Blue Rx Valuesm Formulary

BLUE RX VALUESM FORMULARY

HOW TO READ THE FORMULARY All drugs are listed by their generic names and/or most common proprietary (brand) name. Specific drug listings may be accessed either by generic (in lowercase) or brand name (in uppercase) and by therapeutic drug tier. Any drug not found in this formulary listing, or any formulary updates published by Wellmark, shall be considered excluded from your benefit. Once the product is located, the following items can be viewed: Drug Tier: Drugs are categorized within tiers on the formulary. Each tier is assigned a cost, which is determined by the member’s pharmacy benefit plan. Tier Designation in Formulary Below

Tier 1 Tier 2 Value Plan 2 Tier Tier 1 Tier 2 Value Plan 1 Tier Tier 1 and Tier 2 combined

Pharmacy Durable Medical Equipment (RxDME): Devices available on this tier include select durable medical equipment (DME) that are used in conjunction with a drug and may be obtained from a pharmacy.

Specialty Drugs (SP): Specialty drugs are high-cost injectable, infused, oral or inhaled drugs for the ongoing treatment of a chronic condition. These drugs generally require close supervision and monitoring of the patient’s drug therapy. Specialty drugs may be categorized within tiers on the formulary or as drugs covered under your medical benefit. Specialty Drugs Preferred (SP-P): Drugs in this category will process with the preferred specialty drug cost-share. Specialty Medical (SP-M): Drugs in this category will be covered under your medical benefit. Drug Name: This lists the generic name for the product (lowercase) OR the brand name or common reference name for the product (UPPERCASE). Requirements/Limits: This lists Wellmark Pharmacy programs that may impact a particular drug or class of drugs and are described in the legend below.

HEALTH CARE REFORM PREVENTIVE DRUGS Preventive drugs with an “A” or “B” rating in the current recommendations of the United States Preventive Services Task Force (USPSTF) and immunizations as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention are not associated with any cost share for members on plans with this benefit. A complete list of recommendations and guidelines related to preventive services can be found at Healthcare.gov. Recommended preventive items and services are subject to change and are subject to medical management.

BENEFIT COVERAGE AND LIMITATIONS This printed formulary does not define benefit coverage and limitations. Many members have specific benefit inclusions, exclusions, copayments or a lack of coverage, which are not reflected in the Blue Rx Value formulary. Members should contact their Plan Sponsor or Wellmark Customer Service at the number on the back of their ID card if they have questions regarding their coverage. Please note that the formulary process is evolutionary, and changes can occur throughout the year. The following topics may or may not be applicable depending on the parameters of your specific benefits.

FORMULARY EXCEPTION PROCESS Drugs not included in this list shall be considered non-formulary and are NOT COVERED. In some instances, Wellmark will consider coverage exceptions. Coverage of non-formulary drugs may be requested by the health care professional through an exception request for a non-formulary prescription drug (outlined below). Generally, one of the following guidelines must be documented for an exception to be granted: All covered formulary drugs on any tier will be ineffective; OR All covered formulary drugs on any tier have been ineffective; OR All covered formulary drugs on any tier would not be as effective as the non-formulary drug; OR All covered formulary drugs would have adverse effects.

©2021 Wellmark, Inc. 1 COMMON DRUG EXCLUSIONS Due to benefit design parameters, some plan sponsors may choose to exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded drugs may include, but are not limited to: Over-the-counter (OTC) drugs or their equivalents unless otherwise specified in the formulary listing. Drug products used for cosmetic purposes. Experimental drug products, or any drug product used in an experimental manner. Replacement of a lost or stolen drug. Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA).

CONTACT INFORMATION The Blue Rx Value formulary is designed to assist physicians, members and other health care professionals in the selection of cost- effective agents. Wellmark encourages your input and feedback on how we can assist in improving this document and the formulary management process. Please direct your communications to: Wellmark Blue Cross and Blue Shield 1331 Grand Avenue P.O. Box 9232 Des Moines, IA 50306 In addition to the Blue Rx Value formulary, other quick reference guides are available at Wellmark.com.

1 TIER 1 2 TIER 2 3 SP-P 4 RX-DME 5 P&T 6 T6 TYPE DESCRIPTION

There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame. Amounts over the QL Quantity Limit specified quantity limits are not a covered benefit unless Post- Quantity Limit Prior Authorization is available. This indicates a drug requires prior authorization before it is covered under your benefit. Your health care provider will need to contact our PA Prior Authorization Pharmacy program at 800-600-8065. Hours of operation are Monday- Friday: 8 a.m. to 6 p.m. CST. This prescription drug may only be covered if you meet the minimum AL Age Limit or maximum age limit. This indicates a preferred biosimilar or generic specialty drug. Please Specialty Biosimilars and SBG read your enrollment information to see how specialty biosimilars and Specialty Generics specialty generics are covered specific to your plan. This indicates a drug requires prior authorization before it is covered under your benefit. Your health care provider will need to contact our Pharmacy program at 800-600- 8065. Hours of operation are Medical Necessity Prior MN-PA Monday - Friday: 8 a.m. to 6 p.m. CST. The intent of formulary Authorization medical necessity prior authorization is to confirm the appropriate coverage of the target drugs when evidence is provided documenting a trial and failure of the preferred formulary alternatives. A quantity limit on this drug limits the amount covered per prescription, or time period, and may vary based on the diagnosis. QLV Quantity Limit (Varies) Amounts over the quantity limit are not a covered benefit unless Post Quantity Limit Prior Authorization is available. This indicates a greater quantity may be covered under your benefit Post-Quantity Limit Prior if Post-Quantity Limit Prior Authorization is obtained. Your health PA-QL Authorization care provider will need to contact our Pharmacy program at 800-600- 8065. Hours of operation are Monday-Friday: 8 a.m. to 6 p.m. CST

©2021 Wellmark, Inc. 3 Indicates a generic equivalent is available for a brand name drug. In most cases, when you purchase a brand name drug that has an FDA-approved A-rated generic equivalent, Wellmark will pay only GA Generic Available what it would have paid for the equivalent generic drug. You will be responsible for your payment obligation for the equivalent generic drug and any remaining cost difference up to the maximum allowed fee for the brand name drug. Preventive drugs are prescribed to prevent the occurrence of a disease or condition and are defined by the Internal Revenue Service. The preventive drug enhanced benefit is available on PV Preventive specific high deductible health plans. This is an optional benefit that waives the deductible for preventive drugs. Please read your enrollment information to see how preventive drugs are covered specific to your plan.

BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

butalbital-aspirin- butalbital-aspirin-caffeine TIER 1 caffeine 50-325-40 mg cap cataflam cataflam 50 mg tab TIER 1 celecoxib (50 mg cap, 100 celecoxib TIER 1 QL (60 PER 30 DAYS) mg cap, 200 mg cap) choline-mag choline-mag trisalicylate TIER 1 trisalicylate 500 mg/5ml liquid diclofenac epolamine 1.3 % diclofenac epolamine TIER 1 PA, QL (60 PER 30 DAY(S)) patch diclofenac potassium 50 mg diclofenac potassium TIER 1 tab diclofenac sodium (25 mg diclofenac sodium tab dr, 50 mg tab dr, 75 mg TIER 1 tab dr) diclofenac sodium 1.5 % diclofenac sodium TIER 1 QL (300 PER 30 DAY(S)) solution diclofenac sodium er 100 diclofenac sodium er TIER 1 mg tab er 24h diclofenac-misoprostol (50- diclofenac- 0.2 mg tab dr, 75-0.2 mg TIER 1 misoprostol tab dr) diflunisal diflunisal 500 mg tab TIER 1 ec-naproxen (375 mg tab ec-naproxen TIER 1 dr, 500 mg tab dr) etodolac (200 mg cap, 300 etodolac mg cap, 400 mg tab, 500 TIER 1 mg tab) etodolac er (er 400 mg tab etodolac er er 24h, er 500 mg tab er TIER 1 24h, er 600 mg tab er 24h) fenoprofen calcium (400 mg fenoprofen calcium TIER 1 cap, 600 mg tab) flurbiprofen (50 mg tab, 100 flurbiprofen TIER 1 mg tab) ibu (400 mg tab, 600 mg ibu TIER 1 tab, 800 mg tab) ibuprofen (400 mg tab, 600 ibuprofen TIER 1 mg tab, 800 mg tab)

©2021 Wellmark, Inc. 5 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS INDOCIN 25 MG/5ML PA, QL (1200 PER 30 INDOCIN SUSPENSION TIER 2 DAY(S)) indomethacin indomethacin (25 mg cap, indomethacin TIER 1 50 mg cap) indomethacin er 75 mg cap indomethacin er TIER 1 er ketoprofen (50 mg cap, 75 ketoprofen TIER 1 mg cap) KETOPROFEN ER 200 MG KETOPROFEN ER CAP ER 24H TIER 1 ketoprofen ketorolac ketorolac tromethamine (10 TIER 1 tromethamine mg tab, 30 mg/ml solution) klofensaid ii klofensaid ii 1.5 % solution TIER 1 QL (300 PER 30 DAY(S)) MECLOFENAMATE MECLOFENAMATE SODIUM (50 MG CAP, 100 TIER 1 SODIUM MG CAP) meclofenamate sodium mefenamic acid 250 mg mefenamic acid TIER 1 cap meloxicam (7.5 mg tab, 15 meloxicam TIER 1 mg tab) nabumetone (500 mg tab, nabumetone TIER 1 750 mg tab) naproxen (250 mg tab, 375 naproxen mg tab, 375 mg tab dr, 500 TIER 1 mg tab, 500 mg tab dr) naproxen sodium (275 mg naproxen sodium TIER 1 tab, 550 mg tab) oxaprozin oxaprozin 600 mg tab TIER 1 piroxicam (10 mg cap, 20 piroxicam TIER 1 mg cap) profeno profeno 600 mg tab TIER 1 relafen (500 mg tab, 750 relafen TIER 1 mg tab) salsalate (500 mg tab, 750 salsalate TIER 1 mg tab) sulindac (150 mg tab, 200 sulindac TIER 1 mg tab) TOLMETIN SODIUM (200 MG TAB, 400 MG CAP, TOLMETIN SODIUM TIER 1 600 MG TAB) tolmetin sodium

OPIOID ANALGESICS, LONG-ACTING

buprenorphine (5 patch wk, buprenorphine 7.5 patch wk, 10 patch wk, TIER 1 PA, QL (4 PER 25) 15 patch wk, 20 patch wk) fentanyl (12 patch 72hr, 25 patch 72hr, 37.5 patch 72hr, 50 patch 72hr, 62.5 fentanyl TIER 1 PA, QL (10 PER 25) patch 72hr, 75 patch 72hr, 87.5 patch 72hr, 100 patch 72hr) hydrocodone bitartrate er (er 10 mg cap er 12h, er 15 mg cap er 12h, er 20 mg hydrocodone cap er 12h, er 30 mg cap er TIER 1 PA, QL (60 PER 25) bitartrate er 12h, er 40 mg cap er 12h, er 50 mg cap er 12h, er 100 mg tb24 deter) hydrocodone bitartrate er (er 20 mg tb24 deter, er 30 hydrocodone mg tb24 deter, er 40 mg TIER 1 PA, QL (30 PER 25) bitartrate er tb24 deter, er 60 mg tb24 deter, er 80 mg tb24 deter, er 120 mg tb24 deter) hydromorphone hcl er (er 8 mg tab er 24h, er 12 mg tab hydromorphone hcl er TIER 1 PA, QL (30 PER 25 DAY(S)) er 24h, er 16 mg tab er 24h, er 32 mg tab er 24h) levorphanol tartrate 2 mg levorphanol tartrate TIER 1 PA, QL (120 PER 25) tab methadone hcl (10 mg tab, methadone hcl TIER 1 PA, QL (60 PER 25) 10 mg/ml conc) methadone hcl 10 mg/5ml methadone hcl TIER 1 PA, QL (300 PER 25) solution methadone hcl 40 mg tab methadone hcl TIER 1 sol methadone hcl methadone hcl 5 mg tab TIER 1 PA, QL (90 PER 25) methadone hcl 5 mg/5ml methadone hcl TIER 1 PA, QL (450 PER 25) solution methadone hcl methadone hcl intensol 10 TIER 1 PA, QL (60 PER 25) intensol mg/ml conc methadose methadose 10 mg tab TIER 1 PA, QL (60 PER 25) methadose methadose 40 mg tab sol TIER 1

©2021 Wellmark, Inc. 7 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MORPHINE SULFATE ER (ER 10 MG CAP ER 24H, ER 20 MG CAP ER 24H, ER 30 MG CAP ER 24H, MORPHINE ER 40 MG CAP ER 24H, TIER 1 PA, QL (60 PER 25) SULFATE ER ER 100 MG CAP ER 24H, ER 100 MG TAB ER, ER 200 MG TAB ER) morphine sulfate morphine sulfate er (er 15 morphine sulfate er mg tab er, er 30 mg tab er, TIER 1 PA, QL (90 PER 25) er 60 mg tab er) morphine sulfate er (er 50 mg cap er 24h, er 60 mg morphine sulfate er TIER 1 PA, QL (30 PER 25) cap er 24h, er 80 mg cap er 24h) OXYCODONE HCL ER (ER 10 MG TB12 DETER, ER OXYCODONE HCL 20 MG TB12 DETER, ER TIER 2 PA, QL (60 PER 25) ER 80 MG TB12 DETER) oxycodone hcl oxycodone hcl er (er 15 mg oxycodone hcl er tb12 deter, er 30 mg tb12 TIER 1 PA, QL (60 PER 25) deter, er 60 mg tb12 deter) OXYCODONE HCL ER 40 OXYCODONE HCL MG TB12 DETER TIER 2 PA, QL (90 PER 25) ER oxycodone hcl OXYCONTIN (10 MG TB12 DETER, 15 MG TB12 DETER, 20 MG TB12 DETER, 30 MG TB12 OXYCONTIN TIER 2 PA, QL (60 PER 25) DETER, 60 MG TB12 DETER, 80 MG TB12 DETER) oxycodone hcl OXYCONTIN 40 MG TB12 OXYCONTIN DETER TIER 2 PA, QL (90 PER 25) oxycodone hcl OXYMORPHONE HCL ER (ER 5 MG TAB ER 12H, ER 7.5 MG TAB ER 12H, ER OXYMORPHONE 10 MG TAB ER 12H, ER 15 TIER 1 PA, QL (60 PER 25) HCL ER MG TAB ER 12H, ER 30 MG TAB ER 12H, ER 40 MG TAB ER 12H) oxymorphone hcl OXYMORPHONE HCL ER OXYMORPHONE 20 MG TAB ER 12H TIER 1 PA, QL (90 PER 25) HCL ER oxymorphone hcl

©2021 Wellmark, Inc. 8 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS tramadol hcl er (biphasic) tramadol hcl er (er 100 mg tab er 24h, er TIER 1 PA, QL (30 PER 25) (biphasic) 200 mg tab er 24h, er 300 mg tab er 24h) tramadol hcl er (er 100 mg tramadol hcl er tab er 24h, er 200 mg tab er TIER 1 PA, QL (30 PER 25) 24h, er 300 mg tab er 24h)

OPIOID ANALGESICS, SHORT-ACTING

acetaminophen- acetaminophen-codeine #2 TIER 1 QL (400 PER 25) codeine #2 300-15 mg tab acetaminophen- acetaminophen-codeine #3 TIER 1 QL (360 PER 25) codeine #3 300-30 mg tab acetaminophen- acetaminophen-codeine #4 TIER 1 QL (180 PER 25) codeine #4 300-60 mg tab acetaminophen- acetaminophen-codeine TIER 1 QL (2700 PER 25) codeine 120-12 mg/5ml solution acetaminophen- acetaminophen-codeine TIER 1 QL (400 PER 25) codeine 300-15 mg tab acetaminophen- acetaminophen-codeine TIER 1 QL (360 PER 25) codeine 300-30 mg tab acetaminophen- acetaminophen-codeine TIER 1 QL (180 PER 25) codeine 300-60 mg tab apap-caff-dihydrocodeine apap-caff- (320.5-30-16 mg cap, 325- TIER 1 QL (300 PER 25) dihydrocodeine 30-16 mg tab) ascomp-codeine 50-325- ascomp-codeine TIER 1 40-30 mg cap aspirin-caff- aspirin-caff-dihydrocodeine TIER 1 dihydrocodeine 356.4-30-16 mg cap butalbital-apap-caff-cod butalbital-apap-caff- (50-300-40-30 mg cap, 50- TIER 1 cod 325-40-30 mg cap) butalbital-asa-caff- butalbital-asa-caff-codeine TIER 1 codeine 50-325-40-30 mg cap butorphanol tartrate 10 butorphanol tartrate TIER 1 QL (4 PER 30 DAYS) mg/ml solution carisoprodol-aspirin- carisoprodol-aspirin- TIER 1 codeine codeine 200-325-16 mg tab codeine sulfate (15 mg tab, codeine sulfate TIER 1 PA, QL (42 PER 25) 30 mg tab, 60 mg tab) dvorah dvorah 325-30-16 mg tab TIER 1 QL (300 PER 25) endocet (2.5-325 mg tab, 5- endocet TIER 1 QL (360 PER 25) 325 mg tab)

©2021 Wellmark, Inc. 9 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS endocet endocet 10-325 mg tab TIER 1 QL (180 PER 25) endocet endocet 7.5-325 mg tab TIER 1 QL (240 PER 25) fentanyl citrate (100 mcg tab, 200 mcg tab, 400 mcg fentanyl citrate TIER 1 PA tab, 600 mcg tab, 800 mcg tab) fentanyl citrate (200 mcg loz handle, 400 mcg loz handle, 600 mcg loz fentanyl citrate handle, 800 mcg loz TIER 1 PA handle, 1200 mcg loz handle, 1600 mcg loz handle) hydrocodone- hydrocodone- acetaminophen (10-300 mg TIER 1 QL (180 PER 25 DAY(S)) acetaminophen tab, 10-325 mg tab) hydrocodone- acetaminophen (2.5-108 hydrocodone- mg/5ml solution, 5-217 TIER 1 QL (2700 PER 25) acetaminophen mg/10ml solution, 7.5-325 mg/15ml solution) hydrocodone- hydrocodone- acetaminophen (5-300 mg TIER 1 QL (240 PER 25) acetaminophen tab, 5-325 mg tab) hydrocodone- hydrocodone- acetaminophen (7.5-300 TIER 1 QL (180 PER 25) acetaminophen mg tab, 7.5-325 mg tab) hydrocodone- hydrocodone- acetaminophen 10-660 mg TIER 1 acetaminophen tab hydrocodone- hydrocodone- acetaminophen 2.5-325 mg TIER 1 QL (360 PER 25) acetaminophen tab hydrocodone-ibuprofen (5- hydrocodone- 200 mg tab, 7.5-200 mg TIER 1 QL (50 PER 25) ibuprofen tab, 10-200 mg tab) hydromorphone hcl 1 mg/ml hydromorphone hcl TIER 1 PA, QL (600 PER 25) liquid hydromorphone hcl 2 mg hydromorphone hcl TIER 1 PA, QL (180 PER 25) tab HYDROMORPHONE HCL HYDROMORPHONE 3 MG SUPPOS TIER 1 PA, QL (120 PER 25) HCL hydromorphone hcl hydromorphone hcl 4 mg hydromorphone hcl TIER 1 PA, QL (150 PER 25) tab hydromorphone hcl 8 mg hydromorphone hcl TIER 1 PA, QL (60 PER 25) tab

©2021 Wellmark, Inc. 10 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ibudone (5-200 mg tab, 10- ibudone TIER 1 QL (50 PER 25) 200 mg tab) lorcet lorcet 5-325 mg tab TIER 1 QL (240 PER 25) lorcet hd lorcet hd 10-325 mg tab TIER 1 QL (180 PER 25 DAY(S)) lorcet plus lorcet plus 7.5-325 mg tab TIER 1 QL (180 PER 25) meperidine hcl (50 mg tab, meperidine hcl TIER 1 PA, QL (18 PER 25) 100 mg tab) MEPERIDINE HCL 50 MEPERIDINE HCL MG/5ML SOLUTION TIER 1 PA, QL (90 PER 25) meperidine hcl morphine sulfate (30 mg morphine sulfate TIER 1 PA, QL (90 PER 25) suppos, 30 mg tab) MORPHINE SULFATE (5 MORPHINE MG SUPPOS, 10 MG TIER 1 PA, QL (180 PER 25) SULFATE SUPPOS, 15 MG TAB) morphine sulfate morphine sulfate morphine sulfate (concentrate) (20 mg/ml TIER 1 PA, QL (135 PER 25) (concentrate) solution, 100 mg/5ml solution) morphine sulfate 10 mg/5ml morphine sulfate TIER 1 PA, QL (900 PER 25) solution MORPHINE SULFATE 20 MORPHINE MG SUPPOS TIER 1 PA, QL (120 PER 25) SULFATE morphine sulfate morphine sulfate 20 mg/5ml morphine sulfate TIER 1 PA, QL (675 PER 25) solution oxycodone hcl (20 mg tab, oxycodone hcl TIER 1 PA, QL (90 PER 25) 100 mg/5ml conc) oxycodone hcl (5 mg cap, 5 oxycodone hcl TIER 1 PA, QL (180 PER 25) mg tab, 10 mg tab) oxycodone hcl oxycodone hcl 15 mg tab TIER 1 PA, QL (120 PER 25) oxycodone hcl oxycodone hcl 30 mg tab TIER 1 PA, QL (60 PER 25) oxycodone hcl 5 mg/5ml oxycodone hcl TIER 1 PA, QL (900 PER 25) solution oxycodone-acetaminophen oxycodone- (2.5-325 mg tab, 5-325 mg TIER 1 QL (360 PER 25) acetaminophen tab) oxycodone- oxycodone-acetaminophen TIER 1 QL (180 PER 25) acetaminophen 10-325 mg tab OXYCODONE- ACETAMINOPHEN 5-325 OXYCODONE- MG/5ML SOLUTION TIER 1 QL (1800 PER 25) ACETAMINOPHEN oxycodone w/ acetaminophen

©2021 Wellmark, Inc. 11 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS oxycodone- oxycodone-acetaminophen TIER 1 QL (240 PER 25) acetaminophen 7.5-325 mg tab oxycodone-aspirin 4.8355- oxycodone-aspirin TIER 1 QL (360 PER 25) 325 mg tab OXYCODONE- OXYCODONE- IBUPROFEN 5-400 MG TIER 1 QL (28 PER 25) IBUPROFEN TAB oxycodone-ibuprofen oxymorphone hcl oxymorphone hcl 10 mg tab TIER 1 PA, QL (90 PER 25) oxymorphone hcl oxymorphone hcl 5 mg tab TIER 1 PA, QL (180 PER 25) panlor panlor 325-30-16 mg tab TIER 1 QL (300 PER 25) pentazocine-naloxone pentazocine-naloxone hcl TIER 1 PA, QL (120 PER 25) hcl 50-0.5 mg tab tramadol hcl tramadol hcl 50 mg tab TIER 1 PA, QL (180 PER 25) tramadol- tramadol-acetaminophen TIER 1 QL (40 PER 25) acetaminophen 37.5-325 mg tab trezix trezix 320.5-30-16 mg cap TIER 1 QL (300 PER 25) VERDROCET 2.5-325 MG TAB VERDROCET TIER 1 QL (360 PER 25), GA hydrocodone- acetaminophen vicodin vicodin 5-300 mg tab TIER 1 QL (240 PER 25) vicodin es vicodin es 7.5-300 mg tab TIER 1 QL (180 PER 25) vicodin hp vicodin hp 10-300 mg tab TIER 1 QL (180 PER 25 DAY(S)) xylon xylon 10-200 mg tab TIER 1 QL (50 PER 25) ZAMICET 10-325 MG/15ML SOLUTION ZAMICET TIER 1 QL (2700 PER 25 DAY(S)) hydrocodone- acetaminophen

ANESTHETICS

LOCAL ANESTHETICS

7t lido 7t lido 2 % gel TIER 1 glydo glydo 2 % prsyr TIER 1 lidocaine lidocaine 5 % ointment TIER 1 lidocaine lidocaine 5 % patch TIER 1 QL (3 PER DAY) LIDOCAINE HCL 4 % LIDOCAINE HCL SOLUTION TIER 1 lidocaine hcl (mouth-throat) lidocaine hcl lidocaine hcl urethral/mucosal (2 % gel, TIER 1 urethral/mucosal 2 % prsyr)

©2021 Wellmark, Inc. 12 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS lidocaine pak lidocaine pak 5 % ointment TIER 1 lidocaine viscous hcl 2 % lidocaine viscous hcl TIER 1 solution lidocaine-prilocaine 2.5-2.5 lidocaine-prilocaine TIER 1 % cream premium lidocaine 5 % premium lidocaine TIER 1 ointment

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTS/ANTI-CRAVING

acamprosate calcium 333 acamprosate calcium TIER 1 PV mg tab dr disulfiram (250 mg tab, 500 disulfiram TIER 1 PV mg tab) naltrexone hcl naltrexone hcl 50 mg tab TIER 1 PV

OPIOID DEPENDENCE TREATMENTS

buprenorphine hcl (2 mg sl buprenorphine hcl TIER 1 PV tab, 8 mg sl tab) buprenorphine hcl-naloxone hcl (-naloxone 2-0.5 mg film, -naloxone 2-0.5 mg sl buprenorphine hcl- tab, -naloxone 4-1 mg film, TIER 1 PV naloxone hcl -naloxone 8-2 mg film, - naloxone 8-2 mg sl tab, - naloxone 12-3 mg film)

OPIOID REVERSAL AGENTS

KLOXXADO 8 MG/0.1ML KLOXXADO LIQUID TIER 2 naloxone hcl naloxone hcl (0.4 mg/ml naloxone hcl soln cart, 2 mg/2ml soln TIER 1 prsyr) NARCAN 4 MG/0.1ML NARCAN LIQUID TIER 2 naloxone hcl

ANTIBACTERIALS

AMINOGLYCOSIDES

ARIKAYCE 590 MG/8.4ML ARIKAYCE SUSPENSION SP-P QL (236 PER 28 DAY(S)) amikacin sulfate liposome

©2021 Wellmark, Inc. 13 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GENTAK 0.3 % OINTMENT GENTAK TIER 1 GA gentamicin sulfate (ophth) gentamicin sulfate (0.1 % cream, 0.1 % ointment, 0.3 gentamicin sulfate TIER 1 % ointment, 0.3 % solution, 10 mg/ml solution) neomycin sulfate 500 mg neomycin sulfate TIER 1 tab paromomycin sulfate 250 paromomycin sulfate TIER 1 mg cap tobramycin tobramycin 0.3 % solution TIER 1 tobramycin sulfate (1.2 gm recon soln, 1.2 gm/30ml tobramycin sulfate solution, 2 gm/50ml TIER 1 solution, 10 mg/ml solution, 80 mg/2ml solution)

ANTIBACTERIALS, OTHER

azuphen mb azuphen mb 120 mg cap TIER 1 BACITRACIN 500 BACITRACIN UNIT/GM OINTMENT TIER 1 bacitracin (ophthalmic) benzoyl peroxide- benzoyl peroxide- TIER 1 erythromycin erythromycin 5-3 % gel CLEOCIN PHOSPHATE (300 MG/2ML SOLUTION, CLEOCIN 600 MG/4ML SOLUTION, TIER 1 GA PHOSPHATE 900 MG/6ML SOLUTION) clindamycin phosphate clindacin etz clindacin etz 1 % swab TIER 1 clindacin-p clindacin-p 1 % swab TIER 1 clindamycin hcl (75 mg cap, clindamycin hcl TIER 1 150 mg cap, 300 mg cap) clindamycin palmitate clindamycin palmitate hcl TIER 1 hcl 75 mg/5ml recon soln clindamycin phosphate (1 % gel, 1 % lotion, 1 % clindamycin swab, 2 % cream, 300 TIER 1 phosphate mg/2ml solution, 600 mg/4ml solution, 900 mg/6ml solution) clindamycin clindamycin phosphate 1 % TIER 1 PA phosphate foam clindamycin clindamycin phosphate 1 % TIER 1 QL (180 PER 30 DAY(S)) phosphate solution

©2021 Wellmark, Inc. 14 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS colistimethate sodium colistimethate sodium (cba) T6 (cba) 150 mg recon soln COLY-MYCIN M 150 MG COLY-MYCIN M RECON SOLN T6 GA colistimethate sodium FIRVANQ (25 MG/ML RECON SOLN, 50 MG/ML FIRVANQ TIER 2 QL (450 PER 23 DAY(S)) RECON SOLN) vancomycin hcl fosfomycin fosfomycin tromethamine 3 TIER 1 tromethamine gm packet hyolev mb hyolev mb 81 mg tab TIER 1 HYOPHEN 81.6 MG TAB methenamine-hyosc- HYOPHEN TIER 1 GA methylene blue-benzoic acid-phenyl sal KIMYRSA 1200 MG KIMYRSA RECON SOLN T6 oritavancin diphosphate linezolid (100 mg/5ml recon linezolid TIER 1 susp, 600 mg tab) mafenide acetate 5 % mafenide acetate TIER 1 packet me/naphos/mb/hyo1 81.6 me/naphos/mb/hyo1 TIER 1 mg tab methenamine methenamine hippurate 1 TIER 1 hippurate gm tab methenamine methenamine mandelate TIER 1 mandelate (0.5 gm tab, 1 gm tab) metronidazole (0.75 % gel, metronidazole 250 mg tab, 375 mg cap, TIER 1 500 mg tab) mupirocin mupirocin 2 % ointment TIER 1 mupirocin calcium 2 % mupirocin calcium TIER 1 QL (60 PER 30 DAY(S)) cream nitrofurantoin 25 mg/5ml nitrofurantoin TIER 1 suspension nitrofurantoin macrocrystal nitrofurantoin (25 mg cap, 50 mg cap, TIER 1 macrocrystal 100 mg cap) nitrofurantoin nitrofurantoin monohyd TIER 1 monohyd macro macro 100 mg cap phosphasal phosphasal 81.6 mg tab TIER 1 tinidazole (250 mg tab, 500 tinidazole TIER 1 mg tab)

©2021 Wellmark, Inc. 15 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS trimethoprim trimethoprim 100 mg tab TIER 1 ur n-c ur n-c 81.6 mg tab TIER 1 uramit mb uramit mb 118 mg cap TIER 1 urelle urelle 81 mg tab TIER 1 uretron d/s uretron d/s 81.6 mg tab TIER 1 uribel uribel 118 mg cap TIER 1 urin ds urin ds 81.6 mg tab TIER 1 uro-458 uro-458 81 mg tab TIER 1 uro-mp uro-mp 118 mg cap TIER 1 urophen mb urophen mb 81.6 mg tab TIER 1 uryl uryl 81.6 mg tab TIER 1 ustell ustell 120 mg cap TIER 1 uticap uticap 120 mg cap TIER 1 utira-c utira-c 81.6 mg tab TIER 1 utrona-c utrona-c 81.6 mg tab TIER 1 vancomycin hcl (5 gm vancomycin hcl recon soln, 750 mg recon TIER 1 soln) vandazole vandazole 0.75 % gel TIER 1 vilamit mb vilamit mb 118 mg cap TIER 1 vilevev mb vilevev mb 81 mg tab TIER 1 XIFAXAN (200 MG TAB, XIFAXAN 550 MG TAB) TIER 2 rifaximin

BETA-LACTAM, CEPHALOSPORINS

cefaclor (125 mg/5ml recon susp, 250 mg cap, 250 cefaclor mg/5ml recon susp, 375 TIER 1 mg/5ml recon susp, 500 mg cap) cefadroxil (1 gm tab, 250 mg/5ml recon susp, 500 mg cefadroxil TIER 1 cap, 500 mg/5ml recon susp) cefdinir (125 mg/5ml recon cefdinir susp, 250 mg/5ml recon TIER 1 susp, 300 mg cap) cefditoren pivoxil (200 mg cefditoren pivoxil TIER 1 tab, 400 mg tab) cefepime hcl 1 gm recon cefepime hcl TIER 2 soln

©2021 Wellmark, Inc. 16 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CEFEPIME-DEXTROSE 1- CEFEPIME- 5 GM-%(50ML) RECON TIER 2 DEXTROSE SOLN cefepime hcl-dextrose cefixime (100 mg/5ml recon cefixime susp, 200 mg/5ml recon TIER 1 susp, 400 mg cap) cefpodoxime proxetil (50 mg/5ml recon susp, 100 mg cefpodoxime proxetil TIER 1 tab, 100 mg/5ml recon susp, 200 mg tab) cefprozil (125 mg/5ml recon susp, 250 mg tab, 250 cefprozil TIER 1 mg/5ml recon susp, 500 mg tab) ceftibuten (180 mg/5ml ceftibuten TIER 1 recon susp, 400 mg cap) ceftriaxone sodium (1 gm ceftriaxone sodium recon soln, 250 mg recon TIER 1 soln, 500 mg recon soln) cefuroxime axetil (250 mg cefuroxime axetil TIER 1 tab, 500 mg tab) cephalexin (125 mg/5ml recon susp, 250 mg cap, cephalexin 250 mg tab, 250 mg/5ml TIER 1 recon susp, 500 mg cap, 500 mg tab, 750 mg cap) MAXIPIME 1 GM RECON MAXIPIME SOLN TIER 2 GA cefepime hcl

BETA-LACTAM, OTHER

AZACTAM 1 GM RECON AZACTAM SOLN TIER 2 GA aztreonam aztreonam aztreonam 1 gm recon soln TIER 2

BETA-LACTAM, PENICILLINS

amoxicillin (125 mg chew tab, 125 mg/5ml recon susp, 200 mg/5ml recon susp, 250 mg cap, 250 mg amoxicillin TIER 1 chew tab, 250 mg/5ml recon susp, 400 mg/5ml recon susp, 500 mg cap, 500 mg tab, 875 mg tab) amoxicillin-pot clavulanate (200-28.5 mg chew tab, 200-28.5 mg/5ml recon susp, 250-125 mg tab, 250- amoxicillin-pot 62.5 mg/5ml recon susp, TIER 1 clavulanate 400-57 mg chew tab, 400- 57 mg/5ml recon susp, 500- 125 mg tab, 600-42.9 mg/5ml recon susp, 875- 125 mg tab) amoxicillin-pot amoxicillin-pot clavulanate TIER 1 clavulanate er er 1000-62.5 mg tab er 12h AMPICILLIN 500 MG CAP AMPICILLIN TIER 1 ampicillin BICILLIN L-A (600000 UNIT/ML SUSPENSION, 1200000 UNIT/2ML BICILLIN L-A TIER 1 SUSPENSION, 2400000 UNIT/4ML SUSPENSION) penicillin g benzathine dicloxacillin sodium (250 dicloxacillin sodium TIER 1 mg cap, 500 mg cap) penicillin v potassium (125 mg/5ml recon soln, 250 mg penicillin v potassium TIER 1 tab, 250 mg/5ml recon soln, 500 mg tab)

MACROLIDES

azithromycin (100 mg/5ml recon susp, 200 mg/5ml azithromycin TIER 1 recon susp, 250 mg tab, 500 mg tab, 600 mg tab) clarithromycin (125 mg/5ml recon susp, 250 mg tab, clarithromycin TIER 1 250 mg/5ml recon susp, 500 mg tab) clarithromycin er 500 mg clarithromycin er TIER 1 tab er 24h

©2021 Wellmark, Inc. 18 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS e.e.s. 400 e.e.s. 400 400 mg tab TIER 1 ERY 2 % PAD ERY TIER 1 GA erythromycin (acne aid) ery-tab (250 mg tab dr, 333 ery-tab TIER 1 mg tab dr, 500 mg tab dr) ERYTHROCIN STEARATE ERYTHROCIN 250 MG TAB TIER 1 STEARATE erythromycin stearate erythromycin (2 % gel, 2 % pad, 2 % solution, 5 mg/gm erythromycin ointment, 250 mg tab dr, TIER 1 333 mg tab dr, 500 mg tab dr) erythromycin base (250 mg cp dr part, 250 mg tab, 250 erythromycin base TIER 1 mg tab dr, 333 mg tab dr, 500 mg tab, 500 mg tab dr) erythromycin ethylsuccinate erythromycin (200 mg/5ml recon susp, TIER 1 ethylsuccinate 400 mg tab, 400 mg/5ml recon susp) romycin romycin 5 mg/gm ointment TIER 1

QUINOLONES

ciprofloxacin (250 (5%) ciprofloxacin recon susp, 500 (10%) TIER 1 recon susp) ciprofloxacin hcl (0.2 % solution, 0.3 % solution, ciprofloxacin hcl TIER 1 100 mg tab, 250 mg tab, 500 mg tab, 750 mg tab) CIPROFLOXACIN- CIPROFLOX HCL ER (ER CIPROFLOXACIN- 500 MG TAB ER 24H, ER TIER 1 CIPROFLOX HCL ER 1000 MG TAB ER 24H) ciprofloxacin-ciprofloxacin hcl gatifloxacin gatifloxacin 0.5 % solution TIER 1 levofloxacin (0.5 % solution, 25 mg/ml solution, 250 mg levofloxacin TIER 1 tab, 500 mg tab, 750 mg tab) moxifloxacin hcl (0.5 % moxifloxacin hcl TIER 1 solution, 400 mg tab) moxifloxacin hcl (2x moxifloxacin hcl (2x day) TIER 1 day) 0.5 % solution

SULFONAMIDES

silver sulfadiazine 1 % silver sulfadiazine TIER 1 cream ssd ssd 1 % cream TIER 1 sulfacetamide sodium (10 sulfacetamide sodium TIER 1 % ointment, 10 % solution) sulfacetamide sodium sulfacetamide sodium TIER 1 (acne) (acne) 10 % lotion SULFADIAZINE 500 MG SULFADIAZINE TAB TIER 1 sulfadiazine sulfamethoxazole- sulfamethoxazole- trimethoprim (200-40 TIER 1 trimethoprim mg/5ml suspension, 400-80 mg tab, 800-160 mg tab) sulfatrim pediatric 200-40 sulfatrim pediatric TIER 1 mg/5ml suspension

TETRACYCLINES

avidoxy avidoxy 100 mg tab TIER 1 coremino (45 mg tab er coremino 24h, 90 mg tab er 24h, 135 TIER 1 PA mg tab er 24h) demeclocycline hcl (150 mg demeclocycline hcl TIER 1 tab, 300 mg tab) doxycycline hyclate (20 mg doxycycline hyclate tab, 50 mg cap, 100 mg TIER 1 cap, 100 mg tab) doxycycline hyclate (50 mg doxycycline hyclate tab dr, 75 mg tab dr, 100 TIER 1 PA mg tab dr, 150 mg tab dr) doxycycline monohydrate (25 mg/5ml recon susp, 50 doxycycline mg cap, 50 mg tab, 75 mg TIER 1 monohydrate tab, 100 mg cap, 100 mg tab) minocycline hcl (50 mg cap, 50 mg tab, 75 mg cap, 75 minocycline hcl TIER 1 mg tab, 100 mg cap, 100 mg tab)

©2021 Wellmark, Inc. 20 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS minocycline hcl er (er 45 mg tab er 24h, er 90 mg tab minocycline hcl er TIER 1 PA er 24h, er 135 mg tab er 24h) mondoxyne nl (50 mg cap, mondoxyne nl TIER 1 100 mg cap) morgidox (50 mg cap, 100 morgidox TIER 1 mg cap) okebo okebo 100 mg cap TIER 1 SOLODYN (55 MG TAB ER 24H, 65 MG TAB ER 24H, 80 MG TAB ER 24H, 105 SOLODYN TIER 1 PA, GA MG TAB ER 24H, 115 MG TAB ER 24H) minocycline hcl soloxide soloxide 150 mg tab dr TIER 1 PA tetracycline hcl (250 mg tetracycline hcl TIER 1 cap, 500 mg cap)

ANTICONVULSANTS

ANTICONVULSANTS, OTHER

DIACOMIT (250 MG CAP, PA, QL (360 PER 30 DIACOMIT 250 MG PACKET) SP-P DAY(S)) stiripentol DIACOMIT (500 MG CAP, PA, QL (180 PER 30 DIACOMIT 500 MG PACKET) SP-P DAY(S)) stiripentol EPIDIOLEX 100 MG/ML PA, QL (600 PER 30 EPIDIOLEX SOLUTION SP-P DAY(S)) cannabidiol levetiracetam (100 mg/ml solution, 250 mg tab, 500 levetiracetam TIER 1 PV mg tab, 750 mg tab, 1000 mg tab) levetiracetam er (er 500 mg levetiracetam er tab er 24h, er 750 mg tab er TIER 1 PV 24h) roweepra (500 mg tab, 750 roweepra TIER 1 PV mg tab, 1000 mg tab) roweepra xr (500 mg tab er roweepra xr TIER 1 PV 24h, 750 mg tab er 24h)

CALCIUM CHANNEL MODIFYING AGENTS

CELONTIN 300 MG CAP CELONTIN TIER 2 PV methsuximide ethosuximide (250 mg cap, ethosuximide TIER 1 PV 250 mg/5ml solution) zonisamide (25 mg cap, 50 zonisamide TIER 1 PV mg cap, 100 mg cap)

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

PA, QL (120 PER 30 DAYS), clobazam clobazam 10 mg tab TIER 1 PV clobazam 2.5 mg/ml PA, QL (480 PER 30 DAYS), clobazam TIER 1 suspension PV PA, QL (60 PER 30 DAYS), clobazam clobazam 20 mg tab TIER 1 PV diazepam (2.5 mg gel, 10 diazepam TIER 1 mg gel, 20 mg gel) divalproex sodium (125 mg divalproex sodium cap dr, 125 mg tab dr, 250 TIER 1 PV mg tab dr, 500 mg tab dr) divalproex sodium er (er divalproex sodium er 250 mg tab er 24h, er 500 TIER 1 PV mg tab er 24h) gabapentin (100 mg cap, 250 mg/5ml solution, 300 gabapentin mg cap, 300 mg/6ml TIER 1 solution, 400 mg cap, 600 mg tab, 800 mg tab) phenobarbital (15 mg tab, 16.2 mg tab, 20 mg/5ml elixir, 20 mg/5ml solution, phenobarbital TIER 1 PV 30 mg tab, 32.4 mg tab, 60 mg tab, 64.8 mg tab, 97.2 mg tab, 100 mg tab) pregabalin er (er 82.5 mg pregabalin er tab er 24h, er 165 mg tab er TIER 1 24h, er 330 mg tab er 24h) primidone (50 mg tab, 250 primidone TIER 1 PV mg tab) tiagabine hcl (2 mg tab, 4 tiagabine hcl mg tab, 12 mg tab, 16 mg TIER 1 PV tab) valproate sodium 250 valproate sodium TIER 1 PV mg/5ml solution valproic acid (250 mg cap, valproic acid TIER 1 PV 250 mg/5ml solution)

©2021 Wellmark, Inc. 22 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (180 PER 30 DAYS), vigabatrin (500 mg packet, vigabatrin SP-P SBG (Specialty Biosimilars 500 mg tab) and Specialty generics) QL (180 PER 30 DAYS), vigadrone vigadrone 500 mg packet SP-P SBG (Specialty Biosimilars and Specialty generics)

GLUTAMATE REDUCING AGENTS

felbamate (400 mg tab, 600 felbamate mg tab, 600 mg/5ml TIER 1 PV suspension) lamotrigine (5 mg chew tab, 25 mg chew tab, 25 mg tab, 25 mg tab disp, 50 mg tab lamotrigine TIER 1 PV disp, 100 mg tab, 100 mg tab disp, 150 mg tab, 200 mg tab, 200 mg tab disp) lamotrigine er (er 25 mg tab er 24h, er 50 mg tab er 24h, er 100 mg tab er 24h, er lamotrigine er TIER 1 PV 200 mg tab er 24h, er 250 mg tab er 24h, er 300 mg tab er 24h) subvenite (25 mg tab, 100 subvenite mg tab, 150 mg tab, 200 TIER 1 PV mg tab) topiramate (15 mg cap sprink, 25 mg cap sprink, topiramate TIER 1 PV 25 mg tab, 50 mg tab, 100 mg tab, 200 mg tab) topiramate er (er 25 mg cp24 sprnk, er 50 mg cp24 sprnk, er 100 mg cp24 topiramate er TIER 1 PV sprnk, er 150 mg cp24 sprnk, er 200 mg cp24 sprnk)

SODIUM CHANNEL AGENTS

carbamazepine (100 mg carbamazepine chew tab, 100 mg/5ml TIER 1 PV suspension, 200 mg tab)

©2021 Wellmark, Inc. 23 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS carbamazepine er (er 100 mg cap er 12h, er 100 mg tab er 12h, er 200 mg cap carbamazepine er TIER 1 PV er 12h, er 200 mg tab er 12h, er 300 mg cap er 12h, er 400 mg tab er 12h) epitol epitol 200 mg tab TIER 1 PV oxcarbazepine (150 mg tab, oxcarbazepine 300 mg tab, 300 mg/5ml TIER 1 PV suspension, 600 mg tab) PEGANONE 250 MG TAB PEGANONE TIER 2 PV ethotoin phenytoin (50 mg chew tab, phenytoin 100 mg/4ml suspension, TIER 1 PV 125 mg/5ml suspension) phenytoin infatabs 50 mg phenytoin infatabs TIER 1 PV chew tab phenytoin sodium extended phenytoin sodium (100 mg cap, 200 mg cap, TIER 1 PV extended 300 mg cap) rufinamide (200 mg tab, PA, QL (240 PER 30 DAYS), rufinamide TIER 1 400 mg tab) PV rufinamide 40 mg/ml PA, QL (2400 PER 30 rufinamide TIER 1 suspension DAYS), PV VIMPAT (10 MG/ML SOLUTION, 50 MG TAB, VIMPAT 100 MG TAB, 150 MG TAB, TIER 2 PV 200 MG TAB) lacosamide

ANTIDEMENTIA AGENTS

ANTIDEMENTIA AGENTS, OTHER

AJOVY 225 MG/1.5ML AJOVY SOLN A-INJ SP-P PA, QL (1 PER 28 DAY(S)) fremanezumab-vfrm ERGOLOID MESYLATES 1 ERGOLOID MG TAB TIER 1 MESYLATES ergoloid mesylates

CHOLINESTERASE INHIBITORS

donepezil hcl (5 mg tab, 5 donepezil hcl mg tab disp, 10 mg tab, 10 TIER 1 mg tab disp, 23 mg tab) galantamine hydrobromide galantamine (4 mg tab, 8 mg tab, 12 mg TIER 1 hydrobromide tab)

©2021 Wellmark, Inc. 24 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS galantamine hydrobromide galantamine er (er 8 mg cap er 24h, er TIER 1 hydrobromide er 16 mg cap er 24h, er 24 mg cap er 24h) rivastigmine (4.6 mg/24hr patch 24hr, 9.5 mg/24hr rivastigmine TIER 1 patch 24hr, 13.3 mg/24hr patch 24hr) rivastigmine tartrate (1.5 rivastigmine tartrate mg cap, 3 mg cap, 4.5 mg TIER 1 cap, 6 mg cap)

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST

memantine hcl (2 mg/ml PA, QL (300 PER 30 memantine hcl solution, 10 mg/5ml TIER 1 DAY(S)) solution) memantine hcl (5 mg tab, memantine hcl TIER 1 10 mg tab) memantine hcl er (er 7 mg cap er 24h, er 14 mg cap er memantine hcl er TIER 1 24h, er 21 mg cap er 24h, er 28 mg cap er 24h)

ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER

bupropion hcl (75 mg tab, bupropion hcl TIER 1 PV 100 mg tab) bupropion hcl er (sr) (er 100 mg tab er 12h, er 150 mg bupropion hcl er (sr) TIER 1 PV tab er 12h, er 200 mg tab er 12h) bupropion hcl er (xl) (er 150 bupropion hcl er (xl) mg tab er 24h, er 300 mg TIER 1 PV tab er 24h) CHLORDIAZEPOXIDE- AMITRIPTYLINE (5-12.5 CHLORDIAZEPOXID MG TAB, 10-25 MG TAB) TIER 1 E-AMITRIPTYLINE chlordiazepoxide- amitriptyline mirtazapine (7.5 mg tab, 15 mg tab, 15 mg tab disp, 30 mirtazapine TIER 1 PV mg tab, 30 mg tab disp, 45 mg tab, 45 mg tab disp)

©2021 Wellmark, Inc. 25 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS olanzapine-fluoxetine hcl olanzapine-fluoxetine (3-25 mg cap, 6-25 mg cap, TIER 1 hcl 6-50 mg cap, 12-25 mg cap, 12-50 mg cap) PERPHENAZINE- AMITRIPTYLINE (2-10 MG PERPHENAZINE- TAB, 2-25 MG TAB, 4-10 TIER 1 AMITRIPTYLINE MG TAB, 4-25 MG TAB, 4- 50 MG TAB) perphenazine-amitriptyline

MONOAMINE OXIDASE INHIBITORS

MARPLAN 10 MG TAB MARPLAN TIER 2 PV isocarboxazid phenelzine sulfate 15 mg phenelzine sulfate TIER 1 PV tab tranylcypromine tranylcypromine sulfate 10 TIER 1 PV sulfate mg tab

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITOR/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)

citalopram hydrobromide citalopram (10 mg tab, 20 mg tab, 40 TIER 1 PV hydrobromide mg tab) citalopram citalopram hydrobromide 10 PA, QL (600 PER 30 TIER 1 hydrobromide mg/5ml solution DAY(S)), PV desvenlafaxine er (er 50 mg PA, QL (30 PER 30 DAYS), desvenlafaxine er tab er 24h, er 100 mg tab er TIER 1 PV 24h) desvenlafaxine succinate er desvenlafaxine (er 25 mg tab er 24h, er 50 TIER 1 QL (30 PER 30 DAYS), PV succinate er mg tab er 24h, er 100 mg tab er 24h) escitalopram oxalate (5 mg escitalopram oxalate tab, 5 mg/5ml solution, 10 TIER 1 PV mg tab, 20 mg tab) FLUOXETINE HCL (10 MG CAP, 20 MG CAP, 20 FLUOXETINE HCL MG/5ML SOLUTION, 40 TIER 1 PV MG CAP, 90 MG CAP DR) fluoxetine hcl fluoxetine hcl (pmdd) (10 fluoxetine hcl (pmdd) TIER 1 mg cap, 20 mg cap) fluvoxamine maleate (25 fluvoxamine maleate mg tab, 50 mg tab, 100 mg TIER 1 PV tab)

©2021 Wellmark, Inc. 26 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS fluvoxamine maleate er (er fluvoxamine maleate 100 mg cap er 24h, er 150 TIER 1 PA, PV er mg cap er 24h) MAPROTILINE HCL (25 MG TAB, 50 MG TAB, 75 MAPROTILINE HCL TIER 1 PV MG TAB) maprotiline hcl nefazodone hcl (50 mg tab, nefazodone hcl 100 mg tab, 150 mg tab, TIER 1 PV 200 mg tab, 250 mg tab) paroxetine hcl (10 mg tab, paroxetine hcl 20 mg tab, 30 mg tab, 40 TIER 1 PV mg tab) paroxetine hcl er (er 12.5 mg tab er 24h, er 25 mg tab paroxetine hcl er TIER 1 PV er 24h, er 37.5 mg tab er 24h) paroxetine mesylate 7.5 mg paroxetine mesylate TIER 1 QL (30 PER 30 DAYS) cap sertraline hcl (20 mg/ml sertraline hcl conc, 25 mg tab, 50 mg tab, TIER 1 PV 100 mg tab) trazodone hcl (50 mg tab, trazodone hcl TIER 1 PV 100 mg tab, 150 mg tab) venlafaxine hcl (25 mg tab, venlafaxine hcl 37.5 mg tab, 50 mg tab, 75 TIER 1 PV mg tab, 100 mg tab) venlafaxine hcl er (er 37.5 mg cap er 24h, er 75 mg venlafaxine hcl er TIER 1 PV cap er 24h, er 150 mg cap er 24h)

TRICYCLICS

amitriptyline hcl (10 mg tab, 25 mg tab, 50 mg tab, 75 amitriptyline hcl TIER 1 PV mg tab, 100 mg tab, 150 mg tab) AMOXAPINE (25 MG TAB, 50 MG TAB, 100 MG TAB, AMOXAPINE TIER 1 PV 150 MG TAB) amoxapine clomipramine hcl (25 mg clomipramine hcl TIER 1 PV cap, 50 mg cap, 75 mg cap)

©2021 Wellmark, Inc. 27 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS desipramine hcl (10 mg tab, 25 mg tab, 50 mg tab, 75 desipramine hcl TIER 1 PV mg tab, 100 mg tab, 150 mg tab) doxepin hcl (10 mg cap, 10 mg/ml conc, 25 mg cap, 50 doxepin hcl TIER 1 PV mg cap, 75 mg cap, 100 mg cap, 150 mg cap) imipramine hcl (10 mg tab, imipramine hcl TIER 1 PV 25 mg tab, 50 mg tab) nortriptyline hcl (10 mg cap, nortriptyline hcl 25 mg cap, 50 mg cap, 75 TIER 1 PV mg cap) nortriptyline hcl 10 mg/5ml PA, QL (2400 PER 30 nortriptyline hcl TIER 1 solution DAY(S)) protriptyline hcl (5 mg tab, protriptyline hcl TIER 1 PV 10 mg tab) trimipramine maleate (25 trimipramine maleate mg cap, 50 mg cap, 100 mg TIER 1 PV cap)

ANTIEMETICS

ANTIEMETICS, OTHER

compro compro 25 mg suppos TIER 1 metoclopramide hcl (5 mg tab, 5 mg/5ml solution, 10 metoclopramide hcl TIER 1 mg tab, 10 mg/10ml solution) perphenazine (2 mg tab, 4 perphenazine mg tab, 8 mg tab, 16 mg TIER 1 PV tab) phenadoz (12.5 mg suppos, phenadoz TIER 1 25 mg suppos) phenergan (12.5 mg phenergan suppos, 25 mg suppos, 50 TIER 1 mg suppos) prochlorperazine 25 mg prochlorperazine TIER 1 suppos prochlorperazine prochlorperazine maleate TIER 1 maleate (5 mg tab, 10 mg tab) promethazine hcl (12.5 mg suppos, 12.5 mg tab, 25 mg promethazine hcl TIER 1 suppos, 25 mg tab, 50 mg suppos, 50 mg tab)

©2021 Wellmark, Inc. 28 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PROMETHEGAN (12.5 MG SUPPOS, 25 MG PROMETHEGAN SUPPOS, 50 MG TIER 1 GA SUPPOS) promethazine hcl scopolamine 1 mg/3days scopolamine TIER 1 patch 72hr trimethobenzamide trimethobenzamide hcl 300 TIER 1 hcl mg cap

EMETOGENIC THERAPY ADJUNCTS

ANZEMET (50 MG TAB, ANZEMET 100 MG TAB) TIER 2 dolasetron mesylate aprepitant (40 mg cap, 80 & 125 mg cap, 80 & 125 mg aprepitant TIER 1 misc, 80 mg cap, 125 mg cap) CESAMET 1 MG CAP CESAMET TIER 2 nabilone dronabinol (2.5 mg cap, 5 dronabinol TIER 1 mg cap, 10 mg cap) EMEND 125 MG/5ML EMEND RECON SUSP TIER 2 aprepitant granisetron hcl granisetron hcl 1 mg tab TIER 1 ondansetron (4 mg tab ondansetron TIER 1 disp, 8 mg tab disp) ondansetron hcl (4 mg tab, ondansetron hcl TIER 1 8 mg tab, 24 mg tab) ondansetron hcl 4 mg/5ml ondansetron hcl TIER 1 QL (300 PER 30 DAYS) solution

ANTIFUNGALS

bio-statin bio-statin powder TIER 1 ciclodan (0.77 % cream, 8 ciclodan TIER 1 % solution) ciclopirox (0.77 % gel, 1 % ciclopirox TIER 1 shampoo, 8 % solution) ciclopirox olamine (0.77 % ciclopirox olamine TIER 1 cream, 0.77 % suspension) clotrimazole clotrimazole 10 mg troche TIER 1 econazole nitrate 1 % econazole nitrate TIER 1 QL (170 PER 30 DAY(S)) cream

©2021 Wellmark, Inc. 29 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS fluconazole (10 mg/ml recon susp, 40 mg/ml recon fluconazole susp, 50 mg tab, 100 mg TIER 1 tab, 150 mg tab, 200 mg tab) flucytosine (250 mg cap, flucytosine TIER 1 500 mg cap) griseofulvin microsize (125 griseofulvin microsize mg/5ml suspension, 500 TIER 1 mg tab) griseofulvin griseofulvin ultramicrosize TIER 1 ultramicrosize (125 mg tab, 250 mg tab) itraconazole (10 mg/ml itraconazole TIER 1 PA solution, 100 mg cap) ketoconazole (2 % ketoconazole TIER 1 shampoo, 200 mg tab) ketoconazole ketoconazole 2 % cream TIER 1 QL (240 PER 30 DAY(S)) ketoconazole ketoconazole 2 % foam TIER 1 QL (200 PER 30 DAY(S)) ketodan ketodan 2 % foam TIER 1 QL (200 PER 30 DAY(S)) luliconazole luliconazole 1 % cream TIER 1 miconazole-zinc oxide- miconazole-zinc petrolat 0.25-15-81.35 % TIER 1 oxide-petrolat ointment naftifine hcl (1 % cream, 1 naftifine hcl TIER 1 % gel, 2 % cream) nyamyc 100000 unit/gm nyamyc TIER 1 powder nyata 100000 unit/gm nyata TIER 1 powder nystatin (100000 unit/gm cream, 100000 unit/gm ointment, 100000 unit/gm nystatin TIER 1 powder, 100000 unit/ml suspension, 500000 unit tab) nystatin-triamcinolone nystatin-triamcinolone TIER 1 (cream, ointment) nystop 100000 unit/gm nystop TIER 1 powder posaconazole 100 mg tab posaconazole TIER 1 dr sulconazole nitrate (1 % sulconazole nitrate TIER 1 cream, 1 % solution) terbinafine hcl terbinafine hcl 250 mg tab TIER 1

©2021 Wellmark, Inc. 30 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS terconazole (0.4 % cream, terconazole 0.8 % cream, 80 mg TIER 1 suppos) VFEND IV 200 MG RECON VFEND IV SOLN TIER 2 GA voriconazole voriconazole (40 mg/ml voriconazole recon susp, 50 mg tab, 200 TIER 1 mg tab) voriconazole 200 mg recon voriconazole TIER 2 soln

ANTIGOUT AGENTS

allopurinol (100 mg tab, 300 allopurinol TIER 1 mg tab) colchicine (0.6 mg cap, 0.6 colchicine TIER 1 mg tab) colchicine-probenecid 0.5- colchicine-probenecid TIER 1 500 mg tab febuxostat (40 mg tab, 80 febuxostat TIER 1 mg tab) probenecid probenecid 500 mg tab TIER 1

ANTIMIGRAINE AGENTS

ERGOT ALKALOIDS

dihydroergotamine dihydroergotamine TIER 1 mesylate mesylate 1 mg/ml solution ergotamine-caffeine 1-100 ergotamine-caffeine TIER 1 mg tab migergot migergot 2-100 mg suppos TIER 1

SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

almotriptan malate (6.25 almotriptan malate TIER 1 QL (12 PER 30 DAYS) mg tab, 12.5 mg tab) eletriptan eletriptan hydrobromide (20 TIER 1 PA, QL (12 PER 30 DAYS) hydrobromide mg tab, 40 mg tab) frovatriptan succinate 2.5 frovatriptan succinate TIER 1 PA, QL (18 PER 30 DAYS) mg tab naratriptan hcl (1 mg tab, naratriptan hcl TIER 1 QL (12 PER 30 DAYS) 2.5 mg tab) rizatriptan benzoate (5 mg rizatriptan benzoate tab, 5 mg tab disp, 10 mg TIER 1 QL (18 PER 30 DAYS) tab, 10 mg tab disp)

©2021 Wellmark, Inc. 31 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS sumatriptan 20 mg/act sumatriptan TIER 1 QL (12 PER 30 DAYS) solution sumatriptan 5 mg/act sumatriptan TIER 1 QL (24 PER 30 DAYS) solution sumatriptan succinate (25 sumatriptan succinate mg tab, 50 mg tab, 100 mg TIER 1 QL (12 PER 30 DAYS) tab) sumatriptan succinate (6 sumatriptan succinate soln a-inj, 6 soln prsyr, 6 TIER 1 PA, QL (12 PER 30 DAYS) solution) sumatriptan succinate 4 sumatriptan succinate TIER 1 PA, QL (18 PER 30 DAYS) mg/0.5ml soln a-inj sumatriptan succinate sumatriptan succinate refill TIER 1 PA, QL (18 PER 30 DAYS) refill 4 mg/0.5ml soln cart sumatriptan succinate sumatriptan succinate refill TIER 1 PA, QL (12 PER 30 DAYS) refill 6 mg/0.5ml soln cart sumatriptan-naproxen sumatriptan-naproxen TIER 1 PA, QL (9 PER 30 DAYS) sodium sodium 85-500 mg tab zolmitriptan (2.5 mg zolmitriptan TIER 1 PA, QL (12 PER 30 DAYS) solution, 5 mg solution) zolmitriptan (2.5 mg tab, 2.5 zolmitriptan mg tab disp, 5 mg tab, 5 mg TIER 1 QL (12 PER 30 DAYS) tab disp)

ANTIMIGRAINE AGENTS, OTHER

AIMOVIG (140 MG DOSE) AIMOVIG (140 MG 70 MG/ML SOLN A-INJ SP-P PA, QL (1 PER 30 DAY(S)) DOSE) erenumab-aooe AIMOVIG (70 MG/ML SOLN A-INJ, 140 MG/ML AIMOVIG SP-P PA, QL (1 PER 30 DAY(S)) SOLN A-INJ) erenumab-aooe AJOVY 225 MG/1.5ML AJOVY SOLN PRSYR SP-P PA, QL (3 PER 90 DAY(S)) fremanezumab-vfrm EMGALITY (120 MG/ML SOLN A-INJ, 120 MG/ML EMGALITY SP-P PA, QL (1 PER 28 DAY(S)) SOLN PRSYR) galcanezumab-gnlm EMGALITY (300 MG EMGALITY (300 MG DOSE) 100 MG/ML SOLN SP-P PA, QL (1 PER 28 DAY(S)) DOSE) PRSYR galcanezumab-gnlm

PROPHYLACTIC

VYEPTI 100 MG/ML VYEPTI SOLUTION T6 eptinezumab-jjmr

ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICS

pyridostigmine pyridostigmine bromide (60 TIER 1 bromide mg tab, 60 mg/5ml solution) pyridostigmine pyridostigmine bromide er TIER 1 bromide er 180 mg tab er RUZURGI 10 MG TAB PA, QL (240 PER 30 RUZURGI SP-P amifampridine DAY(S))

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHER

dapsone (25 mg tab, 100 dapsone TIER 1 mg tab) rifabutin rifabutin 150 mg cap TIER 1

ANTITUBERCULARS

cycloserine cycloserine 250 mg cap TIER 1 ethambutol hcl (100 mg tab, ethambutol hcl TIER 1 400 mg tab) ISONIAZID (50 MG/5ML SYRUP, 100 MG TAB, 300 ISONIAZID TIER 1 MG TAB) isoniazid PASER 4 GM PACKET PASER TIER 1 aminosalicylic acid pyrazinamide pyrazinamide 500 mg tab TIER 1 rifampin (150 mg cap, 300 rifampin TIER 1 mg cap)

ANTINEOPLASTICS

ALKYLATING AGENTS

CYCLOPHOSPHAMIDE (1 CYCLOPHOSPHAMI GM/5ML SOLUTION, 500 T6 DE MG/2.5ML SOLUTION) cyclophosphamide cyclophosphamide (25 mg cyclophosphamide TIER 1 cap, 50 mg cap)

©2021 Wellmark, Inc. 33 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GLEOSTINE (5 MG CAP, 10 MG CAP, 40 MG CAP, GLEOSTINE TIER 2 100 MG CAP) lomustine HEXALEN 50 MG CAP HEXALEN TIER 2 altretamine LEUKERAN 2 MG TAB LEUKERAN TIER 2 chlorambucil MATULANE 50 MG CAP MATULANE TIER 2 procarbazine hcl melphalan melphalan 2 mg tab TIER 1 MYLERAN 2 MG TAB MYLERAN TIER 2 busulfan temozolomide (5 mg cap, 20 mg cap, 100 mg cap, SBG (Specialty Biosimilars temozolomide SP-P 140 mg cap, 180 mg cap, and Specialty generics) 250 mg cap) VALCHLOR 0.016 % GEL VALCHLOR mechlorethamine hcl SP-P (topical)

ANTIANDROGENS

abiraterone acetate (250 SBG (Specialty Biosimilars abiraterone acetate SP-P mg tab, 500 mg tab) and Specialty generics) bicalutamide bicalutamide 50 mg tab TIER 1 ERLEADA 60 MG TAB ERLEADA SP-P apalutamide flutamide flutamide 125 mg cap TIER 1 nilutamide nilutamide 150 mg tab TIER 1 NUBEQA 300 MG TAB NUBEQA SP-P darolutamide XTANDI 40 MG CAP XTANDI SP-P enzalutamide YONSA 125 MG TAB YONSA SP-P abiraterone acetate

ANTIANGIOGENIC AGENTS

POMALYST (1 MG CAP, 2 MG CAP, 3 MG CAP, 4 MG POMALYST SP-P CAP) pomalidomide

©2021 Wellmark, Inc. 34 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS REVLIMID (2.5 MG CAP, 5 MG CAP, 10 MG CAP, 15 REVLIMID MG CAP, 20 MG CAP, 25 SP-P MG CAP) lenalidomide THALOMID (50 MG CAP, 100 MG CAP, 150 MG THALOMID SP-P CAP, 200 MG CAP) thalidomide

ANTIESTROGENS/MODIFIERS

EMCYT 140 MG CAP EMCYT estramustine phosphate SP-P sodium SOLTAMOX 10 MG/5ML SOLTAMOX SOLUTION TIER 2 PA, PV tamoxifen citrate tamoxifen citrate (10 mg tamoxifen citrate TIER 1 PA, PV tab, 20 mg tab) toremifene citrate 60 mg toremifene citrate TIER 1 tab

ANTIMETABOLITES

capecitabine (150 mg tab, SBG (Specialty Biosimilars capecitabine SP-P 500 mg tab) and Specialty generics) FLUOROURACIL (2 % SOLUTION, 5 % CREAM, 5 FLUOROURACIL TIER 1 % SOLUTION) fluorouracil (topical) hydroxyurea hydroxyurea 500 mg cap TIER 1 mercaptopurine mercaptopurine 50 mg tab TIER 1 TABLOID 40 MG TAB TABLOID TIER 2 thioguanine

ANTINEOPLASTICS, OTHER

ALUNBRIG (30 MG TAB, 90 & 180 MG TAB THPK, ALUNBRIG SP-P 90 MG TAB, 180 MG TAB) brigatinib AYVAKIT (25 MG TAB, 50 MG TAB, 100 MG TAB, 200 AYVAKIT SP-P MG TAB, 300 MG TAB) avapritinib BALVERSA (3 MG TAB, 4 BALVERSA MG TAB, 5 MG TAB) SP-P erdafitinib

©2021 Wellmark, Inc. 35 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BRUKINSA 80 MG CAP BRUKINSA SP-P zanubrutinib IDHIFA (50 MG TAB, 100 IDHIFA MG TAB) SP-P enasidenib mesylate leucovorin calcium (5 mg tab, 10 mg tab, 15 mg tab, leucovorin calcium TIER 1 25 mg tab, 50 mg recon soln) LONSURF (15-6.14 MG LONSURF TAB, 20-8.19 MG TAB) SP-P trifluridine-tipiracil LYSODREN 500 MG TAB LYSODREN TIER 2 mitotane NINLARO (2.3 MG CAP, 3 NINLARO MG CAP, 4 MG CAP) SP-P ixazomib citrate ONUREG (200 MG TAB, ONUREG 300 MG TAB) SP-P azacitidine PEMAZYRE (4.5 MG TAB, PEMAZYRE 9 MG TAB, 13.5 MG TAB) SP-P pemigatinib PHESGO (60-60-2000 SOLUTION, 80-40-2000 PHESGO SOLUTION) T6 pertuzumab-trastuzumab- hyaluronidase-zzxf QINLOCK 50 MG TAB QINLOCK SP-P ripretinib RETEVMO (40 MG CAP, RETEVMO 80 MG CAP) SP-P selpercatinib ROZLYTREK 100 MG CAP ROZLYTREK SP-P QL (30 PER 30 DAY(S)) entrectinib ROZLYTREK 200 MG CAP ROZLYTREK SP-P QL (90 PER 30 DAY(S)) entrectinib RUBRACA (200 MG TAB, 250 MG TAB, 300 MG RUBRACA SP-P TAB) rucaparib camsylate RYDAPT 25 MG CAP RYDAPT SP-P midostaurin

©2021 Wellmark, Inc. 36 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SYLATRON (200 MCG KIT, 300 MCG KIT, 600 MCG SYLATRON KIT) SP-P peginterferon alfa-2b (antineoplastic) SYNRIBO 3.5 MG RECON SOLN SYNRIBO T6 omacetaxine mepesuccinate TABRECTA (150 MG TAB, TABRECTA 200 MG TAB) SP-P capmatinib hcl TAZVERIK 200 MG TAB TAZVERIK SP-P tazemetostat hbr TECARTUS TECARTUS SUSPENSION T6 brexucabtagene autoleucel TIBSOVO 250 MG TAB TIBSOVO SP-P ivosidenib TURALIO 200 MG CAP PA, QL (120 PER 30 TURALIO SP-P pexidartinib hcl DAY(S)) VITRAKVI (20 MG/ML SOLUTION, 25 MG CAP, VITRAKVI SP-P 100 MG CAP) larotrectinib sulfate VIZIMPRO (15 MG TAB, 30 VIZIMPRO MG TAB, 45 MG TAB) SP-P dacomitinib XOSPATA 40 MG TAB XOSPATA SP-P gilteritinib fumarate XPOVIO (100 MG ONCE WEEKLY) (MG 20 MG TAB XPOVIO (100 MG THPK, MG 50 MG TAB SP-P ONCE WEEKLY) THPK) selinexor XPOVIO (40 MG ONCE WEEKLY) (MG 20 MG TAB XPOVIO (40 MG THPK, MG 40 MG TAB SP-P ONCE WEEKLY) THPK) selinexor XPOVIO (40 MG TWICE WEEKLY) (MG 20 MG TAB XPOVIO (40 MG THPK, MG 40 MG TAB SP-P TWICE WEEKLY) THPK) selinexor

©2021 Wellmark, Inc. 37 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS XPOVIO (60 MG ONCE WEEKLY) (MG 20 MG TAB XPOVIO (60 MG THPK, MG 60 MG TAB SP-P ONCE WEEKLY) THPK) selinexor XPOVIO (60 MG TWICE XPOVIO (60 MG WEEKLY) 20 MG TAB SP-P TWICE WEEKLY) THPK selinexor XPOVIO (80 MG ONCE WEEKLY) (MG 20 MG TAB XPOVIO (80 MG THPK, MG 40 MG TAB SP-P ONCE WEEKLY) THPK) selinexor XPOVIO (80 MG TWICE XPOVIO (80 MG WEEKLY) 20 MG TAB SP-P TWICE WEEKLY) THPK selinexor ZEJULA 100 MG CAP ZEJULA SP-P niraparib tosylate ZOLINZA 100 MG CAP ZOLINZA SP-P vorinostat

AROMATASE INHIBITORS, 3RD GENERATION

anastrozole anastrozole 1 mg tab TIER 1 PA, PV exemestane exemestane 25 mg tab TIER 1 PA, PV letrozole letrozole 2.5 mg tab TIER 1 PV

ENZYME INHIBITORS

SBG (Specialty Biosimilars etoposide etoposide 50 mg cap SP-P and Specialty generics) GAVRETO 100 MG CAP GAVRETO SP-P pralsetinib HYCAMTIN (0.25 MG CAP, HYCAMTIN 1 MG CAP) SP-P topotecan hcl LORBRENA (25 MG TAB, LORBRENA 100 MG TAB) SP-P lorlatinib PIQRAY (200 MG DAILY PIQRAY (200 MG DOSE) 200 MG TAB THPK SP-P DAILY DOSE) alpelisib PIQRAY (250 MG DAILY PIQRAY (250 MG DOSE) 200 & 50 MG TAB SP-P DAILY DOSE) THPK alpelisib

MOLECULAR TARGET INHIBITORS

AFINITOR 10 MG TAB AFINITOR SP-P QL (60 PER 30 DAYS) everolimus AFINITOR DISPERZ (2 MG TAB SOL, 3 MG TAB SOL, AFINITOR DISPERZ SP-P 5 MG TAB SOL) everolimus ALECENSA 150 MG CAP ALECENSA SP-P alectinib hcl BOSULIF (100 MG TAB, 400 MG TAB, 500 MG BOSULIF SP-P TAB) bosutinib BRAFTOVI (50 MG CAP, BRAFTOVI 75 MG CAP) SP-P encorafenib CABOMETYX (20 MG TAB, CABOMETYX 40 MG TAB, 60 MG TAB) SP-P cabozantinib s-malate CALQUENCE 100 MG CAP CALQUENCE TIER 2 acalabrutinib CAPRELSA (100 MG TAB, CAPRELSA 300 MG TAB) SP-P vandetanib COMETRIQ (100 MG COMETRIQ (100 MG DAILY DOSE) 80 & 20 MG SP-P DAILY DOSE) KIT cabozantinib s-malate COMETRIQ (140 MG COMETRIQ (140 MG DAILY DOSE) 3 X 20 MG & SP-P DAILY DOSE) 80 MG KIT cabozantinib s-malate COMETRIQ (60 MG DAILY COMETRIQ (60 MG DOSE) 20 MG KIT SP-P DAILY DOSE) cabozantinib s-malate COPIKTRA (15 MG CAP, COPIKTRA 25 MG CAP) SP-P duvelisib COTELLIC 20 MG TAB COTELLIC SP-P cobimetinib fumarate

©2021 Wellmark, Inc. 39 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DAURISMO (25 MG TAB, DAURISMO 100 MG TAB) SP-P glasdegib maleate ERIVEDGE 150 MG CAP ERIVEDGE SP-P vismodegib erlotinib hcl (25 mg tab, 100 SBG (Specialty Biosimilars erlotinib hcl SP-P mg tab, 150 mg tab) and Specialty generics) QL (60 PER 30 DAYS), SBG everolimus (2.5 mg tab, 7.5 everolimus SP-P (Specialty Biosimilars and mg tab) Specialty generics) QL (120 PER 30 DAYS), everolimus everolimus 5 mg tab SP-P SBG (Specialty Biosimilars and Specialty generics) FARYDAK (10 MG CAP, 15 FARYDAK MG CAP, 20 MG CAP) SP-P panobinostat lactate GILOTRIF (20 MG TAB, 30 GILOTRIF MG TAB, 40 MG TAB) SP-P afatinib dimaleate IBRANCE (75 MG CAP, 75 MG TAB, 100 MG CAP, IBRANCE 100 MG TAB, 125 MG SP-P CAP, 125 MG TAB) palbociclib ICLUSIG (10 MG TAB, 15 MG TAB, 30 MG TAB, 45 ICLUSIG SP-P MG TAB) ponatinib hcl imatinib mesylate (100 mg SBG (Specialty Biosimilars imatinib mesylate SP-P tab, 400 mg tab) and Specialty generics) IMBRUVICA (70 MG CAP, 140 MG CAP, 140 MG IMBRUVICA TAB, 280 MG TAB, 420 MG SP-P TAB, 560 MG TAB) ibrutinib INLYTA (1 MG TAB, 5 MG INLYTA TAB) SP-P axitinib INREBIC 100 MG CAP INREBIC SP-P QL (120 PER 30 DAY(S)) fedratinib hcl IRESSA 250 MG TAB IRESSA SP-P gefitinib

©2021 Wellmark, Inc. 40 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS JAKAFI (5 MG TAB, 10 MG TAB, 15 MG TAB, 20 MG JAKAFI SP-P TAB, 25 MG TAB) ruxolitinib phosphate KANJINTI (150 MG RECON SOLN, 420 MG KANJINTI T6 RECON SOLN) trastuzumab-anns KISQALI (200 MG DOSE) KISQALI (200 MG 200 MG TAB THPK SP-P DOSE) ribociclib succinate KISQALI (400 MG DOSE) KISQALI (400 MG 200 MG TAB THPK SP-P DOSE) ribociclib succinate KISQALI (600 MG DOSE) KISQALI (600 MG 200 MG TAB THPK SP-P DOSE) ribociclib succinate KISQALI FEMARA (400 MG DOSE) 200 & 2.5 MG KISQALI FEMARA TAB THPK SP-P (400 MG DOSE) ribociclib succinate- letrozole KISQALI FEMARA (600 MG DOSE) 200 & 2.5 MG KISQALI FEMARA TAB THPK SP-P (600 MG DOSE) ribociclib succinate- letrozole KISQALI FEMARA(200 MG KISQALI DOSE) 200 & 2.5 MG TAB FEMARA(200 MG THPK SP-P DOSE) ribociclib succinate- letrozole KOSELUGO (10 MG CAP, KOSELUGO 25 MG CAP) SP-P PA, QL (4 PER DAY(S)) selumetinib sulfate QL (180 PER 30 DAYS), lapatinib ditosylate 250 mg lapatinib ditosylate SP-P SBG (Specialty Biosimilars tab and Specialty generics) LENVIMA (10 MG DAILY LENVIMA (10 MG DOSE) 10 MG CAP THPK SP-P DAILY DOSE) lenvatinib mesylate LENVIMA (12 MG DAILY LENVIMA (12 MG DOSE) 3 X 4 MG CAP SP-P DAILY DOSE) THPK lenvatinib mesylate

©2021 Wellmark, Inc. 41 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LENVIMA (14 MG DAILY LENVIMA (14 MG DOSE) 10 & 4 MG CAP SP-P DAILY DOSE) THPK lenvatinib mesylate LENVIMA (18 MG DAILY LENVIMA (18 MG DOSE) 10 MG & 2 X 4 MG SP-P DAILY DOSE) CAP THPK lenvatinib mesylate LENVIMA (20 MG DAILY LENVIMA (20 MG DOSE) 2 X 10 MG CAP SP-P DAILY DOSE) THPK lenvatinib mesylate LENVIMA (24 MG DAILY LENVIMA (24 MG DOSE) 2 X 10 MG & 4 MG SP-P DAILY DOSE) CAP THPK lenvatinib mesylate LENVIMA (4 MG DAILY LENVIMA (4 MG DOSE) 4 MG CAP THPK SP-P DAILY DOSE) lenvatinib mesylate LENVIMA (8 MG DAILY LENVIMA (8 MG DOSE) 2 X 4 MG CAP SP-P DAILY DOSE) THPK lenvatinib mesylate LYNPARZA (50 MG CAP, 100 MG TAB, 150 MG LYNPARZA SP-P TAB) olaparib MEKINIST (0.5 MG TAB, 2 MG TAB) MEKINIST SP-P trametinib dimethyl sulfoxide MEKTOVI 15 MG TAB MEKTOVI SP-P binimetinib NERLYNX 40 MG TAB NERLYNX TIER 2 neratinib maleate NEXAVAR 200 MG TAB NEXAVAR SP-P sorafenib tosylate ODOMZO 200 MG CAP ODOMZO SP-P sonidegib phosphate OGIVRI (150 MG RECON SOLN, 420 MG RECON OGIVRI T6 SOLN) trastuzumab-dkst

©2021 Wellmark, Inc. 42 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SPRYCEL (20 MG TAB, 50 MG TAB, 70 MG TAB, 80 SPRYCEL MG TAB, 100 MG TAB, 140 SP-P MG TAB) dasatinib STIVARGA 40 MG TAB STIVARGA SP-P regorafenib sunitinib malate (12.5 mg SBG (Specialty Biosimilars sunitinib malate cap, 25 mg cap, 37.5 mg SP-P and Specialty generics) cap, 50 mg cap) TAFINLAR (50 MG CAP, TAFINLAR 75 MG CAP) SP-P dabrafenib mesylate TAGRISSO (40 MG TAB, TAGRISSO 80 MG TAB) SP-P osimertinib mesylate TALZENNA (0.25 MG CAP, TALZENNA 1 MG CAP) SP-P PA talazoparib tosylate TASIGNA (50 MG CAP, 150 MG CAP, 200 MG TASIGNA SP-P CAP) nilotinib hcl TRAZIMERA (150 MG RECON SOLN, 420 MG TRAZIMERA T6 RECON SOLN) trastuzumab-qyyp TUKYSA (50 MG TAB, 150 TUKYSA MG TAB) SP-P tucatinib VENCLEXTA (10 MG TAB, VENCLEXTA 50 MG TAB, 100 MG TAB) SP-P venetoclax VENCLEXTA STARTING VENCLEXTA PACK 10 & 50 & 100 MG SP-P STARTING PACK TAB THPK venetoclax VOTRIENT 200 MG TAB VOTRIENT SP-P pazopanib hcl XALKORI (200 MG CAP, XALKORI 250 MG CAP) SP-P crizotinib ZELBORAF 240 MG TAB ZELBORAF SP-P vemurafenib ZYDELIG (100 MG TAB, ZYDELIG 150 MG TAB) SP-P idelalisib

MONOCLONAL ANTIBODY/ANTIBODY-DRUG CONJUGATE

AVASTIN (100 MG/4ML SOLUTION, 400 MG/16ML AVASTIN T6 SOLUTION) bevacizumab BLENREP 100 MG RECON BLENREP SOLN T6 belantamab mafodotin-blmf DARZALEX FASPRO 1800-30000 MG-UT/15ML DARZALEX FASPRO SOLUTION T6 daratumumab- hyaluronidase-fihj HERCEPTIN (150 MG RECON SOLN, 440 MG HERCEPTIN T6 RECON SOLN) trastuzumab HERZUMA (150 MG RECON SOLN, 420 MG HERZUMA T6 RECON SOLN) trastuzumab-pkrb MONJUVI 200 MG RECON MONJUVI SOLN T6 tafasitamab-cxix POLIVY (30 MG RECON SOLN, 140 MG RECON POLIVY T6 SOLN) polatuzumab vedotin-piiq RIABNI (100 MG/10ML SOLUTION, 500 MG/50ML RIABNI T6 SOLUTION) rituximab-arrx

RETINOIDS

SBG (Specialty Biosimilars bexarotene bexarotene 75 mg cap SP-P and Specialty generics) TARGRETIN 1 % GEL TARGRETIN SP-P bexarotene (topical) tretinoin tretinoin 10 mg cap TIER 1

TREATMENT ADJUNCTS

MESNEX 400 MG TAB MESNEX TIER 2 mesna

ANTIPARASITICS

ANTIHELMINTHICS

albendazole albendazole 200 mg tab TIER 1 ivermectin (0.5 % lotion, 3 ivermectin TIER 1 mg tab) praziquantel praziquantel 600 mg tab TIER 1

ANTIPROTOZOALS

atovaquone 750 mg/5ml atovaquone TIER 1 suspension atovaquone-proguanil hcl atovaquone-proguanil (62.5-25 mg tab, 250-100 TIER 1 PV hcl mg tab) chloroquine chloroquine phosphate (250 TIER 1 PV phosphate mg tab, 500 mg tab) DARAPRIM 25 MG TAB DARAPRIM TIER 2 GA pyrimethamine hydroxychloroquine hydroxychloroquine sulfate TIER 1 sulfate 200 mg tab mefloquine hcl mefloquine hcl 250 mg tab TIER 1 PV QL (20 PER 10 DAY(S)), PA- nitazoxanide nitazoxanide 500 mg tab TIER 1 QL (QL varies) pentamidine pentamidine isethionate TIER 1 isethionate 300 mg recon soln primaquine primaquine phosphate 26.3 TIER 1 PV phosphate (15 base) mg tab pyrimethamine pyrimethamine 25 mg tab TIER 1 quinine sulfate quinine sulfate 324 mg cap TIER 1

PEDICULICIDES/SCABICIDES

acticin acticin 5 % cream TIER 1 CROTAN 10 % LOTION CROTAN TIER 1 crotamiton LINDANE 1 % SHAMPOO LINDANE TIER 1 lindane malathion malathion 0.5 % lotion TIER 1 permethrin permethrin 5 % cream TIER 1

ANTIPARKINSON AGENTS

ANTICHOLINERGICS

benztropine mesylate (0.5 benztropine mesylate TIER 1 mg tab, 1 mg tab, 2 mg tab) trihexyphenidyl hcl (0.4 trihexyphenidyl hcl mg/ml solution, 2 mg tab, 5 TIER 1 mg tab)

ANTIPARKINSON AGENTS, OTHER

amantadine hcl (50 mg/5ml amantadine hcl syrup, 100 mg cap, 100 mg TIER 1 tab) carbidopa-levodopa- entacapone (12.5-50-200 mg tab, 18.75-75-200 mg carbidopa-levodopa- tab, 25-100-200 mg tab, TIER 1 entacapone 31.25-125-200 mg tab, 37.5-150-200 mg tab, 50- 200-200 mg tab) entacapone entacapone 200 mg tab TIER 1 tolcapone tolcapone 100 mg tab TIER 1 PA

DOPAMINE AGONISTS

APOKYN 30 MG/3ML APOKYN SOLN CART T6 apomorphine hydrochloride bromocriptine bromocriptine mesylate (2.5 TIER 1 mesylate mg tab, 5 mg cap) pramipexole dihydrochloride (0.125 mg pramipexole tab, 0.25 mg tab, 0.5 mg TIER 1 dihydrochloride tab, 0.75 mg tab, 1 mg tab, 1.5 mg tab) pramipexole dihydrochloride er (er 0.375 mg tab er 24h, er 0.75 mg pramipexole tab er 24h, er 1.5 mg tab er TIER 1 PA dihydrochloride er 24h, er 2.25 mg tab er 24h, er 3 mg tab er 24h, er 3.75 mg tab er 24h, er 4.5 mg tab er 24h) ropinirole hcl (0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg ropinirole hcl TIER 1 tab, 3 mg tab, 4 mg tab, 5 mg tab)

©2021 Wellmark, Inc. 46 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ropinirole hcl er (er 2 mg tab er 24h, er 4 mg tab er ropinirole hcl er 24h, er 6 mg tab er 24h, er TIER 1 PA 8 mg tab er 24h, er 12 mg tab er 24h)

DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS

carbidopa carbidopa 25 mg tab TIER 1 carbidopa-levodopa (10- 100 mg tab disp, 25-100 carbidopa-levodopa TIER 2 mg tab disp, 25-250 mg tab disp) carbidopa-levodopa (10- carbidopa-levodopa 100 mg tab, 25-100 mg tab, TIER 1 25-250 mg tab) carbidopa-levodopa er (er carbidopa-levodopa 25-100 mg tab er, er 50- TIER 1 er 200 mg tab er)

MONOAMINE OXIDASE B (MAO-B) INHIBITORS

rasagiline mesylate (0.5 mg rasagiline mesylate TIER 1 tab, 1 mg tab) selegiline hcl (5 mg cap, 5 selegiline hcl TIER 1 mg tab)

ANTIPSYCHOTICS

1ST GENERATION/TYPICAL

chlorpromazine hcl (10 mg chlorpromazine hcl tab, 25 mg tab, 50 mg tab, TIER 1 PV 100 mg tab, 200 mg tab) FLUPHENAZINE HCL (1 MG TAB, 2.5 MG TAB, 2.5 FLUPHENAZINE MG/5ML ELIXIR, 5 MG TIER 1 PV HCL TAB, 5 MG/ML CONC, 10 MG TAB) fluphenazine hcl haloperidol (0.5 mg tab, 1 haloperidol mg tab, 2 mg tab, 5 mg tab, TIER 1 PV 10 mg tab, 20 mg tab) haloperidol lactate 2 mg/ml haloperidol lactate TIER 1 PV conc loxapine succinate (5 mg loxapine succinate cap, 10 mg cap, 25 mg cap, TIER 1 PV 50 mg cap)

©2021 Wellmark, Inc. 47 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PIMOZIDE (1 MG TAB, 2 PIMOZIDE MG TAB) TIER 1 pimozide thioridazine hcl (10 mg tab, thioridazine hcl 25 mg tab, 50 mg tab, 100 TIER 1 PV mg tab) thiothixene (1 mg cap, 2 mg thiothixene TIER 1 PV cap, 5 mg cap, 10 mg cap) trifluoperazine hcl (1 mg trifluoperazine hcl tab, 2 mg tab, 5 mg tab, 10 TIER 1 PV mg tab)

2ND GENERATION/ATYPICAL

aripiprazole (2 mg tab, 5 mg tab, 10 mg tab, 10 mg aripiprazole tab disp, 15 mg tab, 15 mg TIER 1 PV tab disp, 20 mg tab, 30 mg tab) aripiprazole 1 mg/ml PA, QL (900 PER 30 aripiprazole TIER 1 solution DAY(S)), PV asenapine maleate (2.5 mg asenapine maleate sl tab, 5 mg sl tab, 10 mg sl TIER 1 tab) olanzapine (2.5 mg tab, 5 mg tab, 5 mg tab disp, 7.5 mg tab, 10 mg tab, 10 mg olanzapine TIER 1 PV tab disp, 15 mg tab, 15 mg tab disp, 20 mg tab, 20 mg tab disp) paliperidone er (er 1.5 mg tab er 24h, er 3 mg tab er paliperidone er TIER 1 PV 24h, er 6 mg tab er 24h, er 9 mg tab er 24h) quetiapine fumarate (25 mg tab, 50 mg tab, 100 mg tab, quetiapine fumarate TIER 1 PV 200 mg tab, 300 mg tab, 400 mg tab) quetiapine fumarate er (er 50 mg tab er 24h, er 150 quetiapine fumarate mg tab er 24h, er 200 mg TIER 1 PV er tab er 24h, er 300 mg tab er 24h, er 400 mg tab er 24h) risperidone (0.25 mg tab disp, 0.5 mg tab disp, 1 mg risperidone TIER 1 PA, PV tab disp, 2 mg tab disp, 3 mg tab disp, 4 mg tab disp)

©2021 Wellmark, Inc. 48 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS risperidone (0.25 mg tab, risperidone 0.5 mg tab, 1 mg tab, 2 mg TIER 1 PV tab, 3 mg tab, 4 mg tab) risperidone 1 mg/ml PA, QL (480 PER 30 risperidone TIER 1 solution DAY(S)), PV risperidone m-tab (0.5 mg tab disp, 1 mg tab disp, 2 risperidone m-tab TIER 1 PA, PV mg tab disp, 3 mg tab disp, 4 mg tab disp) ziprasidone hcl (20 mg cap, ziprasidone hcl 40 mg cap, 60 mg cap, 80 TIER 1 PV mg cap)

TREATMENT-RESISTANT

clozapine (12.5 mg tab disp, 25 mg tab, 25 mg tab clozapine disp, 50 mg tab, 100 mg TIER 1 PV tab, 100 mg tab disp, 200 mg tab, 200 mg tab disp) CLOZAPINE 200 MG TAB CLOZAPINE DISP TIER 1 PV, GA clozapine

ANTISPASTICITY AGENTS

baclofen (10 mg tab, 20 mg baclofen TIER 1 tab) BOTOX (100 RECON BOTOX SOLN, 200 RECON SOLN) T6 onabotulinumtoxina dantrolene sodium (25 mg dantrolene sodium cap, 50 mg cap, 100 mg TIER 1 cap) tizanidine hcl (2 mg tab, 4 tizanidine hcl TIER 1 mg tab)

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

JULUCA 50-25 MG TAB JULUCA dolutegravir sodium- TIER 2 rilpivirine hcl valganciclovir hcl (50 mg/ml valganciclovir hcl TIER 1 recon soln, 450 mg tab)

ANTI-HEPATITIS B (HBV) AGENTS

adefovir dipivoxil adefovir dipivoxil 10 mg tab TIER 1

©2021 Wellmark, Inc. 49 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS entecavir (0.5 mg tab, 1 mg entecavir TIER 1 tab) lamivudine lamivudine 100 mg tab TIER 1 VEMLIDY 25 MG TAB VEMLIDY tenofovir alafenamide SP-P fumarate

ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS

EPCLUSA 200-50 MG TAB EPCLUSA SP-P PA, QL (28 PER 28 DAY(S)) sofosbuvir-velpatasvir EPCLUSA 400-100 MG EPCLUSA TAB SP-P PA, QL (28 PER 28 DAYS) sofosbuvir-velpatasvir HARVONI (33.75-150 MG PACKET, 45-200 MG HARVONI SP-P PA, QL (28 PER 28 DAY(S)) PACKET, 45-200 MG TAB) ledipasvir-sofosbuvir HARVONI 90-400 MG TAB HARVONI SP-P PA, QL (28 PER 28 DAYS) ledipasvir-sofosbuvir LEDIPASVIR- LEDIPASVIR- SOFOSBUVIR 90-400 MG SP-P PA, QL (28 PER 28 DAYS) SOFOSBUVIR TAB ledipasvir-sofosbuvir MAVYRET 100-40 MG TAB MAVYRET SP-P PA, QL (84 PER 28 DAY(S)) glecaprevir-pibrentasvir SOFOSBUVIR- SOFOSBUVIR- VELPATASVIR 400-100 SP-P PA, QL (28 PER 28 DAYS) VELPATASVIR MG TAB sofosbuvir-velpatasvir VOSEVI 400-100-100 MG TAB VOSEVI SP-P PA, QL (28 PER 28 DAY(S)) sofosbuvir-velpatasvir- voxilaprevir

ANTI-HEPATITIS C (HCV) AGENTS, OTHER

moderiba moderiba 200 mg tab TIER 1 PEG-INTRON REDIPEN PEG-INTRON 120 MCG/0.5ML KIT SP-P REDIPEN peginterferon alfa-2b PEGASYS (180 MCG/0.5ML SOLUTION, PEGASYS SP-P PA, QL (4 PER 28 DAYS) 180 MCG/ML SOLUTION) peginterferon alfa-2a

©2021 Wellmark, Inc. 50 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PEGASYS PROCLICK PEGASYS (135 SOLUTION, 180 SP-P PA, QL (4 PER 28 DAYS) PROCLICK SOLUTION) peginterferon alfa-2a PEGINTRON 50 PEGINTRON MCG/0.5ML KIT SP-P peginterferon alfa-2b ribasphere (200 mg cap, ribasphere TIER 1 200 mg tab) ribavirin (200 mg cap, 200 ribavirin TIER 1 mg tab)

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)

GENVOYA 150-150-200-10 MG TAB GENVOYA elvitegravir-cobicistat- TIER 2 emtricitabine-tenofovir alafenamide ISENTRESS (25 MG CHEW TAB, 100 MG ISENTRESS TIER 2 CHEW TAB, 400 MG TAB) raltegravir potassium ISENTRESS HD 600 MG ISENTRESS HD TAB TIER 2 raltegravir potassium STRIBILD 150-150-200- 300 MG TAB STRIBILD TIER 2 elvitegravir-cobicistat- emtricitabine-tenofovir df SYMTUZA 800-150-200-10 MG TAB SYMTUZA darunavir-cobicistat- TIER 2 emtricitabine-tenofovir alafenamide TIVICAY (10 MG TAB, 25 TIVICAY MG TAB, 50 MG TAB) TIER 2 dolutegravir sodium TIVICAY PD 5 MG TAB TIVICAY PD SOL TIER 2 dolutegravir sodium

ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

COMPLERA 200-25-300 MG TAB COMPLERA emtricitabine-rilpivirine- TIER 2 tenofovir disoproxil fumarate

©2021 Wellmark, Inc. 51 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DELSTRIGO 100-300-300 MG TAB DELSTRIGO doravirine-lamivudine- TIER 2 tenofovir disoproxil fumarate EDURANT 25 MG TAB EDURANT TIER 2 rilpivirine hcl efavirenz (50 mg cap, 200 efavirenz TIER 1 mg cap, 600 mg tab) efavirenz-emtricitab- efavirenz-emtricitab- tenofovir 600-200-300 mg TIER 1 tenofovir tab etravirine (100 mg tab, 200 etravirine TIER 1 mg tab) INTELENCE 25 MG TAB INTELENCE TIER 2 etravirine nevirapine (50 mg/5ml nevirapine TIER 1 suspension, 200 mg tab) nevirapine er (er 100 mg nevirapine er tab er 24h, er 400 mg tab er TIER 1 24h) ODEFSEY 200-25-25 MG TAB ODEFSEY emtricitabine-rilpivirine- TIER 2 tenofovir alafenamide fumarate PIFELTRO 100 MG TAB PIFELTRO TIER 2 doravirine RESCRIPTOR (100 MG RESCRIPTOR TAB, 200 MG TAB) TIER 2 delavirdine mesylate

ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)

abacavir sulfate (20 mg/ml abacavir sulfate TIER 1 solution, 300 mg tab) abacavir sulfate- abacavir sulfate-lamivudine TIER 1 lamivudine 600-300 mg tab abacavir-lamivudine- abacavir-lamivudine- zidovudine 300-150-300 mg TIER 1 zidovudine tab CIMDUO 300-300 MG TAB CIMDUO lamivudine-tenofovir TIER 2 disoproxil fumarate didanosine (200 mg cap dr, didanosine 250 mg cap dr, 400 mg cap TIER 1 dr)

©2021 Wellmark, Inc. 52 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS emtricitabine emtricitabine 200 mg cap TIER 1 emtricitabine-tenofovir df emtricitabine-tenofovir (100-150 mg tab, 133-200 TIER 1 PV df mg tab, 167-250 mg tab, 200-300 mg tab) EMTRIVA 10 MG/ML EMTRIVA SOLUTION TIER 2 emtricitabine lamivudine (10 mg/ml lamivudine solution, 150 mg tab, 300 TIER 1 mg tab) lamivudine- lamivudine-zidovudine 150- TIER 1 zidovudine 300 mg tab stavudine (15 mg cap, 20 stavudine mg cap, 30 mg cap, 40 mg TIER 1 cap) TEMIXYS 300-300 MG TAB TEMIXYS TIER 2 lamivudine-tenofovir disoproxil fumarate tenofovir disoproxil tenofovir disoproxil TIER 1 fumarate fumarate 300 mg tab VIREAD (150 MG TAB, 200 MG TAB, 250 MG TAB) VIREAD TIER 2 tenofovir disoproxil fumarate zidovudine (50 mg/5ml zidovudine syrup, 100 mg cap, 300 mg TIER 1 tab)

ANTI-HIV AGENTS, OTHER

BIKTARVY 50-200-25 MG TAB BIKTARVY bictegravir-emtricitabine- TIER 2 tenofovir alafenamide fumarate CABENUVA (400 600 MG/2ML SUSP, 600 900 CABENUVA T6 MG/3ML SUSP) cabotegravir & rilpivirine DESCOVY 200-25 MG TAB DESCOVY emtricitabine-tenofovir TIER 2 PA, PV alafenamide fumarate DOVATO 50-300 MG TAB DOVATO dolutegravir sodium- TIER 2 lamivudine

©2021 Wellmark, Inc. 53 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS efavirenz-lamivudine- efavirenz-lamivudine- tenofovir (400-300-300 mg TIER 1 tenofovir tab, 600-300-300 mg tab) FUZEON 90 MG RECON FUZEON SOLN SP-P enfuvirtide RUKOBIA 600 MG TAB ER RUKOBIA 12H SP-P fostemsavir tromethamine SELZENTRY (25 MG TAB, 75 MG TAB, 150 MG TAB, SELZENTRY TIER 2 300 MG TAB) maraviroc TRIUMEQ 600-50-300 MG TAB TRIUMEQ TIER 2 abacavir-dolutegravir- lamivudine TYBOST 150 MG TAB TYBOST TIER 2 cobicistat

ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS 250 MG CAP APTIVUS TIER 2 tipranavir atazanavir sulfate (150 mg atazanavir sulfate cap, 200 mg cap, 300 mg TIER 1 cap) CRIXIVAN (200 MG CAP, CRIXIVAN 400 MG CAP) TIER 2 indinavir sulfate fosamprenavir fosamprenavir calcium 700 TIER 1 calcium mg tab INVIRASE (200 MG CAP, INVIRASE 500 MG TAB) TIER 2 saquinavir mesylate lopinavir-ritonavir (100-25 lopinavir-ritonavir mg tab, 200-50 mg tab, TIER 1 400-100 mg/5ml solution) NORVIR 100 MG CAP NORVIR TIER 2 ritonavir PREZISTA (75 MG TAB, 150 MG TAB, 600 MG TAB, PREZISTA TIER 2 800 MG TAB) darunavir ethanolate ritonavir ritonavir 100 mg tab TIER 1

ANTI-INFLUENZA AGENTS

oseltamivir phosphate (6 oseltamivir phosphate mg/ml recon susp, 30 mg TIER 1 cap, 45 mg cap, 75 mg cap) RELENZA DISKHALER 5 RELENZA MG/BLISTER AER POW TIER 2 DISKHALER BA zanamivir RIMANTADINE HCL 100 RIMANTADINE HCL MG TAB TIER 1 rimantadine hydrochloride

ANTIHERPETIC AGENTS

acyclovir (5 % cream, 5 % ointment, 200 mg cap, 200 acyclovir TIER 1 mg/5ml suspension, 400 mg tab, 800 mg tab) famciclovir (125 mg tab, famciclovir TIER 1 250 mg tab, 500 mg tab) trifluridine trifluridine 1 % solution TIER 1 valacyclovir hcl (1 gm tab, valacyclovir hcl TIER 1 500 mg tab)

ANXIOLYTICS

ANXIOLYTICS, OTHER

buspirone hcl (5 mg tab, 7.5 buspirone hcl mg tab, 10 mg tab, 15 mg TIER 1 tab, 30 mg tab) meprobamate (200 mg tab, meprobamate TIER 1 400 mg tab)

BENZODIAZEPINES

alprazolam (0.25 mg tab, 0.25 mg tab disp, 0.5 mg alprazolam tab, 0.5 mg tab disp, 1 mg TIER 1 tab, 1 mg tab disp, 2 mg tab, 2 mg tab disp) alprazolam er (er 0.5 mg tab er 24h, er 1 mg tab er alprazolam er TIER 1 24h, er 2 mg tab er 24h, er 3 mg tab er 24h)

©2021 Wellmark, Inc. 55 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ALPRAZOLAM INTENSOL ALPRAZOLAM 1 MG/ML CONC TIER 1 INTENSOL alprazolam alprazolam xr (0.5 mg tab er 24h, 1 mg tab er 24h, 2 alprazolam xr TIER 1 mg tab er 24h, 3 mg tab er 24h) chlordiazepoxide hcl (5 mg chlordiazepoxide hcl TIER 1 cap, 10 mg cap, 25 mg cap) clonazepam (0.125 mg tab disp, 0.25 mg tab disp, 0.5 clonazepam mg tab, 0.5 mg tab disp, 1 TIER 1 PV mg tab, 1 mg tab disp, 2 mg tab, 2 mg tab disp) clorazepate dipotassium clorazepate (3.75 mg tab, 7.5 mg tab, TIER 1 dipotassium 15 mg tab) diazepam (2 mg tab, 5 mg diazepam tab, 5 mg/5ml solution, 5 TIER 1 mg/ml conc, 10 mg tab) diazepam intensol 5 mg/ml diazepam intensol TIER 1 conc lorazepam (0.5 mg tab, 1 lorazepam mg tab, 2 mg tab, 2 mg/ml TIER 1 conc) lorazepam intensol 2 mg/ml lorazepam intensol TIER 1 conc oxazepam (10 mg cap, 15 oxazepam TIER 1 mg cap, 30 mg cap)

BIPOLAR AGENTS

MOOD STABILIZERS

lithium carbonate (150 mg lithium carbonate cap, 300 mg cap, 300 mg TIER 1 tab, 600 mg cap) lithium carbonate er (er 300 lithium carbonate er mg tab er, er 450 mg tab TIER 1 er)

BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTS

acarbose (25 mg tab, 50 acarbose TIER 1 PV mg tab, 100 mg tab) alogliptin benzoate (6.25 alogliptin benzoate mg tab, 12.5 mg tab, 25 mg TIER 1 PV tab)

©2021 Wellmark, Inc. 56 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS alogliptin-metformin hcl alogliptin-metformin (12.5-1000 mg tab, 12.5- TIER 1 PV hcl 500 mg tab) alogliptin-pioglitazone (12.5-15 mg tab, 12.5-30 alogliptin-pioglitazone mg tab, 12.5-45 mg tab, 25- TIER 1 PV 15 mg tab, 25-30 mg tab, 25-45 mg tab) AVANDAMET 2-1000 MG TAB AVANDAMET TIER 2 rosiglitazone maleate- metformin hcl BYDUREON (2 MG PEN, 2 BYDUREON MG SRER) TIER 2 QL (4 PER 28 DAYS), PV exenatide BYDUREON BCISE 2 BYDUREON BCISE MG/0.85ML A-INJ TIER 2 QL (4 PER 28 DAY(S)), PV exenatide CHLORPROPAMIDE (100 CHLORPROPAMIDE MG TAB, 250 MG TAB) TIER 1 PV chlorpropamide FARXIGA (5 MG TAB, 10 FARXIGA MG TAB) TIER 2 PV dapagliflozin propanediol glimepiride (1 mg tab, 2 mg glimepiride TIER 1 PV tab, 4 mg tab) glipizide (5 mg tab, 10 mg glipizide TIER 1 PV tab) glipizide er (er 2.5 mg tab glipizide er er 24h, er 5 mg tab er 24h, TIER 1 PV er 10 mg tab er 24h) glipizide xl (2.5 mg tab er glipizide xl 24h, 5 mg tab er 24h, 10 TIER 1 PV mg tab er 24h) glipizide-metformin hcl (2.5- glipizide-metformin 250 mg tab, 2.5-500 mg TIER 1 PV hcl tab, 5-500 mg tab) glyburide (1.25 mg tab, 2.5 glyburide TIER 1 PV mg tab, 5 mg tab) glyburide micronized (1.5 glyburide micronized TIER 1 PV mg tab, 3 mg tab, 6 mg tab) glyburide-metformin (1.25- glyburide-metformin 250 mg tab, 2.5-500 mg TIER 1 PV tab, 5-500 mg tab)

©2021 Wellmark, Inc. 57 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GLYXAMBI (10-5 MG TAB, GLYXAMBI 25-5 MG TAB) TIER 2 PV empagliflozin-linagliptin JANUMET (50-1000 MG JANUMET TAB, 50-500 MG TAB) TIER 2 PV sitagliptin-metformin hcl JANUMET XR (50-1000 MG TAB ER 24H, 50-500 JANUMET XR MG TAB ER 24H, 100-1000 TIER 2 PV MG TAB ER 24H) sitagliptin-metformin hcl JANUVIA (25 MG TAB, 50 JANUVIA MG TAB, 100 MG TAB) TIER 2 PV sitagliptin phosphate JARDIANCE (10 MG TAB, JARDIANCE 25 MG TAB) TIER 2 PV empagliflozin metformin hcl (500 mg tab, metformin hcl TIER 1 PV 850 mg tab, 1000 mg tab) metformin hcl 500 mg/5ml PA, QL (765 PER 30 metformin hcl TIER 1 solution DAY(S)), PV metformin hcl er (er 500 mg metformin hcl er tab er 24h, er 750 mg tab er TIER 1 PV 24h) miglitol (25 mg tab, 50 mg miglitol TIER 1 PV tab, 100 mg tab) nateglinide (60 mg tab, 120 nateglinide TIER 1 PV mg tab) OZEMPIC (0.25 OR 0.5 OZEMPIC (0.25 OR MG/DOSE) 2 MG/1.5ML TIER 2 QL (1 PER 28 DAY(S)), PV 0.5 MG/DOSE) SOLN PEN semaglutide OZEMPIC (1 MG/DOSE) (2 OZEMPIC (1 MG/1.5ML SOLN PEN, 4 TIER 2 QL (2 PER 28 DAY(S)) MG/DOSE) MG/3ML SOLN PEN) semaglutide pioglitazone hcl (15 mg tab, pioglitazone hcl TIER 1 PV 30 mg tab, 45 mg tab) pioglitazone hcl- pioglitazone hcl-glimepiride TIER 1 PV glimepiride (30-2 mg tab, 30-4 mg tab) pioglitazone hcl-metformin pioglitazone hcl- hcl (-metformin 15-500 mg TIER 1 PV metformin hcl tab, -metformin 15-850 mg tab) repaglinide (0.5 mg tab, 1 repaglinide TIER 1 PV mg tab, 2 mg tab)

©2021 Wellmark, Inc. 58 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS REPAGLINIDE- REPAGLINIDE- METFORMIN HCL (1-500 TIER 1 METFORMIN HCL MG TAB, 2-500 MG TAB) repaglinide-metformin hcl RIOMET ER 500 MG/5ML PA, QL (765 PER 30 RIOMET ER SRER TIER 2 DAY(S)), PV metformin hcl RYBELSUS (3 MG TAB, 7 RYBELSUS MG TAB, 14 MG TAB) TIER 2 PV semaglutide SYMLINPEN 120 2700 SYMLINPEN 120 MCG/2.7ML SOLN PEN TIER 2 PV pramlintide acetate SYMLINPEN 60 1500 SYMLINPEN 60 MCG/1.5ML SOLN PEN TIER 2 PV pramlintide acetate SYNJARDY (5-1000 MG TAB, 5-500 MG TAB, 12.5- SYNJARDY 1000 MG TAB, 12.5-500 TIER 2 PV MG TAB) empagliflozin-metformin hcl SYNJARDY XR (5-1000 MG TAB ER 24H, 10-1000 MG TAB ER 24H, 12.5- SYNJARDY XR TIER 2 PV 1000 MG TAB ER 24H, 25- 1000 MG TAB ER 24H) empagliflozin-metformin hcl TOLAZAMIDE (250 MG TOLAZAMIDE TAB, 500 MG TAB) TIER 1 PV tolazamide TOLBUTAMIDE 500 MG TOLBUTAMIDE TAB TIER 1 PV tolbutamide TRIJARDY XR (5-2.5-1000 MG TAB ER 24H, 10-5- 1000 MG TAB ER 24H, 12.5-2.5-1000 MG TAB ER TRIJARDY XR TIER 2 PV 24H, 25-5-1000 MG TAB ER 24H) empagliflozin-linagliptin- metformin VICTOZA 18 MG/3ML VICTOZA SOLN PEN TIER 2 QL (3 PER 30 DAYS), PV liraglutide

©2021 Wellmark, Inc. 59 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS XIGDUO XR (2.5-1000 MG TAB ER 24H, 5-1000 MG TAB ER 24H, 5-500 MG XIGDUO XR TAB ER 24H, 10-1000 MG TIER 2 PV TAB ER 24H, 10-500 MG TAB ER 24H) dapagliflozin-metformin hcl

GLYCEMIC AGENTS

BAQSIMI ONE PACK 3 BAQSIMI ONE PACK MG/DOSE POWDER TIER 2 QL (2 PER RX) glucagon BAQSIMI TWO PACK 3 BAQSIMI TWO PACK MG/DOSE POWDER TIER 2 QL (2 PER RX) glucagon diazoxide 50 mg/ml diazoxide TIER 1 suspension GLUCAGEN HYPOKIT 1 GLUCAGEN MG RECON SOLN TIER 2 HYPOKIT glucagon hcl (rdna) glucagon emergency 1 mg glucagon emergency TIER 1 kit GLUCAGON EMERGENCY GLUCAGON 1 MG/ML RECON SOLN TIER 2 QL (2 PER RX) EMERGENCY glucagon hcl GVOKE HYPOPEN 1- PACK (0.5 MG/0.1ML GVOKE HYPOPEN SOLN A-INJ, 1 MG/0.2ML TIER 2 QL (2 PER FILL(S)) 1-PACK SOLN A-INJ) glucagon GVOKE HYPOPEN 2- PACK (0.5 MG/0.1ML GVOKE HYPOPEN SOLN A-INJ, 1 MG/0.2ML TIER 2 QL (2 PER FILL(S)) 2-PACK SOLN A-INJ) glucagon GVOKE PFS (0.5 MG/0.1ML SOLN PRSYR, GVOKE PFS 1 MG/0.2ML SOLN TIER 2 QL (2 PER RX) PRSYR) glucagon

INSULINS

BASAGLAR KWIKPEN 100 BASAGLAR UNIT/ML SOLN PEN TIER 2 PV KWIKPEN insulin glargine

©2021 Wellmark, Inc. 60 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FIASP 100 UNIT/ML SOLUTION FIASP TIER 2 PV insulin aspart (with niacinamide) FIASP FLEXTOUCH 100 UNIT/ML SOLN PEN FIASP FLEXTOUCH TIER 2 PV insulin aspart (with niacinamide) FIASP PENFILL 100 UNIT/ML SOLN CART FIASP PENFILL TIER 2 PV insulin aspart (with niacinamide) HUMULIN R U-500 HUMULIN R U-500 (CONCENTRATED) 500 TIER 2 PV (CONCENTRATED) UNIT/ML SOLUTION insulin regular (human) HUMULIN R U-500 HUMULIN R U-500 KWIKPEN 500 UNIT/ML TIER 2 PV KWIKPEN SOLN PEN insulin regular (human) INSULIN ASP PROT & ASP FLEXPEN (70-30) 100 INSULIN ASP PROT UNIT/ML SUSP PEN TIER 2 PV & ASP FLEXPEN insulin aspart protamine & aspart (human) INSULIN ASPART 100 INSULIN ASPART UNIT/ML SOLUTION TIER 2 PV insulin aspart INSULIN ASPART INSULIN ASPART FLEXPEN 100 UNIT/ML TIER 2 PV FLEXPEN SOLN PEN insulin aspart INSULIN ASPART INSULIN ASPART PENFILL 100 UNIT/ML TIER 2 PV PENFILL SOLN CART insulin aspart INSULIN ASPART PROT & ASPART (70-30) 100 INSULIN ASPART UNIT/ML SUSPENSION TIER 2 PV PROT & ASPART insulin aspart protamine & aspart (human) LEVEMIR 100 UNIT/ML LEVEMIR SOLUTION TIER 2 PV insulin detemir LEVEMIR FLEXTOUCH LEVEMIR 100 UNIT/ML SOLN PEN TIER 2 PV FLEXTOUCH insulin detemir

©2021 Wellmark, Inc. 61 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NOVOLIN 70/30 (70-30) 100 UNIT/ML NOVOLIN 70/30 SUSPENSION TIER 2 PV insulin nph isophane & reg (human) NOVOLIN 70/30 FLEXPEN (70-30) 100 UNIT/ML NOVOLIN 70/30 SUSP PEN TIER 2 FLEXPEN insulin nph isophane & reg (human) NOVOLIN 70/30 FLEXPEN RELION (70-30) 100 NOVOLIN 70/30 UNIT/ML SUSP PEN TIER 2 FLEXPEN RELION insulin nph isophane & reg (human) NOVOLIN 70/30 RELION (70-30) 100 UNIT/ML NOVOLIN 70/30 SUSPENSION TIER 2 PV RELION insulin nph isophane & reg (human) NOVOLIN N 100 UNIT/ML SUSPENSION NOVOLIN N TIER 2 PV insulin nph (human) (isophane) NOVOLIN N FLEXPEN 100 NOVOLIN N UNIT/ML SUSP PEN TIER 2 PV FLEXPEN insulin nph (human) (isophane) NOVOLIN N FLEXPEN RELION 100 UNIT/ML NOVOLIN N SUSP PEN TIER 2 PV FLEXPEN RELION insulin nph (human) (isophane) NOVOLIN N RELION 100 UNIT/ML SUSPENSION NOVOLIN N RELION TIER 2 PV insulin nph (human) (isophane) NOVOLIN R 100 UNIT/ML NOVOLIN R SOLUTION TIER 2 PV insulin regular (human) NOVOLIN R FLEXPEN 100 NOVOLIN R UNIT/ML SOLN PEN TIER 2 PV FLEXPEN insulin regular (human) NOVOLIN R FLEXPEN NOVOLIN R RELION 100 UNIT/ML TIER 2 PV FLEXPEN RELION SOLN PEN insulin regular (human)

©2021 Wellmark, Inc. 62 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NOVOLIN R RELION 100 NOVOLIN R RELION UNIT/ML SOLUTION TIER 2 PV insulin regular (human) NOVOLOG 100 UNIT/ML NOVOLOG SOLUTION TIER 2 PV insulin aspart NOVOLOG 70/30 FLEXPEN RELION (70-30) NOVOLOG 70/30 100 UNIT/ML SUSP PEN TIER 2 PV FLEXPEN RELION insulin aspart protamine & aspart (human) NOVOLOG FLEXPEN 100 NOVOLOG UNIT/ML SOLN PEN TIER 2 PV FLEXPEN insulin aspart NOVOLOG FLEXPEN NOVOLOG RELION 100 UNIT/ML TIER 2 PV FLEXPEN RELION SOLN PEN insulin aspart NOVOLOG MIX 70/30 (70- 30) 100 UNIT/ML NOVOLOG MIX SUSPENSION TIER 2 PV 70/30 insulin aspart protamine & aspart (human) NOVOLOG MIX 70/30 FLEXPEN (70-30) 100 NOVOLOG MIX UNIT/ML SUSP PEN TIER 2 PV 70/30 FLEXPEN insulin aspart protamine & aspart (human) NOVOLOG MIX 70/30 RELION (70-30) 100 NOVOLOG MIX UNIT/ML SUSPENSION TIER 2 PV 70/30 RELION insulin aspart protamine & aspart (human) NOVOLOG PENFILL 100 NOVOLOG PENFILL UNIT/ML SOLN CART TIER 2 PV insulin aspart NOVOLOG RELION 100 NOVOLOG RELION UNIT/ML SOLUTION TIER 2 PV insulin aspart TRESIBA 100 UNIT/ML TRESIBA SOLUTION TIER 2 PV insulin degludec TRESIBA FLEXTOUCH TRESIBA (100 SOLN PEN, 200 TIER 2 PV FLEXTOUCH SOLN PEN) insulin degludec

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS

ANTICOAGULANTS

COUMADIN (1 MG TAB, 2 MG TAB, 2.5 MG TAB, 3 MG TAB, 4 MG TAB, 5 MG COUMADIN TIER 2 GA TAB, 6 MG TAB, 7.5 MG TAB, 10 MG TAB) warfarin sodium ELIQUIS (2.5 MG TAB, 5 ELIQUIS MG TAB) TIER 2 PV apixaban ELIQUIS DVT/PE ELIQUIS DVT/PE STARTER PACK 5 MG TIER 2 PV STARTER PACK TAB THPK apixaban enoxaparin sodium (30 mg/0.3ml solution, 40 mg/0.4ml solution, 60 mg/0.6ml solution, 80 enoxaparin sodium mg/0.8ml solution, 100 TIER 1 PV mg/ml solution, 120 mg/0.8ml solution, 150 mg/ml solution, 300 mg/3ml solution) fondaparinux sodium (2.5 mg/0.5ml solution, 5 fondaparinux sodium mg/0.4ml solution, 7.5 TIER 1 PV mg/0.6ml solution, 10 mg/0.8ml solution) FRAGMIN (2500 UNIT/0.2ML SOLUTION, 5000 UNIT/0.2ML SOLUTION, 7500 UNIT/0.3ML SOLUTION, 10000 UNIT/ML SOLUTION, 12500 FRAGMIN TIER 2 PV UNIT/0.5ML SOLUTION, 15000 UNIT/0.6ML SOLUTION, 18000 UNT/0.72ML SOLUTION, 95000 UNIT/3.8ML SOLUTION) dalteparin sodium

©2021 Wellmark, Inc. 64 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HEPARIN LOCK FLUSH (1 SOLUTION, 2 SOLUTION, HEPARIN LOCK 10 SOLUTION, 100 TIER 1 FLUSH SOLUTION) heparin sodium (porcine) lock flush heparin sodium (porcine) heparin sodium (5000 solution, 10000 TIER 1 (porcine) solution) heparin sodium heparin sodium (porcine) pf TIER 1 (porcine) pf 5000 unit/0.5ml solution heparin sodium lock heparin sodium lock flush TIER 1 flush 100 unit/ml solution IPRIVASK 15 MG RECON IPRIVASK SOLN T6 desirudin jantoven (1 mg tab, 2 mg tab, 2.5 mg tab, 3 mg tab, 4 jantoven TIER 1 PV mg tab, 5 mg tab, 6 mg tab, 7.5 mg tab, 10 mg tab) warfarin sodium (1 mg tab, 2 mg tab, 2.5 mg tab, 3 mg warfarin sodium tab, 4 mg tab, 5 mg tab, 6 TIER 1 PV mg tab, 7.5 mg tab, 10 mg tab) XARELTO (2.5 MG TAB, 10 MG TAB, 15 MG TAB, XARELTO TIER 2 PV 20 MG TAB) rivaroxaban XARELTO STARTER XARELTO STARTER PACK 15 & 20 MG TAB TIER 2 PV PACK THPK rivaroxaban

BLOOD FORMATION MODIFIERS

anagrelide hcl (0.5 mg cap, anagrelide hcl TIER 1 1 mg cap)

©2021 Wellmark, Inc. 65 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ARANESP (ALBUMIN FREE) (10 MCG/0.4ML SOLN PRSYR, 25 MCG/0.42ML SOLN PRSYR, 25 MCG/ML SOLUTION, 40 MCG/0.4ML SOLN PRSYR, 40 MCG/ML SOLUTION, 60 MCG/0.3ML SOLN PRSYR, 60 MCG/ML ARANESP (ALBUMIN SOLUTION, 100 SP-P FREE) MCG/0.5ML SOLN PRSYR, 100 MCG/ML SOLUTION, 150 MCG/0.3ML SOLN PRSYR, 200 MCG/0.4ML SOLN PRSYR, 200 MCG/ML SOLUTION, 300 MCG/0.6ML SOLN PRSYR, 300 MCG/ML SOLUTION, 500 MCG/ML SOLN PRSYR) darbepoetin alfa CABLIVI 11 MG KIT CABLIVI SP-P caplacizumab-yhdp DOPTELET 20 MG TAB DOPTELET SP-P QL (60 PER 30 DAY(S)) avatrombopag maleate EPOGEN (2000 SOLUTION, 3000 SOLUTION, 4000 MN-PA (Medically Necessary EPOGEN SOLUTION, 10000 SP-P Prior Authorization) SOLUTION, 20000 SOLUTION) epoetin alfa FULPHILA 6 MG/0.6ML SBG (Specialty Biosimilars FULPHILA SOLN PRSYR SP-P and Specialty generics) pegfilgrastim-jmdb MIRCERA (30 SOLN PRSYR, 50 SOLN PRSYR, 75 SOLN PRSYR, 100 SOLN PRSYR, 150 SOLN MN-PA (Medically Necessary MIRCERA SP-P PRSYR, 200 SOLN Prior Authorization) PRSYR) methoxy polyethylene glycol-epoetin beta MOZOBIL 24 MG/1.2ML MOZOBIL SOLUTION T6 plerixafor

©2021 Wellmark, Inc. 66 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MULPLETA 3 MG TAB MULPLETA SP-P QL (7 PER 14 DAY(S)) lusutrombopag NEULASTA 6 MG/0.6ML MN-PA (Medically Necessary NEULASTA SOLN PRSYR SP-P Prior Authorization) pegfilgrastim NEULASTA ONPRO 6 NEULASTA ONPRO MG/0.6ML PREF SY KT SP-P PA pegfilgrastim NIVESTYM (300 MCG/0.5ML SOLN PRSYR, 300 MCG/ML SOLUTION, SBG (Specialty Biosimilars NIVESTYM 480 MCG/0.8ML SOLN SP-P and Specialty generics) PRSYR, 480 MCG/1.6ML SOLUTION) filgrastim-aafi NPLATE (125 MCG RECON SOLN, 250 MCG NPLATE RECON SOLN, 500 MCG T6 RECON SOLN) romiplostim NYVEPRIA 6 MG/0.6ML SBG (Specialty Biosimilars NYVEPRIA SOLN PRSYR SP-P and Specialty generics) pegfilgrastim-apgf PROCRIT (2000 SOLUTION, 3000 SOLUTION, 4000 SOLUTION, 10000 MN-PA (Medically Necessary PROCRIT SP-P SOLUTION, 20000 Prior Authorization) SOLUTION, 40000 SOLUTION) epoetin alfa PROMACTA (12.5 MG PROMACTA PACKET, 25 MG PACKET) SP-P QL (90 PER 30 DAY(S)) eltrombopag olamine PROMACTA (25 MG TAB, PROMACTA 50 MG TAB) SP-P QL (90 PER 30 DAYS) eltrombopag olamine PROMACTA 12.5 MG TAB PROMACTA SP-P QL (30 PER 30 DAYS) eltrombopag olamine PROMACTA 75 MG TAB PROMACTA SP-P QL (60 PER 30 DAYS) eltrombopag olamine REBLOZYL (25 MG RECON SOLN, 75 MG REBLOZYL T6 RECON SOLN) luspatercept-aamt

©2021 Wellmark, Inc. 67 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS RETACRIT (2000 SOLUTION, 3000 SOLUTION, 4000 SOLUTION, 10000 SBG (Specialty Biosimilars RETACRIT SP-P SOLUTION, 20000 and Specialty generics) SOLUTION, 40000 SOLUTION) epoetin alfa-epbx TAVALISSE (100 MG TAB, TAVALISSE 150 MG TAB) SP-P PA fostamatinib disodium UDENYCA 6 MG/0.6ML SBG (Specialty Biosimilars UDENYCA SOLN PRSYR SP-P and Specialty generics) pegfilgrastim-cbqv ZARXIO (300 MCG/0.5ML SOLN PRSYR, 480 SBG (Specialty Biosimilars ZARXIO SP-P MCG/0.8ML SOLN PRSYR) and Specialty generics) filgrastim-sndz ZIEXTENZO 6 MG/0.6ML SBG (Specialty Biosimilars ZIEXTENZO SOLN PRSYR SP-P and Specialty generics) pegfilgrastim-bmez

HEMOSTASIS AGENTS

ADVATE (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 1500 RECON SOLN, 2000 RECON SOLN, 3000 ADVATE T6 RECON SOLN, 4000 RECON SOLN) antihemophilic factor (rcmb) plasma/albumin free (rahf- pfm) ADYNOVATE (250 RECON SOLN, 500 RECON SOLN, 750 RECON SOLN, 1000 RECON SOLN, 1500 ADYNOVATE RECON SOLN, 2000 T6 RECON SOLN, 3000 RECON SOLN) antihemophilic factor (recombinant) pegylated

©2021 Wellmark, Inc. 68 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS AFSTYLA (250 KIT, 500 KIT, 1000 KIT, 1500 KIT, 2000 KIT, 2500 KIT, 3000 AFSTYLA T6 KIT) antihemophilic factor (recombinant) single chain ALPHANATE (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 1500 RECON SOLN, 2000 ALPHANATE T6 RECON SOLN) antihemophilic factor/von willebrand factor complex (human) ALPHANATE/VWF COMPLEX/HUMAN (250 RECON SOLN, 500 RECON SOLN, 1000 ALPHANATE/VWF RECON SOLN, 1500 T6 COMPLEX/HUMAN RECON SOLN, 2000 RECON SOLN) antihemophilic factor/von willebrand factor complex (human) ALPHANINE SD (500 RECON SOLN, 1000 ALPHANINE SD RECON SOLN, 1500 T6 RECON SOLN) coagulation factor ix ALPROLIX (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 2000 RECON SOLN, 3000 ALPROLIX RECON SOLN, 4000 T6 RECON SOLN) coagulation factor ix (recomb) fc fusion protein (rfixfc) aminocaproic acid (0.25 aminocaproic acid gm/ml solution, 500 mg tab, TIER 1 1000 mg tab) BEBULIN 200-1200 UNIT BEBULIN RECON SOLN T6 factor ix complex

©2021 Wellmark, Inc. 69 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BENEFIX (250 KIT, 500 KIT, 1000 KIT, 2000 KIT, BENEFIX 3000 KIT) T6 coagulation factor ix (recombinant) COAGADEX (250 RECON SOLN, 500 RECON SOLN) COAGADEX T6 coagulation factor x (human) ELOCTATE (250 RECON SOLN, 500 RECON SOLN, 750 RECON SOLN, 1000 RECON SOLN, 1500 RECON SOLN, 2000 RECON SOLN, 3000 ELOCTATE T6 RECON SOLN, 4000 RECON SOLN, 5000 RECON SOLN, 6000 RECON SOLN) antihemophilic factor (rcmb) fc fusion protein(bdd-rfviiifc) FEIBA (500 RECON SOLN, 1000 RECON SOLN, 2500 FEIBA RECON SOLN) T6 antiinhibitor coagulant complex FEIBA NF RECON SOLN FEIBA NF antiinhibitor coagulant T6 complex HELIXATE FS (250 KIT, 500 KIT, 1000 KIT, 2000 HELIXATE FS KIT, 3000 KIT) T6 antihemophilic factor (recombinant) HEMLIBRA (30 MG/ML SOLUTION, 60 MG/0.4ML SOLUTION, 105 MG/0.7ML HEMLIBRA T6 SOLUTION, 150 MG/ML SOLUTION) emicizumab-kxwh HEMOFIL M (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 1700 HEMOFIL M T6 RECON SOLN) antihemophilic factor (human)

©2021 Wellmark, Inc. 70 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HUMATE-P (250-600 RECON SOLN, 500-1200 RECON SOLN, 1000-2400 HUMATE-P RECON SOLN) T6 antihemophilic factor/von willebrand factor complex (human) IDELVION (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 2000 RECON SOLN, 3500 IDELVION T6 RECON SOLN) coagulation factor ix recomb albumin fusion protein (rix-fp) IXINITY (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 1500 RECON SOLN, 2000 IXINITY T6 RECON SOLN, 3000 RECON SOLN) coagulation factor ix (recombinant) JIVI (500 RECON SOLN, 1000 RECON SOLN, 2000 RECON SOLN, 3000 JIVI RECON SOLN) T6 antihemophil fact(rcmb) pegylated-aucl (bdd-rfviii peg-aucl) KOATE (250 RECON SOLN, 500 RECON SOLN, KOATE 1000 RECON SOLN) T6 antihemophilic factor (human) KOATE-DVI (250 RECON SOLN, 500 RECON SOLN, KOATE-DVI 1000 RECON SOLN) T6 antihemophilic factor (human) KOGENATE FS (250 KIT, 500 KIT, 1000 KIT, 2000 KOGENATE FS KIT, 3000 KIT) T6 antihemophilic factor (recombinant)

©2021 Wellmark, Inc. 71 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS KOGENATE FS BIO-SET (250 KIT, 500 KIT, 1000 KOGENATE FS BIO- KIT, 2000 KIT, 3000 KIT) T6 SET antihemophilic factor (recombinant) KOVALTRY (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 2000 RECON SOLN, 3000 KOVALTRY T6 RECON SOLN) antihemophilic factor (rcmb) plasma/albumin free (rahf- pfm) MONOCLATE-P (1000 KIT, 1500 KIT) MONOCLATE-P T6 antihemophilic factor (human) MONONINE 1000 UNIT MONONINE RECON SOLN T6 coagulation factor ix NOVOEIGHT (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 1500 RECON SOLN, 2000 NOVOEIGHT T6 RECON SOLN, 3000 RECON SOLN) antihemophilic factor (rcmb) bd truncated (bd trunc-rfviii) NOVOSEVEN RT (1 MG RECON SOLN, 2 MG RECON SOLN, 5 MG NOVOSEVEN RT RECON SOLN, 8 MG T6 RECON SOLN) coagulation factor viia (recombinant)

©2021 Wellmark, Inc. 72 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NUWIQ (250 KIT, 250 RECON SOLN, 500 KIT, 500 RECON SOLN, 1000 KIT, 1000 RECON SOLN, 2000 KIT, 2000 RECON SOLN, 2500 KIT, 2500 NUWIQ T6 RECON SOLN, 3000 KIT, 3000 RECON SOLN, 4000 KIT, 4000 RECON SOLN) antihemophilic factor (rcmb) simoctocog alfa(bdd- rfviii,sim) OBIZUR 500 UNIT RECON SOLN OBIZUR antihemophilic factor T6 (recombinant porcine) (rpfviii) PROFILNINE (500 RECON SOLN, 1000 RECON PROFILNINE SOLN, 1500 RECON T6 SOLN) factor ix complex PROFILNINE SD 500 UNIT PROFILNINE SD RECON SOLN T6 factor ix complex REBINYN (500 RECON SOLN, 1000 RECON SOLN, 2000 RECON REBINYN SOLN) T6 coagulation factor ix (recombinant) glycopegylated RECOMBINATE (220-400 RECON SOLN, 401-800 RECON SOLN, 801-1240 RECON SOLN, 1241-1800 RECOMBINATE T6 RECON SOLN, 1801-2400 RECON SOLN) antihemophilic factor (recombinant) RIXUBIS (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 2000 RIXUBIS RECON SOLN, 3000 T6 RECON SOLN) coagulation factor ix (recombinant)

©2021 Wellmark, Inc. 73 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SEVENFACT (1 MG RECON SOLN, 5 MG SEVENFACT RECON SOLN) T6 coagulation factor viia (recombinant)-jncw tranexamic acid tranexamic acid 650 mg tab TIER 1 VONVENDI (650 RECON SOLN, 1300 RECON VONVENDI SOLN) T6 von willebrand factor (recombinant) WILATE (500-500 KIT, 1000-1000 KIT) WILATE antihemophilic factor/von T6 willebrand factor complex (human) XYNTHA (250 KIT, 500 KIT, 1000 KIT, 2000 KIT) XYNTHA antihemophilic factor (rcmb) T6 moroctocog alfa(bdd- rfviii,mor) XYNTHA SOLOFUSE (250 KIT, 500 KIT, 1000 KIT, 2000 KIT, 3000 KIT) XYNTHA SOLOFUSE T6 antihemophilic factor (rcmb) moroctocog alfa(bdd- rfviii,mor)

PLATELET MODIFYING AGENTS

ADAKVEO 100 MG/10ML ADAKVEO SOLUTION T6 crizanlizumab-tmca aspirin-dipyridamole aspirin-dipyridamole er 25- TIER 1 PV er 200 mg cap er 12h BRILINTA (60 MG TAB, 90 BRILINTA MG TAB) TIER 2 PV ticagrelor cilostazol (50 mg tab, 100 cilostazol TIER 1 mg tab) clopidogrel bisulfate (75 mg clopidogrel bisulfate TIER 1 PV tab, 300 mg tab) dipyridamole (25 mg tab, 50 dipyridamole TIER 1 PV mg tab, 75 mg tab) prasugrel hcl (5 mg tab, 10 prasugrel hcl TIER 1 PV mg tab)

COAGULANTS

phytonadione phytonadione 5 mg tab TIER 1

CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

clonidine (0.1 mg/24hr patch wk, 0.2 mg/24hr clonidine TIER 1 PV patch wk, 0.3 mg/24hr patch wk) clonidine hcl (0.1 mg tab, clonidine hcl TIER 1 PV 0.2 mg tab, 0.3 mg tab) guanfacine hcl (1 mg tab, 2 guanfacine hcl TIER 1 QL (30 PER 30 DAY(S)), PV mg tab) methyldopa (250 mg tab, methyldopa TIER 1 PV 500 mg tab) midodrine hcl (2.5 mg tab, 5 midodrine hcl TIER 1 mg tab, 10 mg tab)

ALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate (1 mg doxazosin mesylate tab, 2 mg tab, 4 mg tab, 8 TIER 1 mg tab) phenoxybenzamine phenoxybenzamine hcl 10 TIER 1 hcl mg cap prazosin hcl (1 mg cap, 2 prazosin hcl TIER 1 mg cap, 5 mg cap) terazosin hcl (1 mg cap, 2 terazosin hcl mg cap, 5 mg cap, 10 mg TIER 1 cap)

ANGIOTENSIN II RECEPTOR ANTAGONISTS

candesartan cilexetil (4 mg candesartan cilexetil tab, 8 mg tab, 16 mg tab, TIER 1 PV 32 mg tab) EPROSARTAN EPROSARTAN MESYLATE 600 MG TAB TIER 1 PV MESYLATE eprosartan mesylate irbesartan (75 mg tab, 150 irbesartan TIER 1 PV mg tab, 300 mg tab) losartan potassium (25 mg losartan potassium TIER 1 PV tab, 50 mg tab, 100 mg tab) olmesartan medoxomil (5 olmesartan mg tab, 20 mg tab, 40 mg TIER 1 PV medoxomil tab)

©2021 Wellmark, Inc. 75 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS telmisartan (20 mg tab, 40 telmisartan TIER 1 PV mg tab, 80 mg tab) valsartan (40 mg tab, 80 valsartan mg tab, 160 mg tab, 320 TIER 1 PV mg tab)

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

benazepril hcl (5 mg tab, 10 benazepril hcl mg tab, 20 mg tab, 40 mg TIER 1 PV tab) captopril (12.5 mg tab, 25 captopril mg tab, 50 mg tab, 100 mg TIER 1 PV tab) enalapril maleate (2.5 mg enalapril maleate tab, 5 mg tab, 10 mg tab, TIER 1 PV 20 mg tab) enalapril maleate 1 mg/ml PA, QL (1200 PER 30 enalapril maleate TIER 1 solution DAY(S)) fosinopril sodium (10 mg fosinopril sodium TIER 1 PV tab, 20 mg tab, 40 mg tab) lisinopril (2.5 mg tab, 5 mg lisinopril tab, 10 mg tab, 20 mg tab, TIER 1 PV 30 mg tab, 40 mg tab) moexipril hcl (7.5 mg tab, moexipril hcl TIER 1 PV 15 mg tab) perindopril erbumine (2 mg perindopril erbumine TIER 1 PV tab, 4 mg tab, 8 mg tab) quinapril hcl (5 mg tab, 10 quinapril hcl mg tab, 20 mg tab, 40 mg TIER 1 PV tab) ramipril (1.25 mg cap, 2.5 ramipril mg cap, 5 mg cap, 10 mg TIER 1 PV cap) trandolapril (1 mg tab, 2 mg trandolapril TIER 1 PV tab, 4 mg tab)

ANTIARRHYTHMICS

amiodarone hcl (100 mg amiodarone hcl tab, 200 mg tab, 400 mg TIER 1 PV tab) disopyramide disopyramide phosphate TIER 1 PV phosphate (100 mg cap, 150 mg cap) dofetilide (125 mcg cap, dofetilide TIER 1 PV 250 mcg cap, 500 mcg cap) flecainide acetate (50 mg flecainide acetate tab, 100 mg tab, 150 mg TIER 1 PV tab)

©2021 Wellmark, Inc. 76 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS mexiletine hcl (150 mg cap, mexiletine hcl TIER 1 200 mg cap, 250 mg cap) pacerone (100 mg tab, 200 pacerone TIER 1 PV mg tab, 400 mg tab) propafenone hcl (150 mg propafenone hcl tab, 225 mg tab, 300 mg TIER 1 PV tab) propafenone hcl er (er 225 mg cap er 12h, er 325 mg propafenone hcl er TIER 1 PV cap er 12h, er 425 mg cap er 12h) quinidine gluconate er 324 quinidine gluconate er TIER 1 mg tab er QUINIDINE SULFATE (200 QUINIDINE MG TAB, 300 MG TAB) TIER 1 SULFATE quinidine sulfate sorine (80 mg tab, 120 mg sorine tab, 160 mg tab, 240 mg TIER 1 PV tab) sotalol hcl (80 mg tab, 120 sotalol hcl mg tab, 160 mg tab, 240 TIER 1 PV mg tab) sotalol hcl (af) (80 mg tab, sotalol hcl (af) TIER 1 PV 120 mg tab, 160 mg tab)

BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl (200 mg cap, acebutolol hcl TIER 1 PV 400 mg cap) atenolol (25 mg tab, 50 mg atenolol TIER 1 PV tab, 100 mg tab) betaxolol hcl (10 mg tab, 20 betaxolol hcl TIER 1 PV mg tab) bisoprolol fumarate (5 mg bisoprolol fumarate TIER 1 PV tab, 10 mg tab) carvedilol (3.125 mg tab, carvedilol 6.25 mg tab, 12.5 mg tab, TIER 1 PV 25 mg tab) carvedilol phosphate er (er carvedilol phosphate 10 mg cap er 24h, er 20 mg TIER 1 PV er cap er 24h, er 40 mg cap er 24h, er 80 mg cap er 24h) labetalol hcl (100 mg tab, labetalol hcl TIER 1 PV 200 mg tab, 300 mg tab)

©2021 Wellmark, Inc. 77 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS metoprolol succinate er (er metoprolol succinate 25 mg tab er 24h, er 50 mg TIER 1 PV er tab er 24h, er 100 mg tab er 24h, er 200 mg tab er 24h) metoprolol tartrate (25 mg metoprolol tartrate TIER 1 PV tab, 50 mg tab, 100 mg tab) nadolol (20 mg tab, 40 mg nadolol TIER 1 PV tab, 80 mg tab) pindolol (5 mg tab, 10 mg pindolol TIER 1 PV tab) propranolol hcl (10 mg tab, 20 mg tab, 20 mg/5ml propranolol hcl solution, 40 mg tab, 40 TIER 1 PV mg/5ml solution, 60 mg tab, 80 mg tab) propranolol hcl er (er 60 mg cap er 24h, er 80 mg cap er propranolol hcl er TIER 1 PV 24h, er 120 mg cap er 24h, er 160 mg cap er 24h) timolol maleate (5 mg tab, timolol maleate TIER 1 PV 10 mg tab, 20 mg tab)

CALCIUM CHANNEL BLOCKING AGENTS

afeditab cr (30 mg tab er afeditab cr TIER 1 PV 24h, 60 mg tab er 24h) amlodipine besylate (2.5 amlodipine besylate mg tab, 5 mg tab, 10 mg TIER 1 PV tab) cartia xt (120 mg cap er 24h, 180 mg cap er 24h, cartia xt TIER 1 PV 240 mg cap er 24h, 300 mg cap er 24h) dilt-xr (120 mg cap er 24h, dilt-xr 180 mg cap er 24h, 240 mg TIER 1 PV cap er 24h) diltiazem cd (120 mg cap er 24h, 180 mg cap er 24h, diltiazem cd TIER 1 PV 240 mg cap er 24h, 300 mg cap er 24h) diltiazem hcl (25 mg/5ml diltiazem hcl solution, 30 mg tab, 60 mg TIER 1 PV tab, 90 mg tab, 120 mg tab)

©2021 Wellmark, Inc. 78 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS diltiazem hcl er (er 60 mg cap er 12h, er 90 mg cap er 12h, er 120 mg cap er 12h, diltiazem hcl er TIER 1 PV er 120 mg cap er 24h, er 180 mg cap er 24h, er 240 mg cap er 24h) diltiazem hcl er beads (er beads 120 mg cap er 24h, er beads 180 mg cap er 24h, er beads 240 mg cap diltiazem hcl er beads TIER 1 PV er 24h, er beads 300 mg cap er 24h, er beads 360 mg cap er 24h, er beads 420 mg cap er 24h) diltiazem hcl er coated beads (er beads 120 mg cap er 24h, er beads 180 mg cap er 24h, er beads 180 mg tab er 24h, er beads 240 mg cap er 24h, diltiazem hcl er er beads 240 mg tab er TIER 1 PV coated beads 24h, er beads 300 mg cap er 24h, er beads 300 mg tab er 24h, er beads 360 mg cap er 24h, er beads 360 mg tab er 24h, er beads 420 mg tab er 24h) felodipine er (er 2.5 mg tab felodipine er er 24h, er 5 mg tab er 24h, TIER 1 PV er 10 mg tab er 24h) isradipine (2.5 mg cap, 5 isradipine TIER 1 PV mg cap) matzim la (180 mg tab er 24h, 240 mg tab er 24h, matzim la 300 mg tab er 24h, 360 mg TIER 1 PV tab er 24h, 420 mg tab er 24h) nicardipine hcl (20 mg cap, nicardipine hcl TIER 1 PV 30 mg cap) nifediac cc (30 mg tab er nifediac cc TIER 1 PV 24h, 60 mg tab er 24h) nifedipine (10 mg cap, 20 nifedipine TIER 1 PV mg cap) nifedipine er (er 30 mg tab nifedipine er er 24h, er 60 mg tab er 24h, TIER 1 PV er 90 mg tab er 24h)

©2021 Wellmark, Inc. 79 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS nifedipine er osmotic nifedipine er osmotic release (er 30 mg tab er TIER 1 PV release 24h, er 60 mg tab er 24h, er 90 mg tab er 24h) nimodipine nimodipine 30 mg cap TIER 1 nisoldipine er (er 8.5 mg tab er 24h, er 17 mg tab er 24h, er 20 mg tab er 24h, er 25.5 nisoldipine er TIER 1 PV mg tab er 24h, er 30 mg tab er 24h, er 34 mg tab er 24h, er 40 mg tab er 24h) taztia xt (120 mg cap er 24h, 180 mg cap er 24h, taztia xt 240 mg cap er 24h, 300 mg TIER 1 PV cap er 24h, 360 mg cap er 24h) tiadylt er (er 120 mg cap er 24h, er 180 mg cap er 24h, er 240 mg cap er 24h, er tiadylt er TIER 1 PV 300 mg cap er 24h, er 360 mg cap er 24h, er 420 mg cap er 24h) verapamil hcl (40 mg tab, verapamil hcl TIER 1 PV 80 mg tab, 120 mg tab) VERAPAMIL HCL ER (ER 100 MG CAP ER 24H, ER 120 MG CAP ER 24H, ER 120 MG TAB ER, ER 180 MG CAP ER 24H, ER 180 MG TAB ER, ER 200 MG VERAPAMIL HCL ER TIER 1 PV CAP ER 24H, ER 240 MG CAP ER 24H, ER 240 MG TAB ER, ER 300 MG CAP ER 24H, ER 360 MG CAP ER 24H) verapamil hcl

CARDIOVASCULAR AGENTS, OTHER

aliskiren fumarate (150 mg aliskiren fumarate TIER 1 PV tab, 300 mg tab) amiloride- amiloride- hydrochlorothiazide 5-50 TIER 1 PV hydrochlorothiazide mg tab

©2021 Wellmark, Inc. 80 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS amlodipine besy-benazepril hcl (2.5-10 mg cap, 5-10 amlodipine besy- mg cap, 5-20 mg cap, 5-40 TIER 1 PV benazepril hcl mg cap, 10-20 mg cap, 10- 40 mg cap) amlodipine besylate- amlodipine besylate- valsartan (5-160 mg tab, 5- TIER 1 PV valsartan 320 mg tab, 10-160 mg tab, 10-320 mg tab) amlodipine-atorvastatin (2.5-10 mg tab, 2.5-20 mg tab, 2.5-40 mg tab, 5-10 mg amlodipine- tab, 5-20 mg tab, 5-40 mg TIER 1 PV atorvastatin tab, 5-80 mg tab, 10-10 mg tab, 10-20 mg tab, 10-40 mg tab, 10-80 mg tab) amlodipine-olmesartan (5- amlodipine- 20 mg tab, 5-40 mg tab, 10- TIER 1 PV olmesartan 20 mg tab, 10-40 mg tab) amlodipine-valsartan-hctz (5-160-12.5 mg tab, 5-160- amlodipine-valsartan- 25 mg tab, 10-160-12.5 mg TIER 1 PV hctz tab, 10-160-25 mg tab, 10- 320-25 mg tab) atenolol- atenolol-chlorthalidone (50- TIER 1 PV chlorthalidone 25 mg tab, 100-25 mg tab) benazepril- benazepril- hydrochlorothiazide (5-6.25 TIER 1 PV hydrochlorothiazide mg tab, 10-12.5 mg tab, 20- 12.5 mg tab, 20-25 mg tab) bisoprolol- bisoprolol- hydrochlorothiazide (2.5- TIER 1 PV hydrochlorothiazide 6.25 mg tab, 5-6.25 mg tab, 10-6.25 mg tab) candesartan cilexetil-hctz candesartan cilexetil- (16-12.5 mg tab, 32-12.5 TIER 1 PV hctz mg tab, 32-25 mg tab) CAPTOPRIL- HYDROCHLOROTHIAZIDE CAPTOPRIL- (25-15 MG TAB, 25-25 MG HYDROCHLOROTHI TAB, 50-15 MG TAB, 50-25 TIER 1 PV AZIDE MG TAB) captopril & hydrochlorothiazide digitek (125 mcg tab, 250 digitek TIER 1 mcg tab) digox (125 mcg tab, 250 digox TIER 1 mcg tab)

©2021 Wellmark, Inc. 81 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS digoxin (0.05 mg/ml digoxin solution, 125 mcg tab, 250 TIER 1 mcg tab) enalapril- enalapril- hydrochlorothiazide (5-12.5 TIER 1 PV hydrochlorothiazide mg tab, 10-25 mg tab) ENTRESTO (24-26 MG TAB, 49-51 MG TAB, 97- ENTRESTO TIER 2 PA, QL (60 PER 30 DAYS) 103 MG TAB) sacubitril-valsartan fosinopril sodium-hctz (10- fosinopril sodium-hctz 12.5 mg tab, 20-12.5 mg TIER 1 PV tab) irbesartan- irbesartan- hydrochlorothiazide (150- TIER 1 PV hydrochlorothiazide 12.5 mg tab, 300-12.5 mg tab) isoxsuprine hcl (10 mg tab, isoxsuprine hcl TIER 1 20 mg tab) lisinopril- lisinopril- hydrochlorothiazide (10- TIER 1 PV hydrochlorothiazide 12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab) losartan potassium-hctz losartan potassium- (50-12.5 mg tab, 100-12.5 TIER 1 PV hctz mg tab, 100-25 mg tab) METHYLDOPA- HYDROCHLOROTHIAZIDE METHYLDOPA- (250-15 MG TAB, 250-25 HYDROCHLOROTHI TIER 1 PV MG TAB) AZIDE methyldopa & hydrochlorothiazide metoprolol- metoprolol- hydrochlorothiazide (50-25 TIER 1 PV hydrochlorothiazide mg tab, 100-25 mg tab, 100-50 mg tab) metyrosine metyrosine 250 mg cap TIER 1 moexipril- moexipril- hydrochlorothiazide (7.5- TIER 1 PV hydrochlorothiazide 12.5 mg tab, 15-12.5 mg tab, 15-25 mg tab) nadolol- nadolol- bendroflumethiazide (40-5 TIER 1 PV bendroflumethiazide mg tab, 80-5 mg tab) olmesartan medoxomil-hctz olmesartan (20-12.5 mg tab, 40-12.5 TIER 1 PV medoxomil-hctz mg tab, 40-25 mg tab)

©2021 Wellmark, Inc. 82 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS olmesartan-amlodipine-hctz (20-5-12.5 mg tab, 40-10- olmesartan- 12.5 mg tab, 40-10-25 mg TIER 1 PV amlodipine-hctz tab, 40-5-12.5 mg tab, 40- 5-25 mg tab) pentoxifylline er 400 mg tab pentoxifylline er TIER 1 er PROPRANOLOL-HCTZ (40-25 MG TAB, 80-25 MG PROPRANOLOL- TAB) TIER 1 PV HCTZ propranolol & hydrochlorothiazide quinapril- quinapril- hydrochlorothiazide (10- TIER 1 PV hydrochlorothiazide 12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab) ranolazine er (er 500 mg ranolazine er tab er 12h, er 1000 mg tab TIER 1 er 12h) spironolactone-hctz 25-25 spironolactone-hctz TIER 1 PV mg tab telmisartan-amlodipine (40- telmisartan- 10 mg tab, 40-5 mg tab, 80- TIER 1 PV amlodipine 10 mg tab, 80-5 mg tab) telmisartan-hctz (40-12.5 telmisartan-hctz mg tab, 80-12.5 mg tab, 80- TIER 1 PV 25 mg tab) trandolapril-verapamil hcl er trandolapril-verapamil (er 1-240 mg tab er, er 2- TIER 1 PV hcl er 180 mg tab er, er 2-240 mg tab er, er 4-240 mg tab er) triamterene-hctz (37.5-25 triamterene-hctz mg cap, 37.5-25 mg tab, TIER 1 PV 75-50 mg tab) valsartan- hydrochlorothiazide (80- valsartan- 12.5 mg tab, 160-12.5 mg TIER 1 PV hydrochlorothiazide tab, 160-25 mg tab, 320- 12.5 mg tab, 320-25 mg tab) VYNDAMAX 61 MG CAP VYNDAMAX SP-P PA, QL (30 PER 30 DAY(S)) tafamidis VYNDAQEL 20 MG CAP PA, QL (120 PER 30 VYNDAQEL tafamidis meglumine SP-P DAY(S)) (cardiac)

DIURETICS, CARBONIC ANHYDRASE INHIBITORS

acetazolamide (125 mg tab, acetazolamide TIER 1 250 mg tab) acetazolamide er 500 mg acetazolamide er TIER 1 cap er 12h KEVEYIS 50 MG TAB KEVEYIS SP-P dichlorphenamide

DIURETICS, LOOP

bumetanide (0.5 mg tab, 1 bumetanide TIER 1 mg tab, 2 mg tab) ethacrynic acid ethacrynic acid 25 mg tab TIER 1 furosemide (8 mg/ml solution, 10 mg/ml solution, furosemide TIER 1 20 mg tab, 40 mg tab, 80 mg tab) torsemide (5 mg tab, 10 mg torsemide TIER 1 tab, 20 mg tab, 100 mg tab)

DIURETICS, POTASSIUM-SPARING

amiloride hcl amiloride hcl 5 mg tab TIER 1 eplerenone (25 mg tab, 50 eplerenone TIER 1 mg tab) spironolactone (25 mg tab, spironolactone TIER 1 50 mg tab, 100 mg tab) triamterene (50 mg cap, triamterene TIER 1 100 mg cap)

DIURETICS, THIAZIDE

chlorothiazide (250 mg tab, chlorothiazide TIER 1 PV 500 mg tab) chlorthalidone (25 mg tab, chlorthalidone TIER 1 PV 50 mg tab) hydrochlorothiazide (12.5 hydrochlorothiazide mg cap, 12.5 mg tab, 25 TIER 1 PV mg tab, 50 mg tab) indapamide (1.25 mg tab, indapamide TIER 1 PV 2.5 mg tab) METHYCLOTHIAZIDE 5 METHYCLOTHIAZID MG TAB TIER 1 PV E methyclothiazide metolazone (2.5 mg tab, 5 metolazone TIER 1 mg tab, 10 mg tab)

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

fenofibrate (48 mg tab, 50 mg cap, 54 mg tab, 67 mg fenofibrate cap, 134 mg cap, 145 mg TIER 1 PV tab, 150 mg cap, 160 mg tab, 200 mg cap) fenofibrate micronized (43 mg cap, 67 mg cap, 130 mg fenofibrate micronized TIER 1 PV cap, 134 mg cap, 200 mg cap) fenofibric acid (45 mg cap fenofibric acid TIER 1 PV dr, 135 mg cap dr) gemfibrozil gemfibrozil 600 mg tab TIER 1 PV

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

atorvastatin calcium (10 mg atorvastatin calcium tab, 20 mg tab, 40 mg tab, TIER 1 PV 80 mg tab) fluvastatin sodium (20 mg fluvastatin sodium TIER 1 PV cap, 40 mg cap) fluvastatin sodium er 80 mg fluvastatin sodium er TIER 1 PV tab er 24h LIVALO (1 MG TAB, 2 MG LIVALO TAB, 4 MG TAB) TIER 2 PV pitavastatin calcium lovastatin (10 mg tab, 20 lovastatin TIER 1 PV mg tab, 40 mg tab) pravastatin sodium (10 mg pravastatin sodium tab, 20 mg tab, 40 mg tab, TIER 1 PV 80 mg tab) rosuvastatin calcium (5 mg rosuvastatin calcium tab, 10 mg tab, 20 mg tab, TIER 1 PV 40 mg tab) simvastatin (5 mg tab, 10 simvastatin mg tab, 20 mg tab, 40 mg TIER 1 PV tab, 80 mg tab) ZYPITAMAG (1 MG TAB, 2 ZYPITAMAG MG TAB, 4 MG TAB) TIER 2 PV pitavastatin magnesium

DYSLIPIDEMICS, OTHER

cholestyramine (4 gm cholestyramine TIER 1 PV packet, 4 gm/dose powder) cholestyramine light (4 gm cholestyramine light TIER 1 PV packet, 4 gm/dose powder)

©2021 Wellmark, Inc. 85 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS colesevelam hcl (3.75 gm colesevelam hcl TIER 1 PV packet, 625 mg tab) colestipol hcl (1 gm tab, 5 colestipol hcl TIER 1 PV gm granules, 5 gm packet) ezetimibe ezetimibe 10 mg tab TIER 1 PV ezetimibe-simvastatin (10- 10 mg tab, 10-20 mg tab, ezetimibe-simvastatin TIER 1 10-40 mg tab, 10-80 mg tab) JUXTAPID (5 MG CAP, 10 MG CAP, 20 MG CAP, 30 JUXTAPID MG CAP, 40 MG CAP, 60 SP-P PA, QL (30 PER 30 DAYS) MG CAP) lomitapide mesylate KYNAMRO 200 MG/ML KYNAMRO SOLN PRSYR SP-P PA, QL (4 PER 28 DAYS) mipomersen sodium niacin er niacin er (antihyperlipidemic) (er 500 TIER 1 PV (antihyperlipidemic) mg tab er, er 750 mg tab er, er 1000 mg tab er) prevalite (4 gm packet, 4 prevalite TIER 1 PV gm/dose powder)

VASODILATORS, DIRECT-ACTING ARTERIAL

hydralazine hcl (10 mg tab, hydralazine hcl 25 mg tab, 50 mg tab, 100 TIER 1 PV mg tab) minoxidil (2.5 mg tab, 10 minoxidil TIER 1 PV mg tab)

VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS

isoditrate er isoditrate er 40 mg tab er TIER 1 isosorbide dinitrate (5 mg isosorbide dinitrate tab, 10 mg tab, 20 mg tab, TIER 1 PV 30 mg tab) ISOSORBIDE DINITRATE ISOSORBIDE ER 40 MG TAB ER TIER 1 PV, GA DINITRATE ER isosorbide dinitrate isosorbide isosorbide mononitrate (10 TIER 1 PV mononitrate mg tab, 20 mg tab) isosorbide mononitrate er isosorbide (er 30 mg tab er 24h, er 60 TIER 1 PV mononitrate er mg tab er 24h, er 120 mg tab er 24h)

©2021 Wellmark, Inc. 86 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS minitran (0.1 patch 24hr, minitran 0.2 patch 24hr, 0.4 patch TIER 1 PV 24hr, 0.6 patch 24hr) NITRO-TIME (2.5 MG CAP ER, 6.5 MG CAP ER, 9 MG NITRO-TIME TIER 1 PV, GA CAP ER) nitroglycerin nitroglycerin (0.1 mg/hr patch 24hr, 0.2 mg/hr patch 24hr, 0.3 mg sl tab, 0.4 mg sl tab, 0.4 mg/hr patch nitroglycerin TIER 1 PV 24hr, 0.4 mg/spray solution, 0.6 mg sl tab, 0.6 mg/hr patch 24hr, 400 mcg/spray aero soln) nitroglycerin er (er 2.5 mg nitroglycerin er cap er, er 6.5 mg cap er, er TIER 1 PV 9 mg cap er)

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

amphetamine- dextroamphet er (er 5 mg cap er 24h, er 10 mg cap er amphetamine- 24h, er 15 mg cap er 24h, TIER 1 PA dextroamphet er er 20 mg cap er 24h, er 25 mg cap er 24h, er 30 mg cap er 24h) amphetamine- dextroamphetamine (5 mg amphetamine- tab, 7.5 mg tab, 10 mg tab, TIER 1 dextroamphetamine 12.5 mg tab, 15 mg tab, 20 mg tab, 30 mg tab) dexedrine dexedrine 10 mg tab TIER 1 dextroamphetamine sulfate dextroamphetamine (5 mg tab, 5 mg/5ml TIER 1 sulfate solution, 10 mg tab) dextroamphetamine sulfate dextroamphetamine er (er 5 mg cap er 24h, er TIER 1 PA sulfate er 10 mg cap er 24h, er 15 mg cap er 24h) methamphetamine hcl 5 mg methamphetamine hcl TIER 1 tab procentra procentra 5 mg/5ml solution TIER 1 zenzedi (5 mg tab, 10 mg zenzedi TIER 1 tab)

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES

atomoxetine hcl (10 mg atomoxetine hcl cap, 18 mg cap, 25 mg cap, TIER 1 QL (60 PER 30 DAYS) 40 mg cap, 60 mg cap) atomoxetine hcl (80 mg atomoxetine hcl TIER 1 QL (30 PER 30 DAYS) cap, 100 mg cap) clonidine hcl er 0.1 mg tab clonidine hcl er TIER 1 er 12h dexmethylphenidate hcl dexmethylphenidate (2.5 mg tab, 5 mg tab, 10 TIER 1 hcl mg tab) dexmethylphenidate hcl er (er 5 mg cap er 24h, er 10 mg cap er 24h, er 15 mg dexmethylphenidate cap er 24h, er 20 mg cap er TIER 1 PA hcl er 24h, er 25 mg cap er 24h, er 30 mg cap er 24h, er 35 mg cap er 24h, er 40 mg cap er 24h) guanfacine hcl er (er 1 mg tab er 24h, er 2 mg tab er guanfacine hcl er TIER 1 24h, er 3 mg tab er 24h, er 4 mg tab er 24h) metadate er metadate er 20 mg tab er TIER 1 PA methylphenidate hcl (2.5 mg chew tab, 5 mg chew tab, 5 mg tab, 5 mg/5ml methylphenidate hcl TIER 1 solution, 10 mg chew tab, 10 mg tab, 10 mg/5ml solution, 20 mg tab) methylphenidate hcl er (cd) (er 10 mg cap er, er 20 mg methylphenidate hcl cap er, er 30 mg cap er, er TIER 1 PA er (cd) 40 mg cap er, er 50 mg cap er, er 60 mg cap er)

©2021 Wellmark, Inc. 88 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS methylphenidate hcl er (er 10 mg tab er, er 18 mg tab er, er 18 mg tab er 24h, er 20 mg tab er, er 27 mg tab methylphenidate hcl er, er 27 mg tab er 24h, er TIER 1 PA er 36 mg tab er, er 36 mg tab er 24h, er 54 mg tab er, er 54 mg tab er 24h, er 72 mg tab er) methylphenidate hcl er (la) (er 10 mg cap er 24h, er 20 methylphenidate hcl mg cap er 24h, er 30 mg TIER 1 PA er (la) cap er 24h, er 40 mg cap er 24h, er 60 mg cap er 24h)

CENTRAL NERVOUS SYSTEM, OTHER

AUSTEDO (6 MG TAB, 9 AUSTEDO MG TAB, 12 MG TAB) SP-P deutetrabenazine bac bac 50-325-40 mg tab TIER 1 butalbital- butalbital-acetaminophen TIER 1 acetaminophen 50-325 mg tab butalbital-apap 50-325 mg butalbital-apap TIER 1 tab butalbital-apap-caffeine butalbital-apap- (50-300-40 mg cap, 50- TIER 1 caffeine 325-40 mg cap, 50-325-40 mg tab) capacet capacet 50-325-40 mg cap TIER 1 esgic esgic 50-325-40 mg cap TIER 1 EVRYSDI 0.75 MG/ML PA, QL (120 PER 24 EVRYSDI RECON SOLN SP-P DAY(S)) risdiplam INGREZZA (40 MG CAP, INGREZZA 80 MG CAP) SP-P PA valbenazine tosylate INGREZZA 60 MG CAP INGREZZA SP-P PA, QL (1 PER 1 DAY(S)) valbenazine tosylate marten-tab marten-tab 50-325 mg tab TIER 1 phrenilin forte 50-300-40 phrenilin forte TIER 1 mg cap RADICAVA 30 MG/100ML RADICAVA SOLUTION T6 edaravone riluzole riluzole 50 mg tab TIER 1

©2021 Wellmark, Inc. 89 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TEGSEDI 284 MG/1.5ML TEGSEDI SOLN PRSYR SP-P PA, QL (4 PER 28 DAY(S)) inotersen sodium TENCON 50-325 MG TAB TENCON TIER 1 GA butalbital-acetaminophen QL (240 PER 30 DAYS), tetrabenazine tetrabenazine 12.5 mg tab SP-P SBG (Specialty Biosimilars and Specialty generics) QL (120 PER 30 DAYS), tetrabenazine tetrabenazine 25 mg tab SP-P SBG (Specialty Biosimilars and Specialty generics) zebutal zebutal 50-325-40 mg cap TIER 1

FIBROMYALGIA AGENTS

duloxetine hcl (20 mg cp dr part, 30 mg cp dr part, 40 duloxetine hcl TIER 1 PV mg cp dr part, 60 mg cp dr part) pregabalin (25 mg cap, 50 mg cap, 75 mg cap, 100 mg pregabalin cap, 150 mg cap, 200 mg TIER 1 cap, 225 mg cap, 300 mg cap) pregabalin 20 mg/ml PA, QL (900 PER 30 pregabalin TIER 1 solution DAY(S))

MULTIPLE SCLEROSIS AGENTS

AUBAGIO (7 MG TAB, 14 AUBAGIO MG TAB) SP-P PA, QL (30 PER 30 DAYS) teriflunomide BAFIERTAM 95 MG CAP BAFIERTAM DR SP-P PA, QL (4 PER DAY(S)) monomethyl fumarate BETASERON 0.3 MG KIT BETASERON SP-P PA, QL (15 PER 30 DAYS) interferon beta-1b COPAXONE 40 MG/ML PA, QL (12 PER 28 DAYS), COPAXONE SOLN PRSYR SP-P GA glatiramer acetate QL (60 PER 30 DAYS), SBG dalfampridine er 10 mg tab dalfampridine er SP-P (Specialty Biosimilars and er 12h Specialty generics) PA, QL (60 PER 30 DAYS), dimethyl fumarate (120 mg dimethyl fumarate SP-P SBG (Specialty Biosimilars cap dr, 240 mg cap dr) and Specialty generics) PA, QL (1 PER FILL), SBG dimethyl fumarate dimethyl fumarate starter SP-P (Specialty Biosimilars and starter pack pack 120 & 240 mg misc Specialty generics)

©2021 Wellmark, Inc. 90 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GILENYA 0.25 MG CAP GILENYA SP-P PA, QL (30 PER 30 DAY(S)) fingolimod hcl GILENYA 0.5 MG CAP GILENYA SP-P PA, QL (30 PER 30 DAYS) fingolimod hcl PA, QL (12 PER 28 DAYS), glatiramer acetate 40 mg/ml glatiramer acetate SP-P SBG (Specialty Biosimilars soln prsyr and Specialty generics) PA, QL (12 PER 28 DAYS), glatopa glatopa 40 mg/ml soln prsyr SP-P SBG (Specialty Biosimilars and Specialty generics) LEMTRADA 12 MG/1.2ML LEMTRADA SOLUTION T6 alemtuzumab (ms) MAVENCLAD (10 TABS) MAVENCLAD (10 10 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis) MAVENCLAD (4 TABS) 10 MAVENCLAD (4 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis) MAVENCLAD (5 TABS) 10 MAVENCLAD (5 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis) MAVENCLAD (6 TABS) 10 MAVENCLAD (6 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis) MAVENCLAD (7 TABS) 10 MAVENCLAD (7 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis) MAVENCLAD (8 TABS) 10 MAVENCLAD (8 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis) MAVENCLAD (9 TABS) 10 MAVENCLAD (9 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis) MAYZENT 0.25 MG TAB PA, QL (112 PER 28 MAYZENT SP-P siponimod fumarate DAY(S)) MAYZENT 2 MG TAB MAYZENT SP-P PA, QL (30 PER 30 DAY(S)) siponimod fumarate

©2021 Wellmark, Inc. 91 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MAYZENT STARTER MAYZENT STARTER PACK 12 X 0.25 MG TAB SP-P PA, QL (12 PER 5 DAY(S)) PACK THPK siponimod fumarate OCREVUS 300 MG/10ML OCREVUS SOLUTION T6 ocrelizumab REBIF (22 SOLN PRSYR, REBIF 44 SOLN PRSYR) SP-P PA, QL (12 PER 28 DAYS) interferon beta-1a REBIF REBIDOSE (22 SOLN A-INJ, 44 SOLN A- REBIF REBIDOSE SP-P PA, QL (12 PER 28 DAYS) INJ) interferon beta-1a REBIF REBIDOSE REBIF REBIDOSE TITRATION PACK 6X8.8 & SP-P PA, QL (12 PER 28 DAYS) TITRATION PACK 6X22 MCG SOLN A-INJ interferon beta-1a REBIF TITRATION PACK REBIF TITRATION 6X8.8 & 6X22 MCG SOLN SP-P PA, QL (12 PER 28 DAYS) PACK PRSYR interferon beta-1a TYSABRI 300 MG/15ML TYSABRI CONC T6 natalizumab

DENTAL AND ORAL AGENTS

cevimeline hcl cevimeline hcl 30 mg cap TIER 1 chlorhexidine chlorhexidine gluconate TIER 1 gluconate 0.12 % solution oralone oralone 0.1 % paste TIER 1 paroex paroex 0.12 % solution TIER 1 periogard periogard 0.12 % solution TIER 1 pilocarpine hcl (5 mg tab, pilocarpine hcl TIER 1 7.5 mg tab) triamcinolone triamcinolone acetonide TIER 1 acetonide (0.1 % cream, 0.1 % paste)

DERMATOLOGICAL AGENTS

accutane (10 mg cap, 20 accutane mg cap, 30 mg cap, 40 mg TIER 1 cap) acitretin (10 mg cap, 17.5 acitretin TIER 1 mg cap, 25 mg cap) adapalene adapalene 0.3 % gel TIER 1 PA

©2021 Wellmark, Inc. 92 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS amnesteem (10 mg cap, 20 amnesteem TIER 1 mg cap, 40 mg cap) avita (0.025 % cream, avita TIER 1 PA 0.025 % gel) azelaic acid azelaic acid 15 % gel TIER 1 calcipotriene (0.005 % calcipotriene foam, 0.005 % ointment, TIER 1 0.005 % solution) calcipotriene 0.005 % calcipotriene TIER 1 QL (120 PER 30 DAY(S)) cream calcipotriene-betameth calcipotriene- diprop 0.005-0.064 % TIER 1 QL (120 PER 30 DAY(S)) betameth diprop ointment calcipotriene-betameth calcipotriene- diprop 0.005-0.064 % TIER 1 betameth diprop suspension calcitrene calcitrene 0.005 % ointment TIER 1 calcitriol calcitriol 3 mcg/gm ointment TIER 1 claravis (10 mg cap, 20 mg claravis TIER 1 cap, 30 mg cap, 40 mg cap) clindamycin phos-benzoyl clindamycin phos- perox (1-5 % gel, 1.2-2.5 % TIER 1 PA benzoyl perox gel, 1.2-5 % gel) clindamycin-tretinoin 1.2- clindamycin-tretinoin TIER 1 PA 0.025 % gel clotrimazole- clotrimazole- betamethasone (% cream, TIER 1 betamethasone % lotion) COSENTYX (300 MG COSENTYX (300 MG DOSE) 150 MG/ML SOLN SP-P PA, QL (2 PER 28 DAYS) DOSE) PRSYR secukinumab COSENTYX 75 MG/0.5ML COSENTYX SOLN PRSYR SP-P PA, QL (1 PER 28 DAY(S)) secukinumab COSENTYX COSENTYX SENSOREADY (300 MG) SENSOREADY (300 SP-P PA, QL (2 PER 28 DAYS) 150 MG/ML SOLN A-INJ MG) secukinumab dapsone (5 % gel, 7.5 % dapsone TIER 1 PA gel)

©2021 Wellmark, Inc. 93 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DUPIXENT (200 MG/1.14ML SOLN PEN, 200 MG/1.14ML SOLN DUPIXENT PRSYR, 300 MG/2ML SP-P PA, QL (2 PER 28 DAY(S)) SOLN PEN, 300 MG/2ML SOLN PRSYR) dupilumab DUROLANE 60 MG/3ML PRSYR DUROLANE T6 sodium hyaluronate (viscosupplement) fluorouracil fluorouracil 0.5 % cream TIER 1 PA fluorouracil fluorouracil 5 % cream TIER 1 hydrocort-pramoxine hydrocort-pramoxine TIER 1 (perianal) (perianal) 2.5-1 % cream hydrocortisone ace- hydrocortisone ace- TIER 1 pramoxine pramoxine 1-1 % cream ILUMYA 100 MG/ML SOLN ILUMYA PRSYR T6 tildrakizumab-asmn imiquimod imiquimod 3.75 % cream TIER 1 PA imiquimod imiquimod 5 % cream TIER 1 imiquimod pump 3.75 % imiquimod pump TIER 1 PA cream isotretinoin (10 mg cap, 20 isotretinoin mg cap, 30 mg cap, 40 mg TIER 1 cap) ivermectin ivermectin 1 % cream TIER 1 PA lidocaine-hydrocort lidocaine-hydrocort TIER 1 (perianal) (perianal) 3-0.5 % cream lidocaine-hydrocortisone lidocaine- ace (2.8-0.55 % gel, 3-0.5 TIER 1 hydrocortisone ace % kit, 3-1 % kit, 3-2.5 % kit) lidocort lidocort 3-0.5 % cream TIER 1 methoxsalen rapid 10 mg methoxsalen rapid TIER 1 cap metronidazole (0.75 % metronidazole cream, 0.75 % gel, 0.75 % TIER 1 lotion, 1 % gel) myorisan (10 mg cap, 20 myorisan mg cap, 30 mg cap, 40 mg TIER 1 cap) neuac neuac 1.2-5 % gel TIER 1 PA pimecrolimus pimecrolimus 1 % cream TIER 1 QL (100 PER 30 DAY(S))

©2021 Wellmark, Inc. 94 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PODOCON 25 % PODOCON SOLUTION TIER 1 podophyllum resin podofilox podofilox 0.5 % solution TIER 1 rosadan (0.75 % cream, rosadan TIER 1 0.75 % gel) SCENESSE 16 MG SCENESSE IMPLANT T6 afamelanotide acetate selenium sulfide 2.5 % selenium sulfide TIER 1 lotion SKYRIZI (150 MG DOSE) SKYRIZI (150 MG 75 MG/0.83ML PREF SY SP-P PA, QL (2 PER 84 DAY(S)) DOSE) KT risankizumab-rzaa STELARA (45 MG/0.5ML SOLN PRSYR, 45 PA, QLV (Quantity Limit STELARA MG/0.5ML SOLUTION, 90 SP-P Varies), PA-QL (for Crohn's MG/ML SOLN PRSYR) Disease) ustekinumab STELARA 130 MG/26ML STELARA SOLUTION T6 ustekinumab (iv) SULFACETAMIDE- SULFUR IN UREA 10-5 % SULFACETAMIDE- GEL TIER 1 SULFUR IN UREA sulfacetamide sodium- sulfur in urea vehicle tacrolimus (0.03 % tacrolimus TIER 1 ointment, 0.1 % ointment) tazarotene tazarotene 0.1 % cream TIER 1 tretinoin (0.01 % gel, 0.025 % cream, 0.025 % gel, 0.05 tretinoin TIER 1 PA % cream, 0.05 % gel, 0.1 % cream) tretinoin microsphere (0.04 tretinoin microsphere TIER 1 PA % gel, 0.1 % gel) tretinoin microsphere pump tretinoin microsphere (pump 0.04 % gel, pump TIER 1 PA pump 0.1 % gel) zenatane (10 mg cap, 20 zenatane mg cap, 30 mg cap, 40 mg TIER 1 cap)

ELECTROLYTES/MINERALS/METALS/VITAMINS

ELECTROLYTE/MINERAL REPLACEMENT

bd posiflush bd posiflush 0.9 % solution TIER 1 calcium acetate calcium acetate 667 mg tab TIER 1 CRYSVITA (10 MG/ML SOLUTION, 20 MG/ML CRYSVITA SOLUTION, 30 MG/ML T6 SOLUTION) burosumab-twza DOJOLVI 100 % LIQUID DOJOLVI SP-P PA triheptanoin effervescent pot effervescent pot chloride 25 TIER 1 chloride meq effer tab klor-con (8 tab er, 20 klor-con TIER 1 packet) klor-con 10 klor-con 10 10 meq tab er TIER 1 klor-con m10 klor-con m10 10 meq tab er TIER 1 klor-con m15 klor-con m15 15 meq tab er TIER 1 klor-con m20 klor-con m20 20 meq tab er TIER 1 klor-con sprinkle (8 cap er, klor-con sprinkle TIER 1 10 cap er) levocarnitine (1 gm/10ml levocarnitine TIER 1 solution, 330 mg tab) levocarnitine sf 1 gm/10ml levocarnitine sf TIER 1 solution LOKELMA (5 GM PACKET, 10 GM PACKET) LOKELMA SP-P sodium zirconium cyclosilicate MONOFERRIC 1000 MONOFERRIC MG/10ML SOLUTION T6 ferric derisomaltose monoject flush monoject flush syringe 0.9 TIER 1 syringe % solution monoject sodium monoject sodium chloride TIER 1 chloride flush flush 0.9 % solution normal saline flush 0.9 % normal saline flush TIER 1 solution POT BICARB-POT POT BICARB-POT CHLORIDE 25 MEQ TIER 1 GA CHLORIDE EFFER TAB potassium bicarb & chloride

©2021 Wellmark, Inc. 96 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS potassium chloride (10 % solution, 20 meq packet, 20 potassium chloride meq/15ml (10%) solution, TIER 1 40 meq/15ml (20%) solution) potassium chloride crys er potassium chloride (crys er 10 tab er, crys er TIER 1 crys er 15 tab er, crys er 20 tab er) potassium chloride er (er 8 cap er, er 8 tab er, er 10 potassium chloride er TIER 1 cap er, er 10 tab er, er 20 tab er) saline flush saline flush 0.9 % solution TIER 1 saline flush zr 0.9 % saline flush zr TIER 1 solution sodium bicarbonate (4.2 % sodium bicarbonate TIER 1 solution, 7.5 % solution) sodium chloride (0.9 % sodium chloride solution, 4 meq/ml solution, TIER 1 23.4 % solution) sodium chloride (pf) 0.9 % sodium chloride (pf) TIER 1 solution sodium chloride flush 0.9 % sodium chloride flush TIER 1 solution swabflush saline flush 0.9 swabflush saline flush TIER 1 % solution

ELECTROLYTE/MINERAL/METAL MODIFIERS

CHEMET 100 MG CAP CHEMET TIER 2 succimer SBG (Specialty Biosimilars clovique clovique 250 mg cap SP-P and Specialty generics) deferasirox (90 mg packet, 90 mg tab, 125 mg tab sol, 180 mg packet, 180 mg tab, SBG (Specialty Biosimilars deferasirox SP-P 250 mg tab sol, 360 mg and Specialty generics) packet, 360 mg tab, 500 mg tab sol) deferasirox granules (granules 90 mg packet, SBG (Specialty Biosimilars deferasirox granules SP-P granules 180 mg packet, and Specialty generics) granules 360 mg packet) SBG (Specialty Biosimilars deferiprone deferiprone 500 mg tab SP-P and Specialty generics)

©2021 Wellmark, Inc. 97 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FERRIPROX (100 MG/ML FERRIPROX SOLUTION, 1000 MG TAB) SP-P deferiprone FERRIPROX TWICE-A- FERRIPROX TWICE- DAY 1000 MG TAB SP-P A-DAY deferiprone JYNARQUE (15 MG TAB THPK, 30 & 15 MG TAB THPK, 45 & 15 MG TAB JYNARQUE THPK, 60 & 30 MG TAB SP-P PA, QL (56 PER 28 DAY(S)) THPK, 90 & 30 MG TAB THPK) tolvaptan JYNARQUE (15 MG TAB, PA, QL (60 PER 30 DAYS), JYNARQUE 30 MG TAB) SP-P GA tolvaptan kionex kionex (15gm/60mlsuspension, TIER 1 powder) SAMSCA 15 MG TAB PA, QL (60 PER 30 DAYS), SAMSCA SP-P tolvaptan GA sodium polystyrene sulfonate (15 gm/60ml sodium polystyrene suspension, 30 gm/120ml TIER 1 sulfonate suspension, 50 gm/200ml suspension, powder) SPS 15 GM/60ML SUSPENSION SPS TIER 1 GA sodium polystyrene sulfonate PA, QL (60 PER 30 DAYS), tolvaptan (15 mg tab, 30 tolvaptan SP-P SBG (Specialty Biosimilars mg tab) and Specialty generics) SBG (Specialty Biosimilars trientine hcl trientine hcl 250 mg cap SP-P and Specialty generics)

PHOSPHATE BINDERS

calcium acetate (phos calcium acetate (phos binder) (667 mg cap, 667 TIER 1 binder) mg tab) lanthanum carbonate (500 lanthanum carbonate mg chew tab, 750 mg chew TIER 1 tab, 1000 mg chew tab) phospha 250 neutral 155- phospha 250 neutral TIER 1 852-130 mg tab phospho-trin 250 phospho-trin 250 neutral TIER 1 neutral 155-852-130 mg tab

©2021 Wellmark, Inc. 98 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS phosphorous 155-852-130 phosphorous TIER 1 mg tab sevelamer carbonate (0.8 sevelamer carbonate gm packet, 2.4 gm packet, TIER 1 800 mg tab) sevelamer hcl (400 mg tab, sevelamer hcl TIER 1 800 mg tab) VELTASSA (8.4 GM PACKET, 16.8 GM VELTASSA PACKET, 25.2 GM SP-P PACKET) patiromer sorbitex calcium virt-phos 250 neutral 155- virt-phos 250 neutral TIER 1 852-130 mg tab

VITAMINS

ATABEX EC 29-1 MG TAB DR ATABEX EC TIER 2 PV prenatal vit w/ docusate- iron carbonyl-folic acid ATABEX OB 29-1 MG TAB prenatal vit w/ fe ATABEX OB TIER 2 PV bisglycinate chelate-folic acid BP FOLINATAL PLUS B 1 MG TAB BP FOLINATAL prenatal w/ calcium TIER 2 PLUS B carbonate-vit b6-vit b12- folic acid BP MULTINATAL PLUS (30-1 MG TAB, 40-1 MG BP MULTINATAL CHEW TAB) TIER 2 PV PLUS prenatal without a vit w/ fe fumarate-folic acid COMPLETE NATAL DHA 29-1-200 & 250 MG MISC COMPLETE NATAL prenatal mv & min w/fe TIER 2 PV DHA bisglyc-fe prot succ-fa-ca- omega 3 COMPLETENATE 29-1 MG CHEW TAB COMPLETENATE TIER 2 PV prenatal vit w/ ferrous fumarate-folic acid

©2021 Wellmark, Inc. 99 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CONCEPT OB 130-92.4-1 MG CAP CONCEPT OB prenatal without a vit w/ fe TIER 2 PV fum-iron polysacch complex -fa cyanocobalamin 1000 cyanocobalamin TIER 1 mcg/ml solution FOLIVANE-OB 130-92.4-1 MG CAP FOLIVANE-OB prenatal without a vit w/ fe TIER 2 PV fum-iron polysacch complex -fa HEMENATAL OB + DHA 28-6-1 & 203 MG MISC HEMENATAL OB + prenatal vit w/ fe poly TIER 2 PV DHA cmplx-fe heme polypept-fa & omega 3 INATAL GT TAB INATAL GT prenatal vit w/ docusate- TIER 2 PV iron carbonyl-folic acid MYNATAL (90-1MGTAB, CAP) MYNATAL TIER 2 PV prenatal vit w/ docusate- iron carbonyl-folic acid MYNATAL ADVANCE TAB MYNATAL ADVANCE TIER 2 PV prenatal vit w/ docusate- iron carbonyl-folic acid MYNATE 90 PLUS TAB ER MYNATE 90 PLUS TIER 2 PV prenatal vit w/ docusate-fe fumarate-folic acid NATALVIT TAB NATALVIT prenatal vit w/ ferrous TIER 2 PV fumarate-folic acid O-CAL PRENATAL TAB O-CAL PRENATAL prenatal vit w/ ferrous TIER 2 PV fumarate-folic acid OBSTETRIX DHA 29-1 & 387 MG MISC OBSTETRIX DHA TIER 2 PV prenatal w/fe carbonyl-fa- dss-omega 3 fatty acids OBSTETRIX EC 29-1 MG TAB OBSTETRIX EC TIER 2 PV prenatal vit w/ docusate- iron carbonyl-folic acid

©2021 Wellmark, Inc. 100 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PNV PRENATAL PLUS MULTIVIT+DHA 27-1 & 312 PNV PRENATAL MG MISC PLUS TIER 2 prenatal vit w/ ferrous MULTIVIT+DHA fumarate-fa-omega 3 fatty acids PNV TABS 29-1 29-1 MG TAB PNV TABS 29-1 TIER 2 PV prenatal vit w/ iron carbonyl-folic acid PNV-VP-U 106.5-1 MG CAP PNV-VP-U TIER 2 PV prenatal without a vit w/ fe fumarate-folic acid PR NATAL 400 29-1-200 & 400 MG MISC PR NATAL 400 prenatal mv & min w/fe TIER 2 PV bisglyc-fe prot succ-fa-ca- omega 3 PR NATAL 400 EC 29-1- 200 & 400 MG (DR) MISC PR NATAL 400 EC prenatal mv & min w/fe TIER 2 PV bisglyc-fe prot succ-fa-ca- omega 3 PR NATAL 430 29-1-200 & 430 MG MISC PR NATAL 430 prenatal mv & min w/fe TIER 2 PV bisglyc-fe prot succ-fa-ca- omega 3 PR NATAL 430 EC 29-1- 200 & 430 MG (DR) MISC PR NATAL 430 EC prenatal mv & min w/fe TIER 2 PV bisglyc-fe prot succ-fa-ca- omega 3 PRENAISSANCE NEXT PRENAISSANCE 1.2 MG TAB TIER 2 PV NEXT prenatal w/ calcium-vit b6- folic acid-ginger PRENATA 29-1 MG CHEW TAB PRENATA TIER 2 PV prenatal without a vit w/ fe fumarate-folic acid PRENATABS FA 29-1 MG TAB PRENATABS FA TIER 2 PV prenatal vit w/ ferrous fumarate-folic acid

©2021 Wellmark, Inc. 101 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PRENATABS RX 29-1 MG TAB PRENATABS RX TIER 2 PV prenatal vit w/ iron carbonyl-folic acid PRENATAL 19 (19CHEWTAB, 19TAB, 1929-1MGCHEWTAB, PRENATAL 19 TIER 2 PV 1929-1MGTAB) prenatal vit w/ docusate-fe fumarate-folic acid PRENATAL PLUS IRON PRENATAL PLUS 29-1 MG TAB TIER 2 PV IRON prenatal vit w/ iron carbonyl-folic acid PRENATAL-U 106.5-1 MG CAP PRENATAL-U TIER 2 PV prenatal without a vit w/ fe fumarate-folic acid PRETAB 29-1 MG TAB PRETAB prenatal vit w/ ferrous TIER 2 PV fumarate-folic acid PROVIDA OB 20-20-1.25 MG CAP PROVIDA OB prenatal without a vit w/ fe TIER 2 PV fum-iron polysacch complex -fa PUREFE OB PLUS 162- 115.2-1 MG CAP PUREFE OB PLUS prenatal without a vit w/ fe TIER 2 PV fum-iron polysacch complex -fa SE-NATAL 19 (19 MG CHEW TAB, 19 MG TAB) SE-NATAL 19 TIER 2 PV prenatal vit w/ docusate-fe fumarate-folic acid TARON-BC 20-1 MG & 2 X 25 MG MISC TARON-BC TIER 2 PV prenatal without vit a w/ iron carbonyl-folic acid & vit b6 THRIVITE RX 29-1 MG TAB THRIVITE RX TIER 2 PV prenatal vit w/ iron carbonyl-folic acid

©2021 Wellmark, Inc. 102 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TL FOLATE 27-0.5-0.5 MG TAB TL FOLATE prenatal vit w/ ferrous TIER 2 PV fumarate-l methylfolate-folic acid TRIADVANCE 90-1 MG TAB TRIADVANCE TIER 2 PV prenatal vit w/ docusate- iron carbonyl-folic acid TRINATAL GT 90-1 MG TAB TRINATAL GT TIER 2 PV prenatal vit w/ docusate- iron carbonyl-folic acid TRINATAL RX 1 60-1 MG TAB TRINATAL RX 1 TIER 2 PV prenatal vit w/ ferrous fumarate-folic acid TRINATE TAB TRINATE prenatal vit w/ ferrous TIER 2 PV fumarate-folic acid TRIVEEN-DUO DHA 29-1- 200 & 400 MG MISC TRIVEEN-DUO DHA prenatal mv & min w/fe TIER 2 PV bisglyc-fe prot succ-fa-ca- omega 3 VIL-RX 29-1 MG TAB VIL-RX prenatal vit w/ iron TIER 2 PV carbonyl-folic acid VINATE AZ EXTRA 29-1 MG TAB VINATE AZ EXTRA prenatal vit w/ fe TIER 2 PV bisglycinate chelate-folic acid VINATE C 30-1 MG TAB VINATE C prenatal without a vit w/ fe TIER 2 fumarate-folic acid VINATE CALCIUM 27-1 MG TAB VINATE CALCIUM prenatal vit w/ iron TIER 2 carbonyl-fe gluconate-folic acid VINATE IC 162-115.2-1 MG CAP VINATE IC prenatal without a vit w/ fe TIER 2 PV fum-iron polysacch complex -fa

©2021 Wellmark, Inc. 103 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VINATE II 29-1 MG TAB prenatal vit w/ fe VINATE II TIER 2 PV bisglycinate chelate-folic acid VINATE M 27-1 MG TAB VINATE M prenatal vit w/ selenium-fe TIER 2 PV fumarate-folic acid VINATE ONE 60-1 MG TAB VINATE ONE TIER 2 PV prenatal vit w/ ferrous fumarate-folic acid VIRT NATE 28-1 MG TAB VIRT NATE prenatal vit w/ ferrous TIER 2 PV fumarate-folic acid VIRT-ADVANCE 90-1 MG TAB VIRT-ADVANCE TIER 2 PV prenatal vit w/ docusate- iron carbonyl-folic acid VIRT-VITE GT 90-1 MG TAB VIRT-VITE GT TIER 2 PV prenatal vit w/ docusate- iron carbonyl-folic acid VOL-NATE 28-1 MG TAB VOL-NATE prenatal vit w/ ferrous TIER 2 PV fumarate-folic acid VOL-TAB RX 29-1 MG TAB VOL-TAB RX prenatal vit w/ iron TIER 2 PV carbonyl-folic acid VP-GGR-B6 PRENATAL VP-GGR-B6 1.2 MG TAB TIER 2 PV PRENATAL prenatal w/ calcium-vit b6- folic acid-ginger VP-HEME OB + DHA 28-6- 1 & 203 MG MISC VP-HEME OB + DHA prenatal vit w/ fe poly TIER 2 PV cmplx-fe heme polypept-fa & omega 3

GASTROINTESTINAL AGENTS

ANTISPASMODICS, GASTROINTESTINAL

chlordiazepoxide- chlordiazepoxide-clidinium TIER 1 clidinium 5-2.5 mg cap dicyclomine hcl (10 mg cap, dicyclomine hcl 10 mg/5ml solution, 20 mg TIER 1 tab) ed-spaz ed-spaz 0.125 mg tab disp TIER 1

©2021 Wellmark, Inc. 104 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS glycopyrrolate (1 mg tab, 2 glycopyrrolate TIER 1 mg tab) hyoscyamine sulfate (0.125 mg sl tab, 0.125 mg tab, hyoscyamine sulfate 0.125 mg tab disp, 0.125 TIER 1 mg/5ml elixir, 0.125 mg/ml solution) hyoscyamine sulfate hyoscyamine sulfate er TIER 1 er 0.375 mg tab er 12h hyoscyamine sulfate hyoscyamine sulfate sl TIER 1 sl 0.125 mg sl tab hyosyne (0.125 mg/5ml hyosyne TIER 1 elixir, 0.125 mg/ml solution) methscopolamine methscopolamine bromide TIER 1 bromide (2.5 mg tab, 5 mg tab) nulev nulev 0.125 mg tab disp TIER 1 oscimin (0.125 mg sl tab, oscimin 0.125 mg tab, 0.125 mg tab TIER 1 disp) oscimin sr 0.375 mg tab er oscimin sr TIER 1 12h PROPANTHELINE PROPANTHELINE BROMIDE 15 MG TAB TIER 1 BROMIDE propantheline bromide symax-sl symax-sl 0.125 mg sl tab TIER 1 symax-sr 0.375 mg tab er symax-sr TIER 1 12h

GASTROINTESTINAL AGENTS, OTHER

alvimopan alvimopan 12 mg cap TIER 1 amoxicill-clarithro- amoxicill-clarithro-lansopraz TIER 1 lansopraz misc CHENODAL 250 MG TAB CHENODAL TIER 2 chenodiol cromolyn sodium 100 cromolyn sodium TIER 1 mg/5ml conc DIPHENOXYLATE- DIPHENOXYLATE- ATROPINE (MG TAB, TIER 1 ATROPINE MG/5ML LIQUID) diphenoxylate w/ atropine GATTEX 5 MG KIT GATTEX T6 teduglutide (rdna) MOVANTIK (12.5 MG TAB, MOVANTIK 25 MG TAB) TIER 2 PA naloxegol oxalate

©2021 Wellmark, Inc. 105 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS opium 10 mg/ml (1%) opium TIER 1 tincture PAREGORIC 2 MG/5ML PAREGORIC TINCTURE TIER 1 paregoric ursodiol (250 mg tab, 300 ursodiol TIER 1 mg cap, 500 mg tab)

HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

cimetidine (300 mg tab, 400 cimetidine TIER 1 mg tab, 800 mg tab) cimetidine hcl (300 mg/5ml cimetidine hcl solution, 400 mg/6.67ml TIER 1 solution) famotidine (40 mg tab, 40 famotidine TIER 1 mg/5ml recon susp) nizatidine (15 mg/ml nizatidine solution, 150 mg cap, 300 TIER 1 mg cap) ranitidine hcl (15 mg/ml syrup, 75 mg/5ml syrup, ranitidine hcl 150 mg cap, 150 mg/10ml TIER 1 syrup, 300 mg cap, 300 mg tab)

IRRITABLE BOWEL SYNDROME AGENTS

alosetron hcl (0.5 mg tab, 1 alosetron hcl TIER 1 mg tab) LINZESS (72 MCG CAP, 145 MCG CAP, 290 MCG LINZESS TIER 2 CAP) linaclotide lubiprostone (8 mcg cap, 24 lubiprostone TIER 1 mcg cap)

LAXATIVES

CASCARA SAGRADA 1 CASCARA GM/ML FL EXTRACT TIER 2 SAGRADA cascara sagrada constulose 10 gm/15ml constulose TIER 1 solution enulose 10 gm/15ml enulose TIER 1 solution

©2021 Wellmark, Inc. 106 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GAVILYTE-C 240 GM RECON SOLN GAVILYTE-C TIER 1 PV, GA peg 3350-kcl-sod bicarb- sod chloride-sod sulfate gavilyte-g 236 gm recon gavilyte-g TIER 1 PV soln gavilyte-n with flavor gavilyte-n with flavor pack TIER 1 PV pack 420 gm recon soln generlac 10 gm/15ml generlac TIER 1 solution lactulose (10 gm/15ml lactulose solution, 20 gm/30ml TIER 1 solution) lactulose lactulose encephalopathy TIER 1 encephalopathy 10 gm/15ml solution OSMOPREP 1.102-0.398 GM TAB OSMOPREP sodium phosphate TIER 2 PV monobasic-sodium phosphate dibasic peg 3350-kcl-na peg 3350-kcl-na bicarb-nacl TIER 1 PV bicarb-nacl 420 gm recon soln peg 3350/electrolytes 240 peg 3350/electrolytes TIER 1 PV gm recon soln peg-3350/electrolytes 236 peg-3350/electrolytes TIER 1 PV gm recon soln peg- peg- 3350/electrolytes/asc 3350/electrolytes/ascorbat TIER 1 PV orbat 100 gm recon soln peg-kcl-nacl-nasulf-na peg-kcl-nacl-nasulf-na asc- TIER 1 PV asc-c c 100 gm recon soln SUPREP BOWEL PREP KIT 17.5-3.13-1.6 SUPREP BOWEL GM/177ML SOLUTION TIER 2 PV PREP KIT sodium sulfate-potassium sulfate-magnesium sulfate trilyte trilyte 420 gm recon soln TIER 1 PV

PROTECTANTS

misoprostol (100 mcg tab, misoprostol TIER 1 200 mcg tab) sucralfate (1 gm tab, 1 sucralfate TIER 1 gm/10ml suspension)

PROTON PUMP INHIBITORS

cvs lansoprazole 15 mg tab cvs lansoprazole TIER 1 PA-QL (90 / 30 days) dr disp esomeprazole magnesium esomeprazole (10 mg packet, 20 mg PA, QL (60 PER 30 DAYS), TIER 1 magnesium packet, 40 mg cap dr, 40 PA-QL (90 / 30 days) mg packet) lansoprazole (15 mg tab dr PA, QL (60 PER 30 DAYS), lansoprazole TIER 1 disp, 30 mg tab dr disp) PA-QL (90 / 30 days) QL (60 PER 30 DAYS), PA- lansoprazole lansoprazole 30 mg cap dr TIER 1 QL (90 / 30 days) omeprazole (10 mg cap dr, QL (60 PER 30 DAYS), PA- omeprazole TIER 1 40 mg cap dr) QL (90 / 30 days) pantoprazole sodium (20 QL (60 PER 30 DAYS), PA- pantoprazole sodium TIER 1 mg tab dr, 40 mg tab dr) QL (90 / 30 days) pantoprazole sodium 40 mg PA, QL (60 PER 30 DAYS), pantoprazole sodium TIER 1 packet PA-QL (90 / 30 days) rabeprazole sodium 20 mg PA, QL (60 PER 30 DAYS), rabeprazole sodium TIER 1 tab dr PA-QL (90 / 30 days)

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

ALDURAZYME 2.9 ALDURAZYME MG/5ML SOLUTION T6 laronidase CARBAGLU 200 MG TAB CARBAGLU SP-P carglumic acid CERDELGA 84 MG CAP CERDELGA SP-P PA eliglustat tartrate CEREZYME 400 UNIT CEREZYME RECON SOLN T6 imiglucerase CREON (3000-9500 CP DR PART, 6000 CP DR PART, 12000 CP DR PART, 24000-76000 CP DR CREON TIER 2 PART, 36000 CP DR PART) pancrelipase (lipase- protease-amylase) CYSTADANE POWDER CYSTADANE SP-P betaine CYSTAGON (50 MG CAP, CYSTAGON 150 MG CAP) TIER 2 cysteamine bitartrate

©2021 Wellmark, Inc. 108 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ELAPRASE 6 MG/3ML ELAPRASE SOLUTION T6 idursulfase ELELYSO 200 UNIT ELELYSO RECON SOLN T6 taliglucerase alfa FABRAZYME (5 MG RECON SOLN, 35 MG FABRAZYME T6 RECON SOLN) agalsidase beta GALAFOLD 123 MG CAP GALAFOLD SP-P PA, QL (14 PER 28 DAY(S)) migalastat hcl GIVLAARI 189 MG/ML GIVLAARI SOLUTION T6 givosiran sodium LUMIZYME 50 MG RECON LUMIZYME SOLN T6 alglucosidase alfa PA, SBG (Specialty miglustat miglustat 100 mg cap SP-P Biosimilars and Specialty generics) NAGLAZYME 1 MG/ML NAGLAZYME SOLUTION T6 galsulfase nitisinone (2 mg cap, 5 mg SBG (Specialty Biosimilars nitisinone SP-P cap, 10 mg cap) and Specialty generics) OCALIVA 10 MG TAB OCALIVA SP-P PA, QL (60 PER 30 DAYS) obeticholic acid OCALIVA 5 MG TAB OCALIVA SP-P PA, QL (30 PER 30 DAYS) obeticholic acid ORFADIN (4 MG/ML SUSPENSION, 20 MG ORFADIN SP-P CAP) nitisinone OXLUMO 94.5 MG/0.5ML OXLUMO SOLUTION T6 lumasiran sodium PALYNZIQ (2.5 MG/0.5ML SOLN PRSYR, 10 PALYNZIQ MG/0.5ML SOLN PRSYR, SP-P PA 20 MG/ML SOLN PRSYR) pegvaliase-pqpz

©2021 Wellmark, Inc. 109 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PANCREAZE (2600 CP DR PART, 2600-8800 CP DR PART, 4200 CP DR PART, 10500 CP DR PART, 16800 CP DR PART, PANCREAZE TIER 2 21000 CP DR PART, 37000-97300 CP DR PART) pancrelipase (lipase- protease-amylase) PERTZYE (4000 CP DR PART, 8000 CP DR PART, 16000 CP DR PART, PERTZYE 24000-86250 CP DR TIER 2 PART) pancrelipase (lipase- protease-amylase) PROCYSBI (25 MG CAP DR, 75 MG CAP DR, 75 PROCYSBI MG PACKET, 300 MG SP-P PACKET) cysteamine bitartrate RAVICTI 1.1 GM/ML RAVICTI LIQUID SP-P PA, QL (525 PER 30 DAYS) glycerol phenylbutyrate sapropterin dihydrochloride sapropterin SBG (Specialty Biosimilars (100 mg packet, 100 mg SP-P dihydrochloride and Specialty generics) tab, 500 mg packet) sodium phenylbutyrate (3 sodium SBG (Specialty Biosimilars gm/tsp powder, 500 mg SP-P phenylbutyrate and Specialty generics) tab) STRENSIQ (18 MG/0.45ML SOLUTION, 28 MG/0.7ML SOLUTION, 40 MG/ML STRENSIQ SP-P PA SOLUTION, 80 MG/0.8ML SOLUTION) asfotase alfa SUCRAID 8500 UNIT/ML SUCRAID SOLUTION TIER 2 sacrosidase VIOKACE (10440-39150 TAB, 20880 TAB) VIOKACE TIER 2 pancrelipase (lipase- protease-amylase) VPRIV 400 UNIT RECON VPRIV SOLN T6 velaglucerase alfa

©2021 Wellmark, Inc. 110 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ZENPEP (3000-14000 CP DR PART, 5000-24000 CP DR PART, 10000-32000 CP DR PART, 15000- 47000 CP DR PART, ZENPEP 20000-63000 CP DR TIER 2 PART, 25000-79000 CP DR PART, 40000-126000 CP DR PART) pancrelipase (lipase- protease-amylase) ZOKINVY (50 MG CAP, 75 ZOKINVY MG CAP) SP-P QLV (Quantity Limit Varies) lonafarnib

GENITOURINARY AGENTS

ANTISPASMODICS, URINARY

darifenacin hydrobromide darifenacin er (er 7.5 mg tab er 24h, er TIER 1 hydrobromide er 15 mg tab er 24h) flavoxate hcl flavoxate hcl 100 mg tab TIER 1 oxybutynin chloride (5 mg oxybutynin chloride TIER 1 tab, 5 mg/5ml syrup) oxybutynin chloride er (er 5 mg tab er 24h, er 10 mg tab oxybutynin chloride er TIER 1 er 24h, er 15 mg tab er 24h) solifenacin succinate (5 mg solifenacin succinate TIER 1 tab, 10 mg tab) tolterodine tartrate (1 mg tolterodine tartrate TIER 1 tab, 2 mg tab) tolterodine tartrate er (er 2 tolterodine tartrate er mg cap er 24h, er 4 mg cap TIER 1 er 24h) trospium chloride trospium chloride 20 mg tab TIER 1 trospium chloride er 60 mg trospium chloride er TIER 1 cap er 24h

BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin hcl er 10 mg tab alfuzosin hcl er TIER 1 er 24h dutasteride dutasteride 0.5 mg cap TIER 1 dutasteride- dutasteride-tamsulosin hcl TIER 1 tamsulosin hcl 0.5-0.4 mg cap finasteride finasteride 5 mg tab TIER 1

©2021 Wellmark, Inc. 111 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS silodosin (4 mg cap, 8 mg silodosin TIER 1 QL (30 PER 30 DAYS) cap) tadalafil (10 mg tab, 20 mg tadalafil TIER 1 QL (6 PER 30 DAYS) tab) tadalafil (2.5 mg tab, 5 mg tadalafil TIER 1 QL (30 PER 30 DAYS) tab) tamsulosin hcl tamsulosin hcl 0.4 mg cap TIER 1

GENITOURINARY AGENTS, OTHER

bethanechol chloride (5 mg bethanechol chloride tab, 10 mg tab, 25 mg tab, TIER 1 50 mg tab) CYTRA K CRYSTALS CYTRA K 3300-1002 MG PACKET TIER 1 GA CRYSTALS potassium citrate-citric acid D-PENAMINE 125 MG TAB D-PENAMINE TIER 2 penicillamine penicillamine penicillamine 250 mg tab SP-P phenazo phenazo 200 mg tab TIER 1 phenazopyridine hcl 200 phenazopyridine hcl TIER 1 mg tab pot & sod cit-cit ac 550- pot & sod cit-cit ac TIER 1 500-334 mg/5ml solution potassium citrate er (er 5 potassium citrate er (540 tab er, er 10 (1080 tab TIER 1 er, er 15 (1620 tab er) potassium citrate-citric acid potassium citrate- (1100-334 mg/5ml solution, TIER 1 citric acid 3300-1002 mg packet) sildenafil citrate (25 mg tab, sildenafil citrate TIER 1 QL (6 PER 30 DAYS) 50 mg tab, 100 mg tab) sod citrate-citric acid 500- sod citrate-citric acid TIER 1 334 mg/5ml solution taron-crystals 3300-1002 taron-crystals TIER 1 mg packet THIOLA EC (EC 100 MG TAB DR, EC 300 MG TAB THIOLA EC SP-P DR) tiopronin tiopronin tiopronin 100 mg tab SP-P tricitrates 550-500-334 tricitrates TIER 1 mg/5ml solution vardenafil hcl (2.5 mg tab, 5 vardenafil hcl mg tab, 10 mg tab, 10 mg TIER 1 QL (6 PER 30 DAYS) tab disp, 20 mg tab)

©2021 Wellmark, Inc. 112 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS virtrate-2 500-334 mg/5ml virtrate-2 TIER 1 solution virtrate-3 550-500-334 virtrate-3 TIER 1 mg/5ml solution virtrate-k 1100-334 mg/5ml virtrate-k TIER 1 solution

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

ACTHAR 80 UNIT/ML GEL ACTHAR T6 corticotropin ala-cort ala-cort 2.5 % cream TIER 1 alclometasone dipropionate alclometasone (0.05 % cream, 0.05 % TIER 1 dipropionate ointment) AMCINONIDE (0.1 % CREAM, 0.1 % LOTION, AMCINONIDE TIER 1 0.1 % OINTMENT) amcinonide baycadron baycadron 0.5 mg/5ml elixir TIER 1 beser beser 0.05 % lotion TIER 1 betamethasone betamethasone dipropionate (0.05 % TIER 1 dipropionate cream, 0.05 % lotion, 0.05 % ointment) betamethasone betamethasone dipropionate aug (0.05 % TIER 1 dipropionate aug cream, 0.05 % gel, 0.05 % lotion, 0.05 % ointment) betamethasone valerate betamethasone (0.1 % cream, 0.1 % lotion, TIER 1 valerate 0.1 % ointment, 0.12 % foam) clobetasol prop clobetasol prop emollient TIER 1 emollient base base 0.05 % cream clobetasol propionate (0.05 % cream, 0.05 % foam, 0.05 % gel, 0.05 % liquid, clobetasol propionate TIER 1 0.05 % lotion, 0.05 % ointment, 0.05 % shampoo, 0.05 % solution) clobetasol propionate clobetasol propionate e TIER 1 e 0.05 % cream clobetasol propionate clobetasol propionate TIER 1 emulsion emulsion 0.05 % foam clocortolone pivalate 0.1 % clocortolone pivalate TIER 1 QL (90 PER 30 DAY(S)) cream

©2021 Wellmark, Inc. 113 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS clocortolone pivalate clocortolone pivalate pump TIER 1 QL (90 PER 30 DAY(S)) pump 0.1 % cream clodan clodan 0.05 % shampoo TIER 1 cormax scalp cormax scalp application TIER 1 application 0.05 % solution decadron (0.5 mg tab, 0.5 decadron mg/5ml elixir, 0.75 mg tab, TIER 1 4 mg tab, 6 mg tab) deltasone deltasone 20 mg tab TIER 1 DEPO-MEDROL 20 MG/ML DEPO-MEDROL SUSPENSION TIER 1 methylprednisolone acetate desonide (0.05 % cream, desonide 0.05 % gel, 0.05 % lotion, TIER 1 0.05 % ointment) desoximetasone (0.05 % cream, 0.05 % gel, 0.05 % desoximetasone ointment, 0.25 % cream, TIER 1 0.25 % liquid, 0.25 % ointment) desrx desrx 0.05 % gel TIER 1 dexamethasone (0.5 mg tab, 0.5 mg/5ml elixir, 0.5 dexamethasone mg/5ml solution, 0.75 mg TIER 1 tab, 1 mg tab, 1.5 mg tab, 2 mg tab, 4 mg tab, 6 mg tab) DEXAMETHASONE DEXAMETHASONE INTENSOL 1 MG/ML TIER 1 INTENSOL CONC dexamethasone dexamethasone sod dexamethasone sod phosphate pf 10 mg/ml TIER 1 phosphate pf solution dexamethasone sodium dexamethasone phosphate 20 mg/5ml TIER 1 sodium phosphate solution EMFLAZA (6 MG TAB, 18 MG TAB, 22.75 MG/ML EMFLAZA SUSPENSION, 30 MG SP-P PA TAB, 36 MG TAB) deflazacort fludrocortisone fludrocortisone acetate 0.1 TIER 1 acetate mg tab

©2021 Wellmark, Inc. 114 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS fluocinolone acetonide fluocinolone (0.01 % cream, 0.01 % TIER 1 acetonide solution, 0.025 % cream, 0.025 % ointment) fluocinolone fluocinolone acetonide body TIER 1 acetonide body 0.01 % oil fluocinolone fluocinolone acetonide TIER 1 acetonide scalp scalp 0.01 % oil fluocinonide (0.05 % cream, fluocinonide 0.05 % gel, 0.05 % TIER 1 ointment, 0.05 % solution) fluocinonide fluocinonide 0.1 % cream TIER 1 QL (120 PER 30 DAY(S)) fluocinonide fluocinonide emulsified TIER 1 emulsified base base 0.05 % cream flurandrenolide (0.05 % flurandrenolide TIER 1 cream, 0.05 % ointment) flurandrenolide 0.05 % flurandrenolide TIER 1 QL (120 PER 30 DAY(S)) lotion fluticasone propionate fluticasone propionate (0.005 % ointment, 0.05 % TIER 1 cream, 0.05 % lotion) halobetasol propionate halobetasol (0.05 % cream, 0.05 % TIER 1 propionate ointment) hydrocort-pramoxine hydrocort-pramoxine TIER 1 (perianal) (perianal) 2.5-1 % cream hydrocortisone (2.5 % cream, 2.5 % lotion, 2.5 % hydrocortisone TIER 1 ointment, 5 mg tab, 10 mg tab, 20 mg tab) hydrocortisone ace- hydrocortisone ace- TIER 1 pramoxine pramoxine 2.5-1 % cream hydrocortisone butyr hydrocortisone butyr lipo TIER 1 QL (60 PER 30 DAY(S)) lipo base base 0.1 % cream hydrocortisone butyrate hydrocortisone (0.1 % cream, 0.1 % lotion, TIER 1 butyrate 0.1 % ointment, 0.1 % solution) hydrocortisone hydrocortisone valerate (0.2 TIER 1 valerate % cream, 0.2 % ointment) KORLYM 300 MG TAB PA, QL (120 PER 30 KORLYM mifepristone SP-P DAY(S)) (hyperglycemia) lokara lokara 0.05 % lotion TIER 1

©2021 Wellmark, Inc. 115 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS methylprednisolone (4 mg methylprednisolone tab, 4 mg tab thpk, 8 mg TIER 1 tab, 16 mg tab, 32 mg tab) methylprednisolone methylprednisolone sodium TIER 1 sodium succ succ 500 mg recon soln mometasone furoate (0.1 % mometasone furoate cream, 0.1 % ointment, 0.1 TIER 1 % solution) nolix nolix 0.05 % cream TIER 1 nolix nolix 0.05 % lotion TIER 1 QL (120 PER 30 DAY(S)) PRAMOSONE (1-1 % CREAM, 1-1 % LOTION, 1- PRAMOSONE TIER 1 2.5 % LOTION) pramoxine-hc PREDNICARBATE (0.1 % CREAM, 0.1 % PREDNICARBATE TIER 1 OINTMENT) prednicarbate prednisolone (15 solution, prednisolone TIER 1 15 syrup) prednisolone sodium phosphate (6.7 (5 base) mg/5ml solution, 10 mg tab prednisolone sodium disp, 10 mg/5ml solution, TIER 1 phosphate 15 mg tab disp, 15 mg/5ml solution, 20 mg/5ml solution, 25 mg/5ml solution, 30 mg tab disp) prednisolone sodium prednisolone sodium phosphate 25 mg/5ml TIER 1 phosphate solution prednisone (1 mg tab, 2.5 mg tab, 5 mg (21) tab thpk, 5 mg (48) tab thpk, 5 mg prednisone tab, 5 mg/5ml solution, 10 TIER 1 mg (21) tab thpk, 10 mg (48) tab thpk, 10 mg tab, 20 mg tab, 50 mg tab) PREDNISONE INTENSOL PREDNISONE 5 MG/ML CONC TIER 1 INTENSOL prednisone SOLU-CORTEF (100 MG RECON SOLN, 250 MG RECON SOLN, 500 MG SOLU-CORTEF TIER 1 RECON SOLN) hydrocortisone sod succinate

©2021 Wellmark, Inc. 116 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SOLU-MEDROL 500 MG RECON SOLN SOLU-MEDROL TIER 1 GA methylprednisolone sod succ tovet tovet 0.05 % foam TIER 1 triamcinolone acetonide (0.025 % cream, 0.025 % lotion, 0.025 % ointment, triamcinolone 0.1 % cream, 0.1 % lotion, TIER 1 acetonide 0.1 % ointment, 0.5 % cream, 0.5 % ointment, 40 mg/ml suspension) triamcinolone triamcinolone acetonide TIER 1 QL (4.5 PER 1 DAY(S)) acetonide 0.147 mg/gm aero soln triderm (0.1 % cream, 0.5 triderm TIER 1 % cream)

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

desmopressin ace desmopressin ace spray TIER 1 spray refrig refrig 0.01 % solution desmopressin acetate (0.1 desmopressin acetate TIER 1 mg tab, 0.2 mg tab) desmopressin acetate desmopressin acetate TIER 1 spray spray 0.01 % solution INCRELEX 40 MG/4ML INCRELEX SOLUTION SP-P PA mecasermin NORDITROPIN FLEXPRO (5 MG/1.5ML SOLN PEN, NORDITROPIN 10 MG/1.5ML SOLN PEN, SP-P PA FLEXPRO 15 MG/1.5ML SOLN PEN, 30 MG/3ML SOLN PEN) somatropin

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)

ANABOLIC STEROIDS

ANADROL-50 50 MG TAB ANADROL-50 TIER 2 oxymetholone oxandrolone (2.5 mg tab, oxandrolone TIER 1 10 mg tab)

ANDROGENS

danazol (50 mg cap, 100 danazol TIER 1 mg cap, 200 mg cap) methyltestosterone 10 mg methyltestosterone TIER 1 PA cap

©2021 Wellmark, Inc. 117 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS testosterone (1.62 % gel, 12.5 mg/act (1%) gel, 20.25 mg/1.25gm (1.62%) gel, 20.25 mg/act (1.62%) gel, testosterone TIER 2 PA 25 mg/2.5gm (1%) gel, 30 mg/act solution, 40.5 mg/2.5gm (1.62%) gel, 50 mg/5gm (1%) gel) testosterone cypionate (100 testosterone mg/ml solution, 200 mg/ml TIER 1 cypionate solution) testosterone testosterone enanthate 200 TIER 1 enanthate mg/ml solution

ESTROGENS

afirmelle 0.1-20 mg-mcg afirmelle TIER 1 PV tab altavera 0.15-30 mg-mcg altavera TIER 1 PV tab alyacen 1/35 1-35 mg-mcg alyacen 1/35 TIER 1 PV tab alyacen 7/7/7 0.5/0.75/1-35 alyacen 7/7/7 TIER 1 PV mg-mcg tab amabelz (0.5-0.1 mg tab, 1- amabelz TIER 1 0.5 mg tab) amethia 0.15-0.03 &0.01 amethia TIER 1 PV mg tab amethia lo 0.1-0.02 & 0.01 amethia lo TIER 1 PV mg tab amethyst amethyst 90-20 mcg tab TIER 1 PV apri apri 0.15-30 mg-mcg tab TIER 1 PV aranelle 0.5/1/0.5-35 mg- aranelle TIER 1 PV mcg tab ashlyna 0.15-0.03 &0.01 ashlyna TIER 1 PV mg tab aubra aubra 0.1-20 mg-mcg tab TIER 1 PV aubra eq 0.1-20 mg-mcg aubra eq TIER 1 PV tab aurovela 1.5/30 1.5-30 mg- aurovela 1.5/30 TIER 1 PV mcg tab aurovela 1/20 1-20 mg-mcg aurovela 1/20 TIER 1 PV tab aurovela 24 fe 1-20 mg- aurovela 24 fe TIER 1 PV mcg(24) tab

©2021 Wellmark, Inc. 118 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS aurovela fe 1.5/30 1.5-30 aurovela fe 1.5/30 TIER 1 PV mg-mcg tab aurovela fe 1/20 1-20 mg- aurovela fe 1/20 TIER 1 PV mcg tab aviane aviane 0.1-20 mg-mcg tab TIER 1 PV ayuna ayuna 0.15-30 mg-mcg tab TIER 1 PV azurette 0.15-0.02/0.01 mg azurette TIER 1 PV (21/5) tab balziva balziva 0.4-35 mg-mcg tab TIER 1 PV bekyree 0.15-0.02/0.01 mg bekyree TIER 1 PV (21/5) tab blisovi 24 fe 1-20 mg- blisovi 24 fe TIER 1 PV mcg(24) tab blisovi fe 1.5/30 1.5-30 mg- blisovi fe 1.5/30 TIER 1 PV mcg tab blisovi fe 1/20 1-20 mg-mcg blisovi fe 1/20 TIER 1 PV tab briellyn briellyn 0.4-35 mg-mcg tab TIER 1 PV camrese 0.15-0.03 &0.01 camrese TIER 1 PV mg tab camrese lo 0.1-0.02 & 0.01 camrese lo TIER 1 PV mg tab caziant 0.1/0.125/0.15 - caziant TIER 1 PV 0.025 mg tab charlotte 24 fe 1-20 mg- charlotte 24 fe TIER 1 PV mcg(24) chew tab chateal 0.15-30 mg-mcg chateal TIER 1 PV tab chateal eq 0.15-30 mg-mcg chateal eq TIER 1 PV tab covaryx covaryx 1.25-2.5 mg tab TIER 1 covaryx hs 0.625-1.25 mg covaryx hs TIER 1 tab cryselle-28 0.3-30 mg-mcg cryselle-28 TIER 1 PV tab cyclafem 1/35 1-35 mg-mcg cyclafem 1/35 TIER 1 PV tab cyclafem 7/7/7 0.5/0.75/1- cyclafem 7/7/7 TIER 1 PV 35 mg-mcg tab cyred cyred 0.15-30 mg-mcg tab TIER 1 PV cyred eq 0.15-30 mg-mcg cyred eq TIER 1 PV tab dasetta 1/35 1-35 mg-mcg dasetta 1/35 TIER 1 PV tab

©2021 Wellmark, Inc. 119 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS dasetta 7/7/7 0.5/0.75/1-35 dasetta 7/7/7 TIER 1 PV mg-mcg tab daysee 0.15-0.03 &0.01 mg daysee TIER 1 PV tab DELESTROGEN (20 MG/ML OIL, 40 MG/ML DELESTROGEN TIER 1 GA OIL) estradiol valerate delyla delyla 0.1-20 mg-mcg tab TIER 1 PV DEPO-ESTRADIOL 5 DEPO-ESTRADIOL MG/ML OIL TIER 1 estradiol cypionate desogestrel-ethinyl desogestrel-ethinyl estradiol (0.15-0.02/0.01 TIER 1 PV estradiol mg (21/5) tab, 0.15-30 mg- mcg tab) dolishale dolishale 90-20 mcg tab TIER 1 PV dotti (0.025 mg/24hr patch tw, 0.0375 mg/24hr patch dotti tw, 0.05 mg/24hr patch tw, TIER 1 QL (8 PER 28 DAYS) 0.075 mg/24hr patch tw, 0.1 mg/24hr patch tw) drospiren-eth estrad- drospiren-eth estrad- levomefol (3-0.02-0.451 mg TIER 1 PV levomefol tab, 3-0.03-0.451 mg tab) drospirenone-ethinyl drospirenone-ethinyl estradiol (3-0.02 mg tab, 3- TIER 1 PV estradiol 0.03 mg tab) eemt eemt 1.25-2.5 mg tab TIER 1 eemt hs eemt hs 0.625-1.25 mg tab TIER 1 elinest elinest 0.3-30 mg-mcg tab TIER 1 PV eluryng 0.12-0.015 mg/24hr eluryng TIER 1 PV ring emoquette 0.15-30 mg-mcg emoquette TIER 1 PV tab enpresse-28 50-30/75-40/ enpresse-28 TIER 1 PV 125-30 mcg tab enskyce 0.15-30 mg-mcg enskyce TIER 1 PV tab est estrogens-methyltest est estrogens- (rogens-methylt0.625-1.25 TIER 1 methyltest mg tab, rogens- methylt1.25-2.5 mg tab) est estrogens- est estrogens-methyltest ds TIER 1 methyltest ds 1.25-2.5 mg tab

©2021 Wellmark, Inc. 120 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS est estrogens- est estrogens-methyltest hs TIER 1 methyltest hs 0.625-1.25 mg tab estarylla 0.25-35 mg-mcg estarylla TIER 1 PV tab estradiol (0.025 mg/24hr patch tw, 0.0375 mg/24hr patch tw, 0.05 mg/24hr estradiol TIER 1 QL (8 PER 28 DAYS) patch tw, 0.075 mg/24hr patch tw, 0.1 mg/24hr patch tw) estradiol (0.025 mg/24hr patch wk, 0.0375 mg/24hr patch wk, 0.05 mg/24hr patch wk, 0.06 mg/24hr estradiol patch wk, 0.075 mg/24hr TIER 1 patch wk, 0.1 mg/24hr patch wk, 0.1 mg/gm cream, 0.5 mg tab, 1 mg tab, 2 mg tab, 10 mcg tab) estradiol valerate (20 mg/ml estradiol valerate TIER 1 oil, 40 mg/ml oil) estradiol-norethindrone estradiol- acet (0.5-0.1 mg tab, 1-0.5 TIER 1 norethindrone acet mg tab) ESTROPIPATE (0.75 MG TAB, 1.5 MG TAB, 3 MG ESTROPIPATE TIER 1 TAB) estropipate ethynodiol diac-eth ethynodiol diac-eth estradiol (1-35 tab, 1-50 TIER 1 PV estradiol tab) etonogestrel-ethinyl etonogestrel-ethinyl estradiol 0.12-0.015 TIER 1 PV estradiol mg/24hr ring falmina falmina 0.1-20 mg-mcg tab TIER 1 PV fayosim 42-21-21-7 days fayosim TIER 1 PV tab femynor 0.25-35 mg-mcg femynor TIER 1 PV tab fyavolv (0.5-2.5 tab, 1-5 fyavolv TIER 1 tab) gemmily 1-20 mg-mcg(24) gemmily TIER 1 cap gianvi gianvi 3-0.02 mg tab TIER 1 PV gildagia gildagia 0.4-35 mg-mcg tab TIER 1 PV hailey 1.5/30 1.5-30 mg- hailey 1.5/30 TIER 1 PV mcg tab

©2021 Wellmark, Inc. 121 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS hailey 24 fe 1-20 mg- hailey 24 fe TIER 1 PV mcg(24) tab hailey fe 1.5/30 1.5-30 mg- hailey fe 1.5/30 TIER 1 PV mcg tab hailey fe 1/20 1-20 mg-mcg hailey fe 1/20 TIER 1 PV tab iclevia iclevia 0.15-0.03 mg tab TIER 1 PV introvale introvale 0.15-0.03 mg tab TIER 1 PV isibloom 0.15-30 mg-mcg isibloom TIER 1 PV tab jaimiess 0.15-0.03 &0.01 jaimiess TIER 1 PV mg tab jasmiel jasmiel 3-0.02 mg tab TIER 1 PV jevantique lo 0.5-2.5 mg- jevantique lo TIER 1 mcg tab jinteli jinteli 1-5 mg-mcg tab TIER 1 jolessa jolessa 0.15-0.03 mg tab TIER 1 PV juleber juleber 0.15-30 mg-mcg tab TIER 1 PV junel 1.5/30 1.5-30 mg-mcg junel 1.5/30 TIER 1 PV tab junel 1/20 junel 1/20 1-20 mg-mcg tab TIER 1 PV junel fe 1.5/30 1.5-30 mg- junel fe 1.5/30 TIER 1 PV mcg tab junel fe 1/20 1-20 mg-mcg junel fe 1/20 TIER 1 PV tab junel fe 24 1-20 mg- junel fe 24 TIER 1 PV mcg(24) tab kaitlib fe 0.8-25 mg-mcg kaitlib fe TIER 1 PV chew tab kalliga kalliga 0.15-30 mg-mcg tab TIER 1 PV kariva 0.15-0.02/0.01 mg kariva TIER 1 PV (21/5) tab kelnor 1/35 1-35 mg-mcg kelnor 1/35 TIER 1 PV tab kelnor 1/50 1-50 mg-mcg kelnor 1/50 TIER 1 PV tab kimidess 0.15-0.02/0.01 mg kimidess TIER 1 PV (21/5) tab kurvelo 0.15-30 mg-mcg kurvelo TIER 1 PV tab larin 1.5/30 1.5-30 mg-mcg larin 1.5/30 TIER 1 PV tab larin 1/20 larin 1/20 1-20 mg-mcg tab TIER 1 PV

©2021 Wellmark, Inc. 122 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS larin 24 fe 1-20 mg-mcg(24) larin 24 fe TIER 1 PV tab larin fe 1.5/30 1.5-30 mg- larin fe 1.5/30 TIER 1 PV mcg tab larin fe 1/20 1-20 mg-mcg larin fe 1/20 TIER 1 PV tab larissia larissia 0.1-20 mg-mcg tab TIER 1 PV layolis fe 0.8-25 mg-mcg layolis fe TIER 1 PV chew tab leena 0.5/1/0.5-35 mg-mcg leena TIER 1 PV tab lessina lessina 0.1-20 mg-mcg tab TIER 1 PV levonest 50-30/75-40/ 125- levonest TIER 1 PV 30 mcg tab levonorg-eth estrad levonorg-eth estrad triphasic 50-30/75-40/ 125- TIER 1 PV triphasic 30 mcg tab levonorgest-eth est & levonorgest-eth est & eth TIER 1 PV eth est est 42-21-21-7 days tab levonorgest-eth estrad 91- levonorgest-eth day (0.1-0.02 & 0.01 mg TIER 1 PV estrad 91-day tab, 0.15-0.03 &0.01 mg tab, 0.15-0.03 mg tab) levonorgestrel-ethinyl levonorgestrel-ethinyl estrad (0.1-20 mg-mcg tab, TIER 1 PV estrad 0.15-30 mg-mcg tab, 90-20 mcg tab) levora 0.15/30 (28) 0.15-30 levora 0.15/30 (28) TIER 1 PV mg-mcg tab lillow lillow 0.15-30 mg-mcg tab TIER 1 PV lo-zumandimine 3-0.02 mg lo-zumandimine TIER 1 PV tab loestrin 1.5/30 (21) 1.5-30 loestrin 1.5/30 (21) TIER 1 PV mg-mcg tab loestrin 1/20 (21) 1-20 mg- loestrin 1/20 (21) TIER 1 PV mcg tab loestrin fe 1.5/30 1.5-30 loestrin fe 1.5/30 TIER 1 PV mg-mcg tab loestrin fe 1/20 1-20 mg- loestrin fe 1/20 TIER 1 PV mcg tab lojaimiess 0.1-0.02 & 0.01 lojaimiess TIER 1 PV mg tab lomedia 24 fe 1-20 mg- lomedia 24 fe TIER 1 PV mcg(24) tab

©2021 Wellmark, Inc. 123 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS lopreeza (0.5-0.1 mg tab, 1- lopreeza TIER 1 0.5 mg tab) loryna loryna 3-0.02 mg tab TIER 1 PV low-ogestrel 0.3-30 mg-mcg low-ogestrel TIER 1 PV tab lutera lutera 0.1-20 mg-mcg tab TIER 1 PV lyllana (0.025 mg/24hr patch tw, 0.0375 mg/24hr patch tw, 0.05 mg/24hr lyllana TIER 1 QL (8 PER 28 DAYS) patch tw, 0.075 mg/24hr patch tw, 0.1 mg/24hr patch tw) marlissa 0.15-30 mg-mcg marlissa TIER 1 PV tab melodetta 24 fe 1-20 mg- melodetta 24 fe TIER 1 PV mcg(24) chew tab merzee 1-20 mg-mcg(24) merzee TIER 1 cap mibelas 24 fe 1-20 mg- mibelas 24 fe TIER 1 PV mcg(24) chew tab microgestin 1.5/30 1.5-30 microgestin 1.5/30 TIER 1 PV mg-mcg tab microgestin 1/20 1-20 mg- microgestin 1/20 TIER 1 PV mcg tab microgestin 24 fe 1-20 mg- microgestin 24 fe TIER 1 PV mcg tab microgestin fe 1.5/30 1.5-30 microgestin fe 1.5/30 TIER 1 PV mg-mcg tab microgestin fe 1/20 1-20 microgestin fe 1/20 TIER 1 PV mg-mcg tab mili mili 0.25-35 mg-mcg tab TIER 1 PV mimvey mimvey 1-0.5 mg tab TIER 1 mimvey lo mimvey lo 0.5-0.1 mg tab TIER 1 mono-linyah 0.25-35 mg- mono-linyah TIER 1 PV mcg tab mononessa 0.25-35 mg- mononessa TIER 1 PV mcg tab myzilra 50-30/75-40/ 125- myzilra TIER 1 PV 30 mcg tab necon 0.5/35 (28) 0.5-35 necon 0.5/35 (28) TIER 1 PV mg-mcg tab necon 7/7/7 0.5/0.75/1-35 necon 7/7/7 TIER 1 PV mg-mcg tab nikki nikki 3-0.02 mg tab TIER 1 PV

©2021 Wellmark, Inc. 124 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS norethin ace-eth estrad-fe (1-20 mg-mcg tab, 1-20 norethin ace-eth mg-mcg(24) cap, 1-20 mg- TIER 1 PV estrad-fe mcg(24) chew tab, 1-20 mg-mcg(24) tab, 1.5-30 mg-mcg tab) norethin-eth estradiol-fe norethin-eth estradiol- (0.4-35 chew tab, 0.8-25 TIER 1 PV fe chew tab) norethindrone acet-ethinyl norethindrone acet- est (1-20 mg-mcg tab, 1-20 TIER 1 PV ethinyl est mg-mcg(24) chew tab, 1.5- 30 mg-mcg tab) norethindrone-eth norethindrone-eth estradiol TIER 1 estradiol (0.5-2.5 tab, 1-5 tab) norgestim-eth estrad norgestim-eth estrad triphasic (mg-25 mcg tab, TIER 1 PV triphasic mg-35 mcg tab) norgestimate-eth norgestimate-eth estradiol TIER 1 PV estradiol 0.25-35 mg-mcg tab nortrel 0.5/35 (28) 0.5-35 nortrel 0.5/35 (28) TIER 1 PV mg-mcg tab nortrel 1/35 (21) 1-35 mg- nortrel 1/35 (21) TIER 1 PV mcg tab nortrel 1/35 (28) 1-35 mg- nortrel 1/35 (28) TIER 1 PV mcg tab nortrel 7/7/7 0.5/0.75/1-35 nortrel 7/7/7 TIER 1 PV mg-mcg tab nylia 7/7/7 0.5/0.75/1-35 nylia 7/7/7 TIER 1 PV mg-mcg tab nymyo nymyo 0.25-35 mg-mcg tab TIER 1 PV ocella ocella 3-0.03 mg tab TIER 1 PV OGESTREL 0.5-50 MG- MCG TAB OGESTREL TIER 1 PV norgestrel & ethinyl estradiol orsythia orsythia 0.1-20 mg-mcg tab TIER 1 PV philith philith 0.4-35 mg-mcg tab TIER 1 PV pimtrea 0.15-0.02/0.01 mg pimtrea TIER 1 PV (21/5) tab pirmella 1/35 1-35 mg-mcg pirmella 1/35 TIER 1 PV tab pirmella 7/7/7 0.5/0.75/1-35 pirmella 7/7/7 TIER 1 PV mg-mcg tab portia-28 0.15-30 mg-mcg portia-28 TIER 1 PV tab

©2021 Wellmark, Inc. 125 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PREMARIN (0.3 MG TAB, 0.45 MG TAB, 0.625 MG TAB, 0.625 MG/GM PREMARIN TIER 2 CREAM, 0.9 MG TAB, 1.25 MG TAB) estrogens, conjugated PREMPHASE 0.625-5 MG TAB PREMPHASE conjugated estrogens- TIER 2 medroxyprogesterone acetate PREMPRO (0.3-1.5 MG TAB, 0.45-1.5 MG TAB, 0.625-2.5 MG TAB, 0.625-5 PREMPRO MG TAB) TIER 2 conjugated estrogens- medroxyprogesterone acetate previfem 0.25-35 mg-mcg previfem TIER 1 PV tab quasense quasense 0.15-0.03 mg tab TIER 1 PV rajani rajani 3-0.02-0.451 mg tab TIER 1 PV reclipsen 0.15-30 mg-mcg reclipsen TIER 1 PV tab rivelsa rivelsa 42-21-21-7 days tab TIER 1 PV setlakin setlakin 0.15-0.03 mg tab TIER 1 PV simliya 0.15-0.02/0.01 mg simliya TIER 1 PV (21/5) tab simpesse 0.15-0.03 &0.01 simpesse TIER 1 PV mg tab sprintec 28 0.25-35 mg- sprintec 28 TIER 1 PV mcg tab sronyx sronyx 0.1-20 mg-mcg tab TIER 1 PV syeda syeda 3-0.03 mg tab TIER 1 PV tarina 24 fe 1-20 mg- tarina 24 fe TIER 1 PV mcg(24) tab tarina fe 1/20 1-20 mg-mcg tarina fe 1/20 TIER 1 PV tab tarina fe 1/20 eq 1-20 mg- tarina fe 1/20 eq TIER 1 PV mcg tab taysofy 1-20 mg-mcg(24) taysofy TIER 1 cap tilia fe 1-20/1-30/1-35 mg- tilia fe TIER 1 PV mcg tab tri femynor 0.18/0.215/0.25 tri femynor TIER 1 PV mg-35 mcg tab

©2021 Wellmark, Inc. 126 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS tri-estarylla 0.18/0.215/0.25 tri-estarylla TIER 1 PV mg-35 mcg tab tri-legest fe 1-20/1-30/1-35 tri-legest fe TIER 1 PV mg-mcg tab tri-linyah 0.18/0.215/0.25 tri-linyah TIER 1 PV mg-35 mcg tab tri-lo-estarylla tri-lo-estarylla 0.18/0.215/0.25 mg-25 mcg TIER 1 PV tab tri-lo-marzia tri-lo-marzia 0.18/0.215/0.25 mg-25 mcg TIER 1 PV tab tri-lo-mili 0.18/0.215/0.25 tri-lo-mili TIER 1 PV mg-25 mcg tab tri-lo-sprintec tri-lo-sprintec 0.18/0.215/0.25 mg-25 mcg TIER 1 PV tab tri-mili 0.18/0.215/0.25 mg- tri-mili TIER 1 PV 35 mcg tab tri-nymyo 0.18/0.215/0.25 tri-nymyo TIER 1 PV mg-35 mcg tab tri-previfem 0.18/0.215/0.25 tri-previfem TIER 1 PV mg-35 mcg tab tri-sprintec 0.18/0.215/0.25 tri-sprintec TIER 1 PV mg-35 mcg tab tri-vylibra 0.18/0.215/0.25 tri-vylibra TIER 1 PV mg-35 mcg tab tri-vylibra lo 0.18/0.215/0.25 tri-vylibra lo TIER 1 PV mg-25 mcg tab trinessa (28) trinessa (28) 0.18/0.215/0.25 mg-35 mcg TIER 1 PV tab trinessa lo 0.18/0.215/0.25 trinessa lo TIER 1 PV mg-25 mcg tab trivora (28) 50-30/75-40/ trivora (28) TIER 1 PV 125-30 mcg tab tydemy 3-0.03-0.451 mg tydemy TIER 1 PV tab velivet 0.1/0.125/0.15 - velivet TIER 1 PV 0.025 mg tab vestura vestura 3-0.02 mg tab TIER 1 PV vienva vienva 0.1-20 mg-mcg tab TIER 1 PV viorele 0.15-0.02/0.01 mg viorele TIER 1 PV (21/5) tab

©2021 Wellmark, Inc. 127 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS volnea 0.15-0.02/0.01 mg volnea TIER 1 PV (21/5) tab vyfemla vyfemla 0.4-35 mg-mcg tab TIER 1 PV vylibra vylibra 0.25-35 mg-mcg tab TIER 1 PV wera wera 0.5-35 mg-mcg tab TIER 1 PV wymzya fe 0.4-35 mg-mcg wymzya fe TIER 1 PV chew tab xulane 150-35 mcg/24hr xulane TIER 1 PV patch wk yuvafem yuvafem 10 mcg tab TIER 1 zafemy 150-35 mcg/24hr zafemy TIER 1 patch wk zarah zarah 3-0.03 mg tab TIER 1 PV zenchent 0.4-35 mg-mcg zenchent TIER 1 PV tab zenchent fe 0.4-35 mg-mcg zenchent fe TIER 1 PV chew tab zovia 1/35 (28) 1-35 mg- zovia 1/35 (28) TIER 1 PV mcg tab zovia 1/35e (28) 1-35 mg- zovia 1/35e (28) TIER 1 PV mcg tab zovia 1/50e (28) 1-50 mg- zovia 1/50e (28) TIER 1 PV mcg tab zumandimine zumandimine 3-0.03 mg tab TIER 1 PV

PROGESTINS

camila camila 0.35 mg tab TIER 1 PV deblitane deblitane 0.35 mg tab TIER 1 PV errin errin 0.35 mg tab TIER 1 PV heather heather 0.35 mg tab TIER 1 PV hydroxyprogesterone hydroxyprogesterone caproate (1.25 gm/5ml T6 caproate solution, 250 mg/ml oil) incassia incassia 0.35 mg tab TIER 1 PV jencycla jencycla 0.35 mg tab TIER 1 PV jolivette jolivette 0.35 mg tab TIER 1 PV KYLEENA 19.5 MG IUD KYLEENA T6 levonorgestrel (iud) LILETTA (52 MG) 19.5 LILETTA (52 MG) MCG/DAY IUD T6 levonorgestrel (iud) lyleq lyleq 0.35 mg tab TIER 1 PV

©2021 Wellmark, Inc. 128 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS lyza lyza 0.35 mg tab TIER 1 PV MAKENA (250 MG/ML OIL, 275 MG/1.1ML SOLN A- MAKENA INJ) T6 hydroxyprogesterone caproate medroxyprogesterone acetate (2.5 mg tab, 5 mg medroxyprogesterone tab, 10 mg tab, 150 mg/ml TIER 1 acetate susp prsyr, 150 mg/ml suspension) megestrol acetate (20 mg tab, 40 mg tab, 40 mg/ml megestrol acetate suspension, 400 mg/10ml TIER 1 suspension, 625 mg/5ml suspension) MIRENA (52 MG) 20 MIRENA (52 MG) MCG/24HR IUD T6 levonorgestrel (iud) nora-be nora-be 0.35 mg tab TIER 1 PV norethindrone norethindrone 0.35 mg tab TIER 1 PV norethindrone acetate 5 mg norethindrone acetate TIER 1 tab norlyda norlyda 0.35 mg tab TIER 1 PV norlyroc norlyroc 0.35 mg tab TIER 1 PV progesterone (50 mg/ml oil, progesterone TIER 1 100 mg cap, 200 mg cap) sharobel sharobel 0.35 mg tab TIER 1 PV SKYLA 13.5 MG IUD SKYLA T6 levonorgestrel (iud) tulana tulana 0.35 mg tab TIER 1 PV

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS

raloxifene hcl raloxifene hcl 60 mg tab TIER 1 PA, PV

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

euthyrox (25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 mcg tab, 112 euthyrox TIER 1 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab)

©2021 Wellmark, Inc. 129 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS levo-t (25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 mcg tab, 112 mcg levo-t tab, 125 mcg tab, 137 mcg TIER 1 tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 300 mcg tab) levothyroxine sodium (25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 levothyroxine sodium mcg tab, 112 mcg tab, 125 TIER 1 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 300 mcg tab) levoxyl (25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 mcg tab, 112 levoxyl TIER 1 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab) liothyronine sodium (5 mcg liothyronine sodium tab, 25 mcg tab, 50 mcg TIER 1 tab) np thyroid (15 mg tab, 30 np thyroid mg tab, 60 mg tab, 90 mg TIER 1 tab, 120 mg tab) SYNTHROID (25 MCG TAB, 50 MCG TAB, 75 MCG TAB, 88 MCG TAB, 100 MCG TAB, 112 MCG SYNTHROID TAB, 125 MCG TAB, 137 TIER 2 GA MCG TAB, 150 MCG TAB, 175 MCG TAB, 200 MCG TAB, 300 MCG TAB) levothyroxine sodium thyroid (15 mg tab, 30 mg thyroid tab, 60 mg tab, 90 mg tab, TIER 1 120 mg tab) unithroid (25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 mcg tab, 112 unithroid mcg tab, 125 mcg tab, 137 TIER 1 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 300 mcg tab)

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

BYNFEZIA PEN 2500 MCG/ML (2.8 ML) SOLN BYNFEZIA PEN SP-P PEN octreotide acetate cabergoline cabergoline 0.5 mg tab TIER 1 ELIGARD (7.5 MG KIT, 22.5 MG KIT, 30 MG KIT, ELIGARD T6 45 MG KIT) leuprolide acetate FENSOLVI (6 MONTH) 45 FENSOLVI (6 MG (PED) KIT T6 MONTH) leuprolide acetate (cpp) (6 month) FIRMAGON (240 MG FIRMAGON (240 MG DOSE) 120 MG/VIAL T6 DOSE) RECON SOLN degarelix acetate FIRMAGON 80 MG FIRMAGON RECON SOLN T6 degarelix acetate LUPANETA PACK (PACK3.755MGKIT, LUPANETA PACK PACK11.255MGKIT) T6 leuprolide acetate & norethindrone acetate LUPRON DEPOT (1- LUPRON DEPOT (1- MONTH) (3.75 MG KIT, 7.5 T6 MONTH) MG KIT) leuprolide acetate LUPRON DEPOT (3- MONTH) (11.25 MG KIT, LUPRON DEPOT (3- 22.5 MG KIT) T6 MONTH) leuprolide acetate (3 month) LUPRON DEPOT (4- LUPRON DEPOT (4- MONTH) 30 MG KIT T6 MONTH) leuprolide acetate (4 month) LUPRON DEPOT (6- LUPRON DEPOT (6- MONTH) 45 MG KIT T6 MONTH) leuprolide acetate (6 month)

©2021 Wellmark, Inc. 131 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LUPRON DEPOT-PED (1- LUPRON DEPOT- MONTH) (7.5 MG KIT, T6 PED (1-MONTH) 11.25 MG KIT, 15 MG KIT) leuprolide acetate (cpp) LUPRON DEPOT-PED (3- MONTH) (11.25 MG KIT, LUPRON DEPOT- 30 MG KIT) T6 PED (3-MONTH) leuprolide acetate (cpp) (3 month) octreotide acetate (50 mcg/ml solution, 100 mcg/ml solution, 200 SBG (Specialty Biosimilars octreotide acetate mcg/ml solution, 500 SP-P and Specialty generics) mcg/ml solution, 1000 mcg/5ml solution, 1000 mcg/ml solution) ORGOVYX 120 MG TAB ORGOVYX SP-P relugolix SANDOSTATIN LAR SANDOSTATIN LAR DEPOT (10 MG KIT, 20 T6 DEPOT MG KIT, 30 MG KIT) octreotide acetate SIGNIFOR (0.3 MG/ML SOLUTION, 0.6 MG/ML SIGNIFOR SOLUTION, 0.9 MG/ML SP-P SOLUTION) pasireotide diaspartate SOMATULINE DEPOT (60 MG/0.2ML SOLUTION, 90 SOMATULINE MG/0.3ML SOLUTION, 120 T6 DEPOT MG/0.5ML SOLUTION) lanreotide acetate SOMAVERT (10 MG RECON SOLN, 15 MG RECON SOLN, 20 MG MN-PA (Medically Necessary SOMAVERT RECON SOLN, 25 MG SP-P Prior Authorization) RECON SOLN, 30 MG RECON SOLN) pegvisomant TRELSTAR MIXJECT (3.75 MG RECON SUSP, 11.25 TRELSTAR MIXJECT MG RECON SUSP, 22.5 T6 MG RECON SUSP) triptorelin pamoate

HORMONAL AGENTS, SUPPRESSANT (THYROID)

ANTITHYROID AGENTS

methimazole (5 mg tab, 10 methimazole TIER 1 mg tab) propylthiouracil propylthiouracil 50 mg tab TIER 1

IMMUNOLOGICAL AGENTS

ANGIOEDEMA AGENTS

BERINERT 500 UNIT KIT BERINERT c1 esterase inhibitor T6 (human) CINRYZE 500 UNIT RECON SOLN CINRYZE T6 c1 esterase inhibitor (human) HAEGARDA (2000 RECON SOLN, 3000 RECON HAEGARDA SOLN) SP-P PA c1 esterase inhibitor (human) PA, SBG (Specialty icatibant acetate 30 mg/3ml icatibant acetate SP-P Biosimilars and Specialty solution generics) KALBITOR 10 MG/ML KALBITOR SOLUTION T6 ecallantide ORLADEYO (110 MG CAP, ORLADEYO 150 MG CAP) SP-P PA, QL (30 PER 30 DAY(S)) berotralstat hcl RUCONEST 2100 UNIT RECON SOLN RUCONEST T6 c1 esterase inhibitor (recombinant) PA, SBG (Specialty sajazir sajazir 30 mg/3ml solution SP-P Biosimilars and Specialty generics) TAKHZYRO 300 MG/2ML TAKHZYRO SOLUTION SP-P PA lanadelumab-flyo

IMMUNE SUPPRESSANTS

ASTAGRAF XL (0.5 MG CAP ER 24H, 1 MG CAP ASTAGRAF XL ER 24H, 5 MG CAP ER SP-P PV 24H) tacrolimus AVSOLA 100 MG RECON AVSOLA SOLN T6 infliximab-axxq azathioprine azathioprine 50 mg tab TIER 1 CELLCEPT (200 MG/ML RECON SUSP, 250 MG CELLCEPT TIER 2 GA CAP, 500 MG TAB) mycophenolate mofetil cyclosporine (25 mg cap, cyclosporine TIER 1 PV 100 mg cap) cyclosporine modified (25 cyclosporine modified mg cap, 50 mg cap, 100 mg TIER 1 PV cap, 100 mg/ml solution) ENBREL (25 MG RECON SOLN, 25 MG/0.5ML SOLN ENBREL PRSYR, 50 MG/ML SOLN SP-P PA, QL (8 PER 28 DAYS) PRSYR) etanercept ENBREL 25 MG/0.5ML ENBREL SOLUTION SP-P PA, QL (8 PER 28 DAY(S)) etanercept ENBREL MINI 50 MG/ML ENBREL MINI SOLN CART SP-P PA, QL (8 PER 28 DAY(S)) etanercept ENBREL SURECLICK 50 ENBREL MG/ML SOLN A-INJ SP-P PA, QL (8 PER 28 DAYS) SURECLICK etanercept ENSPRYNG 120 MG/ML ENSPRYNG SOLN PRSYR SP-P PA satralizumab-mwge ENTYVIO 300 MG RECON ENTYVIO SOLN T6 vedolizumab ENVARSUS XR (0.75 MG TAB ER 24H, 1 MG TAB ENVARSUS XR ER 24H, 4 MG TAB ER SP-P 24H) tacrolimus everolimus (0.25 mg tab, SBG (Specialty Biosimilars everolimus SP-P 0.5 mg tab, 0.75 mg tab) and Specialty generics)

©2021 Wellmark, Inc. 134 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GAMIFANT (10 MG/2ML SOLUTION, 50 MG/10ML GAMIFANT SOLUTION, 100 MG/20ML T6 SOLUTION) emapalumab-lzsg gengraf (25 mg cap, 50 mg gengraf cap, 100 mg cap, 100 TIER 1 PV mg/ml solution) HUMIRA (10 MG/0.1ML PREF SY KT, 20 MG/0.2ML PREF SY KT, HUMIRA SP-P PA, QL (4 PER 28 DAY(S)) 40 MG/0.4ML PREF SY KT) adalimumab HUMIRA (10 MG/0.2ML PREF SY KT, 20 MG/0.4ML PREF SY KT, HUMIRA SP-P PA, QL (4 PER 28 DAYS) 40 MG/0.8ML PREF SY KT) adalimumab HUMIRA 80 MG/0.8ML HUMIRA PEN KIT SP-P PA, QL (1 PER LIFETIME) adalimumab HUMIRA PEDIATRIC CROHNS START (80 & HUMIRA PEDIATRIC 40MG/0.4ML PREF SY KT, SP-P PA, QL (1 PER LIFETIME) CROHNS START 80 PREF SY KT) adalimumab HUMIRA PEDIATRIC HUMIRA PEDIATRIC CROHNS START 40 SP-P PA, QL (4 PER 28 DAYS) CROHNS START MG/0.8ML PREF SY KT adalimumab HUMIRA PEN 40 HUMIRA PEN MG/0.4ML PEN KIT SP-P PA, QL (4 PER 28 DAY(S)) adalimumab HUMIRA PEN 40 HUMIRA PEN MG/0.8ML PEN KIT SP-P PA, QL (4 PER 28 DAYS) adalimumab HUMIRA PEN-CD/UC/HS HUMIRA PEN- STARTER 40 MG/0.8ML SP-P PA, QL (4 PER 28 DAYS) CD/UC/HS STARTER PEN KIT adalimumab HUMIRA PEN-CD/UC/HS HUMIRA PEN- STARTER 80 MG/0.8ML SP-P PA, QL (1 PER LIFETIME) CD/UC/HS STARTER PEN KIT adalimumab

©2021 Wellmark, Inc. 135 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HUMIRA PEN-PEDIATRIC HUMIRA PEN- UC START 80 MG/0.8ML PEDIATRIC UC SP-P PA, QL (1 PER LIFETIME) PEN KIT START adalimumab HUMIRA PEN- HUMIRA PEN- PS/UV/ADOL HS START PS/UV/ADOL HS SP-P PA, QL (4 PER 28 DAYS) 40 MG/0.8ML PEN KIT START adalimumab HUMIRA PEN- HUMIRA PEN- PSOR/UVEIT STARTER 80 PSOR/UVEIT MG/0.8ML & 40MG/0.4ML SP-P PA, QL (1 PER LIFETIME) STARTER PEN KIT adalimumab INFLECTRA 100 MG INFLECTRA RECON SOLN T6 infliximab-dyyb methotrexate methotrexate 2.5 mg tab TIER 1 methotrexate sodium (2.5 methotrexate sodium mg tab, 50 mg/2ml solution, TIER 1 250 mg/10ml solution) methotrexate sodium (pf) (1 methotrexate sodium gm/40ml solution, 50 TIER 1 (pf) mg/2ml solution, 250 mg/10ml solution) mycophenolate mofetil (200 mycophenolate mg/ml recon susp, 250 mg TIER 1 PV mofetil cap, 500 mg tab) mycophenolate sodium mycophenolate (180 mg tab dr, 360 mg tab TIER 1 PV sodium dr) ORENCIA 250 MG RECON ORENCIA SOLN T6 abatacept OTREXUP (10 SOLN A- INJ, 12.5 SOLN A-INJ, 15 SOLN A-INJ, 17.5 SOLN A- INJ, 20 SOLN A-INJ, 22.5 OTREXUP T6 SOLN A-INJ, 25 SOLN A- INJ) methotrexate (antirheumatic)

©2021 Wellmark, Inc. 136 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS RASUVO (7.5 MG/0.15ML SOLN A-INJ, 10 MG/0.2ML SOLN A-INJ, 12.5 MG/0.25ML SOLN A-INJ, 15 MG/0.3ML SOLN A-INJ, 17.5 MG/0.35ML SOLN A- RASUVO INJ, 20 MG/0.4ML SOLN A- T6 INJ, 22.5 MG/0.45ML SOLN A-INJ, 25 MG/0.5ML SOLN A-INJ, 30 MG/0.6ML SOLN A-INJ) methotrexate (antirheumatic) REDITREX (7.5 MG/0.3ML SOLN PRSYR, 10 MG/0.4ML SOLN PRSYR, 12.5 MG/0.05ML SOLN PRSYR, 15 MG/0.6ML SOLN PRSYR, 17.5 REDITREX MG/0.7ML SOLN PRSYR, T6 20 MG/0.8ML SOLN PRSYR, 22.5 MG/0.9ML SOLN PRSYR, 25 MG/ML SOLN PRSYR) methotrexate (antirheumatic) REMICADE 100 MG REMICADE RECON SOLN T6 infliximab RENFLEXIS 100 MG RENFLEXIS RECON SOLN T6 infliximab-abda RINVOQ 15 MG TAB ER RINVOQ 24H SP-P PA, QL (30 PER 30 DAY(S)) upadacitinib SIMPONI ARIA 50 MG/4ML SIMPONI ARIA SOLUTION T6 golimumab sirolimus (0.5 mg tab, 1 mg sirolimus TIER 1 PV tab, 2 mg tab) PA, QL (1200 PER 30 sirolimus sirolimus 1 mg/ml solution TIER 1 DAY(S)), PV tacrolimus (0.5 mg cap, 1 tacrolimus TIER 1 PV mg cap, 5 mg cap) UPLIZNA 100 MG/10ML UPLIZNA SOLUTION T6 inebilizumab-cdon

©2021 Wellmark, Inc. 137 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS XELJANZ 10 MG TAB XELJANZ SP-P PA, QL (60 PER 30 DAY(S)) tofacitinib citrate XELJANZ 5 MG TAB XELJANZ SP-P PA, QL (60 PER 30 DAYS) tofacitinib citrate XELJANZ XR 11 MG TAB XELJANZ XR ER 24H SP-P PA, QL (30 PER 30 DAYS) tofacitinib citrate XELJANZ XR 22 MG TAB XELJANZ XR ER 24H SP-P PA, QL (30 PER 30 DAY(S)) tofacitinib citrate ZORTRESS (0.25 MG TAB, 0.5 MG TAB, 0.75 MG TAB, ZORTRESS 1 MG TAB) SP-P everolimus (immunosuppressant)

IMMUNIZING AGENTS, PASSIVE

ASCENIV 5 GM/50ML SOLUTION ASCENIV T6 immune globulin (human)- slra BIVIGAM (5 GM/50ML SOLUTION, 10 GM/100ML BIVIGAM T6 SOLUTION) immune globulin (human) iv CARIMUNE NF (6 GM RECON SOLN, 12 GM CARIMUNE NF T6 RECON SOLN) immune globulin (human) iv CUTAQUIG (1 GM/6ML SOLUTION, 1.65 GM/10ML SOLUTION, 2 GM/12ML SOLUTION, 3.3 GM/20ML CUTAQUIG SOLUTION, 4 GM/24ML T6 SOLUTION, 8 GM/48ML SOLUTION) immune globulin (human)- hipp CUVITRU (1 GM/5ML SOLUTION, 2 GM/10ML SOLUTION, 4 GM/20ML SOLUTION, 8 GM/40ML CUVITRU T6 SOLUTION, 10 GM/50ML SOLUTION) immune globulin (human) subcutaneous

©2021 Wellmark, Inc. 138 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CYTOGAM 50 MG/ML INJECTABLE CYTOGAM T6 cytomegalovirus immune globulin (human) FLEBOGAMMA DIF (0.5 GM/10ML SOLUTION, 2.5 GM/50ML SOLUTION, 5 GM/100ML SOLUTION, 5 GM/50ML SOLUTION, 10 FLEBOGAMMA DIF T6 GM/100ML SOLUTION, 10 GM/200ML SOLUTION, 20 GM/200ML SOLUTION, 20 GM/400ML SOLUTION) immune globulin (human) iv GAMASTAN INJECTABLE GAMASTAN T6 immune globulin (human) im GAMMAGARD (1 GM/10ML SOLUTION, 2.5 GM/25ML SOLUTION, 5 GM/50ML SOLUTION, 10 GAMMAGARD GM/100ML SOLUTION, 20 T6 GM/200ML SOLUTION, 30 GM/300ML SOLUTION) immune globulin (human) iv or subcutaneous GAMMAGARD S/D LESS GAMMAGARD S/D IGA (5 GM RECON SOLN, T6 LESS IGA 10 GM RECON SOLN) immune globulin (human) iv GAMMAKED (1 GM/10ML SOLUTION, 2.5 GM/25ML SOLUTION, 5 GM/50ML SOLUTION, 10 GM/100ML GAMMAKED T6 SOLUTION, 20 GM/200ML SOLUTION) immune globulin (human) iv or subcutaneous

©2021 Wellmark, Inc. 139 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GAMMAPLEX (5 GM/100ML SOLUTION, 5 GM/50ML SOLUTION, 10 GM/100ML SOLUTION, 10 GAMMAPLEX T6 GM/200ML SOLUTION, 20 GM/200ML SOLUTION, 20 GM/400ML SOLUTION) immune globulin (human) iv GAMUNEX-C (1 GM/10ML SOLUTION, 2.5 GM/25ML SOLUTION, 5 GM/50ML SOLUTION, 10 GM/100ML GAMUNEX-C SOLUTION, 20 GM/200ML T6 SOLUTION, 40 GM/400ML SOLUTION) immune globulin (human) iv or subcutaneous HIZENTRA (1 GM/5ML SOLN PRSYR, 1 GM/5ML SOLUTION, 2 GM/10ML SOLN PRSYR, 2 GM/10ML SOLUTION, 4 GM/20ML HIZENTRA T6 SOLN PRSYR, 4 GM/20ML SOLUTION, 10 GM/50ML SOLUTION) immune globulin (human) subcutaneous HYPERRHO S/D (250 SOLN PRSYR, 1500 SOLN HYPERRHO S/D PRSYR) T6 rho d immune globulin (human) HYQVIA (2.5 GM/25ML KIT, 5 GM/50ML KIT, 10 GM/100ML KIT, 20 GM/200ML KIT, 30 HYQVIA T6 GM/300ML KIT) immune globulin (human)- hyaluronidase (human recombinant) MICRHOGAM ULTRA- MICRHOGAM FILTERED PLUS 250 UNIT ULTRA-FILTERED SOLN PRSYR T6 PLUS rho d immune globulin (human)

©2021 Wellmark, Inc. 140 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OCTAGAM (1 GM/20ML SOLUTION, 2 GM/20ML SOLUTION, 2.5 GM/50ML SOLUTION, 5 GM/100ML SOLUTION, 5 GM/50ML SOLUTION, 10 GM/100ML OCTAGAM T6 SOLUTION, 10 GM/200ML SOLUTION, 20 GM/200ML SOLUTION, 25 GM/500ML SOLUTION, 30 GM/300ML SOLUTION) immune globulin (human) iv PANZYGA (1 GM/10ML SOLUTION, 2.5 GM/25ML SOLUTION, 5 GM/50ML SOLUTION, 10 GM/100ML PANZYGA SOLUTION, 20 GM/200ML T6 SOLUTION, 30 GM/300ML SOLUTION) immune globulin (human)- ifas PRIVIGEN (5 GM/50ML SOLUTION, 10 GM/100ML SOLUTION, 20 GM/200ML PRIVIGEN T6 SOLUTION, 40 GM/400ML SOLUTION) immune globulin (human) iv RHOGAM ULTRA- FILTERED PLUS 1500 RHOGAM ULTRA- UNIT SOLN PRSYR T6 FILTERED PLUS rho d immune globulin (human) RHOPHYLAC 1500 UNIT/2ML SOLN PRSYR RHOPHYLAC T6 rho d immune globulin (human) VARIZIG 125 UNIT/1.2ML SOLUTION VARIZIG T6 varicella-zoster immune globulin (human) XEMBIFY (1 GM/5ML SOLUTION, 2 GM/10ML SOLUTION, 4 GM/20ML XEMBIFY SOLUTION, 10 GM/50ML T6 SOLUTION) immune globulin (human)- klhw

IMMUNOMODULATORS

ACTEMRA (80 MG/4ML SOLUTION, 200 MG/10ML ACTEMRA SOLUTION, 400 MG/20ML T6 SOLUTION) tocilizumab ACTIMMUNE 2000000 ACTIMMUNE UNIT/0.5ML SOLUTION SP-P interferon gamma-1b ARCALYST 220 MG ARCALYST RECON SOLN SP-P rilonacept BENLYSTA (200 MG/ML SOLN A-INJ, 200 MG/ML BENLYSTA SP-P SOLN PRSYR) belimumab ILARIS (150 MG RECON SOLN, 150 MG/ML ILARIS T6 SOLUTION) canakinumab leflunomide (10 mg tab, 20 leflunomide TIER 1 mg tab) OTEZLA 10 & 20 & 30 MG OTEZLA TAB THPK SP-P PA, QL (2 PER LIFETIME) apremilast OTEZLA 30 MG TAB OTEZLA SP-P PA, QL (60 PER 30 DAYS) apremilast RIDAURA 3 MG CAP RIDAURA TIER 2 auranofin SYNAGIS (50 MG/0.5ML SOLUTION, 100 MG/ML SYNAGIS T6 SOLUTION) palivizumab

VACCINES

ACTHIB RECON SOLN ACTHIB haemophilus b polysac conj TIER 2 PV vac ADACEL 5-2-15.5 LF- MCG/0.5 SUSPENSION ADACEL tetanus toxoid-diphtheria- TIER 2 PV acellular pertussis adsorb (tdap) AFLURIA SUSPENSION AFLURIA TIER 2 PV influenza virus vaccine split

©2021 Wellmark, Inc. 142 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS AFLURIA PRESERVATIVE AFLURIA FREE 0.5 ML SUSP PRESERVATIVE PRSYR TIER 2 PV FREE influenza virus vaccine split preservative free AFLURIA QUADRIVALENT (0.25 ML SUSP PRSYR, AFLURIA 0.5 ML SUSP PRSYR, TIER 2 PV QUADRIVALENT SUSPENSION) influenza virus vaccine split quadrivalent BEXSERO SUSP PRSYR meningococcal vac group b BEXSERO TIER 2 PV (recombant omv adjuvanted) BOOSTRIX 5-2.5-18.5 LF- MCG/0.5 SUSPENSION BOOSTRIX tetanus toxoid-diphtheria- TIER 2 PV acellular pertussis adsorb (tdap) DAPTACEL 23-15-5 SUSPENSION DAPTACEL TIER 2 PV diphtheria, acellular pertussis & tetanus toxoids DIPHTHERIA-TETANUS DIPHTHERIA- TOXOIDS DT 25-5 TETANUS TOXOIDS LFU/0.5ML SUSPENSION TIER 2 PV DT diphtheria-tetanus toxoids (dt) ENGERIX-B (10 MCG/0.5ML SUSPENSION, 20 ENGERIX-B TIER 2 PV MCG/ML SUSPENSION) hepatitis b vaccine (recomb) FLUAD 0.5 ML SUSP PRSYR FLUAD influenza virus vaccine TIER 2 PV types a & b surface antigen adjuvant FLUAD QUADRIVALENT 0.5 ML PRSYR FLUAD influenza virus vacc types a TIER 2 PV QUADRIVALENT & b surf antigen adjuvant quad

©2021 Wellmark, Inc. 143 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FLUARIX QUADRIVALENT FLUARIX 0.5 ML SUSP PRSYR TIER 2 PV QUADRIVALENT influenza virus vaccine split quadrivalent FLUBLOK SOLUTION influenza virus vaccine FLUBLOK TIER 2 PV recombinant hemagglutinin (ha) FLUBLOK QUADRIVALENT 0.5 ML FLUBLOK SOLN PRSYR TIER 2 PV QUADRIVALENT influenza virus vac recomb hemagglutinin (ha) quadrivalent FLUCELVAX QUADRIVALENT (0.5MLSUSPPRSYR, FLUCELVAX SUSPENSION) TIER 2 PV QUADRIVALENT influenza virus vaccine tissue-cultured subunit quadrivalent FLULAVAL QUADRIVALENT FLULAVAL (0.5MLSUSPPRSYR, TIER 2 PV QUADRIVALENT SUSPENSION) influenza virus vaccine split quadrivalent FLUMIST 10E6.5-7.5 FLUMIST LIQUID TIER 2 PV influenza virus vaccine live FLUMIST QUADRIVALENT FLUMIST SUSPENSION TIER 2 PV QUADRIVALENT influenza virus vaccine live quadrivalent FLUVIRIN (0.5MLSUSPPRSYR, FLUVIRIN SUSPENSION) TIER 2 PV influenza virus vaccine types a & b surface antigen FLUZONE HIGH-DOSE 0.5 FLUZONE HIGH- ML SUSP PRSYR TIER 2 PV DOSE influenza virus vaccine split high-dose preservative free

©2021 Wellmark, Inc. 144 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FLUZONE HIGH-DOSE QUADRIVALENT 0.7 ML FLUZONE HIGH- SUSP PRSYR DOSE TIER 2 PV influenza virus vac split QUADRIVALENT high-dose quad preservative free FLUZONE QUADRIVALENT (0.25 ML SUSP PRSYR, 0.5 ML SUSP PRSYR, 0.5 ML FLUZONE SUSPENSION, 9 TIER 2 PV QUADRIVALENT MCG/STRAIN SUSP PEN, SUSPENSION) influenza virus vaccine split quadrivalent GARDASIL 9 (9SUSPENSION, 9SUSPPRSYR) GARDASIL 9 TIER 2 PV human papillomavirus (hpv) 9-valent recombinant vaccine HAVRIX (720 U/0.5ML SUSPENSION, 1440 U/ML HAVRIX TIER 2 PV SUSPENSION) hepatitis a vaccine HEPLISAV-B (20 SOLN PRSYR, 20 SOLUTION) HEPLISAV-B TIER 2 PV hepatitis b vaccine recombinant adjuvanted HIBERIX 10 MCG RECON SOLN HIBERIX TIER 2 PV haemophilus b polysac conj vac INFANRIX 25-58-10 SUSPENSION INFANRIX TIER 2 PV diphtheria, acellular pertussis & tetanus toxoids IPOL INJECTABLE IPOL TIER 2 PV poliovirus vaccine, ipv JANSSEN COVID-19 VACCINE 0.5 ML JANSSEN COVID-19 SUSPENSION TIER 2 PV VACCINE covid-19 (sars-cov-2) adenovirus vaccine KINRIX SUSPENSION diph-tetanus tox ad-acell KINRIX TIER 2 PV pertussis & polio virus, ipv vac

©2021 Wellmark, Inc. 145 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS M-M-R II RECON SOLN M-M-R II measles, mumps & rubella TIER 2 PV virus vaccines MENACTRA (4MCG/0.5MLINJECTABLE , INJECTABLE) MENACTRA TIER 2 PV meningococcal (a,c,y&w- 135) polysaccharide conjugate vaccine MENQUADFI INJECTABLE MENQUADFI meningococcal (a,c,y&w- TIER 2 PV 135) polysaccharide conjugate vaccine MENVEO RECON SOLN meningococcal (a,c,y&w- MENVEO TIER 2 PV 135) oligosaccharide conjugate vac MODERNA COVID-19 VACCINE 100 MCG/0.5ML MODERNA COVID- SUSPENSION TIER 2 PV 19 VACCINE covid-19 (sars-cov-2) mrna virus vaccine PEDIARIX SUSPENSION diph-tetanus tox-acell pert- PEDIARIX TIER 2 PV hepatitis b recomb-polio ipv vac PEDVAX HIB 7.5 MCG/0.5ML SUSPENSION PEDVAX HIB TIER 2 PV haemophilus b polysac conj vac PENTACEL RECON SUSP PENTACEL TIER 2 PV diph-ac pert-tet tox ad-polio ipv-haemophil b poly vac PFIZER-BIONTECH COVID-19 VACC 30 PFIZER-BIONTECH MCG/0.3ML SUSPENSION TIER 2 PV COVID-19 VACC covid-19 (sars-cov-2) mrna virus vaccine PNEUMOVAX 23 25 MCG/0.5ML INJECTABLE PNEUMOVAX 23 TIER 2 PV pneumococcal vac polyvalent PREVNAR 13 SUSPENSION PREVNAR 13 TIER 2 PV pneumococcal 13-valent conjugate vaccine

©2021 Wellmark, Inc. 146 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PROQUAD RECON SUSP PROQUAD TIER 2 PV measles-mumps-rubella- varicella virus vaccines QUADRACEL SUSPENSION QUADRACEL diph-tetanus tox ad-acell TIER 2 PV pertussis & polio virus, ipv vac RECOMBIVAX HB (5 MCG/0.5ML SUSPENSION, 10 MCG/ML SUSPENSION, RECOMBIVAX HB TIER 2 PV 40 MCG/ML SUSPENSION) hepatitis b vaccine (recomb) ROTARIX RECON SUSP ROTARIX TIER 2 PV rotavirus vaccine, live oral ROTATEQ SOLUTION ROTATEQ rotavirus vaccine, live oral TIER 2 PV pentavalent SHINGRIX 50 MCG/0.5ML RECON SUSP SHINGRIX TIER 2 AL (At least 50 yrs old), PV zoster vaccine recombinant adjuvanted TDVAX 2-2 LF/0.5ML SUSPENSION TDVAX TIER 2 PV tetanus-diphtheria toxoids (td) TENIVAC 5-2 LFU INJECTABLE TENIVAC TIER 2 PV tetanus-diphtheria toxoids (td) TETANUS-DIPHTHERIA TETANUS- TOXOIDS TD 2-2 LF/0.5ML DIPHTHERIA SUSPENSION TIER 2 PV TOXOIDS TD tetanus-diphtheria toxoids (td) TRUMENBA SUSP PRSYR TRUMENBA TIER 2 PV meningococcal group b vaccine (recombinant)

©2021 Wellmark, Inc. 147 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TWINRIX 720-20 ELU- MCG/ML SUSP PRSYR TWINRIX hepatitis a (inactivated)- TIER 2 PV hepatitis b (recombinant) vaccines VAQTA (25 UNIT/0.5ML SUSPENSION, 50 VAQTA TIER 2 PV UNIT/ML SUSPENSION) hepatitis a vaccine VARIVAX 1350 PFU/0.5ML VARIVAX INJECTABLE TIER 2 PV varicella virus vaccine live VAXELIS (SUSPENSION, SUSPPRSYR) VAXELIS diph-tet tox-acell pert ad- TIER 2 PV polio ipv-hib-hepatitis b recomb

INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATES

balsalazide disodium 750 balsalazide disodium TIER 1 mg cap DIPENTUM 250 MG CAP DIPENTUM TIER 2 olsalazine sodium mesalamine (1.2 gm tab dr, 4 gm enema, 400 mg cap mesalamine TIER 1 dr, 800 mg tab dr, 1000 mg suppos) mesalamine er 0.375 gm mesalamine er TIER 1 cap er 24h

GLUCOCORTICOIDS

anucort-hc anucort-hc 25 mg suppos TIER 1 budesonide budesonide 3 mg cp dr part TIER 1 budesonide er 9 mg tab er budesonide er TIER 1 24h colocort 100 mg/60ml colocort TIER 1 enema hemmorex-hc (25 mg hemmorex-hc TIER 1 suppos, 30 mg suppos) hydrocortisone hydrocortisone (perianal) (1 TIER 1 (perianal) % cream, 2.5 % cream) hydrocortisone 100 hydrocortisone TIER 1 mg/60ml enema

©2021 Wellmark, Inc. 148 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS hydrocortisone hydrocortisone acetate (25 TIER 1 acetate mg suppos, 30 mg suppos) procto-med hc procto-med hc 2.5 % cream TIER 1 procto-pak procto-pak 1 % cream TIER 1 proctosol hc proctosol hc 2.5 % cream TIER 1 proctozone-hc proctozone-hc 2.5 % cream TIER 1

SULFONAMIDES

sulfasalazine (500 mg tab, sulfasalazine TIER 1 500 mg tab dr)

METABOLIC BONE DISEASE AGENTS

alendronate sodium (5 mg alendronate sodium tab, 10 mg tab, 35 mg tab, TIER 1 PV 40 mg tab, 70 mg tab) calcitonin (salmon) 200 calcitonin (salmon) TIER 1 PV unit/act solution calcitriol (0.25 mcg cap, 0.5 calcitriol TIER 1 mcg cap) cinacalcet hcl (30 mg tab, SBG (Specialty Biosimilars cinacalcet hcl SP-P 60 mg tab, 90 mg tab) and Specialty generics) doxercalciferol (0.5 mcg doxercalciferol cap, 1 mcg cap, 2.5 mcg TIER 1 cap) ergocalciferol (1.25 mg ergocalciferol (50000 ut) cap, 50000 unit TIER 1 cap) ETIDRONATE DISODIUM ETIDRONATE (200 MG TAB, 400 MG TIER 1 DISODIUM TAB) etidronate disodium EVENITY 105 MG/1.17ML EVENITY SOLN PRSYR T6 romosozumab-aqqg ibandronate sodium 150 mg ibandronate sodium TIER 1 PV tab NATPARA (25 MCG CARTRIDGE, 50 MCG CARTRIDGE, 75 MCG NATPARA CARTRIDGE, 100 MCG T6 CARTRIDGE) parathyroid hormone (recombinant) paricalcitol (1 mcg cap, 2 paricalcitol TIER 1 mcg cap, 4 mcg cap)

©2021 Wellmark, Inc. 149 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PROLIA 60 MG/ML SOLN PROLIA PRSYR T6 denosumab RECLAST 5 MG/100ML RECLAST SOLUTION T6 GA zoledronic acid risedronate sodium (5 mg risedronate sodium tab, 30 mg tab, 35 mg tab, TIER 1 PV 35 mg tab dr, 150 mg tab) TERIPARATIDE TERIPARATIDE (RECOMBINANT) 620 SP-P PA (RECOMBINANT) MCG/2.48ML SOLN PEN teriparatide (recombinant) vitamin d vitamin d (ergocalciferol) TIER 1 (ergocalciferol) 1.25 mg (50000 ut) cap XGEVA 120 MG/1.7ML XGEVA SOLUTION T6 denosumab zoledronic acid (4 mg recon soln, 4 mg/100ml solution, zoledronic acid T6 4 mg/5ml conc, 5 mg/100ml solution) ZOMETA (4 MG/100ML SOLUTION, 4 MG/5ML ZOMETA T6 GA CONC) zoledronic acid

MISCELLANEOUS THERAPEUTIC AGENTS

AEROCHAMBER MINI AEROCHAMBER CHAMBER DEVICE RX-DME MINI CHAMBER spacer/aerosol-holding chambers AEROCHAMBER MV MISC AEROCHAMBER MV RX-DME spacer/aerosol-holding chambers AEROCHAMBER PLUS AEROCHAMBER FLO-VU MISC RX-DME PLUS FLO-VU spacer/aerosol-holding chambers AEROCHAMBER PLUS AEROCHAMBER FLO-VU LARGE MISC PLUS FLO-VU RX-DME spacer/aerosol-holding LARGE chambers

©2021 Wellmark, Inc. 150 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS AEROCHAMBER PLUS AEROCHAMBER FLO-VU MEDIUM MISC PLUS FLO-VU RX-DME spacer/aerosol-holding MEDIUM chambers AEROCHAMBER PLUS AEROCHAMBER FLO-VU SMALL MISC PLUS FLO-VU RX-DME spacer/aerosol-holding SMALL chambers AEROCHAMBER PLUS AEROCHAMBER FLO-VU W/MASK MISC PLUS FLO-VU RX-DME spacer/aerosol-holding W/MASK chambers AEROCHAMBER PLUS AEROCHAMBER FLOW VU MISC RX-DME PLUS FLOW VU spacer/aerosol-holding chambers AEROCHAMBER AEROCHAMBER W/FLOWSIGNAL MISC RX-DME W/FLOWSIGNAL spacer/aerosol-holding chambers AEROCHAMBER Z-STAT AEROCHAMBER Z- PLUS MISC RX-DME STAT PLUS spacer/aerosol-holding chambers AEROCHAMBER Z-STAT AEROCHAMBER Z- PLUS CHAMBR MISC STAT PLUS RX-DME spacer/aerosol-holding CHAMBR chambers AEROCHAMBER Z-STAT AEROCHAMBER Z- PLUS/LARGE MISC RX-DME STAT PLUS/LARGE spacer/aerosol-holding chambers AEROCHAMBER Z-STAT AEROCHAMBER Z- PLUS/MEDIUM MISC RX-DME STAT PLUS/MEDIUM spacer/aerosol-holding chambers AEROCHAMBER Z-STAT AEROCHAMBER Z- PLUS/SMALL MISC RX-DME STAT PLUS/SMALL spacer/aerosol-holding chambers AEROVENT PLUS DEVICE AEROVENT PLUS RX-DME spacer/aerosol-holding chambers ARIAL CHAMBER DEVICE ARIAL CHAMBER RX-DME spacer/aerosol-holding chambers

©2021 Wellmark, Inc. 151 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BD SWAB SINGLE USE BD SWAB SINGLE REGULAR PAD TIER 2 USE REGULAR alcohol swabs BREATHE EASE LARGE BREATHE EASE DEVICE RX-DME LARGE spacer/aerosol-holding chambers BREATHE EASE MEDIUM BREATHE EASE DEVICE RX-DME MEDIUM spacer/aerosol-holding chambers BREATHE EASE SMALL BREATHE EASE DEVICE RX-DME SMALL spacer/aerosol-holding chambers BREATHERITE MISC BREATHERITE spacer/aerosol-holding RX-DME chambers BREATHERITE COLL BREATHERITE SPACER ADULT MISC COLL SPACER RX-DME spacer/aerosol-holding ADULT chambers BREATHERITE COLL BREATHERITE SPACER CHILD MISC COLL SPACER RX-DME spacer/aerosol-holding CHILD chambers BREATHERITE COLL BREATHERITE SPACER INFANT MISC COLL SPACER RX-DME spacer/aerosol-holding INFANT chambers BREATHERITE RIGID BREATHERITE SPACER/MASK MISC RIGID RX-DME spacer/aerosol-holding SPACER/MASK chambers BREATHERITE SPACER BREATHERITE NEONATE MISC RX-DME SPACER NEONATE spacer/aerosol-holding chambers BREATHERITE SPACER BREATHERITE SMALL CHILD MISC SPACER SMALL RX-DME spacer/aerosol-holding CHILD chambers BREATHERITE/LARGE BREATHERITE/LAR MASK MISC RX-DME GE MASK spacer/aerosol-holding chambers

©2021 Wellmark, Inc. 152 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BREATHERITE/MEDIUM BREATHERITE/MEDI MASK MISC RX-DME UM MASK spacer/aerosol-holding chambers BREATHERITE/SMALL BREATHERITE/SMA MASK MISC RX-DME LL MASK spacer/aerosol-holding chambers CHEK-STIX CONTROL CHEK-STIX STRIP TIER 2 PV CONTROL acetone (urine) test CHEMSTRIP 10 MD CHEMSTRIP 10 MD STRIP TIER 2 PV multiple urine tests CHEMSTRIP 10/SG CHEMSTRIP 10/SG STRIP TIER 2 PV multiple urine tests CHEMSTRIP 2 GP STRIP CHEMSTRIP 2 GP TIER 2 PV multiple urine tests CHEMSTRIP 5 OB STRIP CHEMSTRIP 5 OB TIER 2 PV multiple urine tests CHEMSTRIP 7 STRIP CHEMSTRIP 7 TIER 2 PV multiple urine tests CHEMSTRIP 9 STRIP CHEMSTRIP 9 TIER 2 PV multiple urine tests CHEMSTRIP K STRIP CHEMSTRIP K TIER 2 PV acetone (urine) test CHEMSTRIP UGK STRIP CHEMSTRIP UGK TIER 2 PV urine glucose-ketones test CLEVER CHOICE HOLDING CHAMBER CLEVER CHOICE DEVICE RX-DME HOLDING CHAMBER spacer/aerosol-holding chambers CLINISTIX STRIP CLINISTIX glucose urine test-(glucose TIER 2 PV oxidase) COMBISTIX STRIP COMBISTIX TIER 2 PV multiple urine tests COMPACT SPACE COMPACT SPACE CHAMBER DEVICE RX-DME CHAMBER spacer/aerosol-holding chambers

©2021 Wellmark, Inc. 153 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS COMPACT SPACE CHAMBER/LG MASK COMPACT SPACE DEVICE RX-DME CHAMBER/LG MASK spacer/aerosol-holding chambers COMPACT SPACE COMPACT SPACE CHAMBER/MED MASK CHAMBER/MED DEVICE RX-DME MASK spacer/aerosol-holding chambers COMPACT SPACE COMPACT SPACE CHAMBER/SM MASK CHAMBER/SM DEVICE RX-DME MASK spacer/aerosol-holding chambers CONTOUR NEXT TEST CONTOUR NEXT QL (150 PER 30 DAYS), PA- STRIP TIER 2 TEST QL (300 / 30 days), PV glucose blood CONTOUR TEST STRIP QL (150 PER 30 DAYS), PA- CONTOUR TEST TIER 2 glucose blood QL (300 / 30 days), PV CVS KETONE CARE CVS KETONE CARE STRIP TIER 2 PV urine glucose-ketones test DIASTIX STRIP DIASTIX glucose urine test-(glucose TIER 2 PV oxidase) DURAXIN 300-200-20 MG CAP DURAXIN acetaminophen- TIER 1 GA salicylamide- phenyltoloxamine EASIVENT MISC EASIVENT spacer/aerosol-holding RX-DME chambers EASIVENT MASK LARGE EASIVENT MASK MISC RX-DME LARGE spacer/aerosol-holding chambers EASIVENT MASK MEDIUM EASIVENT MASK MISC RX-DME MEDIUM spacer/aerosol-holding chambers EASIVENT MASK SMALL EASIVENT MASK MISC RX-DME SMALL spacer/aerosol-holding chambers ed-flex ed-flex 300-200-20 mg cap TIER 1

©2021 Wellmark, Inc. 154 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS EQ SPACE CHAMBER EQ SPACE ANTI-STATIC DEVICE CHAMBER ANTI- RX-DME spacer/aerosol-holding STATIC chambers EQ SPACE CHAMBER EQ SPACE ANTI-STATIC L DEVICE CHAMBER ANTI- RX-DME spacer/aerosol-holding STATIC L chambers EQ SPACE CHAMBER EQ SPACE ANTI-STATIC M DEVICE CHAMBER ANTI- RX-DME spacer/aerosol-holding STATIC M chambers EQ SPACE CHAMBER EQ SPACE ANTI-STATIC S DEVICE CHAMBER ANTI- RX-DME spacer/aerosol-holding STATIC S chambers EUFLEXXA 20 MG/2ML SOLN PRSYR EUFLEXXA T6 sodium hyaluronate (viscosupplement) FLEXICHAMBER DEVICE FLEXICHAMBER spacer/aerosol-holding RX-DME chambers FLEXICHAMBER ADULT FLEXICHAMBER MASK/SMALL MISC ADULT RX-DME spacer/aerosol-holding MASK/SMALL chamber supplies - masks FLEXICHAMBER CHILD FLEXICHAMBER MASK/LARGE MISC RX-DME CHILD MASK/LARGE spacer/aerosol-holding chamber supplies - masks FLEXICHAMBER CHILD FLEXICHAMBER MASK/SMALL MISC RX-DME CHILD MASK/SMALL spacer/aerosol-holding chamber supplies - masks FORA GTEL BLOOD FORA GTEL BLOOD KETONE TEST STRIP TIER 2 PV KETONE TEST ketone blood test GEL-ONE 30 MG/3ML GEL-ONE PRSYR T6 cross-linked hyaluronate GELSYN-3 16.8 MG/2ML SOLN PRSYR GELSYN-3 T6 sodium hyaluronate (viscosupplement)

©2021 Wellmark, Inc. 155 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GENVISC 850 25 MG/2.5ML SOLN PRSYR GENVISC 850 T6 sodium hyaluronate (viscosupplement) GOJJI BLOOD KETONE GOJJI BLOOD TEST STRIP TIER 2 PV KETONE TEST ketone blood test HEMA-COMBISTIX HEMA-COMBISTIX STRIP TIER 2 PV multiple urine tests HYALGAN (20 SOLN PRSYR, 20 SOLUTION) HYALGAN T6 sodium hyaluronate (viscosupplement) HYMOVIS 24 MG/3ML HYMOVIS SOLN PRSYR T6 hyaluronan INSPIRACHAMBER/LARG INSPIRACHAMBER/L E DEVICE RX-DME ARGE spacer/aerosol-holding chambers INSPIRACHAMBER/MEDI INSPIRACHAMBER/ UM DEVICE RX-DME MEDIUM spacer/aerosol-holding chambers INSPIRACHAMBER/MOUT INSPIRACHAMBER/ HPIECE DEVICE RX-DME MOUTHPIECE spacer/aerosol-holding chambers INSPIRACHAMBER/SMAL INSPIRACHAMBER/ L DEVICE RX-DME SMALL spacer/aerosol-holding chambers INSPIREASE MISC INSPIREASE spacer/aerosol-holding RX-DME chambers INSULIN PEN INSULIN PEN NEEDLE TIER 2 PV NEEDLE insulin pen needle INSULIN SYRINGE INSULIN SYRINGE TIER 2 PV insulin syringe INSULIN SYRINGE INSULIN SYRINGE NEEDLE TIER 2 PV NEEDLE insulin syringe needle ISOMETHEPTENE- CAFFEINE-APAP 65-20- ISOMETHEPTENE- 325 MG TAB TIER 1 CAFFEINE-APAP isometheptene-caffeine- acetaminophen

©2021 Wellmark, Inc. 156 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS KETO-DIASTIX STRIP KETO-DIASTIX TIER 2 PV urine glucose-ketones test KETONE TEST STRIP KETONE TEST TIER 2 PV acetone (urine) test KETOSTIX STRIP KETOSTIX TIER 2 PV acetone (urine) test LABSTIX STRIP LABSTIX TIER 2 PV multiple urine tests LANCETS LANCETS TIER 2 QL (150 PER 30 DAY(S)) lancets LANCETS QL (150 PER 30 DAYS), PA- LANCETS TIER 2 lancets QL (300 / 30 days), PV LITEAIRE DEVICE LITEAIRE spacer/aerosol-holding RX-DME chambers MASK VORTEX MISC MASK VORTEX spacer/aerosol-holding RX-DME chamber supplies - masks MASK MASK VORTEX/CHILD/FROG VORTEX/CHILD/FRO MISC RX-DME G spacer/aerosol-holding chamber supplies - masks MASK MASK VORTEX/TODDLER/LADY VORTEX/TODDLER/ BUG MISC RX-DME LADYBUG spacer/aerosol-holding chamber supplies - masks methergine methergine 0.2 mg tab TIER 1 methylergonovine methylergonovine maleate TIER 1 maleate 0.2 mg tab MICROCHAMBER (DEVICE, MISC) MICROCHAMBER RX-DME spacer/aerosol-holding chambers MICROSPACER MISC MICROSPACER spacer/aerosol-holding RX-DME chambers MONOVISC 88 MG/4ML MONOVISC SOLN PRSYR T6 hyaluronan MULTISTIX STRIP MULTISTIX TIER 2 PV multiple urine tests MULTISTIX 10 SG STRIP MULTISTIX 10 SG TIER 2 PV multiple urine tests

©2021 Wellmark, Inc. 157 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MULTISTIX 5 STRIP MULTISTIX 5 TIER 2 PV multiple urine tests MULTISTIX 7 STRIP MULTISTIX 7 TIER 2 PV multiple urine tests MULTISTIX 8 STRIP MULTISTIX 8 TIER 2 PV multiple urine tests MULTISTIX 9 STRIP MULTISTIX 9 TIER 2 PV multiple urine tests MULTISTIX 9 SG STRIP MULTISTIX 9 SG TIER 2 PV multiple urine tests NOVA MAX PLUS NOVA MAX PLUS KETONE TEST STRIP TIER 2 PV KETONE TEST ketone blood test OMNIPOD DASH 5 PACK OMNIPOD DASH 5 PODS MISC RX-DME QL (30 PER 30 DAY(S)) PACK PODS insulin infusion disposable pump ONETOUCH TEST STRIP QL (150 PER 30 DAYS), PA- ONETOUCH TEST TIER 2 glucose blood QL (300 / 30 days), PV ONETOUCH ULTRA QL (150 PER 30 DAYS), PA- ONETOUCH ULTRA STRIP TIER 2 QL (300 / 30 days), PV glucose blood ONETOUCH VERIO QL (150 PER 30 DAYS), PA- ONETOUCH VERIO STRIP TIER 2 QL (300 / 30 days), PV glucose blood OPTICHAMBER OPTICHAMBER ADVANTAGE MISC RX-DME ADVANTAGE spacer/aerosol-holding chambers OPTICHAMBER OPTICHAMBER ADVANTAGE-LG MASK ADVANTAGE-LG MISC RX-DME MASK spacer/aerosol-holding chambers OPTICHAMBER OPTICHAMBER ADVANTAGE-MED MASK ADVANTAGE-MED MISC RX-DME MASK spacer/aerosol-holding chambers OPTICHAMBER OPTICHAMBER ADVANTAGE-SM MASK ADVANTAGE-SM MISC RX-DME MASK spacer/aerosol-holding chambers

©2021 Wellmark, Inc. 158 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OPTICHAMBER DIAMOND OPTICHAMBER (DEVICE, MISC) RX-DME DIAMOND spacer/aerosol-holding chambers OPTICHAMBER DIAMOND-LG MASK OPTICHAMBER DEVICE RX-DME DIAMOND-LG MASK spacer/aerosol-holding chambers OPTICHAMBER DIAMOND-MD MASK OPTICHAMBER MISC RX-DME DIAMOND-MD MASK spacer/aerosol-holding chambers OPTICHAMBER DIAMOND-SM MASK OPTICHAMBER MISC RX-DME DIAMOND-SM MASK spacer/aerosol-holding chambers OPTICHAMBER FACE OPTICHAMBER MASK-LARGE MISC RX-DME FACE MASK-LARGE spacer/aerosol-holding chambers OPTICHAMBER FACE OPTICHAMBER MASK-MEDIUM MISC FACE MASK- RX-DME spacer/aerosol-holding MEDIUM chambers OPTICHAMBER FACE OPTICHAMBER MASK-SMALL MISC RX-DME FACE MASK-SMALL spacer/aerosol-holding chambers OPTIHALER (DEVICE, MISC) OPTIHALER RX-DME spacer/aerosol-holding chambers ORTHOVISC 30 MG/2ML ORTHOVISC SOLN PRSYR T6 hyaluronan PANDA MASK LARGE PANDA MASK MISC RX-DME LARGE spacer/aerosol-holding chamber supplies - masks PANDA MASK MEDIUM PANDA MASK MISC RX-DME MEDIUM spacer/aerosol-holding chamber supplies - masks

©2021 Wellmark, Inc. 159 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PANDA MASK SMALL PANDA MASK MISC RX-DME SMALL spacer/aerosol-holding chamber supplies - masks PARAGARD PARAGARD INTRAUTERINE COPPER INTRAUTERINE T6 IUD COPPER copper (iud) PEDIATRIC PANDA MASK PEDIATRIC PANDA MISC RX-DME MASK spacer/aerosol-holding chamber supplies - masks POCKET CHAMBER DEVICE POCKET CHAMBER RX-DME spacer/aerosol-holding chambers PRECISION XTRA PRECISION XTRA KETONE STRIP TIER 2 PV KETONE ketone blood test PRO COMFORT SPACER PRO COMFORT ADULT MISC RX-DME SPACER ADULT spacer/aerosol-holding chambers PRO COMFORT SPACER PRO COMFORT CHILD MISC RX-DME SPACER CHILD spacer/aerosol-holding chambers PRO COMFORT SPACER PRO COMFORT INFANT DEVICE RX-DME SPACER INFANT spacer/aerosol-holding chambers PROCARE PROCARE SPACER/ADULT MASK SPACER/ADULT DEVICE RX-DME MASK spacer/aerosol-holding chambers PROCARE PROCARE SPACER/CHILD MASK SPACER/CHILD DEVICE RX-DME MASK spacer/aerosol-holding chambers PTS PANELS KETONE PTS PANELS TEST STRIP TIER 2 PV KETONE TEST ketone blood test RA ALCOHOL SWABS 70 RA ALCOHOL % PAD TIER 2 SWABS alcohol swabs

©2021 Wellmark, Inc. 160 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS RELION KETONE STRIP RELION KETONE TIER 2 PV acetone (urine) test RELION KETONE TEST RELION KETONE STRIP TIER 2 PV TEST acetone (urine) test RITEFLO DEVICE RITEFLO spacer/aerosol-holding RX-DME chambers SM ALCOHOL PREP SM ALCOHOL PREP (70%PAD, PAD) TIER 2 alcohol swabs SODIUM HYALURONATE SODIUM 20 MG/2ML SOLN PRSYR T6 HYALURONATE sodium hyaluronate (viscosupplement) SOLESTA 50-15 MG/ML GEL SOLESTA T6 dextranomer-sodium hyaluronate SOLIRIS 300 MG/30ML SOLIRIS SOLUTION T6 eculizumab SUPARTZ FX 25 MG/2.5ML SOLN PRSYR SUPARTZ FX T6 sodium hyaluronate (viscosupplement) SYNVISC 16 MG/2ML SYNVISC SOLN PRSYR T6 hylan SYNVISC ONE 48 MG/6ML SYNVISC ONE SOLN PRSYR T6 hylan THYROGEN 1.1 MG THYROGEN RECON SOLN T6 thyrotropin alfa TRILURON 20 MG/2ML SOLN PRSYR TRILURON T6 sodium hyaluronate (viscosupplement) TRIVISC 25 MG/2.5ML SOLN PRSYR TRIVISC T6 sodium hyaluronate (viscosupplement)

©2021 Wellmark, Inc. 161 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ULTOMIRIS (300 MG/30ML SOLUTION, 300 MG/3ML ULTOMIRIS SOLUTION, 1100 T6 MG/11ML SOLUTION) ravulizumab-cwvz URISTIX STRIP URISTIX TIER 2 PV multiple urine tests URISTIX 4 STRIP URISTIX 4 TIER 2 PV multiple urine tests VALVED HOLDING VALVED HOLDING CHAMBER DEVICE RX-DME CHAMBER spacer/aerosol-holding chambers VISCO-3 25 MG/2.5ML SOLN PRSYR VISCO-3 T6 sodium hyaluronate (viscosupplement) VISTOGARD 10 GM PACKET VISTOGARD SP-P uridine triacetate (emergency treatment) VORTEX VALVED HOLDING CHAMBER VORTEX VALVED DEVICE RX-DME HOLDING CHAMBER spacer/aerosol-holding chambers WATCHHALER DEVICE WATCHHALER spacer/aerosol-holding RX-DME chambers

OPHTHALMIC AGENTS

OPHTHALMIC AGENTS, OTHER

ak-poly-bac 500-10000 ak-poly-bac TIER 1 unit/gm ointment altacaine altacaine 0.5 % solution TIER 1 altafrin (2.5 % solution, 10 altafrin TIER 1 % solution) atropine sulfate 1 % atropine sulfate TIER 1 solution bacitra-neomycin- bacitra-neomycin- TIER 1 polymyxin-hc polymyxin-hc 1 % ointment bacitracin-polymyxin bacitracin-polymyxin b 500- TIER 1 b 10000 unit/gm ointment

©2021 Wellmark, Inc. 162 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS cyclopentolate hcl (0.5 % cyclopentolate hcl solution, 1 % solution, 2 % TIER 1 solution) CYSTADROPS 0.37 % CYSTADROPS SOLUTION SP-P QL (4 PER 28 DAY(S)) cysteamine hcl CYSTARAN 0.44 % CYSTARAN SOLUTION SP-P cysteamine hcl HOMATROPAIRE 5 % HOMATROPAIRE SOLUTION TIER 1 GA homatropine hbr homatropine hbr 5 % homatropine hbr TIER 1 solution ISOPTO ATROPINE 1 % SOLUTION ISOPTO ATROPINE TIER 1 GA atropine sulfate (ophthalmic) mydral (0.5 % solution, 1 % mydral TIER 1 solution) neo-polycin 3.5-400-10000 neo-polycin TIER 1 ointment neo-polycin hc 1 % neo-polycin hc TIER 1 ointment neomycin-bacitracin zn- neomycin-bacitracin polymyx (3.5-400- TIER 1 zn-polymyx 10000ointment, 5-400- 10000ointment) neomycin-polymyxin- neomycin-polymyxin- dexameth (ointment, TIER 1 dexameth suspension) NEOMYCIN-POLYMYXIN- NEOMYCIN- GRAMICIDIN 1.75-10000- POLYMYXIN- .025 SOLUTION TIER 1 GRAMICIDIN neomycin-polymyxin- gramicidin NEOMYCIN-POLYMYXIN- HC 3.5-10000-1 NEOMYCIN- SUSPENSION TIER 1 POLYMYXIN-HC neomycin-polymyxin-hc (ophth) OXERVATE 0.002 % OXERVATE SOLUTION SP-P PA, QL (8 PER LIFETIME) cenegermin-bkbj phenylephrine hcl (2.5 % phenylephrine hcl TIER 1 solution, 10 % solution)

©2021 Wellmark, Inc. 163 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS poly-dex 3.5-10000-0.1 poly-dex TIER 1 ointment polycin 500-10000 unit/gm polycin TIER 1 ointment polymyxin b-trimethoprim polymyxin b- 10000-0.1 unit/ml-% TIER 1 trimethoprim solution proparacaine hcl 0.5 % proparacaine hcl TIER 1 solution RESTASIS 0.05 % RESTASIS EMULSION TIER 2 cyclosporine (ophth) RESTASIS MULTIDOSE RESTASIS 0.05 % EMULSION TIER 2 MULTIDOSE cyclosporine (ophth) sulfacetamide- sulfacetamide-prednisolone TIER 1 prednisolone 10-0.23 % solution TEPEZZA 500 MG RECON TEPEZZA SOLN T6 teprotumumab-trbw tetcaine tetcaine 0.5 % solution TIER 1 tetracaine hcl 0.5 % tetracaine hcl TIER 1 solution tetravisc tetravisc 0.5 % solution TIER 1 tetravisc forte 0.5 % tetravisc forte TIER 1 solution tobramycin- tobramycin-dexamethasone TIER 1 dexamethasone 0.3-0.1 % suspension tropicamide (0.5 % solution, tropicamide TIER 1 1 % solution) VISUDYNE 15 MG RECON VISUDYNE SOLN T6 verteporfin XIIDRA 5 % SOLUTION XIIDRA TIER 2 lifitegrast

OPHTHALMIC ANTI-ALLERGY AGENTS

azelastine hcl 0.05 % azelastine hcl TIER 1 solution bepotastine besilate 1.5 % bepotastine besilate TIER 1 solution cromolyn sodium 4 % cromolyn sodium TIER 1 solution epinastine hcl 0.05 % epinastine hcl TIER 1 solution

OPHTHALMIC ANTI-INFLAMMATORIES

bromfenac sodium bromfenac sodium (once- TIER 1 (once-daily) daily) 0.09 % solution BROMFENAC SODIUM BROMFENAC 0.09 % SOLUTION TIER 1 SODIUM bromfenac sodium (ophth) DEXAMETHASONE DEXAMETHASONE SODIUM PHOSPHATE 0.1 SODIUM % SOLUTION TIER 1 PHOSPHATE dexamethasone sodium phosphate (ophth) diclofenac sodium 0.1 % diclofenac sodium TIER 1 solution fluorometholone 0.1 % fluorometholone TIER 1 suspension flurbiprofen sodium 0.03 % flurbiprofen sodium TIER 1 solution ketorolac tromethamine ketorolac (0.4 % solution, 0.5 % TIER 1 tromethamine solution) loteprednol etabonate (0.5 loteprednol etabonate TIER 1 % gel, 0.5 % suspension) prednisolone acetate 1 % prednisolone acetate TIER 1 suspension PREDNISOLONE SODIUM PREDNISOLONE PHOSPHATE 1 % SODIUM SOLUTION TIER 1 PHOSPHATE prednisolone sodium phosphate (ophth)

OPHTHALMIC ANTIGLAUCOMA AGENTS

apraclonidine hcl 0.5 % apraclonidine hcl TIER 1 solution betaxolol hcl betaxolol hcl 0.5 % solution TIER 1 BETIMOL (0.25 % SOLUTION, 0.5 % BETIMOL TIER 2 SOLUTION) timolol BETOPTIC-S 0.25 % BETOPTIC-S SUSPENSION TIER 2 betaxolol hcl (ophth) brimonidine tartrate (0.15 % brimonidine tartrate TIER 1 solution, 0.2 % solution) brinzolamide 1 % brinzolamide TIER 1 suspension

©2021 Wellmark, Inc. 165 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS carteolol hcl carteolol hcl 1 % solution TIER 1 dorzolamide hcl 2 % dorzolamide hcl TIER 1 solution dorzolamide hcl- dorzolamide hcl-timolol mal TIER 1 timolol mal 22.3-6.8 mg/ml solution dorzolamide hcl- dorzolamide hcl-timolol mal TIER 1 timolol mal pf pf 2-0.5 % solution levobunolol hcl 0.5 % levobunolol hcl TIER 1 solution methazolamide (25 mg tab, methazolamide TIER 1 50 mg tab) METIPRANOLOL 0.3 % METIPRANOLOL SOLUTION TIER 1 metipranolol pilocarpine hcl (1 % pilocarpine hcl solution, 2 % solution, 4 % TIER 1 solution) timolol maleate (0.25 % gel f soln, 0.25 % solution, 0.5 timolol maleate TIER 1 % (daily) solution, 0.5 % gel f soln, 0.5 % solution) timolol maleate timolol maleate ocudose TIER 1 ocudose 0.5 % solution timolol maleate pf 0.5 % timolol maleate pf TIER 1 solution

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS

bimatoprost bimatoprost 0.03 % solution TIER 1 DURYSTA 10 MCG DURYSTA IMPLANT T6 bimatoprost latanoprost 0.005 % latanoprost TIER 1 solution LUMIGAN 0.01 % LUMIGAN SOLUTION TIER 2 bimatoprost travoprost (bak free) 0.004 travoprost (bak free) TIER 1 % solution

OTIC AGENTS

acetasol hc acetasol hc 2-1 % solution TIER 1 acetic acid acetic acid 2 % solution TIER 1 ciprofloxacin- ciprofloxacin- dexamethasone 0.3-0.1 % TIER 1 dexamethasone suspension

©2021 Wellmark, Inc. 166 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS flac flac 0.01 % oil TIER 1 fluocinolone fluocinolone acetonide 0.01 TIER 1 acetonide % oil hydrocortisone-acetic hydrocortisone-acetic acid TIER 1 acid 1-2 % solution neomycin-polymyxin-hc (1 % solution, 3.5-10000-1 neomycin-polymyxin- solution, 3.5-10000-1 TIER 1 hc suspension, 3.5-10000-1 solution)

RESPIRATORY TRACT/PULMONARY AGENTS

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

ASMANEX (120 METERED DOSES) 220 MCG/INH ASMANEX (120 AER POW BA TIER 1 PV METERED DOSES) mometasone furoate (inhalation) ASMANEX (14 METERED DOSES) 220 MCG/INH ASMANEX (14 AER POW BA TIER 1 PV METERED DOSES) mometasone furoate (inhalation) ASMANEX (30 METERED DOSES) (110 AER POW ASMANEX (30 BA, 220 AER POW BA) TIER 1 PV METERED DOSES) mometasone furoate (inhalation) ASMANEX (60 METERED DOSES) 220 MCG/INH ASMANEX (60 AER POW BA TIER 1 PV METERED DOSES) mometasone furoate (inhalation) ASMANEX (7 METERED DOSES) 110 MCG/INH ASMANEX (7 AER POW BA TIER 1 PV METERED DOSES) mometasone furoate (inhalation) ASMANEX HFA (50 AEROSOL, 100 AEROSOL, 200 ASMANEX HFA TIER 1 PV AEROSOL) mometasone furoate (inhalation) budesonide (0.25 budesonide suspension, 0.5 TIER 1 PV suspension, 1 suspension)

©2021 Wellmark, Inc. 167 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FLUNISOLIDE 25 MCG/ACT (0.025%) FLUNISOLIDE TIER 1 SOLUTION flunisolide (nasal) mometasone furoate 50 mometasone furoate TIER 1 PA mcg/act suspension QVAR (40 AERO SOLN, 80 AERO SOLN) QVAR TIER 1 PV beclomethasone dipropionate QVAR REDIHALER (40 AERO BA, 80 AERO BA) QVAR REDIHALER TIER 1 PV beclomethasone dipropionate hfa TRELEGY ELLIPTA (100- 62.5-25 AER POW BA, TRELEGY ELLIPTA 200-62.5-25 AER POW BA) TIER 2 PV fluticasone-umeclidinium- vilanterol

ANTIHISTAMINES

azelastine hcl (0.1 % azelastine hcl solution, 0.15 % solution, TIER 1 137 mcg/spray solution) BROMPHENIRAMINE BROMPHENIRAMIN TANNATE 12 MG CHEW TIER 1 E TANNATE TAB brompheniramine tannate carbinoxamine carbinoxamine maleate (4 TIER 1 maleate mg tab, 4 mg/5ml solution) CLEMASTINE FUMARATE CLEMASTINE 2.68 MG TAB TIER 1 FUMARATE clemastine fumarate cyproheptadine hcl (2 cyproheptadine hcl TIER 1 mg/5ml syrup, 4 mg tab) DESLORATADINE (2.5 MG TAB DISP, 5 MG TAB, 5 DESLORATADINE TIER 1 MG TAB DISP) desloratadine diphenhydramine hcl 50 diphenhydramine hcl TIER 1 mg/ml solution hydroxyzine hcl (10 mg tab, hydroxyzine hcl 10 mg/5ml syrup, 25 mg TIER 1 tab, 50 mg tab) hydroxyzine pamoate (25 hydroxyzine pamoate mg cap, 50 mg cap, 100 mg TIER 1 cap)

©2021 Wellmark, Inc. 168 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS olopatadine hcl 0.6 % olopatadine hcl TIER 1 solution promethazine hcl (6.25 promethazine hcl TIER 1 solution, 6.25 syrup)

ANTILEUKOTRIENES

montelukast sodium (4 mg montelukast sodium chew tab, 4 mg packet, 5 TIER 1 PV mg chew tab, 10 mg tab) zafirlukast (10 mg tab, 20 zafirlukast TIER 1 PV mg tab) zileuton er 600 mg tab er zileuton er TIER 1 PV 12h

BRONCHODILATORS, ANTICHOLINERGIC

ATROVENT HFA 17 ATROVENT HFA MCG/ACT AERO SOLN TIER 2 ipratropium bromide hfa ipratropium bromide (0.02 ipratropium bromide % solution, 0.03 % solution, TIER 1 0.06 % solution) SPIRIVA HANDIHALER 18 SPIRIVA MCG CAP TIER 2 HANDIHALER tiotropium bromide monohydrate SPIRIVA RESPIMAT (1.25 AERO SOLN, 2.5 AERO SPIRIVA RESPIMAT SOLN) TIER 2 PV tiotropium bromide monohydrate

BRONCHODILATORS, SYMPATHOMIMETIC

ADRENALIN 1 MG/ML ADRENALIN SOLUTION TIER 1 epinephrine (anaphylaxis) albuterol sulfate (0.63 mg/3ml nebu soln, 1.25 mg/3ml nebu soln, 2 mg tab, 2 mg/5ml syrup, (2.5 albuterol sulfate TIER 1 mg/3ml) 0.083% nebu soln, 2.5 mg/0.5ml nebu soln, 4 mg tab, (5 mg/ml) 0.5% nebu soln) albuterol sulfate er (er 4 mg albuterol sulfate er tab er 12h, er 8 mg tab er TIER 1 12h)

©2021 Wellmark, Inc. 169 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS albuterol sulfate hfa 108 (90 albuterol sulfate hfa TIER 1 base) mcg/act aero soln arformoterol tartrate 15 arformoterol tartrate TIER 1 PV mcg/2ml nebu soln epinephrine hcl epinephrine hcl (nasal) 0.1 TIER 1 (nasal) % solution epinephrine hcl 1 mg/ml epinephrine hcl TIER 1 solution EPIPEN 2-PAK 0.3 EPIPEN 2-PAK MG/0.3ML SOLN A-INJ TIER 2 QL (2 PER RX) epinephrine (anaphylaxis) EPIPEN JR 2-PAK 0.15 EPIPEN JR 2-PAK MG/0.3ML SOLN A-INJ TIER 2 QL (2 PER RX) epinephrine (anaphylaxis) formoterol fumarate 20 formoterol fumarate TIER 1 PV mcg/2ml nebu soln levalbuterol hcl (0.31 mg/3ml nebu soln, 0.63 levalbuterol hcl mg/3ml nebu soln, 1.25 TIER 1 mg/0.5ml nebu soln, 1.25 mg/3ml nebu soln) levalbuterol tartrate 45 levalbuterol tartrate TIER 2 mcg/act aerosol METAPROTERENOL SULFATE (10 MG TAB, 10 METAPROTERENOL MG/5ML SYRUP, 20 MG TIER 1 SULFATE TAB) metaproterenol sulfate SEREVENT DISKUS 50 SEREVENT DISKUS MCG/DOSE AER POW BA TIER 2 PV salmeterol xinafoate SYMJEPI (0.15 SOLN PRSYR, 0.3 SOLN SYMJEPI TIER 2 QL (2 PER FILL(S)) PRSYR) epinephrine (anaphylaxis) terbutaline sulfate (2.5 mg terbutaline sulfate TIER 1 tab, 5 mg tab)

CYSTIC FIBROSIS AGENTS

CAYSTON 75 MG RECON CAYSTON SOLN SP-P aztreonam lysine KALYDECO (50 MG PACKET, 75 MG PACKET, KALYDECO SP-P PA, QL (56 PER 28 DAYS) 150 MG TAB) ivacaftor

©2021 Wellmark, Inc. 170 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS KALYDECO 25 MG KALYDECO PACKET SP-P PA, QL (56 PER 28 DAY(S)) ivacaftor ORKAMBI (100-125 MG PACKET, 150-188 MG ORKAMBI SP-P PA, QL (56 PER 28 DAY(S)) PACKET) lumacaftor-ivacaftor ORKAMBI (100-125 MG ORKAMBI TAB, 200-125 MG TAB) SP-P PA, QL (112 PER 28 DAYS) lumacaftor-ivacaftor PULMOZYME 1 MG/ML PULMOZYME SOLUTION SP-P dornase alfa SYMDEKO (50-75 75 MG TAB THPK, 100-150 150 SYMDEKO SP-P PA, QL (56 PER 28 DAY(S)) MG TAB THPK) tezacaftor-ivacaftor TOBI PODHALER 28 MG TOBI PODHALER CAP SP-P tobramycin tobramycin (300 mg/4ml SBG (Specialty Biosimilars tobramycin nebu soln, 300 mg/5ml SP-P and Specialty generics) nebu soln) TRIKAFTA 100-50-75 & 150 MG TAB THPK TRIKAFTA SP-P PA, QL (84 PER 28 DAY(S)) elexacaftor-tezacaftor- ivacaftor TRIKAFTA 50-25-37.5 & 75 MG TAB THPK TRIKAFTA SP-P PA, QL (3 PER DAY(S)) elexacaftor-tezacaftor- ivacaftor

MAST CELL STABILIZERS

cromolyn sodium 20 cromolyn sodium TIER 1 PV mg/2ml nebu soln

PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE

caffeine citrate (20 mg/ml caffeine citrate solution, 60 mg/3ml TIER 1 solution) theochron (100 mg tab er theochron 12h, 200 mg tab er 12h, TIER 1 300 mg tab er 12h) theophylline 80 mg/15ml theophylline TIER 1 solution

©2021 Wellmark, Inc. 171 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS theophylline er (er 100 mg tab er 12h, er 200 mg tab er 12h, er 300 mg tab er 12h, theophylline er TIER 1 er 400 mg tab er 24h, er 450 mg tab er 12h, er 600 mg tab er 24h)

PULMONARY ANTIHYPERTENSIVES

ADEMPAS (0.5 MG TAB, 1 MG TAB, 1.5 MG TAB, 2 ADEMPAS SP-P PA, QL (90 PER 30 DAYS) MG TAB, 2.5 MG TAB) riociguat PA, QL (60 PER 30 DAYS), alyq alyq 20 mg tab SP-P SBG (Specialty Biosimilars and Specialty generics) PA, QL (30 PER 30 DAYS), ambrisentan (5 mg tab, 10 ambrisentan SP-P SBG (Specialty Biosimilars mg tab) and Specialty generics) PA, QL (60 PER 30 DAY(S)), bosentan (62.5 mg tab, 125 bosentan SP-P SBG (Specialty Biosimilars mg tab) and Specialty generics) epoprostenol sodium (0.5 epoprostenol sodium mg recon soln, 1.5 mg T6 recon soln) FLOLAN (0.5 MG RECON SOLN, 1.5 MG RECON FLOLAN T6 GA SOLN) epoprostenol sodium OPSUMIT 10 MG TAB OPSUMIT SP-P PA, QL (30 PER 30 DAYS) macitentan ORENITRAM (0.125 MG TAB ER, 0.25 MG TAB ER, ORENITRAM 1 MG TAB ER, 2.5 MG TAB SP-P PA ER, 5 MG TAB ER) treprostinil diolamine REMODULIN (20 SOLUTION, 50 SOLUTION, 100 REMODULIN T6 GA SOLUTION, 200 SOLUTION) treprostinil REVATIO 10 MG/12.5ML SOLUTION REVATIO T6 GA sildenafil citrate (pulmonary hypertension) sildenafil citrate 10 sildenafil citrate T6 mg/12.5ml solution

©2021 Wellmark, Inc. 172 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PA, QL (720 PER 30 DAYS), sildenafil citrate 10 mg/ml sildenafil citrate SP-P SBG (Specialty Biosimilars recon susp and Specialty generics) PA, QL (360 PER 30 DAYS), sildenafil citrate sildenafil citrate 20 mg tab SP-P SBG (Specialty Biosimilars and Specialty generics) PA, QL (60 PER 30 DAYS), tadalafil (pah) tadalafil (pah) 20 mg tab SP-P SBG (Specialty Biosimilars and Specialty generics) TRACLEER 32 MG TAB PA, QL (120 PER 30 TRACLEER SOL SP-P DAY(S)) bosentan treprostinil (20 solution, 50 treprostinil solution, 100 solution, 200 T6 solution) TYVASO 0.6 MG/ML TYVASO SOLUTION SP-P PA, QL (30 PER 30 DAYS) treprostinil TYVASO REFILL 0.6 TYVASO REFILL MG/ML SOLUTION SP-P PA, QL (30 PER 30 DAYS) treprostinil TYVASO STARTER 0.6 TYVASO STARTER MG/ML SOLUTION SP-P PA, QL (30 PER 30 DAYS) treprostinil UPTRAVI (200 MCG TAB, 400 MCG TAB, 600 MCG TAB, 800 MCG TAB, 1000 UPTRAVI MCG TAB, 1200 MCG SP-P PA, QL (60 PER 30 DAYS) TAB, 1400 MCG TAB, 1600 MCG TAB) selexipag UPTRAVI 200 & 800 MCG UPTRAVI TAB THPK SP-P PA, QL (1 PER LIFETIME) selexipag VELETRI (0.5 MG RECON SOLN, 1.5 MG RECON VELETRI T6 GA SOLN) epoprostenol sodium VENTAVIS (10 MCG/ML SOLUTION, 20 MCG/ML VENTAVIS SP-P PA, QL (9 PER DAY) SOLUTION) iloprost

PULMONARY FIBROSIS AGENTS

ESBRIET (267 MG TAB, PA, QL (2403 PER 1 ESBRIET 801 MG TAB) SP-P DAY(S)) pirfenidone

©2021 Wellmark, Inc. 173 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ESBRIET 267 MG CAP ESBRIET SP-P PA, QL (270 PER 30 DAYS) pirfenidone OFEV (100 MG CAP, 150 OFEV MG CAP) SP-P PA, QL (60 PER 30 DAYS) nintedanib esylate

RESPIRATORY TRACT AGENTS, OTHER

acetylcysteine (10 % acetylcysteine TIER 1 solution, 20 % solution) ADVAIR DISKUS (100-50 AER POW BA, 250-50 AER ADVAIR DISKUS POW BA, 500-50 AER TIER 1 PV, GA POW BA) fluticasone-salmeterol ADVAIR HFA (45-21 AEROSOL, 115-21 ADVAIR HFA AEROSOL, 230-21 TIER 2 PV AEROSOL) fluticasone-salmeterol ANORO ELLIPTA 62.5-25 ANORO ELLIPTA MCG/INH AER POW BA TIER 2 umeclidinium-vilanterol azelastine-fluticasone 137- azelastine-fluticasone TIER 1 PA 50 mcg/act suspension benzonatate (100 mg cap, benzonatate TIER 1 200 mg cap) BREO ELLIPTA (100-25 AER POW BA, 200-25 AER BREO ELLIPTA POW BA) TIER 2 PV fluticasone furoate- vilanterol bromfed dm 30-2-10 bromfed dm TIER 1 mg/5ml syrup budesonide-formoterol budesonide- MN-PA (Medically Necessary fumarate (80-4.5 aerosol, TIER 1 formoterol fumarate Prior Authorization), PV 160-4.5 aerosol) CINQAIR 100 MG/10ML CINQAIR SOLUTION T6 reslizumab COMBIVENT RESPIMAT COMBIVENT 20-100 MCG/ACT AERO TIER 2 RESPIMAT SOLN ipratropium-albuterol difil-g forte 100-100 mg/5ml difil-g forte TIER 1 liquid

©2021 Wellmark, Inc. 174 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FASENRA 30 MG/ML FASENRA SOLN PRSYR T6 benralizumab FASENRA PEN 30 MG/ML FASENRA PEN SOLN A-INJ T6 benralizumab fluticasone-salmeterol (55- 14 aer pow ba, 113-14 aer fluticasone-salmeterol TIER 1 PV pow ba, 232-14 aer pow ba) giltuss pediatric 2.5-7.5-88 giltuss pediatric TIER 1 mg/ml liquid hydrocod polst-cpm hydrocod polst-cpm polst er TIER 1 polst er 10-8 mg/5ml susp hydrocodone- hydrocodone-homatropine TIER 1 homatropine (mg tab, mg/5ml syrup) hydromet 5-1.5 mg/5ml hydromet TIER 1 syrup ipratropium-albuterol 0.5- ipratropium-albuterol TIER 1 2.5 (3) mg/3ml solution nebusal nebusal 3 % nebu soln TIER 1 NUCALA (100 MG RECON SOLN, 100 MG/ML SOLN NUCALA A-INJ, 100 MG/ML SOLN T6 PRSYR) mepolizumab phenylephrine- phenylephrine-guaifenesin TIER 1 guaifenesin 1.5-20 mg/ml liquid promethazine vc 6.25-5 promethazine vc TIER 1 mg/5ml syrup promethazine vc plain 6.25- promethazine vc plain TIER 1 5 mg/5ml solution promethazine promethazine vc/codeine TIER 1 vc/codeine 6.25-5-10 mg/5ml syrup promethazine- promethazine-codeine TIER 1 codeine (solution, syrup) promethazine-dm (solution, promethazine-dm TIER 1 syrup) promethazine-phenyleph- promethazine- codeine 6.25-5-10 mg/5ml TIER 1 phenyleph-codeine syrup promethazine- promethazine- phenylephrine 6.25-5 TIER 1 phenylephrine mg/5ml syrup pseudoeph- pseudoeph-bromphen-dm TIER 1 bromphen-dm 30-2-10 mg/5ml syrup

©2021 Wellmark, Inc. 175 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS pseudoeph-chlorphen- pseudoeph- hydrocod 60-4-5 mg/5ml TIER 1 chlorphen-hydrocod solution pulmosal pulmosal 7 % nebu soln TIER 1 sodium chloride (0.9 % nebu soln, 3 % nebu soln, 7 sodium chloride TIER 1 % nebu soln, 10 % nebu soln) STIOLTO RESPIMAT 2.5- 2.5 MCG/ACT AERO SOLN STIOLTO RESPIMAT TIER 2 tiotropium bromide- olodaterol hcl SYMBICORT (80-4.5 AEROSOL, 160-4.5 SYMBICORT AEROSOL) TIER 2 PV, GA budesonide-formoterol fumarate dihydrate tussigon tussigon 5-1.5 mg tab TIER 1 XOLAIR (75 MG/0.5ML SOLN PRSYR, 150 MG XOLAIR RECON SOLN, 150 MG/ML T6 SOLN PRSYR) omalizumab

SKELETAL MUSCLE RELAXANTS

carisoprodol (250 mg tab, carisoprodol TIER 1 350 mg tab) carisoprodol-aspirin 200- carisoprodol-aspirin TIER 1 325 mg tab chlorzoxazone (375 mg tab, chlorzoxazone TIER 1 500 mg tab, 750 mg tab) cyclobenzaprine hcl (5 mg cyclobenzaprine hcl TIER 1 tab, 10 mg tab) DYSPORT (300 RECON DYSPORT SOLN, 500 RECON SOLN) T6 abobotulinumtoxina lorzone (375 mg tab, 750 lorzone TIER 1 mg tab) metaxall metaxall 800 mg tab TIER 1 metaxalone (400 mg tab, metaxalone TIER 1 800 mg tab) methocarbamol (500 mg methocarbamol TIER 1 tab, 750 mg tab)

©2021 Wellmark, Inc. 176 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MYOBLOC (2500 UNIT/0.5ML SOLUTION, 5000 UNIT/ML SOLUTION, MYOBLOC T6 10000 UNIT/2ML SOLUTION) rimabotulinumtoxinb orphenadrine citrate orphenadrine citrate er 100 TIER 1 er mg tab er 12h vanadom vanadom 350 mg tab TIER 1 XEOMIN (50 RECON SOLN, 100 RECON SOLN, XEOMIN T6 200 RECON SOLN) incobotulinumtoxina

SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORS

estazolam (1 mg tab, 2 mg estazolam TIER 1 tab) eszopiclone (1 mg tab, 2 eszopiclone TIER 1 PA mg tab, 3 mg tab) FLURAZEPAM HCL (15 FLURAZEPAM HCL MG CAP, 30 MG CAP) TIER 1 flurazepam hcl temazepam (7.5 mg cap, temazepam 15 mg cap, 22.5 mg cap, 30 TIER 1 mg cap) triazolam (0.125 mg tab, triazolam TIER 1 0.25 mg tab) zaleplon (5 mg cap, 10 mg zaleplon TIER 1 cap) zolpidem tartrate (1.75 mg zolpidem tartrate TIER 1 PA sl tab, 3.5 mg sl tab) zolpidem tartrate (5 mg tab, zolpidem tartrate TIER 1 10 mg tab) zolpidem tartrate er (er 6.25 zolpidem tartrate er mg tab er, er 12.5 mg tab TIER 1 PA er)

SLEEP DISORDERS, OTHER

armodafinil (50 mg tab, 150 armodafinil mg tab, 200 mg tab, 250 TIER 1 PA, QL (30 PER 30 DAYS) mg tab) doxepin hcl (3 mg tab, 6 mg doxepin hcl TIER 1 PA tab)

©2021 Wellmark, Inc. 177 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HETLIOZ 20 MG CAP HETLIOZ SP-P PA, QL (30 PER 30 DAYS) tasimelteon modafinil (100 mg tab, 200 modafinil TIER 1 PA, QL (60 PER 30 DAYS) mg tab) ramelteon ramelteon 8 mg tab TIER 1 PA XYREM 500 MG/ML XYREM SOLUTION SP-P PA, QL (540 PER 30 DAYS) sodium oxybate

Uncategorized

Unclassified

ABECMA SUSPENSION ABECMA T6 idecabtagene vicleucel ADUHELM (170 MG/1.7ML SOLUTION, 300 MG/3ML ADUHELM P&T SOLUTION) aducanumab-avwa AZSTARYS (26.1-5.2 MG CAP, 39.2-7.8 MG CAP, 52.3-10.4 MG CAP) AZSTARYS P&T PA, QL (1 PER DAY(S)) serdexmethylphenidate chloride- dexmethylphenidate hcl BYLVAY (400 MCG CAP, BYLVAY 1200 MCG CAP) P&T odevixibat BYLVAY (PELLETS) (200 MCG CAP SPRINK, 600 BYLVAY (PELLETS) P&T MCG CAP SPRINK) odevixibat COSELA 300 MG RECON COSELA SOLN T6 trilaciclib dihydrochloride CYCLOPHOSPHAMIDE CYCLOPHOSPHAMI (25 MG TAB, 50 MG TAB) TIER 1 DE cyclophosphamide EMPAVELI 1080 MG/20ML EMPAVELI SOLUTION P&T pegcetacoplan ENGERIX-B (10 MCG/0.5ML INJECTABLE, ENGERIX-B 20 MCG/ML INJECTABLE) TIER 2 PV hepatitis b vaccine (recomb)

©2021 Wellmark, Inc. 178 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS EVKEEZA (345 MG/2.3ML SOLUTION, 1200 MG/8ML EVKEEZA T6 SOLUTION) evinacumab-dgnb FOTIVDA (0.89 MG CAP, FOTIVDA 1.34 MG CAP) SP-P QL (21 PER 28 DAY(S)) tivozanib hcl HETLIOZ LQ 4 MG/ML HETLIOZ LQ SUSPENSION SP-P PA, QL (5 PER 1 DAY(S)) tasimelteon JEMPERLI 500 MG/10ML JEMPERLI SOLUTION T6 dostarlimab-gxly KERENDIA (10 MG TAB, KERENDIA 20 MG TAB) P&T finerenone LUMAKRAS 120 MG TAB LUMAKRAS SP-P sotorasib MARGENZA 250 MG/10ML MARGENZA SOLUTION T6 margetuximab-cmkb NEXVIAZYME 100 MG NEXVIAZYME RECON SOLN P&T avalglucosidase alfa-ngpt NULIBRY 9.5 MG RECON SOLN NULIBRY T6 fosdenopterin hydrobromide PEPAXTO 20 MG RECON PEPAXTO SOLN T6 melphalan flufenamide hcl PREVNAR 20 0.5 ML SUSP PRSYR PREVNAR 20 TIER 2 PV pneumococcal 20-valent conjugate vaccine REZUROCK 200 MG TAB REZUROCK P&T belumosudil mesylate RYBREVANT 350 MG/7ML RYBREVANT SOLUTION T6 amivantamab-vmjw RYLAZE 10 MG/0.5ML SOLUTION RYLAZE asparaginase erwinia T6 chrysanthemi (recombinant)-rywn

©2021 Wellmark, Inc. 179 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SAPHNELO 300 MG/2ML SAPHNELO SOLUTION P&T anifrolumab-fnia SKYRIZI (150 MG/ML SOLN A-INJ, 150 MG/ML SKYRIZI SP-P PA, QL (1 PER 84 DAY(S)) SOLN PRSYR) risankizumab-rzaa TEPMETKO 225 MG TAB TEPMETKO SP-P tepotinib hcl TRUSELTIQ (100MG TRUSELTIQ (100MG DAILY DOSE) 100 MG SP-P DAILY DOSE) CAP THPK infigratinib phosphate TRUSELTIQ (125MG TRUSELTIQ (125MG DAILY DOSE) 100 & 25 SP-P DAILY DOSE) MG CAP THPK infigratinib phosphate TRUSELTIQ (50MG DAILY TRUSELTIQ (50MG DOSE) 25 MG CAP THPK SP-P DAILY DOSE) infigratinib phosphate TRUSELTIQ (75MG DAILY TRUSELTIQ (75MG DOSE) 25 MG CAP THPK SP-P DAILY DOSE) infigratinib phosphate UKONIQ 200 MG TAB UKONIQ SP-P umbralisib tosylate UPTRAVI 1800 MCG UPTRAVI RECON SOLN T6 selexipag WELIREG 40 MG TAB WELIREG P&T belzutifan XELJANZ 1 MG/ML XELJANZ SOLUTION SP-P PA, QL (10 PER 1 DAY(S)) tofacitinib citrate XTANDI (40 MG TAB, 80 XTANDI MG TAB) SP-P enzalutamide ZYNLONTA 10 MG ZYNLONTA RECON SOLN T6 loncastuximab tesirine-lpyl

©2021 Wellmark, Inc. 180 Index of covered drugs Advate 68 A Adynovate 68 ABACAVIR SULFATE 52 AeroChamber Mini Chamber 150 ABACAVIR SULFATE-LAMIVUDINE 52 AeroChamber MV 150 ABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE 52 AeroChamber Plus Flo-Vu 150 ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE 54 AeroChamber Plus Flo-Vu Large 150 ABATACEPT 136 AeroChamber Plus Flo-Vu Medium 151 Abecma 178 AeroChamber Plus Flo-Vu Small 151 ABIRATERONE ACETATE 34 AeroChamber Plus Flo-Vu w/Mask 151 ABOBOTULINUMTOXINA 176 AeroChamber Plus Flow VU 151 ACALABRUTINIB 39 AeroChamber w/FLOWSIGnal 151 ACAMPROSATE CALCIUM 13 AeroChamber Z-Stat Plus 151 ACARBOSE 56 AeroChamber Z-Stat Plus Chambr 151 ACEBUTOLOL HCL 77 AeroChamber Z-Stat Plus/Large 151 ACETAMINOPHEN W/ CODEINE 9 AeroChamber Z-Stat Plus/Medium 151 ACETAMINOPHEN-CAFF-DIHYDROCOD 9,12 AeroChamber Z-Stat Plus/Small 151 ACETAMINOPHEN-SALICYLAMIDE- AeroVent Plus 151 PHENYLTOLOXAMINE 154 AFAMELANOTIDE ACETATE 95 Acetaminophen-Salicylamide-Phenyltoloxamine 154 AFATINIB DIMALEATE 40 ACETAZOLAMIDE 84 Afinitor 39 ACETIC ACID (OTIC) 166 Afinitor Disperz 39 ACETONE (URINE) TEST 153,157,161 Afluria 142 Acetone (Urine) Test 157 Afluria Preservative Free 143 ACETYLCYSTEINE 174 Afluria Quadrivalent 143 ACITRETIN 92 Afstyla 69 Actemra 142 AGALSIDASE BETA 109 Acthar 113 Aimovig 32 ActHIB 142 Aimovig (140 MG Dose) 32 Actimmune 142 Ajovy 24,32 ACYCLOVIR 55 ALBENDAZOLE 45 Adacel 142 ALBUTEROL SULFATE 169,170 Adakveo 74 ALCLOMETASONE DIPROPIONATE 113 ADALIMUMAB 135,136 ALCOHOL SWABS 152,160,161 ADAPALENE 92 Aldurazyme 108 ADEFOVIR DIPIVOXIL 49 Alecensa 39 Adempas 172 ALECTINIB HCL 39 Adrenalin 169 ALEMTUZUMAB (MS) 91 ADUCANUMAB-AVWA 178 ALENDRONATE SODIUM 149 Aduhelm 178 ALFUZOSIN HCL 111 Advair Diskus 174 ALGLUCOSIDASE ALFA 109 Advair HFA 174 ALISKIREN FUMARATE 80

©2021 Wellmark, Inc. 181 ALLOPURINOL 31 AMOXICILLIN & POT CLAVULANATE 18 ALMOTRIPTAN MALATE 31 AMOXICILLIN-CLARITHROMYCIN W/ ALOGLIPTIN BENZOATE 56 LANSOPRAZOLE 105 ALOGLIPTIN-METFORMIN HCL 57 AMPHETAMINE-DEXTROAMPHETAMINE 87 ALOGLIPTIN-PIOGLITAZONE 57 AMPICILLIN 18 ALOSETRON HCL 106 Ampicillin 18 ALPELISIB 38,39 Anadrol-50 117 Alphanate 69 ANAGRELIDE HCL 65 Alphanate/VWF Complex/Human 69 ANASTROZOLE 38 AlphaNine SD 69 ANIFROLUMAB-FNIA 180 ALPRAZOLAM 55,56 Anoro Ellipta 174 ALPRAZolam Intensol 56 ANTIHEMOPHIL FACT(RCMB) PEGYLATED-AUCL Alprolix 69 (BDD-RFVIII PEG-AUCL) 71 ALTRETAMINE 34 ANTIHEMOPHILIC FACTOR (HUMAN) 70,71,72 Alunbrig 35 ANTIHEMOPHILIC FACTOR (RCMB) BD ALVIMOPAN 105 TRUNCATED (BD TRUNC-RFVIII) 72 AMANTADINE HCL 46 ANTIHEMOPHILIC FACTOR (RCMB) FC FUSION AMBRISENTAN 172 PROTEIN(BDD-RFVIIIFC) 70 AMCINONIDE 113 ANTIHEMOPHILIC FACTOR (RCMB) Amcinonide 113 MOROCTOCOG ALFA(BDD-RFVIII,MOR) 74 AMIFAMPRIDINE 33 ANTIHEMOPHILIC FACTOR (RCMB) AMIKACIN SULFATE LIPOSOME 13 PLASMA/ALBUMIN FREE (RAHF-PFM) 68,72 AMILORIDE & HYDROCHLOROTHIAZIDE 80 ANTIHEMOPHILIC FACTOR (RCMB) SIMOCTOCOG AMILORIDE HCL 84 ALFA(BDD-RFVIII,SIM) 73 AMINOCAPROIC ACID 69 ANTIHEMOPHILIC FACTOR (RECOMBINANT AMINOSALICYLIC ACID 33 PORCINE) (RPFVIII) 73 AMIODARONE HCL 76,77 ANTIHEMOPHILIC FACTOR AMITRIPTYLINE HCL 27 (RECOMBINANT) 70,71,72,73 AMIVANTAMAB-VMJW 179 ANTIHEMOPHILIC FACTOR (RECOMBINANT) AMLODIPINE BESYLATE 78 PEGYLATED 68 AMLODIPINE BESYLATE-ATORVASTATIN ANTIHEMOPHILIC FACTOR (RECOMBINANT) CALCIUM 81 SINGLE CHAIN 69 AMLODIPINE BESYLATE-BENAZEPRIL HCL 81 ANTIHEMOPHILIC FACTOR/VON WILLEBRAND AMLODIPINE BESYLATE-OLMESARTAN FACTOR COMPLEX (HUMAN) 69,71,74 MEDOXOMIL 81 ANTIINHIBITOR COAGULANT COMPLEX 70 AMLODIPINE BESYLATE-VALSARTAN 81 Antiinhibitor Coagulant Complex 70 AMLODIPINE-VALSARTAN- Anzemet 29 HYDROCHLOROTHIAZIDE 81 APALUTAMIDE 34 AMOXAPINE 27 APIXABAN 64 Amoxapine 27 Apokyn 46 AMOXICILLIN 18 APOMORPHINE HYDROCHLORIDE 46

©2021 Wellmark, Inc. 182 APRACLONIDINE HCL 165 AVALGLUCOSIDASE ALFA-NGPT 179 APREMILAST 142 Avandamet 57 APREPITANT 29 AVAPRITINIB 35 Aptivus 54 Avastin 44 Aranesp (Albumin Free) 66 AVATROMBOPAG MALEATE 66 Arcalyst 142 Avsola 134 ARFORMOTEROL TARTRATE 170 AXITINIB 40 Arial Chamber 151 Ayvakit 35 Arikayce 13 AZACITIDINE 36 ARIPIPRAZOLE 48 Azactam 17 ARMODAFINIL 177 AZATHIOPRINE 134 Asceniv 138 AZELAIC ACID 93 ASENAPINE MALEATE 48 AZELASTINE HCL 168 ASFOTASE ALFA 110 AZELASTINE HCL (OPHTH) 164 Asmanex (120 Metered Doses) 167 AZELASTINE HCL-FLUTICASONE PROPIONATE 174 Asmanex (14 Metered Doses) 167 AZITHROMYCIN 18 Asmanex (30 Metered Doses) 167 Azstarys 178 Asmanex (60 Metered Doses) 167 AZTREONAM 17 Asmanex (7 Metered Doses) 167 AZTREONAM LYSINE 170 Asmanex HFA 167 ASPARAGINASE ERWINIA CHRYSANTHEMI B (RECOMBINANT)-RYWN 179 Bacitracin 14 ASPIRIN-CAFFEINE-DIHYDROCODEINE BACITRACIN (OPHTHALMIC) 14 BITARTRATE 9 BACITRACIN-POLY-NEOMYCIN-HC 162,163 ASPIRIN-DIPYRIDAMOLE 74 BACITRACIN-POLYMYXIN B (OPHTH) 162,164 Astagraf XL 134 BACLOFEN 49 Atabex EC 99 Bafiertam 90 Atabex OB 99 BALSALAZIDE DISODIUM 148 ATAZANAVIR SULFATE 54 Balversa 35 ATENOLOL 77 Baqsimi One Pack 60 ATENOLOL & CHLORTHALIDONE 81 Baqsimi Two Pack 60 ATOMOXETINE HCL 88 Basaglar KwikPen 60 ATORVASTATIN CALCIUM 85 BD Swab Single Use Regular 152 ATOVAQUONE 45 Bebulin 69 ATOVAQUONE-PROGUANIL HCL 45 BECLOMETHASONE DIPROPIONATE 168 Atropine Sulfate (Ophthalmic) 162 BECLOMETHASONE DIPROPIONATE HFA 168 ATROPINE SULFATE (OPHTHALMIC) 163 BELANTAMAB MAFODOTIN-BLMF 44 Atrovent HFA 169 BELIMUMAB 142 Aubagio 90 BELUMOSUDIL MESYLATE 179 AURANOFIN 142 BELZUTIFAN 180 Austedo 89 BENAZEPRIL & HYDROCHLOROTHIAZIDE 81

©2021 Wellmark, Inc. 183 BENAZEPRIL HCL 76 BP FoliNatal Plus B 99 BeneFIX 70 BP MultiNatal Plus 99 Benlysta 142 Braftovi 39 BENRALIZUMAB 175 Breathe Ease Large 152 BENZONATATE 174 Breathe Ease Medium 152 BENZOYL PEROXIDE-ERYTHROMYCIN 14 Breathe Ease Small 152 BENZTROPINE MESYLATE 46 BreatheRite 152 BEPOTASTINE BESILATE 164 BreatheRite Coll Spacer Adult 152 Berinert 133 BreatheRite Coll Spacer Child 152 BEROTRALSTAT HCL 133 BreatheRite Coll Spacer Infant 152 BETAINE 108 BreatheRite Rigid Spacer/Mask 152 BETAMETHASONE DIPROPIONATE (TOPICAL) 113 BreatheRite Spacer Neonate 152 BETAMETHASONE DIPROPIONATE BreatheRite Spacer Small Child 152 AUGMENTED 113 BreatheRite/Large Mask 152 BETAMETHASONE VALERATE 113 BreatheRite/Medium Mask 153 Betaseron 90 BreatheRite/Small Mask 153 BETAXOLOL HCL 77 Breo Ellipta 174 BETAXOLOL HCL (OPHTH) 165 BREXUCABTAGENE AUTOLEUCEL 37 BETHANECHOL CHLORIDE 112 BRIGATINIB 35 Betimol 165 Brilinta 74 Betoptic-S 165 BRIMONIDINE TARTRATE 165 BEVACIZUMAB 44 BRINZOLAMIDE 165 BEXAROTENE 44 Bromfenac Sodium 165 BEXAROTENE (TOPICAL) 44 BROMFENAC SODIUM (OPHTH) 165 Bexsero 143 BROMOCRIPTINE MESYLATE 46 BICALUTAMIDE 34 BROMPHENIRAMINE TANNATE 168 Bicillin L-A 18 Brompheniramine Tannate 168 BICTEGRAVIR-EMTRICITABINE-TENOFOVIR Brukinsa 36 ALAFENAMIDE FUMARATE 53 BUDESONIDE 148 Biktarvy 53 BUDESONIDE (INHALATION) 167 BIMATOPROST 166 BUDESONIDE-FORMOTEROL FUMARATE BINIMETINIB 42 DIHYDRATE 174,176 BISOPROLOL & HYDROCHLOROTHIAZIDE 81 BUMETANIDE 84 BISOPROLOL FUMARATE 77 BUPRENORPHINE 7 Bivigam 138 BUPRENORPHINE HCL 13 Blenrep 44 BUPRENORPHINE HCL-NALOXONE HCL Boostrix 143 DIHYDRATE 13 BOSENTAN 172,173 BUPROPION HCL 25 Bosulif 39 BUROSUMAB-TWZA 96 BOSUTINIB 39 BUSPIRONE HCL 55 Botox 49 BUSULFAN 34

©2021 Wellmark, Inc. 184 BUTALBITAL-ACETAMINOPHEN 89,90 CAPTOPRIL & HYDROCHLOROTHIAZIDE 81 BUTALBITAL-ACETAMINOPHEN-CAFFEINE 89,90 Captopril-Hydrochlorothiazide 81 BUTALBITAL-ACETAMINOPHEN-CAFFEINE W/ Carbaglu 108 CODEINE 9 CARBAMAZEPINE 23,24 BUTALBITAL-ASPIRIN-CAFFEINE 5 Carbamazepine 24 BUTALBITAL-ASPIRIN-CAFFEINE W/COD 9 CARBIDOPA 47 BUTORPHANOL TARTRATE 9 CARBIDOPA-LEVODOPA 47 Bydureon 57 CARBIDOPA-LEVODOPA-ENTACAPONE 46 Bydureon BCise 57 CARBINOXAMINE MALEATE 168 Bylvay 178 CARGLUMIC ACID 108 Bylvay (Pellets) 178 Carimune NF 138 Bynfezia Pen 131 CARISOPRODOL 176,177 CARISOPRODOL W/ ASPIRIN 176 C CARISOPRODOL W/ ASPIRIN & CODEINE 9 C1 ESTERASE INHIBITOR (HUMAN) 133 CARTEOLOL HCL (OPHTH) 166 C1 ESTERASE INHIBITOR (RECOMBINANT) 133 CARVEDILOL 77 Cabenuva 53 CARVEDILOL PHOSPHATE 77 CABERGOLINE 131 CASCARA SAGRADA 106 Cablivi 66 Cascara Sagrada 106 Cabometyx 39 Cayston 170 CABOTEGRAVIR & RILPIVIRINE 53 CEFACLOR 16 CABOZANTINIB S-MALATE 39 CEFADROXIL 16 CAFFEINE CITRATE 171 CEFDINIR 16 CALCIPOTRIENE 93 CEFDITOREN PIVOXIL 16 CALCIPOTRIENE-BETAMETHASONE CEFEPIME HCL 16,17 DIPROPIONATE 93 CEFEPIME HCL-DEXTROSE 17 CALCITONIN (SALMON) 149 Cefepime-Dextrose 17 CALCITRIOL 149 CEFIXIME 17 CALCITRIOL (TOPICAL) 93 CEFPODOXIME PROXETIL 17 CALCIUM ACETATE (PHOSPHATE BINDER) 96,98 CEFPROZIL 17 Calquence 39 CEFTIBUTEN 17 CANAKINUMAB 142 CEFTRIAXONE SODIUM 17 CANDESARTAN CILEXETIL 75 CEFUROXIME AXETIL 17 CANDESARTAN CILEXETIL- CELECOXIB 5 HYDROCHLOROTHIAZIDE 81 CellCept 134 CANNABIDIOL 21 Celontin 22 CAPECITABINE 35 CENEGERMIN-BKBJ 163 CAPLACIZUMAB-YHDP 66 CEPHALEXIN 17 CAPMATINIB HCL 37 Cerdelga 108 Caprelsa 39 Cerezyme 108 CAPTOPRIL 76 CERITINIB 44

©2021 Wellmark, Inc. 185 Cesamet 29 CIPROFLOXACIN 19 CEVIMELINE HCL 92 CIPROFLOXACIN HCL 19 Chek-Stix Control 153 Ciprofloxacin-Ciproflox HCl ER 19 Chemet 97 CIPROFLOXACIN-CIPROFLOXACIN HCL 19 Chemstrip 10 MD 153 CIPROFLOXACIN-DEXAMETHASONE 166 Chemstrip 10/SG 153 CITALOPRAM HYDROBROMIDE 26 Chemstrip 2 GP 153 CLADRIBINE (MULTIPLE SCLEROSIS) 91 Chemstrip 5 OB 153 CLARITHROMYCIN 18 Chemstrip 7 153 CLEMASTINE FUMARATE 168 Chemstrip 9 153 Clemastine Fumarate 168 Chemstrip K 153 Cleocin Phosphate 14 Chemstrip uGK 153 Clever Choice Holding Chamber 153 Chenodal 105 CLINDAMYCIN HCL 14 CHENODIOL 105 CLINDAMYCIN PALMITATE HYDROCHLORIDE 14 CHLORAMBUCIL 34 CLINDAMYCIN PHOSPHATE 14 CHLORDIAZEPOXIDE HCL 56 CLINDAMYCIN PHOSPHATE (TOPICAL) 14 Chlordiazepoxide HCl-Clidinium Bromide 104 CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE CHLORDIAZEPOXIDE-AMITRIPTYLINE 25 (REFRIGERATE) 93,94 Chlordiazepoxide-Amitriptyline 25 CLINDAMYCIN PHOSPHATE-TRETINOIN 93 CHLORHEXIDINE GLUCONATE (MOUTH- Clinistix 153 THROAT) 92 CLOBAZAM 22 CHLOROQUINE PHOSPHATE 45 CLOBETASOL PROPIONATE 113,114 CHLOROTHIAZIDE 84 CLOBETASOL PROPIONATE EMOLLIENT BASE 113 CHLORPROMAZINE HCL 47 CLOBETASOL PROPIONATE EMULSION 113,117 CHLORPROPAMIDE 57 CLOCORTOLONE PIVALATE 113,114 ChlorproPAMIDE 57 CLOMIPRAMINE HCL 27 CHLORTHALIDONE 84 CLONAZEPAM 56 CHLORZOXAZONE 176 CLONIDINE 75 CHOLESTYRAMINE 85 CLONIDINE HCL 75 CHOLESTYRAMINE LIGHT 85,86 CLONIDINE HCL (ADHD) 88 CHOLINE & MAG SALICYLATE 5 CLOPIDOGREL BISULFATE 74 CHOLINE FENOFIBRATE 85 CLORAZEPATE DIPOTASSIUM 56 CICLOPIROX 29 CLOTRIMAZOLE 29 CICLOPIROX OLAMINE 29 CLOTRIMAZOLE W/ BETAMETHASONE 93 CILOSTAZOL 74 CLOZAPINE 49 Cimduo 52 cloZAPine 49 CIMETIDINE 106 Coagadex 70 CIMETIDINE HCL 106 COAGULATION FACTOR IX 69,72 CINACALCET HCL 149 COAGULATION FACTOR IX (RECOMB) FC FUSION Cinqair 174 PROTEIN (RFIXFC) 69 Cinryze 133

©2021 Wellmark, Inc. 186 COAGULATION FACTOR IX Cosentyx 93 (RECOMBINANT) 70,71,73 Cosentyx (300 MG Dose) 93 COAGULATION FACTOR IX (RECOMBINANT) Cosentyx Sensoready (300 MG) 93 GLYCOPEGYLATED 73 Cotellic 39 COAGULATION FACTOR IX RECOMB ALBUMIN Coumadin 64 FUSION PROTEIN (RIX-FP) 71 COVID-19 (SARS-COV-2) ADENOVIRUS COAGULATION FACTOR VIIA (RECOMBINANT) 72 VACCINE 145 COAGULATION FACTOR VIIA (RECOMBINANT)- COVID-19 (SARS-COV-2) MRNA VIRUS JNCW 74 VACCINE 146 COAGULATION FACTOR X (HUMAN) 70 Creon 108 COBICISTAT 54 Crixivan 54 COBIMETINIB FUMARATE 39 CRIZANLIZUMAB-TMCA 74 CODEINE SULFATE 9 CRIZOTINIB 43 COLCHICINE 31 CROMOLYN SODIUM 171 COLCHICINE W/ PROBENECID 31 CROMOLYN SODIUM (MASTOCYTOSIS) 105 COLESEVELAM HCL 86 CROMOLYN SODIUM (OPHTH) 164 COLESTIPOL HCL 86 CROSS-LINKED HYALURONATE 155 COLISTIMETHATE SODIUM 15 CROTAMITON 45 Coly-Mycin M 15 Crotan 45 Combistix 153 Crysvita 96 Combivent Respimat 174 Cutaquig 138 Cometriq (100 mg Daily Dose) 39 Cuvitru 138 Cometriq (140 mg Daily Dose) 39 CVS Ketone Care 154 Cometriq (60 mg Daily Dose) 39 CYANOCOBALAMIN 100 Compact Space Chamber 153 CYCLOBENZAPRINE HCL 176 Compact Space Chamber/Lg Mask 154 CYCLOPENTOLATE HCL 163 Compact Space Chamber/Med Mask 154 CYCLOPHOSPHAMIDE 33,178 Compact Space Chamber/Sm Mask 154 Cyclophosphamide 33,178 Complera 51 CYCLOSERINE 33 Complete Natal DHA 99 CYCLOSPORINE 134 CompleteNate 99 CYCLOSPORINE (OPHTH) 164 Concept OB 100 CYCLOSPORINE MODIFIED (FOR CONJUGATED ESTROGENS- MICROEMULSION) 134,135 MEDROXYPROGESTERONE ACETATE 126 CYPROHEPTADINE HCL 168 Contour Next Test 154 Cystadane 108 Contour Test 154 Cystadrops 163 Copaxone 90 Cystagon 108 Copiktra 39 Cystaran 163 COPPER (IUD) 160 CYSTEAMINE BITARTRATE 108,110 CORTICOTROPIN 113 CYSTEAMINE HCL 163 Cosela 178 Cytogam 139

©2021 Wellmark, Inc. 187 CYTOMEGALOVIRUS IMMUNE GLOBULIN DESIRUDIN 65 (HUMAN) 139 DESLORATADINE 168 Cytra K Crystals 112 Desloratadine 168 DESMOPRESSIN ACETATE 117 D DESMOPRESSIN ACETATE SPRAY 117 D-Penamine 112 DESMOPRESSIN ACETATE SPRAY DABRAFENIB MESYLATE 43 REFRIGERATED 117 DACOMITINIB 37 DESOGESTREL & ETHINYL DALFAMPRIDINE 90 ESTRADIOL 118,119,120,122,126 DALTEPARIN SODIUM 64 DESOGESTREL-ETHINYL ESTRADIOL DANAZOL 117 (BIPHASIC) 119,122,125,126,127,128 DANTROLENE SODIUM 49 DESOGESTREL-ETHINYL ESTRADIOL DAPAGLIFLOZIN PROPANEDIOL 57 (TRIPHASIC) 119,127 DAPAGLIFLOZIN-METFORMIN HCL 60 DESONIDE 114,115 DAPSONE 33 DESOXIMETASONE 114 DAPSONE (TOPICAL) 93 DESVENLAFAXINE 26 Daptacel 143 DESVENLAFAXINE SUCCINATE 26 Daraprim 45 DEUTETRABENAZINE 89 DARATUMUMAB-HYALURONIDASE-FIHJ 44 Dexamethasone 113 DARBEPOETIN ALFA 66 DEXAMETHASONE 114 DARIFENACIN HYDROBROMIDE 111 Dexamethasone Intensol 114 DAROLUTAMIDE 34 DEXAMETHASONE SODIUM PHOSPHATE 114 DARUNAVIR ETHANOLATE 54 Dexamethasone Sodium Phosphate 165 DARUNAVIR-COBICISTAT-EMTRICITABINE- DEXAMETHASONE SODIUM PHOSPHATE TENOFOVIR ALAFENAMIDE 51 (OPHTH) 165 Darzalex Faspro 44 DEXMETHYLPHENIDATE HCL 88 DASATINIB 43 DEXTRANOMER-SODIUM HYALURONATE 161 Daurismo 40 DEXTROAMPHETAMINE SULFATE 87 DEFERASIROX 97 Diacomit 21 DEFERIPRONE 97,98 Diastix 154 DEFLAZACORT 114 DIAZEPAM 56 DEGARELIX ACETATE 131 DIAZEPAM (ANTICONVULSANT) 22 DELAVIRDINE MESYLATE 52 DIAZOXIDE 60 Delestrogen 120 DICHLORPHENAMIDE 84 Delstrigo 52 DICLOFENAC EPOLAMINE 5 DEMECLOCYCLINE HCL 20 DICLOFENAC POTASSIUM 5 DENOSUMAB 150 DICLOFENAC SODIUM 5 Depo-Estradiol 120 DICLOFENAC SODIUM (OPHTH) 165 DEPO-Medrol 114 DICLOFENAC SODIUM (TOPICAL) 5,6 Descovy 53 DICLOFENAC W/ MISOPROSTOL 5 DESIPRAMINE HCL 28 DICLOXACILLIN SODIUM 18

©2021 Wellmark, Inc. 188 DICYCLOMINE HCL 104 DORZOLAMIDE HCL 166 DIDANOSINE 52 DORZOLAMIDE HCL-TIMOLOL MALEATE 166 DIFLUNISAL 5 DOSTARLIMAB-GXLY 179 DIGOXIN 81,82 Dovato 53 DIHYDROERGOTAMINE MESYLATE 31 DOXAZOSIN MESYLATE 75 DILTIAZEM HCL 78,79 DOXEPIN HCL 28 DILTIAZEM HCL COATED BEADS 78,79 DOXEPIN HCL (SLEEP) 177 DILTIAZEM HCL EXTENDED RELEASE BEADS 79,80 DOXERCALCIFEROL 149 DIMETHYL FUMARATE 90 DOXYCYCLINE (MONOHYDRATE) 20,21 Dipentum 148 DOXYCYCLINE HYCLATE 20,21 DIPH-AC PERT-TET TOX AD-POLIO IPV- DRONABINOL 29 HAEMOPHIL B POLY VAC 146 DROSPIRENONE-ETHINYL DIPH-TET TOX-ACELL PERT AD-POLIO IPV-HIB- ESTRADIOL 120,121,122,123,124,125,126,127,128 HEPATITIS B RECOMB 148 DROSPIRENONE-ETHINYL ESTRADIOL- DIPH-TETANUS TOX AD-ACELL PERTUSSIS & LEVOMEFOLATE CALCIUM 120,126,127 POLIO VIRUS, IPV VAC 145,147 DULOXETINE HCL 90 DIPH-TETANUS TOX-ACELL PERT-HEPATITIS B DUPILUMAB 94 RECOMB-POLIO IPV VAC 146 Dupixent 94 DIPHENHYDRAMINE HCL 168 Duraxin 154 DIPHENOXYLATE W/ ATROPINE 105 Durolane 94 Diphenoxylate-Atropine 105 Durysta 166 DIPHTHERIA, ACELLULAR PERTUSSIS & TETANUS DUTASTERIDE 111 TOXOIDS 143,145 DUTASTERIDE-TAMSULOSIN HCL 111 DIPHTHERIA-TETANUS TOXOIDS (DT) 143 DUVELISIB 39 Diphtheria-Tetanus Toxoids DT 143 DYPHYLLINE-GUAIFENESIN 174 DIPYRIDAMOLE 74 Dysport 176 DISOPYRAMIDE PHOSPHATE 76 DISULFIRAM 13 E DIVALPROEX SODIUM 22 EasiVent 154 DOFETILIDE 76 EasiVent Mask Large 154 Dojolvi 96 EasiVent Mask Medium 154 DOLASETRON MESYLATE 29 EasiVent Mask Small 154 DOLUTEGRAVIR SODIUM 51 ECALLANTIDE 133 DOLUTEGRAVIR SODIUM-LAMIVUDINE 53 ECONAZOLE NITRATE 29 DOLUTEGRAVIR SODIUM-RILPIVIRINE HCL 49 ECULIZUMAB 161 DONEPEZIL HYDROCHLORIDE 24 EDARAVONE 89 Doptelet 66 Edurant 52 DORAVIRINE 52 EFAVIRENZ 52 DORAVIRINE-LAMIVUDINE-TENOFOVIR EFAVIRENZ-EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE 52 DISOPROXIL FUMARATE 52 DORNASE ALFA 171

©2021 Wellmark, Inc. 189 EFAVIRENZ-LAMIVUDINE-TENOFOVIR ENASIDENIB MESYLATE 36 DISOPROXIL FUMARATE 54 Enbrel 134 Elaprase 109 Enbrel Mini 134 Elelyso 109 Enbrel SureClick 134 ELETRIPTAN HYDROBROMIDE 31 ENCORAFENIB 39 ELEXACAFTOR-TEZACAFTOR-IVACAFTOR 171 ENFUVIRTIDE 54 Eligard 131 Engerix-B 143,178 ELIGLUSTAT TARTRATE 108 ENOXAPARIN SODIUM 64 Eliquis 64 Enspryng 134 Eliquis DVT/PE Starter Pack 64 ENTACAPONE 46 Eloctate 70 ENTECAVIR 50 ELTROMBOPAG OLAMINE 67 ENTRECTINIB 36 ELVITEGRAVIR-COBICISTAT-EMTRICITABINE- Entresto 82 TENOFOVIR ALAFENAMIDE 51 Entyvio 134 ELVITEGRAVIR-COBICISTAT-EMTRICITABINE- Envarsus XR 134 TENOFOVIR DF 51 ENZALUTAMIDE 34,180 EMAPALUMAB-LZSG 135 Epclusa 50 Emcyt 35 Epidiolex 21 Emend 29 Epinastine HCl (Ophth) 164 Emflaza 114 EPINEPHRINE (ANAPHYLAXIS) 169,170 Emgality 32 Epinephrine HCl 170 Emgality (300 MG Dose) 32 EPINEPHRINE HCL (NASAL) 170 EMICIZUMAB-KXWH 70 EpiPen 2-Pak 170 EMPAGLIFLOZIN 58 EpiPen Jr 2-Pak 170 EMPAGLIFLOZIN-LINAGLIPTIN 58 EPLERENONE 84 EMPAGLIFLOZIN-LINAGLIPTIN-METFORMIN 59 EPOETIN ALFA 66,67 EMPAGLIFLOZIN-METFORMIN HCL 59 EPOETIN ALFA-EPBX 68 Empaveli 178 Epogen 66 EMTRICITABINE 53 EPOPROSTENOL SODIUM 172,173 EMTRICITABINE-RILPIVIRINE-TENOFOVIR EPROSARTAN MESYLATE 75 ALAFENAMIDE FUMARATE 52 Eprosartan Mesylate 75 EMTRICITABINE-RILPIVIRINE-TENOFOVIR EPTINEZUMAB-JJMR 33 DISOPROXIL FUMARATE 51 EQ Space Chamber Anti-Static 155 EMTRICITABINE-TENOFOVIR ALAFENAMIDE EQ Space Chamber Anti-Static L 155 FUMARATE 53 EQ Space Chamber Anti-Static M 155 EMTRICITABINE-TENOFOVIR DISOPROXIL EQ Space Chamber Anti-Static S 155 FUMARATE 53 ERDAFITINIB 35 Emtriva 53 ERENUMAB-AOOE 32 ENALAPRIL MALEATE 76 Ergocalciferol 149 ENALAPRIL MALEATE & ERGOCALCIFEROL 150 HYDROCHLOROTHIAZIDE 82 ERGOLOID MESYLATES 24

©2021 Wellmark, Inc. 190 Ergoloid Mesylates 24 Euflexxa 155 ERGOTAMINE W/ CAFFEINE 31 Evenity 149 Erivedge 40 EVEROLIMUS 39,40 Erleada 34 EVEROLIMUS (IMMUNOSUPPRESSANT) 134,138 ERLOTINIB HCL 40 EVINACUMAB-DGNB 179 Ery 19 Evkeeza 179 Erythrocin Stearate 19 Evrysdi 89 ERYTHROMYCIN (ACNE AID) 19 EXEMESTANE 38 Erythromycin (Ophth) 19 EXENATIDE 57 ERYTHROMYCIN BASE 19 EZETIMIBE 86 ERYTHROMYCIN ETHYLSUCCINATE 19 EZETIMIBE-SIMVASTATIN 86 ERYTHROMYCIN STEARATE 19 Esbriet 173,174 F ESCITALOPRAM OXALATE 26 Fabrazyme 109 ESOMEPRAZOLE MAGNESIUM 108 FACTOR IX COMPLEX 69,73 ESTAZOLAM 177 FAMCICLOVIR 55 ESTERIFIED ESTROGENS & FAMOTIDINE 106 METHYLTESTOSTERONE 119,120,121 Farxiga 57 ESTRADIOL 120,121,124 Farydak 40 ESTRADIOL & NORETHINDRONE Fasenra 175 ACETATE 118,121,124 Fasenra Pen 175 ESTRADIOL CYPIONATE 120 FEBUXOSTAT 31 ESTRADIOL VAGINAL 128 FEDRATINIB HCL 40 ESTRADIOL VALERATE 120,121 Feiba 70 ESTRAMUSTINE PHOSPHATE SODIUM 35 Feiba NF 70 ESTROGENS, CONJUGATED 126 FELBAMATE 23 ESTROPIPATE 121 FELODIPINE 79 Estropipate 121 FENOFIBRATE MICRONIZED 85 ESZOPICLONE 177 FENOPROFEN CALCIUM 5,6 ETANERCEPT 134 Fensolvi (6 Month) 131 ETHACRYNIC ACID 84 FENTANYL 7 ETHAMBUTOL HCL 33 FENTANYL CITRATE 10 ETHOSUXIMIDE 22 FERRIC DERISOMALTOSE 96 ETHOTOIN 24 Ferriprox 98 ETHYNODIOL DIACET & ETH ESTRAD 121,122,128 Ferriprox Twice-A-Day 98 ETIDRONATE DISODIUM 149 Fiasp 61 Etidronate Disodium 149 Fiasp FlexTouch 61 ETODOLAC 5 Fiasp PenFill 61 ETONOGESTREL-ETHINYL ESTRADIOL 120,121 FILGRASTIM-AAFI 67 ETOPOSIDE 38 FILGRASTIM-SNDZ 68 ETRAVIRINE 52 FINASTERIDE 111

©2021 Wellmark, Inc. 191 FINERENONE 179 Flurazepam HCl 177 FINGOLIMOD HCL 91 FLURBIPROFEN 5 Firmagon 131 FLURBIPROFEN SODIUM 165 Firmagon (240 MG Dose) 131 FLUTAMIDE 34 Firvanq 15 FLUTICASONE FUROATE-VILANTEROL 174 FLAVOXATE HCL 111 FLUTICASONE PROPIONATE 113,115 Flebogamma DIF 139 FLUTICASONE-SALMETEROL 174,175 FLECAINIDE ACETATE 76 FLUTICASONE-UMECLIDINIUM-VILANTEROL 168 Flexichamber 155 FLUVASTATIN SODIUM 85 Flexichamber Adult Mask/Small 155 Fluvirin 144 Flexichamber Child Mask/Large 155 FLUVOXAMINE MALEATE 26,27 Flexichamber Child Mask/Small 155 Fluzone High-Dose 144 Flolan 172 Fluzone High-Dose Quadrivalent 145 Fluad 143 Fluzone Quadrivalent 145 Fluad Quadrivalent 143 Folivane-OB 100 Fluarix Quadrivalent 144 FONDAPARINUX SODIUM 64 Flublok 144 FORA GTel Blood Ketone Test 155 Flublok Quadrivalent 144 FORMOTEROL FUMARATE 170 Flucelvax Quadrivalent 144 FOSAMPRENAVIR CALCIUM 54 FLUCONAZOLE 30 FOSDENOPTERIN HYDROBROMIDE 179 FLUCYTOSINE 30 FOSFOMYCIN TROMETHAMINE 15 FLUDROCORTISONE ACETATE 114 FOSINOPRIL SODIUM 76 Flulaval Quadrivalent 144 FOSINOPRIL SODIUM & FluMist 144 HYDROCHLOROTHIAZIDE 82 FluMist Quadrivalent 144 FOSTAMATINIB DISODIUM 68 Flunisolide 168 FOSTEMSAVIR TROMETHAMINE 54 FLUNISOLIDE (NASAL) 168 Fotivda 179 FLUOCINOLONE ACETONIDE 115 Fragmin 64 FLUOCINOLONE ACETONIDE (OTIC) 167 FREMANEZUMAB-VFRM 24,32 FLUOCINONIDE 115 FROVATRIPTAN SUCCINATE 31 FLUOCINONIDE EMULSIFIED BASE 115 Fulphila 66 FLUOROMETHOLONE (OPHTH) 165 FUROSEMIDE 84 Fluorouracil 35 Fuzeon 54 FLUOROURACIL (TOPICAL) 35,94 FLUOXETINE HCL 26 G FLUoxetine HCl 26 GABAPENTIN 22 Fluoxetine HCl (PMDD) 26 Galafold 109 FLUPHENAZINE HCL 47 GALANTAMINE HYDROBROMIDE 24,25 FluPHENAZine HCl 47 GALCANEZUMAB-GNLM 32 FLURANDRENOLIDE 115,116 GALSULFASE 109 FLURAZEPAM HCL 177 GamaSTAN 139

©2021 Wellmark, Inc. 192 Gamifant 135 GLUCOSE URINE TEST-(GLUCOSE OXIDASE) 154 Gammagard 139 GLYBURIDE 57 Gammagard S/D Less IgA 139 GLYBURIDE MICRONIZED 57 Gammaked 139 GLYBURIDE-METFORMIN 57 Gammaplex 140 GLYCEROL PHENYLBUTYRATE 110 Gamunex-C 140 GLYCOPYRROLATE 105 Gardasil 9 145 Glyxambi 58 GATIFLOXACIN (OPHTH) 19 Gojji Blood Ketone Test 156 Gattex 105 GOLIMUMAB 137 GaviLyte-C 107 GRANISETRON HCL 29 Gavreto 38 GRISEOFULVIN MICROSIZE 30 GEFITINIB 40 GRISEOFULVIN ULTRAMICROSIZE 30 Gel-One 155 GUANFACINE HCL 75 Gelsyn-3 155 GUANFACINE HCL (ADHD) 88 GEMFIBROZIL 85 Gvoke HypoPen 1-Pack 60 Gentak 14 Gvoke HypoPen 2-Pack 60 Gentamicin Sulfate 14 Gvoke PFS 60 GENTAMICIN SULFATE (OPHTH) 14 GenVisc 850 156 H Genvoya 51 Haegarda 133 Gilenya 91 HAEMOPHILUS B POLYSAC CONJ VAC 142,145,146 Gilotrif 40 HALOBETASOL PROPIONATE 115 GILTERITINIB FUMARATE 37 HALOPERIDOL 47 Givlaari 109 HALOPERIDOL LACTATE 47 GIVOSIRAN SODIUM 109 Harvoni 50 GLASDEGIB MALEATE 40 Havrix 145 GLATIRAMER ACETATE 90,91 Helixate FS 70 GLECAPREVIR-PIBRENTASVIR 50 Hema-Combistix 156 Gleostine 34 HemeNatal OB + DHA 100 GLIMEPIRIDE 57 Hemlibra 70 GLIPIZIDE 57 Hemofil M 70 GLIPIZIDE-METFORMIN HCL 57 Heparin Lock Flush 65 GlucaGen HypoKit 60 HEPARIN SODIUM (PORCINE) 65 GLUCAGON 60 Heparin Sodium (Porcine) 65 GLUCAGON (RDNA) 60 Heparin Sodium (Porcine) Lock Flush 65 Glucagon Emergency 60 HEPARIN SODIUM (PORCINE) LOCK FLUSH 65 GLUCAGON HCL 60 HEPATITIS A (INACTIVATED)-HEPATITIS B GLUCAGON HCL (RDNA) 60 (RECOMBINANT) VACCINES 148 GLUCOSE BLOOD 154,158 HEPATITIS A VACCINE 145,148 Glucose Blood 158 HEPATITIS B VACCINE (RECOMB) 143,147,178 Glucose Urine Test-(Glucose Oxidase) 153

©2021 Wellmark, Inc. 193 HEPATITIS B VACCINE RECOMBINANT HYDROCORTISONE ACETATE W/ ADJUVANTED 145 PRAMOXINE 94,115 Heplisav-B 145 HYDROCORTISONE BUTYRATE 115 Herceptin 44 HYDROCORTISONE BUTYRATE HYDROPHILIC Herzuma 44 LIPO BASE 115 Hetlioz 178 HYDROCORTISONE SOD SUCCINATE 116 Hetlioz LQ 179 HYDROCORTISONE VALERATE 115 Hexalen 34 HYDROCORTISONE W/ACETIC ACID 166,167 Hiberix 145 HYDROMORPHONE HCL 7,10 Hizentra 140 HYDROmorphone HCl 10 Homatropaire 163 HYDROXYCHLOROQUINE SULFATE 45 HOMATROPINE HBR 163 HYDROXYPROGESTERONE CAPROATE 128,129 HUMAN PAPILLOMAVIRUS (HPV) 9-VALENT HYDROXYUREA 35 RECOMBINANT VACCINE 145 HYDROXYZINE HCL 168 Humate-P 71 HYDROXYZINE PAMOATE 168 Humira 135 HYLAN 161 Humira Pediatric Crohns Start 135 Hymovis 156 Humira Pen 135 Hyophen 15 Humira Pen-CD/UC/HS Starter 135 HYOSCYAMINE SULFATE 104,105 Humira Pen-Pediatric UC Start 136 HyperRHO S/D 140 Humira Pen-Ps/UV/Adol HS Start 136 Hyqvia 140 Humira Pen-Psor/Uveit Starter 136 HumuLIN R U-500 (CONCENTRATED) 61 I HumuLIN R U-500 KwikPen 61 IBANDRONATE SODIUM 149 Hyalgan 156 Ibrance 40 HYALURONAN 156,157,159 IBRUTINIB 40 Hycamtin 38 IBUPROFEN 5 HYDRALAZINE HCL 86 ICATIBANT ACETATE 133 HYDROCHLOROTHIAZIDE 84 Iclusig 40 HYDROCODONE BITARTRATE 7 IDECABTAGENE VICLEUCEL 178 HYDROCODONE POLISTIREX- IDELALISIB 43 CHLORPHENIRAMINE POLISTIREX 175 Idelvion 71 HYDROCODONE W/ HOMATROPINE 175,176 IDHIFA 36 HYDROCODONE-ACETAMINOPHEN 10,11,12 IDURSULFASE 109 Hydrocodone-Acetaminophen 10 Ilaris 142 HYDROCODONE-IBUPROFEN 10,11,12 ILOPROST 173 HYDROCORTISONE 115 Ilumya 94 HYDROCORTISONE (INTRARECTAL) 148 IMATINIB MESYLATE 40 HYDROCORTISONE (RECTAL) 148,149 Imbruvica 40 HYDROCORTISONE (TOPICAL) 113 IMIGLUCERASE 108 HYDROCORTISONE ACETATE (RECTAL) 148,149 IMIPRAMINE HCL 28

©2021 Wellmark, Inc. 194 IMIQUIMOD 94 INFLUENZA VIRUS VACCINE SPLIT HIGH-DOSE IMMUNE GLOBULIN (HUMAN) IM 139 PRESERVATIVE FREE 144 IMMUNE GLOBULIN (HUMAN) IV 138,139,140,141 INFLUENZA VIRUS VACCINE SPLIT IMMUNE GLOBULIN (HUMAN) IV OR PRESERVATIVE FREE 143 SUBCUTANEOUS 139,140 INFLUENZA VIRUS VACCINE SPLIT IMMUNE GLOBULIN (HUMAN) QUADRIVALENT 143,144,145 SUBCUTANEOUS 138,140 INFLUENZA VIRUS VACCINE TISSUE-CULTURED IMMUNE GLOBULIN (HUMAN)-HIPP 138 SUBUNIT QUADRIVALENT 144 IMMUNE GLOBULIN (HUMAN)-HYALURONIDASE INFLUENZA VIRUS VACCINE TYPES A & B (HUMAN RECOMBINANT) 140 SURFACE ANTIGEN 144 IMMUNE GLOBULIN (HUMAN)-IFAS 141 INFLUENZA VIRUS VACCINE TYPES A & B IMMUNE GLOBULIN (HUMAN)-KLHW 141 SURFACE ANTIGEN ADJUVANT 143 IMMUNE GLOBULIN (HUMAN)-SLRA 138 Ingrezza 89 Inatal GT 100 Inlyta 40 INCOBOTULINUMTOXINA 177 INOTERSEN SODIUM 90 Increlex 117 Inrebic 40 INDAPAMIDE 84 InspiraChamber/Large 156 INDINAVIR SULFATE 54 InspiraChamber/Medium 156 Indocin 6 InspiraChamber/Mouthpiece 156 INDOMETHACIN 6 InspiraChamber/Small 156 INEBILIZUMAB-CDON 137 Inspirease 156 Infanrix 145 Insulin Asp Prot & Asp FlexPen 61 INFIGRATINIB PHOSPHATE 180 INSULIN ASPART 61,63 Inflectra 136 Insulin Aspart 61 INFLIXIMAB 137 INSULIN ASPART (WITH NIACINAMIDE) 61 INFLIXIMAB-ABDA 137 Insulin Aspart FlexPen 61 INFLIXIMAB-AXXQ 134 Insulin Aspart PenFill 61 INFLIXIMAB-DYYB 136 Insulin Aspart Prot & Aspart 61 INFLUENZA VIRUS VAC RECOMB INSULIN ASPART PROTAMINE & ASPART HEMAGGLUTININ (HA) QUADRIVALENT 144 (HUMAN) 61,63 INFLUENZA VIRUS VAC SPLIT HIGH-DOSE QUAD INSULIN DEGLUDEC 63 PRESERVATIVE FREE 145 INSULIN DETEMIR 61 INFLUENZA VIRUS VACC TYPES A & B SURF INSULIN GLARGINE 60 ANTIGEN ADJUVANT QUAD 143 INSULIN INFUSION DISPOSABLE PUMP 158 Influenza Virus Vaccine Live 144 INSULIN NPH (HUMAN) (ISOPHANE) 62 INFLUENZA VIRUS VACCINE LIVE INSULIN NPH ISOPHANE & REG (HUMAN) 62 QUADRIVALENT 144 INSULIN PEN NEEDLE 156 INFLUENZA VIRUS VACCINE RECOMBINANT INSULIN REGULAR (HUMAN) 61,62,63 HEMAGGLUTININ (HA) 144 INSULIN SYRINGE 156 Influenza Virus Vaccine Split 142 INSULIN SYRINGE NEEDLE 156 Intelence 52

©2021 Wellmark, Inc. 195 INTERFERON BETA-1A 92 Januvia 58 INTERFERON BETA-1B 90 Jardiance 58 INTERFERON GAMMA-1B 142 Jemperli 179 Invirase 54 Jivi 71 Ipol 145 Juluca 49 IPRATROPIUM BROMIDE (NASAL) 169 Juxtapid 86 IPRATROPIUM BROMIDE HFA 169 Jynarque 98 IPRATROPIUM-ALBUTEROL 174,175 Iprivask 65 K IRBESARTAN 75 Kalbitor 133 IRBESARTAN-HYDROCHLOROTHIAZIDE 82 Kalydeco 170,171 Iressa 40 Kanjinti 41 Isentress 51 Kerendia 179 Isentress HD 51 Keto-Diastix 157 ISOCARBOXAZID 26 KETOCONAZOLE 30 ISOMETHEPTENE-CAFFEINE- KETOCONAZOLE (TOPICAL) 30 ACETAMINOPHEN 156 KETONE BLOOD TEST 155,156,158,160 Isometheptene-Caffeine-APAP 156 Ketone Test 157 ISONIAZID 33 KETOPROFEN 6 Isoniazid 33 Ketoprofen ER 6 Isopto Atropine 163 KETOROLAC TROMETHAMINE 6 Isosorbide Dinitrate 86 KETOROLAC TROMETHAMINE (OPHTH) 165 ISOSORBIDE DINITRATE 86 Ketostix 157 Isosorbide Dinitrate ER 86 Keveyis 84 ISOSORBIDE MONONITRATE 86 Kimyrsa 15 ISOTRETINOIN 92,93,94,95 Kinrix 145 ISOXSUPRINE HCL 82 Kisqali (200 MG Dose) 41 ISRADIPINE 79 Kisqali (400 MG Dose) 41 ITRACONAZOLE 30 Kisqali (600 MG Dose) 41 IVACAFTOR 170,171 Kisqali Femara (400 MG Dose) 41 IVERMECTIN 45 Kisqali Femara (600 MG Dose) 41 IVERMECTIN (ROSACEA) 94 Kisqali Femara(200 MG Dose) 41 IVOSIDENIB 37 Kloxxado 13 IXAZOMIB CITRATE 36 Koate 71 Ixinity 71 Koate-DVI 71 Kogenate FS 71 J Kogenate FS Bio-Set 72 Jakafi 41 Korlym 115 Janssen COVID-19 Vaccine 145 Koselugo 41 Janumet 58 Kovaltry 72 Janumet XR 58 Kyleena 128

©2021 Wellmark, Inc. 196 Kynamro 86 LEUPROLIDE ACETATE & NORETHINDRONE ACETATE 131 L LEUPROLIDE ACETATE (3 MONTH) 131 LABETALOL HCL 77 LEUPROLIDE ACETATE (4 MONTH) 131 Labstix 157 LEUPROLIDE ACETATE (6 MONTH) 131 LACOSAMIDE 24 LEUPROLIDE ACETATE (CPP) 132 LACTULOSE 106,107 LEUPROLIDE ACETATE (CPP) (3 MONTH) 132 LACTULOSE (ENCEPHALOPATHY) 106,107 LEUPROLIDE ACETATE (CPP) (6 MONTH) 131 LAMIVUDINE 53 LEVALBUTEROL HCL 170 LAMIVUDINE (HBV) 50 LEVALBUTEROL TARTRATE 170 LAMIVUDINE-TENOFOVIR DISOPROXIL Levemir 61 FUMARATE 52,53 Levemir FlexTouch 61 LAMIVUDINE-ZIDOVUDINE 53 Levetiracetam 21 LAMOTRIGINE 23 LEVETIRACETAM 21 LANADELUMAB-FLYO 133 LEVOBUNOLOL HCL 166 LANCETS 157 LEVOCARNITINE (METABOLIC MODIFIERS) 96 LANREOTIDE ACETATE 132 LEVOFLOXACIN 19 LANSOPRAZOLE 108 LEVONORGESTREL & ETH LANTHANUM CARBONATE 98 ESTRADIOL 118,119,120,121,122,123,124,125,126,12 LAPATINIB DITOSYLATE 41 7 LARONIDASE 108 LEVONORGESTREL (IUD) 128,129 LAROTRECTINIB SULFATE 37 LEVONORGESTREL-ETH ESTRADIOL LATANOPROST 166 (TRIPHASIC) 120,123,124,127 LEDIPASVIR-SOFOSBUVIR 50 LEVONORGESTREL-ETHINYL ESTRADIOL (91- Ledipasvir-Sofosbuvir 50 DAY) 118,119,120,121,122,123,126 LEFLUNOMIDE 142 LEVONORGESTREL-ETHINYL ESTRADIOL Lemtrada 91 (CONTINUOUS) 118,120,123 LENALIDOMIDE 35 LEVORPHANOL TARTRATE 7 LENVATINIB MESYLATE 41,42 LEVOTHYROXINE SODIUM 129,130 Lenvima (10 MG Daily Dose) 41 LIDOCAINE 12,13 Lenvima (12 MG Daily Dose) 41 LIDOCAINE HCL 12 Lenvima (14 MG Daily Dose) 42 Lidocaine HCl 12 Lenvima (18 MG Daily Dose) 42 LIDOCAINE HCL (MOUTH-THROAT) 12,13 Lenvima (20 MG Daily Dose) 42 LIDOCAINE-HYDROCORTISONE ACETATE Lenvima (24 MG Daily Dose) 42 (RECTAL) 94 Lenvima (4 MG Daily Dose) 42 LIDOCAINE-PRILOCAINE 13 Lenvima (8 MG Daily Dose) 42 LIFITEGRAST 164 LETROZOLE 38 Liletta (52 MG) 128 LEUCOVORIN CALCIUM 36 LINACLOTIDE 106 Leukeran 34 LINDANE 45 LEUPROLIDE ACETATE 131 Lindane 45

©2021 Wellmark, Inc. 197 LINEZOLID 15 Lynparza 42 Linzess 106 Lysodren 36 LIOTHYRONINE SODIUM 130 LIRAGLUTIDE 59 M LISINOPRIL 76 M-M-R II 146 LISINOPRIL & HYDROCHLOROTHIAZIDE 82 MACITENTAN 172 LiteAire 157 MAFENIDE ACETATE 15 LITHIUM CARBONATE 56 Makena 129 Livalo 85 MALATHION 45 Lokelma 96 MAPROTILINE HCL 27 LOMITAPIDE MESYLATE 86 Maprotiline HCl 27 LOMUSTINE 34 MARAVIROC 54 LONAFARNIB 111 Margenza 179 LONCASTUXIMAB TESIRINE-LPYL 180 MARGETUXIMAB-CMKB 179 Lonsurf 36 Marplan 26 LOPINAVIR-RITONAVIR 54 Mask Vortex 157 LORAZEPAM 56 Mask Vortex/Child/Frog 157 Lorbrena 38 Mask Vortex/Toddler/Ladybug 157 LORLATINIB 38 Matulane 34 LOSARTAN POTASSIUM 75 Mavenclad (10 Tabs) 91 LOSARTAN POTASSIUM & Mavenclad (4 Tabs) 91 HYDROCHLOROTHIAZIDE 82 Mavenclad (5 Tabs) 91 LOTEPREDNOL ETABONATE 165 Mavenclad (6 Tabs) 91 LOVASTATIN 85 Mavenclad (7 Tabs) 91 LOXAPINE SUCCINATE 47 Mavenclad (8 Tabs) 91 LUBIPROSTONE 106 Mavenclad (9 Tabs) 91 LULICONAZOLE 30 Mavyret 50 LUMACAFTOR-IVACAFTOR 171 Maxipime 17 Lumakras 179 Mayzent 91 LUMASIRAN SODIUM 109 Mayzent Starter Pack 92 Lumigan 166 MEASLES, MUMPS & RUBELLA VIRUS Lumizyme 109 VACCINES 146 Lupaneta Pack 131 MEASLES-MUMPS-RUBELLA-VARICELLA VIRUS Lupron Depot (1-Month) 131 VACCINES 147 Lupron Depot (3-Month) 131 MECASERMIN 117 Lupron Depot (4-Month) 131 MECHLORETHAMINE HCL (TOPICAL) 34 Lupron Depot (6-Month) 131 MECLOFENAMATE SODIUM 6 Lupron Depot-Ped (1-Month) 132 Meclofenamate Sodium 6 Lupron Depot-Ped (3-Month) 132 MEDROXYPROGESTERONE ACETATE 129 LUSPATERCEPT-AAMT 67 MEFENAMIC ACID 6 LUSUTROMBOPAG 67 MEFLOQUINE HCL 45

©2021 Wellmark, Inc. 198 MEGESTROL ACETATE (APPETITE) 129 METHENAMINE-HYOSC-METHYLENE BLUE-SOD Mekinist 42 PHOS-PHENYL SAL 14,15,16 Mektovi 42 METHENAMINE-HYOSCAMINE-METHYLENE BLUE- MELOXICAM 6 SODIUM PHOSPHATE 15,16 MELPHALAN 34 METHIMAZOLE 133 MELPHALAN FLUFENAMIDE HCL 179 METHOCARBAMOL 176 MEMANTINE HCL 25 METHOTREXATE (ANTIRHEUMATIC) 136,137 Menactra 146 METHOTREXATE SODIUM 136 MENINGOCOCCAL (A,C,Y&W-135) METHOXSALEN RAPID 94 OLIGOSACCHARIDE CONJUGATE VAC 146 METHOXY POLYETHYLENE GLYCOL-EPOETIN Meningococcal (A,C,Y&W-135) Polysaccharide BETA 66 Conjugate Vaccine 146 METHSCOPOLAMINE BROMIDE 105 MENINGOCOCCAL (A,C,Y&W-135) METHSUXIMIDE 22 POLYSACCHARIDE CONJUGATE VACCINE 146 METHYCLOTHIAZIDE 84 MENINGOCOCCAL GROUP B VACCINE Methyclothiazide 84 (RECOMBINANT) 147 METHYLDOPA 75 MENINGOCOCCAL VAC GROUP B (RECOMBANT METHYLDOPA & HYDROCHLOROTHIAZIDE 82 OMV ADJUVANTED) 143 Methyldopa-Hydrochlorothiazide 82 MenQuadfi 146 METHYLERGONOVINE MALEATE 157 Menveo 146 METHYLPHENIDATE HCL 88,89 MEPERIDINE HCL 11 METHYLPREDNISOLONE 116 Meperidine HCl 11 METHYLPREDNISOLONE ACETATE 114 MEPOLIZUMAB 175 METHYLPREDNISOLONE SOD SUCC 116,117 MEPROBAMATE 55 METHYLTESTOSTERONE 117 MERCAPTOPURINE 35 METIPRANOLOL 166 MESALAMINE 148 Metipranolol 166 MESNA 45 METOCLOPRAMIDE HCL 28 Mesnex 45 METOLAZONE 84 METAPROTERENOL SULFATE 170 METOPROLOL & HYDROCHLOROTHIAZIDE 82 Metaproterenol Sulfate 170 METOPROLOL SUCCINATE 78 METAXALONE 176 METOPROLOL TARTRATE 78 METFORMIN HCL 58,59 METRONIDAZOLE 15 Metformin HCl 58 METRONIDAZOLE (TOPICAL) 94,95 METHADONE HCL 7 METRONIDAZOLE VAGINAL 16 Methadone HCl 7 METYROSINE 82 METHAMPHETAMINE HCL 87 MEXILETINE HCL 77 METHAZOLAMIDE 166 MICONAZOLE-ZINC OXIDE-WHITE PETROLATUM30 METHENAMINE HIPPURATE 15 MICRhoGAM Ultra-Filtered Plus 140 METHENAMINE MANDELATE 15 Microchamber 157 METHENAMINE-HYOSC-METHYLENE BLUE- Microspacer 157 BENZOIC ACID-PHENYL SAL 15,16 MIDODRINE HCL 75

©2021 Wellmark, Inc. 199 MIDOSTAURIN 36 Multistix 9 158 MIFEPRISTONE (HYPERGLYCEMIA) 115 Multistix 9 SG 158 MIGALASTAT HCL 109 MUPIROCIN 15 MIGLITOL 58 MUPIROCIN CALCIUM (TOPICAL) 15 MIGLUSTAT 109 MYCOPHENOLATE MOFETIL 134,136 MINOCYCLINE HCL 20,21 MYCOPHENOLATE SODIUM 136 MINOXIDIL 86 Myleran 34 MIPOMERSEN SODIUM 86 Mynatal 100 Mircera 66 Mynatal Advance 100 Mirena (52 MG) 129 Mynate 90 Plus 100 MIRTAZAPINE 25 Myobloc 177 MISOPROSTOL 107 MITOTANE 36 N MODAFINIL 178 NABILONE 29 Moderna COVID-19 Vaccine 146 NABUMETONE 6 MOEXIPRIL HCL 76 NADOLOL 78 MOEXIPRIL-HYDROCHLOROTHIAZIDE 82 NADOLOL & BENDROFLUMETHIAZIDE 82 MOMETASONE FUROATE 116 NAFTIFINE HCL 30 MOMETASONE FUROATE (INHALATION) 167 Naglazyme 109 MOMETASONE FUROATE (NASAL) 168 NALOXEGOL OXALATE 105 Monjuvi 44 NALOXONE HCL 13 Monoclate-P 72 NALTREXONE HCL 13 Monoferric 96 NAPROXEN 5,6 MONOMETHYL FUMARATE 90 NAPROXEN SODIUM 6 Mononine 72 NARATRIPTAN HCL 31 Monovisc 157 Narcan 13 MONTELUKAST SODIUM 169 NATALIZUMAB 92 MORPHINE SULFATE 8,11 Natalvit 100 Morphine Sulfate 11 NATEGLINIDE 58 Morphine Sulfate ER 8 Natpara 149 Movantik 105 NEFAZODONE HCL 27 MOXIFLOXACIN HCL 19 NELFINAVIR MESYLATE 55 MOXIFLOXACIN HCL (OPHTH) 19 NEOMYCIN SULFATE 14 Mozobil 66 NEOMYCIN-BACITRACIN ZN-POLYMYXIN 163 Mulpleta 67 NEOMYCIN-POLYMY-DEXAMETH 163 MULTIPLE URINE TESTS 153,156,157,158,162 Neomycin-Polymy-Dexameth 164 Multistix 157 NEOMYCIN-POLYMYXIN-GRAMICIDIN 163 Multistix 10 SG 157 Neomycin-Polymyxin-Gramicidin 163 Multistix 5 158 Neomycin-Polymyxin-HC 163 Multistix 7 158 NEOMYCIN-POLYMYXIN-HC (OPHTH) 163 Multistix 8 158 Neomycin-Polymyxin-HC (Otic) 167

©2021 Wellmark, Inc. 200 NERATINIB MALEATE 42 NORETHINDRONE ACETATE-ETHINYL Nerlynx 42 ESTRADIOL-FE 126,127 Neulasta 67 NORETHINDRONE-ETH ESTRADIOL Neulasta Onpro 67 (TRIPHASIC) 118,119,120,123,124,125 NEVIRAPINE 52 NORGESTIMATE-ETHINYL NexAVAR 42 ESTRADIOL 121,124,125,126,128 Nexviazyme 179 NORGESTIMATE-ETHINYL ESTRADIOL NIACIN (ANTIHYPERLIPIDEMIC) 86 (TRIPHASIC) 125,126,127 NICARDIPINE HCL 79 NORGESTREL & ETHINYL NIFEDIPINE 78,79,80 ESTRADIOL 119,120,124,125 Nifedipine 79 NORTRIPTYLINE HCL 28 NILOTINIB HCL 43 Norvir 54 NILUTAMIDE 34 Nova Max Plus Ketone Test 158 NIMODIPINE 80 Novoeight 72 Ninlaro 36 NovoLIN 70/30 62 NINTEDANIB ESYLATE 174 NovoLIN 70/30 FlexPen 62 NIRAPARIB TOSYLATE 38 NovoLIN 70/30 FlexPen Relion 62 NISOLDIPINE 80 NovoLIN 70/30 ReliOn 62 NITAZOXANIDE 45 NovoLIN N 62 NITISINONE 109 NovoLIN N FlexPen 62 Nitro-Time 87 NovoLIN N FlexPen ReliOn 62 NITROFURANTOIN 15 NovoLIN N ReliOn 62 NITROFURANTOIN MACROCRYSTAL 15 NovoLIN R 62 NITROFURANTOIN MONOHYD MACRO 15 NovoLIN R FlexPen 62 NITROGLYCERIN 87 NovoLIN R FlexPen ReliOn 62 Nivestym 67 NovoLIN R ReliOn 63 NIZATIDINE 106 NovoLOG 63 Norditropin FlexPro 117 NovoLOG 70/30 FlexPen ReliOn 63 NORELGESTROMIN-ETHINYL ESTRADIOL 128 NovoLOG FlexPen 63 NORETHIN ACET & ESTRAD- NovoLOG FlexPen ReliOn 63 FE 118,119,121,122,123,124,125,126 NovoLOG Mix 70/30 63 NORETHINDRONE & ETH NovoLOG Mix 70/30 FlexPen 63 ESTRADIOL 118,119,121,124,125,128 NovoLOG Mix 70/30 ReliOn 63 NORETHINDRONE & ETHINYL ESTRADIOL- NovoLOG PenFill 63 FE 122,123,125,128 NovoLOG ReliOn 63 NORETHINDRONE (CONTRACEPTIVE) 128,129 NovoSeven RT 72 NORETHINDRONE ACET & ETH Nplate 67 ESTRA 118,121,122,123,124,125 Nubeqa 34 NORETHINDRONE ACETATE 129 Nucala 175 NORETHINDRONE ACETATE-ETHINYL Nulibry 179 ESTRADIOL 121,122,125 Nuwiq 73

©2021 Wellmark, Inc. 201 NYSTATIN 29,30 OneTouch Ultra 158 NYSTATIN (TOPICAL) 30 OneTouch Verio 158 NYSTATIN-TRIAMCINOLONE 30 Onureg 36 Nyvepria 67 OPIUM TINCTURE 106 Opsumit 172 O OptiChamber Advantage 158 O-Cal Prenatal 100 OptiChamber Advantage-Lg Mask 158 OBETICHOLIC ACID 109 OptiChamber Advantage-Med Mask 158 Obizur 73 OptiChamber Advantage-Sm Mask 158 Obstetrix DHA 100 OptiChamber Diamond 159 Obstetrix EC 100 OptiChamber Diamond-Lg Mask 159 Ocaliva 109 OptiChamber Diamond-Md Mask 159 OCRELIZUMAB 92 OptiChamber Diamond-Sm Mask 159 Ocrevus 92 OptiChamber Face Mask-Large 159 Octagam 141 OptiChamber Face Mask-Medium 159 OCTREOTIDE ACETATE 131,132 OptiChamber Face Mask-Small 159 Odefsey 52 OptiHaler 159 ODEVIXIBAT 178 Orencia 136 Odomzo 42 Orenitram 172 Ofev 174 Orfadin 109 OFLOXACIN 20 Orgovyx 132 Ogestrel 125 ORITAVANCIN DIPHOSPHATE 15 Ogivri 42 Orkambi 171 OLANZAPINE 48 Orladeyo 133 OLANZAPINE-FLUOXETINE HCL 26 ORPHENADRINE CITRATE 177 OLAPARIB 42 OrthoVisc 159 OLMESARTAN MEDOXOMIL 75 OSELTAMIVIR PHOSPHATE 55 OLMESARTAN MEDOXOMIL-AMLODIPINE- OSIMERTINIB MESYLATE 43 HYDROCHLOROTHIAZIDE 83 OsmoPrep 107 OLMESARTAN MEDOXOMIL- Otezla 142 HYDROCHLOROTHIAZIDE 82 Otrexup 136 OLOPATADINE HCL (NASAL) 169 OXANDROLONE 117 OLSALAZINE SODIUM 148 OXAPROZIN 6 OMACETAXINE MEPESUCCINATE 37 OXAZEPAM 56 OMALIZUMAB 176 OXCARBAZEPINE 24 OMEPRAZOLE 108 Oxervate 163 OmniPod Dash 5 Pack Pods 158 Oxlumo 109 ONABOTULINUMTOXINA 49 OXYBUTYNIN CHLORIDE 111 Ondansetron 29 OXYCODONE HCL 8,11 ONDANSETRON HCL 29 OxyCODONE HCl ER 8 OneTouch Test 158 OXYCODONE W/ ACETAMINOPHEN 9,10,11,12

©2021 Wellmark, Inc. 202 Oxycodone-Acetaminophen 11 PEG 3350-KCL-NACL-NA SULFATE-NA OXYCODONE-ASPIRIN 12 ASCORBATE-ASCORBIC ACID 107 OXYCODONE-IBUPROFEN 12 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD Oxycodone-Ibuprofen 12 SULFATE 107 OxyCONTIN 8 PEG 3350-POTASSIUM CHLORIDE-SOD OXYMETHOLONE 117 BICARBONATE-SOD CHLORIDE 107 OXYMORPHONE HCL 8,12 PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod OxyMORphone HCl ER 8 Chloride 107 Ozempic (0.25 or 0.5 MG/DOSE) 58 Peg-Intron Redipen 50 Ozempic (1 MG/DOSE) 58 Peganone 24 Pegasys 50 P Pegasys ProClick 51 PALBOCICLIB 40 PEGCETACOPLAN 178 PALIPERIDONE 48 PEGFILGRASTIM 67 PALIVIZUMAB 142 PEGFILGRASTIM-APGF 67 Palynziq 109 PEGFILGRASTIM-BMEZ 68 Pancreaze 110 PEGFILGRASTIM-CBQV 68 PANCRELIPASE (LIPASE-PROTEASE- PEGFILGRASTIM-JMDB 66 AMYLASE) 108,110,111 PEGINTERFERON ALFA-2A 50,51 Panda Mask Large 159 PEGINTERFERON ALFA-2B 50,51 Panda Mask Medium 159 PEGINTERFERON ALFA-2B (ANTINEOPLASTIC) 37 Panda Mask Small 160 PegIntron 51 PANOBINOSTAT LACTATE 40 PEGVALIASE-PQPZ 109 PANTOPRAZOLE SODIUM 108 PEGVISOMANT 132 Panzyga 141 Pemazyre 36 Paragard Intrauterine Copper 160 PEMIGATINIB 36 PARATHYROID HORMONE (RECOMBINANT) 149 PENICILLAMINE 112 PAREGORIC 106 PENICILLIN G BENZATHINE 18 Paregoric 106 PENICILLIN V POTASSIUM 18 PARICALCITOL 149 Pentacel 146 PAROMOMYCIN SULFATE 14 PENTAMIDINE ISETHIONATE 45 PAROXETINE HCL 27 PENTAZOCINE W/ NALOXONE 12 Paroxetine HCl 27 PENTOXIFYLLINE 83 PAROXETINE MESYLATE (VASOMOTOR) 27 Pepaxto 179 Paser 33 PERINDOPRIL ERBUMINE 76 PASIREOTIDE DIASPARTATE 132 Permethrin 45 PATIROMER SORBITEX CALCIUM 99 PERMETHRIN 45 PAZOPANIB HCL 43 PERPHENAZINE 28 Pediarix 146 PERPHENAZINE-AMITRIPTYLINE 26 Pediatric Panda Mask 160 Perphenazine-Amitriptyline 26 Pedvax HIB 146

©2021 Wellmark, Inc. 203 PERTUZUMAB-TRASTUZUMAB-HYALURONIDASE- PNV Prenatal Plus Multivit+DHA 101 ZZXF 36 PNV Tabs 29-1 101 Pertzye 110 PNV-VP-U 101 PEXIDARTINIB HCL 37 Pocket Chamber 160 Pfizer-BioNTech COVID-19 Vacc 146 Podocon 95 PHENAZOPYRIDINE HCL 112 PODOFILOX 95 PHENELZINE SULFATE 26 PODOPHYLLUM RESIN 95 PHENOBARBITAL 22 POLATUZUMAB VEDOTIN-PIIQ 44 PHENOXYBENZAMINE HCL 75 POLIOVIRUS VACCINE, IPV 145 PHENYLEPHRINE HCL (MYDRIATIC) 163 Polivy 44 PHENYLEPHRINE HCL (OPHTH) 162 POLYMYXIN B-TRIMETHOPRIM 164 PHENYLEPHRINE W/ DM-GG 175 POMALIDOMIDE 34 Phenylephrine-Guaifenesin 175 Pomalyst 34 PHENYTOIN 24 PONATINIB HCL 40 PHENYTOIN SODIUM EXTENDED 24 POSACONAZOLE 30 Phesgo 36 POT & SOD CITRATES W/CITRIC AC 112,113 PHYTONADIONE 75 Pot Bicarb-Pot Chloride 96 Pifeltro 52 POT PHOSPHATE MONOBASIC W/ SOD PILOCARPINE HCL 166 PHOSPHATE DIBASIC & MONOBASIC 98,99 PILOCARPINE HCL (ORAL) 92 POTASSIUM BICARB & CHLORIDE 96 PIMECROLIMUS 94 POTASSIUM CHLORIDE 96,97 PIMOZIDE 48 POTASSIUM CHLORIDE MICROENCAPSULATED Pimozide 48 CRYSTALS ER 96,97 PINDOLOL 78 POTASSIUM CITRATE (ALKALINIZER) 112 PIOGLITAZONE HCL 58 POTASSIUM CITRATE-CITRIC ACID 112,113 PIOGLITAZONE HCL-GLIMEPIRIDE 58 PR Natal 400 101 PIOGLITAZONE HCL-METFORMIN HCL 58 PR Natal 400 ec 101 Piqray (200 MG Daily Dose) 38 PR Natal 430 101 Piqray (250 MG Daily Dose) 38 PR Natal 430 ec 101 Piqray (300 MG Daily Dose) 39 PRALSETINIB 38 PIRFENIDONE 173,174 PRAMIPEXOLE DIHYDROCHLORIDE 46 PIROXICAM 6 PRAMLINTIDE ACETATE 59 PITAVASTATIN CALCIUM 85 Pramosone 116 PITAVASTATIN MAGNESIUM 85 PRAMOXINE-HC 115,116 PLERIXAFOR 66 PRASUGREL HCL 74 PNEUMOCOCCAL 13-VALENT CONJUGATE PRAVASTATIN SODIUM 85 VACCINE 146 PRAZIQUANTEL 45 PNEUMOCOCCAL 20-VALENT CONJUGATE PRAZOSIN HCL 75 VACCINE 179 Precision Xtra Ketone 160 PNEUMOCOCCAL VAC POLYVALENT 146 PREDNICARBATE 116 Pneumovax 23 146 Prednicarbate 116

©2021 Wellmark, Inc. 204 PREDNISOLONE 116 PRENATAL VIT W/ IRON CARBONYL-FOLIC PREDNISOLONE ACETATE (OPHTH) 165 ACID 101,102,103,104 PREDNISOLONE SODIUM PHOSPHATE 116 PRENATAL VIT W/ SELENIUM-FE FUMARATE- PrednisoLONE Sodium Phosphate 165 FOLIC ACID 104 PREDNISOLONE SODIUM PHOSPHATE PRENATAL W/ CALCIUM CARBONATE-VIT B6-VIT (OPHTH) 165 B12-FOLIC ACID 99 PREDNISONE 114,116 PRENATAL W/ CALCIUM-VIT B6-FOLIC ACID- PredniSONE Intensol 116 GINGER 101,104 PREGABALIN 90 PRENATAL W/FE CARBONYL-FA-DSS-OMEGA 3 PREGABALIN (ONCE-DAILY) 22 FATTY ACIDS 100 Premarin 126 PRENATAL WITHOUT A VIT W/ FE FUM-IRON Premphase 126 POLYSACCH COMPLEX -FA 100,102,103 Prempro 126 Prenatal without A Vit w/ Fe Fumarate-Folic Prenaissance Next 101 Acid 99,103 PreNata 101 PRENATAL WITHOUT A VIT W/ FE FUMARATE- Prenatabs FA 101 FOLIC ACID 101,102 Prenatabs Rx 102 PRENATAL WITHOUT VIT A W/ IRON CARBONYL- Prenatal 19 102 FOLIC ACID & VIT B6 102 PRENATAL MV & MIN W/FE BISGLYC-FE PROT Prenatal-U 102 SUCC-FA-CA-OMEGA 3 99,101,103 PreTAB 102 Prenatal Plus Iron 102 Prevnar 13 146 PRENATAL VIT W/ DOCUSATE-FE FUMARATE- Prevnar 20 179 FOLIC ACID 100,102 Prezista 54 PRENATAL VIT W/ DOCUSATE-IRON CARBONYL- PRIMAQUINE PHOSPHATE 45 FOLIC ACID 99,100,103,104 PRIMIDONE 22 Prenatal Vit w/ Docusate-Iron Carbonyl-Folic Acid 100 Privigen 141 PRENATAL VIT W/ FE BISGLYCINATE CHELATE- Pro Comfort Spacer Adult 160 FOLIC ACID 99 Pro Comfort Spacer Child 160 Prenatal Vit w/ Fe Bisglycinate Chelate-Folic Pro Comfort Spacer Infant 160 Acid 103,104 PROBENECID 31 PRENATAL VIT W/ FE POLY CMPLX-FE HEME PROCARBAZINE HCL 34 POLYPEPT-FA & OMEGA 3 100,104 Procare Spacer/Adult Mask 160 PRENATAL VIT W/ FERROUS FUMARATE-FA- Procare Spacer/Child Mask 160 OMEGA 3 FATTY ACIDS 101 PROCHLORPERAZINE 28 PRENATAL VIT W/ FERROUS FUMARATE-FOLIC PROCHLORPERAZINE MALEATE 28 ACID 99,100,101,102,103,104 Procrit 67 PRENATAL VIT W/ FERROUS FUMARATE-L Procysbi 110 METHYLFOLATE-FOLIC ACID 103 Profilnine 73 PRENATAL VIT W/ IRON CARBONYL-FE Profilnine SD 73 GLUCONATE-FOLIC ACID 103 PROGESTERONE 129 Prolia 150

©2021 Wellmark, Inc. 205 Promacta 67 PROMETHAZINE & PHENYLEPHRINE 175 R PROMETHAZINE HCL 28,29,169 RA Alcohol Swabs 160 PROMETHAZINE W/CODEINE 175 RABEPRAZOLE SODIUM 108 PROMETHAZINE-DM 175 Radicava 89 PROMETHAZINE-PHENYLEPHRINE-CODEINE 175 RALOXIFENE HCL 129 Promethegan 29 RALTEGRAVIR POTASSIUM 51 PROPAFENONE HCL 77 RAMELTEON 178 PROPANTHELINE BROMIDE 105 RAMIPRIL 76 Propantheline Bromide 105 RANITIDINE HCL 106 PROPARACAINE HCL 164 RANOLAZINE 83 PROPRANOLOL & HYDROCHLOROTHIAZIDE 83 RASAGILINE MESYLATE 47 PROPRANOLOL HCL 78 Rasuvo 137 Propranolol-HCTZ 83 Ravicti 110 PROPYLTHIOURACIL 133 RAVULIZUMAB-CWVZ 162 ProQuad 147 Rebif 92 PROTRIPTYLINE HCL 28 Rebif Rebidose 92 Provida OB 102 Rebif Rebidose Titration Pack 92 PSEUDOEPHED-BROMPHEN-DM 174,175 Rebif Titration Pack 92 PSEUDOEPHED-CPM W/ HYDROCOD 176 Rebinyn 73 PTS Panels Ketone Test 160 Reblozyl 67 Pulmozyme 171 Reclast 150 PureFe OB Plus 102 Recombinate 73 PYRAZINAMIDE 33 Recombivax HB 147 PYRIDOSTIGMINE BROMIDE 33 RediTrex 137 PYRIMETHAMINE 45 REGORAFENIB 43 Relenza Diskhaler 55 Q ReliOn Ketone 161 Qinlock 36 ReliOn Ketone Test 161 Quadracel 147 RELUGOLIX 132 QUETIAPINE FUMARATE 48 Remicade 137 Quinapril HCl 76 Remodulin 172 QUINAPRIL-HYDROCHLOROTHIAZIDE 83 Renflexis 137 QUINIDINE GLUCONATE 77 REPAGLINIDE 58 QUINIDINE SULFATE 77 REPAGLINIDE-METFORMIN HCL 59 QuiNIDine Sulfate 77 Repaglinide-Metformin HCl 59 QUININE SULFATE 45 Rescriptor 52 Qvar 168 RESLIZUMAB 174 Qvar RediHaler 168 Restasis 164 Restasis Multidose 164 Retacrit 68

©2021 Wellmark, Inc. 206 Retevmo 36 ROSUVASTATIN CALCIUM 85 Revatio 172 Rotarix 147 Revlimid 35 RotaTeq 147 Rezurock 179 ROTAVIRUS VACCINE, LIVE ORAL 147 RHO D IMMUNE GLOBULIN (HUMAN) 140,141 ROTAVIRUS VACCINE, LIVE ORAL RhoGAM Ultra-Filtered Plus 141 PENTAVALENT 147 Rhophylac 141 Rozlytrek 36 Riabni 44 Rubraca 36 RIBAVIRIN (HEPATITIS C) 50,51 RUCAPARIB CAMSYLATE 36 RIBOCICLIB SUCCINATE 41 Ruconest 133 RIBOCICLIB SUCCINATE-LETROZOLE 41 RUFINAMIDE 24 Ridaura 142 Rukobia 54 RIFABUTIN 33 RUXOLITINIB PHOSPHATE 41 RIFAMPIN 33 Ruzurgi 33 RIFAXIMIN 16 Rybelsus 59 RILONACEPT 142 Rybrevant 179 RILPIVIRINE HCL 52 Rydapt 36 RILUZOLE 89 Rylaze 179 RIMABOTULINUMTOXINB 177 RiMANTAdine HCl 55 S RIMANTADINE HYDROCHLORIDE 55 SACROSIDASE 110 Rinvoq 137 SACUBITRIL-VALSARTAN 82 RIOCIGUAT 172 SALMETEROL XINAFOATE 170 Riomet ER 59 SALSALATE 6 RIPRETINIB 36 Samsca 98 RISANKIZUMAB-RZAA 95,180 SandoSTATIN LAR Depot 132 RISDIPLAM 89 Saphnelo 180 RISEDRONATE SODIUM 150 SAPROPTERIN DIHYDROCHLORIDE 110 RISPERIDONE 48,49 SAQUINAVIR MESYLATE 54 RiteFlo 161 SATRALIZUMAB-MWGE 134 RITONAVIR 54 Scenesse 95 RITUXIMAB-ARRX 44 SCOPOLAMINE 29 RIVAROXABAN 65 Se-Natal 19 102 RIVASTIGMINE 25 SECUKINUMAB 93 RIVASTIGMINE TARTRATE 25 SELEGILINE HCL 47 Rixubis 73 SELENIUM SULFIDE 95 RIZATRIPTAN BENZOATE 31 SELEXIPAG 173,180 ROMIPLOSTIM 67 SELINEXOR 37,38 ROMOSOZUMAB-AQQG 149 SELPERCATINIB 36 ROPINIROLE HYDROCHLORIDE 46,47 SELUMETINIB SULFATE 41 ROSIGLITAZONE MALEATE-METFORMIN HCL 57 Selzentry 54

©2021 Wellmark, Inc. 207 SEMAGLUTIDE 58,59 SOFOSBUVIR-VELPATASVIR 50 SERDEXMETHYLPHENIDATE CHLORIDE- Sofosbuvir-Velpatasvir 50 DEXMETHYLPHENIDATE HCL 178 SOFOSBUVIR-VELPATASVIR-VOXILAPREVIR 50 Serevent Diskus 170 Solesta 161 SERTRALINE HCL 27 SOLIFENACIN SUCCINATE 111 SEVELAMER CARBONATE 99 Soliris 161 SEVELAMER HCL 99 Solodyn 21 Sevenfact 74 Soltamox 35 Shingrix 147 Solu-CORTEF 116 Signifor 132 SOLU-medrol 117 SILDENAFIL CITRATE 112 SOMATROPIN 117 SILDENAFIL CITRATE (PULMONARY Somatuline Depot 132 HYPERTENSION) 172,173 Somavert 132 SILODOSIN 112 SONIDEGIB PHOSPHATE 42 SILVER SULFADIAZINE 20 SORAFENIB TOSYLATE 42 Simponi Aria 137 SOTALOL HCL 77 SIMVASTATIN 85 SOTALOL HCL (AFIB/AFL) 77 SIPONIMOD FUMARATE 91,92 SOTORASIB 179 SIROLIMUS 137 SPACER/AEROSOL-HOLDING CHAMBER SITAGLIPTIN PHOSPHATE 58 SUPPLIES - MASKS 155,157,159,160 SITAGLIPTIN-METFORMIN HCL 58 SPACER/AEROSOL-HOLDING Skyla 129 CHAMBERS 150,151,152,153,154,155,156,157,158,15 Skyrizi 180 9,160,161,162 Skyrizi (150 MG Dose) 95 Spacer/Aerosol-Holding Chambers 156,158 SM Alcohol Prep 161 Spiriva HandiHaler 169 Sodium Bicarbonate 97 Spiriva Respimat 169 SODIUM CHLORIDE 97 SPIRONOLACTONE 84 SODIUM CHLORIDE (INHALANT) 175,176 SPIRONOLACTONE & HYDROCHLOROTHIAZIDE 83 SODIUM CHLORIDE FLUSH 96,97 Sprycel 43 SODIUM CITRATE & CITRIC ACID 112,113 SPS 98 Sodium Hyaluronate 161 STAVUDINE 53 SODIUM HYALURONATE Stelara 95 (VISCOSUPPLEMENT) 94,155,156,161,162 Stiolto Respimat 176 SODIUM OXYBATE 178 STIRIPENTOL 21 SODIUM PHENYLBUTYRATE 110 Stivarga 43 SODIUM PHOSPHATE MONOBASIC-SODIUM Strensiq 110 PHOSPHATE DIBASIC 107 Stribild 51 SODIUM POLYSTYRENE SULFONATE 98 SUCCIMER 97 SODIUM SULFATE-POTASSIUM SULFATE- Sucraid 110 MAGNESIUM SULFATE 107 SUCRALFATE 107 SODIUM ZIRCONIUM CYCLOSILICATE 96 SULCONAZOLE NITRATE 30

©2021 Wellmark, Inc. 208 SULFACETAMIDE SOD-PREDNISOLONE 164 TAFASITAMAB-CXIX 44 SULFACETAMIDE SODIUM (ACNE) 20 Tafinlar 43 SULFACETAMIDE SODIUM (OPHTH) 20 Tagrisso 43 SULFACETAMIDE SODIUM-SULFUR IN UREA Takhzyro 133 VEHICLE 95 TALAZOPARIB TOSYLATE 43 Sulfacetamide-Sulfur in Urea 95 TALIGLUCERASE ALFA 109 SULFADIAZINE 20 Talzenna 43 SulfADIAZINE 20 TAMOXIFEN CITRATE 35 SULFAMETHOXAZOLE-TRIMETHOPRIM 20 TAMSULOSIN HCL 112 SULFASALAZINE 149 Targretin 44 SULINDAC 6 Taron-Bc 102 SUMATRIPTAN 32 Tasigna 43 SUMATRIPTAN SUCCINATE 32 TASIMELTEON 178,179 SUMATRIPTAN-NAPROXEN SODIUM 32 Tavalisse 68 SUNITINIB MALATE 43 TAZAROTENE 95 Supartz FX 161 TAZEMETOSTAT HBR 37 Suprep Bowel Prep Kit 107 Tazverik 37 Sylatron 37 TDVAX 147 Symbicort 176 Tecartus 37 Symdeko 171 TEDUGLUTIDE (RDNA) 105 Symjepi 170 Tegsedi 90 SymlinPen 120 59 TELMISARTAN 76 SymlinPen 60 59 TELMISARTAN-AMLODIPINE 83 Symtuza 51 TELMISARTAN-HYDROCHLOROTHIAZIDE 83 Synagis 142 TEMAZEPAM 177 Synjardy 59 Temixys 53 Synjardy XR 59 TEMOZOLOMIDE 34 Synribo 37 Tencon 90 Synthroid 130 Tenivac 147 Synvisc 161 TENOFOVIR ALAFENAMIDE FUMARATE 50 Synvisc One 161 TENOFOVIR DISOPROXIL FUMARATE 53 Tepezza 164 T Tepmetko 180 Tabloid 35 TEPOTINIB HCL 180 Tabrecta 37 TEPROTUMUMAB-TRBW 164 TACROLIMUS 134,137 TERAZOSIN HCL 75 TACROLIMUS (TOPICAL) 95 TERBINAFINE HCL 30 TADALAFIL 112 TERBUTALINE SULFATE 170 TADALAFIL (PULMONARY HYPERTENSION)172,173 TERCONAZOLE VAGINAL 31 TAFAMIDIS 83 TERIFLUNOMIDE 90 TAFAMIDIS MEGLUMINE (CARDIAC) 83 TERIPARATIDE (RECOMBINANT) 150

©2021 Wellmark, Inc. 209 Teriparatide (Recombinant) 150 TOBRAMYCIN 171 TESTOSTERONE 118 TOBRAMYCIN (OPHTH) 14 TESTOSTERONE CYPIONATE 118 TOBRAMYCIN SULFATE 14 TESTOSTERONE ENANTHATE 118 TOBRAMYCIN-DEXAMETHASONE 164 TETANUS TOXOID-DIPHTHERIA-ACELLULAR TOCILIZUMAB 142 PERTUSSIS ADSORB (TDAP) 142,143 TOFACITINIB CITRATE 138,180 TETANUS-DIPHTHERIA TOXOIDS (TD) 147 TOLAZAMIDE 59 Tetanus-Diphtheria Toxoids Td 147 TOLAZamide 59 TETRABENAZINE 90 TOLBUTAMIDE 59 TETRACAINE HCL (OPHTH) 162,164 TOLBUTamide 59 TETRACYCLINE HCL 21 TOLCAPONE 46 TEZACAFTOR-IVACAFTOR 171 TOLMETIN SODIUM 6 THALIDOMIDE 35 Tolmetin Sodium 6 Thalomid 35 TOLTERODINE TARTRATE 111 THEOPHYLLINE 171,172 TOLVAPTAN 98 THIOGUANINE 35 TOPIRAMATE 23 Thiola EC 112 TOPOTECAN HCL 38 THIORIDAZINE HCL 48 TOREMIFENE CITRATE 35 THIOTHIXENE 48 TORSEMIDE 84 Thrivite Rx 102 Tracleer 173 Thyrogen 161 TRAMADOL HCL 9,12 THYROID 130 TRAMADOL-ACETAMINOPHEN 12 THYROTROPIN ALFA 161 TRAMETINIB DIMETHYL SULFOXIDE 42 TIAGABINE HCL 22 Trandolapril 76 Tibsovo 37 TRANDOLAPRIL-VERAPAMIL HCL 83 TICAGRELOR 74 TRANEXAMIC ACID 74 TILDRAKIZUMAB-ASMN 94 TRANYLCYPROMINE SULFATE 26 TIMOLOL 165 TRASTUZUMAB 44 TIMOLOL MALEATE 78 TRASTUZUMAB-ANNS 41 TIMOLOL MALEATE (OPHTH) 166 TRASTUZUMAB-DKST 42 TINIDAZOLE 15 TRASTUZUMAB-PKRB 44 TIOPRONIN 112 TRASTUZUMAB-QYYP 43 TIOTROPIUM BROMIDE MONOHYDRATE 169 TRAVOPROST 166 TIOTROPIUM BROMIDE-OLODATEROL HCL 176 Trazimera 43 TIPRANAVIR 54 Trazodone HCl 27 Tivicay 51 Trelegy Ellipta 168 Tivicay PD 51 Trelstar Mixject 132 TIVOZANIB HCL 179 TREPROSTINIL 172,173 TIZANIDINE HCL 49 TREPROSTINIL DIOLAMINE 172 TL Folate 103 Tresiba 63 Tobi Podhaler 171 Tresiba FlexTouch 63

©2021 Wellmark, Inc. 210 TRETINOIN 93,95 Twinrix 148 TRETINOIN (CHEMOTHERAPY) 44 Tybost 54 TRETINOIN MICROSPHERE 95 Tysabri 92 TriAdvance 103 Tyvaso 173 TRIAMCINOLONE ACETONIDE 117 Tyvaso Refill 173 TRIAMCINOLONE ACETONIDE (MOUTH) 92 Tyvaso Starter 173 TRIAMCINOLONE ACETONIDE (TOPICAL) 117 TRIAMTERENE 84 U TRIAMTERENE & HYDROCHLOROTHIAZIDE 83 Udenyca 68 TRIAZOLAM 177 Ukoniq 180 TRIENTINE HCL 97,98 Ultomiris 162 TRIFLUOPERAZINE HCL 48 UMBRALISIB TOSYLATE 180 TRIFLURIDINE 55 UMECLIDINIUM-VILANTEROL 174 TRIFLURIDINE-TIPIRACIL 36 UPADACITINIB 137 TRIHEPTANOIN 96 Uplizna 137 TRIHEXYPHENIDYL HCL 46 Uptravi 173,180 Trijardy XR 59 URIDINE TRIACETATE (EMERGENCY Trikafta 171 TREATMENT) 162 TRILACICLIB DIHYDROCHLORIDE 178 URINE GLUCOSE-KETONES TEST 153,154,157 Triluron 161 Uristix 162 TRIMETHOBENZAMIDE HCL 29 Uristix 4 162 TRIMETHOPRIM 16 URSODIOL 106 TRIMIPRAMINE MALEATE 28 USTEKINUMAB 95 Trinatal GT 103 USTEKINUMAB (IV) 95 Trinatal Rx 1 103 Trinate 103 V TRIPTORELIN PAMOATE 132 VALACYCLOVIR HCL 55 Triumeq 54 VALBENAZINE TOSYLATE 89 Triveen-Duo DHA 103 Valchlor 34 TriVisc 161 VALGANCICLOVIR HCL 49 Tropicamide 163 VALPROATE SODIUM 22 TROPICAMIDE 164 VALSARTAN 76 TROSPIUM CHLORIDE 111 VALSARTAN-HYDROCHLOROTHIAZIDE 83 Trumenba 147 Valved Holding Chamber 162 Truseltiq (100MG Daily Dose) 180 VANCOMYCIN HCL 15,16 Truseltiq (125MG Daily Dose) 180 VANDETANIB 39 Truseltiq (50MG Daily Dose) 180 Vaqta 148 Truseltiq (75MG Daily Dose) 180 VARDENAFIL HCL 112 TUCATINIB 43 VARICELLA VIRUS VACCINE LIVE 148 Tukysa 43 VARICELLA-ZOSTER IMMUNE GLOBULIN Turalio 37 (HUMAN) 141

©2021 Wellmark, Inc. 211 Varivax 148 Vitrakvi 37 VariZIG 141 Vizimpro 37 Vaxelis 148 Vol-Nate 104 VEDOLIZUMAB 134 Vol-Tab Rx 104 VELAGLUCERASE ALFA 110 VON WILLEBRAND FACTOR (RECOMBINANT) 74 Veletri 173 Vonvendi 74 Veltassa 99 VORICONAZOLE 31 Vemlidy 50 VORINOSTAT 38 VEMURAFENIB 43 Vortex Valved Holding Chamber 162 Venclexta 43 Vosevi 50 Venclexta Starting Pack 43 Votrient 43 VENETOCLAX 43 VP-GGR-B6 Prenatal 104 VENLAFAXINE HCL 27 VP-Heme OB + DHA 104 Venlafaxine HCl 27 Vpriv 110 Ventavis 173 Vyepti 33 VERAPAMIL HCL 80 Vyndamax 83 Verapamil HCl ER 80 Vyndaqel 83 Verdrocet 12 VERTEPORFIN 164 W Vfend IV 31 WARFARIN SODIUM 64,65 Victoza 59 Warfarin Sodium 65 VIGABATRIN 23 Watchhaler 162 Vil-Rx 103 Welireg 180 Vimpat 24 Wilate 74 Vinate AZ Extra 103 Vinate C 103 X Vinate Calcium 103 Xalkori 43 Vinate IC 103 Xarelto 65 Vinate II 104 Xarelto Starter Pack 65 Vinate M 104 Xeljanz 138,180 Vinate One 104 Xeljanz XR 138 Viokace 110 Xembify 141 Viracept 55 Xeomin 177 Viread 53 Xgeva 150 Virt Nate 104 Xifaxan 16 Virt-Advance 104 Xigduo XR 60 Virt-Vite GT 104 Xiidra 164 Visco-3 162 Xolair 176 VISMODEGIB 40 Xospata 37 Vistogard 162 Xpovio (100 MG Once Weekly) 37 Visudyne 164 Xpovio (40 MG Once Weekly) 37

©2021 Wellmark, Inc. 212 Xpovio (40 MG Twice Weekly) 37 Zypitamag 85 Xpovio (60 MG Once Weekly) 38 Xpovio (60 MG Twice Weekly) 38 Xpovio (80 MG Once Weekly) 38 Xpovio (80 MG Twice Weekly) 38 Xtandi 34,180 Xyntha 74 Xyntha Solofuse 74 Xyrem 178

Y Yonsa 34

Z ZAFIRLUKAST 169 ZALEPLON 177 Zamicet 12 ZANAMIVIR 55 ZANUBRUTINIB 36 Zarxio 68 Zejula 38 Zelboraf 43 Zenpep 111 ZIDOVUDINE 53 Ziextenzo 68 ZILEUTON 169 ZIPRASIDONE HCL 49 Zokinvy 111 ZOLEDRONIC ACID 150 Zolinza 38 ZOLMITRIPTAN 32 ZOLPIDEM TARTRATE 177 Zolpidem Tartrate 177 Zometa 150 ZONISAMIDE 22 Zortress 138 ZOSTER VACCINE RECOMBINANT ADJUVANTED 147 Zydelig 43 Zykadia 44 Zynlonta 180

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CHÚ Ý: Nếu quý vị nói tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ miễn phí có PAG-UKULAN NG PANSIN: Kung Tagalog ang wikang ginagamit mo, sẵn cho quý vị. Xin hãy liên hệ 800-524-9242 hoặc (TTY: 888-781-4262). may makukuha kang mga serbisyong tulong sa wika na walang bayad. Makipag-ugnayan sa 800-524-9242 o (TTY: 888-781-4262). NAPOMENA: Ako govorite hrvatski, dostupna Vam je besplatna podrška na Vašem jeziku. Kontaktirajte 800-524-9242 ili (tekstualni telefon za w>'k;oh.ng= erh>uwdR unDusdm< usdmw>rRpXRw>zH;w>rRwz.< vXwb.vXmbl;vJ< td.vXe*D>vDRI qJ;usd;ql osobe oštećena sluha: 888-781-4262). 800=524=9242 rhwrh> (TTY: 888=781=4262) wuh>I

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ማሳሰቢያ፦ አማርኛ የሚናገሩ ከሆነ፣ የቋንቋ እገዛ አገልግሎቶች፣ ከክፍያ ነፃ፣ ສ່ ງຄວນເອິ ົາໃຈໃສ,່ ພາສາລາວ ຖາທ້ ານເວ່ າົ້ : ພວກເຮາມົ ບີ ລໍ ການິ ຄວາມຊວຍເຫ່ ຼອດື ານພາສາ້ ያገኛሉ። በ ወይም (በ ) ደውለው ያነጋግሩን። ໃຫທ້ ານໂດຍບ່ ່ ເສຍໍ ຄາ່ ຫຼ ື 800-524-9242 ຕດຕິ ່ ໍທ່ .ີ (TTY: 888-781-4262.) 800-524-9242 TTY: 888-781-4262

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Ge’: Diné k’ehj7 y1n7[ti’go n7k1 bizaad bee 1k1’ adoowo[, t’11 jiik’4, n1h0l=. Koj8’ h0lne’ 800-524-9242 doodaii’ (TTY: 888-781-4262)

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