Every Member Is Important

Iron County School District

2019 EMI Health Member Benefits Guide

Every Member is Important www.emihealth.com Administered by Educators Mutual Insurance Association EMI Health Customer Service 801-262-7475 or 1-800-662-5851 Self Funded Employee Medical Benefit Plan All services are subject to the EMI Health Maximum Allowable Charge. When using a Non-participating Provider, the Covered Person is responsible for all fees in excess of the Maximum Allowable Charge. Iron County School District #288 Care Plus September 01, 2019 - August 31, 2020 Participating Non-Participating Option 1 QHDHP Provider Option Provider Option GENERAL INFORMATION YOU PAY Benefit Accumulator Contract Year Dependent Age Limit 26 Out-of-Pocket Maximum (Per Single/Family Per Year) $3,500 / $6,500 $7,500 / $15,000 Medical Deductible (Per Single/Family Per Year). Please note ♦ $1,750 / $3,500 $3,500 / $7,000 Non-Preauthorization Patient Penalty Not Applicable 50% Reduction in Benefits Non-Preauthorization Provider Sanction 50% Reduction in Payment Not Applicable PRESCRIPTION DRUG BENEFITS (If brand is purchased when generic is YOU PAY available, member pays the copay plus the difference between the generic and the brand price) Participating Pharmacy (30 day supply) ♦Generic - 20% ♦Preferred - 30% ♦Non-Preferred - 50% Non-Participating Pharmacy Not Covered Mail Order (90 day supply) ♦Generic - $10 ♦Preferred - $30 ♦Non-Preferred - $60 PREVENTIVE SERVICES YOU PAY Routine Physical Exam (1 visit per Year) Covered 100% Not Covered Routine Gynecological Exam (1 visit per Year) Covered 100% Not Covered Family History Exam (1 visit per Year) Covered 100% Not Covered Routine Pap Smear & Mammogram (1 per Year) Covered 100% Not Covered Routine Well-Baby Exams Covered 100% Not Covered Covered Immunizations Covered 100% Not Covered Routine Vision Exam (1 visit per Year) Covered 100% Not Covered Routine Hearing Exam (1 visit per Year) Covered 100% Not Covered PHYSICIAN & PROFESSIONAL SERVICES YOU PAY Physician Office Visits (primary care) ♦$35 ♦50% Physician Office Visits (secondary care) ♦$45 ♦50% Physician Office Visits (after hours) ♦$45 ♦50% Physician Visits (Inpatient) ♦20% ♦50% Physician Visits (Outpatient) ♦20% ♦50% Major Diagnostic Test, CT Scan, MRI, NMR (office) ♦20% ♦50% Minor Diagnostic Test, Radiology, Lab (office) ♦20% ♦50% Minor Diagnostic Test, Radiology, Lab (Inpatient) ♦20% ♦50% Minor Diagnostic Test, Radiology, Lab (Outpatient) ♦20% ♦50% Injections (office) ♦20% ♦50% Surgery (office) ♦20% ♦50% Surgery (Inpatient) ♦20% ♦50% Surgery (Outpatient) ♦20% ♦50% Anesthesiology (office) ♦20% ♦50% Anesthesiology (Inpatient) ♦20% ♦50% Anesthesiology (Outpatient) ♦20% ♦50% Routine Prenatal & Delivery (Dependent maternity included) ♦20% ♦50% Home Health and Hospice Care (in lieu of Hospital) (for supplies, see Medical ♦20% ♦50% Supplies and Equipment) Rehabilitation Therapy (Outpatient physical, speech, occupational, cardiac, or ♦$35 ♦50% pulmonary - 20 visits per Year) Chiropractic Therapy (20 visits per Year) ♦$35 ♦50% Allergy Testing ♦20% ♦50%

1 Iron County School District #288 Care Plus September 01, 2019 - August 31, 2020 Participating Non-Participating Option 1 QHDHP Provider Option Provider Option Allergy Treatment/Serum ♦20% Not Covered HOSPITAL/FACILITY BENEFITS YOU PAY (Physician & Professional Services are not included in this section.) Medical/Surgical/Maternity/Intensive Care (semi-private room) ♦20% ♦50% Medical/Surgical/Maternity/Intensive Care (Inpatient Ancillary) ♦20% ♦50% Skilled Nursing Facility (30 days per Year) (Admission must be within 5 days of ♦20% ♦50% discharge from Hospital Confinement) Medical/Surgical Care (Outpatient) ♦20% ♦50% Emergency Room (ER) ♦20% ♦20% Major Diagnostic Test, CT Scan, MRI, NMR (Outpatient) ♦20% ♦50% Minor Diagnostic Test, X-ray, Lab (Inpatient) ♦20% ♦50% Minor Diagnostic Test, X-ray, Lab (Outpatient) ♦20% ♦50% Newborn ♦20% ♦50% InstaCare/Urgent Care Clinic ♦$45 ♦50% Eligible Preventive Services Covered 100% Not Covered REHABILITATION THERAPY BENEFIT YOU PAY Inpatient – physical, speech, occupational, cardiac, or pulmonary (40 days per ♦20% ♦50% person per Year) ACCIDENT AND LIFE THREATENING CONDITION YOU PAY Medical/Surgical – Physician/Facility/ER Covered as any other condition Ambulance Land/Air (Accident & Life-threatening) ♦20% Covered as a Participating Benefit to Orthodontic Injury Treatment ♦20% the Maximum Allowable Charge Dental Injury Treatment ♦20% TRANSPLANT BENEFIT YOU PAY Heart, Liver, Pancreas, Bone Marrow, Cornea, Lung, Kidney Covered as any other condition Not Covered MEDICAL SUPPLIES & EQUIPMENT YOU PAY Diabetic Testing Supplies (90 day supply) ♦$30 ♦50% Medical Supplies ♦20% ♦50% Medical Supplies (office) ♦20% ♦50% Durable Medical Equipment/Prosthetics/Orthotic Devices ♦20% ♦50% Orthotic Supplies (foot inserts & arch supports) ♦20% Not Covered Growth Hormone ♦20% ♦50% MENTAL HEALTH & DRUG/ALCOHOL TREATMENT YOU PAY Inpatient Services (non-residential) (21 days per Year) ♦20% ♦50% Residential Treatment Not Covered Not Covered Outpatient Services (20 days per Year) ♦20% ♦50% Physician Office Visits (20 visits per Year, 1 visit per day) ♦20% ♦50% Psychologist / LCSW / APRN / Psychiatrist ADDITIONAL BENEFITS YOU PAY Adoption Indemnity Benefit The Plan pays a maximum of $4,000 towards adoption expenses. TMJ Syndrome diagnosis & non-surgical treatment ♦20% Not Covered Orthognathic/Mandibular Osteotomy ♦20% Not Covered Total Parenteral Nutrition (TPN) ♦20% Not Covered Initial assessment and diagnosis of Primary Infertility ♦20% Not Covered Reduction Mammoplasty ♦20% Not Covered Autism Applied Behavior Analysis (Ages 2 thru 9, up to 600 hours per Year) ♦20% ♦50% Services designated ♦ are subject to first dollar Medical Deductible Services designated *, premiums, balance-billed charges, charges for services this Plan doesn’t cover, amounts in excess of benefit limits, and penalties for failure to obtain Preauthorization, do not accumulate toward your Out-of-pocket Maximum. Single/Family note: The Single Deductible and Out-of-Pocket Maximum amounts apply only to those Covered Persons with single coverage. Covered Persons with family (two-party or more) coverage, must meet the Family Deductible and Out-of-Pocket Maximum amounts, either individually or accumulatively as a family. PROVIDER NETWORK Utah EMI Health Care Plus Outside of Utah Cigna PPO

PLEASE NOTE: This is a summary only and does not guarantee benefits. All benefits are subject to the terms, limitations, and exclusions set forth in the Plan document and in the Summary Plan Description (SPD)/handbook of the Plan. Any discrepancies between this summary, the SPD/handbook, and the Plan document are resolved in favor of the Plan document. For more information, including Preauthorization, refer to the SPD/ handbook or the Plan document, or contact EMI Health Customer Service Department.

2 TeleMedicine Reach a doctor 24/7/365. 1-877-872-0370 Som e 70% of doctor visits can be handled over the phone, and 40% of urgent care visits can be m anaged using TeleMedicine. Save tim e and m oney while still getting the treatm ent you need through EMI Health TeleMed offered through WellVia.

W hen to Use TeleMed WellVia doctors diagnose acute, non-em ergent m edical conditions and prescribe m edications when clinically appropriate.

Speak with a doctor anytim e and pay no consultation fee rather than paying the high costs associated with office visits, urgent care visits, and em ergency room visits.

Just call 1-877-872-0370.

Common Conditions Acid Reflux Ear Pain* Pink Eye Allerg ies Fever Rashes Asthm a Gout Sinus Conditions Bladder Infection Headache Sore Throat Bronchitis Hemorrhoids Stom ach Virus Cold & Flu High Blood Pressure Thyroid Conditions Constipation Joint Pain Urinary Tract Infections Coug h Nausea Yeast Infections

Common Medications Albuterol Flonase Lipitor Alleg ra Ibuprofen 800 m g Nasonex Asthm a Levaquin Many Others

*In accordance with telem edicine guidelines, ear infections are only diagnosed for patients that are 18 years of age or older. Dow n load t h e WellVia mobile app

3 Corporate (801)262-7475 Customer Service (800)662-5851 EMIHealth.com

DENTAL COVERAGE BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL DENTAL EXPENSES OUTLINE OF COVERAGE Read Your Policy Carefully-This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY! Group: Iron County School District (Plan #288) Plan: Premier PPO Underwritten & Administered by: Educators Mutual Insurance Association, a Utah Company Effective Date: 9/1/2019 Benefit Year: Contract Plan Type: Contributory / Fully Insured In-Network Out-of-Network Type 1 - Preventive 80% 80% up to TOA* Oral Exams, Cleanings, X-rays, Fluoride Type 2 - Basic 80% 80% up to TOA* Fillings Type 3 - Major 50% 50% up to TOA* Crowns, Bridges, Prosthodontics, Oral Surgery Type 4 - Orthodontics 50% after $250 deductible 50% after $250 deductible Dependent children ages 7 through 18 Adults Discount Only (Up to 25%) No Coverage Orthodontic Discount (All Members) Up to 25% Discount No Discount Endodontics Type 2 - Basic Type 2 - Basic Periodontics Type 2 - Basic Type 2 - Basic Sealants Type 3 - Major Type 3 - Major Space Maintainers Type 2 - Basic Type 2 - Basic Waiting periods Type 2 - Basic None Type 3 - Major Failure to enroll at first opportunity results in a 12 month waiting period Type 4 - Orthodontics Deductible Per Person $0.00 $0.00 Family Max $0.00 $0.00 Deductible Applies To N / A N / A Annual Maximum Per Person $1,500.00 Orthodontic Lifetime Maximum $1,000.00 Network / Reimbursement Schedule Premier Premier Provisions / Limitations / Exclusions Exams (including Periodontal), Cleanings and Fluoride 2 per year Fluoride Any Age Sealants Dependent Children Only Space Maintainers Up to age 17 Bitewing X-Rays 2 per year Periapical X-Rays Covered in Type 1 Panoramic X-Ray 1 every 3 years Impacted Teeth Covered in Type 2 - Basic Anesthesia- (Age 8 and over for the extraction of impacted teeth only) Covered in Type 3 - Major** Anesthesia - (For children age 7 and under, once per year) Covered in Type 3 - Major** Implants / Implant Abutments Covered in Type 3 (Limited to $225) Crowns, Pontics, Abutments, Onlays and Dentures 1 every 5 years per tooth Fillings on the same surface 1 every 18 months * All Services are subject to EMI Health Table of Allowances (TOA). When using a Non-participating Provider, the insured is responsible for all fees in excess of the Table of Allowances (TOA). ** Anesthesia is not subject to waiting periods. EMIA.D.PREM.OUT.B

4 Your ID Card (front) It is important that you present your ID card each time you receive services. Your EMI Health ID card contains a lot of useful inform ation for you and your provider.

Card Fron t

B F

C G H D I E J K

A EMI Health is your insurance F Your unique m em ber num ber is J If you have vision coverage with EMI carrier. required in order to verify Health, the nam e of your vision plan coverage, determ ine benefits, and will appear here. This also indicates pay claim s for you and your your vision participating provider B The em ployee's nam e is listed on dependents. network. To verify a provider's status, the ID card. Covered dependents visit em ihealth.com or call are not listed. 800-662-5851. G Express Scripts is your Pharm acy Benefits Manager. If this section is not on your card, you C This is the nam e of your m edical do not have vision coverage through plan and also indicates your EMI Health. participating provider network. To These are your basic pharm acy verify a provider's status, visit H copays and coinsurance am ounts. This is the phone num ber to call for a em ihealth.com or call K Telem ed consultation with a WellVia 800-662-5851. physician. EMI Telem ed can elim inate I If you have dental coverage with the need for office visits for m any D These are your basic copay, EMI Health, the nam e of your common conditions. coinsurance, and deductible dental plan will appear here. This am ounts when you visit a also indicates your dental If this section is not on your card, you participating provider. For m ore participating provider network. To do not have TeleMed services through detailed benefits inform ation, see verify a provider's status, visit EMI Health. your Sum m ary of Benefits and em ihealth.com or call 800-662-5851. member handbook. If this section is not on your card, you do not have dental coverage through EMI Health. E This is your m edical participating provider network when traveling outside of Utah. To verify a provider's status, visit em ihealth.com or call 800-662-5851.

5 Your ID Card (back)

Card Back

C E

A This is the claim s subm ission C These are your participating E These are your participating address for Utah m edical claim s provider m edical networks for Utah provider dental networks outside of and all dental claim s. In m ost and nationally. To verify a provider's Utah. To verify a provider's status, cases, your provider will subm it status, visit em ihealth.com or call visit em ihealth.com or call claim s directly to EMI Health. 800-662-5851. 800-662-5851.

D This is the telephone num ber to call If this section is not on your card, B This is the telephone num ber to for preauthorizations. you do not have dental coverage call for custom er service inquiries. through EMI Health.

6 Reading Your EOB

7 Reading Your EOB

8 Preventive Care

Preventive care detects potential problems early when they are easier to treat. The Affordable Care Act (ACA) provides for preventive services rated A or B to be covered 100 percent when received by participating providers.

Preventive services are those provided when no sym ptom s or diagnosed m edical conditions exist. For services to be covered as preventive, your doctor m ust bill claim s with preventive codes. If a preventive service identifies a condition that needs further testing or treatm ent, regular copaym ents, coinsurance, or deductibles m ay apply. Here are some some preventive services covered with no patient cost: - Routine physical exam - Routine gynecological exam - Screening colonoscopy - Routine vision exam - Routine Pap sm ear - FDA-approved contraception - Routine hearing exam - Screening m am m ogram

Im m unizations recom m ended by the Advisory Com m ittee on Im m unizations Practices of the Center for Disease Controls and Prevention (CDC) are covered 100 percent if received from a participating provider. As of Novem ber 2017, those recom m endations are as follows: Children VACCINE Birth 1 Mo 2 Mo 4 Mo 6 Mo 12 Mo 15 Mo 18 Mo 19-23 Mo 2-3 Yrs 4-6 Yrs 7-10 Yrs 11-12 Yrs 13-18 Yrs

Hepatitis B HepB HepB HepB HepB Catch Up Rotavirus RV RV RV DTaP DTaP Catch Diphtheria, Tetanus, Pertussis DTaP DTaP DTaP DTaP DTaP DTaP Catch Up Up Haem ophilus Influenzae Type b Hib Hib Hib Hib Inactivated Poliovirus IPV IPV IPV IPV Poliovirus Catch Up Measles, Mum ps, Rubella MMR MMR MMR Catch Up Varicella Varicella Varicella Varicella Catch Up Pneum ococcal PCV PCV PCV PCV Influenza Influenza (Yearly) Hepatitis A HepA (2 Doses) HepA Catch Up Meningococcal MenACW Y MenACW Y HPV Hum an Papillom avirus HPV Catch Up Adults 27-49 VACCINE 19-26 Yrs 50-59 Yrs 60-64 Yrs ? 65 Yrs Yrs Diphtheria, Tetanus, Pertussis (Td/Tdap One dose of Tdap; then boost with Td every 10 years Influenza One dose annually Pneum ococcal 1 or 2 doses 1 dose Shing rix® vaccine: 2-dose im m unization after 50 Zoster (Shing les)* Zostavax® vaccine: 1-dose after age 60 IF NOT RECEIVED AS A CHILD Measles Mum ps, Rubella MMR Hum an Papillom avirus HPV Varicella Varicella

*Only one of the shingles vaccines are necessary. EMI Health covers both old and new vaccines. If you have already had the shingles vaccine, you do not need the new vaccine and a second, unnecessary vaccine is not covered by EMI Health.

Find the full list of preventive services at http://bit.ly/USPSTF_AB. The list is subject to chang e based on federal guidelines. This inform ation does not apply to grandfathered plans. Please see your sum m ary of benefits and m em ber handbook on the details of your specific plan. 9 Diabetes Managem ent

Your medical plan covers diabetic supplies under your major medical benefit instead of the prescription drug benefit. Here are som e com m on coverages. Contact custom er service for the specifics of your plan.

MAJOR MEDICAL BENEFITS? Most EMI Health plans cover the following supplies under the Medical Supplies & Equipm ent benefit. Refer to the Diabetic Testing Supplies (90-day supply) line item of your benefit sum m ary for your m em ber cost-share. -Blood sugar (glucose) test strips -Lancet devices and lancets EMI Health has contracted providers for diabetes testing supplies. Testing supplies obtained through any other provider (including pharm acies) m ay not be covered; or if covered, will be subject to your Non-Participating Provider benefit option. The participating suppliers are -Edgepark / Cardinal - 877-215-2568 -Byram Healthcare - 800-775-4372 -JQ Medical Supply - 801-942-8582 The following item s are covered under the Durable m edical Equipm ent benefit. See your benefit sum m ary for your m em ber cost-share. -Therapeutic shoes or inserts -Insulin pum p and insulin pum p supplies, subject to preauthorization criteria and plan review -Continuous Glucose Monitoring System s (CGMS) and sensors, subject to preauthorization criteria and plan review

PRESCRIPTION DRUG (PHARMACY) BENEFITS?

- Diabetic testing supplies are covered under the pharmacy benefit. The only brand in the 2019 form ulary is One Touch. All other brands are excluded from coverage.

- Insulin is covered under the pharmacy benefit. You m ay receive up to a 30-day supply (m axim um of two vials) per retail copaym ent or up to a 90-day supply (m axim um of six vials) per m ail-order copaym ent. If necessary, additional vials m ay be purchased by paying an additional copaym ent.

- Prescription medicines for diabetes are covered under the pharmacy benefit. This includes Glucagon, GLP1 agents (i.e., Byetta, Bydureon, Tradjenta) and oral agents for Type 2 diabetes (i.e., Glucophage, Avandia, Am aryl). Blood sugar testing m onitors, glucose control solutions, and weight loss m edications are NOT covered under the m edical or pharm acy benefit. *Please refer to the Prescription Drug section of your benefit sum m ary for your m em ber cost-share.

10 My EMI Health Account Setup

All your benefit answers. One website. Find everything related to your benefits from general plan docum ents to detailed claim s inform ation.

Get Started 1. Go to emihealth.com. 2. Click Login and select My EMI Health. 3. Select Register and choose Mem ber as the type of account . 4. Enter the data to identify yourself and click Continue.

* You will need your Mem ber ID found on your EMI Health ID card. Also, for your security, your passw ord m ust be at least six characters and include a special character, e.g., !, @, # , $, etc.

W hat You Can Do

View benefit descriptions

Check claim s status

Order ID cards

View EOBs

Access the Sm art Cost Calculator

Review eligibility/enrollm ent status

Manage prescription benefits

11 My EMI Health

As a m ember of EMI Health, you have access to the following online tools and services.

My EMI Health My EMI Healt h

Manage your medical, dental, vision, and disability plans:

- View benefit descriptions - Review eligibility/enrollm ent status - Check claim s status - View Explanation of Benefits (EOBs) im p ort an t - Order ID cards Your Explanation of Benefits (EOB) can only be found online through Express Scripts your My EMI Health account.

It is im portant to note that paper Manage your prescription benefits: copies of your EOB are not m ailed. - Refill prescriptions TM - Check order status - Price m edications - Locate participating pharm acies

SMART COST CALCULATOR Transparency Tool

Com pare and Save:

- Com pare costs of different facilities - See the prices of seeing specific providers - Find the cost of a certain procedure

TeleMed

Care is just a phone call away:

- $0 physician consultations - 24/7/365 access to physician care - Convenience of care from your own hom e

12 Find Participating Providers

Find in-network providers. Save Money.

Utah Provider Search

To search for m edical providers in Utah or dental and vision providers both in Utah and nationally, g o to emihealth.com and click on Provider Search along the upper part of the hom e page.

1. Select the network type: Med ical, Den t al or Vision and choose your plan (found on your ID Card). Medical Plan: Care Plus Dental Plans: Prem ier, Advantage, Value, Sum m it, or Sum m it Plus Vision Plans: Opticare, VSP Choice, or VSP Choice Plus 2. Now, enter your provider's details and click Search.

That's all there is to it!

You will see a list of participating providers along with their contact inform ation, address, and the ability to m ap the location of their offices. You can also download the results as a PDF to print.

National Cigna PPO Medical Provider Search To search for m edical providers outside Utah, go to emihealth.com and click on Provider Search along the upper part of the hom e page.

1. Select m edical as the network type and choose Care Plu s as your plan. Select the state in which you'd like to search. When you select a state other than Utah, you will be asked to select a logo. Choose the Cigna logo. 2. Once on the Cigna website, choose the type of provider (Doctor, Hospital, Pharm acy, or Facility). 3. Use your current location or input the city/state in which you'd like to search. 4. Under Select a Plan , choose PPO, Ch oice Fu n d PPO 5. Under Looking For, choose a specialty or facility type. 6. Now, enter your provider's details and click Search .

Dow nload The Mobile App To Search On The Go. In addition to being another convenient way to search for providers, the EMI Health m obile app allows you to do even m ore.

View your ID Card. View your plan grids

Update your profile View your EOBs and search by inform ation like em ail address, person, service, date, and m ore. password, or security questions.

Access current and past issues of the Hope Health newsletter.

Please Note: Not all plans have participating provider benefits outside of your state of residence. To confirm your benefits, or if you have any questions, please contact the EMI Health custom er service team toll free at 800.662.5851.

13 Mobile App

Your benefits. Anytime. Anywhere.

ID Card Access your ID Card from anywhere at any tim e.

Provider Search EOBs Find in-network providers and facilities. View your EOBs and search by person, service, date, and m ore. Plan In form at ion Customer Service View and download your plan Need to talk to a person? grids so you always know the No problem . benefits you have. Call us from the app. Log in/Register Other Features Download the app and log in using your My EMI Health - Access current and past usernam e and password. issues of the Hope Health newsletter. If you haven't registered your account, you can do so in the - Update your profile app or online at inform ation like em ail em ihealth.com . address, passw ord, or security questions.

Scan this QR code with your phone to download.

14 Integrated Care Managem ent

One connection for all your clinical needs. EMI Health has partnered with Magellan Rx Managem ent to support our m em bers through their wellness journey. We offer a robust Health & Wellness Program . This program works to ensure that m em bers with com plex m edical needs receive care in a cost effective and tim ely m anner.

How do we do this? Nurses, pharm acists, m ental health social workers, and wellness coaches work together within the sam e team to m ake sure the care, advice, and assistance you need is consistent. This elim inates wasted tim e and decreases costs to both you and your plan.

Personal Care Think of an integrated team in this way: you won't have to repeat your story to m ultiple professionals across different disciplines because the Magellan Rx Managem ent team sits together and works together so they are m ore aware of you and your needs.

Keep healthy and enjoy lowers costs through a healthy lifestyle and a resource to help you take advantage of your benefits because when you are healthy, everyone is happy.

15 Sm art Cost Calculator

Know your costs before you go. EMI Health's Sm art Cost Calculator allows you to com pare different procedures, providers, and hospitals to see estim ated costs based on your search criteria.

Procedure Costs See data from local hospitals and providers near you or search in a specified area. See how m uch specific procedures typically cost and your out of pocket expenses.

Provider Reviews Search for providers and see the reviews their patients left. This tool helps ensure you are visiting a provider that will m eet your needs.

Facility Locations and Costs Get hospital and clinic directions, patient reviews, and overall hospital ratings so you visit the proper facility that will take care of your com plete healthcare situation.

Here's how to use it 1. Log in to your My EMI Health account.

2. Click the Smart Cost Calculator button .

3. Search for services Enter the doctor, hospital, or procedure you're looking for.

4. Compare costs Select the doctor, hospital, or procedure to see reviews, com pare costs, and get m ore details on what you need.

*Change Healthcare is a cost transparency solution the provides pricing inform ation on som e m edical services and prescriptions. This inform ation is intended to be an estim ate of the total am ount you m ay expect to pay for the prescription or service, and is not guaranteed at the point of care.

16 Pharm acy, Mail Order & Retail 90

Get a 90-day supply of maintenance medications at three participating pharmacies: Costco, Sam 's Club, and Walm art .

How Does the 90-Day Retail Fill Work?

1.Ask your doctor for a prescription for a 90-day supply (plus refills, as applicable). 2.Take your prescription to a Costco, Sam ?s Club, or Walm art pharm acy. 3.You will pay three tim es the 30-day retail copaym ent for your plan. The exact am ount you pay will depend on whether your m edication is generic, preferred, or non-preferred brand. Please refer to your Sum m ary of Benefits for the details of your plan.

How Does Mail Order Work?

1. Ask your doctor for a prescription for a 90-day supply (plus refills, as applicable). 2. If you need to start taking the m edication right away, ask for another prescription for up to a 30-day supply to be refilled at a retail pharm acy. 3. Send the 90-day prescription, along with the com pleted m ail-order form (which can be downloaded from www.em ihealth.com ) and the appropriate copaym ent, to Express Scripts at the address on the form . (You m ay also ask your doctor to fax your order to Express Scripts) 4. You will pay the Mail-order Copaym ent am ount indicated on your Sum m ary of Benefits. The exact am ount will depend on whether your m edication is generic, preferred, or non-preferred brand. 5. Express Scripts will process the order and return it via U.S. Mail or UPS, along with instructions for future refills. Allow up to 14 days for delivery from the tim e you m ail the prescription.

Not e Plans enrolled in the Sm art 90 m aintenance program are not eligible for this benefit.

17 Opioid Disposal

EMI Health takes the opioid crisis very seriously, which is why it is im portant to properly dispose of opioid m edications. Im proper disposal of opioid m edications can lead to addiction and suffering by others and harm ful im pacts on the environm ent.

DO: Dispose of leftover or expired op ioid s. Keeping leftover or expired opioids around is dangerous to you and others who m ay com e across these m edications.

Use a local Rx drop box. These perm anent drop sites are free and can be found at participating pharm acies and law enforcem ent agencies throughout your state.

Find the nearest location using the DEA's website here: deadiverstion.usdoj.gov/pubdispsearch/

DON'T: Give leftover opioids to friends or family. Most people addicted to opioids get them from a fam ily m em ber. Do not be the source of their addiction.

Throw your medications in the trash. People can still accidentally or intentionally com e across these m edications through your garbage.

Flush your medications down the sink or toilet. Flushing opioids down the sink or toilet can harm both the groundwater and local wildlife. By the numbers You CAN make a difference. 116 Am ericans Help put a STOP to the opioid epidemic. die every day from opioid overdose. 4 0% of all opioid overdose deaths involve a prescription opioid.

11.5 Million people Sources: m isused prescription opioids in 2016. 1. CDC/NCHS, National Vital Statistics System s, Mortality. CDC Wonder, Atlanta, GA: US Departm ent of Health and Hum an Services, CDC;2017. Https://wonder.cdc.gov. 2. http://useonlyasdirected.org/throw-out/

18 MPIONS The following is a list of the most commonly prescribed drugs. It represents an EXPRESS SCRIPTS' ��: f·-jj BETTER" EM1f(HEALTH" abbreviated version of the drug list (formulary) that is at the core of your prescription plan. The list is not all-inclusive and does not guarantee coverage. In addition to using this list, you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. 2019 Express Scripts PLEASE NOTE: Brand-name drugs may move to nonformulary status if a generic National Preferred Formulary version becomes available during the year. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered For EMI Health and the copayments for your prescription plan. For specific questions about your coverage, please call the phone number printed on your member ID card.

KEY BD AUTOSHIELD clonidine enalapril GENOTROPIN [INJ] [INJ] - Injectable Drug DUO NEEDLES clopidogrel ENBREL [INJ] GENVOYA Brand-name drugs are listed BD ULTRAFINE clotrimazole/betamethasone enoxaparin [INJ] GILENYA in CAPITALletters. INSULIN SYRINGES di propionate ENSTILAR GILOTRIF Generic drugs are listed BD ULTRAFINE PEN NEEDLES COLCRYS ENTRESTO glimepiride in lower case letters. BELBUCA COMBIGAN EPCLUSA glipizide benazepril COMBIPATCH EPIDIOLEX glipizide ext-release A benzonatate COMBIVENT RESPIMAT EPIDUO FORTE GLUCAGEN [INJ] ------BEPREVE COPAXONE 40 MG [INJ] epinephrine autoinjector GLUCAGON [INJ] ABILIFY MAINTENA [INJ] BETASERON [INJ] CORLANOR (by Mylan) [INJ] glyburide ABSORICA BETHKIS COSENTYX [INJ] EPIPEN, EPIPEN JR [INJ] GLYXAMBI ACANYA BEVESPI AEROSPHERE CREON ergocalciferol GONAL-F, GONAL-F RFF, acetaminophen/codeine BIKTARVY CRINONE ERIVEDGE GONAL-F RFF ACTEMRA [INJ] bisoprolol/hctz cyanocobalamin [INJ] ERLEADA REDI-JECT [INJ] acyclovir blisovi fe cyclobenzaprine ervthromycin eye ointment GRALISE ADEM PAS BOSULIF ESBRIET GRANIX [INJ] ADVAIR DISKUS BREO ELLIPTA D escitalopram GRASTEK ADVAIR HFA BRILINTA ------esomeprazole magnesium guanfacine ext-release AFSTYLA [INJ] budesonide nebulization DALI RESP delayed-release AIMOVIG [INJ] suspension DARAPRIM estradiol H AKYNZEO bupropion DAYTRANA estradiol patches albuterol nebulization bupropion ext-release DESCOVY estradiol/norethindrone HARVONI solution buspirone desloratadine acetate HELIXATE FS [INJ] alendronate butalbital/aceta mi nophen/ desvenlafaxine succinate ESTRING HUMALOG [INJ] allopurinol caffeine ext-release eszopiclone HUMIRA [INJ] ALPHAGAN P 0.1 % BYDUREON [INJ] dexamethasone EUFLEXXA [INJ] HUMULIN [INJ] alprazolam BYETTA [INJ] DEXCOM RECEIVER, SENSOR, ezetimibe hydralazine ALREX SYSTOLIC TRANSMITTER ezetimibe/simvastatin hydrochloroth iazide amiodarone BYVALSON dexmethylphenidate hydrocodone/aceta minophen AMITIZA ext-release F hydrocodone/ amitriptyline C dextroamphetamine/ ------chlorpheniramine polistirex amlodipine ------amphetamine famotidine ext-release am lodipine/benazepril CABOMETYX dextroamphetamine/ FARXIGA hydrocortisone topical am lodipine/valsartan CANASA amphetamine ext-release fenofibrate hydromorphone amoxicillin CARAC diazepam fenofibrate micronized hydroxychloroq uine amoxicillin/potassium CARAFATE SUSPENSION diclofenac sodium fenofibric acid hydroxyzine hcl clavulanate carbidopa/levodopa delayed-release delayed-release hydroxyzine pamoate a nastrozole carvedilol dicyclomine fentanyl patches HYSINGLA ER ANDRODERM cefdinir digoxin FETZIMA ANORO ELLIPTA cefuroxime axetil diltiazem ext-release FINACEA FOAM I APRISO celecoxib diphenoxylate/atropine finasteride ARCAPTA NEOHALER cephalexin divalproex delayed-release FIRAZYR [INJ] ibandronate ARIKAYCE CERDELGA divalproex ext-release FLECTOR IBRANCE aripiprazole CEREZYME [INJ] DIVIGEL FLOVENT DISKUS ibuprofen ARISTADA [INJ] CETROTIDE [INJ] donepezil FLOVENT HFA ILEVRO ARMONAIR RESPICLICK CHANTIX doxazosin fluconazole INCRUSE ELLIPTA ARNUITY ELLIPTA chlorhexidine gluconate doxycycline hyclate fluocinonide indomethacin ASMANEX HFA chlorthalidone doxycycline monohydrate fluoxetine INLYTA ASMANEX TWISTHALER CIMDUO DUAVEE fluticasone nasal spray INVOKAMET atenolol CIPRODEX DULERA folic acid INVOKAMET XR atenolol/chlorthalidone ciprofloxacin duloxetine delayed-release FORTEO [INJ] INVOKANA atomoxetine citalopram DUPIXENT [INJ] FRAGMIN [INJ] irbesartan atorvastatin clarithromycin DYMISTA FREESTYLE LIBRE READER, IRESSA AVONEX [INJ] CLENPIQ SENSOR isosorbide mononitrate AZASITE clindamycin hcl f furosemide ext -release azelastine nasal spray clindamycin phosphate ------FYCOMPA azithromycin topical EDARBI J clindamycin phosphate/ EDARBYCLOR G B benzoyl peroxide ELIDEL JANUMET, JANUMET XR clobetasol propionate ELIQUIS gabapentin JANUVIA baclofen clomiphene citrate EMGALITY [INJ] GELNIQUE JARDIANCE BARACLUDE SOLUTION clonazepam EMVERM gemfibrozil JENTADUETO (continued) Go to express-scripts.com/2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com. © 2019 Express Scripts. All Rights Reseried. 19 2477, 2478 NP-A All trademarks are the propertyof their respective owners. PRMTEMIANP-19 (01/01/19) JENTADUETO XR MONOVISC [INJ] p ropinirole TRESIBA [INJJ JIVI [INJJ montelukast ------rosuvastatin triamcinolone topical junel morphine sulfate ext-release pantoprazole delayed-release RUCONEST [INJ] triamterene/hctz junel fe MOVANTIK paroxetine hcl tri-lo-marzia MOXEZA PAZEO s trinessa K moxifloxacin eye solution penicillin v potassium ------TRIPTODUR [INJ] ------mupirocin PENTASA SANCUSO tri-spri ntec ketoconazole topical MUSE PERFOROMIST SAVELLA TRULANCE ketorolac MYDAYIS PHOSLYRA SEGLUROMET TRULICITY [INJ] KITABIS PAK MYRBETRIQ PICATO SEREVENT DISKUS TUDORZA PRESSAIR KOGENATE FS [INJ] pioglitazone sertraline TYMLOS [INJJ KOVALTRY [INJ] N PLEGRIDY [INJ] SIMPON! 100 MG (for KYLEENA ------polymyxin/trimethoprim ulcerative colitis only) [INJ] U nabumetone eye solution simvastatin ------L NAMZARIC POMALYST SKYLA UCERIS FOAM ------naproxen, naproxen sodium potassium chloride SOLIQUA [INJ] ULORIC labetalol neomycin/polymyxin/ ext-release SOLODYN UPTRAVI lamotrigine hydrocortisone ear solution PRALUENT [INJ] SOMATULINE DEPOT [INJ] lansoprazole delayed-release NEXIUM PACKETS pramipexole SOOLANTRA V LANTUS [INJ] niacin ext-release pravastatin SPIRIVA RESPIMAT latanoprost eye solution nifedipine ext-release prednisolone acetate spironolactone valacyclovir LATUDA nitrofurantoin macrocrystal eye suspension sprintec valsartan LETAIRIS NITYR prednisolone sodium SPRYCEL valsartan/hctz LEVEMIR [INJ] NORDITROPIN [INJ] phosphate STEGLATRO VARUBI levetiracetam nortriptyline prednisone STELARA SC [INJ] VASCEPA levoceti rizine NOVAREL [INJ] PREMARIN CREAM STIOLTO RESPIMAT VELPHORO levofloxacin NOVOEIGHT [INJ] PREMARIN TABLETS STRENSIQ [INJ] VELTASSA levothyroxine sodium NOVOFINE AUTOSHIELD PREMPHASE STRIVERDI RESPIMAT venlafaxine lidocaine patches NEEDLES PREMPRO SUBOXONE SL FILM venlafaxine ext-release LINZESS NOVOFINE NEEDLES PREPOPIK sulfamethoxazole/ VENTOLIN HFA liothyronine NOVOTWIST NEEDLES PROAIR HFA trimethoprim verapamil ext-release LIPOFEN NUCALA [INJ] PROAIR RESPICLICK sumatriptan VESICARE lisinopril NUCYNTA, NUCYNTA ER PROCRIT [INJ] SUPREP VIBERZI lisinopril/hctz NUEDEXTA progesterone micronized SUTENT VIIBRYD LIVALO NUVARING PROLASTIN C [INJ] SYMBICORT VIMPAT LO LOESTRIN FE NUWIQ [INJ] PROLENSA SYMFI VIOKACE LOKELMA nystatin promethazine SYMFI LO VOSEVI lorazepam nystatin topical promethazine/ SYMLINPEN [INJ] VYVANSE losartan dextromethorphan SYMPROIC losartan/hctz 0 propranolol SYNJARDY, SYNJARDY XR LOTEMAX ------propranolol ext-release w lovastatin ODACTRA PULMICORT FLEXHALER T warfarin LUMI GAN OFEV PYLERA LYRICA ofloxacin TACLONEX SUSPENSION X olanzapine Q tacrolimus topical M olmesartan �------tamoxifen XALKORI ------olmesartan/hctz QBREXZA tamsulosin ext-release XARELTO meclizine olopatadine eye solution QNASL TARCEVA XELJANZ, XELJANZ XR medroxyprogesterone omega-3 acid ethyl esters QUDEXY XR TASIGNA XIFAXAN meloxicam omeprazole delayed-release quetiapine TAYTULLA XIGDUO XR MESTINON SYRUP ondansetron QUILLICHEW ER TAZORAC GEL XIIDRA metaxalone ondansetron orally QUILLIVANT XR TAZORAC 0.05% CREAM XOFLUZA metformin disintegrating tablets guinapril TECFIDERA XOLAIR [INJ] metformin ext-release ONETOUCH KITS/METERS; QVAR TEKTURNA, TEKTURNA HGT XTANDI methimazole ULTRA 2, ULTRAMINI, QVAR REDIHALER terazosin XULTOPHY [INJ] methocarbamol VERIO, VERIO FLEX, terconazole vaginal methotrexate VERIO IQ, VERIO SYNC R testosterone cypionate [INJJ y methylphenidate ONETOUCH TEST STRIPS; ------THALOMID methylphenidate ext-release ULTRA, VERIO rabeprazole delayed-release timolol maleate eye solution YONSA methylpredn isolone ONEXTON RAGWITEK tizanidine yuvafem metoclopramide OPSUMIT raloxifene TOBI PODHALER metoprolol succinate ORACEA ramipril TOBRADEX OINTMENT ext-release ORFADIN RANEXA TOBRADEX ST z metoprolol tartrate ORTHOVISC [INJ] ranitidine tobramycin eye solution ZARXIO [INJ] metronidazole oseltamivir RAPAFLO tobramycin/dexamethasone ZENPEP metronidazole topical OTEZLA RASUVO [INJ] eye suspension ZEPATIER metronidazole vaginal OTOVEL REBIF [INJ] topiramate zolpidem microgestin fe OTREXUP [INJ] RECTIV TOUJEO [INJ] zolpidem ext-release MINIVELLE OVIDREL [INJ] RELISTOR [INJ] TOVIAZ ZOMIG NASAL minocycline oxcarbazepine REMICADE [INJ] TRACLEER ZONTIVITY MIRENA oxybutynin ext-release RESTASIS TRADJENTA ZOVIRAX CREAM mirtazapine oxycodone RETACRIT [INJ] tramadol ZTLIDO MIRVASO oxycodone/acetami nophen REVLIMID TRAVATAN Z ZUBSOLV MITIGARE OXYCONTIN RHO PR ESSA trazodone ZYLET moderiba OZEMPIC [INJ] risperidone TRELEGY ELLIPTA ZYTIGA mometasone rizatriptan TREMFYA [INJ] Go to express-scripts.com/2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TD CHANGE. You can find more information at express-scripts.com. © 2019 Express Scripts. All Rights Reser1ed. 20 2477, 2478 NP-A All trademarks are the propertyof their respective owners. PRMTEMIANP-19 (01/01/19) CHAMPIONS fl,EXPRESS SCRIPTS• FOR ·- BETTER'" 2019 EMI Health Preferred Drug List Exclusions The excluded medications shown below are not covered on the EMI Health drug list. In most cases, if you fill a prescription for one of these drugs, you will pay the full retail price. Take action to avoid paying full price. If you're currently using one of the excluded medications, please ask your doctor to consider writing you a new prescription for one of the following preferred alternatives. Additional covered alternatives may be available. Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your plan. For specific questions about your coverage, please call the number on your member ID card. Express Scripts manages your prescription plan for your employer, plan sponsor, health plan or benefit fund. Drug Class Excluded Medications Preferred Alternatives

AUTONOMIC & CENTRAL NERVOUS SYSTEM LUCEMYRA clonidine Alpha-2 Adrenergic Agonists (for Opioid Withdrawal) Anti-Migraine Therapy SUMAVELDOSEPRO sumatriptan injection amantadine capsules, amantadine tablets, GOCOVRI ER, OSMOLEX ER Antiparkinsonism Agents amantadine oral solution XADAGO rasagiline, selegiline AVONEX ADMINISTRATION PACK, AVONEXPEN, BETASERON, Beta Interferonsfor Multiple Sclerosis EXTAVIA PLEGRIDY,REBIF, REBIF REBIDOSE Calcitonin Gene-Related Peptide Antagonists AJOVY AIMOVIG, EMGALITY EMFLAZA prednisone solution, prednisone tablets Duchenne Muscular Dystrophy (DMD) Agents EXONDYS 51 No alternatives recommended hydromorphone ER, morphine sulfate ER, oxymorphoneER, Long-Acting Opioid Oral Analgesics EMBEDA,OXYCODONE ER HYSINGLA ER, NUCYNTA ER, OXYCONTIN Narcotic Analgesics BUTRANS BELBUCA Neuropathic Agents LYRICACR gabapentin,GRALISE, LYRICA Transmucosal Fentanyl Analgesics ABSTRAL, FENTORA, LAZANDA fentanyl citrate lozenges

CARDIOVASCULAR PRADAXA, SAVAYSA ELIQUIS, XARELTO Anticoagulants Beta Blockers KAPSPARGO SPRINKLE metoprolol succinate HMG & Cholesterol Inhibitor Combinations ALTOPREV, ZYPITAMAG atorvastatin, lovastatin,rosuvastatin, simvastatin, LIVALO PCSK9 Inhibitors REPATHA PRALUENT

DERMATOLOGICAL MINOCYCLINE ER 55 MG TABLETS, MINOLIRA minocycline ER Oral Agents for Acne Oral Agents for Rosacea DOXYCYCLINE 40 MG CAPSULES ORACEA TopicalAcne PLIXDA adapalene clindamycin/benzoyl peroxide, clindamycin/tretinoin, TopicalAcne/Antibiotic Combinations AKTIPAK, VELTIN erythromycin/benzoyl peroxide, ACANYA, ONEXTON

diclofenac 3% gel, fluorouracil 2% solution, FLUOROURACIL 0.5% CREAM, TopicalAgents for Actinic Keratosis fluorouracil 5% cream, imiquimod 5% cream, IMIQUIMOD 3.75% CREAM PUMP, ZYCLARA CARAC, PICATO

TopicalAntifungals LULICONAZOLE ciclopirox, econazole, ketoconazole,naftifine, oxiconazole acyclovir capsules, acyclovir tablets, famciclovir tablets, TopicalAntiviral Agents XERESE CREAM valacyclovir tablets, ZOVIRAX CREAM desonide 0.05% cream/lotion/ointment, TopicalCorticosteroids TOPICORT SPRAY, VERDESO FOAM desoximetasone 0.25% cream/ointment

Miscellaneous Topical Dermatological Agents ALCORTIN A hydrocortisone, mupirocin

Continued © 2018 Express Scripts. All Rights Reserved. 2477, 2478 All trademarks are the propertyof their respective owners. 21 0L44109Q-EMl· 19 (12/05/2018) Drug Class Excluded Medications Preferred Alternatives

ABBOTT (FREESTYLE, PRECISION), BAYER (BREEZE, CONTOUR),NATIONAL MEDICAL (ADVOCATE),OMNIS DIABETES HEALTH (EMBRACE, VICTORY), ROCHE (ACCU-CHEK), LIFESCAN (ONETOUCH) Blood Glucose Meters & Test Strips TRIVIDIA (TRUETEST,TRUETRACK), UNISTRIP ALL OTHER METERS & STRIPS THAT ARE NOT LIFESCAN BRAND

ALOGLIPTIN, NESINA,ONGLYZA JANUVIA,TRADJENTA Dipeptidyl Peptidase-4 Inhibitors & Combinations ALOGLIPTIN/METFORMIN, KAZANO, KOMBIGLYZEXR JANUMET,JANUMET XR,JENTADUETO, JENTADUETO XR

Glucagon-Like Peptide-1 Agonists ADLYXIN, TANZEUM, VICTOZA BYDUREON, BYETTA, OZEMPIC,TRULICITY

NOVOLIN HUMULIN Insulins ADMELOG, APIDRA, FIASP,NOVOLOG HUMALOG

EAR/NDSE BECONASE AQ,OMNARIS, ZETONNA budesonide, flunisolide, fluticasone, mometasone, QNASL Nasal Steroids

ciprofloxacin ear solution, ofloxacin ear solution, Otic Fluoroquinolone Antibiotics CETRAXAL CIPRODEX, OTOVEL

ENDOCRINE (OTHER) CLIMARA PRO COMBIPATCH Combination Patches

estradiol patches, estradiol tablets, yuvafem, Estrogen and Estrogen Modifiers for Vaginal Symptoms FEMRING ESTRING, PREMARIN CREAM, PREMARIN TABLETS

Gonadotropin Releasing Hormone (GnRH) Agonists LUPRON DEPOT-PED TRIPTODUR (for Central Precocious Puberty)

HUMATROPE, NUTROPIN AQ NUSPIN,OMNITROPE, Growth Hormones GENOTROPIN, NORDITROPIN FLEXPRO SAIZEN,SAIZENPREP, ZOMACTON

Somatostatin Analogs SANDOSTATIN LAR DEPOT, SIGNIFOR LAR SOMATULINE DEPOT

TopicalEstrogen Gels ESTROGEL DIVIGEL

GASTROINTESTINAL CORTIFOAM hydrocortisoneenema, UCERIS FOAM Corticosteroids (Rectal Formulations)

balsalazide disodium, mesalamine 1.2 gm delayed release, Inflammatory Bowel Agents DELZICOL, DIPENTUM sulfasalazine,APRISO, PENTASA

Pancreatic Enzymes PANCREAZE,PERTZYE CREON,ZENPEP

ACIPHEX SPRINKLE,PRILOSEC SUSPENSION, esomeprazole, lansoprazole, omeprazole, pantoprazole, Proton Pump Inhibitors PROTONIX SUSPENSION rabeprazole, NEXIUM PACKETS

HEMATOLOGICAL ARANESP, EPOGEN, MIRCERA PROCRIT, RETACRIT Erythropoiesis-Stimulating Agents

ADVATE, ADYNOVATE, AFSTYLA,HELIXATE FS, JIVI, Factor VIII Recombinant Products ELOCTATE, RECOMBINATE, XYNTHA, XYNTHA SOLOFUSE KOGENATE FS,KOVALTRY, NOVOEIGHT, NUWIQ

Granulocyte Colony Stimulating Factors NEUPOGEN,NIVESTYM GRANIX, ZARXIO

HEPATITIS DAKLINZA, LEDIPASVIR/SOFOSBUVIR,MAVYRET, OLYSIO, EPCLUSA, HARVONI,VOSEVI, ZEPATIER Hepatitis C SOFOSBUVIRNELPATASVIR, SOVALDI

BIKTARVY,GENVOYA, ODEFSEY, STRIBILD, SYMFI, SYMFI LO, ATRIPLA, DELSTRIGO, SYMTUZA HIV TRIUMEQ Antiretrovirals PIFELTRO efavirenz, nevirapine ER, EDURANT, INTELENCE, RESCRIPTOR

MUSCULOSKELETAL & RHEUMATOLOGY COLCHICINE COLCRYS, MITIGARE Gout Therapy DUZALLO, ZURAMPIC allopurinol,probenecid

fenoprofen calcium tablets, diclofenac, ibuprofen, Nonsteroidal Anti-InflammatoryDrugs (NSAIDs) FENOPROFEN CAPSULES, FENORTHO, NALFON CAPSULES indomethacin, meloxicam, nabumetone, naproxen

OBSTETRICAL & GYNECOLOGICAL Gonadotropin-Releasing Hormone (GnRH) GANIRELIX ACETATE CETROTIDE Antagonists (for Infertility)

Continued © 2018 Express Scripts. All Rights Reserved. 2477, 2478 All trademarks are the propertyof their respective owners. 22 0L44109Q-EMl-19 (12/05/2018) Drug Class Excluded Medications Preferred Alternatives

OBSTETRICAL & GYNECOLOGICAL (continued) Gonadotropin-Releasing Hormone (GnRH) ORILISSA LUPRON DEPOT, SYNAREL, ZOLADEX Receptor Antagonists (for Endometriosis)

Human Chorionic Gonadotropin CHORIONIC GONADOTROPIN, PREGNYL NOVAREL, OVIDREL

Ovulatory Stimulants (Follitropins) BRAVELLE,FOLLISTIM AQ GONAL-F,GONAL-F RFF,GONAL-F RFF REDI-JECT

Vaginal Progesterones ENDOMETRIN CRINONE 8% GEL

OPHTHALMIC betaxolol drops, levobunolol drops,timolol drops, TIMOPTIC OCUDOSE Antiglaucoma Drugs (Beta-Adrenergic Blockers) ALPHAGAN P 0.1 %, COMBIGAN

Antiglaucoma Drugs (Ophthalmic Prostaglandins) ZIOPTAN bimatoprost drops, latanoprost drops,LUMIGAN, TRAVATAN Z

azelastine drops, cromolyn drops, olopatadine drops, Ophthalmic Anti-Allergic ALOCRIL, ALOMIDE, EMADINE ALREX,BEPREVE,PAZEO

dexamethasone drops,fluorometholone drops, Ophthalmic Anti-Inflammatory FLAREX, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD prednisolone drops, LOTEMAX

Ophthalmic Non-Steroidal Anti-Inflammatory Drugs bromfenac drops, diclofenac drops,ketorolac drops, ACUVAIL, NEVANAC (NSAIDs) ILEVRO, PROLENSA

DUROLANE,GEL-ONE, GELSYN-3, GENVISC 850, HYALGAN, OSTEOARTHRITIS HYMOVIS,SUPARTZ FX,SYNVISC, SYNVISC-ONE, TRIVISC, EUFLEXXA,MONOVISC, ORTHOVISC Hyaluronic Acid Derivatives VISC0-3

RENAL DISEASE FOSRENOL POWDER PACKETS, RENAGEL lanthanum,sevelamer carbonate,PHOSLYRA, VELPHORO Phosphate Binders

RESPIRATORY AUVI-Q, EPINEPHRINE AUTO-INJECTOR EPINEPHRINE AUTO-INJECTOR (BY MYLAN), Epinephrine Auto-Injector Systems (BY A-S MEDICATION,IMPAX & LINEAGE) EPIPEN, EPIPEN JR

Long-Acting Beta Agonist Nebulized BROVANA PERFOROMIST

ARMONAIR RESPICLICK,ARNUITY ELLIPTA, Pulmonary Anti-Inflammatory Inhalers ALVESCO ASMANEX HFA/TWISTHALER, FLOVENT DISKUS/HFA, PULMICORT FLEXHALER,QVAR

Short-Acting Beta2-Agonist Inhalers LEVALBUTEROL HFA,PROVENTIL HFA, XOPENEX HFA PROAIR HFA/RESPICLICK, VENTOLIN HFA HYDROXYPROGESTERONE 1,250 MG/5 ML hydroxyprogesterone caproate 250 mg/ml (single dose vial)

MISCELLANEOUS AGENTS SIKLOS DROXIA

NOCTIVA desmopressin tablets

Hereditary Angioedem a BERINERT RUCONEST

Polyneuropathy of Hereditary ONPATTRO No alternatives recommended Transthyretin-Mediated Amyloidosis

Indication Based Management Drug Class Nonpreferred Medications Preferred Alternatives

All other Brand Name medications for Inflammatory Conditions are Nonpreferred. Approval may be granted ACTEMRA,COSENTYX, ENBREL, HUMIRA, following a coverage review. A trial of one or more Preferred INFLECTRA,OTEZLA, REMICADE,RENFLEXIS, INFLAMMATORY CONDITIONS:!: medications is required prior to initiating therapy with a SIMPONI 100 MG (FOR ULCERATIVE COLITIS ONLY), Non preferred medication. A formulary exception may be STELARA SC, TREMFYA*, XEUANZ, XEUANZ XR granted for patients already established on therapy with a Nonpreferred medication.

:f: Pleasenote that product placement for treatmentfor InflammatoryConditions are subject to change throughout theyear based upon changes in marketdynamics, new indicationsfor existing products, biosimilar and new product launches. * Thismedication may be subject to step therapy.

Continued © 2018 Express Scripts. All Rights Reserved. 2477, 2478 All trademarks are the propertyof their respective owners. 23 0L44109Q-EMl-19 (12/05/2018) Excluded Medications/Products at a Glance ABBOTT (FREESTYLE, PRECISION) FLAREX PLAQUENIL" ABILIFY" FLUOROURACIL 0.5% CREAM PLAVIX" ABSTRAL FML FORTE,FML S.O.P. PLIXDA ACIPHEX" FOLLISTIM AQ PRADAXA ACIPHEX SPRINKLE FOSRENOL CHEWABLE TABLETS" PRED MILD ACUVAIL FOSRENOL POWDER PACKETS PREGNYL ADCIRCA" GANIRELIX ACETATE PREVACID", PREVACID SOLUTAB" ADDERALL" GEL-ONE PRILOSEC SUSPENSION ADLYXIN GELSYN-3 PRISTIQ" ADMELOG GENVISC 850 PROTONIX" AJOVY GLEEVEC" PROTONIX SUSPENSION AKTIPAK GLUCOPHAGE",GLUCOPHAGE XR" PROVENTIL HFA ALCORTIN A GLUMETZA" PROVIGIL" ALOCRIL GOCOVRI ER PROZAC" ALOGLIPTIN HUMATROPE PULMICORT RESPULES" ALOGLIPTIN/METFORMIN HYALGAN RECOMBINATE ALOMIDE HYDROXYPROGESTERONE 1,250 MG/5 ML RENAGEL ALTOPREV HYMOVIS REPATHA ALVESCO IMIQUIMOD 3.75% CREAM PUMP ROCHE (ACCU-CHEK) ANDROGEL 1% " IMITREX" SAIZEN, SAIZENPREP ANUSOL-HC" INDERAL LA" SANDOSTATIN LAR DEPOT APIDRA INTUNIV" SAVAYSA ARANESP ISTALOL" SEROQUEL",SEROQUEL XR" ARI MIDEX" KAPSPARGO SPRINKLE SIGNIFOR LAR ASACOL HD" KAZANO SIKLOS ATACAND", ATACAND HCT" KEPPRA", KEPPRA XR" SINGULAIR" ATRIPLA KOMBIGLYZE XR SOFOSBUVIRNELPATASVIR AUVI-Q LAMICTAL ", LAMICTALODT", LAMICTAL XR" SOVALDI AVALIDE", AVAPRO" LAZANDA STRATTERA" AVODART" LEDIPASVIR/SOFOSBUVIR SUMAVEL DOSEPRO AZOR" LEVALBUTEROL HFA SUPARTZ FX BAYER (BREEZE, CONTOUR) LEXAPRO" SYMTUZA BECONASE AQ LIBRAX" SYNVISC, SYNVISC-ONE BENI CAR", BENI CAR HCT" LIDODERM" TANZEUM BERINERT LIPITOR" TESTIM" BRAVELLE LOESTRIN", LOESTRIN FE" TIKOSYN" BRISDELLE" LOTREL" TIMOPTIC OCUDOSE BROVANA LOVENOX" TOBI SOLUTION" BUPAP" LUCEMYRA TOPAMAX" BUTRANS LULICONAZOLE TOPICORT SPRAY CELEBREX" LUNESTA" TRIBENZOR" CELEXA" LUPRON DEPOT-PED TRICOR" CETRAXAL LYRICACR TRILEPTAL" CHORIONIC GONADOTROPIN MAVYRET TRIVIDIA (TRUETEST, TRUETRACK) CLIMARA PRO MAXALT", MAXALT MLT" TRIVISC COLCHICINE MAXIDEX UNISTRIP COREG" MICARDIS", MICARDIS HCT" UROXATRAL" CORTIFOAM MINASTRIN 24 FE" VAGIFEM" COSOPT" MINOCYCLINE ER 55 MG TABLETS VALIUM" COZAAR", HYZAAR" MINOLIRA VALTREX" CRESTOR" MIRCERA VELTIN CYMBALTA" NALFON CAPSULES VERDESO FOAM CYTOMEL" NAMENDA XR" VICTOZA DAKLINZA NASONEX" VISC0-3 DELSTRIGO NATIONAL MEDICAL (ADVOCATE) VIVELLE-DOT" DELZICOL NESINA VYTORIN" DETROL ", DETROL LA" NEUPOGEN WELLBUTRIN SR" DIOVAN", DIOVAN HCT" NEURONTIN" XADAGO DIPENTUM NEVANAC XALATAN" DOXYCYCLINE 40 MG CAPSULES NIVESTYM XANAX", XANAX XR" DUROLANE NOCTIVA XENAZINE" DUZALLO NORCO" XERESE CREAM EFFEXOR XR" NORVASC" XOPENEX HFA ELOCTATE NOVOLIN XYNTHA, XYNTHA SOLOFUSE EMADINE NOVOLOG YASMIN" EMBEDA NUTROPIN AQ NUSPIN ZEGERID" EMFLAZA NUVIGIL" ZETIA" ENDOMETRIN OLYSIO ZETONNA EPINEPHRINE AUTO-INJECTOR OMNARIS ZIOPTAN (BY A-S MEDICATION,IMPAX & LINEAGE) OMNIS HEALTH (EMBRACE,VICTORY) ZOCOR" EPOGEN OMNITROPE ZOLOFT" ESTROGEL ONGLYZA ZOMACTON EXFORGE", EXFORGE HCT" ONPATTRO ZOMIG TABLETS", ZOMIG ZMT" EXONDYS 51 ORILISSA ZONEGRAN" EXTAVIA ORTHO TRI-CYCLEN", ORTHO TRI-CYCLEN LO" ZURAMPIC FEMRING OSMOLEX ER ZYCLARA FENOPROFEN CAPSULES OXYCODONE ER ZYFLO CR" FENORTHO PANCREAZE ZYPITAMAG FENTORA PERTZYE FIASP PIFELTRO 11 Multisource brandexclusion - The genericequivalent of thisbrand-name medication is covered under your plan. FDA-approvedgeneric medications meet strictstandards and contain the same activeingredients as theircorresponding brand-name medications, althoughthey may havea differentappearance. As new generic medications become available, additional multisourcebrand products may become excluded.

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30 5101 S Commerce Drive | Murray, Utah 84107 Local: 801.262.7475 Toll free: 800.662.5851

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