relion#, Reveal#, Supreme#, True Metrix#, Truetest#, Truetrack#, Ultima#, Unistrip# Bold type = Brand-name drug Plain type = Generic drug

OptumRx | optumrx.com Step Therapy Medications Continued Condition Step 1 Step 2 DPP4 Inhibitors Any one of the following generics: Janumet, Janumet XR, Januvia, metformin, metformin ER, glipizide- Jentadueto, Jentadueto XR, metformin, glyburide-metformin, Tradjenta pioglitazone-metformin Any one of the following alogliptin, alogliptin-metformin, preferred brands: alogliptin-pioglitazone, Kazano, Janumet†, Janumet XR†, Januvia† Kombiglyze XR, Nesina, Onglyza, Oseni AND any one of the following preferred brands: Jentadueto†, Jentadueto XR†, Tradjenta† GLP-1 Agonist Any one of the following Xultophy# Combinations preferred brands: Bydureon†, Byetta†, Trulicity†, Victoza†, Lantus, Levemir, or Toujeo Any one of the following: Soliqua# Adlyxin†, Bydureon†, Byetta†, Tanzeum†, Trulicity†, Victoza†, Basaglar†, Lantus, Levemir, Tresiba or Toujeo SGLT2 Inhibitors Any one of the following generics: Invokamet, Invokamet XR, metformin, metformin ER, glipizide- Invokana, Jardiance, Synjardy, metformin, glyburide-metformin, Synjardy XR pioglitazone-metformin Any one of the following Farxiga, Glyxambi, Xigduo XR preferred brands: Invokamet†, Invokana†, Invokamet XR† AND any one of the following preferred brands: Jardiance†, Synjardy†, Synjardy XR† Bold type = Brand-name drug Plain type = Generic drug

7 Step Therapy Program

Step Therapy Medications Continued Condition Step 1 Step 2 Short-Acting Any one of the following Apidra Insulin preferred brands: Humalog, Novolog Gastroenterology Constipation Any one of the following generics: Amitiza#, Linzess# Agents lactulose, polyethylene glycol Any one of the following generics: Trulance# lactulose, polyethylene glycol AND both of the following brands: Amitiza#, Linzess# Gastroprotective Any one of the following generics: Duexis# Agents diclofenac, etodolac, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin Irritable Bowel Apriso Asacol HD, Delzicol, mesalamine DR Syndrome Opioid-Induced Amitiza† Movantik# Constipation Pancreatic Both of the following preferred Pancreaze, Pertzye, Ultresa, Enzymes brands: Viokace Creon, Zenpep Proton Pump Any two of the following generics or Aciphex#, esomeprazole Inhibitors preferred brands: strontium#, First-Lansoprazole, esomeprazole, omeprazole, First-Omeprazole, Prevacid#, lansoprazole, pantoprazole Prilosec#, Protonix#, Zegerid# Dexilant Any one of the following Prevpac preferred brands: Omeclamox-Pak, Pylera Bold type = Brand-name drug Plain type = Generic drug

OptumRx | optumrx.com Step Therapy Medications Continued Condition Step 1 Step 2 Miscellaneous Antigout Agents Colcrys Mitigare, colchicine allopurinol Uloric, Zurampic Ophthalmology Ophthalmic Any one of the following generics or Bepreve, Lastacaft Antihistamines preferred brands: azelastine, olopatadine Pataday Ophthalmic Bromsite Prolensa# Antiinflammatory Agents

Respiratory Epinephrine Auto Any one of the following generics: Adrenaclick, Auvi-Q, Epipen, Injectors* generic Epipen (manufactured by Mylan), Epipen-Jr, epinephrine generic Epipen-Jr (manufactured by Mylan) Inhaled Any two of the following Alvesco#, Armonair Respiclick#, Corticosteroids preferred brands: Asmanex# Arnuity Ellipta, Flovent, Pulmicort Flexhaler, QVAR Inhaled Cystic Bethkis Kitabis, Tobi, Tobi Podhaler#, to- Fibrosis Agents bramycin nebulizer solution Leukotriene Any one of the following generics: zileuton ER, Zyflo, Zyflo CR Modifiers montelukast, zafirlukast Bold type = Brand-name drug Plain type = Generic drug

9 Step Therapy Program

Step Therapy Medications Continued Condition Step 1 Step 2 Long-Acting Any two of the following Arcapta#, Striverdi Respimat# Bronchodilators preferred brands: Advair, Breo Ellipta, Serevent, Symbicort Both of the following preferred brands: Seebri Neohaler#, Incruse Ellipta, Spiriva Tudorza Pressair# Long-Acting Any two of the following generics Airduo Respiclick#, Dulera# Bronchodilator or preferred brands: Combinations fluticasone-salmeterol, Advair, Breo Ellipta, Symbicort Any one of the following preferred Bevespi Aerosphere#, brands: Utibron Neohaler# Advair, Breo Ellipta, Serevent, Symbicort AND any one of the following preferred brands: Spiriva Short-Acting Any one of the following levalbuterol HFA#, Beta Agonist preferred brands: Proventil HFA#, Xopenex HFA# Inhalers Ventolin HFA AND any one of the following preferred brands: ProAir HFA, ProAir Respiclick Urology BPH Agents Any two of the following generics or Cardura XL preferred brands: alfuzosin, doxazosin, tamsulosin, terazosin Rapaflo Bold type = Brand-name drug Plain type = Generic drug

Step therapy requirements are effective as of January 1, 2018. The list of step therapy medications is subject to change without notice. Step therapy requirements may vary by benefit plan. Additional clinical programs, including quantity limits and prior authorization, may exist for the above medications which may affect your prescription drug coverage.

† These agents are also subject to additional step requirements as indicated in table.

# Quantity limits may also apply. Please refer to the Select Quantity Limits document.

* Applies to new starts only

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A well-balanced pharmacy network offers you convenient access and competitive discounts for brand and generic medications. Our national retail pharmacy network includes more than 64,000 chain and independent retail pharmacies, so you’re sure to find one close to home or work.

Using your ID card When you fill a prescription through a participating pharmacy, show the pharmacy your ID card so they can submit a claim for coverage by your pharmacy benefit plan. When you pick up your prescription, the pharmacy then collects your applicable member contribution as defined by your plan. If you do not present your ID card or you fill a prescription at a non-participating pharmacy, you pay the full retail price for your medication. If the prescription is eligible for coverage under your pharmacy benefit plan, you may submit a claim to request reimbursement (forms are available at optumrx.com or by calling customer service). When you submit a claim using the reimbursement form, OptumRx first determines if your plan covers the medication. If it is covered, the amount you receive is based on contracted pharmacy rates less your plan’s out-of-pocket member contribution. All prescription claims are subject to your pharmacy benefit plan’s rules and restrictions. Retail pharmacy network

Finding a network pharmacy You can choose from three easy ways to find participating pharmacies near you: 1. Review the partial list included on the following pages. 2. Go to our website and use the LOCATE A PHARMACY tool. 3. Contact customer service using the number on the back of your benefit plan member ID card.

A E I A S Medication Solutions E Medrx Solutions IHC Health Services AADP Eaton Apothecary Ingles Markets Pharmacy Accesshealth Epic Pharmacy Network Innovatix Network Accesshealth Plus F Innovatix Specialty Network Albertsons F & F Pharmacies Inserra Supermarkets American Drug Stores Fairview Health Services Insty Meds American Pharmacy Network Solutions Fairview Pharmacy Services K Amerita Family Care Pharmacy Network K Mart Pharmacy Aurora Pharmacy Ff Acquisition King Soopers Pharmacy Co B Food City-K-Va-T Food Stores Kinney Drugs Balls Four B Corp Food Lion Kleins Family Markets Bi Lo Fred Meyer Klingensmiths Drug Store Bimart Corporation Freds Pharmacy Kohlls Pharmacy And Homecare Biorx Freds Stores Of Tennessee KS Management Services Brookshire Bros Fruth Pharmacy L Brookshire Grocery Company Frys Food And Drug Stores Leader Drug Stores C G Leader Puerto Rico Cardinal Health Managed Care Servic Gerimed Network LML Enterprises Carrs Quality Center Giant Eagle Longs Drug Stores California Central Dakota Pharmacys Global M Cigna Medical Group Pharmacy Good Neighbor Phcy Provider M K Stores City Market H Major Value Third Party Network Complete Claims Processing Hannaford Bros Co Marianos Pharmacies Costco Pharmacies Harris Teeter Marshfield Clinic Pharmacy Curators Of The University Of Mo Harvard Vanguard Medical Associates Maxor National Phcy Srvs Corp CVS Pharmacy Heb Grocery Company Mayo Clinic Pharmacy D Horton And Converse Pharmacy Mds Rx Dallas Metrocare Services Humana Pharmacy Inc Pharmacy Medicap Pharmacies Dillon Stores Hy-Vee Medicine Shoppe International Discount Drug Mart Meijer Doctors Choice Pharmacies Mha Long Term Care Network Myrx

OptumRx | optumrx.com N S W Nai Saturn Eastern S R S Walgreens Drug Store Navarro Discount Pharmacies Safeway Walmart Stores NCPRX Saker Shoprites Wegman Food Market Neighborcare Pharmacy Services Sav Mor Drug Stores Weis Pharmacies Northeast Phcy Svce Corp Save Mart Supermarkets Welgo Northwest Health Ventures Schnuck Markets Winn Dixie Pharmacy O Seip Drug Z Omnicare Inc Ncs Healthcare Shaws Supermarket Zallie Supermarkets Oncology Pharmacy Services Shopko Stores Operating Co P Shoprite Financial Services Shoprite Supermarkets Pacmed Clinics Smiths Food And Drug Center Patient First Corporation Stop And Shop Pharmacy Pharmerica Supervalu Pharmacies Physicians Pharmaceutical Corp Swift Rx Llc Physicians Pharmaceutical Corp Planned Parenthood Of The Pacific S T Poc Network Technologies Target Corporation Ppok Rxselect Phcy Network Tempest Med Price Chopper House Calls Pharma The Bartell Drug Company Procare Pharmacy The Kroger Co Progressive Pharmacies Third Party Station Provider Services Of America Third Party Station Cp Publix Super Markets Third Party Station Pr Q Thrifty Drug Stores Tom Thumb Pharmacies QCP Networx Tops Markets Quality Food Centers Quick Chek Corporation U R Ucsd Medical Center Phcy United Drugs Raleys Drug Center United Drugs Rural Network Ralphs Pharmacy United Pharmacy Tx Randalls Food And Drug University Of Utah Pharmacies Recept Healthcare Services Red Cross Pharmacy V Redners Markets Valley Wholesale Drug Co Rite Aid Corporation Vantage Rx Dispensing Services Ronetco Supermarkets Village Supermarkets Roundys Pharmacies Vons Companies optumrx.com

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Mail Service Saver is a program that helps you better manage the medication you take on an ongoing basis. You can save both time and money by filling your prescriptions for maintenance medication through home delivery with OptumRx. Not only is home delivery safe and reliable, it also offers the following advantages:

Cost savings: You may pay less for your medication with a three-month supply through OptumRx.

Convenience: Get free standard shipping on medications delivered to your mailbox.

24/7 access and reminders: Speak to a pharmacist who can answer your questions any time, any day. Even set up text and email reminders to help you remember to take or refill your medications.*

How Mail Service Saver works If you are currently taking maintenance medication on a regular basis, your pharmacy benefit plan strongly encourages you to use home delivery. Your health plan covers only a limited number of maintenance medication refills from a retail pharmacy (call Customer Service at the member phone number on the back of your health plan ID card for the number of fills covered by your specific plan). After the allowed fills, you must move to home delivery through OptumRx or you will pay an increased cost at your retail pharmacy. Whether you have a new prescription or need to transfer an existing prescription, it’s easy to get started with OptumRx home delivery.

Here is how: By online registration: Visit optumrx.com, register and follow the simple step-by-step instructions. You can manage your medication online, including filling new prescriptions and transferring other prescriptions to home delivery. You can also set up text message reminders to help manage your medication schedule. Be sure to have your health plan ID card and medication bottles on hand. By phone: Just call the member phone number on the back of your plan ID card to talk with a customer service representative right now. It’s helpful to have your plan ID card and medication bottle available. The representative can also contact your doctor directly if you need a new prescription.

By mail: Ask your doctor for a new prescription for up to a three-month supply, plus refills for up to one year. Then go to optumrx.com and download the new prescription order form. Mail it to the address provided on the bottom of the form.

By fax / ePrescribe: Ask your doctor to call 1-800-791-7658 for instructions on how to fax your prescription directly to OptumR. Or your doctor can send an electronic prescription to OptumRx.

*OptumRx provides this service at no cost. Standard message and data rates charged by your carrier may apply.

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OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an OptumTM company — a leading provider of integrated health services. Learn more at optum.com.

All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners.

©2015 Optum, Inc. All rights reserved. ORX7321-MSS_150608 49994-082015 New Prescription Mail-In Order Form 1 Member and physician information — please use black or blue ink. One form per member. Member ID Number

(Additional coverage, if applicable) Secondary Member ID Number

Last Name First Name MI

Delivery Address Apt. #

City State ZIP

Phone Number with Area Code

Date of Birth (mm/dd/yyyy) Gender Email  M  F Physician Name

Physician Phone Number with Area Code

2 Health history Medication Allergies:  Aspirin  Erythromycin  Quinolones  Others:  None known  Cephalosporins  NSAIDs  Sulfa  Amoxil/Ampicillin  Codeine  Penicillin  Tetracyclines Health Conditions:  Asthma  Glaucoma  High cholesterol  Others:  None known  Cancer  Heart condition  Osteoporosis  Arthritis  Diabetes  High blood pressure  Thyroid Disease Over-the-counter/herbal medications taken regularly:

3 Payment and shipping information — do not send cash Standard delivery is included at no charge. New prescriptions should arrive within about 10 business days from the date the completed order is received. Completed refill orders should arrive within about 7 business days. OptumRx will contact you if there will be an extended delay in delivering your medications. You may log on to optumrx.com to see if drug pricing information is available before enclosing payment. Once shipped, medications may not be returned for a refund or adjustment. Ship overnight. Add $12.50 to New Credit Card Number order amount (subject to change). Check enclosed. All checks must be signed and made payable to: OptumRx. Expiration Date (Month/Year) Visa, MasterCard, AMEX Charge to my credit card on file. and Discover are accepted. Charge to my NEW credit card. Signature: Date: For new prescription orders and maintenance refills, this credit card will be billed for copay/coinsurance and other such expenses related to prescription orders. By supplying my credit card number, I authorize OptumRx to maintain my credit card on file as payment method for any future charges. To modify payment selection, contact customer service at any time. 4 Mail this completed order form with your new prescription(s) to OptumRx, P.O. Box 2975, Mission, KS 66201. DO NOT STAPLE OR TAPE PRESCRIPTIONS TO THE ORDER FORM.

ORX5633_140915 NRX001 Welcome to your specialty pharmacy

Specialty medications can be important to maintaining or improving your health — and your quality of life. BriovaRx®, the OptumRx® specialty pharmacy, provides the resources and personalized, condition-specific support you need to help you better manage your condition.

What is a specialty medication?

We define an injectable, oral or inhaled medication as a specialty medication if it:

• May require ongoing clinical oversight and Specialty medication additional education for best management resources • Has unique storage or shipping requirements Customer service • May not be available at retail pharmacies Call 1-855-4BRIOVA (1-855-427-4682)

BriovaRx: A specialty pharmacy to meet your needs Online at optumrx.com Price your medication BriovaRx offers support to help you and find additional manage your condition. Take advantage resources including of personalized patient support from information specific knowledgeable pharmacists and nurses to your condition. who specialize in your condition at no additional cost to you. In addition, you’ll receive:

• Access to your medications at the lowest cost

• 24/7 access to pharmacists

• Support through clinical and adherence programs

• Any medication-related supplies at no additional cost

• Proactive refill emindersr

• Timely delivery and shipping in confidential packaging Rx guide for specialty medications

Guiding your health journey under your pharmacy benefit We understand the challenge of living with and managing a complex health condition. That’s where BriovaRx comes in, to assist you every step of the way.

Getting started: Transfer your prescriptions Monitor your health. Enroll in the specialty pharmacy program If you need help with anything else from with BriovaRx. weight loss to back pain and even smoking If you haven’t done so yet, call BriovaRx cessation, your specialty pharmacist or nurse at 1-855-4BRIOVA (1-855-427-4682) can help you locate wellness coaching and to get started. disease management programs to help you stay on track with your health. Access to a pharmacist 24/7. Follow your care plan. Our specialty pharmacists and patient care coordinators are available 24/7 and will take If you’re part of a clinical management program, care of everything for you, including: be sure to follow your care plan and tell your pharmacist or nurse about any new medications • Transferring your prescription to BriovaRx you’re taking. • Helping you find affordable access to your medication and manage any side effects Staying on track with your treatment • Explaining how the specialty pharmacy works Quick and easy refills. Personalized support. We make it easy for you to remember to take Once you start getting your specialty your medication with a reminder phone call a medications through BriovaRx, you’ll also few days prior to the time when you need to experience personalized, one-on-one support refill your prescription. You can even sign up for from pharmacists and nurses. They’re there for text message reminders online or by phone. you any time you have questions about your Overnight delivery. medication, side effects and more. With your specialty pharmacy, shipping your medication is quick, easy and safe. Refrigerated Working with your pharmacist or nurse medications will be delivered overnight directly Continued conversations. to your home or office, in a temperature- controlled package. Others will be shipped Tell your pharmacist or nurse about any changes within one to three days. Supplies will also be or complications in your therapy, such as: provided at no extra cost. • Any side effects Save more time and money. • Trouble remembering to take your medication If you’re looking to save money on your medications, finding lower-cost alternatives and transferring your non-specialty prescriptions through the mail can help.

optumrx.com

All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners.

January 1, 2018

BriovaRx®, the OptumRx® specialty pharmacy, provides comprehensive support services, including access to pharmacists around the clock, for high-cost oral and injectable medications used to treat rare and complex conditions. In addition, your medications will be shipped to you at no extra cost.

OptumRx | optumrx.com Specialty pharmacy drug list

Characteristics of specialty medications

“Specialty” medications are defined as high-cost oral or injectable medications used to treat rare and complex conditions. These are highly complex medications, typically biology-based, that structurally mimic compounds found within the body. Medications must have at least one of the following characteristics in order to be classified as a specialty medication by BriovaRx:

High cost • Typically priced at more than $1,000 per 30-day supply.

High complexity • Biotechnology products†

• Medications that treat ultra rare conditions

• Medications that are included in a specialty therapeutic drug class strategy

High-touch medications that require: • Temperature control or other special handling and shipping requirements (e.g., refrigerated or frozen shipping)

• Ongoing management by a pharmacist and/or physician specializing in treating the condition

• Focused, in-depth education including how to administer injections, adhere to the treatment protocol, and manage side effects

† Protein or protein-based molecular entities Specialty pharmacy drug list

Adult incontinence Asthma Duchenne muscular Carbaglu dystrophy Cerdelga PA Solesta Cinqair PA Cerezyme PA Fasenra PA EmflazaPA Cholbam PA Nucala PA Ammonia detoxicants Cystagon PA Endocrine Xolair PA PA Elaprase Ravicti PA Cuprimine PA Birth control Elelyso PA Egrifta Fabrazyme PA Anemia PA Nexplanon Firmagon Glassia PA PA Aranesp PA Hydroxy Capr Kanuma PA Cardiovascular PA Epogen PA, ST Korlym Lumizyme PA PA Mircera PA Northera PA Kuvan Naglazyme PA PA Procrit PA Lupaneta Orfadin Central nervous PA Makena Phenylbutyra system agents PA Myalept PA Anticoagulation Prolastin-C PA Austedo PA Natpara Sodium Pheny Arixtra Brineura PA Nityr Strensiq PA PA Enoxaparin Hetlioz PA Octreotide Sucraid Fondaparinux Radicava PA Parsabiv Vimizim PA PA Fragmin Sabril PA Procysbi Vpriv PA Lovenox Tetrabenazin PA Samsca Zavesca PA PA Vigabatrin PA Sandostatin Zemaira PA PA Anti-Gout agent Xenazine PA Signifor Somatuline PA PA Gastrointestinal agents Krystexxa Cystic fibrosis Somavert PA Supprelin LA PA Gattex PA Bethkis Antihyperlipidemic Syprine PA Ocaliva PA Cayston PA Thiola Xermelo PA Juxtapid PA Kalydeco PA Thyrogen PA Kynamro PA Kitabis Pak ST Triptodur PA Praluent PA, ST Orkambi PA GROWTH HORMONE Vantas PA, ST Repatha PA, ST Pulmozyme PA DEFICIENCY Xuriden PA Tobi ST PA, ST ST Genotropin Anti-infective Tobramycin Enzyme therapy Humatrope PA, ST Daraprim PA Diagnostic Adagen Increlex PA, ST Aldurazyme PA Norditropin PA, ST Acthrel Aralast NP PA Nutropin AQ PA, ST Buphenyl Omnitrope PA, ST

PA – Prior authorization required • ST – Step therapy 3 Specialty pharmacy drug list

Specialty pharmacy drug list

Saizen PA, ST Monoclate-P Sovaldi PA Lexiva Serostim PA, ST Mononine Technivie PA Lopin/riton Zomacton PA, ST Novoeight Viekira PA Nevirapine Zorbtive PA, ST Novoseven RT Vosevi PA, ST Norvir Nuwiq Zepatier PA, ST Odefsey Hematological agents Obizur Prezcobix Hereditary angioedema Mozobil PA Profilnine Prezista Nplate PA Rebinyn Berinert PA Rescriptor Panhematin Recombinate Cinryze PA Retrovir Promacta PA Rixubis Firazyr PA Reyataz Riastap Tretten Haegarda PA Selzentry Soliris PA Vonvendi Kalbitor PA Stavudine Thrombat III Wilate Ruconest PA Stribild Xyntha Sustiva Hemophilia HIV Tivicay Hepatitis B Advate ABACAV/LAMIV Triumeq Adynovate Adefov Dipiv Abacavir Trizivir Afstyla Baraclude Aptivus Truvada Alphanate Entecavir Atripla Tybost Alphanine SD Epivir HBV Combivir Videx Alprolix Hepsera Complera Viracept Bebulin Lamivudine Crixivan Viramune Benefix Vemlidy Descovy Viread Ceprotin Didanosine Zerit Coagadex Hepatitis C Edurant Ziagen Corifact Emtriva Zidovudine Copegus Eloctate Epivir Daklinza PA Immune globulin Feiba Epzicom Epclusa PA. ST Helixate FS Evotaz Atgam PA Harvoni PA Hemlibra Fosamprenavi Bivigam PA Mavyret PA Hemofil M Fuzeon Carimune NF Moderiba PA Humate-P Genvoya Cuvitru PA Olysio PA Idelvion Intelence Cytogam PA, ST Pegasys PA Ixinity Invirase Flebogamma PA, ST Pegintron PA Koate Isentress Gamastan S/D Rebetol PA Koate-DVI Kaletra Gammagard Ribapak PA Kogenate FS Lamivud/zido Gammaked Ribasphere PA Kovaltry Lamivudine Gammaplex Ribavirin

4 OptumRx | optumrx.com Gamunex-C PA Kevzara PA Narcolepsy Bortezomib PA Hizentra PA Kineret PA, ST Busulfan Xyrem PA Hyperrab S/D Orencia PA, ST Busulfex Hyperrho S/D Otezla PA Neurological agents Campath Hyqvia PA Remicade PA Camptosar PA Imogam Rabie RenflexisPA Botox Carboplatin PA Micrhogam Siliq PA, ST Dysport Cisplatin PA Octagam PA Simponi PA, ST Myobloc Cladribine PA Privigen PA Stelara PA, ST Xeomin Clofarabine Taltz PA Clolar Immunological agents Neutropenia Tremfya PA, ST Cosmegen PA Actimmune Xeljanz PA, ST Granix Cyclophosph PA Arcalyst PA H.P. Acthar Cyramza PA Metabolic bone disease PA Benlysta PA Leukine Cytarabine PA Ilaris PA Reclast Neulasta Dacarbazine PA Lemtrada PA Zoledronic Neupogen Dacogen PA PA Zometa Zarxio Darzalex PA Infertility Daunorubicin Oncology - injectable Multiple sclerosis PA Bravelle PA, ST Decitabine Cetrotide PA Ampyra PA Abraxane Dexrazoxane PA Chor Gonadot PA Aubagio PA Adcetris Docetaxel Follistim AQ PA Avonex PA Adriamycin Doxil Ganirelix AC PA Betaseron PA Adrucil Doxorubicin PA Gonal-F PA Copaxone PA Alferon N Eligard Menopur PA Extavia PA Alimta Ellence PA PA Novarel PA Gilenya PA, ST Aliqopa Empliciti Ovidrel Glatiramer PA Alkeran Epirubicin PA Pregnyl PA Glatopa PA Arranon Erbitux PA Ocrevus PA Arzerra Erwinaze Inflammatory conditions Plegridy PA Avastin Etopophos PA, ST Azacitidine Etoposide Actemra PA, ST Rebif PA PA Bavencio Evomela Cimzia PA, ST Tecfidera PA PA Beleodaq Faslodex Cosentyx PA Tysabri PA Bendeka FE Pyrophosp Dupixent PA Zinbryta Besponsa PA Floxuridine Enbrel PA Musculoskeletal agents Bicnu Fludarabine Entyvio PA Bleo 15k Fluorouracil Injectable Humira PA Exondys 51 PA, ST Bleomycin Folotyn PA InflectraPA Spinraza PA Blincyto PA Fusilev XiaflexPA

PA – Prior authorization required • ST – Step therapy 5 Specialty pharmacy drug list

Specialty pharmacy drug list

Gazyva PA Opdivo PA Yescarta PA Matulane Gemcitabine Oxaliplatin Yondelis Mekinist PA Gemzar Paclitaxel Zaltrap PA Mercaptopurine Halaven PA Pamidronate Zanosar Mesnex Herceptin PA Perjeta PA Zevalin Nerlynx PA Hycamtin Photofrin Zinecard Nexavar PA Idarubicin Portrazza PA Zoladex Nilandron Ifex Proleukin Nilutamide Oncology - oral Ifosfamide Rituxan PA Ninlaro PA ImfinziPA Sod Pyrophos AfinitorPA Odomzo PA Imlygic Sylatron PA Alecensa PA Pomalyst PA Intron A PA Sylvant PA Alunbrig PA Purixan Irinotecan Synribo PA Bexarotene PA Revlimid PA Istodax OVR PA Taxotere Bosulif PA, ST Rubraca PA Ixempra kit Tecentriq PA Cabometyx PA Rydapt PA Jevtana PA Temodar PA Calquence PA Sprycel PA, ST Kadcyla PA Teniposide Capecitabine PA Stivarga PA Kepivance Tepadina Caprelsa PA Sutent PA Keytruda PA Theracys Cometriq PA TafinlarPA Kymriah PA Thiotepa Cotellic PA Tagrisso PA Kyprolis PA Tice BCG Erivedge PA Tarceva PA Lartruvo PA Toposar Etoposide Targretin PA L-Asparagine Topotecan Farydak PA Tasigna PA Leuprolide PA Torisel Gilotrif PA Temodar PA Levoleucovor Totect Gleevec PA Temozolomide PA Lipodox 50 Treanda Gleostine Thalomid PA Lupron Depot PA Trelstar mix Hycamtin Tretinoin Marqibo Trisenox Ibrance PA Tykerb PA Melphalan Unituxin PA Iclusig PA Venclexta PA Mesna Valstar Idhifa PA Verzenio PA Mesnex Vectibix Imatinib Mes PA Votrient PA Mitomycin Velcade PA Imbruvica PA Xalkori PA Mitoxantron PA Vidaza Inlyta PA Xeloda PA Mustargen Vinblastine Iressa PA, ST Xtandi PA Mylotarg PA Vincasar PFS JakafiPA Zejula PA Navelbine Vincristine Kisqali PA Zelboraf PA Nipent Vinorelbine Lenvima PA Zolinza PA Oncaspar Vyxeos PA Lonsurf PA Zydelig PA Onivyde Xgeva PA Lynparza PA Zykadia PA Yervoy PA Zytiga PA

6 OptumRx | optumrx.com Oncology - topical Pain management Substance abuse treatment Valchlor PA Prialt Vivitrol PA Ophthalmic agents Parkinson’s disease Transplant Cystaran PA Apokyn PA Eylea Astagraf XL Pulmonary fibrosis Iluvien Cellcept Jetrea Esbriet PA Cellcept IV Keveyis PA Ofev PA Cyclosporine Lucentis Envarsus XR Macugen Pulmonary hypertension Gengraf Visudyne Adcirca PA Mycophenolat PA Mycophenolic Osteoarthritis Adempas Epoprostenol PA Myfortic Durolane PA Flolan PA Neoral PA EuflexxaPA, ST Letairis PA Nulojix Gel-one PA, ST Opsumit PA Prograf Gelsyn-3 PA Orenitram PA Rapamune Genvisc 850 PA, ST Remodulin PA Sandimmune Hyalgan PA, ST Revatio PA Sirolimus Hymovis PA SildenafilPA Tacrolimus PA Monovisc PA Tracleer PA Zortress Orthovisc PA Tyvaso PA Supartz PA, ST Uptravi PA Synvisc PA Veletri PA Visco-3 PA, ST Ventavis PA

Osteoporosis RSV

Forteo PA Ribavirin inhal Prolia PA Synagis PA Tymlos PA Virazole

PA – Prior authorization required • ST – Step therapy 7 Specialty pharmacy drug list

About OptumRx

OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. BriovaRx is our specialty pharmacy. Our high-quality, integrated services deliver optimal member outcomes, superior savings and outstanding customer service. We are an Optum® company — a leading provider of integrated health services. Learn more at optum.com.

To fill a prescription for a specialty medication on this list, please call 1-855-4BRIOVA (855-427-4682) or visit optumrx.com.

This specialty pharmacy drug list may not be a complete representation of all available specialty medications; this list is subject to change at any time without prior notice.

Non-specialty alternatives may be a recommended first-line therapy to treat your condition. Please consult your physician.

2300 Main Street, Irvine, CA 92614

All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners.

Specialty medications are an important component to managing complex diseases and conditions, and sometimes it takes time for members to find the right dose and comfort level before they’re able to follow their regimen. The Smart Fill program from BriovaRx®, the OptumRx® specialty pharmacy, offers two strategies for dispensing specialty medications so that members get the medications they need, adhere to their therapy, and reduce waste due to intolerance. Our split fill strategy enables twice-monthly prescription refills, while the 90-day fill program provides refills every three months.

Smart fill has two program strategies

Split fill 90-day fill

Eligible classes Oral oncology HIV, MS, RA, Transplant Member stability Unstable on medication Stable on medication Clinical benefits Adjust to medication Adherence Program outcome Avoid waste Member convenience # Fills/duration 6 fills over first 3 months 4 fills over 12 months Copays 1/2 copay 3x copay Split fill program strategy

Some specialty drugs can cause side effects that lead members to stop taking and discard their medications. A recent OptumRx analysis found that almost half of patients on select oral oncology drugs discontinued their therapy within 90 days — an expensive loss for them and their plan sponsor alike. Reduce costs By being more proactive, Our split fill program helps avoid costs associated with early-discontinuation split fill may save you up waste by filling half the prescription twice a month, rather than a full to 50 percent in costs prescription once a month when a member starts a new regimen of oral associated with drug waste. oncology drugs. Members who tolerate the new drug for three months will Shorter fills also means be returned to standard days supply for duration of therapy. By increasing smaller, prorated copays the frequency, this enables: for members. Split fill is available to clients who use • More frequent conversations with the member BriovaRx as their exclusive • Early identification of adverse events specialty pharmacy. • Timely clinical intervention • Adherence monitoring

90-day fill program strategy

Our 90-day program is a convenient option for members taking medications for HIV, rheumatoid arthritis, multiple sclerosis, and transplant. If members demonstrate regimen stability and adherence, they have the option of receiving three month’s worth of medication per refill.

Instead of 12 refills and 12 copays per year, members who take advantage of the 90-day fill program get four refills, with three copays per refill. The program is voluntary and enables:

• Enhanced member convenience • Adherence monitoring • Improved member satisfaction

Manage drug waste, adherence and costs

To see how BriovaRx can help you better serve members with specialty conditions, email us at [email protected] or visit us at optum.com/optumrx.

[email protected] | optum.com/optumrx

2300 Main Street, Irvine, CA 92614

All Optum® trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners.

Get your flu shot and other routine vaccines

Flu shots The flu affects millions of people each year and can lead to serious illness, or even death. The flu can be a contagious illness caused by influenza viruses that infect the lungs, throat and nose. According to the Centers for Disease Control and Prevention (CDC), one of the best ways to prevent the flu is by getting vaccinated each year.1 The CDC recommends a yearly flu vaccine for everyone 6 months of age and older as the first and most important step in protecting against this serious disease.2 Many vaccines can be Routine vaccines You can also keep yourself and your family members healthy with routine obtained on a walk in vaccines that prevent illnesses like tetanus, pneumonia and shingles. Routine basis. Show your OptumRx vaccines are available on most plans, and can help you and your family ID card before getting maintain better overall health. your flu shot or vaccine. Most OptumRx plans cover routine vaccines at 100% Easy access to flu shots and other vaccines when you use network OptumRx contracts with a variety of national pharmacy chains to provide pharmacies. members with easy access to flu shots and other routine vaccines. Plus, members get the highest level of benefit coverage (100% for many plans) for See the pharmacy list vaccines obtained from contracted pharmacies that participate in the Vaccine on page 2. Immunization/Injection Network administered by OptumRx.3 Many vaccines can be obtained on a walk-in basis by presenting the OptumRx ID card at the time of service. Members should review their benefit plan to determine coverage for vaccines. Retail Pharmacies Routine vaccines4 This list represents the larger retail Most of the following routine vaccines are available at pharmacies that chain pharmacies in our network, participate in the Vaccine Immunization/Injection Network administered but is not the full list. For a more by OptumRx. complete list, you can log in to Age restrictions or limitations may apply. Check with your network pharmacy www.optumrx.com or call the number for specific age, flu shot and vaccine requirements. on your health plan or prescription ID card. Pharmacists administer the Flu Shots & Nasal Mists vaccines at these locations. Flu (Influenza)  The Great Atlantic & Pacific Tea Afluria Fluzone HD Fluarix Quad Company (A&P, FoodBasics, Fluarix Fluzone ID Flulaval Quad The Food Emporium, Pathmark, Flulaval Fluzone PED Fluzone Quad Superfresh, Waldbaums) Fluvirin Flucelvax Flublok  Ahold USA (Giant Food Stores, Fluzone Flumist Quad Giant of Maryland, Stop and Shop Routine Adult Vaccines Supermarkets, Ukrop’s Hepatitis A (Adult and Pediatric) Super Markets)  Albertsons Havrix Vaqta  CVS Pharmacy Hepatitis B (Adult and Pediatric)  Four B Corporation (Hen House, Engerix-B Recombivax-HB Price Chopper) Human Papilloma Virus (HPV) – Vaccine prevents cervical cancer  H-E-B Pharmacy Cervarix Gardasil Gardasil 9  Hy-Vee Pharmacy Measles, Mumps, Rubella - MMR-II  Kmart Pharmacy Meningococcal - Vaccine prevents meningitis Groups A, C, Y and W-135  K-VA-T Food Stores, Inc. (Food City) Menactra Menomune Menveo  Marsh Drugs LLC  Meijer Pharmacies Meningococcal - Vaccine prevents meningitis Group B  Publix Bexsero Trumenba  Roundy’s (Pick’n Save, Copps, Pneumococcal – Vaccine prevents pneumonia Rainbow, Metro Market, Mariano’s) Prevnar13  Safeway Affiliated Pharmacies Pneumovax 23 (Carrs, Pavilion’s, Randalls, Tdap – Vaccine prevents tetanus, diptheria, pertussis Safeway, Tom Thumb, Vons) Adacel Boostrix  Shopko Stores Tetanus Diptheria - TD  SUPERVALU Affiliated Pharmacies (BIGGS, Osco, Sav-On, Shaw’s Tenivac Supermarket) Tetanus toxoid  Thrifty White Pharmacy Varicella – Vaccine prevents chicken pox  Tops Markets Varivax  Walgreens Pharmacy (Duane Reade) Zoster – Vaccine prevents shingles  Wegmans Zostavax Ask your employer or check your plan documents for your plan’s specific coverage details. Not all vaccines on this list are available at all network pharmacies. Contact your local network pharmacy to confirm vaccine availability.

1 Sources: http://www.cdc.gov/flu/ 2 www.cdc.gov/flu/protect/keyfacts.htm#flu-vaccination For more information 3 There may be some instances where a particular location for one of the vaccine providers is not participating in the national OptumRx Vaccine Immunization/Injection Network. log in to optumrx.com 4 Not all vaccines on this list are available at all participating pharmacies. Members should or call the number on contact their participating pharmacy of choice to confirm vaccine availability. All trademarks are the property of their respective owners. your OptumRx ID card. M54390-A 1/16 ©2016 Optum, Inc. All rights reserved.