National Direct Drug List

Drug list — Four Tier Drug Plan

Your prescription benefit comes with a drug list, which is also called a formulary. This list is made up of brand-name and generic prescription drugs approved by the U.S. Food & Drug Administration (FDA).

If you are a current Anthem member with questions about your pharmacy benefits, we're here to help. Just call us at the Pharmacy Member Services number on your ID card.

Here are a few things to remember:

o You can view and search our current drug lists when you visit anthem.com/ca and choose Prescription Benefits. Please note: The formulary is subject to change and all previous versions of the formulary are no longer in effect.

o Additional tools and resources are available for current Anthem members to view the most up-to-date list of drugs for your plan - including drugs that have been added, generic drugs and more – by logging in at anthem.com/ca.

o Your coverage has limitations and exclusions, which means there are certain rules about what's covered by your plan and what isn't. Already a member? You can view your Certificate/Evidence of Coverage or your Summary Plan Description by logging in at anthem.com/ca and go to My Plan ->Benefits-> Plan Documents.

o You and your doctor can use this list as a guide to choose drugs that are best for you. Drugs that aren’t on this list may not be covered by your plan and may cost you more out of pocket. To help you see how the drug list works with your drug benefit, we've included some frequently asked questions (FAQ) in this document about how the list is set up and what to do if a drug you take isn't on it.

Last Updated: September 1, 2021 DMHC National Direct Drug List Four Tier

Table of Contents

INFORMATIONAL SECTION...... 4 *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* - DRUGS FOR THE NERVOUS SYSTEM...... 11 *ALLERGENIC EXTRACTS/BIOLOGICALS MISC* - BIOLOGICAL AGENTS...... 15 *AMEBICIDES* - DRUGS FOR INFECTIONS...... 19 *AMINOGLYCOSIDES* - DRUGS FOR INFECTIONS...... 19 *ANALGESICS - ANTI-INFLAMMATORY* - DRUGS FOR PAIN AND FEVER...... 19 *ANALGESICS - NONNARCOTIC* - DRUGS FOR PAIN AND FEVER...... 22 *ANALGESICS - OPIOID* - DRUGS FOR PAIN AND FEVER...... 23 *ANDROGENS-ANABOLIC* - HORMONES...... 27 *ANORECTAL AND RELATED PRODUCTS* - RECTAL PREPARATIONS...... 27 *ANTACIDS* - DRUGS FOR THE STOMACH...... 28 *ANTHELMINTICS* - DRUGS FOR INFECTIONS...... 28 *ANTIANGINAL AGENTS* - DRUGS FOR THE HEART...... 28 *ANTIANXIETY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 29 *ANTIARRHYTHMICS* - DRUGS FOR THE HEART...... 30 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* - DRUGS FOR THE LUNGS...... 31 *ANTICOAGULANTS* - DRUGS FOR THE BLOOD...... 34 *ANTICONVULSANTS* - DRUGS FOR THE NERVOUS SYSTEM...... 35 *ANTIDEPRESSANTS* - DRUGS FOR THE NERVOUS SYSTEM...... 39 *ANTIDIABETICS* - HORMONES...... 42 *ANTIDIARRHEAL/PROBIOTIC AGENTS* - DRUGS FOR THE STOMACH...... 45 *ANTIDOTES AND SPECIFIC ANTAGONISTS* - DRUGS FOR OVERDOSE OR POISONING...... 46 *ANTIEMETICS* - DRUGS FOR THE STOMACH...... 47 *ANTIFUNGALS* - DRUGS FOR INFECTIONS...... 48 *ANTIHISTAMINES* - DRUGS FOR THE LUNGS...... 50 *ANTIHYPERLIPIDEMICS* - DRUGS FOR THE HEART...... 51 *ANTIHYPERTENSIVES* - DRUGS FOR THE HEART...... 53 *ANTI-INFECTIVE AGENTS - MISC.* - DRUGS FOR INFECTIONS...... 57 *ANTIMALARIALS* - DRUGS FOR INFECTIONS...... 60 *ANTIMYASTHENIC/CHOLINERGIC AGENTS* - DRUGS FOR NERVES AND MUSCLES...... 60 *ANTIMYCOBACTERIAL AGENTS* - DRUGS FOR INFECTIONS...... 61 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* - DRUGS FOR CANCER...... 61 *ANTIPARKINSON AND RELATED THERAPY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 77 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 79 *ANTISEPTICS & DISINFECTANTS* - ANTISEPTICS AND DISINFECTANTS...... 82 *ANTIVIRALS* - DRUGS FOR INFECTIONS...... 82 *BETA BLOCKERS* - DRUGS FOR THE HEART...... 88 *CALCIUM CHANNEL BLOCKERS* - DRUGS FOR THE HEART...... 89 *CARDIOTONICS* - DRUGS FOR THE HEART...... 91 *CARDIOVASCULAR AGENTS - MISC.* - DRUGS FOR THE HEART...... 92 *CEPHALOSPORINS* - DRUGS FOR INFECTIONS...... 94 *CONTRACEPTIVES* - DRUGS FOR WOMEN...... 96 *CORTICOSTEROIDS* - HORMONES...... 102 *COUGH/COLD/ALLERGY* - DRUGS FOR THE LUNGS...... 104 *DERMATOLOGICALS* - DRUGS FOR THE SKIN...... 105 *DIGESTIVE AIDS* - DRUGS FOR THE STOMACH...... 116 *DIURETICS* - DRUGS FOR THE HEART...... 116 *ENDOCRINE AND METABOLIC AGENTS - MISC.* - HORMONES...... 118 *ESTROGENS* - HORMONES...... 124 *FLUOROQUINOLONES* - DRUGS FOR INFECTIONS...... 125 *GASTROINTESTINAL AGENTS - MISC.* - DRUGS FOR THE STOMACH...... 126 *GENERAL ANESTHETICS* - DRUGS FOR PAIN AND FEVER...... 128 *GENITOURINARY AGENTS - MISCELLANEOUS* - DRUGS FOR THE URINARY SYSTEM...... 129 *GOUT AGENTS* - DRUGS FOR PAIN AND FEVER...... 131 *HEMATOLOGICAL AGENTS - MISC.* - DRUGS FOR THE BLOOD...... 131 *HEMATOPOIETIC AGENTS* - DRUGS FOR NUTRITION...... 135 *HEMOSTATICS* - DRUGS FOR THE BLOOD...... 138 *HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 139 TOC-2 *LAXATIVES* - DRUGS FOR THE STOMACH...... 141 *LOCAL ANESTHETICS-PARENTERAL* - DRUGS FOR PAIN AND FEVER...... 142 *MACROLIDES* - DRUGS FOR INFECTIONS...... 143 *MEDICAL DEVICES AND SUPPLIES* - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT...... 144 *MIGRAINE PRODUCTS* - DRUGS FOR THE NERVOUS SYSTEM...... 147 *MINERALS & ELECTROLYTES* - DRUGS FOR NUTRITION...... 148 *MISCELLANEOUS THERAPEUTIC CLASSES* - VITAMINS AND MINERALS...... 150 *MOUTH/THROAT/DENTAL AGENTS* - DRUGS FOR THE MOUTH AND THROAT...... 155 *MULTIVITAMINS* - DRUGS FOR NUTRITION...... 156 *MUSCULOSKELETAL THERAPY AGENTS* - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES...... 161 *NASAL AGENTS - SYSTEMIC AND TOPICAL* - DRUGS FOR THE NOSE...... 163 *NEUROMUSCULAR AGENTS* - DRUGS FOR NERVES AND MUSCLES...... 164 *NUTRIENTS* - DRUGS FOR NUTRITION...... 165 *OPHTHALMIC AGENTS* - DRUGS FOR THE EYE...... 166 *OTIC AGENTS* - DRUGS FOR THE EAR...... 173 *OXYTOCICS* - HORMONES...... 174 *PASSIVE IMMUNIZING AND TREATMENT AGENTS* - BIOLOGICAL AGENTS...... 174 *PENICILLINS* - DRUGS FOR INFECTIONS...... 176 *PROGESTINS* - HORMONES...... 177 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* - DRUGS FOR THE NERVOUS SYSTEM...... 177 *RESPIRATORY AGENTS - MISC.* - DRUGS FOR THE LUNGS...... 182 *SULFONAMIDES* - DRUGS FOR INFECTIONS...... 183 *TETRACYCLINES* - DRUGS FOR INFECTIONS...... 183 *THYROID AGENTS* - HORMONES...... 184 *TOXOIDS* - BIOLOGICAL AGENTS...... 185 *ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS* - DRUGS FOR THE STOMACH...... 185 *URINARY ANTISPASMODICS* - DRUGS FOR THE URINARY SYSTEM...... 187 *VACCINES* - BIOLOGICAL AGENTS...... 188 *VAGINAL AND RELATED PRODUCTS* - DRUGS FOR WOMEN...... 190 *VASOPRESSORS* - DRUGS FOR THE HEART...... 191 *VITAMINS* - DRUGS FOR NUTRITION...... 192

TOC-3 National Direct Drug List – Informational Section

Definitions

“$0” next to a drug means this is a preventive drug. For some members, this product may be covered at 100% with $0 cost share with a prescription from your provider if specified criteria are met.

“BRAND name drug” means a drug that is marketed under a proprietary, trademark-protected name. A BRAND name drug is listed in this formulary in all CAPITAL letters.

“Coinsurance” means a percentage of the cost of a covered health care benefit that an enrollee pays after the enrollee has paid the deductible, if a deductible applies to the health care benefit, such as the prescription drug benefit.

“Copayment” means a fixed dollar amount that an enrollee pays for a covered health care benefit after the enrollee has paid the deductible, if a deductible applies to the health care benefit, such as the prescription drug benefit.

“Deductible” means the amount an enrollee pays for covered health care benefits before the enrollee’s health plan begins payment for all or part of the cost of the health care benefit under the terms of the policy.

“Dose Optimization (DO)” means dose optimization. Usually, this means you may have to switch from taking a drug twice a day to taking it once a day at a higher strength.

“Drug Tier” is a group of prescription drugs that corresponds to a specified cost sharing tier in the health plan’s prescription drug coverage. The tier in which a prescription drug is placed determines the enrollee’s portion of the cost for the drug.

“Enrollee” is a person enrolled in a health plan who is entitled to receive services from the plan. All references to enrollees in this this formulary template shall also include subscriber as defined in this section below.

“Exigent circumstances” means when you are suffering from a medical condition that may seriously jeopardize your life, health, or ability to regain maximum function, or when you are undergoing a current course of treatment using a non-formulary drug.

“Formulary” or “prescription drug list” is the complete list of drugs preferred for use and eligible for coverage under a health plan product, and includes all drugs covered under the outpatient prescription drug benefit of the health plan product. Formulary is also known as a prescription drug list.

“Generic drug” is the same drug as its BRAND name equivalent in dosage, safety, strength, how it is taken, quality, performance, and intended use. A generic drug is listed in bold and italicized lowercase letters.

“Limited Distribution (LD)” means limited distribution. These drugs are available only through certain pharmacies or wholesalers, depending on what the manufacturer decides.

“Medically Necessary” means health care benefits needed to diagnose, treat, or prevent a medical condition or its symptoms and that meet accepted standards of medicine. Health insurance usually does not cover health care benefits that are not medically necessary.

“Nonformulary drug” is a prescription drug that is not listed on the health plan’s formulary.

“Oral Chemotherapy (OC)” Notwithstanding any deductible, the total amount of copayments and coinsurance an insured is required to pay shall not exceed two hundred dollars ($200) for an individual prescription of up to a 30-day supply of a prescribed orally administered anticancer medication covered by the policy.

“Out-of-pocket costs” are copayments, coinsurance, and the applicable deductible, plus all costs for health care services that are not covered by the health plan.

“Prescribing provider” is a health care provider authorized to write a prescription to treat a medical condition for a health plan enrollee.

“Prescription” is an oral, written, or electronic order by a prescribing provider for a specific enrollee that contains the name of the prescription drug, the quantity of the prescribed drug, the date of issue, the name and contact information of the prescribing provider, the signature of the prescribing provider if the prescription is in writing, and if requested by the enrollee, the medical condition or purpose for which the drug is being prescribed.

“Prescription drug” is a drug that is prescribed by the enrollee’s prescribing provider and requires a prescription under applicable law.

“Prior Authorization (PA)” is a health plan’s requirement that the enrollee or the enrollee’s prescribing provider obtain the health plan’s authorization for a prescription drug before the health plan will cover the drug. The health plan shall grant a prior authorization when it is medically necessary for the enrollee to obtain the drug.

“Quantity limit (QL)” means a restriction on the number of doses of a prescription drug covered by a health insurance product during a specific time period, or any other limitation on the quantity of a drug that is covered.

“Specialty Drugs (SP)” means specialty drugs. Specialty drugs are used to treat difficult, long-term conditions. You may need to get this drug through a specialty pharmacy.

“Step therapy (ST)” is a process specifying the sequence in which different prescription drugs for a given medical condition and medically appropriate for a particular patient are prescribed. The health plan may require the enrollee to try one or more drugs to treat the enrollee’s medical condition before the health plan will cover a particular drug for the condition pursuant to a step therapy request.

“Subscriber” means the person who is responsible for payment to a plan or whose employment or other status, except for family dependency, is the basis for eligibility for membership in the plan.

Frequently Asked Questions

How do I know what drugs are covered under my benefits? This is a complete listing of all the drugs on the drug list. But, it’s possible a drug(s) on this list may not be covered, depending on your plan’s design.

Your pharmacy benefit covers prescription drugs, including Specialty Drugs, that may be administered to you as part of a doctor’s visit, home care visit, or at an outpatient Facility when they are Covered Services. Benefits that are administered to you in your provider’s office are typically covered under your medical benefit. This may include Drugs for infusion therapy, chemotherapy, blood products, certain injectables and any drug that must be administered by a Provider.

How can I find a drug on the list? (A) A prescription drug may be located by looking up the therapeutic category and class to which the drug belongs or the BRAND name or generic name of the drug in the alphabetical index; and (B) If a generic equivalent for a BRAND name drug is not available on the market or is not covered, the drug will not be separately listed by its generic name.

You can search the PDF drug list by:

o Drug name, using Ctrl + F on your keyboard, then type in the name of the drug you’re looking for. o Drug class, using the categories listed in alphabetical order.

How are drugs shown on the list? o A drug is listed alphabetically by its BRAND name and generic names in the therapeutic category and class to which it belongs; o The generic name for a BRAND name drug is included after the BRAND name in parentheses and all bold and italicized lowercase letters;

o If a generic equivalent for a BRAND name drug is both available and covered, the generic drug will be listed separately from the BRAND name drug in all bold and italicized lowercase letters; and

o If a generic drug is marketed under a proprietary, trademark-protected BRAND name, the BRAND name will be listed after the generic name in parentheses and regular typeface with the first letter of each word capitalized.

The “Under Coverage Requirements and Limits” section will indicate if you need preapproval before you can take the drug (called prior authorization or PA), or if you need to try other drugs first for your treatment (called step therapy or ST).

Note: The presence of a prescription drug on the formulary does not guarantee that your doctor will prescribe that prescription drug for a particular medical condition.

What are my options for getting my prescriptions? You have plenty of choices about how and where to get your prescription medicines, including local pharmacies in your plan, convenient home delivery or specialty pharmacies. Most plans include our home delivery program at no extra cost to you.

Current Anthem members can find out more by logging in at anthem.com/ca and choose Prescription Benefits or call 833-203-1739. For more details about your coverage, you can call the phone number on your member ID card.

What if my drug isn’t on the list? We understand that only you and your doctor know what is best for you. If you want to take a drug that’s not on the drug list, you may have to pay the full cost for it. You can also talk to your doctor or pharmacist to see if there’s another drug covered by your plan that will work just as well, or if generic or OTC drugs are an option. Only you and your doctor can decide what drugs are right for you.

If a drug you’re taking isn’t covered, your doctor can ask us to review the coverage. This process is called preapproval or prior authorization.

Your doctor can get the process started by completing an electronic Prior Authorization, calling the Member Services number on the back of your member ID card or by downloading a prior authorization form from our website and submitting it. If your request is approved, the amount you pay for the drug will depend on your plan’s benefit.

There are a few options for your doctor to start the Prior Authorization (PA) process: 1. Submit an electronic PA request by going to https://www.covermymeds.com/main/partners/anthem. 2. Log in at anthem.com/ca and choose Pharmacy. o Go to Pharmacy Resources and Search Your Drug List for your medication. o Choose the correct medication strength and form. o Scroll down to Definition of Restrictions and locate the applicable Fax Form in the table. o Your doctor completes and faxes the form to us at 844-474-3347. 3. Calling Member Services number on the back of your member ID card.

Who decides what drugs are on the list? The drugs on the list are reviewed through our Pharmacy and Therapeutics (P&T) process. In this process, a group of independent doctors, pharmacists and other health care professionals decides which drugs we include on our lists. This group meets regularly to look at new and existing drugs and recommends drugs based on how safe they are, how well they work and the value they offer our members.

What is a specialty drug and how do I get them? If you’re taking a medicine that is considered a specialty drug, you may need to use a specialty pharmacy in order for your drug to be covered. Specialty drugs come in many forms like pills, liquids, injections (shots), infusions or inhalers and may need special storage and handling. Typically benefits for specialty drugs that are self-administered will be covered under the pharmacy benefit. Benefits for specialty drugs that are administered to you in your provider’s office are typically covered under your medical benefit. If you use pharmacies that are not in the network, your medicine may not be covered and you may have to pay the full cost. For more details about your coverage, you can call the phone number on your member ID card.

Does the drug list change, and how will I know if it does? Drugs on our list are reviewed and updated on a monthly basis. Sometimes, drugs are added, removed, change tiers or have updated requirements. The changes will usually go into effect the first day of the month. But don’t worry, we’ll let you know if a drug you take is taken off the list and, in some cases, if a drug you take is moved to a higher tier.

You can always check the drug list to make sure medicines you take are still on it. You’ll find the most up-to-date drug list when you log in at anthem.com/ca.

What kind of drugs can I find on the formulary? We cover FDA-approved preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA) and California state regulations. Your doctor may need to write a prescription for these preventive services to be covered by your plan, even if they are listed as over-the-counter. The availability or coverage of these medications without cost-sharing may be subject to criteria established by the health plan.

We cover FDA-approved equipment and supplies for the management and treatment of insulin-using diabetes, non-insulin-using diabetes and gestational diabetes as medically necessary. Medication encompasses insulin, insulin pumps, and oral hypoglycemic agents. Covered supplies and equipment are limited to glucose monitors, test strips, syringes and lancets. Covered benefits also include outpatient self-management and educational services used to treat diabetes if services are provided through a program authorized by the State's Diabetes Control Project within the Bureau of Health.

What drugs can I find in each tier? We place drugs on different tiers based on how well they work to improve health, whether there are over-the-counter (OTC) options and their costs compared to other drugs used for the same type of treatment. The lower the tier, the lower your share of the cost. Here’s a breakdown of the tiers in your plan:

o Tier 1 drugs have the lowest cost share for you. These are usually generic drugs that offer the best value compared to other drugs that treat the same conditions. Some plans split Tier 1 into Tier 1a and Tier 1b:

- Tier 1a drugs have the lowest cost share. These are often generic drugs that offer the greatest value compared to others that treat the same conditions. - Tier 1b drugs have a low cost share. These are typically generic drugs that offer the greatest value compared to others that treat the same conditions.

o Tier 2 drugs have a higher cost share than Tier 1. They may be preferred BRAND drugs, based on how well they work and their cost compared to other drugs used for the same type of treatment. Some are generic drugs that may cost more because they're newer to the market.

o Tier 3 drugs have a higher cost share. They often include BRAND and generic drugs that may cost more than drugs on lower tiers that are used to treat the same condition. Tier 3 may also include drugs recently approved by the FDA.

o Tier 4 drugs have the highest cost share and usually include specialty BRAND and generic drugs. They may cost more than drugs on lower tiers that are used to treat the same condition. Tier 4 may also include drugs recently approved by the FDA or specialty drugs used to treat serious, long-term health conditions and that may need special handling.

How will I know how much my drug will cost? Current Anthem members can go online and with the Price a Medication Tool, get pharmacy-specific pricing from a number of local retail pharmacies in your zip code.

Note: For oral chemotherapy drugs - Notwithstanding any deductible, the total amount of copayments and coinsurance an insured is required to pay shall not exceed two hundred dollars ($200) for an individual prescription of up to a 30- day supply of a prescribed orally administered anticancer medication covered by the policy.

How does Anthem promote safety? When you go to a pharmacy, the pharmacist will get an electronic message from Anthem if a drug needs prior authorization, requires step therapy or has a limit on the amount that can be given. Here’s a closer look at all of the programs we’ve put into place to help make sure you get the care you need, while helping to keep you safe.1

Our clinical edit programs are:  Prior authorization, which requires you to get approval before taking a medicine. This helps make sure a drug is used properly and focuses on drugs that may have: — Risk of side effects. — Risk of harmful effects when taken with other drugs. — Potential for incorrect use or abuse. — Rules for use with certain conditions.  Step therapy, which requires that other drugs be tried first. It focuses on whether a drug is right for your condition.  Dose optimization, which involves changing from taking a dose twice a day to once a day, when medically appropriate. Taking fewer doses may lower your costs; a single higher dose of a drug taken once a day may cost less than a lower dose taken twice a day.  Quantity Limits impose a limit on the amount in a prescription and how often it can be refilled. — If a refill request is submitted too soon or the doctor prescribes an amount that's higher than what is allowed, the drug won't be covered at that time. — If there are medical reasons to prescribe the drug as originally dosed, the doctor can ask for review by our Prior Authorization Center.

Also, If you’re taking a medicine that is considered a specialty drug, you may need to use a specialty pharmacy in order for your drug to be covered. How does my doctor start the Prior Authorization process? If your drug is on our formulary but requires a PA or Step Therapy, there are a few options for your doctor to start the Prior Authorization (PA) process: 1. Submit an electronic PA request by going to https://www.covermymeds.com/main/partners/anthem. 2. Log in at anthem.com/ca and choose Pharmacy. o Go to Pharmacy Resources and Search Your Drug List for your medication. o Choose the correct medication strength and form. o Scroll down to Definition of Restrictions and locate the applicable Fax Form in the table. o Your doctor completes the form and faxes it to Anthem at 844-474-3347. 3. Calling Pharmacy Member Services number on the back of your member ID card.

What is Step Therapy? How does it work? Step therapy requires trying other drugs before certain medications may be covered. The pharmacy will let you know if step therapy is required and you must first try the drug or treatment included in the program. If the drug or treatment does not treat the condition well, the doctor can contact our Prior Authorization Center to ask that we approve the original drug.1

A note about opioid analgesics. The member cost share for certain abuse-deterrent opioid analgesics may be lower in some states because of laws in those states. Opioid analgesics are a type of painkiller. In response to the global opioid epidemic, the U.S. Food and Drug Administration (FDA) has encouraged drug manufacturers to develop opioids with properties that help deter their misuse and abuse.

Drug(s) may be excluded from the list based on your plan's benefit design.

1 If the Prior Authorization Center concludes the prescription claim should be denied, members and their doctors will get letters that explain the appeals and/or grievance process.

KEY Here are some terms and notes you’ll find on the drug list.

BRAND name drugs are in UPPER CASE, plain type. generic drugs are in lower case, italic bold type. $0 = preventive drugs. For some members, this Tier 1 = drugs have the lowest cost share for you. product may be covered at 100% with $0 cost share These are usually generic drugs that offer the best with a prescription from your provider if specified value compared to other drugs that treat the same criteria are met. conditions.

DO = dose optimization. Usually, this means you may Tier 1a = drugs have the lowest cost share. These are have to switch from taking a drug twice a day to taking often generic drugs that offer the greatest value it once a day at a higher strength. compared to others that treat the same conditions.

LD = limited distribution. These drugs are available Tier 1b = drugs have a low cost share. These are only through certain pharmacies or wholesalers, typically generic drugs that offer the greatest value depending on what the manufacturer decides. compared to others that treat the same conditions.

OC = oral chemotherapy. These drugs after deductible Tier 2 = drugs have a higher cost share than Tier 1. shall not exceed $200 per an individual prescription for They may be preferred BRAND drugs, based on how up to a 30 day supply. well they work and their cost compared to other drugs used for the same type of treatment. Some are PA = prior authorization. You may need to get benefits generic drugs that may cost more because they’re approved before certain prescriptions can be filled. newer to the market.

QL = quantity limits. There are limits on the amount of Tier 3 = drugs have a higher cost share. They often medicine covered within a certain amount of time. include BRAND and generic drugs that may cost more than drugs on lower tiers that are used to treat the SP = specialty drugs. Specialty drugs are used to treat same condition. difficult, long-term conditions. You may need to get this drug through a specialty pharmacy. Tier 4 = drugs have the highest cost share and usually include specialty BRAND and generic drugs. ST = step therapy. You may need to use another They may cost more than drugs on lower tiers that recommended drug first before a prescribed drug is are used to treat the same condition. covered.

Four Tier

CURRENT AS OF 9/1/2021

Coverage Requirements and Prescription Drug Name Drug Tier Limits *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* - DRUGS FOR THE NERVOUS SYSTEM *ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS*** - DRUGS FOR ATTENTION DEFICIT DISORDER clonidine hcl er oral tablet extended release 12 hour 1 or 1b* PA; QL (4 tablets per 1 day) guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg 1 or 1b* PA guanfacine hcl er oral tablet extended release 24 hour 3 mg, 4 mg 1 or 1b* PA; QL (1 tablet per 1 day) KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR (clonidine 3 PA; QL (4 tablets per 1 day) hcl) *ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR*** - DRUGS FOR ATTENTION DEFICIT DISORDER atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg, 40 mg 1 or 1b* PA atomoxetine hcl oral capsule 100 mg, 60 mg, 80 mg 1 or 1b* PA; QL (1 capsule per 1 day) *AMPHETAMINE MIXTURES*** - DRUGS FOR ATTENTION DEFICIT DISORDER amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 1 or 1b* PA 15 mg, 5 mg amphetamine-dextroamphet er oral capsule extended release 24 hour 20 mg, 1 or 1b* PA; QL (1 capsule per 1 day) 25 mg, 30 mg amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 5 mg, 1 or 1b* PA 7.5 mg amphetamine-dextroamphetamine oral tablet 20 mg 1 or 1b* PA; QL (3 tablets per 1 day) amphetamine-dextroamphetamine oral tablet 30 mg 1 or 1b* PA; QL (2 tablets per 1 day) MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 ST; QL (1 capsule per 1 day) (amphetamine-dextroamphetamine) *AMPHETAMINES*** - DRUGS FOR ATTENTION DEFICIT DISORDER ADZENYS ER ORAL SUSPENSION EXTENDED RELEASE 3 PA; QL (15 mL per 1 day) (amphetamine) ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE 3 ST; QL (1 tablet per 1 day) DISPERSIBLE (amphetamine) amphetamine er oral suspension extended release 1 or 1b* QL (15 mL per 1 day) amphetamine sulfate oral tablet 10 mg 1 or 1b* QL (6 tablets per 1 day) amphetamine sulfate oral tablet 5 mg 1 or 1b* dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 1 or 1b* PA; QL (4 capsules per 1 day) 15 mg dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg 1 or 1b* PA dextroamphetamine sulfate oral solution 1 or 1b* PA; QL (60 mL per 1 day) dextroamphetamine sulfate oral tablet 10 mg 1 or 1b* PA; QL (6 tablets per 1 day) dextroamphetamine sulfate oral tablet 5 mg 1 or 1b* PA DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE 3 ST; QL (8 mL per 1 day) (amphetamine) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 11 Coverage Requirements and Prescription Drug Name Drug Tier Limits EVEKEO ODT ORAL TABLET DISPERSIBLE (amphetamine sulfate) 3 ST; QL (2 tablets per 1 day) procentra oral solution 1 or 1b* PA; QL (60 mL per 1 day) VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG (lisdexamfetamine 2 PA dimesylate) VYVANSE ORAL CAPSULE 40 MG, 50 MG, 60 MG, 70 MG 2 PA; QL (1 capsule per 1 day) (lisdexamfetamine dimesylate) VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, 30 MG 2 PA (lisdexamfetamine dimesylate) VYVANSE ORAL TABLET CHEWABLE 40 MG, 50 MG, 60 MG 2 PA; QL (1 tablet per 1 day) (lisdexamfetamine dimesylate) zenzedi oral tablet 10 mg, 7.5 mg 1 or 1b* PA; QL (6 tablets per 1 day) zenzedi oral tablet 15 mg 1 or 1b* PA; QL (3 tablets per 1 day) zenzedi oral tablet 2.5 mg, 5 mg 1 or 1b* PA zenzedi oral tablet 20 mg, 30 mg 1 or 1b* PA; QL (2 tablets per 1 day) *ANALEPTICS*** - DRUGS FOR THE NERVOUS SYSTEM CAFCIT INTRAVENOUS SOLUTION (caffeine citrate) 3 caffeine citrate intravenous solution 1 or 1b* caffeine citrate oral solution 1 or 1b* DOPRAM INTRAVENOUS SOLUTION (doxapram hcl) 3 *ANOREXIANT COMBINATIONS*** - DRUGS FOR THE NERVOUS SYSTEM PLENITY ORAL CAPSULE (carboxymeth-cellulose-citricac) 3 PLENITY WELCOME KIT ORAL CAPSULE (carboxymeth-cellulose- 3 citricac) QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 PA (phentermine-topiramate) *ANOREXIANTS NON-AMPHETAMINE*** - DRUGS FOR THE NERVOUS SYSTEM ADIPEX-P ORAL CAPSULE (phentermine hcl) 3 PA ADIPEX-P ORAL TABLET (phentermine hcl) 3 PA benzphetamine hcl oral tablet 25 mg 1 or 1b* benzphetamine hcl oral tablet 50 mg 1 or 1b* PA diethylpropion hcl er oral tablet extended release 24 hour 1 or 1b* PA diethylpropion hcl oral tablet 1 or 1b* PA LOMAIRA ORAL TABLET (phentermine hcl) 3 PA phendimetrazine tartrate er oral capsule extended release 24 hour 1 or 1b* PA phendimetrazine tartrate oral tablet 1 or 1b* PA phentermine hcl oral capsule 1 or 1b* PA phentermine hcl oral tablet 1 or 1b* PA *ANTI-OBESITY - GLP-1 RECEPTOR AGONISTS*** - DRUGS FOR THE NERVOUS SYSTEM SAXENDA SUBCUTANEOUS SOLUTION PEN-INJECTOR (liraglutide - 3 PA weight management)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 12 Coverage Requirements and Prescription Drug Name Drug Tier Limits WEGOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR (semaglutide- 3 PA weight management) *ANTI-OBESITY AGENT COMBINATIONS** - DRUGS FOR THE NERVOUS SYSTEM CONTRAVE ORAL TABLET EXTENDED RELEASE 12 HOUR 3 PA (naltrexone-bupropion hcl) *DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS)*** - DRUGS FOR SLEEP DISORDER SUNOSI ORAL TABLET 150 MG (solriamfetol hcl) 3 PA; QL (1 tablet per 1 day) SUNOSI ORAL TABLET 75 MG (solriamfetol hcl) 3 PA *HISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTS*** - DRUGS FOR SLEEP DISORDER PA; LD; SP; QL (2 tablets per 1 WAKIX ORAL TABLET 17.8 MG (pitolisant hcl) 4 day) WAKIX ORAL TABLET 4.45 MG (pitolisant hcl) 4 PA; LD; SP *LIPASE INHIBITORS*** - DRUGS FOR THE NERVOUS SYSTEM XENICAL ORAL CAPSULE (orlistat) 3 PA *MELANOCORTIN 4 (MC4) RECEPTOR AGONISTS*** - DRUGS FOR THE NERVOUS SYSTEM IMCIVREE SUBCUTANEOUS SOLUTION (setmelanotide acetate) 4 PA; LD; QL (9 vials per 30 days) *STIMULANTS - MISC.*** - DRUGS FOR ATTENTION DEFICIT DISORDER ADHANSIA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 ST; QL (1 capsule per 1 day) (methylphenidate hcl) APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 3 ST MG, 15 MG, 20 MG, 30 MG (methylphenidate hcl) APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 40 3 ST; QL (1 capsule per 1 day) MG, 50 MG, 60 MG (methylphenidate hcl) armodafinil oral tablet 150 mg, 200 mg, 250 mg 1 or 1b* PA; QL (1 tablet per 1 day) armodafinil oral tablet 50 mg 1 or 1b* PA; QL (2 tablets per 1 day) COTEMPLA XR-ODT ORAL TABLET EXTENDED RELEASE 3 ST; QL (2 tablets per 1 day) DISPERSIBLE (methylphenidate) DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 MG/9HR 3 ST (methylphenidate) DAYTRANA TRANSDERMAL PATCH 20 MG/9HR, 30 MG/9HR 3 ST; QL (1 patch per 1 day) (methylphenidate) dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 1 or 1b* PA mg, 20 mg, 5 mg dexmethylphenidate hcl er oral capsule extended release 24 hour 25 mg, 30 1 or 1b* PA; QL (1 capsule per 1 day) mg, 35 mg, 40 mg dexmethylphenidate hcl oral tablet 10 mg 1 or 1b* PA; QL (2 tablets per 1 day) dexmethylphenidate hcl oral tablet 2.5 mg, 5 mg 1 or 1b* PA FOCALIN ORAL TABLET 10 MG (dexmethylphenidate hcl) 3 PA; QL (2 tablets per 1 day) FOCALIN ORAL TABLET 2.5 MG, 5 MG (dexmethylphenidate hcl) 3 PA JORNAY PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 3 ST; QL (1 capsule per 1 day) 60 MG, 80 MG (methylphenidate hcl)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 13 Coverage Requirements and Prescription Drug Name Drug Tier Limits JORNAY PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG, 3 ST 40 MG (methylphenidate hcl) METHYLIN ORAL SOLUTION 10 MG/5ML (methylphenidate hcl) 3 ST; QL (30 mL per 1 day) METHYLIN ORAL SOLUTION 5 MG/5ML (methylphenidate hcl) 3 ST; QL (60 mL per 1 day) methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 1 or 1b* PA mg methylphenidate hcl er (cd) oral capsule extended release 40 mg, 50 mg, 60 1 or 1b* PA; QL (1 capsule per 1 day) mg methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 1 or 1b* PA mg methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg 1 or 1b* PA; QL (2 capsules per 1 day) methylphenidate hcl er (la) oral capsule extended release 24 hour 40 mg, 60 1 or 1b* PA; QL (1 capsule per 1 day) mg methylphenidate hcl er (xr) oral capsule extended release 24 hour 10 mg, 15 1 or 1b* PA mg, 20 mg, 30 mg methylphenidate hcl er (xr) oral capsule extended release 24 hour 40 mg, 50 1 or 1b* PA; QL (1 capsule per 1 day) mg, 60 mg methylphenidate hcl er oral tablet extended release 10 mg, 18 mg, 27 mg 1 or 1b* PA methylphenidate hcl er oral tablet extended release 20 mg 1 or 1b* PA; QL (3 tablets per 1 day) methylphenidate hcl er oral tablet extended release 24 hour 1 or 1b* PA methylphenidate hcl er oral tablet extended release 36 mg 1 or 1b* PA; QL (2 tablets per 1 day) methylphenidate hcl er oral tablet extended release 54 mg 1 or 1b* PA; QL (1 tablet per 1 day) METHYLPHENIDATE HCL ER ORAL TABLET EXTENDED RELEASE 3 ST; QL (1 tablet per 1 day) 72 MG methylphenidate hcl oral solution 10 mg/5ml 1 or 1b* PA; QL (30 mL per 1 day) methylphenidate hcl oral solution 5 mg/5ml 1 or 1b* PA; QL (60 mL per 1 day) methylphenidate hcl oral tablet 10 mg, 5 mg 1 or 1b* PA methylphenidate hcl oral tablet 20 mg 1 or 1b* PA; QL (3 tablets per 1 day) methylphenidate hcl oral tablet chewable 10 mg 1 or 1b* PA; QL (3 tablets per 1 day) methylphenidate hcl oral tablet chewable 2.5 mg 1 or 1b* ST methylphenidate hcl oral tablet chewable 5 mg 1 or 1b* PA modafinil oral tablet 100 mg 1 or 1b* PA modafinil oral tablet 200 mg 1 or 1b* PA; QL (1 tablet per 1 day) QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 3 ST 20 MG (methylphenidate hcl) QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 3 ST; QL (2 tablets per 1 day) 30 MG (methylphenidate hcl) QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 3 ST; QL (1 tablet per 1 day) 40 MG (methylphenidate hcl) QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED ER 3 QL (12 mL per 1 day) (methylphenidate hcl) RELEXXII ORAL TABLET EXTENDED RELEASE (methylphenidate hcl) 3 ST; QL (1 tablet per 1 day) RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 3 PA 20 MG (methylphenidate hcl)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 14 Coverage Requirements and Prescription Drug Name Drug Tier Limits RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 30 MG 3 PA; QL (2 capsules per 1 day) (methylphenidate hcl) RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 40 MG 3 PA; QL (1 capsule per 1 day) (methylphenidate hcl) RITALIN ORAL TABLET 10 MG, 5 MG (methylphenidate hcl) 3 PA RITALIN ORAL TABLET 20 MG (methylphenidate hcl) 3 PA; QL (3 tablets per 1 day) *ALLERGENIC EXTRACTS/BIOLOGICALS MISC* - BIOLOGICAL AGENTS *ALLERGENIC EXTRACTS*** - BIOLOGICAL AGENTS ACACIA SUBCUTANEOUS SOLUTION 3 ACREMONIUM SUBCUTANEOUS SOLUTION 3 ALDER SUBCUTANEOUS SOLUTION 3 ALTERNARIA SUBCUTANEOUS SOLUTION 3 AMERICAN BEECH SUBCUTANEOUS SOLUTION 3 AMERICAN COCKROACH SUBCUTANEOUS SOLUTION 3 AMERICAN ELM SUBCUTANEOUS SOLUTION 3 ARIZONA CYPRESS SUBCUTANEOUS SOLUTION 3 ASPERGILLUS FUMIGATUS INJECTION SOLUTION 3 AUREOBASIDIUM PULLULANS INJECTION SOLUTION 3 AUREOBASIDIUM SUBCUTANEOUS SOLUTION 3 AUSTRALIAN PINE SUBCUTANEOUS SOLUTION 3 BAHIA SUBCUTANEOUS SOLUTION 3 BALD CYPRESS SUBCUTANEOUS SOLUTION 3 BAYBERRY (WAX MYRTLE) SUBCUTANEOUS SOLUTION 3 BERMUDA GRASS INJECTION SOLUTION 3 BERMUDA GRASS SUBCUTANEOUS SOLUTION 3 BLACK WILLOW SUBCUTANEOUS SOLUTION 3 BOTRYTIS INJECTION SOLUTION 3 BOTRYTIS SUBCUTANEOUS SOLUTION 3 BROME SUBCUTANEOUS SOLUTION 3 CALIFORNIA PEPPER TREE SUBCUTANEOUS SOLUTION 3 CANDIDA ALBICANS EXTRACT INJECTION SOLUTION 3 CANDIDA ALBICANS EXTRACT SUBCUTANEOUS SOLUTION 3 CAT HAIR EXTRACT INJECTION SOLUTION 3 CAT HAIR EXTRACT SUBCUTANEOUS SOLUTION 3 CATTLE EPITHELIUM SUBCUTANEOUS SOLUTION 3 CEDAR ELM SUBCUTANEOUS SOLUTION 3 CLADOSPORIUM CLADOSPORIOIDES INJECTION SOLUTION 3 CLADOSPORIUM CLADOSPORIOIDES INTRADERMAL SOLUTION 3 CLADOSPORIUM CLADOSPORIOIDES SUBCUTANEOUS SOLUTION 3 CLADOSPORIUM SPHAEROSPERMUM SUBCUTANEOUS SOLUTION 3 COCKLEBUR SUBCUTANEOUS SOLUTION 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 15 Coverage Requirements and Prescription Drug Name Drug Tier Limits CORN POLLEN SUBCUTANEOUS SOLUTION 3 CURVULARIA SUBCUTANEOUS SOLUTION 3 DANDELION SUBCUTANEOUS SOLUTION 3 DOG EPITHELIUM SUBCUTANEOUS SOLUTION 3 DOG FENNEL SUBCUTANEOUS SOLUTION 3 DRECHSLERA SUBCUTANEOUS SOLUTION 3 EASTERN COTTONWOOD SUBCUTANEOUS SOLUTION 3 EPICOCCUM NIGRUM INJECTION SOLUTION 3 EPICOCCUM SUBCUTANEOUS SOLUTION 3 FIRE ANT SUBCUTANEOUS SOLUTION 3 FUSARIUM SUBCUTANEOUS SOLUTION 3 GERMAN COCKROACH SUBCUTANEOUS SOLUTION 3 GOLDENROD SUBCUTANEOUS SOLUTION 3 GRASS POLLEN(K-O-R-T-SWT VERN) INJECTION SOLUTION 3 GRASTEK SUBLINGUAL TABLET SUBLINGUAL (timothy grass pollen 3 PA; QL (1 tablet per 1 day) allergen) HACKBERRY SUBCUTANEOUS SOLUTION 3 HONEY BEE VENOM PROTEIN INJECTION SOLUTION 3 RECONSTITUTED (honey bee venom) HONEY BEE VENOM SUBCUTANEOUS SOLUTION RECONSTITUTED 3 HORSE EPITHELIUM SUBCUTANEOUS SOLUTION 3 JOHNSON GRASS SUBCUTANEOUS SOLUTION 3 JUNE GRASS POLLEN STANDARDIZED SUBCUTANEOUS SOLUTION 3 KAPOK SUBCUTANEOUS SOLUTION 3 KOCHIA SUBCUTANEOUS SOLUTION 3 LENSCALE SUBCUTANEOUS SOLUTION 3 MEADOW FESCUE GRASS POLLEN SUBCUTANEOUS SOLUTION 3 MELALEUCA SUBCUTANEOUS SOLUTION 3 MESQUITE SUBCUTANEOUS SOLUTION 3 MITE (D. FARINAE) INJECTION SOLUTION 3 MITE (D. FARINAE) SUBCUTANEOUS SOLUTION 3 MITE (D. PTERONYSSINUS) INJECTION SOLUTION 3 MITE (D. PTERONYSSINUS) SUBCUTANEOUS SOLUTION 3 MIXED RAGWEED SUBCUTANEOUS SOLUTION 3 MIXED VESPID VENOM PROTEIN INJECTION SOLUTION 3 RECONSTITUTED MIXED VESPID VENOM PROTEIN SUBCUTANEOUS SOLUTION 3 RECONSTITUTED MOUNTAIN CEDAR SUBCUTANEOUS SOLUTION 3 MOUSE EPITHELIUM SUBCUTANEOUS SOLUTION 3 MUCOR INJECTION SOLUTION 3 MUCOR INTRADERMAL SOLUTION 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 16 Coverage Requirements and Prescription Drug Name Drug Tier Limits MUCOR SUBCUTANEOUS SOLUTION 3 MUGWORT SUBCUTANEOUS SOLUTION 3 OLIVE TREE SUBCUTANEOUS SOLUTION 3 ORCHARD GRASS POLLEN SUBCUTANEOUS SOLUTION 3 PALFORZIA (12 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (120 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (160 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (20 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (200 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (240 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (3 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (300 MG MAINTENANCE) ORAL PACKET (peanut powder- PA; LD; SP; QL (1 packet per 1 4 dnfp) day) PALFORZIA (300 MG TITRATION) ORAL PACKET (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (40 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (6 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (80 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA INITIAL ESCALATION ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PENICILLIUM NOTATUM INJECTION SOLUTION 3 PENICILLIUM NOTATUM SUBCUTANEOUS SOLUTION 3 PERENNIAL RYE GRASS POLLEN INJECTION SOLUTION 3 PHOMA EXIGUA SUBCUTANEOUS SOLUTION 3 PRIVET SUBCUTANEOUS SOLUTION 3 QUEEN PALM SUBCUTANEOUS SOLUTION 3 RABBIT EPITHELIUM SUBCUTANEOUS SOLUTION 3 RAGWITEK SUBLINGUAL TABLET SUBLINGUAL (short ragweed pollen 3 PA; QL (1 tablet per 1 day) ext) RED MAPLE SUBCUTANEOUS SOLUTION 3 RED MULBERRY SUBCUTANEOUS SOLUTION 3 RED TOP GRASS POLLEN SUBCUTANEOUS SOLUTION 3 RHIZOPUS SUBCUTANEOUS SOLUTION 3 ROUGH MARSH ELDER SUBCUTANEOUS SOLUTION 3 RUSSIAN THISTLE SUBCUTANEOUS SOLUTION 3 SACCHAROMYCES CEREVISIAE INJECTION SOLUTION 3 SACCHAROMYCES CEREVISIAE SUBCUTANEOUS SOLUTION 3 SHAGBARK HICKORY SUBCUTANEOUS SOLUTION 3 SHEEP SORREL SUBCUTANEOUS SOLUTION 3 SHORT RAGWEED POLLEN EXT SUBCUTANEOUS SOLUTION 3 SPINY PIGWEED SUBCUTANEOUS SOLUTION 3 STEMPHYLIUM SUBCUTANEOUS SOLUTION 3 SWEET GUM SUBCUTANEOUS SOLUTION 3 SWEET VERNAL GRASS POLLEN SUBCUTANEOUS SOLUTION 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 17 Coverage Requirements and Prescription Drug Name Drug Tier Limits TALL RAGWEED SUBCUTANEOUS SOLUTION 3 TIMOTHY GRASS POLLEN ALLERGEN INJECTION SOLUTION 3 TIMOTHY GRASS POLLEN ALLERGEN SUBCUTANEOUS SOLUTION 3 TRICHOPHYTON MENTAGROPHYTES SUBCUTANEOUS SOLUTION 3 TRICHOPHYTON SUBCUTANEOUS SOLUTION 3 VENOMIL HONEY BEE VENOM INJECTION KIT (honey bee venom) 3 VENOMIL MIXED VESPID VENOM INJECTION SOLUTION 3 RECONSTITUTED (mixed vespid venom) VENOMIL WASP VENOM INJECTION KIT (wasp venom) 3 VENOMIL WHITE FACED HORNET INJECTION KIT (white faced hornet 3 venom) VENOMIL YELLOW HORNET VENOM INJECTION KIT (yellow hornet 3 venom) VENOMIL YELLOW JACKET VENOM INJECTION KIT (yellow jacket 3 venom) WASP VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 3 WASP VENOM PROTEIN SUBCUTANEOUS SOLUTION 3 RECONSTITUTED WESTERN JUNIPER SUBCUTANEOUS SOLUTION 3 WHITE BIRCH SUBCUTANEOUS SOLUTION 3 WHITE FACED HORNET VENOM SUBCUTANEOUS SOLUTION 3 RECONSTITUTED WHITE MULBERRY SUBCUTANEOUS SOLUTION 3 WHITE OAK SUBCUTANEOUS SOLUTION 3 WHITE PINE SUBCUTANEOUS SOLUTION 3 WHITE-FACED HORNET VENOM INJECTION SOLUTION 3 RECONSTITUTED (white faced hornet venom) YELLOW DOCK SUBCUTANEOUS SOLUTION 3 YELLOW HORNET VENOM PROTEIN INJECTION SOLUTION 3 RECONSTITUTED YELLOW HORNET VENOM PROTEIN SUBCUTANEOUS SOLUTION 3 RECONSTITUTED YELLOW JACKET VENOM PROTEIN INJECTION SOLUTION 3 RECONSTITUTED YELLOW JACKET VENOM PROTEIN SUBCUTANEOUS SOLUTION 3 RECONSTITUTED *MIXED ALLERGENIC EXTRACTS*** - BIOLOGICAL AGENTS DUST MITE MIXED ALLERGEN EXT INJECTION SOLUTION 3 DUST MITE MIXED ALLERGEN EXT SUBCUTANEOUS SOLUTION 3 MIXED ASPERGILLUS SUBCUTANEOUS SOLUTION 3 MIXED FEATHERS SUBCUTANEOUS SOLUTION 3 ODACTRA SUBLINGUAL TABLET SUBLINGUAL (dust mite mixed 3 PA; QL (1 tablet per 1 day) allergen ext) ORALAIR SUBLINGUAL TABLET SUBLINGUAL (grass mix pollens 3 PA; LD; QL (1 tablet per 1 day) allergen ext)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 18 Coverage Requirements and Prescription Drug Name Drug Tier Limits SORREL/DOCK MIX SUBCUTANEOUS SOLUTION 3 *AMEBICIDES* - DRUGS FOR INFECTIONS *AMEBICIDES*** - DRUGS FOR PARASITES SOLOSEC ORAL PACKET (secnidazole) 3 ST; QL (2 grams per 1 fill) *AMINOGLYCOSIDES* - DRUGS FOR INFECTIONS *AMINOGLYCOSIDES*** - ANTIBIOTICS amikacin sulfate injection solution 1 or 1b* ARIKAYCE INHALATION SUSPENSION (amikacin sulfate liposome) 4 PA; LD; QL (1 kit per 28 days) BETHKIS INHALATION NEBULIZATION SOLUTION (tobramycin) 4 LD; SP; QL (224 mL per 28 days) gentamicin in saline intravenous solution 1 or 1b* gentamicin sulfate injection solution 1 or 1b* HUMATIN ORAL CAPSULE (paromomycin sulfate) 3 neomycin sulfate oral tablet 1 or 1a* paromomycin sulfate oral capsule 1 or 1b* streptomycin sulfate intramuscular solution reconstituted 1 or 1b* LD; SP; QL (224 capsules per 28 TOBI PODHALER INHALATION CAPSULE (tobramycin) 4 days) tobramycin inhalation nebulization solution 300 mg/4ml 4 SP; QL (224 mL per 28 days) tobramycin inhalation nebulization solution 300 mg/5ml 4 SP; QL (9.4 mL per 1 day) tobramycin sulfate injection solution 1 or 1b* tobramycin sulfate injection solution reconstituted 1 or 1b* QL (30 vials per 30 days) ZEMDRI INTRAVENOUS SOLUTION (plazomicin sulfate) 3 *ANALGESICS - ANTI-INFLAMMATORY* - DRUGS FOR PAIN AND FEVER *ANTIRHEUMATIC - JANUS KINASE (JAK) INHIBITORS*** - ARTHRITIS AND PAIN DRUGS RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR (upadacitinib) 4 PA; SP; QL (1 tablet per 1 day) XELJANZ ORAL SOLUTION (tofacitinib citrate) 4 PA; SP; QL (10 ML per 1 day) XELJANZ ORAL TABLET (tofacitinib citrate) 4 PA; SP; QL (2 tablets per 1 day) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG 4 PA; SP; QL (1 tablet per 1 day) (tofacitinib citrate) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 22 MG 4 PA; QL (1 tablet per 1 day) (tofacitinib citrate) *ANTIRHEUMATIC ANTIMETABOLITES*** - ARTHRITIS AND PAIN DRUGS OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; SP; QL (4 auto-injector per 28 4 (methotrexate (anti-rheumatic)) days) RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR (methotrexate PA; SP; QL (4 auto-injector per 28 4 (anti-rheumatic)) days) REDITREX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; QL (4 auto-injector per 28 4 (methotrexate (anti-rheumatic)) days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 19 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES*** - ARTHRITIS AND PAIN DRUGS HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED 4 PA; SP; QL (1 kit per 365 days) SYRINGE KIT (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML 4 PA; SP; QL (2 EA per 28 days) (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML 4 PA; SP; QL (2 pens per 28 days) (adalimumab) PA; SP; QL (2 kits per 28 days (QL HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML 4 exception needed for maintenance (adalimumab) therapys) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR 4 PA; SP; QL (1 kit per 365 days) KIT (adalimumab) HUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS PEN- 4 PA; SP; QL (1 kit per 365 days) INJECTOR KIT (adalimumab) HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN- 4 PA; SP; QL (1 kit per 365 days) INJECTOR KIT (adalimumab) HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PEN- 4 PA; SP; QL (1 kit per 365 days) INJECTOR KIT (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 20 4 PA; SP; QL (2 EA per 28 days) MG/0.2ML, 40 MG/0.4ML (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML 4 PA; SP; QL (2 syringes per 28 days) (adalimumab) SIMPONI ARIA INTRAVENOUS SOLUTION (golimumab) 4 PA; SP *CYCLOOXYGENASE 2 (COX-2) INHIBITORS*** - ARTHRITIS AND PAIN DRUGS celecoxib oral capsule 100 mg, 200 mg, 50 mg 1 or 1b* ST; QL (2 capsules per 1 day) celecoxib oral capsule 400 mg 1 or 1b* ST; QL (1 capsule per 1 day) *GOLD COMPOUNDS*** - ARTHRITIS AND PAIN DRUGS RIDAURA ORAL CAPSULE (auranofin) 2 *INTERLEUKIN-1 BLOCKERS*** - ARTHRITIS AND PAIN DRUGS ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED PA; LD; SP; QL (4 vials per 28 4 (rilonacept) days) *INTERLEUKIN-1BETA BLOCKERS*** - ARTHRITIS AND PAIN DRUGS PA; LD; SP; QL (2 vials per 28 ILARIS SUBCUTANEOUS SOLUTION (canakinumab) 4 days) *NONSTEROIDAL ANTI-INFLAMMATORY AGENT COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS diclofenac-misoprostol oral tablet delayed release 50-0.2 mg 1 or 1b* ST; QL (4 tablets per 1 day) diclofenac-misoprostol oral tablet delayed release 75-0.2 mg 1 or 1b* ST; QL (2 tablets per 1 day) *NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)*** - ARTHRITIS AND PAIN DRUGS ANJESO INTRAVENOUS INJECTABLE (meloxicam) 3 CALDOLOR INTRAVENOUS SOLUTION (ibuprofen) 3 cataflam oral tablet 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 20 Coverage Requirements and Prescription Drug Name Drug Tier Limits DAYPRO ORAL TABLET (oxaprozin) 3 QL (2 tablets per 1 day) diclofenac potassium oral tablet 1 or 1b* diclofenac sodium er oral tablet extended release 24 hour 1 or 1b* QL (2 tablets per 1 day) diclofenac sodium oral tablet delayed release 25 mg 1 or 1b* QL (5 tablets per 1 day) diclofenac sodium oral tablet delayed release 50 mg 1 or 1b* QL (4 tablets per 1 day) diclofenac sodium oral tablet delayed release 75 mg 1 or 1b* QL (2 tablets per 1 day) ec-naproxen oral tablet delayed release 1 or 1b* etodolac er oral tablet extended release 24 hour 400 mg, 500 mg 1 or 1b* QL (2 tablets per 1 day) etodolac er oral tablet extended release 24 hour 600 mg 1 or 1b* QL (1 tablet per 1 day) etodolac oral capsule 200 mg 1 or 1b* QL (4 capsules per 1 day) etodolac oral capsule 300 mg 1 or 1b* QL (3 capsules per 1 day) etodolac oral tablet 1 or 1b* QL (2 tablets per 1 day) FELDENE ORAL CAPSULE (piroxicam) 3 QL (1 capsule per 1 day) fenoprofen calcium oral tablet 1 or 1b* QL (4 tablets per 1 day) flurbiprofen oral tablet 100 mg 1 or 1b* QL (3 tablets per 1 day) flurbiprofen oral tablet 50 mg 1 or 1b* QL (4 tablets per 1 day) ibu oral tablet 1 or 1a* QL (4 tablets per 1 day) ibuprofen lysine intravenous solution 1 or 1b* ibuprofen oral suspension 1 or 1a* QL (4 mL per 1 day) ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 or 1a* QL (4 tablets per 1 day) indomethacin er oral capsule extended release 1 or 1b* QL (2 capsules per 1 day) indomethacin oral capsule 25 mg 1 or 1b* QL (3 capsule per 1 day) indomethacin oral capsule 50 mg 1 or 1b* QL (4 capsule per 1 day) indomethacin sodium intravenous solution reconstituted 1 or 1b* ketoprofen er oral capsule extended release 24 hour 1 or 1b* QL (1 capsule per 1 day) ketoprofen oral capsule 50 mg 1 or 1b* ketoprofen oral capsule 75 mg 1 or 1b* QL (4 capsules per 1 day) ketorolac tromethamine injection solution 15 mg/ml 1 or 1b* QL (4 mL per 30 days) ketorolac tromethamine injection solution 30 mg/ml 1 or 1b* QL (2 mL per 30 days) ketorolac tromethamine intramuscular solution 1 or 1b* QL (2 mL per 30 days) ketorolac tromethamine oral tablet 1 or 1a* QL (20 tablets per 30 days) LODINE ORAL TABLET (etodolac) 3 QL (2 tablets per 1 day) meclofenamate sodium oral capsule 1 or 1b* QL (4 capsules per 1 day) mefenamic acid oral capsule 1 or 1b* QL (29 capsule per 1 fill) meloxicam oral tablet 1 or 1b* QL (1 tablet per 1 day) nabumetone oral tablet 500 mg 1 or 1b* QL (4 tablets per 1 day) nabumetone oral tablet 750 mg 1 or 1b* QL (2 tablets per 1 day) naproxen oral suspension 1 or 1b* naproxen oral tablet 1 or 1b* naproxen oral tablet delayed release 1 or 1b* naproxen sodium oral tablet 275 mg 1 or 1b* QL (4 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 21 Coverage Requirements and Prescription Drug Name Drug Tier Limits naproxen sodium oral tablet 550 mg 1 or 1b* QL (2 tablets per 1 day) NEOPROFEN INTRAVENOUS SOLUTION (ibuprofen lysine) 3 oxaprozin oral tablet 1 or 1b* QL (2 tablets per 1 day) piroxicam oral capsule 1 or 1b* QL (1 capsule per 1 day) relafen oral tablet 500 mg 1 or 1b* QL (4 tablets per 1 day) relafen oral tablet 750 mg 1 or 1b* QL (2 tablets per 1 day) sulindac oral tablet 1 or 1b* QL (2 tablets per 1 day) *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS*** - ARTHRITIS AND PAIN DRUGS OTEZLA ORAL TABLET (apremilast) 4 PA; SP; QL (2 tablets per 1 day) OTEZLA ORAL TABLET THERAPY PACK (apremilast) 4 PA; SP; QL (1 pack per 365 days) *PYRIMIDINE SYNTHESIS INHIBITORS*** - ARTHRITIS AND PAIN DRUGS ARAVA ORAL TABLET (leflunomide) 3 leflunomide oral tablet 1 or 1b* *SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS*** - ARTHRITIS AND PAIN DRUGS PA; SP; QL (4 cartridge per 28 ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE (etanercept) 4 days) PA; SP; QL (8 injections per 28 ENBREL SUBCUTANEOUS SOLUTION (etanercept) 4 days) ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 4 PA; SP; QL (8 syringes per 28 days) MG/0.5ML (etanercept) ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 4 PA; SP; QL (4 syringes per 28 days) MG/ML (etanercept) ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED (etanercept) 4 PA; SP; QL (8 vials per 28 days) ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 4 PA; SP; QL (4 pens per 28 days) (etanercept) *ANALGESICS - NONNARCOTIC* - DRUGS FOR PAIN AND FEVER *ANALGESICS OTHER*** - ARTHRITIS AND PAIN DRUGS acetaminophen intravenous solution 1 or 1b* clonidine hcl (analgesia) epidural solution 1 or 1b* DURACLON EPIDURAL SOLUTION (clonidine hcl (analgesia)) 3 OFIRMEV INTRAVENOUS SOLUTION (acetaminophen) 3 *ANALGESICS-SEDATIVES*** - ARTHRITIS AND PAIN DRUGS bac oral tablet 1 or 1b* QL (6 tablets per 1 day) bupap oral tablet 1 or 1b* QL (6 tablets per 1 day) butalbital-acetaminophen oral capsule 1 or 1b* QL (6 capsules per 1 day) butalbital-acetaminophen oral tablet 25-325 mg 1 or 1b* QL (12 tablets per 1 day) butalbital-acetaminophen oral tablet 50-300 mg, 50-325 mg 1 or 1b* QL (6 tablets per 1 day) butalbital-apap-caffeine oral capsule 1 or 1b* QL (6 capsules per 1 day) butalbital-apap-caffeine oral tablet 1 or 1b* QL (6 tablets per 1 day) butalbital-aspirin-caffeine oral capsule 1 or 1b* QL (6 capsules per 1 day) esgic oral capsule 1 or 1b* QL (6 capsules per 1 day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 22 Coverage Requirements and Prescription Drug Name Drug Tier Limits tencon oral tablet 1 or 1b* QL (6 tablets per 1 day) zebutal oral capsule 1 or 1b* QL (6 capsules per 1 day) *SALICYLATES*** - ARTHRITIS AND PAIN DRUGS diflunisal oral tablet 1 or 1b* *SELECTIVE N-TYPE NEURONAL CALCIUM CHANNEL BLOCKERS*** - ARTHRITIS AND PAIN DRUGS PRIALT INTRATHECAL SOLUTION (ziconotide acetate) 4 PA; LD *ANALGESICS - OPIOID* - DRUGS FOR PAIN AND FEVER *CODEINE COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS acetaminophen-codeine #2 oral tablet 1 or 1a* QL (6 tablets per 1 day) acetaminophen-codeine #3 oral tablet 1 or 1a* QL (6 tablet per 1 day) acetaminophen-codeine #4 oral tablet 1 or 1a* QL (6 tablet per 1 day) acetaminophen-codeine oral solution 1 or 1a* QL (30 mL per 1 day) acetaminophen-codeine oral tablet 300-15 mg 1 or 1a* QL (6 tablets per 1 day) acetaminophen-codeine oral tablet 300-30 mg, 300-60 mg 1 or 1a* QL (6 tablet per 1 day) ascomp-codeine oral capsule 1 or 1b* QL (6 capsule per 1 day) butalbital-apap-caff-cod oral capsule 50-300-40-30 mg 1 or 1b* QL (6 capsules per 1 day) butalbital-apap-caff-cod oral capsule 50-325-40-30 mg 1 or 1b* QL (6 capsule per 1 day) butalbital-asa-caff-codeine oral capsule 1 or 1b* QL (6 capsule per 1 day) *DIHYDROCODEINE COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS apap-caff-dihydrocodeine oral capsule 1 or 1b* QL (6 capsules per 1 day) apap-caff-dihydrocodeine oral tablet 1 or 1b* QL (6 tablets per 1 day) trezix oral capsule 1 or 1b* QL (6 capsules per 1 day) *FENTANYL COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS FENTANYL CIT-ROPIVACAINE-NACL EPIDURAL SOLUTION 0.4-0.2- 3 0.9 MG/200ML-% FENTANYL-BUPIVACAINE-NACL EPIDURAL SOLUTION 0.8-0.1667- 3 0.9 MG/200ML-% *HYDROCODONE COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS hydrocodone-acetaminophen oral solution 1 or 1b* QL (90 mL per 1 day) hydrocodone-acetaminophen oral tablet 1 or 1b* QL (6 tablets per 1 day) hydrocodone-ibuprofen oral tablet 1 or 1b* QL (5 tablets per 1 day) *OPIOID AGONISTS*** - ARTHRITIS AND PAIN DRUGS ALFENTANIL HCL INTRAVENOUS SOLUTION 3 CODEINE SULFATE ORAL TABLET 15 MG, 60 MG 3 QL (6 tablets per 1 day) codeine sulfate oral tablet 30 mg 1 or 1b* QL (6 tablets per 1 day) CONZIP ORAL CAPSULE EXTENDED RELEASE 24 HOUR (tramadol hcl) 3 PA; QL (1 capsule per 1 day) DEMEROL INJECTION SOLUTION (meperidine hcl) 3 QL (4 mL per 1 day) DILAUDID INJECTION SOLUTION (hydromorphone hcl) 3 QL (6 mL per 1 day) DILAUDID ORAL LIQUID (hydromorphone hcl) 3 QL (24 mL per 1 day) DILAUDID ORAL TABLET (hydromorphone hcl) 3 QL (6 tablets per 1 day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 23 Coverage Requirements and Prescription Drug Name Drug Tier Limits DSUVIA SUBLINGUAL TABLET SUBLINGUAL (sufentanil citrate) 3 DURAGESIC-100 TRANSDERMAL PATCH 72 HOUR (fentanyl) 3 PA; QL (15 patches per 30 days) DURAGESIC-12 TRANSDERMAL PATCH 72 HOUR (fentanyl) 3 PA; QL (15 patches per 30 days) DURAGESIC-25 TRANSDERMAL PATCH 72 HOUR (fentanyl) 3 PA; QL (15 patches per 30 days) DURAGESIC-50 TRANSDERMAL PATCH 72 HOUR (fentanyl) 3 PA; QL (15 patches per 30 days) DURAGESIC-75 TRANSDERMAL PATCH 72 HOUR (fentanyl) 3 PA; QL (15 patches per 30 days) duramorph injection solution 1 or 1b* QL (6 mL per 1 day) FENTANYL CITRATE (PF) INJECTION SOLUTION 100 MCG/2ML, 250 3 MCG/5ML, 50 MCG/ML fentanyl citrate (pf) injection solution 1000 mcg/20ml, 2500 mcg/50ml, 500 1 or 1b* mcg/10ml fentanyl citrate (pf) injection solution cartridge 1 or 1b* fentanyl citrate buccal lozenge on a handle 1 or 1b* PA; QL (4 lozenge per 1 day) fentanyl citrate buccal tablet 1 or 1b* PA; QL (4 tablet per 1 day) FENTANYL CITRATE INTRAVENOUS SOLUTION 1500 MCG/30ML, 3 2500 MCG/50ML FENTANYL CITRATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 100 MCG/10ML, 1000 MCG/20ML, 20 MCG/2ML, 50 3 MCG/5ML, 500 MCG/50ML FENTANYL CITRATE PF INJECTION SOLUTION PREFILLED SYRINGE 3 FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 100-0.9 MCG/10ML-%, 500-0.9 MCG/50ML-% fentanyl transdermal patch 72 hour 1 or 1b* PA; QL (15 patches per 30 days) FENTORA BUCCAL TABLET (fentanyl citrate) 3 PA; QL (4 tablet per 1 day) hydrocodone bitartrate er oral tablet er 24 hour abuse-deterrent 1 or 1b* PA; QL (1 tablet per 1 day) hydromorphone hcl er oral tablet extended release 24 hour 1 or 1b* PA; QL (1 tablet per 1 day) hydromorphone hcl injection solution 4 mg/ml 1 or 1b* QL (2 mL per 1 day) hydromorphone hcl oral liquid 1 or 1b* QL (24 mL per 1 day) hydromorphone hcl oral tablet 1 or 1b* QL (6 tablets per 1 day) HYDROMORPHONE HCL PF INJECTION SOLUTION 1 MG/ML, 2 3 QL (6 mL per 1 day) MG/ML HYDROMORPHONE HCL PF INJECTION SOLUTION 10 MG/ML 3 QL (1 injection per 30 days) HYDROMORPHONE HCL PF INJECTION SOLUTION 4 MG/ML 3 QL (2 mL per 1 day) hydromorphone hcl pf injection solution 50 mg/5ml, 500 mg/50ml 1 or 1b* QL (1 injection per 30 days) HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE 15-0.9 MG/30ML-%, 5-0.9 MG/25ML-% INFUMORPH 200 INJECTION SOLUTION (morphine sulfate 3 QL (2 vials per 30 days) microinfusion) INFUMORPH 500 INJECTION SOLUTION (morphine sulfate 3 QL (2 vials per 30 days) microinfusion) levorphanol tartrate oral tablet 1 or 1b* PA; QL (6 tablets per 1 day) meperidine hcl injection solution 1 or 1b* QL (4 mL per 1 day) meperidine hcl oral solution 1 or 1b* QL (7 days per 1 fill) meperidine hcl oral tablet 1 or 1b* QL (6 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 24 Coverage Requirements and Prescription Drug Name Drug Tier Limits METHADONE HCL INJECTION SOLUTION 3 PA; QL (1 mL per 1 day) methadone hcl intensol oral concentrate 1 or 1b* PA; QL (6 mL per 1 day) methadone hcl oral concentrate 1 or 1b* PA; QL (6 mL per 1 day) methadone hcl oral solution 10 mg/5ml 1 or 1b* PA; QL (30 mL per 1 day) methadone hcl oral solution 5 mg/5ml 1 or 1b* PA; QL (60 mL per 1 day) methadone hcl oral tablet 10 mg 1 or 1b* PA; QL (6 tablet per 1 day) methadone hcl oral tablet 5 mg 1 or 1b* PA; QL (6 tablets per 1 day) methadone hcl oral tablet soluble 1 or 1b* PA; QL (1 tablet per 1 day) METHADOSE ORAL CONCENTRATE 10 MG/ML (methadone hcl) 3 PA; QL (6 mL per 1 day) methadose oral tablet soluble 1 or 1b* PA; QL (1 tablet per 1 day) METHADOSE SUGAR-FREE ORAL CONCENTRATE (methadone hcl) 3 PA; QL (6 mL per 1 day) mitigo injection solution 1 or 1b* QL (2 vials per 30 days) morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml 1 or 1b* QL (6 mL per 1 day) morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml 1 or 1b* QL (6 mL per 1 day) MORPHINE SULFATE (PF) INJECTION SOLUTION 10 MG/ML, 2 3 QL (6 mL per 1 day) MG/ML, 4 MG/ML, 5 MG/ML, 8 MG/ML MORPHINE SULFATE (PF) INTRAVENOUS SOLUTION 3 QL (6 mL per 1 day) morphine sulfate er beads oral capsule extended release 24 hour 1 or 1b* PA; QL (1 capsule per 1 day) morphine sulfate er oral capsule extended release 24 hour 1 or 1b* PA; QL (2 capsules per 1 day) morphine sulfate er oral tablet extended release 100 mg, 200 mg 1 or 1b* PA; QL (2 tablets per 1 day) morphine sulfate er oral tablet extended release 15 mg, 30 mg, 60 mg 1 or 1b* PA; QL (3 tablet per 1 day) MORPHINE SULFATE INJECTION SOLUTION 2 MG/ML, 4 MG/ML 3 QL (6 mL per 1 day) morphine sulfate oral solution 1 or 1b* QL (30 mL per 1 day) morphine sulfate oral tablet 1 or 1b* QL (6 tablets per 1 day) MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 1-0.9 MG/ML-% NUCYNTA ORAL TABLET 100 MG (tapentadol hcl) 3 QL (181 tablets per 30 days) NUCYNTA ORAL TABLET 50 MG (tapentadol hcl) 3 QL (6 tablets per 1 day) NUCYNTA ORAL TABLET 75 MG (tapentadol hcl) 3 QL (8 tablet per 1 day) OLINVYK INTRAVENOUS SOLUTION (oliceridine fumarate) 3 OXAYDO ORAL TABLET (oxycodone hcl) 3 QL (6 tablets per 1 day) oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg, 15 mg, 20 mg, 3 PA; QL (2 tablets per 1 day) 30 mg, 40 mg, 60 mg oxycodone hcl er oral tablet er 12 hour abuse-deterrent 80 mg 3 PA; QL (2 tablet per 1 day) oxycodone hcl oral capsule 1 or 1b* QL (7 days per 1 fill) oxycodone hcl oral concentrate 100 mg/5ml 1 or 1b* QL (6 mL per 1 day) oxycodone hcl oral solution 1 or 1b* QL (30 mL per 1 day) oxycodone hcl oral tablet 1 or 1b* QL (6 tablets per 1 day) OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG, 3 PA; QL (2 tablets per 1 day) 15 MG, 20 MG, 30 MG, 40 MG (oxycodone hcl) OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 60 MG, 3 PA; QL (2 tablet per 1 day) 80 MG (oxycodone hcl) oxymorphone hcl er oral tablet extended release 12 hour 1 or 1b* PA; QL (2 tablets per 1 day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 25 Coverage Requirements and Prescription Drug Name Drug Tier Limits oxymorphone hcl oral tablet 10 mg 1 or 1b* QL (6 tablet per 1 day) oxymorphone hcl oral tablet 5 mg 1 or 1b* QL (6 tablets per 1 day) QDOLO ORAL SOLUTION (tramadol hcl) 3 QL (80 mL per 1 day) remifentanil hcl intravenous solution reconstituted 1 or 1b* ROXICODONE ORAL TABLET (oxycodone hcl) 3 QL (6 tablets per 1 day) SUFENTANIL CITRATE INTRAVENOUS SOLUTION 3 tramadol hcl er (biphasic) oral tablet extended release 24 hour 1 or 1b* PA; QL (1 tablet per 1 day) tramadol hcl er oral capsule extended release 24 hour 1 or 1b* PA; QL (1 capsule per 1 day) tramadol hcl er oral tablet extended release 24 hour 1 or 1b* PA; QL (1 tablet per 1 day) tramadol hcl oral tablet 100 mg 1 or 1b* QL (4 tablets per 1 day) tramadol hcl oral tablet 50 mg 1 or 1b* QL (8 tablet per 1 day) ULTIVA INTRAVENOUS SOLUTION RECONSTITUTED (remifentanil 3 hcl) *OPIOID COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS APADAZ ORAL TABLET (benzhydrocodone-acetaminophen) 3 QL (6 tablets per 1 day) BENZHYDROCODONE-ACETAMINOPHEN ORAL TABLET 3 QL (6 tablets per 1 day) endocet oral tablet 10-325 mg, 2.5-325 mg, 7.5-325 mg 1 or 1b* QL (6 tablets per 1 day) endocet oral tablet 5-325 mg 1 or 1b* QL (6 tablet per 1 day) oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 7.5-325 mg 1 or 1b* QL (6 tablets per 1 day) oxycodone-acetaminophen oral tablet 5-325 mg 1 or 1b* QL (6 tablet per 1 day) *OPIOID PARTIAL AGONISTS*** - ARTHRITIS AND PAIN DRUGS BELBUCA BUCCAL FILM (buprenorphine hcl) 3 PA; QL (2 film per 1 day) BUNAVAIL BUCCAL FILM 4.2-0.7 MG (buprenorphine hcl-naloxone hcl) 3 QL (3 films per 1 day) BUNAVAIL BUCCAL FILM 6.3-1 MG (buprenorphine hcl-naloxone hcl) 3 QL (2 films per 1 day) BUPRENEX INJECTION SOLUTION (buprenorphine hcl) 3 QL (3 mL per 1 day) buprenorphine hcl injection solution 1 or 1b* QL (3 mL per 1 day) buprenorphine hcl sublingual tablet sublingual 2 mg 1 or 1b* QL (12 tablets per 90 days) buprenorphine hcl sublingual tablet sublingual 8 mg 1 or 1b* QL (3 tablets per 90 days) buprenorphine hcl-naloxone hcl sublingual film 12-3 mg 1 or 1b* QL (2 films per 1 day) buprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg 1 or 1b* QL (12 films per 1 day) buprenorphine hcl-naloxone hcl sublingual film 4-1 mg 1 or 1b* QL (6 films per 1 day) buprenorphine hcl-naloxone hcl sublingual film 8-2 mg 1 or 1b* QL (3 films per 1 day) buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg 1 or 1b* QL (12 tablets per 1 day) buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg 1 or 1b* QL (3 tablets per 1 day) buprenorphine transdermal patch weekly 1 or 1b* PA; QL (1 package per 28 days) butorphanol tartrate injection solution 1 mg/ml 1 or 1b* QL (8 mL per 1 day) butorphanol tartrate injection solution 2 mg/ml 1 or 1b* QL (4 mL per 1 day) butorphanol tartrate nasal solution 1 or 1b* QL (2 bottles per 30 days) BUTRANS TRANSDERMAL PATCH WEEKLY (buprenorphine) 3 PA; QL (1 package per 28 days) nalbuphine hcl injection solution 1 or 1b* QL (2 mL per 1 day) pentazocine-naloxone hcl oral tablet 1 or 1b* QL (6 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 26 Coverage Requirements and Prescription Drug Name Drug Tier Limits PROBUPHINE IMPLANT KIT SUBCUTANEOUS IMPLANT 3 PA; LD (buprenorphine hcl) SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 LD; QL (1 syringe per 28 days) (buprenorphine) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7-0.18 MG 2 QL (23 tablets per 1 day) (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG 2 QL (12 tablets per 1 day) (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 11.4-2.9 MG 2 QL (1 tablet per 1 day) (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 2.9-0.71 MG 2 QL (5 tablets per 1 day) (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 5.7-1.4 MG 2 QL (3 tablets per 1 day) (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 8.6-2.1 MG 2 QL (2 tablets per 1 day) (buprenorphine hcl-naloxone hcl) *TRAMADOL COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS tramadol-acetaminophen oral tablet 1 or 1b* QL (8 tablet per 1 day) *ANDROGENS-ANABOLIC* - HORMONES *ANABOLIC STEROIDS*** - DRUGS FOR MEN oxandrolone oral tablet 1 or 1b* PA *ANDROGENS*** - DRUGS FOR MEN ANDRODERM TRANSDERMAL PATCH 24 HOUR (testosterone) 3 PA; QL (1 patch per 1 day) danazol oral capsule 1 or 1b* DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION (testosterone 3 PA cypionate) JATENZO ORAL CAPSULE 158 MG, 198 MG (testosterone undecanoate) 3 PA; QL (4 capsules per 1 day) JATENZO ORAL CAPSULE 237 MG (testosterone undecanoate) 3 PA; QL (2 capsules per 1 day) TESTOPEL IMPLANT PELLET (testosterone) 3 PA; LD testosterone cypionate intramuscular solution 1 or 1b* PA testosterone enanthate intramuscular solution 1 or 1b* PA testosterone transdermal gel 1.62 %, 12.5 mg/act (1%), 20.25 mg/act (1.62%) 1 or 1b* PA; QL (1 bottle per 30 days) testosterone transdermal gel 10 mg/act (2%) 1 or 1b* PA; QL (1 pump per 30 days) testosterone transdermal gel 20.25 mg/1.25gm (1.62%), 40.5 mg/2.5gm 1 or 1b* PA; QL (1 packet per 1 day) (1.62%), 50 mg/5gm (1%) testosterone transdermal gel 25 mg/2.5gm (1%) 1 or 1b* PA; QL (2 packet per 1 day) testosterone transdermal solution 1 or 1b* PA; QL (1 pump bottle per 30 days) *ANORECTAL AND RELATED PRODUCTS* - RECTAL PREPARATIONS *INTRARECTAL STEROIDS*** - RECTAL PREPARATIONS CORTENEMA RECTAL ENEMA (hydrocortisone) 3 CORTIFOAM EXTERNAL FOAM (hydrocortisone acetate) 3 QL (2.15 gram per 1 day) hydrocortisone rectal enema 1 or 1b* UCERIS RECTAL FOAM (budesonide) 2 QL (4.78 gm per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 27 Coverage Requirements and Prescription Drug Name Drug Tier Limits *NITRATE VASODILATING AGENTS*** - RECTAL PREPARATIONS RECTIV RECTAL OINTMENT (nitroglycerin) 3 QL (1 unit per 1 day) *RECTAL ANESTHETIC/STEROIDS*** - RECTAL PREPARATIONS ANALPRAM-HC EXTERNAL CREAM (hydrocortisone ace-pramoxine) 3 ANALPRAM-HC EXTERNAL LOTION (hydrocortisone ace-pramoxine) 3 hydrocortisone ace-pramoxine external cream 1-1 % 1 or 1b* PROCTOFOAM HC EXTERNAL FOAM (hydrocortisone ace-pramoxine) 3 *RECTAL LOCAL ANESTHETICS*** - RECTAL PREPARATIONS LIDOCAINE (ANORECTAL) RECTAL SUPPOSITORY 3 *RECTAL STEROIDS*** - RECTAL PREPARATIONS ANUSOL-HC EXTERNAL CREAM (hydrocortisone) 3 hydrocortisone (perianal) external cream 1 or 1b* PROCTOCORT EXTERNAL CREAM (hydrocortisone) 3 procto-med hc external cream 1 or 1b* procto-pak external cream 1 or 1b* proctozone-hc external cream 1 or 1b* *ANTACIDS* - DRUGS FOR THE STOMACH *ANTACIDS - BICARBONATE*** - DRUGS FOR ULCERS AND STOMACH ACID SODIUM BICARBONATE ORAL POWDER 3 *ANTHELMINTICS* - DRUGS FOR INFECTIONS *ANTHELMINTICS*** - DRUGS FOR PARASITES albendazole oral tablet 1 or 1b* PA; QL (4 tablets per 1 day) ALBENZA ORAL TABLET (albendazole) 3 PA; QL (4 tablets per 1 day) BENZNIDAZOLE ORAL TABLET 3 BILTRICIDE ORAL TABLET (praziquantel) 3 EMVERM ORAL TABLET CHEWABLE (mebendazole) 3 ivermectin oral tablet 1 or 1b* praziquantel oral tablet 1 or 1b* STROMECTOL ORAL TABLET (ivermectin) 3 *ANTIANGINAL AGENTS* - DRUGS FOR THE HEART *ANTIANGINALS-OTHER*** - DRUGS FOR ANGINA RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR (ranolazine) 3 ranolazine er oral tablet extended release 12 hour 1 or 1b* *NITRATES*** - DRUGS FOR ANGINA DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE (isosorbide 2 dinitrate) GONITRO SUBLINGUAL PACKET (nitroglycerin) 3 ISORDIL TITRADOSE ORAL TABLET (isosorbide dinitrate) 3 isosorbide dinitrate oral tablet 1 or 1b* isosorbide mononitrate er oral tablet extended release 24 hour 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 28 Coverage Requirements and Prescription Drug Name Drug Tier Limits isosorbide mononitrate oral tablet 1 or 1b* minitran transdermal patch 24 hour 1 or 1b* NITRO-BID TRANSDERMAL OINTMENT (nitroglycerin) 3 NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 3 0.4 MG/HR, 0.6 MG/HR (nitroglycerin) NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR 2 (nitroglycerin) nitroglycerin in d5w intravenous solution 1 or 1b* NITROGLYCERIN INTRAVENOUS SOLUTION 3 nitroglycerin sublingual tablet sublingual 1 or 1b* nitroglycerin transdermal patch 24 hour 1 or 1b* nitroglycerin translingual solution 1 or 1b* NITROLINGUAL TRANSLINGUAL SOLUTION (nitroglycerin) 3 NITROMIST TRANSLINGUAL AEROSOL SOLUTION (nitroglycerin) 3 NITROSTAT SUBLINGUAL TABLET SUBLINGUAL (nitroglycerin) 3 *ANTIANXIETY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM *ANTIANXIETY AGENTS - MISC.*** - DRUGS FOR ANXIETY buspirone hcl oral tablet 1 or 1b* droperidol injection solution 1 or 1b* hydroxyzine hcl intramuscular solution 1 or 1b* hydroxyzine hcl oral syrup 1 or 1b* hydroxyzine hcl oral tablet 1 or 1b* hydroxyzine pamoate oral capsule 1 or 1a* meprobamate oral tablet 1 or 1b* VISTARIL ORAL CAPSULE (hydroxyzine pamoate) 3 *BENZODIAZEPINES*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN alprazolam er oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) ALPRAZOLAM INTENSOL ORAL CONCENTRATE (alprazolam) 3 QL (4 mL per 1 day) alprazolam oral tablet 1 or 1b* QL (3 tablets per 1 day) alprazolam oral tablet dispersible 1 or 1b* QL (3 tablets per 1 day) alprazolam xr oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) chlordiazepoxide hcl oral capsule 1 or 1b* QL (4 capsules per 1 day) clorazepate dipotassium oral tablet 1 or 1b* QL (4 tablets per 1 day) diazepam injection solution 1 or 1a* diazepam intensol oral concentrate 1 or 1a* QL (8 mL per 1 day) DIAZEPAM INTRAMUSCULAR SOLUTION AUTO-INJECTOR 3 diazepam oral concentrate 1 or 1a* QL (8 mL per 1 day) diazepam oral solution 1 or 1a* diazepam oral tablet 1 or 1a* QL (4 tablets per 1 day) lorazepam injection solution 1 or 1b* lorazepam intensol oral concentrate 1 or 1b* QL (3 mL per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 29 Coverage Requirements and Prescription Drug Name Drug Tier Limits lorazepam oral concentrate 2 mg/ml 1 or 1b* QL (3 mL per 1 day) lorazepam oral tablet 1 or 1b* QL (3 tablets per 1 day) oxazepam oral capsule 1 or 1b* QL (4 capsules per 1 day) *ANTIARRHYTHMICS* - DRUGS FOR THE HEART *ANTIARRHYTHMICS - MISC.*** - DRUGS FOR ABNORMAL HEART RHYTHMS adenosine intravenous solution 12 mg/4ml, 6 mg/2ml 1 or 1b* *ANTIARRHYTHMICS TYPE I-A*** - DRUGS FOR ABNORMAL HEART RHYTHMS disopyramide phosphate oral capsule 1 or 1b* NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 2 (disopyramide phosphate) NORPACE ORAL CAPSULE (disopyramide phosphate) 3 procainamide hcl injection solution 1 or 1b* quinidine gluconate er oral tablet extended release 1 or 1b* quinidine sulfate oral tablet 1 or 1a* *ANTIARRHYTHMICS TYPE I-B*** - DRUGS FOR ABNORMAL HEART RHYTHMS LIDOCAINE HCL (CARDIAC) INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 100 MG/10ML LIDOCAINE HCL (CARDIAC) INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 100 MG/5ML lidocaine hcl (cardiac) intravenous solution prefilled syringe 50 mg/5ml 1 or 1b* LIDOCAINE HCL (CARDIAC) PF INTRAVENOUS SOLUTION 3 lidocaine hcl (cardiac) pf intravenous solution prefilled syringe 1 or 1b* lidocaine in d5w intravenous solution 4-5 mg/ml-%, 8-5 mg/ml-% 1 or 1b* mexiletine hcl oral capsule 1 or 1b* *ANTIARRHYTHMICS TYPE I-C*** - DRUGS FOR ABNORMAL HEART RHYTHMS flecainide acetate oral tablet 100 mg 1 or 1b* QL (4 tablets per 1 day) flecainide acetate oral tablet 150 mg 1 or 1b* QL (2 tablets per 1 day) flecainide acetate oral tablet 50 mg 1 or 1b* QL (3 tablets per 1 day) propafenone hcl er oral capsule extended release 12 hour 1 or 1b* propafenone hcl oral tablet 1 or 1b* RYTHMOL SR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 3 (propafenone hcl) *ANTIARRHYTHMICS TYPE III*** - DRUGS FOR ABNORMAL HEART RHYTHMS AMIODARONE HCL IN DEXTROSE INTRAVENOUS SOLUTION 3 amiodarone hcl intravenous solution 1 or 1b* amiodarone hcl oral tablet 100 mg, 400 mg 1 or 1b* amiodarone hcl oral tablet 200 mg 1 or 1b* QL (3 tablets per 1 day) BRETYLIUM TOSYLATE INJECTION SOLUTION 3 CORVERT INTRAVENOUS SOLUTION (ibutilide fumarate) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 30 Coverage Requirements and Prescription Drug Name Drug Tier Limits dofetilide oral capsule 1 or 1b* ibutilide fumarate intravenous solution 1 or 1b* MULTAQ ORAL TABLET (dronedarone hcl) 3 QL (2 tablets per 1 day) NEXTERONE INTRAVENOUS SOLUTION (amiodarone hcl in dextrose) 3 pacerone oral tablet 100 mg, 400 mg 1 or 1b* pacerone oral tablet 200 mg 1 or 1b* QL (3 tablets per 1 day) *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* - DRUGS FOR THE LUNGS *ADRENERGIC COMBINATIONS*** - DRUGS FOR ASTHMA/COPD ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH 1 or 1b* QL (1 package per 30 days) ACTIVATED (fluticasone-salmeterol) ADVAIR HFA INHALATION AEROSOL (fluticasone-salmeterol) 2 QL (1 inhaler per 30 days) ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH 2 QL (1 inhaler per 30 days) ACTIVATED (umeclidinium-vilanterol) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH 2 QL (1 inhaler per 30 days) ACTIVATED (fluticasone furoate-vilanterol) BREZTRI AEROSPHERE INHALATION AEROSOL (budeson-glycopyrrol- 3 QL (1 inhaler per 30 days) formoterol) budesonide-formoterol fumarate inhalation aerosol 1 or 1b* QL (3 inhalers per 30 days) COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 2 QL (2 inhalers per 30 days) (ipratropium-albuterol) fluticasone-salmeterol inhalation aerosol powder breath activated 113-14 1 or 1b* QL (1 inhaler per 30 days) mcg/act, 232-14 mcg/act, 55-14 mcg/act ipratropium-albuterol inhalation solution 1 or 1b* STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION (tiotropium 2 QL (1 inhaler per 30 days) bromide-olodaterol) SYMBICORT INHALATION AEROSOL (budesonide-formoterol fumarate) 2 QL (3 inhalers per 30 days) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH 2 QL (1 inhaler per 30 days) ACTIVATED (fluticasone-umeclidin-vilant) *ANTI-IGE MONOCLONAL ANTIBODIES*** - DRUGS FOR ASTHMA/COPD XOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; SP (omalizumab) XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED (omalizumab) 4 PA; LD; SP *ANTI-INFLAMMATORY AGENTS*** - DRUGS FOR ASTHMA/COPD cromolyn sodium inhalation nebulization solution 1 or 1b* *BETA ADRENERGICS*** - DRUGS FOR ASTHMA/COPD albuterol sulfate hfa inhalation aerosol solution 1 or 1b* QL (2 inhalers per 30 days) albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 1 or 1b* QL (360 mL per 30 days) mg/3ml, 1.25 mg/3ml albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5%, 2.5 1 or 1b* QL (60 mL per 30 days) mg/0.5ml albuterol sulfate oral syrup 1 or 1b* albuterol sulfate oral tablet 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 31 Coverage Requirements and Prescription Drug Name Drug Tier Limits arformoterol tartrate inhalation nebulization solution 1 or 1b* QL (60 vial per 30 days) BROVANA INHALATION NEBULIZATION SOLUTION (arformoterol 3 QL (60 vial per 30 days) tartrate) formoterol fumarate inhalation nebulization solution 1 or 1b* QL (120 ML per 30 days) isoproterenol hcl injection solution 1 or 1b* ISOPROTERENOL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 ISUPREL INJECTION SOLUTION (isoproterenol hcl) 3 levalbuterol hcl inhalation nebulization solution 1 or 1b* QL (90 mL per 30 days) levalbuterol tartrate inhalation aerosol 1 or 1b* QL (2 inhalers per 30 days) PERFOROMIST INHALATION NEBULIZATION SOLUTION (formoterol 3 QL (120 ML per 30 days) fumarate) PROAIR DIGIHALER INHALATION AEROSOL POWDER BREATH 3 ST; QL (2 inhalers per 30 days) ACTIVATED (albuterol sulfate) PROAIR HFA INHALATION AEROSOL SOLUTION (albuterol sulfate) 2 ST; QL (2 inhalers per 30 days) PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH 2 QL (2 inhalers per 30 days) ACTIVATED (albuterol sulfate) PROVENTIL HFA INHALATION AEROSOL SOLUTION (albuterol 3 ST; QL (2 inhalers per 30 days) sulfate) SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH 2 QL (1 inhaler per 30 days) ACTIVATED (salmeterol xinafoate) STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION (olodaterol 3 QL (1 inhaler per 30 days) hcl) terbutaline sulfate injection solution 1 or 1b* terbutaline sulfate oral tablet 1 or 1b* VENTOLIN HFA INHALATION AEROSOL SOLUTION (albuterol sulfate) 2 ST; QL (2 inhalers per 30 days) XOPENEX HFA INHALATION AEROSOL (levalbuterol tartrate) 3 QL (2 inhalers per 30 days) *BRONCHODILATORS - ANTICHOLINERGICS*** - DRUGS FOR ASTHMA/COPD ATROVENT HFA INHALATION AEROSOL SOLUTION (ipratropium 2 QL (2 inhalers per 30 days) bromide hfa) ipratropium bromide inhalation solution 1 or 1b* QL (378 ML per 30 days) LONHALA MAGNAIR REFILL KIT INHALATION SOLUTION 3 ST; QL (2 vials per 1 day) (glycopyrrolate) LONHALA MAGNAIR STARTER KIT INHALATION SOLUTION 3 ST; QL (1 kit per 365 days) (glycopyrrolate) SPIRIVA HANDIHALER INHALATION CAPSULE (tiotropium bromide 2 QL (30 capsules per 30 days) monohydrate) SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION (tiotropium 2 QL (1 inhaler per 30 days) bromide monohydrate) YUPELRI INHALATION SOLUTION (revefenacin) 3 ST; QL (1 vial per 1 day) *INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)*** - DRUGS FOR ASTHMA/COPD FASENRA PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; LD; QL (1 autoinjector per 8 4 (benralizumab) weekss) FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; SP; QL (1 syringes per 8 4 (benralizumab) weekss)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 32 Coverage Requirements and Prescription Drug Name Drug Tier Limits NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; LD; SP; QL (1 autoinjector per 4 (mepolizumab) 4 weekss) NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; SP; QL (1 syringe per 4 4 (mepolizumab) weekss) NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED PA; LD; SP; QL (1 injections per 28 4 (mepolizumab) days) *INTERLEUKIN-5 ANTAGONISTS (IGG4 KAPPA)*** - DRUGS FOR ASTHMA/COPD CINQAIR INTRAVENOUS SOLUTION (reslizumab) 4 PA; LD; SP *LEUKOTRIENE RECEPTOR ANTAGONISTS*** - DRUGS FOR ASTHMA/COPD ACCOLATE ORAL TABLET (zafirlukast) 3 QL (2 tablets per 1 day) montelukast sodium oral packet 1 or 1b* QL (1 packet per 1 day) montelukast sodium oral tablet 1 or 1b* QL (1 tablet per 1 day) montelukast sodium oral tablet chewable 1 or 1b* QL (1 tablet per 1 day) zafirlukast oral tablet 1 or 1b* QL (2 tablets per 1 day) *SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS*** - DRUGS FOR ASTHMA/COPD DALIRESP ORAL TABLET (roflumilast) 3 PA; QL (1 tablet per 1 day) *STEROID INHALANTS*** - DRUGS FOR ASTHMA/COPD ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH 2 QL (1 inhaler per 30 days) ACTIVATED (fluticasone furoate) budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml 1 or 1b* QL (120 ML per 30 days) budesonide inhalation suspension 1 mg/2ml 1 or 1b* QL (60 ML per 30 days) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST (fluticasone propionate 2 QL (1 inhaler per 30 days) (inhal)) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH 2 QL (4 inhalers per 30 days) ACTIVATED 250 MCG/BLIST (fluticasone propionate (inhal)) FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 44 MCG/ACT 2 QL (1 inhaler per 30 days) (fluticasone propionate hfa) FLOVENT HFA INHALATION AEROSOL 220 MCG/ACT (fluticasone 2 QL (2 inhalers per 30 days) propionate hfa) PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH 2 QL (2 inhalers per 30 days) ACTIVATED (budesonide) QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 2 QL (1 inhaler per 30 days) MCG/ACT (beclomethasone diprop hfa) QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 80 2 QL (2 inhalers per 30 days) MCG/ACT (beclomethasone diprop hfa) *XANTHINES*** - DRUGS FOR ASTHMA/COPD aminophylline intravenous solution 1 or 1b* ELIXOPHYLLIN ORAL ELIXIR (theophylline) 2 QL (112.5 mL per 1 day) THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG 2 QL (4 tablets per 1 day) (theophylline) THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG 2 QL (3 capsules per 1 day) (theophylline)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 33 Coverage Requirements and Prescription Drug Name Drug Tier Limits THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 300 MG, 400 2 QL (2 capsules per 1 day) MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg 1 or 1b* QL (2 tablets per 1 day) theophylline er oral tablet extended release 12 hour 450 mg 1 or 1b* QL (1 tablet per 1 day) theophylline er oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) THEOPHYLLINE IN D5W INTRAVENOUS SOLUTION 3 theophylline oral solution 1 or 1b* QL (112.5 mL per 1 day) *ANTICOAGULANTS* - DRUGS FOR THE BLOOD *ANTICOAGULANTS - MISC.*** - DRUGS TO PREVENT BLOOD CLOTS SODIUM CITRATE LOCK FLUSH INTRAVENOUS SOLUTION 3 SODIUM CITRATE LOCK FLUSH INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE *COUMARIN ANTICOAGULANTS*** - DRUGS TO PREVENT BLOOD CLOTS jantoven oral tablet 1 or 1a* warfarin sodium oral tablet 1 or 1a* *DIRECT FACTOR XA INHIBITORS*** - DRUGS TO PREVENT BLOOD CLOTS ELIQUIS DVT/PE STARTER PACK ORAL TABLET THERAPY PACK 2 QL (74 tablets per 30 days) (apixaban) ELIQUIS ORAL TABLET 2.5 MG (apixaban) 2 QL (2 tablets per 1 day) ELIQUIS ORAL TABLET 5 MG (apixaban) 2 QL (74 tablets per 30 days) XARELTO ORAL TABLET 10 MG, 20 MG (rivaroxaban) 2 QL (1 tablet per 1 day) XARELTO ORAL TABLET 15 MG (rivaroxaban) 2 QL (42 tablet per 1 fill) XARELTO ORAL TABLET 2.5 MG (rivaroxaban) 2 QL (2 tablets per 1 day) XARELTO STARTER PACK ORAL TABLET THERAPY PACK 2 QL (1 pack per 365 days) (rivaroxaban) *HEPARINS AND HEPARINOID-LIKE AGENTS*** - DRUGS TO PREVENT BLOOD CLOTS heparin (porcine) in nacl intravenous solution 1000-0.9 ut/500ml-%, 2000- 1 or 1b* 0.9 unit/l-% HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 12500-0.45 3 UT/250ML-%, 25000-0.45 UT/250ML-%, 25000-0.45 UT/500ML-% HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 2500-0.9 UT/500ML-%, 30000-0.9 UNIT/L-%, 500-0.9 UT/500ML-%, 5000-0.9 3 UNIT/L-%, 5000-0.9 UT/500ML-% heparin lock flush intravenous solution 1 or 1b* HEPARIN SOD (PORCINE) IN D5W INTRAVENOUS SOLUTION 100 3 UNIT/ML, 25000-5 UT/500ML-% heparin sod (porcine) in d5w intravenous solution 40-5 unit/ml-% 1 or 1b* heparin sodium (porcine) injection solution 1 or 1b* HEPARIN SODIUM (PORCINE) INJECTION SOLUTION PREFILLED 3 SYRINGE heparin sodium (porcine) pf injection solution 5000 unit/0.5ml 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 34 Coverage Requirements and Prescription Drug Name Drug Tier Limits HEPARIN SODIUM (PORCINE) PF INJECTION SOLUTION 5000 3 UNIT/ML heparin sodium lock flush intravenous solution 1 or 1b* *LOW MOLECULAR WEIGHT HEPARINS*** - DRUGS TO PREVENT BLOOD CLOTS enoxaparin sodium injection solution 4 QL (30 syringes per 30 days) enoxaparin sodium subcutaneous solution 4 QL (30 syringes per 30 days) FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 4 QL (30 syringes per 30 days) 5000 UNIT/0.2ML, 7500 UNIT/0.3ML (dalteparin sodium) FRAGMIN SUBCUTANEOUS SOLUTION 95000 UNIT/3.8ML (dalteparin 4 QL (6 vials per 30 days) sodium) *SYNTHETIC HEPARINOID-LIKE AGENTS*** - DRUGS TO PREVENT BLOOD CLOTS ARIXTRA SUBCUTANEOUS SOLUTION (fondaparinux sodium) 4 QL (30 syringes per 30 days) fondaparinux sodium subcutaneous solution 4 QL (30 syringes per 30 days) *THROMBIN INHIBITORS - HIRUDIN TYPE*** - DRUGS TO PREVENT BLOOD CLOTS ANGIOMAX INTRAVENOUS SOLUTION RECONSTITUTED (bivalirudin 3 trifluoroacetate) BIVALIRUDIN RTU INTRAVENOUS SOLUTION 3 BIVALIRUDIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 *THROMBIN INHIBITORS - SELECTIVE DIRECT & REVERSIBLE*** - DRUGS TO PREVENT BLOOD CLOTS ARGATROBAN IN SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 ARGATROBAN INTRAVENOUS SOLUTION 3 *ANTICONVULSANTS* - DRUGS FOR THE NERVOUS SYSTEM *AMPA GLUTAMATE RECEPTOR ANTAGONISTS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN FYCOMPA ORAL SUSPENSION (perampanel) 3 QL (24 mL per 1 day) FYCOMPA ORAL TABLET (perampanel) 3 QL (1 tablet per 1 day) *ANTICONVULSANTS - BENZODIAZEPINES*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN clobazam oral suspension 1 or 1b* QL (16 mL per 1 day) clobazam oral tablet 1 or 1b* QL (2 tablets per 1 day) clonazepam oral tablet 1 or 1b* QL (3 tablets per 1 day) clonazepam oral tablet dispersible 1 or 1b* QL (3 tablets per 1 day) DIASTAT ACUDIAL RECTAL GEL (diazepam) 3 QL (2 syringes per 1 fill) DIASTAT PEDIATRIC RECTAL GEL (diazepam) 3 QL (2 syringes per 1 fill) diazepam rectal gel 1 or 1b* QL (2 syringes per 1 fill) NAYZILAM NASAL SOLUTION (midazolam (anticonvulsant)) 3 PA; QL (50 mg per 30 days) SYMPAZAN ORAL FILM 10 MG, 20 MG (clobazam) 3 QL (2 film strips per 1 day) SYMPAZAN ORAL FILM 5 MG (clobazam) 3 QL (1 film strip per 1 day) PA; QL (10 blister packs per 30 VALTOCO 10 MG DOSE NASAL LIQUID (diazepam) 3 days) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 35 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; QL (10 blister packs per 30 VALTOCO 15 MG DOSE NASAL LIQUID THERAPY PACK (diazepam) 3 days) PA; QL (10 blister packs per 30 VALTOCO 20 MG DOSE NASAL LIQUID THERAPY PACK (diazepam) 3 days) PA; QL (10 blister packs per 30 VALTOCO 5 MG DOSE NASAL LIQUID (diazepam) 3 days) *ANTICONVULSANTS - MISC.*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN APTIOM ORAL TABLET 200 MG, 400 MG (eslicarbazepine acetate) 3 APTIOM ORAL TABLET 600 MG, 800 MG (eslicarbazepine acetate) 3 QL (2 tablets per 1 day) BANZEL ORAL SUSPENSION (rufinamide) 3 QL (80 mL per 1 day) BANZEL ORAL TABLET 200 MG (rufinamide) 3 QL (6 tablets per 1 day) BANZEL ORAL TABLET 400 MG (rufinamide) 3 QL (8 tablets per 1 day) BRIVIACT INTRAVENOUS SOLUTION (brivaracetam) 3 BRIVIACT ORAL SOLUTION (brivaracetam) 3 QL (20 mg per 1 day) BRIVIACT ORAL TABLET 10 MG (brivaracetam) 3 BRIVIACT ORAL TABLET 100 MG, 25 MG, 50 MG, 75 MG (brivaracetam) 3 QL (2 tablets per 1 day) carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg 1 or 1b* QL (2 capsules per 1 day) carbamazepine er oral capsule extended release 12 hour 300 mg 1 or 1b* QL (5 capsules per 1 day) carbamazepine er oral tablet extended release 12 hour 100 mg, 200 mg 1 or 1b* QL (2 tablets per 1 day) carbamazepine er oral tablet extended release 12 hour 400 mg 1 or 1b* QL (4 tablets per 1 day) carbamazepine oral suspension 1 or 1b* QL (50 mL per 1 day) carbamazepine oral tablet 1 or 1b* QL (8 tablets per 1 day) carbamazepine oral tablet chewable 1 or 1b* QL (10 tablets per 1 day) DIACOMIT ORAL CAPSULE 250 MG (stiripentol) 4 PA; LD; QL (12 capsules per 1 day) DIACOMIT ORAL CAPSULE 500 MG (stiripentol) 4 PA; LD; QL (6 capsules per 1 day) DIACOMIT ORAL PACKET 250 MG (stiripentol) 4 PA; LD; QL (8 packets per 1 day) DIACOMIT ORAL PACKET 500 MG (stiripentol) 4 PA; LD; QL (6 packets per 1 day) ELEPSIA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 QL (2 tablets per 1 day) (levetiracetam) EPIDIOLEX ORAL SOLUTION (cannabidiol) 4 PA; LD; SP epitol oral tablet 1 or 1b* QL (8 tablets per 1 day) FINTEPLA ORAL SOLUTION (fenfluramine hcl) 4 PA; LD; QL (26 mg per 1 day) gabapentin oral capsule 100 mg, 400 mg 1 or 1b* QL (6 capsules per 1 day) gabapentin oral capsule 300 mg 1 or 1b* QL (9 capsules per 1 day) gabapentin oral solution 1 or 1b* QL (72 mL per 1 day) gabapentin oral tablet 600 mg 1 or 1b* QL (6 tablets per 1 day) gabapentin oral tablet 800 mg 1 or 1b* QL (4 tablets per 1 day) lamotrigine er oral tablet extended release 24 hour 100 mg 1 or 1b* QL (4 tablets per 1 day) lamotrigine er oral tablet extended release 24 hour 200 mg, 250 mg, 300 mg 1 or 1b* QL (2 tablets per 1 day) lamotrigine er oral tablet extended release 24 hour 25 mg, 50 mg 1 or 1b* QL (3 tablets per 1 day) lamotrigine oral kit 1 or 1b* QL (1 kit per 35 days) lamotrigine oral tablet 1 or 1b* QL (2 tablets per 1 day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 36 Coverage Requirements and Prescription Drug Name Drug Tier Limits lamotrigine oral tablet chewable 25 mg 1 or 1b* QL (2 tablets per 1 day) lamotrigine oral tablet chewable 5 mg 1 or 1b* QL (4 tablets per 1 day) lamotrigine oral tablet dispersible 100 mg, 200 mg 1 or 1b* QL (2 tablets per 1 day) lamotrigine oral tablet dispersible 25 mg 1 or 1b* QL (3 tablets per 1 day) lamotrigine oral tablet dispersible 50 mg 1 or 1b* QL (4 tablets per 1 day) lamotrigine starter kit-blue oral kit 1 or 1b* QL (1 kit per 28 days) lamotrigine starter kit-green oral kit 1 or 1b* QL (1 kit per 35 days) lamotrigine starter kit-orange oral kit 1 or 1b* QL (1 kit per 35 days) levetiracetam er oral tablet extended release 24 hour 500 mg 1 or 1b* QL (6 tablets per 1 day) levetiracetam er oral tablet extended release 24 hour 750 mg 1 or 1b* QL (4 tablets per 1 day) LEVETIRACETAM IN NACL INTRAVENOUS SOLUTION 3 levetiracetam intravenous solution 1 or 1b* levetiracetam oral solution 1 or 1b* levetiracetam oral tablet 1000 mg 1 or 1b* QL (3 tablets per 1 day) levetiracetam oral tablet 250 mg 1 or 1b* QL (2 tablets per 1 day) levetiracetam oral tablet 500 mg 1 or 1b* QL (6 tablets per 1 day) levetiracetam oral tablet 750 mg 1 or 1b* QL (4 tablets per 1 day) oxcarbazepine oral suspension 1 or 1b* QL (40 mL per 1 day) oxcarbazepine oral tablet 150 mg, 300 mg 1 or 1b* QL (2 tablets per 1 day) oxcarbazepine oral tablet 600 mg 1 or 1b* QL (4 tablets per 1 day) OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 3 QL (3 tablets per 1 day) MG, 300 MG (oxcarbazepine) OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 600 3 QL (4 tablets per 1 day) MG (oxcarbazepine) pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 mg 1 or 1b* QL (3 capsule per 1 day) pregabalin oral capsule 225 mg, 300 mg, 75 mg 1 or 1b* QL (2 capsules per 1 day) pregabalin oral solution 1 or 1b* QL (30 mL per 1 day) primidone oral tablet 1 or 1b* QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 25 MG, 3 QL (1 capsule per 1 day) 50 MG (topiramate) QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 150 MG, 200 MG 3 QL (2 capsules per 1 day) (topiramate) roweepra oral tablet 1 or 1b* QL (6 tablets per 1 day) rufinamide oral suspension 1 or 1b* QL (80 mL per 1 day) rufinamide oral tablet 200 mg 1 or 1b* QL (6 tablets per 1 day) rufinamide oral tablet 400 mg 1 or 1b* QL (8 tablets per 1 day) SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 250 3 QL (2 tablets per 1 day) MG, 500 MG (levetiracetam) SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 750 MG 3 QL (4 tablets per 1 day) (levetiracetam) subvenite oral tablet 1 or 1b* QL (2 tablets per 1 day) subvenite starter kit-blue oral kit 1 or 1b* QL (1 kit per 28 days) subvenite starter kit-green oral kit 1 or 1b* QL (1 kit per 35 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 37 Coverage Requirements and Prescription Drug Name Drug Tier Limits subvenite starter kit-orange oral kit 1 or 1b* QL (1 kit per 35 days) topiramate er oral capsule er 24 hour sprinkle 100 mg, 25 mg, 50 mg 1 or 1b* QL (1 capsule per 1 day) topiramate er oral capsule er 24 hour sprinkle 150 mg, 200 mg 1 or 1b* QL (2 capsules per 1 day) topiramate oral capsule sprinkle 1 or 1b* QL (2 capsules per 1 day) topiramate oral tablet 1 or 1b* QL (2 tablets per 1 day) TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 2 QL (1 capsule per 1 day) MG, 25 MG, 50 MG (topiramate) TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 2 QL (2 capsules per 1 day) MG (topiramate) VIMPAT INTRAVENOUS SOLUTION (lacosamide) 3 VIMPAT ORAL SOLUTION (lacosamide) 3 QL (40 mL per 1 day) VIMPAT ORAL TABLET (lacosamide) 3 QL (2 tablets per 1 day) zonisamide oral capsule 1 or 1b* QL (6 capsule per 1 day) *CARBAMATES*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN felbamate oral suspension 1 or 1b* felbamate oral tablet 1 or 1b* XCOPRI (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 100 & 3 QL (1 blister pack per 28 days) 150 MG (cenobamate) XCOPRI (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 50 & 3 QL (1 pack per 28 days) 200 MG (cenobamate) XCOPRI (350 MG DAILY DOSE) ORAL TABLET THERAPY PACK 3 QL (1 pack per 28 days) (cenobamate) XCOPRI ORAL TABLET 100 MG, 150 MG, 50 MG (cenobamate) 3 QL (1 tablet per 1 day) XCOPRI ORAL TABLET 200 MG (cenobamate) 3 QL (2 tablets per 1 day) XCOPRI ORAL TABLET THERAPY PACK (cenobamate) 3 QL (1 pack per 28 days) *GABA MODULATORS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN tiagabine hcl oral tablet 1 or 1b* vigabatrin oral packet 1 or 1b* LD; SP; QL (6 packets per 1 day) vigabatrin oral tablet 1 or 1b* LD; SP; QL (6 tablets per 1 day) vigadrone oral packet 1 or 1b* LD; QL (6 packets per 1 day) *HYDANTOINS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN CEREBYX INJECTION SOLUTION (fosphenytoin sodium) 3 DILANTIN INFATABS ORAL TABLET CHEWABLE (phenytoin) 3 DILANTIN ORAL CAPSULE 100 MG (phenytoin sodium extended) 3 DILANTIN ORAL CAPSULE 30 MG (phenytoin sodium extended) 2 DILANTIN ORAL SUSPENSION (phenytoin) 3 fosphenytoin sodium injection solution 1 or 1b* PHENYTEK ORAL CAPSULE (phenytoin sodium extended) 3 phenytoin infatabs oral tablet chewable 1 or 1b* phenytoin oral suspension 1 or 1b* phenytoin oral tablet chewable 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 38 Coverage Requirements and Prescription Drug Name Drug Tier Limits phenytoin sodium extended oral capsule 1 or 1b* phenytoin sodium injection solution 1 or 1b* *SUCCINIMIDES*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN CELONTIN ORAL CAPSULE (methsuximide) 3 ethosuximide oral capsule 1 or 1b* ethosuximide oral solution 1 or 1b* *VALPROIC ACID*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN divalproex sodium er oral tablet extended release 24 hour 250 mg 1 or 1b* QL (2 tablets per 1 day) divalproex sodium er oral tablet extended release 24 hour 500 mg 1 or 1b* QL (7 tablets per 1 day) divalproex sodium oral capsule delayed release sprinkle 1 or 1b* QL (8 capsules per 1 day) divalproex sodium oral tablet delayed release 125 mg, 250 mg 1 or 1b* QL (2 tablets per 1 day) divalproex sodium oral tablet delayed release 500 mg 1 or 1b* QL (7 tablets per 1 day) valproate sodium intravenous solution 1 or 1b* valproic acid oral capsule 1 or 1b* QL (4 capsules per 1 day) valproic acid oral solution 1 or 1b* *ANTIDEPRESSANTS* - DRUGS FOR THE NERVOUS SYSTEM *ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)*** - DRUGS FOR DEPRESSION mirtazapine oral tablet 1 or 1b* mirtazapine oral tablet dispersible 1 or 1b* REMERON ORAL TABLET (mirtazapine) 3 REMERON SOLTAB ORAL TABLET DISPERSIBLE (mirtazapine) 3 *ANTIDEPRESSANTS - MISC.*** - DRUGS FOR DEPRESSION APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR 174 MG 3 ST (bupropion hbr) APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR 348 MG, 3 ST; QL (1 tablet per 1 day) 522 MG (bupropion hbr) bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg 1 or 1b* bupropion hcl er (sr) oral tablet extended release 12 hour 150 mg, 200 mg 1 or 1b* QL (2 tablets per 1 day) bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg 1 or 1b* bupropion hcl er (xl) oral tablet extended release 24 hour 300 mg, 450 mg 1 or 1b* QL (1 tablet per 1 day) bupropion hcl oral tablet 100 mg 1 or 1b* QL (4.5 tablet per 1 day) bupropion hcl oral tablet 75 mg 1 or 1b* *GABA RECEPTOR MODULATOR - NEUROACTIVE STEROID*** - DRUGS FOR DEPRESSION ZULRESSO INTRAVENOUS SOLUTION (brexanolone) 4 PA; LD; SP *MONOAMINE OXIDASE INHIBITORS (MAOIS)*** - DRUGS FOR DEPRESSION EMSAM TRANSDERMAL PATCH 24 HOUR (selegiline) 3 MARPLAN ORAL TABLET (isocarboxazid) 3 QL (6 tablets per 1 day) NARDIL ORAL TABLET (phenelzine sulfate) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 39 Coverage Requirements and Prescription Drug Name Drug Tier Limits PARNATE ORAL TABLET (tranylcypromine sulfate) 3 phenelzine sulfate oral tablet 1 or 1b* tranylcypromine sulfate oral tablet 1 or 1b* *N-METHYL-D-ASPARTIC ACID (NMDA) RECEPTOR ANTAGONISTS*** - DRUGS FOR DEPRESSION SPRAVATO (56 MG DOSE) NASAL SOLUTION THERAPY PACK 4 PA; LD; QL (4 kits per 28 days) (esketamine hcl) SPRAVATO (84 MG DOSE) NASAL SOLUTION THERAPY PACK 4 PA; LD; QL (4 kits per 28 days) (esketamine hcl) *SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)*** - DRUGS FOR DEPRESSION citalopram hydrobromide oral solution 1 or 1b* QL (20 mL per 1 day) citalopram hydrobromide oral tablet 10 mg, 20 mg 1 or 1b* citalopram hydrobromide oral tablet 40 mg 1 or 1b* QL (1 tablet per 1 day) escitalopram oxalate oral solution 1 or 1b* QL (20 mL per 1 day) escitalopram oxalate oral tablet 10 mg, 5 mg 1 or 1b* escitalopram oxalate oral tablet 20 mg 1 or 1b* QL (1 tablet per 1 day) fluoxetine hcl oral capsule 10 mg 1 or 1b* fluoxetine hcl oral capsule 20 mg 1 or 1b* QL (4 capsules per 1 day) fluoxetine hcl oral capsule 40 mg 1 or 1b* QL (2 capsules per 1 day) fluoxetine hcl oral capsule delayed release 1 or 1b* QL (4 capsules per 28 days) fluoxetine hcl oral solution 1 or 1b* QL (20 mL per 1 day) fluoxetine hcl oral tablet 10 mg 1 or 1b* fluoxetine hcl oral tablet 20 mg 1 or 1b* QL (4 tablets per 1 day) FLUOXETINE HCL ORAL TABLET 60 MG 3 QL (1 tablet per 1 day) fluvoxamine maleate er oral capsule extended release 24 hour 1 or 1b* QL (2 capsules per 1 day) fluvoxamine maleate oral tablet 100 mg 1 or 1b* QL (3 tablet per 1 day) fluvoxamine maleate oral tablet 25 mg, 50 mg 1 or 1b* paroxetine hcl er oral tablet extended release 24 hour 12.5 mg 1 or 1b* paroxetine hcl er oral tablet extended release 24 hour 25 mg, 37.5 mg 1 or 1b* QL (2 tablets per 1 day) paroxetine hcl oral tablet 10 mg, 20 mg 1 or 1b* paroxetine hcl oral tablet 30 mg 1 or 1b* QL (2 tablets per 1 day) paroxetine hcl oral tablet 40 mg 1 or 1b* QL (1.5 tablet per 1 day) PAXIL ORAL SUSPENSION (paroxetine hcl) 3 ST; QL (30 mL per 1 day) PEXEVA ORAL TABLET 10 MG, 20 MG (paroxetine mesylate) 3 ST PEXEVA ORAL TABLET 30 MG (paroxetine mesylate) 3 ST; QL (2 tablets per 1 day) PEXEVA ORAL TABLET 40 MG (paroxetine mesylate) 3 ST; QL (1.5 tablet per 1 day) sertraline hcl oral concentrate 1 or 1b* QL (10 mL per 1 day) sertraline hcl oral tablet 100 mg 1 or 1b* QL (2 tablets per 1 day) sertraline hcl oral tablet 25 mg, 50 mg 1 or 1b* *SEROTONIN MODULATORS*** - DRUGS FOR DEPRESSION nefazodone hcl oral tablet 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 40 Coverage Requirements and Prescription Drug Name Drug Tier Limits trazodone hcl oral tablet 1 or 1a* TRINTELLIX ORAL TABLET 10 MG, 5 MG (vortioxetine hbr) 3 TRINTELLIX ORAL TABLET 20 MG (vortioxetine hbr) 3 QL (1 tablet per 1 day) *SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)*** - DRUGS FOR DEPRESSION DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 3 ST; QL (1 tablet per 1 day) HOUR 100 MG DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 3 ST HOUR 50 MG desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg 1 or 1b* QL (1 tablet per 1 day) desvenlafaxine succinate er oral tablet extended release 24 hour 25 mg, 50 1 or 1b* mg duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg 1 or 1b* QL (2 capsules per 1 day) duloxetine hcl oral capsule delayed release particles 30 mg 1 or 1b* duloxetine hcl oral capsule delayed release particles 40 mg 1 or 1b* QL (3 capsule per 1 day) FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 ST; QL (1 capsule per 1 day) (levomilnacipran hcl) FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK 3 ST; QL (28 pack per 365 days) (levomilnacipran hcl) venlafaxine hcl er oral capsule extended release 24 hour 150 mg 1 or 1b* QL (1 capsule per 1 day) venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg, 75 mg 1 or 1b* venlafaxine hcl er oral tablet extended release 24 hour 150 mg, 225 mg 1 or 1b* QL (1 tablet per 1 day) venlafaxine hcl er oral tablet extended release 24 hour 37.5 mg, 75 mg 1 or 1b* venlafaxine hcl oral tablet 1 or 1b* QL (3 tablet per 1 day) *TRICYCLIC AGENTS*** - DRUGS FOR DEPRESSION amitriptyline hcl oral tablet 1 or 1a* amoxapine oral tablet 100 mg 1 or 1b* QL (4 tablets per 1 day) amoxapine oral tablet 150 mg 1 or 1b* QL (2 tablets per 1 day) amoxapine oral tablet 25 mg, 50 mg 1 or 1b* clomipramine hcl oral capsule 1 or 1b* desipramine hcl oral tablet 1 or 1b* doxepin hcl oral capsule 1 or 1b* doxepin hcl oral concentrate 1 or 1b* imipramine hcl oral tablet 1 or 1b* imipramine pamoate oral capsule 1 or 1b* NORPRAMIN ORAL TABLET (desipramine hcl) 3 nortriptyline hcl oral capsule 1 or 1b* nortriptyline hcl oral solution 1 or 1b* PAMELOR ORAL CAPSULE (nortriptyline hcl) 3 protriptyline hcl oral tablet 1 or 1b* trimipramine maleate oral capsule 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 41 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTIDIABETICS* - HORMONES *ALPHA-GLUCOSIDASE INHIBITORS*** - DRUGS FOR DIABETES acarbose oral tablet 1 or 1b* QL (3 tablets per 1 day) miglitol oral tablet 1 or 1b* QL (3 tablets per 1 day) PRECOSE ORAL TABLET (acarbose) 3 QL (3 tablets per 1 day) *ANTIDIABETIC - AMYLIN ANALOGS*** - DRUGS FOR DIABETES SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (4 pens per 30 days) (pramlintide acetate) SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (2 boxes per 30 days) (pramlintide acetate) *BIGUANIDES*** - DRUGS FOR DIABETES metformin hcl er oral tablet extended release 24 hour 1 or 1b* metformin hcl oral solution 1 or 1b* PA; QL (2 bottles per 30 days) metformin hcl oral tablet 1 or 1b* RIOMET ORAL SOLUTION (metformin hcl) 3 PA; QL (2 bottles per 30 days) *DIABETIC OTHER*** - DRUGS FOR DIABETES BAQSIMI ONE PACK NASAL POWDER (glucagon) 3 QL (2 packs per 30 days) BAQSIMI TWO PACK NASAL POWDER (glucagon) 3 QL (1 pack per 30 days) diazoxide oral suspension 1 or 1b* GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 2 QL (2 kits per 30 days) (glucagon hcl (rdna)) GLUCAGON EMERGENCY INJECTION KIT 1 or 1b* QL (2 kits per 30 days) GLUCAGON EMERGENCY INJECTION SOLUTION RECONSTITUTED 3 GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION AUTO- 3 QL (2 packs per 30 days) INJECTOR (glucagon) GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION AUTO- 3 QL (2 packs per 30 days) INJECTOR (glucagon) GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 QL (2 packs per 30 days) (glucagon) PROGLYCEM ORAL SUSPENSION (diazoxide) 3 ZEGALOGUE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 (dasiglucagon hcl) ZEGALOGUE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 (dasiglucagon hcl) *DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS*** - DRUGS FOR DIABETES alogliptin benzoate oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) JANUVIA ORAL TABLET (sitagliptin phosphate) 2 ST; QL (1 tablet per 1 day) *DIPEPTIDYL PEPTIDASE-4 INHIBITOR-BIGUANIDE COMBINATIONS*** - DRUGS FOR DIABETES alogliptin-metformin hcl oral tablet 1 or 1b* ST; QL (2 tablets per 1 day) JANUMET ORAL TABLET (sitagliptin-metformin hcl) 2 ST; QL (2 tablets per 1 day) JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 2 ST; QL (1 tablet per 1 day) MG (sitagliptin-metformin hcl)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 42 Coverage Requirements and Prescription Drug Name Drug Tier Limits JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 50-1000 2 ST; QL (2 tablets per 1 day) MG, 50-500 MG (sitagliptin-metformin hcl) *DOPAMINE RECEPTOR AGONISTS - ERGOT DERIVATIVES*** - DRUGS FOR DIABETES CYCLOSET ORAL TABLET (bromocriptine mesylate) 3 *DPP-4 INHIBITOR-THIAZOLIDINEDIONE COMBINATIONS*** - DRUGS FOR DIABETES alogliptin-pioglitazone oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) *HUMAN INSULIN*** - DRUGS FOR DIABETES BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (30 mL per 30 days) (insulin glargine) HUMALOG JUNIOR KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 QL (30 mL per 30 days) INJECTOR (insulin lispro) HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (30 mL per 30 days) (insulin lispro) HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- 2 QL (30 mL per 30 days) INJECTOR (insulin lispro prot & lispro) HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (insulin lispro 2 QL (30 mL per 30 days) prot & lispro) HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- 2 QL (30 mL per 30 days) INJECTOR (insulin lispro prot & lispro) HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (insulin lispro 2 QL (30 mL per 30 days) prot & lispro) HUMALOG SUBCUTANEOUS SOLUTION (insulin lispro) 2 QL (30 mL per 30 days) HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE (insulin lispro) 2 QL (30 mL per 30 days) HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 2 PA; QL (20 mL per 30 days) (insulin regular human) HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 PA; QL (18 mL per 30 days) INJECTOR (insulin regular human) LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (30 mL per 30 days) (insulin detemir) LEVEMIR SUBCUTANEOUS SOLUTION (insulin detemir) 2 QL (30 mL per 30 days) MYXREDLIN INTRAVENOUS SOLUTION (insulin regular(human) in 3 nacl) TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 2 QL (12 mL per 30 days) INJECTOR (insulin glargine) TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (13.5 mL per 30 days) (insulin glargine) TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (30 mL per 30 days) 100 UNIT/ML (insulin degludec) TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (18 mL per 30 days) 200 UNIT/ML (insulin degludec) TRESIBA SUBCUTANEOUS SOLUTION (insulin degludec) 2 QL (30 mL per 30 days) *INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)*** - DRUGS FOR DIABETES OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION PEN- 2 ST; QL (1 pen per 28 days) INJECTOR (semaglutide)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 43 Coverage Requirements and Prescription Drug Name Drug Tier Limits OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 2 ST; QL (2 pens per 28 days) MG/1.5ML (semaglutide) OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 4 2 ST; QL (1 unit per 28 days) MG/3ML (semaglutide) RYBELSUS ORAL TABLET 14 MG, 7 MG (semaglutide) 2 ST; QL (1 carton per 30 days) RYBELSUS ORAL TABLET 3 MG (semaglutide) 2 ST; QL (1 carton per 1 fill) TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 2 ST; QL (4 pens per 28 days) MG/0.5ML, 1.5 MG/0.5ML (dulaglutide) TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 3 MG/0.5ML, 2 ST; QL (4 syringes per 28 days) 4.5 MG/0.5ML (dulaglutide) VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR (liraglutide) 2 ST; QL (1 box per 30 days) *INSULIN-INCRETIN MIMETIC COMBINATIONS*** - DRUGS FOR DIABETES SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR (insulin 2 QL (5 pen per 25 days) glargine-lixisenatide) XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR (insulin 2 QL (5 pen per 30 days) degludec-liraglutide) *MEGLITINIDE ANALOGUES*** - DRUGS FOR DIABETES nateglinide oral tablet 1 or 1b* QL (3 tablets per 1 day) repaglinide oral tablet 0.5 mg, 1 mg 1 or 1b* QL (4 tablets per 1 day) repaglinide oral tablet 2 mg 1 or 1b* QL (8 tablets per 1 day) *PROGESTERONE RECEPTOR ANTAGONISTS*** - DRUGS FOR DIABETES KORLYM ORAL TABLET (mifepristone) 4 PA; LD *SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS*** - DRUGS FOR DIABETES GLYXAMBI ORAL TABLET (empagliflozin-linagliptin) 2 QL (1 tablet per 1 day) *SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS*** - DRUGS FOR DIABETES FARXIGA ORAL TABLET (dapagliflozin propanediol) 2 ST; QL (1 tablet per 1 day) JARDIANCE ORAL TABLET (empagliflozin) 2 ST; QL (1 tablet per 1 day) *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR- BIGUANIDE COMB*** - DRUGS FOR DIABETES SYNJARDY ORAL TABLET (empagliflozin-metformin hcl) 2 ST; QL (2 tablets per 1 day) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10- 2 ST; QL (2 tablets per 1 day) 1000 MG, 12.5-1000 MG, 5-1000 MG (empagliflozin-metformin hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 25- 2 ST; QL (1 tablet per 1 day) 1000 MG (empagliflozin-metformin hcl) XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 2 ST; QL (1 tablet per 1 day) MG, 10-500 MG, 5-500 MG (dapagliflozin-metformin hcl) XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 2 ST; QL (2 tablet per 1 day) MG (dapagliflozin-metformin hcl) XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 2 ST; QL (2 tablets per 1 day) MG (dapagliflozin-metformin hcl)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 44 Coverage Requirements and Prescription Drug Name Drug Tier Limits *SULFONYLUREA-BIGUANIDE COMBINATIONS*** - DRUGS FOR DIABETES glipizide-metformin hcl oral tablet 1 or 1b* ST glyburide-metformin oral tablet 1 or 1b* ST *SULFONYLUREAS*** - DRUGS FOR DIABETES AMARYL ORAL TABLET (glimepiride) 3 ST glimepiride oral tablet 1 or 1b* ST glipizide er oral tablet extended release 24 hour 1 or 1a* ST glipizide oral tablet 1 or 1a* ST glipizide xl oral tablet extended release 24 hour 1 or 1a* ST GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 ST (glipizide) glyburide micronized oral tablet 1 or 1b* ST glyburide oral tablet 1 or 1b* ST GLYNASE ORAL TABLET (glyburide micronized) 3 ST tolbutamide oral tablet 1 or 1b* ST *SULFONYLUREA-THIAZOLIDINEDIONE COMBINATIONS*** - DRUGS FOR DIABETES DUETACT ORAL TABLET (pioglitazone hcl-glimepiride) 3 ST; QL (1 tablet per 1 day) pioglitazone hcl-glimepiride oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) *THIAZOLIDINEDIONE-BIGUANIDE COMBINATIONS*** - DRUGS FOR DIABETES ACTOPLUS MET ORAL TABLET (pioglitazone hcl-metformin hcl) 3 ST; QL (3 tablet per 1 day) pioglitazone hcl-metformin hcl oral tablet 1 or 1b* ST; QL (3 tablets per 1 day) *THIAZOLIDINEDIONES*** - DRUGS FOR DIABETES pioglitazone hcl oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) *ANTIDIARRHEAL/PROBIOTIC AGENTS* - DRUGS FOR THE STOMACH *ANTIDIARRHEAL - CHLORIDE CHANNEL ANTAGONISTS*** - DRUGS FOR DIARRHEA MYTESI ORAL TABLET DELAYED RELEASE (crofelemer) 3 PA; LD; QL (2 tablets per 1 day) *ANTIDIARRHEAL/PROBIOTIC COMBINATIONS*** - DRUGS FOR DIARRHEA RESTORA RX ORAL CAPSULE (lactobacillus casei-folic acid) 3 *ANTIPERISTALTIC AGENTS*** - DRUGS FOR DIARRHEA diphenoxylate-atropine oral liquid 1 or 1b* diphenoxylate-atropine oral tablet 1 or 1b* LOMOTIL ORAL TABLET (diphenoxylate-atropine) 3 loperamide hcl oral capsule 1 or 1b* MOTOFEN ORAL TABLET (difenoxin-atropine) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 45 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTIDOTES AND SPECIFIC ANTAGONISTS* - DRUGS FOR OVERDOSE OR POISONING *ANTIDOTE COMBINATIONS*** - DRUGS FOR OVERDOSE OR POISONING DUODOTE INTRAMUSCULAR SOLUTION AUTO-INJECTOR (atropine- 3 pralidoxime chloride) NITHIODOTE INTRAVENOUS KIT (sodium nitrite-sod thiosulfate) 3 *ANTIDOTES - CHELATING AGENTS*** - DRUGS FOR OVERDOSE OR POISONING CHEMET ORAL CAPSULE (succimer) 3 deferasirox granules oral packet 4 PA; SP deferasirox oral packet 4 PA; SP deferasirox oral tablet 180 mg 4 SP deferasirox oral tablet 360 mg, 90 mg 4 PA; SP deferasirox oral tablet soluble 4 PA; SP deferiprone oral tablet 4 PA EXJADE ORAL TABLET SOLUBLE (deferasirox) 4 PA; LD; SP FERRIPROX ORAL SOLUTION (deferiprone) 4 PA; LD FERRIPROX ORAL TABLET (deferiprone) 4 PA; LD FERRIPROX TWICE-A-DAY ORAL TABLET (deferiprone) 4 PA; LD JADENU ORAL TABLET (deferasirox) 4 PA; LD; SP JADENU SPRINKLE ORAL PACKET (deferasirox) 4 PA; LD; SP PENTETATE CALCIUM TRISODIUM COMBINATION SOLUTION 3 PENTETATE ZINC TRISODIUM COMBINATION SOLUTION 3 *ANTIDOTES AND SPECIFIC ANTAGONISTS*** - DRUGS FOR OVERDOSE OR POISONING ACETADOTE INTRAVENOUS SOLUTION (acetylcysteine) 3 acetylcysteine intravenous solution 1 or 1b* ANDEXXA INTRAVENOUS SOLUTION RECONSTITUTED (coag fact xa 3 inactivated-zhzo) BAL IN OIL INTRAMUSCULAR SOLUTION 3 BRIDION INTRAVENOUS SOLUTION (sugammadex sodium) 3 CALCIUM DISODIUM VERSENATE INJECTION SOLUTION 3 CYANOKIT INTRAVENOUS SOLUTION RECONSTITUTED 3 (hydroxocobalamin) deferoxamine mesylate injection solution reconstituted 4 SP DESFERAL INJECTION SOLUTION RECONSTITUTED (deferoxamine 4 SP mesylate) DIGIFAB INTRAVENOUS SOLUTION RECONSTITUTED (digoxin 3 immune fab) fomepizole intravenous solution 1 or 1b* PRAXBIND INTRAVENOUS SOLUTION (idarucizumab) 3 PROTOPAM CHLORIDE INTRAVENOUS SOLUTION RECONSTITUTED 3 (pralidoxime chloride)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 46 Coverage Requirements and Prescription Drug Name Drug Tier Limits PROVAYBLUE INTRAVENOUS SOLUTION (methylene blue (antidote)) 3 RADIOGARDASE ORAL CAPSULE (prussian blue insoluble) 3 SODIUM NITRITE INTRAVENOUS SOLUTION 3 PA; LD; QL (20 packets per 30 VISTOGARD ORAL PACKET (uridine triacetate) 3 days) *BENZODIAZEPINE ANTAGONISTS*** - DRUGS FOR OVERDOSE OR POISONING flumazenil intravenous solution 1 or 1b* *OPIOID ANTAGONISTS*** - DRUGS FOR OVERDOSE OR POISONING naloxone hcl injection solution 1 or 1b* QL (6 vial per 90 days) naloxone hcl injection solution cartridge 1 or 1b* QL (6 syringe per 90 days) naloxone hcl injection solution prefilled syringe 1 or 1b* QL (6 syringe per 90 days) naltrexone hcl oral tablet 1 or 1b* NARCAN NASAL LIQUID (naloxone hcl) 2 QL (6 nasal spray per 90 days) VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 4 SP; QL (1 vial per 28 days) (naltrexone) *ANTIEMETICS* - DRUGS FOR THE STOMACH *5-HT3 RECEPTOR ANTAGONISTS*** - DRUGS FOR VOMITING AND NAUSEA ALOXI INTRAVENOUS SOLUTION (palonosetron hcl) 3 PA granisetron hcl intravenous solution 1 or 1b* granisetron hcl oral tablet 1 or 1b* QL (10 tablets per 30 days) ondansetron hcl injection solution 1 or 1b* ondansetron hcl oral solution 1 or 1b* QL (8 mL per 1 day) ondansetron hcl oral tablet 24 mg 1 or 1b* QL (8 tablet per 30 days) ondansetron hcl oral tablet 4 mg 1 or 1b* QL (48 tablets per 30 days) ondansetron hcl oral tablet 8 mg 1 or 1b* QL (24 tablets per 30 days) ondansetron oral tablet dispersible 4 mg 1 or 1b* QL (48 tablets per 30 days) ondansetron oral tablet dispersible 8 mg 1 or 1b* QL (24 tablets per 30 days) PALONOSETRON HCL INTRAVENOUS SOLUTION 0.25 MG/2ML 3 PA palonosetron hcl intravenous solution 0.25 mg/5ml 1 or 1b* PA palonosetron hcl intravenous solution prefilled syringe 1 or 1b* PA SANCUSO TRANSDERMAL PATCH (granisetron) 3 QL (4 patches per 28 days) SUSTOL SUBCUTANEOUS PREFILLED SYRINGE (granisetron) 3 ZOFRAN ORAL TABLET (ondansetron hcl) 3 QL (48 tablets per 30 days) ZUPLENZ ORAL FILM 4 MG (ondansetron) 3 QL (48 films per 30 days) ZUPLENZ ORAL FILM 8 MG (ondansetron) 3 QL (24 films per 30 days) *ANTIEMETIC COMBINATIONS*** - DRUGS FOR VOMITING AND NAUSEA AKYNZEO INTRAVENOUS SOLUTION (fosnetupitant-palonosetron) 3 PA; QL (5 vials per 30 days) AKYNZEO INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; QL (5 vials per 30 days) (fosnetupitant-palonosetron)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 47 Coverage Requirements and Prescription Drug Name Drug Tier Limits AKYNZEO ORAL CAPSULE (netupitant-palonosetron) 3 QL (5 capsules per 25 days) BONJESTA ORAL TABLET EXTENDED RELEASE (doxylamine- 3 PA; QL (4 tablet per 1 day) pyridoxine) doxylamine-pyridoxine oral tablet delayed release 1 or 1b* PA; QL (4 tablet per 1 day) *ANTIEMETICS - ANTICHOLINERGIC*** - DRUGS FOR VOMITING AND NAUSEA DIMENHYDRINATE INJECTION SOLUTION 3 meclizine hcl oral tablet 1 or 1a* meclizine hcl oral tablet chewable 1 or 1a* scopolamine transdermal patch 72 hour 1 or 1b* TIGAN INTRAMUSCULAR SOLUTION (trimethobenzamide hcl) 3 trimethobenzamide hcl oral capsule 1 or 1b* *ANTIEMETICS - ANTIDOPAMINERGIC*** - DRUGS FOR VOMITING AND NAUSEA BARHEMSYS INTRAVENOUS SOLUTION (amisulpride (antiemetic)) 3 *ANTIEMETICS - MISCELLANEOUS*** - DRUGS FOR VOMITING AND NAUSEA dronabinol oral capsule 1 or 1b* MARINOL ORAL CAPSULE (dronabinol) 3 SYNDROS ORAL SOLUTION (dronabinol) 3 *SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS*** - DRUGS FOR VOMITING AND NAUSEA aprepitant oral 1 or 1b* QL (15 capsules per 25 days) aprepitant oral capsule 125 mg 1 or 1b* QL (5 capsules per 25 days) aprepitant oral capsule 40 mg 1 or 1b* QL (1 capsule per 1 fill) aprepitant oral capsule 80 & 125 mg 1 or 1b* QL (15 capsules per 25 days) aprepitant oral capsule 80 mg 1 or 1b* QL (10 capsules per 25 days) CINVANTI INTRAVENOUS EMULSION (aprepitant) 3 PA; QL (5 vials per 30 days) EMEND ORAL SUSPENSION RECONSTITUTED (aprepitant) 3 QL (15 kit per 30 days) fosaprepitant dimeglumine intravenous solution reconstituted 1 or 1b* PA; QL (5 vial per 30 days) VARUBI (180 MG DOSE) ORAL TABLET THERAPY PACK (rolapitant 3 QL (4 capsules per 28 days) hcl) *ANTIFUNGALS* - DRUGS FOR INFECTIONS *ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS)*** - ANTIBIOTICS CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED (caspofungin 3 acetate) CASPOFUNGIN ACETATE INTRAVENOUS SOLUTION 3 RECONSTITUTED ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED (anidulafungin) 3 micafungin sodium intravenous solution reconstituted 1 or 1b* MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED (micafungin 3 sodium)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 48 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTIFUNGALS*** - DRUGS FOR FUNGUS ABELCET INTRAVENOUS SUSPENSION (amphotericin b lipid) 3 AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 3 (amphotericin b liposome) amphotericin b intravenous solution reconstituted 1 or 1b* ANCOBON ORAL CAPSULE (flucytosine) 3 PA flucytosine oral capsule 1 or 1b* PA griseofulvin microsize oral suspension 1 or 1b* griseofulvin microsize oral tablet 1 or 1b* griseofulvin ultramicrosize oral tablet 1 or 1b* nystatin oral tablet 1 or 1b* terbinafine hcl oral tablet 1 or 1b* QL (1 tablet per 1 day) *IMIDAZOLES*** - DRUGS FOR FUNGUS ketoconazole oral tablet 1 or 1b* QL (2 tablets per 1 day) *TRIAZOLES*** - DRUGS FOR FUNGUS CRESEMBA INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; QL (1 vial per 1 day) (isavuconazonium sulfate) CRESEMBA ORAL CAPSULE (isavuconazonium sulfate) 3 PA; QL (2 capsules per 1 day) DIFLUCAN ORAL SUSPENSION RECONSTITUTED 10 MG/ML 3 QL (40 mL per 1 day) (fluconazole) DIFLUCAN ORAL SUSPENSION RECONSTITUTED 40 MG/ML 3 QL (10 mL per 1 day) (fluconazole) DIFLUCAN ORAL TABLET 100 MG (fluconazole) 3 QL (4 tablet per 1 day) DIFLUCAN ORAL TABLET 150 MG, 200 MG (fluconazole) 3 QL (2 tablets per 1 day) DIFLUCAN ORAL TABLET 50 MG (fluconazole) 3 QL (8 tablet per 1 day) fluconazole in sodium chloride intravenous solution 1 or 1b* fluconazole oral suspension reconstituted 10 mg/ml 1 or 1b* QL (40 mL per 1 day) fluconazole oral suspension reconstituted 40 mg/ml 1 or 1b* QL (10 mL per 1 day) fluconazole oral tablet 100 mg 1 or 1b* QL (4 tablet per 1 day) fluconazole oral tablet 150 mg, 200 mg 1 or 1b* QL (2 tablets per 1 day) fluconazole oral tablet 50 mg 1 or 1b* QL (8 tablet per 1 day) itraconazole oral capsule 1 or 1b* PA; QL (4.2 capsules per 1 day) itraconazole oral solution 1 or 1b* PA; QL (20 mL per 1 day) NOXAFIL INTRAVENOUS SOLUTION (posaconazole) 3 NOXAFIL ORAL SUSPENSION (posaconazole) 3 PA; QL (20 mL per 1 day) NOXAFIL ORAL TABLET DELAYED RELEASE (posaconazole) 3 PA; QL (8 tablet per 1 day) posaconazole oral tablet delayed release 1 or 1b* PA; QL (8 tablet per 1 day) SPORANOX ORAL CAPSULE (itraconazole) 3 PA; QL (4.2 capsules per 1 day) SPORANOX ORAL SOLUTION (itraconazole) 3 PA; QL (20 mL per 1 day) SPORANOX PULSEPAK ORAL CAPSULE (itraconazole) 3 PA; QL (4.2 capsules per 1 day) TOLSURA ORAL CAPSULE 3 PA; QL (126 capsules per 30 days) VFEND ORAL SUSPENSION RECONSTITUTED (voriconazole) 3 PA; QL (10 mL per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 49 Coverage Requirements and Prescription Drug Name Drug Tier Limits VFEND ORAL TABLET 200 MG (voriconazole) 3 PA; QL (2 tablets per 1 day) VFEND ORAL TABLET 50 MG (voriconazole) 3 PA; QL (4 tablet per 1 day) voriconazole intravenous solution reconstituted 1 or 1b* voriconazole oral suspension reconstituted 1 or 1b* PA; QL (10 mL per 1 day) voriconazole oral tablet 200 mg 1 or 1b* PA; QL (2 tablets per 1 day) voriconazole oral tablet 50 mg 1 or 1b* PA; QL (4 tablet per 1 day) *ANTIHISTAMINES* - DRUGS FOR THE LUNGS *ANTIHISTAMINES - ALKYLAMINES*** - DRUGS FOR ALLERGIES ryclora oral solution 1 or 1b* *ANTIHISTAMINES - ETHANOLAMINES*** - DRUGS FOR ALLERGIES carbinoxamine maleate oral solution 1 or 1b* carbinoxamine maleate oral tablet 4 mg 1 or 1b* CLEMASTINE FUMARATE ORAL SYRUP 3 clemastine fumarate oral tablet 2.68 mg 1 or 1b* diphen oral elixir 1 or 1a* QL (4 mL per 1 day) di-phen oral elixir 1 or 1a* QL (4 mL per 1 day) diphenhydramine hcl injection solution 1 or 1b* diphenhydramine hcl oral elixir 1 or 1a* QL (4 mL per 1 day) KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE 3 QL (40 mL per 1 day) (carbinoxamine maleate) RYVENT ORAL TABLET (carbinoxamine maleate) 1 or 1b* QL (4 tablets per 1 day) *ANTIHISTAMINES - NON-SEDATING*** - DRUGS FOR ALLERGIES cetirizine hcl oral solution 1 or 1b* CLARINEX ORAL TABLET (desloratadine) 3 ST; QL (1 tablet per 1 day) desloratadine oral tablet 1 or 1b* QL (1 tablet per 1 day) desloratadine oral tablet dispersible 1 or 1b* QL (1 tablet per 1 day) levocetirizine dihydrochloride oral solution 1 or 1b* QL (10 mL per 1 day) levocetirizine dihydrochloride oral tablet 1 or 1b* QL (1 tablet per 1 day) QUZYTTIR INTRAVENOUS SOLUTION (cetirizine hcl) 3 *ANTIHISTAMINES - PHENOTHIAZINES*** - DRUGS FOR ALLERGIES PHENERGAN INJECTION SOLUTION (promethazine hcl) 3 promethazine hcl injection solution 1 or 1a* promethazine hcl oral solution 1 or 1a* promethazine hcl oral syrup 1 or 1a* promethazine hcl oral tablet 12.5 mg, 50 mg 1 or 1a* promethazine hcl oral tablet 25 mg 1 or 1a* QL (4 tablets per 1 day) promethazine hcl rectal suppository 1 or 1b* promethegan rectal suppository 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 50 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTIHISTAMINES - PIPERIDINES*** - DRUGS FOR ALLERGIES cyproheptadine hcl oral syrup 1 or 1b* cyproheptadine hcl oral tablet 1 or 1b* *ANTIHYPERLIPIDEMICS* - DRUGS FOR THE HEART *ACL INHIB-INTESTINAL CHOLESTEROL ABSORPTION INHIB COMB*** - DRUGS FOR CHOLESTEROL NEXLIZET ORAL TABLET (bempedoic acid-ezetimibe) 3 PA; QL (1 tablet per 1 day) *ADENOSINE TRIPHOSPHATE-CITRATE LYASE (ACL) INHIBITORS*** - DRUGS FOR CHOLESTEROL NEXLETOL ORAL TABLET (bempedoic acid) 3 PA; QL (1 tablet per 1 day) *ANGIOPOIETIN-LIKE PROTEIN 3 (ANGPTL3) INHIBITORS*** - DRUGS FOR CHOLESTEROL EVKEEZA INTRAVENOUS SOLUTION (evinacumab-dgnb) 4 PA; LD *ANTIHYPERLIPIDEMICS - MISC.*** - DRUGS FOR CHOLESTEROL icosapent ethyl oral capsule 1 or 1b* PA; QL (4 capsule per 1 day) omega-3-acid ethyl esters oral capsule 1 or 1b* PA; QL (4 capsule per 1 day) VASCEPA ORAL CAPSULE 0.5 GM (icosapent ethyl) 2 PA; QL (8 capsules per 1 day) VASCEPA ORAL CAPSULE 1 GM (icosapent ethyl) 2 PA; QL (4 capsule per 1 day) *BILE ACID SEQUESTRANTS*** - DRUGS FOR CHOLESTEROL cholestyramine light oral packet 1 or 1b* QL (24 grams per 1 day) cholestyramine light oral powder 1 or 1b* QL (24 grams per 1 day) cholestyramine oral packet 1 or 1b* QL (6 packets per 1 day) cholestyramine oral powder 1 or 1b* QL (54 gm per 1 day) colesevelam hcl oral packet 1 or 1b* QL (1 packet per 1 day) colesevelam hcl oral tablet 1 or 1b* QL (6 tablets per 1 day) COLESTID FLAVORED ORAL GRANULES (colestipol hcl) 3 QL (30 grams per 1 day) COLESTID FLAVORED ORAL PACKET (colestipol hcl) 3 QL (30 grams per 1 day) COLESTID ORAL GRANULES (colestipol hcl) 3 QL (30 grams per 1 day) COLESTID ORAL PACKET (colestipol hcl) 3 QL (30 grams per 1 day) COLESTID ORAL TABLET (colestipol hcl) 3 QL (16 tablets per 1 day) colestipol hcl oral granules 1 or 1b* QL (30 grams per 1 day) colestipol hcl oral packet 1 or 1b* QL (30 grams per 1 day) colestipol hcl oral tablet 1 or 1b* QL (16 tablets per 1 day) prevalite oral packet 1 or 1b* QL (24 grams per 1 day) prevalite oral powder 1 or 1b* QL (24 grams per 1 day) QUESTRAN LIGHT ORAL POWDER (cholestyramine light) 3 QL (24 grams per 1 day) QUESTRAN ORAL PACKET (cholestyramine) 3 QL (6 packets per 1 day) QUESTRAN ORAL POWDER (cholestyramine) 3 QL (54 gm per 1 day) *FIBRIC ACID DERIVATIVES*** - DRUGS FOR CHOLESTEROL fenofibrate micronized oral capsule 1 or 1b* QL (1 capsule per 1 day) fenofibrate oral capsule 1 or 1b* QL (1 capsule per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 51 Coverage Requirements and Prescription Drug Name Drug Tier Limits fenofibrate oral tablet 1 or 1b* QL (1 tablet per 1 day) fenofibric acid oral capsule delayed release 1 or 1b* QL (1 capsule per 1 day) fenofibric acid oral tablet 1 or 1b* QL (1 tablet per 1 day) FENOGLIDE ORAL TABLET (fenofibrate) 3 ST; QL (1 tablet per 1 day) FIBRICOR ORAL TABLET (fenofibric acid) 3 ST; QL (1 tablet per 1 day) gemfibrozil oral tablet 1 or 1b* QL (2 tablets per 1 day) LIPOFEN ORAL CAPSULE (fenofibrate) 3 ST; QL (1 capsule per 1 day) LOPID ORAL TABLET (gemfibrozil) 3 ST; QL (2 tablets per 1 day) TRICOR ORAL TABLET (fenofibrate) 3 ST; QL (1 tablet per 1 day) TRILIPIX ORAL CAPSULE DELAYED RELEASE (choline fenofibrate) 3 ST; QL (1 capsule per 1 day) *HMG COA REDUCTASE INHIBITORS*** - DRUGS FOR CHOLESTEROL atorvastatin calcium oral tablet 10 mg, 20 mg 1 or 1b*; $0 atorvastatin calcium oral tablet 40 mg 1 or 1b* atorvastatin calcium oral tablet 80 mg 1 or 1b* QL (1 tablet per 1 day) fluvastatin sodium er oral tablet extended release 24 hour 1 or 1b*; $0 QL (1 tablet per 1 day) fluvastatin sodium oral capsule 1 or 1b*; $0 lovastatin oral tablet 10 mg, 20 mg 1 or 1b*; $0 lovastatin oral tablet 40 mg 1 or 1b*; $0 QL (2 tablets per 1 day) pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg 1 or 1b*; $0 pravastatin sodium oral tablet 80 mg 1 or 1b*; $0 QL (1 tablet per 1 day) rosuvastatin calcium oral tablet 10 mg, 5 mg 1 or 1b*; $0 rosuvastatin calcium oral tablet 20 mg 1 or 1b* rosuvastatin calcium oral tablet 40 mg 1 or 1b* QL (1 tablet per 1 day) simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 or 1b*; $0 simvastatin oral tablet 80 mg 1 or 1b* PA; QL (1 tablet per 1 day) *INTEST CHOLEST ABSORP INHIB-HMG COA REDUCTASE INHIB COMB*** - DRUGS FOR CHOLESTEROL ezetimibe-simvastatin oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) *INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS*** - DRUGS FOR CHOLESTEROL ezetimibe oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) *MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN INHIBITORS*** - DRUGS FOR CHOLESTEROL JUXTAPID ORAL CAPSULE (lomitapide mesylate) 3 PA; LD *NICOTINIC ACID DERIVATIVES*** - DRUGS FOR CHOLESTEROL niacin (antihyperlipidemic) oral tablet 1 or 1b* ST; QL (12 tablets per 1 day) niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 750 mg 1 or 1b* ST; QL (2 tablets per 1 day) niacin er (antihyperlipidemic) oral tablet extended release 500 mg 1 or 1b* ST; QL (1 tablet per 1 day) niacor oral tablet 1 or 1b* ST; QL (12 tablets per 1 day) NIASPAN ORAL TABLET EXTENDED RELEASE 1000 MG, 750 MG 3 ST; QL (2 tablets per 1 day) (niacin (antihyperlipidemic))

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 52 Coverage Requirements and Prescription Drug Name Drug Tier Limits NIASPAN ORAL TABLET EXTENDED RELEASE 500 MG (niacin 3 ST; QL (1 tablet per 1 day) (antihyperlipidemic)) *PCSK9 INHIBITORS*** - DRUGS FOR CHOLESTEROL PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 PA; QL (2 injection per 28 days) (alirocumab) REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION 3 PA; QL (1 injector per 30 days) CARTRIDGE (evolocumab) REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 PA; QL (2 syringe per 28 days) (evolocumab) REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 PA; QL (2 syringe per 28 days) (evolocumab) *ANTIHYPERTENSIVES* - DRUGS FOR THE HEART *ACE INHIBITOR & CALCIUM CHANNEL BLOCKER COMBINATIONS*** - DRUGS FOR HIGH BLOOD PRESSURE amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 5-40 mg 1 or 1b* QL (1 capsule per 1 day) amlodipine besy-benazepril hcl oral capsule 2.5-10 mg, 5-10 mg, 5-20 mg 1 or 1b* PRESTALIA ORAL TABLET 14-10 MG (perindopril arg-amlodipine) 3 QL (1 tablet per 1 day) PRESTALIA ORAL TABLET 3.5-2.5 MG, 7-5 MG (perindopril arg- 3 amlodipine) TARKA ORAL TABLET EXTENDED RELEASE (trandolapril-verapamil 3 QL (1 tablet per 1 day) hcl) trandolapril-verapamil hcl er oral tablet extended release 1-240 mg 1 or 1b* trandolapril-verapamil hcl er oral tablet extended release 2-180 mg, 2-240 1 or 1b* QL (1 tablet per 1 day) mg, 4-240 mg *ACE INHIBITORS & THIAZIDE/THIAZIDE-LIKE*** - DRUGS FOR HIGH BLOOD PRESSURE ACCURETIC ORAL TABLET (quinapril-hydrochlorothiazide) 3 QL (2 tablets per 1 day) benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 5-6.25 mg 1 or 1b* benazepril-hydrochlorothiazide oral tablet 20-12.5 mg, 20-25 mg 1 or 1b* QL (1 tablet per 1 day) enalapril-hydrochlorothiazide oral tablet 1 or 1b* QL (2 tablets per 1 day) fosinopril sodium-hctz oral tablet 10-12.5 mg 1 or 1b* QL (2 tablets per 1 day) fosinopril sodium-hctz oral tablet 20-12.5 mg 1 or 1b* QL (4 tablets per 1 day) lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg 1 or 1b* lisinopril-hydrochlorothiazide oral tablet 20-12.5 mg 1 or 1b* QL (4 tablets per 1 day) lisinopril-hydrochlorothiazide oral tablet 20-25 mg 1 or 1b* QL (2 tablets per 1 day) LOTENSIN HCT ORAL TABLET 10-12.5 MG (benazepril- 3 hydrochlorothiazide) LOTENSIN HCT ORAL TABLET 20-12.5 MG, 20-25 MG (benazepril- 3 QL (1 tablet per 1 day) hydrochlorothiazide) quinapril-hydrochlorothiazide oral tablet 1 or 1b* QL (2 tablets per 1 day) VASERETIC ORAL TABLET (enalapril-hydrochlorothiazide) 3 QL (2 tablets per 1 day) ZESTORETIC ORAL TABLET 10-12.5 MG (lisinopril-hydrochlorothiazide) 3 ZESTORETIC ORAL TABLET 20-12.5 MG (lisinopril-hydrochlorothiazide) 3 QL (4 tablets per 1 day) ZESTORETIC ORAL TABLET 20-25 MG (lisinopril-hydrochlorothiazide) 3 QL (2 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 53 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ACE INHIBITORS*** - DRUGS FOR HIGH BLOOD PRESSURE benazepril hcl oral tablet 1 or 1a* QL (2 tablets per 1 day) captopril oral tablet 1 or 1b* QL (3 tablets per 1 day) enalapril maleate oral tablet 1 or 1b* QL (2 tablets per 1 day) enalaprilat intravenous injectable 1 or 1b* EPANED ORAL SOLUTION (enalapril maleate) 3 QL (40 mg per 1 day) fosinopril sodium oral tablet 1 or 1b* QL (2 tablets per 1 day) lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 or 1a* lisinopril oral tablet 30 mg, 40 mg 1 or 1a* QL (2 tablets per 1 day) LOTENSIN ORAL TABLET (benazepril hcl) 3 QL (2 tablets per 1 day) moexipril hcl oral tablet 15 mg 1 or 1b* QL (4 tablets per 1 day) moexipril hcl oral tablet 7.5 mg 1 or 1b* QL (2 tablets per 1 day) perindopril erbumine oral tablet 1 or 1b* QL (2 tablets per 1 day) QBRELIS ORAL SOLUTION (lisinopril) 3 QL (40 mg per 1 day) quinapril hcl oral tablet 1 or 1b* QL (2 tablets per 1 day) ramipril oral capsule 1 or 1b* QL (2 capsules per 1 day) trandolapril oral tablet 1 or 1b* QL (2 tablets per 1 day) *AGENTS FOR PHEOCHROMOCYTOMA*** - DRUGS FOR HIGH BLOOD PRESSURE DEMSER ORAL CAPSULE (metyrosine) 3 PA; QL (16 capsules per 1 day) DIBENZYLINE ORAL CAPSULE (phenoxybenzamine hcl) 3 PA; QL (12 capsules per 1 day) metyrosine oral capsule 1 or 1b* PA; QL (16 capsules per 1 day) phenoxybenzamine hcl oral capsule 1 or 1b* PA; QL (12 capsules per 1 day) phentolamine mesylate injection solution reconstituted 1 or 1b* *ANGIOTENSIN II RECEPTOR ANTAG & CA CHANNEL BLOCKER COMB*** - DRUGS FOR HIGH BLOOD PRESSURE amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, 5-320 mg 1 or 1b* QL (1 tablet per 1 day) amlodipine besylate-valsartan oral tablet 5-160 mg 1 or 1b* amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-40 mg 1 or 1b* QL (1 tablet per 1 day) amlodipine-olmesartan oral tablet 5-20 mg 1 or 1b* telmisartan-amlodipine oral tablet 40-10 mg, 80-10 mg, 80-5 mg 1 or 1b* QL (1 tablet per 1 day) telmisartan-amlodipine oral tablet 40-5 mg 1 or 1b* TWYNSTA ORAL TABLET 40-10 MG, 80-10 MG, 80-5 MG (telmisartan- 3 QL (1 tablet per 1 day) amlodipine) TWYNSTA ORAL TABLET 40-5 MG (telmisartan-amlodipine) 3 *ANGIOTENSIN II RECEPTOR ANTAG & THIAZIDE/THIAZIDE- LIKE*** - DRUGS FOR HIGH BLOOD PRESSURE candesartan cilexetil-hctz oral tablet 16-12.5 mg 1 or 1b* QL (2 tablets per 1 day) candesartan cilexetil-hctz oral tablet 32-12.5 mg, 32-25 mg 1 or 1b* QL (1 tablet per 1 day) EDARBYCLOR ORAL TABLET (azilsartan-chlorthalidone) 3 QL (1 tablet per 1 day) irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg 1 or 1b* QL (2 tablets per 1 day) irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg 1 or 1b* QL (1 tablet per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 54 Coverage Requirements and Prescription Drug Name Drug Tier Limits losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg 1 or 1b* QL (1 tablet per 1 day) losartan potassium-hctz oral tablet 50-12.5 mg 1 or 1b* olmesartan medoxomil-hctz oral tablet 20-12.5 mg 1 or 1b* olmesartan medoxomil-hctz oral tablet 40-12.5 mg, 40-25 mg 1 or 1b* QL (1 tablet per 1 day) telmisartan-hctz oral tablet 40-12.5 mg 1 or 1b* telmisartan-hctz oral tablet 80-12.5 mg 1 or 1b* QL (2 tablets per 1 day) telmisartan-hctz oral tablet 80-25 mg 1 or 1b* QL (1 tablet per 1 day) valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 80-12.5 mg 1 or 1b* valsartan-hydrochlorothiazide oral tablet 160-25 mg, 320-12.5 mg, 320-25 mg 1 or 1b* QL (1 tablet per 1 day) *ANGIOTENSIN II RECEPTOR ANTAGONISTS*** - DRUGS FOR HIGH BLOOD PRESSURE candesartan cilexetil oral tablet 16 mg, 4 mg, 8 mg 1 or 1b* QL (2 tablets per 1 day) candesartan cilexetil oral tablet 32 mg 1 or 1b* QL (1 tablet per 1 day) EDARBI ORAL TABLET 40 MG (azilsartan medoxomil) 3 EDARBI ORAL TABLET 80 MG (azilsartan medoxomil) 3 QL (1 tablet per 1 day) irbesartan oral tablet 150 mg, 75 mg 1 or 1b* irbesartan oral tablet 300 mg 1 or 1b* QL (1 tablet per 1 day) losartan potassium oral tablet 100 mg 1 or 1b* QL (1 tablet per 1 day) losartan potassium oral tablet 25 mg, 50 mg 1 or 1b* QL (2 tablets per 1 day) olmesartan medoxomil oral tablet 20 mg 1 or 1b* olmesartan medoxomil oral tablet 40 mg 1 or 1b* QL (1 tablet per 1 day) olmesartan medoxomil oral tablet 5 mg 1 or 1b* QL (2 tablets per 1 day) telmisartan oral tablet 20 mg, 40 mg 1 or 1b* telmisartan oral tablet 80 mg 1 or 1b* QL (2 tablets per 1 day) valsartan oral tablet 160 mg 1 or 1b* QL (2 tablets per 1 day) valsartan oral tablet 320 mg 1 or 1b* QL (1 tablet per 1 day) valsartan oral tablet 40 mg, 80 mg 1 or 1b* QL (3 tablet per 1 day) *ANGIOTENSIN II RECEPTOR ANT-CA CHANNEL BLOCKER- THIAZIDES*** - DRUGS FOR HIGH BLOOD PRESSURE amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320- 1 or 1b* QL (1 tablet per 1 day) 25 mg, 5-160-25 mg amlodipine-valsartan-hctz oral tablet 5-160-12.5 mg 1 or 1b* olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg 1 or 1b* olmesartan-amlodipine-hctz oral tablet 40-10-12.5 mg, 40-10-25 mg, 40-5- 1 or 1b* QL (1 tablet per 1 day) 12.5 mg, 40-5-25 mg *ANTIADRENERGICS - CENTRALLY ACTING*** - DRUGS FOR HIGH BLOOD PRESSURE CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY (clonidine) 3 CATAPRES-TTS-2 TRANSDERMAL PATCH WEEKLY (clonidine) 3 CATAPRES-TTS-3 TRANSDERMAL PATCH WEEKLY (clonidine) 3 clonidine hcl oral tablet 1 or 1a* QL (4 tablets per 1 day) clonidine transdermal patch weekly 1 or 1b* guanfacine hcl oral tablet 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 55 Coverage Requirements and Prescription Drug Name Drug Tier Limits methyldopa oral tablet 250 mg 1 or 1b* methyldopa oral tablet 500 mg 1 or 1b* QL (6 tablets per 1 day) *ANTIADRENERGICS - PERIPHERALLY ACTING*** - DRUGS FOR HIGH BLOOD PRESSURE CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG (doxazosin mesylate) 3 QL (1 tablet per 1 day) CARDURA ORAL TABLET 8 MG (doxazosin mesylate) 3 QL (2 tablets per 1 day) doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg 1 or 1b* QL (1 tablet per 1 day) doxazosin mesylate oral tablet 8 mg 1 or 1b* QL (2 tablets per 1 day) MINIPRESS ORAL CAPSULE (prazosin hcl) 3 prazosin hcl oral capsule 1 or 1b* terazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1 or 1b* QL (1 capsule per 1 day) terazosin hcl oral capsule 10 mg 1 or 1b* QL (2 capsules per 1 day) *ANTIHYPERTENSIVES - MISC.*** - DRUGS FOR HIGH BLOOD PRESSURE VECAMYL ORAL TABLET (mecamylamine hcl) 3 *BETA BLOCKER & DIURETIC COMBINATIONS*** - DRUGS FOR HIGH BLOOD PRESSURE atenolol-chlorthalidone oral tablet 1 or 1b* QL (1 tablet per 1 day) bisoprolol-hydrochlorothiazide oral tablet 1 or 1b* QL (2 tablets per 1 day) DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 QL (2 tablets per 1 day) (metoprolol-hydrochlorothiazide) metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 50-25 mg 1 or 1b* QL (2 tablets per 1 day) metoprolol-hydrochlorothiazide oral tablet 100-50 mg 1 or 1b* QL (1 tablet per 1 day) TENORETIC 100 ORAL TABLET (atenolol-chlorthalidone) 3 QL (1 tablet per 1 day) TENORETIC 50 ORAL TABLET (atenolol-chlorthalidone) 3 QL (1 tablet per 1 day) ZIAC ORAL TABLET (bisoprolol-hydrochlorothiazide) 3 QL (2 tablets per 1 day) *DIRECT RENIN INHIBITORS & THIAZIDE/THIAZIDE-LIKE COMB*** - DRUGS FOR HIGH BLOOD PRESSURE TEKTURNA HCT ORAL TABLET 150-12.5 MG (aliskiren- 3 hydrochlorothiazide) TEKTURNA HCT ORAL TABLET 150-25 MG, 300-12.5 MG, 300-25 MG 3 QL (1 tablet per 1 day) (aliskiren-hydrochlorothiazide) *DIRECT RENIN INHIBITORS*** - DRUGS FOR HIGH BLOOD PRESSURE aliskiren fumarate oral tablet 150 mg 1 or 1b* aliskiren fumarate oral tablet 300 mg 1 or 1b* QL (1 tablet per 1 day) *DOPAMINE D1 RECEPTOR AGONISTS*** - DRUGS FOR HIGH BLOOD PRESSURE CORLOPAM INTRAVENOUS SOLUTION (fenoldopam mesylate) 3 *SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)*** - DRUGS FOR HIGH BLOOD PRESSURE eplerenone oral tablet 1 or 1b* INSPRA ORAL TABLET (eplerenone) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 56 Coverage Requirements and Prescription Drug Name Drug Tier Limits *VASODILATORS*** - DRUGS FOR HIGH BLOOD PRESSURE hydralazine hcl injection solution 1 or 1b* hydralazine hcl oral tablet 1 or 1b* minoxidil oral tablet 1 or 1b* NIPRIDE RTU INTRAVENOUS SOLUTION (nitroprusside sodium-nacl) 3 nitroprusside sodium intravenous solution 1 or 1b* sodium nitroprusside intravenous solution 1 or 1b* *ANTI-INFECTIVE AGENTS - MISC.* - DRUGS FOR INFECTIONS *ANTI-INFECTIVE AGENTS - MISC.*** - DRUGS FOR INFECTIONS AEMCOLO ORAL TABLET DELAYED RELEASE (rifamycin sodium) 3 PA; QL (12 tablets per 30 days) bacitracin intramuscular solution reconstituted 1 or 1b* FLAGYL ORAL CAPSULE (metronidazole) 3 FLAGYL ORAL TABLET (metronidazole) 3 IMPAVIDO ORAL CAPSULE (miltefosine) 3 PA; QL (84 capsules per 1 fill) metronidazole in nacl intravenous solution 5-0.79 mg/ml-%, 500-0.79 1 or 1b* mg/100ml-% METRONIDAZOLE IN NACL INTRAVENOUS SOLUTION 500-0.74 3 MG/100ML-% metronidazole oral capsule 1 or 1a* metronidazole oral tablet 1 or 1a* NEBUPENT INHALATION SOLUTION RECONSTITUTED (pentamidine 3 isethionate) PENTAM INJECTION SOLUTION RECONSTITUTED (pentamidine 4 isethionate) pentamidine isethionate inhalation solution reconstituted 1 or 1b* pentamidine isethionate injection solution reconstituted 4 PRIMSOL ORAL SOLUTION (trimethoprim hcl) 3 tinidazole oral tablet 250 mg 1 or 1b* QL (5 tablets per 28 days) tinidazole oral tablet 500 mg 1 or 1b* QL (20 tablets per 1 fill) trimethoprim oral tablet 1 or 1a* XIFAXAN ORAL TABLET 200 MG (rifaximin) 3 PA; QL (9 tablets per 30 days) XIFAXAN ORAL TABLET 550 MG (rifaximin) 3 PA; QL (126 tablet per 252 days) *ANTI-INFECTIVE MISC. - COMBINATIONS*** - ANTIBIOTICS BACTRIM DS ORAL TABLET (sulfamethoxazole-trimethoprim) 3 BACTRIM ORAL TABLET (sulfamethoxazole-trimethoprim) 3 sulfamethoxazole-trimethoprim intravenous solution 1 or 1b* sulfamethoxazole-trimethoprim oral suspension 1 or 1a* sulfamethoxazole-trimethoprim oral tablet 1 or 1a* sulfatrim pediatric oral suspension 1 or 1a* *ANTIPROTOZOAL AGENTS*** - DRUGS FOR PARASITES ALINIA ORAL SUSPENSION RECONSTITUTED (nitazoxanide) 3 ALINIA ORAL TABLET (nitazoxanide) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 57 Coverage Requirements and Prescription Drug Name Drug Tier Limits atovaquone oral suspension 1 or 1b* LAMPIT ORAL TABLET (nifurtimox) 3 MEPRON ORAL SUSPENSION (atovaquone) 3 nitazoxanide oral tablet 1 or 1b* *CARBAPENEM COMBINATIONS*** - ANTIBIOTICS imipenem-cilastatin intravenous solution reconstituted 1 or 1b* PRIMAXIN IV INTRAVENOUS SOLUTION RECONSTITUTED 3 (imipenem-cilastatin) RECARBRIO INTRAVENOUS SOLUTION RECONSTITUTED (imipenem- 3 cilastatin-relebactam) VABOMERE INTRAVENOUS SOLUTION RECONSTITUTED 3 (meropenem-vaborbactam) *CARBAPENEMS*** - ANTIBIOTICS ertapenem sodium injection solution reconstituted 1 or 1b* INVANZ INJECTION SOLUTION RECONSTITUTED (ertapenem sodium) 3 meropenem intravenous solution reconstituted 1 or 1b* MEROPENEM-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 RECONSTITUTED *CHLORAMPHENICALS*** - ANTIBIOTICS chloramphenicol sod succinate intravenous solution reconstituted 1 or 1b* *CYCLIC LIPOPEPTIDES*** - ANTIBIOTICS CUBICIN INTRAVENOUS SOLUTION RECONSTITUTED (daptomycin) 3 CUBICIN RF INTRAVENOUS SOLUTION RECONSTITUTED 3 (daptomycin) DAPTOMYCIN INTRAVENOUS SOLUTION RECONSTITUTED 350 MG 3 daptomycin intravenous solution reconstituted 500 mg 1 or 1b* *GLYCOPEPTIDES*** - ANTIBIOTICS DALVANCE INTRAVENOUS SOLUTION RECONSTITUTED 3 (dalbavancin hcl) FIRVANQ ORAL SOLUTION RECONSTITUTED (vancomycin hcl) 3 PA; QL (1200 mL per 30 days) ORBACTIV INTRAVENOUS SOLUTION RECONSTITUTED (oritavancin 3 diphosphate) VANCOCIN HCL ORAL CAPSULE (vancomycin hcl) 3 PA; QL (240 capsules per 30 days) VANCOCIN ORAL CAPSULE (vancomycin hcl) 3 PA; QL (240 capsules per 30 days) VANCOMYCIN HCL IN DEXTROSE INTRAVENOUS SOLUTION 1-5 3 GM/200ML-%, 500-5 MG/100ML-%, 750-5 MG/150ML-% VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 1.5-0.9 3 GM/250ML-%, 1.5-0.9 GM/500ML-%, 1.75-0.9 GM/250ML-% VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 1-0.9 3 GM/200ML-%, 500-0.9 MG/100ML-%, 750-0.9 MG/150ML-% VANCOMYCIN HCL INTRAVENOUS SOLUTION 3 vancomycin hcl intravenous solution reconstituted 1 gm, 1000 mg, 500 mg 1 or 1b* QL (2 vials per 1 day) VANCOMYCIN HCL INTRAVENOUS SOLUTION RECONSTITUTED 3 1.25 GM, 1.5 GM, 250 MG

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 58 Coverage Requirements and Prescription Drug Name Drug Tier Limits vancomycin hcl intravenous solution reconstituted 10 gm, 100 gm, 5 gm, 750 1 or 1b* mg vancomycin hcl oral capsule 1 or 1b* PA; QL (240 capsules per 30 days) VANCOMYCIN HCL ORAL SOLUTION RECONSTITUTED 3 PA; QL (1200 mL per 30 days) VIBATIV INTRAVENOUS SOLUTION RECONSTITUTED (telavancin hcl) 3 *LEPROSTATICS*** - ANTIBIOTICS dapsone oral tablet 1 or 1b* *LINCOSAMIDES*** - ANTIBIOTICS CLEOCIN ORAL CAPSULE (clindamycin hcl) 3 CLEOCIN ORAL SOLUTION RECONSTITUTED (clindamycin palmitate 3 hcl) CLEOCIN PHOSPHATE INJECTION SOLUTION (clindamycin phosphate) 3 QL (20 mL per 1 day) clindamycin hcl oral capsule 1 or 1b* clindamycin palmitate hcl oral solution reconstituted 1 or 1b* clindamycin phosphate in d5w intravenous solution 1 or 1b* CLINDAMYCIN PHOSPHATE IN NACL INTRAVENOUS SOLUTION 3 clindamycin phosphate injection solution 1 or 1b* QL (20 mL per 1 day) LINCOCIN INJECTION SOLUTION (lincomycin hcl) 3 lincomycin hcl injection solution 1 or 1b* *MONOBACTAMS*** - ANTIBIOTICS AZACTAM INJECTION SOLUTION RECONSTITUTED (aztreonam) 3 aztreonam injection solution reconstituted 1 or 1b* CAYSTON INHALATION SOLUTION RECONSTITUTED (aztreonam 4 LD; SP; QL (84 vials per 28 days) lysine) *OXAZOLIDINONES*** - ANTIBIOTICS linezolid in sodium chloride intravenous solution 1 or 1b* linezolid intravenous solution 1 or 1b* linezolid oral suspension reconstituted 1 or 1b* PA; QL (900 mL per 30 days) linezolid oral tablet 1 or 1b* PA; QL (28 tablet per 30 days) SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED (tedizolid 3 phosphate) SIVEXTRO ORAL TABLET (tedizolid phosphate) 3 PA; QL (6 tablet per 30 days) ZYVOX INTRAVENOUS SOLUTION (linezolid) 3 ZYVOX ORAL SUSPENSION RECONSTITUTED (linezolid) 3 PA; QL (900 mL per 30 days) ZYVOX ORAL TABLET (linezolid) 3 PA; QL (28 tablet per 30 days) *PLEUROMUTILINS*** - ANTIBIOTICS XENLETA INTRAVENOUS SOLUTION (lefamulin acetate) 3 LD XENLETA ORAL TABLET (lefamulin acetate) 3 PA; LD; QL (10 tablets per 30 days) *POLYMYXINS*** - ANTIBIOTICS colistimethate sodium (cba) injection solution reconstituted 1 or 1b* COLY-MYCIN M INJECTION SOLUTION RECONSTITUTED 3 (colistimethate sodium) polymyxin b sulfate injection solution reconstituted 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 59 Coverage Requirements and Prescription Drug Name Drug Tier Limits *STREPTOGRAMIN COMBINATIONS*** - ANTIBIOTICS SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED 3 (quinupristin-dalfopristin) *URINARY ANTI-INFECTIVES*** - ANTIBIOTICS fosfomycin tromethamine oral packet 1 or 1b* QL (1 pack per 1 fill) HIPREX ORAL TABLET (methenamine hippurate) 3 MACROBID ORAL CAPSULE (nitrofurantoin monohyd macro) 3 QL (14 capsules per 1 fill) MACRODANTIN ORAL CAPSULE (nitrofurantoin macrocrystal) 3 QL (4 capsules per 1 day) methenamine hippurate oral tablet 1 or 1b* MONUROL ORAL PACKET (fosfomycin tromethamine) 3 QL (1 pack per 1 fill) nitrofurantoin macrocrystal oral capsule 1 or 1b* QL (4 capsules per 1 day) nitrofurantoin monohyd macro oral capsule 1 or 1b* QL (14 capsules per 1 fill) nitrofurantoin oral suspension 1 or 1b* QL (80 mL per 1 day) *ANTIMALARIALS* - DRUGS FOR INFECTIONS *ANTIMALARIAL COMBINATIONS*** - DRUGS FOR PARASITES atovaquone-proguanil hcl oral tablet 1 or 1b* COARTEM ORAL TABLET (artemether-lumefantrine) 3 MALARONE ORAL TABLET (atovaquone-proguanil hcl) 3 *ANTIMALARIALS*** - DRUGS FOR PARASITES ARAKODA ORAL TABLET (tafenoquine succinate) 3 QL (56 tablets per 1 year) ARTESUNATE INTRAVENOUS SOLUTION RECONSTITUTED 3 chloroquine phosphate oral tablet 1 or 1a* DARAPRIM ORAL TABLET (pyrimethamine) 3 PA; LD; QL (3 tablets per 1 day) hydroxychloroquine sulfate oral tablet 1 or 1b* QL (90 tablets per 30 days) KRINTAFEL ORAL TABLET (tafenoquine succinate) 3 QL (2 tablets per 1 fill) mefloquine hcl oral tablet 1 or 1b* QL (5 tablets per 28 days) PRIMAQUINE PHOSPHATE ORAL TABLET 3 pyrimethamine oral tablet 1 or 1b* PA; QL (3 tablets per 1 day) QUALAQUIN ORAL CAPSULE (quinine sulfate) 3 PA; QL (60 capsule per 365 days) quinine sulfate oral capsule 1 or 1b* PA; QL (60 capsule per 365 days) *ANTIMYASTHENIC/CHOLINERGIC AGENTS* - DRUGS FOR NERVES AND MUSCLES *ANTIMYASTHENIC/CHOLINERGIC AGENTS*** - DRUGS FOR NERVES AND MUSCLES BLOXIVERZ INTRAVENOUS SOLUTION (neostigmine methylsulfate) 3 FIRDAPSE ORAL TABLET (amifampridine phosphate) 4 PA; LD; QL (8 tablets per 1 day) MESTINON ORAL SOLUTION (pyridostigmine bromide) 3 MESTINON ORAL TABLET (pyridostigmine bromide) 3 MESTINON ORAL TABLET EXTENDED RELEASE (pyridostigmine 3 bromide) NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION 10 3 MG/10ML, 5 MG/10ML pyridostigmine bromide er oral tablet extended release 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 60 Coverage Requirements and Prescription Drug Name Drug Tier Limits pyridostigmine bromide oral solution 1 or 1b* pyridostigmine bromide oral tablet 1 or 1b* REGONOL INTRAVENOUS SOLUTION (pyridostigmine bromide) 3 RUZURGI ORAL TABLET (amifampridine) 4 PA; LD; QL (10 tablets per 1 day) *ANTIMYCOBACTERIAL AGENTS* - DRUGS FOR INFECTIONS *ANTIMYCOBACTERIAL AGENTS*** - ANTIBIOTICS CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 3 (capreomycin sulfate) cycloserine oral capsule 1 or 1b* ethambutol hcl oral tablet 1 or 1b* isoniazid injection solution 1 or 1a* isoniazid oral syrup 1 or 1a* isoniazid oral tablet 1 or 1a* MYAMBUTOL ORAL TABLET (ethambutol hcl) 3 MYCOBUTIN ORAL CAPSULE (rifabutin) 3 PASER ORAL PACKET (aminosalicylic acid) 3 PRETOMANID ORAL TABLET 3 PRIFTIN ORAL TABLET (rifapentine) 2 pyrazinamide oral tablet 1 or 1b* rifabutin oral capsule 1 or 1b* RIFADIN INTRAVENOUS SOLUTION RECONSTITUTED (rifampin) 3 rifampin intravenous solution reconstituted 1 or 1b* rifampin oral capsule 1 or 1b* SIRTURO ORAL TABLET (bedaquiline fumarate) 3 TRECATOR ORAL TABLET (ethionamide) 3 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* - DRUGS FOR CANCER *ALKYLATING AGENTS*** - DRUGS FOR CANCER BELRAPZO INTRAVENOUS SOLUTION (bendamustine hcl) 3 PA; LD; SP BENDEKA INTRAVENOUS SOLUTION (bendamustine hcl) 3 PA; LD; SP busulfan intravenous solution 1 or 1b* SP BUSULFEX INTRAVENOUS SOLUTION (busulfan) 3 SP carboplatin intravenous solution 1 or 1b* SP cisplatin intravenous solution 1 or 1b* SP CISPLATIN INTRAVENOUS SOLUTION RECONSTITUTED 3 SP MYLERAN ORAL TABLET (busulfan) 2; OC oxaliplatin intravenous solution 1 or 1b* SP oxaliplatin intravenous solution reconstituted 1 or 1b* SP paraplatin intravenous solution 1 or 1b* SP TEPADINA INJECTION SOLUTION RECONSTITUTED (thiotepa) 3 SP thiotepa injection solution reconstituted 1 or 1b* SP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 61 Coverage Requirements and Prescription Drug Name Drug Tier Limits TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (bendamustine hcl) ZEPZELCA INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (lurbinectedin) *ANDROGEN BIOSYNTHESIS INHIBITORS*** - DRUGS FOR CANCER abiraterone acetate oral tablet 250 mg 1 or 1b*; OC PA; SP; QL (4 tablet per 1 day) abiraterone acetate oral tablet 500 mg 1 or 1b*; OC PA; SP; QL (2 tablets per 1 day) PA; LD; SP; QL (4 tablets per 1 YONSA ORAL TABLET (abiraterone acetate) 3; OC day) ZYTIGA ORAL TABLET 250 MG (abiraterone acetate) 3; OC PA; LD; SP; QL (4 tablet per 1 day) PA; LD; SP; QL (2 tablets per 1 ZYTIGA ORAL TABLET 500 MG (abiraterone acetate) 3; OC day) *ANTIADRENALS*** - DRUGS FOR CANCER LYSODREN ORAL TABLET (mitotane) 2; OC LD; QL (38 tablet per 1 day) *ANTIANDROGENS*** - DRUGS FOR CANCER bicalutamide oral tablet 1 or 1b*; OC CASODEX ORAL TABLET (bicalutamide) 3; OC PA; LD; SP; QL (4 tablets per 1 ERLEADA ORAL TABLET (apalutamide) 2; OC day) flutamide oral capsule 1 or 1b*; OC NILANDRON ORAL TABLET (nilutamide) 3; OC QL (1 tablet per 1 day) nilutamide oral tablet 1 or 1b*; OC QL (1 tablet per 1 day) PA; LD; SP; QL (4 tablets per 1 NUBEQA ORAL TABLET (darolutamide) 3; OC day) PA; LD; SP; QL (4 capsules per 1 XTANDI ORAL CAPSULE (enzalutamide) 2; OC day) PA; LD; SP; QL (4 tablets per 1 XTANDI ORAL TABLET 40 MG (enzalutamide) 2; OC day) PA; LD; SP; QL (2 tablets per 1 XTANDI ORAL TABLET 80 MG (enzalutamide) 2; OC day) *ANTIESTROGENS*** - DRUGS FOR CANCER FARESTON ORAL TABLET (toremifene citrate) 3; OC QL (1 tablet per 1 day) SOLTAMOX ORAL SOLUTION (tamoxifen citrate) 2; OC; $0 tamoxifen citrate oral tablet 1 or 1b*; OC; $0 toremifene citrate oral tablet 1 or 1b*; OC QL (1 tablet per 1 day) *ANTIMETABOLITES*** - DRUGS FOR CANCER ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED (pemetrexed 3 PA; SP disodium) ARRANON INTRAVENOUS SOLUTION (nelarabine) 3 SP azacitidine injection suspension reconstituted 1 or 1b* PA; SP capecitabine oral tablet 1 or 1b*; OC PA; SP cladribine intravenous solution 1 or 1b* SP clofarabine intravenous solution 1 or 1b* SP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 62 Coverage Requirements and Prescription Drug Name Drug Tier Limits CLOLAR INTRAVENOUS SOLUTION (clofarabine) 3 SP cytarabine (pf) injection solution 1 or 1b* SP cytarabine injection solution 1 or 1b* SP DACOGEN INTRAVENOUS SOLUTION RECONSTITUTED (decitabine) 3 SP decitabine intravenous solution reconstituted 1 or 1b* SP floxuridine injection solution reconstituted 1 or 1b* SP fludarabine phosphate intravenous solution 1 or 1b* SP fludarabine phosphate intravenous solution reconstituted 1 or 1b* SP fluorouracil intravenous solution 1 or 1b* SP FOLOTYN INTRAVENOUS SOLUTION (pralatrexate) 3 SP GEMCITABINE HCL INTRAVENOUS SOLUTION 3 SP gemcitabine hcl intravenous solution reconstituted 1 or 1b* SP INFUGEM INTRAVENOUS SOLUTION (gemcitabine hcl-nacl) 3 SP mercaptopurine oral tablet 1 or 1b*; OC methotrexate oral tablet 1 or 1b*; OC methotrexate sodium (pf) injection solution 1 or 1b* methotrexate sodium injection solution 1 or 1b* methotrexate sodium injection solution reconstituted 1 or 1b* methotrexate sodium oral tablet 1 or 1b*; OC PA; LD; SP; QL (14 tablets per 28 ONUREG ORAL TABLET (azacitidine) 3; OC days) PURIXAN ORAL SUSPENSION (mercaptopurine) 3; OC PA; LD TABLOID ORAL TABLET (thioguanine) 2; OC TREXALL ORAL TABLET (methotrexate sodium) 2; OC VIDAZA INJECTION SUSPENSION RECONSTITUTED (azacitidine) 3 PA; LD; SP XATMEP ORAL SOLUTION (methotrexate) 3; OC PA; SP XELODA ORAL TABLET (capecitabine) 3; OC PA; LD; SP *ANTINEOPLASTIC - ALK INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (8 capsule per 1 ALECENSA ORAL CAPSULE (alectinib hcl) 3; OC day) ALUNBRIG ORAL TABLET 180 MG (brigatinib) 3; OC PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (6 tablets per 1 ALUNBRIG ORAL TABLET 30 MG (brigatinib) 3; OC day) PA; LD; SP; QL (2 tablets per 1 ALUNBRIG ORAL TABLET 90 MG (brigatinib) 3; OC day) PA; LD; SP; QL (1 pack per 30 ALUNBRIG ORAL TABLET THERAPY PACK (brigatinib) 3; OC days) LORBRENA ORAL TABLET 100 MG (lorlatinib) 3; OC PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (3 tablets per 1 LORBRENA ORAL TABLET 25 MG (lorlatinib) 3; OC day) PA; LD; SP; QL (4 capsules per 1 XALKORI ORAL CAPSULE (crizotinib) 2; OC day) PA; LD; SP; QL (3 capsules per 1 ZYKADIA ORAL TABLET (ceritinib) 3; OC day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 63 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTINEOPLASTIC - ANTI-BCMA ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER BLENREP INTRAVENOUS SOLUTION RECONSTITUTED (belantamab 3 PA; LD; SP mafodotin-blmf) *ANTINEOPLASTIC - ANTI-CCR4 ANTIBODIES*** - DRUGS FOR CANCER POTELIGEO INTRAVENOUS SOLUTION (mogamulizumab-kpkc) 3 LD; SP *ANTINEOPLASTIC - ANTI-CD19 ANTIBODIES*** - DRUGS FOR CANCER MONJUVI INTRAVENOUS SOLUTION RECONSTITUTED (tafasitamab- 3 PA; LD cxix) *ANTINEOPLASTIC - ANTI-CD19 ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER ZYNLONTA INTRAVENOUS SOLUTION RECONSTITUTED 3 LD (loncastuximab tesirine-lpyl) *ANTINEOPLASTIC - ANTI-CD20 ANTIBODIES*** - DRUGS FOR CANCER ARZERRA INTRAVENOUS CONCENTRATE (ofatumumab) 3 PA; LD; SP GAZYVA INTRAVENOUS SOLUTION (obinutuzumab) 3 PA; LD; SP RIABNI INTRAVENOUS SOLUTION (rituximab-arrx) 3 PA; LD; SP RITUXAN INTRAVENOUS SOLUTION (rituximab) 3 PA; LD; SP RUXIENCE INTRAVENOUS SOLUTION (rituximab-pvvr) 3 PA; SP TRUXIMA INTRAVENOUS SOLUTION (rituximab-abbs) 3 PA; SP *ANTINEOPLASTIC - ANTI-CD22 ANTIBODIES*** - DRUGS FOR CANCER LUMOXITI INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (moxetumomab pasudotox-tdfk) *ANTINEOPLASTIC - ANTI-CD22 ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER BESPONSA INTRAVENOUS SOLUTION RECONSTITUTED (inotuzumab 3 PA; LD; SP ozogamicin) *ANTINEOPLASTIC - ANTI-CD30 ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER ADCETRIS INTRAVENOUS SOLUTION RECONSTITUTED (brentuximab 3 PA; LD; SP vedotin) *ANTINEOPLASTIC - ANTI-CD33 ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (gemtuzumab ozogamicin) *ANTINEOPLASTIC - ANTI-CD38 ANTIBODIES*** - DRUGS FOR CANCER DARZALEX INTRAVENOUS SOLUTION (daratumumab) 3 PA; LD; SP SARCLISA INTRAVENOUS SOLUTION (isatuximab-irfc) 3 PA; LD; SP *ANTINEOPLASTIC - ANTI-CD79B ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER POLIVY INTRAVENOUS SOLUTION RECONSTITUTED (polatuzumab 3 PA; LD; SP vedotin-piiq) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 64 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTINEOPLASTIC - ANTI-CTLA-4 ANTIBODIES*** - DRUGS FOR CANCER YERVOY INTRAVENOUS SOLUTION (ipilimumab) 3 PA; LD; SP *ANTINEOPLASTIC - ANTI-GD2 ANTIBODIES*** - DRUGS FOR CANCER DANYELZA INTRAVENOUS SOLUTION (naxitamab-gqgk) 3 PA; LD UNITUXIN INTRAVENOUS SOLUTION (dinutuximab) 3 LD *ANTINEOPLASTIC - ANTI-HER2 AGENTS*** - DRUGS FOR CANCER HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 3 LD; SP (trastuzumab) HERZUMA INTRAVENOUS SOLUTION RECONSTITUTED (trastuzumab- 3 LD; SP pkrb) KANJINTI INTRAVENOUS SOLUTION RECONSTITUTED (trastuzumab- 3 LD; SP anns) MARGENZA INTRAVENOUS SOLUTION (margetuximab-cmkb) 3 PA; LD OGIVRI INTRAVENOUS SOLUTION RECONSTITUTED (trastuzumab- 3 LD; SP dkst) ONTRUZANT INTRAVENOUS SOLUTION RECONSTITUTED 3 LD; SP (trastuzumab-dttb) PERJETA INTRAVENOUS SOLUTION (pertuzumab) 3 PA; LD; SP TRAZIMERA INTRAVENOUS SOLUTION RECONSTITUTED 3 SP (trastuzumab-qyyp) TUKYSA ORAL TABLET (tucatinib) 3; OC PA; LD; QL (4 tablets per 1 day) *ANTINEOPLASTIC - ANTI-NECTIN-4 ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER PADCEV INTRAVENOUS SOLUTION RECONSTITUTED (enfortumab 3 PA; LD; SP vedotin-ejfv) *ANTINEOPLASTIC - ANTI-PD-1 ANTIBODIES*** - DRUGS FOR CANCER JEMPERLI INTRAVENOUS SOLUTION (dostarlimab-gxly) 3 LD; SP KEYTRUDA INTRAVENOUS SOLUTION (pembrolizumab) 3 PA; LD; SP LIBTAYO INTRAVENOUS SOLUTION (cemiplimab-rwlc) 3 PA; LD OPDIVO INTRAVENOUS SOLUTION (nivolumab) 3 PA; LD; SP *ANTINEOPLASTIC - ANTI-PD-L1 ANTIBODIES*** - DRUGS FOR CANCER BAVENCIO INTRAVENOUS SOLUTION (avelumab) 3 PA; LD IMFINZI INTRAVENOUS SOLUTION (durvalumab) 3 PA; LD; SP TECENTRIQ INTRAVENOUS SOLUTION (atezolizumab) 3 PA; LD; SP *ANTINEOPLASTIC - ANTI-SLAMF7 ANTIBODIES*** - DRUGS FOR CANCER EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED (elotuzumab) 3 PA; LD; SP *ANTINEOPLASTIC - AUTOLOGOUS CELLULAR IMMUNOTHERAPY*** - DRUGS FOR CANCER PROVENGE INTRAVENOUS SUSPENSION (sipuleucel-t) 4 PA; LD

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 65 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTINEOPLASTIC - BCL-2 INHIBITORS*** - DRUGS FOR CANCER VENCLEXTA ORAL TABLET 10 MG (venetoclax) 3; OC PA; LD; QL (2 tablets per 1 day) VENCLEXTA ORAL TABLET 100 MG (venetoclax) 3; OC PA; LD; QL (6 tablet per 1 day) VENCLEXTA ORAL TABLET 50 MG (venetoclax) 3; OC PA; LD; QL (1 tablet per 1 day) VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 pack per 365 days) (venetoclax) *ANTINEOPLASTIC - BCR-ABL KINASE INHIBITORS*** - DRUGS FOR CANCER BOSULIF ORAL TABLET 100 MG (bosutinib) 2; OC PA; SP; QL (4 tablet per 1 day) BOSULIF ORAL TABLET 400 MG, 500 MG (bosutinib) 2; OC PA; SP; QL (1 tablet per 1 day) ICLUSIG ORAL TABLET 10 MG, 30 MG, 45 MG (ponatinib hcl) 2; OC PA; LD; QL (1 tablet per 1 day) ICLUSIG ORAL TABLET 15 MG (ponatinib hcl) 2; OC PA; LD; QL (2 tablets per 1 day) imatinib mesylate oral tablet 1 or 1b*; OC PA; SP; QL (2 tablets per 1 day) SPRYCEL ORAL TABLET (dasatinib) 2; OC PA; SP; QL (1 tablet per 1 day) TASIGNA ORAL CAPSULE (nilotinib hcl) 2; OC PA; SP; QL (4 capsules per 1 day) *ANTINEOPLASTIC - BISPECIFIC T-CELL ENGAGERS*** - DRUGS FOR CANCER BLINCYTO INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (blinatumomab) *ANTINEOPLASTIC - BRAF KINASE INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (6 capsules per 1 BRAFTOVI ORAL CAPSULE (encorafenib) 3; OC day) PA; LD; SP; QL (4 capsule per 1 TAFINLAR ORAL CAPSULE (dabrafenib mesylate) 3; OC day) ZELBORAF ORAL TABLET (vemurafenib) 2; OC PA; LD; SP; QL (8 tablet per 1 day) *ANTINEOPLASTIC - BTK INHIBITORS*** - DRUGS FOR CANCER BRUKINSA ORAL CAPSULE (zanubrutinib) 3; OC PA; LD; QL (4 capsules per 1 day) CALQUENCE ORAL CAPSULE (acalabrutinib) 3; OC PA; LD; QL (1 capsule per 1 day) IMBRUVICA ORAL CAPSULE 140 MG (ibrutinib) 3; OC PA; LD; QL (3 capsule per 1 day) IMBRUVICA ORAL CAPSULE 70 MG (ibrutinib) 3; OC PA; LD; QL (1 tablet per 1 day) IMBRUVICA ORAL TABLET (ibrutinib) 3; OC PA; LD; QL (1 tablet per 1 day) *ANTINEOPLASTIC - EGFR INHIBITORS*** - DRUGS FOR CANCER ERBITUX INTRAVENOUS SOLUTION (cetuximab) 3 PA; SP erlotinib hcl oral tablet 100 mg, 150 mg 1 or 1b*; OC PA; SP; QL (1 tablet per 1 day) erlotinib hcl oral tablet 25 mg 1 or 1b*; OC PA; SP; QL (3 tablets per 1 day) GILOTRIF ORAL TABLET (afatinib dimaleate) 3; OC PA; LD; QL (1 tablet per 1 day) IRESSA ORAL TABLET (gefitinib) 2; OC PA; LD; SP; QL (1 tablet per 1 day) PORTRAZZA INTRAVENOUS SOLUTION (necitumumab) 3 LD; SP TAGRISSO ORAL TABLET (osimertinib mesylate) 3; OC PA; LD; SP; QL (1 tablet per 1 day) TARCEVA ORAL TABLET 100 MG, 150 MG (erlotinib hcl) 3; OC PA; LD; SP; QL (1 tablet per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 66 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; LD; SP; QL (3 tablets per 1 TARCEVA ORAL TABLET 25 MG (erlotinib hcl) 3; OC day) VECTIBIX INTRAVENOUS SOLUTION (panitumumab) 3 PA; SP VIZIMPRO ORAL TABLET (dacomitinib) 3; OC PA; LD; SP; QL (1 tablet per 1 day) *ANTINEOPLASTIC - FGFR KINASE INHIBITORS*** - DRUGS FOR CANCER BALVERSA ORAL TABLET 3 MG (erdafitinib) 3; OC PA; LD; QL (3 tablets per 1 day) BALVERSA ORAL TABLET 4 MG (erdafitinib) 3; OC PA; LD; QL (2 tablets per 1 day) BALVERSA ORAL TABLET 5 MG (erdafitinib) 3; OC PA; LD; QL (1 tablet per 1 day) PEMAZYRE ORAL TABLET (pemigatinib) 3; OC PA; LD; QL (14 tablets per 21 days) *ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS*** - DRUGS FOR CANCER DAURISMO ORAL TABLET 100 MG (glasdegib maleate) 3; OC PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (2 tablets per 1 DAURISMO ORAL TABLET 25 MG (glasdegib maleate) 3; OC day) PA; LD; SP; QL (1 capsule per 1 ERIVEDGE ORAL CAPSULE (vismodegib) 2; OC day) PA; LD; SP; QL (1 capsule per 1 ODOMZO ORAL CAPSULE (sonidegib phosphate) 3; OC day) *ANTINEOPLASTIC - HISTONE DEACETYLASE INHIBITORS*** - DRUGS FOR CANCER BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED (belinostat) 3 PA; LD; SP PA; LD; SP; QL (1 capsule per 1 FARYDAK ORAL CAPSULE (panobinostat lactate) 3; OC day) ISTODAX (OVERFILL) INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (romidepsin) ROMIDEPSIN INTRAVENOUS SOLUTION 3 PA; SP ZOLINZA ORAL CAPSULE (vorinostat) 2; OC PA; SP; QL (4 capsule per 1 day) *ANTINEOPLASTIC - HORMONAL AND RELATED AGENT COMBINATIONS*** - DRUGS FOR CANCER LEUPROLIDE ACETATE-BUPIVACAINE INTRAMUSCULAR 3 SOLUTION *ANTINEOPLASTIC - IMMUNOMODULATORS*** - DRUGS FOR CANCER PA; LD; SP; QL (21 capsules per 28 POMALYST ORAL CAPSULE (pomalidomide) 3; OC days) *ANTINEOPLASTIC - MEK INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (3 tablets per 1 COTELLIC ORAL TABLET (cobimetinib fumarate) 3; OC day) KOSELUGO ORAL CAPSULE 10 MG (selumetinib sulfate) 3; OC PA; LD; QL (8 capsules per 1 day) KOSELUGO ORAL CAPSULE 25 MG (selumetinib sulfate) 3; OC PA; LD; QL (4 capsules per 1 day) PA; LD; SP; QL (3 tablets per 1 MEKINIST ORAL TABLET 0.5 MG (trametinib dimethyl sulfoxide) 3; OC day) MEKINIST ORAL TABLET 2 MG (trametinib dimethyl sulfoxide) 3; OC PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (6 tablets per 1 MEKTOVI ORAL TABLET (binimetinib) 3; OC day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 67 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTINEOPLASTIC - MET INHIBITORS*** - DRUGS FOR CANCER TABRECTA ORAL TABLET (capmatinib hcl) 3; OC PA; SP; QL (4 tablets per 1 day) *ANTINEOPLASTIC - METHYLTRANSFERASE INHIBITORS*** - DRUGS FOR CANCER TAZVERIK ORAL TABLET (tazemetostat hbr) 3; OC PA; LD; QL (8 tablets per 1 day) *ANTINEOPLASTIC - MTOR KINASE INHIBITORS*** - DRUGS FOR CANCER AFINITOR DISPERZ ORAL TABLET SOLUBLE (everolimus) 3; OC PA; SP AFINITOR ORAL TABLET 10 MG (everolimus) 2; OC PA; SP AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG (everolimus) 3; OC PA; SP everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg 1 or 1b*; OC PA; SP temsirolimus intravenous solution 1 or 1b* PA; SP TORISEL INTRAVENOUS SOLUTION (temsirolimus) 3 PA; SP *ANTINEOPLASTIC - MULTIKINASE INHIBITORS*** - DRUGS FOR CANCER CABOMETYX ORAL TABLET (cabozantinib s-malate) 3; OC PA; LD; SP; QL (1 tablet per 1 day) CAPRELSA ORAL TABLET 100 MG (vandetanib) 2; OC PA; LD; QL (3 tablet per 1 day) CAPRELSA ORAL TABLET 300 MG (vandetanib) 2; OC PA; LD; QL (1 tablet per 1 day) PA; LD; SP; QL (1 dose-pack per COMETRIQ (100 MG DAILY DOSE) ORAL KIT (cabozantinib s-malate) 3; OC 56 days) PA; LD; SP; QL (1 dose pack per COMETRIQ (140 MG DAILY DOSE) ORAL KIT (cabozantinib s-malate) 3; OC 28 days) PA; LD; SP; QL (1 dose pack per COMETRIQ (60 MG DAILY DOSE) ORAL KIT (cabozantinib s-malate) 3; OC 28 days) FOTIVDA ORAL CAPSULE (tivozanib hcl) 3; OC LD lapatinib ditosylate oral tablet 1 or 1b*; OC PA; SP; QL (6 tablet per 1 day) PA; LD; SP; QL (6 tablets per 1 NERLYNX ORAL TABLET (neratinib maleate) 3; OC day) NEXAVAR ORAL TABLET (sorafenib tosylate) 2; OC PA; LD; SP; QL (4 tablet per 1 day) QINLOCK ORAL TABLET (ripretinib) 3; OC PA; LD; QL (3 tablets per 1 day) RYDAPT ORAL CAPSULE (midostaurin) 3; OC PA; SP; QL (8 capsules per 1 day) PA; LD; SP; QL (84 tablets per 28 STIVARGA ORAL TABLET (regorafenib) 2; OC days) PA; LD; SP; QL (1 capsule per 1 SUTENT ORAL CAPSULE (sunitinib malate) 2; OC day) TEPMETKO ORAL TABLET (tepotinib hcl) 3; OC PA; LD; QL (2 tablets per 1 day) TURALIO ORAL CAPSULE (pexidartinib hcl) 3; OC PA; LD; QL (4 tablets per 1 day) TYKERB ORAL TABLET (lapatinib ditosylate) 3; OC PA; LD; SP; QL (6 tablet per 1 day) UKONIQ ORAL TABLET (umbralisib tosylate) 3; OC PA; LD; QL (4 tablets per 1 day) VOTRIENT ORAL TABLET (pazopanib hcl) 2; OC PA; LD; SP; QL (4 tablet per 1 day) XOSPATA ORAL TABLET (gilteritinib fumarate) 3; OC PA; LD; QL (3 tablets per 1 day) *ANTINEOPLASTIC - PDGFR-ALPHA INHIBITORS*** - DRUGS FOR CANCER AYVAKIT ORAL TABLET (avapritinib) 3; OC PA; LD; QL (1 tablet per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 68 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTINEOPLASTIC - PROTEASOME INHIBITORS*** - DRUGS FOR CANCER BORTEZOMIB INTRAVENOUS SOLUTION RECONSTITUTED 3 PA KYPROLIS INTRAVENOUS SOLUTION RECONSTITUTED (carfilzomib) 3 PA; LD; SP PA; LD; SP; QL (3 capsule per 28 NINLARO ORAL CAPSULE (ixazomib citrate) 3; OC days) VELCADE INJECTION SOLUTION RECONSTITUTED (bortezomib) 3 PA; SP *ANTINEOPLASTIC - RET INHIBITORS*** - DRUGS FOR CANCER GAVRETO ORAL CAPSULE (pralsetinib) 3; OC PA; LD; QL (4 capsules per 1 day) PA; LD; SP; QL (6 capsules per 1 RETEVMO ORAL CAPSULE 40 MG (selpercatinib) 3; OC day) PA; LD; SP; QL (4 capsules per 1 RETEVMO ORAL CAPSULE 80 MG (selpercatinib) 3; OC day) *ANTINEOPLASTIC - TROPOMYOSIN RECEPTOR KINASE INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (1 capsule per 1 ROZLYTREK ORAL CAPSULE 100 MG (entrectinib) 3; OC day) PA; LD; SP; QL (3 capsules per 1 ROZLYTREK ORAL CAPSULE 200 MG (entrectinib) 3; OC day) PA; LD; SP; QL (2 tablets per 1 VITRAKVI ORAL CAPSULE 100 MG (larotrectinib sulfate) 3; OC day) PA; LD; SP; QL (6 tablets per 1 VITRAKVI ORAL CAPSULE 25 MG (larotrectinib sulfate) 3; OC day) VITRAKVI ORAL SOLUTION (larotrectinib sulfate) 3; OC PA; LD; SP; QL (10 mL per 1 day) *ANTINEOPLASTIC - XPO1 INHIBITORS*** - DRUGS FOR CANCER XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 carton per 28 days) (selinexor) XPOVIO (40 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 carton per 28 days) (selinexor) XPOVIO (40 MG TWICE WEEKLY) ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 carton per 28 days) (selinexor) XPOVIO (60 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 carton per 28 days) (selinexor) XPOVIO (60 MG TWICE WEEKLY) ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 pack per 1 week) (selinexor) XPOVIO (80 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 carton per 28 days) (selinexor) XPOVIO (80 MG TWICE WEEKLY) ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 pack per 1 week) (selinexor) *ANTINEOPLASTIC ANTIBIOTICS*** - DRUGS FOR CANCER adriamycin intravenous solution 1 or 1b* SP adriamycin intravenous solution reconstituted 1 or 1b* SP bleomycin sulfate injection solution reconstituted 1 or 1b* SP COSMEGEN INTRAVENOUS SOLUTION RECONSTITUTED 3 SP (dactinomycin)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 69 Coverage Requirements and Prescription Drug Name Drug Tier Limits dactinomycin intravenous solution reconstituted 1 or 1b* SP DAUNORUBICIN HCL INTRAVENOUS SOLUTION 3 SP DOXIL INTRAVENOUS INJECTABLE (doxorubicin hcl liposomal) 3 PA; SP doxorubicin hcl intravenous solution 1 or 1b* SP doxorubicin hcl intravenous solution reconstituted 1 or 1b* SP doxorubicin hcl liposomal intravenous injectable 1 or 1b* PA; SP ELLENCE INTRAVENOUS SOLUTION (epirubicin hcl) 3 PA; SP epirubicin hcl intravenous solution 1 or 1b* PA; SP IDAMYCIN PFS INTRAVENOUS SOLUTION (idarubicin hcl) 3 SP idarubicin hcl intravenous solution 1 or 1b* SP JELMYTO SOLUTION RECONSTITUTED (mitomycin) 3 PA; LD mitomycin intravenous solution reconstituted 1 or 1b* SP MITOMYCIN INTRAVESICAL SOLUTION PREFILLED SYRINGE 3 mitoxantrone hcl intravenous concentrate 1 or 1b* SP mutamycin intravenous solution reconstituted 1 or 1b* SP valrubicin intravesical solution 1 or 1b* SP VALSTAR INTRAVESICAL SOLUTION (valrubicin) 3 LD; SP *ANTINEOPLASTIC -ANTIBODY FOR RADIOPHARMACEUTICAL THERAPY*** - DRUGS FOR CANCER ZEVALIN Y-90 INTRAVENOUS KIT (ibritumomab tiuxetan for y-90) 3 PA; LD *ANTINEOPLASTIC ANTIBODY-DRUG COMPLEXES*** - DRUGS FOR CANCER ENHERTU INTRAVENOUS SOLUTION RECONSTITUTED (fam- 3 PA; LD; SP trastuzumab deruxtec-nxki) KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED (ado- 3 PA; LD; SP trastuzumab emtansine) *ANTINEOPLASTIC COMBINATIONS*** - DRUGS FOR CANCER DARZALEX FASPRO SUBCUTANEOUS SOLUTION (daratumumab- 3 PA; LD; SP hyaluronidase-fihj) HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION (trastuzumab- 3 LD; SP hyaluronidase-oysk) PA; LD; SP; QL (5 tablets per 28 INQOVI ORAL TABLET (decitabine-cedazuridine) 3; OC days) KISQALI FEMARA (400 MG DOSE) ORAL TABLET THERAPY PACK 2; OC PA; SP; QL (0.04 unit per 1 day) (ribociclib-letrozole) KISQALI FEMARA (600 MG DOSE) ORAL TABLET THERAPY PACK 2; OC PA; SP; QL (0.04 unit per 1 day) (ribociclib-letrozole) KISQALI FEMARA(200 MG DOSE) ORAL TABLET THERAPY PACK 2; OC PA; SP; QL (0.04 unit per 1 day) (ribociclib-letrozole) LONSURF ORAL TABLET (trifluridine-tipiracil) 3; OC PA; LD; SP PHESGO SUBCUTANEOUS SOLUTION (pertuz-trastuz-hyaluron-zzxf) 3 PA; LD; SP RITUXAN HYCELA SUBCUTANEOUS SOLUTION (rituximab- 3 LD; SP hyaluronidase human) VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED 3 LD; SP (daunorubicin-cytarabine lipo) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 70 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTINEOPLASTIC ENZYMES*** - DRUGS FOR CANCER ASPARLAS INTRAVENOUS SOLUTION (calaspargase pegol-mknl) 3 PA; LD; SP ERWINASE INJECTION SOLUTION RECONSTITUTED (asparaginase 3 PA; LD; SP erwinia chrysanth) ERWINAZE INJECTION SOLUTION RECONSTITUTED (asparaginase 3 PA; LD; SP erwinia chrysanth) ONCASPAR INJECTION SOLUTION (pegaspargase) 3 PA; SP *ANTINEOPLASTIC RADIOPHARMACEUTICALS*** - DRUGS FOR CANCER AZEDRA DOSIMETRIC INTRAVENOUS SOLUTION (iobenguane i 131) 4 PA; LD AZEDRA THERAPEUTIC INTRAVENOUS SOLUTION (iobenguane i 131) 4 PA; LD LUTATHERA INTRAVENOUS SOLUTION (lutetium lu 177 dotatate) 3 PA; LD QUADRAMET INTRAVENOUS SOLUTION (samarium sm 153 3 lexidronam) STRONTIUM CHLORIDE SR-89 INTRAVENOUS SOLUTION 3 XOFIGO INTRAVENOUS SOLUTION (radium ra 223 dichloride) 3 PA; LD *ANTINEOPLASTICS - INTERLEUKINS*** - DRUGS FOR CANCER ELZONRIS INTRAVENOUS SOLUTION (tagraxofusp-erzs) 3 PA; LD PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; SP (aldesleukin) *ANTINEOPLASTICS - PHOTOACTIVATED AGENTS*** - DRUGS FOR CANCER PHOTOFRIN INTRAVENOUS SOLUTION RECONSTITUTED (porfimer 3 sodium) UVADEX INJECTION SOLUTION (methoxsalen (photopheresis)) 3 *ANTINEOPLASTICS MISC.*** - DRUGS FOR CANCER ACTIMMUNE SUBCUTANEOUS SOLUTION (interferon gamma-1b) 4 PA; LD; SP ALFERON N INJECTION SOLUTION (interferon alfa-n3) 4 SP arsenic trioxide intravenous solution 1 or 1b* SP dacarbazine intravenous solution reconstituted 1 or 1b* SP HYDREA ORAL CAPSULE (hydroxyurea) 3; OC hydroxyurea oral capsule 1 or 1b*; OC INTRON A INJECTION SOLUTION (interferon alfa-2b) 4 LD; SP INTRON A INJECTION SOLUTION RECONSTITUTED (interferon alfa- 4 LD; SP 2b) MATULANE ORAL CAPSULE (procarbazine hcl) 2; OC LD NIPENT INTRAVENOUS SOLUTION RECONSTITUTED (pentostatin) 3 SP SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3 PA; LD (omacetaxine mepesuccinate) TICE BCG INTRAVESICAL SUSPENSION RECONSTITUTED (bcg live) 4 SP TRISENOX INTRAVENOUS SOLUTION (arsenic trioxide) 3 LD; SP *AROMATASE INHIBITORS*** - DRUGS FOR CANCER anastrozole oral tablet 1 or 1b*; OC; $0 QL (1 tablet per 1 day) AROMASIN ORAL TABLET (exemestane) 3; OC QL (2 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 71 Coverage Requirements and Prescription Drug Name Drug Tier Limits exemestane oral tablet 1 or 1b*; OC; $0 QL (2 tablets per 1 day) FEMARA ORAL TABLET (letrozole) 3; OC QL (1 tablet per 1 day) letrozole oral tablet 1 or 1b*; OC; $0 QL (1 tablet per 1 day) *CARBOXYPEPTIDASE ENZYME AGENTS*** - DRUGS FOR CANCER VORAXAZE INTRAVENOUS SOLUTION RECONSTITUTED 3 LD (glucarpidase) *CARDIAC PROTECTIVE AGENTS*** - DRUGS FOR CANCER dexrazoxane hcl intravenous solution reconstituted 1 or 1b* SP TOTECT INTRAVENOUS SOLUTION RECONSTITUTED (dexrazoxane 3 SP hcl) *CHEMOTHERAPY ADJUNCTS - HYPERURICEMIA AGENTS*** - DRUGS FOR CANCER ELITEK INTRAVENOUS SOLUTION RECONSTITUTED (rasburicase) 3 PA; SP *CHEMOTHERAPY ADJUNCTS - KERATINOCYTE GROWTH FACTORS*** - DRUGS FOR CANCER KEPIVANCE INTRAVENOUS SOLUTION RECONSTITUTED (palifermin) 4 *CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (21 capsules per 28 IBRANCE ORAL CAPSULE (palbociclib) 2; OC days) PA; LD; SP; QL (21 tablets per 28 IBRANCE ORAL TABLET 100 MG, 75 MG (palbociclib) 2; OC days) IBRANCE ORAL TABLET 125 MG (palbociclib) 2; OC PA; LD; SP; QL (1 tablet per 1 day) KISQALI (200 MG DOSE) ORAL TABLET THERAPY PACK (ribociclib 2; OC PA; SP; QL (3 tablets per 1 day) succinate) KISQALI (400 MG DOSE) ORAL TABLET THERAPY PACK (ribociclib 2; OC PA; SP; QL (3 tablets per 1 day) succinate) KISQALI (600 MG DOSE) ORAL TABLET THERAPY PACK (ribociclib 2; OC PA; SP; QL (3 tablets per 1 day) succinate) PA; LD; SP; QL (2 tablets per 1 VERZENIO ORAL TABLET (abemaciclib) 3; OC day) *ESTROGEN RECEPTOR ANTAGONIST*** - DRUGS FOR CANCER FASLODEX INTRAMUSCULAR SOLUTION (fulvestrant) 3 PA; SP fulvestrant intramuscular solution 1 or 1b* PA; SP *ESTROGENS-ANTINEOPLASTIC*** - DRUGS FOR CANCER EMCYT ORAL CAPSULE (estramustine phosphate sodium) 2; OC PA *FOLIC ACID ANTAGONISTS RESCUE AGENTS*** - DRUGS FOR CANCER KHAPZORY INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (levoleucovorin) leucovorin calcium injection solution 1 or 1b* leucovorin calcium injection solution reconstituted 1 or 1b* leucovorin calcium oral tablet 1 or 1b* levoleucovorin calcium intravenous solution reconstituted 1 or 1b* PA

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 72 Coverage Requirements and Prescription Drug Name Drug Tier Limits levoleucovorin calcium pf intravenous solution 1 or 1b* *GONADOTROPIN RELEASING HORMONE (GNRH) ANTAGONISTS*** - DRUGS FOR CANCER FIRMAGON (240 MG DOSE) SUBCUTANEOUS SOLUTION 3 PA; SP; QL (2 units per 310 days) RECONSTITUTED (degarelix acetate) FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED (degarelix 3 PA; SP; QL (1 kit per 28 days) acetate) ORGOVYX ORAL TABLET (relugolix) 3; OC PA; LD; QL (1 tablet per 1 day) *IMIDAZOTETRAZINES*** - DRUGS FOR CANCER TEMODAR INTRAVENOUS SOLUTION RECONSTITUTED 2 PA; SP (temozolomide) TEMODAR ORAL CAPSULE (temozolomide) 3; OC PA; SP; QL (2 capsules per 1 day) temozolomide oral capsule 100 mg, 140 mg, 180 mg, 250 mg 1 or 1b*; OC PA; SP; QL (2 capsules per 1 day) temozolomide oral capsule 20 mg 1 or 1b*; OC PA; SP; QL (4 capsule per 1 day) temozolomide oral capsule 5 mg 1 or 1b*; OC PA; SP; QL (3 capsule per 1 day) *ISOCITRATE DEHYDROGENASE-1 (IDH1) INHIBITORS*** - DRUGS FOR CANCER TIBSOVO ORAL TABLET (ivosidenib) 3; OC PA; LD; QL (2 tablets per 1 day) *ISOCITRATE DEHYDROGENASE-2 (IDH2) INHIBITORS*** - DRUGS FOR CANCER IDHIFA ORAL TABLET 100 MG (enasidenib mesylate) 3; OC PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (2 tablets per 1 IDHIFA ORAL TABLET 50 MG (enasidenib mesylate) 3; OC day) *JANUS ASSOCIATED KINASE (JAK) INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (4 capsules per 1 INREBIC ORAL CAPSULE (fedratinib hcl) 3; OC day) PA; LD; SP; QL (2 tablets per 1 JAKAFI ORAL TABLET (ruxolitinib phosphate) 2; OC day) *LHRH ANALOGS*** - DRUGS FOR CANCER ELIGARD SUBCUTANEOUS KIT 22.5 MG (leuprolide acetate (3 month)) 3 PA; SP; QL (1 syringe per 84 days) PA; SP; QL (1 syringe per 112 ELIGARD SUBCUTANEOUS KIT 30 MG (leuprolide acetate (4 month)) 3 days) PA; SP; QL (1 syringe per 168 ELIGARD SUBCUTANEOUS KIT 45 MG (leuprolide acetate (6 month)) 3 days) ELIGARD SUBCUTANEOUS KIT 7.5 MG (leuprolide acetate) 3 PA; SP; QL (1 syringe per 28 days) leuprolide acetate injection kit 1 or 1b* PA; SP LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG PA; SP; QL (1 syringe kit per 28 4 (leuprolide acetate) days) LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 7.5 MG (leuprolide 2 SP; QL (1 kit per 28 days) acetate) LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG 4 PA; SP; QL (1 kit per 84 days) (leuprolide acetate (3 month)) LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 22.5 MG 2 SP; QL (1 kit per 84 days) (leuprolide acetate (3 month))

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 73 Coverage Requirements and Prescription Drug Name Drug Tier Limits LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT (leuprolide acetate 2 SP; QL (1 kit per 112 days) (4 month)) LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT (leuprolide acetate 2 SP; QL (1 syringe kit per 168 days) (6 month)) TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION 3 PA; SP; QL (1 vial per 84 days) RECONSTITUTED 11.25 MG (triptorelin pamoate) TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION PA; SP; QL (1 syringe per 168 3 RECONSTITUTED 22.5 MG (triptorelin pamoate) days) TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION 3 PA; SP; QL (1 kit per 28 days) RECONSTITUTED 3.75 MG (triptorelin pamoate) PA; LD; SP; QL (1 implant per 365 VANTAS SUBCUTANEOUS KIT (histrelin acetate) 3 days) ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG (goserelin acetate) 3 PA; SP; QL (1 EA per 84 days) ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG (goserelin acetate) 3 PA; SP; QL (1 unit per 28 days) *MITOTIC INHIBITORS*** - DRUGS FOR CANCER ABRAXANE INTRAVENOUS SUSPENSION RECONSTITUTED 3 PA; LD; SP (paclitaxel protein-bound part) DOCETAXEL INTRAVENOUS CONCENTRATE 3 PA; SP DOCETAXEL INTRAVENOUS SOLUTION 3 PA; SP ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED (etoposide 3 SP phosphate) etoposide intravenous solution 1 or 1b* SP etoposide oral capsule 1 or 1b*; OC SP HALAVEN INTRAVENOUS SOLUTION (eribulin mesylate) 3 PA; SP IXEMPRA KIT INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; SP (ixabepilone) JEVTANA INTRAVENOUS SOLUTION (cabazitaxel) 3 PA; LD; SP MARQIBO INTRAVENOUS SUSPENSION (vincristine sulfate liposome) 3 LD NAVELBINE INTRAVENOUS SOLUTION (vinorelbine tartrate) 3 SP paclitaxel intravenous concentrate 1 or 1b* SP TENIPOSIDE INTRAVENOUS SOLUTION 3 SP toposar intravenous solution 1 or 1b* SP vinblastine sulfate intravenous solution 1 or 1b* SP vincristine sulfate intravenous solution 1 or 1b* SP vinorelbine tartrate intravenous solution 1 or 1b* SP *MYELOPROTECTIVE AGENTS*** - DRUGS FOR CANCER COSELA INTRAVENOUS SOLUTION RECONSTITUTED (trilaciclib 3 LD dihydrochloride) *NITROGEN MUSTARDS*** - DRUGS FOR CANCER ALKERAN INTRAVENOUS SOLUTION RECONSTITUTED (melphalan 3 SP hcl) ALKERAN ORAL TABLET (melphalan) 3; OC SP cyclophosphamide injection solution reconstituted 1 or 1b* SP CYCLOPHOSPHAMIDE INTRAVENOUS SOLUTION 3 SP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 74 Coverage Requirements and Prescription Drug Name Drug Tier Limits cyclophosphamide oral capsule 1 or 1b*; OC SP CYCLOPHOSPHAMIDE ORAL TABLET 3; OC EVOMELA INTRAVENOUS SOLUTION RECONSTITUTED (melphalan 3 LD; SP hcl) IFEX INTRAVENOUS SOLUTION RECONSTITUTED (ifosfamide) 3 SP ifosfamide intravenous solution 1 or 1b* SP ifosfamide intravenous solution reconstituted 1 gm 1 or 1b* SP IFOSFAMIDE INTRAVENOUS SOLUTION RECONSTITUTED 3 GM 3 SP LEUKERAN ORAL TABLET (chlorambucil) 2; OC melphalan hcl intravenous solution reconstituted 1 or 1b* SP melphalan oral tablet 1 or 1b*; OC SP PEPAXTO INTRAVENOUS SOLUTION RECONSTITUTED (melphalan 3 LD flufenamide hcl) *NITROSOUREAS*** - DRUGS FOR CANCER BICNU INTRAVENOUS SOLUTION RECONSTITUTED (carmustine) 3 SP carmustine intravenous solution reconstituted 1 or 1b* SP GLEOSTINE ORAL CAPSULE (lomustine) 3; OC PA GLIADEL WAFER IMPLANT WAFER (carmustine in polifeprosan) 3 ZANOSAR INTRAVENOUS SOLUTION RECONSTITUTED (streptozocin) 3 LD; SP *ONCOLYTIC VIRAL AGENTS - HSV1*** - DRUGS FOR CANCER IMLYGIC INTRALESIONAL SUSPENSION (talimogene laherparepvec) 3 LD *PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS*** - DRUGS FOR CANCER ALIQOPA INTRAVENOUS SOLUTION RECONSTITUTED (copanlisib 3 PA; LD hcl) COPIKTRA ORAL CAPSULE (duvelisib) 3; OC PA; LD; QL (2 tablets per 1 day) PIQRAY (200 MG DAILY DOSE) ORAL TABLET THERAPY PACK 3; OC PA; SP; QL (1 pack per 28 days) (alpelisib) PIQRAY (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 3; OC PA; SP; QL (1 pack per 28 days) (alpelisib) PIQRAY (300 MG DAILY DOSE) ORAL TABLET THERAPY PACK 3; OC PA; SP; QL (1 pack per 28 days) (alpelisib) PA; LD; SP; QL (2 tablets per 1 ZYDELIG ORAL TABLET (idelalisib) 3; OC day) *POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (4 tablets per 1 LYNPARZA ORAL TABLET (olaparib) 3; OC day) RUBRACA ORAL TABLET 200 MG, 300 MG (rucaparib camsylate) 3; OC PA; LD; SP; QL (4 tablet per 1 day) PA; LD; SP; QL (4 tablets per 1 RUBRACA ORAL TABLET 250 MG (rucaparib camsylate) 3; OC day) PA; LD; SP; QL (3 capsules per 1 TALZENNA ORAL CAPSULE 0.25 MG (talazoparib tosylate) 3; OC day) PA; LD; SP; QL (1 capsule per 1 TALZENNA ORAL CAPSULE 1 MG (talazoparib tosylate) 3; OC day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 75 Coverage Requirements and Prescription Drug Name Drug Tier Limits ZEJULA ORAL CAPSULE (niraparib tosylate) 3; OC PA; LD; QL (3 capsules per 1 day) *PROGESTINS-ANTINEOPLASTIC*** - DRUGS FOR CANCER hydroxyprogesterone caproate intramuscular solution 1 or 1b* PA; LD megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml 1 or 1b*; OC megestrol acetate oral tablet 1 or 1b*; OC *RETINOIDS*** - DRUGS FOR CANCER tretinoin oral capsule 1 or 1b*; OC *SELECTIVE RETINOID X RECEPTOR AGONISTS*** - DRUGS FOR CANCER bexarotene oral capsule 1 or 1b*; OC PA; SP; QL (10 capsules per 1 day) *TETRAHYDROISOQUINOLINES*** - DRUGS FOR CANCER YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED (trabectedin) 3 LD; SP *TOPOISOMERASE I INHIBITORS - ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER TRODELVY INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD (sacituzumab govitecan-hziy) *TOPOISOMERASE I INHIBITORS*** - DRUGS FOR CANCER CAMPTOSAR INTRAVENOUS SOLUTION (irinotecan hcl) 3 SP HYCAMTIN INTRAVENOUS SOLUTION RECONSTITUTED (topotecan 3 SP hcl) HYCAMTIN ORAL CAPSULE (topotecan hcl) 2; OC PA; SP irinotecan hcl intravenous solution 1 or 1b* SP ONIVYDE INTRAVENOUS INJECTABLE (irinotecan hcl liposome) 3 LD TOPOTECAN HCL INTRAVENOUS SOLUTION 3 SP topotecan hcl intravenous solution reconstituted 1 or 1b* SP *URINARY TRACT PROTECTIVE AGENTS*** - DRUGS FOR CANCER ETHYOL INTRAVENOUS SOLUTION RECONSTITUTED (amifostine) 3 PA; SP mesna intravenous solution 1 or 1b* PA MESNEX INTRAVENOUS SOLUTION (mesna) 3 PA MESNEX ORAL TABLET (mesna) 2 PA *VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) INHIBITORS*** - DRUGS FOR CANCER AVASTIN INTRAVENOUS SOLUTION (bevacizumab) 3 PA; LD; SP CYRAMZA INTRAVENOUS SOLUTION (ramucirumab) 3 PA; LD; SP PA; LD; SP; QL (6 tablets per 1 INLYTA ORAL TABLET 1 MG (axitinib) 2; OC day) INLYTA ORAL TABLET 5 MG (axitinib) 2; OC PA; LD; SP; QL (4 tablet per 1 day) LENVIMA (10 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (30 capsules per 30 3; OC (lenvatinib mesylate) days) LENVIMA (12 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (1 pack per 30 3; OC (lenvatinib mesylate) days) LENVIMA (14 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (60 capsules per 30 3; OC (lenvatinib mesylate) days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 76 Coverage Requirements and Prescription Drug Name Drug Tier Limits LENVIMA (18 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (1 pack per 30 3; OC (lenvatinib mesylate) days) LENVIMA (20 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (60 capsules per 30 3; OC (lenvatinib mesylate) days) LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (90 capsules per 30 3; OC (lenvatinib mesylate) days) LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (30 capsules per 30 3; OC (lenvatinib mesylate) days) LENVIMA (8 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (1 pack per 30 3; OC (lenvatinib mesylate) days) MVASI INTRAVENOUS SOLUTION (bevacizumab-awwb) 3 PA; LD; SP ZALTRAP INTRAVENOUS SOLUTION (ziv-aflibercept) 3 PA; LD; SP ZIRABEV INTRAVENOUS SOLUTION (bevacizumab-bvzr) 3 PA; LD; SP *ANTIPARKINSON AND RELATED THERAPY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM *ADENOSINE RECEPTOR ANTAGONIST*** - DRUGS FOR PARKINSON NOURIANZ ORAL TABLET (istradefylline) 4 PA; LD; SP; QL (1 tablet per 1 day) *ANTIPARKINSON ANTICHOLINERGICS*** - DRUGS FOR PARKINSON benztropine mesylate injection solution 1 or 1a* benztropine mesylate oral tablet 1 or 1a* COGENTIN INJECTION SOLUTION (benztropine mesylate) 3 trihexyphenidyl hcl oral solution 1 or 1a* trihexyphenidyl hcl oral tablet 1 or 1a* *ANTIPARKINSON DOPAMINERGICS*** - DRUGS FOR PARKINSON amantadine hcl oral capsule 1 or 1b* QL (4 capsule per 1 day) amantadine hcl oral syrup 1 or 1b* QL (40 mL per 1 day) amantadine hcl oral tablet 1 or 1b* QL (4 tablet per 1 day) bromocriptine mesylate oral capsule 1 or 1b* bromocriptine mesylate oral tablet 1 or 1b* GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR 137 MG 3 PA; LD; QL (2 capsules per 1 day) (amantadine hcl) GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR 68.5 MG 3 PA; LD (amantadine hcl) INBRIJA INHALATION CAPSULE (levodopa) 4 PA; LD; QL (5 kits per 30 days) OSMOLEX ER ORAL TABLET ER 24 HOUR THERAPY PACK 3 PA; LD; QL (2 tablets per 1 day) (amantadine hcl) OSMOLEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 129 MG 3 PA; LD (amantadine hcl) OSMOLEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 193 MG, 3 PA; LD; QL (1 tablet per 1 day) 258 MG (amantadine hcl) PARLODEL ORAL CAPSULE (bromocriptine mesylate) 3 PARLODEL ORAL TABLET (bromocriptine mesylate) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 77 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS*** - DRUGS FOR PARKINSON AZILECT ORAL TABLET (rasagiline mesylate) 3 rasagiline mesylate oral tablet 1 or 1b* selegiline hcl oral capsule 1 or 1b* selegiline hcl oral tablet 1 or 1b* XADAGO ORAL TABLET 100 MG (safinamide mesylate) 3 PA; QL (1 tablet per 1 day) XADAGO ORAL TABLET 50 MG (safinamide mesylate) 3 PA; QL (2 tablets per 1 day) ZELAPAR ORAL TABLET DISPERSIBLE (selegiline hcl) 3 PA; QL (2 tablets per 1 day) *CENTRAL/PERIPHERAL COMT INHIBITORS*** - DRUGS FOR PARKINSON TASMAR ORAL TABLET (tolcapone) 3 PA; QL (6 tablet per 1 day) tolcapone oral tablet 1 or 1b* PA; QL (6 tablet per 1 day) *DECARBOXYLASE INHIBITORS*** - DRUGS FOR PARKINSON carbidopa oral tablet 1 or 1b* LODOSYN ORAL TABLET (carbidopa) 3 *LEVODOPA COMBINATIONS*** - DRUGS FOR PARKINSON carbidopa-levodopa er oral tablet extended release 1 or 1b* carbidopa-levodopa oral tablet 1 or 1b* carbidopa-levodopa oral tablet dispersible 1 or 1b* carbidopa-levodopa-entacapone oral tablet 1 or 1b* DUOPA ENTERAL SUSPENSION (carbidopa-levodopa) 3 PA; LD; SP RYTARY ORAL CAPSULE EXTENDED RELEASE (carbidopa-levodopa) 3 SINEMET ORAL TABLET (carbidopa-levodopa) 3 STALEVO 100 ORAL TABLET (carbidopa-levodopa-entacapone) 3 STALEVO 125 ORAL TABLET (carbidopa-levodopa-entacapone) 3 STALEVO 150 ORAL TABLET (carbidopa-levodopa-entacapone) 3 STALEVO 200 ORAL TABLET (carbidopa-levodopa-entacapone) 3 STALEVO 50 ORAL TABLET (carbidopa-levodopa-entacapone) 3 STALEVO 75 ORAL TABLET (carbidopa-levodopa-entacapone) 3 *NONERGOLINE DOPAMINE RECEPTOR AGONISTS*** - DRUGS FOR PARKINSON APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE (apomorphine hcl) 4 PA; LD; SP; QL (2 mL per 1 day) KYNMOBI SUBLINGUAL FILM (apomorphine hcl) 3 PA; LD; QL (5 films per 1 day) MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 3 QL (1 tablet per 1 day) (pramipexole dihydrochloride) MIRAPEX ORAL TABLET (pramipexole dihydrochloride) 3 QL (3 tablet per 1 day) NEUPRO TRANSDERMAL PATCH 24 HOUR (rotigotine) 3 QL (1 patch per 1 day) pramipexole dihydrochloride er oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) pramipexole dihydrochloride oral tablet 1 or 1b* QL (3 tablet per 1 day) ropinirole hcl er oral tablet extended release 24 hour 1 or 1b* ropinirole hcl oral tablet 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 78 Coverage Requirements and Prescription Drug Name Drug Tier Limits *PERIPHERAL COMT INHIBITORS*** - DRUGS FOR PARKINSON COMTAN ORAL TABLET (entacapone) 3 QL (8 tablet per 1 day) entacapone oral tablet 1 or 1b* QL (8 tablet per 1 day) ONGENTYS ORAL CAPSULE 25 MG (opicapone) 3 PA; QL (1 tablet per 1 day) ONGENTYS ORAL CAPSULE 50 MG (opicapone) 3 PA; QL (6 tablets per 1 day) *ANTIPSYCHOTICS/ANTIMANIC AGENTS* - DRUGS FOR THE NERVOUS SYSTEM *ANTIMANIC AGENTS*** - DRUGS FOR SEVERE MENTAL DISORDERS lithium carbonate er oral tablet extended release 1 or 1a* lithium carbonate oral capsule 1 or 1a* lithium carbonate oral tablet 1 or 1a* *ANTIPSYCHOTICS - MISC.*** - DRUGS FOR SEVERE MENTAL DISORDERS CAPLYTA ORAL CAPSULE (lumateperone tosylate) 3 ST; QL (1 capsule per 1 day) EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 3 QL (8 capsules per 1 day) 200 MG (carbamazepine (antipsychotic)) EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 300 MG 3 QL (5 capsules per 1 day) (carbamazepine (antipsychotic)) GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 3 (ziprasidone mesylate) LATUDA ORAL TABLET 120 MG (lurasidone hcl) 3 QL (1 tablet per 1 day) LATUDA ORAL TABLET 20 MG, 40 MG, 60 MG (lurasidone hcl) 3 LATUDA ORAL TABLET 80 MG (lurasidone hcl) 3 QL (2 tablets per 1 day) PA; LD; SP; QL (1 capsule per 1 NUPLAZID ORAL CAPSULE (pimavanserin tartrate) 4 day) NUPLAZID ORAL TABLET (pimavanserin tartrate) 4 PA; LD; SP; QL (1 tablet per 1 day) VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG (cariprazine hcl) 3 ST VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG (cariprazine hcl) 3 ST; QL (1 capsule per 1 day) VRAYLAR ORAL CAPSULE THERAPY PACK (cariprazine hcl) 3 ST; QL (1 pack per 1 year) ziprasidone hcl oral capsule 20 mg, 40 mg 1 or 1b* ziprasidone hcl oral capsule 60 mg, 80 mg 1 or 1b* QL (2 capsules per 1 day) ziprasidone mesylate intramuscular solution reconstituted 1 or 1b* *BENZISOXAZOLES*** - DRUGS FOR SEVERE MENTAL DISORDERS FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG, 6 MG (iloperidone) 3 ST FANAPT ORAL TABLET 10 MG, 12 MG, 8 MG (iloperidone) 3 ST; QL (2 tablets per 1 day) FANAPT TITRATION PACK ORAL TABLET (iloperidone) 3 ST; QL (1 pack per 1 year) INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED 3 QL (1 syringe per 28 days) SYRINGE (paliperidone palmitate) INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED 3 QL (1 syringe per 90 days) SYRINGE (paliperidone palmitate) paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg 1 or 1b* paliperidone er oral tablet extended release 24 hour 6 mg 1 or 1b* QL (2 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 79 Coverage Requirements and Prescription Drug Name Drug Tier Limits paliperidone er oral tablet extended release 24 hour 9 mg 1 or 1b* QL (1 tablet per 1 day) PERSERIS SUBCUTANEOUS PREFILLED SYRINGE (risperidone) 3 QL (1 syringe per 30 days) RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION 2 QL (2 injections per 1 day) RECONSTITUTED ER 12.5 MG (risperidone microspheres) RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION 2 QL (2 injections per 28 days) RECONSTITUTED ER 25 MG, 37.5 MG, 50 MG (risperidone microspheres) risperidone oral solution 1 or 1b* ST; QL (8 mL per 1 day) risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 or 1b* QL (2 tablets per 1 day) risperidone oral tablet 3 mg, 4 mg 1 or 1b* QL (4 tablets per 1 day) risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 or 1b* QL (2 tablets per 1 day) risperidone oral tablet dispersible 3 mg, 4 mg 1 or 1b* QL (4 tablets per 1 day) *BUTYROPHENONES*** - DRUGS FOR SEVERE MENTAL DISORDERS HALDOL DECANOATE INTRAMUSCULAR SOLUTION 100 MG/ML 3 QL (5 injections per 30 days) (haloperidol decanoate) HALDOL DECANOATE INTRAMUSCULAR SOLUTION 50 MG/ML 3 QL (5 ampules per 30 days) (haloperidol decanoate) HALDOL INJECTION SOLUTION (haloperidol lactate) 3 haloperidol decanoate intramuscular solution 100 mg/ml 1 or 1b* QL (5 injections per 30 days) haloperidol decanoate intramuscular solution 50 mg/ml 1 or 1b* QL (5 ampules per 30 days) haloperidol lactate injection solution 1 or 1b* haloperidol lactate oral concentrate 1 or 1b* haloperidol oral tablet 1 or 1b* *DIBENZODIAZEPINES*** - DRUGS FOR SEVERE MENTAL DISORDERS clozapine oral tablet 100 mg 1 or 1b* QL (9 tablets per 1 day) clozapine oral tablet 200 mg 1 or 1b* QL (4 tablets per 1 day) clozapine oral tablet 25 mg, 50 mg 1 or 1b* clozapine oral tablet dispersible 100 mg 1 or 1b* QL (9 tablets per 1 day) clozapine oral tablet dispersible 12.5 mg, 25 mg 1 or 1b* clozapine oral tablet dispersible 150 mg 1 or 1b* QL (6 tablets per 1 day) clozapine oral tablet dispersible 200 mg 1 or 1b* QL (4 tablets per 1 day) VERSACLOZ ORAL SUSPENSION (clozapine) 3 QL (18 mL per 1 day) *DIBENZO-OXEPINO PYRROLES*** - DRUGS FOR SEVERE MENTAL DISORDERS asenapine maleate sublingual tablet sublingual 10 mg 1 or 1b* QL (2 tablets per 1 day) asenapine maleate sublingual tablet sublingual 2.5 mg, 5 mg 1 or 1b* SECUADO TRANSDERMAL PATCH 24 HOUR (asenapine) 3 ST; QL (1 patch per 1 day) *DIBENZOTHIAZEPINES*** - DRUGS FOR SEVERE MENTAL DISORDERS quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 200 mg 1 or 1b* quetiapine fumarate er oral tablet extended release 24 hour 300 mg, 400 mg, 1 or 1b* QL (2 tablets per 1 day) 50 mg quetiapine fumarate oral tablet 100 mg, 25 mg, 50 mg 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 80 Coverage Requirements and Prescription Drug Name Drug Tier Limits quetiapine fumarate oral tablet 200 mg 1 or 1b* QL (3 tablets per 1 day) quetiapine fumarate oral tablet 300 mg, 400 mg 1 or 1b* QL (2 tablets per 1 day) *DIBENZOXAZEPINES*** - DRUGS FOR SEVERE MENTAL DISORDERS ADASUVE INHALATION AEROSOL POWDER BREATH ACTIVATED 3 (loxapine) loxapine succinate oral capsule 1 or 1b* *DIHYDROINDOLONES*** - DRUGS FOR SEVERE MENTAL DISORDERS molindone hcl oral tablet 1 or 1b* *PHENOTHIAZINES*** - DRUGS FOR SEVERE MENTAL DISORDERS chlorpromazine hcl injection solution 1 or 1b* chlorpromazine hcl oral tablet 1 or 1b* compro rectal suppository 1 or 1b* fluphenazine decanoate injection solution 1 or 1b* fluphenazine hcl injection solution 1 or 1b* fluphenazine hcl oral concentrate 1 or 1b* fluphenazine hcl oral elixir 1 or 1b* fluphenazine hcl oral tablet 1 or 1b* perphenazine oral tablet 1 or 1b* prochlorperazine edisylate injection solution 1 or 1b* prochlorperazine maleate oral tablet 1 or 1a* prochlorperazine rectal suppository 1 or 1b* thioridazine hcl oral tablet 1 or 1b* trifluoperazine hcl oral tablet 1 or 1b* *QUINOLINONE DERIVATIVES*** - DRUGS FOR SEVERE MENTAL DISORDERS ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 3 (aripiprazole) ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION 3 QL (1 injection per 30 days) RECONSTITUTED ER (aripiprazole) ABILIFY MYCITE MAINTENANCE KIT ORAL TABLET 10 MG, 15 MG, 3 ST 2 MG, 5 MG (aripiprazole) ABILIFY MYCITE MAINTENANCE KIT ORAL TABLET 20 MG, 30 MG 3 ST; QL (1 tablet per 1 day) (aripiprazole) ABILIFY MYCITE ORAL TABLET 10 MG, 15 MG, 2 MG, 5 MG 3 ST (aripiprazole) ABILIFY MYCITE ORAL TABLET 20 MG, 30 MG (aripiprazole) 3 ST; QL (1 tablet per 1 day) ABILIFY MYCITE STARTER KIT ORAL TABLET 10 MG, 15 MG, 2 MG, 3 ST 5 MG (aripiprazole) ABILIFY MYCITE STARTER KIT ORAL TABLET 20 MG, 30 MG 3 ST; QL (1 tablet per 1 day) (aripiprazole) aripiprazole oral solution 1 or 1b* QL (30 mL per 1 day) aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 5 mg 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 81 Coverage Requirements and Prescription Drug Name Drug Tier Limits aripiprazole oral tablet 20 mg, 30 mg 1 or 1b* QL (1 tablet per 1 day) aripiprazole oral tablet dispersible 10 mg 1 or 1b* QL (3 tablets per 1 day) aripiprazole oral tablet dispersible 15 mg 1 or 1b* QL (2 tablets per 1 day) ARISTADA INITIO INTRAMUSCULAR PREFILLED SYRINGE 3 QL (1 syringe per 1 fill) (aripiprazole lauroxil) ARISTADA INTRAMUSCULAR PREFILLED SYRINGE (aripiprazole 3 lauroxil) REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG (brexpiprazole) 3 ST REXULTI ORAL TABLET 3 MG, 4 MG (brexpiprazole) 3 ST; QL (1 tablet per 1 day) *THIENBENZODIAZEPINES*** - DRUGS FOR SEVERE MENTAL DISORDERS olanzapine intramuscular solution reconstituted 1 or 1b* olanzapine oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg 1 or 1b* olanzapine oral tablet 15 mg, 20 mg 1 or 1b* QL (1 tablets per 1 day) olanzapine oral tablet dispersible 10 mg, 5 mg 1 or 1b* olanzapine oral tablet dispersible 15 mg 1 or 1b* QL (1 tablets per 1 day) olanzapine oral tablet dispersible 20 mg 1 or 1b* QL (1 tablet per 1 day) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION 3 RECONSTITUTED (olanzapine pamoate) *THIOXANTHENES*** - DRUGS FOR SEVERE MENTAL DISORDERS thiothixene oral capsule 1 or 1b* *ANTISEPTICS & DISINFECTANTS* - ANTISEPTICS AND DISINFECTANTS *ANTISEPTICS & DISINFECTANTS*** - ANTISEPTICS AND DISINFECTANTS FORMALDEHYDE EXTERNAL SOLUTION 37 % 3 GLUTARALDEHYDE EXTERNAL SOLUTION 2 *CHLORINE ANTISEPTICS*** - ANTISEPTICS AND DISINFECTANTS BENZALKONIUM CHLORIDE EXTERNAL SOLUTION 3 *IODINE ANTISEPTICS*** - ANTISEPTICS AND DISINFECTANTS IODINE TINCTURE EXTERNAL TINCTURE 2 % 3 IODOFLEX EXTERNAL PAD (cadexomer iodine) 3 IODOSORB EXTERNAL GEL (cadexomer iodine) 3 *ANTIVIRALS* - DRUGS FOR INFECTIONS *ANTIRETROVIRAL COMBINATIONS*** - DRUGS FOR VIRAL INFECTIONS abacavir sulfate-lamivudine oral tablet 1 or 1b* QL (1 tablet per 1 day) abacavir-lamivudine-zidovudine oral tablet 1 or 1b* QL (2 tablets per 1 day) BIKTARVY ORAL TABLET (bictegravir-emtricitab-tenofov) 2 QL (1 tablet per 1 day) CABENUVA INTRAMUSCULAR SUSPENSION EXTENDED RELEASE 3 PA; LD; QL (1 kit per 28 days) 400 & 600 MG/2ML

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 82 Coverage Requirements and Prescription Drug Name Drug Tier Limits CABENUVA INTRAMUSCULAR SUSPENSION EXTENDED RELEASE PA; LD; QL (1 kit per 1 one-time 3 600 & 900 MG/3ML fill) CIMDUO ORAL TABLET (lamivudine-tenofovir) 3 QL (1 tablet per 1 day) COMBIVIR ORAL TABLET (lamivudine-zidovudine) 3 QL (2 tablets per 1 day) COMPLERA ORAL TABLET (emtricitab-rilpivir-tenofovir) 3 PA; QL (1 tablet per 1 day) DELSTRIGO ORAL TABLET (doravirin-lamivudin-tenofov df) 3 QL (1 tablet per 1 day) DESCOVY ORAL TABLET (emtricitabine-tenofovir af) 2; $0 QL (1 tablet per 1 day) DOVATO ORAL TABLET (dolutegravir-lamivudine) 2 QL (1 tablet per 1 day) efavirenz-emtricitab-tenofovir oral tablet 1 or 1b* QL (1 tablet per 1 day) efavirenz-lamivudine-tenofovir oral tablet 1 or 1b* QL (1 tablet per 1 day) emtricitabine-tenofovir df oral tablet 100-150 mg, 133-200 mg, 167-250 mg 1 or 1b* QL (1 tablet per 1 day) emtricitabine-tenofovir df oral tablet 200-300 mg 1 or 1b*; $0 QL (1 tablet per 1 day) EPZICOM ORAL TABLET (abacavir sulfate-lamivudine) 3 QL (1 tablet per 1 day) EVOTAZ ORAL TABLET (atazanavir-cobicistat) 3 QL (1 tablet per 1 day) GENVOYA ORAL TABLET (elviteg-cobic-emtricit-tenofaf) 2 QL (1 tablet per 1 day) JULUCA ORAL TABLET (dolutegravir-rilpivirine) 3 PA; QL (1 tablet per 1 day) KALETRA ORAL SOLUTION (lopinavir-ritonavir) 3 QL (16 mL per 1 day) KALETRA ORAL TABLET 100-25 MG (lopinavir-ritonavir) 2 QL (10 tablets per 1 day) KALETRA ORAL TABLET 200-50 MG (lopinavir-ritonavir) 2 QL (4 tablets per 1 day) lamivudine-zidovudine oral tablet 1 or 1b* QL (2 tablets per 1 day) lopinavir-ritonavir oral solution 1 or 1b* QL (16 mL per 1 day) lopinavir-ritonavir oral tablet 100-25 mg 1 or 1b* QL (10 tablets per 1 day) lopinavir-ritonavir oral tablet 200-50 mg 1 or 1b* QL (4 tablets per 1 day) ODEFSEY ORAL TABLET (emtricitab-rilpivir-tenofov af) 2 QL (1 tablet per 1 day) PREZCOBIX ORAL TABLET (darunavir-cobicistat) 3 QL (1 tablet per 1 day) STRIBILD ORAL TABLET (elviteg-cobic-emtricit-tenofdf) 2 QL (1 tablet per 1 day) SYMTUZA ORAL TABLET (darun-cobic-emtricit-tenofaf) 3 QL (1 tablet per 1 day) TEMIXYS ORAL TABLET (lamivudine-tenofovir) 3 QL (1 tablet per 1 day) TRIUMEQ ORAL TABLET (abacavir-dolutegravir-lamivud) 2 QL (1 tablet per 1 day) TRIZIVIR ORAL TABLET (abacavir-lamivudine-zidovudine) 3 QL (2 tablets per 1 day) TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG 2 ST; QL (1 tablet per 1 day) (emtricitabine-tenofovir df) *ANTIRETROVIRALS - CCR5 ANTAGONISTS (ENTRY INHIBITOR)*** - DRUGS FOR VIRAL INFECTIONS SELZENTRY ORAL SOLUTION (maraviroc) 3 QL (62 mL per 1 day) SELZENTRY ORAL TABLET 150 MG, 300 MG (maraviroc) 2 QL (4 tablets per 1 day) SELZENTRY ORAL TABLET 25 MG (maraviroc) 2 QL (8 tablets per 1 day) SELZENTRY ORAL TABLET 75 MG (maraviroc) 2 QL (2 tablets per 1 day) *ANTIRETROVIRALS - CD4-DIRECTED POST-ATTACHMENT INHIBITOR*** - DRUGS FOR VIRAL INFECTIONS TROGARZO INTRAVENOUS SOLUTION (ibalizumab-uiyk) 3 PA; LD; QL (8 vials per 28 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 83 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTIRETROVIRALS - FUSION INHIBITORS*** - DRUGS FOR VIRAL INFECTIONS FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED (enfuvirtide) 2 PA; LD; QL (60 vials per 30 days) *ANTIRETROVIRALS - GP120-DIRECTED ATTACHMENT INHIBITOR*** - DRUGS FOR VIRAL INFECTIONS RUKOBIA ORAL TABLET EXTENDED RELEASE 12 HOUR (fostemsavir 3 PA; QL (2 tablets per 1 day) tromethamine) *ANTIRETROVIRALS - INTEGRASE INHIBITORS*** - DRUGS FOR VIRAL INFECTIONS ISENTRESS HD ORAL TABLET (raltegravir potassium) 3 QL (2 tablets per 1 day) ISENTRESS ORAL PACKET (raltegravir potassium) 3 QL (2 packets per 1 day) ISENTRESS ORAL TABLET (raltegravir potassium) 2 QL (4 tablets per 1 day) ISENTRESS ORAL TABLET CHEWABLE 100 MG (raltegravir potassium) 2 QL (6 tablets per 1 day) ISENTRESS ORAL TABLET CHEWABLE 25 MG (raltegravir potassium) 2 QL (24 tablets per 1 day) TIVICAY ORAL TABLET 10 MG (dolutegravir sodium) 3 QL (4 tablets per 1 day) TIVICAY ORAL TABLET 25 MG, 50 MG (dolutegravir sodium) 3 QL (2 tablets per 1 day) TIVICAY PD ORAL TABLET SOLUBLE (dolutegravir sodium) 3 QL (12 tablets per 1 day) *ANTIRETROVIRALS - PROTEASE INHIBITORS*** - DRUGS FOR VIRAL INFECTIONS APTIVUS ORAL CAPSULE (tipranavir) 2 PA; QL (4 capsules per 1 day) atazanavir sulfate oral capsule 150 mg, 200 mg 1 or 1b* QL (2 capsules per 1 day) atazanavir sulfate oral capsule 300 mg 1 or 1b* QL (1 capsule per 1 day) CRIXIVAN ORAL CAPSULE (indinavir sulfate) 2 QL (6 capsules per 1 day) fosamprenavir calcium oral tablet 1 or 1b* QL (4 tablets per 1 day) INVIRASE ORAL TABLET (saquinavir mesylate) 2 QL (4 tablets per 1 day) LEXIVA ORAL SUSPENSION (fosamprenavir calcium) 2 QL (60 mL per 1 day) LEXIVA ORAL TABLET (fosamprenavir calcium) 3 QL (4 tablets per 1 day) NORVIR ORAL PACKET (ritonavir) 3 QL (12 packets per 1 day) NORVIR ORAL SOLUTION (ritonavir) 2 QL (16 mL per 1 day) NORVIR ORAL TABLET (ritonavir) 3 QL (12 tablets per 1 day) PREZISTA ORAL SUSPENSION (darunavir ethanolate) 2 QL (14 mL per 1 day) PREZISTA ORAL TABLET 150 MG (darunavir ethanolate) 2 QL (6 tablets per 1 day) PREZISTA ORAL TABLET 600 MG (darunavir ethanolate) 2 QL (2 tablets per 1 day) PREZISTA ORAL TABLET 75 MG (darunavir ethanolate) 2 QL (10 tablets per 1 day) PREZISTA ORAL TABLET 800 MG (darunavir ethanolate) 2 QL (1 tablet per 1 day) REYATAZ ORAL CAPSULE 150 MG, 200 MG (atazanavir sulfate) 3 QL (2 capsules per 1 day) REYATAZ ORAL CAPSULE 300 MG (atazanavir sulfate) 3 QL (1 capsule per 1 day) REYATAZ ORAL PACKET (atazanavir sulfate) 2 QL (5 packets per 1 day) ritonavir oral tablet 1 or 1b* QL (12 tablets per 1 day) VIRACEPT ORAL TABLET 250 MG (nelfinavir mesylate) 2 QL (10 tablets per 1 day) VIRACEPT ORAL TABLET 625 MG (nelfinavir mesylate) 2 QL (4 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 84 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTIRETROVIRALS - RTI-NON-NUCLEOSIDE ANALOGUES*** - DRUGS FOR VIRAL INFECTIONS EDURANT ORAL TABLET (rilpivirine hcl) 2 PA; QL (1 tablet per 1 day) efavirenz oral capsule 200 mg 1 or 1b* QL (4 capsules per 1 day) efavirenz oral capsule 50 mg 1 or 1b* QL (12 capsules per 1 day) efavirenz oral tablet 1 or 1b* QL (1 tablet per 1 day) etravirine oral tablet 100 mg 1 or 1b* PA; QL (4 tablets per 1 day) etravirine oral tablet 200 mg 1 or 1b* PA; QL (2 tablets per 1 day) INTELENCE ORAL TABLET 100 MG (etravirine) 2 PA; QL (4 tablets per 1 day) INTELENCE ORAL TABLET 200 MG (etravirine) 2 PA; QL (2 tablets per 1 day) INTELENCE ORAL TABLET 25 MG (etravirine) 2 PA; QL (16 tablets per 1 day) nevirapine er oral tablet extended release 24 hour 100 mg 1 or 1b* QL (3 tablets per 1 day) nevirapine er oral tablet extended release 24 hour 400 mg 1 or 1b* QL (1 tablet per 1 day) nevirapine oral suspension 1 or 1b* QL (40 mL per 1 day) nevirapine oral tablet 1 or 1b* QL (2 tablets per 1 day) PIFELTRO ORAL TABLET (doravirine) 3 QL (1 tablet per 1 day) SUSTIVA ORAL CAPSULE 200 MG (efavirenz) 3 QL (4 capsules per 1 day) SUSTIVA ORAL CAPSULE 50 MG (efavirenz) 3 QL (12 capsules per 1 day) SUSTIVA ORAL TABLET (efavirenz) 3 QL (1 tablet per 1 day) VIRAMUNE ORAL SUSPENSION (nevirapine) 3 QL (40 mL per 1 day) VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 QL (1 tablet per 1 day) (nevirapine) *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- PURINES*** - DRUGS FOR VIRAL INFECTIONS abacavir sulfate oral solution 1 or 1b* QL (32 mL per 1 day) abacavir sulfate oral tablet 1 or 1b* QL (2 tablets per 1 day) ZIAGEN ORAL SOLUTION (abacavir sulfate) 3 QL (32 mL per 1 day) ZIAGEN ORAL TABLET (abacavir sulfate) 3 QL (2 tablets per 1 day) *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- PYRIMIDINES*** - DRUGS FOR VIRAL INFECTIONS emtricitabine oral capsule 1 or 1b*; $0 QL (1 capsule per 1 day) EMTRIVA ORAL CAPSULE (emtricitabine) 3 QL (1 capsule per 1 day) EMTRIVA ORAL SOLUTION (emtricitabine) 2 QL (29 mL per 1 day) EPIVIR ORAL SOLUTION (lamivudine) 3 QL (32 mL per 1 day) EPIVIR ORAL TABLET 150 MG (lamivudine) 3 QL (2 tablets per 1 day) EPIVIR ORAL TABLET 300 MG (lamivudine) 3 QL (1 tablet per 1 day) lamivudine oral solution 1 or 1b* QL (32 mL per 1 day) lamivudine oral tablet 150 mg 1 or 1b* QL (2 tablets per 1 day) lamivudine oral tablet 300 mg 1 or 1b* QL (1 tablet per 1 day) *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- THYMIDINES*** - DRUGS FOR VIRAL INFECTIONS RETROVIR INTRAVENOUS SOLUTION (zidovudine) 2 RETROVIR ORAL CAPSULE (zidovudine) 3 QL (6 capsules per 1 day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 85 Coverage Requirements and Prescription Drug Name Drug Tier Limits RETROVIR ORAL SYRUP (zidovudine) 3 QL (64 mL per 1 day) stavudine oral capsule 15 mg, 20 mg 1 or 1b* QL (4 capsules per 1 day) stavudine oral capsule 30 mg, 40 mg 1 or 1b* QL (2 capsules per 1 day) zidovudine oral capsule 1 or 1b* QL (6 capsules per 1 day) zidovudine oral syrup 1 or 1b* QL (64 mL per 1 day) zidovudine oral tablet 1 or 1b* QL (2 tablets per 1 day) *ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES*** - DRUGS FOR VIRAL INFECTIONS tenofovir disoproxil fumarate oral tablet 1 or 1b*; $0 QL (1 tablet per 1 day) VIREAD ORAL POWDER (tenofovir disoproxil fumarate) 2 QL (8 grams per 1 day) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG (tenofovir disoproxil 2 QL (1 tablet per 1 day) fumarate) *ANTIRETROVIRALS ADJUVANTS*** - DRUGS FOR VIRAL INFECTIONS TYBOST ORAL TABLET (cobicistat) 3 QL (1 tablet per 1 day) *CMV AGENTS*** - DRUGS FOR VIRAL INFECTIONS cidofovir intravenous solution 1 or 1b* foscarnet sodium intravenous solution 1 or 1b* FOSCAVIR INTRAVENOUS SOLUTION (foscarnet sodium) 3 GANCICLOVIR INTRAVENOUS SOLUTION 4 SP GANCICLOVIR SODIUM INTRAVENOUS SOLUTION 4 SP ganciclovir sodium intravenous solution reconstituted 4 SP PREVYMIS INTRAVENOUS SOLUTION (letermovir) 4 PA; SP; QL (1 vial per 1 day) PREVYMIS ORAL TABLET (letermovir) 4 PA; SP; QL (1 tablet per 1 day) VALCYTE ORAL SOLUTION RECONSTITUTED (valganciclovir hcl) 3 VALCYTE ORAL TABLET (valganciclovir hcl) 3 valganciclovir hcl oral solution reconstituted 1 or 1b* valganciclovir hcl oral tablet 1 or 1b* *HEPATITIS B AGENTS*** - DRUGS FOR VIRAL INFECTIONS adefovir dipivoxil oral tablet 4 SP; QL (1 tablet per 1 day) BARACLUDE ORAL SOLUTION (entecavir) 4 QL (20 mL per 1 day) entecavir oral tablet 4 QL (1 tablet per 1 day) EPIVIR HBV ORAL SOLUTION (lamivudine) 4 QL (20 mL per 1 day) EPIVIR HBV ORAL TABLET (lamivudine) 4 QL (1 tablet per 1 day) HEPSERA ORAL TABLET (adefovir dipivoxil) 4 SP; QL (1 tablet per 1 day) lamivudine oral tablet 100 mg 1 or 1b* QL (1 tablet per 1 day) VEMLIDY ORAL TABLET (tenofovir alafenamide fumarate) 4 SP; QL (1 tablet per 1 day) *HEPATITIS C AGENT - COMBINATIONS*** - DRUGS FOR VIRAL INFECTIONS EPCLUSA ORAL TABLET (sofosbuvir-velpatasvir) 4 PA; SP; QL (1 tablet per 1 day) HARVONI ORAL PACKET 33.75-150 MG (ledipasvir-sofosbuvir) 4 PA; QL (1 packet per 1 day) HARVONI ORAL PACKET 45-200 MG (ledipasvir-sofosbuvir) 4 PA; QL (2 packets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 86 Coverage Requirements and Prescription Drug Name Drug Tier Limits HARVONI ORAL TABLET 45-200 MG (ledipasvir-sofosbuvir) 4 PA; QL (1 tablet per 1 day) HARVONI ORAL TABLET 90-400 MG (ledipasvir-sofosbuvir) 4 PA; SP; QL (1 tablet per 1 day) VOSEVI ORAL TABLET (sofosbuv-velpatasv-voxilaprev) 4 PA; SP; QL (1 tablet per 1 day) *HEPATITIS C AGENTS*** - DRUGS FOR VIRAL INFECTIONS PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML (peginterferon 4 LD; SP; QL (2 syringe per 28 days) alfa-2a) PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML (peginterferon 4 LD; SP; QL (4 vials per 28 days) alfa-2a) ribavirin oral capsule 4 SP ribavirin oral tablet 4 SP *HERPES AGENTS - PURINE ANALOGUES*** - DRUGS FOR VIRAL INFECTIONS acyclovir oral capsule 1 or 1b* acyclovir oral suspension 1 or 1b* acyclovir oral tablet 1 or 1b* acyclovir sodium intravenous solution 1 or 1b* valacyclovir hcl oral tablet 1 gm 1 or 1b* QL (30 tablets per 1 fill) valacyclovir hcl oral tablet 500 mg 1 or 1b* QL (60 tablets per 1 fill) ZOVIRAX ORAL SUSPENSION (acyclovir) 3 *HERPES AGENTS - THYMIDINE ANALOGUES*** - DRUGS FOR VIRAL INFECTIONS famciclovir oral tablet 125 mg, 250 mg 1 or 1b* QL (60 tablets per 1 fill) famciclovir oral tablet 500 mg 1 or 1b* QL (21 tablets per 1 fill) *INFLUENZA AGENTS*** - DRUGS FOR VIRAL INFECTIONS rimantadine hcl oral tablet 1 or 1b* *NEURAMINIDASE INHIBITORS*** - DRUGS FOR VIRAL INFECTIONS oseltamivir phosphate oral capsule 30 mg 1 or 1b* QL (20 capsule per 90 days) oseltamivir phosphate oral capsule 45 mg, 75 mg 1 or 1b* QL (10 capsule per 90 days) oseltamivir phosphate oral suspension reconstituted 1 or 1b* QL (180 mL per 90 days) RAPIVAB INTRAVENOUS SOLUTION (peramivir) 3 RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH 2 QL (1 package per 90 days) ACTIVATED (zanamivir) TAMIFLU ORAL CAPSULE 30 MG (oseltamivir phosphate) 3 QL (20 capsule per 90 days) TAMIFLU ORAL CAPSULE 45 MG, 75 MG (oseltamivir phosphate) 3 QL (10 capsule per 90 days) TAMIFLU ORAL SUSPENSION RECONSTITUTED (oseltamivir 3 QL (180 mL per 90 days) phosphate) *PA ENDONUCLEASE INHIBITORS*** - DRUGS FOR VIRAL INFECTIONS XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY PACK (baloxavir 3 QL (1 dose pack per 90 days) marboxil) XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY PACK (baloxavir 3 QL (1 dose pack per 90 days) marboxil)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 87 Coverage Requirements and Prescription Drug Name Drug Tier Limits *RSV AGENTS - NUCLEOSIDE ANALOGUES*** - DRUGS FOR VIRAL INFECTIONS ribavirin inhalation solution reconstituted 1 or 1b* VIRAZOLE INHALATION SOLUTION RECONSTITUTED (ribavirin) 3 *BETA BLOCKERS* - DRUGS FOR THE HEART *ALPHA-BETA BLOCKERS*** - DRUGS FOR HIGH BLOOD PRESSURE carvedilol oral tablet 12.5 mg, 3.125 mg, 6.25 mg 1 or 1b* QL (2 tablets per 1 day) carvedilol oral tablet 25 mg 1 or 1b* QL (4 tablets per 1 day) carvedilol phosphate er oral capsule extended release 24 hour 1 or 1b* QL (1 capsule per 1 day) labetalol hcl oral tablet 1 or 1b* QL (8 tablets per 1 day) LABETALOL HCL-DEXTROSE INTRAVENOUS SOLUTION 3 LABETALOL HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 *BETA BLOCKERS CARDIO-SELECTIVE*** - DRUGS FOR HIGH BLOOD PRESSURE acebutolol hcl oral capsule 200 mg 1 or 1b* QL (6 capsules per 1 day) acebutolol hcl oral capsule 400 mg 1 or 1b* QL (3 capsules per 1 day) atenolol oral tablet 1 or 1a* QL (2 tablets per 1 day) betaxolol hcl oral tablet 10 mg 1 or 1b* QL (1 tablet per 1 day) betaxolol hcl oral tablet 20 mg 1 or 1b* QL (2 tablets per 1 day) bisoprolol fumarate oral tablet 10 mg 1 or 1b* QL (2 tablets per 1 day) bisoprolol fumarate oral tablet 5 mg 1 or 1b* QL (1 tablet per 1 day) BREVIBLOC IN NACL INTRAVENOUS SOLUTION (esmolol hcl-sodium 3 chloride) BREVIBLOC INTRAVENOUS SOLUTION (esmolol hcl) 3 BREVIBLOC PREMIXED DS INTRAVENOUS SOLUTION (esmolol hcl- 3 sodium chloride) BREVIBLOC PREMIXED INTRAVENOUS SOLUTION (esmolol hcl- 3 sodium chloride) BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 5 MG (nebivolol hcl) 2 QL (1 tablet per 1 day) BYSTOLIC ORAL TABLET 20 MG (nebivolol hcl) 2 QL (2 tablets per 1 day) esmolol hcl intravenous solution 100 mg/10ml 1 or 1b* ESMOLOL HCL INTRAVENOUS SOLUTION 2000 MG/100ML, 2500 3 MG/250ML ESMOLOL HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE 3 esmolol hcl-sodium chloride intravenous solution 1 or 1b* KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 3 QL (1 capsule per 1 day) MG, 25 MG, 50 MG (metoprolol succinate) KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 200 3 QL (2 capsules per 1 day) MG (metoprolol succinate) metoprolol succinate er oral tablet extended release 24 hour 1 or 1b* metoprolol tartrate intravenous solution 1 or 1a* metoprolol tartrate oral tablet 100 mg 1 or 1a* QL (4 tablets per 1 day) metoprolol tartrate oral tablet 25 mg, 37.5 mg, 50 mg, 75 mg 1 or 1a* QL (2 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 88 Coverage Requirements and Prescription Drug Name Drug Tier Limits *BETA BLOCKERS NON-SELECTIVE*** - DRUGS FOR HIGH BLOOD PRESSURE HEMANGEOL ORAL SOLUTION (propranolol hcl) 3 INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 QL (1 capsule per 1 day) (propranolol hcl sr beads) INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 QL (1 capsule per 1 day) (propranolol hcl sr beads) nadolol oral tablet 20 mg 1 or 1b* QL (1 tablet per 1 day) nadolol oral tablet 40 mg 1 or 1b* QL (3 tablets per 1 day) nadolol oral tablet 80 mg 1 or 1b* QL (4 tablets per 1 day) pindolol oral tablet 1 or 1b* QL (6 tablets per 1 day) propranolol hcl er oral capsule extended release 24 hour 120 mg 1 or 1b* QL (2 capsules per 1 day) propranolol hcl er oral capsule extended release 24 hour 160 mg 1 or 1b* QL (4 capsules per 1 day) propranolol hcl er oral capsule extended release 24 hour 60 mg, 80 mg 1 or 1b* QL (1 capsule per 1 day) propranolol hcl intravenous solution 1 or 1b* propranolol hcl oral solution 20 mg/5ml 1 or 1b* QL (20 mL per 1 day) propranolol hcl oral solution 40 mg/5ml 1 or 1b* QL (80 mL per 1 day) propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg 1 or 1b* QL (4 tablets per 1 day) propranolol hcl oral tablet 80 mg 1 or 1b* QL (8 tablets per 1 day) sorine oral tablet 120 mg, 80 mg 1 or 1b* QL (3 tablets per 1 day) sorine oral tablet 160 mg 1 or 1b* QL (4 tablets per 1 day) sorine oral tablet 240 mg 1 or 1b* QL (2 tablets per 1 day) sotalol hcl (af) oral tablet 1 or 1b* SOTALOL HCL INTRAVENOUS SOLUTION 3 sotalol hcl oral tablet 120 mg, 80 mg 1 or 1b* QL (3 tablets per 1 day) sotalol hcl oral tablet 160 mg 1 or 1b* QL (4 tablets per 1 day) sotalol hcl oral tablet 240 mg 1 or 1b* QL (2 tablets per 1 day) SOTYLIZE ORAL SOLUTION (sotalol hcl) 3 timolol maleate oral tablet 10 mg, 5 mg 1 or 1b* QL (6 tablets per 1 day) timolol maleate oral tablet 20 mg 1 or 1b* QL (3 tablets per 1 day) *CALCIUM CHANNEL BLOCKERS* - DRUGS FOR THE HEART *CALCIUM CHANNEL BLOCKERS*** - DRUGS FOR HIGH BLOOD PRESSURE amlodipine besylate oral tablet 10 mg 1 or 1b* QL (1 tablet per 1 day) amlodipine besylate oral tablet 2.5 mg, 5 mg 1 or 1b* CALAN SR ORAL TABLET EXTENDED RELEASE (verapamil hcl) 3 QL (2 tablets per 1 day) CARDENE IV INTRAVENOUS SOLUTION (nicardipine hcl in nacl) 3 CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 3 MG (diltiazem hcl coated beads) CARDIZEM ORAL TABLET 120 MG (diltiazem hcl) 3 QL (3 tablet per 1 day) CARDIZEM ORAL TABLET 30 MG, 60 MG (diltiazem hcl) 3 cartia xt oral capsule extended release 24 hour 120 mg, 180 mg 1 or 1b* cartia xt oral capsule extended release 24 hour 240 mg, 300 mg 1 or 1b* QL (1 capsule per 1 day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 89 Coverage Requirements and Prescription Drug Name Drug Tier Limits CLEVIPREX INTRAVENOUS EMULSION (clevidipine) 3 CONJUPRI ORAL TABLET 2.5 MG (levamlodipine maleate) 3 ST CONJUPRI ORAL TABLET 5 MG (levamlodipine maleate) 3 ST; QL (1 tablet per 1 day) diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 1 or 1b* 360 mg diltiazem hcl er beads oral capsule extended release 24 hour 240 mg, 300 mg, 1 or 1b* QL (1 capsule per 1 day) 420 mg diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 1 or 1b* 180 mg diltiazem hcl er coated beads oral capsule extended release 24 hour 240 mg, 1 or 1b* QL (1 capsule per 1 day) 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 hour 180 mg 1 or 1b* diltiazem hcl er coated beads oral tablet extended release 24 hour 240 mg, 1 or 1b* QL (1 tablet per 1 day) 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 1 or 1b* QL (2 capsules per 1 day) diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg 1 or 1b* diltiazem hcl er oral capsule extended release 24 hour 240 mg 1 or 1b* QL (1 capsule per 1 day) diltiazem hcl intravenous solution 1 or 1b* DILTIAZEM HCL INTRAVENOUS SOLUTION RECONSTITUTED 3 diltiazem hcl oral tablet 120 mg 1 or 1b* QL (3 tablet per 1 day) diltiazem hcl oral tablet 30 mg, 60 mg 1 or 1b* diltiazem hcl oral tablet 90 mg 1 or 1b* QL (4 tablet per 1 day) DILTIAZEM HCL-DEXTROSE INTRAVENOUS SOLUTION 3 DILTIAZEM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 125- 3 0.7 MG/125ML-% dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg 1 or 1b* dilt-xr oral capsule extended release 24 hour 240 mg 1 or 1b* QL (1 capsule per 1 day) felodipine er oral tablet extended release 24 hour 10 mg 1 or 1b* QL (1 tablet per 1 day) felodipine er oral tablet extended release 24 hour 2.5 mg, 5 mg 1 or 1b* isradipine oral capsule 2.5 mg 1 or 1b* QL (2 capsules per 1 day) isradipine oral capsule 5 mg 1 or 1b* QL (4 capsule per 1 day) KATERZIA ORAL SUSPENSION (amlodipine benzoate) 3 QL (300 mL per 30 days) matzim la oral tablet extended release 24 hour 180 mg 1 or 1b* matzim la oral tablet extended release 24 hour 240 mg, 300 mg, 360 mg, 420 1 or 1b* QL (1 tablet per 1 day) mg NICARDIPINE HCL IN NACL INTRAVENOUS SOLUTION 3 NICARDIPINE HCL IN NACL INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE nicardipine hcl intravenous solution 1 or 1b* nicardipine hcl oral capsule 20 mg 1 or 1b* QL (6 capsule per 1 day) nicardipine hcl oral capsule 30 mg 1 or 1b* QL (4 capsule per 1 day) nifedipine er oral tablet extended release 24 hour 30 mg 1 or 1b* nifedipine er oral tablet extended release 24 hour 60 mg, 90 mg 1 or 1b* QL (1 tablet per 1 day) nifedipine er osmotic release oral tablet extended release 24 hour 30 mg 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 90 Coverage Requirements and Prescription Drug Name Drug Tier Limits nifedipine er osmotic release oral tablet extended release 24 hour 60 mg, 90 1 or 1b* QL (1 tablet per 1 day) mg nifedipine oral capsule 1 or 1b* QL (4 capsule per 1 day) nimodipine oral capsule 1 or 1b* QL (12 capsule per 1 day) nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, 8.5 mg 1 or 1b* nisoldipine er oral tablet extended release 24 hour 25.5 mg, 30 mg, 34 mg, 40 1 or 1b* QL (1 tablet per 1 day) mg NYMALIZE ORAL SOLUTION (nimodipine) 3 QL (60 mL per 1 day) PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 30 3 MG (nifedipine) PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 60 3 QL (1 tablet per 1 day) MG, 90 MG (nifedipine) SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 MG, 8.5 MG 3 (nisoldipine) SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 34 MG 3 QL (1 tablet per 1 day) (nisoldipine) taztia xt oral capsule extended release 24 hour 120 mg, 180 mg, 360 mg 1 or 1b* taztia xt oral capsule extended release 24 hour 240 mg, 300 mg 1 or 1b* QL (1 capsule per 1 day) tiadylt er oral capsule extended release 24 hour 120 mg, 180 mg, 360 mg 1 or 1b* tiadylt er oral capsule extended release 24 hour 240 mg, 300 mg, 420 mg 1 or 1b* QL (1 capsule per 1 day) TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 3 MG, 360 MG (diltiazem hcl er beads) TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 240 MG, 300 3 QL (1 capsule per 1 day) MG, 420 MG (diltiazem hcl er beads) verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 1 or 1b* mg verapamil hcl er oral capsule extended release 24 hour 200 mg, 300 mg, 360 1 or 1b* QL (1 capsule per 1 day) mg verapamil hcl er oral capsule extended release 24 hour 240 mg 1 or 1b* QL (2 capsules per 1 day) verapamil hcl er oral tablet extended release 1 or 1b* QL (2 tablets per 1 day) verapamil hcl intravenous solution 1 or 1b* verapamil hcl oral tablet 120 mg, 80 mg 1 or 1b* QL (4 tablet per 1 day) verapamil hcl oral tablet 40 mg 1 or 1b* QL (3 tablet per 1 day) VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 3 180 MG (verapamil hcl) VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 240 MG 3 QL (2 capsules per 1 day) (verapamil hcl) VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 360 MG 3 QL (1 capsule per 1 day) (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 3 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 3 QL (1 capsule per 1 day) MG, 300 MG (verapamil hcl) *CARDIOTONICS* - DRUGS FOR THE HEART *CARDIAC GLYCOSIDES*** - DRUGS FOR THE HEART digitek oral tablet 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 91 Coverage Requirements and Prescription Drug Name Drug Tier Limits digox oral tablet 1 or 1b* digoxin injection solution 1 or 1b* digoxin oral solution 1 or 1b* digoxin oral tablet 1 or 1b* LANOXIN INJECTION SOLUTION (digoxin) 3 LANOXIN ORAL TABLET 62.5 MCG (digoxin) 2 LANOXIN PEDIATRIC INJECTION SOLUTION (digoxin) 2 *INOTROPES*** - DRUGS FOR SERIOUS ALLERGIC REACTION dobutamine hcl intravenous solution 1 or 1b* DOBUTAMINE IN D5W INTRAVENOUS SOLUTION 3 dopamine hcl intravenous solution 1 or 1b* DOPAMINE IN D5W INTRAVENOUS SOLUTION 3 milrinone lactate in dextrose intravenous solution 1 or 1b* milrinone lactate intravenous solution 1 or 1b* *CARDIOVASCULAR AGENTS - MISC.* - DRUGS FOR THE HEART *CALCIUM CHANNEL BLOCKER & HMG COA REDUCTASE INHIBIT COMB*** - DRUGS FOR CHOLESTEROL amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 1 or 1b* QL (1 tablet per 1 day) 5-80 mg amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 1 or 1b* 5-20 mg, 5-40 mg CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5-80 3 QL (1 tablet per 1 day) MG (amlodipine-atorvastatin) CADUET ORAL TABLET 5-10 MG, 5-20 MG, 5-40 MG (amlodipine- 3 atorvastatin) *CARDIOPLEGIC SOLUTIONS*** - DRUGS FOR THE HEART ADENOCAINE INTRAVENOUS SOLUTION PREFILLED SYRINGE 3 (cardioplegic soln) PLEGISOL PERFUSION SOLUTION (cardioplegic soln) 3 *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** - DRUGS FOR HIGH BLOOD PRESSURE ENTRESTO ORAL TABLET 24-26 MG (sacubitril-valsartan) 2 QL (6 tablets per 1 day) ENTRESTO ORAL TABLET 49-51 MG, 97-103 MG (sacubitril-valsartan) 2 QL (2 tablets per 1 day) *NITRATE & VASODILATOR COMBINATIONS*** - DRUGS FOR HIGH BLOOD PRESSURE BIDIL ORAL TABLET (isosorb dinitrate-hydralazine) 2 *PROSTAGLANDIN - IMPOTENCE AGENTS*** - DRUGS FOR THE HEART CAVERJECT IMPULSE INTRACAVERNOSAL KIT (alprostadil 3 PA (vasodilator)) CAVERJECT INTRACAVERNOSAL SOLUTION RECONSTITUTED 3 PA (alprostadil (vasodilator)) EDEX INTRACAVERNOSAL KIT (alprostadil (vasodilator)) 3 PA MUSE URETHRAL PELLET (alprostadil (vasodilator)) 3 PA

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 92 Coverage Requirements and Prescription Drug Name Drug Tier Limits *PROSTAGLANDIN VASODILATORS*** - DRUGS FOR HIGH BLOOD PRESSURE epoprostenol sodium intravenous solution reconstituted 4 PA; LD; SP FLOLAN INTRAVENOUS SOLUTION RECONSTITUTED (epoprostenol 4 PA; LD; SP sodium) ORENITRAM ORAL TABLET EXTENDED RELEASE (treprostinil 4 PA; LD; SP diolamine) REMODULIN INJECTION SOLUTION (treprostinil) 4 PA; LD; SP treprostinil injection solution 4 PA; LD; SP TYVASO INHALATION SOLUTION (treprostinil) 4 PA; LD; SP; QL (1 kit per 28 days) TYVASO REFILL INHALATION SOLUTION (treprostinil) 4 PA; LD; SP; QL (1 kit per 28 days) TYVASO STARTER INHALATION SOLUTION (treprostinil) 4 PA; LD; SP; QL (1 kit per 28 days) VELETRI INTRAVENOUS SOLUTION RECONSTITUTED (epoprostenol 4 PA; LD; SP sodium) VENTAVIS INHALATION SOLUTION (iloprost) 4 PA; LD; SP; QL (9 mL per 1 day) *PULM HYPERTEN-SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC)*** - DRUGS FOR HIGH BLOOD PRESSURE PA; LD; SP; QL (3 tablets per 1 ADEMPAS ORAL TABLET (riociguat) 4 day) *PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS*** - DRUGS FOR HIGH BLOOD PRESSURE ambrisentan oral tablet 4 PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (2 tablets per 1 bosentan oral tablet 4 day) OPSUMIT ORAL TABLET (macitentan) 4 PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (2 tablets per 1 TRACLEER ORAL TABLET (bosentan) 4 day) PA; LD; SP; QL (2 tablets per 1 TRACLEER ORAL TABLET SOLUBLE (bosentan) 4 day) *PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS*** - DRUGS FOR HIGH BLOOD PRESSURE alyq oral tablet 4 PA; SP; QL (2 tablets per 1 day) sildenafil citrate intravenous solution 4 PA; SP; QL (3 vial per 1 day) sildenafil citrate oral suspension reconstituted 4 PA; SP; QL (6 mL per 1 day) sildenafil citrate oral tablet 20 mg 4 PA; SP; QL (3 tablets per 1 day) tadalafil (pah) oral tablet 4 PA; SP; QL (2 tablets per 1 day) *PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST*** - DRUGS FOR HIGH BLOOD PRESSURE PA; LD; SP; QL (2 tablets per 1 UPTRAVI ORAL TABLET (selexipag) 4 day) PA; LD; SP; QL (1 pack per 365 UPTRAVI ORAL TABLET THERAPY PACK (selexipag) 4 days) *SELECTIVE CGMP PHOSPHODIESTERASE TYPE 5 INHIBITORS*** - DRUGS FOR THE HEART sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg 1 or 1b* PA tadalafil oral tablet 10 mg, 20 mg 1 or 1b* PA * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 93 Coverage Requirements and Prescription Drug Name Drug Tier Limits tadalafil oral tablet 2.5 mg, 5 mg 1 or 1b* PA; QL (30 tablets per 30 days) vardenafil hcl oral tablet 1 or 1b* PA vardenafil hcl oral tablet dispersible 1 or 1b* PA *SEPTAL AGENTS - ABLATION** - DRUGS FOR THE HEART ABLYSINOL INTRA-ARTERIAL SOLUTION (dehydrated alcohol) 3 *SINUS NODE INHIBITORS** - DRUGS FOR HIGH BLOOD PRESSURE CORLANOR ORAL SOLUTION (ivabradine hcl) 3 PA; QL (4 ampules per 1 day) CORLANOR ORAL TABLET (ivabradine hcl) 2 PA; QL (2 tablets per 1 day) *TRANSTHYRETIN STABILIZERS*** - DRUGS FOR THE HEART PA; LD; SP; QL (1 capsule per 1 VYNDAMAX ORAL CAPSULE (tafamidis) 4 day) PA; LD; SP; QL (4 capsules per 1 VYNDAQEL ORAL CAPSULE (tafamidis meglumine (cardiac)) 4 day) *CEPHALOSPORINS* - DRUGS FOR INFECTIONS *CEPHALOSPORIN COMBINATIONS*** - ANTIBIOTICS AVYCAZ INTRAVENOUS SOLUTION RECONSTITUTED (ceftazidime- 3 avibactam) ZERBAXA INTRAVENOUS SOLUTION RECONSTITUTED (ceftolozane- 3 tazobactam) *CEPHALOSPORINS - 1ST GENERATION*** - ANTIBIOTICS cefadroxil oral capsule 1 or 1b* cefadroxil oral suspension reconstituted 1 or 1b* cefadroxil oral tablet 1 or 1b* CEFAZOLIN IN SODIUM CHLORIDE INTRAVENOUS SOLUTION 2-0.9 3 GM/100ML-% cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 500 mg 1 or 1b* CEFAZOLIN SODIUM INJECTION SOLUTION RECONSTITUTED 100 3 GM, 300 GM CEFAZOLIN SODIUM INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 1 GM/10ML cefazolin sodium intravenous solution reconstituted 1 or 1b* CEFAZOLIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION 3 CEFAZOLIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION 3 RECONSTITUTED cephalexin oral capsule 1 or 1a* cephalexin oral suspension reconstituted 1 or 1a* cephalexin oral tablet 1 or 1a* KEFLEX ORAL CAPSULE (cephalexin) 3 *CEPHALOSPORINS - 2ND GENERATION*** - ANTIBIOTICS CEFACLOR ER ORAL TABLET EXTENDED RELEASE 12 HOUR 3 cefaclor oral capsule 1 or 1b* cefaclor oral suspension reconstituted 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 94 Coverage Requirements and Prescription Drug Name Drug Tier Limits CEFOTAN INJECTION SOLUTION RECONSTITUTED (cefotetan 3 disodium) cefotetan disodium injection solution reconstituted 1 or 1b* CEFOTETAN DISODIUM-DEXTROSE INTRAVENOUS SOLUTION 3 RECONSTITUTED cefoxitin sodium injection solution reconstituted 1 or 1b* cefoxitin sodium intravenous solution reconstituted 1 or 1b* CEFOXITIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION 3 RECONSTITUTED cefprozil oral suspension reconstituted 1 or 1b* cefprozil oral tablet 1 or 1b* cefuroxime axetil oral tablet 1 or 1b* cefuroxime sodium injection solution reconstituted 1 or 1b* cefuroxime sodium intravenous solution reconstituted 1 or 1b* *CEPHALOSPORINS - 3RD GENERATION*** - ANTIBIOTICS cefdinir oral capsule 1 or 1b* QL (20 capsules per 1 fill) cefdinir oral suspension reconstituted 125 mg/5ml 1 or 1b* QL (240 mL per 1 fill) cefdinir oral suspension reconstituted 250 mg/5ml 1 or 1b* QL (120 mL per 1 fill) cefixime oral capsule 1 or 1b* QL (10 capsules per 1 fill) cefixime oral suspension reconstituted 100 mg/5ml 1 or 1b* QL (200 mL per 1 fill) cefixime oral suspension reconstituted 200 mg/5ml 1 or 1b* QL (100 mL per 1 fill) cefotaxime sodium injection solution reconstituted 1 or 1b* cefpodoxime proxetil oral suspension reconstituted 1 or 1b* cefpodoxime proxetil oral tablet 1 or 1b* CEFTAZIDIME AND DEXTROSE INTRAVENOUS SOLUTION 3 RECONSTITUTED ceftazidime injection solution reconstituted 1 or 1b* ceftriaxone sodium in dextrose intravenous solution 1 or 1b* QL (3000 mL per 30 days) ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 500 mg 1 or 1b* QL (60 vials per 30 fills) CEFTRIAXONE SODIUM INJECTION SOLUTION RECONSTITUTED 100 3 GM ceftriaxone sodium injection solution reconstituted 250 mg 1 or 1b* QL (1 vial per 30 fills) ceftriaxone sodium intravenous solution reconstituted 1 gm, 2 gm 1 or 1b* QL (60 vials per 30 days) ceftriaxone sodium intravenous solution reconstituted 10 gm 1 or 1b* CEFTRIAXONE SODIUM-DEXTROSE INTRAVENOUS SOLUTION 3 QL (60 IV Bags per 30 days) RECONSTITUTED FORTAZ INJECTION SOLUTION RECONSTITUTED (ceftazidime) 3 FORTAZ INTRAVENOUS SOLUTION RECONSTITUTED (ceftazidime) 3 SUPRAX ORAL CAPSULE (cefixime) 3 QL (10 capsules per 1 fill) SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML (cefixime) 3 QL (200 mL per 1 fill) SUPRAX ORAL SUSPENSION RECONSTITUTED 200 MG/5ML (cefixime) 3 QL (100 mL per 1 fill) SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML (cefixime) 3 QL (40 mL per 1 fill) SUPRAX ORAL TABLET CHEWABLE 100 MG (cefixime) 3 QL (40 tablets per 1 fill)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 95 Coverage Requirements and Prescription Drug Name Drug Tier Limits SUPRAX ORAL TABLET CHEWABLE 200 MG (cefixime) 3 QL (20 tablets per 1 fill) tazicef injection solution reconstituted 1 or 1b* TAZICEF INTRAVENOUS SOLUTION (ceftazidime sodium in dextrose) 3 tazicef intravenous solution reconstituted 1 or 1b* *CEPHALOSPORINS - 4TH GENERATION*** - ANTIBIOTICS cefepime hcl injection solution reconstituted 1 or 1b* CEFEPIME HCL INTRAVENOUS SOLUTION 3 CEFEPIME HCL INTRAVENOUS SOLUTION RECONSTITUTED 3 CEFEPIME-DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 3 *CEPHALOSPORINS - 5TH GENERATION*** - ANTIBIOTICS TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED (ceftaroline 3 fosamil) *CEPHALOSPORINS - SIDEROPHORES*** - ANTIBIOTICS FETROJA INTRAVENOUS SOLUTION RECONSTITUTED (cefiderocol 3 sulfate tosylate) *CONTRACEPTIVES* - DRUGS FOR WOMEN *BIPHASIC CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS azurette oral tablet 1 or 1b*; $0 bekyree oral tablet 1 or 1b*; $0 desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5) 1 or 1b*; $0 kariva oral tablet 1 or 1b*; $0 LO LOESTRIN FE ORAL TABLET (norethin-eth estrad-fe biphas) 2 MIRCETTE ORAL TABLET (desogestrel-ethinyl estradiol) 3 pimtrea oral tablet 1 or 1b*; $0 simliya oral tablet 1 or 1b*; $0 viorele oral tablet 1 or 1b*; $0 volnea oral tablet 1 or 1b*; $0 *COMBINATION CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS afirmelle oral tablet 1 or 1a*; $0 altavera oral tablet 1 or 1a*; $0 alyacen 1/35 oral tablet 1 or 1a*; $0 apri oral tablet 1 or 1a*; $0 aubra eq oral tablet 1 or 1a*; $0 aubra oral tablet 1 or 1a*; $0 aurovela 1.5/30 oral tablet 1 or 1a*; $0 aurovela 1/20 oral tablet 1 or 1a*; $0 aurovela 24 fe oral tablet 1 or 1a*; $0 aurovela fe 1.5/30 oral tablet 1 or 1a*; $0 aurovela fe 1/20 oral tablet 1 or 1a*; $0 aviane oral tablet 1 or 1a*; $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 96 Coverage Requirements and Prescription Drug Name Drug Tier Limits ayuna oral tablet 1 or 1a*; $0 BALCOLTRA ORAL TABLET (levonorgest-eth estrad-fe bisg) 3 balziva oral tablet 1 or 1a*; $0 BEYAZ ORAL TABLET (drospiren-eth estrad-levomefol) 3 blisovi 24 fe oral tablet 1 or 1a*; $0 blisovi fe 1.5/30 oral tablet 1 or 1a*; $0 blisovi fe 1/20 oral tablet 1 or 1a*; $0 briellyn oral tablet 1 or 1a*; $0 charlotte 24 fe oral tablet chewable 1 or 1a*; $0 chateal eq oral tablet 1 or 1a*; $0 chateal oral tablet 1 or 1a*; $0 cryselle-28 oral tablet 1 or 1a*; $0 cyclafem 1/35 oral tablet 1 or 1a*; $0 cyred eq oral tablet 1 or 1a*; $0 cyred oral tablet 1 or 1a*; $0 dasetta 1/35 oral tablet 1 or 1a*; $0 delyla oral tablet 1 or 1a*; $0 desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg 1 or 1a*; $0 drospiren-eth estrad-levomefol oral tablet 1 or 1b*; $0 drospirenone-ethinyl estradiol oral tablet 1 or 1b*; $0 elinest oral tablet 1 or 1a*; $0 emoquette oral tablet 1 or 1a*; $0 enskyce oral tablet 1 or 1a*; $0 estarylla oral tablet 1 or 1a*; $0 ethynodiol diac-eth estradiol oral tablet 1 or 1a*; $0 FALESSA ORAL KIT (levonorgestrel-eth estrad & fa) 3 falmina oral tablet 1 or 1a*; $0 femynor oral tablet 1 or 1a*; $0 gemmily oral capsule 1 or 1b*; $0 GENERESS FE ORAL TABLET CHEWABLE (norethin-eth estradiol-fe) 3 hailey 1.5/30 oral tablet 1 or 1a*; $0 hailey 24 fe oral tablet 1 or 1a*; $0 hailey fe 1.5/30 oral tablet 1 or 1a*; $0 hailey fe 1/20 oral tablet 1 or 1a*; $0 isibloom oral tablet 1 or 1a*; $0 jasmiel oral tablet 1 or 1b*; $0 juleber oral tablet 1 or 1a*; $0 junel 1.5/30 oral tablet 1 or 1a*; $0 junel 1/20 oral tablet 1 or 1a*; $0 junel fe 1.5/30 oral tablet 1 or 1a*; $0 junel fe 1/20 oral tablet 1 or 1a*; $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 97 Coverage Requirements and Prescription Drug Name Drug Tier Limits junel fe 24 oral tablet 1 or 1a*; $0 kaitlib fe oral tablet chewable 1 or 1b*; $0 kalliga oral tablet 1 or 1a*; $0 kelnor 1/35 oral tablet 1 or 1a*; $0 kelnor 1/50 oral tablet 1 or 1a*; $0 kurvelo oral tablet 1 or 1a*; $0 larin 1.5/30 oral tablet 1 or 1a*; $0 larin 1/20 oral tablet 1 or 1a*; $0 larin 24 fe oral tablet 1 or 1a*; $0 larin fe 1.5/30 oral tablet 1 or 1a*; $0 larin fe 1/20 oral tablet 1 or 1a*; $0 larissia oral tablet 1 or 1a*; $0 layolis fe oral tablet chewable 1 or 1b*; $0 lessina oral tablet 1 or 1a*; $0 levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg 1 or 1a*; $0 levora 0.15/30 (28) oral tablet 1 or 1a*; $0 lillow oral tablet 1 or 1a*; $0 loestrin 1.5/30 (21) oral tablet 1 or 1a*; $0 loestrin 1/20 (21) oral tablet 1 or 1a*; $0 loestrin fe 1.5/30 oral tablet 1 or 1a*; $0 loestrin fe 1/20 oral tablet 1 or 1a*; $0 loryna oral tablet 1 or 1b*; $0 low-ogestrel oral tablet 1 or 1a*; $0 lo-zumandimine oral tablet 1 or 1b*; $0 lutera oral tablet 1 or 1a*; $0 marlissa oral tablet 1 or 1a*; $0 merzee oral capsule 1 or 1b*; $0 mibelas 24 fe oral tablet chewable 1 or 1a*; $0 microgestin 1.5/30 oral tablet 1 or 1a*; $0 microgestin 1/20 oral tablet 1 or 1a*; $0 microgestin 24 fe oral tablet 1 or 1a*; $0 microgestin fe 1.5/30 oral tablet 1 or 1a*; $0 microgestin fe 1/20 oral tablet 1 or 1a*; $0 mili oral tablet 1 or 1a*; $0 MINASTRIN 24 FE ORAL TABLET CHEWABLE (norethin ace-eth estrad- 3 fe) mono-linyah oral tablet 1 or 1a*; $0 necon 0.5/35 (28) oral tablet 1 or 1a*; $0 NEXTSTELLIS ORAL TABLET (drospirenone-estetrol) 3 nikki oral tablet 1 or 1b*; $0 norethin ace-eth estrad-fe oral capsule 1 or 1b*; $0 norethin ace-eth estrad-fe oral tablet 1 or 1a*; $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 98 Coverage Requirements and Prescription Drug Name Drug Tier Limits norethin ace-eth estrad-fe oral tablet chewable 1 or 1a*; $0 norethindrone acet-ethinyl est oral tablet 1 or 1a*; $0 norethin-eth estradiol-fe oral tablet chewable 1 or 1b*; $0 norgestimate-eth estradiol oral tablet 1 or 1a*; $0 nortrel 0.5/35 (28) oral tablet 1 or 1a*; $0 nortrel 1/35 (21) oral tablet 1 or 1a*; $0 nortrel 1/35 (28) oral tablet 1 or 1a*; $0 nymyo oral tablet 1 or 1a*; $0 ocella oral tablet 1 or 1b*; $0 orsythia oral tablet 1 or 1a*; $0 philith oral tablet 1 or 1a*; $0 pirmella 1/35 oral tablet 1 or 1a*; $0 portia-28 oral tablet 1 or 1a*; $0 previfem oral tablet 1 or 1a*; $0 reclipsen oral tablet 1 or 1a*; $0 SAFYRAL ORAL TABLET (drospiren-eth estrad-levomefol) 3 sprintec 28 oral tablet 1 or 1a*; $0 sronyx oral tablet 1 or 1a*; $0 syeda oral tablet 1 or 1b*; $0 tarina 24 fe oral tablet 1 or 1a*; $0 tarina fe 1/20 eq oral tablet 1 or 1a*; $0 tarina fe 1/20 oral tablet 1 or 1a*; $0 TAYTULLA ORAL CAPSULE (norethin ace-eth estrad-fe) 3 TYBLUME ORAL TABLET CHEWABLE (levonorgestrel-ethinyl estrad) 3 tydemy oral tablet 1 or 1b*; $0 vestura oral tablet 1 or 1b*; $0 vienva oral tablet 1 or 1a*; $0 vyfemla oral tablet 1 or 1a*; $0 vylibra oral tablet 1 or 1a*; $0 wera oral tablet 1 or 1a*; $0 wymzya fe oral tablet chewable 1 or 1b*; $0 YASMIN 28 ORAL TABLET (drospirenone-ethinyl estradiol) 3 YAZ ORAL TABLET (drospirenone-ethinyl estradiol) 3 zarah oral tablet 1 or 1b*; $0 zovia 1/35 (28) oral tablet 1 or 1a*; $0 zovia 1/35e (28) oral tablet 1 or 1a*; $0 zumandimine oral tablet 1 or 1b*; $0 *COMBINATION CONTRACEPTIVES - TRANSDERMAL*** - BIRTH CONTROL PILLS TWIRLA TRANSDERMAL PATCH WEEKLY (levonorgestrel-eth estradiol) 3 xulane transdermal patch weekly 1 or 1b*; $0 zafemy transdermal patch weekly 1 or 1b*; $0 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 99 Coverage Requirements and Prescription Drug Name Drug Tier Limits *COMBINATION CONTRACEPTIVES - VAGINAL*** - BIRTH CONTROL PILLS ANNOVERA VAGINAL RING (segesterone-ethinyl estradiol) 3 eluryng vaginal ring 1 or 1b*; $0 etonogestrel-ethinyl estradiol vaginal ring 1 or 1b*; $0 NUVARING VAGINAL RING (etonogestrel-ethinyl estradiol) 3 *CONTINUOUS CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS amethyst oral tablet 1 or 1b*; $0 dolishale oral tablet 1 or 1b*; $0 levonorgestrel-ethinyl estrad oral tablet 90-20 mcg 1 or 1b*; $0 *COPPER CONTRACEPTIVES - IUD*** - BIRTH CONTROL PILLS PARAGARD INTRAUTERINE COPPER INTRAUTERINE 3 INTRAUTERINE DEVICE (copper) *EMERGENCY CONTRACEPTIVES*** - BIRTH CONTROL PILLS ELLA ORAL TABLET (ulipristal acetate) 3; $0 *EXTENDED-CYCLE CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS amethia oral tablet 1 or 1b*; $0 ashlyna oral tablet 1 or 1b*; $0 camrese lo oral tablet 1 or 1b*; $0 camrese oral tablet 1 or 1b*; $0 daysee oral tablet 1 or 1b*; $0 fayosim oral tablet 1 or 1b*; $0 iclevia oral tablet 1 or 1b*; $0 introvale oral tablet 1 or 1b*; $0 jaimiess oral tablet 1 or 1b*; $0 jolessa oral tablet 1 or 1b*; $0 levonorgest-eth est & eth est oral tablet 1 or 1b*; $0 levonorgest-eth estrad 91-day oral tablet 1 or 1b*; $0 lojaimiess oral tablet 1 or 1b*; $0 LOSEASONIQUE ORAL TABLET (levonorgest-eth estrad 91-day) 3 QUARTETTE ORAL TABLET (levonorgest-eth estrad 91-day) 3 rivelsa oral tablet 1 or 1b*; $0 SEASONIQUE ORAL TABLET (levonorgest-eth estrad 91-day) 3 setlakin oral tablet 1 or 1b*; $0 simpesse oral tablet 1 or 1b*; $0 *FOUR PHASE CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS NATAZIA ORAL TABLET (estradiol valerate-dienogest) 3 *PROGESTIN CONTRACEPTIVES - IMPLANTS*** - BIRTH CONTROL PILLS NEXPLANON SUBCUTANEOUS IMPLANT (etonogestrel) 4 LD; SP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 100 Coverage Requirements and Prescription Drug Name Drug Tier Limits *PROGESTIN CONTRACEPTIVES - INJECTABLE*** - BIRTH CONTROL PILLS DEPO-PROVERA INTRAMUSCULAR SUSPENSION 3 (medroxyprogesterone acetate) DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED 3 SYRINGE (medroxyprogesterone acetate) DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION 3; $0 PREFILLED SYRINGE (medroxyprogesterone acetate) medroxyprogesterone acetate intramuscular suspension 1 or 1b*; $0 medroxyprogesterone acetate intramuscular suspension prefilled syringe 1 or 1b*; $0 *PROGESTIN CONTRACEPTIVES - IUD*** - BIRTH CONTROL PILLS KYLEENA INTRAUTERINE INTRAUTERINE DEVICE (levonorgestrel) 4 LD; SP LILETTA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 3 LD; SP (levonorgestrel) MIRENA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 3 LD; SP (levonorgestrel) SKYLA INTRAUTERINE INTRAUTERINE DEVICE (levonorgestrel) 3 LD; SP *PROGESTIN CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS camila oral tablet 1 or 1b*; $0 deblitane oral tablet 1 or 1b*; $0 errin oral tablet 1 or 1b*; $0 heather oral tablet 1 or 1b*; $0 incassia oral tablet 1 or 1b*; $0 jencycla oral tablet 1 or 1b*; $0 lyleq oral tablet 1 or 1b*; $0 lyza oral tablet 1 or 1b*; $0 nora-be oral tablet 1 or 1b*; $0 norethindrone oral tablet 1 or 1b*; $0 norlyda oral tablet 1 or 1b*; $0 norlyroc oral tablet 1 or 1b*; $0 sharobel oral tablet 1 or 1b*; $0 SLYND ORAL TABLET (drospirenone) 3 tulana oral tablet 1 or 1b*; $0 *TRIPHASIC CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS alyacen 7/7/7 oral tablet 1 or 1a*; $0 aranelle oral tablet 1 or 1a*; $0 caziant oral tablet 1 or 1a*; $0 cyclafem 7/7/7 oral tablet 1 or 1a*; $0 dasetta 7/7/7 oral tablet 1 or 1a*; $0 enpresse-28 oral tablet 1 or 1a*; $0 ESTROSTEP FE ORAL TABLET (norethindron-ethinyl estrad-fe) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 101 Coverage Requirements and Prescription Drug Name Drug Tier Limits leena oral tablet 1 or 1a*; $0 levonest oral tablet 1 or 1a*; $0 levonorg-eth estrad triphasic oral tablet 1 or 1a*; $0 norgestim-eth estrad triphasic oral tablet 1 or 1b*; $0 nortrel 7/7/7 oral tablet 1 or 1a*; $0 nylia 7/7/7 oral tablet 1 or 1a*; $0 pirmella 7/7/7 oral tablet 1 or 1a*; $0 tilia fe oral tablet 1 or 1b*; $0 tri femynor oral tablet 1 or 1b*; $0 tri-estarylla oral tablet 1 or 1b*; $0 tri-legest fe oral tablet 1 or 1b*; $0 tri-linyah oral tablet 1 or 1b*; $0 tri-lo-estarylla oral tablet 1 or 1b*; $0 tri-lo-marzia oral tablet 1 or 1b*; $0 tri-lo-mili oral tablet 1 or 1b*; $0 tri-lo-sprintec oral tablet 1 or 1b*; $0 tri-mili oral tablet 1 or 1b*; $0 tri-nymyo oral tablet 1 or 1b*; $0 tri-previfem oral tablet 1 or 1b*; $0 tri-sprintec oral tablet 1 or 1b*; $0 trivora (28) oral tablet 1 or 1a*; $0 tri-vylibra lo oral tablet 1 or 1b*; $0 tri-vylibra oral tablet 1 or 1b*; $0 velivet oral tablet 1 or 1a*; $0 *CORTICOSTEROIDS* - HORMONES *GLUCOCORTICOSTEROIDS*** - DRUGS FOR INFLAMMATION ALKINDI SPRINKLE ORAL CAPSULE SPRINKLE (hydrocortisone) 3 PA; LD budesonide er oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) budesonide oral capsule delayed release particles 1 or 1b* QL (3 capsule per 1 day) CORTEF ORAL TABLET (hydrocortisone) 3 decadron oral tablet 1 or 1a* DEPO-MEDROL INJECTION SUSPENSION (methylprednisolone acetate) 3 DEXABLISS ORAL TABLET THERAPY PACK 3 DEXAMETHASONE INTENSOL ORAL CONCENTRATE (dexamethasone) 2 dexamethasone oral elixir 1 or 1a* dexamethasone oral solution 1 or 1a* dexamethasone oral tablet 1 or 1a* dexamethasone oral tablet therapy pack 1 or 1b* DEXAMETHASONE SOD PHOS-NACL INTRAVENOUS SOLUTION 3 dexamethasone sod phosphate pf injection solution 1 or 1b* DEXAMETHASONE SOD PHOSPHATE PF INJECTION SOLUTION 3 PREFILLED SYRINGE * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 102 Coverage Requirements and Prescription Drug Name Drug Tier Limits DEXAMETHASONE SODIUM PHOSPHATE INJECTION SOLUTION 10 3 MG/ML, 4 MG/ML dexamethasone sodium phosphate injection solution 100 mg/10ml, 120 1 or 1b* mg/30ml, 20 mg/5ml DXEVO 11-DAY ORAL TABLET THERAPY PACK (dexamethasone) 3 ENTOCORT EC ORAL CAPSULE DELAYED RELEASE PARTICLES 3 QL (3 capsule per 1 day) (budesonide) HEMADY ORAL TABLET (dexamethasone) 3 PA; QL (2 tablets per 1 day) hydrocortisone oral tablet 1 or 1b* KENALOG INJECTION SUSPENSION (triamcinolone acetonide) 3 KENALOG-80 INJECTION SUSPENSION (triamcinolone acetonide) 3 MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG 3 (methylprednisolone) MEDROL ORAL TABLET 2 MG (methylprednisolone) 2 MEDROL ORAL TABLET THERAPY PACK (methylprednisolone) 3 methylprednisolone oral tablet 1 or 1a* methylprednisolone oral tablet therapy pack 1 or 1a* methylprednisolone sodium succ injection solution reconstituted 1 or 1b* MILLIPRED ORAL TABLET (prednisolone) 3 ORAPRED ODT ORAL TABLET DISPERSIBLE 10 MG, 30 MG 3 QL (2 tablets per 1 day) (prednisolone sodium phosphate) ORAPRED ODT ORAL TABLET DISPERSIBLE 15 MG (prednisolone 3 sodium phosphate) ORTIKOS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 QL (1 capsule per 1 day) (budesonide) PEDIAPRED ORAL SOLUTION (prednisolone sodium phosphate) 3 prednisolone oral solution 1 or 1a* prednisolone sodium phosphate oral solution 1 or 1a* prednisolone sodium phosphate oral tablet dispersible 10 mg, 30 mg 1 or 1a* QL (2 tablets per 1 day) prednisolone sodium phosphate oral tablet dispersible 15 mg 1 or 1a* PREDNISONE INTENSOL ORAL CONCENTRATE (prednisone) 3 prednisone oral solution 1 or 1a* prednisone oral tablet 1 or 1a* prednisone oral tablet therapy pack 1 or 1a* SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 3 (hydrocortisone sod succinate) SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 3 (methylprednisolone sodium succ) taperdex 12-day oral tablet therapy pack 1 or 1b* taperdex 6-day oral tablet therapy pack 1 or 1b* taperdex 7-day oral tablet therapy pack 1 or 1b* UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR (budesonide) 3 PA; QL (1 tablet per 1 day) ZCORT 7-DAY ORAL TABLET THERAPY PACK 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 103 Coverage Requirements and Prescription Drug Name Drug Tier Limits ZILRETTA INTRA-ARTICULAR SUSPENSION RECONSTITUTED ER 4 PA; LD; QL (1 injection per 1 knee) (triamcinolone acetonide) *MINERALOCORTICOIDS*** - DRUGS FOR INFLAMMATION fludrocortisone acetate oral tablet 1 or 1b* *STEROID COMBINATIONS*** - DRUGS FOR INFLAMMATION BSP 0820 INJECTION KIT 3 CELESTONE SOLUSPAN INJECTION SUSPENSION (betamethasone sod 3 phos & acet) *COUGH/COLD/ALLERGY* - DRUGS FOR THE LUNGS *ANTITUSSIVE - NONNARCOTIC*** - DRUGS FOR ALLERGIES benzonatate oral capsule 1 or 1b* TESSALON PERLES ORAL CAPSULE (benzonatate) 3 *ANTITUSSIVE - OPIOID*** - DRUGS FOR COUGH AND COLD HYCODAN ORAL SYRUP (hydrocodone-homatropine) 3 hydrocodone-homatropine oral syrup 1 or 1a* hydrocodone-homatropine oral tablet 1 or 1a* hydromet oral syrup 1 or 1a* *DECONGESTANT & ANTIHISTAMINE*** - DRUGS FOR COUGH AND COLD CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 3 ST; QL (2 tablets per 1 day) HOUR (desloratadine-pseudoephedrine) promethazine vc oral syrup 1 or 1b* QL (120 mL per 1 fill) promethazine-phenylephrine oral syrup 1 or 1b* QL (120 mL per 1 fill) *DECONGESTANT W/ EXPECTORANT*** - DRUGS FOR COUGH AND COLD GILPHEX TR ORAL TABLET (phenylephrine-guaifenesin) 3 *IODINE EXPECTORANTS*** - DRUGS FOR COUGH AND COLD SSKI ORAL SOLUTION (potassium iodide (expectorant)) 3 *MISC. RESPIRATORY INHALANTS*** - DRUGS FOR ALLERGIES HYPERSAL INHALATION NEBULIZATION SOLUTION (sodium 3 chloride) sodium chloride inhalation nebulization solution 1 or 1b* *MUCOLYTICS*** - DRUGS FOR THE LUNGS acetylcysteine inhalation solution 1 or 1b* *NON-NARC ANTITUSSIVE-ANTIHISTAMINE*** - DRUGS FOR COUGH AND COLD promethazine-dm oral syrup 1 or 1a* QL (120 mL per 1 fill) *NON-NARC ANTITUSSIVE-DECONGESTANT- ANTIHISTAMINE*** - DRUGS FOR COUGH AND COLD pseudoeph-bromphen-dm oral syrup 1 or 1b* *OPIOID ANTITUSSIVE-ANTIHISTAMINE*** - DRUGS FOR COUGH AND COLD hydrocod polst-cpm polst er oral suspension extended release 1 or 1b* QL (120 mL per 1 fill) promethazine-codeine oral solution 1 or 1a* QL (120 mL per 1 fill)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 104 Coverage Requirements and Prescription Drug Name Drug Tier Limits promethazine-codeine oral syrup 1 or 1a* QL (120 mL per 1 fill) TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 HOUR (hydrocod 2 polst-chlorphen polst) TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 HOUR 3 (chlorpheniramine-codeine) TUZISTRA XR ORAL SUSPENSION EXTENDED RELEASE (codeine 3 polst-chlorphen polst) *OPIOID ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE*** - DRUGS FOR COUGH AND COLD promethazine vc/codeine oral syrup 1 or 1b* QL (120 mL per 1 fill) promethazine-phenyleph-codeine oral syrup 1 or 1b* QL (120 mL per 1 fill) *DERMATOLOGICALS* - DRUGS FOR THE SKIN *ACNE ANTIBIOTICS*** - DRUGS FOR THE SKIN CLEOCIN-T EXTERNAL LOTION (clindamycin phosphate) 3 ST; QL (4 mL per 1 day) clindacin etz external swab 1 or 1b* QL (2 pads per 1 day) clindacin-p external swab 1 or 1b* QL (2 pads per 1 day) clindamycin phosphate external foam 1 or 1b* QL (100 grams per 30 days) clindamycin phosphate external gel 1 or 1b* QL (60 grams per 30 days) clindamycin phosphate external lotion 1 or 1b* QL (4 mL per 1 day) clindamycin phosphate external solution 1 or 1b* QL (4 mL per 1 day) clindamycin phosphate external swab 1 or 1b* QL (2 pads per 1 day) dapsone external gel 1 or 1b* ST; QL (60 grams per 30 days) ery external pad 1 or 1b* QL (2 pads per 1 day) ERYGEL EXTERNAL GEL (erythromycin) 3 QL (60 grams per 30 days) erythromycin external gel 1 or 1b* QL (60 grams per 30 days) erythromycin external solution 1 or 1b* EVOCLIN EXTERNAL FOAM (clindamycin phosphate) 3 ST; QL (100 grams per 30 days) KLARON EXTERNAL LOTION (sulfacetamide sodium (acne)) 3 sulfacetamide sodium (acne) external lotion 1 or 1b* *ACNE COMBINATIONS*** - DRUGS FOR THE SKIN adapalene-benzoyl peroxide external gel 1 or 1b* PA; QL (45 grams per 30 days) BENZAMYCIN EXTERNAL GEL (benzoyl peroxide-erythromycin) 3 ST; QL (46.6 grams per 30 days) benzoyl peroxide-erythromycin external gel 1 or 1b* QL (2 packets per 1 day) clindamycin phos-benzoyl perox external gel 1.2-5 % 1 or 1b* QL (45 grams per 30 days) clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 % 1 or 1b* QL (50 grams per 30 days) clindamycin-tretinoin external gel 1 or 1b* neuac external gel 1 or 1b* QL (45 grams per 30 days) ONEXTON EXTERNAL GEL (clindamycin phos-benzoyl perox) 2 QL (50 grams per 30 days) sulfacetamide sod-sulfur wash external liquid 1 or 1b* PA TAROXIA EXTERNAL GEL 3 *ACNE PRODUCTS*** - DRUGS FOR THE SKIN ABSORICA LD ORAL CAPSULE (isotretinoin micronized) 3 PA

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 105 Coverage Requirements and Prescription Drug Name Drug Tier Limits ABSORICA ORAL CAPSULE (isotretinoin) 3 PA accutane oral capsule 2 PA adapalene external cream 1 or 1b* PA; QL (1.5 grams per 1 day) adapalene external gel 1 or 1b* PA; QL (45 grams per 30 days) adapalene external pad 1 or 1b* PA AKLIEF EXTERNAL CREAM (trifarotene) 3 ST; QL (1 pump per 30 days) amnesteem oral capsule 2 PA ARAZLO EXTERNAL LOTION (tazarotene) 3 ST; QL (45 grams per 30 days) avita external cream 1 or 1b* PA; QL (45 grams per 30 days) avita external gel 1 or 1b* PA; QL (45 grams per 30 days) bp wash external liquid 2.5 %, 7 % 1 or 1b* claravis oral capsule 2 PA isotretinoin oral capsule 2 PA myorisan oral capsule 2 PA tretinoin external cream 1 or 1b* PA; QL (45 grams per 30 days) tretinoin external gel 1 or 1b* PA; QL (45 grams per 30 days) tretinoin microsphere external gel 1 or 1b* PA; QL (45 grams per 30 days) tretinoin microsphere pump external gel 1 or 1b* PA; QL (45 grams per 30 days) zenatane oral capsule 2 PA *AGENTS FOR EXTERNAL GENITAL AND PERIANAL WARTS*** - DRUGS FOR THE SKIN VEREGEN EXTERNAL OINTMENT (sinecatechins) 3 *AGENTS FOR FACIAL WRINKLES - RETINOIDS*** - DRUGS FOR THE SKIN refissa external cream 1 or 1b* PA; QL (40 grams per 30 days) RENOVA EXTERNAL CREAM (tretinoin (facial wrinkles)) 3 PA; QL (40 grams per 30 days) RENOVA PUMP EXTERNAL CREAM (tretinoin (facial wrinkles)) 3 PA; QL (44 grams per 30 days) tretinoin (emollient) external cream 1 or 1b* PA; QL (40 grams per 30 days) *ANTIBIOTIC STEROID COMBINATIONS - TOPICAL*** - DRUGS FOR THE SKIN NEO-SYNALAR EXTERNAL CREAM (neomycin-fluocinolone) 3 *ANTIBIOTICS - TOPICAL*** - DRUGS FOR THE SKIN ALTABAX EXTERNAL OINTMENT (retapamulin) 2 QL (30 grams per 1 fill) CENTANY EXTERNAL OINTMENT (mupirocin) 3 QL (30 grams per 1 fill) gentamicin sulfate external cream 1 or 1b* QL (30 grams per 1 fill) gentamicin sulfate external ointment 1 or 1b* QL (30 grams per 1 fill) mupirocin calcium external cream 1 or 1b* QL (30 grams per 1 fill) mupirocin external ointment 1 or 1b* QL (30 grams per 1 fill) XEPI EXTERNAL CREAM (ozenoxacin) 3 QL (45 grams per 1 fill) *ANTIFUNGALS - TOPICAL COMBINATIONS*** - DRUGS FOR THE SKIN clotrimazole-betamethasone external cream 1 or 1b* QL (120 grams per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 106 Coverage Requirements and Prescription Drug Name Drug Tier Limits clotrimazole-betamethasone external lotion 1 or 1b* QL (120 mL per 30 days) miconazole-zinc oxide-petrolat external ointment 1 or 1b* QL (50 grams per 30 days) nystatin-triamcinolone external cream 1 or 1b* QL (120 grams per 30 days) nystatin-triamcinolone external ointment 1 or 1b* QL (120 grams per 30 days) VUSION EXTERNAL OINTMENT (miconazole-zinc oxide-petrolat) 3 QL (50 grams per 30 days) *ANTIFUNGALS - TOPICAL*** - DRUGS FOR THE SKIN ciclopirox external gel 1 or 1b* QL (100 grams per 30 days) ciclopirox external shampoo 1 or 1b* QL (120 mL per 30 days) ciclopirox external solution 1 or 1b* QL (7 mL per 30 days) ciclopirox olamine external cream 1 or 1b* QL (90 grams per 30 days) ciclopirox olamine external suspension 1 or 1b* QL (60 mL per 30 days) LOPROX EXTERNAL CREAM (ciclopirox olamine) 3 ST; QL (90 grams per 30 days) LOPROX EXTERNAL SHAMPOO (ciclopirox) 3 QL (120 mL per 30 days) LOPROX EXTERNAL SUSPENSION (ciclopirox olamine) 3 ST; QL (60 mL per 30 days) MENTAX EXTERNAL CREAM (butenafine hcl) 3 ST; QL (30 grams per 30 days) naftifine hcl external cream 1 % 1 or 1b* ST; QL (90 grams per 30 days) naftifine hcl external cream 2 % 1 or 1b* QL (60 grams per 30 days) naftifine hcl external gel 1 or 1b* ST; QL (90 grams per 30 days) NAFTIN EXTERNAL GEL 1 % (naftifine hcl) 3 ST; QL (90 grams per 30 days) NAFTIN EXTERNAL GEL 2 % (naftifine hcl) 3 ST; QL (60 grams per 30 days) nyamyc external powder 1 or 1b* QL (30 grams per 30 days) nystatin external cream 1 or 1b* QL (120 grams per 30 days) nystatin external ointment 1 or 1b* QL (120 grams per 30 days) nystatin external powder 1 or 1b* QL (30 grams per 30 days) nystop external powder 1 or 1b* QL (30 grams per 30 days) *ANTI-INFLAMMATORY AGENTS - TOPICAL*** - DRUGS FOR THE SKIN diclofenac sodium external gel 1 % 1 or 1b* QL (1000 gm per 30 days) *ANTI-INFLAMMATORY COMBINATIONS - TOPICAL*** - DRUGS FOR THE SKIN ziclopro combination therapy pack 1 or 1b* *ANTINEOPLASTIC ALKYLATING AGENTS - TOPICAL*** - DRUGS FOR THE SKIN VALCHLOR EXTERNAL GEL (mechlorethamine hcl (topical)) 3 PA; LD; QL (1 tube per 30 days) *ANTINEOPLASTIC ANTIMETABOLITES - TOPICAL*** - DRUGS FOR THE SKIN CARAC EXTERNAL CREAM (fluorouracil) 3 ST; QL (30 gm per 365 days) EFUDEX EXTERNAL CREAM (fluorouracil) 3 ST; QL (40 gm per 365 days) FLUOROPLEX EXTERNAL CREAM (fluorouracil) 3 ST; QL (60 gm per 365 days) fluorouracil external cream 0.5 % 1 or 1b* ST; QL (30 gm per 365 days) fluorouracil external cream 5 % 1 or 1b* QL (40 gm per 365 days) fluorouracil external solution 1 or 1b* QL (10 mL per 365 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 107 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTINEOPLASTIC RETINOIDS - TOPICAL*** - DRUGS FOR THE SKIN PANRETIN EXTERNAL GEL (alitretinoin) 3 SP *ANTIPRURITICS - TOPICAL*** - DRUGS FOR THE SKIN doxepin hcl external cream 1 or 1b* PA; QL (1 tube per 1 fill) *ANTIPSORIATICS - SYSTEMIC*** - DRUGS FOR THE SKIN acitretin oral capsule 1 or 1b* COSENTYX (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED PA; LD; SP; QL (2 syringes per 28 4 SYRINGE (secukinumab) days) COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS SOLUTION PA; LD; SP; QL (2 pens per 28 4 AUTO-INJECTOR (secukinumab) days) COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO- 4 PA; LD; SP; QL (1 pen per 28 days) INJECTOR (secukinumab) COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; SP; QL (1 syringe per 28 4 (secukinumab) days) methoxsalen rapid oral capsule 1 or 1b*; OC SP SKYRIZI (150 MG DOSE) SUBCUTANEOUS PREFILLED SYRINGE KIT 4 PA; SP; QL (2 syringes per 84 days) (risankizumab-rzaa) SKYRIZI PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 4 PA; SP; QL (1 carton per 84 days) (risankizumab-rzaa) SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (1 carton per 84 days) (risankizumab-rzaa) SORIATANE ORAL CAPSULE (acitretin) 3 STELARA SUBCUTANEOUS SOLUTION (ustekinumab) 4 PA; SP; QL (1 vial per 84 days) STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (1 syringe per 84 days) (ustekinumab) PA; SP; QL (1 autoinjector per 56 TREMFYA SUBCUTANEOUS SOLUTION PEN-INJECTOR (guselkumab) 4 days) TREMFYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (1 syringe per 47 days) (guselkumab) *ANTIPSORIATICS*** - DRUGS FOR THE SKIN calcipotriene external cream 1 or 1b* QL (120 grams per 30 days) calcipotriene external foam 1 or 1b* QL (120 grams per 30 days) calcipotriene external ointment 1 or 1b* QL (120 grams per 30 days) calcipotriene external solution 1 or 1b* QL (60 mL per 30 days) calcitrene external ointment 1 or 1b* QL (120 grams per 30 days) calcitriol external ointment 1 or 1b* QL (800 grams per 28 days) DOVONEX EXTERNAL CREAM (calcipotriene) 3 QL (120 grams per 30 days) SORILUX EXTERNAL FOAM (calcipotriene) 3 QL (120 grams per 30 days) tazarotene external cream 1 or 1b* QL (30 grams per 30 days) TAZORAC EXTERNAL CREAM 0.05 % (tazarotene) 2 QL (30 grams per 30 days) TAZORAC EXTERNAL GEL 0.05 % (tazarotene) 2 QL (30 grams per 30 days) TAZORAC EXTERNAL GEL 0.1 % (tazarotene) 2 QL (1 gram per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 108 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTISEBORRHEIC COMBINATIONS*** - DRUGS FOR THE SKIN PROMISEB EXTERNAL CREAM (antiseborrheic products, misc.) 3 SODIUM SULFACETAMIDE-BAKUCHIOL EXTERNAL LIQUID 3 *ANTISEBORRHEIC PRODUCTS*** - DRUGS FOR THE SKIN selenium sulfide external lotion 1 or 1a* QL (120 mL per 30 days) *ANTIVIRAL TOPICAL COMBINATIONS*** - DRUGS FOR THE SKIN XERESE EXTERNAL CREAM (acyclovir-hydrocortisone) 3 PA; QL (5 gm per 30 days) *ANTIVIRALS - TOPICAL*** - DRUGS FOR THE SKIN acyclovir external cream 1 or 1b* PA; QL (5 gm per 30 days) acyclovir external ointment 1 or 1b* QL (30 gm per 30 days) DENAVIR EXTERNAL CREAM (penciclovir) 3 PA; QL (5 gm per 30 days) ZOVIRAX EXTERNAL OINTMENT (acyclovir) 3 QL (30 gm per 30 days) *ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES*** - DRUGS FOR THE SKIN DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR (dupilumab) 4 SP; QL (2 syringes per 28 days) DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 SP; QL (2 syringes per 28 days) (dupilumab) *BURN PRODUCTS*** - DRUGS FOR THE SKIN mafenide acetate external packet 1 or 1b* SILVADENE EXTERNAL CREAM (silver sulfadiazine) 3 silver sulfadiazine external cream 1 or 1a* ssd external cream 1 or 1a* SULFAMYLON EXTERNAL CREAM (mafenide acetate) 3 SULFAMYLON EXTERNAL PACKET (mafenide acetate) 3 *CORTICOSTEROIDS - TOPICAL*** - DRUGS FOR THE SKIN ala-cort external cream 1 or 1a* QL (454 grams per 30 days) alclometasone dipropionate external cream 1 or 1b* QL (60 grams per 30 days) alclometasone dipropionate external ointment 1 or 1b* QL (2 grams per 1 day) amcinonide external cream 3 ST; QL (60 grams per 30 days) amcinonide external lotion 3 ST; QL (60 mL per 30 days) beser external lotion 1 or 1b* QL (120 mL per 30 days) betamethasone dipropionate aug external cream 1 or 1b* QL (50 grams per 30 days) betamethasone dipropionate aug external gel 1 or 1b* QL (50 grams per 30 days) betamethasone dipropionate aug external lotion 1 or 1b* QL (60 mL per 30 days) betamethasone dipropionate aug external ointment 1 or 1b* QL (50 grams per 30 days) betamethasone dipropionate external cream 1 or 1b* QL (45 grams per 30 days) betamethasone dipropionate external lotion 1 or 1b* QL (60 mL per 30 days) betamethasone dipropionate external ointment 1 or 1b* QL (45 grams per 30 days) betamethasone valerate external cream 1 or 1b* QL (45 grams per 30 days) betamethasone valerate external foam 3 ST; QL (100 grams per 30 days) betamethasone valerate external lotion 1 or 1b* ST; QL (60 mL per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 109 Coverage Requirements and Prescription Drug Name Drug Tier Limits betamethasone valerate external ointment 1 or 1b* QL (45 grams per 30 days) clobetasol prop emollient base external cream 1 or 1b* QL (60 grams per 30 days) clobetasol propionate e external cream 1 or 1b* QL (60 grams per 30 days) clobetasol propionate emulsion external foam 1 or 1b* QL (100 grams per 30 days) clobetasol propionate external cream 1 or 1b* QL (60 grams per 30 days) clobetasol propionate external foam 1 or 1b* QL (100 mL per 30 days) clobetasol propionate external gel 1 or 1b* QL (60 grams per 30 days) clobetasol propionate external liquid 1 or 1b* QL (125 mL per 30 days) clobetasol propionate external lotion 1 or 1b* QL (118 mL per 30 days) clobetasol propionate external ointment 1 or 1b* QL (60 grams per 30 days) clobetasol propionate external shampoo 1 or 1b* QL (3.94 mL per 1 day) clobetasol propionate external solution 1 or 1b* QL (50 mL per 30 days) clocortolone pivalate external cream 3 ST; QL (90 grams per 30 days) clodan external shampoo 1 or 1b* QL (3.94 mL per 1 day) desonide external cream 1 or 1b* QL (60 grams per 30 days) desonide external gel 1 or 1b* QL (2 grams per 1 day) desonide external lotion 1 or 1b* QL (118 mL per 30 days) desonide external ointment 1 or 1b* QL (60 grams per 30 days) desoximetasone external cream 3 ST; QL (100 grams per 30 days) desoximetasone external gel 3 ST; QL (60 grams per 30 days) desoximetasone external liquid 3 ST; QL (100 mL per 30 days) desoximetasone external ointment 3 ST; QL (100 grams per 30 days) desrx external gel 1 or 1b* QL (2 grams per 1 day) diflorasone diacetate external cream 3 ST; QL (60 grams per 30 days) diflorasone diacetate external ointment 3 ST; QL (60 grams per 30 days) fluocinolone acetonide body external oil 1 or 1b* ST; QL (120 mL per 30 days) fluocinolone acetonide external cream 0.01 % 1 or 1b* QL (60 grams per 30 days) fluocinolone acetonide external cream 0.025 % 1 or 1b* QL (120 grams per 30 days) fluocinolone acetonide external ointment 1 or 1b* QL (120 grams per 30 days) fluocinolone acetonide external solution 1 or 1b* QL (90 mL per 30 days) fluocinolone acetonide scalp external oil 1 or 1b* QL (120 mL per 30 days) fluocinonide emulsified base external cream 1 or 1b* QL (60 grams per 30 days) fluocinonide external cream 1 or 1b* QL (120 grams per 30 days) fluocinonide external gel 1 or 1b* QL (60 grams per 30 days) fluocinonide external ointment 1 or 1b* QL (60 grams per 30 days) fluocinonide external solution 1 or 1b* QL (60 mL per 30 days) flurandrenolide external cream 3 ST; QL (120 grams per 30 days) flurandrenolide external lotion 3 ST; QL (120 mL per 30 days) flurandrenolide external ointment 3 ST; QL (60 grams per 30 days) fluticasone propionate external cream 1 or 1b* QL (60 grams per 30 days) fluticasone propionate external lotion 1 or 1b* QL (120 mL per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 110 Coverage Requirements and Prescription Drug Name Drug Tier Limits fluticasone propionate external ointment 1 or 1b* QL (60 grams per 30 days) halcinonide external cream 3 ST; QL (60 grams per 30 days) halobetasol propionate external cream 1 or 1b* QL (50 grams per 30 days) halobetasol propionate external ointment 1 or 1b* QL (50 grams per 30 days) hydrocortisone butyr lipo base external cream 3 ST; QL (60 grams per 30 days) hydrocortisone butyrate external cream 3 ST; QL (60 grams per 30 days) hydrocortisone butyrate external lotion 3 ST; QL (3.94 mL per 1 day) hydrocortisone butyrate external ointment 3 ST; QL (60 grams per 30 days) hydrocortisone butyrate external solution 3 ST; QL (60 mL per 30 days) hydrocortisone external cream 1 %, 2.5 % 1 or 1a* QL (454 grams per 30 days) hydrocortisone external lotion 2.5 % 1 or 1a* QL (118 mL per 30 days) hydrocortisone external ointment 1 %, 2.5 % 1 or 1a* QL (454 grams per 30 days) hydrocortisone valerate external cream 3 ST; QL (60 grams per 30 days) hydrocortisone valerate external ointment 3 ST; QL (60 grams per 30 days) mometasone furoate external cream 1 or 1b* QL (50 grams per 30 days) mometasone furoate external ointment 1 or 1b* QL (50 grams per 30 days) mometasone furoate external solution 1 or 1b* QL (60 mL per 30 days) nolix external lotion 3 ST; QL (120 mL per 30 days) prednicarbate external ointment 1 or 1b* QL (60 grams per 30 days) tovet external foam 1 or 1b* QL (100 grams per 30 days) triamcinolone acetonide external aerosol solution 3 ST; QL (100 grams per 30 days) triamcinolone acetonide external cream 1 or 1a* QL (454 grams per 30 days) triamcinolone acetonide external lotion 1 or 1a* QL (60 mL per 30 days) triamcinolone acetonide external ointment 0.025 %, 0.1 % 1 or 1a* QL (454 grams per 30 days) triamcinolone acetonide external ointment 0.05 % 3 ST; QL (430 grams per 30 days) triamcinolone acetonide external ointment 0.5 % 1 or 1a* QL (30 grams per 30 days) triderm external cream 1 or 1a* QL (454 grams per 30 days) tritocin external ointment 3 QL (430 grams per 30 days) *DEPIGMENTING AGENTS*** - DRUGS FOR THE SKIN blanche external cream 1 or 1b* *DEPIGMENTING COMBINATIONS*** - DRUGS FOR THE SKIN TRI-LUMA EXTERNAL CREAM (fluocin-hydroquinone-tretinoin) 3 *EMOLLIENT COMBINATIONS*** - DRUGS FOR THE SKIN LACTIC ACID E EXTERNAL CREAM 3 *EMOLLIENT/KERATOLYTIC AGENTS*** - DRUGS FOR THE SKIN CEROVEL EXTERNAL LOTION (urea) 3 *EMOLLIENTS*** - DRUGS FOR THE SKIN ammonium lactate external cream 1 or 1b* QL (450 grams per 30 days) ammonium lactate external lotion 1 or 1b* LACTIC ACID EXTERNAL LOTION 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 111 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ENZYMES - TOPICAL*** - DRUGS FOR THE SKIN SANTYL EXTERNAL OINTMENT (collagenase) 3 QL (30 grams per 30 days) *GLABELLAR LINES (FROWN LINES) AGENTS*** - DRUGS FOR THE SKIN BOTOX COSMETIC INTRAMUSCULAR SOLUTION RECONSTITUTED 4 PA (onabotulinumtoxina (cosmetic)) *IMIDAZOLE-RELATED ANTIFUNGALS - TOPICAL*** - DRUGS FOR THE SKIN clotrimazole external cream 1 or 1b* QL (1 gram per 1 day) clotrimazole external solution 1 or 1b* QL (60 mL per 30 days) econazole nitrate external cream 1 or 1b* QL (85 grams per 30 days) ECOZA EXTERNAL FOAM (econazole nitrate) 3 ST; QL (70 grams per 30 days) ERTACZO EXTERNAL CREAM (sertaconazole nitrate) 3 ST; QL (60 grams per 30 days) EXELDERM EXTERNAL CREAM (sulconazole nitrate) 3 ST; QL (60 grams per 30 days) EXELDERM EXTERNAL SOLUTION (sulconazole nitrate) 3 ST; QL (60 mL per 30 days) EXTINA EXTERNAL FOAM (ketoconazole) 3 QL (100 grams per 30 days) JUBLIA EXTERNAL SOLUTION (efinaconazole) 3 QL (4 mL per 1 day) ketoconazole external cream 1 or 1b* QL (120 grams per 30 days) ketoconazole external foam 1 or 1b* QL (100 grams per 30 days) ketoconazole external shampoo 1 or 1b* QL (120 mL per 30 days) luliconazole external cream 1 or 1b* ST; QL (60 grams per 30 days) LUZU EXTERNAL CREAM (luliconazole) 3 ST; QL (60 grams per 30 days) oxiconazole nitrate external cream 1 or 1b* QL (60 grams per 30 days) OXISTAT EXTERNAL CREAM (oxiconazole nitrate) 3 ST; QL (60 grams per 30 days) OXISTAT EXTERNAL LOTION (oxiconazole nitrate) 3 ST; QL (60 mL per 30 days) sulconazole nitrate external cream 1 or 1b* ST; QL (60 grams per 30 days) sulconazole nitrate external solution 1 or 1b* ST; QL (60 mL per 30 days) XOLEGEL EXTERNAL GEL (ketoconazole) 3 QL (45 grams per 30 days) *IMMUNOMODULATORS IMIDAZOQUINOLINAMINES - TOPICAL*** - DRUGS FOR THE SKIN ALDARA EXTERNAL CREAM (imiquimod) 3 ST; QL (48 packet per 365 days) imiquimod external cream 3.75 % 1 or 1b* ST; QL (28 units per 28 days) imiquimod external cream 5 % 1 or 1b* QL (48 packet per 365 days) imiquimod pump external cream 1 or 1b* ST; QL (1 pump bottle per 28 days) ZYCLARA EXTERNAL CREAM (imiquimod) 3 ST; QL (28 units per 28 days) ZYCLARA PUMP EXTERNAL CREAM 2.5 % (imiquimod) 3 ST; QL (1 pump bottle per 28 days) ZYCLARA PUMP EXTERNAL CREAM 3.75 % (imiquimod) 3 ST; QL (1 bottle per 28 days) *KERATOLYTIC/ANTIMITOTIC AGENTS*** - DRUGS FOR THE SKIN ACNESIC EXTERNAL GEL (salicylic acid) 3 CONDYLOX EXTERNAL GEL (podofilox) 3 podofilox external solution 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 112 Coverage Requirements and Prescription Drug Name Drug Tier Limits *LOCAL ANESTHETICS - TOPICAL*** - DRUGS FOR THE SKIN glydo external prefilled syringe 1 or 1b* lidocaine external ointment 5 % 1 or 1b* QL (5 grams per 1 day) lidocaine external patch 5 % 1 or 1b* PA; QL (3 patches per 1 day) lidocaine hcl external solution 1 or 1b* QL (10 mL per 1 day) lidocaine hcl urethral/mucosal external gel 1 or 1b* lidocaine hcl urethral/mucosal external prefilled syringe 1 or 1b* QUTENZA (4 PATCH) EXTERNAL KIT (capsaicin-cleansing gel) 3 LD *MACROLIDE IMMUNOSUPPRESSANTS - TOPICAL*** - DRUGS FOR THE SKIN pimecrolimus external cream 1 or 1b* ST; QL (100 grams per 90 days) tacrolimus external ointment 1 or 1b* ST; QL (100 grams per 90 days) *MELANOCORTIN RECEPTOR AGONISTS (UV PROTECTIVE)*** - DRUGS FOR THE SKIN PA; LD; QL (1 implant per 2 SCENESSE SUBCUTANEOUS IMPLANT (afamelanotide acetate) 3 monthss) *MICROTUBULE INHIBITORS - TOPICAL*** - DRUGS FOR THE SKIN KLISYRI EXTERNAL OINTMENT (tirbanibulin) 3 ST; QL (5 packets per 1 fill) *MISC. DERMATOLOGICAL PRODUCTS*** - DRUGS FOR THE SKIN ILIDERM EXTERNAL EMULSION 3 *MISC. TOPICAL*** - DRUGS FOR THE SKIN BORIC ACID EXTERNAL GRANULES 3 QBREXZA EXTERNAL PAD (glycopyrronium tosylate) 3 PA; QL (1 cloth per 1 day) *ORNITHINE DECARBOXYLASE (ODC) INHIBITORS - TOPICAL*** - DRUGS FOR THE SKIN VANIQA EXTERNAL CREAM (eflornithine hcl) 3 *OXABOROLE-RELATED ANTIFUNGALS - TOPICAL*** - DRUGS FOR THE SKIN tavaborole external solution 1 or 1b* ST; QL (1 bottle per 30 days) *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL*** - DRUGS FOR THE SKIN EUCRISA EXTERNAL OINTMENT (crisaborole) 3 ST; QL (100 grams per 30 days) *PHOTODYNAMIC THERAPY AGENTS - TOPICAL*** - DRUGS FOR THE SKIN AMELUZ EXTERNAL GEL (aminolevulinic acid hcl) 3 LEVULAN KERASTICK EXTERNAL SOLUTION RECONSTITUTED 3 (aminolevulinic acid hcl) *PROSTAGLANDINS - TOPICAL*** - DRUGS FOR THE SKIN bimatoprost external solution 1 or 1b* LATISSE EXTERNAL SOLUTION (bimatoprost) 3 *ROSACEA AGENTS*** - DRUGS FOR THE SKIN azelaic acid external gel 1 or 1b* QL (50 grams per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 113 Coverage Requirements and Prescription Drug Name Drug Tier Limits FINACEA EXTERNAL FOAM (azelaic acid) 2 QL (1.67 grams per 1 day) ivermectin external cream 1 or 1b* QL (45 grams per 30 days) METROCREAM EXTERNAL CREAM (metronidazole) 3 ST; QL (45 grams per 30 days) metronidazole external cream 1 or 1b* QL (45 grams per 30 days) metronidazole external gel 0.75 % 1 or 1b* QL (45 grams per 30 days) metronidazole external gel 1 % 1 or 1b* QL (55 grams per 30 days) metronidazole external lotion 1 or 1b* QL (59 mL per 30 days) MIRVASO EXTERNAL GEL (brimonidine tartrate) 3 QL (30 grams per 30 days) NORITATE EXTERNAL CREAM (metronidazole) 3 ST; QL (60 grams per 30 days) RHOFADE EXTERNAL CREAM (oxymetazoline hcl) 3 QL (60 grams per 30 days) rosadan external cream 1 or 1b* QL (45 grams per 30 days) rosadan external gel 1 or 1b* QL (45 grams per 30 days) SOOLANTRA EXTERNAL CREAM (ivermectin) 2 QL (45 grams per 30 days) ZILXI EXTERNAL FOAM (minocycline hcl micronized) 3 ST; QL (1 gram per 1 day) *SCABICIDES & PEDICULICIDES*** - DRUGS FOR THE SKIN crotan external lotion 1 or 1b* QL (60 mL per 30 days) ivermectin external lotion 1 or 1b* QL (120 grams per 30 days) lindane external shampoo 1 or 1b* QL (60 mL per 30 days) malathion external lotion 1 or 1b* QL (4 mL per 1 day) NATROBA EXTERNAL SUSPENSION (spinosad) 3 QL (120 mL per 7 days) OVIDE EXTERNAL LOTION (malathion) 3 QL (4 mL per 1 day) permethrin external cream 1 or 1b* QL (120 grams per 30 days) spinosad external suspension 1 or 1b* QL (120 mL per 7 days) SULFURATED LIME EXTERNAL SOLUTION 3 *SEBORRHEIC KERATOSIS PRODUCTS** - DRUGS FOR THE SKIN ESKATA EXTERNAL SOLUTION (hydrogen peroxide) 3 *STEROID-LOCAL ANESTHETIC COMBINATIONS*** - DRUGS FOR THE SKIN EPIFOAM EXTERNAL FOAM (pramoxine-hc) 3 PRAMOSONE EXTERNAL CREAM 1-1 % (pramoxine-hc) 2 PRAMOSONE EXTERNAL LOTION (pramoxine-hc) 2 *TAR PRODUCTS*** - DRUGS FOR THE SKIN coal tar external solution 1 or 1b* *TISSUE REPLACEMENTS*** - DRUGS FOR THE SKIN AFFINITY EXTERNAL SHEET (amniotic membrane allograft) 3 AMNIOFIX INJECTION SUSPENSION RECONSTITUTED (amniotic 3 membrane allograft) AMNIOTEXT EXTERNAL SHEET (amniotic membrane allograft) 3 AMPHENOL-40 INJECTION SUSPENSION RECONSTITUTED 3 APLIGRAF EXTERNAL DISK (cultured skin substitute) 3 BIOVANCE EXTERNAL SHEET (amniotic membrane allograft) 3 EPICORD EXTERNAL SHEET (umbilical cord allograft) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 114 Coverage Requirements and Prescription Drug Name Drug Tier Limits EPIFIX EXTERNAL DISK (amniotic membrane allograft) 3 EPIFIX EXTERNAL SHEET (amniotic membrane allograft) 3 EPIFIX MICRONIZED INJECTION SUSPENSION RECONSTITUTED 3 (amniotic membrane allograft) KARDIAMEMBRANE EXTERNAL SHEET (amniotic membrane allograft) 3 NEOX 100 EXTERNAL SHEET (amniotic membrane allograft) 3 NEOX CORD 1K EXTERNAL SHEET (amniotic membrane allograft) 3 NOVACHOR EXTERNAL SHEET (chorion membrane allograft) 3 NUSHIELD EXTERNAL DISK (amniotic membrane allograft) 3 NUSHIELD EXTERNAL SHEET 2 CM X 4 CM , 4 CM X 3 CM , 4 CM X 4 3 CM , 4 CM X 6 CM , 6 CM X 6 CM (amniotic membrane allograft) PALINGEN FLOW INJECTION INJECTABLE (amniotic memb-fluid 3 allograft) PALINGEN HYDROMEMBRANE EXTERNAL SHEET (amniotic 3 membrane allograft) PALINGEN INOVOFLO INJECTION INJECTABLE (amniotic fluid 3 allograft) PALINGEN MEMBRANE EXTERNAL SHEET (amniotic membrane 3 allograft) PALINGEN XPLUS HYDROMEMBRANE EXTERNAL SHEET (amniotic 3 membrane allograft) PALINGEN XPLUS MEMBRANE EXTERNAL SHEET (amniotic 3 membrane allograft) STRAVIX EXTERNAL SHEET (amniotic membrane allograft) 3 TRUSKIN EXTERNAL SHEET (skin allograft (human)) 3 *TOPICAL ANESTHETIC COMBINATIONS*** - DRUGS FOR THE SKIN CETACAINE EXTERNAL GEL (butamben-tetracaine-benzocaine) 3 FLEXIN EXTERNAL PATCH 3 lidocaine-prilocaine external kit 1 or 1b* QL (1 kit per 30 days) PRILO PATCH II EXTERNAL KIT (lidocaine-prilocaine) 3 REAL HEAL-I EXTERNAL KIT (lidocaine-prilocaine-dressing) 3 VENIPUNCTURE PX1 PHLEBOTOMY EXTERNAL KIT (lidocaine hcl- 3 blood collection) *TOPICAL ANESTHETIC GASES*** - DRUGS FOR THE SKIN CRYODOSE TA EXTERNAL AEROSOL (pentafluoroprop-tetrafluoroeth) 3 *TOPICAL SELECTIVE RETINOID X RECEPTOR AGONISTS*** - DRUGS FOR THE SKIN TARGRETIN EXTERNAL GEL (bexarotene) 2 PA; SP *TOPICAL STEROID COMBINATIONS*** - DRUGS FOR THE SKIN calcipotriene-betameth diprop external ointment 1 or 1b* ST; QL (400 grams per 28 days) calcipotriene-betameth diprop external suspension 1 or 1b* ST; QL (420 grams per 28 days) DUOBRII EXTERNAL LOTION (halobetasol prop-tazarotene) 3 PA; QL (200 grams per 30 days) ENSTILAR EXTERNAL FOAM (calcipotriene-betameth diprop) 3 QL (420 grams per 28 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 115 Coverage Requirements and Prescription Drug Name Drug Tier Limits TACLONEX EXTERNAL OINTMENT (calcipotriene-betameth diprop) 3 ST; QL (400 grams per 28 days) TACLONEX EXTERNAL SUSPENSION (calcipotriene-betameth diprop) 3 ST; QL (420 grams per 28 days) *TYPE II 5-ALPHA REDUCTASE INHIBITORS*** - DRUGS FOR THE SKIN finasteride oral tablet 1 mg 1 or 1b* PROPECIA ORAL TABLET (finasteride) 3 *WOUND CARE - GROWTH FACTOR AGENTS*** - DRUGS FOR THE SKIN REGRANEX EXTERNAL GEL (becaplermin) 3 *WOUND DRESSINGS*** - DRUGS FOR THE SKIN KENDALL HYDROGEL WOUND DRESS EXTERNAL (hydroactive 3 dressings) TEGADERM AG MESH EXTERNAL PAD 2"X2" (silver) 2 WOUNDGELHA MATRIX EXTERNAL GEL (hyaluronate sodium) 3 *DIGESTIVE AIDS* - DRUGS FOR THE STOMACH *DIGESTIVE ENZYMES*** - DRUGS FOR THE STOMACH CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 2 QL (25 capsules per 1 day) (pancrelipase (lip-prot-amyl)) PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500- 35500 UNIT, 16800-56800 UNIT, 21000-54700 UNIT, 2600-8800 UNIT, 3 ST; QL (25 capsules per 1 day) 4200-14200 UNIT (pancrelipase (lip-prot-amyl)) PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 3 ST; QL (25 capsules per 1 day) (pancrelipase (lip-prot-amyl)) SUCRAID ORAL SOLUTION (sacrosidase) 4 PA; LD; QL (4 bottles per 30 days) VIOKACE ORAL TABLET (pancrelipase (lip-prot-amyl)) 2 QL (25 tablets per 1 day) ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 2 QL (25 capsules per 1 day) (pancrelipase (lip-prot-amyl)) *DIURETICS* - DRUGS FOR THE HEART *CARBONIC ANHYDRASE INHIBITORS*** - DRUGS FOR HIGH BLOOD PRESSURE acetazolamide er oral capsule extended release 12 hour 1 or 1b* acetazolamide oral tablet 1 or 1b* acetazolamide sodium injection solution reconstituted 1 or 1b* KEVEYIS ORAL TABLET (dichlorphenamide) 4 PA; LD; QL (4 tablet per 1 day) methazolamide oral tablet 1 or 1b* *DIURETIC COMBINATIONS*** - DRUGS FOR HIGH BLOOD PRESSURE ALDACTAZIDE ORAL TABLET 25-25 MG (spironolactone-hctz) 3 ALDACTAZIDE ORAL TABLET 50-50 MG (spironolactone-hctz) 3 QL (4 tablets per 1 day) amiloride-hydrochlorothiazide oral tablet 1 or 1b* MAXZIDE ORAL TABLET (triamterene-hctz) 3 MAXZIDE-25 ORAL TABLET (triamterene-hctz) 3 spironolactone-hctz oral tablet 1 or 1b* triamterene-hctz oral capsule 1 or 1a*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 116 Coverage Requirements and Prescription Drug Name Drug Tier Limits triamterene-hctz oral tablet 1 or 1a* *LOOP DIURETICS*** - DRUGS FOR HIGH BLOOD PRESSURE bumetanide injection solution 1 or 1b* bumetanide oral tablet 1 or 1b* BUMEX ORAL TABLET (bumetanide) 3 EDECRIN ORAL TABLET (ethacrynic acid) 3 ethacrynate sodium intravenous solution reconstituted 1 or 1b* ethacrynic acid oral tablet 1 or 1b* FUROSEMIDE IN SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 furosemide injection solution 1 or 1a* furosemide oral solution 1 or 1a* furosemide oral tablet 1 or 1a* LASIX ORAL TABLET (furosemide) 3 SODIUM EDECRIN INTRAVENOUS SOLUTION RECONSTITUTED 3 (ethacrynate sodium) torsemide oral tablet 1 or 1b* *OSMOTIC DIURETICS*** - DRUGS FOR HIGH BLOOD PRESSURE mannitol intravenous solution 1 or 1b* osmitrol intravenous solution 1 or 1b* *POTASSIUM SPARING DIURETICS*** - DRUGS FOR HIGH BLOOD PRESSURE ALDACTONE ORAL TABLET 100 MG (spironolactone) 3 QL (4 tablets per 1 day) ALDACTONE ORAL TABLET 25 MG, 50 MG (spironolactone) 3 amiloride hcl oral tablet 1 or 1b* CAROSPIR ORAL SUSPENSION (spironolactone) 3 QL (20 mL per 1 day) spironolactone oral tablet 100 mg 1 or 1a* QL (4 tablets per 1 day) spironolactone oral tablet 25 mg, 50 mg 1 or 1a* triamterene oral capsule 1 or 1b* *THIAZIDES AND THIAZIDE-LIKE DIURETICS*** - DRUGS FOR HIGH BLOOD PRESSURE chlorothiazide sodium intravenous solution reconstituted 1 or 1b* chlorthalidone oral tablet 1 or 1a* DIURIL ORAL SUSPENSION (chlorothiazide) 3 hydrochlorothiazide oral capsule 1 or 1a* hydrochlorothiazide oral tablet 12.5 mg, 25 mg 1 or 1a* hydrochlorothiazide oral tablet 50 mg 1 or 1a* QL (2 tablets per 1 day) indapamide oral tablet 1 or 1b* metolazone oral tablet 1 or 1b* SODIUM DIURIL INTRAVENOUS SOLUTION RECONSTITUTED 3 (chlorothiazide sodium)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 117 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ENDOCRINE AND METABOLIC AGENTS - MISC.* - HORMONES *ABORTIFACIENT - PROGESTERONE RECEPTOR ANTAGONISTS*** - DRUGS FOR WOMEN MIFEPREX ORAL TABLET (mifepristone) 3 mifepristone oral tablet 1 or 1b* *ADENOSINE DEAMINASE SCID TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS REVCOVI INTRAMUSCULAR SOLUTION (elapegademase-lvlr) 4 PA; LD *BISPHOSPHONATES*** - DRUGS FOR MENOPAUSE AND BONE LOSS ACTONEL ORAL TABLET 150 MG (risedronate sodium) 3 QL (1 tablet per 30 days) ACTONEL ORAL TABLET 35 MG (risedronate sodium) 3 QL (4 tablets per 28 days) alendronate sodium oral solution 1 or 1b* QL (10.72 mg per 1 day) alendronate sodium oral tablet 10 mg, 5 mg 1 or 1b* QL (1 tablet per 1 day) alendronate sodium oral tablet 35 mg, 70 mg 1 or 1b* QL (4 tablets per 28 days) ATELVIA ORAL TABLET DELAYED RELEASE (risedronate sodium) 3 QL (4 tablets per 28 days) BINOSTO ORAL TABLET EFFERVESCENT (alendronate sodium) 3 QL (4 tablets per 28 days) BONIVA ORAL TABLET (ibandronate sodium) 3 ST; QL (1 tablet per 28 days) FOSAMAX ORAL TABLET (alendronate sodium) 3 QL (4 tablets per 28 days) FOSAMAX PLUS D ORAL TABLET (alendronate-cholecalciferol) 2 QL (4 tablets per 28 days) ibandronate sodium intravenous solution 1 or 1b* ibandronate sodium oral tablet 1 or 1b* QL (1 tablet per 28 days) pamidronate disodium intravenous solution 30 mg/10ml, 90 mg/10ml 4 SP PAMIDRONATE DISODIUM INTRAVENOUS SOLUTION 6 MG/ML 4 SP RECLAST INTRAVENOUS SOLUTION (zoledronic acid) 4 PA; SP; QL (100 mL per 375 days) risedronate sodium oral tablet 150 mg 1 or 1b* QL (1 tablet per 30 days) risedronate sodium oral tablet 30 mg, 5 mg 1 or 1b* QL (1 tablet per 1 day) risedronate sodium oral tablet 35 mg 1 or 1b* QL (4 tablets per 28 days) risedronate sodium oral tablet delayed release 1 or 1b* QL (4 tablets per 28 days) zoledronic acid intravenous concentrate 1 or 1b* PA; SP ZOLEDRONIC ACID INTRAVENOUS SOLUTION 4 MG/100ML 1 or 1b* PA; SP zoledronic acid intravenous solution 5 mg/100ml 4 PA; SP; QL (100 mL per 375 days) *CALCIMIMETIC AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS cinacalcet hcl oral tablet 30 mg, 60 mg 4 PA; QL (2 tablets per 1 day) cinacalcet hcl oral tablet 90 mg 4 PA; QL (4 tablets per 1 day) PARSABIV INTRAVENOUS SOLUTION (etelcalcetide hcl) 4 PA SENSIPAR ORAL TABLET 30 MG, 60 MG (cinacalcet hcl) 4 PA; QL (2 tablets per 1 day) SENSIPAR ORAL TABLET 90 MG (cinacalcet hcl) 4 PA; QL (4 tablets per 1 day) *CALCITONINS*** - DRUGS FOR MENOPAUSE AND BONE LOSS calcitonin (salmon) injection solution 4 calcitonin (salmon) nasal solution 1 or 1b* QL (1 bottle per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 118 Coverage Requirements and Prescription Drug Name Drug Tier Limits MIACALCIN INJECTION SOLUTION (calcitonin (salmon)) 4 *CARNITINE REPLENISHER - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS CARNITOR INTRAVENOUS SOLUTION (levocarnitine) 3 CARNITOR ORAL SOLUTION (levocarnitine) 3 CARNITOR ORAL TABLET (levocarnitine) 3 CARNITOR SF ORAL SOLUTION (levocarnitine) 3 levocarnitine oral solution 1 or 1b* levocarnitine oral tablet 1 or 1b* levocarnitine sf oral solution 1 or 1b* *CORTICOTROPIN*** - HORMONES ACTHAR INJECTION GEL (corticotropin) 4 PA; LD; SP *CORTISOL SYNTHESIS INHIBITORS*** - HORMONES ISTURISA ORAL TABLET 1 MG, 5 MG (osilodrostat phosphate) 4 PA; LD; QL (4 tablets per 1 day) ISTURISA ORAL TABLET 10 MG (osilodrostat phosphate) 4 PA; LD; QL (6 tablets per 1 day) *DOPAMINE RECEPTOR AGONISTS*** - DRUGS FOR WOMEN cabergoline oral tablet 1 or 1b* QL (16 tablets per 28 days) *FABRY DISEASE - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (agalsidase beta) PA; LD; QL (14 capsules per 30 GALAFOLD ORAL CAPSULE (migalastat hcl) 4 days) *GAA DEFICIENCY TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS LUMIZYME INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (alglucosidase alfa) *GNRH/LHRH ANTAGONISTS*** - DRUGS FOR WOMEN CETROTIDE SUBCUTANEOUS KIT (cetrorelix acetate) 4 PA; SP GANIRELIX ACETATE SUBCUTANEOUS SOLUTION PREFILLED 4 PA; SP SYRINGE ORILISSA ORAL TABLET 150 MG (elagolix sodium) 3 PA; QL (1 tablet per 1 day) ORILISSA ORAL TABLET 200 MG (elagolix sodium) 3 PA; QL (2 tablets per 1 day) *GROWTH HORMONE RECEPTOR ANTAGONISTS*** - DRUGS FOR GROWTH SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; SP; QL (1 vial per 1 day) (pegvisomant) *GROWTH HORMONE RELEASING HORMONES (GHRH)*** - DRUGS FOR GROWTH EGRIFTA SV SUBCUTANEOUS SOLUTION RECONSTITUTED PA; LD; QL (1 package per 30 4 (tesamorelin acetate) days) *GROWTH HORMONES*** - DRUGS FOR GROWTH GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION 4 PA; SP; QL (1 syringe per 1 day) RECONSTITUTED (somatropin)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 119 Coverage Requirements and Prescription Drug Name Drug Tier Limits GENOTROPIN SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; SP; QL (1 vial per 1 day) (somatropin) HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 5 MG, 4 PA; SP; QL (1 vial per 1 day) 6 MG (somatropin) HUMATROPE INJECTION SOLUTION RECONSTITUTED 24 MG 4 PA; SP; QL (1 injection per 1 day) (somatropin) SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG 4 PA; LD; QL (1 vial per 1 day) (somatropin (non-refrigerated)) SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 5 MG, 6 4 PA; LD; QL (1 solution per 1 day) MG (somatropin (non-refrigerated)) ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; SP; QL (1 injection per 1 day) (somatropin (non-refrigerated)) *HEREDITARY OROTIC ACIDURIA TREATMENT - AGENTS** - DRUGS FOR MENOPAUSE AND BONE LOSS XURIDEN ORAL PACKET (uridine triacetate) 3 PA; LD; QL (4 packets per 1 day) *HEREDITARY TYROSINEMIA TYPE 1 (HT-1) TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS nitisinone oral capsule 4 PA; SP NITYR ORAL TABLET (nitisinone) 4 PA; LD ORFADIN ORAL CAPSULE (nitisinone) 4 PA; LD ORFADIN ORAL SUSPENSION (nitisinone) 4 PA; LD *HOMOCYSTINURIA TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS CYSTADANE ORAL POWDER (betaine) 3 LD *HYPERAMMONEMIA TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS CARBAGLU ORAL TABLET (carglumic acid) 4 PA; LD *HYPERPARATHYROID TREATMENT - VITAMIN D ANALOGS*** - DRUGS FOR MENOPAUSE AND BONE LOSS calcitriol intravenous solution 1 or 1b* PA calcitriol oral capsule 1 or 1b* PA calcitriol oral solution 1 or 1b* PA doxercalciferol intravenous solution 1 or 1b* PA doxercalciferol oral capsule 1 or 1b* PA HECTOROL INTRAVENOUS SOLUTION (doxercalciferol) 3 PA paricalcitol intravenous solution 1 or 1b* PA paricalcitol oral capsule 1 or 1b* PA RAYALDEE ORAL CAPSULE EXTENDED RELEASE (calcifediol) 3 PA; QL (2 tablets per 1 day) ROCALTROL ORAL CAPSULE (calcitriol) 3 PA ROCALTROL ORAL SOLUTION (calcitriol) 3 PA ZEMPLAR INTRAVENOUS SOLUTION (paricalcitol) 3 PA ZEMPLAR ORAL CAPSULE (paricalcitol) 3 PA *HYPOPHOSPHATASIA (HPP) AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS STRENSIQ SUBCUTANEOUS SOLUTION (asfotase alfa) 4 PA; LD * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 120 Coverage Requirements and Prescription Drug Name Drug Tier Limits *INSULIN-LIKE GROWTH FACTOR-1 RECEPTOR INHIBITORS(IGF-1R)*** - DRUGS FOR THYROID TEPEZZA INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; QL (8 fills per 168 days) (teprotumumab-trbw) *INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)*** - HORMONES INCRELEX SUBCUTANEOUS SOLUTION (mecasermin) 4 PA; LD; SP *LEPTIN ANALOGUES*** - HORMONES MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD (metreleptin) *LHRH/GNRH AGONIST ANALOG COMBINATIONS*** - DRUGS FOR WOMEN LUPANETA PACK COMBINATION KIT 11.25 & 5 MG (leuprolide & 4 PA; SP; QL (1 kit per 84 days) norethindrone) LUPANETA PACK COMBINATION KIT 3.75 & 5 MG (leuprolide & 4 PA; SP; QL (1 kit per 28 days) norethindrone) *LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS*** - DRUGS FOR WOMEN FENSOLVI (6 MONTH) SUBCUTANEOUS KIT (leuprolide acetate (6 PA; LD; SP; QL (1 kit per 24 3 month)) weekss) LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 11.25 MG, 15 4 PA; SP; QL (1 kit per 28 days) MG (leuprolide acetate) LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 7.5 MG PA; SP; QL (1 syringe kit per 28 4 (leuprolide acetate) days) LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 11.25 MG 4 PA; SP; QL (1 kit per 12 weekss) (PED) (leuprolide acetate (3 month)) LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 30 MG (PED) 4 PA; SP; QL (1 kit per 84 days) (leuprolide acetate (3 month)) PA; LD; SP; QL (1 kit per 365 SUPPRELIN LA SUBCUTANEOUS KIT (histrelin acetate (cpp)) 4 days) SYNAREL NASAL SOLUTION (nafarelin acetate) 4 PA; SP; QL (5 bottle per 30 days) TRIPTODUR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 4 PA; LD; QL (1 vial per 168 days) (triptorelin pamoate) *LYSOSOMAL ACID LIPASE (LAL) DEFICIENCY - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS KANUMA INTRAVENOUS SOLUTION (sebelipase alfa) 3 PA; LD; SP *MOLYBDENUM COFACTOR DEFICIENCY (MOCD) - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS NULIBRY INTRAVENOUS SOLUTION RECONSTITUTED (fosdenopterin 4 LD hydrobromide) *MUCOPOLYSACCHARIDOSIS I (MPS I) - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS ALDURAZYME INTRAVENOUS SOLUTION (laronidase) 4 PA; LD; SP *MUCOPOLYSACCHARIDOSIS II (MPS II) - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS ELAPRASE INTRAVENOUS SOLUTION (idursulfase) 4 PA; LD; SP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 121 Coverage Requirements and Prescription Drug Name Drug Tier Limits *MUCOPOLYSACCHARIDOSIS IV (MPS IV) - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS VIMIZIM INTRAVENOUS SOLUTION (elosulfase alfa) 4 PA; LD; SP *MUCOPOLYSACCHARIDOSIS VI (MPS VI) - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS NAGLAZYME INTRAVENOUS SOLUTION (galsulfase) 4 PA; LD; SP *MUCOPOLYSACCHARIDOSIS VII (MPS VII) - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS MEPSEVII INTRAVENOUS SOLUTION (vestronidase alfa-vjbk) 4 PA; LD *OVULATION STIMULANTS-GONADOTROPINS*** - DRUGS FOR WOMEN CHORIONIC GONADOTROPIN INTRAMUSCULAR SOLUTION 4 PA; SP RECONSTITUTED GONAL-F INJECTION SOLUTION RECONSTITUTED (follitropin alfa) 4 PA; SP GONAL-F RFF REDIJECT SUBCUTANEOUS SOLUTION (follitropin alfa) 4 PA; SP GONAL-F RFF SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; SP (follitropin alfa) MENOPUR SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; SP (menotropins) NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED (chorionic 4 PA; SP gonadotropin) OVIDREL SUBCUTANEOUS INJECTABLE (choriogonadotropin alfa) 4 PA; SP PREGNYL INTRAMUSCULAR SOLUTION RECONSTITUTED (chorionic 4 PA; SP gonadotropin) *OVULATION STIMULANTS-SYNTHETIC*** - DRUGS FOR WOMEN clomiphene citrate oral tablet 1 or 1b* PA *PARATHYROID HORMONE AND DERIVATIVES*** - DRUGS FOR MENOPAUSE AND BONE LOSS FORTEO SUBCUTANEOUS SOLUTION PEN-INJECTOR (teriparatide 4 SP; QL (1 pen per 28 days) (recombinant)) NATPARA SUBCUTANEOUS CARTRIDGE (parathyroid hormone PA; LD; SP; QL (2 cartridge per 30 3 (recomb)) days) TERIPARATIDE (RECOMBINANT) SUBCUTANEOUS SOLUTION PEN- 4 PA; SP; QL (1 pen per 28 days) INJECTOR *PHENYLKETONURIA TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS KUVAN ORAL PACKET (sapropterin dihydrochloride) 4 PA; LD; SP KUVAN ORAL TABLET (sapropterin dihydrochloride) 4 PA; LD; SP PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10 4 PA; LD; SP MG/0.5ML, 2.5 MG/0.5ML (pegvaliase-pqpz) PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 PA; LD; SP; QL (1 syringe per 1 4 MG/ML (pegvaliase-pqpz) day) sapropterin dihydrochloride oral packet 4 PA; SP sapropterin dihydrochloride oral tablet 4 PA; SP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 122 Coverage Requirements and Prescription Drug Name Drug Tier Limits *RANK LIGAND (RANKL) INHIBITORS*** - DRUGS FOR MENOPAUSE AND BONE LOSS PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP; QL (2 injections per 365 3 (denosumab) days) XGEVA SUBCUTANEOUS SOLUTION (denosumab) 3 PA; SP; QL (1 vial per 28 days) *SCLEROSTIN INHIBITORS*** - DRUGS FOR MENOPAUSE AND BONE LOSS EVENITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (2 syringes per 30 days) (romosozumab-aqqg) *SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)*** - DRUGS FOR MENOPAUSE AND BONE LOSS EVISTA ORAL TABLET (raloxifene hcl) 3; $0 OSPHENA ORAL TABLET (ospemifene) 3 PA; QL (1 tablet per 1 day) raloxifene hcl oral tablet 1 or 1b*; $0 *SELECTIVE VASOPRESSIN V2-RECEPTOR ANTAGONISTS*** - HORMONES JYNARQUE ORAL TABLET (tolvaptan) 4 PA; LD; QL (4 tablets per 1 day) JYNARQUE ORAL TABLET THERAPY PACK (tolvaptan) 4 PA; LD; QL (1 carton per 28 days) SAMSCA ORAL TABLET 15 MG (tolvaptan) 3 PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (2 tablets per 1 SAMSCA ORAL TABLET 30 MG (tolvaptan) 3 day) tolvaptan oral tablet 15 mg 1 or 1b* PA; QL (1 tablet per 1 day) tolvaptan oral tablet 30 mg 1 or 1b* PA; QL (2 tablets per 1 day) *SOMATOSTATIC AGENTS*** - DRUGS FOR GROWTH MYCAPSSA ORAL CAPSULE DELAYED RELEASE (octreotide acetate) 4 PA; LD; QL (4 capsules per 1 day) octreotide acetate injection solution 4 PA; SP SANDOSTATIN INJECTION SOLUTION (octreotide acetate) 4 PA; SP SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 30 MG 4 PA; SP; QL (1 kit per 28 days) (octreotide acetate) SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 20 MG (octreotide 4 PA; SP; QL (2 kits per 28 days) acetate) SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 4 PA; LD; QL (1 kit per 28 days) (pasireotide pamoate) SIGNIFOR SUBCUTANEOUS SOLUTION (pasireotide diaspartate) 4 PA; LD; QL (2 mL per 1 day) PA; LD; SP; QL (1 syringe/vial per SOMATULINE DEPOT SUBCUTANEOUS SOLUTION (lanreotide acetate) 4 28 days) *UREA CYCLE DISORDER - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS AMMONUL INTRAVENOUS SOLUTION (sod benz-sod phenylacet) 3 BUPHENYL ORAL POWDER (sodium phenylbutyrate) 3 PA; LD; QL (25 GM per 1 day) BUPHENYL ORAL TABLET (sodium phenylbutyrate) 3 PA; LD; QL (40 tablets per 1 day) CITRULLINE EASY ORAL TABLET EXTENDED RELEASE 3 PA; LD; SP; QL (17.5 mL per 1 RAVICTI ORAL LIQUID (glycerol phenylbutyrate) 3 day) sod benz-sod phenylacet intravenous solution 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 123 Coverage Requirements and Prescription Drug Name Drug Tier Limits sodium phenylbutyrate oral powder 1 or 1b* PA; QL (25 GM per 1 day) sodium phenylbutyrate oral tablet 1 or 1b* PA; QL (40 tablets per 1 day) *V1A/V2-ARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTS*** - HORMONES VAPRISOL INTRAVENOUS SOLUTION (conivaptan hcl in dextrose) 3 *VASOPRESSIN*** - HORMONES DDAVP INJECTION SOLUTION (desmopressin acetate) 3 DDAVP ORAL TABLET 0.1 MG (desmopressin acetate) 3 DDAVP ORAL TABLET 0.2 MG (desmopressin acetate) 3 QL (6 tablets per 1 day) DDAVP PF INJECTION SOLUTION (desmopressin acetate) 3 desmopressin ace spray refrig nasal solution 1 or 1b* desmopressin acetate injection solution 1 or 1b* desmopressin acetate oral tablet 0.1 mg 1 or 1b* desmopressin acetate oral tablet 0.2 mg 1 or 1b* QL (6 tablets per 1 day) desmopressin acetate pf injection solution 1 or 1b* desmopressin acetate spray nasal solution 1 or 1b* NOCDURNA SUBLINGUAL TABLET SUBLINGUAL (desmopressin 4 PA; QL (1 tablet per 1 day) acetate) STIMATE NASAL SOLUTION (desmopressin acetate) 3 PA; QL (5 mL per 30 days) VASOSTRICT INTRAVENOUS SOLUTION (vasopressin) 3 *X-LINKED HYPOPHOSPHATEMIA (XLH) TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS CRYSVITA SUBCUTANEOUS SOLUTION (burosumab-twza) 4 PA; LD; SP *ESTROGENS* - HORMONES *ESTROGEN & ANDROGEN*** - DRUGS FOR WOMEN est estrogens-methyltest oral tablet 0.625-1.25 mg 1 or 1b* *ESTROGEN & PROGESTIN*** - DRUGS FOR WOMEN ACTIVELLA ORAL TABLET (estradiol-norethindrone acet) 3 amabelz oral tablet 1 or 1b* ANGELIQ ORAL TABLET (drospirenone-estradiol) 3 BIJUVA ORAL CAPSULE (estradiol-progesterone) 2 QL (1 capsule per 1 day) CLIMARA PRO TRANSDERMAL PATCH WEEKLY (estradiol- 2 QL (4 patch per 28 days) levonorgestrel) COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY (estradiol- 2 QL (8 patch per 28 days) norethindrone acet) estradiol-norethindrone acet oral tablet 1 or 1b* FEMHRT ORAL TABLET (norethindrone-eth estradiol) 3 fyavolv oral tablet 1 or 1b* jinteli oral tablet 1 or 1b* mimvey oral tablet 1 or 1b* norethindrone-eth estradiol oral tablet 1 or 1b* PREFEST ORAL TABLET (estradiol-norgestimate) 3 PREMPHASE ORAL TABLET (conj estrog-medroxyprogest ace) 2 * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 124 Coverage Requirements and Prescription Drug Name Drug Tier Limits PREMPRO ORAL TABLET (conj estrog-medroxyprogest ace) 2 *ESTROGEN-PROGESTIN-GNRH ANTAGONIST*** - DRUGS FOR WOMAN ORIAHNN ORAL CAPSULE THERAPY PACK (elagolix-estradiol- 3 PA; QL (1 carton per 28 days) norethind) *ESTROGENS*** - DRUGS FOR WOMEN ALORA TRANSDERMAL PATCH TWICE WEEKLY (estradiol) 3 QL (8 patch per 28 days) CLIMARA TRANSDERMAL PATCH WEEKLY (estradiol) 3 QL (4 patches per 28 days) DELESTROGEN INTRAMUSCULAR OIL (estradiol valerate) 3 DEPO-ESTRADIOL INTRAMUSCULAR OIL (estradiol cypionate) 3 DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 2 QL (1 packet per 1 day) MG/0.75GM, 1 MG/GM (estradiol) DIVIGEL TRANSDERMAL GEL 1.25 MG/1.25GM (estradiol) 2 QL (30 packets per 30 days) dotti transdermal patch twice weekly 1 or 1b* QL (8 patch per 28 days) ELESTRIN TRANSDERMAL GEL (estradiol) 3 QL (1 pump per 30 days) ESTRADIOL IMPLANT PELLET 3 estradiol oral tablet 1 or 1b* estradiol transdermal patch twice weekly 1 or 1b* QL (8 patch per 28 days) estradiol transdermal patch weekly 1 or 1b* QL (4 patches per 28 days) estradiol valerate intramuscular oil 1 or 1b* ESTROGEL TRANSDERMAL GEL (estradiol) 3 QL (1 pump per 30 days) EVAMIST TRANSDERMAL SOLUTION (estradiol) 2 QL (2 bottles per 30 days) lyllana transdermal patch twice weekly 1 or 1b* QL (8 patch per 28 days) MENEST ORAL TABLET (esterified estrogens) 2 MENOSTAR TRANSDERMAL PATCH WEEKLY (estradiol) 3 QL (4 patch per 28 days) PREMARIN INJECTION SOLUTION RECONSTITUTED (estrogens 2 conjugated) PREMARIN ORAL TABLET (estrogens conjugated) 2 QL (1 tablet per 1 day) *ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB*** - DRUGS FOR WOMEN DUAVEE ORAL TABLET (conj estrogens-bazedoxifene) 3 PA; QL (1 tablet per 1 day) *FLUOROQUINOLONES* - DRUGS FOR INFECTIONS *FLUOROQUINOLONES*** - ANTIBIOTICS BAXDELA INTRAVENOUS SOLUTION RECONSTITUTED (delafloxacin 3 meglumine) BAXDELA ORAL TABLET (delafloxacin meglumine) 3 PA; QL (28 tablets per 30 days) CIPRO ORAL SUSPENSION RECONSTITUTED (ciprofloxacin) 3 QL (3 bottle per 30 days) CIPRO ORAL TABLET (ciprofloxacin hcl) 3 QL (28 tablets per 30 days) ciprofloxacin hcl oral tablet 1 or 1b* QL (28 tablets per 30 days) ciprofloxacin in d5w intravenous solution 1 or 1b* levofloxacin in d5w intravenous solution 1 or 1b* levofloxacin intravenous solution 1 or 1b* levofloxacin oral solution 1 or 1b* QL (480 mL per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 125 Coverage Requirements and Prescription Drug Name Drug Tier Limits levofloxacin oral tablet 1 or 1b* QL (14 tablets per 30 days) moxifloxacin hcl in nacl intravenous solution 1 or 1b* MOXIFLOXACIN HCL INTRAVENOUS SOLUTION 3 moxifloxacin hcl oral tablet 1 or 1b* QL (21 tablet per 30 days) ofloxacin oral tablet 1 or 1b* QL (28 tablet per 30 days) *GASTROINTESTINAL AGENTS - MISC.* - DRUGS FOR THE STOMACH *BILE ACID SYNTHESIS DISORDER AGENTS*** - DRUGS FOR THE STOMACH CHOLBAM ORAL CAPSULE (cholic acid) 3 PA; LD; QL (4 capsule per 1 day) *FARNESOID X RECEPTOR (FXR) AGONISTS*** - DRUGS FOR THE STOMACH OCALIVA ORAL TABLET (obeticholic acid) 4 PA; LD; SP; QL (1 tablet per 1 day) *GALLSTONE SOLUBILIZING AGENTS*** - DRUGS FOR THE STOMACH CHENODAL ORAL TABLET (chenodiol) 3 PA; LD; QL (7 tablets per 1 day) URSO 250 ORAL TABLET (ursodiol) 3 URSO FORTE ORAL TABLET (ursodiol) 3 ursodiol oral capsule 1 or 1b* ursodiol oral tablet 1 or 1b* *GASTROINTESTINAL ANTIALLERGY AGENTS*** - DRUGS FOR THE STOMACH cromolyn sodium oral concentrate 1 or 1b* GASTROCROM ORAL CONCENTRATE (cromolyn sodium) 3 *GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS*** - DRUGS FOR IRRITABLE BOWEL SYNDROME lubiprostone oral capsule 1 or 1b* QL (2 capsules per 1 day) *GASTROINTESTINAL STIMULANTS*** - DRUGS FOR THE STOMACH DEXPANTHENOL INJECTION SOLUTION 3 GIMOTI NASAL SOLUTION (metoclopramide hcl) 3 PA; QL (1 bottle per 4 weekss) metoclopramide hcl injection solution 1 or 1a* metoclopramide hcl oral solution 1 or 1a* QL (60 mL per 1 day) metoclopramide hcl oral tablet 10 mg 1 or 1a* QL (6 tablets per 1 day) metoclopramide hcl oral tablet 5 mg 1 or 1a* QL (12 tablets per 1 day) METOCLOPRAMIDE HCL ORAL TABLET DISPERSIBLE 10 MG 3 ST; QL (6 tablets per 1 day) metoclopramide hcl oral tablet dispersible 5 mg 1 or 1a* ST; QL (12 tablets per 1 day) REGLAN ORAL TABLET 10 MG (metoclopramide hcl) 3 QL (6 tablets per 1 day) REGLAN ORAL TABLET 5 MG (metoclopramide hcl) 3 QL (12 tablets per 1 day) *GLUCAGON-LIKE PEPTIDE-2 (GLP-2) ANALOGS*** - DRUGS FOR THE STOMACH GATTEX SUBCUTANEOUS KIT (teduglutide (rdna)) 3 PA; LD; SP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 126 Coverage Requirements and Prescription Drug Name Drug Tier Limits *IBS AGENT - GUANYLATE CYCLASE-C (GC-C) AGONISTS*** - DRUGS FOR CONSTIPATION LINZESS ORAL CAPSULE (linaclotide) 2 QL (1 capsule per 1 day) *IBS AGENT - MU-OPIOID RECEPTOR AGONISTS*** - DRUGS FOR IRRITABLE BOWEL SYNDROME VIBERZI ORAL TABLET (eluxadoline) 2 QL (2 tablets per 1 day) *IBS AGENT - SELECTIVE 5-HT3 RECEPTOR ANTAGONISTS*** - DRUGS FOR IRRITABLE BOWEL SYNDROME alosetron hcl oral tablet 1 or 1b* PA; QL (2 tablets per 1 day) LOTRONEX ORAL TABLET (alosetron hcl) 3 PA; QL (2 tablets per 1 day) *INFLAMMATORY BOWEL AGENTS*** - DRUGS FOR INFLAMMATORY BOWEL DISEASE APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR (mesalamine) 3 ST; QL (4 capsule per 1 day) AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 3 QL (8 tablet per 1 day) (sulfasalazine) AZULFIDINE ORAL TABLET (sulfasalazine) 3 QL (8 tablet per 1 day) balsalazide disodium oral capsule 1 or 1b* QL (9 capsule per 1 day) CANASA RECTAL SUPPOSITORY (mesalamine) 3 QL (1 suppository per 1 day) DELZICOL ORAL CAPSULE DELAYED RELEASE (mesalamine) 3 ST; QL (6 tablets per 1 day) DIPENTUM ORAL CAPSULE (olsalazine sodium) 3 ST; QL (4 capsule per 1 day) mesalamine er oral capsule extended release 24 hour 1 or 1b* QL (4 capsules per 1 day) mesalamine oral capsule delayed release 1 or 1b* QL (6 tablets per 1 day) mesalamine oral tablet delayed release 1.2 gm 1 or 1b* QL (4 tablets per 1 day) mesalamine oral tablet delayed release 800 mg 1 or 1b* QL (6 tablet per 1 day) mesalamine rectal enema 1 or 1b* QL (60 mL per 1 day) mesalamine rectal suppository 1 or 1b* QL (1 suppository per 1 day) mesalamine-cleanser rectal kit 1 or 1b* QL (1 kit per 28 days) PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG (mesalamine) 2 QL (16 capsule per 1 day) PENTASA ORAL CAPSULE EXTENDED RELEASE 500 MG (mesalamine) 2 QL (8 capsule per 1 day) ROWASA RECTAL KIT (mesalamine-cleanser) 3 QL (1 kit per 28 days) SFROWASA RECTAL ENEMA (mesalamine) 3 QL (60 mL per 1 day) sulfasalazine oral tablet 1 or 1b* QL (8 tablet per 1 day) sulfasalazine oral tablet delayed release 1 or 1b* QL (8 tablet per 1 day) *INTEGRIN RECEPTOR ANTAGONISTS*** - DRUGS FOR INFLAMMATORY BOWEL DISEASE ENTYVIO INTRAVENOUS SOLUTION RECONSTITUTED (vedolizumab) 4 PA; LD; SP; QL (1 vial per 56 days) *INTERLEUKIN ANTAGONISTS*** - DRUGS FOR INFLAMMATORY BOWEL DISEASE PA; LD; SP; QL (4 vial per 365 STELARA INTRAVENOUS SOLUTION (ustekinumab) 4 days) *INTESTINAL ACIDIFIERS*** - DRUGS FOR THE STOMACH enulose oral solution 1 or 1b* generlac oral solution 1 or 1b* lactulose encephalopathy oral solution 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 127 Coverage Requirements and Prescription Drug Name Drug Tier Limits *PERIPHERAL OPIOID RECEPTOR ANTAGONISTS*** - DRUGS FOR THE STOMACH alvimopan oral capsule 1 or 1b* ENTEREG ORAL CAPSULE (alvimopan) 3 MOVANTIK ORAL TABLET (naloxegol oxalate) 2 QL (1 tablet per 1 day) RELISTOR ORAL TABLET (methylnaltrexone bromide) 3 ST; QL (3 tablets per 1 day) RELISTOR SUBCUTANEOUS SOLUTION (methylnaltrexone bromide) 3 ST; QL (1 syringe per 1 day) SYMPROIC ORAL TABLET (naldemedine tosylate) 3 ST; QL (1 tablet per 1 day) *PHOSPHATE BINDER AGENTS*** - DRUGS FOR THE STOMACH AURYXIA ORAL TABLET (ferric citrate) 3 ST; QL (9 tablets per 1 day) calcium acetate (phos binder) oral capsule 1 or 1b* QL (12 capsules per 1 day) calcium acetate (phos binder) oral tablet 1 or 1b* QL (12 tablets per 1 day) calcium acetate oral tablet 667 mg 1 or 1b* QL (12 tablets per 1 day) FOSRENOL ORAL PACKET (lanthanum carbonate) 3 ST; QL (3 stick packs per 1 day) FOSRENOL ORAL TABLET CHEWABLE (lanthanum carbonate) 3 ST; QL (3 tablets per 1 day) lanthanum carbonate oral tablet chewable 1 or 1b* QL (3 tablets per 1 day) PHOSLYRA ORAL SOLUTION (calcium acetate (phos binder)) 3 ST; QL (60 mL per 1 day) RENVELA ORAL PACKET 0.8 GM (sevelamer carbonate) 3 ST; QL (6 packets per 1 day) RENVELA ORAL PACKET 2.4 GM (sevelamer carbonate) 3 ST; QL (3 packets per 1 day) RENVELA ORAL TABLET (sevelamer carbonate) 3 ST; QL (9 tablets per 1 day) sevelamer carbonate oral packet 0.8 gm 1 or 1b* QL (6 packets per 1 day) sevelamer carbonate oral packet 2.4 gm 1 or 1b* QL (3 packets per 1 day) sevelamer carbonate oral tablet 1 or 1b* QL (9 tablets per 1 day) sevelamer hcl oral tablet 400 mg 1 or 1b* QL (15 tablets per 1 day) sevelamer hcl oral tablet 800 mg 1 or 1b* QL (9 tablets per 1 day) VELPHORO ORAL TABLET CHEWABLE (sucroferric oxyhydroxide) 2 QL (3 tablets per 1 day) *TRYPTOPHAN HYDROXYLASE INHIBITORS*** - DRUGS FOR DIARRHEA XERMELO ORAL TABLET (telotristat etiprate) 4 PA; LD; QL (3 tablets per 1 day) *TUMOR NECROSIS FACTOR ALPHA BLOCKERS*** - DRUGS FOR INFLAMMATORY BOWEL DISEASE INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED (infliximab- 4 PA; LD; SP dyyb) REMICADE INTRAVENOUS SOLUTION RECONSTITUTED (infliximab) 4 PA; LD; SP *GENERAL ANESTHETICS* - DRUGS FOR PAIN AND FEVER *ANESTHETICS - MISC.*** - DRUGS FOR SEDATION AMIDATE INTRAVENOUS SOLUTION (etomidate) 3 ANESTHESIA S/I-40A INTRAVENOUS KIT 3 ANESTHESIA S/I-40H INTRAVENOUS KIT 3 ANESTHESIA S/I-40S INTRAVENOUS KIT 3 DIPRIVAN INTRAVENOUS EMULSION (propofol) 3 etomidate intravenous solution 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 128 Coverage Requirements and Prescription Drug Name Drug Tier Limits fresenius propoven intravenous emulsion 1000 mg/100ml, 200 mg/20ml, 500 1 or 1b* mg/50ml KETALAR INJECTION SOLUTION (ketamine hcl) 3 ketamine hcl injection solution 10 mg/ml, 100 mg/ml, 50 mg/ml 1 or 1b* KETAMINE HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE 3 KETAMINE HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE propofol intravenous emulsion 1 or 1b* propofol-lipuro intravenous emulsion 1 or 1b* *BARBITURATE ANESTHETICS*** - DRUGS FOR SEDATION BREVITAL SODIUM INJECTION SOLUTION RECONSTITUTED 3 (methohexital sodium) METHOHEXITAL SODIUM INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE *VOLATILE ANESTHETICS*** - DRUGS FOR SEDATION desflurane inhalation solution 1 or 1b* FORANE INHALATION SOLUTION (isoflurane) 3 isoflurane inhalation solution 1 or 1b* sevoflurane inhalation solution 1 or 1b* SUPRANE INHALATION SOLUTION (desflurane) 3 terrell inhalation solution 1 or 1b* ULTANE INHALATION SOLUTION (sevoflurane) 3 *GENITOURINARY AGENTS - MISCELLANEOUS* - DRUGS FOR THE URINARY SYSTEM *5-ALPHA REDUCTASE INHIBITORS*** - DRUGS FOR THE PROSTATE dutasteride oral capsule 1 or 1b* QL (1 capsule per 1 day) finasteride oral tablet 5 mg 1 or 1b* QL (1 tablet per 1 day) PROSCAR ORAL TABLET (finasteride) 3 QL (1 tablet per 1 day) *ALPHA 1-ADRENOCEPTOR ANTAGONISTS*** - DRUGS FOR THE PROSTATE alfuzosin hcl er oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) CARDURA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 QL (1 tablet per 1 day) (doxazosin mesylate) silodosin oral capsule 1 or 1b* QL (1 capsule per 1 day) tamsulosin hcl oral capsule 1 or 1b* QL (2 capsules per 1 day) *ANTI-INFECTIVE GENITOURINARY IRRIGANTS*** - DRUGS FOR THE URINARY SYSTEM neomycin-polymyxin b gu irrigation solution 1 or 1b* *CITRATES*** - DRUGS FOR INFECTIONS pot & sod cit-cit ac oral solution 1 or 1b* potassium citrate er oral tablet extended release 1 or 1b* UROCIT-K 10 ORAL TABLET EXTENDED RELEASE (potassium citrate) 3 UROCIT-K 15 ORAL TABLET EXTENDED RELEASE (potassium citrate) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 129 Coverage Requirements and Prescription Drug Name Drug Tier Limits UROCIT-K 5 ORAL TABLET EXTENDED RELEASE (potassium citrate) 3 *CYSTINOSIS AGENTS*** - DRUGS FOR THE URINARY SYSTEM CYSTAGON ORAL CAPSULE (cysteamine bitartrate) 4 LD; SP PROCYSBI ORAL CAPSULE DELAYED RELEASE (cysteamine bitartrate) 4 ST; LD PROCYSBI ORAL PACKET (cysteamine bitartrate) 4 ST; LD *GENITOURINARY IRRIGANTS*** - DRUGS FOR THE URINARY SYSTEM acetic acid irrigation solution 1 or 1b* aminoacetic acid irrigation solution 1 or 1b* argyle sterile saline irrigation solution 1 or 1b* curity sterile saline irrigation solution 1 or 1b* glycine irrigation solution 1 or 1b* glycine urologic irrigation solution 1 or 1b* RENACIDIN IRRIGATION SOLUTION (citric ac-gluconolact-mg carb) 3 RESECTISOL IRRIGATION SOLUTION (mannitol (gu irrigant)) 3 sodium chloride irrigation solution 1 or 1b* SORBITOL IRRIGATION SOLUTION 3 SORBITOL-MANNITOL IRRIGATION SOLUTION 3 *INTERSTITIAL CYSTITIS AGENTS*** - DRUGS FOR THE URINARY SYSTEM ELMIRON ORAL CAPSULE (pentosan polysulfate sodium) 3 QL (3 capsules per 1 day) RIMSO-50 INTRAVESICAL SOLUTION (dimethyl sulfoxide) 3 *PHOSPHATES*** - DRUGS FOR INFECTIONS K-PHOS NO 2 ORAL TABLET (pot & sod ac phosphates) 3 *PROSTATIC HYPERTROPHY AGENT COMBINATIONS*** - DRUGS FOR THE PROSTATE dutasteride-tamsulosin hcl oral capsule 1 or 1b* QL (1 capsule per 1 day) JALYN ORAL CAPSULE (dutasteride-tamsulosin hcl) 3 QL (1 capsule per 1 day) *SMALL INTERFERING RIBONUCLEIC ACID AGENTS (SIRNA)*** - DRUGS FOR THE URINARY SYSTEM OXLUMO SUBCUTANEOUS SOLUTION (lumasiran sodium) 4 PA; LD *URINARY STONE AGENTS*** - DRUGS FOR THE URINARY SYSTEM LITHOSTAT ORAL TABLET (acetohydroxamic acid) 3 THIOLA EC ORAL TABLET DELAYED RELEASE 100 MG (tiopronin) 3 PA; LD; QL (10 tablet per 1 day) THIOLA EC ORAL TABLET DELAYED RELEASE 300 MG (tiopronin) 3 PA; LD; QL (3 tablet per 1 day) THIOLA ORAL TABLET (tiopronin) 3 PA; LD; QL (10 tablet per 1 day) tiopronin oral tablet 1 or 1b* PA; QL (10 tablet per 1 day) *VESICOURETERAL REFLUX (VUR) AGENT COMBINATIONS*** - DRUGS FOR THE URINARY SYSTEM DEFLUX INJECTION PREFILLED SYRINGE (dextranomer-hyaluronic 3 acid)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 130 Coverage Requirements and Prescription Drug Name Drug Tier Limits *GOUT AGENTS* - DRUGS FOR PAIN AND FEVER *GOUT AGENT COMBINATIONS*** - GOUT DRUGS colchicine-probenecid oral tablet 1 or 1b* *GOUT AGENTS*** - GOUT DRUGS allopurinol oral tablet 1 or 1a* allopurinol sodium intravenous solution reconstituted 1 or 1b* ALOPRIM INTRAVENOUS SOLUTION RECONSTITUTED (allopurinol 3 sodium) colchicine oral tablet 2 QL (2.3 tablet per 1 day) febuxostat oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) GLOPERBA ORAL SOLUTION (colchicine) 3 ST; QL (2 bottles per 30 days) PA; LD; SP; QL (0.08 mL per 1 KRYSTEXXA INTRAVENOUS SOLUTION (pegloticase) 4 day) ZYLOPRIM ORAL TABLET (allopurinol) 3 *URICOSURICS*** - GOUT DRUGS probenecid oral tablet 1 or 1b* *HEMATOLOGICAL AGENTS - MISC.* - DRUGS FOR THE BLOOD *AMINOLEVULINATE SYNTHASE 1-DIRECTED SIRNA*** - DRUGS FOR THE BLOOD GIVLAARI SUBCUTANEOUS SOLUTION (givosiran sodium) 4 PA; LD *ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES*** - DRUGS FOR THE BLOOD HEMLIBRA SUBCUTANEOUS SOLUTION (emicizumab-kxwh) 4 PA; LD; SP *ANTIHEMOPHILIC PRODUCTS*** - DRUGS TO PREVENT BLEEDING ADVATE INTRAVENOUS SOLUTION RECONSTITUTED (antihemophil 4 PA; LD; SP factor (rahf-pfm)) ADYNOVATE INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP AFSTYLA INTRAVENOUS KIT (antihemophil fact single chain) 4 PA; LD; SP ALPHANATE INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemophilic factor-vwf) ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor ix) ALPROLIX INTRAVENOUS SOLUTION RECONSTITUTED (coagulation 4 PA; LD; SP factor ix (rfixfc)) BENEFIX INTRAVENOUS KIT (coagulation factor ix (recomb)) 4 PA; LD; SP COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor x (human)) CORIFACT INTRAVENOUS KIT (factor xiii concentrate human) 4 PA; LD; SP ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED (antihem fact 4 PA; LD; SP (bdd-rfviiifc)) ESPEROCT INTRAVENOUS SOLUTION RECONSTITUTED (antihemoph 4 PA; LD; SP fact rcmb gpeg-exei) FEIBA INTRAVENOUS SOLUTION RECONSTITUTED (antiinhibitor 4 PA; LD; SP coagulant cmplx)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 131 Coverage Requirements and Prescription Drug Name Drug Tier Limits FIBRYGA INTRAVENOUS SOLUTION RECONSTITUTED (fibrinogen 4 PA; LD concentrate (human)) HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemophilic factor) HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemophilic factor-vwf) IDELVION INTRAVENOUS SOLUTION RECONSTITUTED (coagulation 4 PA; LD; SP factor ix (rix-fp)) IXINITY INTRAVENOUS SOLUTION RECONSTITUTED (coagulation 4 PA; LD; SP factor ix (recomb)) JIVI INTRAVENOUS SOLUTION RECONSTITUTED (ahf (bdd-rfviii peg- 4 PA; LD; SP aucl)) KCENTRA INTRAVENOUS KIT (prothrombin complex conc human) 3 KOATE INTRAVENOUS SOLUTION RECONSTITUTED (antihemophilic 4 PA; LD; SP factor) KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemophilic factor) KOGENATE FS INTRAVENOUS KIT (antihem factor recomb (rfviii)) 4 PA; LD; SP KOVALTRY INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemophil factor (rahf-pfm)) MONONINE INTRAVENOUS SOLUTION RECONSTITUTED (coagulation 4 PA; LD; SP factor ix) NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 4 LD; SP (antihemophil fact bd truncated) NOVOSEVEN RT INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor viia recomb) NUWIQ INTRAVENOUS KIT (antihem fact (bdd-rfviii,sim)) 4 PA; LD; SP NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED (antihem fact 4 PA; LD; SP (bdd-rfviii,sim)) OBIZUR INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED (factor ix 4 PA; LD; SP complex) REBINYN INTRAVENOUS SOLUTION RECONSTITUTED (coagulation 4 PA; LD; SP factor ix glycopeg) RECOMBINATE INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihem factor recomb (rfviii)) RIASTAP INTRAVENOUS SOLUTION RECONSTITUTED (fibrinogen 3 PA; LD concentrate (human)) RIXUBIS INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP SEVENFACT INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor viia-jncw) TRETTEN INTRAVENOUS SOLUTION RECONSTITUTED (coagulation 4 PA; LD; SP factor xiii a-sub) VONVENDI INTRAVENOUS SOLUTION RECONSTITUTED (von 4 PA; LD; SP willebrand factor (recomb)) WILATE INTRAVENOUS KIT (antihemophilic factor-vwf) 4 PA; LD; SP XYNTHA INTRAVENOUS KIT (antihem fact (bdd-rfviii,mor)) 4 PA; LD; SP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 132 Coverage Requirements and Prescription Drug Name Drug Tier Limits XYNTHA SOLOFUSE INTRAVENOUS KIT (antihem fact (bdd-rfviii,mor)) 4 PA; LD; SP *ANTI-VON WILLEBRAND FACTOR AGENTS*** - DRUGS FOR THE BLOOD CABLIVI INJECTION KIT (caplacizumab-yhdp) 4 PA; LD *BRADYKININ B2 RECEPTOR ANTAGONISTS*** - DRUGS FOR THE BLOOD PA; LD; SP; QL (24 syringes per 30 FIRAZYR SUBCUTANEOUS SOLUTION (icatibant acetate) 4 days) PA; SP; QL (24 syringes per 30 icatibant acetate subcutaneous solution 4 days) *C1 INHIBITORS*** - DRUGS FOR THE BLOOD PA; LD; SP; QL (24 vials per 30 BERINERT INTRAVENOUS KIT (c1 esterase inhibitor (human)) 4 days) CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED (c1 esterase PA; LD; SP; QL (20 vials per 30 4 inhibitor (human)) days) HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED 2000 PA; LD; SP; QL (24 vials per 28 4 UNIT (c1 esterase inhibitor (human)) days) HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED 3000 PA; LD; SP; QL (16 vials per 28 4 UNIT (c1 esterase inhibitor (human)) days) RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED (c1 esterase PA; LD; SP; QL (16 vials per 30 4 inhibitor (recomb)) days) *COMPLEMENT INHIBITORS*** - DRUGS FOR THE BLOOD EMPAVELI SUBCUTANEOUS SOLUTION (pegcetacoplan) 4 PA; LD; QL (9 vials per 28 days) SOLIRIS INTRAVENOUS SOLUTION (eculizumab) 4 PA; LD; SP ULTOMIRIS INTRAVENOUS SOLUTION 1100 MG/11ML (ravulizumab- PA; LD; SP; QL (3 vials per 56 4 cwvz) days) ULTOMIRIS INTRAVENOUS SOLUTION 300 MG/3ML (ravulizumab- PA; LD; SP; QL (12 vials per 56 4 cwvz) days) *DIRECT-ACTING P2Y12 INHIBITORS*** - DRUGS FOR THE BLOOD BRILINTA ORAL TABLET (ticagrelor) 2 QL (2 tablets per 1 day) KENGREAL INTRAVENOUS SOLUTION RECONSTITUTED (cangrelor 3 tetrasodium) *GLYCOPROTEIN IIB/IIIA RECEPTOR INHIBITORS*** - DRUGS FOR THE BLOOD AGGRASTAT INTRAVENOUS CONCENTRATE (tirofiban hcl) 3 AGGRASTAT INTRAVENOUS SOLUTION (tirofiban hcl in nacl) 3 eptifibatide intravenous solution 1 or 1b* *HEMATORHEOLOGIC AGENTS*** - DRUGS FOR THE BLOOD pentoxifylline er oral tablet extended release 1 or 1b* *HEMIN*** - DRUGS FOR THE BLOOD PANHEMATIN INTRAVENOUS SOLUTION RECONSTITUTED (hemin) 3 *HUMAN PROTEIN C*** - DRUGS FOR THE BLOOD CEPROTIN INTRAVENOUS SOLUTION RECONSTITUTED (protein c 4 LD; SP concentrate (human))

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 133 Coverage Requirements and Prescription Drug Name Drug Tier Limits *PHOSPHODIESTERASE III INHIBITORS*** - DRUGS FOR THE BLOOD cilostazol oral tablet 1 or 1b* *PLASMA EXPANDERS*** - DRUGS FOR THE BLOOD HESPAN INTRAVENOUS SOLUTION (hetastarch-nacl) 3 hetastarch-nacl intravenous solution 1 or 1b* HEXTEND INTRAVENOUS SOLUTION (hetastarch in lact electrolyte) 3 lmd in d5w intravenous solution 1 or 1b* lmd in nacl intravenous solution 1 or 1b* *PLASMA KALLIKREIN INHIBITORS - MONOCLONAL ANTIBODIES*** - DRUGS FOR THE BLOOD PA; LD; SP; QL (1 syringe per 28 TAKHZYRO SUBCUTANEOUS SOLUTION (lanadelumab-flyo) 4 days) *PLASMA KALLIKREIN INHIBITORS*** - DRUGS FOR THE BLOOD PA; LD; SP; QL (48 vials per 30 KALBITOR SUBCUTANEOUS SOLUTION (ecallantide) 4 days) ORLADEYO ORAL CAPSULE (berotralstat hcl) 4 PA; LD; QL (1 capsule per 1 day) *PLASMA PROTEINS*** - DRUGS FOR THE BLOOD ALBUKED 25 INTRAVENOUS SOLUTION (albumin human) 3 ALBUKED 5 INTRAVENOUS SOLUTION (albumin human) 3 ALBUMIN HUMAN INTRAVENOUS SOLUTION 3 ALBUMINEX INTRAVENOUS SOLUTION (albumin human-kjda) 3 ALBUMIN-ZLB INTRAVENOUS SOLUTION 3 ALBURX INTRAVENOUS SOLUTION 3 ALBUTEIN INTRAVENOUS SOLUTION (albumin human) 3 FLEXBUMIN INTRAVENOUS SOLUTION (albumin human) 3 HUMAN ALBUMIN GRIFOLS INTRAVENOUS SOLUTION (albumin 3 human) KEDBUMIN INTRAVENOUS SOLUTION 3 OCTAPLAS BLOOD GROUP A INTRAVENOUS SOLUTION (plasma 3 human) OCTAPLAS BLOOD GROUP AB INTRAVENOUS SOLUTION (plasma 3 human) OCTAPLAS BLOOD GROUP B INTRAVENOUS SOLUTION (plasma 3 human) OCTAPLAS BLOOD GROUP O INTRAVENOUS SOLUTION (plasma 3 human) PLASBUMIN-25 INTRAVENOUS SOLUTION (albumin human) 3 PLASBUMIN-5 INTRAVENOUS SOLUTION (albumin human) 3 PLASMANATE INTRAVENOUS SOLUTION (plasma protein fraction) 3 THROMBATE III INTRAVENOUS SOLUTION RECONSTITUTED 3 (antithrombin iii (human))

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 134 Coverage Requirements and Prescription Drug Name Drug Tier Limits *PLATELET AGGREGATION INHIBITOR COMBINATIONS*** - DRUGS FOR THE BLOOD aspirin-dipyridamole er oral capsule extended release 12 hour 1 or 1b* QL (2 capsules per 1 day) ASPIRIN-OMEPRAZOLE ORAL TABLET DELAYED RELEASE 3 PA; QL (1 tablet per 1 day) YOSPRALA ORAL TABLET DELAYED RELEASE (aspirin-omeprazole) 3 PA; QL (1 tablet per 1 day) *PLATELET AGGREGATION INHIBITORS*** - DRUGS FOR THE BLOOD dipyridamole oral tablet 1 or 1b* DURLAZA ORAL CAPSULE EXTENDED RELEASE 24 HOUR (aspirin) 3 PA; QL (1 capsule per 1 day) *PROTAMINE*** - DRUGS FOR THE BLOOD protamine sulfate intravenous solution 1 or 1b* *PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS*** - DRUGS FOR THE BLOOD ZONTIVITY ORAL TABLET (vorapaxar sulfate) 3 PA; QL (1 tablet per 1 day) *QUINAZOLINE AGENTS*** - DRUGS FOR THE BLOOD AGRYLIN ORAL CAPSULE (anagrelide hcl) 3 anagrelide hcl oral capsule 1 or 1b* *SPLEEN TYROSINE KINASE (SYK) INHIBITORS*** - DRUGS FOR THE BLOOD TAVALISSE ORAL TABLET (fostamatinib disodium) 4 PA; LD; QL (2 tablets per 1 day) *THIENOPYRIDINE DERIVATIVES*** - DRUGS FOR THE BLOOD clopidogrel bisulfate oral tablet 300 mg 1 or 1b* clopidogrel bisulfate oral tablet 75 mg 1 or 1b* QL (1 tablet per 1 day) prasugrel hcl oral tablet 10 mg 1 or 1b* QL (1 tablet per 1 day) prasugrel hcl oral tablet 5 mg 1 or 1b* *THROMBOLYTIC AGENT - MISC*** - DRUGS FOR THE BLOOD DEFITELIO INTRAVENOUS SOLUTION (defibrotide sodium) 4 *TISSUE PLASMINOGEN ACTIVATORS*** - DRUGS FOR THE BLOOD ACTIVASE INTRAVENOUS SOLUTION RECONSTITUTED (alteplase) 3 CATHFLO ACTIVASE INJECTION SOLUTION RECONSTITUTED 3 (alteplase) RETAVASE HALF-KIT INTRAVENOUS KIT (reteplase) 3 RETAVASE INTRAVENOUS KIT (reteplase) 3 TNKASE INTRAVENOUS KIT (tenecteplase) 3 *HEMATOPOIETIC AGENTS* - DRUGS FOR NUTRITION *AGENTS FOR GAUCHER DISEASE*** - DRUGS FOR NUTRITION CERDELGA ORAL CAPSULE (eliglustat tartrate) 4 PA; LD; SP CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (imiglucerase) ELELYSO INTRAVENOUS SOLUTION RECONSTITUTED (taliglucerase 4 PA; LD; SP alfa) miglustat oral capsule 4 PA; SP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 135 Coverage Requirements and Prescription Drug Name Drug Tier Limits VPRIV INTRAVENOUS SOLUTION RECONSTITUTED (velaglucerase 4 PA; LD; SP alfa) *AMINO ACIDS*** - DRUGS FOR NUTRITION ENDARI ORAL PACKET (glutamine (sickle cell)) 4 PA; LD *COBALAMIN COMBINATIONS*** - DRUGS FOR NUTRITION LIPO-B INTRAMUSCULAR SOLUTION 3 NEURIN-SL SUBLINGUAL TABLET SUBLINGUAL 3 *COBALAMINS*** - DRUGS FOR NUTRITION cyanocobalamin injection solution 1000 mcg/ml 1 or 1a* CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML 3 hydroxocobalamin acetate intramuscular solution 1 or 1b* METHYLCOBALAMIN INJECTION SOLUTION RECONSTITUTED 3 *CXCR4 RECEPTOR ANTAGONIST*** - DRUGS FOR NUTRITION MOZOBIL SUBCUTANEOUS SOLUTION (plerixafor) 4 PA; LD; SP *CYTOTOXIC AGENTS*** - DRUGS FOR NUTRITION DROXIA ORAL CAPSULE (hydroxyurea) 2 SIKLOS ORAL TABLET (hydroxyurea) 3 PA; SP *ERYTHROID MATURATION AGENTS*** - DRUGS FOR NUTRITION REBLOZYL SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (luspatercept-aamt) *ERYTHROPOIESIS-STIMULATING AGENTS (ESAS)*** - DRUGS FOR NUTRITION ARANESP (ALBUMIN FREE) INJECTION SOLUTION (darbepoetin alfa) 4 PA; SP; QL (4 vials per 28 days) ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 100 MCG/0.5ML, 150 MCG/0.3ML, 200 4 PA; SP; QL (4 syringes per 28 days) MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 60 MCG/0.3ML (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED 4 PA; SP; QL (4 syringes per 30 days) SYRINGE 500 MCG/ML (darbepoetin alfa) EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 4 PA; SP; QL (12 mL per 28 days) UNIT/ML, 4000 UNIT/ML (epoetin alfa) EPOGEN INJECTION SOLUTION 20000 UNIT/ML (epoetin alfa) 4 PA; SP; QL (24 vials per 28 days) MIRCERA INJECTION SOLUTION PREFILLED SYRINGE (methoxy peg- PA; LD; QL (2 syringes per 28 4 epoetin beta) days) PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 4 PA; SP; QL (12 mL per 28 days) UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML (epoetin alfa) PROCRIT INJECTION SOLUTION 20000 UNIT/ML (epoetin alfa) 4 PA; SP; QL (24 vials per 28 days) RETACRIT INJECTION SOLUTION (epoetin alfa-epbx) 4 PA; SP; QL (12 mL per 28 days) *FOLIC ACID/FOLATE COMBINATIONS*** - DRUGS FOR NUTRITION fa-vitamin b-6-vitamin b-12 oral tablet 1 or 1b* FOLGARD RX ORAL TABLET (folic acid-vit b6-vit b12) 3 *FOLIC ACID/FOLATES*** - DRUGS FOR NUTRITION folic acid injection solution 1 or 1a* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 136 Coverage Requirements and Prescription Drug Name Drug Tier Limits folic acid oral tablet 1 mg 1 or 1a* *GRANULOCYTE COLONY-STIMULATING FACTORS (G-CSF)*** - DRUGS FOR NUTRITION FULPHILA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (2 syringes per 28 days) (pegfilgrastim-jmdb) GRANIX SUBCUTANEOUS SOLUTION (tbo-filgrastim) 4 PA; SP GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE (tbo- 4 PA; SP filgrastim) NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT PA; SP; QL (2 injectors/kits per 28 4 (pegfilgrastim) days) NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (2 syringes per 28 days) (pegfilgrastim) NEUPOGEN INJECTION SOLUTION (filgrastim) 4 PA; SP NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE (filgrastim) 4 PA; SP NIVESTYM INJECTION SOLUTION (filgrastim-aafi) 4 PA; SP NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE (filgrastim- 4 PA; SP aafi) NYVEPRIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (2 syringes per 28 days) (pegfilgrastim-apgf) UDENYCA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (2 syringes per 28 days) (pegfilgrastim-cbqv) ZARXIO INJECTION SOLUTION PREFILLED SYRINGE (filgrastim-sndz) 4 PA; SP ZIEXTENZO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; SP; QL (2 injections per 28 4 (pegfilgrastim-bmez) days) *GRANULOCYTE/MACROPHAGE COLONY-STIMULATING FACTOR(GM-CSF)*** - DRUGS FOR NUTRITION LEUKINE INJECTION SOLUTION RECONSTITUTED (sargramostim) 4 PA; SP *HEMOGLOBIN S (HBS) POLYMERIZATION INHIBITORS*** - DRUGS FOR NUTRITION PA; LD; SP; QL (3 tablets per 1 OXBRYTA ORAL TABLET (voxelotor) 4 day) *IRON COMBINATIONS*** - DRUGS FOR NUTRITION foltrin oral capsule 1 or 1b* *IRON*** - DRUGS FOR NUTRITION ACCRUFER ORAL CAPSULE (ferric maltol) 3 FERAHEME INTRAVENOUS SOLUTION (ferumoxytol) 4 PA; SP; QL (2 vials per 6 days) FERRLECIT INTRAVENOUS SOLUTION (na ferric gluc cplx in sucrose) 4 PA; SP; QL (16 vials per 8 weekss) INFED INJECTION SOLUTION (iron dextran) 4 PA; SP INJECTAFER INTRAVENOUS SOLUTION (ferric carboxymaltose) 4 PA; SP; QL (2 vials per 14 days) MONOFERRIC INTRAVENOUS SOLUTION (ferric derisomaltose) 3 PA; SP; QL (1 vial per 1 day) na ferric gluc cplx in sucrose intravenous solution 4 SP TRIFERIC HEMODIALYSIS PACKET (ferric pyrophosphate citrate) 4 PA TRIFERIC HEMODIALYSIS SOLUTION (ferric pyrophosphate citrate) 4 PA VENOFER INTRAVENOUS SOLUTION (iron sucrose) 4 PA; SP; QL (15 mL per 71 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 137 Coverage Requirements and Prescription Drug Name Drug Tier Limits *SELECTIN BLOCKERS*** - DRUGS FOR NUTRITION ADAKVEO INTRAVENOUS SOLUTION (crizanlizumab-tmca) 4 PA; SP *THROMBOPOIETIN (TPO) RECEPTOR AGONISTS*** - DRUGS FOR NUTRITION PA; LD; SP; QL (60 tablets per 30 DOPTELET ORAL TABLET (avatrombopag maleate) 4 days) MULPLETA ORAL TABLET (lusutrombopag) 4 PA; SP; QL (1 tablet per 1 day) NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED 125 MCG 4 PA (romiplostim) NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED 250 MCG, 4 PA; SP 500 MCG (romiplostim) PROMACTA ORAL PACKET 12.5 MG (eltrombopag olamine) 4 PA; LD; SP PA; LD; SP; QL (3 dose-packs per 1 PROMACTA ORAL PACKET 25 MG (eltrombopag olamine) 4 day) PROMACTA ORAL TABLET 12.5 MG, 25 MG (eltrombopag olamine) 4 PA; LD; SP PA; LD; SP; QL (3 tablets per 1 PROMACTA ORAL TABLET 50 MG (eltrombopag olamine) 4 day) PROMACTA ORAL TABLET 75 MG (eltrombopag olamine) 4 PA; LD; SP; QL (1 tablet per 1 day) *HEMOSTATICS* - DRUGS FOR THE BLOOD *HEMOSTATIC COMBINATIONS - TOPICAL*** - DRUGS TO PREVENT BLEEDING ARTISS EXTERNAL SOLUTION (fibrin sealant component) 3 THROMBI-GEL 10 EXTERNAL PAD (thrombin-cmc-cacl-gelatin) 3 THROMBI-GEL 100 EXTERNAL PAD (thrombin-cmc-cacl-gelatin) 3 THROMBI-GEL 40 EXTERNAL PAD (thrombin-cmc-cacl-gelatin) 3 THROMBI-PAD EXTERNAL PAD (thrombin-cmc-cacl) 3 TISSEEL EXTERNAL KIT (fibrin sealant component) 3 TISSEEL EXTERNAL SOLUTION (fibrin sealant component) 3 *HEMOSTATICS - SYSTEMIC*** - DRUGS TO PREVENT BLEEDING AMICAR ORAL SOLUTION (aminocaproic acid) 3 QL (120 mL per 1 day) AMICAR ORAL TABLET 1000 MG (aminocaproic acid) 3 AMICAR ORAL TABLET 500 MG (aminocaproic acid) 3 QL (60 tablets per 1 day) aminocaproic acid intravenous solution 1 or 1b* aminocaproic acid oral solution 1 or 1b* QL (120 mL per 1 day) aminocaproic acid oral tablet 1000 mg 1 or 1b* aminocaproic acid oral tablet 500 mg 1 or 1b* QL (60 tablets per 1 day) CYKLOKAPRON INTRAVENOUS SOLUTION (tranexamic acid) 3 LYSTEDA ORAL TABLET (tranexamic acid) 3 QL (6 tablets per 1 day) tranexamic acid intravenous solution 1 or 1b* tranexamic acid oral tablet 1 or 1b* QL (6 tablets per 1 day) TRANEXAMIC ACID-NACL INTRAVENOUS SOLUTION 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 138 Coverage Requirements and Prescription Drug Name Drug Tier Limits *HEMOSTATICS - TOPICAL*** - DRUGS TO PREVENT BLEEDING ACTIFOAM COLLAGEN SPONGE EXTERNAL (absorbable collagen 3 hemostat) AVITENE EXTERNAL PAD (microfibrillar coll hemostat) 3 AVITENE FLOUR EXTERNAL POWDER (microfibrillar coll hemostat) 3 ENDO AVITENE EXTERNAL (absorbable collagen hemostat) 3 GEL-FLOW NT EXTERNAL PREFILLED SYRINGE (gelatin absorbable) 3 GELFOAM COMPRESSED SIZE 100 EXTERNAL (gelatin absorbable) 3 GELFOAM DENTAL PACK SIZE 4 EXTERNAL (gelatin absorbable) 3 GELFOAM MOUTH/THROAT POWDER (gelatin absorbable) 3 GELFOAM SPONGE EXTERNAL (gelatin absorbable) 3 GELFOAM SPONGE SIZE 100 EXTERNAL (gelatin absorbable) 3 GELFOAM SPONGE SIZE 200 EXTERNAL (gelatin absorbable) 3 GELFOAM SPONGE SIZE 50 EXTERNAL (gelatin absorbable) 3 INSTAT EXTERNAL PAD (absorbable collagen hemostat) 3 INTERCEED (TC7) EXTERNAL PAD (oxidized cellulose) 3 INTERCEED EXTERNAL PAD (oxidized cellulose) 3 RECOTHROM EXTERNAL SOLUTION RECONSTITUTED (thrombin 3 (recombinant)) RECOTHROM SPRAY KIT EXTERNAL SOLUTION RECONSTITUTED 3 (thrombin (recombinant)) SURGICEL FIBRILLAR EXTERNAL PAD (oxidized cellulose) 3 SURGICEL NU-KNIT EXTERNAL PAD (oxidized cellulose) 3 SYRINGE AVITENE EXTERNAL (absorbable collagen hemostat) 3 TACHOSIL EXTERNAL PATCH (absorbable fibrin sealant) 3 THROMBIN-JMI EPISTAXIS EXTERNAL KIT (thrombin) 3 THROMBIN-JMI EXTERNAL KIT (thrombin) 3 THROMBIN-JMI EXTERNAL SOLUTION RECONSTITUTED (thrombin) 3 THROMBOGEN EXTERNAL KIT (thrombin) 3 THROMBOGEN EXTERNAL SOLUTION RECONSTITUTED (thrombin) 3 ULTRAFOAM SPONGE 2X6.25X7CM EXTERNAL (microfibrillar coll 3 hemostat) ULTRAFOAM SPONGE 8X12.5X1CM EXTERNAL (microfibrillar coll 3 hemostat) ULTRAFOAM SPONGE 8X12.5X3CM EXTERNAL (microfibrillar coll 3 hemostat) ULTRAFOAM SPONGE 8X25X1CM EXTERNAL (microfibrillar coll 3 hemostat) ULTRAFOAM SPONGE 8X6.25X1CM EXTERNAL (microfibrillar coll 3 hemostat) *HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS* - DRUGS FOR THE NERVOUS SYSTEM *BARBITURATE HYPNOTICS*** - DRUGS FOR INSOMNIA NEMBUTAL INJECTION SOLUTION (pentobarbital sodium) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 139 Coverage Requirements and Prescription Drug Name Drug Tier Limits pentobarbital sodium injection solution 1 or 1b* phenobarbital oral elixir 1 or 1b* QL (100 mL per 1 day) phenobarbital oral tablet 100 mg 1 or 1b* QL (4 tablets per 1 day) phenobarbital oral tablet 15 mg 1 or 1b* QL (800 tablets per 30 days) phenobarbital oral tablet 16.2 mg 1 or 1b* QL (741 tablets per 30 days) phenobarbital oral tablet 30 mg 1 or 1b* QL (400 tablets per 30 days) phenobarbital oral tablet 32.4 mg 1 or 1b* QL (370 tablets per 30 days) phenobarbital oral tablet 60 mg 1 or 1b* QL (200 tablets per 30 days) phenobarbital oral tablet 64.8 mg 1 or 1b* QL (185 tablets per 30 days) phenobarbital oral tablet 97.2 mg 1 or 1b* QL (123 tablets per 30 days) phenobarbital sodium injection solution 1 or 1b* *BENZODIAZEPINE HYPNOTICS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN BYFAVO INTRAVENOUS SOLUTION RECONSTITUTED (remimazolam 4 besylate) DORAL ORAL TABLET (quazepam) 3 ST; QL (1 tablet per 1 day) estazolam oral tablet 1 or 1b* QL (1 tablet per 1 day) flurazepam hcl oral capsule 1 or 1b* QL (1 capsule per 1 day) HALCION ORAL TABLET (triazolam) 3 QL (1 tablet per 1 day) midazolam hcl (pf) injection solution 1 or 1b* midazolam hcl injection solution 1 or 1b* midazolam hcl oral syrup 1 or 1b* QL (10 mL per 1 fill) MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 100-0.8 MG/100ML-%, 50-0.8 MG/50ML-% MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE MIDAZOLAM INTRAVENOUS SOLUTION PREFILLED SYRINGE 2 3 MG/2ML, 25 MG/25ML MIDAZOLAM-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 MIDAZOLAM-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 30-0.9 MG/30ML-%, 50-0.9 MG/50ML-%, 60-0.9 3 MG/30ML-% quazepam oral tablet 1 or 1b* QL (1 tablet per 1 day) RESTORIL ORAL CAPSULE (temazepam) 3 QL (1 capsule per 1 day) temazepam oral capsule 1 or 1b* QL (1 capsule per 1 day) triazolam oral tablet 1 or 1b* QL (1 tablet per 1 day) *HYPNOTICS - TRICYCLIC AGENTS*** - DRUGS FOR INSOMNIA doxepin hcl oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) SILENOR ORAL TABLET (doxepin hcl) 3 ST; QL (1 tablet per 1 day) *NON-BENZODIAZEPINE - GABA-RECEPTOR MODULATORS*** - DRUGS FOR INSOMNIA EDLUAR SUBLINGUAL TABLET SUBLINGUAL (zolpidem tartrate) 3 ST; QL (1 tablet per 1 day) eszopiclone oral tablet 1 or 1b* QL (1 tablet per 1 day) zaleplon oral capsule 1 or 1b* QL (1 capsule per 1 day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 140 Coverage Requirements and Prescription Drug Name Drug Tier Limits zolpidem tartrate er oral tablet extended release 1 or 1b* ST; QL (1 tablet per 1 day) zolpidem tartrate oral tablet 1 or 1b* QL (1 tablet per 1 day) zolpidem tartrate sublingual tablet sublingual 1 or 1b* ST; QL (1 tablet per 1 day) ZOLPIMIST ORAL SOLUTION (zolpidem tartrate) 3 ST; QL (1 bottle per 30 days) *OREXIN RECEPTOR ANTAGONISTS*** - DRUGS FOR INSOMNIA BELSOMRA ORAL TABLET (suvorexant) 3 ST; QL (1 tablet per 1 day) DAYVIGO ORAL TABLET (lemborexant) 3 ST; QL (1 tablet per 1 day) *SELECTIVE ALPHA2-ADRENORECEPTOR AGONIST SEDATIVES*** - DRUGS FOR INSOMNIA dexmedetomidine hcl in nacl intravenous solution 1 or 1b* DEXMEDETOMIDINE HCL IN NACL INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE DEXMEDETOMIDINE HCL INTRAVENOUS SOLUTION 1000 3 MCG/10ML, 400 MCG/4ML dexmedetomidine hcl intravenous solution 200 mcg/2ml 1 or 1b* DEXMEDETOMIDINE HCL-DEXTROSE INTRAVENOUS SOLUTION 3 PRECEDEX INTRAVENOUS SOLUTION (dexmedetomidine hcl) 3 *SELECTIVE MELATONIN RECEPTOR AGONISTS*** - DRUGS FOR INSOMNIA HETLIOZ LQ ORAL SUSPENSION (tasimelteon) 4 LD HETLIOZ ORAL CAPSULE (tasimelteon) 4 PA; LD; QL (1 capsule per 1 day) ramelteon oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) *LAXATIVES* - DRUGS FOR THE STOMACH *BOWEL EVACUANT COMBINATIONS*** - DRUGS TO PREVENT CONSTIPATION CLENPIQ ORAL SOLUTION (sod picosulfate-mag ox-cit acd) 3 QL (320 mL per 30 days) gavilyte-c oral solution reconstituted 1 or 1a*; $0 QL (4000 grams per 30 days) gavilyte-g oral solution reconstituted 1 or 1a*; $0 QL (4000 grams per 30 days) gavilyte-n with flavor pack oral solution reconstituted 1 or 1a*; $0 QL (4000 grams per 30 days) GOLYTELY ORAL SOLUTION RECONSTITUTED (peg 3350-kcl-nabcb- 3 QL (4000 grams per 30 days) nacl-nasulf) MOVIPREP ORAL SOLUTION RECONSTITUTED (peg-kcl-nacl-nasulf-na 3 QL (1 gram per 30 days) asc-c) NULYTELY LEMON-LIME ORAL SOLUTION RECONSTITUTED (peg 3 QL (4000 grams per 30 days) 3350-kcl-na bicarb-nacl) peg 3350-kcl-na bicarb-nacl oral solution reconstituted 1 or 1a*; $0 QL (4000 grams per 30 days) peg-3350/electrolytes oral solution reconstituted 1 or 1a*; $0 QL (4000 grams per 30 days) peg-3350/electrolytes/ascorbat oral solution reconstituted 1 or 1b*; $0 QL (1 gram per 30 days) peg-kcl-nacl-nasulf-na asc-c oral solution reconstituted 1 or 1b*; $0 QL (1 gram per 30 days) peg-prep oral kit 1 or 1b*; $0 QL (1 kit per 30 days) PLENVU ORAL SOLUTION RECONSTITUTED (peg-kcl-nacl-nasulf-na 3 QL (1 gram per 30 days) asc-c) SUPREP BOWEL PREP KIT ORAL SOLUTION (na sulfate-k sulfate-mg 2 QL (1 kit per 30 days) sulf)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 141 Coverage Requirements and Prescription Drug Name Drug Tier Limits *LAXATIVES - MISCELLANEOUS*** - DRUGS TO PREVENT CONSTIPATION constulose oral solution 1 or 1b* KRISTALOSE ORAL PACKET (lactulose) 3 LACTULOSE ORAL PACKET 1 or 1b* lactulose oral solution 1 or 1b* polyethylene glycol 3350 oral packet 17 gm 1 or 1b*; $0 polyethylene glycol 3350 oral powder 1 or 1b*; $0 *LUBRICANT LAXATIVES*** - DRUGS TO PREVENT CONSTIPATION mineral oil heavy oral oil 1 or 1b* *SALINE LAXATIVE MIXTURES*** - DRUGS TO PREVENT CONSTIPATION OSMOPREP ORAL TABLET (sod phos mono-sod phos dibasic) 3 QL (32 tablet per 30 days) *STIMULANT LAXATIVES*** - DRUGS TO PREVENT CONSTIPATION CASCARA SAGRADA ORAL FLUID EXTRACT 3 *LOCAL ANESTHETICS-PARENTERAL* - DRUGS FOR PAIN AND FEVER *LOCAL ANESTHETIC & SYMPATHOMIMETIC*** - DRUGS FOR SEDATION articadent dental injection solution cartridge 3 bupivacaine-epinephrine (pf) injection solution 1 or 1b* bupivacaine-epinephrine injection solution 1 or 1b* lidocaine-epinephrine injection solution 1 or 1b* MARCAINE/EPINEPHRINE INJECTION SOLUTION (bupivacaine- 3 epinephrine) MARCAINE/EPINEPHRINE PF INJECTION SOLUTION (bupivacaine- 3 epinephrine) ORABLOC INJECTION SOLUTION CARTRIDGE (articaine-epinephrine) 3 sensorcaine/epinephrine injection solution 1 or 1b* sensorcaine-mpf/epinephrine injection solution 0.25% -1:200000, 0.5% - 1 or 1b* 1:200000 SENSORCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 0.75- 3 1:200000 % (bupivacaine-epinephrine) XYLOCAINE/EPINEPHRINE INJECTION SOLUTION (lidocaine- 3 epinephrine) XYLOCAINE-MPF/EPINEPHRINE INJECTION SOLUTION (lidocaine- 3 epinephrine) *LOCAL ANESTHETIC COMBINATIONS*** - DRUGS FOR SEDATION LIDOCAINE-SODIUM BICARBONATE INJECTION SOLUTION 3 PREFILLED SYRINGE POINT OF CARE LM-2.5 INJECTION KIT (lidocaine hcl-bupivacaine hcl) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 142 Coverage Requirements and Prescription Drug Name Drug Tier Limits *LOCAL ANESTHETICS - AMIDES*** - DRUGS FOR SEDATION BUPIVACAINE FISIOPHARMA INJECTION SOLUTION 3 bupivacaine hcl (pf) injection solution 1 or 1b* bupivacaine hcl injection solution 0.25 %, 0.5 % 1 or 1b* BUPIVACAINE HCL-NACL EPIDURAL SOLUTION 3 BUPIVACAINE HCL-NACL EPIDURAL SOLUTION PREFILLED 3 SYRINGE bupivacaine in dextrose intrathecal solution 1 or 1b* bupivacaine spinal intrathecal solution 1 or 1b* CARBOCAINE INJECTION SOLUTION (mepivacaine hcl) 3 CARBOCAINE PRESERVATIVE-FREE INJECTION SOLUTION 3 (mepivacaine hcl) lidocaine hcl (pf) injection solution 1 or 1b* lidocaine hcl injection solution 0.5 % 1 or 1b* LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 200 3 MG/10ML lidocaine hcl intradermal jet-injector 1 or 1b* LIDOCAINE IN DEXTROSE SOLUTION 3 MARCAINE INJECTION SOLUTION (bupivacaine hcl) 3 MARCAINE PRESERVATIVE FREE INJECTION SOLUTION (bupivacaine 3 hcl) MARCAINE SPINAL INTRATHECAL SOLUTION (bupivacaine in 3 dextrose) MONOJECT BONE MARROW BIOPSY INJECTION KIT (lidocaine hcl) 3 NAROPIN INJECTION SOLUTION (ropivacaine hcl) 3 polocaine injection solution 1 or 1b* polocaine-mpf injection solution 1 or 1b* ropivacaine hcl injection solution 10 mg/ml, 5 mg/ml, 7.5 mg/ml 1 or 1b* ROPIVACAINE HCL-NACL EPIDURAL SOLUTION 3 sensorcaine injection solution 1 or 1b* sensorcaine-mpf injection solution 1 or 1b* XARACOLL IMPLANT IMPLANT (bupivacaine hcl) 3 XYLOCAINE INJECTION SOLUTION (lidocaine hcl) 3 XYLOCAINE-MPF INJECTION SOLUTION (lidocaine hcl) 3 ZINGO INTRADERMAL JET-INJECTOR (lidocaine hcl) 3 *LOCAL ANESTHETICS - ESTERS*** - DRUGS FOR SEDATION chloroprocaine hcl (pf) injection solution 1 or 1b* CLOROTEKAL INTRATHECAL SOLUTION (chloroprocaine hcl) 3 NESACAINE INJECTION SOLUTION (chloroprocaine hcl) 3 NESACAINE-MPF INJECTION SOLUTION (chloroprocaine hcl) 3 *MACROLIDES* - DRUGS FOR INFECTIONS *AZITHROMYCIN*** - ANTIBIOTICS azithromycin intravenous solution reconstituted 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 143 Coverage Requirements and Prescription Drug Name Drug Tier Limits azithromycin oral packet 1 or 1b* QL (2 packets per 30 days) azithromycin oral suspension reconstituted 100 mg/5ml 1 or 1b* QL (15 ML per 30 days) azithromycin oral suspension reconstituted 200 mg/5ml 1 or 1b* QL (15 mL per 30 days) azithromycin oral tablet 250 mg 1 or 1b* QL (6 tablets per 30 days) azithromycin oral tablet 500 mg 1 or 1b* QL (3 tablets per 30 days) azithromycin oral tablet 600 mg 1 or 1b* QL (8 tablet per 28 days) ZITHROMAX INTRAVENOUS SOLUTION RECONSTITUTED 3 (azithromycin) ZITHROMAX ORAL PACKET (azithromycin) 3 QL (2 packets per 30 days) ZITHROMAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML 3 QL (15 ML per 30 days) (azithromycin) ZITHROMAX ORAL SUSPENSION RECONSTITUTED 200 MG/5ML 3 QL (15 mL per 30 days) (azithromycin) ZITHROMAX ORAL TABLET 250 MG (azithromycin) 3 QL (6 tablets per 30 days) ZITHROMAX ORAL TABLET 500 MG (azithromycin) 3 QL (3 tablets per 30 days) ZITHROMAX TRI-PAK ORAL TABLET (azithromycin) 3 QL (3 tablets per 30 days) ZITHROMAX Z-PAK ORAL TABLET (azithromycin) 3 QL (6 tablets per 30 days) *CLARITHROMYCIN*** - ANTIBIOTICS clarithromycin er oral tablet extended release 24 hour 1 or 1b* clarithromycin oral suspension reconstituted 1 or 1b* QL (300 mL per 1 fill) clarithromycin oral tablet 1 or 1b* QL (28 tablets per 1 fill) *ERYTHROMYCINS*** - ANTIBIOTICS ery-tab oral tablet delayed release 1 or 1b* ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION 3 RECONSTITUTED (erythromycin lactobionate) erythrocin stearate oral tablet 1 or 1b* erythromycin base oral capsule delayed release particles 1 or 1b* erythromycin base oral tablet 1 or 1b* erythromycin base oral tablet delayed release 1 or 1b* erythromycin ethylsuccinate oral suspension reconstituted 1 or 1b* erythromycin ethylsuccinate oral tablet 1 or 1b* erythromycin oral tablet delayed release 1 or 1b* *FIDAXOMICIN*** - ANTIBIOTICS DIFICID ORAL SUSPENSION RECONSTITUTED (fidaxomicin) 3 DIFICID ORAL TABLET (fidaxomicin) 3 *MEDICAL DEVICES AND SUPPLIES* - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT *CERVICAL CAPS*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT FEMCAP VAGINAL DEVICE (cervical caps) 2; $0 *DENTAL DESENSITIZING PRODUCTS*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT REMESENSE DENTAL (dental desensitizing product) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 144 Coverage Requirements and Prescription Drug Name Drug Tier Limits *DENTIFRICES*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT MI PASTE DENTAL PASTE (dentifrices) 3 MI PASTE PLUS DENTAL PASTE (dentifrices) 3 *DIAPHRAGMS*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT CAYA VAGINAL DIAPHRAGM (diaphragm arc-spring) 2; $0 OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM (diaphragms) 3 WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM (diaphragm wide 2; $0 seal) WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM (diaphragm wide 2; $0 seal) WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM (diaphragm wide 2; $0 seal) WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM (diaphragm wide 2; $0 seal) WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM (diaphragm wide 2; $0 seal) WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM (diaphragm wide 2; $0 seal) WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM (diaphragm wide 2; $0 seal) WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM (diaphragm wide 2; $0 seal) *GLUCOSE MONITORING TEST SUPPLIES*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT DEXCOM G4 PLAT PED RCV/SHARE DEVICE (continuous blood gluc 2 PA; QL (1 unit per 365 days) receiver) DEXCOM G4 PLAT PED RECEIVER DEVICE (continuous blood gluc 2 PA; QL (1 unit per 365 days) receiver) DEXCOM G4 PLATINUM RCV/SHARE DEVICE (continuous blood gluc 2 PA; QL (1 unit per 365 days) receiver) DEXCOM G4 PLATINUM RECEIVER DEVICE (continuous blood gluc 2 PA; QL (1 unit per 365 days) receiver) DEXCOM G4 PLATINUM TRANSMITTER (continuous blood gluc 2 PA transmit) DEXCOM G4 SENSOR (continuous blood gluc sensor) 2 PA DEXCOM G5 MOB/G4 PLAT SENSOR (continuous blood gluc sensor) 2 PA; QL (5 units per 30 days) DEXCOM G5 MOBILE RECEIVER DEVICE (continuous blood gluc 2 PA; QL (1 unit per 365 days) receiver) DEXCOM G5 MOBILE TRANSMITTER (continuous blood gluc transmit) 2 PA; QL (1 unit per 90 days) DEXCOM G5 RECEIVER KIT DEVICE (continuous blood gluc receiver) 2 PA; QL (1 unit per 365 days) DEXCOM G6 RECEIVER DEVICE (continuous blood gluc receiver) 2 PA; QL (1 unit per 365 days) DEXCOM G6 SENSOR (continuous blood gluc sensor) 2 PA; QL (3 units per 30 days) DEXCOM G6 TRANSMITTER (continuous blood gluc transmit) 2 PA; QL (1 unit per 90 days) ENLITE GLUCOSE SENSOR (continuous blood gluc sensor) 3 PA

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 145 Coverage Requirements and Prescription Drug Name Drug Tier Limits EVERSENSE SENSOR/HOLDER (continuous blood gluc sensor) 3 PA EVERSENSE SMART TRANSMITTER (continuous blood gluc transmit) 3 PA; QL (1 unit per 365 days) FREESTYLE LIBRE 14 DAY READER DEVICE (continuous blood gluc 2 PA; QL (1 unit per 365 days) receiver) FREESTYLE LIBRE 14 DAY SENSOR (continuous blood gluc sensor) 2 PA; QL (2 units per 28 days) FREESTYLE LIBRE 2 READER DEVICE (continuous blood gluc receiver) 2 PA; QL (1 reader per 1 year) FREESTYLE LIBRE 2 SENSOR (continuous blood gluc sensor) 2 PA; QL (2 units per 28 days) FREESTYLE LIBRE READER DEVICE (continuous blood gluc receiver) 2 PA; QL (1 unit per 365 days) FREESTYLE LIBRE SENSOR SYSTEM (continuous blood gluc sensor) 2 PA; QL (2 units per 28 days) GUARDIAN CONNECT TRANSMITTER (continuous blood gluc transmit) 3 PA; QL (2 units per 365 days) GUARDIAN LINK 3 TRANSMITTER (continuous blood gluc transmit) 3 PA GUARDIAN REAL-TIME REPLACE PED DEVICE (continuous blood gluc 3 PA; QL (1 unit per 365 days) receiver) GUARDIAN SENSOR (3) (continuous blood gluc sensor) 3 PA; QL (5 units per 30 days) GUARDIAN SENSOR 3 3 PA; QL (5 units per 30 days) MINILINK REAL-TIME TRANSMITTER (continuous blood gluc transmit) 3 PA MINIMED 630G GUARDIAN PRESS (continuous blood gluc transmit) 3 PA MINIMED GUARDIAN LINK 3 (continuous blood gluc transmit) 3 PA PARADIGM REAL-TIME TRANSMITTER (continuous blood gluc 3 PA transmit) *INSULIN ADMINISTRATION SUPPLIES*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT OMNIPOD 5 PACK (insulin disposable pump) 2 PA; QL (15 pods per 30 days) OMNIPOD DASH 5 PACK PODS (insulin disposable pump) 2 PA; QL (15 pods per 30 days) OMNIPOD STARTER KIT (insulin disposable pump) 2 PA; QL (1 unit per 4 yearss) *NEEDLES & SYRINGES*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT ASSURE ID INSULIN SAFETY SYR (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) BD INSULIN SYRINGE U-500 (insulin syringe/needle u-500) 2 QL (200 syringes per 30 days) BD PEN NEEDLE NANO U/F (insulin pen needle) 2 ST; QL (200 needles per 30 days) BD SAFETYGLIDE INSULIN SYRINGE 31G X 15/64" 0.3 ML (insulin 2 ST; QL (200 syringes per 30 days) syringe-needle u-100) DROPLET PEN NEEDLES 30G X 8 MM (insulin pen needle) 3 ST; QL (200 needles per 30 days) MAGELLAN INSULIN SAFETY SYR (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) MARATHON MEDICAL PENTIPS (insulin pen needle) 3 ST; QL (200 needles per 30 days) MONOJECT INSULIN SYRINGE 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 3 ST; QL (200 syringes per 30 days) 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML (insulin syringe-needle u-100) MONOJECT INSULIN SYRINGE U-100 1 ML (insulin syringes 3 ST; QL (200 syringes per 30 days) (disposable)) MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML (insulin syringe-needle u- 3 ST; QL (200 syringes per 30 days) 100)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 146 Coverage Requirements and Prescription Drug Name Drug Tier Limits PENTIPS 29G X 12MM , 31G X 5 MM , 31G X 8 MM , 32G X 4 MM 3 ST; QL (200 needles per 30 days) (insulin pen needle) PRO COMFORT PEN NEEDLES 31G X 8 MM , 32G X 4 MM , 32G X 5 3 ST; QL (200 needles per 30 days) MM ULTICARE INSULIN SAFETY SYR (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ULTILET INSULIN SYRINGE 31G X 15/64" 0.3 ML (insulin syringe-needle 3 ST; QL (200 syringes per 30 days) u-100) *MIGRAINE PRODUCTS* - DRUGS FOR THE NERVOUS SYSTEM *CALCITONIN GENE-RELATED PEPTIDE RECEPTOR ANTAG (CGRP)*** - DRUGS FOR MIGRAINE HEADACHES NURTEC ORAL TABLET DISPERSIBLE (rimegepant sulfate) 2 PA; QL (8 tablets per 30 days) *CGRP RECEPTOR ANTAGONISTS - MONOCOLONAL ANTIBODIES*** - DRUGS FOR MIGRAINE HEADACHES AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR (erenumab- 3 QL (1 autoinjector per 30 days) aooe) EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED 3 QL (1 syringe per 30 days) SYRINGE (galcanezumab-gnlm) EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 QL (1 pen per 30 days) (galcanezumab-gnlm) EMGALITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 QL (1 syringe per 30 days) (galcanezumab-gnlm) *ERGOT COMBINATIONS*** - DRUGS FOR MIGRAINE HEADACHES ergotamine-caffeine oral tablet 1 or 1b* migergot rectal suppository 1 or 1b* *MIGRAINE PRODUCTS*** - DRUGS FOR MIGRAINE HEADACHES dihydroergotamine mesylate injection solution 1 or 1b* PA *SELECTIVE SEROTONIN AGONIST-NSAID COMBINATIONS*** - DRUGS FOR MIGRAINE HEADACHES sumatriptan-naproxen sodium oral tablet 1 or 1b* ST; QL (9 tablets per 30 days) *SELECTIVE SEROTONIN AGONISTS 5-HT(1)*** - DRUGS FOR MIGRAINE HEADACHES almotriptan malate oral tablet 1 or 1b* QL (9 tablets per 30 days) eletriptan hydrobromide oral tablet 1 or 1b* QL (9 tablets per 30 days) frovatriptan succinate oral tablet 1 or 1b* ST; QL (9 tablets per 30 days) naratriptan hcl oral tablet 1 or 1b* QL (9 tablets per 30 days) rizatriptan benzoate oral tablet 1 or 1b* QL (9 tablets per 30 days) rizatriptan benzoate oral tablet dispersible 1 or 1b* QL (9 tablets per 30 days) sumatriptan nasal solution 1 or 1b* QL (6 nasal inhalers per 30 days) sumatriptan succinate oral tablet 1 or 1b* QL (9 tablets per 30 days) sumatriptan succinate refill subcutaneous solution cartridge 1 or 1b* QL (6 cartridges per 30 days) sumatriptan succinate subcutaneous solution 1 or 1b* QL (5 vials per 30 days) sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml 1 or 1b* QL (6 syringes (2 ML) per 30 days) sumatriptan succinate subcutaneous solution auto-injector 6 mg/0.5ml 1 or 1b* QL (6 cartridges (2ml) per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 147 Coverage Requirements and Prescription Drug Name Drug Tier Limits ST; QL (6 nasal inhalers per 30 zolmitriptan nasal solution 1 or 1b* days) zolmitriptan oral tablet 1 or 1b* QL (9 tablets per 30 days) zolmitriptan oral tablet dispersible 1 or 1b* QL (9 tablets per 30 days) *MINERALS & ELECTROLYTES* - DRUGS FOR NUTRITION *BICARBONATES*** - DRUGS FOR NUTRITION SODIUM ACETATE INTRAVENOUS SOLUTION 2 MEQ/ML 3 sodium bicarbonate intravenous solution 7.5 % 1 or 1b* THAM INTRAVENOUS SOLUTION (tromethamine) 3 *CALCIUM COMBINATIONS*** - DRUGS FOR NUTRITION CALCIUM GLUCONATE-NACL INTRAVENOUS SOLUTION 3 *CALCIUM*** - DRUGS FOR NUTRITION CALCIUM GLUCONATE INTRAVENOUS SOLUTION 3 *ELECTROLYTES & DEXTROSE*** - DRUGS FOR NUTRITION DEXTROSE 5%/ELECTROLYTE #48 INTRAVENOUS SOLUTION 3 dextrose in lactated ringers intravenous solution 1 or 1b* DEXTROSE-NACL INTRAVENOUS SOLUTION 10-0.2 %, 2.5-0.45 % 3 dextrose-nacl intravenous solution 10-0.45 %, 5-0.2 %, 5-0.33 %, 5-0.45 %, 1 or 1b* 5-0.9 % dextrose-sodium chloride intravenous solution 2.5-0.45 %, 5-0.45 %, 5-0.9 % 1 or 1b* DEXTROSE-SODIUM CHLORIDE INTRAVENOUS SOLUTION 5-0.225 3 %, 5-0.3 % ELLIOTTS B INTRATHECAL SOLUTION (intrathecal elec-dextrose) 3 IONOSOL-MB IN D5W INTRAVENOUS SOLUTION (electrolyte-mb in 3 dextrose) ISOLYTE-P IN D5W INTRAVENOUS SOLUTION (electrolyte-p in 3 dextrose) kcl in dextrose-nacl intravenous solution 10-5-0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.45 meq/l-%-%, 20-5-0.9 meq/l-%-%, 30-5-0.45 meq/l-%- 1 or 1b* %, 40-5-0.45 meq/l-%-% KCL IN DEXTROSE-NACL INTRAVENOUS SOLUTION 20-5-0.225 3 MEQ/L-%-%, 40-5-0.9 MEQ/L-%-% KCL-LACTATED RINGERS-D5W INTRAVENOUS SOLUTION 3 NORMOSOL-M IN D5W INTRAVENOUS SOLUTION (electrolyte-m in 3 dextrose) NORMOSOL-R IN D5W INTRAVENOUS SOLUTION (electrolyte-r in 3 dextrose) potassium chloride in dextrose intravenous solution 1 or 1b* *ELECTROLYTES PARENTERAL*** - DRUGS FOR NUTRITION ISOLYTE-S INTRAVENOUS SOLUTION (electrolyte-s) 3 ISOLYTE-S PH 7.4 INTRAVENOUS SOLUTION (electrolyte-s (ph 7.4)) 3 KCL (IN NACL 0.9%) INTRAVENOUS SOLUTION 3 lactated ringers intravenous solution 1 or 1b* NORMOSOL-R INTRAVENOUS SOLUTION (electrolyte-r) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 148 Coverage Requirements and Prescription Drug Name Drug Tier Limits NORMOSOL-R PH 7.4 INTRAVENOUS SOLUTION (electrolyte-r (ph 7.4)) 3 PLASMA-LYTE 148 INTRAVENOUS SOLUTION (electrolyte-148) 3 PLASMA-LYTE A INTRAVENOUS SOLUTION (electrolyte-a) 3 POTASSIUM CHLORIDE IN NACL INTRAVENOUS SOLUTION 20-0.45 3 MEQ/L-%, 40-0.9 MEQ/L-% potassium chloride in nacl intravenous solution 20-0.9 meq/l-% 1 or 1b* ringers intravenous solution 1 or 1b* TPN ELECTROLYTES INTRAVENOUS CONCENTRATE (parenteral 3 electrolytes) *FLUORIDE COMBINATIONS*** - DRUGS FOR NUTRITION FLORIVA ORAL LIQUID (sodium fluoride-vitamin d) 3 *FLUORIDE*** - DRUGS FOR NUTRITION fluoritab oral solution 1 or 1a*; $0 nafrinse drops oral solution 1 or 1a*; $0 nafrinse oral tablet chewable 1 or 1a*; $0 sodium fluoride oral solution 1.1 (0.5 f) mg/ml 1 or 1a*; $0 QL (2 mL per 1 day) sodium fluoride oral tablet 1 or 1a*; $0 sodium fluoride oral tablet chewable 1 or 1a*; $0 *MAGNESIUM*** - DRUGS FOR NUTRITION MAGNESIUM SULFATE IN D5W INTRAVENOUS SOLUTION 3 MAGNESIUM SULFATE INTRAVENOUS SOLUTION 3 *MANGANESE*** - DRUGS FOR NUTRITION manganese chloride intravenous solution 1 or 1b* *PHOSPHATE*** - DRUGS FOR NUTRITION K-PHOS ORAL TABLET (potassium phosphate monobasic) 2 K-PHOS-NEUTRAL ORAL TABLET (k phos mono-sod phos di & mono) 3 phosphorous oral tablet 1 or 1b* phospho-trin 250 neutral oral tablet 1 or 1b* POTASSIUM PHOSPHATES INTRAVENOUS SOLUTION 15 3 MMOLE/5ML, 150 MMOLE/50ML potassium phosphates intravenous solution 45 mmole/15ml 1 or 1b* potassium phosphates(66 meq k) intravenous solution 1 or 1b* POTASSIUM PHOSPHATES(71 MEQ K) INTRAVENOUS SOLUTION 3 sodium phosphates intravenous solution 15 mmole/5ml 1 or 1b* virt-phos 250 neutral oral tablet 1 or 1b* *POTASSIUM*** - DRUGS FOR NUTRITION klor-con 10 oral tablet extended release 1 or 1b* klor-con m10 oral tablet extended release 1 or 1a* klor-con m15 oral tablet extended release 1 or 1a* klor-con m20 oral tablet extended release 1 or 1a* klor-con oral packet 1 or 1b* klor-con oral tablet extended release 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 149 Coverage Requirements and Prescription Drug Name Drug Tier Limits K-TAB ORAL TABLET EXTENDED RELEASE (potassium chloride) 3 potassium acetate intravenous solution 1 or 1b* potassium chloride crys er oral tablet extended release 10 meq, 20 meq 1 or 1a* potassium chloride er oral capsule extended release 1 or 1b* potassium chloride er oral tablet extended release 1 or 1b* POTASSIUM CHLORIDE INTRAVENOUS SOLUTION 10 MEQ/100ML, 3 10 MEQ/50ML, 20 MEQ/100ML, 20 MEQ/50ML, 40 MEQ/100ML potassium chloride intravenous solution 2 meq/ml 1 or 1b* potassium chloride oral packet 1 or 1b* potassium chloride oral solution 1 or 1b* *SODIUM*** - DRUGS FOR NUTRITION monoject flush syringe intravenous solution 1 or 1b* QL (200 syringes per 30 days) monoject sodium chloride flush intravenous solution 1 or 1b* normal saline flush intravenous solution 1 or 1b* sodium chloride flush intravenous solution 1 or 1b* sodium chloride injection solution 1 or 1b* sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 5 % 1 or 1b* *TRACE MINERAL COMBINATIONS*** - DRUGS FOR NUTRITION THE LIQUILIFT TRACE INTRAVENOUS KIT (trace minerals cr-cu-mn-se- 3 zn) TRALEMENT INTRAVENOUS SOLUTION (trace minerals cu-mn-se-zn) 3 *TRACE MINERALS*** - DRUGS FOR NUTRITION chromic chloride intravenous solution 1 or 1b* cupric chloride intravenous solution 1 or 1b* SELENIOUS ACID INTRAVENOUS SOLUTION 3 *ZINC*** - DRUGS FOR NUTRITION GALZIN ORAL CAPSULE (zinc acetate (oral)) 3 WILZIN ORAL CAPSULE (zinc acetate (oral)) 3 zinc chloride intravenous solution 1 or 1b* zinc sulfate intravenous solution 3 mg/ml, 5 mg/ml 1 or 1b* *MISCELLANEOUS THERAPEUTIC CLASSES* - VITAMINS AND MINERALS *ANTILEPROTICS*** - VITAMINS AND MINERALS PA; LD; SP; QL (1 capsule per 1 THALOMID ORAL CAPSULE 100 MG, 50 MG (thalidomide) 2; OC day) PA; LD; SP; QL (2 capsules per 1 THALOMID ORAL CAPSULE 150 MG, 200 MG (thalidomide) 2; OC day) *B-LYMPHOCYTE STIMULATOR (BLYS)-SPECIFIC INHIBITORS*** - VITAMINS AND MINERALS BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED (belimumab) 4 PA; LD; SP BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; LD; SP; QL (4 autoinjectors per 4 (belimumab) 28 days) BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; SP; QL (4 pens per 28 4 (belimumab) days) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 150 Coverage Requirements and Prescription Drug Name Drug Tier Limits *CHELATING AGENTS*** - VITAMINS AND MINERALS clovique oral capsule 1 or 1b* PA; SP; QL (8 capsules per 1 day) DEPEN TITRATABS ORAL TABLET (penicillamine) 3 PA; QL (8 tablets per 1 day) EDETATE DISODIUM INTRAVENOUS SOLUTION 3 penicillamine oral capsule 1 or 1b* PA; QL (8 capsules per 1 day) penicillamine oral tablet 1 or 1b* PA; QL (8 tablets per 1 day) trientine hcl oral capsule 1 or 1b* PA; SP; QL (8 capsules per 1 day) *CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT) SOLUTIONS*** - VITAMINS AND MINERALS PHOXILLUM B22K4/0 INTRAVENOUS SOLUTION 3 PHOXILLUM BK4/2.5 INTRAVENOUS SOLUTION 3 PRISMASOL B22GK 4/0 INTRAVENOUS SOLUTION (bicarb-dextrose-k 3 (crrt)) PRISMASOL BGK 0/2.5 INTRAVENOUS SOLUTION (bicarb-dextrose-ca 3 (crrt)) PRISMASOL BGK 2/0 INTRAVENOUS SOLUTION (bicarb-dextrose-k 3 (crrt)) PRISMASOL BGK 2/3.5 INTRAVENOUS SOLUTION (bicarb-dextrose-k-ca 3 (crrt)) PRISMASOL BGK 4/0/1.2 INTRAVENOUS SOLUTION (bicarb-dextose-k- 3 mg (crrt)) PRISMASOL BGK 4/2.5 INTRAVENOUS SOLUTION (bicarb-dextrose-k-ca 3 (crrt)) PRISMASOL BK 0/0/1.2 INTRAVENOUS SOLUTION (bicarb-mg (crrt)) 3 *CYCLOSPORINE ANALOGS*** - VITAMINS AND MINERALS cyclosporine intravenous solution 1 or 1b* SP cyclosporine modified oral capsule 1 or 1b* cyclosporine modified oral solution 1 or 1b* cyclosporine oral capsule 1 or 1b* gengraf oral capsule 1 or 1b* gengraf oral solution 1 or 1b* LUPKYNIS ORAL CAPSULE (voclosporin) 4 PA; LD; QL (6 capsules per 1 day) NEORAL ORAL CAPSULE (cyclosporine modified) 3 NEORAL ORAL SOLUTION (cyclosporine modified) 3 SANDIMMUNE INTRAVENOUS SOLUTION (cyclosporine) 3 SP SANDIMMUNE ORAL CAPSULE (cyclosporine) 3 SANDIMMUNE ORAL SOLUTION (cyclosporine) 3 *ENZYMES*** - VITAMINS AND MINERALS AMPHADASE INJECTION SOLUTION (hyaluronidase bovine) 3 HYLENEX INJECTION SOLUTION (hyaluronidase human) 3 VITRASE INJECTION SOLUTION (hyaluronidase ovine) 3 XIAFLEX INJECTION SOLUTION RECONSTITUTED (collagenase 4 PA; LD clostrid histolyt)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 151 Coverage Requirements and Prescription Drug Name Drug Tier Limits *FARNESYLTRANSFERASE INHIBITORS*** - VITAMINS AND MINERALS ZOKINVY ORAL CAPSULE (lonafarnib) 4 PA; LD; QL (4 capsules per 1 day) *FECAL INCONTINENCE BULKING AGENT - COMBINATIONS*** - VITAMINS AND MINERALS SOLESTA INJECTION GEL (dextranomer-sodium hyaluronate) 4 LD; SP *IMMUNE GLOBULIN IMMUNOSUPPRESSANTS*** - VITAMINS AND MINERALS ATGAM INTRAVENOUS INJECTABLE (lymphocyte,anti-thymo imm glob) 3 SP THYMOGLOBULIN INTRAVENOUS SOLUTION RECONSTITUTED 3 SP (anti-thymocyte glob (rabbit)) *IMMUNOMODULATORS FOR MYELODYSPLASTIC SYNDROMES*** - VITAMINS AND MINERALS PA; LD; SP; QL (1 capsule per 1 REVLIMID ORAL CAPSULE (lenalidomide) 2; OC day) *INOSINE MONOPHOSPHATE DEHYDROGENASE INHIBITORS*** - VITAMINS AND MINERALS CELLCEPT INTRAVENOUS INTRAVENOUS SOLUTION 3 SP RECONSTITUTED (mycophenolate mofetil hcl) CELLCEPT ORAL CAPSULE (mycophenolate mofetil) 3 CELLCEPT ORAL SUSPENSION RECONSTITUTED (mycophenolate 3 mofetil) CELLCEPT ORAL TABLET (mycophenolate mofetil) 3 mycophenolate mofetil hcl intravenous solution reconstituted 1 or 1b* SP mycophenolate mofetil intravenous solution reconstituted 1 or 1b* SP mycophenolate mofetil oral capsule 1 or 1b* mycophenolate mofetil oral suspension reconstituted 1 or 1b* mycophenolate mofetil oral tablet 1 or 1b* mycophenolate sodium oral tablet delayed release 1 or 1b* MYFORTIC ORAL TABLET DELAYED RELEASE (mycophenolate 3 sodium) *INTERLEUKIN-6 (IL-6) ANTAGONISTS*** - VITAMINS AND MINERALS SYLVANT INTRAVENOUS SOLUTION RECONSTITUTED (siltuximab) 4 PA; LD; SP *IRRIGATION SOLUTIONS*** - VITAMINS AND MINERALS argyle sterile water irrigation solution 1 or 1b* lactated ringers irrigation solution 1 or 1b* physiolyte irrigation solution 1 or 1b* physiosol irrigation irrigation solution 1 or 1b* ringers irrigation irrigation solution 1 or 1b* sterile water for irrigation irrigation solution 1 or 1b* tis-u-sol irrigation solution 1 or 1b* water for irrigation, sterile irrigation solution 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 152 Coverage Requirements and Prescription Drug Name Drug Tier Limits *MACROLIDE IMMUNOSUPPRESSANTS*** - VITAMINS AND MINERALS ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 (tacrolimus) ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 (tacrolimus) everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg 1 or 1b* PROGRAF INTRAVENOUS SOLUTION (tacrolimus) 2 SP PROGRAF ORAL CAPSULE (tacrolimus) 3 PROGRAF ORAL PACKET (tacrolimus) 3 RAPAMUNE ORAL SOLUTION (sirolimus) 3 RAPAMUNE ORAL TABLET (sirolimus) 3 sirolimus oral solution 1 or 1b* sirolimus oral tablet 1 or 1b* tacrolimus oral capsule 1 or 1b* ZORTRESS ORAL TABLET (everolimus) 3 *MISCELLANEOUS THERAPEUTIC CLASSES*** - VITAMINS AND MINERALS NEXAVIR INJECTION SOLUTION (liver derivative complex) 3 *MONOCLONAL ANTIBODIES*** - VITAMINS AND MINERALS ENSPRYNG SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; SP; QL (1 syringe per 28 4 (satralizumab-mwge) days) GAMIFANT INTRAVENOUS SOLUTION (emapalumab-lzsg) 3 PA; LD; SP SIMULECT INTRAVENOUS SOLUTION RECONSTITUTED (basiliximab) 3 UPLIZNA INTRAVENOUS SOLUTION (inebilizumab-cdon) 4 PA; LD; QL (30 mL per 180 days) *PERITONEAL DIALYSIS SOLUTIONS*** - VITAMINS AND MINERALS DELFLEX-LC/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DELFLEX-LC/2.5% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DELFLEX-LC/4.25% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DELFLEX-SM/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 2 (peritoneal dialysis solutions) DELFLEX-SM/2.5% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DIANEAL LOW CALCIUM/1.5% DEX INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DIANEAL LOW CALCIUM/2.5% DEX INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DIANEAL LOW CALCIUM/4.25% DEX INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DIANEAL PD-2/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 153 Coverage Requirements and Prescription Drug Name Drug Tier Limits DIANEAL PD-2/2.5% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DIANEAL PD-2/4.25% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) EXTRANEAL INTRAPERITONEAL SOLUTION (icodextrin-electrolytes) 3 ULTRABAG/DIANEAL PD-2/1.5% DEX INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) ULTRABAG/DIANEAL PD-2/2.5% DEX INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) ULTRABAG/DIANEAL PD-2/4.25%DEX INTRAPERITONEAL 3 SOLUTION (peritoneal dialysis solutions) ULTRABAG/DIANEAL/1.5% DEXTROSE INTRAPERITONEAL 3 SOLUTION (peritoneal dialysis solutions) ULTRABAG/DIANEAL/2.5% DEXTROSE INTRAPERITONEAL 3 SOLUTION (peritoneal dialysis solutions) ULTRABAG/DIANEAL/4.25% DEX INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) *POTASSIUM REMOVING AGENTS*** - VITAMINS AND MINERALS LOKELMA ORAL PACKET (sodium zirconium cyclosilicate) 3 sodium polystyrene sulfonate oral powder 1 or 1b* sps oral suspension 1 or 1b* VELTASSA ORAL PACKET (patiromer sorbitex calcium) 3 LD *PROSTAGLANDINS*** - VITAMINS AND MINERALS alprostadil injection solution 1 or 1b* PROSTIN VR INJECTION SOLUTION (alprostadil) 3 *PURINE ANALOGS*** - VITAMINS AND MINERALS AZASAN ORAL TABLET (azathioprine) 3 azathioprine oral tablet 1 or 1b* AZATHIOPRINE SODIUM INJECTION SOLUTION RECONSTITUTED 3 IMURAN ORAL TABLET (azathioprine) 3 *SCLEROSING AGENTS*** - VITAMINS AND MINERALS ASCLERA INTRAVENOUS SOLUTION (polidocanol) 3 ETHAMOLIN INTRAVENOUS SOLUTION (ethanolamine oleate) 3 sodium tetradecyl sulfate intravenous solution 1 or 1b* SOTRADECOL INTRAVENOUS SOLUTION 1 % (sodium tetradecyl 3 sulfate) sotradecol intravenous solution 3 % 1 or 1b* VARITHENA INTRAVENOUS FOAM (polidocanol) 3 LD *SELECTIVE T-CELL COSTIMULATION BLOCKERS*** - VITAMINS AND MINERALS NULOJIX INTRAVENOUS SOLUTION RECONSTITUTED (belatacept) 3 PA; SP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 154 Coverage Requirements and Prescription Drug Name Drug Tier Limits *MOUTH/THROAT/DENTAL AGENTS* - DRUGS FOR THE MOUTH AND THROAT *ANESTHETICS TOPICAL ORAL*** - DRUGS FOR THE MOUTH AND THROAT lidocaine hcl mouth/throat solution 1 or 1a* QL (10 mL per 1 day) lidocaine viscous hcl mouth/throat solution 1 or 1a* QL (10 mL per 1 day) *ANTI-INFECTIVES - THROAT*** - DRUGS FOR THE MOUTH AND THROAT clotrimazole mouth/throat troche 1 or 1b* QL (5 tablet per 1 day) nystatin mouth/throat suspension 1 or 1b* QL (750 mL per 30 days) ORAVIG BUCCAL TABLET (miconazole) 3 *ANTISEPTICS - MOUTH/THROAT*** - DRUGS FOR THE MOUTH AND THROAT chlorhexidine gluconate mouth/throat solution 1 or 1a* QL (480 mL per 30 days) PERIDEX MOUTH/THROAT SOLUTION (chlorhexidine gluconate) 3 QL (480 mL per 30 days) periogard mouth/throat solution 1 or 1a* QL (480 mL per 30 days) *DENTAL PRODUCTS - COMBINATIONS*** - DRUGS FOR THE MOUTH AND THROAT fluoridex sensitivity relief dental paste 1 or 1b* NAFRINSE DAILY ACIDULATED MOUTH/THROAT SOLUTION 3 RECONSTITUTED (sodium fluoride-phosphoric acd) PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE (sod fluoride- 3 potassium nitrate) PREVIDENT 5000 SENSITIVE DENTAL PASTE (sod fluoride-potassium 3 nitrate) sodium fluoride 5000 enamel dental paste 1 or 1b* sodium fluoride 5000 sensitive dental paste 1 or 1b* *FLUORIDE DENTAL PRODUCTS*** - DRUGS FOR THE MOUTH AND THROAT cavarest dental gel 1 or 1b* clinpro 5000 dental paste 1 or 1b* denta 5000 plus dental cream 1 or 1b* dentagel dental gel 1 or 1a* easygel dental gel 1 or 1b* fluoridex daily renewal mouth/throat concentrate 1 or 1b* fluoridex dental paste 1 or 1b* fluoridex enhanced whitening dental paste 1 or 1b* NAFRINSE DAILY/NEUTRAL MOUTH/THROAT SOLUTION 3 RECONSTITUTED (sodium fluoride) NAFRINSE WEEKLY MOUTH/THROAT SOLUTION RECONSTITUTED 3 (sodium fluoride) PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE (sodium fluoride) 3 PREVIDENT 5000 DRY MOUTH DENTAL GEL (sodium fluoride) 3 PREVIDENT 5000 ORTHO DEFENSE DENTAL PASTE (sodium fluoride) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 155 Coverage Requirements and Prescription Drug Name Drug Tier Limits PREVIDENT 5000 PLUS DENTAL CREAM (sodium fluoride) 3 PREVIDENT DENTAL GEL (sodium fluoride) 3 PREVIDENT MOUTH/THROAT SOLUTION (sodium fluoride) 3 sf 5000 plus dental cream 1 or 1b* sf dental gel 1 or 1a* sodium fluoride 5000 plus dental cream 1 or 1b* sodium fluoride 5000 ppm dental cream 1 or 1b* sodium fluoride 5000 ppm dental paste 1 or 1b* sodium fluoride dental cream 1 or 1b* sodium fluoride dental gel 1 or 1b* sodium fluoride mouth/throat solution 1 or 1a* *SALIVA STIMULANTS*** - DRUGS FOR THE MOUTH AND THROAT cevimeline hcl oral capsule 1 or 1b* EVOXAC ORAL CAPSULE (cevimeline hcl) 3 pilocarpine hcl oral tablet 1 or 1b* QL (4 tablets per 1 day) SALAGEN ORAL TABLET (pilocarpine hcl) 3 QL (4 tablets per 1 day) *STEROIDS - MOUTH/THROAT/DENTAL*** - DRUGS FOR THE MOUTH AND THROAT oralone mouth/throat paste 1 or 1b* triamcinolone acetonide mouth/throat paste 1 or 1b* *MULTIVITAMINS* - DRUGS FOR NUTRITION *B-COMPLEX VITAMINS*** - DRUGS FOR NUTRITION B-COMPLEX INJECTION INJECTABLE 3 *BIOFLAVONOID PRODUCTS*** - DRUGS FOR NUTRITION ADRENAL C FORMULA ORAL TABLET (bioflavonoid products) 3 *MULTIPLE VITAMINS & FLUORIDE-FOLIC ACID*** - DRUGS FOR NUTRITION MULTIVITAMIN/FLUORIDE ORAL TABLET CHEWABLE 0.25-0.3 MG, 3 0.5-0.3 MG, 1-0.3 MG *MULTIPLE VITAMINS W/ MINERALS & CALCIUM-FOLIC ACID*** - DRUGS FOR NUTRITION FOLGARD OS ORAL TABLET (multiple vit-min-calcium-fa) 3 *MULTIPLE VITAMINS W/ MINERALS & FLUORIDE-IRON-FOLIC ACID*** - DRUGS FOR NUTRITION QUFLORA FE ORAL TABLET CHEWABLE (multi vit-min-fluoride-fe-fa) 3 *MULTIPLE VITAMINS W/ MINERALS*** - DRUGS FOR NUTRITION VENEXA ORAL TABLET (multiple vitamins-minerals) 3 VITRANOL FE ORAL TABLET (multiple vitamins-minerals) 3 ZYVANA ORAL CAPSULE 3 *MULTIVITAMINS*** - DRUGS FOR NUTRITION INFUVITE ADULT INTRAVENOUS INJECTABLE (multiple vitamin) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 156 Coverage Requirements and Prescription Drug Name Drug Tier Limits M.V.I. ADULT INTRAVENOUS INJECTABLE (multiple vitamin) 3 *PED MULTI VITAMINS W/FL & FE*** - DRUGS FOR NUTRITION multi-vit/iron/fluoride oral solution 1 or 1b* multi-vitamin/fluoride/iron oral solution 1 or 1b* POLY-VI-FLOR/IRON ORAL SUSPENSION (ped multivitamins-fl-iron) 3 POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE (ped multivitamins-fl- 3 iron) QUFLORA FE PEDIATRIC ORAL LIQUID (ped multivitamins-fl-iron) 3 *PED MV W/ FLUORIDE*** - DRUGS FOR NUTRITION FLORIVA PLUS ORAL SOLUTION (pediatric multivitamins-fl) 3 multivitamin/fluoride oral solution 1 or 1b*; $0 multi-vitamin/fluoride oral solution 1 or 1b*; $0 multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg 1 or 1b*; $0 POLY-VI-FLOR ORAL SUSPENSION (pediatric multivitamins-fl) 3 POLY-VI-FLOR ORAL TABLET CHEWABLE (pediatric multivitamins-fl) 3 QUFLORA GUMMIES ORAL TABLET CHEWABLE (pediatric 2 multivitamins-fl) QUFLORA PEDIATRIC ORAL SOLUTION (pediatric multivitamins-fl) 3 QUFLORA PEDIATRIC ORAL TABLET CHEWABLE (pediatric 3 multivitamins-fl) *PED VITAMINS ACD & FA W/ FLUORIDE*** - DRUGS FOR NUTRITION TRI-VI-FLOR ORAL SUSPENSION (ped vit a-c-d-methylfolate-fl) 3 TRI-VI-FLORO ORAL SUSPENSION 3 *PED VITAMINS ACD W/ FLUORIDE*** - DRUGS FOR NUTRITION adc/f (0.5mg/ml) oral solution 1 or 1b*; $0 tri-vite/fluoride oral solution 1 or 1b*; $0 vitamins acd-fluoride oral solution 1 or 1b*; $0 *PEDIATRIC MULTIPLE VITAMINS & MINERALS W/ FLUORIDE*** - DRUGS FOR NUTRITION FLORIVA ORAL TABLET CHEWABLE (ped multiple vit-minerals-fl) 3 *PEDIATRIC MULTIPLE VITAMINS*** - DRUGS FOR NUTRITION INFUVITE PEDIATRIC INTRAVENOUS SOLUTION (pediatric multiple 3 vitamins) M.V.I. PEDIATRIC INTRAVENOUS SOLUTION RECONSTITUTED 3 (pediatric multiple vitamins) *PRENATAL MV & MIN W/FE-FA*** - DRUGS FOR NUTRITION ATABEX EC ORAL TABLET DELAYED RELEASE (prenatal vit-dss-fe 3 QL (1 tablet per 1 day) cbn-fa) ATABEX OB ORAL TABLET (prenatal vit w/ fe bisg-fa) 3 QL (1 tablet per 1 day) AZESCHEW PRENATAL/POSTNATAL ORAL TABLET CHEWABLE 3 ST; QL (1 tablet per 1 day) AZESCO ORAL TABLET 3 ST; QL (1 tablet per 1 day) CITRANATAL B-CALM ORAL (prenat w/o a fecbnfeglu-fa &b6) 3 QL (3 EA per 1 day) CITRANATAL BLOOM ORAL TABLET (prenatal-dss-fecb-fegl-fa) 3 ST; QL (2 tablets per 1 day) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 157 Coverage Requirements and Prescription Drug Name Drug Tier Limits CITRANATAL RX ORAL TABLET (prenat w/o a-fecb-fegl-dss-fa) 3 ST; QL (1 tablet per 1 day) C-NATE DHA ORAL CAPSULE 3 QL (1 capsule per 1 day) COMPLETENATE ORAL TABLET CHEWABLE 2 QL (1 tablet per 1 day) CO-NATAL FA ORAL TABLET (prenatal vit-fe fumarate-fa) 3 QL (1 tablet per 1 day) CONCEPT DHA ORAL CAPSULE (prenat-fefum-fepo-fa-omega 3) 3 QL (1 capsule per 1 day) CONCEPT OB ORAL CAPSULE (prenat w/o a vit-fefum-fepo-fa) 3 QL (1 capsule per 1 day) DUET DHA 400 ORAL (prenat-fepoly-fered-fa-omega 3) 3 ST; QL (2 units per 1 day) DUET DHA BALANCED ORAL (prenat-fepoly-fered-fa-omega 3) 3 ST; QL (2 units per 1 day) elite-ob oral tablet 1 or 1b* QL (1 tablet per 1 day) ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa-omega) 3 ST; QL (1 capsule per 1 day) FOLIVANE-OB ORAL CAPSULE (prenat w/o a vit-fefum-fepo-fa) 2 QL (1 capsule per 1 day) inatal gt oral tablet 1 or 1b* QL (1 tablet per 1 day) JENLIVA PRENATAL/POSTNATAL ORAL CAPSULE 2 QL (1 capsule per 1 day) KOSHER PRENATAL PLUS IRON ORAL TABLET 3 ST; QL (1 tablet per 1 day) M-NATAL PLUS ORAL TABLET 3 QL (1 tablet per 1 day) MYNATAL ORAL CAPSULE (prenatal multivit-min-fe-fa) 3 QL (1 capsule per 1 day) MYNATAL PLUS ORAL TABLET 2 QL (1 tablet per 1 day) MYNATAL-Z ORAL TABLET 2 QL (1 tablet per 1 day) NATACHEW ORAL TABLET CHEWABLE (prenatal vit-fe fum-fe bisg-fa) 3 ST; QL (1 tablet per 1 day) NATALVIT ORAL TABLET (prenatal vit-fe fumarate-fa) 3 QL (1 tablet per 1 day) NEEVO DHA ORAL CAPSULE (prenat w/oa-fefum-methf-omegas) 3 ST; QL (1 capsule per 1 day) NEONATAL COMPLETE ORAL TABLET 3 ST; QL (1 tablet per 1 day) NEONATAL FE ORAL TABLET 3 ST; QL (1 tablet per 1 day) NEONATAL PLUS ORAL TABLET (prenatal vit-fe fumarate-fa) 3 ST; QL (1 tablet per 1 day) NESTABS DHA ORAL (prenat-w/oa-fe bisgly-fa-omega) 3 ST; QL (2 tablets per 1 day) NESTABS ORAL TABLET (prenat-fe bisgly-fa-w/o vit a) 3 ST; QL (2 tablets per 1 day) NIVA-PLUS ORAL TABLET (prenatal vit-fe fumarate-fa) 3 QL (1 tablet per 1 day) OB COMPLETE ONE ORAL CAPSULE (prenat-fecbn-feaspgl-fa-fish) 3 ST; QL (1 capsule per 1 day) OB COMPLETE ORAL TABLET (prenatal vit-iron carbonyl-fa) 3 ST; QL (1 tablet per 1 day) OB COMPLETE PETITE ORAL CAPSULE (prenat-fecbn-feaspgl-fa-omega) 3 ST; QL (1 capsule per 1 day) OB COMPLETE PREMIER ORAL TABLET (prenatal-fe cbn-fe asp gly-fa) 3 ST; QL (1 tablet per 1 day) OB COMPLETE/DHA ORAL CAPSULE (prenat-fecbn-feaspgl-fa-omega) 3 ST; QL (1 capsule per 1 day) OBSTETRIX DHA ORAL (prenatal-fecbn-fa-dss-omega 3) 3 QL (1 EA per 1 day) OBSTETRIX EC ORAL TABLET (prenatal vit-dss-fe cbn-fa) 3 QL (1 tablet per 1 day) O-CAL PRENATAL ORAL TABLET (prenatal vit-fe fumarate-fa) 3 QL (1 tablet per 1 day) ONE VITE WOMENS PLUS ORAL TABLET 3 QL (1 tablet per 1 day) PNV TABS 20-1 ORAL TABLET 3 ST; QL (1 tablet per 1 day) PNV TABS 29-1 ORAL TABLET 2 QL (1 tablet per 1 day) PNV-OMEGA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) pnv-select oral tablet 1 or 1b* QL (1 tablet per 1 day) PREGENNA ORAL TABLET 3 ST; QL (1 tablet per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 158 Coverage Requirements and Prescription Drug Name Drug Tier Limits PRENA1 PEARL ORAL CAPSULE EXTENDED RELEASE 3 ST; QL (1 capsule per 1 day) PRENARA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) prenatabs rx oral tablet 1 or 1a* QL (1 tablet per 1 day) PRENATAL 19 ORAL TABLET 29-1 MG 3 QL (1 tablet per 1 day) prenatal 19 oral tablet chewable 1 or 1a* QL (1 tablet per 1 day) PRENATAL 19 ORAL TABLET CHEWABLE 29-1 MG 3 QL (1 tablet per 1 day) PRENATAL ORAL TABLET 27-0.8 MG 2; $0 QL (1 tablet per 1 day) PRENATAL ORAL TABLET 27-1 MG 2 QL (1 tablet per 1 day) PRENATAL PLUS IRON ORAL TABLET 2 QL (1 tablet per 1 day) PRENATAL VITAMIN PLUS LOW IRON ORAL TABLET 2 QL (1 tablet per 1 day) PRENATAL-U ORAL CAPSULE (prenatal w/o a vit-fe fum-fa) 2 QL (1 capsule per 1 day) PRENATE ELITE ORAL TABLET (prenatal-feaspgly-methylfol-fa) 3 ST; QL (1 tablet per 1 day) PRENATRIX ORAL TABLET (prenatal vit-fe fumarate-fa) 3 ST; QL (1 tablet per 1 day) PRENATRYL ORAL TABLET (prenatal vit-fe fumarate-fa) 3 ST; QL (1 tablet per 1 day) PRENATVITE COMPLETE ORAL TABLET 3 ST; QL (1 tablet per 1 day) PRENATVITE PLUS ORAL TABLET 3 ST; QL (1 tablet per 1 day) PRENATVITE RX ORAL TABLET 3 ST; QL (1 tablet per 1 day) PREPLUS ORAL TABLET 2 QL (1 tablet per 1 day) PRETAB ORAL TABLET 2 QL (1 tablet per 1 day) PRIMACARE ORAL CAPSULE (pren-fe-meth-fa-omeg w/o a) 3 ST; QL (1 capsule per 1 day) PROVIDA OB ORAL CAPSULE (prenat w/o a vit-fefum-fepo-fa) 3 QL (1 capsule per 1 day) RELNATE DHA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) SELECT-OB ORAL TABLET CHEWABLE (prenatal vit-fe psac cmplx-fa) 3 ST; QL (1 tablet per 1 day) SE-NATAL 19 ORAL TABLET 2 QL (1 tablet per 1 day) SE-NATAL 19 ORAL TABLET CHEWABLE 2 QL (1 tablet per 1 day) TARON-C DHA ORAL CAPSULE (prenat-fefum-fepo-fa-omega 3) 3 QL (1 capsule per 1 day) THRIVITE RX ORAL TABLET 2 QL (1 tablet per 1 day) TRICARE ORAL TABLET (prenatal vit-fe fumarate-fa) 3 QL (1 tablet per 1 day) TRICARE PRENATAL DHA ONE ORAL CAPSULE (prenatal-fefum-fa- 3 ST; QL (1 capsule per 1 day) dss-fish oil) TRINATAL RX 1 ORAL TABLET 2 QL (1 tablet per 1 day) trinate oral tablet 1 or 1a* QL (1 tablet per 1 day) TRINAZ ORAL TABLET 3 ST; QL (1 tablet per 1 day) VINATE DHA RF ORAL CAPSULE (prenat w/oa-fefum-methf-omegas) 3 ST; QL (1 capsule per 1 day) VINATE II ORAL TABLET (prenatal vit w/ fe bisg-fa) 2 QL (1 tablet per 1 day) VINATE ONE ORAL TABLET (prenatal vit-fe fumarate-fa) 2 QL (1 tablet per 1 day) VIRT-C DHA ORAL CAPSULE 3 QL (1 capsule per 1 day) VIRT-NATE DHA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) VIRT-PN PLUS ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) VITAFOL GUMMIES ORAL TABLET CHEWABLE (prenatal vit-fe phos- 3 QL (1 tablet per 1 day) fa-omega) VITAFOL-NANO ORAL TABLET (prenatal-fe fum-methf-fa w/o a) 3 ST; QL (1 tablet per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 159 Coverage Requirements and Prescription Drug Name Drug Tier Limits VITAFOL-OB ORAL TABLET (prenatal vit-fe fumarate-fa) 3 ST; QL (1 tablet per 1 day) VITAPEARL ORAL CAPSULE EXTENDED RELEASE (prenat-fefum- 3 ST; QL (1 capsule per 1 day) fered-fa-dha w/oa) VITATHELY WITH GINGER ORAL TABLET (prenatal vit-fe fumarate-fa) 3 ST; QL (1 tablet per 1 day) VIVA DHA ORAL CAPSULE (prenatal vit-fe fum-fa-omega) 3 ST; QL (1 capsule per 1 day) VP-PNV-DHA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) WESTAB PLUS ORAL TABLET 3 QL (1 tablet per 1 day) ZALVIT ORAL TABLET 3 ST; QL (1 tablet per 1 day) ZATEAN-PN PLUS ORAL CAPSULE (prenat w/o a-fe-methf-fa-omega) 3 ST; QL (1 capsule per 1 day) *PRENATAL MV & MIN W/FE-FA-CA-OMEGA 3 FISH OIL*** - DRUGS FOR NUTRITION COMPLETE NATAL DHA ORAL 3 TRIVEEN-DUO DHA ORAL (prenat-febis-fepro-fa-ca-omega) 2 *PRENATAL MV & MIN W/FE-FA-DHA*** - DRUGS FOR NUTRITION CITRANATAL 90 DHA ORAL (prenat w/o a-fecbgl-dss-fa-dha) 3 ST; QL (1 EA per 1 day) CITRANATAL ASSURE ORAL (prenat w/o a-fecbgl-dss-fa-dha) 3 ST; QL (2 units per 1 day) CITRANATAL BLOOM DHA ORAL (prenat w/o a-fecbgl-dss-fa-dha) 3 ST; QL (1 EA per 1 day) CITRANATAL DHA ORAL (prenat w/o a-fecbgl-dss-fa-dha) 3 ST; QL (2 units per 1 day) CITRANATAL ESSENCE ORAL THERAPY PACK (prenat w/o a-fecbgl-fa- 3 dha) CITRANATAL HARMONY ORAL CAPSULE (prenat-fefmcb-dss-fa-dha 3 ST; QL (1 capsule per 1 day) w/o a) CITRANATAL MEDLEY ORAL CAPSULE (prenat-fecb-fefum-fa-dha w/o 3 ST; QL (1 capsule per 1 day) a) NEONATAL + DHA ORAL 3 ST; QL (1 tablet per 1 day) NESTABS ONE ORAL CAPSULE (prenat-fe-methylfol-dha w/o a) 3 ST; QL (1 capsule per 1 day) OBSTETRIX ONE ORAL CAPSULE (prenat-fe-methyl-dss-dha w/o a) 3 QL (1 capsule per 1 day) pnv-dha oral capsule 1 or 1b* ST; QL (1 capsule per 1 day) PNV-DHA+DOCUSATE ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) PREGEN DHA ORAL CAPSULE 3 ST; QL (1 tablet per 1 day) PRENA 1 TRUE ORAL 3 QL (2 tablets per 1 day) PRENAISSANCE ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) PRENAISSANCE PLUS ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) PRENATE DHA ORAL CAPSULE (prenat-feasp-meth-fa-dha w/o a) 3 ST; QL (1 capsule per 1 day) PRENATE ENHANCE ORAL CAPSULE (prenat w/o a-fe-methfol-fa-dha) 3 ST; QL (1 capsule per 1 day) PRENATE ESSENTIAL ORAL CAPSULE (prenat-feasp-meth-fa-dha w/o a) 3 ST; QL (1 capsule per 1 day) PRENATE MINI ORAL CAPSULE (prenat-fecbn-feasp-meth-fa-dha) 3 ST; QL (1 capsule per 1 day) PRENATE PIXIE ORAL CAPSULE (prenat-feasp-meth-fa-dha w/o a) 3 ST; QL (1 capsule per 1 day) PRENATE RESTORE ORAL CAPSULE (prenat w/o a-fe-methfol-fa-dha) 3 ST; QL (1 capsule per 1 day) SELECT-OB+DHA ORAL (prenatal vit-fepoly-fa-dha) 3 ST; QL (2 units per 1 day) TARON-PREX ORAL CAPSULE (prenat-fefum-dss-fa-dha w/o a) 3 QL (1 capsule per 1 day) TRISTART DHA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 160 Coverage Requirements and Prescription Drug Name Drug Tier Limits TRISTART FREE ORAL CAPSULE (prenat w/o a-fecbn-meth-fa-dha) 3 TRISTART ONE ORAL CAPSULE (prenat w/o a-fecbn-meth-fa-dha) 3 ST; QL (1 capsule per 1 day) VIRT-PN DHA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) VITAFOL FE+ ORAL CAPSULE (prenat-fe poly-methfol-fa-dha) 3 ST; QL (2 capsules per 1 day) VITAFOL ULTRA ORAL CAPSULE (prenat-fe poly-methfol-fa-dha) 3 ST; QL (1 capsule per 1 day) VITAFOL-OB+DHA ORAL (prenatal mv-min-fe fum-fa-dha) 3 ST; QL (2 units per 1 day) VITAFOL-ONE ORAL CAPSULE (prenatal vit-fepoly-fa-dha) 3 ST; QL (1 capsule per 1 day) VITAMEDMD ONE RX/QUATREFOLIC ORAL CAPSULE (prenat w/o a- 3 ST; QL (1 capsule per 1 day) fe-methfol-fa-dha) VITATRUE ORAL (prenat-fechel-fa-dha w/o vit a) 3 ST; QL (2 tablets per 1 day) WESTGEL DHA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) ZATEAN-PN DHA ORAL CAPSULE (prenat w/o a-fe-methfol-fa-dha) 3 ST; QL (1 capsule per 1 day) *PRENATAL MV & MINERALS W/FA WITHOUT IRON*** - DRUGS FOR NUTRITION PRENATE ORAL TABLET CHEWABLE (prenat mv-min-methylfolate-fa) 3 ST; QL (1 tablet per 1 day) *PRENATAL VITAMINS*** - DRUGS FOR NUTRITION NEONATAL 19 ORAL TABLET 3 ST; QL (1 tablet per 1 day) PREMESISRX ORAL TABLET (prenatal ca-b6-b12-fa-ginger) 2 ST; QL (1 tablet per 1 day) PRENA1 ORAL TABLET CHEWABLE 2 ST; QL (1 tablet per 1 day) PRENATE AM ORAL TABLET (prenatal ca-b6-b12-fa-ginger) 3 ST; QL (1 tablet per 1 day) VITAFOL STRIPS ORAL FILM (prenatal-b6-b12-d3-folic acid) 3 QL (1 EA per 1 day) VITAMEDMD REDICHEW RX ORAL TABLET CHEWABLE (prenat-b2- 3 ST; QL (1 tablet per 1 day) b6-b12-d3-fa) *VITAMINS A & D*** - DRUGS FOR NUTRITION COD LIVER OIL ORAL OIL 3 *MUSCULOSKELETAL THERAPY AGENTS* - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES *CENTRAL MUSCLE RELAXANTS*** - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES baclofen intrathecal solution 4 baclofen oral tablet 10 mg, 5 mg 1 or 1b* QL (3 tablets per 1 day) baclofen oral tablet 20 mg 1 or 1b* QL (4 tablets per 1 day) carisoprodol oral tablet 1 or 1b* QL (4 tablets per 1 day) chlorzoxazone oral tablet 375 mg, 750 mg 1 or 1b* ST; QL (4 tablets per 1 day) chlorzoxazone oral tablet 500 mg 1 or 1b* QL (4 tablets per 1 day) cyclobenzaprine hcl oral tablet 1 or 1b* QL (3 tablets per 1 day) fexmid oral tablet 1 or 1b* ST; QL (3 tablets per 1 day) GABLOFEN INTRATHECAL SOLUTION (baclofen) 4 GABLOFEN INTRATHECAL SOLUTION PREFILLED SYRINGE 4 (baclofen) LIORESAL INTRATHECAL SOLUTION (baclofen) 3 lorzone oral tablet 1 or 1b* ST; QL (4 tablets per 1 day) metaxalone oral tablet 1 or 1b* ST; QL (4 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 161 Coverage Requirements and Prescription Drug Name Drug Tier Limits methocarbamol injection solution 1 or 1b* methocarbamol oral tablet 500 mg 1 or 1b* QL (8 tablets per 1 day) methocarbamol oral tablet 750 mg 1 or 1b* QL (6 tablets per 1 day) orphenadrine citrate er oral tablet extended release 12 hour 1 or 1b* QL (2 tablets per 1 day) orphenadrine citrate injection solution 1 or 1b* ROBAXIN INJECTION SOLUTION (methocarbamol) 3 ST SKELAXIN ORAL TABLET (metaxalone) 3 ST; QL (4 tablets per 1 day) SOMA ORAL TABLET (carisoprodol) 3 ST; QL (4 tablets per 1 day) tizanidine hcl oral capsule 2 mg 1 or 1b* QL (4 capsules per 1 day) tizanidine hcl oral capsule 4 mg 1 or 1b* QL (9 capsules per 1 day) tizanidine hcl oral capsule 6 mg 1 or 1b* QL (6 capsules per 1 day) tizanidine hcl oral tablet 2 mg 1 or 1b* QL (4 tablets per 1 day) tizanidine hcl oral tablet 4 mg 1 or 1b* QL (9 tablets per 1 day) ZANAFLEX ORAL CAPSULE 2 MG (tizanidine hcl) 3 ST; QL (4 capsules per 1 day) ZANAFLEX ORAL CAPSULE 4 MG (tizanidine hcl) 3 ST; QL (9 capsules per 1 day) ZANAFLEX ORAL CAPSULE 6 MG (tizanidine hcl) 3 ST; QL (6 capsules per 1 day) ZANAFLEX ORAL TABLET (tizanidine hcl) 3 ST; QL (9 tablets per 1 day) *DIRECT MUSCLE RELAXANTS*** - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES DANTRIUM INTRAVENOUS SOLUTION RECONSTITUTED (dantrolene 3 sodium) DANTRIUM ORAL CAPSULE (dantrolene sodium) 3 dantrolene sodium intravenous solution reconstituted 1 or 1b* dantrolene sodium oral capsule 1 or 1b* revonto intravenous solution reconstituted 1 or 1b* RYANODEX INTRAVENOUS SUSPENSION RECONSTITUTED 3 (dantrolene sodium) *MUSCLE RELAXANT COMBINATIONS*** - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES carisoprodol-aspirin-codeine oral tablet 1 or 1b* QL (40 tablets per 30 days) CYCLOPAK COMBINATION THERAPY PACK (cyclobenz-lido-prilo-swall 3 spr) orphenadrine-asa-caffeine oral tablet 1 or 1b* ST orphengesic forte oral tablet 1 or 1b* ST *VISCOSUPPLEMENTS*** - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES DUROLANE INTRA-ARTICULAR PREFILLED SYRINGE (sodium 4 PA hyaluronate (viscosup)) EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA (sodium hyaluronate (viscosup)) GEL-ONE INTRA-ARTICULAR PREFILLED SYRINGE (cross-linked 4 SP hyaluronate) GELSYN-3 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 SP (sodium hyaluronate (viscosup))

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 162 Coverage Requirements and Prescription Drug Name Drug Tier Limits HYALGAN INTRA-ARTICULAR SOLUTION (sodium hyaluronate 4 PA (viscosup)) HYALGAN INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA (sodium hyaluronate (viscosup)) HYMOVIS INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA; LD; SP (hyaluronan) MONOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA (hyaluronan) ORTHOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA (hyaluronan) SUPARTZ FX INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 (sodium hyaluronate (viscosup)) SYNVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA (hylan) SYNVISC ONE INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA (hylan) TRILURON INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA; SP (sodium hyaluronate (viscosup)) VISCO-3 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 SP (sodium hyaluronate (viscosup)) *NASAL AGENTS - SYSTEMIC AND TOPICAL* - DRUGS FOR THE NOSE *ANTIHISTAMINE-STEROID*** - ALLERGY azelastine-fluticasone nasal suspension 1 or 1b* QL (1 bottle per 30 days) DYMISTA NASAL SUSPENSION (azelastine-fluticasone) 3 QL (1 bottle per 30 days) *NASAL ANESTHETICS*** - ALLERGY GOPRELTO NASAL SOLUTION 3 NUMBRINO NASAL SOLUTION (cocaine hcl (nasal anesthetic)) 3 *NASAL ANTICHOLINERGICS*** - ALLERGY ipratropium bromide nasal solution 0.03 % 1 or 1b* QL (2 bottles per 30 days) ipratropium bromide nasal solution 0.06 % 1 or 1b* QL (1 mL per 1 day) *NASAL ANTIHISTAMINES*** - ALLERGY azelastine hcl nasal solution 0.1 %, 137 mcg/spray 1 or 1b* QL (1 package per 25 days) azelastine hcl nasal solution 0.15 % 1 or 1b* QL (1 bottle per 25 days) olopatadine hcl nasal solution 1 or 1b* QL (1 bottle per 30 days) PATANASE NASAL SOLUTION (olopatadine hcl) 3 QL (1 bottle per 30 days) *NASAL STEROIDS*** - ALLERGY flunisolide nasal solution 3 ST; QL (1 bottle per 30 days) fluticasone propionate nasal suspension 1 or 1a* QL (1 bottle per 30 days) mometasone furoate nasal suspension 3 ST; QL (1 bottle per 30 days) PROPEL MINI NASAL IMPLANT (mometasone furoate) 3 PROPEL NASAL IMPLANT (mometasone furoate) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 163 Coverage Requirements and Prescription Drug Name Drug Tier Limits *NEUROMUSCULAR AGENTS* - DRUGS FOR NERVES AND MUSCLES *BENZATHIAZOLES*** - DRUGS FOR NERVES AND MUSCLES RILUTEK ORAL TABLET (riluzole) 4 SP; QL (4 tablets per 1 day) riluzole oral tablet 4 SP; QL (4 tablets per 1 day) TIGLUTIK ORAL SUSPENSION (riluzole) 4 LD *DEPOLARIZING MUSCLE RELAXANTS*** - DRUGS FOR NERVES AND MUSCLES ANECTINE INJECTION SOLUTION (succinylcholine chloride) 3 QUELICIN INJECTION SOLUTION (succinylcholine chloride) 3 SUCCINYLCHOLINE CHLORIDE INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE 140 MG/7ML *MUSCULAR DYSTROPHY AGENTS*** - DRUGS FOR NERVES AND MUSCLES AMONDYS 45 INTRAVENOUS SOLUTION 4 LD EXONDYS 51 INTRAVENOUS SOLUTION (eteplirsen) 4 PA; LD VILTEPSO INTRAVENOUS SOLUTION (viltolarsen) 4 PA; LD VYONDYS 53 INTRAVENOUS SOLUTION (golodirsen) 4 PA; LD *NEUROMUSCULAR BLOCKING AGENT - NEUROTOXINS*** - DRUGS FOR NERVES AND MUSCLES BOTOX INJECTION SOLUTION RECONSTITUTED (onabotulinumtoxina) 4 PA; SP DYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED 4 PA; SP (abobotulinumtoxina) MYOBLOC INTRAMUSCULAR SOLUTION (rimabotulinumtoxinb) 4 PA; SP XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED 4 PA; LD; SP (incobotulinumtoxina) *NONDEPOLARIZING MUSCLE RELAXANTS*** - DRUGS FOR NERVES AND MUSCLES atracurium besylate intravenous solution 1 or 1b* cisatracurium besylate (pf) intravenous solution 1 or 1b* cisatracurium besylate intravenous solution 1 or 1b* NIMBEX INTRAVENOUS SOLUTION (cisatracurium besylate) 3 pancuronium bromide intravenous solution 1 or 1b* rocuronium bromide intravenous solution 1 or 1b* ROCURONIUM BROMIDE INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 100 MG/10ML VECURONIUM BROMIDE INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE vecuronium bromide intravenous solution reconstituted 1 or 1b* *SPINAL MUSCULAR ATROPHY-SMN2 SPLICING MODIFIERS*** - DRUGS FOR NERVES AND MUSCLES EVRYSDI ORAL SOLUTION RECONSTITUTED (risdiplam) 4 PA; LD; QL (5 mg per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 164 Coverage Requirements and Prescription Drug Name Drug Tier Limits *NUTRIENTS* - DRUGS FOR NUTRITION *AMINO ACID MIXTURES*** - DRUGS FOR NUTRITION AMINOPROTECT INTRAVENOUS SOLUTION (amino acid infusion) 3 AMINOSYN II INTRAVENOUS SOLUTION (amino acid infusion) 3 AMINOSYN-PF INTRAVENOUS SOLUTION (amino acid infusion) 3 CLINIMIX E/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION (amino ac 3 elect-calc in d5w) CLINIMIX E/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION (amino ac 3 elect-calc in d10w) CLINIMIX E/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION (amino ac 3 elect-calc in d5w) CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS SOLUTION (amino ac 3 elect-calc in d15w) CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS SOLUTION (amino ac 3 elect-calc in d20w) CLINIMIX E/DEXTROSE (8/10) INTRAVENOUS SOLUTION 3 CLINIMIX E/DEXTROSE (8/14) INTRAVENOUS SOLUTION 3 CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION (amino acid 3 infusion in d10w) CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION (amino acid 3 infusion in d5w) CLINIMIX/DEXTROSE (5/15) INTRAVENOUS SOLUTION (amino acid 3 infusion in d15w) CLINIMIX/DEXTROSE (5/20) INTRAVENOUS SOLUTION (amino acid 3 infusion in d20w) CLINIMIX/DEXTROSE (6/5) INTRAVENOUS SOLUTION 3 CLINIMIX/DEXTROSE (8/10) INTRAVENOUS SOLUTION 3 CLINIMIX/DEXTROSE (8/14) INTRAVENOUS SOLUTION 3 clinisol sf intravenous solution 1 or 1b* FREAMINE HBC INTRAVENOUS SOLUTION (amino acid infusion) 3 FREAMINE III INTRAVENOUS SOLUTION (amino acid infusion) 3 plenamine intravenous solution 1 or 1b* PREMASOL INTRAVENOUS SOLUTION (amino acid infusion) 3 PROCALAMINE INTRAVENOUS SOLUTION (amino acd electrolyte 3 infusion) PROSOL INTRAVENOUS SOLUTION (amino acid infusion) 3 TRAVASOL INTRAVENOUS SOLUTION (amino acid infusion) 3 TROPHAMINE INTRAVENOUS SOLUTION (amino acid infusion) 3 *AMINO ACIDS-SINGLE*** - DRUGS FOR NUTRITION ARGININE HCL INJECTION SOLUTION 3 ELCYS INTRAVENOUS SOLUTION (cysteine hcl) 3 GLUTATHIONE INJECTION SOLUTION 3 GLUTATHIONE INTRAVENOUS SOLUTION 3 GLYCINE INJECTION SOLUTION 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 165 Coverage Requirements and Prescription Drug Name Drug Tier Limits LYSINE HCL INJECTION SOLUTION 3 n-acetyl-l-cysteine oral capsule 1 or 1b* TAURINE INJECTION SOLUTION 3 *CARBOHYDRATES*** - DRUGS FOR NUTRITION dextrose intravenous solution 10 %, 250 mg/ml, 5 %, 70 % 1 or 1b* DEXTROSE INTRAVENOUS SOLUTION 20 %, 40 % 3 *LIPIDS*** - DRUGS FOR NUTRITION CLINOLIPID INTRAVENOUS EMULSION (fat emulsion plant based) 3 PA; LD; SP; QL (2 bottles per 30 DOJOLVI ORAL LIQUID (triheptanoin) 4 days) INTRALIPID INTRAVENOUS EMULSION (fat emulsion plant based) 3 NUTRILIPID INTRAVENOUS EMULSION (fat emulsion plant based) 3 OMEGAVEN INTRAVENOUS EMULSION (fish oil triglyceride based) 3 SMOFLIPID INTRAVENOUS EMULSION (fat emul fish oil/plant based) 3 *LIPOTROPIC COMBINATIONS*** - DRUGS FOR NUTRITION LIPO INTRAMUSCULAR SOLUTION 3 LIPO-C INTRAMUSCULAR SOLUTION 3 *PROTEIN COMBINATIONS*** - DRUGS FOR NUTRITION TRI-AMINO INJECTION SOLUTION 3 *PROTEIN-CARBOHYDRATE-LIPID WITH ELECTROLYTE COMBINATIONS*** - DRUGS FOR NUTRITION KABIVEN INTRAVENOUS EMULSION (amino ac-dext-lipid-electrolyt) 3 PERIKABIVEN INTRAVENOUS EMULSION (amino ac-dext-lipid- 3 electrolyt) *OPHTHALMIC AGENTS* - DRUGS FOR THE EYE *ALPHA ADRENERGIC AGONIST & CARBONIC ANHYDRASE INHIB COMB*** - DRUGS FOR GLAUCOMA SIMBRINZA OPHTHALMIC SUSPENSION (brinzolamide-brimonidine) 2 QL (8 mL per 30 days) *BETA-BLOCKERS - OPHTHALMIC COMBINATIONS*** - DRUGS FOR GLAUCOMA COMBIGAN OPHTHALMIC SOLUTION (brimonidine tartrate-timolol) 2 QL (15 mL per 30 days) dorzolamide hcl-timolol mal ophthalmic solution 1 or 1b* QL (10 mL per 30 days) dorzolamide hcl-timolol mal pf ophthalmic solution 1 or 1b* QL (12 mL per 30 days) *BETA-BLOCKERS - OPHTHALMIC*** - DRUGS FOR GLAUCOMA betaxolol hcl ophthalmic solution 1 or 1b* QL (0.5 mL per 1 day) BETIMOL OPHTHALMIC SOLUTION (timolol hemihydrate) 3 QL (15 mL per 30 days) BETOPTIC-S OPHTHALMIC SUSPENSION (betaxolol hcl) 2 QL (15 mL per 30 days) carteolol hcl ophthalmic solution 1 or 1a* levobunolol hcl ophthalmic solution 1 or 1b* timolol maleate ocudose ophthalmic solution 1 or 1b* timolol maleate ophthalmic gel forming solution 1 or 1b* QL (5 mL per 30 days) timolol maleate ophthalmic solution 0.25 %, 0.5 % 1 or 1b* QL (20 mL per 30 days) timolol maleate ophthalmic solution 0.5 % (daily) 1 or 1b* QL (5 mL per 30 days) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 166 Coverage Requirements and Prescription Drug Name Drug Tier Limits timolol maleate pf ophthalmic solution 1 or 1b* QL (20 mL per 30 days) TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 % (timolol 3 QL (18 mL per 30 days) maleate) TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.5 % (timolol maleate) 3 QL (20 mL per 30 days) TIMOPTIC OPHTHALMIC SOLUTION (timolol maleate) 3 QL (20 mL per 30 days) TIMOPTIC-XE OPHTHALMIC GEL FORMING SOLUTION (timolol 3 QL (5 mL per 30 days) maleate) *CYCLOPLEGIC MYDRIATIC COMBINATIONS*** - DRUGS FOR THE EYE CYCLOMYDRIL OPHTHALMIC SOLUTION (cyclopentolate- 3 phenylephrine) *CYCLOPLEGIC MYDRIATICS*** - DRUGS FOR THE EYE altafrin ophthalmic solution 1 or 1b* atropine sulfate ophthalmic ointment 1 or 1b* QL (3.5 grams per 30 days) ATROPINE SULFATE OPHTHALMIC SOLUTION 0.01 % 3 ATROPINE SULFATE OPHTHALMIC SOLUTION 1 % 3 QL (30 mL per 30 days) CYCLOGYL OPHTHALMIC SOLUTION 0.5 %, 2 % (cyclopentolate hcl) 3 CYCLOGYL OPHTHALMIC SOLUTION 1 % (cyclopentolate hcl) 3 QL (15 mL per 30 days) cyclopentolate hcl ophthalmic solution 0.5 %, 2 % 1 or 1b* cyclopentolate hcl ophthalmic solution 1 % 1 or 1b* QL (15 mL per 30 days) ISOPTO ATROPINE OPHTHALMIC SOLUTION (atropine sulfate) 3 QL (30 mL per 30 days) MYDRIACYL OPHTHALMIC SOLUTION (tropicamide) 3 PHENYLEPHRINE HCL INTRAOCULAR SOLUTION PREFILLED 3 SYRINGE phenylephrine hcl ophthalmic solution 1 or 1b* tropicamide ophthalmic solution 1 or 1b* *LYMPHOCYTE FUNCTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAG*** - ANTI-INFECTIVE/ANTI-INFLAMMATORIES XIIDRA OPHTHALMIC SOLUTION (lifitegrast) 2 QL (2 vial per 1 day) *MIOTICS - DIRECT ACTING*** - DRUGS FOR GLAUCOMA ISOPTO CARPINE OPHTHALMIC SOLUTION (pilocarpine hcl) 3 MIOCHOL-E INTRAOCULAR SOLUTION RECONSTITUTED 3 (acetylcholine chloride) MIOSTAT INTRAOCULAR SOLUTION (carbachol) 3 pilocarpine hcl ophthalmic solution 1 or 1b* *OPHTHALMIC ADRENERGIC AGENTS*** - DRUGS FOR THE EYE EPINEPHRINE HCL INTRAOCULAR SOLUTION PREFILLED SYRINGE 3 *OPHTHALMIC ANTIALLERGIC*** - DRUGS FOR ITCHY EYE azelastine hcl ophthalmic solution 1 or 1b* QL (1 bottle per 24 days) cromolyn sodium ophthalmic solution 1 or 1a* QL (1 bottle per 30 days) epinastine hcl ophthalmic solution 1 or 1b* QL (1 bottle per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 167 Coverage Requirements and Prescription Drug Name Drug Tier Limits *OPHTHALMIC ANTIBIOTICS*** - ANTI-INFECTIVE/ANTI- INFLAMMATORIES AZASITE OPHTHALMIC SOLUTION (azithromycin) 3 bacitracin ophthalmic ointment 1 or 1b* QL (7 grams per 30 days) BESIVANCE OPHTHALMIC SUSPENSION (besifloxacin hcl) 3 CILOXAN OPHTHALMIC OINTMENT (ciprofloxacin hcl) 3 QL (3.5 grams per 30 days) CILOXAN OPHTHALMIC SOLUTION (ciprofloxacin hcl) 3 ciprofloxacin hcl ophthalmic solution 1 or 1a* erythromycin ophthalmic ointment 1 or 1a* QL (3.5 grams per 30 days) gatifloxacin ophthalmic solution 1 or 1b* gentak ophthalmic ointment 1 or 1a* QL (7 grams per 30 days) gentamicin sulfate ophthalmic solution 1 or 1a* QL (10 mL per 30 days) levofloxacin ophthalmic solution 1 or 1b* MITOMYCIN INTRAOCULAR SOLUTION PREFILLED SYRINGE 3 MITOSOL OPHTHALMIC KIT (mitomycin) 3 MOXEZA OPHTHALMIC SOLUTION (moxifloxacin hcl) 3 QL (3 mL per 30 days) moxifloxacin hcl (2x day) ophthalmic solution 1 or 1b* QL (3 mL per 30 days) MOXIFLOXACIN HCL INTRAOCULAR SOLUTION 3 MOXIFLOXACIN HCL INTRAOCULAR SOLUTION PREFILLED 3 SYRINGE moxifloxacin hcl ophthalmic solution 1 or 1b* QL (1 vial per 30 days) OCUFLOX OPHTHALMIC SOLUTION (ofloxacin) 3 QL (10 mL per 30 days) ofloxacin ophthalmic solution 1 or 1a* QL (10 mL per 30 days) tobramycin ophthalmic solution 1 or 1a* QL (20 mL per 30 days) TOBREX OPHTHALMIC OINTMENT (tobramycin) 3 QL (3.5 grams per 30 days) TOBREX OPHTHALMIC SOLUTION (tobramycin) 3 QL (20 mL per 30 days) VIGAMOX OPHTHALMIC SOLUTION (moxifloxacin hcl) 3 QL (1 vial per 30 days) ZYMAXID OPHTHALMIC SOLUTION (gatifloxacin) 3 *OPHTHALMIC ANTIFUNGAL*** - DRUGS FOR THE EYE NATACYN OPHTHALMIC SUSPENSION (natamycin) 3 *OPHTHALMIC ANTI-INFECTIVE COMBINATIONS*** - ANTI- INFECTIVE/ANTI-INFLAMMATORIES ak-poly-bac ophthalmic ointment 1 or 1a* bacitracin-polymyxin b ophthalmic ointment 1 or 1a* neomycin-bacitracin zn-polymyx ophthalmic ointment 1 or 1b* neomycin-polymyxin-gramicidin ophthalmic solution 1 or 1b* QL (10 mL per 30 days) neo-polycin ophthalmic ointment 1 or 1b* polycin ophthalmic ointment 1 or 1a* polymyxin b-trimethoprim ophthalmic solution 1 or 1a* QL (10 mL per 30 days) POLYTRIM OPHTHALMIC SOLUTION (polymyxin b-trimethoprim) 3 QL (10 mL per 30 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 168 Coverage Requirements and Prescription Drug Name Drug Tier Limits *OPHTHALMIC ANTISEPTICS*** - ANTI-INFECTIVE/ANTI- INFLAMMATORIES BETADINE OPHTHALMIC PREP OPHTHALMIC SOLUTION (povidone- 3 iodine) *OPHTHALMIC ANTIVIRALS*** - ANTI-INFECTIVE/ANTI- INFLAMMATORIES trifluridine ophthalmic solution 1 or 1b* QL (7.5 mL per 30 days) ZIRGAN OPHTHALMIC GEL (ganciclovir) 3 QL (5 gram per 7 days) *OPHTHALMIC CARBONIC ANHYDRASE INHIBITORS*** - DRUGS FOR GLAUCOMA AZOPT OPHTHALMIC SUSPENSION (brinzolamide) 3 QL (15 ML per 30 days) brinzolamide ophthalmic suspension 1 or 1b* QL (15 mL per 30 days) dorzolamide hcl ophthalmic solution 1 or 1b* QL (10 mL per 30 days) TRUSOPT OPHTHALMIC SOLUTION (dorzolamide hcl) 3 QL (10 mL per 30 days) *OPHTHALMIC DIAGNOSTIC PRODUCTS*** - DRUGS FOR THE EYE ak-fluor intravenous solution 10 % 1 or 1b* AK-FLUOR INTRAVENOUS SOLUTION 25 % 3 altafluor benox ophthalmic solution 1 or 1b* FLUORESCEIN SODIUM/BENOXINATE OPHTHALMIC SOLUTION 3 fluorescein-benoxinate ophthalmic solution 1 or 1b* FLUORESCITE INTRAVENOUS SOLUTION (fluorescein sodium) 3 fluor-i-strips a.t. ophthalmic strip 1 or 1b* FLURA-SAFE OPHTHALMIC SOLUTION (fluorexon-benoxinate) 3 PAREMYD OPHTHALMIC SOLUTION (hydroxyamphetamine- 3 tropicamide) proparacaine-fluorescein ophthalmic solution 1 or 1b* *OPHTHALMIC IMMUNOMODULATORS*** - ANTI- INFECTIVE/ANTI-INFLAMMATORIES RESTASIS MULTIDOSE OPHTHALMIC EMULSION (cyclosporine) 2 QL (1 bottle per 28 days) RESTASIS OPHTHALMIC EMULSION (cyclosporine) 2 QL (2 vials per 1 day) *OPHTHALMIC IRRIGATION SOLUTIONS*** - DRUGS FOR THE EYE balanced salt intraocular solution 1 or 1b* BSS INTRAOCULAR SOLUTION (ophth irr soln-intraocular) 3 BSS PLUS INTRAOCULAR SOLUTION (ophth irr soln-intraocular) 3 *OPHTHALMIC KINASE INHIBITORS - COMBINATIONS*** - DRUGS FOR GLAUCOMA ROCKLATAN OPHTHALMIC SOLUTION (netarsudil-latanoprost) 3 QL (2.5 mL per 30 days) *OPHTHALMIC LOCAL ANESTHETIC - COMBINATIONS*** - DRUGS FOR THE EYE LIDOCAINE-EPINEPHRINE INTRAOCULAR SOLUTION 3 LIDOCAINE-PHENYLEPHRINE INTRAOCULAR SOLUTION 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 169 Coverage Requirements and Prescription Drug Name Drug Tier Limits LIDOCAINE-PHENYLEPHRINE-BSS INTRAOCULAR SOLUTION 3 PREFILLED SYRINGE *OPHTHALMIC LOCAL ANESTHETICS*** - DRUGS FOR THE EYE AKTEN OPHTHALMIC GEL (lidocaine hcl) 3 ALCAINE OPHTHALMIC SOLUTION (proparacaine hcl) 3 proparacaine hcl ophthalmic solution 1 or 1b* tetracaine hcl ophthalmic solution 1 or 1b* *OPHTHALMIC NERVE GROWTH FACTORS*** - DRUGS FOR THE EYE OXERVATE OPHTHALMIC SOLUTION (cenegermin-bkbj) 4 PA; LD; QL (2 vials per 1 day) *OPHTHALMIC NONSTEROIDAL ANTI-INFLAMMATORY AGENTS*** - ANTI-INFECTIVE/ANTI-INFLAMMATORIES ACULAR LS OPHTHALMIC SOLUTION (ketorolac tromethamine) 3 QL (5 mL per 30 days) ACULAR OPHTHALMIC SOLUTION (ketorolac tromethamine) 3 QL (5 mL per 30 days) ACUVAIL OPHTHALMIC SOLUTION (ketorolac tromethamine) 3 QL (1 box per 30 days) bromfenac sodium (once-daily) ophthalmic solution 1 or 1b* QL (1.7 mL per 30 days) BROMSITE OPHTHALMIC SOLUTION (bromfenac sodium) 3 QL (5 mL per 30 days) diclofenac sodium ophthalmic solution 1 or 1b* QL (5 mL per 30 days) flurbiprofen sodium ophthalmic solution 1 or 1b* QL (2.5 mL per 30 days) ILEVRO OPHTHALMIC SUSPENSION (nepafenac) 2 QL (3 mL per 30 days) ketorolac tromethamine ophthalmic solution 1 or 1b* QL (5 mL per 30 days) NEVANAC OPHTHALMIC SUSPENSION (nepafenac) 3 QL (3 mL per 30 days) PROLENSA OPHTHALMIC SOLUTION (bromfenac sodium) 3 QL (3 mL per 30 days) *OPHTHALMIC PHOTODYNAMIC THERAPY AGENTS*** - DRUGS FOR THE EYE VISUDYNE INTRAVENOUS SOLUTION RECONSTITUTED (verteporfin) 4 LD; SP *OPHTHALMIC PHOTOENHANCER COMBINATIONS*** - DRUGS FOR THE EYE PHOTREXA VISCOUS OPHTHALMIC SOLUTION PREFILLED 3 SYRINGE (riboflavin 5-phosphate-dextran) PHOTREXA-PHOTREXA VISCOUS KIT OPHTHALMIC SOLUTION 3 PREFILLED SYRINGE (riboflav5 & riboflav5-dextran) *OPHTHALMIC RHO KINASE INHIBITORS*** - DRUGS FOR GLAUCOMA RHOPRESSA OPHTHALMIC SOLUTION (netarsudil dimesylate) 3 QL (2.5 mL per 30 days) *OPHTHALMIC SELECTIVE ALPHA ADRENERGIC AGONISTS*** - DRUGS FOR GLAUCOMA ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % (brimonidine tartrate) 2 QL (15 mL per 30 days) ALPHAGAN P OPHTHALMIC SOLUTION 0.15 % (brimonidine tartrate) 3 QL (15 mL per 30 days) apraclonidine hcl ophthalmic solution 1 or 1b* brimonidine tartrate ophthalmic solution 1 or 1b* QL (15 mL per 30 days) IOPIDINE OPHTHALMIC SOLUTION (apraclonidine hcl) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 170 Coverage Requirements and Prescription Drug Name Drug Tier Limits *OPHTHALMIC STEROID COMBINATIONS*** - ANTI- INFECTIVE/ANTI-INFLAMMATORIES bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 or 1b* BLEPHAMIDE OPHTHALMIC SUSPENSION (sulfacetamide-prednisolone) 3 QL (15 mL per 30 days) BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT (sulfacetamide- 3 prednisolone) DEXAMETHASONE-MOXIFLOXACIN INTRAOCULAR SOLUTION 3 DEXAMETH-MOXIFLOX-KETOROLAC INTRAOCULAR SOLUTION 3 MAXITROL OPHTHALMIC OINTMENT (neomycin-polymyxin-dexameth) 3 MAXITROL OPHTHALMIC SUSPENSION (neomycin-polymyxin- 3 dexameth) neomycin-polymyxin-dexameth ophthalmic ointment 1 or 1a* neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 1 or 1a* neomycin-polymyxin-hc ophthalmic suspension 1 or 1b* neo-polycin hc ophthalmic ointment 1 or 1b* PRED-G OPHTHALMIC SUSPENSION (gentamicin-prednisolone acet) 3 PRED-G S.O.P. OPHTHALMIC OINTMENT (gentamicin-prednisolone acet) 3 sulfacetamide-prednisolone ophthalmic solution 1 or 1a* QL (15 mL per 30 days) TOBRADEX OPHTHALMIC OINTMENT (tobramycin-dexamethasone) 2 TOBRADEX OPHTHALMIC SUSPENSION (tobramycin-dexamethasone) 3 QL (10 mL per 30 days) TOBRADEX ST OPHTHALMIC SUSPENSION (tobramycin- 3 QL (10 mL per 30 days) dexamethasone) tobramycin-dexamethasone ophthalmic suspension 1 or 1b* QL (10 mL per 30 days) TRIAMCINOLONE-MOXIFLOXACIN INTRAOCULAR SUSPENSION 3 ZYLET OPHTHALMIC SUSPENSION (loteprednol-tobramycin) 2 *OPHTHALMIC STEROIDS*** - ANTI-INFECTIVE/ANTI- INFLAMMATORIES ALREX OPHTHALMIC SUSPENSION (loteprednol etabonate) 3 dexamethasone sodium phosphate ophthalmic solution 1 or 1b* DEXTENZA OPHTHALMIC INSERT (dexamethasone) 3 DEXYCU INTRAOCULAR SUSPENSION (dexamethasone) 3 DUREZOL OPHTHALMIC EMULSION (difluprednate) 2 QL (10 mL per 30 days) FLAREX OPHTHALMIC SUSPENSION (fluorometholone acetate) 3 fluorometholone ophthalmic suspension 1 or 1b* FML FORTE OPHTHALMIC SUSPENSION (fluorometholone) 3 FML LIQUIFILM OPHTHALMIC SUSPENSION (fluorometholone) 3 FML OPHTHALMIC OINTMENT (fluorometholone) 3 ILUVIEN INTRAVITREAL IMPLANT (fluocinolone acetonide) 4 PA; LD; SP INVELTYS OPHTHALMIC SUSPENSION (loteprednol etabonate) 3 QL (5.6 mL per 30 days) LOTEMAX OPHTHALMIC GEL (loteprednol etabonate) 3 QL (10 grams per 30 days) LOTEMAX OPHTHALMIC OINTMENT (loteprednol etabonate) 3 QL (7 grams per 30 days) LOTEMAX OPHTHALMIC SUSPENSION (loteprednol etabonate) 3 QL (30 mL per 30 days) LOTEMAX SM OPHTHALMIC GEL (loteprednol etabonate) 3 QL (10 grams per 30 days) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 171 Coverage Requirements and Prescription Drug Name Drug Tier Limits loteprednol etabonate ophthalmic gel 1 or 1b* QL (10 grams per 30 days) loteprednol etabonate ophthalmic suspension 1 or 1b* QL (30 mL per 30 days) MAXIDEX OPHTHALMIC SUSPENSION (dexamethasone) 3 OZURDEX INTRAVITREAL IMPLANT (dexamethasone) 3 PA; LD; SP PRED MILD OPHTHALMIC SUSPENSION (prednisolone acetate) 3 prednisolone acetate ophthalmic suspension 1 or 1b* QL (20 mL per 30 days) PREDNISOLONE SODIUM PHOSPHATE OPHTHALMIC SOLUTION 3 QL (20 mL per 30 days) RETISERT INTRAVITREAL IMPLANT (fluocinolone acetonide) 3 PA; LD; SP TRIESENCE INTRAOCULAR SUSPENSION (triamcinolone acetonide) 3 YUTIQ INTRAVITREAL IMPLANT (fluocinolone acetonide) 3 PA; LD *OPHTHALMIC SULFONAMIDES*** - ANTI-INFECTIVE/ANTI- INFLAMMATORIES BLEPH-10 OPHTHALMIC SOLUTION (sulfacetamide sodium) 3 QL (15 mL per 30 days) sulfacetamide sodium ophthalmic ointment 1 or 1b* QL (3.5 grams per 30 days) sulfacetamide sodium ophthalmic solution 1 or 1b* QL (15 mL per 30 days) *OPHTHALMIC SURGICAL AIDS - COMBINATIONS*** - DRUGS FOR THE EYE DISCOVISC INTRAOCULAR SOLUTION (na chondroit sulf-na hyaluron) 3 DUOVISC INTRAOCULAR KIT 0.4-0.35 ML, 0.55-0.5 ML (na hyalur & na 3 chond-na hyalur) OMIDRIA INTRAOCULAR SOLUTION (phenylephrine-ketorolac) 3 VISCOAT INTRAOCULAR SOLUTION (na chondroit sulf-na hyaluron) 3 *OPHTHALMIC SURGICAL AIDS*** - DRUGS FOR THE EYE AMVISC INTRAOCULAR SOLUTION (sodium hyaluronate) 4 AMVISC PLUS INTRAOCULAR SOLUTION (sodium hyaluronate) 4 CELLUGEL INTRAOCULAR SOLUTION (hypromellose) 3 HEALON DUET PRO INTRAOCULAR SOLUTION PREFILLED SYRINGE 4 (sodium hyaluronate) HEALON GV INTRAOCULAR SOLUTION (sodium hyaluronate) 4 HEALON GV PRO INTRAOCULAR SOLUTION (sodium hyaluronate) 4 HEALON INTRAOCULAR SOLUTION (sodium hyaluronate) 4 HEALON PRO INTRAOCULAR SOLUTION (sodium hyaluronate) 4 HEALON5 INTRAOCULAR SOLUTION (sodium hyaluronate) 4 HEALON5 PRO INTRAOCULAR SOLUTION (sodium hyaluronate) 4 HYALURONIDASE (INTRAOCULAR) INTRAOCULAR SOLUTION 3 MEMBRANEBLUE OPHTHALMIC SOLUTION (trypan blue) 3 ocucoat viscoadherent intraocular solution 1 or 1b* PROVISC INTRAOCULAR SOLUTION (sodium hyaluronate) 4 TISSUEBLUE INTRAOCULAR SOLUTION PREFILLED SYRINGE 3 (brilliant blue g) VISIONBLUE OPHTHALMIC SOLUTION (trypan blue) 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 172 Coverage Requirements and Prescription Drug Name Drug Tier Limits *OPHTHALMICS - BLEPHAROPTOSIS AGENTS** - DRUGS FOR THE EYE UPNEEQ OPHTHALMIC SOLUTION (oxymetazoline hcl) 3 PA; QL (30 containers per 30 days) *OPHTHALMICS - CYSTINOSIS AGENTS** - DRUGS FOR THE EYE CYSTADROPS OPHTHALMIC SOLUTION (cysteamine hcl) 4 PA; LD; QL (4 bottles per 28 days) CYSTARAN OPHTHALMIC SOLUTION (cysteamine hcl) 3 PA; LD; QL (60 mL per 28 days) *PROSTAGLANDINS - OPHTHALMIC*** - DRUGS FOR GLAUCOMA bimatoprost ophthalmic solution 1 or 1b* PA; LD; SP; QL (2 applicators per 1 DURYSTA INTRAOCULAR IMPLANT (bimatoprost) 4 lifetime) latanoprost ophthalmic solution 1 or 1b* QL (5 mL per 30 days) LUMIGAN OPHTHALMIC SOLUTION (bimatoprost) 2 QL (7.5 mL per 30 days) travoprost (bak free) ophthalmic solution 1 or 1b* QL (5 mL per 30 days) VYZULTA OPHTHALMIC SOLUTION (latanoprostene bunod) 3 QL (5 mL per 30 days) XELPROS OPHTHALMIC EMULSION (latanoprost) 3 QL (5 mL per 30 days) ZIOPTAN OPHTHALMIC SOLUTION (tafluprost) 3 QL (9 mL per 30 days) *VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) ANTAGONISTS*** - DRUGS FOR THE EYE BEOVU INTRAVITREAL SOLUTION (brolucizumab-dbll) 4 PA; LD; SP BEVACIZUMAB INTRAOCULAR SOLUTION PREFILLED SYRINGE 3 PA EYLEA INTRAVITREAL SOLUTION (aflibercept) 4 PA; LD; SP EYLEA INTRAVITREAL SOLUTION PREFILLED SYRINGE (aflibercept) 4 PA; LD LUCENTIS INTRAVITREAL SOLUTION (ranibizumab) 4 PA; LD; SP LUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINGE 4 PA; LD; SP (ranibizumab) *OTIC AGENTS* - DRUGS FOR THE EAR *OTIC AGENTS - MISCELLANEOUS*** - WAX REMOVAL acetic acid otic solution 1 or 1b* *OTIC ANALGESIC COMBINATIONS*** - ANTI-INFECTIVE/ANTI- INFLAMMATORIES PRAMOTIC OTIC LIQUID (pramoxine-chloroxylenol) 3 *OTIC ANTI-INFECTIVES*** - ANTIBIOTICS CETRAXAL OTIC SOLUTION (ciprofloxacin hcl) 3 QL (28 containers per 1 fill) ciprofloxacin hcl otic solution 1 or 1b* QL (28 containers per 1 fill) ofloxacin otic solution 1 or 1b* QL (10 mL per 1 fill) OTIPRIO INTRATYMPANIC SUSPENSION (ciprofloxacin) 3 *OTIC STEROID-ANTI-INFECTIVE COMBINATIONS*** - ANTI- INFECTIVE/ANTI-INFLAMMATORIES CIPRO HC OTIC SUSPENSION (ciprofloxacin-hydrocortisone) 3 QL (10 mL per 1 fill) CIPRODEX OTIC SUSPENSION (ciprofloxacin-dexamethasone) 3 QL (7.5 mL per 1 fill) ciprofloxacin-dexamethasone otic suspension 1 or 1b* QL (7.5 mL per 1 fill) ciprofloxacin-fluocinolone pf otic solution 1 or 1b* QL (28 vials per 1 fill)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 173 Coverage Requirements and Prescription Drug Name Drug Tier Limits CORTISPORIN-TC OTIC SUSPENSION (neomycin-colist-hc-thonzonium) 3 neomycin-polymyxin-hc otic solution 1 or 1b* neomycin-polymyxin-hc otic suspension 1 or 1b* OTOVEL OTIC SOLUTION (ciprofloxacin-fluocinolone) 3 QL (28 vials per 1 fill) *OTIC STEROIDS*** - ANTI-INFECTIVE/ANTI-INFLAMMATORIES DERMOTIC OTIC OIL (fluocinolone acetonide) 3 flac otic oil 1 or 1b* fluocinolone acetonide otic oil 1 or 1b* hydrocortisone-acetic acid otic solution 1 or 1b* QL (10 mL per 1 fill) *OXYTOCICS* - HORMONES *ABORTIFACIENTS/CERVICAL RIPENING - PROSTAGLANDINS*** - DRUGS FOR WOMEN carboprost tromethamine intramuscular solution 1 or 1b* CERVIDIL VAGINAL INSERT (dinoprostone) 3 HEMABATE INTRAMUSCULAR SOLUTION (carboprost tromethamine) 3 PREPIDIL VAGINAL GEL (dinoprostone) 3 PROSTIN E2 VAGINAL SUPPOSITORY (dinoprostone) 3 *OXYTOCICS*** - DRUGS FOR WOMEN methergine oral tablet 1 or 1b* methylergonovine maleate injection solution 1 or 1b* methylergonovine maleate oral tablet 1 or 1b* oxytocin injection solution 1 or 1b* OXYTOCIN-LACTATED RINGERS INTRAVENOUS SOLUTION 3 OXYTOCIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION 15-0.9 3 UT/250ML-%, 20-0.9 UNIT/L-%, 20-0.9 UNT/L-% PITOCIN INJECTION SOLUTION (oxytocin) 3 *PASSIVE IMMUNIZING AND TREATMENT AGENTS* - BIOLOGICAL AGENTS *ANTITOXINS-ANTIVENINS*** - BIOLOGICAL AGENTS ANASCORP INTRAVENOUS SOLUTION RECONSTITUTED 3 (centruroides (scorpion) im fab) ANAVIP INTRAVENOUS SOLUTION RECONSTITUTED (crotalidae 3 immune fab (equine)) ANTIVENIN LATRODECTUS MACTANS INJECTION KIT 3 ANTIVENIN MICRURUS FULVIUS INTRAVENOUS SOLUTION 3 RECONSTITUTED CROFAB INTRAVENOUS SOLUTION RECONSTITUTED (crotalidae 3 polyval immune fab) *ANTIVIRAL MONOCLONAL ANTIBODIES*** - BIOLOGICAL AGENTS SOTROVIMAB INTRAVENOUS SOLUTION 4 SYNAGIS INTRAMUSCULAR SOLUTION (palivizumab) 4 PA; LD; SP

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 174 Coverage Requirements and Prescription Drug Name Drug Tier Limits *BACTERIAL MONOCLONAL ANTIBODIES*** - BIOLOGICAL AGENTS ZINPLAVA INTRAVENOUS SOLUTION (bezlotoxumab) 3 PA *IMMUNE SERUMS*** - BIOLOGICAL AGENTS ASCENIV INTRAVENOUS SOLUTION (immune globulin (human)-slra) 4 PA; LD; SP BIVIGAM INTRAVENOUS SOLUTION (immune globulin (human)) 4 PA; LD; SP CUTAQUIG SUBCUTANEOUS SOLUTION (immune globulin (human)- 4 PA; LD; SP hipp) CUVITRU SUBCUTANEOUS SOLUTION (immune globulin (human)) 4 PA; LD; SP CYTOGAM INTRAVENOUS INJECTABLE (cytomegalovirus immune glob) 4 SP FLEBOGAMMA DIF INTRAVENOUS SOLUTION (immune globulin 4 PA; LD; SP (human)) GAMASTAN INTRAMUSCULAR INJECTABLE (immune globulin 4 PA; LD; SP (human)) GAMMAGARD INJECTION SOLUTION (immune globulin (human)) 4 PA; LD; SP GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION 4 PA; LD; SP RECONSTITUTED (immune globulin (human)) GAMMAKED INJECTION SOLUTION (immune globulin (human)) 4 PA; LD; SP GAMMAPLEX INTRAVENOUS SOLUTION (immune globulin (human)) 4 PA; LD; SP GAMUNEX-C INJECTION SOLUTION (immune globulin (human)) 4 PA; LD; SP HEPAGAM B INJECTION SOLUTION (hepatitis b immune globulin) 4 SP HIZENTRA SUBCUTANEOUS SOLUTION (immune globulin (human)) 4 PA; LD; SP HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; SP (immune globulin (human)) HYPERHEP B INTRAMUSCULAR SOLUTION (hepatitis b immune 4 LD; SP globulin) HYPERRAB INJECTION SOLUTION (rabies immune globulin) 4 SP HYPERRHO S/D INTRAMUSCULAR SOLUTION PREFILLED SYRINGE LD; SP; QL (2 syringes per 365 4 (rho d immune globulin) days) HYPERTET S/D INTRAMUSCULAR INJECTABLE (tetanus immune 3 globulin) IMOGAM RABIES-HT INJECTION SOLUTION (rabies immune globulin) 4 SP KEDRAB INJECTION SOLUTION 4 SP MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION 4 SP; QL (2 syringes per 365 days) PREFILLED SYRINGE (rho d immune globulin) NABI-HB INTRAMUSCULAR SOLUTION (hepatitis b immune globulin) 4 LD; SP OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 20 GM/200ML, 25 GM/500ML, 5 4 PA; LD; SP GM/100ML, 5 GM/50ML (immune globulin (human)) OCTAGAM INTRAVENOUS SOLUTION 30 GM/300ML (immune globulin 4 PA; LD (human)) PANZYGA INTRAVENOUS SOLUTION (immune globulin (human)-ifas) 4 PA; LD; SP PRIVIGEN INTRAVENOUS SOLUTION (immune globulin (human)) 4 PA; LD; SP RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION 4 SP; QL (2 syringes per 365 days) PREFILLED SYRINGE (rho d immune globulin)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 175 Coverage Requirements and Prescription Drug Name Drug Tier Limits RHOPHYLAC INJECTION SOLUTION PREFILLED SYRINGE (rho d 4 LD; SP; QL (2 fills per 365 days) immune globulin) VARIZIG INTRAMUSCULAR SOLUTION (varicella-zoster immune glob) 3 WINRHO SDF INJECTION SOLUTION (rho d immune globulin) 4 SP; QL (2 fills per 365 days) XEMBIFY SUBCUTANEOUS SOLUTION (immune globulin (human)- 4 PA; LD; SP klhw) *MONOCLONAL ANTIBODY - COMBINATIONS*** - BIOLOGICAL AGENTS REGEN-COV INTRAVENOUS SOLUTION (casirivimab-imdevimab) 4 *PASSIVE IMMUNIZING AGENTS - COMBINATIONS*** - BIOLOGICAL AGENTS HYQVIA SUBCUTANEOUS KIT (immune globulin-hyaluronidase) 4 PA; LD; SP *PENICILLINS* - DRUGS FOR INFECTIONS *AMINOPENICILLINS*** - ANTIBIOTICS amoxicillin oral capsule 1 or 1a* amoxicillin oral suspension reconstituted 1 or 1a* QL (500 mL per 1 fill) amoxicillin oral tablet 1 or 1a* amoxicillin oral tablet chewable 1 or 1a* ampicillin oral capsule 1 or 1a* ampicillin sodium injection solution reconstituted 1 or 1b* ampicillin sodium intravenous solution reconstituted 1 or 1b* *NATURAL PENICILLINS*** - ANTIBIOTICS BICILLIN L-A INTRAMUSCULAR SUSPENSION (penicillin g benzathine) 3 PENICILLIN G POT IN DEXTROSE INTRAVENOUS SOLUTION 3 penicillin g potassium injection solution reconstituted 1 or 1b* PENICILLIN G PROCAINE INTRAMUSCULAR SUSPENSION 3 penicillin g sodium injection solution reconstituted 1 or 1b* penicillin v potassium oral solution reconstituted 1 or 1b* penicillin v potassium oral tablet 1 or 1b* pfizerpen injection solution reconstituted 1 or 1b* *PENICILLIN COMBINATIONS*** - ANTIBIOTICS amoxicillin-pot clavulanate er oral tablet extended release 12 hour 1 or 1b* QL (40 tablets per 1 fill) amoxicillin-pot clavulanate oral suspension reconstituted 1 or 1b* amoxicillin-pot clavulanate oral tablet 1 or 1b* amoxicillin-pot clavulanate oral tablet chewable 1 or 1b* ampicillin-sulbactam sodium injection solution reconstituted 1 or 1b* ampicillin-sulbactam sodium intravenous solution reconstituted 1 or 1b* AUGMENTIN ES-600 ORAL SUSPENSION RECONSTITUTED 3 (amoxicillin-pot clavulanate) AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 2 MG/5ML (amoxicillin-pot clavulanate) AUGMENTIN ORAL SUSPENSION RECONSTITUTED 250-62.5 MG/5ML 3 (amoxicillin-pot clavulanate)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 176 Coverage Requirements and Prescription Drug Name Drug Tier Limits AUGMENTIN ORAL TABLET (amoxicillin-pot clavulanate) 3 BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION (penicillin g 3 benzathine & proc) BICILLIN C-R INTRAMUSCULAR SUSPENSION (penicillin g benzathine 3 & proc) piperacillin sod-tazobactam so intravenous solution reconstituted 1 or 1b* UNASYN INJECTION SOLUTION RECONSTITUTED (ampicillin- 3 sulbactam sodium) UNASYN INTRAVENOUS SOLUTION RECONSTITUTED (ampicillin- 3 sulbactam sodium) ZOSYN INTRAVENOUS SOLUTION (piperacillin-tazobactam in dex) 3 *PENICILLINASE-RESISTANT PENICILLINS*** - ANTIBIOTICS dicloxacillin sodium oral capsule 1 or 1b* NAFCILLIN SODIUM IN DEXTROSE INTRAVENOUS SOLUTION 3 nafcillin sodium injection solution reconstituted 1 or 1b* nafcillin sodium intravenous solution reconstituted 1 or 1b* OXACILLIN SODIUM IN DEXTROSE INTRAVENOUS SOLUTION 3 oxacillin sodium injection solution reconstituted 1 or 1b* oxacillin sodium intravenous solution reconstituted 1 or 1b* *PROGESTINS* - HORMONES *PROGESTINS*** - DRUGS FOR WOMEN AYGESTIN ORAL TABLET (norethindrone acetate) 3 hydroxyprogesterone caproate intramuscular oil 4 PA; SP; QL (25 mL per 21 weekss) PA; LD; SP; QL (25 mL per 21 MAKENA INTRAMUSCULAR OIL (hydroxyprogesterone caproate) 4 weekss) MAKENA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; LD; SP; QL (25 mL per 21 4 (hydroxyprogesterone caproate) weekss) medroxyprogesterone acetate oral tablet 1 or 1a* QL (1 tablet per 1 day) megestrol acetate oral suspension 625 mg/5ml 1 or 1b*; OC norethindrone acetate oral tablet 1 or 1b* progesterone intramuscular oil 1 or 1b* progesterone oral capsule 100 mg 1 or 1b* QL (2 capsules per 1 day) progesterone oral capsule 200 mg 1 or 1b* QL (1 capsule per 1 day) PROVERA ORAL TABLET (medroxyprogesterone acetate) 3 QL (1 tablet per 1 day) *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* - DRUGS FOR THE NERVOUS SYSTEM *AGENTS FOR OPIOID WITHDRAWAL*** - DRUGS FOR THE NERVOUS SYSTEM LUCEMYRA ORAL TABLET (lofexidine hcl) 3 QL (16 tablets per 1 day) *ALCOHOL DETERRENTS*** - DRUGS FOR THE NERVOUS SYSTEM acamprosate calcium oral tablet delayed release 1 or 1b* QL (6 tablet per 1 day) disulfiram oral tablet 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 177 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTI-CATAPLECTIC AGENTS*** - DRUGS FOR SLEEP DISORDER XYREM ORAL SOLUTION (sodium oxybate) 3 PA; LD; QL (18 mL per 1 day) *ANTIDEMENTIA AGENT COMBINATIONS*** - DRUGS FOR ALZHEIMER'S DISEASE NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK (memantine 2 hcl-donepezil hcl) NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 QL (1 capsule per 1 day) (memantine hcl-donepezil hcl) *ANTISENSE OLIGONUCLEOTIDE (ASO) INHIBITOR AGENTS*** - DRUGS FOR THE NERVOUS SYSTEM TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; QL (4 syringes per 28 4 (inotersen sodium) days) *BENZODIAZEPINES & TRICYCLIC AGENTS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN chlordiazepoxide-amitriptyline oral tablet 1 or 1b* *CHOLINOMIMETICS - ACHE INHIBITORS*** - DRUGS FOR ALZHEIMER'S DISEASE ARICEPT ORAL TABLET 10 MG, 23 MG (donepezil hcl) 3 QL (1 tablet per 1 day) ARICEPT ORAL TABLET 5 MG (donepezil hcl) 3 donepezil hcl oral tablet 10 mg, 23 mg 1 or 1b* QL (1 tablet per 1 day) donepezil hcl oral tablet 5 mg 1 or 1b* donepezil hcl oral tablet dispersible 1 or 1b* QL (1 tablet per 1 day) EXELON TRANSDERMAL PATCH 24 HOUR 13.3 MG/24HR, 9.5 3 ST; QL (1 patch per 1 day) MG/24HR (rivastigmine) EXELON TRANSDERMAL PATCH 24 HOUR 4.6 MG/24HR (rivastigmine) 3 ST; QL (1 gram per 1 day) galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 1 or 1b* QL (1 capsule per 1 day) 24 mg galantamine hydrobromide er oral capsule extended release 24 hour 8 mg 1 or 1b* galantamine hydrobromide oral solution 1 or 1b* galantamine hydrobromide oral tablet 12 mg, 8 mg 1 or 1b* QL (2 tablets per 1 day) galantamine hydrobromide oral tablet 4 mg 1 or 1b* RAZADYNE ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 16 3 QL (1 capsule per 1 day) MG, 24 MG (galantamine hydrobromide) RAZADYNE ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 8 MG 3 (galantamine hydrobromide) rivastigmine tartrate oral capsule 1.5 mg, 3 mg 1 or 1b* rivastigmine tartrate oral capsule 4.5 mg, 6 mg 1 or 1b* QL (2 capsules per 1 day) rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 9.5 mg/24hr 1 or 1b* QL (1 patch per 1 day) rivastigmine transdermal patch 24 hour 4.6 mg/24hr 1 or 1b* QL (1 gram per 1 day) *FIBROMYALGIA AGENT - SNRIS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN SAVELLA ORAL TABLET (milnacipran hcl) 2 QL (2 tablets per 1 day) SAVELLA TITRATION PACK ORAL (milnacipran hcl) 2 QL (1 pack per 365 days)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 178 Coverage Requirements and Prescription Drug Name Drug Tier Limits *MELANOCORTIN RECEPTOR AGONISTS*** - DRUGS FOR THE NERVOUS SYSTEM VYLEESI SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; LD; QL (4 autoinjectors per 30 3 (bremelanotide acetate) days) *MOVEMENT DISORDER DRUG THERAPY*** - DRUGS FOR THE NERVOUS SYSTEM PA; LD; SP; QL (4 tablets per 1 AUSTEDO ORAL TABLET (deutetrabenazine) 4 day) INGREZZA ORAL CAPSULE 40 MG (valbenazine tosylate) 4 PA; LD INGREZZA ORAL CAPSULE 60 MG, 80 MG (valbenazine tosylate) 4 PA; LD; QL (1 capsule per 1 day) INGREZZA ORAL CAPSULE THERAPY PACK (valbenazine tosylate) 4 PA; LD; QL (1 pack per 1 year) tetrabenazine oral tablet 12.5 mg 1 or 1b* PA; SP; QL (8 tablets per 1 day) tetrabenazine oral tablet 25 mg 1 or 1b* PA; SP; QL (4 tablets per 1 day) PA; LD; SP; QL (8 tablets per 1 XENAZINE ORAL TABLET 12.5 MG (tetrabenazine) 3 day) PA; LD; SP; QL (4 tablets per 1 XENAZINE ORAL TABLET 25 MG (tetrabenazine) 3 day) *MS AGENTS - PYRIMIDINE SYNTHESIS INHIBITORS*** - DRUGS FOR MULTIPLE SCLEROSIS AUBAGIO ORAL TABLET (teriflunomide) 4 PA; LD; SP; QL (1 tablet per 1 day) *MULTIPLE SCLEROSIS AGENTS - ANTIMETABOLITES*** - DRUGS FOR MULTIPLE SCLEROSIS PA; LD; SP; QL (2 packs per 46 MAVENCLAD (10 TABS) ORAL TABLET THERAPY PACK (cladribine) 4 weekss) PA; LD; SP; QL (2 packs per 46 MAVENCLAD (4 TABS) ORAL TABLET THERAPY PACK (cladribine) 4 weekss) PA; LD; SP; QL (2 packs per 46 MAVENCLAD (5 TABS) ORAL TABLET THERAPY PACK (cladribine) 4 weekss) PA; LD; SP; QL (2 packs per 46 MAVENCLAD (6 TABS) ORAL TABLET THERAPY PACK (cladribine) 4 weekss) PA; LD; SP; QL (2 packs per 46 MAVENCLAD (7 TABS) ORAL TABLET THERAPY PACK (cladribine) 4 weekss) PA; LD; SP; QL (2 packs per 46 MAVENCLAD (8 TABS) ORAL TABLET THERAPY PACK (cladribine) 4 weekss) PA; LD; SP; QL (2 packs per 46 MAVENCLAD (9 TABS) ORAL TABLET THERAPY PACK (cladribine) 4 weekss) *MULTIPLE SCLEROSIS AGENTS - INTERFERONS*** - DRUGS FOR MULTIPLE SCLEROSIS BETASERON SUBCUTANEOUS KIT (interferon beta-1b) 4 SP; QL (15 kits per 30 days) REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 4 PA; SP; QL (12 ML per 28 days) (interferon beta-1a) REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION 4 PA; SP; QL (4.2 ML per 28 days) AUTO-INJECTOR (interferon beta-1a) REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE (interferon 4 PA; SP beta-1a) REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED 4 PA; SP SYRINGE (interferon beta-1a)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 179 Coverage Requirements and Prescription Drug Name Drug Tier Limits *MULTIPLE SCLEROSIS AGENTS - MONOCLONAL ANTIBODIES*** - DRUGS FOR MULTIPLE SCLEROSIS KESIMPTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; LD; SP; QL (1 syringe per 28 4 (ofatumumab) days) PA; LD; SP; QL (3 vials per 365 LEMTRADA INTRAVENOUS SOLUTION (alemtuzumab) 4 days) TYSABRI INTRAVENOUS CONCENTRATE (natalizumab) 4 PA; LD; SP; QL (1 vial per 28 days) *MULTIPLE SCLEROSIS AGENTS - NRF2 PATHWAY ACTIVATORS*** - DRUGS FOR MULTIPLE SCLEROSIS PA; LD; SP; QL (14 capsules per dimethyl fumarate oral capsule delayed release 120 mg 4 365 days) PA; LD; SP; QL (2 capsules per 1 dimethyl fumarate oral capsule delayed release 240 mg 4 day) dimethyl fumarate starter pack oral 4 PA; SP; QL (1 kit per 365 days) *MULTIPLE SCLEROSIS AGENTS - POTASSIUM CHANNEL BLOCKERS*** - DRUGS FOR MULTIPLE SCLEROSIS AMPYRA ORAL TABLET EXTENDED RELEASE 12 HOUR PA; LD; SP; QL (2 tablets per 1 4 (dalfampridine) day) dalfampridine er oral tablet extended release 12 hour 4 PA; SP; QL (2 tablets per 1 day) *MULTIPLE SCLEROSIS AGENTS*** - DRUGS FOR MULTIPLE SCLEROSIS COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 PA; LD; SP; QL (1 syringe per 1 4 MG/ML (glatiramer acetate) day) COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 PA; LD; SP; QL (12 ML per 28 4 MG/ML (glatiramer acetate) days) *N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTS*** - DRUGS FOR ALZHEIMER'S DISEASE memantine hcl er oral capsule extended release 24 hour 14 mg, 7 mg 1 or 1b* memantine hcl er oral capsule extended release 24 hour 21 mg, 28 mg 1 or 1b* QL (1 capsule per 1 day) memantine hcl oral solution 1 or 1b* QL (10 mL per 1 day) memantine hcl oral tablet 10 mg 1 or 1b* QL (2 tablets per 1 day) memantine hcl oral tablet 28 x 5 mg & 21 x 10 mg 1 or 1b* QL (1 tablet per 1 day) memantine hcl oral tablet 5 mg 1 or 1b* NAMENDA TITRATION PAK ORAL TABLET (memantine hcl) 3 QL (1 tablet per 1 day) *PHENOTHIAZINES & TRICYCLIC AGENTS*** - DRUGS FOR DEPRESSION perphenazine-amitriptyline oral tablet 1 or 1b* *POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN GRALISE ORAL TABLET 300 MG (gabapentin (once-daily)) 2 PA GRALISE ORAL TABLET 600 MG (gabapentin (once-daily)) 2 PA; QL (3 tablets per 1 day) LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR 165 MG, 3 PA 82.5 MG (pregabalin) LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR 330 MG 3 PA; QL (2 tablets per 1 day) (pregabalin)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 180 Coverage Requirements and Prescription Drug Name Drug Tier Limits pregabalin er oral tablet extended release 24 hour 165 mg, 82.5 mg 1 or 1b* PA pregabalin er oral tablet extended release 24 hour 330 mg 1 or 1b* PA; QL (2 tablets per 1 day) *PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS - SSRIS*** - DRUGS FOR DEPRESSION fluoxetine hcl (pmdd) oral tablet 10 mg 1 or 1b* fluoxetine hcl (pmdd) oral tablet 20 mg 1 or 1b* QL (4 tablets per 1 day) *PSEUDOBULBAR AFFECT AGENT COMBINATIONS*** - DRUGS FOR SEVERE MENTAL DISORDERS NUEDEXTA ORAL CAPSULE (dextromethorphan-quinidine) 3 PA; QL (2 capsules per 1 day) *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*** - DRUGS FOR SEVERE MENTAL DISORDERS ergoloid mesylates oral tablet 1 or 1b* QL (3 tablets per 1 day) pimozide oral tablet 1 or 1b* *RESTLESS LEG SYNDROME (RLS) AGENTS*** - DRUGS FOR THE NERVOUS SYSTEM HORIZANT ORAL TABLET EXTENDED RELEASE (gabapentin 3 PA; QL (2 tablets per 1 day) enacarbil) *SEROTONIN 1A RECEPT AGONIST/SEROTONIN 2A RECEPT ANTAG*** - DRUGS FOR THE NERVOUS SYSTEM ADDYI ORAL TABLET (flibanserin) 3 PA; QL (1 tablet per 1 day) *SMALL INTERFERING RIBONUCLEIC ACID (SIRNA) AGENTS*** - DRUGS FOR THE NERVOUS SYSTEM ONPATTRO INTRAVENOUS SOLUTION (patisiran sodium) 4 PA; LD; QL (0.72 mL per 1 day) *SMOKING DETERRENTS*** - DRUGS FOR DEPRESSION bupropion hcl er (smoking det) oral tablet extended release 12 hour 1 or 1b*; $0 PA; QL (2 tablets per 1 day) CHANTIX CONTINUING MONTH PAK ORAL TABLET (varenicline 3; $0 PA; QL (2 tablet per 1 day) tartrate) CHANTIX ORAL TABLET 0.5 MG (varenicline tartrate) 3; $0 PA; QL (2 tablets per 1 day) CHANTIX ORAL TABLET 1 MG (varenicline tartrate) 3; $0 PA; QL (2 tablet per 1 day) PA; QL (1 starting month pack per CHANTIX STARTING MONTH PAK ORAL TABLET (varenicline tartrate) 3; $0 365 days) NICOTROL INHALATION INHALER (nicotine) 3; $0 PA NICOTROL NS NASAL SOLUTION (nicotine) 3; $0 PA *SPHINGOSINE 1-PHOSPHATE (S1P) RECEPTOR MODULATORS*** - DRUGS FOR MULTIPLE SCLEROSIS GILENYA ORAL CAPSULE 0.5 MG (fingolimod hcl) 4 PA; SP; QL (1 capsule per 1 day) PA; LD; SP; QL (4 tablets per 1 MAYZENT ORAL TABLET 0.25 MG (siponimod fumarate) 4 day) MAYZENT ORAL TABLET 2 MG (siponimod fumarate) 4 PA; LD; SP; QL (1 tablet per 1 day) MAYZENT STARTER PACK ORAL TABLET THERAPY PACK PA; LD; SP; QL (1 pack per 1 one 4 (siponimod fumarate) time fill) ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE THERAPY PACK 4 PA; LD; SP; QL (1 pack per 1 fill) (ozanimod hcl) PA; LD; SP; QL (1 capsule per 1 ZEPOSIA ORAL CAPSULE (ozanimod hcl) 4 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 181 Coverage Requirements and Prescription Drug Name Drug Tier Limits ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY PACK (ozanimod 4 PA; LD; SP; QL (1 pack per 1 fill) hcl) *THIENBENZODIAZEPINES & SSRIS*** - DRUGS FOR SEVERE MENTAL DISORDERS olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 6-50 mg 1 or 1b* QL (1 capsule per 1 day) olanzapine-fluoxetine hcl oral capsule 3-25 mg, 6-25 mg 1 or 1b* SYMBYAX ORAL CAPSULE (olanzapine-fluoxetine hcl) 3 *VASOMOTOR SYMPTOM AGENTS - SSRIS*** - DRUGS FOR THE NERVOUS SYSTEM paroxetine mesylate oral capsule 1 or 1b* *RESPIRATORY AGENTS - MISC.* - DRUGS FOR THE LUNGS *ALPHA-PROTEINASE INHIBITOR (HUMAN)*** - DRUGS FOR ASTHMA/COPD ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED (alpha1- 4 PA; LD; SP proteinase inhibitor) GLASSIA INTRAVENOUS SOLUTION (alpha1-proteinase inhibitor) 4 PA; LD; SP PROLASTIN-C INTRAVENOUS SOLUTION (alpha1-proteinase inhibitor) 4 PA; LD PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED (alpha1- 4 PA; LD proteinase inhibitor) ZEMAIRA INTRAVENOUS SOLUTION RECONSTITUTED (alpha1- 4 PA; LD; SP proteinase inhibitor) *CFTR POTENTIATORS*** - DRUGS FOR CYSTIC FIBROSIS KALYDECO ORAL PACKET 25 MG (ivacaftor) 4 PA; LD; QL (2 packets per 1 day) KALYDECO ORAL PACKET 50 MG, 75 MG (ivacaftor) 4 PA; LD; QL (2 packet per 1 day) KALYDECO ORAL TABLET (ivacaftor) 4 PA; LD; QL (2 tablets per 1 day) *CYSTIC FIBROSIS AGENT - COMBINATIONS*** - DRUGS FOR CYSTIC FIBROSIS ORKAMBI ORAL PACKET (lumacaftor-ivacaftor) 4 PA; LD; QL (2 packets per 1 day) ORKAMBI ORAL TABLET (lumacaftor-ivacaftor) 4 PA; LD; QL (4 tablet per 1 day) SYMDEKO ORAL TABLET THERAPY PACK (tezacaftor-ivacaftor) 4 PA; LD; QL (1 carton per 28 days) TRIKAFTA ORAL TABLET THERAPY PACK (elexacaftor-tezacaftor- 4 PA; LD; QL (1 carton per 28 days) ivacaft) *CYSTIC FIBROSIS AGENTS - MISCELLANEOUS*** - DRUGS FOR CYSTIC FIBROSIS PA; LD; SP; QL (560 tablets per 28 BRONCHITOL INHALATION CAPSULE (mannitol (cystic fibrosis)) 4 days) BRONCHITOL TOLERANCE TEST INHALATION CAPSULE (mannitol 4 PA; LD; SP; QL (1 test per 1 fill) (cystic fibrosis)) *HYDROLYTIC ENZYMES*** - DRUGS FOR THE LUNGS PULMOZYME INHALATION SOLUTION (dornase alfa) 4 LD; SP; QL (150 mL per 30 days) *PLEURAL SCLEROSING AGENTS*** - DRUGS FOR THE LUNGS SCLEROSOL INTRAPLEURAL INTRAPLEURAL AEROSOL POWDER 3 (talc) STERILE TALC POWDER INTRAPLEURAL SUSPENSION 3 RECONSTITUTED (talc)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 182 Coverage Requirements and Prescription Drug Name Drug Tier Limits STERITALC INTRAPLEURAL POWDER (talc) 3 *PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS*** - DRUGS FOR THE LUNGS PA; LD; SP; QL (2 capsules per 1 OFEV ORAL CAPSULE (nintedanib esylate) 4 day) *PULMONARY FIBROSIS AGENTS*** - DRUGS FOR THE LUNGS PA; LD; SP; QL (9 capsule per 1 ESBRIET ORAL CAPSULE (pirfenidone) 4 day) PA; LD; SP; QL (9 tablets per 1 ESBRIET ORAL TABLET 267 MG (pirfenidone) 4 day) PA; LD; SP; QL (3 tablets per 1 ESBRIET ORAL TABLET 801 MG (pirfenidone) 4 day) *RESPIRATORY AGENTS - MISC.*** - DRUGS FOR THE LUNGS CUROSURF INTRATRACHEAL SUSPENSION (poractant alfa) 3 INFASURF INTRATRACHEAL SUSPENSION (calfactant in nacl) 3 SURVANTA INTRATRACHEAL SUSPENSION (beractant in nacl) 3 *SULFONAMIDES* - DRUGS FOR INFECTIONS *SULFONAMIDES*** - ANTIBIOTICS SULFADIAZINE ORAL TABLET 3 *TETRACYCLINES* - DRUGS FOR INFECTIONS *AMINOMETHYLCYCLINES*** - ANTIBIOTICS NUZYRA INTRAVENOUS SOLUTION RECONSTITUTED (omadacycline 3 LD tosylate) NUZYRA ORAL TABLET (omadacycline tosylate) 3 PA; LD; QL (30 tablets per 30 days) *FLUOROCYCLINES*** - ANTIBIOTICS XERAVA INTRAVENOUS SOLUTION RECONSTITUTED (eravacycline 3 dihydrochloride) *GLYCYLCYCLINES*** - ANTIBIOTICS TIGECYCLINE INTRAVENOUS SOLUTION RECONSTITUTED 3 TYGACIL INTRAVENOUS SOLUTION RECONSTITUTED (tigecycline) 3 *TETRACYCLINES*** - ANTIBIOTICS coremino oral tablet extended release 24 hour 1 or 1b* ST demeclocycline hcl oral tablet 1 or 1b* doxy 100 intravenous solution reconstituted 1 or 1b* QL (2 vials per 1 day) doxycycline hyclate intravenous solution reconstituted 1 or 1b* QL (2 vials per 1 day) doxycycline hyclate oral capsule 100 mg 1 or 1b* QL (2 capsules per 1 day) doxycycline hyclate oral capsule 50 mg 1 or 1b* doxycycline hyclate oral tablet 100 mg, 20 mg, 50 mg 1 or 1b* QL (2 tablets per 1 day) doxycycline hyclate oral tablet 150 mg 1 or 1b* ST; QL (1 tablet per 1 day) doxycycline hyclate oral tablet 75 mg 1 or 1b* ST; QL (2 tablets per 1 day) doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 200 mg, 50 1 or 1b* ST; QL (2 tablets per 1 day) mg, 75 mg doxycycline monohydrate oral capsule 100 mg, 50 mg, 75 mg 1 or 1b* QL (2 capsules per 1 day) doxycycline monohydrate oral capsule 150 mg 1 or 1b* * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 183 Coverage Requirements and Prescription Drug Name Drug Tier Limits doxycycline monohydrate oral suspension reconstituted 1 or 1b* QL (600 mL per 30 days) doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg 1 or 1b* QL (2 tablets per 1 day) doxycycline monohydrate oral tablet 150 mg 1 or 1b* MINOCIN INTRAVENOUS SOLUTION RECONSTITUTED (minocycline 3 hcl) minocycline hcl er oral tablet extended release 24 hour 1 or 1b* ST minocycline hcl oral capsule 1 or 1b* minocycline hcl oral tablet 1 or 1b* mondoxyne nl oral capsule 1 or 1b* QL (2 capsules per 1 day) morgidox oral capsule 1 or 1b* QL (2 capsules per 1 day) tetracycline hcl oral capsule 1 or 1b* *THYROID AGENTS* - HORMONES *ANTITHYROID AGENTS - RADIOPHARMACEUTICALS*** - DRUGS FOR THYROID SODIUM IODIDE I-131 ORAL SOLUTION 3 *ANTITHYROID AGENTS*** - DRUGS FOR THYROID methimazole oral tablet 1 or 1a* propylthiouracil oral tablet 1 or 1b* TAPAZOLE ORAL TABLET (methimazole) 3 *THYROID HORMONES*** - DRUGS FOR THYROID ARMOUR THYROID ORAL TABLET (thyroid) 3 CYTOMEL ORAL TABLET (liothyronine sodium) 3 euthyrox oral tablet 1 or 1b* levo-t oral tablet 1 or 1b* LEVOTHYROXINE SODIUM INTRAVENOUS SOLUTION 3 LEVOTHYROXINE SODIUM INTRAVENOUS SOLUTION 3 RECONSTITUTED levothyroxine sodium oral capsule 1 or 1b* levothyroxine sodium oral tablet 1 or 1a* levoxyl oral tablet 1 or 1a* liothyronine sodium intravenous solution 1 or 1b* liothyronine sodium oral tablet 1 or 1b* NATURE-THROID ORAL TABLET (thyroid) 3 np thyroid oral tablet 1 or 1a* SYNTHROID ORAL TABLET (levothyroxine sodium) 3 THYQUIDITY ORAL SOLUTION (levothyroxine sodium) 3 TIROSINT ORAL CAPSULE (levothyroxine sodium) 3 TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 MCG/ML, 200 3 MCG/ML, 25 MCG/ML, 50 MCG/ML, 75 MCG/ML, 88 MCG/ML (levothyroxine sodium) TRIOSTAT INTRAVENOUS SOLUTION (liothyronine sodium) 3 unithroid oral tablet 1 or 1a*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 184 Coverage Requirements and Prescription Drug Name Drug Tier Limits WESTHROID ORAL TABLET (thyroid) 3 WP THYROID ORAL TABLET (thyroid) 3 *TOXOIDS* - BIOLOGICAL AGENTS *TOXOID COMBINATIONS*** - VACCINES ADACEL INTRAMUSCULAR SUSPENSION (tetanus-diphth-acell 3; $0 pertussis) BOOSTRIX INTRAMUSCULAR SUSPENSION (tetanus-diphth-acell 3; $0 pertussis) DAPTACEL INTRAMUSCULAR SUSPENSION (diphth-acell pertussis- 3; $0 tetanus) DIPHTHERIA-TETANUS TOXOIDS DT INTRAMUSCULAR 3; $0 SUSPENSION INFANRIX INTRAMUSCULAR SUSPENSION (diphth-acell pertussis- 3; $0 tetanus) KINRIX INTRAMUSCULAR SUSPENSION (dtap-ipv vaccine) 3; $0 PEDIARIX INTRAMUSCULAR SUSPENSION (dtap-hepatitis b recomb-ipv) 3; $0 PENTACEL INTRAMUSCULAR SUSPENSION RECONSTITUTED (dtap- 3; $0 ipv-hib vaccine) QUADRACEL INTRAMUSCULAR SUSPENSION (dtap-ipv vaccine) 3; $0 TDVAX INTRAMUSCULAR SUSPENSION (tetanus-diphtheria toxoids td) 3; $0 TENIVAC INTRAMUSCULAR INJECTABLE (tetanus-diphtheria toxoids 3; $0 td) TETANUS-DIPHTHERIA TOXOIDS TD INTRAMUSCULAR 3; $0 SUSPENSION VAXELIS INTRAMUSCULAR SUSPENSION (dtap-ipv-hib-hepatitis b 3 recmb) VAXELIS INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 3 (dtap-ipv-hib-hepatitis b recmb) *ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS* - DRUGS FOR THE STOMACH *ANTICHOLINERGIC COMBINATIONS*** - DRUGS FOR STOMACH CRAMPS chlordiazepoxide-clidinium oral capsule 1 or 1b* LIBRAX ORAL CAPSULE (chlordiazepoxide-clidinium) 3 phenohytro oral elixir 1 or 1b* phenohytro oral tablet 1 or 1b* *ANTISPASMODICS*** - DRUGS FOR STOMACH CRAMPS BENTYL INTRAMUSCULAR SOLUTION (dicyclomine hcl) 3 dicyclomine hcl intramuscular solution 1 or 1b* dicyclomine hcl oral capsule 1 or 1a* dicyclomine hcl oral solution 1 or 1a* dicyclomine hcl oral tablet 1 or 1a*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 185 Coverage Requirements and Prescription Drug Name Drug Tier Limits *BELLADONNA ALKALOIDS*** - DRUGS FOR STOMACH CRAMPS ATROPEN INTRAMUSCULAR SOLUTION AUTO-INJECTOR (atropine 3 sulfate) atropine sulfate injection solution prefilled syringe 0.25 mg/5ml 1 or 1b* ATROPINE SULFATE INTRAVENOUS SOLUTION 3 ATROPINE SULFATE INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 0.8 MG/2ML, 1 MG/2.5ML hyoscyamine sulfate er oral tablet extended release 12 hour 1 or 1b* hyoscyamine sulfate sl sublingual tablet sublingual 1 or 1b* hyoscyamine sulfate sublingual tablet sublingual 1 or 1b* *H-2 ANTAGONISTS*** - DRUGS FOR ULCERS AND STOMACH ACID cimetidine hcl oral solution 1 or 1b* cimetidine oral tablet 200 mg 1 or 1b* QL (2 tablets per 1 day) cimetidine oral tablet 300 mg, 400 mg 1 or 1b* QL (4 tablets per 1 day) cimetidine oral tablet 800 mg 1 or 1b* QL (3 tablets per 1 day) famotidine intravenous solution 1 or 1b* famotidine oral suspension reconstituted 1 or 1b* QL (5 mL per 1 day) famotidine oral tablet 20 mg 1 or 1b* QL (4 tablets per 1 day) famotidine oral tablet 40 mg 1 or 1b* QL (2 tablets per 1 day) famotidine premixed intravenous solution 1 or 1b* nizatidine oral capsule 150 mg 1 or 1b* QL (2 capsules per 1 day) nizatidine oral capsule 300 mg 1 or 1b* QL (1 capsule per 1 day) nizatidine oral solution 1 or 1b* QL (20 mL per 1 day) PEPCID ORAL TABLET 20 MG (famotidine) 3 QL (4 tablets per 1 day) PEPCID ORAL TABLET 40 MG (famotidine) 3 QL (2 tablets per 1 day) *MISC. ANTI-ULCER*** - DRUGS FOR ULCERS AND STOMACH ACID CARAFATE ORAL SUSPENSION (sucralfate) 3 CARAFATE ORAL TABLET (sucralfate) 3 sucralfate oral suspension 1 or 1b* sucralfate oral tablet 1 or 1b* *PROTON PUMP INHIBITORS*** - DRUGS FOR ULCERS AND STOMACH ACID DEXILANT ORAL CAPSULE DELAYED RELEASE (dexlansoprazole) 2 ST; QL (1 capsule per 1 day) esomeprazole sodium intravenous solution reconstituted 1 or 1b* NEXIUM I.V. INTRAVENOUS SOLUTION RECONSTITUTED 3 (esomeprazole sodium) omeprazole oral capsule delayed release 1 or 1b* pantoprazole sodium intravenous solution reconstituted 1 or 1b* pantoprazole sodium oral tablet delayed release 1 or 1b* PROTONIX INTRAVENOUS SOLUTION RECONSTITUTED (pantoprazole 3 sodium) * Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 186 Coverage Requirements and Prescription Drug Name Drug Tier Limits *QUATERNARY ANTICHOLINERGICS*** - DRUGS FOR STOMACH CRAMPS CUVPOSA ORAL SOLUTION (glycopyrrolate) 3 GLYCATE ORAL TABLET (glycopyrrolate) 3 PA glycopyrrolate injection solution 1 or 1b* glycopyrrolate oral tablet 1 mg, 2 mg 1 or 1b* GLYCOPYRROLATE ORAL TABLET 1.5 MG 3 PA GLYCOPYRROLATE PF INJECTION SOLUTION PREFILLED SYRINGE 3 GLYRX-PF INJECTION SOLUTION (glycopyrrolate) 3 GLYRX-PF INJECTION SOLUTION PREFILLED SYRINGE 3 (glycopyrrolate) methscopolamine bromide oral tablet 1 or 1b* *ULCER ANTI-INFECTIVE W/ BISMUTH COMBINATIONS*** - DRUGS FOR ULCERS AND STOMACH ACID HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) 3 ST; QL (1 pack per 1 fill) PYLERA ORAL CAPSULE (bis subcit-metronid-tetracyc) 3 ST; QL (1 pack per 1 fill) *ULCER ANTI-INFECTIVE W/ PROTON PUMP INHIBITORS*** - DRUGS FOR ULCERS AND STOMACH ACID amoxicill-clarithro-lansopraz oral 1 or 1b* ST; QL (1 pack per 1 fill) OMECLAMOX-PAK ORAL (amoxicill-clarithro-omeprazole) 3 ST; QL (1 pack per 1 fill) TALICIA ORAL CAPSULE DELAYED RELEASE (amoxicill-rifabutin- 3 ST; QL (1 pack per 1 fill) omeprazole) *ULCER DRUGS - PROSTAGLANDINS*** - DRUGS FOR ULCERS AND STOMACH ACID CYTOTEC ORAL TABLET (misoprostol) 3 misoprostol oral tablet 1 or 1a* *URINARY ANTISPASMODICS* - DRUGS FOR THE URINARY SYSTEM *URINARY ANTISPASMODIC - ANTIMUSCARINIC (ANTICHOLINERGIC)*** - DRUGS FOR THE BLADDER darifenacin hydrobromide er oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg 1 or 1b* QL (2 tablets per 1 day) oxybutynin chloride er oral tablet extended release 24 hour 5 mg 1 or 1b* QL (1 tablet per 1 day) oxybutynin chloride oral syrup 1 or 1b* QL (20 mL per 1 day) oxybutynin chloride oral tablet 1 or 1b* QL (4 tablets per 1 day) solifenacin succinate oral tablet 1 or 1b* QL (1 tablet per 1 day) tolterodine tartrate er oral capsule extended release 24 hour 1 or 1b* QL (1 capsule per 1 day) tolterodine tartrate oral tablet 1 or 1b* QL (2 tablets per 1 day) TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR (fesoterodine 3 QL (1 tablet per 1 day) fumarate) trospium chloride er oral capsule extended release 24 hour 1 or 1b* QL (1 capsule per 1 day) trospium chloride oral tablet 1 or 1b* QL (2 tablets per 1 day)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 187 Coverage Requirements and Prescription Drug Name Drug Tier Limits *URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS*** - DRUGS FOR THE BLADDER MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 3 QL (1 tablet per 1 day) (mirabegron) *URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS*** - DRUGS FOR THE BLADDER bethanechol chloride oral tablet 1 or 1b* *URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS*** - DRUGS FOR THE BLADDER flavoxate hcl oral tablet 1 or 1b* *VACCINES* - BIOLOGICAL AGENTS *BACTERIAL VACCINES*** - VACCINES ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED 3; $0 (haemophilus b polysac conj vac) BCG VACCINE INJECTION INJECTABLE 3; $0 BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 3; $0 (meningococcal b recomb omv adj) BIOTHRAX INTRAMUSCULAR SUSPENSION (anthrax vaccine adsorbed) 3 HIBERIX INJECTION SOLUTION RECONSTITUTED (haemophilus b 3; $0 polysac conj vac) MENACTRA INTRAMUSCULAR INJECTABLE (meningococcal a c y&w- 3; $0 135 conj) MENQUADFI INTRAMUSCULAR INJECTABLE (meningococcal a c y&w- 3; $0 135 conj) MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED 3; $0 (meningococcal a c y&w-135 olig) PEDVAX HIB INTRAMUSCULAR SUSPENSION (haemophilus b polysac 3; $0 conj vac) PNEUMOVAX 23 INJECTION INJECTABLE (pneumococcal vac 2; $0 polyvalent) PREVNAR 13 INTRAMUSCULAR SUSPENSION (pneumococcal 13-val 2; $0 conj vacc) TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 3; $0 (meningococcal b vac (recomb)) TYPHIM VI INTRAMUSCULAR SOLUTION (typhoid vi polysaccharide 3 vacc) VAXCHORA ORAL SUSPENSION RECONSTITUTED (cholera vac live 3 attenuated) *VIRAL VACCINE COMBINATIONS*** - VACCINES M-M-R II INJECTION SOLUTION RECONSTITUTED (measles, mumps & 3; $0 rubella vac) PROQUAD SUBCUTANEOUS SUSPENSION RECONSTITUTED (measles- 3; $0 mumps-rubella-varicell) TWINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 3; $0 (hepatitis a-hep b recomb vac)

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 188 Coverage Requirements and Prescription Drug Name Drug Tier Limits *VIRAL VACCINES*** - VACCINES AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) (influenza vac split quad) AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) PREFILLED SYRINGE (influenza vac split quad) ENGERIX-B INJECTION SUSPENSION (hepatitis b vac recombinant) 3; $0 FLUAD INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2; $0 QL (1 fill per 180 days) (influenza vac a&b surf ant adj) FLUAD QUADRIVALENT INTRAMUSCULAR PREFILLED SYRINGE 2; $0 QL (1 fill per 180 days) (influenza vac a&b sa adj quad) FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) PREFILLED SYRINGE (influenza vac split quad) FLUBLOK QUADRIVALENT INTRAMUSCULAR SOLUTION 2; $0 QL (1 fill per 180 days) PREFILLED SYRINGE (influenza vac recomb ha quad) FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) (influenza vac subunit quad) FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) PREFILLED SYRINGE (influenza vac subunit quad) FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) PREFILLED SYRINGE (influenza vac split quad) FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) (influenza vac split quad) FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) PREFILLED SYRINGE (influenza vac split quad) GARDASIL 9 INTRAMUSCULAR SUSPENSION (hpv 9-valent recomb 2; $0 vaccine) GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2; $0 (hpv 9-valent recomb vaccine) HAVRIX INTRAMUSCULAR SUSPENSION (hepatitis a vaccine) 3; $0 HEPLISAV-B INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 3; $0 (hepatitis b vac recomb adj) IMOVAX RABIES INTRAMUSCULAR INJECTABLE (rabies virus vaccine, 3 hdc) IPOL INJECTION INJECTABLE (poliovirus vaccine inactivated) 3; $0 IXIARO INTRAMUSCULAR SUSPENSION (japanese encephalitis vac 3 inac) RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED 3 (rabies vaccine, pcec) RECOMBIVAX HB INJECTION SUSPENSION (hepatitis b vac 3; $0 recombinant) ROTARIX ORAL SUSPENSION RECONSTITUTED (rotavirus vaccine live 3; $0 oral) ROTATEQ ORAL SOLUTION (rotavirus vac live pentavalent) 3; $0 SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED (zoster 3; $0 vac recomb adjuvanted) STAMARIL INJECTION SUSPENSION RECONSTITUTED 3 VAQTA INTRAMUSCULAR SUSPENSION (hepatitis a vaccine) 3; $0

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 189 Coverage Requirements and Prescription Drug Name Drug Tier Limits VARIVAX SUBCUTANEOUS INJECTABLE (varicella virus vaccine live) 3; $0 YF-VAX SUBCUTANEOUS INJECTABLE (yellow fever vaccine) 3 *VAGINAL AND RELATED PRODUCTS* - DRUGS FOR WOMEN *IMIDAZOLE-RELATED ANTIFUNGALS*** - DRUGS FOR INFECTIONS GYNAZOLE-1 VAGINAL CREAM (butoconazole nitrate (1 dose)) 3 miconazole 3 vaginal suppository 1 or 1b* terconazole vaginal cream 0.4 % 1 or 1b* QL (90 grams per 30 days) terconazole vaginal cream 0.8 % 1 or 1b* QL (40 grams per 30 days) terconazole vaginal suppository 1 or 1b* QL (6 suppositories per 30 days) *MISCELLANEOUS VAGINAL PRODUCTS*** - DRUGS FOR WOMEN INTRAROSA VAGINAL INSERT (prasterone) 3 ST; QL (1 insert per 1 day) *VAGINAL ANTI-INFECTIVES*** - DRUGS FOR INFECTIONS CLEOCIN VAGINAL CREAM (clindamycin phosphate) 3 CLEOCIN VAGINAL SUPPOSITORY (clindamycin phosphate) 2 clindamycin phosphate vaginal cream 1 or 1b* CLINDESSE VAGINAL CREAM (clindamycin phosphate (1 dose)) 3 metronidazole vaginal gel 1 or 1b* NUVESSA VAGINAL GEL (metronidazole) 3 vandazole vaginal gel 1 or 1b* *VAGINAL CONTRACEPTIVE PH MODULATOR - COMBINATIONS*** - DRUGS FOR WOMEN PHEXXI VAGINAL GEL (lactic ac-citric ac-pot bitart) 3 *VAGINAL ESTROGENS*** - DRUGS FOR WOMEN estradiol vaginal cream 1 or 1b* estradiol vaginal tablet 1 or 1b* QL (18 tablet per 28 days) ESTRING VAGINAL RING (estradiol) 3 QL (1 ring per 90 days) FEMRING VAGINAL RING (estradiol acetate) 3 QL (1 ring per 90 days) IMVEXXY MAINTENANCE PACK VAGINAL INSERT 10 MCG 3 QL (18 inserts per 28 days) (estradiol) IMVEXXY MAINTENANCE PACK VAGINAL INSERT 4 MCG (estradiol) 3 QL (18 packs per 28 days) IMVEXXY STARTER PACK VAGINAL INSERT 10 MCG (estradiol) 3 QL (18 inserts per 28 days) IMVEXXY STARTER PACK VAGINAL INSERT 4 MCG (estradiol) 3 QL (18 packs per 28 days) PREMARIN VAGINAL CREAM (estrogens, conjugated) 2 QL (1 gm per 1 day) yuvafem vaginal tablet 1 or 1b* QL (18 tablet per 28 days) *VAGINAL PROGESTINS*** - DRUGS FOR WOMEN CRINONE VAGINAL GEL 4 % (progesterone) 4 SP CRINONE VAGINAL GEL 8 % (progesterone) 4 PA; SP; QL (1 applicator per 1 day) ENDOMETRIN VAGINAL INSERT (progesterone) 3 PA

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 190 Coverage Requirements and Prescription Drug Name Drug Tier Limits *VASOPRESSORS* - DRUGS FOR THE HEART *ANAPHYLAXIS THERAPY AGENTS*** - DRUGS FOR SERIOUS ALLERGIC REACTION ADRENALIN INJECTION SOLUTION (epinephrine) 3 epinephrine (anaphylaxis) injection solution 1 or 1b* epinephrine injection solution auto-injector 1 or 1b* QL (2 pens per 1 fill) SYMJEPI INJECTION SOLUTION PREFILLED SYRINGE (epinephrine) 2 QL (2 syringes per 1 fill) *NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS*** - DRUGS FOR SERIOUS ALLERGIC REACTION droxidopa oral capsule 100 mg 1 or 1b* PA; SP; QL (3 capsules per 1 day) droxidopa oral capsule 200 mg, 300 mg 1 or 1b* PA; SP; QL (6 capsules per 1 day) PA; LD; SP; QL (3 capsules per 1 NORTHERA ORAL CAPSULE 100 MG (droxidopa) 3 day) PA; LD; SP; QL (6 capsules per 1 NORTHERA ORAL CAPSULE 200 MG, 300 MG (droxidopa) 3 day) *VASOPRESSORS*** - DRUGS FOR SERIOUS ALLERGIC REACTION AKOVAZ INTRAVENOUS SOLUTION (ephedrine sulfate (pressors)) 3 BIORPHEN INTRAVENOUS SOLUTION (phenylephrine hcl (pressors)) 3 EMERPHED INTRAVENOUS SOLUTION (ephedrine sulfate (pressors)) 3 EPHEDRINE SULFATE (PRESSORS) INJECTION SOLUTION 3 PREFILLED SYRINGE 50 MG/10ML EPHEDRINE SULFATE INTRAVENOUS SOLUTION 3 EPHEDRINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 10-0.9 MG/ML-%, 100-0.9 MG/10ML-%, 50-0.9 MG/10ML-% EPINEPHRINE HCL-NACL INTRAVENOUS SOLUTION 3 EPINEPHRINE INTRAVENOUS SOLUTION 3 EPINEPHRINE INTRAVENOUS SOLUTION PREFILLED SYRINGE 1 3 MG/10ML EPINEPHRINE PF INJECTION SOLUTION 3 EPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION 3 EPINEPHRINE-NACL INTRAVENOUS SOLUTION 3 GIAPREZA INTRAVENOUS SOLUTION (angiotensin ii acetate) 3 LEVOPHED INTRAVENOUS SOLUTION (norepinephrine bitartrate) 3 midodrine hcl oral tablet 1 or 1b* NOREPINEPHRINE (BASE)-DEXTROSE INTRAVENOUS SOLUTION 4-5 3 MG/250ML-% norepinephrine bitartrate intravenous solution 1 or 1b* NOREPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION 4-5 3 MG/250ML-%, 8-5 MG/250ML-% NOREPINEPHRINE-SODIUM CHLORIDE INTRAVENOUS SOLUTION 8- 3 0.9 MG/500ML-% PHENYLEPHRINE HCL INTRAVENOUS SOLUTION 10 MG/ML 3 PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION 3

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 191 Coverage Requirements and Prescription Drug Name Drug Tier Limits PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.4-0.9 MG/10ML-%, 0.8-0.9 MG/10ML-%, 100-0.9 MCG/10ML- 3 %, 20-0.9 MG/50ML-%, 5-0.9 MG/50ML-% VAZCULEP INTRAVENOUS SOLUTION (phenylephrine hcl (pressors)) 3 *VITAMINS* - DRUGS FOR NUTRITION *VITAMIN A*** - DRUGS FOR NUTRITION AQUASOL A INTRAMUSCULAR SOLUTION (vitamin a) 3 *VITAMIN B-1*** - DRUGS FOR NUTRITION thiamine hcl injection solution 1 or 1b* *VITAMIN B-6*** - DRUGS FOR NUTRITION pyridoxine hcl injection solution 1 or 1b* *VITAMIN C*** - DRUGS FOR NUTRITION ASCOR INTRAVENOUS SOLUTION (ascorbic acid) 3 *VITAMIN D*** - DRUGS FOR NUTRITION DRISDOL ORAL CAPSULE (ergocalciferol) 3 ergocalciferol oral capsule 1 or 1a* vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) 1 or 1a* *VITAMIN K*** - DRUGS FOR NUTRITION MEPHYTON ORAL TABLET (phytonadione) 3 phytonadione injection solution 1 or 1b* phytonadione oral tablet 1 or 1b* vitamin k1 injection solution 1 or 1b*

* Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information. Effective 09/01/2021 192 Index abacavir sulfate...... 85 ADIPEX-P...... 12 alogliptin-pioglitazone...... 43 abacavir sulfate-lamivudine...... 82 ADRENAL C FORMULA...... 156 ALOPRIM...... 131 abacavir-lamivudine-zidovudine...... 82 ADRENALIN...... 191 ALORA...... 125 ABELCET...... 49 adriamycin...... 69 alosetron hcl...... 127 ABILIFY MAINTENA...... 81 ADVAIR DISKUS...... 31 ALOXI...... 47 ABILIFY MYCITE...... 81 ADVAIR HFA...... 31 ALPHAGAN P...... 170 ABILIFY MYCITE MAINTENANCE ADVATE...... 131 ALPHANATE...... 131 KIT...... 81 ADYNOVATE...... 131 ALPHANINE SD...... 131 ABILIFY MYCITE STARTER KIT..... 81 ADZENYS ER...... 11 alprazolam...... 29 abiraterone acetate...... 62 ADZENYS XR-ODT...... 11 alprazolam er...... 29 ABLYSINOL...... 94 AEMCOLO...... 57 ALPRAZOLAM INTENSOL...... 29 ABRAXANE...... 74 AFFINITY...... 114 alprazolam xr...... 29 ABSORICA...... 106 AFINITOR...... 68 ALPROLIX...... 131 ABSORICA LD...... 105 AFINITOR DISPERZ...... 68 alprostadil...... 154 ACACIA...... 15 afirmelle...... 96 ALREX...... 171 acamprosate calcium...... 177 AFLURIA QUADRIVALENT...... 189 ALTABAX...... 106 acarbose...... 42 AFSTYLA...... 131 altafluor benox...... 169 ACCOLATE...... 33 AGGRASTAT...... 133 altafrin...... 167 ACCRUFER...... 137 AGRYLIN...... 135 altavera...... 96 ACCURETIC...... 53 AIMOVIG...... 147 ALTERNARIA...... 15 accutane...... 106 ak-fluor...... 169 ALUNBRIG...... 63 acebutolol hcl...... 88 AK-FLUOR...... 169 alvimopan...... 128 ACETADOTE...... 46 AKLIEF...... 106 alyacen 1/35...... 96 acetaminophen...... 22 AKOVAZ...... 191 alyacen 7/7/7...... 101 acetaminophen-codeine...... 23 ak-poly-bac...... 168 alyq...... 93 acetaminophen-codeine #2...... 23 AKTEN...... 170 amabelz...... 124 acetaminophen-codeine #3...... 23 AKYNZEO...... 47, 48 amantadine hcl...... 77 acetaminophen-codeine #4...... 23 ala-cort...... 109 AMARYL...... 45 acetazolamide...... 116 albendazole...... 28 AMBISOME...... 49 acetazolamide er...... 116 ALBENZA...... 28 ambrisentan...... 93 acetazolamide sodium...... 116 ALBUKED 25...... 134 amcinonide...... 109 acetic acid...... 130, 173 ALBUKED 5...... 134 AMELUZ...... 113 acetylcysteine...... 46, 104 ALBUMIN HUMAN...... 134 AMERICAN BEECH...... 15 acitretin...... 108 ALBUMINEX...... 134 AMERICAN COCKROACH...... 15 ACNESIC...... 112 ALBUMIN-ZLB...... 134 AMERICAN ELM...... 15 ACREMONIUM...... 15 ALBURX...... 134 amethia...... 100 ACTHAR...... 119 ALBUTEIN...... 134 amethyst...... 100 ACTHIB...... 188 albuterol sulfate...... 31 AMICAR...... 138 ACTIFOAM COLLAGEN SPONGE..139 albuterol sulfate hfa...... 31 AMIDATE...... 128 ACTIMMUNE...... 71 ALCAINE...... 170 amikacin sulfate...... 19 ACTIVASE...... 135 alclometasone dipropionate...... 109 amiloride hcl...... 117 ACTIVELLA...... 124 ALDACTAZIDE...... 116 amiloride-hydrochlorothiazide...... 116 ACTONEL...... 118 ALDACTONE...... 117 aminoacetic acid...... 130 ACTOPLUS MET...... 45 ALDARA...... 112 aminocaproic acid...... 138 ACULAR...... 170 ALDER...... 15 aminophylline...... 33 ACULAR LS...... 170 ALDURAZYME...... 121 AMINOPROTECT...... 165 ACUVAIL...... 170 ALECENSA...... 63 AMINOSYN II...... 165 acyclovir...... 87, 109 alendronate sodium...... 118 AMINOSYN-PF...... 165 acyclovir sodium...... 87 ALFENTANIL HCL...... 23 amiodarone hcl...... 30 ADACEL...... 185 ALFERON N...... 71 AMIODARONE HCL IN DEXTROSE.30 ADAKVEO...... 138 alfuzosin hcl er...... 129 amitriptyline hcl...... 41 adapalene...... 106 ALIMTA...... 62 amlodipine besy-benazepril hcl...... 53 adapalene-benzoyl peroxide...... 105 ALINIA...... 57 amlodipine besylate...... 89 ADASUVE...... 81 ALIQOPA...... 75 amlodipine besylate-valsartan...... 54 adc/f (0.5mg/ml)...... 157 aliskiren fumarate...... 56 amlodipine-atorvastatin...... 92 ADCETRIS...... 64 ALKERAN...... 74 amlodipine-olmesartan...... 54 ADDYI...... 181 ALKINDI SPRINKLE...... 102 amlodipine-valsartan-hctz...... 55 adefovir dipivoxil...... 86 allopurinol...... 131 ammonium lactate...... 111 ADEMPAS...... 93 allopurinol sodium...... 131 AMMONUL...... 123 ADENOCAINE...... 92 almotriptan malate...... 147 amnesteem...... 106 adenosine...... 30 alogliptin benzoate...... 42 AMNIOFIX...... 114 ADHANSIA XR...... 13 alogliptin-metformin hcl...... 42 AMNIOTEXT...... 114 193 AMONDYS 45...... 164 ARGATROBAN IN SODIUM AUSTEDO...... 179 amoxapine...... 41 CHLORIDE...... 35 AUSTRALIAN PINE...... 15 amoxicill-clarithro-lansopraz...... 187 ARGININE HCL...... 165 AVASTIN...... 76 amoxicillin...... 176 argyle sterile saline...... 130 aviane...... 96 amoxicillin-pot clavulanate...... 176 argyle sterile water...... 152 avita...... 106 amoxicillin-pot clavulanate er...... 176 ARICEPT...... 178 AVITENE...... 139 AMPHADASE...... 151 ARIKAYCE...... 19 AVITENE FLOUR...... 139 AMPHENOL-40...... 114 aripiprazole...... 81, 82 AVYCAZ...... 94 amphetamine er...... 11 ARISTADA...... 82 AYGESTIN...... 177 amphetamine sulfate...... 11 ARISTADA INITIO...... 82 ayuna...... 97 amphetamine-dextroamphet er...... 11 ARIXTRA...... 35 AYVAKIT...... 68 amphetamine-dextroamphetamine...... 11 ARIZONA CYPRESS...... 15 azacitidine...... 62 amphotericin b...... 49 armodafinil...... 13 AZACTAM...... 59 ampicillin...... 176 ARMOUR THYROID...... 184 AZASAN...... 154 ampicillin sodium...... 176 ARNUITY ELLIPTA...... 33 AZASITE...... 168 ampicillin-sulbactam sodium...... 176 AROMASIN...... 71 azathioprine...... 154 AMPYRA...... 180 ARRANON...... 62 AZATHIOPRINE SODIUM...... 154 AMVISC...... 172 arsenic trioxide...... 71 AZEDRA DOSIMETRIC...... 71 AMVISC PLUS...... 172 ARTESUNATE...... 60 AZEDRA THERAPEUTIC...... 71 anagrelide hcl...... 135 articadent dental...... 142 azelaic acid...... 113 ANALPRAM-HC...... 28 ARTISS...... 138 azelastine hcl...... 163, 167 ANASCORP...... 174 ARZERRA...... 64 azelastine-fluticasone...... 163 anastrozole...... 71 ASCENIV...... 175 AZESCHEW ANAVIP...... 174 ASCLERA...... 154 PRENATAL/POSTNATAL...... 157 ANCOBON...... 49 ascomp-codeine...... 23 AZESCO...... 157 ANDEXXA...... 46 ASCOR...... 192 AZILECT...... 78 ANDRODERM...... 27 asenapine maleate...... 80 azithromycin...... 143, 144 ANECTINE...... 164 ashlyna...... 100 AZOPT...... 169 ANESTHESIA S/I-40A...... 128 ASPARLAS...... 71 aztreonam...... 59 ANESTHESIA S/I-40H...... 128 ASPERGILLUS FUMIGATUS...... 15 AZULFIDINE...... 127 ANESTHESIA S/I-40S...... 128 aspirin-dipyridamole er...... 135 AZULFIDINE EN-TABS...... 127 ANGELIQ...... 124 ASPIRIN-OMEPRAZOLE...... 135 azurette...... 96 ANGIOMAX...... 35 ASSURE ID INSULIN SAFETY SYR146 bac...... 22 ANJESO...... 20 ASTAGRAF XL...... 153 bacitracin...... 57, 168 ANNOVERA...... 100 ATABEX EC...... 157 bacitracin-polymyxin b...... 168 ANORO ELLIPTA...... 31 ATABEX OB...... 157 bacitra-neomycin-polymyxin-hc...... 171 ANTIVENIN LATRODECTUS atazanavir sulfate...... 84 baclofen...... 161 MACTANS...... 174 ATELVIA...... 118 BACTRIM...... 57 ANTIVENIN MICRURUS FULVIUS 174 atenolol...... 88 BACTRIM DS...... 57 ANUSOL-HC...... 28 atenolol-chlorthalidone...... 56 BAHIA...... 15 APADAZ...... 26 ATGAM...... 152 BAL IN OIL...... 46 apap-caff-dihydrocodeine...... 23 atomoxetine hcl...... 11 balanced salt...... 169 APLENZIN...... 39 atorvastatin calcium...... 52 BALCOLTRA...... 97 APLIGRAF...... 114 atovaquone...... 58 BALD CYPRESS...... 15 APOKYN...... 78 atovaquone-proguanil hcl...... 60 balsalazide disodium...... 127 apraclonidine hcl...... 170 atracurium besylate...... 164 BALVERSA...... 67 aprepitant...... 48 ATROPEN...... 186 balziva...... 97 apri...... 96 atropine sulfate...... 167, 186 BANZEL...... 36 APRISO...... 127 ATROPINE SULFATE...... 167, 186 BAQSIMI ONE PACK...... 42 APTENSIO XR...... 13 ATROVENT HFA...... 32 BAQSIMI TWO PACK...... 42 APTIOM...... 36 AUBAGIO...... 179 BARACLUDE...... 86 APTIVUS...... 84 aubra...... 96 BARHEMSYS...... 48 AQUASOL A...... 192 aubra eq...... 96 BASAGLAR KWIKPEN...... 43 ARAKODA...... 60 AUGMENTIN...... 176, 177 BAVENCIO...... 65 ARALAST NP...... 182 AUGMENTIN ES-600...... 176 BAXDELA...... 125 aranelle...... 101 AUREOBASIDIUM...... 15 BAYBERRY (WAX MYRTLE)...... 15 ARANESP (ALBUMIN FREE)...... 136 AUREOBASIDIUM PULLULANS...... 15 BCG VACCINE...... 188 ARAVA...... 22 aurovela 1.5/30...... 96 B-COMPLEX...... 156 ARAZLO...... 106 aurovela 1/20...... 96 BD INSULIN SYRINGE U-500...... 146 ARCALYST...... 20 aurovela 24 fe...... 96 BD PEN NEEDLE NANO U/F...... 146 arformoterol tartrate...... 32 aurovela fe 1.5/30...... 96 BD SAFETYGLIDE INSULIN ARGATROBAN...... 35 aurovela fe 1/20...... 96 SYRINGE...... 146 AURYXIA...... 128 bekyree...... 96 194 BELBUCA...... 26 BLEPH-10...... 172 buprenorphine hcl...... 26 BELEODAQ...... 67 BLEPHAMIDE...... 171 buprenorphine hcl-naloxone hcl...... 26 BELRAPZO...... 61 BLEPHAMIDE S.O.P...... 171 bupropion hcl...... 39 BELSOMRA...... 141 BLINCYTO...... 66 bupropion hcl er (smoking det)...... 181 benazepril hcl...... 54 blisovi 24 fe...... 97 bupropion hcl er (sr)...... 39 benazepril-hydrochlorothiazide...... 53 blisovi fe 1.5/30...... 97 bupropion hcl er (xl)...... 39 BENDEKA...... 61 blisovi fe 1/20...... 97 buspirone hcl...... 29 BENEFIX...... 131 BLOXIVERZ...... 60 busulfan...... 61 BENLYSTA...... 150 BONIVA...... 118 BUSULFEX...... 61 BENTYL...... 185 BONJESTA...... 48 butalbital-acetaminophen...... 22 BENZALKONIUM CHLORIDE...... 82 BOOSTRIX...... 185 butalbital-apap-caff-cod...... 23 BENZAMYCIN...... 105 BORIC ACID...... 113 butalbital-apap-caffeine...... 22 BENZHYDROCODONE- BORTEZOMIB...... 69 butalbital-asa-caff-codeine...... 23 ACETAMINOPHEN...... 26 bosentan...... 93 butalbital-aspirin-caffeine...... 22 BENZNIDAZOLE...... 28 BOSULIF...... 66 butorphanol tartrate...... 26 benzonatate...... 104 BOTOX...... 164 BUTRANS...... 26 benzoyl peroxide-erythromycin...... 105 BOTOX COSMETIC...... 112 BYFAVO...... 140 benzphetamine hcl...... 12 BOTRYTIS...... 15 BYSTOLIC...... 88 benztropine mesylate...... 77 bp wash...... 106 CABENUVA...... 82, 83 BEOVU...... 173 BRAFTOVI...... 66 cabergoline...... 119 BERINERT...... 133 BREO ELLIPTA...... 31 CABLIVI...... 133 BERMUDA GRASS...... 15 BRETYLIUM TOSYLATE...... 30 CABOMETYX...... 68 beser...... 109 BREVIBLOC...... 88 CADUET...... 92 BESIVANCE...... 168 BREVIBLOC IN NACL...... 88 CAFCIT...... 12 BESPONSA...... 64 BREVIBLOC PREMIXED...... 88 caffeine citrate...... 12 BETADINE OPHTHALMIC PREP.... 169 BREVIBLOC PREMIXED DS...... 88 CALAN SR...... 89 betamethasone dipropionate...... 109 BREVITAL SODIUM...... 129 calcipotriene...... 108 betamethasone dipropionate aug...... 109 BREZTRI AEROSPHERE...... 31 calcipotriene-betameth diprop...... 115 betamethasone valerate...... 109, 110 BRIDION...... 46 calcitonin (salmon)...... 118 BETASERON...... 179 briellyn...... 97 calcitrene...... 108 betaxolol hcl...... 88, 166 BRILINTA...... 133 calcitriol...... 108, 120 bethanechol chloride...... 188 brimonidine tartrate...... 170 calcium acetate...... 128 BETHKIS...... 19 brinzolamide...... 169 calcium acetate (phos binder)...... 128 BETIMOL...... 166 BRIVIACT...... 36 CALCIUM DISODIUM VERSENATE 46 BETOPTIC-S...... 166 BROME...... 15 CALCIUM GLUCONATE...... 148 BEVACIZUMAB...... 173 bromfenac sodium (once-daily)...... 170 CALCIUM GLUCONATE-NACL...... 148 bexarotene...... 76 bromocriptine mesylate...... 77 CALDOLOR...... 20 BEXSERO...... 188 BROMSITE...... 170 CALIFORNIA PEPPER TREE...... 15 BEYAZ...... 97 BRONCHITOL...... 182 CALQUENCE...... 66 bicalutamide...... 62 BRONCHITOL TOLERANCE TEST.182 camila...... 101 BICILLIN C-R...... 177 BROVANA...... 32 CAMPTOSAR...... 76 BICILLIN C-R 900/300...... 177 BRUKINSA...... 66 camrese...... 100 BICILLIN L-A...... 176 BSP 0820...... 104 camrese lo...... 100 BICNU...... 75 BSS...... 169 CANASA...... 127 BIDIL...... 92 BSS PLUS...... 169 CANCIDAS...... 48 BIJUVA...... 124 budesonide...... 33, 102 candesartan cilexetil...... 55 BIKTARVY...... 82 budesonide er...... 102 candesartan cilexetil-hctz...... 54 BILTRICIDE...... 28 budesonide-formoterol fumarate...... 31 CANDIDA ALBICANS EXTRACT..... 15 bimatoprost...... 113, 173 bumetanide...... 117 CAPASTAT SULFATE...... 61 BINOSTO...... 118 BUMEX...... 117 capecitabine...... 62 BIORPHEN...... 191 BUNAVAIL...... 26 CAPLYTA...... 79 BIOTHRAX...... 188 bupap...... 22 CAPRELSA...... 68 BIOVANCE...... 114 BUPHENYL...... 123 captopril...... 54 bisoprolol fumarate...... 88 BUPIVACAINE FISIOPHARMA...... 143 CARAC...... 107 bisoprolol-hydrochlorothiazide...... 56 bupivacaine hcl...... 143 CARAFATE...... 186 BIVALIRUDIN RTU...... 35 bupivacaine hcl (pf)...... 143 CARBAGLU...... 120 BIVALIRUDIN-SODIUM BUPIVACAINE HCL-NACL...... 143 carbamazepine...... 36 CHLORIDE...... 35 bupivacaine in dextrose...... 143 carbamazepine er...... 36 BIVIGAM...... 175 bupivacaine spinal...... 143 carbidopa...... 78 BLACK WILLOW...... 15 bupivacaine-epinephrine...... 142 carbidopa-levodopa...... 78 blanche...... 111 bupivacaine-epinephrine (pf)...... 142 carbidopa-levodopa er...... 78 BLENREP...... 64 BUPRENEX...... 26 carbidopa-levodopa-entacapone...... 78 bleomycin sulfate...... 69 buprenorphine...... 26 carbinoxamine maleate...... 50 195 CARBOCAINE...... 143 ceftriaxone sodium in dextrose...... 95 CIPRO HC...... 173 CARBOCAINE PRESERVATIVE- CEFTRIAXONE SODIUM- CIPRODEX...... 173 FREE...... 143 DEXTROSE...... 95 ciprofloxacin hcl...... 125, 168, 173 carboplatin...... 61 cefuroxime axetil...... 95 ciprofloxacin in d5w...... 125 carboprost tromethamine...... 174 cefuroxime sodium...... 95 ciprofloxacin-dexamethasone...... 173 CARDENE IV...... 89 celecoxib...... 20 ciprofloxacin-fluocinolone pf...... 173 CARDIZEM...... 89 CELESTONE SOLUSPAN...... 104 cisatracurium besylate...... 164 CARDIZEM LA...... 89 CELLCEPT...... 152 cisatracurium besylate (pf)...... 164 CARDURA...... 56 CELLCEPT INTRAVENOUS...... 152 cisplatin...... 61 CARDURA XL...... 129 CELLUGEL...... 172 CISPLATIN...... 61 carisoprodol...... 161 CELONTIN...... 39 citalopram hydrobromide...... 40 carisoprodol-aspirin-codeine...... 162 CENTANY...... 106 CITRANATAL 90 DHA...... 160 carmustine...... 75 cephalexin...... 94 CITRANATAL ASSURE...... 160 CARNITOR...... 119 CEPROTIN...... 133 CITRANATAL B-CALM...... 157 CARNITOR SF...... 119 CERDELGA...... 135 CITRANATAL BLOOM...... 157 CAROSPIR...... 117 CEREBYX...... 38 CITRANATAL BLOOM DHA...... 160 carteolol hcl...... 166 CEREZYME...... 135 CITRANATAL DHA...... 160 cartia xt...... 89 CEROVEL...... 111 CITRANATAL ESSENCE...... 160 carvedilol...... 88 CERVIDIL...... 174 CITRANATAL HARMONY...... 160 carvedilol phosphate er...... 88 CETACAINE...... 115 CITRANATAL MEDLEY...... 160 CASCARA SAGRADA...... 142 cetirizine hcl...... 50 CITRANATAL RX...... 158 CASODEX...... 62 CETRAXAL...... 173 CITRULLINE EASY...... 123 CASPOFUNGIN ACETATE...... 48 CETROTIDE...... 119 CLADOSPORIUM CAT HAIR EXTRACT...... 15 cevimeline hcl...... 156 CLADOSPORIOIDES...... 15 cataflam...... 20 CHANTIX...... 181 CLADOSPORIUM CATAPRES-TTS-1...... 55 CHANTIX CONTINUING MONTH SPHAEROSPERMUM...... 15 CATAPRES-TTS-2...... 55 PAK...... 181 cladribine...... 62 CATAPRES-TTS-3...... 55 CHANTIX STARTING MONTH PAK claravis...... 106 CATHFLO ACTIVASE...... 135 ...... 181 CLARINEX...... 50 CATTLE EPITHELIUM...... 15 charlotte 24 fe...... 97 CLARINEX-D 12 HOUR...... 104 cavarest...... 155 chateal...... 97 clarithromycin...... 144 CAVERJECT...... 92 chateal eq...... 97 clarithromycin er...... 144 CAVERJECT IMPULSE...... 92 CHEMET...... 46 CLEMASTINE FUMARATE...... 50 CAYA...... 145 CHENODAL...... 126 clemastine fumarate...... 50 CAYSTON...... 59 chloramphenicol sod succinate...... 58 CLENPIQ...... 141 caziant...... 101 chlordiazepoxide hcl...... 29 CLEOCIN...... 59, 190 CEDAR ELM...... 15 chlordiazepoxide-amitriptyline...... 178 CLEOCIN PHOSPHATE...... 59 cefaclor...... 94 chlordiazepoxide-clidinium...... 185 CLEOCIN-T...... 105 CEFACLOR ER...... 94 chlorhexidine gluconate...... 155 CLEVIPREX...... 90 cefadroxil...... 94 chloroprocaine hcl (pf)...... 143 CLIMARA...... 125 CEFAZOLIN IN SODIUM chloroquine phosphate...... 60 CLIMARA PRO...... 124 CHLORIDE...... 94 chlorothiazide sodium...... 117 clindacin etz...... 105 cefazolin sodium...... 94 chlorpromazine hcl...... 81 clindacin-p...... 105 CEFAZOLIN SODIUM...... 94 chlorthalidone...... 117 clindamycin hcl...... 59 CEFAZOLIN SODIUM-DEXTROSE...94 chlorzoxazone...... 161 clindamycin palmitate hcl...... 59 cefdinir...... 95 CHOLBAM...... 126 clindamycin phos-benzoyl perox...... 105 cefepime hcl...... 96 cholestyramine...... 51 clindamycin phosphate...... 59, 105, 190 CEFEPIME HCL...... 96 cholestyramine light...... 51 clindamycin phosphate in d5w...... 59 CEFEPIME-DEXTROSE...... 96 CHORIONIC GONADOTROPIN...... 122 CLINDAMYCIN PHOSPHATE IN cefixime...... 95 chromic chloride...... 150 NACL...... 59 CEFOTAN...... 95 ciclopirox...... 107 clindamycin-tretinoin...... 105 cefotaxime sodium...... 95 ciclopirox olamine...... 107 CLINDESSE...... 190 cefotetan disodium...... 95 cidofovir...... 86 CLINIMIX E/DEXTROSE (2.75/5).... 165 CEFOTETAN DISODIUM- cilostazol...... 134 CLINIMIX E/DEXTROSE (4.25/10).. 165 DEXTROSE...... 95 CILOXAN...... 168 CLINIMIX E/DEXTROSE (4.25/5).... 165 cefoxitin sodium...... 95 CIMDUO...... 83 CLINIMIX E/DEXTROSE (5/15)...... 165 CEFOXITIN SODIUM-DEXTROSE....95 cimetidine...... 186 CLINIMIX E/DEXTROSE (5/20)...... 165 cefpodoxime proxetil...... 95 cimetidine hcl...... 186 CLINIMIX E/DEXTROSE (8/10)...... 165 cefprozil...... 95 cinacalcet hcl...... 118 CLINIMIX E/DEXTROSE (8/14)...... 165 ceftazidime...... 95 CINQAIR...... 33 CLINIMIX/DEXTROSE (4.25/10)...... 165 CEFTAZIDIME AND DEXTROSE...... 95 CINRYZE...... 133 CLINIMIX/DEXTROSE (4.25/5)...... 165 ceftriaxone sodium...... 95 CINVANTI...... 48 CLINIMIX/DEXTROSE (5/15)...... 165 CEFTRIAXONE SODIUM...... 95 CIPRO...... 125 CLINIMIX/DEXTROSE (5/20)...... 165 196 CLINIMIX/DEXTROSE (6/5)...... 165 constulose...... 142 cyred eq...... 97 CLINIMIX/DEXTROSE (8/10)...... 165 CONTRAVE...... 13 CYSTADANE...... 120 CLINIMIX/DEXTROSE (8/14)...... 165 CONZIP...... 23 CYSTADROPS...... 173 clinisol sf...... 165 COPAXONE...... 180 CYSTAGON...... 130 CLINOLIPID...... 166 COPIKTRA...... 75 CYSTARAN...... 173 clinpro 5000...... 155 coremino...... 183 cytarabine...... 63 clobazam...... 35 CORIFACT...... 131 cytarabine (pf)...... 63 clobetasol prop emollient base...... 110 CORLANOR...... 94 CYTOGAM...... 175 clobetasol propionate...... 110 CORLOPAM...... 56 CYTOMEL...... 184 clobetasol propionate e...... 110 CORN POLLEN...... 16 CYTOTEC...... 187 clobetasol propionate emulsion...... 110 CORTEF...... 102 dacarbazine...... 71 clocortolone pivalate...... 110 CORTENEMA...... 27 DACOGEN...... 63 clodan...... 110 CORTIFOAM...... 27 dactinomycin...... 70 clofarabine...... 62 CORTISPORIN-TC...... 174 dalfampridine er...... 180 CLOLAR...... 63 CORVERT...... 30 DALIRESP...... 33 clomiphene citrate...... 122 COSELA...... 74 DALVANCE...... 58 clomipramine hcl...... 41 COSENTYX...... 108 danazol...... 27 clonazepam...... 35 COSENTYX (300 MG DOSE)...... 108 DANDELION...... 16 clonidine...... 55 COSENTYX SENSOREADY (300 DANTRIUM...... 162 clonidine hcl...... 55 MG)...... 108 dantrolene sodium...... 162 clonidine hcl (analgesia)...... 22 COSENTYX SENSOREADY PEN.....108 DANYELZA...... 65 clonidine hcl er...... 11 COSMEGEN...... 69 dapsone...... 59, 105 clopidogrel bisulfate...... 135 COTELLIC...... 67 DAPTACEL...... 185 clorazepate dipotassium...... 29 COTEMPLA XR-ODT...... 13 DAPTOMYCIN...... 58 CLOROTEKAL...... 143 CREON...... 116 daptomycin...... 58 clotrimazole...... 112, 155 CRESEMBA...... 49 DARAPRIM...... 60 clotrimazole-betamethasone...... 106, 107 CRINONE...... 190 darifenacin hydrobromide er...... 187 clovique...... 151 CRIXIVAN...... 84 DARZALEX...... 64 clozapine...... 80 CROFAB...... 174 DARZALEX FASPRO...... 70 C-NATE DHA...... 158 cromolyn sodium...... 31, 126, 167 dasetta 1/35...... 97 COAGADEX...... 131 crotan...... 114 dasetta 7/7/7...... 101 coal tar...... 114 CRYODOSE TA...... 115 DAUNORUBICIN HCL...... 70 COARTEM...... 60 cryselle-28...... 97 DAURISMO...... 67 COCKLEBUR...... 15 CRYSVITA...... 124 DAYPRO...... 21 COD LIVER OIL...... 161 CUBICIN...... 58 daysee...... 100 CODEINE SULFATE...... 23 CUBICIN RF...... 58 DAYTRANA...... 13 codeine sulfate...... 23 cupric chloride...... 150 DAYVIGO...... 141 COGENTIN...... 77 curity sterile saline...... 130 DDAVP...... 124 colchicine...... 131 CUROSURF...... 183 DDAVP PF...... 124 colchicine-probenecid...... 131 CURVULARIA...... 16 deblitane...... 101 colesevelam hcl...... 51 CUTAQUIG...... 175 decadron...... 102 COLESTID...... 51 CUVITRU...... 175 decitabine...... 63 COLESTID FLAVORED...... 51 CUVPOSA...... 187 deferasirox...... 46 colestipol hcl...... 51 cyanocobalamin...... 136 deferasirox granules...... 46 colistimethate sodium (cba)...... 59 CYANOCOBALAMIN...... 136 deferiprone...... 46 COLY-MYCIN M...... 59 CYANOKIT...... 46 deferoxamine mesylate...... 46 COMBIGAN...... 166 cyclafem 1/35...... 97 DEFITELIO...... 135 COMBIPATCH...... 124 cyclafem 7/7/7...... 101 DEFLUX...... 130 COMBIVENT RESPIMAT...... 31 cyclobenzaprine hcl...... 161 DELESTROGEN...... 125 COMBIVIR...... 83 CYCLOGYL...... 167 DELFLEX-LC/1.5% DEXTROSE...... 153 COMETRIQ (100 MG DAILY DOSE). 68 CYCLOMYDRIL...... 167 DELFLEX-LC/2.5% DEXTROSE...... 153 COMETRIQ (140 MG DAILY DOSE). 68 CYCLOPAK...... 162 DELFLEX-LC/4.25% DEXTROSE.... 153 COMETRIQ (60 MG DAILY DOSE)... 68 cyclopentolate hcl...... 167 DELFLEX-SM/1.5% DEXTROSE...... 153 COMPLERA...... 83 cyclophosphamide...... 74, 75 DELFLEX-SM/2.5% DEXTROSE...... 153 COMPLETE NATAL DHA...... 160 CYCLOPHOSPHAMIDE...... 74, 75 DELSTRIGO...... 83 COMPLETENATE...... 158 cycloserine...... 61 delyla...... 97 compro...... 81 CYCLOSET...... 43 DELZICOL...... 127 COMTAN...... 79 cyclosporine...... 151 demeclocycline hcl...... 183 CO-NATAL FA...... 158 cyclosporine modified...... 151 DEMEROL...... 23 CONCEPT DHA...... 158 CYKLOKAPRON...... 138 DEMSER...... 54 CONCEPT OB...... 158 cyproheptadine hcl...... 51 DENAVIR...... 109 CONDYLOX...... 112 CYRAMZA...... 76 denta 5000 plus...... 155 CONJUPRI...... 90 cyred...... 97 dentagel...... 155 197 DEPEN TITRATABS...... 151 DEXMEDETOMIDINE HCL IN diltiazem hcl er coated beads...... 90 DEPO-ESTRADIOL...... 125 NACL...... 141 DILTIAZEM HCL-DEXTROSE...... 90 DEPO-MEDROL...... 102 DEXMEDETOMIDINE HCL- DILTIAZEM HCL-SODIUM DEPO-PROVERA...... 101 DEXTROSE...... 141 CHLORIDE...... 90 DEPO-SUBQ PROVERA 104...... 101 dexmethylphenidate hcl...... 13 dilt-xr...... 90 DEPO-TESTOSTERONE...... 27 dexmethylphenidate hcl er...... 13 DIMENHYDRINATE...... 48 DERMOTIC...... 174 DEXPANTHENOL...... 126 dimethyl fumarate...... 180 DESCOVY...... 83 dexrazoxane hcl...... 72 dimethyl fumarate starter pack...... 180 DESFERAL...... 46 DEXTENZA...... 171 DIPENTUM...... 127 desflurane...... 129 dextroamphetamine sulfate...... 11 diphen...... 50 desipramine hcl...... 41 dextroamphetamine sulfate er...... 11 di-phen...... 50 desloratadine...... 50 dextrose...... 166 diphenhydramine hcl...... 50 desmopressin ace spray refrig...... 124 DEXTROSE...... 166 diphenoxylate-atropine...... 45 desmopressin acetate...... 124 DEXTROSE 5%/ELECTROLYTE #48 DIPHTHERIA-TETANUS TOXOIDS desmopressin acetate pf...... 124 ...... 148 DT...... 185 desmopressin acetate spray...... 124 dextrose in lactated ringers...... 148 DIPRIVAN...... 128 desogestrel-ethinyl estradiol...... 96, 97 DEXTROSE-NACL...... 148 dipyridamole...... 135 desonide...... 110 dextrose-nacl...... 148 DISCOVISC...... 172 desoximetasone...... 110 dextrose-sodium chloride...... 148 disopyramide phosphate...... 30 desrx...... 110 DEXTROSE-SODIUM CHLORIDE...148 disulfiram...... 177 DESVENLAFAXINE ER...... 41 DEXYCU...... 171 DIURIL...... 117 desvenlafaxine succinate er...... 41 DIACOMIT...... 36 divalproex sodium...... 39 DEXABLISS...... 102 DIANEAL LOW CALCIUM/1.5% divalproex sodium er...... 39 dexamethasone...... 102 DEX...... 153 DIVIGEL...... 125 DEXAMETHASONE INTENSOL...... 102 DIANEAL LOW CALCIUM/2.5% dobutamine hcl...... 92 DEXAMETHASONE SOD PHOS- DEX...... 153 DOBUTAMINE IN D5W...... 92 NACL...... 102 DIANEAL LOW CALCIUM/4.25% DOCETAXEL...... 74 dexamethasone sod phosphate pf...... 102 DEX...... 153 dofetilide...... 31 DEXAMETHASONE SOD DIANEAL PD-2/1.5% DEXTROSE... 153 DOG EPITHELIUM...... 16 PHOSPHATE PF...... 102 DIANEAL PD-2/2.5% DEXTROSE... 154 DOG FENNEL...... 16 DEXAMETHASONE SODIUM DIANEAL PD-2/4.25% DEXTROSE. 154 DOJOLVI...... 166 PHOSPHATE...... 103 DIASTAT ACUDIAL...... 35 dolishale...... 100 dexamethasone sodium phosphate DIASTAT PEDIATRIC...... 35 donepezil hcl...... 178 ...... 103, 171 diazepam...... 29, 35 dopamine hcl...... 92 DEXAMETHASONE- DIAZEPAM...... 29 DOPAMINE IN D5W...... 92 MOXIFLOXACIN...... 171 diazepam intensol...... 29 DOPRAM...... 12 DEXAMETH-MOXIFLOX- diazoxide...... 42 DOPTELET...... 138 KETOROLAC...... 171 DIBENZYLINE...... 54 DORAL...... 140 DEXCOM G4 PLAT PED diclofenac potassium...... 21 dorzolamide hcl...... 169 RCV/SHARE...... 145 diclofenac sodium...... 21, 107, 170 dorzolamide hcl-timolol mal...... 166 DEXCOM G4 PLAT PED RECEIVER diclofenac sodium er...... 21 dorzolamide hcl-timolol mal pf...... 166 ...... 145 diclofenac-misoprostol...... 20 dotti...... 125 DEXCOM G4 PLATINUM dicloxacillin sodium...... 177 DOVATO...... 83 RCV/SHARE...... 145 dicyclomine hcl...... 185 DOVONEX...... 108 DEXCOM G4 PLATINUM diethylpropion hcl...... 12 doxazosin mesylate...... 56 RECEIVER...... 145 diethylpropion hcl er...... 12 doxepin hcl...... 41, 108, 140 DEXCOM G4 PLATINUM DIFICID...... 144 doxercalciferol...... 120 TRANSMITTER...... 145 diflorasone diacetate...... 110 DOXIL...... 70 DEXCOM G4 SENSOR...... 145 DIFLUCAN...... 49 doxorubicin hcl...... 70 DEXCOM G5 MOB/G4 PLAT diflunisal...... 23 doxorubicin hcl liposomal...... 70 SENSOR...... 145 DIGIFAB...... 46 doxy 100...... 183 DEXCOM G5 MOBILE RECEIVER..145 digitek...... 91 doxycycline hyclate...... 183 DEXCOM G5 MOBILE digox...... 92 doxycycline monohydrate...... 183, 184 TRANSMITTER...... 145 digoxin...... 92 doxylamine-pyridoxine...... 48 DEXCOM G5 RECEIVER KIT...... 145 dihydroergotamine mesylate...... 147 DRECHSLERA...... 16 DEXCOM G6 RECEIVER...... 145 DILANTIN...... 38 DRISDOL...... 192 DEXCOM G6 SENSOR...... 145 DILANTIN INFATABS...... 38 dronabinol...... 48 DEXCOM G6 TRANSMITTER...... 145 DILATRATE-SR...... 28 droperidol...... 29 DEXILANT...... 186 DILAUDID...... 23 DROPLET PEN NEEDLES...... 146 DEXMEDETOMIDINE HCL...... 141 diltiazem hcl...... 90 drospiren-eth estrad-levomefol...... 97 dexmedetomidine hcl...... 141 DILTIAZEM HCL...... 90 drospirenone-ethinyl estradiol...... 97 dexmedetomidine hcl in nacl...... 141 diltiazem hcl er...... 90 DROXIA...... 136 diltiazem hcl er beads...... 90 droxidopa...... 191 198 DSUVIA...... 24 ELLIOTTS B...... 148 EPINEPHRINE HCL-NACL...... 191 DUAVEE...... 125 ELMIRON...... 130 EPINEPHRINE PF...... 191 DUET DHA 400...... 158 ELOCTATE...... 131 EPINEPHRINE-DEXTROSE...... 191 DUET DHA BALANCED...... 158 eluryng...... 100 EPINEPHRINE-NACL...... 191 DUETACT...... 45 ELZONRIS...... 71 epirubicin hcl...... 70 duloxetine hcl...... 41 EMCYT...... 72 epitol...... 36 DUOBRII...... 115 EMEND...... 48 EPIVIR...... 85 DUODOTE...... 46 EMERPHED...... 191 EPIVIR HBV...... 86 DUOPA...... 78 EMGALITY...... 147 eplerenone...... 56 DUOVISC...... 172 EMGALITY (300 MG DOSE)...... 147 EPOGEN...... 136 DUPIXENT...... 109 emoquette...... 97 epoprostenol sodium...... 93 DURACLON...... 22 EMPAVELI...... 133 eptifibatide...... 133 DURAGESIC-100...... 24 EMPLICITI...... 65 EPZICOM...... 83 DURAGESIC-12...... 24 EMSAM...... 39 EQUETRO...... 79 DURAGESIC-25...... 24 emtricitabine...... 85 ERAXIS...... 48 DURAGESIC-50...... 24 emtricitabine-tenofovir df...... 83 ERBITUX...... 66 DURAGESIC-75...... 24 EMTRIVA...... 85 ergocalciferol...... 192 duramorph...... 24 EMVERM...... 28 ergoloid mesylates...... 181 DUREZOL...... 171 enalapril maleate...... 54 ergotamine-caffeine...... 147 DURLAZA...... 135 enalaprilat...... 54 ERIVEDGE...... 67 DUROLANE...... 162 enalapril-hydrochlorothiazide...... 53 ERLEADA...... 62 DURYSTA...... 173 ENBRACE HR...... 158 erlotinib hcl...... 66 DUST MITE MIXED ALLERGEN ENBREL...... 22 errin...... 101 EXT...... 18 ENBREL MINI...... 22 ERTACZO...... 112 dutasteride...... 129 ENBREL SURECLICK...... 22 ertapenem sodium...... 58 dutasteride-tamsulosin hcl...... 130 ENDARI...... 136 ERWINASE...... 71 DUTOPROL...... 56 ENDO AVITENE...... 139 ERWINAZE...... 71 DXEVO 11-DAY...... 103 endocet...... 26 ery...... 105 DYANAVEL XR...... 11 ENDOMETRIN...... 190 ERYGEL...... 105 DYMISTA...... 163 ENGERIX-B...... 189 ery-tab...... 144 DYSPORT...... 164 ENHERTU...... 70 ERYTHROCIN LACTOBIONATE.... 144 EASTERN COTTONWOOD...... 16 ENLITE GLUCOSE SENSOR...... 145 erythrocin stearate...... 144 easygel...... 155 enoxaparin sodium...... 35 erythromycin...... 105, 144, 168 ec-naproxen...... 21 enpresse-28...... 101 erythromycin base...... 144 econazole nitrate...... 112 enskyce...... 97 erythromycin ethylsuccinate...... 144 ECOZA...... 112 ENSPRYNG...... 153 ESBRIET...... 183 EDARBI...... 55 ENSTILAR...... 115 escitalopram oxalate...... 40 EDARBYCLOR...... 54 entacapone...... 79 esgic...... 22 EDECRIN...... 117 entecavir...... 86 ESKATA...... 114 EDETATE DISODIUM...... 151 ENTEREG...... 128 esmolol hcl...... 88 EDEX...... 92 ENTOCORT EC...... 103 ESMOLOL HCL...... 88 EDLUAR...... 140 ENTRESTO...... 92 esmolol hcl-sodium chloride...... 88 EDURANT...... 85 ENTYVIO...... 127 esomeprazole sodium...... 186 efavirenz...... 85 enulose...... 127 ESPEROCT...... 131 efavirenz-emtricitab-tenofovir...... 83 ENVARSUS XR...... 153 est estrogens-methyltest...... 124 efavirenz-lamivudine-tenofovir...... 83 EPANED...... 54 estarylla...... 97 EFUDEX...... 107 EPCLUSA...... 86 estazolam...... 140 EGRIFTA SV...... 119 EPHEDRINE SULFATE...... 191 ESTRADIOL...... 125 ELAPRASE...... 121 EPHEDRINE SULFATE estradiol...... 125, 190 ELCYS...... 165 (PRESSORS)...... 191 estradiol valerate...... 125 ELELYSO...... 135 EPHEDRINE SULFATE-NACL...... 191 estradiol-norethindrone acet...... 124 ELEPSIA XR...... 36 EPICOCCUM...... 16 ESTRING...... 190 ELESTRIN...... 125 EPICOCCUM NIGRUM...... 16 ESTROGEL...... 125 eletriptan hydrobromide...... 147 EPICORD...... 114 ESTROSTEP FE...... 101 ELIGARD...... 73 EPIDIOLEX...... 36 eszopiclone...... 140 elinest...... 97 EPIFIX...... 115 ethacrynate sodium...... 117 ELIQUIS...... 34 EPIFIX MICRONIZED...... 115 ethacrynic acid...... 117 ELIQUIS DVT/PE STARTER PACK...34 EPIFOAM...... 114 ethambutol hcl...... 61 ELITEK...... 72 epinastine hcl...... 167 ETHAMOLIN...... 154 elite-ob...... 158 epinephrine...... 191 ethosuximide...... 39 ELIXOPHYLLIN...... 33 EPINEPHRINE...... 191 ethynodiol diac-eth estradiol...... 97 ELLA...... 100 epinephrine (anaphylaxis)...... 191 ETHYOL...... 76 ELLENCE...... 70 EPINEPHRINE HCL...... 167 etodolac...... 21 199 etodolac er...... 21 fenoprofen calcium...... 21 fluocinonide emulsified base...... 110 etomidate...... 128 FENSOLVI (6 MONTH)...... 121 FLUORESCEIN etonogestrel-ethinyl estradiol...... 100 fentanyl...... 24 SODIUM/BENOXINATE...... 169 ETOPOPHOS...... 74 fentanyl citrate...... 24 fluorescein-benoxinate...... 169 etoposide...... 74 FENTANYL CITRATE...... 24 FLUORESCITE...... 169 etravirine...... 85 FENTANYL CITRATE (PF)...... 24 fluoridex...... 155 EUCRISA...... 113 fentanyl citrate (pf)...... 24 fluoridex daily renewal...... 155 EUFLEXXA...... 162 FENTANYL CITRATE PF...... 24 fluoridex enhanced whitening...... 155 euthyrox...... 184 FENTANYL CITRATE-NACL...... 24 fluoridex sensitivity relief...... 155 EVAMIST...... 125 FENTANYL CIT-ROPIVACAINE- fluor-i-strips a.t...... 169 EVEKEO ODT...... 12 NACL...... 23 fluoritab...... 149 EVENITY...... 123 FENTANYL-BUPIVACAINE-NACL.. 23 fluorometholone...... 171 everolimus...... 68, 153 FENTORA...... 24 FLUOROPLEX...... 107 EVERSENSE SENSOR/HOLDER...... 146 FERAHEME...... 137 fluorouracil...... 63, 107 EVERSENSE SMART FERRIPROX...... 46 fluoxetine hcl...... 40 TRANSMITTER...... 146 FERRIPROX TWICE-A-DAY...... 46 FLUOXETINE HCL...... 40 EVISTA...... 123 FERRLECIT...... 137 fluoxetine hcl (pmdd)...... 181 EVKEEZA...... 51 FETROJA...... 96 fluphenazine decanoate...... 81 EVOCLIN...... 105 FETZIMA...... 41 fluphenazine hcl...... 81 EVOMELA...... 75 FETZIMA TITRATION...... 41 flurandrenolide...... 110 EVOTAZ...... 83 fexmid...... 161 FLURA-SAFE...... 169 EVOXAC...... 156 FIBRICOR...... 52 flurazepam hcl...... 140 EVRYSDI...... 164 FIBRYGA...... 132 flurbiprofen...... 21 EXELDERM...... 112 FINACEA...... 114 flurbiprofen sodium...... 170 EXELON...... 178 finasteride...... 116, 129 flutamide...... 62 exemestane...... 72 FINTEPLA...... 36 fluticasone propionate...... 110, 111, 163 EXJADE...... 46 FIRAZYR...... 133 fluticasone-salmeterol...... 31 EXONDYS 51...... 164 FIRDAPSE...... 60 fluvastatin sodium...... 52 EXTINA...... 112 FIRE ANT...... 16 fluvastatin sodium er...... 52 EXTRANEAL...... 154 FIRMAGON...... 73 fluvoxamine maleate...... 40 EYLEA...... 173 FIRMAGON (240 MG DOSE)...... 73 fluvoxamine maleate er...... 40 ezetimibe...... 52 FIRVANQ...... 58 FLUZONE QUADRIVALENT...... 189 ezetimibe-simvastatin...... 52 flac...... 174 FML...... 171 FABRAZYME...... 119 FLAGYL...... 57 FML FORTE...... 171 FALESSA...... 97 FLAREX...... 171 FML LIQUIFILM...... 171 falmina...... 97 flavoxate hcl...... 188 FOCALIN...... 13 famciclovir...... 87 FLEBOGAMMA DIF...... 175 FOLGARD OS...... 156 famotidine...... 186 flecainide acetate...... 30 FOLGARD RX...... 136 famotidine premixed...... 186 FLEXBUMIN...... 134 folic acid...... 136, 137 FANAPT...... 79 FLEXIN...... 115 FOLIVANE-OB...... 158 FANAPT TITRATION PACK...... 79 FLOLAN...... 93 FOLOTYN...... 63 FARESTON...... 62 FLORIVA...... 149, 157 foltrin...... 137 FARXIGA...... 44 FLORIVA PLUS...... 157 fomepizole...... 46 FARYDAK...... 67 FLOVENT DISKUS...... 33 fondaparinux sodium...... 35 FASENRA...... 32 FLOVENT HFA...... 33 FORANE...... 129 FASENRA PEN...... 32 floxuridine...... 63 FORMALDEHYDE...... 82 FASLODEX...... 72 FLUAD...... 189 formoterol fumarate...... 32 fa-vitamin b-6-vitamin b-12...... 136 FLUAD QUADRIVALENT...... 189 FORTAZ...... 95 fayosim...... 100 FLUARIX QUADRIVALENT...... 189 FORTEO...... 122 febuxostat...... 131 FLUBLOK QUADRIVALENT...... 189 FOSAMAX...... 118 FEIBA...... 131 FLUCELVAX QUADRIVALENT...... 189 FOSAMAX PLUS D...... 118 felbamate...... 38 fluconazole...... 49 fosamprenavir calcium...... 84 FELDENE...... 21 fluconazole in sodium chloride...... 49 fosaprepitant dimeglumine...... 48 felodipine er...... 90 flucytosine...... 49 foscarnet sodium...... 86 FEMARA...... 72 fludarabine phosphate...... 63 FOSCAVIR...... 86 FEMCAP...... 144 fludrocortisone acetate...... 104 fosfomycin tromethamine...... 60 FEMHRT...... 124 FLULAVAL QUADRIVALENT...... 189 fosinopril sodium...... 54 FEMRING...... 190 flumazenil...... 47 fosinopril sodium-hctz...... 53 femynor...... 97 flunisolide...... 163 fosphenytoin sodium...... 38 fenofibrate...... 51, 52 fluocinolone acetonide...... 110, 174 FOSRENOL...... 128 fenofibrate micronized...... 51 fluocinolone acetonide body...... 110 FOTIVDA...... 68 fenofibric acid...... 52 fluocinolone acetonide scalp...... 110 FRAGMIN...... 35 FENOGLIDE...... 52 fluocinonide...... 110 FREAMINE HBC...... 165 200 FREAMINE III...... 165 generlac...... 127 GUARDIAN CONNECT FREESTYLE LIBRE 14 DAY gengraf...... 151 TRANSMITTER...... 146 READER...... 146 GENOTROPIN...... 120 GUARDIAN LINK 3 FREESTYLE LIBRE 14 DAY GENOTROPIN MINIQUICK...... 119 TRANSMITTER...... 146 SENSOR...... 146 gentak...... 168 GUARDIAN REAL-TIME REPLACE FREESTYLE LIBRE 2 READER...... 146 gentamicin in saline...... 19 PED...... 146 FREESTYLE LIBRE 2 SENSOR...... 146 gentamicin sulfate...... 19, 106, 168 GUARDIAN SENSOR (3)...... 146 FREESTYLE LIBRE READER...... 146 GENVOYA...... 83 GUARDIAN SENSOR 3...... 146 FREESTYLE LIBRE SENSOR GEODON...... 79 GVOKE HYPOPEN 1-PACK...... 42 SYSTEM...... 146 GERMAN COCKROACH...... 16 GVOKE HYPOPEN 2-PACK...... 42 fresenius propoven...... 129 GIAPREZA...... 191 GVOKE PFS...... 42 frovatriptan succinate...... 147 GILENYA...... 181 GYNAZOLE-1...... 190 FULPHILA...... 137 GILOTRIF...... 66 HACKBERRY...... 16 fulvestrant...... 72 GILPHEX TR...... 104 HAEGARDA...... 133 furosemide...... 117 GIMOTI...... 126 hailey 1.5/30...... 97 FUROSEMIDE IN SODIUM GIVLAARI...... 131 hailey 24 fe...... 97 CHLORIDE...... 117 GLASSIA...... 182 hailey fe 1.5/30...... 97 FUSARIUM...... 16 GLEOSTINE...... 75 hailey fe 1/20...... 97 FUZEON...... 84 GLIADEL WAFER...... 75 HALAVEN...... 74 fyavolv...... 124 glimepiride...... 45 halcinonide...... 111 FYCOMPA...... 35 glipizide...... 45 HALCION...... 140 gabapentin...... 36 glipizide er...... 45 HALDOL...... 80 GABLOFEN...... 161 glipizide xl...... 45 HALDOL DECANOATE...... 80 GALAFOLD...... 119 glipizide-metformin hcl...... 45 halobetasol propionate...... 111 galantamine hydrobromide...... 178 GLOPERBA...... 131 haloperidol...... 80 galantamine hydrobromide er...... 178 GLUCAGEN HYPOKIT...... 42 haloperidol decanoate...... 80 GALZIN...... 150 GLUCAGON EMERGENCY...... 42 haloperidol lactate...... 80 GAMASTAN...... 175 GLUCOTROL XL...... 45 HARVONI...... 86, 87 GAMIFANT...... 153 GLUTARALDEHYDE...... 82 HAVRIX...... 189 GAMMAGARD...... 175 GLUTATHIONE...... 165 HEALON...... 172 GAMMAGARD S/D LESS IGA...... 175 glyburide...... 45 HEALON DUET PRO...... 172 GAMMAKED...... 175 glyburide micronized...... 45 HEALON GV...... 172 GAMMAPLEX...... 175 glyburide-metformin...... 45 HEALON GV PRO...... 172 GAMUNEX-C...... 175 GLYCATE...... 187 HEALON PRO...... 172 GANCICLOVIR...... 86 glycine...... 130 HEALON5...... 172 GANCICLOVIR SODIUM...... 86 GLYCINE...... 165 HEALON5 PRO...... 172 ganciclovir sodium...... 86 glycine urologic...... 130 heather...... 101 GANIRELIX ACETATE...... 119 glycopyrrolate...... 187 HECTOROL...... 120 GARDASIL 9...... 189 GLYCOPYRROLATE...... 187 HELIDAC THERAPY...... 187 GASTROCROM...... 126 GLYCOPYRROLATE PF...... 187 HEMABATE...... 174 gatifloxacin...... 168 glydo...... 113 HEMADY...... 103 GATTEX...... 126 GLYNASE...... 45 HEMANGEOL...... 89 gavilyte-c...... 141 GLYRX-PF...... 187 HEMLIBRA...... 131 gavilyte-g...... 141 GLYXAMBI...... 44 HEMOFIL M...... 132 gavilyte-n with flavor pack...... 141 GOCOVRI...... 77 HEPAGAM B...... 175 GAVRETO...... 69 GOLDENROD...... 16 heparin (porcine) in nacl...... 34 GAZYVA...... 64 GOLYTELY...... 141 HEPARIN (PORCINE) IN NACL...... 34 GEL-FLOW NT...... 139 GONAL-F...... 122 heparin lock flush...... 34 GELFOAM...... 139 GONAL-F RFF...... 122 HEPARIN SOD (PORCINE) IN D5W..34 GELFOAM COMPRESSED SIZE 100 GONAL-F RFF REDIJECT...... 122 heparin sod (porcine) in d5w...... 34 ...... 139 GONITRO...... 28 heparin sodium (porcine)...... 34 GELFOAM DENTAL PACK SIZE 4..139 GOPRELTO...... 163 HEPARIN SODIUM (PORCINE)...... 34 GELFOAM SPONGE...... 139 GRALISE...... 180 heparin sodium (porcine) pf...... 34 GELFOAM SPONGE SIZE 100...... 139 granisetron hcl...... 47 HEPARIN SODIUM (PORCINE) PF....35 GELFOAM SPONGE SIZE 200...... 139 GRANIX...... 137 heparin sodium lock flush...... 35 GELFOAM SPONGE SIZE 50...... 139 GRASS POLLEN(K-O-R-T-SWT HEPLISAV-B...... 189 GEL-ONE...... 162 VERN)...... 16 HEPSERA...... 86 GELSYN-3...... 162 GRASTEK...... 16 HERCEPTIN...... 65 GEMCITABINE HCL...... 63 griseofulvin microsize...... 49 HERCEPTIN HYLECTA...... 70 gemcitabine hcl...... 63 griseofulvin ultramicrosize...... 49 HERZUMA...... 65 gemfibrozil...... 52 guanfacine hcl...... 55 HESPAN...... 134 gemmily...... 97 guanfacine hcl er...... 11 hetastarch-nacl...... 134 GENERESS FE...... 97 HETLIOZ...... 141 201 HETLIOZ LQ...... 141 hydroxyurea...... 71 INFLECTRA...... 128 HEXTEND...... 134 hydroxyzine hcl...... 29 INFUGEM...... 63 HIBERIX...... 188 hydroxyzine pamoate...... 29 INFUMORPH 200...... 24 HIPREX...... 60 HYLENEX...... 151 INFUMORPH 500...... 24 HIZENTRA...... 175 HYMOVIS...... 163 INFUVITE ADULT...... 156 HONEY BEE VENOM...... 16 hyoscyamine sulfate...... 186 INFUVITE PEDIATRIC...... 157 HONEY BEE VENOM PROTEIN...... 16 hyoscyamine sulfate er...... 186 INGREZZA...... 179 HORIZANT...... 181 hyoscyamine sulfate sl...... 186 INJECTAFER...... 137 HORSE EPITHELIUM...... 16 HYPERHEP B...... 175 INLYTA...... 76 HUMALOG...... 43 HYPERRAB...... 175 INNOPRAN XL...... 89 HUMALOG JUNIOR KWIKPEN...... 43 HYPERRHO S/D...... 175 INQOVI...... 70 HUMALOG KWIKPEN...... 43 HYPERSAL...... 104 INREBIC...... 73 HUMALOG MIX 50/50...... 43 HYPERTET S/D...... 175 INSPRA...... 56 HUMALOG MIX 50/50 KWIKPEN..... 43 HYQVIA...... 176 INSTAT...... 139 HUMALOG MIX 75/25...... 43 ibandronate sodium...... 118 INTELENCE...... 85 HUMALOG MIX 75/25 KWIKPEN..... 43 IBRANCE...... 72 INTERCEED...... 139 HUMAN ALBUMIN GRIFOLS...... 134 ibu...... 21 INTERCEED (TC7)...... 139 HUMATE-P...... 132 ibuprofen...... 21 INTRALIPID...... 166 HUMATIN...... 19 ibuprofen lysine...... 21 INTRAROSA...... 190 HUMATROPE...... 120 ibutilide fumarate...... 31 INTRON A...... 71 HUMIRA...... 20 icatibant acetate...... 133 introvale...... 100 HUMIRA PEDIATRIC CROHNS iclevia...... 100 INVANZ...... 58 START...... 20 ICLUSIG...... 66 INVEGA SUSTENNA...... 79 HUMIRA PEN...... 20 icosapent ethyl...... 51 INVEGA TRINZA...... 79 HUMIRA PEN-CD/UC/HS STARTER.20 IDAMYCIN PFS...... 70 INVELTYS...... 171 HUMIRA PEN-PEDIATRIC UC idarubicin hcl...... 70 INVIRASE...... 84 START...... 20 IDELVION...... 132 IODINE TINCTURE...... 82 HUMIRA PEN-PS/UV/ADOL HS IDHIFA...... 73 IODOFLEX...... 82 START...... 20 IFEX...... 75 IODOSORB...... 82 HUMIRA PEN-PSOR/UVEIT ifosfamide...... 75 IONOSOL-MB IN D5W...... 148 STARTER...... 20 IFOSFAMIDE...... 75 IOPIDINE...... 170 HUMULIN R U-500 ILARIS...... 20 IPOL...... 189 (CONCENTRATED)...... 43 ILEVRO...... 170 ipratropium bromide...... 32, 163 HUMULIN R U-500 KWIKPEN...... 43 ILIDERM...... 113 ipratropium-albuterol...... 31 HYALGAN...... 163 ILUVIEN...... 171 irbesartan...... 55 HYALURONIDASE imatinib mesylate...... 66 irbesartan-hydrochlorothiazide...... 54 (INTRAOCULAR)...... 172 IMBRUVICA...... 66 IRESSA...... 66 HYCAMTIN...... 76 IMCIVREE...... 13 irinotecan hcl...... 76 HYCODAN...... 104 IMFINZI...... 65 ISENTRESS...... 84 hydralazine hcl...... 57 imipenem-cilastatin...... 58 ISENTRESS HD...... 84 HYDREA...... 71 imipramine hcl...... 41 isibloom...... 97 hydrochlorothiazide...... 117 imipramine pamoate...... 41 isoflurane...... 129 hydrocod polst-cpm polst er...... 104 imiquimod...... 112 ISOLYTE-P IN D5W...... 148 hydrocodone bitartrate er...... 24 imiquimod pump...... 112 ISOLYTE-S...... 148 hydrocodone-acetaminophen...... 23 IMLYGIC...... 75 ISOLYTE-S PH 7.4...... 148 hydrocodone-homatropine...... 104 IMOGAM RABIES-HT...... 175 isoniazid...... 61 hydrocodone-ibuprofen...... 23 IMOVAX RABIES...... 189 isoproterenol hcl...... 32 hydrocortisone...... 27, 103, 111 IMPAVIDO...... 57 ISOPROTERENOL-SODIUM hydrocortisone (perianal)...... 28 IMURAN...... 154 CHLORIDE...... 32 hydrocortisone ace-pramoxine...... 28 IMVEXXY MAINTENANCE PACK. 190 ISOPTO ATROPINE...... 167 hydrocortisone butyr lipo base...... 111 IMVEXXY STARTER PACK...... 190 ISOPTO CARPINE...... 167 hydrocortisone butyrate...... 111 inatal gt...... 158 ISORDIL TITRADOSE...... 28 hydrocortisone valerate...... 111 INBRIJA...... 77 isosorbide dinitrate...... 28 hydrocortisone-acetic acid...... 174 incassia...... 101 isosorbide mononitrate...... 29 hydromet...... 104 INCRELEX...... 121 isosorbide mononitrate er...... 28 hydromorphone hcl...... 24 indapamide...... 117 isotretinoin...... 106 hydromorphone hcl er...... 24 INDERAL XL...... 89 isradipine...... 90 HYDROMORPHONE HCL PF...... 24 indomethacin...... 21 ISTODAX (OVERFILL)...... 67 hydromorphone hcl pf...... 24 indomethacin er...... 21 ISTURISA...... 119 HYDROMORPHONE HCL-NACL...... 24 indomethacin sodium...... 21 ISUPREL...... 32 hydroxocobalamin acetate...... 136 INFANRIX...... 185 itraconazole...... 49 hydroxychloroquine sulfate...... 60 INFASURF...... 183 ivermectin...... 28, 114 hydroxyprogesterone caproate...... 76, 177 INFED...... 137 IXEMPRA KIT...... 74 202 IXIARO...... 189 KENALOG-80...... 103 lamivudine-zidovudine...... 83 IXINITY...... 132 KENDALL HYDROGEL WOUND lamotrigine...... 36, 37 JADENU...... 46 DRESS...... 116 lamotrigine er...... 36 JADENU SPRINKLE...... 46 KENGREAL...... 133 lamotrigine starter kit-blue...... 37 jaimiess...... 100 KEPIVANCE...... 72 lamotrigine starter kit-green...... 37 JAKAFI...... 73 KESIMPTA...... 180 lamotrigine starter kit-orange...... 37 JALYN...... 130 KETALAR...... 129 LAMPIT...... 58 jantoven...... 34 ketamine hcl...... 129 LANOXIN...... 92 JANUMET...... 42 KETAMINE HCL...... 129 LANOXIN PEDIATRIC...... 92 JANUMET XR...... 42, 43 KETAMINE HCL-SODIUM lanthanum carbonate...... 128 JANUVIA...... 42 CHLORIDE...... 129 lapatinib ditosylate...... 68 JARDIANCE...... 44 ketoconazole...... 49, 112 larin 1.5/30...... 98 jasmiel...... 97 ketoprofen...... 21 larin 1/20...... 98 JATENZO...... 27 ketoprofen er...... 21 larin 24 fe...... 98 JELMYTO...... 70 ketorolac tromethamine...... 21, 170 larin fe 1.5/30...... 98 JEMPERLI...... 65 KEVEYIS...... 116 larin fe 1/20...... 98 jencycla...... 101 KEYTRUDA...... 65 larissia...... 98 JENLIVA PRENATAL/POSTNATAL158 KHAPZORY...... 72 LASIX...... 117 JEVTANA...... 74 KINRIX...... 185 latanoprost...... 173 jinteli...... 124 KISQALI (200 MG DOSE)...... 72 LATISSE...... 113 JIVI...... 132 KISQALI (400 MG DOSE)...... 72 LATUDA...... 79 JOHNSON GRASS...... 16 KISQALI (600 MG DOSE)...... 72 layolis fe...... 98 jolessa...... 100 KISQALI FEMARA (400 MG DOSE)..70 leena...... 102 JORNAY PM...... 13, 14 KISQALI FEMARA (600 MG DOSE)..70 leflunomide...... 22 JUBLIA...... 112 KISQALI FEMARA(200 MG DOSE)...70 LEMTRADA...... 180 juleber...... 97 KLARON...... 105 LENSCALE...... 16 JULUCA...... 83 KLISYRI...... 113 LENVIMA (10 MG DAILY DOSE)...... 76 JUNE GRASS POLLEN klor-con...... 149 LENVIMA (12 MG DAILY DOSE)...... 76 STANDARDIZED...... 16 klor-con 10...... 149 LENVIMA (14 MG DAILY DOSE)...... 76 junel 1.5/30...... 97 klor-con m10...... 149 LENVIMA (18 MG DAILY DOSE)...... 77 junel 1/20...... 97 klor-con m15...... 149 LENVIMA (20 MG DAILY DOSE)...... 77 junel fe 1.5/30...... 97 klor-con m20...... 149 LENVIMA (24 MG DAILY DOSE)...... 77 junel fe 1/20...... 97 KOATE...... 132 LENVIMA (4 MG DAILY DOSE)...... 77 junel fe 24...... 98 KOATE-DVI...... 132 LENVIMA (8 MG DAILY DOSE)...... 77 JUXTAPID...... 52 KOCHIA...... 16 lessina...... 98 JYNARQUE...... 123 KOGENATE FS...... 132 letrozole...... 72 KABIVEN...... 166 KORLYM...... 44 leucovorin calcium...... 72 KADCYLA...... 70 KOSELUGO...... 67 LEUKERAN...... 75 kaitlib fe...... 98 KOSHER PRENATAL PLUS IRON...158 LEUKINE...... 137 KALBITOR...... 134 KOVALTRY...... 132 leuprolide acetate...... 73 KALETRA...... 83 K-PHOS...... 149 LEUPROLIDE ACETATE- kalliga...... 98 K-PHOS NO 2...... 130 BUPIVACAINE...... 67 KALYDECO...... 182 K-PHOS-NEUTRAL...... 149 levalbuterol hcl...... 32 KANJINTI...... 65 KRINTAFEL...... 60 levalbuterol tartrate...... 32 KANUMA...... 121 KRISTALOSE...... 142 LEVEMIR...... 43 KAPOK...... 16 KRYSTEXXA...... 131 LEVEMIR FLEXTOUCH...... 43 KAPSPARGO SPRINKLE...... 88 K-TAB...... 150 levetiracetam...... 37 KAPVAY...... 11 kurvelo...... 98 levetiracetam er...... 37 KARBINAL ER...... 50 KUVAN...... 122 LEVETIRACETAM IN NACL...... 37 KARDIAMEMBRANE...... 115 KYLEENA...... 101 levobunolol hcl...... 166 kariva...... 96 KYNMOBI...... 78 levocarnitine...... 119 KATERZIA...... 90 KYPROLIS...... 69 levocarnitine sf...... 119 KCENTRA...... 132 labetalol hcl...... 88 levocetirizine dihydrochloride...... 50 KCL (IN NACL 0.9%)...... 148 LABETALOL HCL-DEXTROSE...... 88 levofloxacin...... 125, 126, 168 kcl in dextrose-nacl...... 148 LABETALOL HCL-SODIUM levofloxacin in d5w...... 125 KCL IN DEXTROSE-NACL...... 148 CHLORIDE...... 88 levoleucovorin calcium...... 72 KCL-LACTATED RINGERS-D5W... 148 lactated ringers...... 148, 152 levoleucovorin calcium pf...... 73 KEDBUMIN...... 134 LACTIC ACID...... 111 levonest...... 102 KEDRAB...... 175 LACTIC ACID E...... 111 levonorgest-eth est & eth est...... 100 KEFLEX...... 94 LACTULOSE...... 142 levonorgest-eth estrad 91-day...... 100 kelnor 1/35...... 98 lactulose...... 142 levonorgestrel-ethinyl estrad...... 98, 100 kelnor 1/50...... 98 lactulose encephalopathy...... 127 levonorg-eth estrad triphasic...... 102 KENALOG...... 103 lamivudine...... 85, 86 LEVOPHED...... 191 203 levora 0.15/30 (28)...... 98 LONHALA MAGNAIR REFILL KIT.. 32 malathion...... 114 levorphanol tartrate...... 24 LONHALA MAGNAIR STARTER manganese chloride...... 149 levo-t...... 184 KIT...... 32 mannitol...... 117 LEVOTHYROXINE SODIUM...... 184 LONSURF...... 70 MARATHON MEDICAL PENTIPS...146 levothyroxine sodium...... 184 loperamide hcl...... 45 MARCAINE...... 143 levoxyl...... 184 LOPID...... 52 MARCAINE PRESERVATIVE FREE143 LEVULAN KERASTICK...... 113 lopinavir-ritonavir...... 83 MARCAINE SPINAL...... 143 LEXIVA...... 84 LOPROX...... 107 MARCAINE/EPINEPHRINE...... 142 LIBRAX...... 185 lorazepam...... 29, 30 MARCAINE/EPINEPHRINE PF...... 142 LIBTAYO...... 65 lorazepam intensol...... 29 MARGENZA...... 65 lidocaine...... 113 LORBRENA...... 63 MARINOL...... 48 LIDOCAINE (ANORECTAL)...... 28 loryna...... 98 marlissa...... 98 lidocaine hcl...... 113, 143, 155 lorzone...... 161 MARPLAN...... 39 LIDOCAINE HCL...... 143 losartan potassium...... 55 MARQIBO...... 74 LIDOCAINE HCL (CARDIAC)...... 30 losartan potassium-hctz...... 55 MATULANE...... 71 lidocaine hcl (cardiac)...... 30 LOSEASONIQUE...... 100 matzim la...... 90 LIDOCAINE HCL (CARDIAC) PF...... 30 LOTEMAX...... 171 MAVENCLAD (10 TABS)...... 179 lidocaine hcl (cardiac) pf...... 30 LOTEMAX SM...... 171 MAVENCLAD (4 TABS)...... 179 lidocaine hcl (pf)...... 143 LOTENSIN...... 54 MAVENCLAD (5 TABS)...... 179 lidocaine hcl urethral/mucosal...... 113 LOTENSIN HCT...... 53 MAVENCLAD (6 TABS)...... 179 lidocaine in d5w...... 30 loteprednol etabonate...... 172 MAVENCLAD (7 TABS)...... 179 LIDOCAINE IN DEXTROSE...... 143 LOTRONEX...... 127 MAVENCLAD (8 TABS)...... 179 lidocaine viscous hcl...... 155 lovastatin...... 52 MAVENCLAD (9 TABS)...... 179 lidocaine-epinephrine...... 142 low-ogestrel...... 98 MAXIDEX...... 172 LIDOCAINE-EPINEPHRINE...... 169 loxapine succinate...... 81 MAXITROL...... 171 LIDOCAINE-PHENYLEPHRINE...... 169 lo-zumandimine...... 98 MAXZIDE...... 116 LIDOCAINE-PHENYLEPHRINE- lubiprostone...... 126 MAXZIDE-25...... 116 BSS...... 170 LUCEMYRA...... 177 MAYZENT...... 181 lidocaine-prilocaine...... 115 LUCENTIS...... 173 MAYZENT STARTER PACK...... 181 LIDOCAINE-SODIUM luliconazole...... 112 MEADOW FESCUE GRASS BICARBONATE...... 142 LUMIGAN...... 173 POLLEN...... 16 LILETTA (52 MG)...... 101 LUMIZYME...... 119 meclizine hcl...... 48 lillow...... 98 LUMOXITI...... 64 meclofenamate sodium...... 21 LINCOCIN...... 59 LUPANETA PACK...... 121 MEDROL...... 103 lincomycin hcl...... 59 LUPKYNIS...... 151 medroxyprogesterone acetate...... 101, 177 lindane...... 114 LUPRON DEPOT (1-MONTH)...... 73 mefenamic acid...... 21 linezolid...... 59 LUPRON DEPOT (3-MONTH)...... 73 mefloquine hcl...... 60 linezolid in sodium chloride...... 59 LUPRON DEPOT (4-MONTH)...... 74 megestrol acetate...... 76, 177 LINZESS...... 127 LUPRON DEPOT (6-MONTH)...... 74 MEKINIST...... 67 LIORESAL...... 161 LUPRON DEPOT-PED (1-MONTH)..121 MEKTOVI...... 67 liothyronine sodium...... 184 LUPRON DEPOT-PED (3-MONTH)..121 MELALEUCA...... 16 LIPO...... 166 LUTATHERA...... 71 meloxicam...... 21 LIPO-B...... 136 lutera...... 98 melphalan...... 75 LIPO-C...... 166 LUZU...... 112 melphalan hcl...... 75 LIPOFEN...... 52 lyleq...... 101 memantine hcl...... 180 lisinopril...... 54 lyllana...... 125 memantine hcl er...... 180 lisinopril-hydrochlorothiazide...... 53 LYNPARZA...... 75 MEMBRANEBLUE...... 172 lithium carbonate...... 79 LYRICA CR...... 180 MENACTRA...... 188 lithium carbonate er...... 79 LYSINE HCL...... 166 MENEST...... 125 LITHOSTAT...... 130 LYSODREN...... 62 MENOPUR...... 122 lmd in d5w...... 134 LYSTEDA...... 138 MENOSTAR...... 125 lmd in nacl...... 134 lyza...... 101 MENQUADFI...... 188 LO LOESTRIN FE...... 96 M.V.I. ADULT...... 157 MENTAX...... 107 LODINE...... 21 M.V.I. PEDIATRIC...... 157 MENVEO...... 188 LODOSYN...... 78 MACROBID...... 60 meperidine hcl...... 24 loestrin 1.5/30 (21)...... 98 MACRODANTIN...... 60 MEPHYTON...... 192 loestrin 1/20 (21)...... 98 mafenide acetate...... 109 meprobamate...... 29 loestrin fe 1.5/30...... 98 MAGELLAN INSULIN SAFETY MEPRON...... 58 loestrin fe 1/20...... 98 SYR...... 146 MEPSEVII...... 122 lojaimiess...... 100 MAGNESIUM SULFATE...... 149 mercaptopurine...... 63 LOKELMA...... 154 MAGNESIUM SULFATE IN D5W....149 meropenem...... 58 LOMAIRA...... 12 MAKENA...... 177 MEROPENEM-SODIUM CHLORIDE.58 LOMOTIL...... 45 MALARONE...... 60 merzee...... 98 204 mesalamine...... 127 microgestin fe 1.5/30...... 98 MONOJECT BONE MARROW mesalamine er...... 127 microgestin fe 1/20...... 98 BIOPSY...... 143 mesalamine-cleanser...... 127 MIDAZOLAM...... 140 monoject flush syringe...... 150 mesna...... 76 midazolam hcl...... 140 MONOJECT INSULIN SYRINGE..... 146 MESNEX...... 76 midazolam hcl (pf)...... 140 monoject sodium chloride flush...... 150 MESQUITE...... 16 MIDAZOLAM HCL-SODIUM MONOJECT ULTRA COMFORT MESTINON...... 60 CHLORIDE...... 140 SYRINGE...... 146 metaxalone...... 161 MIDAZOLAM-SODIUM CHLORIDE mono-linyah...... 98 metformin hcl...... 42 ...... 140 MONONINE...... 132 metformin hcl er...... 42 midodrine hcl...... 191 MONOVISC...... 163 METHADONE HCL...... 25 MIFEPREX...... 118 montelukast sodium...... 33 methadone hcl...... 25 mifepristone...... 118 MONUROL...... 60 methadone hcl intensol...... 25 migergot...... 147 morgidox...... 184 METHADOSE...... 25 miglitol...... 42 MORPHINE SULFATE...... 25 methadose...... 25 miglustat...... 135 morphine sulfate...... 25 METHADOSE SUGAR-FREE...... 25 mili...... 98 morphine sulfate (concentrate)...... 25 methazolamide...... 116 MILLIPRED...... 103 morphine sulfate (pf)...... 25 methenamine hippurate...... 60 milrinone lactate...... 92 MORPHINE SULFATE (PF)...... 25 methergine...... 174 milrinone lactate in dextrose...... 92 morphine sulfate er...... 25 methimazole...... 184 mimvey...... 124 morphine sulfate er beads...... 25 methocarbamol...... 162 MINASTRIN 24 FE...... 98 MORPHINE SULFATE-NACL...... 25 METHOHEXITAL SODIUM...... 129 mineral oil heavy...... 142 MOTOFEN...... 45 methotrexate...... 63 MINILINK REAL-TIME MOUNTAIN CEDAR...... 16 methotrexate sodium...... 63 TRANSMITTER...... 146 MOUSE EPITHELIUM...... 16 methotrexate sodium (pf)...... 63 MINIMED 630G GUARDIAN PRESS MOVANTIK...... 128 methoxsalen rapid...... 108 ...... 146 MOVIPREP...... 141 methscopolamine bromide...... 187 MINIMED GUARDIAN LINK 3...... 146 MOXEZA...... 168 METHYLCOBALAMIN...... 136 MINIPRESS...... 56 MOXIFLOXACIN HCL...... 126, 168 methyldopa...... 56 minitran...... 29 moxifloxacin hcl...... 126, 168 methylergonovine maleate...... 174 MINOCIN...... 184 moxifloxacin hcl (2x day)...... 168 METHYLIN...... 14 minocycline hcl...... 184 moxifloxacin hcl in nacl...... 126 methylphenidate hcl...... 14 minocycline hcl er...... 184 MOZOBIL...... 136 methylphenidate hcl er...... 14 minoxidil...... 57 MUCOR...... 16, 17 METHYLPHENIDATE HCL ER...... 14 MIOCHOL-E...... 167 MUGWORT...... 17 methylphenidate hcl er (cd)...... 14 MIOSTAT...... 167 MULPLETA...... 138 methylphenidate hcl er (la)...... 14 MIRAPEX...... 78 MULTAQ...... 31 methylphenidate hcl er (xr)...... 14 MIRAPEX ER...... 78 multi-vit/iron/fluoride...... 157 methylprednisolone...... 103 MIRCERA...... 136 MULTIVITAMIN/FLUORIDE...... 156 methylprednisolone sodium succ...... 103 MIRCETTE...... 96 multivitamin/fluoride...... 157 metoclopramide hcl...... 126 MIRENA (52 MG)...... 101 multi-vitamin/fluoride...... 157 METOCLOPRAMIDE HCL...... 126 mirtazapine...... 39 multi-vitamin/fluoride/iron...... 157 metolazone...... 117 MIRVASO...... 114 mupirocin...... 106 metoprolol succinate er...... 88 misoprostol...... 187 mupirocin calcium...... 106 metoprolol tartrate...... 88 MITE (D. FARINAE)...... 16 MUSE...... 92 metoprolol-hydrochlorothiazide...... 56 MITE (D. PTERONYSSINUS)...... 16 mutamycin...... 70 METROCREAM...... 114 mitigo...... 25 MVASI...... 77 metronidazole...... 57, 114, 190 mitomycin...... 70 MYALEPT...... 121 metronidazole in nacl...... 57 MITOMYCIN...... 70, 168 MYAMBUTOL...... 61 METRONIDAZOLE IN NACL...... 57 MITOSOL...... 168 MYCAMINE...... 48 metyrosine...... 54 mitoxantrone hcl...... 70 MYCAPSSA...... 123 mexiletine hcl...... 30 MIXED ASPERGILLUS...... 18 MYCOBUTIN...... 61 MI PASTE...... 145 MIXED FEATHERS...... 18 mycophenolate mofetil...... 152 MI PASTE PLUS...... 145 MIXED RAGWEED...... 16 mycophenolate mofetil hcl...... 152 MIACALCIN...... 119 MIXED VESPID VENOM PROTEIN.. 16 mycophenolate sodium...... 152 mibelas 24 fe...... 98 M-M-R II...... 188 MYDAYIS...... 11 micafungin sodium...... 48 M-NATAL PLUS...... 158 MYDRIACYL...... 167 miconazole 3...... 190 modafinil...... 14 MYFORTIC...... 152 miconazole-zinc oxide-petrolat...... 107 moexipril hcl...... 54 MYLERAN...... 61 MICRHOGAM ULTRA-FILTERED molindone hcl...... 81 MYLOTARG...... 64 PLUS...... 175 mometasone furoate...... 111, 163 MYNATAL...... 158 microgestin 1.5/30...... 98 mondoxyne nl...... 184 MYNATAL PLUS...... 158 microgestin 1/20...... 98 MONJUVI...... 64 MYNATAL-Z...... 158 microgestin 24 fe...... 98 MONOFERRIC...... 137 MYOBLOC...... 164 205 myorisan...... 106 NEOX 100...... 115 nizatidine...... 186 MYRBETRIQ...... 188 NEOX CORD 1K...... 115 NOCDURNA...... 124 MYTESI...... 45 NERLYNX...... 68 nolix...... 111 MYXREDLIN...... 43 NESACAINE...... 143 nora-be...... 101 na ferric gluc cplx in sucrose...... 137 NESACAINE-MPF...... 143 NOREPINEPHRINE (BASE)- NABI-HB...... 175 NESTABS...... 158 DEXTROSE...... 191 nabumetone...... 21 NESTABS DHA...... 158 norepinephrine bitartrate...... 191 n-acetyl-l-cysteine...... 166 NESTABS ONE...... 160 NOREPINEPHRINE-DEXTROSE...... 191 nadolol...... 89 neuac...... 105 NOREPINEPHRINE-SODIUM nafcillin sodium...... 177 NEULASTA...... 137 CHLORIDE...... 191 NAFCILLIN SODIUM IN NEULASTA ONPRO...... 137 norethin ace-eth estrad-fe...... 98, 99 DEXTROSE...... 177 NEUPOGEN...... 137 norethindrone...... 101 nafrinse...... 149 NEUPRO...... 78 norethindrone acetate...... 177 NAFRINSE DAILY ACIDULATED.. 155 NEURIN-SL...... 136 norethindrone acet-ethinyl est...... 99 NAFRINSE DAILY/NEUTRAL...... 155 NEVANAC...... 170 norethindrone-eth estradiol...... 124 nafrinse drops...... 149 nevirapine...... 85 norethin-eth estradiol-fe...... 99 NAFRINSE WEEKLY...... 155 nevirapine er...... 85 norgestimate-eth estradiol...... 99 naftifine hcl...... 107 NEXAVAR...... 68 norgestim-eth estrad triphasic...... 102 NAFTIN...... 107 NEXAVIR...... 153 NORITATE...... 114 NAGLAZYME...... 122 NEXIUM I.V...... 186 norlyda...... 101 nalbuphine hcl...... 26 NEXLETOL...... 51 norlyroc...... 101 naloxone hcl...... 47 NEXLIZET...... 51 normal saline flush...... 150 naltrexone hcl...... 47 NEXPLANON...... 100 NORMOSOL-M IN D5W...... 148 NAMENDA TITRATION PAK...... 180 NEXTERONE...... 31 NORMOSOL-R...... 148 NAMZARIC...... 178 NEXTSTELLIS...... 98 NORMOSOL-R IN D5W...... 148 naproxen...... 21 niacin (antihyperlipidemic)...... 52 NORMOSOL-R PH 7.4...... 149 naproxen sodium...... 21, 22 niacin er (antihyperlipidemic)...... 52 NORPACE...... 30 naratriptan hcl...... 147 niacor...... 52 NORPACE CR...... 30 NARCAN...... 47 NIASPAN...... 52, 53 NORPRAMIN...... 41 NARDIL...... 39 nicardipine hcl...... 90 NORTHERA...... 191 NAROPIN...... 143 NICARDIPINE HCL IN NACL...... 90 nortrel 0.5/35 (28)...... 99 NATACHEW...... 158 NICOTROL...... 181 nortrel 1/35 (21)...... 99 NATACYN...... 168 NICOTROL NS...... 181 nortrel 1/35 (28)...... 99 NATALVIT...... 158 nifedipine...... 91 nortrel 7/7/7...... 102 NATAZIA...... 100 nifedipine er...... 90 nortriptyline hcl...... 41 nateglinide...... 44 nifedipine er osmotic release...... 90, 91 NORVIR...... 84 NATPARA...... 122 nikki...... 98 NOURIANZ...... 77 NATROBA...... 114 NILANDRON...... 62 NOVACHOR...... 115 NATURE-THROID...... 184 nilutamide...... 62 NOVAREL...... 122 NAVELBINE...... 74 NIMBEX...... 164 NOVOEIGHT...... 132 NAYZILAM...... 35 nimodipine...... 91 NOVOSEVEN RT...... 132 NEBUPENT...... 57 NINLARO...... 69 NOXAFIL...... 49 necon 0.5/35 (28)...... 98 NIPENT...... 71 np thyroid...... 184 NEEVO DHA...... 158 NIPRIDE RTU...... 57 NPLATE...... 138 nefazodone hcl...... 40 nisoldipine er...... 91 NUBEQA...... 62 NEMBUTAL...... 139 nitazoxanide...... 58 NUCALA...... 33 neomycin sulfate...... 19 NITHIODOTE...... 46 NUCYNTA...... 25 neomycin-bacitracin zn-polymyx...... 168 nitisinone...... 120 NUEDEXTA...... 181 neomycin-polymyxin b gu...... 129 NITRO-BID...... 29 NULIBRY...... 121 neomycin-polymyxin-dexameth...... 171 NITRO-DUR...... 29 NULOJIX...... 154 neomycin-polymyxin-gramicidin...... 168 nitrofurantoin...... 60 NULYTELY LEMON-LIME...... 141 neomycin-polymyxin-hc...... 171, 174 nitrofurantoin macrocrystal...... 60 NUMBRINO...... 163 NEONATAL + DHA...... 160 nitrofurantoin monohyd macro...... 60 NUPLAZID...... 79 NEONATAL 19...... 161 NITROGLYCERIN...... 29 NURTEC...... 147 NEONATAL COMPLETE...... 158 nitroglycerin...... 29 NUSHIELD...... 115 NEONATAL FE...... 158 nitroglycerin in d5w...... 29 NUTRILIPID...... 166 NEONATAL PLUS...... 158 NITROLINGUAL...... 29 NUVARING...... 100 neo-polycin...... 168 NITROMIST...... 29 NUVESSA...... 190 neo-polycin hc...... 171 nitroprusside sodium...... 57 NUWIQ...... 132 NEOPROFEN...... 22 NITROSTAT...... 29 NUZYRA...... 183 NEORAL...... 151 NITYR...... 120 nyamyc...... 107 NEOSTIGMINE METHYLSULFATE. 60 NIVA-PLUS...... 158 nylia 7/7/7...... 102 NEO-SYNALAR...... 106 NIVESTYM...... 137 NYMALIZE...... 91 206 nymyo...... 99 oralone...... 156 PALFORZIA (120 MG DAILY nystatin...... 49, 107, 155 ORAPRED ODT...... 103 DOSE)...... 17 nystatin-triamcinolone...... 107 ORAVIG...... 155 PALFORZIA (160 MG DAILY nystop...... 107 ORBACTIV...... 58 DOSE)...... 17 NYVEPRIA...... 137 ORCHARD GRASS POLLEN...... 17 PALFORZIA (20 MG DAILY DOSE)..17 OB COMPLETE...... 158 ORENITRAM...... 93 PALFORZIA (200 MG DAILY OB COMPLETE ONE...... 158 ORFADIN...... 120 DOSE)...... 17 OB COMPLETE PETITE...... 158 ORGOVYX...... 73 PALFORZIA (240 MG DAILY OB COMPLETE PREMIER...... 158 ORIAHNN...... 125 DOSE)...... 17 OB COMPLETE/DHA...... 158 ORILISSA...... 119 PALFORZIA (3 MG DAILY DOSE)....17 OBIZUR...... 132 ORKAMBI...... 182 PALFORZIA (300 MG OBSTETRIX DHA...... 158 ORLADEYO...... 134 MAINTENANCE)...... 17 OBSTETRIX EC...... 158 orphenadrine citrate...... 162 PALFORZIA (300 MG TITRATION)...17 OBSTETRIX ONE...... 160 orphenadrine citrate er...... 162 PALFORZIA (40 MG DAILY DOSE)..17 O-CAL PRENATAL...... 158 orphenadrine-asa-caffeine...... 162 PALFORZIA (6 MG DAILY DOSE)....17 OCALIVA...... 126 orphengesic forte...... 162 PALFORZIA (80 MG DAILY DOSE)..17 ocella...... 99 orsythia...... 99 PALFORZIA INITIAL ESCALATION 17 OCTAGAM...... 175 ORTHOVISC...... 163 PALINGEN FLOW...... 115 OCTAPLAS BLOOD GROUP A...... 134 ORTIKOS...... 103 PALINGEN HYDROMEMBRANE....115 OCTAPLAS BLOOD GROUP AB..... 134 oseltamivir phosphate...... 87 PALINGEN INOVOFLO...... 115 OCTAPLAS BLOOD GROUP B...... 134 osmitrol...... 117 PALINGEN MEMBRANE...... 115 OCTAPLAS BLOOD GROUP O...... 134 OSMOLEX ER...... 77 PALINGEN XPLUS octreotide acetate...... 123 OSMOPREP...... 142 HYDROMEMBRANE...... 115 ocucoat viscoadherent...... 172 OSPHENA...... 123 PALINGEN XPLUS MEMBRANE.... 115 OCUFLOX...... 168 OTEZLA...... 22 paliperidone er...... 79, 80 ODACTRA...... 18 OTIPRIO...... 173 PALONOSETRON HCL...... 47 ODEFSEY...... 83 OTOVEL...... 174 palonosetron hcl...... 47 ODOMZO...... 67 OTREXUP...... 19 PALYNZIQ...... 122 OFEV...... 183 OVIDE...... 114 PAMELOR...... 41 OFIRMEV...... 22 OVIDREL...... 122 pamidronate disodium...... 118 ofloxacin...... 126, 168, 173 oxacillin sodium...... 177 PAMIDRONATE DISODIUM...... 118 OGIVRI...... 65 OXACILLIN SODIUM IN PANCREAZE...... 116 olanzapine...... 82 DEXTROSE...... 177 pancuronium bromide...... 164 olanzapine-fluoxetine hcl...... 182 oxaliplatin...... 61 PANHEMATIN...... 133 OLINVYK...... 25 oxandrolone...... 27 PANRETIN...... 108 OLIVE TREE...... 17 oxaprozin...... 22 pantoprazole sodium...... 186 olmesartan medoxomil...... 55 OXAYDO...... 25 PANZYGA...... 175 olmesartan medoxomil-hctz...... 55 oxazepam...... 30 PARADIGM REAL-TIME olmesartan-amlodipine-hctz...... 55 OXBRYTA...... 137 TRANSMITTER...... 146 olopatadine hcl...... 163 oxcarbazepine...... 37 PARAGARD INTRAUTERINE OMECLAMOX-PAK...... 187 OXERVATE...... 170 COPPER...... 100 omega-3-acid ethyl esters...... 51 oxiconazole nitrate...... 112 paraplatin...... 61 OMEGAVEN...... 166 OXISTAT...... 112 PAREMYD...... 169 omeprazole...... 186 OXLUMO...... 130 paricalcitol...... 120 OMIDRIA...... 172 OXTELLAR XR...... 37 PARLODEL...... 77 OMNIFLEX DIAPHRAGM...... 145 oxybutynin chloride...... 187 PARNATE...... 40 OMNIPOD 5 PACK...... 146 oxybutynin chloride er...... 187 paromomycin sulfate...... 19 OMNIPOD DASH 5 PACK PODS...... 146 oxycodone hcl...... 25 paroxetine hcl...... 40 OMNIPOD STARTER...... 146 oxycodone hcl er...... 25 paroxetine hcl er...... 40 ONCASPAR...... 71 oxycodone-acetaminophen...... 26 paroxetine mesylate...... 182 ondansetron...... 47 OXYCONTIN...... 25 PARSABIV...... 118 ondansetron hcl...... 47 oxymorphone hcl...... 26 PASER...... 61 ONE VITE WOMENS PLUS...... 158 oxymorphone hcl er...... 25 PATANASE...... 163 ONEXTON...... 105 oxytocin...... 174 PAXIL...... 40 ONGENTYS...... 79 OXYTOCIN-LACTATED RINGERS.174 PEDIAPRED...... 103 ONIVYDE...... 76 OXYTOCIN-SODIUM CHLORIDE...174 PEDIARIX...... 185 ONPATTRO...... 181 OZEMPIC (0.25 OR 0.5 MG/DOSE).... 43 PEDVAX HIB...... 188 ONTRUZANT...... 65 OZEMPIC (1 MG/DOSE)...... 44 peg 3350-kcl-na bicarb-nacl...... 141 ONUREG...... 63 OZURDEX...... 172 peg-3350/electrolytes...... 141 OPDIVO...... 65 pacerone...... 31 peg-3350/electrolytes/ascorbat...... 141 OPSUMIT...... 93 paclitaxel...... 74 PEGASYS...... 87 ORABLOC...... 142 PADCEV...... 65 peg-kcl-nacl-nasulf-na asc-c...... 141 ORALAIR...... 18 PALFORZIA (12 MG DAILY DOSE)..17 peg-prep...... 141 207 PEMAZYRE...... 67 PHOTREXA-PHOTREXA VISCOUS potassium chloride in dextrose...... 148 penicillamine...... 151 KIT...... 170 POTASSIUM CHLORIDE IN NACL.149 PENICILLIN G POT IN DEXTROSE 176 PHOXILLUM B22K4/0...... 151 potassium chloride in nacl...... 149 penicillin g potassium...... 176 PHOXILLUM BK4/2.5...... 151 potassium citrate er...... 129 PENICILLIN G PROCAINE...... 176 physiolyte...... 152 POTASSIUM PHOSPHATES...... 149 penicillin g sodium...... 176 physiosol irrigation...... 152 potassium phosphates...... 149 penicillin v potassium...... 176 phytonadione...... 192 potassium phosphates(66 meq k)...... 149 PENICILLIUM NOTATUM...... 17 PIFELTRO...... 85 POTASSIUM PHOSPHATES(71 PENTACEL...... 185 pilocarpine hcl...... 156, 167 MEQ K)...... 149 PENTAM...... 57 pimecrolimus...... 113 POTELIGEO...... 64 pentamidine isethionate...... 57 pimozide...... 181 PRALUENT...... 53 PENTASA...... 127 pimtrea...... 96 pramipexole dihydrochloride...... 78 pentazocine-naloxone hcl...... 26 pindolol...... 89 pramipexole dihydrochloride er...... 78 PENTETATE CALCIUM pioglitazone hcl...... 45 PRAMOSONE...... 114 TRISODIUM...... 46 pioglitazone hcl-glimepiride...... 45 PRAMOTIC...... 173 PENTETATE ZINC TRISODIUM...... 46 pioglitazone hcl-metformin hcl...... 45 prasugrel hcl...... 135 PENTIPS...... 147 piperacillin sod-tazobactam so...... 177 pravastatin sodium...... 52 pentobarbital sodium...... 140 PIQRAY (200 MG DAILY DOSE)...... 75 PRAXBIND...... 46 pentoxifylline er...... 133 PIQRAY (250 MG DAILY DOSE)...... 75 praziquantel...... 28 PEPAXTO...... 75 PIQRAY (300 MG DAILY DOSE)...... 75 prazosin hcl...... 56 PEPCID...... 186 pirmella 1/35...... 99 PRECEDEX...... 141 PERENNIAL RYE GRASS POLLEN...17 pirmella 7/7/7...... 102 PRECOSE...... 42 PERFOROMIST...... 32 piroxicam...... 22 PRED MILD...... 172 PERIDEX...... 155 PITOCIN...... 174 PRED-G...... 171 PERIKABIVEN...... 166 PLASBUMIN-25...... 134 PRED-G S.O.P...... 171 perindopril erbumine...... 54 PLASBUMIN-5...... 134 prednicarbate...... 111 periogard...... 155 PLASMA-LYTE 148...... 149 prednisolone...... 103 PERJETA...... 65 PLASMA-LYTE A...... 149 prednisolone acetate...... 172 permethrin...... 114 PLASMANATE...... 134 prednisolone sodium phosphate...... 103 perphenazine...... 81 PLEGISOL...... 92 PREDNISOLONE SODIUM perphenazine-amitriptyline...... 180 plenamine...... 165 PHOSPHATE...... 172 PERSERIS...... 80 PLENITY...... 12 prednisone...... 103 PERTZYE...... 116 PLENITY WELCOME KIT...... 12 PREDNISONE INTENSOL...... 103 PEXEVA...... 40 PLENVU...... 141 PREFEST...... 124 pfizerpen...... 176 PNEUMOVAX 23...... 188 pregabalin...... 37 phendimetrazine tartrate...... 12 PNV TABS 20-1...... 158 pregabalin er...... 181 phendimetrazine tartrate er...... 12 PNV TABS 29-1...... 158 PREGEN DHA...... 160 phenelzine sulfate...... 40 pnv-dha...... 160 PREGENNA...... 158 PHENERGAN...... 50 PNV-DHA+DOCUSATE...... 160 PREGNYL...... 122 phenobarbital...... 140 PNV-OMEGA...... 158 PREMARIN...... 125, 190 phenobarbital sodium...... 140 pnv-select...... 158 PREMASOL...... 165 phenohytro...... 185 podofilox...... 112 PREMESISRX...... 161 phenoxybenzamine hcl...... 54 POINT OF CARE LM-2.5...... 142 PREMPHASE...... 124 phentermine hcl...... 12 POLIVY...... 64 PREMPRO...... 125 phentolamine mesylate...... 54 polocaine...... 143 PRENA 1 TRUE...... 160 PHENYLEPHRINE HCL...... 167, 191 polocaine-mpf...... 143 PRENA1...... 161 phenylephrine hcl...... 167 polycin...... 168 PRENA1 PEARL...... 159 PHENYLEPHRINE HCL-NACL 191, 192 polyethylene glycol 3350...... 142 PRENAISSANCE...... 160 PHENYTEK...... 38 polymyxin b sulfate...... 59 PRENAISSANCE PLUS...... 160 phenytoin...... 38 polymyxin b-trimethoprim...... 168 PRENARA...... 159 phenytoin infatabs...... 38 POLYTRIM...... 168 prenatabs rx...... 159 phenytoin sodium...... 39 POLY-VI-FLOR...... 157 PRENATAL...... 159 phenytoin sodium extended...... 39 POLY-VI-FLOR/IRON...... 157 PRENATAL 19...... 159 PHESGO...... 70 POMALYST...... 67 prenatal 19...... 159 PHEXXI...... 190 portia-28...... 99 PRENATAL PLUS IRON...... 159 philith...... 99 PORTRAZZA...... 66 PRENATAL VITAMIN PLUS LOW PHOMA EXIGUA...... 17 posaconazole...... 49 IRON...... 159 PHOSLYRA...... 128 pot & sod cit-cit ac...... 129 PRENATAL-U...... 159 phosphorous...... 149 potassium acetate...... 150 PRENATE...... 161 phospho-trin 250 neutral...... 149 POTASSIUM CHLORIDE...... 150 PRENATE AM...... 161 PHOTOFRIN...... 71 potassium chloride...... 150 PRENATE DHA...... 160 PHOTREXA VISCOUS...... 170 potassium chloride crys er...... 150 PRENATE ELITE...... 159 potassium chloride er...... 150 PRENATE ENHANCE...... 160 208 PRENATE ESSENTIAL...... 160 procto-pak...... 28 QUADRACEL...... 185 PRENATE MINI...... 160 proctozone-hc...... 28 QUADRAMET...... 71 PRENATE PIXIE...... 160 PROCYSBI...... 130 QUALAQUIN...... 60 PRENATE RESTORE...... 160 PROFILNINE...... 132 QUARTETTE...... 100 PRENATRIX...... 159 progesterone...... 177 quazepam...... 140 PRENATRYL...... 159 PROGLYCEM...... 42 QUDEXY XR...... 37 PRENATVITE COMPLETE...... 159 PROGRAF...... 153 QUEEN PALM...... 17 PRENATVITE PLUS...... 159 PROLASTIN-C...... 182 QUELICIN...... 164 PRENATVITE RX...... 159 PROLENSA...... 170 QUESTRAN...... 51 PREPIDIL...... 174 PROLEUKIN...... 71 QUESTRAN LIGHT...... 51 PREPLUS...... 159 PROLIA...... 123 quetiapine fumarate...... 80, 81 PRESTALIA...... 53 PROMACTA...... 138 quetiapine fumarate er...... 80 PRETAB...... 159 promethazine hcl...... 50 QUFLORA FE...... 156 PRETOMANID...... 61 promethazine vc...... 104 QUFLORA FE PEDIATRIC...... 157 prevalite...... 51 promethazine vc/codeine...... 105 QUFLORA GUMMIES...... 157 PREVIDENT...... 156 promethazine-codeine...... 104, 105 QUFLORA PEDIATRIC...... 157 PREVIDENT 5000 BOOSTER PLUS.155 promethazine-dm...... 104 QUILLICHEW ER...... 14 PREVIDENT 5000 DRY MOUTH...... 155 promethazine-phenyleph-codeine...... 105 QUILLIVANT XR...... 14 PREVIDENT 5000 ENAMEL promethazine-phenylephrine...... 104 quinapril hcl...... 54 PROTECT...... 155 promethegan...... 50 quinapril-hydrochlorothiazide...... 53 PREVIDENT 5000 ORTHO PROMISEB...... 109 quinidine gluconate er...... 30 DEFENSE...... 155 propafenone hcl...... 30 quinidine sulfate...... 30 PREVIDENT 5000 PLUS...... 156 propafenone hcl er...... 30 quinine sulfate...... 60 PREVIDENT 5000 SENSITIVE...... 155 proparacaine hcl...... 170 QUTENZA (4 PATCH)...... 113 previfem...... 99 proparacaine-fluorescein...... 169 QUZYTTIR...... 50 PREVNAR 13...... 188 PROPECIA...... 116 QVAR REDIHALER...... 33 PREVYMIS...... 86 PROPEL...... 163 RABAVERT...... 189 PREZCOBIX...... 83 PROPEL MINI...... 163 RABBIT EPITHELIUM...... 17 PREZISTA...... 84 propofol...... 129 RADIOGARDASE...... 47 PRIALT...... 23 propofol-lipuro...... 129 RAGWITEK...... 17 PRIFTIN...... 61 propranolol hcl...... 89 raloxifene hcl...... 123 PRILO PATCH II...... 115 propranolol hcl er...... 89 ramelteon...... 141 PRIMACARE...... 159 propylthiouracil...... 184 ramipril...... 54 PRIMAQUINE PHOSPHATE...... 60 PROQUAD...... 188 RANEXA...... 28 PRIMAXIN IV...... 58 PROSCAR...... 129 ranolazine er...... 28 primidone...... 37 PROSOL...... 165 RAPAMUNE...... 153 PRIMSOL...... 57 PROSTIN E2...... 174 RAPIVAB...... 87 PRISMASOL B22GK 4/0...... 151 PROSTIN VR...... 154 rasagiline mesylate...... 78 PRISMASOL BGK 0/2.5...... 151 protamine sulfate...... 135 RASUVO...... 19 PRISMASOL BGK 2/0...... 151 PROTONIX...... 186 RAVICTI...... 123 PRISMASOL BGK 2/3.5...... 151 PROTOPAM CHLORIDE...... 46 RAYALDEE...... 120 PRISMASOL BGK 4/0/1.2...... 151 protriptyline hcl...... 41 RAZADYNE ER...... 178 PRISMASOL BGK 4/2.5...... 151 PROVAYBLUE...... 47 REAL HEAL-I...... 115 PRISMASOL BK 0/0/1.2...... 151 PROVENGE...... 65 REBIF...... 179 PRIVET...... 17 PROVENTIL HFA...... 32 REBIF REBIDOSE...... 179 PRIVIGEN...... 175 PROVERA...... 177 REBIF REBIDOSE TITRATION PRO COMFORT PEN NEEDLES...... 147 PROVIDA OB...... 159 PACK...... 179 PROAIR DIGIHALER...... 32 PROVISC...... 172 REBIF TITRATION PACK...... 179 PROAIR HFA...... 32 pseudoeph-bromphen-dm...... 104 REBINYN...... 132 PROAIR RESPICLICK...... 32 PULMICORT FLEXHALER...... 33 REBLOZYL...... 136 probenecid...... 131 PULMOZYME...... 182 RECARBRIO...... 58 PROBUPHINE IMPLANT KIT...... 27 PURIXAN...... 63 RECLAST...... 118 procainamide hcl...... 30 PYLERA...... 187 reclipsen...... 99 PROCALAMINE...... 165 pyrazinamide...... 61 RECOMBINATE...... 132 PROCARDIA XL...... 91 pyridostigmine bromide...... 61 RECOMBIVAX HB...... 189 procentra...... 12 pyridostigmine bromide er...... 60 RECOTHROM...... 139 prochlorperazine...... 81 pyridoxine hcl...... 192 RECOTHROM SPRAY KIT...... 139 prochlorperazine edisylate...... 81 pyrimethamine...... 60 RECTIV...... 28 prochlorperazine maleate...... 81 QBRELIS...... 54 RED MAPLE...... 17 PROCRIT...... 136 QBREXZA...... 113 RED MULBERRY...... 17 PROCTOCORT...... 28 QDOLO...... 26 RED TOP GRASS POLLEN...... 17 PROCTOFOAM HC...... 28 QINLOCK...... 68 REDITREX...... 19 procto-med hc...... 28 QSYMIA...... 12 refissa...... 106 209 REGEN-COV...... 176 RITALIN...... 15 SELECT-OB+DHA...... 160 REGLAN...... 126 RITALIN LA...... 14, 15 selegiline hcl...... 78 REGONOL...... 61 ritonavir...... 84 SELENIOUS ACID...... 150 REGRANEX...... 116 RITUXAN...... 64 selenium sulfide...... 109 relafen...... 22 RITUXAN HYCELA...... 70 SELZENTRY...... 83 RELENZA DISKHALER...... 87 rivastigmine...... 178 SE-NATAL 19...... 159 RELEXXII...... 14 rivastigmine tartrate...... 178 SENSIPAR...... 118 RELISTOR...... 128 rivelsa...... 100 sensorcaine...... 143 RELNATE DHA...... 159 RIXUBIS...... 132 sensorcaine/epinephrine...... 142 REMERON...... 39 rizatriptan benzoate...... 147 sensorcaine-mpf...... 143 REMERON SOLTAB...... 39 ROBAXIN...... 162 sensorcaine-mpf/epinephrine...... 142 REMESENSE...... 144 ROCALTROL...... 120 SENSORCAINE-MPF/EPINEPHRINE REMICADE...... 128 ROCKLATAN...... 169 ...... 142 remifentanil hcl...... 26 rocuronium bromide...... 164 SEREVENT DISKUS...... 32 REMODULIN...... 93 ROCURONIUM BROMIDE...... 164 SEROSTIM...... 120 RENACIDIN...... 130 ROMIDEPSIN...... 67 sertraline hcl...... 40 RENOVA...... 106 ropinirole hcl...... 78 setlakin...... 100 RENOVA PUMP...... 106 ropinirole hcl er...... 78 sevelamer carbonate...... 128 RENVELA...... 128 ropivacaine hcl...... 143 sevelamer hcl...... 128 repaglinide...... 44 ROPIVACAINE HCL-NACL...... 143 SEVENFACT...... 132 REPATHA...... 53 rosadan...... 114 sevoflurane...... 129 REPATHA PUSHTRONEX SYSTEM. 53 rosuvastatin calcium...... 52 sf...... 156 REPATHA SURECLICK...... 53 ROTARIX...... 189 sf 5000 plus...... 156 RESECTISOL...... 130 ROTATEQ...... 189 SFROWASA...... 127 RESTASIS...... 169 ROUGH MARSH ELDER...... 17 SHAGBARK HICKORY...... 17 RESTASIS MULTIDOSE...... 169 ROWASA...... 127 sharobel...... 101 RESTORA RX...... 45 roweepra...... 37 SHEEP SORREL...... 17 RESTORIL...... 140 ROXICODONE...... 26 SHINGRIX...... 189 RETACRIT...... 136 ROZLYTREK...... 69 SHORT RAGWEED POLLEN EXT.....17 RETAVASE...... 135 RUBRACA...... 75 SIGNIFOR...... 123 RETAVASE HALF-KIT...... 135 RUCONEST...... 133 SIGNIFOR LAR...... 123 RETEVMO...... 69 rufinamide...... 37 SIKLOS...... 136 RETISERT...... 172 RUKOBIA...... 84 sildenafil citrate...... 93 RETROVIR...... 85, 86 RUSSIAN THISTLE...... 17 SILENOR...... 140 REVCOVI...... 118 RUXIENCE...... 64 silodosin...... 129 REVLIMID...... 152 RUZURGI...... 61 SILVADENE...... 109 revonto...... 162 RYANODEX...... 162 silver sulfadiazine...... 109 REXULTI...... 82 RYBELSUS...... 44 SIMBRINZA...... 166 REYATAZ...... 84 ryclora...... 50 simliya...... 96 RHIZOPUS...... 17 RYDAPT...... 68 simpesse...... 100 RHOFADE...... 114 RYTARY...... 78 SIMPONI ARIA...... 20 RHOGAM ULTRA-FILTERED PLUS RYTHMOL SR...... 30 SIMULECT...... 153 ...... 175 RYVENT...... 50 simvastatin...... 52 RHOPHYLAC...... 176 SACCHAROMYCES CEREVISIAE.... 17 SINEMET...... 78 RHOPRESSA...... 170 SAFYRAL...... 99 sirolimus...... 153 RIABNI...... 64 SALAGEN...... 156 SIRTURO...... 61 RIASTAP...... 132 SAMSCA...... 123 SIVEXTRO...... 59 ribavirin...... 87, 88 SANCUSO...... 47 SKELAXIN...... 162 RIDAURA...... 20 SANDIMMUNE...... 151 SKYLA...... 101 rifabutin...... 61 SANDOSTATIN...... 123 SKYRIZI...... 108 RIFADIN...... 61 SANDOSTATIN LAR DEPOT...... 123 SKYRIZI (150 MG DOSE)...... 108 rifampin...... 61 SANTYL...... 112 SKYRIZI PEN...... 108 RILUTEK...... 164 sapropterin dihydrochloride...... 122 SLYND...... 101 riluzole...... 164 SARCLISA...... 64 SMOFLIPID...... 166 rimantadine hcl...... 87 SAVELLA...... 178 sod benz-sod phenylacet...... 123 RIMSO-50...... 130 SAVELLA TITRATION PACK...... 178 SODIUM ACETATE...... 148 ringers...... 149 SAXENDA...... 12 SODIUM BICARBONATE...... 28 ringers irrigation...... 152 SCENESSE...... 113 sodium bicarbonate...... 148 RINVOQ...... 19 SCLEROSOL INTRAPLEURAL...... 182 sodium chloride...... 104, 130, 150 RIOMET...... 42 scopolamine...... 48 sodium chloride flush...... 150 risedronate sodium...... 118 SEASONIQUE...... 100 SODIUM CITRATE LOCK FLUSH.....34 RISPERDAL CONSTA...... 80 SECUADO...... 80 SODIUM DIURIL...... 117 risperidone...... 80 SELECT-OB...... 159 SODIUM EDECRIN...... 117 210 sodium fluoride...... 149, 156 stavudine...... 86 SYMLINPEN 60...... 42 sodium fluoride 5000 enamel...... 155 STELARA...... 108, 127 SYMPAZAN...... 35 sodium fluoride 5000 plus...... 156 STEMPHYLIUM...... 17 SYMPROIC...... 128 sodium fluoride 5000 ppm...... 156 STERILE TALC POWDER...... 182 SYMTUZA...... 83 sodium fluoride 5000 sensitive...... 155 sterile water for irrigation...... 152 SYNAGIS...... 174 SODIUM IODIDE I-131...... 184 STERITALC...... 183 SYNAREL...... 121 SODIUM NITRITE...... 47 STIMATE...... 124 SYNDROS...... 48 sodium nitroprusside...... 57 STIOLTO RESPIMAT...... 31 SYNERCID...... 60 sodium phenylbutyrate...... 124 STIVARGA...... 68 SYNJARDY...... 44 sodium phosphates...... 149 STRAVIX...... 115 SYNJARDY XR...... 44 sodium polystyrene sulfonate...... 154 STRENSIQ...... 120 SYNRIBO...... 71 SODIUM SULFACETAMIDE- streptomycin sulfate...... 19 SYNTHROID...... 184 BAKUCHIOL...... 109 STRIBILD...... 83 SYNVISC...... 163 sodium tetradecyl sulfate...... 154 STRIVERDI RESPIMAT...... 32 SYNVISC ONE...... 163 SOLESTA...... 152 STROMECTOL...... 28 SYRINGE AVITENE...... 139 solifenacin succinate...... 187 STRONTIUM CHLORIDE SR-89...... 71 TABLOID...... 63 SOLIQUA...... 44 SUBLOCADE...... 27 TABRECTA...... 68 SOLIRIS...... 133 subvenite...... 37 TACHOSIL...... 139 SOLOSEC...... 19 subvenite starter kit-blue...... 37 TACLONEX...... 116 SOLTAMOX...... 62 subvenite starter kit-green...... 37 tacrolimus...... 113, 153 SOLU-CORTEF...... 103 subvenite starter kit-orange...... 38 tadalafil...... 93, 94 SOLU-MEDROL...... 103 SUCCINYLCHOLINE CHLORIDE... 164 tadalafil (pah)...... 93 SOMA...... 162 SUCRAID...... 116 TAFINLAR...... 66 SOMATULINE DEPOT...... 123 sucralfate...... 186 TAGRISSO...... 66 SOMAVERT...... 119 SUFENTANIL CITRATE...... 26 TAKHZYRO...... 134 SOOLANTRA...... 114 SULAR...... 91 TALICIA...... 187 SORBITOL...... 130 sulconazole nitrate...... 112 TALL RAGWEED...... 18 SORBITOL-MANNITOL...... 130 sulfacetamide sodium...... 172 TALZENNA...... 75 SORIATANE...... 108 sulfacetamide sodium (acne)...... 105 TAMIFLU...... 87 SORILUX...... 108 sulfacetamide sod-sulfur wash...... 105 tamoxifen citrate...... 62 sorine...... 89 sulfacetamide-prednisolone...... 171 tamsulosin hcl...... 129 SORREL/DOCK MIX...... 19 SULFADIAZINE...... 183 TAPAZOLE...... 184 SOTALOL HCL...... 89 sulfamethoxazole-trimethoprim...... 57 taperdex 12-day...... 103 sotalol hcl...... 89 SULFAMYLON...... 109 taperdex 6-day...... 103 sotalol hcl (af)...... 89 sulfasalazine...... 127 taperdex 7-day...... 103 SOTRADECOL...... 154 sulfatrim pediatric...... 57 TARCEVA...... 66, 67 sotradecol...... 154 SULFURATED LIME...... 114 TARGRETIN...... 115 SOTROVIMAB...... 174 sulindac...... 22 tarina 24 fe...... 99 SOTYLIZE...... 89 sumatriptan...... 147 tarina fe 1/20...... 99 spinosad...... 114 sumatriptan succinate...... 147 tarina fe 1/20 eq...... 99 SPINY PIGWEED...... 17 sumatriptan succinate refill...... 147 TARKA...... 53 SPIRIVA HANDIHALER...... 32 sumatriptan-naproxen sodium...... 147 TARON-C DHA...... 159 SPIRIVA RESPIMAT...... 32 SUNOSI...... 13 TARON-PREX...... 160 spironolactone...... 117 SUPARTZ FX...... 163 TAROXIA...... 105 spironolactone-hctz...... 116 SUPPRELIN LA...... 121 TASIGNA...... 66 SPORANOX...... 49 SUPRANE...... 129 TASMAR...... 78 SPORANOX PULSEPAK...... 49 SUPRAX...... 95, 96 TAURINE...... 166 SPRAVATO (56 MG DOSE)...... 40 SUPREP BOWEL PREP KIT...... 141 tavaborole...... 113 SPRAVATO (84 MG DOSE)...... 40 SURGICEL FIBRILLAR...... 139 TAVALISSE...... 135 sprintec 28...... 99 SURGICEL NU-KNIT...... 139 TAYTULLA...... 99 SPRITAM...... 37 SURVANTA...... 183 tazarotene...... 108 SPRYCEL...... 66 SUSTIVA...... 85 tazicef...... 96 sps...... 154 SUSTOL...... 47 TAZICEF...... 96 sronyx...... 99 SUTENT...... 68 TAZORAC...... 108 ssd...... 109 SWEET GUM...... 17 taztia xt...... 91 SSKI...... 104 SWEET VERNAL GRASS POLLEN... 17 TAZVERIK...... 68 STALEVO 100...... 78 syeda...... 99 TDVAX...... 185 STALEVO 125...... 78 SYLVANT...... 152 TECENTRIQ...... 65 STALEVO 150...... 78 SYMBICORT...... 31 TEFLARO...... 96 STALEVO 200...... 78 SYMBYAX...... 182 TEGADERM AG MESH...... 116 STALEVO 50...... 78 SYMDEKO...... 182 TEGSEDI...... 178 STALEVO 75...... 78 SYMJEPI...... 191 TEKTURNA HCT...... 56 STAMARIL...... 189 SYMLINPEN 120...... 42 telmisartan...... 55 211 telmisartan-amlodipine...... 54 TIGLUTIK...... 164 TREANDA...... 62 telmisartan-hctz...... 55 tilia fe...... 102 TRECATOR...... 61 temazepam...... 140 timolol maleate...... 89, 166 TRELEGY ELLIPTA...... 31 TEMIXYS...... 83 timolol maleate ocudose...... 166 TRELSTAR MIXJECT...... 74 TEMODAR...... 73 timolol maleate pf...... 167 TREMFYA...... 108 temozolomide...... 73 TIMOPTIC...... 167 treprostinil...... 93 temsirolimus...... 68 TIMOPTIC OCUDOSE...... 167 TRESIBA...... 43 tencon...... 23 TIMOPTIC-XE...... 167 TRESIBA FLEXTOUCH...... 43 TENIPOSIDE...... 74 TIMOTHY GRASS POLLEN tretinoin...... 76, 106 TENIVAC...... 185 ALLERGEN...... 18 tretinoin (emollient)...... 106 tenofovir disoproxil fumarate...... 86 tinidazole...... 57 tretinoin microsphere...... 106 TENORETIC 100...... 56 tiopronin...... 130 tretinoin microsphere pump...... 106 TENORETIC 50...... 56 TIROSINT...... 184 TRETTEN...... 132 TEPADINA...... 61 TIROSINT-SOL...... 184 TREXALL...... 63 TEPEZZA...... 121 TISSEEL...... 138 trezix...... 23 TEPMETKO...... 68 TISSUEBLUE...... 172 tri femynor...... 102 terazosin hcl...... 56 tis-u-sol...... 152 triamcinolone acetonide...... 111, 156 terbinafine hcl...... 49 TIVICAY...... 84 TRIAMCINOLONE- terbutaline sulfate...... 32 TIVICAY PD...... 84 MOXIFLOXACIN...... 171 terconazole...... 190 tizanidine hcl...... 162 TRI-AMINO...... 166 TERIPARATIDE (RECOMBINANT) 122 TNKASE...... 135 triamterene...... 117 terrell...... 129 TOBI PODHALER...... 19 triamterene-hctz...... 116, 117 TESSALON PERLES...... 104 TOBRADEX...... 171 triazolam...... 140 TESTOPEL...... 27 TOBRADEX ST...... 171 TRICARE...... 159 testosterone...... 27 tobramycin...... 19, 168 TRICARE PRENATAL DHA ONE.... 159 testosterone cypionate...... 27 tobramycin sulfate...... 19 TRICHOPHYTON...... 18 testosterone enanthate...... 27 tobramycin-dexamethasone...... 171 TRICHOPHYTON TETANUS-DIPHTHERIA TOXOIDS TOBREX...... 168 MENTAGROPHYTES...... 18 TD...... 185 tolbutamide...... 45 TRICOR...... 52 tetrabenazine...... 179 tolcapone...... 78 triderm...... 111 tetracaine hcl...... 170 TOLSURA...... 49 trientine hcl...... 151 tetracycline hcl...... 184 tolterodine tartrate...... 187 TRIESENCE...... 172 THALOMID...... 150 tolterodine tartrate er...... 187 tri-estarylla...... 102 THAM...... 148 tolvaptan...... 123 TRIFERIC...... 137 THE LIQUILIFT TRACE...... 150 topiramate...... 38 trifluoperazine hcl...... 81 THEO-24...... 33, 34 topiramate er...... 38 trifluridine...... 169 theophylline...... 34 toposar...... 74 trihexyphenidyl hcl...... 77 theophylline er...... 34 TOPOTECAN HCL...... 76 TRIKAFTA...... 182 THEOPHYLLINE IN D5W...... 34 topotecan hcl...... 76 tri-legest fe...... 102 thiamine hcl...... 192 toremifene citrate...... 62 tri-linyah...... 102 THIOLA...... 130 TORISEL...... 68 TRILIPIX...... 52 THIOLA EC...... 130 torsemide...... 117 tri-lo-estarylla...... 102 thioridazine hcl...... 81 TOTECT...... 72 tri-lo-marzia...... 102 thiotepa...... 61 TOUJEO MAX SOLOSTAR...... 43 tri-lo-mili...... 102 thiothixene...... 82 TOUJEO SOLOSTAR...... 43 tri-lo-sprintec...... 102 THRIVITE RX...... 159 tovet...... 111 TRI-LUMA...... 111 THROMBATE III...... 134 TOVIAZ...... 187 TRILURON...... 163 THROMBI-GEL 10...... 138 TPN ELECTROLYTES...... 149 trimethobenzamide hcl...... 48 THROMBI-GEL 100...... 138 TRACLEER...... 93 trimethoprim...... 57 THROMBI-GEL 40...... 138 TRALEMENT...... 150 tri-mili...... 102 THROMBIN-JMI...... 139 tramadol hcl...... 26 trimipramine maleate...... 41 THROMBIN-JMI EPISTAXIS...... 139 tramadol hcl er...... 26 TRINATAL RX 1...... 159 THROMBI-PAD...... 138 tramadol hcl er (biphasic)...... 26 trinate...... 159 THROMBOGEN...... 139 tramadol-acetaminophen...... 27 TRINAZ...... 159 THYMOGLOBULIN...... 152 trandolapril...... 54 TRINTELLIX...... 41 THYQUIDITY...... 184 trandolapril-verapamil hcl er...... 53 tri-nymyo...... 102 tiadylt er...... 91 tranexamic acid...... 138 TRIOSTAT...... 184 tiagabine hcl...... 38 TRANEXAMIC ACID-NACL...... 138 tri-previfem...... 102 TIAZAC...... 91 tranylcypromine sulfate...... 40 TRIPTODUR...... 121 TIBSOVO...... 73 TRAVASOL...... 165 TRISENOX...... 71 TICE BCG...... 71 travoprost (bak free)...... 173 tri-sprintec...... 102 TIGAN...... 48 TRAZIMERA...... 65 TRISTART DHA...... 160 TIGECYCLINE...... 183 trazodone hcl...... 41 TRISTART FREE...... 161 212 TRISTART ONE...... 161 ULTRAFOAM SPONGE VELCADE...... 69 tritocin...... 111 2X6.25X7CM...... 139 VELETRI...... 93 TRIUMEQ...... 83 ULTRAFOAM SPONGE velivet...... 102 TRIVEEN-DUO DHA...... 160 8X12.5X1CM...... 139 VELPHORO...... 128 TRI-VI-FLOR...... 157 ULTRAFOAM SPONGE VELTASSA...... 154 TRI-VI-FLORO...... 157 8X12.5X3CM...... 139 VEMLIDY...... 86 tri-vite/fluoride...... 157 ULTRAFOAM SPONGE 8X25X1CM139 VENCLEXTA...... 66 trivora (28)...... 102 ULTRAFOAM SPONGE VENCLEXTA STARTING PACK...... 66 tri-vylibra...... 102 8X6.25X1CM...... 139 VENEXA...... 156 tri-vylibra lo...... 102 UNASYN...... 177 VENIPUNCTURE PX1 TRIZIVIR...... 83 unithroid...... 184 PHLEBOTOMY...... 115 TRODELVY...... 76 UNITUXIN...... 65 venlafaxine hcl...... 41 TROGARZO...... 83 UPLIZNA...... 153 venlafaxine hcl er...... 41 TROKENDI XR...... 38 UPNEEQ...... 173 VENOFER...... 137 TROPHAMINE...... 165 UPTRAVI...... 93 VENOMIL HONEY BEE VENOM...... 18 tropicamide...... 167 UROCIT-K 10...... 129 VENOMIL MIXED VESPID VENOM.18 trospium chloride...... 187 UROCIT-K 15...... 129 VENOMIL WASP VENOM...... 18 trospium chloride er...... 187 UROCIT-K 5...... 130 VENOMIL WHITE FACED HORNET 18 TRULICITY...... 44 URSO 250...... 126 VENOMIL YELLOW HORNET TRUMENBA...... 188 URSO FORTE...... 126 VENOM...... 18 TRUSKIN...... 115 ursodiol...... 126 VENOMIL YELLOW JACKET TRUSOPT...... 169 UVADEX...... 71 VENOM...... 18 TRUVADA...... 83 VABOMERE...... 58 VENTAVIS...... 93 TRUXIMA...... 64 valacyclovir hcl...... 87 VENTOLIN HFA...... 32 TUKYSA...... 65 VALCHLOR...... 107 verapamil hcl...... 91 tulana...... 101 VALCYTE...... 86 verapamil hcl er...... 91 TURALIO...... 68 valganciclovir hcl...... 86 VEREGEN...... 106 TUSSICAPS...... 105 valproate sodium...... 39 VERELAN...... 91 TUXARIN ER...... 105 valproic acid...... 39 VERELAN PM...... 91 TUZISTRA XR...... 105 valrubicin...... 70 VERSACLOZ...... 80 TWINRIX...... 188 valsartan...... 55 VERZENIO...... 72 TWIRLA...... 99 valsartan-hydrochlorothiazide...... 55 vestura...... 99 TWYNSTA...... 54 VALSTAR...... 70 VFEND...... 49, 50 TYBLUME...... 99 VALTOCO 10 MG DOSE...... 35 VIBATIV...... 59 TYBOST...... 86 VALTOCO 15 MG DOSE...... 36 VIBERZI...... 127 tydemy...... 99 VALTOCO 20 MG DOSE...... 36 VICTOZA...... 44 TYGACIL...... 183 VALTOCO 5 MG DOSE...... 36 VIDAZA...... 63 TYKERB...... 68 VANCOCIN...... 58 vienva...... 99 TYPHIM VI...... 188 VANCOCIN HCL...... 58 vigabatrin...... 38 TYSABRI...... 180 VANCOMYCIN HCL...... 58, 59 vigadrone...... 38 TYVASO...... 93 vancomycin hcl...... 58, 59 VIGAMOX...... 168 TYVASO REFILL...... 93 VANCOMYCIN HCL IN DEXTROSE 58 VILTEPSO...... 164 TYVASO STARTER...... 93 VANCOMYCIN HCL IN NACL...... 58 VIMIZIM...... 122 UCERIS...... 27, 103 vandazole...... 190 VIMPAT...... 38 UDENYCA...... 137 VANIQA...... 113 VINATE DHA RF...... 159 UKONIQ...... 68 VANTAS...... 74 VINATE II...... 159 ULTANE...... 129 VAPRISOL...... 124 VINATE ONE...... 159 ULTICARE INSULIN SAFETY SYR 147 VAQTA...... 189 vinblastine sulfate...... 74 ULTILET INSULIN SYRINGE...... 147 vardenafil hcl...... 94 vincristine sulfate...... 74 ULTIVA...... 26 VARITHENA...... 154 vinorelbine tartrate...... 74 ULTOMIRIS...... 133 VARIVAX...... 190 VIOKACE...... 116 ULTRABAG/DIANEAL PD-2/1.5% VARIZIG...... 176 viorele...... 96 DEX...... 154 VARUBI (180 MG DOSE)...... 48 VIRACEPT...... 84 ULTRABAG/DIANEAL PD-2/2.5% VASCEPA...... 51 VIRAMUNE...... 85 DEX...... 154 VASERETIC...... 53 VIRAMUNE XR...... 85 ULTRABAG/DIANEAL PD- VASOSTRICT...... 124 VIRAZOLE...... 88 2/4.25%DEX...... 154 VAXCHORA...... 188 VIREAD...... 86 ULTRABAG/DIANEAL/1.5% VAXELIS...... 185 VIRT-C DHA...... 159 DEXTROSE...... 154 VAZCULEP...... 192 VIRT-NATE DHA...... 159 ULTRABAG/DIANEAL/2.5% VECAMYL...... 56 virt-phos 250 neutral...... 149 DEXTROSE...... 154 VECTIBIX...... 67 VIRT-PN DHA...... 161 ULTRABAG/DIANEAL/4.25% DEX.154 VECURONIUM BROMIDE...... 164 VIRT-PN PLUS...... 159 vecuronium bromide...... 164 VISCO-3...... 163 213 VISCOAT...... 172 WIDE-SEAL DIAPHRAGM 60...... 145 XYNTHA...... 132 VISIONBLUE...... 172 WIDE-SEAL DIAPHRAGM 65...... 145 XYNTHA SOLOFUSE...... 133 VISTARIL...... 29 WIDE-SEAL DIAPHRAGM 70...... 145 XYREM...... 178 VISTOGARD...... 47 WIDE-SEAL DIAPHRAGM 75...... 145 YASMIN 28...... 99 VISUDYNE...... 170 WIDE-SEAL DIAPHRAGM 80...... 145 YAZ...... 99 VITAFOL FE+...... 161 WIDE-SEAL DIAPHRAGM 85...... 145 YELLOW DOCK...... 18 VITAFOL GUMMIES...... 159 WIDE-SEAL DIAPHRAGM 90...... 145 YELLOW HORNET VENOM VITAFOL STRIPS...... 161 WIDE-SEAL DIAPHRAGM 95...... 145 PROTEIN...... 18 VITAFOL ULTRA...... 161 WILATE...... 132 YELLOW JACKET VENOM VITAFOL-NANO...... 159 WILZIN...... 150 PROTEIN...... 18 VITAFOL-OB...... 160 WINRHO SDF...... 176 YERVOY...... 65 VITAFOL-OB+DHA...... 161 WOUNDGELHA MATRIX...... 116 YF-VAX...... 190 VITAFOL-ONE...... 161 WP THYROID...... 185 YONDELIS...... 76 VITAMEDMD ONE wymzya fe...... 99 YONSA...... 62 RX/QUATREFOLIC...... 161 XADAGO...... 78 YOSPRALA...... 135 VITAMEDMD REDICHEW RX...... 161 XALKORI...... 63 YUPELRI...... 32 vitamin d (ergocalciferol)...... 192 XARACOLL...... 143 YUTIQ...... 172 vitamin k1...... 192 XARELTO...... 34 yuvafem...... 190 vitamins acd-fluoride...... 157 XARELTO STARTER PACK...... 34 zafemy...... 99 VITAPEARL...... 160 XATMEP...... 63 zafirlukast...... 33 VITATHELY WITH GINGER...... 160 XCOPRI...... 38 zaleplon...... 140 VITATRUE...... 161 XCOPRI (250 MG DAILY DOSE)...... 38 ZALTRAP...... 77 VITRAKVI...... 69 XCOPRI (350 MG DAILY DOSE)...... 38 ZALVIT...... 160 VITRANOL FE...... 156 XELJANZ...... 19 ZANAFLEX...... 162 VITRASE...... 151 XELJANZ XR...... 19 ZANOSAR...... 75 VIVA DHA...... 160 XELODA...... 63 zarah...... 99 VIVITROL...... 47 XELPROS...... 173 ZARXIO...... 137 VIZIMPRO...... 67 XEMBIFY...... 176 ZATEAN-PN DHA...... 161 volnea...... 96 XENAZINE...... 179 ZATEAN-PN PLUS...... 160 VONVENDI...... 132 XENICAL...... 13 ZCORT 7-DAY...... 103 VORAXAZE...... 72 XENLETA...... 59 zebutal...... 23 voriconazole...... 50 XEOMIN...... 164 ZEGALOGUE...... 42 VOSEVI...... 87 XEPI...... 106 ZEJULA...... 76 VOTRIENT...... 68 XERAVA...... 183 ZELAPAR...... 78 VP-PNV-DHA...... 160 XERESE...... 109 ZELBORAF...... 66 VPRIV...... 136 XERMELO...... 128 ZEMAIRA...... 182 VRAYLAR...... 79 XGEVA...... 123 ZEMDRI...... 19 VUSION...... 107 XIAFLEX...... 151 ZEMPLAR...... 120 vyfemla...... 99 XIFAXAN...... 57 zenatane...... 106 VYLEESI...... 179 XIGDUO XR...... 44 ZENPEP...... 116 vylibra...... 99 XIIDRA...... 167 zenzedi...... 12 VYNDAMAX...... 94 XOFIGO...... 71 ZEPOSIA...... 181 VYNDAQEL...... 94 XOFLUZA (40 MG DOSE)...... 87 ZEPOSIA 7-DAY STARTER PACK.. 181 VYONDYS 53...... 164 XOFLUZA (80 MG DOSE)...... 87 ZEPOSIA STARTER KIT...... 182 VYVANSE...... 12 XOLAIR...... 31 ZEPZELCA...... 62 VYXEOS...... 70 XOLEGEL...... 112 ZERBAXA...... 94 VYZULTA...... 173 XOPENEX HFA...... 32 ZESTORETIC...... 53 WAKIX...... 13 XOSPATA...... 68 ZEVALIN Y-90...... 70 warfarin sodium...... 34 XPOVIO (100 MG ONCE WEEKLY)..69 ZIAC...... 56 WASP VENOM PROTEIN...... 18 XPOVIO (40 MG ONCE WEEKLY)....69 ZIAGEN...... 85 water for irrigation, sterile...... 152 XPOVIO (40 MG TWICE WEEKLY).. 69 ziclopro...... 107 WEGOVY...... 13 XPOVIO (60 MG ONCE WEEKLY)....69 zidovudine...... 86 wera...... 99 XPOVIO (60 MG TWICE WEEKLY).. 69 ZIEXTENZO...... 137 WESTAB PLUS...... 160 XPOVIO (80 MG ONCE WEEKLY)....69 ZILRETTA...... 104 WESTERN JUNIPER...... 18 XPOVIO (80 MG TWICE WEEKLY).. 69 ZILXI...... 114 WESTGEL DHA...... 161 XTANDI...... 62 zinc chloride...... 150 WESTHROID...... 185 xulane...... 99 zinc sulfate...... 150 WHITE BIRCH...... 18 XULTOPHY...... 44 ZINGO...... 143 WHITE FACED HORNET VENOM.... 18 XURIDEN...... 120 ZINPLAVA...... 175 WHITE MULBERRY...... 18 XYLOCAINE...... 143 ZIOPTAN...... 173 WHITE OAK...... 18 XYLOCAINE/EPINEPHRINE...... 142 ziprasidone hcl...... 79 WHITE PINE...... 18 XYLOCAINE-MPF...... 143 ziprasidone mesylate...... 79 WHITE-FACED HORNET VENOM....18 XYLOCAINE-MPF/EPINEPHRINE.. 142 ZIRABEV...... 77 214 ZIRGAN...... 169 ZITHROMAX...... 144 ZITHROMAX TRI-PAK...... 144 ZITHROMAX Z-PAK...... 144 ZOFRAN...... 47 ZOKINVY...... 152 ZOLADEX...... 74 zoledronic acid...... 118 ZOLEDRONIC ACID...... 118 ZOLINZA...... 67 zolmitriptan...... 148 zolpidem tartrate...... 141 zolpidem tartrate er...... 141 ZOLPIMIST...... 141 zonisamide...... 38 ZONTIVITY...... 135 ZORBTIVE...... 120 ZORTRESS...... 153 ZOSYN...... 177 zovia 1/35 (28)...... 99 zovia 1/35e (28)...... 99 ZOVIRAX...... 87, 109 ZUBSOLV...... 27 ZULRESSO...... 39 zumandimine...... 99 ZUPLENZ...... 47 ZYCLARA...... 112 ZYCLARA PUMP...... 112 ZYDELIG...... 75 ZYKADIA...... 63 ZYLET...... 171 ZYLOPRIM...... 131 ZYMAXID...... 168 ZYNLONTA...... 64 ZYPREXA RELPREVV...... 82 ZYTIGA...... 62 ZYVANA...... 156 ZYVOX...... 59

215 Most plans include our home delivery program at no extra cost to you. Find out more by going online to anthem.com/ca or call 866-297-1013.

For information about your pharmacy benefit, log in at

anthem.com/ca.

You’ll find the most up-to-date drug list and details about your benefits. If you still have questions, we’re here. Just call the Member Services number on your ID card.

Speech and hearing impaired (TDD/TTY) users Call 1-800-221-6915, Monday through Friday, 8:30 a.m. to 5 p.m.ET.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Express Scripts, Inc. is a separate company that manages the pharmacy benefit services for members of our health plans. Rev. 11/18