2018 California Four-Tier Prescription Drug List

California Small Group

2018 California Four-Tier Prescription Drug List Please note: This Prescription Drug List (PDL) is accurate as of July 1, 2018 and is subject to change after this date. Your estimated coverage and copay/coinsurance may vary based on the benefit plan you choose and the effective date of the plan.

Updated February 28, 2018 1 At UnitedHealthcare, we want to help you better understand your medication options. Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we’ve included some of the most commonly asked questions about the Prescription Drug List.

What is a Prescription Drug List (PDL)? This document is a list of covered medications. Medications are listed by common categories or class. They are placed into cost levels known as tiers. It includes both brand and generic prescription medications approved by the Food and Drug Administration (FDA). Please note: Where differences are noted between this PDL and your benefit plan documents, the benefit plan documents will rule. You may also log in to myuhc.com or call the toll-free member phone number on your health plan ID card for more information.

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

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

$ Drug tier Includes Helpful tips

Tier 1 Some brands and generics are also Use Tier 1 drugs for the lowest Your lowest included. out‑of-pocket costs. cost

Tier 2 and 3 Mix of brands and generics. Use Tier 2 or Tier 3 drugs instead of Tier 4 Your mid-range to help reduce your out-of-pocket costs. cost

Tier 4 Mostly brand as well as select Many Tier 4 drugs have lower‑cost Your highest generic drugs. options in Tier 1, 2 or 3. Ask your doctor if they could work for you. cost

Please note: If you have a high deductible plan, the tier cost levels may apply once you hit your deductible. Refer to your enrollment and plan materials on myuhc.com, or call the toll-free number on your health plan ID card for more information about your benefit plan.

2 When does the PDL change? • Medications may move to a lower tier at any time. • Medications may move to a higher tier when a generic becomes available. • Medications may move to a higher tier or become non-formulary most often on January 1 or July 1. When a medication changes tiers, you may have to pay a different amount for that medication. For the most up-to-date list, call customer service at the number on your ID card. Programs and limits Call the number for Member Services listed on your ID card if you have any questions about your prescription drug coverage.

Designated specialty program — For certain Specialty Prescription Drug Products, we may direct you to a Designated Pharmacy with whom we have an arrangement to provide those Prescription Drug Products, which are identified in the Specialty column of the Prescription Drug List (PDL). If you choose not to obtain your Prescription Drug Product from the Designated Pharmacy, you may opt-out of the Designated Pharmacy program by contacting us at myuhc.com or the telephone number on your ID card.

Health care reform preventive — This medication is part of a health care reform preventive benefit and may be available at no cost to you.

Prior authorization required* — Your doctor is required to provide additional information to us to determine coverage. For specific prior authorization requirements, please refer to your Evidence of Coverage.

Supply limit — Amount of medication covered per copayment or in a specific time period.

Step therapy — Trial of a different medication is required before another medication may be covered. For specific step therapy requirements, please refer to your Evidence of Coverage.

*Depending on your benefit, you may have notification or medical necessity requirements for select medications. To learn more about a pharmacy program or to find out if it applies to you, please visitmyuhc.com or call the toll-free member phone number on your health plan ID card. Your Right to Request Access to a Non-formulary Drug When a Prescription Drug Product is not on our formulary, you or your representative may request an exception to gain access to that Prescription Drug Product. To make a request, contact us in writing or call the toll-free number on your ID card. We will notify you of our determination within 72 hours. Urgent Requests If your request requires immediate action and a delay could significantly increase the risk to your health, or the ability to regain maximum function, call us as soon as possible. We will provide a written or electronic determination within 24 hours. External Review If you are not satisfied with our determination of your exception request, you may be entitled to request an external review. You or your representative may request an external review by sending a written request to us to the address set out in the determination letter or by calling the toll-free number on your ID card. The Independent Review Organization (IRO) will notify you of our determination within 72 hours. Expedited External Review If you are not satisfied with our determination of your exception request and it involves an urgent situation, you or your representative may request an expedited external review by calling the toll-free number on your ID card or by sending a written request to the address set out in the determination letter. The IRO will notify you of our determination within 24 hours. Should I talk to my doctor about over-the-counter (OTC) medications? An OTC medication may be the right treatment for some conditions. Talk to your doctor about available options. 3 What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes, the same company that makes a brand-name medication also makes the generic version. What if my doctor writes a brand-name prescription? The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. For some benefit plans, if a brand-name drug is prescribed and a generic equivalent is available, your cost share may be the copay PLUS the cost difference between the brand-name drug and generic equivalent. Visitmyuhc.com to make sure. Are you taking a specialty medication? Specialty medications are high-cost and are used to treat rare or complex conditions that require additional care and support. For most plans, these medications are managed through the Specialty Pharmacy Program. Take advantage of personalized support designed to help you get the most out of your treatment plan. Visit myuhc.com or call the toll-free phone number on your health plan ID card to learn more. If you’re taking a specialty medication that is on Tier 3 or Tier 4, call the toll-free number on your health plan ID card to talk with a pharmacist about finding lower-cost options or a financial assistance program. If you require your specialty medications immediately and a delay could significantly increase the risk to your health, or the ability to regain maximum function, call us as soon as possible for direction or you may pay for the Prescription Drug Product at the time of dispensing and file a claim for reimbursement with us, as described in your Certificate, Section 5: How to File a Claim. We will not reimburse you for the difference between the Out-of-Network Reimbursement Rate and the Out-of-Network Pharmacy’s Usual and Customary Charge for that Prescription Drug Product. We will not reimburse you for any non-covered drug product. A member who would like to receive Prescription Drug Products prescribed to treat or prevent HIV at any retail Network Pharmacy may opt-out of the Designated Specialty Pharmacy program by contacting us at myuhc.com or the telephone number on your ID card. The cost share for Prescription Drug Products prescribed to treat or prevent HIV that are obtained from any retail Network Pharmacy will be the same as that for Specialty Prescription Drug Products obtained from a Preferred Specialty Network Pharmacy. How do I get updated information about my pharmacy benefit? Since the PDL may change during your plan year, we encourage you to visit myuhc.com or call the toll-free member phone number on your health plan ID card for more current information.

Log in to myuhc.com for the following pharmacy And, if home delivery services are included in your information and tools: pharmacy benefit, you can also: • Pharmacy benefit and coverage information • Refill prescriptions • Possible lower-cost medication options • Check the status of your order • Medication interactions and side effects • Set up reminders for refills • Participating retail pharmacies by ZIP code • Manage your account • Your prescription history

Call the toll-free member phone number on your health plan ID card, or visit myuhc.com® for more information.

In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This change in terms does not affect your benefit coverage. Medications are categorized by common therapeutic conditions in this PDL for ease of reference only. These categories do not determine coverage for the medication for your condition. Your benefit plan determines coverage for these medications. 4 Nondiscrimination notice and access to communication services

UnitedHealthcare® does not discriminate on the basis of race, color, national origin, age, disability, or sex in its health programs or activities. If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator. Online: [email protected] Mail: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m. You can also file a complaint with the U.S. Dept. of Health and Human Services. Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card TTY 711, Monday through Friday, 8 a.m. to 8 p.m.

5 Multi-language interpreter services ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please call the toll-free phone number listed on your identification card. ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identificación. 請注意：如果您說中文 (Chinese)，我們免費為您提供語言協助服務。請撥打會員卡所列的免付費會員電話號碼。 XIN LƯU Ý: Nếu quý vị nói tiếng Việt (Vietnamese), quý vị sẽ được cung cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Vui lòng gọi số điện thoại miễn phí ở mặt sau thẻ hội viên của quý vị. 알림: 한국어(Korean)를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다. 귀하의 신분증 카드에 기재된 무료 회원 전화번호로 문의하십시오. PAALALA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng serbisyo ng tulong sa wika. Pakitawagan ang toll-free na numero ng telepono na nasa iyong identification card. ВНИМАНИЕ: бесплатные услуги перевода доступны для людей, чей родной язык является русском (Russian). Позвоните по бесплатному номеру телефона, указанному на вашей идентификационной карте.

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

ध्यान दें: यदि आप हिंदी (Hindi) बोलते है, आपको भाषा सहायता सेबाएं, नि:शुल्क उपलब्ध हैं। कृपया अपने पहचान पत्र पर सूचीबद्ध टोल-फ्री फोन नंबर पर कॉल करें। CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau tus xov tooj hu deb dawb uas teev muaj nyob rau ntawm koj daim yuaj cim qhia tus kheej.

ចំណាប់អារម្មណ៍ៈ បើសិនអ្នកនិយាយភាសាខ្មែរ(Khmer)សេវាជំនួយភាសាដោយឥតគិតថ្លៃ គឺមានសំរាប់អ្នក។ សូមទូរស័ព្ទទៅលេខឥតគិតថ្លៃ ដែលមាននៅលើអត្ដសញ្ញាណប័ណ្ណរបស់អ្នក។ PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Maidawat nga awagan iti toll-free a numero ti telepono nga nakalista ayan iti identification card mo. DÍÍ BAA’ÁKONÍNÍZIN: Diné (Navajo) bizaad bee yániłti’go, saad bee áka›anída›awo›ígíí, t’áá jíík’eh, bee ná’ahóót’i’. T’áá shǫǫdí ninaaltsoos nitł’izí bee nééhozinígíí bine’dę́ ę́› t’áá jíík’ehgo béésh bee hane’í biká’ígíí bee hodíilnih. OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac lambarka telefonka khadka bilaashka ee ku yaalla kaarkaaga aqoonsiga.

6 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Analgesics - Drugs to Treat Pain, HCR ADLT ASA LOW TAB 81MG Inflammation, and Muscle and Joint ASPIRIN TAB DELAYED RELEASE 81 MG Preventive EC Conditions Care Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint ANAPROX DS TAB 550MG NAPROXEN SODIUM TAB 550 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, APAP/CODEINE SOL 120- ACETAMINOPHEN W/ CODEINE SOLN Inflammation, and Muscle and Joint Tier 1 X 12/5 120-12 MG/5ML Conditions Analgesics - Drugs to Treat Pain, APAP/CODEINE TAB 300- ACETAMINOPHEN W/ CODEINE TAB 300- Inflammation, and Muscle and Joint Tier 1 X 15MG 15 MG Conditions Analgesics - Drugs to Treat Pain, APAP/CODEINE TAB 300- ACETAMINOPHEN W/ CODEINE TAB 300- Inflammation, and Muscle and Joint Tier 1 X 30MG 30 MG Conditions Analgesics - Drugs to Treat Pain, APAP/CODEINE TAB 300- ACETAMINOPHEN W/ CODEINE TAB 300- Inflammation, and Muscle and Joint Tier 1 X 60MG 60 MG Conditions Analgesics - Drugs to Treat Pain, APAP-CAFFEIN CAP ACETAMINOPHEN-CAFFEINE- Inflammation, and Muscle and Joint Tier 3 X DIHYDROC DIHYDROCODEINE CAP 320.5-30-16 MG Conditions Analgesics - Drugs to Treat Pain, DICLOFENAC W/ MISOPROSTOL TAB Inflammation, and Muscle and Joint ARTHROTEC 50 TAB Tier 3 DELAYED RELEASE 50-0.2 MG Conditions Analgesics - Drugs to Treat Pain, DICLOFENAC W/ MISOPROSTOL TAB Inflammation, and Muscle and Joint ARTHROTEC 75 TAB Tier 3 DELAYED RELEASE 75-0.2 MG Conditions Analgesics - Drugs to Treat Pain, BUTALBITAL-ASPIRIN-CAFF W/ CODEINE Inflammation, and Muscle and Joint ASCOMP/COD CAP 30MG Tier 1 CAP 50-325-40-30 MG Conditions Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint ASPIR-81 TAB 81MG EC ASPIRIN TAB DELAYED RELEASE 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint ASPIRIN CHW 81MG ASPIRIN CHEW TAB 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint ASPIRIN TAB 325MG ASPIRIN TAB 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint ASPIRIN TAB 325MG ASPIRIN TAB DELAYED RELEASE 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint ASPIRIN TAB 325MG EC ASPIRIN TAB DELAYED RELEASE 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint ASPIRIN TAB 81MG EC ASPIRIN TAB DELAYED RELEASE 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint ASPIRIN 81 TAB 81MG EC ASPIRIN TAB DELAYED RELEASE 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint ASPIRIN ADLT TAB 81MG ASPIRIN TAB DELAYED RELEASE 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint ASPIRIN CHIL CHW 81MG ASPIRIN CHEW TAB 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint ASPIRIN CHLD CHW 81MG ASPIRIN CHEW TAB 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint ASPIRIN LOW CHW 81MG ASPIRIN CHEW TAB 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint ASPIRIN LOW TAB 81MG EC ASPIRIN TAB DELAYED RELEASE 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint ASPIRIN-81 CHW 81MG ASPIRIN CHEW TAB 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint ASPIR-LOW TAB 81MG EC ASPIRIN TAB DELAYED RELEASE 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint ASPIRTAB TAB 324MG EC ASPIRIN TAB DELAYED RELEASE 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint BAYER ASA TAB 325MG ASPIRIN TAB 325 MG Preventive Conditions Care

7 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Analgesics - Drugs to Treat Pain, BUTALBITAL-ACETAMINOPHEN TAB 50- Inflammation, and Muscle and Joint BUPAP TAB 50-300MG Tier 4 300 MG Conditions Analgesics - Drugs to Treat Pain, BUTALBITAL-ACETAMINOPHEN- Inflammation, and Muscle and Joint BUT/APAP/CAF CAP Tier 3 X CAFFEINE CAP 50-300-40 MG Conditions Analgesics - Drugs to Treat Pain, BUTALBITAL-ACETAMINOPHEN- Inflammation, and Muscle and Joint BUT/APAP/CAF CAP Tier 1 X CAFFEINE CAP 50-325-40 MG Conditions Analgesics - Drugs to Treat Pain, BUT/APAP/CAF CAP BUTALBITAL-ACETAMINOPHEN-CAFF W/ Inflammation, and Muscle and Joint Tier 1 X CODEINE COD CAP 50-325-40-30 MG Conditions Analgesics - Drugs to Treat Pain, BUTALBITAL-ACETAMINOPHEN- Inflammation, and Muscle and Joint BUT/APAP/CAF TAB Tier 1 X CAFFEINE TAB 50-325-40 MG Conditions Analgesics - Drugs to Treat Pain, BUTALBITAL-ASPIRIN-CAFFEINE TAB 50- Inflammation, and Muscle and Joint BUT/ASA/CAF TAB Tier 1 325-40 MG Conditions Analgesics - Drugs to Treat Pain, BUT/ASA/CAF/ CAP COD BUTALBITAL-ASPIRIN-CAFF W/ CODEINE Inflammation, and Muscle and Joint Tier 1 30MG CAP 50-325-40-30 MG Conditions Analgesics - Drugs to Treat Pain, BUTALBITAL-ASPIRIN-CAFFEINE CAP 50- Inflammation, and Muscle and Joint BUT/ASA/CAFF CAP Tier 1 325-40 MG Conditions Analgesics - Drugs to Treat Pain, BUTALBITAL-ACETAMINOPHEN TAB 50- Inflammation, and Muscle and Joint BUTAL/APAP TAB 50-325MG Tier 1 325 MG Conditions Analgesics - Drugs to Treat Pain, BUTALB/ACETA TAB 50- BUTALBITAL-ACETAMINOPHEN TAB 50- Inflammation, and Muscle and Joint Tier 3 300MG 300 MG Conditions Analgesics - Drugs to Treat Pain, BUTORPHANOL SOL 10MG/ BUTORPHANOL TARTRATE NASAL SOLN Inflammation, and Muscle and Joint Tier 2 X ML 10 MG/ML Conditions Analgesics - Drugs to Treat Pain, BUTALBITAL-ACETAMINOPHEN- Inflammation, and Muscle and Joint CAPACET CAP Tier 1 X CAFFEINE CAP 50-325-40 MG Conditions Analgesics - Drugs to Treat Pain, ACETAMINOPHEN W/ CODEINE SUSP Inflammation, and Muscle and Joint CAPITAL/COD SUS 120-12/5 Tier 2 X 120-12 MG/5ML Conditions Analgesics - Drugs to Treat Pain, CARISOPRODOL TAB ASA/ CARISOPRODOL W/ ASPIRIN & CODEINE Inflammation, and Muscle and Joint Tier 1 COD TAB 200-325-16 MG Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint CELECOXIB CAP 100MG CELECOXIB CAP 100 MG Tier 2 X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint CELECOXIB CAP 200MG CELECOXIB CAP 200 MG Tier 2 X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint CELECOXIB CAP 400MG CELECOXIB CAP 400 MG Tier 2 X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint CELECOXIB CAP 50MG CELECOXIB CAP 50 MG Tier 2 X Conditions Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint CHILD ASA CHW 81MG ASPIRIN CHEW TAB 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint CHILD ASA LS CHW 81MG ASPIRIN CHEW TAB 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, CHOLINE & MAGNESIUM SALICYLATES Inflammation, and Muscle and Joint CHO MAG TRIS LIQ 500/5ML Tier 1 LIQ 500 MG/5ML Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint CODEINE SULF TAB 15MG CODEINE SULFATE TAB 15 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint CODEINE SULF TAB 30MG CODEINE SULFATE TAB 30 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint CODEINE SULF TAB 60MG CODEINE SULFATE TAB 60 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint CVS ASPIRIN TAB 325MG ASPIRIN TAB DELAYED RELEASE 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint CVS ASPIRIN TAB 325MG ASPIRIN TAB 325 MG Preventive Conditions Care

8 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint CVS ASPIRIN TAB 325MG EC ASPIRIN TAB DELAYED RELEASE 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint CVS ASPIRIN TAB 81MG EC ASPIRIN TAB DELAYED RELEASE 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint CVS CHLD ASA CHW 81MG ASPIRIN CHEW TAB 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint DAYPRO TAB 600MG OXAPROZIN TAB 600 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint DEMEROL TAB 100MG MEPERIDINE HCL TAB 100 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, DICLO/MISOPR TAB 50- DICLOFENAC W/ MISOPROSTOL TAB Inflammation, and Muscle and Joint Tier 3 0.2MG DELAYED RELEASE 50-0.2 MG Conditions Analgesics - Drugs to Treat Pain, DICLO/MISOPR TAB 75- DICLOFENAC W/ MISOPROSTOL TAB Inflammation, and Muscle and Joint Tier 3 0.2MG DELAYED RELEASE 75-0.2 MG Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint DICLOFEN POT TAB 50MG DICLOFENAC POTASSIUM TAB 50 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, DICLOFENAC SODIUM TAB ER 24HR 100 Inflammation, and Muscle and Joint DICLOFENAC TAB 100MG ER Tier 1 MG Conditions Analgesics - Drugs to Treat Pain, DICLOFENAC SODIUM TAB DELAYED Inflammation, and Muscle and Joint DICLOFENAC TAB 25MG DR Tier 1 RELEASE 25 MG Conditions Analgesics - Drugs to Treat Pain, DICLOFENAC SODIUM TAB DELAYED Inflammation, and Muscle and Joint DICLOFENAC TAB 50MG DR Tier 1 RELEASE 50 MG Conditions Analgesics - Drugs to Treat Pain, DICLOFENAC SODIUM TAB DELAYED Inflammation, and Muscle and Joint DICLOFENAC TAB 75MG DR Tier 1 RELEASE 75 MG Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint DIFLUNISAL TAB 500MG DIFLUNISAL TAB 500 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, DIHYDROCOD/ CAP ASA/ ASPIRIN-CAFFEINE-DIHYDROCODEINE Inflammation, and Muscle and Joint Tier 1 CAFF CAP 356.4-30-16 MG Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint DILAUDID LIQ 1MG/ML HYDROMORPHONE HCL LIQD 1 MG/ML Tier 3 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint DILAUDID TAB 2MG HYDROMORPHONE HCL TAB 2 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint DILAUDID TAB 4MG HYDROMORPHONE HCL TAB 4 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint DILAUDID TAB 8MG HYDROMORPHONE HCL TAB 8 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, *DICLOFENAC-GABAPENTIN-LIDOCAINE Inflammation, and Muscle and Joint DIPENTOCAINE CRE 5-5-2% Tier 3 HCL CREAM 5-5-2% (CMPD KIT* Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint DOLOPHINE TAB 10MG METHADONE HCL TAB 10 MG Tier 3 X X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint DOLOPHINE TAB 5MG METHADONE HCL TAB 5 MG Tier 3 X X Conditions Analgesics - Drugs to Treat Pain, ACETAMINOPHEN-SALICYLAMIDE- Inflammation, and Muscle and Joint DURAXIN CAP PHENYLTOLOXAMINE CAP 300-200- Tier 1 Conditions 20MG Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint EC-NAPROSYN TAB 375MG NAPROXEN TAB EC 375 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint EC-NAPROSYN TAB 500MG NAPROXEN TAB EC 500 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint ECPIRIN TAB 325MG EC ASPIRIN TAB DELAYED RELEASE 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, OXYCODONE W/ ACETAMINOPHEN TAB Inflammation, and Muscle and Joint ENDOCET TAB 10-325MG Tier 1 X 10-325 MG Conditions

9 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Analgesics - Drugs to Treat Pain, OXYCODONE W/ ACETAMINOPHEN TAB Inflammation, and Muscle and Joint ENDOCET TAB 2.5-325 Tier 1 X 2.5-325 MG Conditions Analgesics - Drugs to Treat Pain, OXYCODONE W/ ACETAMINOPHEN TAB Inflammation, and Muscle and Joint ENDOCET TAB 5-325MG Tier 1 X 5-325 MG Conditions Analgesics - Drugs to Treat Pain, OXYCODONE W/ ACETAMINOPHEN TAB Inflammation, and Muscle and Joint ENDOCET TAB 7.5-325 Tier 1 X 7.5 - 325 MG Conditions Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint ENTERIC ASA TAB 325MG ASPIRIN TAB DELAYED RELEASE 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint EQ ASPIRIN TAB 325MG ASPIRIN TAB 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint EQ ASPIRIN TAB 325MG EC ASPIRIN TAB DELAYED RELEASE 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint EQ CHILD ASA CHW 81MG ASPIRIN CHEW TAB 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint EQL ASPIRIN CHW 81MG ASPIRIN CHEW TAB 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint EQL ASPIRIN TAB 325MG ASPIRIN TAB 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, BUTALBITAL-ACETAMINOPHEN- Inflammation, and Muscle and Joint ESGIC CAP Tier 3 X CAFFEINE CAP 50-325-40 MG Conditions Analgesics - Drugs to Treat Pain, BUTALBITAL-ACETAMINOPHEN- Inflammation, and Muscle and Joint ESGIC TAB Tier 3 X CAFFEINE TAB 50-325-40 MG Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint ETODOLAC CAP 200MG ETODOLAC CAP 200 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint ETODOLAC CAP 300MG ETODOLAC CAP 300 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint ETODOLAC TAB 400MG ETODOLAC TAB 400 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint ETODOLAC TAB 500MG ETODOLAC TAB 500 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint ETODOLAC ER TAB 400MG ETODOLAC TAB ER 24HR 400 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint ETODOLAC ER TAB 500MG ETODOLAC TAB ER 24HR 500 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint ETODOLAC ER TAB 600MG ETODOLAC TAB ER 24HR 600 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint FELDENE CAP 10MG PIROXICAM CAP 10 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint FELDENE CAP 20MG PIROXICAM CAP 20 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint FENOPROFEN CAP 200MG FENOPROFEN CALCIUM CAP 200 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint FENOPROFEN CAP 400MG FENOPROFEN CALCIUM CAP 400 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint FENOPROFEN TAB 600MG FENOPROFEN CALCIUM TAB 600 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint FENORTHO CAP 200MG FENOPROFEN CALCIUM CAP 200 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint FENORTHO CAP 400MG FENOPROFEN CALCIUM CAP 400 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint FENTANYL DIS 100MCG/H FENTANYL TD PATCH 72HR 100 MCG/HR Tier 2 X X Conditions

10 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint FENTANYL DIS 12MCG/HR FENTANYL TD PATCH 72HR 12 MCG/HR Tier 2 X X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint FENTANYL DIS 25MCG/HR FENTANYL TD PATCH 72HR 25 MCG/HR Tier 2 X X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint FENTANYL DIS 50MCG/HR FENTANYL TD PATCH 72HR 50 MCG/HR Tier 2 X X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint FENTANYL DIS 75MCG/HR FENTANYL TD PATCH 72HR 75 MCG/HR Tier 2 X X Conditions Analgesics - Drugs to Treat Pain, FENTANYL OT LOZ FENTANYL CITRATE LOZENGE ON A Inflammation, and Muscle and Joint Tier 2 X X 1200MCG HANDLE 1200 MCG Conditions Analgesics - Drugs to Treat Pain, FENTANYL OT LOZ FENTANYL CITRATE LOZENGE ON A Inflammation, and Muscle and Joint Tier 2 X X 1600MCG HANDLE 1600 MCG Conditions Analgesics - Drugs to Treat Pain, FENTANYL CITRATE LOZENGE ON A Inflammation, and Muscle and Joint FENTANYL OT LOZ 200MCG Tier 2 X X HANDLE 200 MCG Conditions Analgesics - Drugs to Treat Pain, FENTANYL CITRATE LOZENGE ON A Inflammation, and Muscle and Joint FENTANYL OT LOZ 400MCG Tier 2 X X HANDLE 400 MCG Conditions Analgesics - Drugs to Treat Pain, FENTANYL CITRATE LOZENGE ON A Inflammation, and Muscle and Joint FENTANYL OT LOZ 600MCG Tier 2 X X HANDLE 600 MCG Conditions Analgesics - Drugs to Treat Pain, FENTANYL CITRATE LOZENGE ON A Inflammation, and Muscle and Joint FENTANYL OT LOZ 800MCG Tier 2 X X HANDLE 800 MCG Conditions Analgesics - Drugs to Treat Pain, BUTALBITAL-ACETAMINOPHEN- Inflammation, and Muscle and Joint FIORICET CAP Tier 3 X CAFFEINE CAP 50-300-40 MG Conditions Analgesics - Drugs to Treat Pain, BUTALBITAL-ASPIRIN-CAFFEINE CAP 50- Inflammation, and Muscle and Joint FIORINAL CAP Tier 3 325-40 MG Conditions Analgesics - Drugs to Treat Pain, BUTALBITAL-ASPIRIN-CAFF W/ CODEINE Inflammation, and Muscle and Joint FIORINAL/COD CAP 30MG Tier 3 CAP 50-325-40-30 MG Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint FLURBIPROFEN TAB 100MG FLURBIPROFEN TAB 100 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint FLURBIPROFEN TAB 50MG FLURBIPROFEN TAB 50 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, MEPERIDINE W/ PROMETHAZINE CAP Inflammation, and Muscle and Joint FORTIGAN CAP Tier 1 50-25 MG Conditions Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint GNP ASPIRIN CHW 81MG ASPIRIN CHEW TAB 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint GNP ASPIRIN TAB 325MG ASPIRIN TAB 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint GNP ASPIRIN TAB 325MG EC ASPIRIN TAB DELAYED RELEASE 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint GNP ASPIRIN TAB 81MG EC ASPIRIN TAB DELAYED RELEASE 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint HM ASPIRIN CHW 81MG ASPIRIN CHEW TAB 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint HM ASPIRIN TAB 325MG ASPIRIN TAB 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HYDROCODONE-ACETAMINOPHEN Inflammation, and Muscle and Joint HYCET SOL 7.5-325 Tier 3 X SOLN 7.5-325 MG/15ML Conditions Analgesics - Drugs to Treat Pain, HYDROCO/APAP SOL 7.5- HYDROCODONE-ACETAMINOPHEN Inflammation, and Muscle and Joint Tier 2 X 325 SOLN 7.5-325 MG/15ML Conditions Analgesics - Drugs to Treat Pain, HYDROCO/APAP TAB 10- HYDROCODONE-ACETAMINOPHEN TAB Inflammation, and Muscle and Joint Tier 1 X 325MG 10-325 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCO/APAP TAB 2.5- HYDROCODONE-ACETAMINOPHEN TAB Inflammation, and Muscle and Joint Tier 1 325 2.5-325 MG Conditions

11 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Analgesics - Drugs to Treat Pain, HYDROCO/APAP TAB HYDROCODONE-ACETAMINOPHEN TAB Inflammation, and Muscle and Joint Tier 1 X 5-325MG 5-325 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCO/APAP TAB 7.5- HYDROCODONE-ACETAMINOPHEN TAB Inflammation, and Muscle and Joint Tier 1 X 325 7.5 - 325 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCOD/IBU TAB 10- HYDROCODONE-IBUPROFEN TAB 10- Inflammation, and Muscle and Joint Tier 1 200MG 200 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCOD/IBU TAB HYDROCODONE-IBUPROFEN TAB 5-200 Inflammation, and Muscle and Joint Tier 1 5-200MG MG Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE-IBUPROFEN TAB 7.5- Inflammation, and Muscle and Joint HYDROCOD/IBU TAB 7.5-200 Tier 1 200 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE SOL 10- HYDROCODONE-ACETAMINOPHEN Inflammation, and Muscle and Joint Tier 1 X 325MG SOLN 10-325 MG/15ML Conditions Analgesics - Drugs to Treat Pain, HYDROMORPHON LIQ 1MG/ Inflammation, and Muscle and Joint HYDROMORPHONE HCL LIQD 1 MG/ML Tier 1 ML Conditions Analgesics - Drugs to Treat Pain, HYDROMORPHON TAB HYDROMORPHONE HCL TAB ER 24HR Inflammation, and Muscle and Joint Tier 3 X X X 12MG ER DETER 12 MG Conditions Analgesics - Drugs to Treat Pain, HYDROMORPHON TAB HYDROMORPHONE HCL TAB ER 24HR Inflammation, and Muscle and Joint Tier 3 X X X 16MG ER DETER 16 MG Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint HYDROMORPHON TAB 2MG HYDROMORPHONE HCL TAB 2 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, HYDROMORPHON TAB HYDROMORPHONE HCL TAB ER 24HR Inflammation, and Muscle and Joint Tier 3 X X X 32MG ER DETER 32 MG Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint HYDROMORPHON TAB 4MG HYDROMORPHONE HCL TAB 4 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint HYDROMORPHON TAB 8MG HYDROMORPHONE HCL TAB 8 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, HYDROMORPHON TAB HYDROMORPHONE HCL TAB ER 24HR Inflammation, and Muscle and Joint Tier 3 X X X 8MG ER DETER 8 MG Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint IBU TAB 400MG IBUPROFEN TAB 400 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint IBU TAB 600MG IBUPROFEN TAB 600 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint IBU TAB 800MG IBUPROFEN TAB 800 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE-IBUPROFEN TAB 10- Inflammation, and Muscle and Joint IBUDONE TAB 10-200MG Tier 1 200 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE-IBUPROFEN TAB 5-200 Inflammation, and Muscle and Joint IBUDONE TAB 5-200MG Tier 1 MG Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint IBUPROFEN TAB 400MG IBUPROFEN TAB 400 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint IBUPROFEN TAB 600MG IBUPROFEN TAB 600 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint IBUPROFEN TAB 800MG IBUPROFEN TAB 800 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint INDOCIN SUP 50MG INDOMETHACIN SUPPOS 50 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint INDOCIN SUS 25MG/5ML INDOMETHACIN SUSP 25 MG/5ML Tier 3 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint INDOMETHACIN CAP 25MG INDOMETHACIN CAP 25 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint INDOMETHACIN CAP 50MG INDOMETHACIN CAP 50 MG Tier 1 Conditions

12 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Analgesics - Drugs to Treat Pain, INDOMETHACIN CAP 75MG Inflammation, and Muscle and Joint INDOMETHACIN CAP ER 75 MG Tier 1 ER Conditions Analgesics - Drugs to Treat Pain, ISOMETHEPTENE-CAFFEINE- Inflammation, and Muscle and Joint ISOMETH/CAFF TAB /APAP Tier 1 ACETAMINOPHEN TAB 65-20-325 MG Conditions Analgesics - Drugs to Treat Pain, KETOPROFEN CAP 200MG Inflammation, and Muscle and Joint KETOPROFEN CAP ER 24HR 200 MG Tier 1 ER Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint KETOPROFEN CAP 50MG KETOPROFEN CAP 50 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint KETOPROFEN CAP 75MG KETOPROFEN CAP 75 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, KETOROLAC TROMETHAMINE TAB 10 Inflammation, and Muscle and Joint KETOROLAC TAB 10MG Tier 1 MG Conditions Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint KLS ASPIRIN TAB 325MG EC ASPIRIN TAB DELAYED RELEASE 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint KLS ASPIRIN TAB 81MG EC ASPIRIN TAB DELAYED RELEASE 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint KP ASPIRIN TAB 81MG EC ASPIRIN TAB DELAYED RELEASE 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, FENTANYL CITRATE NASAL SPRAY 100 Inflammation, and Muscle and Joint LAZANDA SPR 100MCG Tier 3 X X MCG/ACT (BASE EQUIV) Conditions Analgesics - Drugs to Treat Pain, FENTANYL CITRATE NASAL SPRAY 300 Inflammation, and Muscle and Joint LAZANDA SPR 300MCG Tier 3 X X MCG/ACT (BASE EQUIV) Conditions Analgesics - Drugs to Treat Pain, FENTANYL CITRATE NASAL SPRAY 400 Inflammation, and Muscle and Joint LAZANDA SPR 400MCG Tier 3 X X MCG/ACT (BASE EQUIV) Conditions Analgesics - Drugs to Treat Pain, ASPIRIN-APAP-SALICYLAMIDE-CAFFEINE Inflammation, and Muscle and Joint LEVACET TAB Tier 3 TAB 500-250-150-32.5 MG Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint LEVORPHANOL TAB 2MG LEVORPHANOL TARTRATE TAB 2 MG Tier 3 X Conditions Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint LO-DOSE ASA TAB 81MG EC ASPIRIN TAB DELAYED RELEASE 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HYDROCODONE-ACETAMINOPHEN TAB Inflammation, and Muscle and Joint LORCET TAB 5-325MG Tier 1 X 5-325 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE-ACETAMINOPHEN TAB Inflammation, and Muscle and Joint LORCET HD TAB 10-325MG Tier 1 X 10-325 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE-ACETAMINOPHEN TAB Inflammation, and Muscle and Joint LORCET PLUS TAB 7.5-325 Tier 1 X 7.5 - 325 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE-ACETAMINOPHEN Inflammation, and Muscle and Joint LORTAB ELX 10-300MG Tier 3 SOLN 10-300 MG/15ML Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE-ACETAMINOPHEN TAB Inflammation, and Muscle and Joint LORTAB TAB 10-325MG Tier 1 X 10-325 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE-ACETAMINOPHEN TAB Inflammation, and Muscle and Joint LORTAB TAB 5-325MG Tier 1 X 5-325 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE-ACETAMINOPHEN TAB Inflammation, and Muscle and Joint LORTAB TAB 7.5-325 Tier 1 X 7.5 - 325 MG Conditions Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint LOW DOSE ASA TAB 81MG ASPIRIN TAB DELAYED RELEASE 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, BUTALBITAL-ACETAMINOPHEN- Inflammation, and Muscle and Joint MARGESIC CAP Tier 1 X CAFFEINE CAP 50-325-40 MG Conditions Analgesics - Drugs to Treat Pain, BUTALBITAL-ACETAMINOPHEN TAB 50- Inflammation, and Muscle and Joint MARTEN-TAB TAB 50-325MG Tier 1 325 MG Conditions Analgesics - Drugs to Treat Pain, MECLOFEN SOD CAP Inflammation, and Muscle and Joint MECLOFENAMATE SODIUM CAP 100 MG Tier 1 100MG Conditions

13 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint MECLOFEN SOD CAP 50MG MECLOFENAMATE SODIUM CAP 50 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, CAPSAICIN-MENTHOL-METHYL Inflammation, and Muscle and Joint MEDI-DERM CRE -RX Tier 3 SALICYLATE CREAM 0.035-5-20% Conditions Analgesics - Drugs to Treat Pain, CAPSAICIN-MENTHOL-METHYL Inflammation, and Muscle and Joint MEDROX-RX OIN Tier 3 SALICYLATE OINT 0.05-7-20% Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint MEFENAM ACID CAP 250MG MEFENAMIC ACID CAP 250 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint MELOXICAM TAB 15MG MELOXICAM TAB 15 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint MELOXICAM TAB 7.5MG MELOXICAM TAB 7.5 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, MEPER/PROMET CAP 50- MEPERIDINE W/ PROMETHAZINE CAP Inflammation, and Muscle and Joint Tier 3 25MG 50-25 MG Conditions Analgesics - Drugs to Treat Pain, MEPERIDINE SOL MEPERIDINE HCL ORAL SOLN 50 Inflammation, and Muscle and Joint Tier 1 50MG/5ML MG/5ML Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint MEPERIDINE TAB 100MG MEPERIDINE HCL TAB 100 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint MEPERIDINE TAB 50MG MEPERIDINE HCL TAB 50 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, METHADONE CON 10MG/ Inflammation, and Muscle and Joint METHADONE HCL CONC 10 MG/ML Tier 1 X ML Conditions Analgesics - Drugs to Treat Pain, METHADONE SOL Inflammation, and Muscle and Joint METHADONE HCL SOLN 10 MG/5ML Tier 1 X X 10MG/5ML Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint METHADONE SOL 5MG/5ML METHADONE HCL SOLN 5 MG/5ML Tier 1 X X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint METHADONE TAB 10MG METHADONE HCL TAB 10 MG Tier 1 X X Conditions Analgesics - Drugs to Treat Pain, METHADONE HCL TAB FOR ORAL SUSP Inflammation, and Muscle and Joint METHADONE TAB 40MG Tier 1 X 40 MG Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint METHADONE TAB 5MG METHADONE HCL TAB 5 MG Tier 1 X X Conditions Analgesics - Drugs to Treat Pain, METHADOSE CON 10MG/ Inflammation, and Muscle and Joint METHADONE HCL CONC 10 MG/ML Tier 1 X ML Conditions Analgesics - Drugs to Treat Pain, METHADONE HCL TAB FOR ORAL SUSP Inflammation, and Muscle and Joint METHADOSE TAB 40MG Tier 1 X 40 MG Conditions Analgesics - Drugs to Treat Pain, METHADOSE SF CON Inflammation, and Muscle and Joint METHADONE HCL CONC 10 MG/ML Tier 1 X 10MG/ML Conditions Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint MINIPRIN LOW TAB 81MG EC ASPIRIN TAB DELAYED RELEASE 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint MOBIC TAB 15MG MELOXICAM TAB 15 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint MOBIC TAB 7.5MG MELOXICAM TAB 7.5 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, MORPHINE SUL CAP 120MG MORPHINE SULFATE BEADS CAP ER Inflammation, and Muscle and Joint Tier 3 X X X ER 24HR 120 MG Conditions Analgesics - Drugs to Treat Pain, MORPHINE SUL CAP 30MG MORPHINE SULFATE BEADS CAP ER Inflammation, and Muscle and Joint Tier 3 X X X ER 24HR 30 MG Conditions Analgesics - Drugs to Treat Pain, MORPHINE SUL CAP 45MG MORPHINE SULFATE BEADS CAP ER Inflammation, and Muscle and Joint Tier 3 X X X ER 24HR 45 MG Conditions Analgesics - Drugs to Treat Pain, MORPHINE SUL CAP 60MG MORPHINE SULFATE BEADS CAP ER Inflammation, and Muscle and Joint Tier 3 X X X ER 24HR 60 MG Conditions

14 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Analgesics - Drugs to Treat Pain, MORPHINE SUL CAP 75MG MORPHINE SULFATE BEADS CAP ER Inflammation, and Muscle and Joint Tier 3 X X X ER 24HR 75 MG Conditions Analgesics - Drugs to Treat Pain, MORPHINE SUL CAP 90MG MORPHINE SULFATE BEADS CAP ER Inflammation, and Muscle and Joint Tier 3 X X X ER 24HR 90 MG Conditions Analgesics - Drugs to Treat Pain, MORPHINE SUL SOL MORPHINE SULFATE ORAL SOLN 100 Inflammation, and Muscle and Joint Tier 1 100/5ML MG/5ML (20 MG/ML) Conditions Analgesics - Drugs to Treat Pain, MORPHINE SUL SOL MORPHINE SULFATE ORAL SOLN 10 Inflammation, and Muscle and Joint Tier 1 10MG/5ML MG/5ML Conditions Analgesics - Drugs to Treat Pain, MORPHINE SUL SOL MORPHINE SULFATE ORAL SOLN 20 Inflammation, and Muscle and Joint Tier 1 20MG/5ML MG/5ML Conditions Analgesics - Drugs to Treat Pain, MORPHINE SUL TAB 100MG Inflammation, and Muscle and Joint MORPHINE SULFATE TAB ER 100 MG Tier 1 X X ER Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint MORPHINE SUL TAB 15MG MORPHINE SULFATE TAB 15 MG Tier 1 X Conditions Analgesics - Drugs to Treat Pain, MORPHINE SUL TAB 15MG Inflammation, and Muscle and Joint MORPHINE SULFATE TAB ER 15 MG Tier 1 X X ER Conditions Analgesics - Drugs to Treat Pain, MORPHINE SUL TAB 200MG Inflammation, and Muscle and Joint MORPHINE SULFATE TAB ER 200 MG Tier 1 X X ER Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint MORPHINE SUL TAB 30MG MORPHINE SULFATE TAB 30 MG Tier 1 X Conditions Analgesics - Drugs to Treat Pain, MORPHINE SUL TAB 30MG Inflammation, and Muscle and Joint MORPHINE SULFATE TAB ER 30 MG Tier 1 X X ER Conditions Analgesics - Drugs to Treat Pain, MORPHINE SUL TAB 60MG Inflammation, and Muscle and Joint MORPHINE SULFATE TAB ER 60 MG Tier 1 X X ER Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint MS CONTIN TAB 100MG ER MORPHINE SULFATE TAB CR 100 MG Tier 3 X X X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint MS CONTIN TAB 100MG ER MORPHINE SULFATE TAB ER 100 MG Tier 3 X X X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint MS CONTIN TAB 15MG ER MORPHINE SULFATE TAB CR 15 MG Tier 3 X X X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint MS CONTIN TAB 15MG ER MORPHINE SULFATE TAB ER 15 MG Tier 3 X X X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint MS CONTIN TAB 200MG ER MORPHINE SULFATE TAB CR 200 MG Tier 3 X X X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint MS CONTIN TAB 200MG ER MORPHINE SULFATE TAB ER 200 MG Tier 3 X X X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint MS CONTIN TAB 30MG ER MORPHINE SULFATE TAB CR 30 MG Tier 3 X X X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint MS CONTIN TAB 30MG ER MORPHINE SULFATE TAB ER 30 MG Tier 3 X X X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint MS CONTIN TAB 60MG ER MORPHINE SULFATE TAB CR 60 MG Tier 3 X X X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint MS CONTIN TAB 60MG ER MORPHINE SULFATE TAB ER 60 MG Tier 3 X X X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NABUMETONE TAB 500MG NABUMETONE TAB 500 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NABUMETONE TAB 750MG NABUMETONE TAB 750 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NALFON CAP 400MG FENOPROFEN CALCIUM CAP 400 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NAPROSYN SUS 125/5ML NAPROXEN SUSP 125 MG/5ML Tier 3 Conditions

15 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NAPROSYN TAB 500MG NAPROXEN TAB 500 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NAPROXEN SUS 125/5ML NAPROXEN SUSP 125 MG/5ML Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NAPROXEN TAB 250MG NAPROXEN TAB 250 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NAPROXEN TAB 375MG NAPROXEN TAB 375 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NAPROXEN TAB 500MG NAPROXEN TAB 500 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NAPROXEN DR TAB 375MG NAPROXEN TAB EC 375 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NAPROXEN DR TAB 500MG NAPROXEN TAB EC 500 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NAPROXEN SOD TAB 275MG NAPROXEN SODIUM TAB 275 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NAPROXEN SOD TAB 550MG NAPROXEN SODIUM TAB 550 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE-ACETAMINOPHEN TAB Inflammation, and Muscle and Joint NORCO TAB 10-325MG Tier 3 X 10-325 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE-ACETAMINOPHEN TAB Inflammation, and Muscle and Joint NORCO TAB 5-325MG Tier 3 X 5-325 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE-ACETAMINOPHEN TAB Inflammation, and Muscle and Joint NORCO TAB 7.5-325 Tier 3 X 7.5 - 325 MG Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NUCYNTA TAB 100MG TAPENTADOL HCL TAB 100 MG Tier 3 X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NUCYNTA TAB 50MG TAPENTADOL HCL TAB 50 MG Tier 3 X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NUCYNTA TAB 75MG TAPENTADOL HCL TAB 75 MG Tier 3 X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NUCYNTA ER TAB 100MG TAPENTADOL HCL TAB ER 12HR 100 MG Tier 3 X X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NUCYNTA ER TAB 150MG TAPENTADOL HCL TAB ER 12HR 150 MG Tier 3 X X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NUCYNTA ER TAB 200MG TAPENTADOL HCL TAB ER 12HR 200 MG Tier 3 X X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NUCYNTA ER TAB 250MG TAPENTADOL HCL TAB ER 12HR 250 MG Tier 3 X X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint NUCYNTA ER TAB 50MG TAPENTADOL HCL TAB ER 12HR 50 MG Tier 3 X X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint OPANA TAB 10MG OXYMORPHONE HCL TAB 10 MG Tier 3 X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint OPANA TAB 5MG OXYMORPHONE HCL TAB 5 MG Tier 3 X Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint OXAPROZIN TAB 600MG OXAPROZIN TAB 600 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, OXYCOD/APAP TAB 10- OXYCODONE W/ ACETAMINOPHEN TAB Inflammation, and Muscle and Joint Tier 1 X 325MG 10-325 MG Conditions Analgesics - Drugs to Treat Pain, OXYCODONE W/ ACETAMINOPHEN TAB Inflammation, and Muscle and Joint OXYCOD/APAP TAB 2.5-325 Tier 1 X 2.5-325 MG Conditions Analgesics - Drugs to Treat Pain, OXYCOD/APAP TAB OXYCODONE W/ ACETAMINOPHEN TAB Inflammation, and Muscle and Joint Tier 1 X 5-325MG 5-325 MG Conditions

16 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Analgesics - Drugs to Treat Pain, OXYCODONE W/ ACETAMINOPHEN TAB Inflammation, and Muscle and Joint OXYCOD/APAP TAB 7.5-325 Tier 1 X 7.5 - 325 MG Conditions Analgesics - Drugs to Treat Pain, OXYCODONE-ASPIRIN TAB 4.8355-325 Inflammation, and Muscle and Joint OXYCOD/ASA TAB Tier 1 MG Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint OXYCOD/IBU TAB 5-400MG OXYCODONE-IBUPROFEN TAB 5-400 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint OXYCODONE CAP 5MG OXYCODONE HCL CAP 5 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, OXYCODONE HCL CONC 100 MG/5ML Inflammation, and Muscle and Joint OXYCODONE CON 10/0.5ML Tier 1 (20 MG/ML) Conditions Analgesics - Drugs to Treat Pain, OXYCODONE HCL CONC 100 MG/5ML Inflammation, and Muscle and Joint OXYCODONE CON 100/5ML Tier 1 (20 MG/ML) Conditions Analgesics - Drugs to Treat Pain, OXYCODONE CON 20MG/ OXYCODONE HCL CONC 100 MG/5ML Inflammation, and Muscle and Joint Tier 1 ML (20 MG/ML) Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint OXYCODONE SOL 5MG/5ML OXYCODONE HCL SOLN 5 MG/5ML Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint OXYCODONE TAB 10MG OXYCODONE HCL TAB 10 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint OXYCODONE TAB 15MG OXYCODONE HCL TAB 15 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint OXYCODONE TAB 20MG OXYCODONE HCL TAB 20 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint OXYCODONE TAB 30MG OXYCODONE HCL TAB 30 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint OXYCODONE TAB 5MG OXYCODONE HCL TAB 5 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, OXYCODONE W/ ACETAMINOPHEN Inflammation, and Muscle and Joint OXYCODONE/ SOL APAP Tier 2 X SOLN 5-325 MG/5ML Conditions Analgesics - Drugs to Treat Pain, OXYMORPHONE TAB 10MG OXYMORPHONE HCL TAB ER 12HR 10 Inflammation, and Muscle and Joint Tier 3 X X X ER MG Conditions Analgesics - Drugs to Treat Pain, OXYMORPHONE TAB 15MG OXYMORPHONE HCL TAB ER 12HR 15 Inflammation, and Muscle and Joint Tier 3 X X X ER MG Conditions Analgesics - Drugs to Treat Pain, OXYMORPHONE TAB 20MG OXYMORPHONE HCL TAB ER 12HR 20 Inflammation, and Muscle and Joint Tier 3 X X X ER MG Conditions Analgesics - Drugs to Treat Pain, OXYMORPHONE TAB 30MG OXYMORPHONE HCL TAB ER 12HR 30 Inflammation, and Muscle and Joint Tier 3 X X X ER MG Conditions Analgesics - Drugs to Treat Pain, OXYMORPHONE TAB 40MG OXYMORPHONE HCL TAB ER 12HR 40 Inflammation, and Muscle and Joint Tier 3 X X X ER MG Conditions Analgesics - Drugs to Treat Pain, OXYMORPHONE TAB 5MG Inflammation, and Muscle and Joint OXYMORPHONE HCL TAB ER 12HR 5 MG Tier 3 X X X ER Conditions Analgesics - Drugs to Treat Pain, OXYMORPHONE TAB 7.5MG OXYMORPHONE HCL TAB ER 12HR 7.5 Inflammation, and Muscle and Joint Tier 3 X X X ER MG Conditions Analgesics - Drugs to Treat Pain, OXYMORPHONE TAB HCL Inflammation, and Muscle and Joint OXYMORPHONE HCL TAB 10 MG Tier 2 X 10MG Conditions Analgesics - Drugs to Treat Pain, OXYMORPHONE TAB HCL Inflammation, and Muscle and Joint OXYMORPHONE HCL TAB 5 MG Tier 2 X 5MG Conditions Analgesics - Drugs to Treat Pain, PENTAZ/NALOX TAB 50- PENTAZOCINE W/ NALOXONE TAB 50- Inflammation, and Muscle and Joint Tier 1 0.5MG 0.5 MG Conditions Analgesics - Drugs to Treat Pain, BUTALBITAL-ACETAMINOPHEN- Inflammation, and Muscle and Joint PHRENILIN CAP FORTE Tier 3 X CAFFEINE CAP 50-300-40 MG Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint PIROXICAM CAP 10MG PIROXICAM CAP 10 MG Tier 1 Conditions

17 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint PIROXICAM CAP 20MG PIROXICAM CAP 20 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint PONSTEL CAP 250MG MEFENAMIC ACID CAP 250 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, OXYCODONE W/ ACETAMINOPHEN TAB Inflammation, and Muscle and Joint PRIMLEV TAB 10-300MG Tier 3 X 10-300 MG Conditions Analgesics - Drugs to Treat Pain, OXYCODONE W/ ACETAMINOPHEN TAB Inflammation, and Muscle and Joint PRIMLEV TAB 5-300MG Tier 3 X 5-300 MG Conditions Analgesics - Drugs to Treat Pain, OXYCODONE W/ ACETAMINOPHEN TAB Inflammation, and Muscle and Joint PRIMLEV TAB 7.5-300 Tier 3 X 7.5 - 300 MG Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint PROFENO TAB 600MG FENOPROFEN CALCIUM TAB 600 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint PX ASPIRIN TAB 325MG ASPIRIN TAB 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint PX ASPIRIN TAB 325MG EC ASPIRIN TAB DELAYED RELEASE 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint QC ASPIRIN TAB 325MG ASPIRIN TAB 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint QC ASPIRIN TAB 325MG EC ASPIRIN TAB DELAYED RELEASE 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint QC CHILD ASA CHW 81MG ASPIRIN CHEW TAB 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint RA ASPIRIN CHW 81MG ASPIRIN CHEW TAB 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint RA ASPIRIN TAB 325MG ASPIRIN TAB 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint RA ASPIRIN TAB 325MG EC ASPIRIN TAB DELAYED RELEASE 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint RA ASPIRIN TAB 81MG EC ASPIRIN TAB DELAYED RELEASE 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint RA CHILD ASA CHW 81MG ASPIRIN CHEW TAB 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HYDROCODONE-IBUPROFEN TAB 10- Inflammation, and Muscle and Joint REPREXAIN TAB 10-200MG Tier 1 200 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE-IBUPROFEN TAB 5-200 Inflammation, and Muscle and Joint REPREXAIN TAB 5-200MG Tier 1 MG Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint ROXICODONE TAB 15MG OXYCODONE HCL TAB 15 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint ROXICODONE TAB 30MG OXYCODONE HCL TAB 30 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint ROXICODONE TAB 5MG OXYCODONE HCL TAB 5 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint SALSALATE TAB 500MG SALSALATE TAB 500 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint SALSALATE TAB 750MG SALSALATE TAB 750 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint SM ASPIRIN CHW 81MG ASPIRIN CHEW TAB 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint SM ASPIRIN TAB 325MG ASPIRIN TAB 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint SM ASPIRIN TAB 325MG EC ASPIRIN TAB DELAYED RELEASE 325 MG Preventive Conditions Care

18 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint SM ASPIRIN TAB 81MG EC ASPIRIN TAB DELAYED RELEASE 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint SM CHILD ASA CHW 81MG ASPIRIN CHEW TAB 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, KETOROLAC TROMETHAMINE NASAL Inflammation, and Muscle and Joint SPRIX SPR 15.75MG Tier 3 SPRAY 15.75 MG/SPRAY Conditions Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint ST JOSEPH CHW LOW 81MG ASPIRIN CHEW TAB 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint SULINDAC TAB 150MG SULINDAC TAB 150 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint SULINDAC TAB 200MG SULINDAC TAB 200 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, ASPIRIN-CAFFEINE-DIHYDROCODEINE Inflammation, and Muscle and Joint SYNALGOS-DC CAP Tier 3 CAP 356.4-30-16 MG Conditions Analgesics - Drugs to Treat Pain, BUTALBITAL-ACETAMINOPHEN TAB 50- Inflammation, and Muscle and Joint TENCON TAB 50-325MG Tier 1 325 MG Conditions Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint TGT ASPIRIN CHW 81MG ASPIRIN CHEW TAB 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint TGT ASPIRIN CHW CHILD ASPIRIN CHEW TAB 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint TGT ASPIRIN TAB 325MG ASPIRIN TAB 325 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint TGT ASPIRIN TAB 81MG ASPIRIN TAB DELAYED RELEASE 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, HCR Inflammation, and Muscle and Joint TGT ASPIRIN TAB 81MG EC ASPIRIN TAB DELAYED RELEASE 81 MG Preventive Conditions Care Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint TOLMETIN SOD CAP 400MG TOLMETIN SODIUM CAP 400 MG Tier 2 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint TOLMETIN SOD TAB 200MG TOLMETIN SODIUM TAB 200 MG Tier 2 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint TOLMETIN SOD TAB 600MG TOLMETIN SODIUM TAB 600 MG Tier 2 Conditions Analgesics - Drugs to Treat Pain, TRAMADL/APAP TAB 37.5- TRAMADOL-ACETAMINOPHEN TAB 37.5- Inflammation, and Muscle and Joint Tier 1 X 325 325 MG Conditions Analgesics - Drugs to Treat Pain, TRAMADOL HCL CAP TRAMADOL HCL CAP ER 24HR BIPHASIC Inflammation, and Muscle and Joint Tier 1 X 150MG ER RELEASE 150 MG Conditions Analgesics - Drugs to Treat Pain, TRAMADOL HCL TAB Inflammation, and Muscle and Joint TRAMADOL HCL TAB ER 24HR 100 MG Tier 2 X 100MG ER Conditions Analgesics - Drugs to Treat Pain, TRAMADOL HCL TAB Inflammation, and Muscle and Joint TRAMADOL HCL TAB ER 24HR 200 MG Tier 2 X 200MG ER Conditions Analgesics - Drugs to Treat Pain, TRAMADOL HCL TAB Inflammation, and Muscle and Joint TRAMADOL HCL TAB ER 24HR 300 MG Tier 2 X 300MG ER Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint TRAMADOL HCL TAB 50MG TRAMADOL HCL TAB 50 MG Tier 1 Conditions Analgesics - Drugs to Treat Pain, ACETAMINOPHEN-CAFFEINE- Inflammation, and Muscle and Joint TREZIX CAP Tier 3 X DIHYDROCODEINE CAP 320.5-30-16 MG Conditions Analgesics - Drugs to Treat Pain, ACETAMINOPHEN W/ CODEINE TAB 300- Inflammation, and Muscle and Joint TYLENOL/COD TAB #3 Tier 3 X 30 MG Conditions Analgesics - Drugs to Treat Pain, ACETAMINOPHEN W/ CODEINE TAB 300- Inflammation, and Muscle and Joint TYLENOL/COD TAB #4 Tier 3 X 60 MG Conditions Analgesics - Drugs to Treat Pain, TRAMADOL-ACETAMINOPHEN TAB 37.5- Inflammation, and Muscle and Joint ULTRACET TAB 37.5-325 Tier 3 X 325 MG Conditions

19 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint ULTRAM TAB 50MG TRAMADOL HCL TAB 50 MG Tier 3 Conditions Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint ULTRAM ER TAB 300MG TRAMADOL HCL TAB ER 24HR 300 MG Tier 3 X Conditions Analgesics - Drugs to Treat Pain, BUTALBITAL-ACETAMINOPHEN- Inflammation, and Muscle and Joint VANATOL LQ SOL Tier 1 X X CAFFEINE SOLN 50-325-40 MG/15ML Conditions Analgesics - Drugs to Treat Pain, BUTALBITAL-ACETAMINOPHEN- Inflammation, and Muscle and Joint VANATOL S SOL Tier 1 X X CAFFEINE SOLN 50-325-40 MG/15ML Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE-ACETAMINOPHEN TAB Inflammation, and Muscle and Joint VERDROCET TAB 2.5-325 Tier 1 2.5-325 MG Conditions Analgesics - Drugs to Treat Pain, OXYCODONE CAP ER 12HR ABUSE- Inflammation, and Muscle and Joint XTAMPZA ER CAP 13.5MG Tier 2 X X DETERRENT 13.5 MG Conditions Analgesics - Drugs to Treat Pain, OXYCODONE CAP ER 12HR ABUSE- Inflammation, and Muscle and Joint XTAMPZA ER CAP 18MG Tier 2 X X DETERRENT 18 MG Conditions Analgesics - Drugs to Treat Pain, OXYCODONE CAP ER 12HR ABUSE- Inflammation, and Muscle and Joint XTAMPZA ER CAP 27MG Tier 2 X X DETERRENT 27 MG Conditions Analgesics - Drugs to Treat Pain, OXYCODONE CAP ER 12HR ABUSE- Inflammation, and Muscle and Joint XTAMPZA ER CAP 36MG Tier 2 X X DETERRENT 36 MG Conditions Analgesics - Drugs to Treat Pain, OXYCODONE CAP ER 12HR ABUSE- Inflammation, and Muscle and Joint XTAMPZA ER CAP 9MG Tier 2 X X DETERRENT 9 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE-IBUPROFEN TAB 10- Inflammation, and Muscle and Joint XYLON TAB 10-200MG Tier 1 200 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE-ACETAMINOPHEN Inflammation, and Muscle and Joint ZAMICET SOL 10-325MG Tier 1 X SOLN 10-325 MG/15ML Conditions Analgesics - Drugs to Treat Pain, BUTALBITAL-ACETAMINOPHEN- Inflammation, and Muscle and Joint ZEBUTAL CAP Tier 1 X CAFFEINE CAP 50-325-40 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE BITARTRATE CAP ER Inflammation, and Muscle and Joint ZOHYDRO ER CAP 10MG Tier 3 X X X 12HR ABUSE-DETERRENT 10 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE BITARTRATE CAP SR Inflammation, and Muscle and Joint ZOHYDRO ER CAP 15MG Tier 3 X X X 12HR ABUSE-DETERRENT 15 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE BITARTRATE CAP ER Inflammation, and Muscle and Joint ZOHYDRO ER CAP 20MG Tier 3 X X X 12HR ABUSE-DETERRENT 20 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE BITARTRATE CAP ER Inflammation, and Muscle and Joint ZOHYDRO ER CAP 30MG Tier 3 X X X 12HR ABUSE-DETERRENT 30 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE BITARTRATE CAP ER Inflammation, and Muscle and Joint ZOHYDRO ER CAP 40MG Tier 3 X X X 12HR ABUSE-DETERRENT 40 MG Conditions Analgesics - Drugs to Treat Pain, HYDROCODONE BITARTRATE CAP SR Inflammation, and Muscle and Joint ZOHYDRO ER CAP 50MG Tier 3 X X X 12HR ABUSE-DETERRENT 50 MG Conditions Anesthetics - Drugs for Numbing BUPIVACAINE POW HCL BUPIVACAINE HCL POWDER Tier 3 LIDOCAINE PATCH 5% & CAPSAICIN Anesthetics - Drugs for Numbing DERMACINRX PAK Tier 3 CREAM 0.025% THERAPY PACK DERMACINRX PAK LIDOCAINE PATCH 5% & MENTHOL- Anesthetics - Drugs for Numbing Tier 3 DUOPATCH METHYL SAL PATCH 3-10% THER PAK LIDOCAINE-PRILOCAINE CREAM 2.5- Anesthetics - Drugs for Numbing LIDO/PRILOCN CRE 2.5-2.5% Tier 1 2.5% Anesthetics - Drugs for Numbing LIDOCAINE GEL 2% JELLY LIDOCAINE HCL GEL 2% Tier 1 Anesthetics - Drugs for Numbing LIDOCAINE OIN 5% LIDOCAINE OINT 5% Tier 2 X Anesthetics - Drugs for Numbing LIDOCAINE OIN PAK 5% LIDOCAINE OINT 5% Tier 2 X Anesthetics - Drugs for Numbing LIDOCAINE PAD 5% LIDOCAINE PATCH 5% Tier 3 X X Anesthetics - Drugs for Numbing LIDOCAINE SOL 2% VISC LIDOCAINE HCL VISCOUS SOLN 2% Tier 1 Anesthetics - Drugs for Numbing LIDOCAINE SOL 4% LIDOCAINE HCL SOLN 4% Tier 1 LIDOCAINE HCL LARYNGOTRACHEAL Anesthetics - Drugs for Numbing LIDOCAINE SOL 4% Tier 1 SOLN 4% Anesthetics - Drugs for Numbing LIDOPIN CRE 3.25% LIDOCAINE HCL CREAM 3.25% Tier 3 Anesthetics - Drugs for Numbing LIDOVEX CRE 3.75% LIDOCAINE CREAM 3.75% Tier 3 LIDOCAINE-CAPSAICIN-CHONDROITIN- Anesthetics - Drugs for Numbing REMAXAZON PAD Tier 3 GLUCOS PATCH 4-0.0285-3-5% Anesthetics - Drugs for Numbing SYNVEXIA TC CRE 4-1% LIDOCAINE-MENTHOL CREAM 4-1% Tier 3 Anesthetics - Drugs for Numbing VELTRIX CRE 4-1% LIDOCAINE-MENTHOL CREAM 4-1% Tier 3 Anesthetics - Drugs for Numbing XYLOCAINE SOL 4% LIDOCAINE HCL SOLN 4% Tier 3 20 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Anti-Addiction/Substance Abuse ACAMPROSATE CALCIUM TAB DELAYED Treatment Agents - Drugs for Overdose ACAMPRO CAL TAB 333MG Tier 1 RELEASE 333 MG or Deterrence Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose ANTABUSE TAB 250MG DISULFIRAM TAB 250 MG Tier 3 or Deterrence Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose ANTABUSE TAB 500MG DISULFIRAM TAB 500 MG Tier 3 or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE HCL BUCCAL FILM Treatment Agents - Drugs for Overdose BELBUCA MIS 150MCG Tier 3 X X 150 MCG (BASE EQUIVALENT) or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE HCL BUCCAL FILM Treatment Agents - Drugs for Overdose BELBUCA MIS 300MCG Tier 3 X X 300 MCG (BASE EQUIVALENT) or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE HCL BUCCAL FILM Treatment Agents - Drugs for Overdose BELBUCA MIS 450MCG Tier 3 X X 450 MCG (BASE EQUIVALENT) or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE HCL BUCCAL FILM Treatment Agents - Drugs for Overdose BELBUCA MIS 600MCG Tier 3 X X 600 MCG (BASE EQUIVALENT) or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE HCL BUCCAL FILM Treatment Agents - Drugs for Overdose BELBUCA MIS 750MCG Tier 3 X X 750 MCG (BASE EQUIVALENT) or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE HCL BUCCAL FILM 75 Treatment Agents - Drugs for Overdose BELBUCA MIS 75MCG Tier 3 X X MCG (BASE EQUIVALENT) or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE HCL BUCCAL FILM Treatment Agents - Drugs for Overdose BELBUCA MIS 900MCG Tier 3 X X 900 MCG (BASE EQUIVALENT) or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE-NALOXONE BUCCAL Treatment Agents - Drugs for Overdose BUNAVAIL MIS 2.1-0.3 Tier 3 X X X FILM 2.1-0.3 MG (BASE EQUIV) or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE-NALOXONE BUCCAL Treatment Agents - Drugs for Overdose BUNAVAIL MIS 4.2-0.7 Tier 3 X X X FILM 4.2-0.7 MG (BASE EQUIV) or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE-NALOXONE BUCCAL Treatment Agents - Drugs for Overdose BUNAVAIL MIS 6.3-1MG Tier 3 X X X FILM 6.3-1 MG (BASE EQUIV) or Deterrence Anti-Addiction/Substance Abuse BUPREN/NALOX SUB BUPRENORPHINE HCL-NALOXONE HCL Treatment Agents - Drugs for Overdose Tier 3 X X X 2-0.5MG SL TAB 2-0.5 MG (BASE EQUIV) or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE HCL-NALOXONE HCL Treatment Agents - Drugs for Overdose BUPREN/NALOX SUB 8-2MG Tier 3 X X X SL TAB 8-2 MG (BASE EQUIV) or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE HCL SL TAB 2 MG Treatment Agents - Drugs for Overdose BUPRENORPHIN SUB 2MG Tier 1 X (BASE EQUIV) or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE HCL SL TAB 8 MG Treatment Agents - Drugs for Overdose BUPRENORPHIN SUB 8MG Tier 1 X (BASE EQUIV) or Deterrence Anti-Addiction/Substance Abuse HCR BUPROPION HCL (SMOKING Treatment Agents - Drugs for Overdose BUPROPION TAB 150MG Preventive DETERRENT) TAB ER 12HR 150 MG or Deterrence Care Anti-Addiction/Substance Abuse HCR VARENICLINE TARTRATE TAB 0.5 MG X Treatment Agents - Drugs for Overdose CHANTIX PAK 0.5& 1MG Preventive X 11 & TAB 1 MG X 42 PACK or Deterrence Care Anti-Addiction/Substance Abuse HCR VARENICLINE TARTRATE TAB 1 MG Treatment Agents - Drugs for Overdose CHANTIX PAK 1MG Preventive X (BASE EQUIV) or Deterrence Care Anti-Addiction/Substance Abuse HCR VARENICLINE TARTRATE TAB 0.5 MG Treatment Agents - Drugs for Overdose CHANTIX TAB 0.5MG Preventive X (BASE EQUIV) or Deterrence Care Anti-Addiction/Substance Abuse HCR VARENICLINE TARTRATE TAB 1 MG Treatment Agents - Drugs for Overdose CHANTIX TAB 1MG Preventive X (BASE EQUIV) or Deterrence Care Anti-Addiction/Substance Abuse HCR CVS NICOTINE DIS Treatment Agents - Drugs for Overdose NICOTINE TD PATCH 24HR 14 MG/24HR Preventive 14MG/24H or Deterrence Care Anti-Addiction/Substance Abuse HCR CVS NICOTINE DIS Treatment Agents - Drugs for Overdose NICOTINE TD PATCH 24HR 21 MG/24HR Preventive 21MG/24H or Deterrence Care Anti-Addiction/Substance Abuse HCR CVS NICOTINE DIS Treatment Agents - Drugs for Overdose NICOTINE TD PATCH 24HR 7 MG/24HR Preventive 7MG/24HR or Deterrence Care Anti-Addiction/Substance Abuse HCR Treatment Agents - Drugs for Overdose CVS NTS DIS STEP 1 NICOTINE TD PATCH 24HR 21 MG/24HR Preventive or Deterrence Care

21 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose DISULFIRAM TAB 250MG DISULFIRAM TAB 250 MG Tier 1 or Deterrence Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose DISULFIRAM TAB 500MG DISULFIRAM TAB 500 MG Tier 1 or Deterrence Anti-Addiction/Substance Abuse HCR Treatment Agents - Drugs for Overdose EQ NICOTINE DIS 14MG/24H NICOTINE TD PATCH 24HR 14 MG/24HR Preventive or Deterrence Care Anti-Addiction/Substance Abuse HCR Treatment Agents - Drugs for Overdose EQ NICOTINE DIS 21MG/24H NICOTINE TD PATCH 24HR 21 MG/24HR Preventive or Deterrence Care Anti-Addiction/Substance Abuse HCR Treatment Agents - Drugs for Overdose EQ NICOTINE DIS 7MG/24HR NICOTINE TD PATCH 24HR 7 MG/24HR Preventive or Deterrence Care Anti-Addiction/Substance Abuse NALOXONE HCL SOLUTION AUTO- Treatment Agents - Drugs for Overdose EVZIO INJ Tier 4 X X INJECTOR 0.4 MG/0.4ML or Deterrence Anti-Addiction/Substance Abuse NALOXONE HCL SOLUTION AUTO- Treatment Agents - Drugs for Overdose EVZIO INJ 2/0.4ML Tier 4 X X INJECTOR 2 MG/0.4ML or Deterrence Anti-Addiction/Substance Abuse HCR GNP NICOTINE DIS Treatment Agents - Drugs for Overdose NICOTINE TD PATCH 24HR 21 MG/24HR Preventive 21MG/24H or Deterrence Care Anti-Addiction/Substance Abuse HCR GNP NICOTINE DIS Treatment Agents - Drugs for Overdose NICOTINE TD PATCH 24HR 7 MG/24HR Preventive 7MG/24HR or Deterrence Care Anti-Addiction/Substance Abuse HCR Treatment Agents - Drugs for Overdose HM NICOTINE DIS 14MG/24H NICOTINE TD PATCH 24HR 14 MG/24HR Preventive or Deterrence Care Anti-Addiction/Substance Abuse HCR Treatment Agents - Drugs for Overdose HM NICOTINE DIS 21MG/24H NICOTINE TD PATCH 24HR 21 MG/24HR Preventive or Deterrence Care Anti-Addiction/Substance Abuse HCR HM NICOTINE DIS Treatment Agents - Drugs for Overdose NICOTINE TD PATCH 24HR 7 MG/24HR Preventive 7MG/24HR or Deterrence Care Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose NALOXONE INJ 0.4MG/ML NALOXONE HCL INJ 0.4 MG/ML Tier 1 or Deterrence Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose NALOXONE INJ 0.4MG/ML NALOXONE HCL INJ 4 MG/10ML Tier 1 or Deterrence Anti-Addiction/Substance Abuse NALOXONE HCL SOLN CARTRIDGE 0.4 Treatment Agents - Drugs for Overdose NALOXONE INJ 0.4MG/ML Tier 1 MG/ML or Deterrence Anti-Addiction/Substance Abuse NALOXONE HCL SOLN PREFILLED Treatment Agents - Drugs for Overdose NALOXONE INJ 1MG/ML Tier 1 SYRINGE 2 MG/2ML or Deterrence Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose NALTREXONE TAB 50MG NALTREXONE HCL TAB 50 MG Tier 1 or Deterrence Anti-Addiction/Substance Abuse NALOXONE HCL NASAL SPRAY 4 Treatment Agents - Drugs for Overdose NARCAN SPR Tier 2 X MG/0.1ML or Deterrence Anti-Addiction/Substance Abuse HCR NICODERM CQ DIS Treatment Agents - Drugs for Overdose NICOTINE TD PATCH 24HR 14 MG/24HR Preventive 14MG/24H or Deterrence Care Anti-Addiction/Substance Abuse HCR NICODERM CQ DIS Treatment Agents - Drugs for Overdose NICOTINE TD PATCH 24HR 21 MG/24HR Preventive 21MG/24H or Deterrence Care Anti-Addiction/Substance Abuse HCR NICODERM CQ DIS Treatment Agents - Drugs for Overdose NICOTINE TD PATCH 24HR 7 MG/24HR Preventive 7MG/24HR or Deterrence Care Anti-Addiction/Substance Abuse HCR Treatment Agents - Drugs for Overdose NICOTINE DIS 14MG/24H NICOTINE TD PATCH 24HR 14 MG/24HR Preventive or Deterrence Care Anti-Addiction/Substance Abuse HCR Treatment Agents - Drugs for Overdose NICOTINE DIS 21MG/24H NICOTINE TD PATCH 24HR 21 MG/24HR Preventive or Deterrence Care Anti-Addiction/Substance Abuse HCR Treatment Agents - Drugs for Overdose NICOTINE DIS 7MG/24HR NICOTINE TD PATCH 24HR 7 MG/24HR Preventive or Deterrence Care Anti-Addiction/Substance Abuse HCR NICOTINE SYS KIT NICOTINE TD PATCH 24 HR KIT 21-14-7 Treatment Agents - Drugs for Overdose Preventive TRANSDER MG/24HR or Deterrence Care Anti-Addiction/Substance Abuse HCR Treatment Agents - Drugs for Overdose NICOTINE TD DIS 14MG/24H NICOTINE TD PATCH 24HR 14 MG/24HR Preventive or Deterrence Care

22 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Anti-Addiction/Substance Abuse HCR Treatment Agents - Drugs for Overdose NICOTINE TD DIS 21MG/24H NICOTINE TD PATCH 24HR 21 MG/24HR Preventive or Deterrence Care Anti-Addiction/Substance Abuse HCR Treatment Agents - Drugs for Overdose NICOTINE TD DIS 7MG/24HR NICOTINE TD PATCH 24HR 7 MG/24HR Preventive or Deterrence Care Anti-Addiction/Substance Abuse HCR NICOTINE INHALER SYSTEM 10 MG (4 Treatment Agents - Drugs for Overdose NICOTROL INH Preventive X MG DELIVERED) or Deterrence Care Anti-Addiction/Substance Abuse HCR NICOTROL NS SPR 10MG/ NICOTINE NASAL SPRAY 10 MG/ML (0.5 Treatment Agents - Drugs for Overdose Preventive X ML MG/SPRAY) or Deterrence Care Anti-Addiction/Substance Abuse HCR Treatment Agents - Drugs for Overdose RA NICOTINE DIS 14MG/24H NICOTINE TD PATCH 24HR 14 MG/24HR Preventive or Deterrence Care Anti-Addiction/Substance Abuse HCR Treatment Agents - Drugs for Overdose RA NICOTINE DIS 21MG/24H NICOTINE TD PATCH 24HR 21 MG/24HR Preventive or Deterrence Care Anti-Addiction/Substance Abuse HCR Treatment Agents - Drugs for Overdose RA NICOTINE DIS 7MG/24HR NICOTINE TD PATCH 24HR 7 MG/24HR Preventive or Deterrence Care Anti-Addiction/Substance Abuse HCR Treatment Agents - Drugs for Overdose SM NICOTINE DIS 14MG/24H NICOTINE TD PATCH 24HR 14 MG/24HR Preventive or Deterrence Care Anti-Addiction/Substance Abuse HCR Treatment Agents - Drugs for Overdose SM NICOTINE DIS 21MG NICOTINE TD PATCH 24HR 21 MG/24HR Preventive or Deterrence Care Anti-Addiction/Substance Abuse HCR Treatment Agents - Drugs for Overdose SM NICOTINE DIS 21MG/24H NICOTINE TD PATCH 24HR 21 MG/24HR Preventive or Deterrence Care Anti-Addiction/Substance Abuse HCR Treatment Agents - Drugs for Overdose SM NICOTINE DIS 7MG/24HR NICOTINE TD PATCH 24HR 7 MG/24HR Preventive or Deterrence Care Anti-Addiction/Substance Abuse BUPRENORPHINE HCL-NALOXONE HCL Treatment Agents - Drugs for Overdose SUBOXONE MIS 12-3MG Tier 3 X X X SL FILM 12-3 MG (BASE EQUIV) or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE HCL-NALOXONE HCL Treatment Agents - Drugs for Overdose SUBOXONE MIS 2-0.5MG Tier 3 X X X SL FILM 2-0.5 MG (BASE EQUIV) or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE HCL-NALOXONE HCL Treatment Agents - Drugs for Overdose SUBOXONE MIS 4-1MG Tier 3 X X X SL FILM 4-1 MG (BASE EQUIV) or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE HCL-NALOXONE HCL Treatment Agents - Drugs for Overdose SUBOXONE MIS 8-2MG Tier 3 X X X SL FILM 8-2 MG (BASE EQUIV) or Deterrence Anti-Addiction/Substance Abuse HCR TGT NICOTINE DIS Treatment Agents - Drugs for Overdose NICOTINE TD PATCH 24HR 14 MG/24HR Preventive 14MG/24H or Deterrence Care Anti-Addiction/Substance Abuse HCR TGT NICOTINE DIS Treatment Agents - Drugs for Overdose NICOTINE TD PATCH 24HR 21 MG/24HR Preventive 21MG/24H or Deterrence Care Anti-Addiction/Substance Abuse HCR TGT NICOTINE DIS Treatment Agents - Drugs for Overdose NICOTINE TD PATCH 24HR 7 MG/24HR Preventive 7MG/24HR or Deterrence Care Anti-Addiction/Substance Abuse BUPRENORPHINE HCL-NALOXONE HCL Treatment Agents - Drugs for Overdose ZUBSOLV SUB 0.7-0.18 Tier 1 X SL TAB 0.7-0.18 MG (BASE EQ) or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE HCL-NALOXONE HCL Treatment Agents - Drugs for Overdose ZUBSOLV SUB 1.4-0.36 Tier 1 X SL TAB 1.4-0.36 MG (BASE EQ) or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE HCL-NALOXONE HCL Treatment Agents - Drugs for Overdose ZUBSOLV SUB 11.4-2.9 Tier 1 X SL TAB 11.4-2.9 MG (BASE EQ) or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE HCL-NALOXONE HCL Treatment Agents - Drugs for Overdose ZUBSOLV SUB 2.9-0.71 Tier 1 X SL TAB 2.9-0.71 MG (BASE EQ) or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE HCL-NALOXONE HCL Treatment Agents - Drugs for Overdose ZUBSOLV SUB 5.7-1.4 Tier 1 X SL TAB 5.7-1.4 MG (BASE EQ) or Deterrence Anti-Addiction/Substance Abuse BUPRENORPHINE HCL-NALOXONE HCL Treatment Agents - Drugs for Overdose ZUBSOLV SUB 8.6-2.1 Tier 1 X SL TAB 8.6-2.1 MG (BASE EQ) or Deterrence Antibacterials - Drugs to Treat Bacterial ALTABAX OIN 1% RETAPAMULIN OINT 1% Tier 3 X Infections Antibacterials - Drugs to Treat Bacterial AMOXICILLIN & K CLAVULANATE CHEW AMOX/K CLAV CHW 200MG Tier 1 Infections TAB 200-28.5 MG Antibacterials - Drugs to Treat Bacterial AMOXICILLIN & K CLAVULANATE CHEW AMOX/K CLAV CHW 400MG Tier 1 Infections TAB 400-57 MG Antibacterials - Drugs to Treat Bacterial AMOXICILLIN & K CLAVULANATE FOR AMOX/K CLAV SUS 200/5ML Tier 1 Infections SUSP 200-28.5 MG/5ML

23 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antibacterials - Drugs to Treat Bacterial AMOXICILLIN & K CLAVULANATE FOR AMOX/K CLAV SUS 250/5ML Tier 1 Infections SUSP 250-62.5 MG/5ML Antibacterials - Drugs to Treat Bacterial AMOXICILLIN & K CLAVULANATE FOR AMOX/K CLAV SUS 400/5ML Tier 1 Infections SUSP 400-57 MG/5ML Antibacterials - Drugs to Treat Bacterial AMOXICILLIN & K CLAVULANATE FOR AMOX/K CLAV SUS 600/5ML Tier 1 Infections SUSP 600-42.9 MG/5ML Antibacterials - Drugs to Treat Bacterial AMOXICILLIN & K CLAVULANATE TAB AMOX/K CLAV TAB 250-125 Tier 1 Infections 250-125 MG Antibacterials - Drugs to Treat Bacterial AMOXICILLIN & K CLAVULANATE TAB AMOX/K CLAV TAB 500-125 Tier 1 Infections 500-125 MG Antibacterials - Drugs to Treat Bacterial AMOXICILLIN & K CLAVULANATE TAB AMOX/K CLAV TAB 875-125 Tier 1 Infections 875-125 MG Antibacterials - Drugs to Treat Bacterial AMOXICILLIN CAP 250MG AMOXICILLIN (TRIHYDRATE) CAP 250 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial AMOXICILLIN CAP 500MG AMOXICILLIN (TRIHYDRATE) CAP 500 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial AMOXICILLIN (TRIHYDRATE) CHEW TAB AMOXICILLIN CHW 125MG Tier 1 Infections 125 MG Antibacterials - Drugs to Treat Bacterial AMOXICILLIN (TRIHYDRATE) CHEW TAB AMOXICILLIN CHW 250MG Tier 1 Infections 250 MG Antibacterials - Drugs to Treat Bacterial AMOXICILLIN (TRIHYDRATE) FOR SUSP AMOXICILLIN SUS 125/5ML Tier 1 Infections 125 MG/5ML Antibacterials - Drugs to Treat Bacterial AMOXICILLIN (TRIHYDRATE) FOR SUSP AMOXICILLIN SUS 200/5ML Tier 1 Infections 200 MG/5ML Antibacterials - Drugs to Treat Bacterial AMOXICILLIN (TRIHYDRATE) FOR SUSP AMOXICILLIN SUS 250/5ML Tier 1 Infections 250 MG/5ML Antibacterials - Drugs to Treat Bacterial AMOXICILLIN SUS AMOXICILLIN (TRIHYDRATE) FOR SUSP Tier 1 Infections 250MG/5M 250 MG/5ML Antibacterials - Drugs to Treat Bacterial AMOXICILLIN (TRIHYDRATE) FOR SUSP AMOXICILLIN SUS 400/5ML Tier 1 Infections 400 MG/5ML Antibacterials - Drugs to Treat Bacterial AMOXICILLIN TAB 500MG AMOXICILLIN (TRIHYDRATE) TAB 500 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial AMOXICILLIN (TRIHYDRATE) TAB SR AMOXICILLIN TAB 775MG Tier 1 Infections 24HR 775 MG Antibacterials - Drugs to Treat Bacterial AMOXICILLIN TAB 875MG AMOXICILLIN (TRIHYDRATE) TAB 875 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial AMPICILLIN CAP 250MG AMPICILLIN CAP 250 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial AMPICILLIN CAP 500MG AMPICILLIN CAP 500 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial AMPICILLIN SUS 125/5ML AMPICILLIN FOR SUSP 125 MG/5ML Tier 1 Infections Antibacterials - Drugs to Treat Bacterial AMPICILLIN SUS 250/5ML AMPICILLIN FOR SUSP 250 MG/5ML Tier 1 Infections Antibacterials - Drugs to Treat Bacterial SILVER NITRATE-POTASSIUM NITRATE ARZOL SILVER MIS NITR APP Tier 3 Infections APPLICATOR 75-25% Antibacterials - Drugs to Treat Bacterial DOXYCYCLINE MONOHYDRATE TAB AVIDOXY TAB 100MG Tier 1 Infections 100 MG Antibacterials - Drugs to Treat Bacterial *DOXYCYCLINE TAB 100 MG & AVIDOXY DK KIT Tier 3 Infections SUNCREEN & SAL ACID WASH 2% KIT** Antibacterials - Drugs to Treat Bacterial AZASITE SOL 1% AZITHROMYCIN OPHTH SOLN 1% Tier 3 Infections Antibacterials - Drugs to Treat Bacterial AZITHROMYCIN POW 1GM AZITHROMYCIN POWD PACK FOR SUSP Tier 1 Infections PAK 1 GM Antibacterials - Drugs to Treat Bacterial AZITHROMYCIN SUS AZITHROMYCIN FOR SUSP 100 MG/5ML Tier 1 Infections 100/5ML Antibacterials - Drugs to Treat Bacterial AZITHROMYCIN SUS AZITHROMYCIN FOR SUSP 200 MG/5ML Tier 1 Infections 200/5ML Antibacterials - Drugs to Treat Bacterial AZITHROMYCIN TAB 250MG AZITHROMYCIN TAB 250 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial AZITHROMYCIN TAB 500MG AZITHROMYCIN TAB 500 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial AZITHROMYCIN TAB 600MG AZITHROMYCIN TAB 600 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial BACITRACIN OIN OP BACITRACIN OPHTH OINT 500 UNIT/GM Tier 1 Infections Antibacterials - Drugs to Treat Bacterial SULFAMETHOXAZOLE-TRIMETHOPRIM BACTRIM TAB 400-80MG Tier 3 Infections TAB 400-80 MG Antibacterials - Drugs to Treat Bacterial SULFAMETHOXAZOLE-TRIMETHOPRIM BACTRIM DS TAB 800-160 Tier 3 Infections TAB 800-160 MG Antibacterials - Drugs to Treat Bacterial BACTROBAN CRE 2% MUPIROCIN CALCIUM CREAM 2% Tier 3 X Infections Antibacterials - Drugs to Treat Bacterial BACTROBAN OIN NASAL 2% MUPIROCIN CALCIUM NASAL OINT 2% Tier 2 Infections Antibacterials - Drugs to Treat Bacterial DELAFLOXACIN MEGLUMINE TAB 450 BAXDELA TAB 450MG Tier 3 Infections MG (BASE EQUIV) Antibacterials - Drugs to Treat Bacterial BENZALKONIUM SOL 50% BENZALKONIUM CHLORIDE SOLN 50% Tier 1 Infections

24 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antibacterials - Drugs to Treat Bacterial BENZALKONIUM SOL NF BENZALKONIUM CHLORIDE SOLN Tier 2 Infections Antibacterials - Drugs to Treat Bacterial BESIFLOXACIN HCL OPHTH SUSP 0.6% BESIVANCE SUS 0.6% Tier 3 Infections (BASE EQUIV) Antibacterials - Drugs to Treat Bacterial BETADINE SOL 5% OP POVIDONE-IODINE OPHTH SOLN 5% Tier 3 Infections Antibacterials - Drugs to Treat Bacterial BETHKIS NEB 300/4ML TOBRAMYCIN NEBU SOLN 300 MG/4ML Tier 2 X X X Infections Antibacterials - Drugs to Treat Bacterial CLARITHROMYCIN FOR SUSP 250 BIAXIN SUS 250/5ML Tier 3 Infections MG/5ML Antibacterials - Drugs to Treat Bacterial BIAXIN TAB 250MG CLARITHROMYCIN TAB 250 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial BIAXIN TAB 500MG CLARITHROMYCIN TAB 500 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial SULFACETAMIDE SODIUM OPHTH SOLN BLEPH-10 SOL 10% OP Tier 3 Infections 10% Antibacterials - Drugs to Treat Bacterial *ANTISEPTIC PRODUCTS MISC - BUCALSEP SOL Tier 3 Infections SOLUTION** Antibacterials - Drugs to Treat Bacterial *ANTISEPTIC PRODUCTS MISC - BUCALSEP SPR Tier 3 Infections LIQUID** Antibacterials - Drugs to Treat Bacterial CEDAX CAP 400MG CEFTIBUTEN CAP 400 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial CEDAX SUS 180/5ML CEFTIBUTEN FOR SUSP 180 MG/5ML Tier 3 Infections Antibacterials - Drugs to Treat Bacterial CEFACLOR CAP 250MG CEFACLOR CAP 250 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEFACLOR CAP 500MG CEFACLOR CAP 500 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEFACLOR SUS 125/5ML CEFACLOR FOR SUSP 125 MG/5ML Tier 3 Infections Antibacterials - Drugs to Treat Bacterial CEFACLOR SUS 250/5ML CEFACLOR FOR SUSP 250 MG/5ML Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEFACLOR SUS 375/5ML CEFACLOR FOR SUSP 375 MG/5ML Tier 3 Infections Antibacterials - Drugs to Treat Bacterial CEFACLOR MONOHYDRATE TAB ER CEFACLOR ER TAB 500MG Tier 1 Infections 12HR 500 MG Antibacterials - Drugs to Treat Bacterial CEFADROXIL CAP 500MG CEFADROXIL CAP 500 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEFADROXIL SUS 250/5ML CEFADROXIL FOR SUSP 250 MG/5ML Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEFADROXIL SUS 500/5ML CEFADROXIL FOR SUSP 500 MG/5ML Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEFADROXIL TAB 1GM CEFADROXIL TAB 1 GM Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEFDINIR CAP 300MG CEFDINIR CAP 300 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEFDINIR SUS 125/5ML CEFDINIR FOR SUSP 125 MG/5ML Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEFDINIR SUS 250/5ML CEFDINIR FOR SUSP 250 MG/5ML Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEFDITOREN PIVOXIL TAB 200 MG (BASE CEFDITOREN TAB 200MG Tier 1 Infections EQUIVALENT) Antibacterials - Drugs to Treat Bacterial CEFDITOREN PIVOXIL TAB 400 MG (BASE CEFDITOREN TAB 400MG Tier 1 Infections EQUIVALENT) Antibacterials - Drugs to Treat Bacterial CEFIXIME SUS 100/5ML CEFIXIME FOR SUSP 100 MG/5ML Tier 3 Infections Antibacterials - Drugs to Treat Bacterial CEFIXIME SUS 200/5ML CEFIXIME FOR SUSP 200 MG/5ML Tier 3 Infections Antibacterials - Drugs to Treat Bacterial CEFPODO PROX SUS CEFPODOXIME PROXETIL FOR SUSP 100 Tier 1 Infections 100/5ML MG/5ML Antibacterials - Drugs to Treat Bacterial CEFPODO PROX SUS CEFPODOXIME PROXETIL FOR SUSP 50 Tier 1 Infections 50MG/5ML MG/5ML Antibacterials - Drugs to Treat Bacterial CEFPODOXIME TAB 100MG CEFPODOXIME PROXETIL TAB 100 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEFPODOXIME TAB 200MG CEFPODOXIME PROXETIL TAB 200 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEFPROZIL SUS 125/5ML CEFPROZIL FOR SUSP 125 MG/5ML Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEFPROZIL SUS 250/5ML CEFPROZIL FOR SUSP 250 MG/5ML Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEFPROZIL TAB 250MG CEFPROZIL TAB 250 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEFPROZIL TAB 500MG CEFPROZIL TAB 500 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEFTIBUTEN CAP 400MG CEFTIBUTEN CAP 400 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEFTIBUTEN SUS 180/5ML CEFTIBUTEN FOR SUSP 180 MG/5ML Tier 1 Infections

25 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antibacterials - Drugs to Treat Bacterial CEFUROXIME AXETIL FOR SUSP 125 CEFTIN SUS 125/5ML Tier 3 Infections MG/5ML Antibacterials - Drugs to Treat Bacterial CEFUROXIME AXETIL FOR SUSP 250 CEFTIN SUS 250/5ML Tier 3 Infections MG/5ML Antibacterials - Drugs to Treat Bacterial CEFTIN TAB 500MG CEFUROXIME AXETIL TAB 500 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial CEFUROXIME TAB 250MG CEFUROXIME AXETIL TAB 250 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEFUROXIME TAB 500MG CEFUROXIME AXETIL TAB 500 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CENTANY OIN 2% MUPIROCIN OINT 2% Tier 3 X Infections Antibacterials - Drugs to Treat Bacterial CEPHALEXIN CAP 250MG CEPHALEXIN CAP 250 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEPHALEXIN CAP 500MG CEPHALEXIN CAP 500 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEPHALEXIN CAP 750MG CEPHALEXIN CAP 750 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEPHALEXIN SUS 125/5ML CEPHALEXIN FOR SUSP 125 MG/5ML Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEPHALEXIN SUS 250/5ML CEPHALEXIN FOR SUSP 250 MG/5ML Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEPHALEXIN TAB 250MG CEPHALEXIN TAB 250 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CEPHALEXIN TAB 500MG CEPHALEXIN TAB 500 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CILOXAN OIN 0.3% OP CIPROFLOXACIN HCL OPHTH OINT 0.3% Tier 3 Infections Antibacterials - Drugs to Treat Bacterial CILOXAN SOL 0.3% OP CIPROFLOXACIN HCL OPHTH SOLN 0.3% Tier 3 Infections Antibacterials - Drugs to Treat Bacterial CIPROFLOXACIN HCL TAB 250 MG (BASE CIPRO TAB 250MG Tier 3 Infections EQUIV) Antibacterials - Drugs to Treat Bacterial CIPROFLOXACIN HCL TAB 500 MG (BASE CIPRO TAB 500MG Tier 3 Infections EQUIV) Antibacterials - Drugs to Treat Bacterial CIPROFLOXACIN FOR ORAL SUSP 500 CIPRO (10%) SUS 500MG/5 Tier 3 Infections MG/5ML (10%) (10 GM/100ML) Antibacterials - Drugs to Treat Bacterial CIPROFLOXACIN FOR ORAL SUSP 250 CIPRO (5%) SUS 250MG/5 Tier 3 Infections MG/5ML (5%) (5 GM/100ML) Antibacterials - Drugs to Treat Bacterial CIPROFLOXACIN-CIPROFLOXACIN HCL CIPRO XR TAB 1000MG Tier 3 Infections TAB SR 24HR 1000 MG(BASE EQ) Antibacterials - Drugs to Treat Bacterial CIPROFLOXACIN-CIPROFLOXACIN HCL CIPRO XR TAB 500MG Tier 3 Infections TAB SR 24HR 500 MG (BASE EQ) Antibacterials - Drugs to Treat Bacterial CIPROFLOXACN SOL 0.3% CIPROFLOXACIN HCL OPHTH SOLN 0.3% Tier 1 Infections OP Antibacterials - Drugs to Treat Bacterial CIPROFLOXACN SUS CIPROFLOXACIN FOR ORAL SUSP 250 Tier 2 Infections 250MG/5 MG/5ML (5%) (5 GM/100ML) Antibacterials - Drugs to Treat Bacterial CIPROFLOXACN SUS CIPROFLOXACIN FOR ORAL SUSP 500 Tier 2 Infections 500MG/5 MG/5ML (10%) (10 GM/100ML) Antibacterials - Drugs to Treat Bacterial CIPROFLOXACN TAB CIPROFLOXACIN-CIPROFLOXACIN HCL Tier 3 Infections 1000MG TAB ER 24HR 1000 MG(BASE EQ) Antibacterials - Drugs to Treat Bacterial CIPROFLOXACIN HCL TAB 100 MG (BASE CIPROFLOXACN TAB 100MG Tier 1 Infections EQUIV) Antibacterials - Drugs to Treat Bacterial CIPROFLOXACIN HCL TAB 250 MG (BASE CIPROFLOXACN TAB 250MG Tier 1 Infections EQUIV) Antibacterials - Drugs to Treat Bacterial CIPROFLOXACIN HCL TAB 500 MG (BASE CIPROFLOXACN TAB 500MG Tier 1 Infections EQUIV) Antibacterials - Drugs to Treat Bacterial CIPROFLOXACN TAB 500MG CIPROFLOXACIN-CIPROFLOXACIN HCL Tier 3 Infections ER TAB ER 24HR 500 MG (BASE EQ) Antibacterials - Drugs to Treat Bacterial CIPROFLOXACIN HCL TAB 750 MG (BASE CIPROFLOXACN TAB 750MG Tier 1 Infections EQUIV) Antibacterials - Drugs to Treat Bacterial CLARITHROMYC SUS CLARITHROMYCIN FOR SUSP 125 Tier 2 Infections 125/5ML MG/5ML Antibacterials - Drugs to Treat Bacterial CLARITHROMYC SUS CLARITHROMYCIN FOR SUSP 250 Tier 2 Infections 250/5ML MG/5ML Antibacterials - Drugs to Treat Bacterial CLARITHROMYC TAB CLARITHROMYCIN TAB 250 MG Tier 1 Infections 250MG Antibacterials - Drugs to Treat Bacterial CLARITHROMYC TAB CLARITHROMYCIN TAB 500 MG Tier 1 Infections 500MG Antibacterials - Drugs to Treat Bacterial CLARITHROMYC TAB CLARITHROMYCIN TAB ER 24HR 500 MG Tier 2 Infections 500MG ER Antibacterials - Drugs to Treat Bacterial CLEOCIN CAP 150MG CLINDAMYCIN HCL CAP 150 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial CLEOCIN CAP 300MG CLINDAMYCIN HCL CAP 300 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial CLEOCIN CAP 75MG CLINDAMYCIN HCL CAP 75 MG Tier 2 Infections Antibacterials - Drugs to Treat Bacterial CLINDAMYCIN PHOSPHATE VAGINAL CLEOCIN CRE 2% VAG Tier 3 Infections CREAM 2%

26 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antibacterials - Drugs to Treat Bacterial CLINDAMYCIN PHOSPHATE VAGINAL CLEOCIN SUP 100MG Tier 2 Infections SUPPOS 100 MG Antibacterials - Drugs to Treat Bacterial CLEOCIN PED SOL CLINDAMYCIN PALMITATE HCL FOR Tier 3 Infections 75MG/5ML SOLN 75 MG/5ML (BASE EQUIV) Antibacterials - Drugs to Treat Bacterial CLEOCIN-T GEL 1% CLINDAMYCIN PHOSPHATE GEL 1% Tier 3 X Infections Antibacterials - Drugs to Treat Bacterial CLEOCIN-T LOT 1% CLINDAMYCIN PHOSPHATE LOTION 1% Tier 3 Infections Antibacterials - Drugs to Treat Bacterial CLEOCIN-T PAD 1% CLINDAMYCIN PHOSPHATE SWAB 1% Tier 3 Infections Antibacterials - Drugs to Treat Bacterial CLEOCIN-T SOL 1% CLINDAMYCIN PHOSPHATE SOLN 1% Tier 3 Infections Antibacterials - Drugs to Treat Bacterial CLINDACIN MIS ETZ 1% CLINDAMYCIN PHOSPHATE SWAB 1% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CLINDACIN-P PAD 1% CLINDAMYCIN PHOSPHATE SWAB 1% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CLINDAMYCIN AER 1% CLINDAMYCIN PHOSPHATE FOAM 1% Tier 3 Infections Antibacterials - Drugs to Treat Bacterial CLINDAMYCIN CAP 150MG CLINDAMYCIN HCL CAP 150 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CLINDAMYCIN CAP 300MG CLINDAMYCIN HCL CAP 300 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CLINDAMYCIN CAP 75MG CLINDAMYCIN HCL CAP 75 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CLINDAMYCIN PHOSPHATE VAGINAL CLINDAMYCIN CRE 2% VAG Tier 2 Infections CREAM 2% Antibacterials - Drugs to Treat Bacterial CLINDAMYCIN GEL 1% CLINDAMYCIN PHOSPHATE GEL 1% Tier 3 X Infections Antibacterials - Drugs to Treat Bacterial CLINDAMYCIN LOT 1% CLINDAMYCIN PHOSPHATE LOTION 1% Tier 3 Infections Antibacterials - Drugs to Treat Bacterial CLINDAMYCIN LOT 10MG/ CLINDAMYCIN PHOSPHATE LOTION 1% Tier 3 Infections ML Antibacterials - Drugs to Treat Bacterial CLINDAMYCIN MIS 1% CLINDAMYCIN PHOSPHATE SWAB 1% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CLINDAMYCIN PAD 1% CLINDAMYCIN PHOSPHATE SWAB 1% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CLINDAMYCIN SOL 1% CLINDAMYCIN PHOSPHATE SOLN 1% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial CLINDAMYCIN SOL CLINDAMYCIN PALMITATE HCL FOR Tier 2 Infections 75MG/5ML SOLN 75 MG/5ML (BASE EQUIV) Antibacterials - Drugs to Treat Bacterial CLINDAMYCIN PHOSPHATE (ONE DOSE) CLINDESSE CRE 2% Tier 2 Infections VAGINAL CREAM 2% Antibacterials - Drugs to Treat Bacterial COLISTIMETHATE SODIUM FOR INJ 150 COLISTIMETH INJ 150MG Tier 1 Infections MG Antibacterials - Drugs to Treat Bacterial COLISTIMETHATE SODIUM FOR INJ 150 COLY-MYCIN M INJ 150MG Tier 3 Infections MG Antibacterials - Drugs to Treat Bacterial DEMECLOCYCL TAB 150MG DEMECLOCYCLINE HCL TAB 150 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial DEMECLOCYCL TAB 300MG DEMECLOCYCLINE HCL TAB 300 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial DICLOXACILL CAP 250MG DICLOXACILLIN SODIUM CAP 250 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial DICLOXACILL CAP 500MG DICLOXACILLIN SODIUM CAP 500 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial DIFICID TAB 200MG FIDAXOMICIN TAB 200 MG Tier 3 X Infections Antibacterials - Drugs to Treat Bacterial DOXYCYC MONO CAP DOXYCYCLINE MONOHYDRATE CAP Tier 1 Infections 100MG 100 MG Antibacterials - Drugs to Treat Bacterial DOXYCYCLINE MONOHYDRATE CAP 50 DOXYCYC MONO CAP 50MG Tier 1 Infections MG Antibacterials - Drugs to Treat Bacterial DOXYCYC MONO TAB DOXYCYCLINE MONOHYDRATE TAB Tier 1 Infections 100MG 100 MG Antibacterials - Drugs to Treat Bacterial DOXYCYC MONO TAB DOXYCYCLINE MONOHYDRATE TAB Tier 1 Infections 150MG 150 MG Antibacterials - Drugs to Treat Bacterial DOXYCYCLINE MONOHYDRATE TAB 50 DOXYCYC MONO TAB 50MG Tier 1 Infections MG Antibacterials - Drugs to Treat Bacterial DOXYCYCLINE MONOHYDRATE TAB 75 DOXYCYC MONO TAB 75MG Tier 1 Infections MG Antibacterials - Drugs to Treat Bacterial DOXYCYCL HYC CAP 100MG DOXYCYCLINE HYCLATE CAP 100 MG Tier 2 Infections Antibacterials - Drugs to Treat Bacterial DOXYCYCL HYC CAP 50MG DOXYCYCLINE HYCLATE CAP 50 MG Tier 2 Infections Antibacterials - Drugs to Treat Bacterial DOXYCYCL HYC TAB 100MG DOXYCYCLINE HYCLATE TAB 100 MG Tier 2 Infections Antibacterials - Drugs to Treat Bacterial DOXYCYCLINE POW DOXYCYCLINE HYCLATE POWDER Tier 3 Infections HYCLATE Antibacterials - Drugs to Treat Bacterial DOXYCYCLINE SUS DOXYCYCLINE MONOHYDRATE FOR Tier 3 Infections 25MG/5ML SUSP 25 MG/5ML

27 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antibacterials - Drugs to Treat Bacterial DOXYCYCLINE TAB 20MG DOXYCYCLINE HYCLATE TAB 20 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial ERYTHROMYCIN ETHYLSUCCINATE FOR E.E.S. GRAN SUS 200/5ML Tier 3 Infections SUSP 200 MG/5ML Antibacterials - Drugs to Treat Bacterial ERY PAD 2% ERYTHROMYCIN PADS 2% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial ERYGEL GEL 2% ERYTHROMYCIN GEL 2% Tier 3 Infections Antibacterials - Drugs to Treat Bacterial ERYTHROMYCIN ETHYLSUCCINATE FOR ERYPED SUS 200/5ML Tier 3 Infections SUSP 200 MG/5ML Antibacterials - Drugs to Treat Bacterial ERYTHROMYCIN ETHYLSUCCINATE FOR ERYPED SUS 400/5ML Tier 3 Infections SUSP 400 MG/5ML Antibacterials - Drugs to Treat Bacterial ERYTHROMYCIN TAB DELAYED ERY-TAB TAB 250MG EC Tier 2 Infections RELEASE 250 MG Antibacterials - Drugs to Treat Bacterial ERYTHROMYCIN TAB DELAYED ERY-TAB TAB 333MG EC Tier 2 Infections RELEASE 333 MG Antibacterials - Drugs to Treat Bacterial ERYTHROMYCIN TAB DELAYED ERY-TAB TAB 500MG EC Tier 2 Infections RELEASE 500 MG Antibacterials - Drugs to Treat Bacterial ERYTHROCIN TAB 250MG ERYTHROMYCIN STEARATE TAB 250 MG Tier 2 Infections Antibacterials - Drugs to Treat Bacterial ERYTHROM ETH SUS ERYTHROMYCIN ETHYLSUCCINATE FOR Tier 1 Infections 200/5ML SUSP 200 MG/5ML Antibacterials - Drugs to Treat Bacterial ERYTHROM ETH TAB ERYTHROMYCIN ETHYLSUCCINATE TAB Tier 1 Infections 400MG 400 MG Antibacterials - Drugs to Treat Bacterial ERYTHROMYCIN CAP ERYTHROMYCIN W/ DELAYED RELEASE Tier 1 Infections 250MG EC PARTICLES CAP 250 MG Antibacterials - Drugs to Treat Bacterial ERYTHROMYCIN GEL 2% ERYTHROMYCIN GEL 2% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial ERYTHROMYCIN OIN 5MG/ ERYTHROMYCIN OPHTH OINT 5 MG/GM Tier 1 Infections GM Antibacterials - Drugs to Treat Bacterial ERYTHROMYCIN OIN OP ERYTHROMYCIN OPHTH OINT 5 MG/GM Tier 1 Infections Antibacterials - Drugs to Treat Bacterial ERYTHROMYCIN PAD 2% ERYTHROMYCIN PADS 2% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial ERYTHROMYCIN SOL 2% ERYTHROMYCIN SOLN 2% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial ERYTHROMYCIN TAB ERYTHROMYCIN TAB 250 MG Tier 1 Infections 250MG BS Antibacterials - Drugs to Treat Bacterial ERYTHROMYCIN TAB ERYTHROMYCIN TAB 500 MG Tier 1 Infections 500MG BS Antibacterials - Drugs to Treat Bacterial EVOCLIN AER 1% CLINDAMYCIN PHOSPHATE FOAM 1% Tier 3 Infections Antibacterials - Drugs to Treat Bacterial GEMIFLOXACIN MESYLATE TAB 320 MG FACTIVE TAB 320MG Tier 3 Infections (BASE EQUIV) Antibacterials - Drugs to Treat Bacterial ACETIC ACID-OXYQUINOLINE VAGINAL FEM PH GEL Tier 3 Infections GEL 0.9-0.025% Antibacterials - Drugs to Treat Bacterial FLAGYL CAP 375MG METRONIDAZOLE CAP 375 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial FLAGYL TAB 250MG METRONIDAZOLE TAB 250 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial FLAGYL TAB 500MG METRONIDAZOLE TAB 500 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial FURADANTIN SUS NITROFURANTOIN SUSP 25 MG/5ML Tier 3 Infections 25MG/5ML Antibacterials - Drugs to Treat Bacterial GATIFLOXACIN SOL 0.5% GATIFLOXACIN OPHTH SOLN 0.5% Tier 3 Infections Antibacterials - Drugs to Treat Bacterial GENTAK OIN 0.3% OP GENTAMICIN SULFATE OPHTH OINT 0.3% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial GENTAMICIN CRE 0.1% GENTAMICIN SULFATE CREAM 0.1% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial GENTAMICIN OIN 0.1% GENTAMICIN SULFATE OINT 0.1% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial GENTAMICIN OIN 0.3% OP GENTAMICIN SULFATE OPHTH OINT 0.3% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial GENTAMICIN SULFATE OPHTH SOLN GENTAMICIN SOL 0.3% OP Tier 1 Infections 0.3% Antibacterials - Drugs to Treat Bacterial HIPREX TAB 1GM METHENAMINE HIPPURATE TAB 1 GM Tier 3 Infections Antibacterials - Drugs to Treat Bacterial IODINE TIN 2% *IODINE TINCTURE** Tier 1 Infections Antibacterials - Drugs to Treat Bacterial KEFLEX CAP 250MG CEPHALEXIN CAP 250 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial KEFLEX CAP 500MG CEPHALEXIN CAP 500 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial KEFLEX CAP 750MG CEPHALEXIN CAP 750 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial KETEK TAB 300MG TELITHROMYCIN TAB 300 MG Tier 3 Infections

28 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antibacterials - Drugs to Treat Bacterial KETEK TAB 400MG TELITHROMYCIN TAB 400 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial LEVAQUIN TAB 250MG LEVOFLOXACIN TAB 250 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial LEVAQUIN TAB 500MG LEVOFLOXACIN TAB 500 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial LEVAQUIN TAB 750MG LEVOFLOXACIN TAB 750 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial LEVOFLOXACIN SOL 0.5% LEVOFLOXACIN OPHTH SOLN 0.5% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial LEVOFLOXACIN SOL 25MG/ LEVOFLOXACIN ORAL SOLN 25 MG/ML Tier 1 Infections ML Antibacterials - Drugs to Treat Bacterial LEVOFLOXACIN TAB 250MG LEVOFLOXACIN TAB 250 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial LEVOFLOXACIN TAB 500MG LEVOFLOXACIN TAB 500 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial LEVOFLOXACIN TAB 750MG LEVOFLOXACIN TAB 750 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial LINEZOLID SUS 100/5ML LINEZOLID FOR SUSP 100 MG/5ML Tier 2 X Infections Antibacterials - Drugs to Treat Bacterial LINEZOLID TAB 600MG LINEZOLID TAB 600 MG Tier 2 X Infections Antibacterials - Drugs to Treat Bacterial LUGOLS SOL STRONG *IODINE SOLUTION** Tier 1 Infections Antibacterials - Drugs to Treat Bacterial NITROFURANTOIN MONOHYDRATE MACROBID CAP 100MG Tier 3 Infections MACROCRYSTALLINE CAP 100 MG Antibacterials - Drugs to Treat Bacterial NITROFURANTOIN MACROCRYSTALLINE MACRODANTIN CAP 100MG Tier 3 Infections CAP 100 MG Antibacterials - Drugs to Treat Bacterial NITROFURANTOIN MACROCRYSTALLINE MACRODANTIN CAP 25MG Tier 3 Infections CAP 25 MG Antibacterials - Drugs to Treat Bacterial NITROFURANTOIN MACROCRYSTALLINE MACRODANTIN CAP 50MG Tier 3 Infections CAP 50 MG Antibacterials - Drugs to Treat Bacterial MAFENIDE ACETATE PACKET FOR MAFENIDE ACE PAK 5% Tier 3 Infections TOPICAL SOLN 5% (50 GM) Antibacterials - Drugs to Treat Bacterial METHENAM HIP TAB 1GM METHENAMINE HIPPURATE TAB 1 GM Tier 1 Infections Antibacterials - Drugs to Treat Bacterial METHENAM MAN TAB METHENAMINE MANDELATE TAB 1 GM Tier 1 Infections 1000MG Antibacterials - Drugs to Treat Bacterial METHENAM MAN TAB 1GM METHENAMINE MANDELATE TAB 1 GM Tier 1 Infections Antibacterials - Drugs to Treat Bacterial METHENAM MAN TAB METHENAMINE MANDELATE TAB 0.5 GM Tier 1 Infections 500MG Antibacterials - Drugs to Treat Bacterial METROCREAM CRE 0.75% METRONIDAZOLE CREAM 0.75% Tier 3 Infections Antibacterials - Drugs to Treat Bacterial METROLOTION LOT 0.75% METRONIDAZOLE LOTION 0.75% Tier 3 Infections Antibacterials - Drugs to Treat Bacterial METRONIDAZOL CAP METRONIDAZOLE CAP 375 MG Tier 1 Infections 375MG Antibacterials - Drugs to Treat Bacterial METRONIDAZOL CRE 0.75% METRONIDAZOLE CREAM 0.75% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial METRONIDAZOL GEL 0.75% METRONIDAZOLE GEL 0.75% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial METRONIDAZOL GEL METRONIDAZOLE VAGINAL GEL 0.75% Tier 2 Infections 0.75%VAG Antibacterials - Drugs to Treat Bacterial METRONIDAZOL LOT 0.75% METRONIDAZOLE LOTION 0.75% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial METRONIDAZOL TAB METRONIDAZOLE TAB 250 MG Tier 1 Infections 250MG Antibacterials - Drugs to Treat Bacterial METRONIDAZOL TAB METRONIDAZOLE TAB 500 MG Tier 1 Infections 500MG Antibacterials - Drugs to Treat Bacterial MINOCYCLINE CAP 100MG MINOCYCLINE HCL CAP 100 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial MINOCYCLINE CAP 50MG MINOCYCLINE HCL CAP 50 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial MINOCYCLINE CAP 75MG MINOCYCLINE HCL CAP 75 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial MONDOXYNE NL CAP DOXYCYCLINE MONOHYDRATE CAP Tier 1 Infections 100MG 100 MG Antibacterials - Drugs to Treat Bacterial DOXYCYCLINE MONOHYDRATE CAP 50 MONDOXYNE NL CAP 50MG Tier 1 Infections MG Antibacterials - Drugs to Treat Bacterial FOSFOMYCIN TROMETHAMINE POWD MONUROL PAK GRANULES Tier 3 Infections PACK 3 GM (BASE EQUIVALENT) Antibacterials - Drugs to Treat Bacterial MORGIDOX CAP 1X100MG DOXYCYCLINE HYCLATE CAP 100 MG Tier 2 Infections Antibacterials - Drugs to Treat Bacterial MORGIDOX CAP 1X50MG DOXYCYCLINE HYCLATE CAP 50 MG Tier 2 Infections Antibacterials - Drugs to Treat Bacterial MORGIDOX CAP 2X100MG DOXYCYCLINE HYCLATE CAP 100 MG Tier 2 Infections

29 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antibacterials - Drugs to Treat Bacterial AMOXICILLIN (TRIHYDRATE) TAB SR MOXATAG TAB 775MG Tier 3 Infections 24HR 775 MG Antibacterials - Drugs to Treat Bacterial AMOXICILLIN (TRIHYDRATE) TAB ER MOXATAG TAB 775MG Tier 3 Infections 24HR 775 MG Antibacterials - Drugs to Treat Bacterial MOXIFLOXACIN HCL OPHTH SOLN 0.5% MOXEZA SOL 0.5% Tier 3 Infections (BASE EQ) (2 TIMES DAILY) Antibacterials - Drugs to Treat Bacterial MOXIFLOXACIN HCL OPHTH SOLN 0.5% MOXIFLOXACIN SOL 0.5% Tier 3 Infections (BASE EQUIV) Antibacterials - Drugs to Treat Bacterial MOXIFLOXACIN HCL TAB 400 MG (BASE MOXIFLOXACIN TAB 400MG Tier 3 Infections EQUIV) Antibacterials - Drugs to Treat Bacterial MUPIROCIN CRE 2% MUPIROCIN CALCIUM CREAM 2% Tier 3 X Infections Antibacterials - Drugs to Treat Bacterial MUPIROCIN OIN 2% MUPIROCIN OINT 2% Tier 1 X Infections Antibacterials - Drugs to Treat Bacterial NEOMYCIN TAB 500MG NEOMYCIN SULFATE TAB 500 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial NITROFURANTOIN MACROCRYSTALLINE NITROFUR MAC CAP 100MG Tier 1 Infections CAP 100 MG Antibacterials - Drugs to Treat Bacterial NITROFURANTOIN MACROCRYSTALLINE NITROFUR MAC CAP 25MG Tier 1 Infections CAP 25 MG Antibacterials - Drugs to Treat Bacterial NITROFURANTOIN MACROCRYSTALLINE NITROFUR MAC CAP 50MG Tier 1 Infections CAP 50 MG Antibacterials - Drugs to Treat Bacterial NITROFURANTN CAP NITROFURANTOIN MONOHYDRATE Tier 1 Infections 100MG MACROCRYSTALLINE CAP 100 MG Antibacterials - Drugs to Treat Bacterial NITROFURANTN SUS NITROFURANTOIN SUSP 25 MG/5ML Tier 1 Infections 25MG/5ML Antibacterials - Drugs to Treat Bacterial *DOXYCYCLINE MONOHYD CAP 75 MG NUTRIDOX KIT Tier 3 Infections W/ OMEGA 3-VIT E CAP KIT* Antibacterials - Drugs to Treat Bacterial OCUFLOX DRO 0.3% OP OFLOXACIN OPHTH SOLN 0.3% Tier 3 Infections Antibacterials - Drugs to Treat Bacterial OFLOXACIN DRO 0.3% OP OFLOXACIN OPHTH SOLN 0.3% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial OFLOXACIN DRO 0.3%OTIC OFLOXACIN OTIC SOLN 0.3% Tier 2 Infections Antibacterials - Drugs to Treat Bacterial OFLOXACIN TAB 300MG OFLOXACIN TAB 300 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial OFLOXACIN TAB 400MG OFLOXACIN TAB 400 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial DOXYCYCLINE MONOHYDRATE CAP OKEBO CAP 100MG Tier 1 Infections 100 MG Antibacterials - Drugs to Treat Bacterial DOXYCYCLINE (ROSACEA) CAP ORACEA CAP 40MG Tier 3 Infections DELAYED RELEASE 40 MG Antibacterials - Drugs to Treat Bacterial PAROMOMYCIN CAP 250MG PAROMOMYCIN SULFATE CAP 250 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial ERYTHROMYCIN W/ ENTERIC COATED PCE TAB 333MG EC Tier 3 Infections PARTICLES TAB 333 MG Antibacterials - Drugs to Treat Bacterial ERYTHROMYCIN W/ ENTERIC COATED PCE TAB 500MG EC Tier 3 Infections PARTICLES TAB 500 MG Antibacterials - Drugs to Treat Bacterial PENICILLIN V POTASSIUM FOR SOLN 125 PENICILLN VK SOL 125/5ML Tier 1 Infections MG/5ML Antibacterials - Drugs to Treat Bacterial PENICILLIN V POTASSIUM FOR SOLN 250 PENICILLN VK SOL 250/5ML Tier 1 Infections MG/5ML Antibacterials - Drugs to Treat Bacterial PENICILLN VK TAB 250MG PENICILLIN V POTASSIUM TAB 250 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial PENICILLN VK TAB 500MG PENICILLIN V POTASSIUM TAB 500 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial PHENOL LIQ PHENOL LIQUID (BULK) Tier 3 Infections Antibacterials - Drugs to Treat Bacterial PHENOL LIQ 89% PHENOL LIQUID (BULK) Tier 3 Infections Antibacterials - Drugs to Treat Bacterial PHENOL LIQ 89% PHENOL LIQUID (BULK) Tier 2 Infections Antibacterials - Drugs to Treat Bacterial TRIMETHOPRIM HCL ORAL SOLN 50 PRIMSOL SOL 50MG/5ML Tier 3 Infections MG/5ML (BASE EQUIV) Antibacterials - Drugs to Treat Bacterial ACETIC ACID-OXYQUINOLINE VAGINAL RELAGARD GEL Tier 3 Infections GEL 0.9-0.025% Antibacterials - Drugs to Treat Bacterial ROSADAN CRE 0.75% METRONIDAZOLE CREAM 0.75% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial ROSADAN GEL 0.75% METRONIDAZOLE GEL 0.75% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial SILVADENE CRE 1% SILVER SULFADIAZINE CREAM 1% Tier 3 Infections Antibacterials - Drugs to Treat Bacterial SILVER NITRA OIN 10% SILVER NITRATE OINT 10% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial SILVER NITRA SOL 0.5% SILVER NITRATE SOLN 0.5% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial SILVER NITRA SOL 10% SILVER NITRATE SOLN 10% Tier 1 Infections

30 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antibacterials - Drugs to Treat Bacterial SILVER NITRA SOL 25% SILVER NITRATE SOLN 25% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial SILVER NITRA SOL 50% SILVER NITRATE SOLN 50% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial SILVER SULFA CRE 1% SILVER SULFADIAZINE CREAM 1% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial SIVEXTRO TAB 200MG TEDIZOLID PHOSPHATE TAB 200 MG Tier 3 X Infections Antibacterials - Drugs to Treat Bacterial SULFAMETHOXAZOLE-TRIMETHOPRIM SMZ/TMP DS TAB 800-160 Tier 1 Infections TAB 800-160 MG Antibacterials - Drugs to Treat Bacterial SULFAMETHOXAZOLE-TRIMETHOPRIM SMZ-TMP SUS 200-40/5 Tier 1 Infections SUSP 200-40 MG/5ML Antibacterials - Drugs to Treat Bacterial SULFAMETHOXAZOLE-TRIMETHOPRIM SMZ-TMP TAB 400-80MG Tier 1 Infections TAB 400-80 MG Antibacterials - Drugs to Treat Bacterial SULFAMETHOXAZOLE-TRIMETHOPRIM SMZ-TMP DS TAB 800-160 Tier 1 Infections TAB 800-160 MG Antibacterials - Drugs to Treat Bacterial SULFACETAMIDE SODIUM OPHTH SOLN SOD SULFACET SOL 10% OP Tier 1 Infections 10% Antibacterials - Drugs to Treat Bacterial CEFDITOREN PIVOXIL TAB 400 MG (BASE SPECTRACEF TAB 400MG Tier 3 Infections EQUIVALENT) Antibacterials - Drugs to Treat Bacterial SSD CRE 1% SILVER SULFADIAZINE CREAM 1% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial SULFACETAMIDE SODIUM OPHTH OINT SULFACET SOD OIN 10% OP Tier 1 Infections 10% Antibacterials - Drugs to Treat Bacterial SULFACETAMIDE SODIUM OPHTH SOLN SULFACET SOD SOL 10% OP Tier 1 Infections 10% Antibacterials - Drugs to Treat Bacterial SULFADIAZINE TAB 500MG SULFADIAZINE TAB 500 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial SULFAMYLON CRE 85MG/ MAFENIDE ACETATE CREAM 85 MG/GM Tier 3 Infections GM Antibacterials - Drugs to Treat Bacterial MAFENIDE ACETATE PACKET FOR SULFAMYLON PAK 5% Tier 3 Infections TOPICAL SOLN 5% (50 GM) Antibacterials - Drugs to Treat Bacterial SULFATRIM PD SUS 200- SULFAMETHOXAZOLE-TRIMETHOPRIM Tier 1 Infections 40/5 SUSP 200-40 MG/5ML Antibacterials - Drugs to Treat Bacterial SUPRAX CAP 400MG CEFIXIME CAP 400 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial SUPRAX CHW 100MG CEFIXIME CHEW TAB 100 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial SUPRAX CHW 200MG CEFIXIME CHEW TAB 200 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial SUPRAX SUS 100/5ML CEFIXIME FOR SUSP 100 MG/5ML Tier 3 Infections Antibacterials - Drugs to Treat Bacterial SUPRAX SUS 200/5ML CEFIXIME FOR SUSP 200 MG/5ML Tier 3 Infections Antibacterials - Drugs to Treat Bacterial SUPRAX SUS 500/5ML CEFIXIME FOR SUSP 500 MG/5ML Tier 3 Infections Antibacterials - Drugs to Treat Bacterial TETRACYCLINE CAP 250MG TETRACYCLINE HCL CAP 250 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial TETRACYCLINE CAP 500MG TETRACYCLINE HCL CAP 500 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial TINDAMAX TAB 500MG TINIDAZOLE TAB 500 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial TINIDAZOLE TAB 250MG TINIDAZOLE TAB 250 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial TINIDAZOLE TAB 500MG TINIDAZOLE TAB 500 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial TOBI PODHALR CAP 28MG TOBRAMYCIN INHAL CAP 28 MG Tier 3 X X X Infections Antibacterials - Drugs to Treat Bacterial TOBRAMYCIN-DEXAMETHASONE TOBRADEX OIN 0.3-0.1% Tier 3 Infections OPHTH OINT 0.3-0.1% Antibacterials - Drugs to Treat Bacterial TOBRAMYCIN SOL 0.3% OP TOBRAMYCIN OPHTH SOLN 0.3% Tier 1 Infections Antibacterials - Drugs to Treat Bacterial TOBREX OIN 0.3% OP TOBRAMYCIN OPHTH OINT 0.3% Tier 3 Infections Antibacterials - Drugs to Treat Bacterial TOBREX SOL 0.3% OP TOBRAMYCIN OPHTH SOLN 0.3% Tier 3 Infections Antibacterials - Drugs to Treat Bacterial TRIMETHOPRIM TAB 100MG TRIMETHOPRIM TAB 100 MG Tier 1 Infections Antibacterials - Drugs to Treat Bacterial TRIMETHOPRIM HCL ORAL SOLN 50 TRIMPEX SOL 50MG/5ML Tier 3 Infections MG/5ML (BASE EQUIV) Antibacterials - Drugs to Treat Bacterial VANCOCIN HCL CAP 250MG VANCOMYCIN HCL CAP 250 MG Tier 3 X Infections Antibacterials - Drugs to Treat Bacterial VANCOMYCIN CAP 125MG VANCOMYCIN HCL CAP 125 MG Tier 1 X Infections Antibacterials - Drugs to Treat Bacterial VANCOMYCIN CAP 250MG VANCOMYCIN HCL CAP 250 MG Tier 1 X Infections Antibacterials - Drugs to Treat Bacterial VANDAZOLE GEL 0.75% METRONIDAZOLE VAGINAL GEL 0.75% Tier 2 Infections

31 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antibacterials - Drugs to Treat Bacterial VIBRAMYCIN CAP 100MG DOXYCYCLINE HYCLATE CAP 100 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial VIBRAMYCIN SUS DOXYCYCLINE MONOHYDRATE FOR Tier 3 Infections 25MG/5ML SUSP 25 MG/5ML Antibacterials - Drugs to Treat Bacterial VIBRAMYCIN SYP DOXYCYCLINE CALCIUM SYRUP 50 Tier 3 Infections 50MG/5ML MG/5ML Antibacterials - Drugs to Treat Bacterial XIFAXAN TAB 200MG RIFAXIMIN TAB 200 MG Tier 3 X X Infections Antibacterials - Drugs to Treat Bacterial XIFAXAN TAB 550MG RIFAXIMIN TAB 550 MG Tier 3 X X Infections Antibacterials - Drugs to Treat Bacterial AZITHROMYCIN POWD PACK FOR SUSP ZITHROMAX POW 1GM PAK Tier 3 Infections 1 GM Antibacterials - Drugs to Treat Bacterial ZITHROMAX SUS 100/5ML AZITHROMYCIN FOR SUSP 100 MG/5ML Tier 3 Infections Antibacterials - Drugs to Treat Bacterial ZITHROMAX SUS 200/5ML AZITHROMYCIN FOR SUSP 200 MG/5ML Tier 3 Infections Antibacterials - Drugs to Treat Bacterial ZITHROMAX TAB 250MG AZITHROMYCIN TAB 250 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial ZITHROMAX TAB 500MG AZITHROMYCIN TAB 500 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial ZITHROMAX TAB 600MG AZITHROMYCIN TAB 600 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial ZITHROMAX TAB TRI-PAK AZITHROMYCIN TAB 500 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial ZITHROMAX TAB Z-PAK AZITHROMYCIN TAB 250 MG Tier 3 Infections Antibacterials - Drugs to Treat Bacterial AZITHROMYCIN EXTENDED RELEASE ZMAX SUS 2GM Tier 3 Infections FOR ORAL SUSP 2 GM Antibacterials - Drugs to Treat Bacterial ZYMAXID SOL 0.5% GATIFLOXACIN OPHTH SOLN 0.5% Tier 3 Infections Antibacterials - Drugs to Treat Bacterial ZYVOX SUS 100MG/5M LINEZOLID FOR SUSP 100 MG/5ML Tier 3 X Infections ESLICARBAZEPINE ACETATE TAB 200 Anticonvulsants - Drugs to Treat Seizures APTIOM TAB 200MG Tier 3 X MG ESLICARBAZEPINE ACETATE TAB 400 Anticonvulsants - Drugs to Treat Seizures APTIOM TAB 400MG Tier 3 X MG ESLICARBAZEPINE ACETATE TAB 600 Anticonvulsants - Drugs to Treat Seizures APTIOM TAB 600MG Tier 3 X MG ESLICARBAZEPINE ACETATE TAB 800 Anticonvulsants - Drugs to Treat Seizures APTIOM TAB 800MG Tier 3 X MG Anticonvulsants - Drugs to Treat Seizures BANZEL SUS 40MG/ML RUFINAMIDE SUSP 40 MG/ML Tier 3 Anticonvulsants - Drugs to Treat Seizures BANZEL TAB 200MG RUFINAMIDE TAB 200 MG Tier 3 X Anticonvulsants - Drugs to Treat Seizures BANZEL TAB 400MG RUFINAMIDE TAB 400 MG Tier 3 X Anticonvulsants - Drugs to Treat Seizures BRIVIACT SOL 10MG/ML BRIVARACETAM ORAL SOLN 10 MG/ML Tier 3 X Anticonvulsants - Drugs to Treat Seizures BRIVIACT TAB 100MG BRIVARACETAM TAB 100 MG Tier 3 X Anticonvulsants - Drugs to Treat Seizures BRIVIACT TAB 10MG BRIVARACETAM TAB 10 MG Tier 3 X Anticonvulsants - Drugs to Treat Seizures BRIVIACT TAB 25MG BRIVARACETAM TAB 25 MG Tier 3 X Anticonvulsants - Drugs to Treat Seizures BRIVIACT TAB 50MG BRIVARACETAM TAB 50 MG Tier 3 X Anticonvulsants - Drugs to Treat Seizures BRIVIACT TAB 75MG BRIVARACETAM TAB 75 MG Tier 3 X CARBAMAZEPIN CAP Anticonvulsants - Drugs to Treat Seizures CARBAMAZEPINE CAP ER 12HR 100 MG Tier 2 100MG ER CARBAMAZEPIN CAP Anticonvulsants - Drugs to Treat Seizures CARBAMAZEPINE CAP ER 12HR 200 MG Tier 2 200MG ER CARBAMAZEPIN CAP Anticonvulsants - Drugs to Treat Seizures CARBAMAZEPINE CAP ER 12HR 300 MG Tier 2 300MG ER CARBAMAZEPIN CHW Anticonvulsants - Drugs to Treat Seizures CARBAMAZEPINE CHEW TAB 100 MG Tier 1 100MG CARBAMAZEPIN SUS Anticonvulsants - Drugs to Treat Seizures CARBAMAZEPINE SUSP 100 MG/5ML Tier 1 100/5ML CARBAMAZEPIN TAB Anticonvulsants - Drugs to Treat Seizures CARBAMAZEPINE TAB ER 12HR 100 MG Tier 3 100MGER CARBAMAZEPIN TAB Anticonvulsants - Drugs to Treat Seizures CARBAMAZEPINE TAB 200 MG Tier 1 200MG CARBAMAZEPIN TAB Anticonvulsants - Drugs to Treat Seizures CARBAMAZEPINE TAB ER 12HR 200 MG Tier 3 200MG ER CARBAMAZEPIN TAB Anticonvulsants - Drugs to Treat Seizures CARBAMAZEPINE TAB ER 12HR 400 MG Tier 3 400MG ER Anticonvulsants - Drugs to Treat Seizures CARBATROL CAP 100MG CARBAMAZEPINE CAP SR 12HR 100 MG Tier 3 Anticonvulsants - Drugs to Treat Seizures CARBATROL CAP 200MG CARBAMAZEPINE CAP ER 12HR 200 MG Tier 3 Anticonvulsants - Drugs to Treat Seizures CARBATROL CAP 300MG CARBAMAZEPINE CAP SR 12HR 300 MG Tier 3 Anticonvulsants - Drugs to Treat Seizures CELONTIN CAP 300MG METHSUXIMIDE CAP 300 MG Tier 2 Anticonvulsants - Drugs to Treat Seizures DEPAKENE CAP 250MG VALPROIC ACID CAP 250 MG Tier 3 VALPROATE SODIUM ORAL SOLN 250 Anticonvulsants - Drugs to Treat Seizures DEPAKENE SOL 250/5ML Tier 3 MG/5ML (BASE EQUIV) DIVALPROEX SODIUM TAB DELAYED Anticonvulsants - Drugs to Treat Seizures DEPAKOTE TAB 125MG DR Tier 3 X RELEASE 125 MG

32 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy DIVALPROEX SODIUM TAB DELAYED Anticonvulsants - Drugs to Treat Seizures DEPAKOTE TAB 250MG DR Tier 3 X RELEASE 250 MG DIVALPROEX SODIUM TAB DELAYED Anticonvulsants - Drugs to Treat Seizures DEPAKOTE TAB 500MG DR Tier 3 X RELEASE 500 MG DIVALPROEX SODIUM TAB SR 24 HR Anticonvulsants - Drugs to Treat Seizures DEPAKOTE ER TAB 250MG Tier 3 X X 250 MG DIVALPROEX SODIUM TAB SR 24 HR Anticonvulsants - Drugs to Treat Seizures DEPAKOTE ER TAB 500MG Tier 3 X X 500 MG DIVALPROEX SODIUM CAP DELAYED Anticonvulsants - Drugs to Treat Seizures DEPAKOTE SPR CAP 125MG Tier 3 X X RELEASE SPRINKLE 125 MG DIAZEPAM RECTAL GEL DELIVERY Anticonvulsants - Drugs to Treat Seizures DIASTAT ACDL GEL 12.5-20 Tier 3 X SYSTEM 20 MG DIAZEPAM RECTAL GEL DELIVERY Anticonvulsants - Drugs to Treat Seizures DIASTAT ACDL GEL 5-10MG Tier 3 X SYSTEM 10 MG DIAZEPAM RECTAL GEL DELIVERY Anticonvulsants - Drugs to Treat Seizures DIASTAT PED GEL 2.5M GEL Tier 2 X SYSTEM 2.5 MG DIAZEPAM RECTAL GEL DELIVERY Anticonvulsants - Drugs to Treat Seizures DIAZEPAM GEL 10MG Tier 1 X SYSTEM 10 MG DIAZEPAM RECTAL GEL DELIVERY Anticonvulsants - Drugs to Treat Seizures DIAZEPAM GEL 2.5MG Tier 1 X SYSTEM 2.5 MG DIAZEPAM RECTAL GEL DELIVERY Anticonvulsants - Drugs to Treat Seizures DIAZEPAM GEL 20MG Tier 1 X SYSTEM 20 MG PHENYTOIN SODIUM EXTENDED CAP Anticonvulsants - Drugs to Treat Seizures DILANTIN CAP 100MG Tier 3 100 MG PHENYTOIN SODIUM EXTENDED CAP Anticonvulsants - Drugs to Treat Seizures DILANTIN CAP 30MG Tier 3 30 MG Anticonvulsants - Drugs to Treat Seizures DILANTIN CHW 50MG PHENYTOIN CHEW TAB 50 MG Tier 3 Anticonvulsants - Drugs to Treat Seizures DILANTIN-125 SUS 125/5ML PHENYTOIN SUSP 125 MG/5ML Tier 3 DIVALPROEX SODIUM CAP DELAYED Anticonvulsants - Drugs to Treat Seizures DIVALPROEX CAP 125MG Tier 2 RELEASE SPRINKLE 125 MG DIVALPROEX SODIUM TAB DELAYED Anticonvulsants - Drugs to Treat Seizures DIVALPROEX TAB 125MG DR Tier 1 RELEASE 125 MG DIVALPROEX SODIUM TAB DELAYED Anticonvulsants - Drugs to Treat Seizures DIVALPROEX TAB 250MG DR Tier 1 RELEASE 250 MG DIVALPROEX SODIUM TAB ER 24 HR Anticonvulsants - Drugs to Treat Seizures DIVALPROEX TAB 250MG ER Tier 2 250 MG DIVALPROEX TAB 500MG DIVALPROEX SODIUM TAB DELAYED Anticonvulsants - Drugs to Treat Seizures Tier 1 DR RELEASE 500 MG DIVALPROEX SODIUM TAB ER 24 HR Anticonvulsants - Drugs to Treat Seizures DIVALPROEX TAB 500MG ER Tier 2 500 MG Anticonvulsants - Drugs to Treat Seizures EPITOL TAB 200MG CARBAMAZEPINE TAB 200 MG Tier 1 CARBAMAZEPINE (ANTIPSYCHOTIC) CAP Anticonvulsants - Drugs to Treat Seizures EQUETRO CAP 100MG Tier 3 ER 12HR 100 MG CARBAMAZEPINE (ANTIPSYCHOTIC) CAP Anticonvulsants - Drugs to Treat Seizures EQUETRO CAP 200MG Tier 3 ER 12HR 200 MG CARBAMAZEPINE (ANTIPSYCHOTIC) CAP Anticonvulsants - Drugs to Treat Seizures EQUETRO CAP 300MG Tier 3 ER 12HR 300 MG Anticonvulsants - Drugs to Treat Seizures ETHOSUXIMIDE CAP 250MG ETHOSUXIMIDE CAP 250 MG Tier 1 ETHOSUXIMIDE SOL Anticonvulsants - Drugs to Treat Seizures ETHOSUXIMIDE SOLN 250 MG/5ML Tier 1 250/5ML Anticonvulsants - Drugs to Treat Seizures FELBAMATE SUS 600/5ML FELBAMATE SUSP 600 MG/5ML Tier 1 Anticonvulsants - Drugs to Treat Seizures FELBAMATE TAB 400MG FELBAMATE TAB 400 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures FELBAMATE TAB 600MG FELBAMATE TAB 600 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures FELBATOL SUS 600/5ML FELBAMATE SUSP 600 MG/5ML Tier 3 X X Anticonvulsants - Drugs to Treat Seizures FELBATOL TAB 400MG FELBAMATE TAB 400 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures FELBATOL TAB 600MG FELBAMATE TAB 600 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures FYCOMPA SUS 0.5MG/ML PERAMPANEL SUSP 0.5 MG/ML Tier 3 X Anticonvulsants - Drugs to Treat Seizures FYCOMPA TAB 10MG PERAMPANEL TAB 10 MG Tier 3 X Anticonvulsants - Drugs to Treat Seizures FYCOMPA TAB 12MG PERAMPANEL TAB 12 MG Tier 3 X Anticonvulsants - Drugs to Treat Seizures FYCOMPA TAB 2MG PERAMPANEL TAB 2 MG Tier 3 X Anticonvulsants - Drugs to Treat Seizures FYCOMPA TAB 4MG PERAMPANEL TAB 4 MG Tier 3 X Anticonvulsants - Drugs to Treat Seizures FYCOMPA TAB 6MG PERAMPANEL TAB 6 MG Tier 3 X Anticonvulsants - Drugs to Treat Seizures FYCOMPA TAB 8MG PERAMPANEL TAB 8 MG Tier 3 X Anticonvulsants - Drugs to Treat Seizures GABAPENTIN CAP 100MG GABAPENTIN CAP 100 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures GABAPENTIN CAP 300MG GABAPENTIN CAP 300 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures GABAPENTIN CAP 400MG GABAPENTIN CAP 400 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures GABAPENTIN SOL 250/5ML GABAPENTIN ORAL SOLN 250 MG/5ML Tier 1 Anticonvulsants - Drugs to Treat Seizures GABAPENTIN TAB 600MG GABAPENTIN TAB 600 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures GABAPENTIN TAB 800MG GABAPENTIN TAB 800 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures GABITRIL TAB 12MG TIAGABINE HCL TAB 12 MG Tier 2 Anticonvulsants - Drugs to Treat Seizures GABITRIL TAB 16MG TIAGABINE HCL TAB 16 MG Tier 2 Anticonvulsants - Drugs to Treat Seizures GABITRIL TAB 2MG TIAGABINE HCL TAB 2 MG Tier 3 Anticonvulsants - Drugs to Treat Seizures GABITRIL TAB 4MG TIAGABINE HCL TAB 4 MG Tier 3 LEVETIRACETAM ORAL SOLN 100 MG/ Anticonvulsants - Drugs to Treat Seizures KEPPRA SOL 100MG/ML Tier 4 X X ML Anticonvulsants - Drugs to Treat Seizures KEPPRA TAB 1000MG LEVETIRACETAM TAB 1000 MG Tier 3 X X

33 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Anticonvulsants - Drugs to Treat Seizures KEPPRA TAB 250MG LEVETIRACETAM TAB 250 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures KEPPRA TAB 500MG LEVETIRACETAM TAB 500 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures KEPPRA TAB 750MG LEVETIRACETAM TAB 750 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures KEPPRA XR TAB 500MG LEVETIRACETAM TAB ER 24HR 500 MG Tier 4 X X Anticonvulsants - Drugs to Treat Seizures KEPPRA XR TAB 750MG LEVETIRACETAM TAB ER 24HR 750 MG Tier 4 X X LAMOTRIGINE TAB CHEWABLE Anticonvulsants - Drugs to Treat Seizures LAMICTAL CHW 25MG Tier 4 X X DISPERSIBLE 25 MG LAMOTRIGINE TAB CHEWABLE Anticonvulsants - Drugs to Treat Seizures LAMICTAL CHW 5MG Tier 4 X X DISPERSIBLE 5 MG LAMOTRIGINE TAB 25 MG (35) STARTER Anticonvulsants - Drugs to Treat Seizures LAMICTAL KIT START 35 Tier 4 X X KIT LAMOTRIGINE TAB 25 MG (42) & 100 MG Anticonvulsants - Drugs to Treat Seizures LAMICTAL KIT START 49 Tier 4 X X (7) STARTER KIT LAMOTRIGINE TAB 25 MG (84) & 100 MG Anticonvulsants - Drugs to Treat Seizures LAMICTAL KIT START 98 Tier 4 X X (14) STARTER KIT Anticonvulsants - Drugs to Treat Seizures LAMICTAL TAB 100MG LAMOTRIGINE TAB 100 MG Tier 4 X X Anticonvulsants - Drugs to Treat Seizures LAMICTAL TAB 150MG LAMOTRIGINE TAB 150 MG Tier 4 X X Anticonvulsants - Drugs to Treat Seizures LAMICTAL TAB 200MG LAMOTRIGINE TAB 200 MG Tier 4 X X Anticonvulsants - Drugs to Treat Seizures LAMICTAL TAB 25MG LAMOTRIGINE TAB 25 MG Tier 4 X X LAMOTRIGINE TAB DISINT 25 (14) & 50 Anticonvulsants - Drugs to Treat Seizures LAMICTAL ODT KIT Tier 4 X X MG (14) & 100 MG (7) KIT LAMOTRIGINE TAB DISINT 25 MG (21) & Anticonvulsants - Drugs to Treat Seizures LAMICTAL ODT KIT Tier 4 X X 50 MG (7) TITRATION KIT LAMOTRIGINE TAB DISINT 50 MG (42)- Anticonvulsants - Drugs to Treat Seizures LAMICTAL ODT KIT Tier 4 X X 100 MG(14) TITRATION KIT LAMOTRIGINE ORALLY DISINTEGRATING Anticonvulsants - Drugs to Treat Seizures LAMICTAL ODT TAB 100MG Tier 4 X X TAB 100 MG LAMOTRIGINE ORALLY DISINTEGRATING Anticonvulsants - Drugs to Treat Seizures LAMICTAL ODT TAB 200MG Tier 4 X X TAB 200 MG LAMOTRIGINE ORALLY DISINTEGRATING Anticonvulsants - Drugs to Treat Seizures LAMICTAL ODT TAB 25MG Tier 4 X X TAB 25 MG LAMOTRIGINE ORALLY DISINTEGRATING Anticonvulsants - Drugs to Treat Seizures LAMICTAL ODT TAB 50MG Tier 4 X X TAB 50 MG LAMOTRIGINE TAB ER 24HR 25 MG (21) & Anticonvulsants - Drugs to Treat Seizures LAMICTAL XR KIT Tier 3 X X 50 MG (7) TITRATION KIT LAMOTRIGINE TAB ER 24HR 50 (14) & Anticonvulsants - Drugs to Treat Seizures LAMICTAL XR KIT Tier 3 X X 100 MG(14) & 200 MG(7) KIT LAMOTRIGINE TAB ER 24HR 25 (14) & 50 Anticonvulsants - Drugs to Treat Seizures LAMICTAL XR KIT Tier 3 X X MG (14) & 100 MG(7) KIT Anticonvulsants - Drugs to Treat Seizures LAMICTAL XR TAB 100MG LAMOTRIGINE TAB ER 24HR 100 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures LAMICTAL XR TAB 200MG LAMOTRIGINE TAB ER 24HR 200 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures LAMICTAL XR TAB 250MG LAMOTRIGINE TAB ER 24HR 250 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures LAMICTAL XR TAB 25MG LAMOTRIGINE TAB ER 24HR 25 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures LAMICTAL XR TAB 300MG LAMOTRIGINE TAB ER 24HR 300 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures LAMICTAL XR TAB 50MG LAMOTRIGINE TAB ER 24HR 50 MG Tier 3 X X LAMOTRIG ODT KIT LAMOTRIGINE TAB DISINT 25 MG (21) & Anticonvulsants - Drugs to Treat Seizures Tier 3 X X 25/50MG 50 MG (7) TITRATION KIT LAMOTRIG ODT KIT LAMOTRIGINE TAB DISINT 50 MG (42)- Anticonvulsants - Drugs to Treat Seizures Tier 3 X X 50/100MG 100 MG(14) TITRATION KIT LAMOTRIGINE ORALLY DISINTEGRATING Anticonvulsants - Drugs to Treat Seizures LAMOTRIG ODT TAB 100MG Tier 3 X TAB 100 MG LAMOTRIGINE TAB CHEWABLE Anticonvulsants - Drugs to Treat Seizures LAMOTRIGINE CHW 25MG Tier 1 DISPERSIBLE 25 MG LAMOTRIGINE TAB CHEWABLE Anticonvulsants - Drugs to Treat Seizures LAMOTRIGINE CHW 5MG Tier 1 DISPERSIBLE 5 MG LAMOTRIGINE TAB DISINT 25 (14) & 50 Anticonvulsants - Drugs to Treat Seizures LAMOTRIGINE KIT ODT Tier 3 X X MG (14) & 100 MG (7) KIT LAMOTRIGINE TAB 25 MG (35) STARTER Anticonvulsants - Drugs to Treat Seizures LAMOTRIGINE KIT START 35 Tier 1 X KIT LAMOTRIGINE TAB 25 MG (42) & 100 MG Anticonvulsants - Drugs to Treat Seizures LAMOTRIGINE KIT START 49 Tier 1 X (7) STARTER KIT LAMOTRIGINE TAB 25 MG (84) & 100 MG Anticonvulsants - Drugs to Treat Seizures LAMOTRIGINE KIT START 98 Tier 1 X (14) STARTER KIT Anticonvulsants - Drugs to Treat Seizures LAMOTRIGINE TAB 100MG LAMOTRIGINE TAB 100 MG Tier 1 LAMOTRIGINE ORALLY DISINTEGRATING Anticonvulsants - Drugs to Treat Seizures LAMOTRIGINE TAB 100MG Tier 3 X TAB 100 MG LAMOTRIGINE TAB 100MG Anticonvulsants - Drugs to Treat Seizures LAMOTRIGINE TAB ER 24HR 100 MG Tier 3 X X ER Anticonvulsants - Drugs to Treat Seizures LAMOTRIGINE TAB 150MG LAMOTRIGINE TAB 150 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures LAMOTRIGINE TAB 200MG LAMOTRIGINE TAB 200 MG Tier 1 LAMOTRIGINE ORALLY DISINTEGRATING Anticonvulsants - Drugs to Treat Seizures LAMOTRIGINE TAB 200MG Tier 3 X TAB 200 MG LAMOTRIGINE TAB 200MG Anticonvulsants - Drugs to Treat Seizures LAMOTRIGINE TAB ER 24HR 200 MG Tier 3 X X ER LAMOTRIGINE TAB 250MG Anticonvulsants - Drugs to Treat Seizures LAMOTRIGINE TAB ER 24HR 250 MG Tier 3 X X ER Anticonvulsants - Drugs to Treat Seizures LAMOTRIGINE TAB 25MG LAMOTRIGINE TAB 25 MG Tier 1 34 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Anticonvulsants - Drugs to Treat Seizures LAMOTRIGINE TAB 25MG ER LAMOTRIGINE TAB ER 24HR 25 MG Tier 3 X X LAMOTRIGINE TAB 25MG LAMOTRIGINE ORALLY DISINTEGRATING Anticonvulsants - Drugs to Treat Seizures Tier 3 X ODT TAB 25 MG LAMOTRIGINE TAB 300MG Anticonvulsants - Drugs to Treat Seizures LAMOTRIGINE TAB ER 24HR 300 MG Tier 3 X X ER Anticonvulsants - Drugs to Treat Seizures LAMOTRIGINE TAB 50MG ER LAMOTRIGINE TAB ER 24HR 50 MG Tier 3 X X LAMOTRIGINE TAB 50MG LAMOTRIGINE ORALLY DISINTEGRATING Anticonvulsants - Drugs to Treat Seizures Tier 3 X ODT TAB 50 MG LEVETIRACETA SOL 100MG/ LEVETIRACETAM ORAL SOLN 100 MG/ Anticonvulsants - Drugs to Treat Seizures Tier 1 ML ML LEVETIRACETA SOL LEVETIRACETAM ORAL SOLN 100 MG/ Anticonvulsants - Drugs to Treat Seizures Tier 1 500/5ML ML LEVETIRACETA TAB Anticonvulsants - Drugs to Treat Seizures LEVETIRACETAM TAB 1000 MG Tier 1 1000MG Anticonvulsants - Drugs to Treat Seizures LEVETIRACETA TAB 250MG LEVETIRACETAM TAB 250 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures LEVETIRACETA TAB 500MG LEVETIRACETAM TAB 500 MG Tier 1 LEVETIRACETA TAB 500MG Anticonvulsants - Drugs to Treat Seizures LEVETIRACETAM TAB ER 24HR 500 MG Tier 2 ER Anticonvulsants - Drugs to Treat Seizures LEVETIRACETA TAB 750MG LEVETIRACETAM TAB 750 MG Tier 1 LEVETIRACETA TAB 750MG Anticonvulsants - Drugs to Treat Seizures LEVETIRACETAM TAB ER 24HR 750 MG Tier 2 ER Anticonvulsants - Drugs to Treat Seizures MYSOLINE TAB 250MG PRIMIDONE TAB 250 MG Tier 2 X X Anticonvulsants - Drugs to Treat Seizures MYSOLINE TAB 50MG PRIMIDONE TAB 50 MG Tier 2 X X Anticonvulsants - Drugs to Treat Seizures NEURONTIN CAP 100MG GABAPENTIN CAP 100 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures NEURONTIN CAP 300MG GABAPENTIN CAP 300 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures NEURONTIN CAP 400MG GABAPENTIN CAP 400 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures NEURONTIN SOL 250/5ML GABAPENTIN ORAL SOLN 250 MG/5ML Tier 3 X X Anticonvulsants - Drugs to Treat Seizures NEURONTIN TAB 600MG GABAPENTIN TAB 600 MG Tier 4 X X Anticonvulsants - Drugs to Treat Seizures NEURONTIN TAB 800MG GABAPENTIN TAB 800 MG Tier 4 X X Anticonvulsants - Drugs to Treat Seizures ONFI SUS 2.5MG/ML CLOBAZAM SUSPENSION 2.5 MG/ML Tier 3 X Anticonvulsants - Drugs to Treat Seizures ONFI TAB 10MG CLOBAZAM TAB 10 MG Tier 3 X Anticonvulsants - Drugs to Treat Seizures ONFI TAB 20MG CLOBAZAM TAB 20 MG Tier 3 X OXCARBAZEPIN SUS OXCARBAZEPINE SUSP 300 MG/5ML (60 Anticonvulsants - Drugs to Treat Seizures Tier 1 300MG/5M MG/ML) Anticonvulsants - Drugs to Treat Seizures OXCARBAZEPIN TAB 150MG OXCARBAZEPINE TAB 150 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures OXCARBAZEPIN TAB 300MG OXCARBAZEPINE TAB 300 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures OXCARBAZEPIN TAB 600MG OXCARBAZEPINE TAB 600 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures PEGANONE TAB 250MG ETHOTOIN TAB 250 MG Tier 2 Anticonvulsants - Drugs to Treat Seizures PHENOBARB ELX 20/5ML PHENOBARBITAL ELIXIR 20 MG/5ML Tier 1 PHENOBARB ELX Anticonvulsants - Drugs to Treat Seizures PHENOBARBITAL ELIXIR 20 MG/5ML Tier 1 20MG/5ML PHENOBARB SOL Anticonvulsants - Drugs to Treat Seizures PHENOBARBITAL ELIXIR 20 MG/5ML Tier 1 20MG/5ML Anticonvulsants - Drugs to Treat Seizures PHENOBARB TAB 100MG PHENOBARBITAL TAB 100 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures PHENOBARB TAB 15MG PHENOBARBITAL TAB 15 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures PHENOBARB TAB 16.2MG PHENOBARBITAL TAB 16.2 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures PHENOBARB TAB 30MG PHENOBARBITAL TAB 30 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures PHENOBARB TAB 32.4MG PHENOBARBITAL TAB 32.4 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures PHENOBARB TAB 60MG PHENOBARBITAL TAB 60 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures PHENOBARB TAB 64.8MG PHENOBARBITAL TAB 64.8 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures PHENOBARB TAB 97.2MG PHENOBARBITAL TAB 97.2 MG Tier 1 PHENYTOIN SODIUM EXTENDED CAP Anticonvulsants - Drugs to Treat Seizures PHENYTEK CAP 200MG Tier 3 200 MG PHENYTOIN SODIUM EXTENDED CAP Anticonvulsants - Drugs to Treat Seizures PHENYTEK CAP 300MG Tier 3 300 MG Anticonvulsants - Drugs to Treat Seizures PHENYTOIN CHW 50MG PHENYTOIN CHEW TAB 50 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures PHENYTOIN SUS 125/5ML PHENYTOIN SUSP 125 MG/5ML Tier 1 PHENYTOIN SODIUM EXTENDED CAP Anticonvulsants - Drugs to Treat Seizures PHENYTOIN EX CAP 100MG Tier 1 100 MG PHENYTOIN SODIUM EXTENDED CAP Anticonvulsants - Drugs to Treat Seizures PHENYTOIN EX CAP 200MG Tier 1 200 MG PHENYTOIN SODIUM EXTENDED CAP Anticonvulsants - Drugs to Treat Seizures PHENYTOIN EX CAP 300MG Tier 1 300 MG Anticonvulsants - Drugs to Treat Seizures POTIGA TAB 200MG EZOGABINE TAB 200 MG Tier 3 Anticonvulsants - Drugs to Treat Seizures POTIGA TAB 300MG EZOGABINE TAB 300 MG Tier 3 Anticonvulsants - Drugs to Treat Seizures POTIGA TAB 400MG EZOGABINE TAB 400 MG Tier 3 Anticonvulsants - Drugs to Treat Seizures POTIGA TAB 50MG EZOGABINE TAB 50 MG Tier 3 Anticonvulsants - Drugs to Treat Seizures PRIMIDONE TAB 250MG PRIMIDONE TAB 250 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures PRIMIDONE TAB 50MG PRIMIDONE TAB 50 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures ROWEEPRA TAB 1000MG LEVETIRACETAM TAB 1000 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures ROWEEPRA TAB 500MG LEVETIRACETAM TAB 500 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures ROWEEPRA TAB 750MG LEVETIRACETAM TAB 750 MG Tier 1 ROWEEPRA XR TAB 500MG Anticonvulsants - Drugs to Treat Seizures LEVETIRACETAM TAB ER 24HR 500 MG Tier 2 XR

35 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy ROWEEPRA XR TAB 750MG Anticonvulsants - Drugs to Treat Seizures LEVETIRACETAM TAB ER 24HR 750 MG Tier 2 XR Anticonvulsants - Drugs to Treat Seizures SABRIL POW 500MG VIGABATRIN POWD PACK 500 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures SABRIL TAB 500MG VIGABATRIN TAB 500 MG Tier 2 X X Anticonvulsants - Drugs to Treat Seizures TEGRETOL SUS 100/5ML CARBAMAZEPINE SUSP 100 MG/5ML Tier 3 Anticonvulsants - Drugs to Treat Seizures TEGRETOL TAB 200MG CARBAMAZEPINE TAB 200 MG Tier 3 Anticonvulsants - Drugs to Treat Seizures TEGRETOL-XR TAB 100MG CARBAMAZEPINE TAB ER 12HR 100 MG Tier 3 Anticonvulsants - Drugs to Treat Seizures TEGRETOL-XR TAB 200MG CARBAMAZEPINE TAB ER 12HR 200 MG Tier 3 Anticonvulsants - Drugs to Treat Seizures TEGRETOL-XR TAB 400MG CARBAMAZEPINE TAB ER 12HR 400 MG Tier 3 Anticonvulsants - Drugs to Treat Seizures TIAGABINE TAB 2MG TIAGABINE HCL TAB 2 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures TIAGABINE TAB 4MG TIAGABINE HCL TAB 4 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures TOPAMAX TAB 100MG TOPIRAMATE TAB 100 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures TOPAMAX TAB 200MG TOPIRAMATE TAB 200 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures TOPAMAX TAB 25MG TOPIRAMATE TAB 25 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures TOPAMAX TAB 50MG TOPIRAMATE TAB 50 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures TOPAMAX SPR CAP 15MG TOPIRAMATE SPRINKLE CAP 15 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures TOPAMAX SPR CAP 25MG TOPIRAMATE SPRINKLE CAP 25 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures TOPIRAMATE CAP 15MG TOPIRAMATE SPRINKLE CAP 15 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures TOPIRAMATE CAP 25MG TOPIRAMATE SPRINKLE CAP 25 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures TOPIRAMATE TAB 100MG TOPIRAMATE TAB 100 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures TOPIRAMATE TAB 200MG TOPIRAMATE TAB 200 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures TOPIRAMATE TAB 25MG TOPIRAMATE TAB 25 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures TOPIRAMATE TAB 50MG TOPIRAMATE TAB 50 MG Tier 1 OXCARBAZEPINE SUSP 300 MG/5ML (60 Anticonvulsants - Drugs to Treat Seizures TRILEPTAL SUS 300MG/5M Tier 3 X X MG/ML) Anticonvulsants - Drugs to Treat Seizures TRILEPTAL TAB 150MG OXCARBAZEPINE TAB 150 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures TRILEPTAL TAB 300MG OXCARBAZEPINE TAB 300 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures TRILEPTAL TAB 600MG OXCARBAZEPINE TAB 600 MG Tier 3 X X Anticonvulsants - Drugs to Treat Seizures VALPROIC ACD CAP 250MG VALPROIC ACID CAP 250 MG Tier 1 VALPROIC ACD SOL VALPROATE SODIUM ORAL SOLN 250 Anticonvulsants - Drugs to Treat Seizures Tier 1 250/5ML MG/5ML (BASE EQUIV) Anticonvulsants - Drugs to Treat Seizures VIGABATRIN PAK 500MG VIGABATRIN POWD PACK 500 MG Tier 2 X X LACOSAMIDE ORAL SOLUTION 10 MG/ Anticonvulsants - Drugs to Treat Seizures VIMPAT SOL 10MG/ML Tier 3 X ML Anticonvulsants - Drugs to Treat Seizures VIMPAT TAB 100MG LACOSAMIDE TAB 100 MG Tier 3 X Anticonvulsants - Drugs to Treat Seizures VIMPAT TAB 150MG LACOSAMIDE TAB 150 MG Tier 3 X Anticonvulsants - Drugs to Treat Seizures VIMPAT TAB 200MG LACOSAMIDE TAB 200 MG Tier 3 X Anticonvulsants - Drugs to Treat Seizures VIMPAT TAB 50MG LACOSAMIDE TAB 50 MG Tier 3 X Anticonvulsants - Drugs to Treat Seizures ZARONTIN CAP 250MG ETHOSUXIMIDE CAP 250 MG Tier 3 Anticonvulsants - Drugs to Treat Seizures ZARONTIN SOL 250/5ML ETHOSUXIMIDE SOLN 250 MG/5ML Tier 3 Anticonvulsants - Drugs to Treat Seizures ZONEGRAN CAP 100MG ZONISAMIDE CAP 100 MG Tier 4 X X Anticonvulsants - Drugs to Treat Seizures ZONEGRAN CAP 25MG ZONISAMIDE CAP 25 MG Tier 4 X X Anticonvulsants - Drugs to Treat Seizures ZONISAMIDE CAP 100MG ZONISAMIDE CAP 100 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures ZONISAMIDE CAP 25MG ZONISAMIDE CAP 25 MG Tier 1 Anticonvulsants - Drugs to Treat Seizures ZONISAMIDE CAP 50MG ZONISAMIDE CAP 50 MG Tier 1 Antidementia Agents - Drugs to Treat DONEPEZIL HYDROCHLORIDE TAB 10 ARICEPT TAB 10MG Tier 3 Alzheimer's Disease and Dementia MG Antidementia Agents - Drugs to Treat ARICEPT TAB 5MG DONEPEZIL HYDROCHLORIDE TAB 5 MG Tier 3 Alzheimer's Disease and Dementia Antidementia Agents - Drugs to Treat DONEPEZIL HYDROCHLORIDE TAB 10 DONEPEZIL TAB 10MG Tier 1 Alzheimer's Disease and Dementia MG Antidementia Agents - Drugs to Treat DONEPEZIL HYDROCHLORIDE ORALLY DONEPEZIL TAB 10MG ODT Tier 1 Alzheimer's Disease and Dementia DISINTEGRATING TAB 10 MG Antidementia Agents - Drugs to Treat DONEPEZIL TAB 5MG DONEPEZIL HYDROCHLORIDE TAB 5 MG Tier 1 Alzheimer's Disease and Dementia Antidementia Agents - Drugs to Treat DONEPEZIL HYDROCHLORIDE ORALLY DONEPEZIL TAB 5MG ODT Tier 1 Alzheimer's Disease and Dementia DISINTEGRATING TAB 5 MG Antidementia Agents - Drugs to Treat EXELON CAP 1.5MG RIVASTIGMINE TARTRATE CAP 1.5 MG Tier 3 Alzheimer's Disease and Dementia Antidementia Agents - Drugs to Treat EXELON CAP 3MG RIVASTIGMINE TARTRATE CAP 3 MG Tier 3 Alzheimer's Disease and Dementia Antidementia Agents - Drugs to Treat EXELON CAP 4.5MG RIVASTIGMINE TARTRATE CAP 4.5 MG Tier 3 Alzheimer's Disease and Dementia Antidementia Agents - Drugs to Treat EXELON CAP 6MG RIVASTIGMINE TARTRATE CAP 6 MG Tier 3 Alzheimer's Disease and Dementia Antidementia Agents - Drugs to Treat GALANTAMINE CAP 16MG GALANTAMINE HYDROBROMIDE CAP ER Tier 1 Alzheimer's Disease and Dementia ER 24HR 16 MG Antidementia Agents - Drugs to Treat GALANTAMINE CAP 24MG GALANTAMINE HYDROBROMIDE CAP ER Tier 1 Alzheimer's Disease and Dementia ER 24HR 24 MG Antidementia Agents - Drugs to Treat GALANTAMINE HYDROBROMIDE CAP ER GALANTAMINE CAP 8MG ER Tier 1 Alzheimer's Disease and Dementia 24HR 8 MG Antidementia Agents - Drugs to Treat GALANTAMINE SOL 4MG/ GALANTAMINE HYDROBROMIDE ORAL Tier 1 Alzheimer's Disease and Dementia ML SOLN 4 MG/ML Antidementia Agents - Drugs to Treat GALANTAMINE HYDROBROMIDE TAB GALANTAMINE TAB 12MG Tier 1 Alzheimer's Disease and Dementia 12 MG

36 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antidementia Agents - Drugs to Treat GALANTAMINE HYDROBROMIDE TAB GALANTAMINE TAB 4MG Tier 1 Alzheimer's Disease and Dementia 4 MG Antidementia Agents - Drugs to Treat GALANTAMINE HYDROBROMIDE TAB GALANTAMINE TAB 8MG Tier 1 Alzheimer's Disease and Dementia 8 MG Antidementia Agents - Drugs to Treat MEMANTINE HCL TAB 5 MG (28) & 10 MG MEMANT TITRA PAK 5-10MG Tier 2 Alzheimer's Disease and Dementia (21) TITRATION PAK Antidementia Agents - Drugs to Treat MEMANTINE TAB HCL 10MG MEMANTINE HCL TAB 10 MG Tier 2 Alzheimer's Disease and Dementia Antidementia Agents - Drugs to Treat MEMANTINE TAB HCL 5MG MEMANTINE HCL TAB 5 MG Tier 2 Alzheimer's Disease and Dementia Antidementia Agents - Drugs to Treat MEMANTINE HC SOL 2MG/ MEMANTINE HCL ORAL SOLUTION 2 Tier 3 Alzheimer's Disease and Dementia ML MG/ML Antidementia Agents - Drugs to Treat MEMANTINE HCL ORAL SOLUTION 2 NAMENDA SOL 10MG/5ML Tier 3 Alzheimer's Disease and Dementia MG/ML Antidementia Agents - Drugs to Treat NAMENDA TAB 10MG MEMANTINE HCL TAB 10 MG Tier 3 Alzheimer's Disease and Dementia Antidementia Agents - Drugs to Treat MEMANTINE HCL TAB 5 MG (28) & 10 MG NAMENDA TAB 5-10MG Tier 3 Alzheimer's Disease and Dementia (21) TITRATION PAK Antidementia Agents - Drugs to Treat NAMENDA TAB 5MG MEMANTINE HCL TAB 5 MG Tier 3 Alzheimer's Disease and Dementia Antidementia Agents - Drugs to Treat GALANTAMINE HYDROBROMIDE TAB RAZADYNE TAB 12MG Tier 3 Alzheimer's Disease and Dementia 12 MG Antidementia Agents - Drugs to Treat GALANTAMINE HYDROBROMIDE TAB RAZADYNE TAB 4MG Tier 3 Alzheimer's Disease and Dementia 4 MG Antidementia Agents - Drugs to Treat GALANTAMINE HYDROBROMIDE TAB RAZADYNE TAB 8MG Tier 3 Alzheimer's Disease and Dementia 8 MG Antidementia Agents - Drugs to Treat GALANTAMINE HYDROBROMIDE CAP SR RAZADYNE ER CAP 16MG Tier 3 Alzheimer's Disease and Dementia 24HR 16 MG Antidementia Agents - Drugs to Treat GALANTAMINE HYDROBROMIDE CAP SR RAZADYNE ER CAP 24MG Tier 3 Alzheimer's Disease and Dementia 24HR 24 MG Antidementia Agents - Drugs to Treat GALANTAMINE HYDROBROMIDE CAP SR RAZADYNE ER CAP 8MG Tier 3 Alzheimer's Disease and Dementia 24HR 8 MG Antidementia Agents - Drugs to Treat RIVASTIGMINE CAP 1.5MG RIVASTIGMINE TARTRATE CAP 1.5 MG Tier 1 Alzheimer's Disease and Dementia Antidementia Agents - Drugs to Treat RIVASTIGMINE CAP 3MG RIVASTIGMINE TARTRATE CAP 3 MG Tier 1 Alzheimer's Disease and Dementia Antidementia Agents - Drugs to Treat RIVASTIGMINE CAP 4.5MG RIVASTIGMINE TARTRATE CAP 4.5 MG Tier 1 Alzheimer's Disease and Dementia Antidementia Agents - Drugs to Treat RIVASTIGMINE CAP 6MG RIVASTIGMINE TARTRATE CAP 6 MG Tier 1 Alzheimer's Disease and Dementia Antidementia Agents - Drugs to Treat RIVASTIGMINE TD PATCH 24HR 13.3 RIVASTIGMINE DIS 13.3/24 Tier 3 Alzheimer's Disease and Dementia MG/24HR Antidementia Agents - Drugs to Treat RIVASTIGMINE TD PATCH 24HR 4.6 RIVASTIGMINE DIS 4.6MG/24 Tier 3 Alzheimer's Disease and Dementia MG/24HR Antidementia Agents - Drugs to Treat RIVASTIGMINE TD PATCH 24HR 9.5 RIVASTIGMINE DIS 9.5MG/24 Tier 3 Alzheimer's Disease and Dementia MG/24HR Antidepressants - Drugs to Treat AMITRIPTYLIN TAB 100MG AMITRIPTYLINE HCL TAB 100 MG Tier 1 Depression Antidepressants - Drugs to Treat AMITRIPTYLIN TAB 10MG AMITRIPTYLINE HCL TAB 10 MG Tier 1 Depression Antidepressants - Drugs to Treat AMITRIPTYLIN TAB 150MG AMITRIPTYLINE HCL TAB 150 MG Tier 1 Depression Antidepressants - Drugs to Treat AMITRIPTYLIN TAB 25MG AMITRIPTYLINE HCL TAB 25 MG Tier 1 Depression Antidepressants - Drugs to Treat AMITRIPTYLIN TAB 50MG AMITRIPTYLINE HCL TAB 50 MG Tier 1 Depression Antidepressants - Drugs to Treat AMITRIPTYLIN TAB 75MG AMITRIPTYLINE HCL TAB 75 MG Tier 1 Depression Antidepressants - Drugs to Treat AMOXAPINE TAB 100MG AMOXAPINE TAB 100 MG Tier 1 Depression Antidepressants - Drugs to Treat AMOXAPINE TAB 150MG AMOXAPINE TAB 150 MG Tier 1 Depression Antidepressants - Drugs to Treat AMOXAPINE TAB 25MG AMOXAPINE TAB 25 MG Tier 1 Depression Antidepressants - Drugs to Treat AMOXAPINE TAB 50MG AMOXAPINE TAB 50 MG Tier 1 Depression Antidepressants - Drugs to Treat BUPROPION TAB 100MG BUPROPION HCL TAB 100 MG Tier 1 Depression Antidepressants - Drugs to Treat BUPROPION TAB 100MG ER BUPROPION HCL TAB ER 12HR 100 MG Tier 1 Depression Antidepressants - Drugs to Treat BUPROPION TAB 100MG SR BUPROPION HCL TAB ER 12HR 100 MG Tier 1 Depression Antidepressants - Drugs to Treat BUPROPION TAB 150MG ER BUPROPION HCL TAB ER 12HR 150 MG Tier 1 Depression Antidepressants - Drugs to Treat BUPROPION TAB 150MG SR BUPROPION HCL TAB ER 12HR 150 MG Tier 1 Depression Antidepressants - Drugs to Treat BUPROPION TAB 200MG ER BUPROPION HCL TAB ER 12HR 200 MG Tier 1 Depression

37 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antidepressants - Drugs to Treat BUPROPION TAB 200MG SR BUPROPION HCL TAB ER 12HR 200 MG Tier 1 Depression Antidepressants - Drugs to Treat BUPROPION TAB 75MG BUPROPION HCL TAB 75 MG Tier 1 Depression Antidepressants - Drugs to Treat BUPROPN HCL TAB 150MG BUPROPION HCL TAB ER 24HR 150 MG Tier 1 Depression XL Antidepressants - Drugs to Treat BUPROPN HCL TAB 300MG BUPROPION HCL TAB ER 24HR 300 MG Tier 1 Depression XL Antidepressants - Drugs to Treat CHLORDIAZEPOXIDE-AMITRIPTYLINE CDP/AMITRIP TAB 10-25MG Tier 1 Depression TAB 10-25 MG Antidepressants - Drugs to Treat CHLORDIAZEPOXIDE-AMITRIPTYLINE CDP/AMITRIP TAB 5-12.5MG Tier 1 Depression TAB 5-12.5 MG Antidepressants - Drugs to Treat CITALOPRAM SOL CITALOPRAM HYDROBROMIDE ORAL Tier 1 Depression 10MG/5ML SOLN 10 MG/5ML Antidepressants - Drugs to Treat CITALOPRAM HYDROBROMIDE TAB 10 CITALOPRAM TAB 10MG Tier 1 Depression MG (BASE EQUIV) Antidepressants - Drugs to Treat CITALOPRAM HYDROBROMIDE TAB 20 CITALOPRAM TAB 20MG Tier 1 Depression MG (BASE EQUIV) Antidepressants - Drugs to Treat CITALOPRAM HYDROBROMIDE TAB 40 CITALOPRAM TAB 40MG Tier 1 Depression MG (BASE EQUIV) Antidepressants - Drugs to Treat CLOMIPRAMINE CAP 25MG CLOMIPRAMINE HCL CAP 25 MG Tier 3 Depression Antidepressants - Drugs to Treat CLOMIPRAMINE CAP 50MG CLOMIPRAMINE HCL CAP 50 MG Tier 3 Depression Antidepressants - Drugs to Treat CLOMIPRAMINE CAP 75MG CLOMIPRAMINE HCL CAP 75 MG Tier 3 Depression Antidepressants - Drugs to Treat DESIPRAMINE TAB 100MG DESIPRAMINE HCL TAB 100 MG Tier 1 Depression Antidepressants - Drugs to Treat DESIPRAMINE TAB 10MG DESIPRAMINE HCL TAB 10 MG Tier 1 Depression Antidepressants - Drugs to Treat DESIPRAMINE TAB 150MG DESIPRAMINE HCL TAB 150 MG Tier 1 Depression Antidepressants - Drugs to Treat DESIPRAMINE TAB 25MG DESIPRAMINE HCL TAB 25 MG Tier 1 Depression Antidepressants - Drugs to Treat DESIPRAMINE TAB 50MG DESIPRAMINE HCL TAB 50 MG Tier 1 Depression Antidepressants - Drugs to Treat DESIPRAMINE TAB 75MG DESIPRAMINE HCL TAB 75 MG Tier 1 Depression Antidepressants - Drugs to Treat DESVENLAFAX TAB 100MG DESVENLAFAXINE SUCCINATE TAB ER Tier 2 X Depression ER 24HR 100 MG (BASE EQUIV) Antidepressants - Drugs to Treat DESVENLAFAX TAB 25MG DESVENLAFAXINE SUCCINATE TAB ER Tier 2 X Depression ER 24HR 25 MG (BASE EQUIV) Antidepressants - Drugs to Treat DESVENLAFAX TAB 50MG DESVENLAFAXINE SUCCINATE TAB ER Tier 2 X Depression ER 24HR 50 MG (BASE EQUIV) Antidepressants - Drugs to Treat DOXEPIN HCL CAP 100MG DOXEPIN HCL CAP 100 MG Tier 1 Depression Antidepressants - Drugs to Treat DOXEPIN HCL CAP 10MG DOXEPIN HCL CAP 10 MG Tier 1 Depression Antidepressants - Drugs to Treat DOXEPIN HCL CAP 150MG DOXEPIN HCL CAP 150 MG Tier 1 Depression Antidepressants - Drugs to Treat DOXEPIN HCL CAP 25MG DOXEPIN HCL CAP 25 MG Tier 1 Depression Antidepressants - Drugs to Treat DOXEPIN HCL CAP 50MG DOXEPIN HCL CAP 50 MG Tier 1 Depression Antidepressants - Drugs to Treat DOXEPIN HCL CAP 75MG DOXEPIN HCL CAP 75 MG Tier 1 Depression Antidepressants - Drugs to Treat DOXEPIN HCL CON 10MG/ DOXEPIN HCL CONC 10 MG/ML Tier 1 Depression ML Antidepressants - Drugs to Treat ELAVIL TAB 25MG AMITRIPTYLINE HCL TAB 25 MG Tier 3 Depression Antidepressants - Drugs to Treat SELEGILINE TD PATCH 24HR 12 EMSAM DIS 12MG/24H Tier 3 Depression MG/24HR Antidepressants - Drugs to Treat EMSAM DIS 6MG/24HR SELEGILINE TD PATCH 24HR 6 MG/24HR Tier 3 Depression Antidepressants - Drugs to Treat EMSAM DIS 9MG/24HR SELEGILINE TD PATCH 24HR 9 MG/24HR Tier 3 Depression Antidepressants - Drugs to Treat ESCITALOPRAM SOL ESCITALOPRAM OXALATE SOLN 5 Tier 3 Depression 5MG/5ML MG/5ML (BASE EQUIV) Antidepressants - Drugs to Treat ESCITALOPRAM OXALATE TAB 10 MG ESCITALOPRAM TAB 10MG Tier 1 Depression (BASE EQUIV) Antidepressants - Drugs to Treat ESCITALOPRAM OXALATE TAB 20 MG ESCITALOPRAM TAB 20MG Tier 1 Depression (BASE EQUIV) Antidepressants - Drugs to Treat ESCITALOPRAM OXALATE TAB 5 MG ESCITALOPRAM TAB 5MG Tier 1 Depression (BASE EQUIV) Antidepressants - Drugs to Treat LEVOMILNACIPRAN HCL CAP ER 24HR FETZIMA CAP 120MG Tier 3 X X Depression 120 MG (BASE EQUIVALENT) Antidepressants - Drugs to Treat LEVOMILNACIPRAN HCL CAP ER 24HR FETZIMA CAP 20MG Tier 3 X X Depression 20 MG (BASE EQUIVALENT)

38 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antidepressants - Drugs to Treat LEVOMILNACIPRAN HCL CAP ER 24HR FETZIMA CAP 40MG Tier 3 X X Depression 40 MG (BASE EQUIVALENT) Antidepressants - Drugs to Treat LEVOMILNACIPRAN HCL CAP ER 24HR FETZIMA CAP 80MG Tier 3 X X Depression 80 MG (BASE EQUIVALENT) Antidepressants - Drugs to Treat LEVOMILNACIPRAN HCL CAP ER 24HR FETZIMA CAP TITRATIO Tier 3 X X Depression 20 & 40 MG THERAPY PACK Antidepressants - Drugs to Treat FLUOXETINE CAP 10MG FLUOXETINE HCL (PMDD) CAP 10 MG Tier 3 Depression Antidepressants - Drugs to Treat FLUOXETINE CAP 10MG FLUOXETINE HCL CAP 10 MG Tier 1 Depression Antidepressants - Drugs to Treat FLUOXETINE CAP 20MG FLUOXETINE HCL (PMDD) CAP 20 MG Tier 3 Depression Antidepressants - Drugs to Treat FLUOXETINE CAP 20MG FLUOXETINE HCL CAP 20 MG Tier 1 Depression Antidepressants - Drugs to Treat FLUOXETINE CAP 40MG FLUOXETINE HCL CAP 40 MG Tier 1 Depression Antidepressants - Drugs to Treat FLUOXETINE HCL CAP DELAYED FLUOXETINE CAP 90MG DR Tier 3 X Depression RELEASE 90 MG Antidepressants - Drugs to Treat FLUOXETINE SOL FLUOXETINE HCL SOLUTION 20 MG/5ML Tier 1 Depression 20MG/5ML Antidepressants - Drugs to Treat FLUOXETINE TAB 10MG FLUOXETINE HCL TAB 10 MG Tier 3 X Depression Antidepressants - Drugs to Treat FLUOXETINE TAB 20MG FLUOXETINE HCL TAB 20 MG Tier 3 Depression Antidepressants - Drugs to Treat FLUVOXAMINE CAP 100MG FLUVOXAMINE MALEATE CAP ER 24HR Tier 3 X Depression ER 100 MG Antidepressants - Drugs to Treat FLUVOXAMINE CAP 150MG FLUVOXAMINE MALEATE CAP ER 24HR Tier 3 X Depression ER 150 MG Antidepressants - Drugs to Treat FLUVOXAMINE TAB 100MG FLUVOXAMINE MALEATE TAB 100 MG Tier 1 Depression Antidepressants - Drugs to Treat FLUVOXAMINE TAB 25MG FLUVOXAMINE MALEATE TAB 25 MG Tier 1 Depression Antidepressants - Drugs to Treat FLUVOXAMINE TAB 50MG FLUVOXAMINE MALEATE TAB 50 MG Tier 1 Depression Antidepressants - Drugs to Treat IMIPRAM HCL TAB 10MG IMIPRAMINE HCL TAB 10 MG Tier 1 Depression Antidepressants - Drugs to Treat IMIPRAM HCL TAB 25MG IMIPRAMINE HCL TAB 25 MG Tier 1 Depression Antidepressants - Drugs to Treat IMIPRAM HCL TAB 50MG IMIPRAMINE HCL TAB 50 MG Tier 1 Depression Antidepressants - Drugs to Treat IMIPRAM PAM CAP 100MG IMIPRAMINE PAMOATE CAP 100 MG Tier 1 Depression Antidepressants - Drugs to Treat IMIPRAM PAM CAP 125MG IMIPRAMINE PAMOATE CAP 125 MG Tier 1 Depression Antidepressants - Drugs to Treat IMIPRAM PAM CAP 150MG IMIPRAMINE PAMOATE CAP 150 MG Tier 1 Depression Antidepressants - Drugs to Treat IMIPRAM PAM CAP 75MG IMIPRAMINE PAMOATE CAP 75 MG Tier 1 Depression Antidepressants - Drugs to Treat MAPROTILINE TAB 25MG MAPROTILINE HCL TAB 25 MG Tier 1 Depression Antidepressants - Drugs to Treat MAPROTILINE TAB 50MG MAPROTILINE HCL TAB 50 MG Tier 1 Depression Antidepressants - Drugs to Treat MAPROTILINE TAB 75MG MAPROTILINE HCL TAB 75 MG Tier 1 Depression Antidepressants - Drugs to Treat MARPLAN TAB 10MG ISOCARBOXAZID TAB 10 MG Tier 3 Depression Antidepressants - Drugs to Treat MIRTAZAPINE TAB 15MG MIRTAZAPINE TAB 15 MG Tier 1 Depression Antidepressants - Drugs to Treat MIRTAZAPINE TAB 15MG MIRTAZAPINE ORALLY DISINTEGRATING Tier 1 Depression ODT TAB 15 MG Antidepressants - Drugs to Treat MIRTAZAPINE TAB 30MG MIRTAZAPINE TAB 30 MG Tier 1 Depression Antidepressants - Drugs to Treat MIRTAZAPINE TAB 30MG MIRTAZAPINE ORALLY DISINTEGRATING Tier 1 Depression ODT TAB 30 MG Antidepressants - Drugs to Treat MIRTAZAPINE TAB 45MG MIRTAZAPINE TAB 45 MG Tier 1 Depression Antidepressants - Drugs to Treat MIRTAZAPINE TAB 45MG MIRTAZAPINE ORALLY DISINTEGRATING Tier 1 Depression ODT TAB 45 MG Antidepressants - Drugs to Treat MIRTAZAPINE TAB 7.5MG MIRTAZAPINE TAB 7.5 MG Tier 1 Depression Antidepressants - Drugs to Treat NARDIL TAB 15MG PHENELZINE SULFATE TAB 15 MG Tier 3 Depression Antidepressants - Drugs to Treat NEFAZODONE TAB 100MG NEFAZODONE HCL TAB 100 MG Tier 1 Depression Antidepressants - Drugs to Treat NEFAZODONE TAB 150MG NEFAZODONE HCL TAB 150 MG Tier 1 Depression Antidepressants - Drugs to Treat NEFAZODONE TAB 200MG NEFAZODONE HCL TAB 200 MG Tier 1 Depression

39 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antidepressants - Drugs to Treat NEFAZODONE TAB 250MG NEFAZODONE HCL TAB 250 MG Tier 1 Depression Antidepressants - Drugs to Treat NEFAZODONE TAB 50MG NEFAZODONE HCL TAB 50 MG Tier 1 Depression Antidepressants - Drugs to Treat NORPRAMIN TAB 10MG DESIPRAMINE HCL TAB 10 MG Tier 3 Depression Antidepressants - Drugs to Treat NORPRAMIN TAB 25MG DESIPRAMINE HCL TAB 25 MG Tier 3 Depression Antidepressants - Drugs to Treat NORTRIPTYLIN CAP 10MG NORTRIPTYLINE HCL CAP 10 MG Tier 1 Depression Antidepressants - Drugs to Treat NORTRIPTYLIN CAP 25MG NORTRIPTYLINE HCL CAP 25 MG Tier 1 Depression Antidepressants - Drugs to Treat NORTRIPTYLIN CAP 50MG NORTRIPTYLINE HCL CAP 50 MG Tier 1 Depression Antidepressants - Drugs to Treat NORTRIPTYLIN CAP 75MG NORTRIPTYLINE HCL CAP 75 MG Tier 1 Depression Antidepressants - Drugs to Treat NORTRIPTYLIN SOL NORTRIPTYLINE HCL SOLN 10 MG/5ML Tier 1 Depression 10MG/5ML Antidepressants - Drugs to Treat OLANZA/FLUOX CAP 12- OLANZAPINE-FLUOXETINE HCL CAP Tier 2 X Depression 25MG 12-25 MG Antidepressants - Drugs to Treat OLANZA/FLUOX CAP 12- OLANZAPINE-FLUOXETINE HCL CAP Tier 2 X Depression 50MG 12-50 MG Antidepressants - Drugs to Treat OLANZA/FLUOX CAP OLANZAPINE-FLUOXETINE HCL CAP Tier 2 X Depression 3-25MG 3-25 MG Antidepressants - Drugs to Treat OLANZA/FLUOX CAP OLANZAPINE-FLUOXETINE HCL CAP Tier 2 X Depression 6-25MG 6-25 MG Antidepressants - Drugs to Treat OLANZA/FLUOX CAP OLANZAPINE-FLUOXETINE HCL CAP Tier 2 X Depression 6-50MG 6-50 MG Antidepressants - Drugs to Treat PAMELOR CAP 10MG NORTRIPTYLINE HCL CAP 10 MG Tier 3 Depression Antidepressants - Drugs to Treat PAMELOR CAP 25MG NORTRIPTYLINE HCL CAP 25 MG Tier 3 Depression Antidepressants - Drugs to Treat PAMELOR CAP 50MG NORTRIPTYLINE HCL CAP 50 MG Tier 3 Depression Antidepressants - Drugs to Treat PAMELOR CAP 75MG NORTRIPTYLINE HCL CAP 75 MG Tier 3 Depression Antidepressants - Drugs to Treat TRANYLCYPROMINE SULFATE TAB 10 PARNATE TAB 10MG Tier 3 Depression MG Antidepressants - Drugs to Treat PAROXETIN ER TAB 12.5MG PAROXETINE HCL TAB ER 24HR 12.5 MG Tier 3 X Depression Antidepressants - Drugs to Treat PAROXETIN ER TAB 37.5MG PAROXETINE HCL TAB ER 24HR 37.5 MG Tier 3 X Depression Antidepressants - Drugs to Treat PAROXETINE TAB 10MG PAROXETINE HCL TAB 10 MG Tier 1 Depression Antidepressants - Drugs to Treat PAROXETINE TAB 20MG PAROXETINE HCL TAB 20 MG Tier 1 Depression Antidepressants - Drugs to Treat PAROXETINE TAB 25MG ER PAROXETINE HCL TAB ER 24HR 25 MG Tier 3 X Depression Antidepressants - Drugs to Treat PAROXETINE TAB 30MG PAROXETINE HCL TAB 30 MG Tier 1 Depression Antidepressants - Drugs to Treat PAROXETINE TAB 40MG PAROXETINE HCL TAB 40 MG Tier 1 Depression Antidepressants - Drugs to Treat PAROXETINE HCL ORAL SUSP 10 PAXIL SUS 10MG/5ML Tier 3 Depression MG/5ML (BASE EQUIV) Antidepressants - Drugs to Treat PAXIL TAB 10MG PAROXETINE HCL TAB 10 MG Tier 3 Depression Antidepressants - Drugs to Treat PAXIL TAB 20MG PAROXETINE HCL TAB 20 MG Tier 3 Depression Antidepressants - Drugs to Treat PAXIL TAB 30MG PAROXETINE HCL TAB 30 MG Tier 3 Depression Antidepressants - Drugs to Treat PAXIL TAB 40MG PAROXETINE HCL TAB 40 MG Tier 3 Depression Antidepressants - Drugs to Treat PAXIL CR TAB 12.5MG PAROXETINE HCL TAB ER 24HR 12.5 MG Tier 3 X Depression Antidepressants - Drugs to Treat PAXIL CR TAB 25MG PAROXETINE HCL TAB ER 24HR 25 MG Tier 3 X Depression Antidepressants - Drugs to Treat PAXIL CR TAB 37.5MG PAROXETINE HCL TAB ER 24HR 37.5 MG Tier 3 X Depression Antidepressants - Drugs to Treat PERPHENAZINE-AMITRIPTYLINE TAB PERPHEN/AMIT TAB 2-10MG Tier 1 Depression 2-10 MG Antidepressants - Drugs to Treat PERPHENAZINE-AMITRIPTYLINE TAB PERPHEN/AMIT TAB 2-25MG Tier 1 Depression 2-25 MG Antidepressants - Drugs to Treat PERPHENAZINE-AMITRIPTYLINE TAB PERPHEN/AMIT TAB 4-10MG Tier 1 Depression 4-10 MG Antidepressants - Drugs to Treat PERPHENAZINE-AMITRIPTYLINE TAB PERPHEN/AMIT TAB 4-25MG Tier 1 Depression 4-25 MG Antidepressants - Drugs to Treat PERPHENAZINE-AMITRIPTYLINE TAB PERPHEN/AMIT TAB 4-50MG Tier 1 Depression 4-50 MG

40 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antidepressants - Drugs to Treat PHENELZINE TAB 15MG PHENELZINE SULFATE TAB 15 MG Tier 1 Depression Antidepressants - Drugs to Treat PROTRIPTYLIN TAB 10MG PROTRIPTYLINE HCL TAB 10 MG Tier 1 Depression Antidepressants - Drugs to Treat PROTRIPTYLIN TAB 5MG PROTRIPTYLINE HCL TAB 5 MG Tier 1 Depression Antidepressants - Drugs to Treat REMERON TAB 15MG MIRTAZAPINE TAB 15 MG Tier 3 Depression Antidepressants - Drugs to Treat REMERON TAB 30MG MIRTAZAPINE TAB 30 MG Tier 3 Depression Antidepressants - Drugs to Treat REMERON TAB 45MG MIRTAZAPINE TAB 45 MG Tier 3 Depression Antidepressants - Drugs to Treat MIRTAZAPINE ORALLY DISINTEGRATING REMERON SLTB TAB 15MG Tier 3 Depression TAB 15 MG Antidepressants - Drugs to Treat MIRTAZAPINE ORALLY DISINTEGRATING REMERON SLTB TAB 30MG Tier 3 Depression TAB 30 MG Antidepressants - Drugs to Treat MIRTAZAPINE ORALLY DISINTEGRATING REMERON SLTB TAB 45MG Tier 3 Depression TAB 45 MG Antidepressants - Drugs to Treat SERTRALINE HCL ORAL CONC 20 MG/ SERTRALINE CON 20MG/ML Tier 1 Depression ML Antidepressants - Drugs to Treat SERTRALINE TAB 100MG SERTRALINE HCL TAB 100 MG Tier 1 Depression Antidepressants - Drugs to Treat SERTRALINE TAB 25MG SERTRALINE HCL TAB 25 MG Tier 1 Depression Antidepressants - Drugs to Treat SERTRALINE TAB 50MG SERTRALINE HCL TAB 50 MG Tier 1 Depression Antidepressants - Drugs to Treat SURMONTIL CAP 100MG TRIMIPRAMINE MALEATE CAP 100 MG Tier 3 Depression Antidepressants - Drugs to Treat SURMONTIL CAP 25MG TRIMIPRAMINE MALEATE CAP 25 MG Tier 3 Depression Antidepressants - Drugs to Treat SURMONTIL CAP 50MG TRIMIPRAMINE MALEATE CAP 50 MG Tier 3 Depression Antidepressants - Drugs to Treat OLANZAPINE-FLUOXETINE HCL CAP SYMBYAX CAP 12-25MG Tier 3 X Depression 12-25 MG Antidepressants - Drugs to Treat OLANZAPINE-FLUOXETINE HCL CAP SYMBYAX CAP 12-50MG Tier 3 X Depression 12-50 MG Antidepressants - Drugs to Treat OLANZAPINE-FLUOXETINE HCL CAP SYMBYAX CAP 3-25MG Tier 3 X Depression 3-25 MG Antidepressants - Drugs to Treat OLANZAPINE-FLUOXETINE HCL CAP SYMBYAX CAP 6-25MG Tier 3 X Depression 6-25 MG Antidepressants - Drugs to Treat OLANZAPINE-FLUOXETINE HCL CAP SYMBYAX CAP 6-50MG Tier 3 X Depression 6-50 MG Antidepressants - Drugs to Treat TOFRANIL TAB 10MG IMIPRAMINE HCL TAB 10 MG Tier 3 Depression Antidepressants - Drugs to Treat TOFRANIL TAB 25MG IMIPRAMINE HCL TAB 25 MG Tier 3 Depression Antidepressants - Drugs to Treat TOFRANIL TAB 50MG IMIPRAMINE HCL TAB 50 MG Tier 3 Depression Antidepressants - Drugs to Treat TRANYLCYPROMINE SULFATE TAB 10 TRANYLCYPROM TAB 10MG Tier 1 Depression MG Antidepressants - Drugs to Treat TRAZODONE TAB 100MG TRAZODONE HCL TAB 100 MG Tier 1 Depression Antidepressants - Drugs to Treat TRAZODONE TAB 150MG TRAZODONE HCL TAB 150 MG Tier 1 Depression Antidepressants - Drugs to Treat TRAZODONE TAB 300MG TRAZODONE HCL TAB 300 MG Tier 1 Depression Antidepressants - Drugs to Treat TRAZODONE TAB 50MG TRAZODONE HCL TAB 50 MG Tier 1 Depression Antidepressants - Drugs to Treat TRIMIPRAMINE CAP 100MG TRIMIPRAMINE MALEATE CAP 100 MG Tier 3 Depression Antidepressants - Drugs to Treat TRIMIPRAMINE CAP 25MG TRIMIPRAMINE MALEATE CAP 25 MG Tier 3 Depression Antidepressants - Drugs to Treat TRIMIPRAMINE CAP 50MG TRIMIPRAMINE MALEATE CAP 50 MG Tier 3 Depression Antidepressants - Drugs to Treat VORTIOXETINE HBR TAB 10 MG (BASE TRINTELLIX TAB 10MG Tier 3 X X Depression EQUIV) Antidepressants - Drugs to Treat VORTIOXETINE HBR TAB 20 MG (BASE TRINTELLIX TAB 20MG Tier 3 X X Depression EQUIV) Antidepressants - Drugs to Treat VORTIOXETINE HBR TAB 5 MG (BASE TRINTELLIX TAB 5MG Tier 3 X X Depression EQUIV) Antidepressants - Drugs to Treat VENLAFAXINE CAP 150MG VENLAFAXINE HCL CAP ER 24HR 150 Tier 1 Depression ER MG (BASE EQUIVALENT) Antidepressants - Drugs to Treat VENLAFAXINE HCL CAP ER 24HR 37.5 VENLAFAXINE CAP 37.5 ER Tier 1 Depression MG (BASE EQUIVALENT) Antidepressants - Drugs to Treat VENLAFAXINE HCL CAP ER 24HR 75 MG VENLAFAXINE CAP 75MG ER Tier 1 Depression (BASE EQUIVALENT) Antidepressants - Drugs to Treat VENLAFAXINE TAB 100MG VENLAFAXINE HCL TAB 100 MG Tier 1 Depression

41 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antidepressants - Drugs to Treat VENLAFAXINE TAB 25MG VENLAFAXINE HCL TAB 25 MG Tier 1 Depression Antidepressants - Drugs to Treat VENLAFAXINE TAB 37.5MG VENLAFAXINE HCL TAB 37.5 MG Tier 1 Depression Antidepressants - Drugs to Treat VENLAFAXINE TAB 50MG VENLAFAXINE HCL TAB 50 MG Tier 1 Depression Antidepressants - Drugs to Treat VENLAFAXINE TAB 75MG VENLAFAXINE HCL TAB 75 MG Tier 1 Depression Antidepressants - Drugs to Treat VILAZODONE HCL TAB STARTER KIT 10 VIIBRYD KIT STARTER Tier 3 Depression (7) & 20 (23) MG Antidepressants - Drugs to Treat VIIBRYD TAB 10MG VILAZODONE HCL TAB 10 MG Tier 3 X Depression Antidepressants - Drugs to Treat VIIBRYD TAB 20MG VILAZODONE HCL TAB 20 MG Tier 3 X Depression Antidepressants - Drugs to Treat VIIBRYD TAB 40MG VILAZODONE HCL TAB 40 MG Tier 3 X Depression Antiemetics - Drugs to Treat Nausea and NETUPITANT-PALONOSETRON CAP 300- AKYNZEO CAP 300-0.5 Tier 3 X Vomiting 0.5 MG Antiemetics - Drugs to Treat Nausea and ANZEMET TAB 100MG DOLASETRON MESYLATE TAB 100 MG Tier 3 X Vomiting Antiemetics - Drugs to Treat Nausea and ANZEMET TAB 50MG DOLASETRON MESYLATE TAB 50 MG Tier 3 X Vomiting Antiemetics - Drugs to Treat Nausea and APREPITANT CAP 125MG APREPITANT CAPSULE 125 MG Tier 2 X Vomiting Antiemetics - Drugs to Treat Nausea and APREPITANT CAP 40MG APREPITANT CAPSULE 40 MG Tier 2 X Vomiting Antiemetics - Drugs to Treat Nausea and APREPITANT CAP 80MG APREPITANT CAPSULE 80 MG Tier 2 X Vomiting Antiemetics - Drugs to Treat Nausea and APREPITANT CAPSULE THERAPY PACK APREPITANT PAK 80 & 125 Tier 2 X Vomiting 80 & 125 MG Antiemetics - Drugs to Treat Nausea and CESAMET CAP 1MG NABILONE CAP 1 MG Tier 3 Vomiting Antiemetics - Drugs to Treat Nausea and COMPRO SUP 25MG PROCHLORPERAZINE SUPPOS 25 MG Tier 1 Vomiting Antiemetics - Drugs to Treat Nausea and DRONABINOL CAP 10MG DRONABINOL CAP 10 MG Tier 1 Vomiting Antiemetics - Drugs to Treat Nausea and DRONABINOL CAP 2.5MG DRONABINOL CAP 2.5 MG Tier 1 Vomiting Antiemetics - Drugs to Treat Nausea and DRONABINOL CAP 5MG DRONABINOL CAP 5 MG Tier 1 Vomiting Antiemetics - Drugs to Treat Nausea and EMEND CAP 125MG APREPITANT CAPSULE 125 MG Tier 3 X Vomiting Antiemetics - Drugs to Treat Nausea and EMEND CAP 40MG APREPITANT CAPSULE 40 MG Tier 3 X Vomiting Antiemetics - Drugs to Treat Nausea and EMEND CAP 80MG APREPITANT CAPSULE 80 MG Tier 3 X Vomiting Antiemetics - Drugs to Treat Nausea and APREPITANT FOR ORAL SUSP 125 MG EMEND SUS 125MG Tier 2 X Vomiting (125 MG/5ML) Antiemetics - Drugs to Treat Nausea and EMEND TRIPAC PAK 80 & APREPITANT CAPSULE THERAPY PACK Tier 3 X Vomiting 125 80 & 125 MG Antiemetics - Drugs to Treat Nausea and GRANISETRON TAB 1MG GRANISETRON HCL TAB 1 MG Tier 2 Vomiting Antiemetics - Drugs to Treat Nausea and MARINOL CAP 10MG DRONABINOL CAP 10 MG Tier 3 Vomiting Antiemetics - Drugs to Treat Nausea and MARINOL CAP 2.5MG DRONABINOL CAP 2.5 MG Tier 3 Vomiting Antiemetics - Drugs to Treat Nausea and MARINOL CAP 5MG DRONABINOL CAP 5 MG Tier 3 Vomiting Antiemetics - Drugs to Treat Nausea and METOCLOPRAM SOL METOCLOPRAMIDE HCL SOLN 5 Tier 1 Vomiting 5MG/5ML MG/5ML (10 MG/10ML) Antiemetics - Drugs to Treat Nausea and METOCLOPRAM TAB 10MG METOCLOPRAMIDE HCL TAB 10 MG Tier 1 Vomiting Antiemetics - Drugs to Treat Nausea and METOCLOPRAM TAB 5MG METOCLOPRAMIDE HCL TAB 5 MG Tier 1 Vomiting Antiemetics - Drugs to Treat Nausea and ONDANSETRON SOL ONDANSETRON HCL ORAL SOLN 4 Tier 1 Vomiting 4MG/5ML MG/5ML Antiemetics - Drugs to Treat Nausea and ONDANSETRON TAB 24MG ONDANSETRON HCL TAB 24 MG Tier 1 Vomiting Antiemetics - Drugs to Treat Nausea and ONDANSETRON TAB 4MG ONDANSETRON HCL TAB 4 MG Tier 1 Vomiting Antiemetics - Drugs to Treat Nausea and ONDANSETRON TAB 4MG ONDANSETRON ORALLY Tier 1 Vomiting ODT DISINTEGRATING TAB 4 MG Antiemetics - Drugs to Treat Nausea and ONDANSETRON TAB 8MG ONDANSETRON HCL TAB 8 MG Tier 1 Vomiting Antiemetics - Drugs to Treat Nausea and ONDANSETRON TAB 8MG ONDANSETRON ORALLY Tier 1 Vomiting ODT DISINTEGRATING TAB 8 MG Antiemetics - Drugs to Treat Nausea and PERPHENAZINE TAB 16MG PERPHENAZINE TAB 16 MG Tier 1 Vomiting

42 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antiemetics - Drugs to Treat Nausea and PERPHENAZINE TAB 2MG PERPHENAZINE TAB 2 MG Tier 1 Vomiting Antiemetics - Drugs to Treat Nausea and PERPHENAZINE TAB 4MG PERPHENAZINE TAB 4 MG Tier 1 Vomiting Antiemetics - Drugs to Treat Nausea and PERPHENAZINE TAB 8MG PERPHENAZINE TAB 8 MG Tier 1 Vomiting Antiemetics - Drugs to Treat Nausea and PROCHLORPER SUP 25MG PROCHLORPERAZINE SUPPOS 25 MG Tier 1 Vomiting Antiemetics - Drugs to Treat Nausea and PROCHLORPERAZINE MALEATE TAB 10 PROCHLORPER TAB 10MG Tier 1 Vomiting MG (BASE EQUIVALENT) Antiemetics - Drugs to Treat Nausea and PROCHLORPERAZINE MALEATE TAB 5 PROCHLORPER TAB 5MG Tier 1 Vomiting MG (BASE EQUIVALENT) Antiemetics - Drugs to Treat Nausea and REGLAN TAB 10MG METOCLOPRAMIDE HCL TAB 10 MG Tier 3 Vomiting Antiemetics - Drugs to Treat Nausea and REGLAN TAB 5MG METOCLOPRAMIDE HCL TAB 5 MG Tier 3 Vomiting Antiemetics - Drugs to Treat Nausea and SCOPOLAMINE DIS SCOPOLAMINE TD PATCH 72HR 1 Tier 3 Vomiting 1MG/3DAY MG/3DAYS Antiemetics - Drugs to Treat Nausea and SYNDROS SOL 5MG/ML DRONABINOL SOLN 5 MG/ML Tier 3 X X Vomiting Antiemetics - Drugs to Treat Nausea and TRIMETHOBENZAMIDE HCL CAP 300 TIGAN CAP 300MG Tier 3 Vomiting MG Antiemetics - Drugs to Treat Nausea and SCOPOLAMINE TD PATCH 72HR 1 TRANSDERM-SC DIS 1.5MG Tier 3 Vomiting MG/3DAYS Antiemetics - Drugs to Treat Nausea and TRIMETHOBENZ CAP TRIMETHOBENZAMIDE HCL CAP 300 Tier 1 Vomiting 300MG MG Antiemetics - Drugs to Treat Nausea and ONDANSETRON HCL ORAL SOLN 4 ZOFRAN SOL 4MG/5ML Tier 4 Vomiting MG/5ML Antiemetics - Drugs to Treat Nausea and ZOFRAN TAB 4MG ONDANSETRON HCL TAB 4 MG Tier 4 Vomiting Antiemetics - Drugs to Treat Nausea and ONDANSETRON ORALLY ZOFRAN TAB 4MG ODT Tier 4 Vomiting DISINTEGRATING TAB 4 MG Antiemetics - Drugs to Treat Nausea and ZOFRAN TAB 8MG ONDANSETRON HCL TAB 8 MG Tier 4 Vomiting Antiemetics - Drugs to Treat Nausea and ONDANSETRON ORALLY ZOFRAN TAB 8MG ODT Tier 4 Vomiting DISINTEGRATING TAB 8 MG Antifungals - Drugs to Treat Fungal ANCOBON CAP 250MG FLUCYTOSINE CAP 250 MG Tier 3 Infections Antifungals - Drugs to Treat Fungal ANCOBON CAP 500MG FLUCYTOSINE CAP 500 MG Tier 3 Infections Antifungals - Drugs to Treat Fungal AVC CRE 15% SULFANILAMIDE VAGINAL CREAM 15% Tier 2 Infections Antifungals - Drugs to Treat Fungal BIO-STATIN CAP 1000000 NYSTATIN CAP 1000000 UNIT Tier 3 Infections Antifungals - Drugs to Treat Fungal BIO-STATIN CAP 500000 NYSTATIN CAP 500000 UNIT Tier 3 Infections Antifungals - Drugs to Treat Fungal BIO-STATIN POW *NYSTATIN ORAL POWDER* Tier 1 Infections Antifungals - Drugs to Treat Fungal CICLOPIROX OLAMINE CREAM 0.77% CICLODAN CRE 0.77% Tier 1 Infections (BASE EQUIV) Antifungals - Drugs to Treat Fungal CICLODAN SOL 8% CICLOPIROX SOLUTION 8% Tier 1 Infections Antifungals - Drugs to Treat Fungal CICLOPIROX OLAMINE CREAM 0.77% CICLOPIROX CRE 0.77% Tier 1 Infections (BASE EQUIV) Antifungals - Drugs to Treat Fungal CICLOPIROX GEL 0.77% CICLOPIROX GEL 0.77% Tier 1 Infections Antifungals - Drugs to Treat Fungal CICLOPIROX SHA 1% CICLOPIROX SHAMPOO 1% Tier 2 Infections Antifungals - Drugs to Treat Fungal CICLOPIROX SOL 8% CICLOPIROX SOLUTION 8% Tier 1 Infections Antifungals - Drugs to Treat Fungal CICLOPIROX OLAMINE SUSP 0.77% CICLOPIROX SUS 0.77% Tier 1 Infections (BASE EQUIV) Antifungals - Drugs to Treat Fungal CLOTRIMAZOLE LOZ 10MG CLOTRIMAZOLE TROCHE 10 MG Tier 1 Infections Antifungals - Drugs to Treat Fungal CLOTRIMAZOLE TRO 10MG CLOTRIMAZOLE TROCHE 10 MG Tier 1 Infections Antifungals - Drugs to Treat Fungal *CICLOPIROX SOLN 8% & LACQUER CNL8 NAIL KIT Tier 3 Infections REMOVAL PADS KIT** Antifungals - Drugs to Treat Fungal ISAVUCONAZONIUM SULFATE CAP 186 CRESEMBA CAP 186 MG Tier 3 Infections MG Antifungals - Drugs to Treat Fungal DIFLUCAN SUS 10MG/ML FLUCONAZOLE FOR SUSP 10 MG/ML Tier 3 Infections Antifungals - Drugs to Treat Fungal DIFLUCAN SUS 40MG/ML FLUCONAZOLE FOR SUSP 40 MG/ML Tier 3 Infections Antifungals - Drugs to Treat Fungal DIFLUCAN TAB 100MG FLUCONAZOLE TAB 100 MG Tier 3 Infections Antifungals - Drugs to Treat Fungal DIFLUCAN TAB 150MG FLUCONAZOLE TAB 150 MG Tier 3 Infections

43 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antifungals - Drugs to Treat Fungal DIFLUCAN TAB 200MG FLUCONAZOLE TAB 200 MG Tier 3 Infections Antifungals - Drugs to Treat Fungal DIFLUCAN TAB 50MG FLUCONAZOLE TAB 50 MG Tier 3 Infections Antifungals - Drugs to Treat Fungal ECONAZOLE CRE 1% ECONAZOLE NITRATE CREAM 1% Tier 3 X Infections Antifungals - Drugs to Treat Fungal EXELDERM CRE 1% SULCONAZOLE NITRATE CREAM 1% Tier 3 Infections Antifungals - Drugs to Treat Fungal EXELDERM SOL 1% SULCONAZOLE NITRATE SOLUTION 1% Tier 3 Infections Antifungals - Drugs to Treat Fungal SODIUM THIOSULFATE-SALICYLIC ACID EXODERM LOT 25-1% Tier 1 Infections LOTION 25-1% Antifungals - Drugs to Treat Fungal EXTINA AER 2% KETOCONAZOLE FOAM 2% Tier 3 X Infections Antifungals - Drugs to Treat Fungal FLUCONAZOLE SUS 10MG/ FLUCONAZOLE FOR SUSP 10 MG/ML Tier 1 Infections ML Antifungals - Drugs to Treat Fungal FLUCONAZOLE SUS 40MG/ FLUCONAZOLE FOR SUSP 40 MG/ML Tier 1 Infections ML Antifungals - Drugs to Treat Fungal FLUCONAZOLE TAB 100MG FLUCONAZOLE TAB 100 MG Tier 1 Infections Antifungals - Drugs to Treat Fungal FLUCONAZOLE TAB 150MG FLUCONAZOLE TAB 150 MG Tier 1 Infections Antifungals - Drugs to Treat Fungal FLUCONAZOLE TAB 200MG FLUCONAZOLE TAB 200 MG Tier 1 Infections Antifungals - Drugs to Treat Fungal FLUCONAZOLE TAB 50MG FLUCONAZOLE TAB 50 MG Tier 1 Infections Antifungals - Drugs to Treat Fungal FLUCYTOSINE CAP 250MG FLUCYTOSINE CAP 250 MG Tier 1 Infections Antifungals - Drugs to Treat Fungal FLUCYTOSINE CAP 500MG FLUCYTOSINE CAP 500 MG Tier 1 Infections Antifungals - Drugs to Treat Fungal *ANTIFUNGAL COMBINATION FUNGIMEZ SOL Tier 3 Infections PRODUCTS MISC - SOLUTION*** Antifungals - Drugs to Treat Fungal GRISEOFULVIN SUS GRISEOFULVIN MICROSIZE SUSP 125 Tier 1 Infections 125/5ML MG/5ML Antifungals - Drugs to Treat Fungal GRISEOFULVIN TAB MICR GRISEOFULVIN MICROSIZE TAB 500 MG Tier 1 Infections 500 Antifungals - Drugs to Treat Fungal GRISEOFULVIN TAB ULTR GRISEOFULVIN ULTRAMICROSIZE TAB Tier 1 Infections 125 125 MG Antifungals - Drugs to Treat Fungal GRISEOFULVIN TAB ULTR GRISEOFULVIN ULTRAMICROSIZE TAB Tier 1 Infections 250 250 MG Antifungals - Drugs to Treat Fungal GRISEOFULVIN ULTRAMICROSIZE TAB GRIS-PEG TAB 125MG Tier 3 Infections 125 MG Antifungals - Drugs to Treat Fungal GRISEOFULVIN ULTRAMICROSIZE TAB GRIS-PEG TAB 250MG Tier 3 Infections 250 MG Antifungals - Drugs to Treat Fungal BUTOCONAZOLE NITRATE (ONE DOSE) GYNAZOLE-1 CRE 2% Tier 3 Infections VAGINAL CREAM 2% Antifungals - Drugs to Treat Fungal HALOTIN CRE 1% HALOPROGIN CREAM 1% Tier 3 Infections Antifungals - Drugs to Treat Fungal ITRACONAZOLE CAP 100MG ITRACONAZOLE CAP 100 MG Tier 1 X Infections Antifungals - Drugs to Treat Fungal JUBLIA SOL 10% EFINACONAZOLE SOLN 10% Tier 3 X X X Infections Antifungals - Drugs to Treat Fungal KERYDIN SOL 5% TAVABOROLE SOLN 5% Tier 3 X X X Infections Antifungals - Drugs to Treat Fungal KETOCONAZOLE AER 2% KETOCONAZOLE FOAM 2% Tier 3 X Infections Antifungals - Drugs to Treat Fungal KETOCONAZOLE CRE 2% KETOCONAZOLE CREAM 2% Tier 1 X Infections Antifungals - Drugs to Treat Fungal KETOCONAZOLE SHA 2% KETOCONAZOLE SHAMPOO 2% Tier 1 Infections Antifungals - Drugs to Treat Fungal KETOCONAZOLE TAB KETOCONAZOLE TAB 200 MG Tier 1 Infections 200MG Antifungals - Drugs to Treat Fungal KETODAN AER 2% KETOCONAZOLE FOAM 2% Tier 3 X Infections Antifungals - Drugs to Treat Fungal LAMISIL TAB 250MG TERBINAFINE HCL TAB 250 MG Tier 3 X Infections Antifungals - Drugs to Treat Fungal MENTAX CRE 1% BUTENAFINE HCL CREAM 1% Tier 3 Infections Antifungals - Drugs to Treat Fungal MICONAZOLE POW NITRATE MICONAZOLE NITRATE POWDER Tier 3 Infections Antifungals - Drugs to Treat Fungal MICONAZOLE NITRATE VAGINAL MICONAZOLE 3 SUP 200MG Tier 1 Infections SUPPOS 200 MG Antifungals - Drugs to Treat Fungal NATACYN SUS 5% OP NATAMYCIN OPHTH SUSP 5% Tier 3 Infections Antifungals - Drugs to Treat Fungal NIZORAL SHA 2% KETOCONAZOLE SHAMPOO 2% Tier 3 Infections Antifungals - Drugs to Treat Fungal NOXAFIL SUS 40MG/ML POSACONAZOLE SUSP 40 MG/ML Tier 2 Infections

44 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antifungals - Drugs to Treat Fungal POSACONAZOLE TAB DELAYED NOXAFIL TAB 100MG Tier 2 Infections RELEASE 100 MG Antifungals - Drugs to Treat Fungal NYSTATIN TOPICAL POWDER 100000 NYAMYC POW 100000 Tier 1 Infections UNIT/GM Antifungals - Drugs to Treat Fungal NYSTATIN TOPICAL POWDER 100000 NYATA POW 100000 Tier 1 Infections UNIT/GM Antifungals - Drugs to Treat Fungal NYSTATIN CRE 100000 NYSTATIN CREAM 100000 UNIT/GM Tier 1 Infections Antifungals - Drugs to Treat Fungal NYSTATIN OIN 100000 NYSTATIN OINT 100000 UNIT/GM Tier 1 Infections Antifungals - Drugs to Treat Fungal NYSTATIN POW NYSTATIN (BULK) POWDER Tier 3 Infections Antifungals - Drugs to Treat Fungal NYSTATIN TOPICAL POWDER 100000 NYSTATIN POW 100000 Tier 1 Infections UNIT/GM Antifungals - Drugs to Treat Fungal NYSTATIN POW 10BU NYSTATIN (BULK) POWDER Tier 3 Infections Antifungals - Drugs to Treat Fungal NYSTATIN POW 150MU NYSTATIN (BULK) POWDER Tier 3 Infections Antifungals - Drugs to Treat Fungal NYSTATIN POW 1BU NYSTATIN (BULK) POWDER Tier 3 Infections Antifungals - Drugs to Treat Fungal NYSTATIN POW 2BU NYSTATIN (BULK) POWDER Tier 3 Infections Antifungals - Drugs to Treat Fungal NYSTATIN POW 500MU NYSTATIN (BULK) POWDER Tier 3 Infections Antifungals - Drugs to Treat Fungal NYSTATIN POW 50MU NYSTATIN (BULK) POWDER Tier 3 Infections Antifungals - Drugs to Treat Fungal NYSTATIN POW 5BU NYSTATIN (BULK) POWDER Tier 3 Infections Antifungals - Drugs to Treat Fungal NYSTATIN SUS 100000 NYSTATIN SUSP 100000 UNIT/ML Tier 1 Infections Antifungals - Drugs to Treat Fungal NYSTATIN TAB 500000 NYSTATIN TAB 500000 UNIT Tier 1 Infections Antifungals - Drugs to Treat Fungal NYSTATIN TOPICAL POWDER 100000 NYSTOP POW 100000 Tier 1 Infections UNIT/GM Antifungals - Drugs to Treat Fungal MICONAZOLE BUCCAL TAB 50 MG ORAVIG TAB 50MG Tier 3 Infections (MOUTH-THROAT) Antifungals - Drugs to Treat Fungal OXICONAZOLE CRE OXICONAZOLE NITRATE CREAM 1% Tier 3 X X X Infections NITRATE Antifungals - Drugs to Treat Fungal OXISTAT CRE 1% OXICONAZOLE NITRATE CREAM 1% Tier 3 X X X Infections Antifungals - Drugs to Treat Fungal SPORANOX CAP 100MG ITRACONAZOLE CAP 100 MG Tier 3 X Infections Antifungals - Drugs to Treat Fungal SPORANOX CAP PULSEPAK ITRACONAZOLE CAP 100 MG Tier 3 X Infections Antifungals - Drugs to Treat Fungal SPORANOX SOL 10MG/ML ITRACONAZOLE ORAL SOLN 10 MG/ML Tier 2 X Infections Antifungals - Drugs to Treat Fungal TERAZOL 3 CRE 0.8% TERCONAZOLE VAGINAL CREAM 0.8% Tier 3 Infections Antifungals - Drugs to Treat Fungal TERAZOL 7 CRE 0.4% TERCONAZOLE VAGINAL CREAM 0.4% Tier 3 Infections Antifungals - Drugs to Treat Fungal TERBINAFINE TAB 250MG TERBINAFINE HCL TAB 250 MG Tier 1 X Infections Antifungals - Drugs to Treat Fungal TERCONAZOLE CRE 0.4% TERCONAZOLE VAGINAL CREAM 0.4% Tier 1 Infections Antifungals - Drugs to Treat Fungal TERCONAZOLE CRE 0.8% TERCONAZOLE VAGINAL CREAM 0.8% Tier 1 Infections Antifungals - Drugs to Treat Fungal TERCONAZOLE VAGINAL SUPPOS 80 TERCONAZOLE SUP 80MG Tier 1 Infections MG Antifungals - Drugs to Treat Fungal VFEND SUS 40MG/ML VORICONAZOLE FOR SUSP 40 MG/ML Tier 3 Infections Antifungals - Drugs to Treat Fungal VFEND TAB 200MG VORICONAZOLE TAB 200 MG Tier 3 X Infections Antifungals - Drugs to Treat Fungal VFEND TAB 50MG VORICONAZOLE TAB 50 MG Tier 3 X Infections Antifungals - Drugs to Treat Fungal VORICONAZOLE SUS 40MG/ VORICONAZOLE FOR SUSP 40 MG/ML Tier 1 Infections ML Antifungals - Drugs to Treat Fungal VORICONAZOLE TAB 200MG VORICONAZOLE TAB 200 MG Tier 1 X Infections Antifungals - Drugs to Treat Fungal VORICONAZOLE TAB 50MG VORICONAZOLE TAB 50 MG Tier 1 X Infections Antifungals - Drugs to Treat Fungal XOLEGEL GEL 2% KETOCONAZOLE GEL 2% Tier 3 Infections Antifungals - Drugs to Treat Fungal KETOCONAZOLE GEL 2% & XOLEGEL KIT COREPAK Tier 3 Infections HYDROCORTISONE GEL 1% KIT Antifungals - Drugs to Treat Fungal XOLEGEL DUO/ KIT KETOCONAZOLE GEL 2% & PYRITHIONE Tier 3 Infections HEAD&SHD ZINC SHAMPOO 1% KIT Antifungals - Drugs to Treat Fungal KETOCONAZOLE GEL 2% & PYRITHIONE XOLEGEL DUO/ KIT XOLEX Tier 3 Infections ZINC SHAMPOO 1% KIT

45 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antifungals - Drugs to Treat Fungal ZAZOLE CRE 0.8% TERCONAZOLE VAGINAL CREAM 0.8% Tier 1 Infections Antifungals - Drugs to Treat Fungal TERCONAZOLE VAGINAL SUPPOS 80 ZAZOLE SUP 80MG Tier 1 Infections MG Antigout Agents - Drugs to Treat Gout ALLOPURINOL TAB 100MG ALLOPURINOL TAB 100 MG Tier 1 Antigout Agents - Drugs to Treat Gout ALLOPURINOL TAB 300MG ALLOPURINOL TAB 300 MG Tier 1 Antigout Agents - Drugs to Treat Gout MITIGARE CAP 0.6MG COLCHICINE CAP 0.6 MG Tier 2 PROBEN/COLCH TAB 500- COLCHICINE W/ PROBENECID TAB 0.5- Antigout Agents - Drugs to Treat Gout Tier 1 0.5 500 MG Antigout Agents - Drugs to Treat Gout PROBENECID TAB 500MG PROBENECID TAB 500 MG Tier 1 Antigout Agents - Drugs to Treat Gout ULORIC TAB 40MG FEBUXOSTAT TAB 40 MG Tier 3 X X Antigout Agents - Drugs to Treat Gout ULORIC TAB 80MG FEBUXOSTAT TAB 80 MG Tier 3 X X Antigout Agents - Drugs to Treat Gout ZURAMPIC TAB 200MG LESINURAD TAB 200 MG Tier 3 X X Antigout Agents - Drugs to Treat Gout ZYLOPRIM TAB 100MG ALLOPURINOL TAB 100 MG Tier 3 Antigout Agents - Drugs to Treat Gout ZYLOPRIM TAB 300MG ALLOPURINOL TAB 300 MG Tier 3 Antimigraine Agents - Drugs to Treat ALMOTRIP MAL TAB 12.5MG ALMOTRIPTAN MALATE TAB 12.5 MG Tier 3 X Migraines Antimigraine Agents - Drugs to Treat ALMOTRIP MAL TAB 6.25MG ALMOTRIPTAN MALATE TAB 6.25 MG Tier 3 X Migraines Antimigraine Agents - Drugs to Treat ALMOTRIPTAN TAB 12.5MG ALMOTRIPTAN MALATE TAB 12.5 MG Tier 3 X Migraines Antimigraine Agents - Drugs to Treat ALMOTRIPTAN TAB 6.25MG ALMOTRIPTAN MALATE TAB 6.25 MG Tier 3 X Migraines Antimigraine Agents - Drugs to Treat NARATRIPTAN HCL TAB 1 MG (BASE AMERGE TAB 1MG Tier 3 X Migraines EQUIV) Antimigraine Agents - Drugs to Treat NARATRIPTAN HCL TAB 2.5 MG (BASE AMERGE TAB 2.5MG Tier 3 X Migraines EQUIV) Antimigraine Agents - Drugs to Treat ERGOTAMINE W/ CAFFEINE TAB 1-100 CAFERGOT TAB 1-100MG Tier 3 Migraines MG Antimigraine Agents - Drugs to Treat DIHYDROERGOT INJ 1MG/ DIHYDROERGOTAMINE MESYLATE INJ Tier 1 Migraines ML 1 MG/ML Antimigraine Agents - Drugs to Treat DIHYDROERGOT POW DIHYDROERGOTAMINE MESYLATE Tier 3 Migraines MESYLATE POWDER Antimigraine Agents - Drugs to Treat DIHYDROERGOT SPR 4MG/ DIHYDROERGOTAMINE MESYLATE Tier 3 X X Migraines ML NASAL SPRAY 4 MG/ML Antimigraine Agents - Drugs to Treat ELETRIPTAN HYDROBROMIDE TAB 20 ELETRIPTAN TAB 20MG Tier 2 X Migraines MG (BASE EQUIVALENT) Antimigraine Agents - Drugs to Treat ELETRIPTAN HYDROBROMIDE TAB 40 ELETRIPTAN TAB 40MG Tier 2 X Migraines MG (BASE EQUIVALENT) Antimigraine Agents - Drugs to Treat ERGOMAR SUB 2MG ERGOTAMINE TARTRATE SL TAB 2 MG Tier 3 X X Migraines Antimigraine Agents - Drugs to Treat ERGOT/CAFFEN TAB ERGOTAMINE W/ CAFFEINE TAB 1-100 Tier 3 Migraines 1-100MG MG Antimigraine Agents - Drugs to Treat FROVATRIPTAN SUCCINATE TAB 2.5 MG FROVA TAB 2.5MG Tier 3 X Migraines (BASE EQUIVALENT) Antimigraine Agents - Drugs to Treat FROVATRIPTAN SUCCINATE TAB 2.5 MG FROVATRIPTAN TAB 2.5MG Tier 3 X Migraines (BASE EQUIVALENT) Antimigraine Agents - Drugs to Treat SUMATRIPTAN NASAL SPRAY 20 MG/ IMITREX SPR 20MG/ACT Tier 3 X Migraines ACT Antimigraine Agents - Drugs to Treat IMITREX SPR 5MG/ACT SUMATRIPTAN NASAL SPRAY 5 MG/ACT Tier 3 X Migraines Antimigraine Agents - Drugs to Treat ERGOTAMINE W/ CAFFEINE SUPPOS MIGERGOT SUP 2/100 Tier 3 Migraines 2-100 MG Antimigraine Agents - Drugs to Treat NARATRIPTAN HCL TAB 1 MG (BASE NARATRIPTAN TAB 1MG Tier 1 X Migraines EQUIV) Antimigraine Agents - Drugs to Treat NARATRIPTAN HCL TAB 2.5 MG (BASE NARATRIPTAN TAB 2.5MG Tier 1 X Migraines EQUIV) Antimigraine Agents - Drugs to Treat RIZATRIPTAN BENZOATE TAB 10 MG RIZATRIPTAN TAB 10MG Tier 1 X Migraines (BASE EQUIVALENT) Antimigraine Agents - Drugs to Treat RIZATRIPTAN TAB 10MG RIZATRIPTAN BENZOATE ORAL Tier 1 X Migraines ODT DISINTEGRATING TAB 10 MG (BASE EQ) Antimigraine Agents - Drugs to Treat RIZATRIPTAN BENZOATE TAB 5 MG RIZATRIPTAN TAB 5MG Tier 1 X Migraines (BASE EQUIVALENT) Antimigraine Agents - Drugs to Treat RIZATRIPTAN BENZOATE ORAL RIZATRIPTAN TAB 5MG ODT Tier 1 X Migraines DISINTEGRATING TAB 5 MG (BASE EQ) Antimigraine Agents - Drugs to Treat SUMATRIPTAN SUCCINATE SOLUTION SUMATRIPTAN INJ 4MG/0.5 Tier 1 X Migraines AUTO-INJECTOR 4 MG/0.5ML Antimigraine Agents - Drugs to Treat SUMATRIPTAN SUCCINATE SOLUTION SUMATRIPTAN INJ 4MG/0.5 Tier 1 X Migraines CARTRIDGE 4 MG/0.5ML Antimigraine Agents - Drugs to Treat SUMATRIPTAN SUCCINATE SOLUTION SUMATRIPTAN INJ 6MG/0.5 Tier 1 X Migraines AUTO-INJECTOR 6 MG/0.5ML Antimigraine Agents - Drugs to Treat SUMATRIPTAN SUCCINATE INJ 6 SUMATRIPTAN INJ 6MG/0.5 Tier 1 X Migraines MG/0.5ML Antimigraine Agents - Drugs to Treat SUMATRIPTAN SUCCINATE SOLUTION SUMATRIPTAN INJ 6MG/0.5 Tier 1 X Migraines CARTRIDGE 6 MG/0.5ML Antimigraine Agents - Drugs to Treat SUMATRIPTAN SUCCINATE SOLUTION SUMATRIPTAN INJ 6MG/0.5 Tier 1 X Migraines PREFILLED SYRINGE 6 MG/0.5ML

46 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antimigraine Agents - Drugs to Treat SUMATRIPTAN SPR 20MG/ SUMATRIPTAN NASAL SPRAY 20 MG/ Tier 2 X Migraines ACT ACT Antimigraine Agents - Drugs to Treat SUMATRIPTAN SPR 5MG/ SUMATRIPTAN NASAL SPRAY 5 MG/ACT Tier 2 X Migraines ACT Antimigraine Agents - Drugs to Treat SUMATRIPTAN TAB 100MG SUMATRIPTAN SUCCINATE TAB 100 MG Tier 1 X Migraines Antimigraine Agents - Drugs to Treat SUMATRIPTAN TAB 25MG SUMATRIPTAN SUCCINATE TAB 25 MG Tier 1 X Migraines Antimigraine Agents - Drugs to Treat SUMATRIPTAN TAB 50MG SUMATRIPTAN SUCCINATE TAB 50 MG Tier 1 X Migraines Antimigraine Agents - Drugs to Treat ZOLMITRIPTAN ORALLY ZOLMITRIPTAN TAB 2.5 MG Tier 3 X Migraines DISINTEGRATING TAB 2.5 MG Antimigraine Agents - Drugs to Treat ZOLMITRIPTAN TAB 2.5MG ZOLMITRIPTAN TAB 2.5 MG Tier 3 X Migraines Antimigraine Agents - Drugs to Treat ZOLMITRIPTAN TAB 5MG ZOLMITRIPTAN TAB 5 MG Tier 3 X Migraines Antimigraine Agents - Drugs to Treat ZOLMITRIPTAN ORALLY ZOLMITRIPTAN TAB 5MG Tier 3 X Migraines DISINTEGRATING TAB 5 MG Antimigraine Agents - Drugs to Treat ZOLMITRIPTAN NASAL SPRAY 2.5 MG/ ZOMIG SPR 2.5MG Tier 3 X Migraines SPRAY UNIT Antimigraine Agents - Drugs to Treat ZOLMITRIPTAN NASAL SPRAY 5 MG/ ZOMIG SPR 5MG Tier 3 X Migraines SPRAY UNIT Antimigraine Agents - Drugs to Treat ZOMIG TAB 2.5MG ZOLMITRIPTAN TAB 2.5 MG Tier 3 X Migraines Antimigraine Agents - Drugs to Treat ZOMIG TAB 5MG ZOLMITRIPTAN TAB 5 MG Tier 3 X Migraines Antimigraine Agents - Drugs to Treat ZOLMITRIPTAN ORALLY ZOMIG ZMT TAB 2.5 MG Tier 3 X Migraines DISINTEGRATING TAB 2.5 MG Antimigraine Agents - Drugs to Treat ZOLMITRIPTAN ORALLY ZOMIG ZMT TAB 5MG Tier 3 X Migraines DISINTEGRATING TAB 5 MG Antimyasthenic Agents - Drugs to Treat GUANIDINE TAB 125MG GUANIDINE HCL TAB 125 MG Tier 3 Myasthenia Gravis Antimyasthenic Agents - Drugs to Treat PYRIDOSTIGMINE BROMIDE SYRUP 60 MESTINON SYP 60MG/5ML Tier 2 Myasthenia Gravis MG/5ML Antimyasthenic Agents - Drugs to Treat MESTINON TAB 60MG PYRIDOSTIGMINE BROMIDE TAB 60 MG Tier 3 Myasthenia Gravis Antimyasthenic Agents - Drugs to Treat PYRIDOSTIGMINE BROMIDE TAB CR MESTINON TAB TIMESPAN Tier 3 Myasthenia Gravis 180 MG Antimyasthenic Agents - Drugs to Treat PYRIDOSTIGM TAB 60MG PYRIDOSTIGMINE BROMIDE TAB 60 MG Tier 1 Myasthenia Gravis Antimyasthenic Agents - Drugs to Treat PYRIDOSTIGMI TAB ER PYRIDOSTIGMINE BROMIDE TAB ER 180 Tier 1 Myasthenia Gravis 180MG MG Antimycobacterials - Drugs to Treat CYCLOSERINE CAP 250MG CYCLOSERINE CAP 250 MG Tier 1 Infections Antimycobacterials - Drugs to Treat DAPSONE TAB 100MG DAPSONE TAB 100 MG Tier 2 Infections Antimycobacterials - Drugs to Treat DAPSONE TAB 25MG DAPSONE TAB 25 MG Tier 2 Infections Antimycobacterials - Drugs to Treat ETHAMBUTOL TAB 100MG ETHAMBUTOL HCL TAB 100 MG Tier 1 Infections Antimycobacterials - Drugs to Treat ETHAMBUTOL TAB 400MG ETHAMBUTOL HCL TAB 400 MG Tier 1 Infections Antimycobacterials - Drugs to Treat ISONIAZID SYP 50MG/5ML ISONIAZID SYRUP 50 MG/5ML Tier 1 Infections Antimycobacterials - Drugs to Treat ISONIAZID TAB 100MG ISONIAZID TAB 100 MG Tier 1 Infections Antimycobacterials - Drugs to Treat ISONIAZID TAB 300MG ISONIAZID TAB 300 MG Tier 1 Infections Antimycobacterials - Drugs to Treat MYAMBUTOL TAB 100MG ETHAMBUTOL HCL TAB 100 MG Tier 3 Infections Antimycobacterials - Drugs to Treat MYAMBUTOL TAB 400MG ETHAMBUTOL HCL TAB 400 MG Tier 3 Infections Antimycobacterials - Drugs to Treat MYCOBUTIN CAP 150MG RIFABUTIN CAP 150 MG Tier 3 Infections Antimycobacterials - Drugs to Treat AMINOSALICYLIC ACID ER GRANULES PASER GRA 4GM Tier 3 Infections PACKET 4 GM Antimycobacterials - Drugs to Treat PRIFTIN TAB 150MG RIFAPENTINE TAB 150 MG Tier 2 Infections Antimycobacterials - Drugs to Treat PYRAZINAMIDE TAB 500MG PYRAZINAMIDE TAB 500 MG Tier 1 Infections Antimycobacterials - Drugs to Treat RIFABUTIN CAP 150MG RIFABUTIN CAP 150 MG Tier 1 Infections Antimycobacterials - Drugs to Treat RIFADIN CAP 150MG RIFAMPIN CAP 150 MG Tier 3 Infections Antimycobacterials - Drugs to Treat RIFADIN CAP 300MG RIFAMPIN CAP 300 MG Tier 3 Infections Antimycobacterials - Drugs to Treat RIFAMATE CAP ISONIAZID & RIFAMPIN CAP 150-300 MG Tier 3 Infections

47 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antimycobacterials - Drugs to Treat RIFAMPIN CAP 150MG RIFAMPIN CAP 150 MG Tier 1 Infections Antimycobacterials - Drugs to Treat RIFAMPIN CAP 300MG RIFAMPIN CAP 300 MG Tier 1 Infections Antimycobacterials - Drugs to Treat ISONIAZID-RIFAMPIN W/ PYRAZINAMIDE RIFATER TAB Tier 2 Infections TAB 50-120-300 MG Antimycobacterials - Drugs to Treat BEDAQUILINE FUMARATE TAB 100 MG SIRTURO TAB 100MG Tier 2 Infections (BASE EQUIV) Antimycobacterials - Drugs to Treat TRECATOR TAB 250MG ETHIONAMIDE TAB 250 MG Tier 2 Infections Antineoplastics - Drugs to Treat Cancer AFINITOR TAB 10MG EVEROLIMUS TAB 10 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer AFINITOR TAB 2.5MG EVEROLIMUS TAB 2.5 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer AFINITOR TAB 5MG EVEROLIMUS TAB 5 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer AFINITOR TAB 7.5MG EVEROLIMUS TAB 7.5 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer AFINITOR DIS TAB 2MG EVEROLIMUS TAB FOR ORAL SUSP 2 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer AFINITOR DIS TAB 3MG EVEROLIMUS TAB FOR ORAL SUSP 3 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer AFINITOR DIS TAB 5MG EVEROLIMUS TAB FOR ORAL SUSP 5 MG Tier 2 X X X ALECTINIB HCL CAP 150 MG (BASE Antineoplastics - Drugs to Treat Cancer ALECENSA CAP 150MG Tier 2 X X X EQUIVALENT) Antineoplastics - Drugs to Treat Cancer ALKERAN TAB 2MG MELPHALAN TAB 2 MG Tier 3 X BRIGATINIB TAB INITIATION THERAPY Antineoplastics - Drugs to Treat Cancer ALUNBRIG PAK Tier 2 X PACK 90 MG & 180 MG Antineoplastics - Drugs to Treat Cancer ALUNBRIG TAB 180MG BRIGATINIB TAB 180 MG Tier 2 X X Antineoplastics - Drugs to Treat Cancer ALUNBRIG TAB 30MG BRIGATINIB TAB 30 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer ALUNBRIG TAB 90MG BRIGATINIB TAB 90 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer ANASTROZOLE POW ANASTROZOLE (BULK) POWDER Tier 3 Antineoplastics - Drugs to Treat Cancer ANASTROZOLE TAB 1MG ANASTROZOLE TAB 1 MG Tier 1 Antineoplastics - Drugs to Treat Cancer AROMASIN TAB 25MG EXEMESTANE TAB 25 MG Tier 4 Antineoplastics - Drugs to Treat Cancer BICALUTAMIDE TAB 50MG BICALUTAMIDE TAB 50 MG Tier 1 Antineoplastics - Drugs to Treat Cancer BOSULIF TAB 100MG BOSUTINIB TAB 100 MG Tier 2 X X X X Antineoplastics - Drugs to Treat Cancer BOSULIF TAB 400MG BOSUTINIB TAB 400 MG Tier 2 X X Antineoplastics - Drugs to Treat Cancer BOSULIF TAB 500MG BOSUTINIB TAB 500 MG Tier 2 X X X X CABOZANTINIB S-MALATE TAB 20 MG Antineoplastics - Drugs to Treat Cancer CABOMETYX TAB 20MG Tier 2 X X X (BASE EQUIVALENT) CABOZANTINIB S-MALATE TAB 40 MG Antineoplastics - Drugs to Treat Cancer CABOMETYX TAB 40MG Tier 2 X X X (BASE EQUIVALENT) CABOZANTINIB S-MALATE TAB 60 MG Antineoplastics - Drugs to Treat Cancer CABOMETYX TAB 60MG Tier 2 X X X (BASE EQUIVALENT) Antineoplastics - Drugs to Treat Cancer CALCIUM POW FOLINATE LEUCOVORIN CALCIUM POWDER Tier 3 Antineoplastics - Drugs to Treat Cancer CALQUENCE CAP 100MG ACALABRUTINIB CAP 100 MG Tier 3 X X X Antineoplastics - Drugs to Treat Cancer CAPRELSA TAB 100MG VANDETANIB TAB 100 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer CAPRELSA TAB 300MG VANDETANIB TAB 300 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer CASODEX TAB 50MG BICALUTAMIDE TAB 50 MG Tier 4 CABOZANTINIB S-MAL CAP 1 X 80 MG & Antineoplastics - Drugs to Treat Cancer COMETRIQ KIT 100MG Tier 2 X X X 1 X 20 MG (100 DOSE) KIT CABOZANTINIB S-MAL CAP 1 X 80 MG & Antineoplastics - Drugs to Treat Cancer COMETRIQ KIT 140MG Tier 2 X X X 3 X 20 MG (140 DOSE) KIT CABOZANTINIB S-MALATE CAP 3 X 20 Antineoplastics - Drugs to Treat Cancer COMETRIQ KIT 60MG Tier 2 X X X MG (60 MG DOSE) KIT Antineoplastics - Drugs to Treat Cancer CYCLOPHOSPH CAP 25MG CYCLOPHOSPHAMIDE CAP 25 MG Tier 2 Antineoplastics - Drugs to Treat Cancer CYCLOPHOSPH CAP 50MG CYCLOPHOSPHAMIDE CAP 50 MG Tier 2 Antineoplastics - Drugs to Treat Cancer CYCLOPHOSPHA POW CYCLOPHOSPHAMIDE (BULK) POWDER Tier 3 X Antineoplastics - Drugs to Treat Cancer DROXIA CAP 200MG HYDROXYUREA CAP 200 MG Tier 2 Antineoplastics - Drugs to Treat Cancer DROXIA CAP 300MG HYDROXYUREA CAP 300 MG Tier 2 Antineoplastics - Drugs to Treat Cancer DROXIA CAP 400MG HYDROXYUREA CAP 400 MG Tier 2 ESTRAMUSTINE PHOSPHATE SODIUM Antineoplastics - Drugs to Treat Cancer EMCYT CAP 140MG Tier 2 CAP 140 MG Antineoplastics - Drugs to Treat Cancer ERIVEDGE CAP 150MG VISMODEGIB CAP 150 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer ETOPOSIDE CAP 50MG ETOPOSIDE CAP 50 MG Tier 1 Antineoplastics - Drugs to Treat Cancer ETOPOSIDE POW ETOPOSIDE (BULK) POWDER Tier 3 Antineoplastics - Drugs to Treat Cancer EXEMESTANE TAB 25MG EXEMESTANE TAB 25 MG Tier 2 TOREMIFENE CITRATE TAB 60 MG (BASE Antineoplastics - Drugs to Treat Cancer FARESTON TAB 60MG Tier 2 EQUIVALENT) PANOBINOSTAT LACTATE CAP 10 MG Antineoplastics - Drugs to Treat Cancer FARYDAK CAP 10MG Tier 2 X X X (BASE EQUIVALENT) PANOBINOSTAT LACTATE CAP 15 MG Antineoplastics - Drugs to Treat Cancer FARYDAK CAP 15MG Tier 2 X X X (BASE EQUIVALENT) PANOBINOSTAT LACTATE CAP 20 MG Antineoplastics - Drugs to Treat Cancer FARYDAK CAP 20MG Tier 2 X X X (BASE EQUIVALENT) Antineoplastics - Drugs to Treat Cancer FLUOROURACIL POW FLUOROURACIL (BULK) POWDER Tier 3 X FLUOROURACIL POW USP/ Antineoplastics - Drugs to Treat Cancer FLUOROURACIL (BULK) POWDER Tier 3 X NF Antineoplastics - Drugs to Treat Cancer FLUTAMIDE CAP 125MG FLUTAMIDE CAP 125 MG Tier 1 AFATINIB DIMALEATE TAB 20 MG (BASE Antineoplastics - Drugs to Treat Cancer GILOTRIF TAB 20MG Tier 3 X X X EQUIVALENT)

48 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy AFATINIB DIMALEATE TAB 30 MG (BASE Antineoplastics - Drugs to Treat Cancer GILOTRIF TAB 30MG Tier 3 X X X EQUIVALENT) AFATINIB DIMALEATE TAB 40 MG (BASE Antineoplastics - Drugs to Treat Cancer GILOTRIF TAB 40MG Tier 3 X X X EQUIVALENT) Antineoplastics - Drugs to Treat Cancer GLEOSTINE CAP 100MG LOMUSTINE CAP 100 MG Tier 2 Antineoplastics - Drugs to Treat Cancer GLEOSTINE CAP 10MG LOMUSTINE CAP 10 MG Tier 2 Antineoplastics - Drugs to Treat Cancer GLEOSTINE CAP 40MG LOMUSTINE CAP 40 MG Tier 2 Antineoplastics - Drugs to Treat Cancer GLEOSTINE CAP 5MG LOMUSTINE CAP 5 MG Tier 2 Antineoplastics - Drugs to Treat Cancer HEXALEN CAP 50MG ALTRETAMINE CAP 50 MG Tier 2 TOPOTECAN HCL CAP 0.25 MG (BASE Antineoplastics - Drugs to Treat Cancer HYCAMTIN CAP 0.25MG Tier 2 X X X EQUIV) TOPOTECAN HCL CAP 1 MG (BASE Antineoplastics - Drugs to Treat Cancer HYCAMTIN CAP 1MG Tier 2 X X X EQUIV) Antineoplastics - Drugs to Treat Cancer HYDREA CAP 500MG HYDROXYUREA CAP 500 MG Tier 3 Antineoplastics - Drugs to Treat Cancer HYDROXYUREA CAP 500MG HYDROXYUREA CAP 500 MG Tier 1 Antineoplastics - Drugs to Treat Cancer HYDROXYUREA POW HYDROXYUREA (BULK) POWDER Tier 3 Antineoplastics - Drugs to Treat Cancer IBRANCE CAP 100MG PALBOCICLIB CAP 100 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer IBRANCE CAP 125MG PALBOCICLIB CAP 125 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer IBRANCE CAP 75MG PALBOCICLIB CAP 75 MG Tier 2 X X X PONATINIB HCL TAB 15 MG (BASE Antineoplastics - Drugs to Treat Cancer ICLUSIG TAB 15MG Tier 3 X X X EQUIV) PONATINIB HCL TAB 45 MG (BASE Antineoplastics - Drugs to Treat Cancer ICLUSIG TAB 45MG Tier 3 X X X EQUIV) ENASIDENIB MESYLATE TAB 100 MG Antineoplastics - Drugs to Treat Cancer IDHIFA TAB 100MG Tier 2 X X X (BASE EQUIVALENT) ENASIDENIB MESYLATE TAB 50 MG Antineoplastics - Drugs to Treat Cancer IDHIFA TAB 50MG Tier 2 X X X (BASE EQUIVALENT) IMATINIB MESYLATE TAB 100 MG (BASE Antineoplastics - Drugs to Treat Cancer IMATINIB MES TAB 100MG Tier 1 X X X EQUIVALENT) IMATINIB MESYLATE TAB 400 MG (BASE Antineoplastics - Drugs to Treat Cancer IMATINIB MES TAB 400MG Tier 1 X X X EQUIVALENT) Antineoplastics - Drugs to Treat Cancer IMBRUVICA CAP 140MG IBRUTINIB CAP 140 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer INLYTA TAB 1MG AXITINIB TAB 1 MG Tier 3 X X X Antineoplastics - Drugs to Treat Cancer INLYTA TAB 5MG AXITINIB TAB 5 MG Tier 3 X X X Antineoplastics - Drugs to Treat Cancer IRESSA TAB 250MG GEFITINIB TAB 250 MG Tier 3 X X X RUXOLITINIB PHOSPHATE TAB 10 MG Antineoplastics - Drugs to Treat Cancer JAKAFI TAB 10MG Tier 2 X X X (BASE EQUIVALENT) RUXOLITINIB PHOSPHATE TAB 15 MG Antineoplastics - Drugs to Treat Cancer JAKAFI TAB 15MG Tier 2 X X X (BASE EQUIVALENT) RUXOLITINIB PHOSPHATE TAB 20 MG Antineoplastics - Drugs to Treat Cancer JAKAFI TAB 20MG Tier 2 X X X (BASE EQUIVALENT) RUXOLITINIB PHOSPHATE TAB 25 MG Antineoplastics - Drugs to Treat Cancer JAKAFI TAB 25MG Tier 2 X X X (BASE EQUIVALENT) RUXOLITINIB PHOSPHATE TAB 5 MG Antineoplastics - Drugs to Treat Cancer JAKAFI TAB 5MG Tier 2 X X X (BASE EQUIVALENT) RIBOCICLIB SUCCINATE TAB 200 MG Antineoplastics - Drugs to Treat Cancer KISQALI TAB 200DOSE Tier 3 X X X (BASE EQUIV) RIBOCICLIB SUCCINATE TAB 200 MG Antineoplastics - Drugs to Treat Cancer KISQALI TAB 400DOSE Tier 3 X X X (BASE EQUIV) RIBOCICLIB SUCCINATE TAB 200 MG Antineoplastics - Drugs to Treat Cancer KISQALI TAB 600DOSE Tier 3 X X X (BASE EQUIV) RIBOCICLIB TAB 200 MG & LETROZOLE Antineoplastics - Drugs to Treat Cancer KISQALI 200 PAK FEMARA Tier 3 X X TAB 2.5 MG THERAPY PACK RIBOCICLIB TAB 200 MG & LETROZOLE Antineoplastics - Drugs to Treat Cancer KISQALI 400 PAK FEMARA Tier 3 X X TAB 2.5 MG THERAPY PACK RIBOCICLIB TAB 200 MG & LETROZOLE Antineoplastics - Drugs to Treat Cancer KISQALI 600 PAK FEMARA Tier 3 X X TAB 2.5 MG THERAPY PACK LENVATINIB CAP THERAPY PACK 10 MG Antineoplastics - Drugs to Treat Cancer LENVIMA CAP 10 MG Tier 3 X X X (10 MG DAILY DOSE) LENVATINIB CAP THERAPY PACK 10 & 4 Antineoplastics - Drugs to Treat Cancer LENVIMA CAP 14 MG Tier 3 X X X MG (14 MG DAILY DOSE) LENVATINIB CAP THERAPY PACK 10 & 4 Antineoplastics - Drugs to Treat Cancer LENVIMA CAP 18 MG Tier 3 X X X (2) MG (18 MG DAILY DOSE) LENVATINIB CAP THERAPY PACK 10 (2) Antineoplastics - Drugs to Treat Cancer LENVIMA CAP 20 MG Tier 3 X X X MG (20 MG DAILY DOSE) LENVATINIB CAP THERAPY PACK 10 (2) & Antineoplastics - Drugs to Treat Cancer LENVIMA CAP 24 MG Tier 3 X X X 4 MG (24 MG DAILY DOSE) LENVATINIB CAP THERAPY PACK 4 (2) Antineoplastics - Drugs to Treat Cancer LENVIMA CAP 8 MG Tier 3 X X X MG (8 MG DAILY DOSE) Antineoplastics - Drugs to Treat Cancer LETROZOLE TAB 2.5MG LETROZOLE TAB 2.5 MG Tier 1 Antineoplastics - Drugs to Treat Cancer LEUCOVOR CA TAB 10MG LEUCOVORIN CALCIUM TAB 10 MG Tier 1 Antineoplastics - Drugs to Treat Cancer LEUCOVOR CA TAB 15MG LEUCOVORIN CALCIUM TAB 15 MG Tier 1 Antineoplastics - Drugs to Treat Cancer LEUCOVOR CA TAB 25MG LEUCOVORIN CALCIUM TAB 25 MG Tier 1 Antineoplastics - Drugs to Treat Cancer LEUCOVOR CA TAB 5MG LEUCOVORIN CALCIUM TAB 5 MG Tier 1 LEUCOVORIN POW Antineoplastics - Drugs to Treat Cancer LEUCOVORIN CALCIUM POWDER Tier 3 CALCIUM Antineoplastics - Drugs to Treat Cancer LEUKERAN TAB 2MG CHLORAMBUCIL TAB 2 MG Tier 2 49 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antineoplastics - Drugs to Treat Cancer LONSURF TAB 15-6.14 TRIFLURIDINE-TIPIRACIL TAB 15-6.14 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer LONSURF TAB 20-8.19 TRIFLURIDINE-TIPIRACIL TAB 20-8.19 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer LYNPARZA CAP 50MG OLAPARIB CAP 50 MG Tier 3 X X X Antineoplastics - Drugs to Treat Cancer LYNPARZA TAB 100MG OLAPARIB TAB 100 MG Tier 3 X X Antineoplastics - Drugs to Treat Cancer LYNPARZA TAB 150MG OLAPARIB TAB 150 MG Tier 3 X X Antineoplastics - Drugs to Treat Cancer MATULANE CAP 50MG PROCARBAZINE HCL CAP 50 MG Tier 2 X TRAMETINIB DIMETHYL SULFOXIDE TAB Antineoplastics - Drugs to Treat Cancer MEKINIST TAB 0.5MG Tier 3 X X X 0.5 MG (BASE EQUIVALENT) TRAMETINIB DIMETHYL SULFOXIDE TAB Antineoplastics - Drugs to Treat Cancer MEKINIST TAB 2MG Tier 3 X X X 2 MG (BASE EQUIVALENT) Antineoplastics - Drugs to Treat Cancer MELPHALAN TAB 2MG MELPHALAN TAB 2 MG Tier 2 X Antineoplastics - Drugs to Treat Cancer MERCAPTOPUR TAB 50MG MERCAPTOPURINE TAB 50 MG Tier 1 MERCAPTOPURINE MONOHYDRATE Antineoplastics - Drugs to Treat Cancer MERCAPTOPURI POW Tier 3 (BULK) POWDER MERCAPTOPURI POW MERCAPTOPURINE MONOHYDRATE Antineoplastics - Drugs to Treat Cancer Tier 3 MONOHYDR (BULK) POWDER Antineoplastics - Drugs to Treat Cancer MESNEX TAB 400MG MESNA TAB 400 MG Tier 3 X Antineoplastics - Drugs to Treat Cancer MITOMYCIN POW MITOMYCIN (BULK) POWDER Tier 3 X Antineoplastics - Drugs to Treat Cancer MITOMYCIN C POW MITOMYCIN (BULK) POWDER Tier 3 X Antineoplastics - Drugs to Treat Cancer MYLERAN TAB 2MG BUSULFAN TAB 2 MG Tier 2 NERATINIB MALEATE TAB 40 MG (BASE Antineoplastics - Drugs to Treat Cancer NERLYNX TAB 40MG Tier 3 X X X EQUIVALENT) SORAFENIB TOSYLATE TAB 200 MG Antineoplastics - Drugs to Treat Cancer NEXAVAR TAB 200MG Tier 2 X X X (BASE EQUIVALENT) Antineoplastics - Drugs to Treat Cancer NILANDRON TAB 150MG NILUTAMIDE TAB 150 MG Tier 3 Antineoplastics - Drugs to Treat Cancer NILUTAMIDE TAB 150MG NILUTAMIDE TAB 150 MG Tier 3 IXAZOMIB CITRATE CAP 2.3 MG (BASE Antineoplastics - Drugs to Treat Cancer NINLARO CAP 2.3MG Tier 2 X X X EQUIVALENT) IXAZOMIB CITRATE CAP 3 MG (BASE Antineoplastics - Drugs to Treat Cancer NINLARO CAP 3MG Tier 2 X X X EQUIVALENT) IXAZOMIB CITRATE CAP 4 MG (BASE Antineoplastics - Drugs to Treat Cancer NINLARO CAP 4MG Tier 2 X X X EQUIVALENT) SONIDEGIB PHOSPHATE CAP 200 MG Antineoplastics - Drugs to Treat Cancer ODOMZO CAP 200MG Tier 2 X X X (BASE EQUIVALENT) Antineoplastics - Drugs to Treat Cancer PANRETIN GEL 0.1% ALITRETINOIN GEL 0.1% Tier 3 Antineoplastics - Drugs to Treat Cancer POMALYST CAP 1MG POMALIDOMIDE CAP 1 MG Tier 3 X X X Antineoplastics - Drugs to Treat Cancer POMALYST CAP 2MG POMALIDOMIDE CAP 2 MG Tier 3 X X X Antineoplastics - Drugs to Treat Cancer POMALYST CAP 3MG POMALIDOMIDE CAP 3 MG Tier 3 X X X Antineoplastics - Drugs to Treat Cancer POMALYST CAP 4MG POMALIDOMIDE CAP 4 MG Tier 3 X X X MERCAPTOPURINE SUSP 2000 Antineoplastics - Drugs to Treat Cancer PURIXAN SUS 20MG/ML Tier 4 X MG/100ML (20 MG/ML) Antineoplastics - Drugs to Treat Cancer REVLIMID CAP 10MG LENALIDOMIDE CAP 10 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer REVLIMID CAP 15MG LENALIDOMIDE CAP 15 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer REVLIMID CAP 2.5MG LENALIDOMIDE CAPS 2.5 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer REVLIMID CAP 20MG LENALIDOMIDE CAP 20 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer REVLIMID CAP 25MG LENALIDOMIDE CAP 25 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer REVLIMID CAP 5MG LENALIDOMIDE CAP 5 MG Tier 2 X X X RUCAPARIB CAMSYLATE TAB 200 MG Antineoplastics - Drugs to Treat Cancer RUBRACA TAB 200MG Tier 3 X X X (BASE EQUIVALENT) RUCAPARIB CAMSYLATE TAB 250 MG Antineoplastics - Drugs to Treat Cancer RUBRACA TAB 250MG Tier 3 X X (BASE EQUIVALENT) RUCAPARIB CAMSYLATE TAB 300 MG Antineoplastics - Drugs to Treat Cancer RUBRACA TAB 300MG Tier 3 X X X (BASE EQUIVALENT) Antineoplastics - Drugs to Treat Cancer RYDAPT CAP 25MG MIDOSTAURIN CAP 25 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer SPRYCEL TAB 100MG DASATINIB TAB 100 MG Tier 4 X X X X Antineoplastics - Drugs to Treat Cancer SPRYCEL TAB 140MG DASATINIB TAB 140 MG Tier 4 X X X X Antineoplastics - Drugs to Treat Cancer SPRYCEL TAB 20MG DASATINIB TAB 20 MG Tier 4 X X X X Antineoplastics - Drugs to Treat Cancer SPRYCEL TAB 50MG DASATINIB TAB 50 MG Tier 4 X X X X Antineoplastics - Drugs to Treat Cancer SPRYCEL TAB 70MG DASATINIB TAB 70 MG Tier 4 X X X X Antineoplastics - Drugs to Treat Cancer SPRYCEL TAB 80MG DASATINIB TAB 80 MG Tier 4 X X X X Antineoplastics - Drugs to Treat Cancer STIVARGA TAB 40MG REGORAFENIB TAB 40 MG Tier 2 X X X SUNITINIB MALATE CAP 12.5 MG (BASE Antineoplastics - Drugs to Treat Cancer SUTENT CAP 12.5MG Tier 2 X X X EQUIVALENT) SUNITINIB MALATE CAP 25 MG (BASE Antineoplastics - Drugs to Treat Cancer SUTENT CAP 25MG Tier 2 X X X EQUIVALENT) SUNITINIB MALATE CAP 37.5 MG (BASE Antineoplastics - Drugs to Treat Cancer SUTENT CAP 37.5MG Tier 2 X X X EQUIVALENT) SUNITINIB MALATE CAP 50 MG (BASE Antineoplastics - Drugs to Treat Cancer SUTENT CAP 50MG Tier 2 X X X EQUIVALENT) Antineoplastics - Drugs to Treat Cancer TABLOID TAB 40MG THIOGUANINE TAB 40 MG Tier 2 DABRAFENIB MESYLATE CAP 50 MG Antineoplastics - Drugs to Treat Cancer TAFINLAR CAP 50MG Tier 3 X X X (BASE EQUIVALENT) DABRAFENIB MESYLATE CAP 75 MG Antineoplastics - Drugs to Treat Cancer TAFINLAR CAP 75MG Tier 3 X X X (BASE EQUIVALENT) OSIMERTINIB MESYLATE TAB 40 MG Antineoplastics - Drugs to Treat Cancer TAGRISSO TAB 40MG Tier 3 X X X (BASE EQUIVALENT) 50 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy OSIMERTINIB MESYLATE TAB 80 MG Antineoplastics - Drugs to Treat Cancer TAGRISSO TAB 80MG Tier 3 X X X (BASE EQUIVALENT) TAMOXIFEN CITRATE TAB 10 MG (BASE Antineoplastics - Drugs to Treat Cancer TAMOXIFEN TAB 10MG Tier 1 EQUIVALENT) HCR TAMOXIFEN CITRATE TAB 20 MG (BASE Antineoplastics - Drugs to Treat Cancer TAMOXIFEN TAB 20MG Preventive EQUIVALENT) Care ERLOTINIB HCL TAB 100 MG (BASE Antineoplastics - Drugs to Treat Cancer TARCEVA TAB 100MG Tier 2 X X X EQUIVALENT) ERLOTINIB HCL TAB 150 MG (BASE Antineoplastics - Drugs to Treat Cancer TARCEVA TAB 150MG Tier 2 X X X EQUIVALENT) ERLOTINIB HCL TAB 25 MG (BASE Antineoplastics - Drugs to Treat Cancer TARCEVA TAB 25MG Tier 2 X X X EQUIVALENT) Antineoplastics - Drugs to Treat Cancer TARGRETIN CAP 75MG BEXAROTENE CAP 75 MG Tier 2 X Antineoplastics - Drugs to Treat Cancer TARGRETIN GEL 1% BEXAROTENE GEL 1% Tier 3 X X NILOTINIB HCL CAP 150 MG (BASE Antineoplastics - Drugs to Treat Cancer TASIGNA CAP 150MG Tier 2 X X X X EQUIVALENT) NILOTINIB HCL CAP 200 MG (BASE Antineoplastics - Drugs to Treat Cancer TASIGNA CAP 200MG Tier 2 X X X X EQUIVALENT) Antineoplastics - Drugs to Treat Cancer TEMODAR CAP 100MG TEMOZOLOMIDE CAP 100 MG Tier 3 X X Antineoplastics - Drugs to Treat Cancer TEMODAR CAP 140MG TEMOZOLOMIDE CAP 140 MG Tier 3 X X Antineoplastics - Drugs to Treat Cancer TEMODAR CAP 180MG TEMOZOLOMIDE CAP 180 MG Tier 3 X X Antineoplastics - Drugs to Treat Cancer TEMODAR CAP 20MG TEMOZOLOMIDE CAP 20 MG Tier 3 X X Antineoplastics - Drugs to Treat Cancer TEMODAR CAP 250MG TEMOZOLOMIDE CAP 250 MG Tier 3 X X Antineoplastics - Drugs to Treat Cancer TEMODAR CAP 5MG TEMOZOLOMIDE CAP 5 MG Tier 3 X X TEMOZOLOMIDE CAP Antineoplastics - Drugs to Treat Cancer TEMOZOLOMIDE CAP 100 MG Tier 1 X X 100MG TEMOZOLOMIDE CAP Antineoplastics - Drugs to Treat Cancer TEMOZOLOMIDE CAP 140 MG Tier 1 X X 140MG TEMOZOLOMIDE CAP Antineoplastics - Drugs to Treat Cancer TEMOZOLOMIDE CAP 180 MG Tier 1 X X 180MG Antineoplastics - Drugs to Treat Cancer TEMOZOLOMIDE CAP 20MG TEMOZOLOMIDE CAP 20 MG Tier 1 X X TEMOZOLOMIDE CAP Antineoplastics - Drugs to Treat Cancer TEMOZOLOMIDE CAP 250 MG Tier 1 X X 250MG Antineoplastics - Drugs to Treat Cancer TEMOZOLOMIDE CAP 5MG TEMOZOLOMIDE CAP 5 MG Tier 1 X X Antineoplastics - Drugs to Treat Cancer THALOMID CAP 100MG THALIDOMIDE CAP 100 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer THALOMID CAP 150MG THALIDOMIDE CAP 150 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer THALOMID CAP 200MG THALIDOMIDE CAP 200 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer THALOMID CAP 50MG THALIDOMIDE CAP 50 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer THIOGUANINE POW THIOGUANINE (BULK) POWDER Tier 3 Antineoplastics - Drugs to Treat Cancer TRETINOIN CAP 10MG TRETINOIN CAP 10 MG Tier 2 X X LAPATINIB DITOSYLATE TAB 250 MG Antineoplastics - Drugs to Treat Cancer TYKERB TAB 250MG Tier 2 X X X (BASE EQUIV) MECHLORETHAMINE HCL GEL 0.016% Antineoplastics - Drugs to Treat Cancer VALCHLOR GEL 0.016% Tier 2 X X X (BASE EQUIVALENT) Antineoplastics - Drugs to Treat Cancer VENCLEXTA TAB 100MG VENETOCLAX TAB 100 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer VENCLEXTA TAB 10MG VENETOCLAX TAB 10 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer VENCLEXTA TAB 50MG VENETOCLAX TAB 50 MG Tier 2 X X X VENETOCLAX TAB THERAPY STARTER Antineoplastics - Drugs to Treat Cancer VENCLEXTA TAB START PK Tier 2 X X X PACK 10 & 50 & 100 MG Antineoplastics - Drugs to Treat Cancer VERZENIO TAB 100MG ABEMACICLIB TAB 100 MG Tier 3 X X X Antineoplastics - Drugs to Treat Cancer VERZENIO TAB 150MG ABEMACICLIB TAB 150 MG Tier 3 X X X Antineoplastics - Drugs to Treat Cancer VERZENIO TAB 200MG ABEMACICLIB TAB 200 MG Tier 3 X X X Antineoplastics - Drugs to Treat Cancer VERZENIO TAB 50MG ABEMACICLIB TAB 50 MG Tier 3 X X X PAZOPANIB HCL TAB 200 MG (BASE Antineoplastics - Drugs to Treat Cancer VOTRIENT TAB 200MG Tier 2 X X X EQUIV) Antineoplastics - Drugs to Treat Cancer XALKORI CAP 200MG CRIZOTINIB CAP 200 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer XALKORI CAP 250MG CRIZOTINIB CAP 250 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer XELODA TAB 150MG CAPECITABINE TAB 150 MG Tier 1 X X Antineoplastics - Drugs to Treat Cancer XELODA TAB 500MG CAPECITABINE TAB 500 MG Tier 1 X X Antineoplastics - Drugs to Treat Cancer XTANDI CAP 40MG ENZALUTAMIDE CAP 40 MG Tier 3 X X X X NIRAPARIB TOSYLATE CAP 100 MG Antineoplastics - Drugs to Treat Cancer ZEJULA CAP 100MG Tier 3 X X X (BASE EQUIVALENT) Antineoplastics - Drugs to Treat Cancer ZELBORAF TAB 240MG VEMURAFENIB TAB 240 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer ZOLINZA CAP 100MG VORINOSTAT CAP 100 MG Tier 2 X X Antineoplastics - Drugs to Treat Cancer ZYDELIG TAB 100MG IDELALISIB TAB 100 MG Tier 3 X X X Antineoplastics - Drugs to Treat Cancer ZYDELIG TAB 150MG IDELALISIB TAB 150 MG Tier 3 X X X Antineoplastics - Drugs to Treat Cancer ZYKADIA CAP 150MG CERITINIB CAP 150 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer ZYTIGA TAB 250MG ABIRATERONE ACETATE TAB 250 MG Tier 2 X X X Antineoplastics - Drugs to Treat Cancer ZYTIGA TAB 500MG ABIRATERONE ACETATE TAB 500 MG Tier 2 X X Antiparasitics - Drugs to Treat Parasitic ALBENZA TAB 200MG ALBENDAZOLE TAB 200 MG Tier 3 X X Infections Antiparasitics - Drugs to Treat Parasitic ALINIA SUS 100/5ML NITAZOXANIDE FOR SUSP 100 MG/5ML Tier 2 X Infections Antiparasitics - Drugs to Treat Parasitic ALINIA TAB 500MG NITAZOXANIDE TAB 500 MG Tier 2 X Infections 51 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antiparasitics - Drugs to Treat Parasitic ATOVAQ/PROGU TAB 250- ATOVAQUONE-PROGUANIL HCL TAB Tier 2 Infections 100 250-100 MG Antiparasitics - Drugs to Treat Parasitic ATOVAQ/PROGU TAB 62.5- ATOVAQUONE-PROGUANIL HCL TAB Tier 2 Infections 25 62.5-25 MG Antiparasitics - Drugs to Treat Parasitic ATOVAQUONE SUS 750/5ML ATOVAQUONE SUSP 750 MG/5ML Tier 2 Infections Antiparasitics - Drugs to Treat Parasitic BILTRICIDE TAB 600MG PRAZIQUANTEL TAB 600 MG Tier 2 Infections Antiparasitics - Drugs to Treat Parasitic CHLOROQUINE PHOSPHATE TAB 250 CHLOROQUINE TAB 250MG Tier 1 Infections MG Antiparasitics - Drugs to Treat Parasitic CHLOROQUINE PHOSPHATE TAB 500 CHLOROQUINE TAB 500MG Tier 1 Infections MG Antiparasitics - Drugs to Treat Parasitic ARTEMETHER-LUMEFANTRINE TAB 20- COARTEM TAB 20-120MG Tier 2 Infections 120 MG Antiparasitics - Drugs to Treat Parasitic DARAPRIM TAB 25MG PYRIMETHAMINE TAB 25 MG Tier 2 X X Infections Antiparasitics - Drugs to Treat Parasitic ELIMITE CRE 5% PERMETHRIN CREAM 5% Tier 3 Infections Antiparasitics - Drugs to Treat Parasitic EMVERM CHW 100MG MEBENDAZOLE CHEW TAB 100 MG Tier 4 X X X Infections Antiparasitics - Drugs to Treat Parasitic EURAX CRE 10% CROTAMITON CREAM 10% Tier 2 Infections Antiparasitics - Drugs to Treat Parasitic EURAX LOT 10% CROTAMITON LOTION 10% Tier 3 Infections Antiparasitics - Drugs to Treat Parasitic HYDROXYCHLOR TAB HYDROXYCHLOROQUINE SULFATE TAB Tier 1 Infections 200MG 200 MG Antiparasitics - Drugs to Treat Parasitic IVERMECTIN TAB 3MG IVERMECTIN TAB 3 MG Tier 1 Infections Antiparasitics - Drugs to Treat Parasitic LINDANE SHA 1% LINDANE SHAMPOO 1% Tier 1 X Infections Antiparasitics - Drugs to Treat Parasitic ATOVAQUONE-PROGUANIL HCL TAB MALARONE TAB 250-100 Tier 3 Infections 250-100 MG Antiparasitics - Drugs to Treat Parasitic ATOVAQUONE-PROGUANIL HCL TAB MALARONE TAB 62.5-25 Tier 3 Infections 62.5-25 MG Antiparasitics - Drugs to Treat Parasitic MALATHION LOT 0.5% MALATHION LOTION 0.5% Tier 1 Infections Antiparasitics - Drugs to Treat Parasitic MEFLOQUINE TAB 250MG MEFLOQUINE HCL TAB 250 MG Tier 1 Infections Antiparasitics - Drugs to Treat Parasitic PENTAMIDINE ISETHIONATE FOR NEBUPENT INH 300MG Tier 2 Infections NEBULIZATION SOLN 300 MG Antiparasitics - Drugs to Treat Parasitic OVIDE LOT 0.5% MALATHION LOTION 0.5% Tier 3 Infections Antiparasitics - Drugs to Treat Parasitic PERMETHRIN CRE 5% PERMETHRIN CREAM 5% Tier 1 Infections Antiparasitics - Drugs to Treat Parasitic HYDROXYCHLOROQUINE SULFATE TAB PLAQUENIL TAB 200MG Tier 3 Infections 200 MG Antiparasitics - Drugs to Treat Parasitic PRIMAQUINE PHOSPHATE TAB 26.3 MG PRIMAQUINE TAB 26.3MG Tier 1 Infections (15 MG BASE) Antiparasitics - Drugs to Treat Parasitic QUALAQUIN CAP 324MG QUININE SULFATE CAP 324 MG Tier 3 X Infections Antiparasitics - Drugs to Treat Parasitic QUININE SULF CAP 324MG QUININE SULFATE CAP 324 MG Tier 1 X Infections Antiparasitics - Drugs to Treat Parasitic SKLICE LOT 0.5% IVERMECTIN LOTION 0.5% Tier 3 X Infections Antiparasitics - Drugs to Treat Parasitic SPINOSAD SUS 0.9% SPINOSAD SUSP 0.9% Tier 3 Infections Antiparasitics - Drugs to Treat Parasitic STROMECTOL TAB 3MG IVERMECTIN TAB 3 MG Tier 3 Infections Antiparasitics - Drugs to Treat Parasitic SULF LIME SOL SULFURATED LIME SOLUTION Tier 3 Infections Antiparasitics - Drugs to Treat Parasitic ULESFIA LOT 5% BENZYL ALCOHOL LOTION 5% Tier 3 Infections Antiparkinson Agents - Drugs to Treat AMANTADINE CAP 100MG AMANTADINE HCL CAP 100 MG Tier 1 Parkinson's Disease Antiparkinson Agents - Drugs to Treat AMANTADINE SYP AMANTADINE HCL SYRUP 50 MG/5ML Tier 1 Parkinson's Disease 50MG/5ML Antiparkinson Agents - Drugs to Treat AMANTADINE TAB 100MG AMANTADINE HCL TAB 100 MG Tier 1 Parkinson's Disease Antiparkinson Agents - Drugs to Treat APOMORPHINE HCL SOLN CARTRIDGE APOKYN INJ 10MG/ML Tier 2 X Parkinson's Disease 30 MG/3ML Antiparkinson Agents - Drugs to Treat BENZTROPINE TAB 0.5MG BENZTROPINE MESYLATE TAB 0.5 MG Tier 1 Parkinson's Disease Antiparkinson Agents - Drugs to Treat BENZTROPINE TAB 1MG BENZTROPINE MESYLATE TAB 1 MG Tier 1 Parkinson's Disease Antiparkinson Agents - Drugs to Treat BENZTROPINE TAB 2MG BENZTROPINE MESYLATE TAB 2 MG Tier 1 Parkinson's Disease Antiparkinson Agents - Drugs to Treat BROMOCRIPTINE MESYLATE CAP 5 MG BROMOCRIPTIN CAP 5MG Tier 1 Parkinson's Disease (BASE EQUIVALENT)

52 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antiparkinson Agents - Drugs to Treat BROMOCRIPTINE MESYLATE TAB 2.5 MG BROMOCRIPTIN TAB 2.5MG Tier 1 Parkinson's Disease (BASE EQUIVALENT) Antiparkinson Agents - Drugs to Treat CARBIDOPA & LEVODOPA TAB 10-100 CARB/LEVO TAB 10-100MG Tier 1 Parkinson's Disease MG Antiparkinson Agents - Drugs to Treat CARBIDOPA & LEVODOPA ORALLY CARB/LEVO TAB 10-100MG Tier 1 Parkinson's Disease DISINTEGRATING TAB 10-100 MG Antiparkinson Agents - Drugs to Treat CARBIDOPA & LEVODOPA TAB 25-100 CARB/LEVO TAB 25-100MG Tier 1 Parkinson's Disease MG Antiparkinson Agents - Drugs to Treat CARBIDOPA & LEVODOPA ORALLY CARB/LEVO TAB 25-100MG Tier 1 Parkinson's Disease DISINTEGRATING TAB 25-100 MG Antiparkinson Agents - Drugs to Treat CARBIDOPA & LEVODOPA TAB 25-250 CARB/LEVO TAB 25-250MG Tier 1 Parkinson's Disease MG Antiparkinson Agents - Drugs to Treat CARBIDOPA & LEVODOPA ORALLY CARB/LEVO TAB 25-250MG Tier 1 Parkinson's Disease DISINTEGRATING TAB 25-250 MG Antiparkinson Agents - Drugs to Treat CARB/LEVO 50 TAB / CARBIDOPA-LEVODOPA-ENTACAPONE Tier 1 Parkinson's Disease ENTACAP TABS 12.5-50-200 MG Antiparkinson Agents - Drugs to Treat CARB/LEVO 75 TAB / CARBIDOPA-LEVODOPA-ENTACAPONE Tier 1 Parkinson's Disease ENTACAP TABS 18.75-75-200 MG Antiparkinson Agents - Drugs to Treat CARB/LEVO ER TAB 25- CARBIDOPA & LEVODOPA TAB ER 25- Tier 1 Parkinson's Disease 100MG 100 MG Antiparkinson Agents - Drugs to Treat CARB/LEVO ER TAB 50- CARBIDOPA & LEVODOPA TAB ER 50- Tier 1 Parkinson's Disease 200MG 200 MG Antiparkinson Agents - Drugs to Treat CARB/LEVO100 TAB / CARBIDOPA-LEVODOPA-ENTACAPONE Tier 1 Parkinson's Disease ENTACAP TABS 25-100-200 MG Antiparkinson Agents - Drugs to Treat CARB/LEVO125 TAB / CARBIDOPA-LEVODOPA-ENTACAPONE Tier 1 Parkinson's Disease ENTACAP TABS 31.25-125-200 MG Antiparkinson Agents - Drugs to Treat CARB/LEVO150 TAB / CARBIDOPA-LEVODOPA-ENTACAPONE Tier 1 Parkinson's Disease ENTACAP TABS 37.5-150-200 MG Antiparkinson Agents - Drugs to Treat CARB/LEVO200 TAB / CARBIDOPA-LEVODOPA-ENTACAPONE Tier 1 Parkinson's Disease ENTACAP TABS 50-200-200 MG Antiparkinson Agents - Drugs to Treat CARBIDOPA TAB 25MG CARBIDOPA TAB 25 MG Tier 1 Parkinson's Disease Antiparkinson Agents - Drugs to Treat COMTAN TAB 200MG ENTACAPONE TAB 200 MG Tier 3 Parkinson's Disease Antiparkinson Agents - Drugs to Treat CARBIDOPA-LEVODOPA ENTERAL SUSP DUOPA SUS 4.63-20 Tier 3 X Parkinson's Disease 4.63-20 MG/ML Antiparkinson Agents - Drugs to Treat ELDEPRYL CAP 5MG SELEGILINE HCL CAP 5 MG Tier 3 Parkinson's Disease Antiparkinson Agents - Drugs to Treat ENTACAPONE TAB 200MG ENTACAPONE TAB 200 MG Tier 1 Parkinson's Disease Antiparkinson Agents - Drugs to Treat PRAMIPEXOLE DIHYDROCHLORIDE TAB MIRAPEX TAB 0.125MG Tier 3 Parkinson's Disease 0.125 MG Antiparkinson Agents - Drugs to Treat PRAMIPEXOLE DIHYDROCHLORIDE TAB MIRAPEX TAB 0.25MG Tier 3 Parkinson's Disease 0.25 MG Antiparkinson Agents - Drugs to Treat PRAMIPEXOLE DIHYDROCHLORIDE TAB MIRAPEX TAB 0.5MG Tier 3 Parkinson's Disease 0.5 MG Antiparkinson Agents - Drugs to Treat PRAMIPEXOLE DIHYDROCHLORIDE TAB MIRAPEX TAB 0.75MG Tier 3 Parkinson's Disease 0.75 MG Antiparkinson Agents - Drugs to Treat PRAMIPEXOLE DIHYDROCHLORIDE TAB MIRAPEX TAB 1.5MG Tier 3 Parkinson's Disease 1.5 MG Antiparkinson Agents - Drugs to Treat PRAMIPEXOLE DIHYDROCHLORIDE TAB MIRAPEX TAB 1MG Tier 3 Parkinson's Disease 1 MG Antiparkinson Agents - Drugs to Treat ROTIGOTINE TD PATCH 24HR 1 NEUPRO DIS 1MG/24HR Tier 3 Parkinson's Disease MG/24HR Antiparkinson Agents - Drugs to Treat ROTIGOTINE TD PATCH 24HR 2 NEUPRO DIS 2MG/24HR Tier 3 Parkinson's Disease MG/24HR Antiparkinson Agents - Drugs to Treat ROTIGOTINE TD PATCH 24HR 3 NEUPRO DIS 3MG/24HR Tier 3 Parkinson's Disease MG/24HR Antiparkinson Agents - Drugs to Treat ROTIGOTINE TD PATCH 24HR 4 NEUPRO DIS 4MG/24HR Tier 3 Parkinson's Disease MG/24HR Antiparkinson Agents - Drugs to Treat ROTIGOTINE TD PATCH 24HR 6 NEUPRO DIS 6MG/24HR Tier 3 Parkinson's Disease MG/24HR Antiparkinson Agents - Drugs to Treat ROTIGOTINE TD PATCH 24HR 8 NEUPRO DIS 8MG/24HR Tier 3 Parkinson's Disease MG/24HR Antiparkinson Agents - Drugs to Treat PRAMIPEXOLE DIHYDROCHLORIDE TAB PRAMIPEXOLE TAB 0.125MG Tier 1 Parkinson's Disease 0.125 MG Antiparkinson Agents - Drugs to Treat PRAMIPEXOLE DIHYDROCHLORIDE TAB PRAMIPEXOLE TAB 0.25MG Tier 1 Parkinson's Disease 0.25 MG Antiparkinson Agents - Drugs to Treat PRAMIPEXOLE DIHYDROCHLORIDE TAB PRAMIPEXOLE TAB 0.5MG Tier 1 Parkinson's Disease 0.5 MG Antiparkinson Agents - Drugs to Treat PRAMIPEXOLE DIHYDROCHLORIDE TAB PRAMIPEXOLE TAB 0.75MG Tier 1 Parkinson's Disease 0.75 MG Antiparkinson Agents - Drugs to Treat PRAMIPEXOLE DIHYDROCHLORIDE TAB PRAMIPEXOLE TAB 1.5MG Tier 1 Parkinson's Disease 1.5 MG Antiparkinson Agents - Drugs to Treat PRAMIPEXOLE DIHYDROCHLORIDE TAB PRAMIPEXOLE TAB 1MG Tier 1 Parkinson's Disease 1 MG Antiparkinson Agents - Drugs to Treat RASAGILINE MESYLATE TAB 0.5 MG RASAGILINE TAB 0.5MG Tier 3 Parkinson's Disease (BASE EQUIV)

53 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antiparkinson Agents - Drugs to Treat RASAGILINE MESYLATE TAB 1 MG (BASE RASAGILINE TAB 1MG Tier 3 Parkinson's Disease EQUIV) Antiparkinson Agents - Drugs to Treat ROPINIROLE HYDROCHLORIDE TAB REQUIP TAB 0.25MG Tier 3 Parkinson's Disease 0.25 MG Antiparkinson Agents - Drugs to Treat ROPINIROLE HYDROCHLORIDE TAB 0.5 REQUIP TAB 0.5MG Tier 3 Parkinson's Disease MG Antiparkinson Agents - Drugs to Treat ROPINIROLE HYDROCHLORIDE TAB 1 REQUIP TAB 1MG Tier 3 Parkinson's Disease MG Antiparkinson Agents - Drugs to Treat ROPINIROLE HYDROCHLORIDE TAB 2 REQUIP TAB 2MG Tier 3 Parkinson's Disease MG Antiparkinson Agents - Drugs to Treat ROPINIROLE HYDROCHLORIDE TAB 3 REQUIP TAB 3MG Tier 3 Parkinson's Disease MG Antiparkinson Agents - Drugs to Treat ROPINIROLE HYDROCHLORIDE TAB 4 REQUIP TAB 4MG Tier 3 Parkinson's Disease MG Antiparkinson Agents - Drugs to Treat ROPINIROLE HYDROCHLORIDE TAB 5 REQUIP TAB 5MG Tier 3 Parkinson's Disease MG Antiparkinson Agents - Drugs to Treat ROPINIROLE HYDROCHLORIDE TAB ROPINIROLE TAB 0.25MG Tier 1 Parkinson's Disease 0.25 MG Antiparkinson Agents - Drugs to Treat ROPINIROLE HYDROCHLORIDE TAB 0.5 ROPINIROLE TAB 0.5MG Tier 1 Parkinson's Disease MG Antiparkinson Agents - Drugs to Treat ROPINIROLE HYDROCHLORIDE TAB 1 ROPINIROLE TAB 1MG Tier 1 Parkinson's Disease MG Antiparkinson Agents - Drugs to Treat ROPINIROLE HYDROCHLORIDE TAB 2 ROPINIROLE TAB 2MG Tier 1 Parkinson's Disease MG Antiparkinson Agents - Drugs to Treat ROPINIROLE HYDROCHLORIDE TAB 3 ROPINIROLE TAB 3MG Tier 1 Parkinson's Disease MG Antiparkinson Agents - Drugs to Treat ROPINIROLE HYDROCHLORIDE TAB 4 ROPINIROLE TAB 4MG Tier 1 Parkinson's Disease MG Antiparkinson Agents - Drugs to Treat ROPINIROLE HYDROCHLORIDE TAB 5 ROPINIROLE TAB 5MG Tier 1 Parkinson's Disease MG Antiparkinson Agents - Drugs to Treat SELEGILINE CAP 5MG SELEGILINE HCL CAP 5 MG Tier 1 Parkinson's Disease Antiparkinson Agents - Drugs to Treat SELEGILINE TAB 5MG SELEGILINE HCL TAB 5 MG Tier 1 Parkinson's Disease Antiparkinson Agents - Drugs to Treat CARBIDOPA & LEVODOPA TAB 10-100 SINEMET TAB 10-100MG Tier 3 Parkinson's Disease MG Antiparkinson Agents - Drugs to Treat CARBIDOPA & LEVODOPA TAB 25-100 SINEMET TAB 25-100MG Tier 3 Parkinson's Disease MG Antiparkinson Agents - Drugs to Treat CARBIDOPA & LEVODOPA TAB 25-250 SINEMET TAB 25-250MG Tier 3 Parkinson's Disease MG Antiparkinson Agents - Drugs to Treat CARBIDOPA & LEVODOPA TAB ER 25- SINEMET CR TAB 25-100MG Tier 3 Parkinson's Disease 100 MG Antiparkinson Agents - Drugs to Treat CARBIDOPA & LEVODOPA TAB ER 50- SINEMET CR TAB 50-200MG Tier 3 Parkinson's Disease 200 MG Antiparkinson Agents - Drugs to Treat CARBIDOPA-LEVODOPA-ENTACAPONE STALEVO 100 TAB Tier 3 Parkinson's Disease TABS 25-100-200 MG Antiparkinson Agents - Drugs to Treat CARBIDOPA-LEVODOPA-ENTACAPONE STALEVO 125 TAB Tier 3 Parkinson's Disease TABS 31.25-125-200 MG Antiparkinson Agents - Drugs to Treat CARBIDOPA-LEVODOPA-ENTACAPONE STALEVO 150 TAB Tier 3 Parkinson's Disease TABS 37.5-150-200 MG Antiparkinson Agents - Drugs to Treat CARBIDOPA-LEVODOPA-ENTACAPONE STALEVO 200 TAB Tier 3 Parkinson's Disease TABS 50-200-200 MG Antiparkinson Agents - Drugs to Treat CARBIDOPA-LEVODOPA-ENTACAPONE STALEVO 50 TAB Tier 3 Parkinson's Disease TABS 12.5-50-200 MG Antiparkinson Agents - Drugs to Treat CARBIDOPA-LEVODOPA-ENTACAPONE STALEVO 75 TAB Tier 3 Parkinson's Disease TABS 18.75-75-200 MG Antiparkinson Agents - Drugs to Treat TOLCAPONE TAB 100MG TOLCAPONE TAB 100 MG Tier 2 Parkinson's Disease Antiparkinson Agents - Drugs to Treat TRIHEXYPHEN ELX 0.4MG/ TRIHEXYPHENIDYL HCL ELIXIR 0.4 MG/ Tier 1 Parkinson's Disease ML ML Antiparkinson Agents - Drugs to Treat TRIHEXYPHEN TAB 2MG TRIHEXYPHENIDYL HCL TAB 2 MG Tier 1 Parkinson's Disease Antiparkinson Agents - Drugs to Treat TRIHEXYPHEN TAB 5MG TRIHEXYPHENIDYL HCL TAB 5 MG Tier 1 Parkinson's Disease Antiparkinson Agents - Drugs to Treat SELEGILINE HCL ORALLY ZELAPAR TAB 1.25MG Tier 3 Parkinson's Disease DISINTEGRATING TAB 1.25 MG Antipsychotics - Drugs to Treat Mood LOXAPINE AEROSOL POWDER BREATH ADASUVE INH 10MG Tier 3 Disorders ACTIVATED 10 MG Antipsychotics - Drugs to Treat Mood ARIPIPRAZOLE ORAL SOLUTION 1 MG/ ARIPIPRAZOLE SOL 1MG/ML Tier 3 Disorders ML Antipsychotics - Drugs to Treat Mood ARIPIPRAZOLE TAB 10MG ARIPIPRAZOLE TAB 10 MG Tier 2 X Disorders Antipsychotics - Drugs to Treat Mood ARIPIPRAZOLE TAB 10MG ARIPIPRAZOLE ORALLY Tier 2 X Disorders ODT DISINTEGRATING TAB 10 MG Antipsychotics - Drugs to Treat Mood ARIPIPRAZOLE TAB 15MG ARIPIPRAZOLE TAB 15 MG Tier 2 X Disorders Antipsychotics - Drugs to Treat Mood ARIPIPRAZOLE TAB 15MG ARIPIPRAZOLE ORALLY Tier 2 X Disorders ODT DISINTEGRATING TAB 15 MG

54 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antipsychotics - Drugs to Treat Mood ARIPIPRAZOLE TAB 20MG ARIPIPRAZOLE TAB 20 MG Tier 2 X Disorders Antipsychotics - Drugs to Treat Mood ARIPIPRAZOLE TAB 2MG ARIPIPRAZOLE TAB 2 MG Tier 2 X Disorders Antipsychotics - Drugs to Treat Mood ARIPIPRAZOLE TAB 30MG ARIPIPRAZOLE TAB 30 MG Tier 2 X Disorders Antipsychotics - Drugs to Treat Mood ARIPIPRAZOLE TAB 5MG ARIPIPRAZOLE TAB 5 MG Tier 2 X Disorders Antipsychotics - Drugs to Treat Mood CHLORPROMAZ POW HCL CHLORPROMAZINE HCL POWDER Tier 3 Disorders Antipsychotics - Drugs to Treat Mood CHLORPROMAZ TAB 100MG CHLORPROMAZINE HCL TAB 100 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood CHLORPROMAZ TAB 10MG CHLORPROMAZINE HCL TAB 10 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood CHLORPROMAZ TAB 200MG CHLORPROMAZINE HCL TAB 200 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood CHLORPROMAZ TAB 25MG CHLORPROMAZINE HCL TAB 25 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood CHLORPROMAZ TAB 50MG CHLORPROMAZINE HCL TAB 50 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood CLOZAPINE ORALLY DISINTEGRATING CLOZAPINE TAB 100/ODT Tier 1 Disorders TAB 100 MG Antipsychotics - Drugs to Treat Mood CLOZAPINE TAB 100MG CLOZAPINE TAB 100 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood CLOZAPINE ORALLY DISINTEGRATING CLOZAPINE TAB 12.5/ODT Tier 1 Disorders TAB 12.5 MG Antipsychotics - Drugs to Treat Mood CLOZAPINE ORALLY DISINTEGRATING CLOZAPINE TAB 150/ODT Tier 1 Disorders TAB 150 MG Antipsychotics - Drugs to Treat Mood CLOZAPINE ORALLY DISINTEGRATING CLOZAPINE TAB 200/ODT Tier 1 Disorders TAB 200 MG Antipsychotics - Drugs to Treat Mood CLOZAPINE TAB 200MG CLOZAPINE TAB 200 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood CLOZAPINE TAB 25MG CLOZAPINE TAB 25 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood CLOZAPINE ORALLY DISINTEGRATING CLOZAPINE TAB 25MG ODT Tier 1 Disorders TAB 25 MG Antipsychotics - Drugs to Treat Mood CLOZAPINE TAB 50MG CLOZAPINE TAB 50 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood CLOZARIL TAB 100MG CLOZAPINE TAB 100 MG Tier 3 Disorders Antipsychotics - Drugs to Treat Mood CLOZARIL TAB 25MG CLOZAPINE TAB 25 MG Tier 3 Disorders Antipsychotics - Drugs to Treat Mood ILOPERIDONE TAB 1 MG & 2 MG & 4 MG FANAPT PAK Tier 3 X Disorders & 6 MG TITRATION PAK Antipsychotics - Drugs to Treat Mood FANAPT TAB 10MG ILOPERIDONE TAB 10 MG Tier 3 X Disorders Antipsychotics - Drugs to Treat Mood FANAPT TAB 12MG ILOPERIDONE TAB 12 MG Tier 3 X Disorders Antipsychotics - Drugs to Treat Mood FANAPT TAB 1MG ILOPERIDONE TAB 1 MG Tier 3 X Disorders Antipsychotics - Drugs to Treat Mood FANAPT TAB 2MG ILOPERIDONE TAB 2 MG Tier 3 X Disorders Antipsychotics - Drugs to Treat Mood FANAPT TAB 4MG ILOPERIDONE TAB 4 MG Tier 3 X Disorders Antipsychotics - Drugs to Treat Mood FANAPT TAB 6MG ILOPERIDONE TAB 6 MG Tier 3 X Disorders Antipsychotics - Drugs to Treat Mood FANAPT TAB 8MG ILOPERIDONE TAB 8 MG Tier 3 X Disorders Antipsychotics - Drugs to Treat Mood CLOZAPINE ORALLY DISINTEGRATING FAZACLO TAB 100 ODT Tier 3 Disorders TAB 100 MG Antipsychotics - Drugs to Treat Mood CLOZAPINE ORALLY DISINTEGRATING FAZACLO TAB 12.5 ODT Tier 3 Disorders TAB 12.5 MG Antipsychotics - Drugs to Treat Mood CLOZAPINE ORALLY DISINTEGRATING FAZACLO TAB 150 ODT Tier 3 Disorders TAB 150 MG Antipsychotics - Drugs to Treat Mood CLOZAPINE ORALLY DISINTEGRATING FAZACLO TAB 200 ODT Tier 3 Disorders TAB 200 MG Antipsychotics - Drugs to Treat Mood CLOZAPINE ORALLY DISINTEGRATING FAZACLO TAB 25MG ODT Tier 3 Disorders TAB 25 MG Antipsychotics - Drugs to Treat Mood FLUPHENAZINE CON 5MG/ FLUPHENAZINE HCL ORAL CONC 5 MG/ Tier 1 Disorders ML ML Antipsychotics - Drugs to Treat Mood FLUPHENAZINE ELX 2.5/5ML FLUPHENAZINE HCL ELIXIR 2.5 MG/5ML Tier 1 Disorders Antipsychotics - Drugs to Treat Mood FLUPHENAZINE TAB 10MG FLUPHENAZINE HCL TAB 10 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood FLUPHENAZINE TAB 1MG FLUPHENAZINE HCL TAB 1 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood FLUPHENAZINE TAB 2.5MG FLUPHENAZINE HCL TAB 2.5 MG Tier 1 Disorders

55 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antipsychotics - Drugs to Treat Mood FLUPHENAZINE TAB 5MG FLUPHENAZINE HCL TAB 5 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood HALOPERIDOL CON 2MG/ HALOPERIDOL LACTATE ORAL CONC 2 Tier 1 Disorders ML MG/ML Antipsychotics - Drugs to Treat Mood HALOPERIDOL TAB 0.5MG HALOPERIDOL TAB 0.5 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood HALOPERIDOL TAB 10MG HALOPERIDOL TAB 10 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood HALOPERIDOL TAB 1MG HALOPERIDOL TAB 1 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood HALOPERIDOL TAB 20MG HALOPERIDOL TAB 20 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood HALOPERIDOL TAB 2MG HALOPERIDOL TAB 2 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood HALOPERIDOL TAB 5MG HALOPERIDOL TAB 5 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood LATUDA TAB 120MG LURASIDONE HCL TAB 120 MG Tier 4 X Disorders Antipsychotics - Drugs to Treat Mood LATUDA TAB 20MG LURASIDONE HCL TAB 20 MG Tier 4 X Disorders Antipsychotics - Drugs to Treat Mood LATUDA TAB 40MG LURASIDONE HCL TAB 40 MG Tier 4 X Disorders Antipsychotics - Drugs to Treat Mood LATUDA TAB 60MG LURASIDONE HCL TAB 60 MG Tier 4 X Disorders Antipsychotics - Drugs to Treat Mood LATUDA TAB 80MG LURASIDONE HCL TAB 80 MG Tier 4 X Disorders Antipsychotics - Drugs to Treat Mood LOXAPINE CAP 10MG LOXAPINE SUCCINATE CAP 10 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood LOXAPINE CAP 25MG LOXAPINE SUCCINATE CAP 25 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood LOXAPINE CAP 50MG LOXAPINE SUCCINATE CAP 50 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood LOXAPINE CAP 5MG LOXAPINE SUCCINATE CAP 5 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood MOLINDONE TAB HCL 10MG MOLINDONE HCL TAB 10 MG Tier 3 Disorders Antipsychotics - Drugs to Treat Mood MOLINDONE TAB HCL 25MG MOLINDONE HCL TAB 25 MG Tier 3 Disorders Antipsychotics - Drugs to Treat Mood MOLINDONE TAB HCL 5MG MOLINDONE HCL TAB 5 MG Tier 3 Disorders Antipsychotics - Drugs to Treat Mood PIMAVANSERIN TARTRATE TAB 17 MG NUPLAZID TAB 17MG Tier 3 X X Disorders (BASE EQUIVALENT) Antipsychotics - Drugs to Treat Mood OLANZAPINE TAB 10MG OLANZAPINE TAB 10 MG Tier 1 X Disorders Antipsychotics - Drugs to Treat Mood OLANZAPINE TAB 10MG OLANZAPINE ORALLY DISINTEGRATING Tier 3 X Disorders ODT TAB 10 MG Antipsychotics - Drugs to Treat Mood OLANZAPINE TAB 15MG OLANZAPINE TAB 15 MG Tier 1 X Disorders Antipsychotics - Drugs to Treat Mood OLANZAPINE TAB 15MG OLANZAPINE ORALLY DISINTEGRATING Tier 3 X Disorders ODT TAB 15 MG Antipsychotics - Drugs to Treat Mood OLANZAPINE TAB 2.5MG OLANZAPINE TAB 2.5 MG Tier 1 X Disorders Antipsychotics - Drugs to Treat Mood OLANZAPINE TAB 20MG OLANZAPINE TAB 20 MG Tier 1 X Disorders Antipsychotics - Drugs to Treat Mood OLANZAPINE TAB 20MG OLANZAPINE ORALLY DISINTEGRATING Tier 3 X Disorders ODT TAB 20 MG Antipsychotics - Drugs to Treat Mood OLANZAPINE TAB 5MG OLANZAPINE TAB 5 MG Tier 1 X Disorders Antipsychotics - Drugs to Treat Mood OLANZAPINE ORALLY DISINTEGRATING OLANZAPINE TAB 5MG ODT Tier 3 X Disorders TAB 5 MG Antipsychotics - Drugs to Treat Mood OLANZAPINE TAB 7.5MG OLANZAPINE TAB 7.5 MG Tier 1 X Disorders Antipsychotics - Drugs to Treat Mood ORAP TAB 1MG PIMOZIDE TAB 1 MG Tier 3 Disorders Antipsychotics - Drugs to Treat Mood ORAP TAB 2MG PIMOZIDE TAB 2 MG Tier 3 Disorders Antipsychotics - Drugs to Treat Mood PALIPERIDONE TAB ER PALIPERIDONE TAB ER 24HR 1.5 MG Tier 3 X Disorders 1.5MG Antipsychotics - Drugs to Treat Mood PALIPERIDONE TAB ER 3MG PALIPERIDONE TAB ER 24HR 3 MG Tier 3 X Disorders Antipsychotics - Drugs to Treat Mood PALIPERIDONE TAB ER 6MG PALIPERIDONE TAB ER 24HR 6 MG Tier 3 X Disorders Antipsychotics - Drugs to Treat Mood PALIPERIDONE TAB ER 9MG PALIPERIDONE TAB ER 24HR 9 MG Tier 3 X Disorders Antipsychotics - Drugs to Treat Mood PIMOZIDE TAB 1MG PIMOZIDE TAB 1 MG Tier 2 Disorders Antipsychotics - Drugs to Treat Mood PIMOZIDE TAB 2MG PIMOZIDE TAB 2 MG Tier 2 Disorders

56 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antipsychotics - Drugs to Treat Mood QUETIAPINE TAB 100MG QUETIAPINE FUMARATE TAB 100 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood QUETIAPINE FUMARATE TAB ER 24HR QUETIAPINE TAB 150MG ER Tier 3 X Disorders 150 MG Antipsychotics - Drugs to Treat Mood QUETIAPINE TAB 200MG QUETIAPINE FUMARATE TAB 200 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood QUETIAPINE FUMARATE TAB ER 24HR QUETIAPINE TAB 200MG ER Tier 3 X Disorders 200 MG Antipsychotics - Drugs to Treat Mood QUETIAPINE TAB 25MG QUETIAPINE FUMARATE TAB 25 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood QUETIAPINE TAB 300MG QUETIAPINE FUMARATE TAB 300 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood QUETIAPINE FUMARATE TAB ER 24HR QUETIAPINE TAB 300MG ER Tier 3 X Disorders 300 MG Antipsychotics - Drugs to Treat Mood QUETIAPINE TAB 400MG QUETIAPINE FUMARATE TAB 400 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood QUETIAPINE FUMARATE TAB ER 24HR QUETIAPINE TAB 400MG ER Tier 3 X Disorders 400 MG Antipsychotics - Drugs to Treat Mood QUETIAPINE TAB 50MG QUETIAPINE FUMARATE TAB 50 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood QUETIAPINE FUMARATE TAB ER 24HR QUETIAPINE TAB 50MG ER Tier 3 X Disorders 50 MG Antipsychotics - Drugs to Treat Mood REXULTI TAB 0.25MG BREXPIPRAZOLE TAB 0.25 MG Tier 4 X X X Disorders Antipsychotics - Drugs to Treat Mood REXULTI TAB 0.5MG BREXPIPRAZOLE TAB 0.5 MG Tier 4 X X X Disorders Antipsychotics - Drugs to Treat Mood REXULTI TAB 1MG BREXPIPRAZOLE TAB 1 MG Tier 4 X X X Disorders Antipsychotics - Drugs to Treat Mood REXULTI TAB 2MG BREXPIPRAZOLE TAB 2 MG Tier 4 X X X Disorders Antipsychotics - Drugs to Treat Mood REXULTI TAB 3MG BREXPIPRAZOLE TAB 3 MG Tier 4 X X X Disorders Antipsychotics - Drugs to Treat Mood REXULTI TAB 4MG BREXPIPRAZOLE TAB 4 MG Tier 4 X X X Disorders Antipsychotics - Drugs to Treat Mood RISPERIDONE SOL 1MG/ML RISPERIDONE SOLN 1 MG/ML Tier 1 Disorders Antipsychotics - Drugs to Treat Mood RISPERIDONE ORALLY DISINTEGRATING RISPERIDONE TAB 0.25 ODT Tier 1 Disorders TAB 0.25 MG Antipsychotics - Drugs to Treat Mood RISPERIDONE TAB 0.25MG RISPERIDONE TAB 0.25 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood RISPERIDONE TAB 0.5MG RISPERIDONE TAB 0.5 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood RISPERIDONE TAB 0.5MG RISPERIDONE ORALLY DISINTEGRATING Tier 1 Disorders OD TAB 0.5 MG Antipsychotics - Drugs to Treat Mood RISPERIDONE TAB 1MG RISPERIDONE TAB 1 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood RISPERIDONE ORALLY DISINTEGRATING RISPERIDONE TAB 1MG ODT Tier 1 Disorders TAB 1 MG Antipsychotics - Drugs to Treat Mood RISPERIDONE TAB 2MG RISPERIDONE TAB 2 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood RISPERIDONE ORALLY DISINTEGRATING RISPERIDONE TAB 2MG ODT Tier 1 Disorders TAB 2 MG Antipsychotics - Drugs to Treat Mood RISPERIDONE TAB 3MG RISPERIDONE TAB 3 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood RISPERIDONE ORALLY DISINTEGRATING RISPERIDONE TAB 3MG ODT Tier 1 Disorders TAB 3 MG Antipsychotics - Drugs to Treat Mood RISPERIDONE TAB 4MG RISPERIDONE TAB 4 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood RISPERIDONE ORALLY DISINTEGRATING RISPERIDONE TAB 4MG ODT Tier 1 Disorders TAB 4 MG Antipsychotics - Drugs to Treat Mood ASENAPINE MALEATE SL TAB 10 MG SAPHRIS SUB 10MG Tier 3 X Disorders (BASE EQUIV) Antipsychotics - Drugs to Treat Mood ASENAPINE MALEATE SL TAB 2.5 MG SAPHRIS SUB 2.5MG Tier 3 X Disorders (BASE EQUIV) Antipsychotics - Drugs to Treat Mood ASENAPINE MALEATE SL TAB 5 MG SAPHRIS SUB 5MG Tier 3 X Disorders (BASE EQUIV) Antipsychotics - Drugs to Treat Mood THIORIDAZINE TAB 100MG THIORIDAZINE HCL TAB 100 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood THIORIDAZINE TAB 10MG THIORIDAZINE HCL TAB 10 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood THIORIDAZINE TAB 25MG THIORIDAZINE HCL TAB 25 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood THIORIDAZINE TAB 50MG THIORIDAZINE HCL TAB 50 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood THIOTHIXENE CAP 10MG THIOTHIXENE CAP 10 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood THIOTHIXENE CAP 1MG THIOTHIXENE CAP 1 MG Tier 1 Disorders

57 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antipsychotics - Drugs to Treat Mood THIOTHIXENE CAP 2MG THIOTHIXENE CAP 2 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood THIOTHIXENE CAP 5MG THIOTHIXENE CAP 5 MG Tier 1 Disorders Antipsychotics - Drugs to Treat Mood TRIFLUOPERAZINE HCL TAB 10 MG TRIFLUOPERAZ TAB 10MG Tier 1 Disorders (BASE EQUIVALENT) Antipsychotics - Drugs to Treat Mood TRIFLUOPERAZINE HCL TAB 1 MG (BASE TRIFLUOPERAZ TAB 1MG Tier 1 Disorders EQUIVALENT) Antipsychotics - Drugs to Treat Mood TRIFLUOPERAZINE HCL TAB 2 MG (BASE TRIFLUOPERAZ TAB 2MG Tier 1 Disorders EQUIVALENT) Antipsychotics - Drugs to Treat Mood TRIFLUOPERAZINE HCL TAB 5 MG (BASE TRIFLUOPERAZ TAB 5MG Tier 1 Disorders EQUIVALENT) Antipsychotics - Drugs to Treat Mood CARIPRAZINE HCL CAP THERAPY PACK VRAYLAR CAP 1.5-3MG Tier 4 X X Disorders 1.5 MG (1) & 3 MG (6) Antipsychotics - Drugs to Treat Mood CARIPRAZINE HCL CAP 1.5 MG (BASE VRAYLAR CAP 1.5MG Tier 4 X X Disorders EQUIVALENT) Antipsychotics - Drugs to Treat Mood CARIPRAZINE HCL CAP 3 MG (BASE VRAYLAR CAP 3MG Tier 4 X X Disorders EQUIVALENT) Antipsychotics - Drugs to Treat Mood CARIPRAZINE HCL CAP 4.5 MG (BASE VRAYLAR CAP 4.5MG Tier 4 X X Disorders EQUIVALENT) Antipsychotics - Drugs to Treat Mood CARIPRAZINE HCL CAP 6 MG (BASE VRAYLAR CAP 6MG Tier 4 X X Disorders EQUIVALENT) Antipsychotics - Drugs to Treat Mood ZIPRASIDONE CAP 20MG ZIPRASIDONE HCL CAP 20 MG Tier 2 X Disorders Antipsychotics - Drugs to Treat Mood ZIPRASIDONE CAP 40MG ZIPRASIDONE HCL CAP 40 MG Tier 2 X Disorders Antipsychotics - Drugs to Treat Mood ZIPRASIDONE CAP 60MG ZIPRASIDONE HCL CAP 60 MG Tier 2 X Disorders Antipsychotics - Drugs to Treat Mood ZIPRASIDONE CAP 80MG ZIPRASIDONE HCL CAP 80 MG Tier 2 X Disorders ABACA/LAMIVU TAB 600- ABACAVIR SULFATE-LAMIVUDINE TAB Antivirals - Drugs to Treat Viral Infections Tier 2 X 300 600-300 MG ABACAV/LAMIV TAB / ABACAVIR SULFATE-LAMIVUDINE- Antivirals - Drugs to Treat Viral Infections Tier 1 X ZIDOVUD ZIDOVUDINE TAB 300-150-300 MG ABACAVIR SULFATE SOLN 20 MG/ML Antivirals - Drugs to Treat Viral Infections ABACAVIR SOL 20MG/ML Tier 1 X (BASE EQUIV) ABACAVIR SULFATE TAB 300 MG (BASE Antivirals - Drugs to Treat Viral Infections ABACAVIR TAB 300MG Tier 1 X EQUIV) Antivirals - Drugs to Treat Viral Infections ACYCLOVIR CAP 200MG ACYCLOVIR CAP 200 MG Tier 1 Antivirals - Drugs to Treat Viral Infections ACYCLOVIR OIN 5% ACYCLOVIR OINT 5% Tier 3 X X X Antivirals - Drugs to Treat Viral Infections ACYCLOVIR SUS 200/5ML ACYCLOVIR SUSP 200 MG/5ML Tier 1 Antivirals - Drugs to Treat Viral Infections ACYCLOVIR TAB 400MG ACYCLOVIR TAB 400 MG Tier 1 Antivirals - Drugs to Treat Viral Infections ACYCLOVIR TAB 800MG ACYCLOVIR TAB 800 MG Tier 1 Antivirals - Drugs to Treat Viral Infections ADEFOV DIPIV TAB 10MG ADEFOVIR DIPIVOXIL TAB 10 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections APTIVUS CAP 250MG TIPRANAVIR CAP 250 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections APTIVUS SOL TIPRANAVIR ORAL SOLN 100 MG/ML Tier 3 X ATAZANAVIR SULFATE CAP 150 MG Antivirals - Drugs to Treat Viral Infections ATAZANAVIR CAP 150MG Tier 2 X (BASE EQUIV) ATAZANAVIR SULFATE CAP 200 MG Antivirals - Drugs to Treat Viral Infections ATAZANAVIR CAP 200MG Tier 2 X (BASE EQUIV) ATAZANAVIR SULFATE CAP 300 MG Antivirals - Drugs to Treat Viral Infections ATAZANAVIR CAP 300MG Tier 2 X (BASE EQUIV) EFAVIRENZ-EMTRICITABINE-TENOFOVIR Antivirals - Drugs to Treat Viral Infections ATRIPLA TAB Tier 2 X DF TAB 600-200-300 MG Antivirals - Drugs to Treat Viral Infections BARACLUDE SOL .05MG/ML ENTECAVIR ORAL SOLN 0.05 MG/ML Tier 2 X LAMIVUDINE-ZIDOVUDINE TAB 150-300 Antivirals - Drugs to Treat Viral Infections COMBIVIR TAB 150-300 Tier 4 X MG EMTRICITABINE-RILPIVIRINE-TENOFOVIR Antivirals - Drugs to Treat Viral Infections COMPLERA TAB Tier 4 X DF TAB 200-25-300 MG Antivirals - Drugs to Treat Viral Infections COPEGUS TAB 200MG RIBAVIRIN TAB 200 MG Tier 3 Antivirals - Drugs to Treat Viral Infections CRIXIVAN CAP 200MG INDINAVIR SULFATE CAP 200 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections CRIXIVAN CAP 400MG INDINAVIR SULFATE CAP 400 MG Tier 2 X DACLATASVIR DIHYDROCHLORIDE TAB Antivirals - Drugs to Treat Viral Infections DAKLINZA TAB 30MG Tier 4 X X X X 30 MG (BASE EQUIVALENT) DACLATASVIR DIHYDROCHLORIDE TAB Antivirals - Drugs to Treat Viral Infections DAKLINZA TAB 60MG Tier 4 X X X X 60 MG (BASE EQUIVALENT) DACLATASVIR DIHYDROCHLORIDE TAB Antivirals - Drugs to Treat Viral Infections DAKLINZA TAB 90MG Tier 4 X X X 90 MG (BASE EQUIVALENT) EMTRICITABINE-TENOFOVIR Antivirals - Drugs to Treat Viral Infections DESCOVY TAB 200/25 ALAFENAMIDE FUMARATE TAB 200-25 Tier 3 X MG DIDANOSINE DELAYED RELEASE Antivirals - Drugs to Treat Viral Infections DIDANOSINE CAP 200MG Tier 1 X CAPSULE 200 MG DIDANOSINE DELAYED RELEASE Antivirals - Drugs to Treat Viral Infections DIDANOSINE CAP 250MG Tier 1 X CAPSULE 250 MG DIDANOSINE DELAYED RELEASE Antivirals - Drugs to Treat Viral Infections DIDANOSINE CAP 400MG Tier 1 X CAPSULE 400 MG

58 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy RILPIVIRINE HCL TAB 25 MG (BASE Antivirals - Drugs to Treat Viral Infections EDURANT TAB 25MG Tier 2 X EQUIVALENT) Antivirals - Drugs to Treat Viral Infections EFAVIRENZ CAP 200MG EFAVIRENZ CAP 200 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections EFAVIRENZ CAP 50MG EFAVIRENZ CAP 50 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections EFAVIRENZ TAB 600MG EFAVIRENZ TAB 600 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections EMTRIVA CAP 200MG EMTRICITABINE CAPS 200 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections EMTRIVA SOL 10MG/ML EMTRICITABINE SOLN 10 MG/ML Tier 2 X Antivirals - Drugs to Treat Viral Infections ENTECAVIR TAB 0.5MG ENTECAVIR TAB 0.5 MG Tier 1 X Antivirals - Drugs to Treat Viral Infections ENTECAVIR TAB 1MG ENTECAVIR TAB 1 MG Tier 1 X SOFOSBUVIR-VELPATASVIR TAB 400-100 Antivirals - Drugs to Treat Viral Infections EPCLUSA TAB 400-100 Tier 2 X X X MG Antivirals - Drugs to Treat Viral Infections EPIVIR SOL 10MG/ML LAMIVUDINE ORAL SOLN 10 MG/ML Tier 3 X Antivirals - Drugs to Treat Viral Infections EPIVIR TAB 150MG LAMIVUDINE TAB 150 MG Tier 3 X Antivirals - Drugs to Treat Viral Infections EPIVIR TAB 300MG LAMIVUDINE TAB 300 MG Tier 3 X Antivirals - Drugs to Treat Viral Infections EPIVIR HBV SOL 5MG/ML LAMIVUDINE ORAL SOLN 5 MG/ML (HBV) Tier 2 X Antivirals - Drugs to Treat Viral Infections EPIVIR HBV TAB 100MG LAMIVUDINE TAB 100 MG (HBV) Tier 3 X ATAZANAVIR SULFATE-COBICISTAT TAB Antivirals - Drugs to Treat Viral Infections EVOTAZ TAB 300-150 Tier 2 X 300-150 MG (BASE EQUIV) Antivirals - Drugs to Treat Viral Infections FAMCICLOVIR TAB 125MG FAMCICLOVIR TAB 125 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections FAMCICLOVIR TAB 250MG FAMCICLOVIR TAB 250 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections FAMCICLOVIR TAB 500MG FAMCICLOVIR TAB 500 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections FAMVIR TAB 125MG FAMCICLOVIR TAB 125 MG Tier 3 X Antivirals - Drugs to Treat Viral Infections FAMVIR TAB 250MG FAMCICLOVIR TAB 250 MG Tier 3 X Antivirals - Drugs to Treat Viral Infections FAMVIR TAB 500MG FAMCICLOVIR TAB 500 MG Tier 3 X RIMANTADINE HYDROCHLORIDE TAB Antivirals - Drugs to Treat Viral Infections FLUMADINE TAB 100MG Tier 3 100 MG FOSAMPRENAVIR CALCIUM TAB 700 MG Antivirals - Drugs to Treat Viral Infections FOSAMPRENAVI TAB 700MG Tier 2 X (BASE EQUIV) Antivirals - Drugs to Treat Viral Infections FUZEON INJ 90MG ENFUVIRTIDE FOR INJ 90 MG Tier 2 X ELVITEGRAV-COBIC-EMTRICITAB- Antivirals - Drugs to Treat Viral Infections GENVOYA TAB Tier 3 X X TENOFOV AF TAB 150-150-200-10 MG LEDIPASVIR-SOFOSBUVIR TAB 90-400 Antivirals - Drugs to Treat Viral Infections HARVONI TAB 90-400MG Tier 2 X X X MG Antivirals - Drugs to Treat Viral Infections HEPSERA TAB 10MG ADEFOVIR DIPIVOXIL TAB 10 MG Tier 3 X Antivirals - Drugs to Treat Viral Infections INTELENCE TAB 100MG ETRAVIRINE TAB 100 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections INTELENCE TAB 200MG ETRAVIRINE TAB 200 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections INTELENCE TAB 25MG ETRAVIRINE TAB 25 MG Tier 2 X INTERFERON ALFA-2B FOR INJ Antivirals - Drugs to Treat Viral Infections INTRON A INJ 10MU Tier 3 X X 10000000 UNIT INTERFERON ALFA-2B FOR INJ Antivirals - Drugs to Treat Viral Infections INTRON A INJ 18MU Tier 3 X X 18000000 UNIT INTERFERON ALFA-2B INJ 6000000 Antivirals - Drugs to Treat Viral Infections INTRON A INJ 18MU Tier 3 X X UNIT/ML INTERFERON ALFA-2B INJ 10000000 Antivirals - Drugs to Treat Viral Infections INTRON A INJ 25MU Tier 3 X X UNIT/ML INTERFERON ALFA-2B FOR INJ Antivirals - Drugs to Treat Viral Infections INTRON A INJ 50MU Tier 3 X X 50000000 UNIT Antivirals - Drugs to Treat Viral Infections INVIRASE CAP 200MG SAQUINAVIR MESYLATE CAP 200 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections INVIRASE TAB 500MG SAQUINAVIR MESYLATE TAB 500 MG Tier 2 X RALTEGRAVIR POTASSIUM CHEW TAB Antivirals - Drugs to Treat Viral Infections ISENTRESS CHW 100MG Tier 2 X 100 MG (BASE EQUIV) RALTEGRAVIR POTASSIUM CHEW TAB Antivirals - Drugs to Treat Viral Infections ISENTRESS CHW 25MG Tier 2 X 25 MG (BASE EQUIV) RALTEGRAVIR POTASSIUM PACKET FOR Antivirals - Drugs to Treat Viral Infections ISENTRESS POW 100MG Tier 2 X SUSP 100 MG (BASE EQUIV) RALTEGRAVIR POTASSIUM TAB 400 MG Antivirals - Drugs to Treat Viral Infections ISENTRESS TAB 400MG Tier 2 X (BASE EQUIV) RALTEGRAVIR POTASSIUM TAB 600 MG Antivirals - Drugs to Treat Viral Infections ISENTRESS HD TAB 600MG Tier 2 X (BASE EQUIV) LOPINAVIR-RITONAVIR SOLN 400-100 Antivirals - Drugs to Treat Viral Infections KALETRA SOL Tier 3 MG/5ML (80-20 MG/ML) Antivirals - Drugs to Treat Viral Infections KALETRA TAB 100-25MG LOPINAVIR-RITONAVIR TAB 100-25 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections KALETRA TAB 200-50MG LOPINAVIR-RITONAVIR TAB 200-50 MG Tier 2 X LAMIVUDINE-ZIDOVUDINE TAB 150-300 Antivirals - Drugs to Treat Viral Infections LAMIVUD/ZIDO TAB 150-300 Tier 1 X MG Antivirals - Drugs to Treat Viral Infections LAMIVUDINE SOL 10MG/ML LAMIVUDINE ORAL SOLN 10 MG/ML Tier 1 X Antivirals - Drugs to Treat Viral Infections LAMIVUDINE TAB 100MG LAMIVUDINE TAB 100 MG (HBV) Tier 1 X Antivirals - Drugs to Treat Viral Infections LAMIVUDINE TAB 150MG LAMIVUDINE TAB 150 MG Tier 1 X Antivirals - Drugs to Treat Viral Infections LAMIVUDINE TAB 300MG LAMIVUDINE TAB 300 MG Tier 1 X FOSAMPRENAVIR CALCIUM SUSP 50 Antivirals - Drugs to Treat Viral Infections LEXIVA SUS 50MG/ML Tier 2 X MG/ML (BASE EQUIV) FOSAMPRENAVIR CALCIUM TAB 700 MG Antivirals - Drugs to Treat Viral Infections LEXIVA TAB 700MG Tier 3 X (BASE EQUIV) LOPINAVIR-RITONAVIR SOLN 400-100 Antivirals - Drugs to Treat Viral Infections LOPIN/RITON SOL 80-20/ML Tier 2 MG/5ML (80-20 MG/ML)

59 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy GLECAPREVIR-PIBRENTASVIR TAB 100- Antivirals - Drugs to Treat Viral Infections MAVYRET TAB 100-40MG Tier 2 X X X 40 MG Antivirals - Drugs to Treat Viral Infections NEVIRAPINE TAB 200MG NEVIRAPINE TAB 200 MG Tier 1 X Antivirals - Drugs to Treat Viral Infections NORVIR CAP 100MG RITONAVIR CAP 100 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections NORVIR SOL 80MG/ML RITONAVIR ORAL SOLN 80 MG/ML Tier 2 X Antivirals - Drugs to Treat Viral Infections NORVIR TAB 100MG RITONAVIR TAB 100 MG Tier 2 X EMTRICITABINE-RILPIVIRINE-TENOFOVIR Antivirals - Drugs to Treat Viral Infections ODEFSEY TAB Tier 4 X AF TAB 200-25-25 MG SIMEPREVIR SODIUM CAP 150 MG (BASE Antivirals - Drugs to Treat Viral Infections OLYSIO CAP 150MG Tier 4 X X X X EQUIVALENT) OSELTAMIVIR PHOSPHATE CAP 30 MG Antivirals - Drugs to Treat Viral Infections OSELTAMIVIR CAP 30MG Tier 2 X (BASE EQUIV) OSELTAMIVIR PHOSPHATE CAP 45 MG Antivirals - Drugs to Treat Viral Infections OSELTAMIVIR CAP 45MG Tier 2 X (BASE EQUIV) OSELTAMIVIR PHOSPHATE CAP 75 MG Antivirals - Drugs to Treat Viral Infections OSELTAMIVIR CAP 75MG Tier 2 X (BASE EQUIV) OSELTAMIVIR PHOSPHATE FOR SUSP 6 Antivirals - Drugs to Treat Viral Infections OSELTAMIVIR SUS 6MG/ML Tier 2 X MG/ML (BASE EQUIV) PEGINTERFERON ALFA-2A INJ 180 Antivirals - Drugs to Treat Viral Infections PEGASYS INJ Tier 2 X X X MCG/0.5ML PEGINTERFERON ALFA-2A INJ 180 MCG/ Antivirals - Drugs to Treat Viral Infections PEGASYS INJ 180MCG/M Tier 2 X X X ML PEGINTERFERON ALFA-2A INJ 135 Antivirals - Drugs to Treat Viral Infections PEGASYS INJ PROCLICK Tier 2 X X X MCG/0.5ML PEGINTERFERON ALFA-2A INJ 180 Antivirals - Drugs to Treat Viral Infections PEGASYS INJ PROCLICK Tier 2 X X X MCG/0.5ML PEGINTERFERON ALFA-2B FOR INJ KIT Antivirals - Drugs to Treat Viral Infections PEGINTRON KIT 120MCG Tier 4 X X X 120 MCG/0.5ML PEGINTERFERON ALFA-2B FOR INJ KIT Antivirals - Drugs to Treat Viral Infections PEGINTRON KIT 150MCG Tier 4 X X X 150 MCG/0.5ML PEGINTERFERON ALFA-2B FOR INJ KIT Antivirals - Drugs to Treat Viral Infections PEGINTRON KIT 50MCG Tier 4 X X X 50 MCG/0.5ML PEGINTERFERON ALFA-2B FOR INJ KIT Antivirals - Drugs to Treat Viral Infections PEGINTRON KIT 80MCG Tier 4 X X X 80 MCG/0.5ML PEGINTERFERON ALFA-2B FOR INJ KIT Antivirals - Drugs to Treat Viral Infections PEG-INTRON KIT 120 RP Tier 4 X X X 120 MCG/0.5ML PEGINTERFERON ALFA-2B FOR INJ KIT Antivirals - Drugs to Treat Viral Infections PEG-INTRON KIT 150 RP Tier 4 X X X 150 MCG/0.5ML PEGINTERFERON ALFA-2B FOR INJ KIT Antivirals - Drugs to Treat Viral Infections PEG-INTRON KIT 50MCG RP Tier 4 X X X 50 MCG/0.5ML PEGINTERFERON ALFA-2B FOR INJ KIT Antivirals - Drugs to Treat Viral Infections PEG-INTRON KIT 80MCG RP Tier 4 X X X 80 MCG/0.5ML DARUNAVIR-COBICISTAT TAB 800-150 Antivirals - Drugs to Treat Viral Infections PREZCOBIX TAB 800-150 Tier 2 X MG DARUNAVIR ETHANOLATE SUSP 100 Antivirals - Drugs to Treat Viral Infections PREZISTA SUS 100MG/ML Tier 2 X MG/ML (BASE EQUIV) DARUNAVIR ETHANOLATE TAB 150 MG Antivirals - Drugs to Treat Viral Infections PREZISTA TAB 150MG Tier 2 X (BASE EQUIV) DARUNAVIR ETHANOLATE TAB 600 MG Antivirals - Drugs to Treat Viral Infections PREZISTA TAB 600MG Tier 2 X (BASE EQUIV) DARUNAVIR ETHANOLATE TAB 75 MG Antivirals - Drugs to Treat Viral Infections PREZISTA TAB 75MG Tier 2 X (BASE EQUIV) DARUNAVIR ETHANOLATE TAB 800 MG Antivirals - Drugs to Treat Viral Infections PREZISTA TAB 800MG Tier 2 X (BASE EQUIV) Antivirals - Drugs to Treat Viral Infections REBETOL CAP 200MG RIBAVIRIN CAP 200 MG Tier 3 Antivirals - Drugs to Treat Viral Infections REBETOL SOL 40MG/ML RIBAVIRIN SOLN 40 MG/ML Tier 2 ZANAMIVIR AERO POWDER BREATH Antivirals - Drugs to Treat Viral Infections RELENZA MIS DISKHALE Tier 3 X ACTIVATED 5 MG/BLISTER Antivirals - Drugs to Treat Viral Infections RESCRIPTOR TAB 100 MG DELAVIRDINE MESYLATE TAB 100 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections RESCRIPTOR TAB 200MG DELAVIRDINE MESYLATE TAB 200 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections RETROVIR CAP 100MG ZIDOVUDINE CAP 100 MG Tier 3 X Antivirals - Drugs to Treat Viral Infections RETROVIR SYP 50MG/5ML ZIDOVUDINE SYRUP 10 MG/ML Tier 3 X ATAZANAVIR SULFATE ORAL POWDER Antivirals - Drugs to Treat Viral Infections REYATAZ POW 50MG Tier 2 X PACKET 50 MG (BASE EQUIV) Antivirals - Drugs to Treat Viral Infections RIBASPHERE CAP 200MG RIBAVIRIN CAP 200 MG Tier 1 Antivirals - Drugs to Treat Viral Infections RIBASPHERE TAB 200MG RIBAVIRIN TAB 200 MG Tier 1 Antivirals - Drugs to Treat Viral Infections RIBASPHERE TAB 400MG RIBAVIRIN TAB 400 MG Tier 1 Antivirals - Drugs to Treat Viral Infections RIBASPHERE TAB 600MG RIBAVIRIN TAB 600 MG Tier 1 Antivirals - Drugs to Treat Viral Infections RIBAVIRIN CAP 200MG RIBAVIRIN CAP 200 MG Tier 1 Antivirals - Drugs to Treat Viral Infections RIBAVIRIN INH 6GM RIBAVIRIN FOR INHAL SOLN 6 GM Tier 3 Antivirals - Drugs to Treat Viral Infections RIBAVIRIN POW RIBAVIRIN (BULK) POWDER Tier 3 Antivirals - Drugs to Treat Viral Infections RIBAVIRIN TAB 200MG RIBAVIRIN TAB 200 MG Tier 1 RIMANTADINE HYDROCHLORIDE TAB Antivirals - Drugs to Treat Viral Infections RIMANTADINE TAB 100MG Tier 1 100 MG Antivirals - Drugs to Treat Viral Infections SELZENTRY SOL 20MG/ML MARAVIROC ORAL SOLN 20 MG/ML Tier 2 X X Antivirals - Drugs to Treat Viral Infections SELZENTRY TAB 150MG MARAVIROC TAB 150 MG Tier 2 X X Antivirals - Drugs to Treat Viral Infections SELZENTRY TAB 25MG MARAVIROC TAB 25 MG Tier 2 X X 60 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Antivirals - Drugs to Treat Viral Infections SELZENTRY TAB 300MG MARAVIROC TAB 300 MG Tier 2 X X Antivirals - Drugs to Treat Viral Infections SELZENTRY TAB 75MG MARAVIROC TAB 75 MG Tier 2 X X Antivirals - Drugs to Treat Viral Infections SOVALDI TAB 400MG SOFOSBUVIR TAB 400 MG Tier 4 X X X X Antivirals - Drugs to Treat Viral Infections STAVUDINE CAP 15MG STAVUDINE CAP 15 MG Tier 1 X Antivirals - Drugs to Treat Viral Infections STAVUDINE CAP 20MG STAVUDINE CAP 20 MG Tier 1 X Antivirals - Drugs to Treat Viral Infections STAVUDINE CAP 30MG STAVUDINE CAP 30 MG Tier 1 X Antivirals - Drugs to Treat Viral Infections STAVUDINE CAP 40MG STAVUDINE CAP 40 MG Tier 1 X ELVITEGRAV-COBIC-EMTRICITAB- Antivirals - Drugs to Treat Viral Infections STRIBILD TAB Tier 3 X X TENOFOVDF TAB 150-150-200-300 MG Antivirals - Drugs to Treat Viral Infections SUSTIVA CAP 200MG EFAVIRENZ CAP 200 MG Tier 3 X Antivirals - Drugs to Treat Viral Infections SUSTIVA CAP 50MG EFAVIRENZ CAP 50 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections SUSTIVA TAB 600MG EFAVIRENZ TAB 600 MG Tier 3 X PEGINTERFERON ALFA-2B FOR INJ KIT Antivirals - Drugs to Treat Viral Infections SYLATRON KIT 200MCG Tier 2 X X X 200 MCG PEGINTERFERON ALFA-2B FOR INJ KIT Antivirals - Drugs to Treat Viral Infections SYLATRON KIT 300MCG Tier 2 X X X 300 MCG PEGINTERFERON ALFA-2B FOR INJ KIT Antivirals - Drugs to Treat Viral Infections SYLATRON KIT 600MCG Tier 2 X X X 600 MCG OSELTAMIVIR PHOSPHATE CAP 30 MG Antivirals - Drugs to Treat Viral Infections TAMIFLU CAP 30MG Tier 2 X (BASE EQUIV) OSELTAMIVIR PHOSPHATE CAP 45 MG Antivirals - Drugs to Treat Viral Infections TAMIFLU CAP 45MG Tier 2 X (BASE EQUIV) OSELTAMIVIR PHOSPHATE CAP 75 MG Antivirals - Drugs to Treat Viral Infections TAMIFLU CAP 75MG Tier 2 X (BASE EQUIV) OMBITASVIR-PARITAPREVIR-RITONAVIR Antivirals - Drugs to Treat Viral Infections TECHNIVIE TAB Tier 4 X X X TAB 12.5-75-50 MG TENOFOVIR DISOPROXIL FUMARATE Antivirals - Drugs to Treat Viral Infections TENOFOVIR TAB 300MG Tier 2 X TAB 300 MG DOLUTEGRAVIR SODIUM TAB 50 MG Antivirals - Drugs to Treat Viral Infections TIVICAY TAB 50MG Tier 3 X (BASE EQUIV) Antivirals - Drugs to Treat Viral Infections TRIFLURIDINE SOL 1% OP TRIFLURIDINE OPHTH SOLN 1% Tier 1 ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE Antivirals - Drugs to Treat Viral Infections TRIUMEQ TAB Tier 2 X TAB 600-50-300 MG ABACAVIR SULFATE-LAMIVUDINE- Antivirals - Drugs to Treat Viral Infections TRIZIVIR TAB Tier 3 X ZIDOVUDINE TAB 300-150-300 MG EMTRICITABINE-TENOFOVIR DISOPROXIL Antivirals - Drugs to Treat Viral Infections TRUVADA TAB 100-150 Tier 3 X FUMARATE TAB 100-150 MG EMTRICITABINE-TENOFOVIR DISOPROXIL Antivirals - Drugs to Treat Viral Infections TRUVADA TAB 133-200 Tier 3 X FUMARATE TAB 133-200 MG EMTRICITABINE-TENOFOVIR DISOPROXIL Antivirals - Drugs to Treat Viral Infections TRUVADA TAB 167-250 Tier 3 X FUMARATE TAB 167-250 MG EMTRICITABINE-TENOFOVIR DISOPROXIL Antivirals - Drugs to Treat Viral Infections TRUVADA TAB 200-300 Tier 3 X FUMARATE TAB 200-300 MG Antivirals - Drugs to Treat Viral Infections TYBOST TAB 150MG COBICISTAT TAB 150 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections TYZEKA TAB 600MG TELBIVUDINE TAB 600 MG Tier 3 X Antivirals - Drugs to Treat Viral Infections VALACYCLOVIR TAB 1GM VALACYCLOVIR HCL TAB 1 GM Tier 1 X Antivirals - Drugs to Treat Viral Infections VALACYCLOVIR TAB 500MG VALACYCLOVIR HCL TAB 500 MG Tier 1 X VALGANCICLOVIR HCL FOR SOLN 50 Antivirals - Drugs to Treat Viral Infections VALCYTE SOL 50MG/ML Tier 3 MG/ML (BASE EQUIV) VALGANCICLOV SOL 50MG/ VALGANCICLOVIR HCL FOR SOLN 50 Antivirals - Drugs to Treat Viral Infections Tier 1 ML MG/ML (BASE EQUIV) VALGANCICLOVIR HCL TAB 450 MG Antivirals - Drugs to Treat Viral Infections VALGANCICLOV TAB 450MG Tier 1 X (BASE EQUIVALENT) TENOFOVIR ALAFENAMIDE FUMARATE Antivirals - Drugs to Treat Viral Infections VEMLIDY TAB 25MG Tier 3 X X TAB 25 MG Antivirals - Drugs to Treat Viral Infections VIDEX SOL 2GM DIDANOSINE FOR SOLN 2 GM Tier 2 X Antivirals - Drugs to Treat Viral Infections VIDEX SOL 4GM DIDANOSINE FOR SOLN 4 GM Tier 2 X DIDANOSINE DELAYED RELEASE Antivirals - Drugs to Treat Viral Infections VIDEX EC CAP 125MG Tier 3 X CAPSULE 125 MG DIDANOSINE DELAYED RELEASE Antivirals - Drugs to Treat Viral Infections VIDEX EC CAP 200MG Tier 3 X CAPSULE 200 MG DIDANOSINE DELAYED RELEASE Antivirals - Drugs to Treat Viral Infections VIDEX EC CAP 250MG Tier 3 X CAPSULE 250 MG DIDANOSINE DELAYED RELEASE Antivirals - Drugs to Treat Viral Infections VIDEX EC CAP 400MG Tier 3 X CAPSULE 400 MG OMBITAS-PARITAPRE-RITON & DASAB Antivirals - Drugs to Treat Viral Infections VIEKIRA PAK TAB Tier 4 X X X X TAB PAK 12.5-75-50 & 250 MG DASAB-OMBIT-PARITAP-RITON TAB SR Antivirals - Drugs to Treat Viral Infections VIEKIRA XR TAB Tier 4 X X X X 24HR 200-8.33-50-33.33 MG Antivirals - Drugs to Treat Viral Infections VIRACEPT TAB 250MG NELFINAVIR MESYLATE TAB 250 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections VIRACEPT TAB 625MG NELFINAVIR MESYLATE TAB 625 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections VIRAMUNE SUS 50MG/5ML NEVIRAPINE SUSP 50 MG/5ML Tier 3 X Antivirals - Drugs to Treat Viral Infections VIRAZOLE INH 6GM RIBAVIRIN FOR INHAL SOLN 6 GM Tier 3 TENOFOVIR DISOPROXIL FUMARATE Antivirals - Drugs to Treat Viral Infections VIREAD POW 40MG/GM Tier 3 X ORAL POWDER 40 MG/GM TENOFOVIR DISOPROXIL FUMARATE Antivirals - Drugs to Treat Viral Infections VIREAD TAB 150MG Tier 2 X TAB 150 MG 61 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy TENOFOVIR DISOPROXIL FUMARATE Antivirals - Drugs to Treat Viral Infections VIREAD TAB 200MG Tier 2 X TAB 200 MG TENOFOVIR DISOPROXIL FUMARATE Antivirals - Drugs to Treat Viral Infections VIREAD TAB 250MG Tier 2 X TAB 250 MG Antivirals - Drugs to Treat Viral Infections VIROPTIC SOL 1% OP TRIFLURIDINE OPHTH SOLN 1% Tier 3 Antivirals - Drugs to Treat Viral Infections VITEKTA TAB 150MG ELVITEGRAVIR TAB 150 MG Tier 2 X Antivirals - Drugs to Treat Viral Infections VITEKTA TAB 85MG ELVITEGRAVIR TAB 85 MG Tier 2 X SOFOSBUVIR-VELPATASVIR- Antivirals - Drugs to Treat Viral Infections VOSEVI TAB Tier 2 X X X VOXILAPREVIR TAB 400-100-100 MG ELBASVIR-GRAZOPREVIR TAB 50-100 Antivirals - Drugs to Treat Viral Infections ZEPATIER TAB 50-100MG Tier 4 X X X X MG Antivirals - Drugs to Treat Viral Infections ZERIT CAP 15MG STAVUDINE CAP 15 MG Tier 3 X Antivirals - Drugs to Treat Viral Infections ZERIT CAP 20MG STAVUDINE CAP 20 MG Tier 3 X Antivirals - Drugs to Treat Viral Infections ZERIT CAP 30MG STAVUDINE CAP 30 MG Tier 3 X Antivirals - Drugs to Treat Viral Infections ZERIT CAP 40MG STAVUDINE CAP 40 MG Tier 3 X Antivirals - Drugs to Treat Viral Infections ZERIT SOL 1MG/ML STAVUDINE FOR ORAL SOLN 1 MG/ML Tier 3 X ABACAVIR SULFATE SOLN 20 MG/ML Antivirals - Drugs to Treat Viral Infections ZIAGEN SOL 20MG/ML Tier 3 X (BASE EQUIV) ABACAVIR SULFATE TAB 300 MG (BASE Antivirals - Drugs to Treat Viral Infections ZIAGEN TAB 300MG Tier 3 X EQUIV) Antivirals - Drugs to Treat Viral Infections ZIDOVUDINE CAP 100MG ZIDOVUDINE CAP 100 MG Tier 1 X Antivirals - Drugs to Treat Viral Infections ZIDOVUDINE SYP 50MG/5ML ZIDOVUDINE SYRUP 10 MG/ML Tier 1 X Antivirals - Drugs to Treat Viral Infections ZIDOVUDINE TAB 300MG ZIDOVUDINE TAB 300 MG Tier 1 X Antivirals - Drugs to Treat Viral Infections ZIRGAN GEL 0.15% GANCICLOVIR OPHTH GEL 0.15% Tier 3 Antivirals - Drugs to Treat Viral Infections ZOVIRAX CAP 200MG ACYCLOVIR CAP 200 MG Tier 3 Antivirals - Drugs to Treat Viral Infections ZOVIRAX SUS 200/5ML ACYCLOVIR SUSP 200 MG/5ML Tier 3 Antivirals - Drugs to Treat Viral Infections ZOVIRAX TAB 400MG ACYCLOVIR TAB 400 MG Tier 3 Antivirals - Drugs to Treat Viral Infections ZOVIRAX TAB 800MG ACYCLOVIR TAB 800 MG Tier 3 ALPRAZOLAM CON 1 MG/ Anxiolytics - Drugs to Treat Anxiety ALPRAZOLAM CONC 1 MG/ML Tier 1 ML ALPRAZOLAM ORALLY DISINTEGRATING Anxiolytics - Drugs to Treat Anxiety ALPRAZOLAM TAB 0.25 ODT Tier 1 TAB 0.25 MG Anxiolytics - Drugs to Treat Anxiety ALPRAZOLAM TAB 0.25MG ALPRAZOLAM TAB 0.25 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety ALPRAZOLAM TAB 0.5MG ALPRAZOLAM TAB 0.5 MG Tier 1 ALPRAZOLAM TAB 0.5MG Anxiolytics - Drugs to Treat Anxiety ALPRAZOLAM TAB ER 24HR 0.5 MG Tier 1 ER ALPRAZOLAM TAB 0.5MG ALPRAZOLAM ORALLY DISINTEGRATING Anxiolytics - Drugs to Treat Anxiety Tier 1 OD TAB 0.5 MG ALPRAZOLAM TAB 0.5MG Anxiolytics - Drugs to Treat Anxiety ALPRAZOLAM TAB ER 24HR 0.5 MG Tier 1 XR Anxiolytics - Drugs to Treat Anxiety ALPRAZOLAM TAB 1MG ALPRAZOLAM TAB 1 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety ALPRAZOLAM TAB 1MG ER ALPRAZOLAM TAB ER 24HR 1 MG Tier 1 ALPRAZOLAM TAB 1MG ALPRAZOLAM ORALLY DISINTEGRATING Anxiolytics - Drugs to Treat Anxiety Tier 1 ODT TAB 1 MG Anxiolytics - Drugs to Treat Anxiety ALPRAZOLAM TAB 1MG XR ALPRAZOLAM TAB ER 24HR 1 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety ALPRAZOLAM TAB 2MG ALPRAZOLAM TAB 2 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety ALPRAZOLAM TAB 2MG ER ALPRAZOLAM TAB ER 24HR 2 MG Tier 1 ALPRAZOLAM TAB 2MG ALPRAZOLAM ORALLY DISINTEGRATING Anxiolytics - Drugs to Treat Anxiety Tier 1 ODT TAB 2 MG Anxiolytics - Drugs to Treat Anxiety ALPRAZOLAM TAB 2MG XR ALPRAZOLAM TAB ER 24HR 2 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety ALPRAZOLAM TAB 3MG ER ALPRAZOLAM TAB ER 24HR 3 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety ALPRAZOLAM TAB 3MG XR ALPRAZOLAM TAB ER 24HR 3 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety BUSPIRONE TAB 10MG BUSPIRONE HCL TAB 10 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety BUSPIRONE TAB 15MG BUSPIRONE HCL TAB 15 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety BUSPIRONE TAB 30MG BUSPIRONE HCL TAB 30 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety BUSPIRONE TAB 5MG BUSPIRONE HCL TAB 5 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety BUSPIRONE TAB 7.5MG BUSPIRONE HCL TAB 7.5 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety CHLORDIAZEP CAP 10MG CHLORDIAZEPOXIDE HCL CAP 10 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety CHLORDIAZEP CAP 25MG CHLORDIAZEPOXIDE HCL CAP 25 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety CHLORDIAZEP CAP 5MG CHLORDIAZEPOXIDE HCL CAP 5 MG Tier 1 CLONAZEP ODT TAB CLONAZEPAM ORALLY DISINTEGRATING Anxiolytics - Drugs to Treat Anxiety Tier 1 0.125MG TAB 0.125 MG CLONAZEP ODT TAB CLONAZEPAM ORALLY DISINTEGRATING Anxiolytics - Drugs to Treat Anxiety Tier 1 0.25MG TAB 0.25 MG CLONAZEPAM ORALLY DISINTEGRATING Anxiolytics - Drugs to Treat Anxiety CLONAZEP ODT TAB 0.5MG Tier 1 TAB 0.5 MG CLONAZEPAM ORALLY DISINTEGRATING Anxiolytics - Drugs to Treat Anxiety CLONAZEP ODT TAB 1MG Tier 1 TAB 1 MG CLONAZEPAM ORALLY DISINTEGRATING Anxiolytics - Drugs to Treat Anxiety CLONAZEP ODT TAB 2MG Tier 1 TAB 2 MG Anxiolytics - Drugs to Treat Anxiety CLONAZEPAM TAB 0.5MG CLONAZEPAM TAB 0.5 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety CLONAZEPAM TAB 1MG CLONAZEPAM TAB 1 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety CLONAZEPAM TAB 2MG CLONAZEPAM TAB 2 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety CLORAZ DIPOT TAB 15MG CLORAZEPATE DIPOTASSIUM TAB 15 MG Tier 1

62 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy CLORAZEPATE DIPOTASSIUM TAB 3.75 Anxiolytics - Drugs to Treat Anxiety CLORAZ DIPOT TAB 3.75MG Tier 1 MG CLORAZEPATE DIPOTASSIUM TAB 7.5 Anxiolytics - Drugs to Treat Anxiety CLORAZ DIPOT TAB 7.5MG Tier 1 MG Anxiolytics - Drugs to Treat Anxiety DIAZEPAM CON 5MG/ML DIAZEPAM CONC 5 MG/ML Tier 1 Anxiolytics - Drugs to Treat Anxiety DIAZEPAM SOL 1MG/ML DIAZEPAM ORAL SOLN 1 MG/ML Tier 1 Anxiolytics - Drugs to Treat Anxiety DIAZEPAM TAB 10MG DIAZEPAM TAB 10 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety DIAZEPAM TAB 2MG DIAZEPAM TAB 2 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety DIAZEPAM TAB 5MG DIAZEPAM TAB 5 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety DORAL TAB 15MG QUAZEPAM TAB 15 MG Tier 3 Anxiolytics - Drugs to Treat Anxiety ESTAZOLAM TAB 1MG ESTAZOLAM TAB 1 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety ESTAZOLAM TAB 2MG ESTAZOLAM TAB 2 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety GENE-XENE TAB 15MG CLORAZEPATE DIPOTASSIUM TAB 15 MG Tier 1 CLORAZEPATE DIPOTASSIUM TAB 3.75 Anxiolytics - Drugs to Treat Anxiety GENE-XENE TAB 3.75MG Tier 1 MG CLORAZEPATE DIPOTASSIUM TAB 7.5 Anxiolytics - Drugs to Treat Anxiety GENE-XENE TAB 7.5MG Tier 1 MG Anxiolytics - Drugs to Treat Anxiety HALCION TAB 0.25MG TRIAZOLAM TAB 0.25 MG Tier 3 HYDROXYZ HCL SYP Anxiolytics - Drugs to Treat Anxiety HYDROXYZINE HCL SYRUP 10 MG/5ML Tier 1 10MG/5ML Anxiolytics - Drugs to Treat Anxiety HYDROXYZ HCL TAB 10MG HYDROXYZINE HCL TAB 10 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety HYDROXYZ HCL TAB 25MG HYDROXYZINE HCL TAB 25 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety HYDROXYZ HCL TAB 50MG HYDROXYZINE HCL TAB 50 MG Tier 1 HYDROXYZ PAM CAP Anxiolytics - Drugs to Treat Anxiety HYDROXYZINE PAMOATE CAP 100 MG Tier 1 100MG Anxiolytics - Drugs to Treat Anxiety HYDROXYZ PAM CAP 25MG HYDROXYZINE PAMOATE CAP 25 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety HYDROXYZ PAM CAP 50MG HYDROXYZINE PAMOATE CAP 50 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety KLONOPIN TAB 0.5MG CLONAZEPAM TAB 0.5 MG Tier 3 Anxiolytics - Drugs to Treat Anxiety KLONOPIN TAB 1MG CLONAZEPAM TAB 1 MG Tier 3 Anxiolytics - Drugs to Treat Anxiety KLONOPIN TAB 2MG CLONAZEPAM TAB 2 MG Tier 3 Anxiolytics - Drugs to Treat Anxiety LORAZEPAM CON 2MG/ML LORAZEPAM CONC 2 MG/ML Tier 1 Anxiolytics - Drugs to Treat Anxiety LORAZEPAM TAB 0.5MG LORAZEPAM TAB 0.5 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety LORAZEPAM TAB 1MG LORAZEPAM TAB 1 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety LORAZEPAM TAB 2MG LORAZEPAM TAB 2 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety MEPROBAMATE TAB 200MG MEPROBAMATE TAB 200 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety MEPROBAMATE TAB 400MG MEPROBAMATE TAB 400 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety MIDAZOLAM POW MIDAZOLAM (BULK) POWDER Tier 3 MIDAZOLAM HCL SYRUP 2 MG/ML Anxiolytics - Drugs to Treat Anxiety MIDAZOLAM SYP 2MG/ML Tier 1 (BASE EQUIVALENT) Anxiolytics - Drugs to Treat Anxiety OXAZEPAM CAP 10MG OXAZEPAM CAP 10 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety OXAZEPAM CAP 15MG OXAZEPAM CAP 15 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety OXAZEPAM CAP 30MG OXAZEPAM CAP 30 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety QUAZEPAM TAB 15MG QUAZEPAM TAB 15 MG Tier 1 CLORAZEPATE DIPOTASSIUM TAB 7.5 Anxiolytics - Drugs to Treat Anxiety TRANXENE T TAB 7.5MG Tier 3 MG Anxiolytics - Drugs to Treat Anxiety TRIAZOLAM TAB 0.125MG TRIAZOLAM TAB 0.125 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety TRIAZOLAM TAB 0.25MG TRIAZOLAM TAB 0.25 MG Tier 1 Anxiolytics - Drugs to Treat Anxiety VISTARIL CAP 25MG HYDROXYZINE PAMOATE CAP 25 MG Tier 3 Anxiolytics - Drugs to Treat Anxiety VISTARIL CAP 50MG HYDROXYZINE PAMOATE CAP 50 MG Tier 3 Bipolar Agents - Drugs to Treat Mood LITHIUM SOL 8MEQ/5ML LITHIUM ORAL SOLUTION 8 MEQ/5ML Tier 1 Disorders Bipolar Agents - Drugs to Treat Mood LITHIUM CARB CAP 150MG LITHIUM CARBONATE CAP 150 MG Tier 1 Disorders Bipolar Agents - Drugs to Treat Mood LITHIUM CARB CAP 300MG LITHIUM CARBONATE CAP 300 MG Tier 1 Disorders Bipolar Agents - Drugs to Treat Mood LITHIUM CARB CAP 600MG LITHIUM CARBONATE CAP 600 MG Tier 1 Disorders Bipolar Agents - Drugs to Treat Mood LITHIUM CARB TAB 300MG LITHIUM CARBONATE TAB 300 MG Tier 1 Disorders Bipolar Agents - Drugs to Treat Mood LITHIUM CARB TAB 300MG LITHIUM CARBONATE TAB ER 300 MG Tier 1 Disorders ER Bipolar Agents - Drugs to Treat Mood LITHIUM CARB TAB 450MG LITHIUM CARBONATE TAB ER 450 MG Tier 1 Disorders ER Bipolar Agents - Drugs to Treat Mood LITHOBID TAB 300MG CR LITHIUM CARBONATE TAB ER 300 MG Tier 3 Disorders Blood Glucose Regulators - Drugs to ACARBOSE TAB 100MG ACARBOSE TAB 100 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to ACARBOSE TAB 25MG ACARBOSE TAB 25 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to ACARBOSE TAB 50MG ACARBOSE TAB 50 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to ACTOPLUS MET TAB 15- PIOGLITAZONE HCL-METFORMIN HCL Tier 3 X Regulate Blood Sugar 500MG TAB 15-500 MG Blood Glucose Regulators - Drugs to ACTOPLUS MET TAB 15- PIOGLITAZONE HCL-METFORMIN HCL Tier 3 X Regulate Blood Sugar 850MG TAB 15-850 MG

63 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Blood Glucose Regulators - Drugs to PIOGLITAZONE HCL-METFORMIN HCL ACTOPLUS MET TAB XR Tier 3 X Regulate Blood Sugar TAB ER 24HR 30-1000 MG Blood Glucose Regulators - Drugs to PIOGLITAZONE HCL-METFORMIN HCL ACTOPLUS MET TAB XR Tier 3 X Regulate Blood Sugar TAB ER 24HR 15-1000 MG Blood Glucose Regulators - Drugs to LIXISENATIDE PEN-INJ STARTER KIT 10 ADLYXIN INJ 10/20MCG Tier 3 X Regulate Blood Sugar MCG/0.2ML & 20 MCG/0.2ML Blood Glucose Regulators - Drugs to LIXISENATIDE SOLN PEN-INJECTOR 20 ADLYXIN INJ 20MCG Tier 3 X Regulate Blood Sugar MCG/0.2ML (100 MCG/ML) Blood Glucose Regulators - Drugs to AMARYL TAB 1MG GLIMEPIRIDE TAB 1 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to AMARYL TAB 2MG GLIMEPIRIDE TAB 2 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to AMARYL TAB 4MG GLIMEPIRIDE TAB 4 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to INSULIN GLULISINE SOLN PEN- APIDRA INJ SOLOSTAR Tier 3 X X Regulate Blood Sugar INJECTOR INJ 100 UNIT/ML Blood Glucose Regulators - Drugs to APIDRA INJ U-100 INSULIN GLULISINE INJ 100 UNIT/ML Tier 3 X X Regulate Blood Sugar Blood Glucose Regulators - Drugs to ROSIGLITAZONE MALEATE TAB 2 MG AVANDIA TAB 2MG Tier 3 X Regulate Blood Sugar (BASE EQUIV) Blood Glucose Regulators - Drugs to ROSIGLITAZONE MALEATE TAB 4 MG AVANDIA TAB 4MG Tier 3 X Regulate Blood Sugar (BASE EQUIV) Blood Glucose Regulators - Drugs to INSULIN GLARGINE SOLN PEN- BASAGLAR INJ 100UNIT Tier 1 X Regulate Blood Sugar INJECTOR 100 UNIT/ML Blood Glucose Regulators - Drugs to EXENATIDE FOR INJ EXTENDED BYDUREON INJ 2MG Tier 2 X Regulate Blood Sugar RELEASE SUSP 2 MG Blood Glucose Regulators - Drugs to EXENATIDE EXTENDED RELEASE SUSP BYDUREON INJ BCISE Tier 2 X Regulate Blood Sugar AUTO-INJECTOR 2 MG/0.85ML Blood Glucose Regulators - Drugs to EXENATIDE EXTENDED RELEASE FOR BYDUREON PEN INJ 2MG Tier 2 X Regulate Blood Sugar SUSP PEN-INJECTOR 2 MG Blood Glucose Regulators - Drugs to EXENATIDE SOLN PEN-INJECTOR 10 BYETTA INJ 10MCG Tier 2 X Regulate Blood Sugar MCG/0.04ML Blood Glucose Regulators - Drugs to EXENATIDE SOLN PEN-INJECTOR 5 BYETTA INJ 5MCG Tier 2 X Regulate Blood Sugar MCG/0.02ML Blood Glucose Regulators - Drugs to CHLORPROPAM TAB 100MG CHLORPROPAMIDE TAB 100 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to CHLORPROPAM TAB 250MG CHLORPROPAMIDE TAB 250 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to BROMOCRIPTINE MESYLATE TAB 0.8 MG CYCLOSET TAB 0.8MG Tier 3 Regulate Blood Sugar (BASE EQUIVALENT) Blood Glucose Regulators - Drugs to PIOGLITAZONE HCL-GLIMEPIRIDE TAB DUETACT TAB 30-2MG Tier 3 X Regulate Blood Sugar 30-2 MG Blood Glucose Regulators - Drugs to PIOGLITAZONE HCL-GLIMEPIRIDE TAB DUETACT TAB 30-4MG Tier 3 X Regulate Blood Sugar 30-4 MG Blood Glucose Regulators - Drugs to DAPAGLIFLOZIN PROPANEDIOL TAB 10 FARXIGA TAB 10MG Tier 3 X X Regulate Blood Sugar MG (BASE EQUIVALENT) Blood Glucose Regulators - Drugs to DAPAGLIFLOZIN PROPANEDIOL TAB 5 FARXIGA TAB 5MG Tier 3 X X Regulate Blood Sugar MG (BASE EQUIVALENT) Blood Glucose Regulators - Drugs to GLIMEPIRIDE TAB 1MG GLIMEPIRIDE TAB 1 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLIMEPIRIDE TAB 2MG GLIMEPIRIDE TAB 2 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLIMEPIRIDE TAB 4MG GLIMEPIRIDE TAB 4 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLIP/METFORM TAB 2.5- GLIPIZIDE-METFORMIN HCL TAB 2.5-250 Tier 2 Regulate Blood Sugar 250M MG Blood Glucose Regulators - Drugs to GLIP/METFORM TAB 2.5- GLIPIZIDE-METFORMIN HCL TAB 2.5-500 Tier 2 Regulate Blood Sugar 500M MG Blood Glucose Regulators - Drugs to GLIP/METFORM TAB GLIPIZIDE-METFORMIN HCL TAB 5-500 Tier 2 Regulate Blood Sugar 5-500MG MG Blood Glucose Regulators - Drugs to GLIPIZIDE POW GLIPIZIDE POWDER Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLIPIZIDE TAB 10MG GLIPIZIDE TAB 10 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLIPIZIDE TAB 5MG GLIPIZIDE TAB 5 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLIPIZIDE ER TAB 10MG GLIPIZIDE TAB ER 24HR 10 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLIPIZIDE ER TAB 2.5MG GLIPIZIDE TAB ER 24HR 2.5 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLIPIZIDE ER TAB 5MG GLIPIZIDE TAB ER 24HR 5 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLIPIZIDE XL TAB 10MG GLIPIZIDE TAB ER 24HR 10 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLIPIZIDE XL TAB 2.5MG GLIPIZIDE TAB ER 24HR 2.5 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLIPIZIDE XL TAB 5MG GLIPIZIDE TAB ER 24HR 5 MG Tier 1 Regulate Blood Sugar

64 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Blood Glucose Regulators - Drugs to GLUCAGON HCL (RDNA) FOR INJ 1 MG GLUCAGEN INJ HYPOKIT Tier 2 X Regulate Blood Sugar (BASE EQUIV) Blood Glucose Regulators - Drugs to GLUCAGON KIT 1MG GLUCAGON (RDNA) FOR INJ KIT 1 MG Tier 2 X Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLUCOPHAGE TAB 1000MG METFORMIN HCL TAB 1000 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLUCOPHAGE TAB 500MG METFORMIN HCL TAB 500 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLUCOPHAGE TAB 500MG METFORMIN HCL TAB ER 24HR 500 MG Tier 3 X Regulate Blood Sugar XR Blood Glucose Regulators - Drugs to GLUCOPHAGE TAB 750MG METFORMIN HCL TAB SR 24HR 750 MG Tier 3 X Regulate Blood Sugar XR Blood Glucose Regulators - Drugs to GLUCOPHAGE TAB 850MG METFORMIN HCL TAB 850 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLUCOTROL TAB 10MG GLIPIZIDE TAB 10 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLUCOTROL TAB 5MG GLIPIZIDE TAB 5 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLUCOTROL XL TAB 10MG GLIPIZIDE TAB ER 24HR 10 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLUCOTROL XL TAB 2.5MG GLIPIZIDE TAB ER 24HR 2.5 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLUCOTROL XL TAB 5MG GLIPIZIDE TAB ER 24HR 5 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLYBURIDE-METFORMIN TAB 2.5-500 GLUCOVANCE TAB 2.5-500 Tier 3 Regulate Blood Sugar MG Blood Glucose Regulators - Drugs to GLUCOVANCE TAB 5-500MG GLYBURIDE-METFORMIN TAB 5-500 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLYB/METFORM TAB 1.25- GLYBURIDE-METFORMIN TAB 1.25-250 Tier 1 Regulate Blood Sugar 250 MG Blood Glucose Regulators - Drugs to GLYB/METFORM TAB 2.5- GLYBURIDE-METFORMIN TAB 2.5-500 Tier 1 Regulate Blood Sugar 500 MG Blood Glucose Regulators - Drugs to GLYB/METFORM TAB GLYBURIDE-METFORMIN TAB 5-500 MG Tier 1 Regulate Blood Sugar 5-500MG Blood Glucose Regulators - Drugs to GLYBURID MCR TAB 1.5MG GLYBURIDE MICRONIZED TAB 1.5 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLYBURID MCR TAB 3MG GLYBURIDE MICRONIZED TAB 3 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLYBURID MCR TAB 6MG GLYBURIDE MICRONIZED TAB 6 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLYBURIDE POW GLYBURIDE POWDER Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLYBURIDE TAB 1.25MG GLYBURIDE TAB 1.25 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLYBURIDE TAB 2.5MG GLYBURIDE TAB 2.5 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLYBURIDE TAB 5MG GLYBURIDE TAB 5 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLYNASE TAB 1.5MG GLYBURIDE MICRONIZED TAB 1.5 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLYNASE TAB 3MG GLYBURIDE MICRONIZED TAB 3 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLYNASE TAB 6MG GLYBURIDE MICRONIZED TAB 6 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLYSET TAB 100MG MIGLITOL TAB 100 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLYSET TAB 25MG MIGLITOL TAB 25 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to GLYSET TAB 50MG MIGLITOL TAB 50 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to HUMALOG INJ 100/ML INSULIN LISPRO INJ 100 UNIT/ML Tier 1 X Regulate Blood Sugar Blood Glucose Regulators - Drugs to INSULIN LISPRO SOLN CARTRIDGE 100 HUMALOG INJ 100/ML Tier 2 X Regulate Blood Sugar UNIT/ML Blood Glucose Regulators - Drugs to INSULIN LISPRO SOLN PEN-INJECTOR HUMALOG JR INJ 100/ML Tier 2 X Regulate Blood Sugar 100 UNIT/ML Blood Glucose Regulators - Drugs to INSULIN LISPRO SOLN PEN-INJECTOR HUMALOG KWIK INJ 100/ML Tier 2 X Regulate Blood Sugar 100 UNIT/ML Blood Glucose Regulators - Drugs to INSULIN LISPRO SOLN PEN-INJECTOR HUMALOG KWIK INJ 200/ML Tier 2 X Regulate Blood Sugar 200 UNIT/ML Blood Glucose Regulators - Drugs to INSULIN LISPRO PROTAMINE & LISPRO HUMALOG MIX INJ 50/50 Tier 1 X Regulate Blood Sugar INJ 100 UNIT/ML (50-50) Blood Glucose Regulators - Drugs to HUMALOG MIX INJ INSULIN LISPRO PROT & LISPRO SUS Tier 2 X Regulate Blood Sugar 50/50KWP PEN-INJ 100 UNIT/ML (50-50) Blood Glucose Regulators - Drugs to HUMALOG MIX INJ INSULIN LISPRO PROT & LISPRO SUS Tier 2 X Regulate Blood Sugar 75/25KWP PEN-INJ 100 UNIT/ML (75-25) Blood Glucose Regulators - Drugs to INSULIN LISPRO PROT & LISPRO INJ 100 HUMALOG MIX SUS 75/25 Tier 1 X Regulate Blood Sugar UNIT/ML (75-25)

65 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Blood Glucose Regulators - Drugs to INSULIN NPH ISOPHANE & REGULAR HUMULIN INJ 70/30 Tier 1 X Regulate Blood Sugar HUMAN INJ 100 UNIT/ML (70-30) Blood Glucose Regulators - Drugs to INSULIN NPH & REGULAR SUSP PEN-INJ HUMULIN INJ 70/30KWP Tier 2 X Regulate Blood Sugar 100 UNIT/ML (70-30) Blood Glucose Regulators - Drugs to INSULIN NPH (HUMAN) (ISOPHANE) INJ HUMULIN N INJ U-100 Tier 1 X Regulate Blood Sugar 100 UNIT/ML Blood Glucose Regulators - Drugs to INSULIN NPH (HUMAN) (ISOPHANE) HUMULIN N INJ U-100KWP Tier 2 X Regulate Blood Sugar SUSP PEN-INJECTOR 100 UNIT/ML Blood Glucose Regulators - Drugs to INSULIN REGULAR (HUMAN) INJ 100 HUMULIN R INJ U-100 Tier 1 X Regulate Blood Sugar UNIT/ML Blood Glucose Regulators - Drugs to INSULIN REGULAR (HUMAN) INJ 500 HUMULIN R INJ U-500 Tier 1 X Regulate Blood Sugar UNIT/ML Blood Glucose Regulators - Drugs to INSULIN REGULAR (HUMAN) SOLN PEN- HUMULIN R INJ U-500 Tier 2 Regulate Blood Sugar INJECTOR 500 UNIT/ML Blood Glucose Regulators - Drugs to CANAGLIFLOZIN-METFORMIN HCL TAB INVOKAMET TAB 150-1000 Tier 2 X Regulate Blood Sugar 150-1000 MG Blood Glucose Regulators - Drugs to CANAGLIFLOZIN-METFORMIN HCL TAB INVOKAMET TAB 150-500 Tier 2 X Regulate Blood Sugar 150-500 MG Blood Glucose Regulators - Drugs to CANAGLIFLOZIN-METFORMIN HCL TAB INVOKAMET TAB 50-1000 Tier 2 X Regulate Blood Sugar 50-1000 MG Blood Glucose Regulators - Drugs to CANAGLIFLOZIN-METFORMIN HCL TAB INVOKAMET TAB 50-500MG Tier 2 X Regulate Blood Sugar 50-500 MG Blood Glucose Regulators - Drugs to INVOKAMET XR TAB 150- CANAGLIFLOZIN-METFORMIN HCL TAB Tier 2 X Regulate Blood Sugar 1000 SR 24HR 150-1000 MG Blood Glucose Regulators - Drugs to INVOKAMET XR TAB 150- CANAGLIFLOZIN-METFORMIN HCL TAB Tier 2 X Regulate Blood Sugar 500 SR 24HR 150-500 MG Blood Glucose Regulators - Drugs to CANAGLIFLOZIN-METFORMIN HCL TAB INVOKAMET XR TAB 50-1000 Tier 2 X Regulate Blood Sugar SR 24HR 50-1000 MG Blood Glucose Regulators - Drugs to INVOKAMET XR TAB 50- CANAGLIFLOZIN-METFORMIN HCL TAB Tier 2 X Regulate Blood Sugar 500MG SR 24HR 50-500 MG Blood Glucose Regulators - Drugs to INVOKANA TAB 100MG CANAGLIFLOZIN TAB 100 MG Tier 2 X X Regulate Blood Sugar Blood Glucose Regulators - Drugs to INVOKANA TAB 300MG CANAGLIFLOZIN TAB 300 MG Tier 2 X X Regulate Blood Sugar Blood Glucose Regulators - Drugs to SITAGLIPTIN-METFORMIN HCL TAB 50- JANUMET TAB 50-1000 Tier 3 X X Regulate Blood Sugar 1000 MG Blood Glucose Regulators - Drugs to SITAGLIPTIN-METFORMIN HCL TAB 50- JANUMET TAB 50-500MG Tier 3 X X Regulate Blood Sugar 500 MG Blood Glucose Regulators - Drugs to SITAGLIPTIN-METFORMIN HCL TAB SR JANUMET XR TAB 100-1000 Tier 3 X X Regulate Blood Sugar 24HR 100-1000 MG Blood Glucose Regulators - Drugs to SITAGLIPTIN-METFORMIN HCL TAB ER JANUMET XR TAB 100-1000 Tier 3 X X Regulate Blood Sugar 24HR 100-1000 MG Blood Glucose Regulators - Drugs to SITAGLIPTIN-METFORMIN HCL TAB SR JANUMET XR TAB 50-1000 Tier 3 X X Regulate Blood Sugar 24HR 50-1000 MG Blood Glucose Regulators - Drugs to SITAGLIPTIN-METFORMIN HCL TAB ER JANUMET XR TAB 50-1000 Tier 3 X X Regulate Blood Sugar 24HR 50-1000 MG Blood Glucose Regulators - Drugs to SITAGLIPTIN-METFORMIN HCL TAB ER JANUMET XR TAB 50-500MG Tier 3 X X Regulate Blood Sugar 24HR 50-500 MG Blood Glucose Regulators - Drugs to SITAGLIPTIN PHOSPHATE TAB 100 MG JANUVIA TAB 100MG Tier 3 X X Regulate Blood Sugar (BASE EQUIV) Blood Glucose Regulators - Drugs to SITAGLIPTIN PHOSPHATE TAB 25 MG JANUVIA TAB 25MG Tier 3 X X Regulate Blood Sugar (BASE EQUIV) Blood Glucose Regulators - Drugs to SITAGLIPTIN PHOSPHATE TAB 50 MG JANUVIA TAB 50MG Tier 3 X X Regulate Blood Sugar (BASE EQUIV) Blood Glucose Regulators - Drugs to JARDIANCE TAB 10MG EMPAGLIFLOZIN TAB 10 MG Tier 2 X X Regulate Blood Sugar Blood Glucose Regulators - Drugs to JARDIANCE TAB 25MG EMPAGLIFLOZIN TAB 25 MG Tier 2 X X Regulate Blood Sugar Blood Glucose Regulators - Drugs to LINAGLIPTIN-METFORMIN HCL TAB 2.5- JENTADUETO TAB 2.5-1000 Tier 2 X Regulate Blood Sugar 1000 MG Blood Glucose Regulators - Drugs to LINAGLIPTIN-METFORMIN HCL TAB 2.5- JENTADUETO TAB 2.5-500 Tier 2 X Regulate Blood Sugar 500 MG Blood Glucose Regulators - Drugs to LINAGLIPTIN-METFORMIN HCL TAB 2.5- JENTADUETO TAB 2.5-850 Tier 2 X Regulate Blood Sugar 850 MG Blood Glucose Regulators - Drugs to LINAGLIPTIN-METFORMIN HCL TAB SR JENTADUETO TAB XR Tier 2 Regulate Blood Sugar 24HR 2.5-1000 MG Blood Glucose Regulators - Drugs to LINAGLIPTIN-METFORMIN HCL TAB SR JENTADUETO TAB XR Tier 2 Regulate Blood Sugar 24HR 5-1000 MG Blood Glucose Regulators - Drugs to ALOGLIPTIN-METFORMIN HCL TAB 12.5- KAZANO 12.5- TAB 1000MG Tier 2 X Regulate Blood Sugar 1000 MG Blood Glucose Regulators - Drugs to ALOGLIPTIN-METFORMIN HCL TAB 12.5- KAZANO 12.5- TAB 500MG Tier 2 X Regulate Blood Sugar 500 MG Blood Glucose Regulators - Drugs to KOMBIGLYZ XR TAB 2.5- SAXAGLIPTIN-METFORMIN HCL TAB ER Tier 2 X Regulate Blood Sugar 1000 24HR 2.5-1000 MG Blood Glucose Regulators - Drugs to KOMBIGLYZ XR TAB SAXAGLIPTIN-METFORMIN HCL TAB ER Tier 2 X Regulate Blood Sugar 5-1000MG 24HR 5-1000 MG Blood Glucose Regulators - Drugs to KOMBIGLYZ XR TAB SAXAGLIPTIN-METFORMIN HCL TAB ER Tier 2 X Regulate Blood Sugar 5-500MG 24HR 5-500 MG

66 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Blood Glucose Regulators - Drugs to LEVEMIR INJ INSULIN DETEMIR INJ 100 UNIT/ML Tier 2 X Regulate Blood Sugar Blood Glucose Regulators - Drugs to INSULIN DETEMIR SOLN PEN-INJECTOR LEVEMIR INJ FLEXTOUC Tier 2 X Regulate Blood Sugar 100 UNIT/ML Blood Glucose Regulators - Drugs to METFORMIN TAB 1000MG METFORMIN HCL TAB 1000 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to METFORMIN TAB 500MG METFORMIN HCL TAB 500 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to METFORMIN TAB 500MG ER METFORMIN HCL TAB ER 24HR 500 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to METFORMIN TAB 750MG ER METFORMIN HCL TAB ER 24HR 750 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to METFORMIN TAB 850MG METFORMIN HCL TAB 850 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to MIGLITOL TAB 100MG MIGLITOL TAB 100 MG Tier 2 Regulate Blood Sugar Blood Glucose Regulators - Drugs to MIGLITOL TAB 25MG MIGLITOL TAB 25 MG Tier 2 Regulate Blood Sugar Blood Glucose Regulators - Drugs to MIGLITOL TAB 50MG MIGLITOL TAB 50 MG Tier 2 Regulate Blood Sugar Blood Glucose Regulators - Drugs to NATEGLINIDE TAB 120MG NATEGLINIDE TAB 120 MG Tier 2 X Regulate Blood Sugar Blood Glucose Regulators - Drugs to NATEGLINIDE TAB 60MG NATEGLINIDE TAB 60 MG Tier 2 X Regulate Blood Sugar Blood Glucose Regulators - Drugs to ALOGLIPTIN BENZOATE TAB 12.5 MG NESINA TAB 12.5MG Tier 2 X Regulate Blood Sugar (BASE EQUIV) Blood Glucose Regulators - Drugs to ALOGLIPTIN BENZOATE TAB 25 MG NESINA TAB 25MG Tier 2 X Regulate Blood Sugar (BASE EQUIV) Blood Glucose Regulators - Drugs to ALOGLIPTIN BENZOATE TAB 6.25 MG NESINA TAB 6.25MG Tier 2 X Regulate Blood Sugar (BASE EQUIV) Blood Glucose Regulators - Drugs to INSULIN NPH ISOPHANE & REGULAR NOVOLIN INJ 70/30 Tier 3 X X Regulate Blood Sugar HUMAN INJ 100 UNIT/ML (70-30) Blood Glucose Regulators - Drugs to INSULIN NPH (HUMAN) (ISOPHANE) INJ NOVOLIN N INJ RELION Tier 3 X X Regulate Blood Sugar 100 UNIT/ML Blood Glucose Regulators - Drugs to INSULIN NPH (HUMAN) (ISOPHANE) INJ NOVOLIN N INJ U-100 Tier 3 X X Regulate Blood Sugar 100 UNIT/ML Blood Glucose Regulators - Drugs to INSULIN REGULAR (HUMAN) INJ 100 NOVOLIN R INJ RELION Tier 3 X X Regulate Blood Sugar UNIT/ML Blood Glucose Regulators - Drugs to INSULIN REGULAR (HUMAN) INJ 100 NOVOLIN R INJ U-100 Tier 3 X X Regulate Blood Sugar UNIT/ML Blood Glucose Regulators - Drugs to INSULIN NPH ISOPHANE & REGULAR NOVOLIN70/30 INJ RELION Tier 3 X X Regulate Blood Sugar HUMAN INJ 100 UNIT/ML (70-30) Blood Glucose Regulators - Drugs to NOVOLOG INJ 100/ML INSULIN ASPART INJ 100 UNIT/ML Tier 3 X X Regulate Blood Sugar Blood Glucose Regulators - Drugs to INSULIN ASPART SOLN PEN-INJECTOR NOVOLOG INJ FLEXPEN Tier 3 X X Regulate Blood Sugar 100 UNIT/ML Blood Glucose Regulators - Drugs to INSULIN ASPART SOLN CARTRIDGE 100 NOVOLOG INJ PENFILL Tier 3 X X Regulate Blood Sugar UNIT/ML Blood Glucose Regulators - Drugs to INSULIN ASPART PROT & ASPART NOVOLOG MIX INJ 70/30 Tier 3 X X Regulate Blood Sugar (HUMAN) INJ 100 UNIT/ML (70-30) Blood Glucose Regulators - Drugs to INSULIN ASPART PROT & ASPART SUS NOVOLOG MIX INJ FLEXPEN Tier 3 X X Regulate Blood Sugar PEN-INJ 100 UNIT/ML (70-30) Blood Glucose Regulators - Drugs to SAXAGLIPTIN HCL TAB 2.5 MG (BASE ONGLYZA TAB 2.5MG Tier 2 X Regulate Blood Sugar EQUIV) Blood Glucose Regulators - Drugs to SAXAGLIPTIN HCL TAB 5 MG (BASE ONGLYZA TAB 5MG Tier 2 X Regulate Blood Sugar EQUIV) Blood Glucose Regulators - Drugs to ALOGLIPTIN-PIOGLITAZONE TAB 12.5-15 OSENI TAB 12.5-15 Tier 2 X Regulate Blood Sugar MG Blood Glucose Regulators - Drugs to ALOGLIPTIN-PIOGLITAZONE TAB 12.5- OSENI TAB 12.5-30 Tier 2 X Regulate Blood Sugar 30 MG Blood Glucose Regulators - Drugs to ALOGLIPTIN-PIOGLITAZONE TAB 12.5- OSENI TAB 12.5-45 Tier 2 X Regulate Blood Sugar 45 MG Blood Glucose Regulators - Drugs to ALOGLIPTIN-PIOGLITAZONE TAB 25-15 OSENI TAB 25-15MG Tier 2 X Regulate Blood Sugar MG Blood Glucose Regulators - Drugs to ALOGLIPTIN-PIOGLITAZONE TAB 25-30 OSENI TAB 25-30MG Tier 2 X Regulate Blood Sugar MG Blood Glucose Regulators - Drugs to ALOGLIPTIN-PIOGLITAZONE TAB 25-45 OSENI TAB 25-45MG Tier 2 X Regulate Blood Sugar MG Blood Glucose Regulators - Drugs to PIOGLITAZONE HCL-GLIMEPIRIDE TAB PIOGLIT/GLIM TAB 30-2MG Tier 1 X Regulate Blood Sugar 30-2 MG Blood Glucose Regulators - Drugs to PIOGLITAZONE HCL-GLIMEPIRIDE TAB PIOGLIT/GLIM TAB 30-4MG Tier 1 X Regulate Blood Sugar 30-4 MG Blood Glucose Regulators - Drugs to PIOGLITA/MET TAB 15- PIOGLITAZONE HCL-METFORMIN HCL Tier 2 X Regulate Blood Sugar 500MG TAB 15-500 MG Blood Glucose Regulators - Drugs to PIOGLITA/MET TAB 15- PIOGLITAZONE HCL-METFORMIN HCL Tier 2 X Regulate Blood Sugar 850MG TAB 15-850 MG Blood Glucose Regulators - Drugs to PIOGLITAZONE HCL TAB 15 MG (BASE PIOGLITAZONE TAB 15MG Tier 1 X Regulate Blood Sugar EQUIV)

67 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Blood Glucose Regulators - Drugs to PIOGLITAZONE HCL TAB 30 MG (BASE PIOGLITAZONE TAB 30MG Tier 1 X Regulate Blood Sugar EQUIV) Blood Glucose Regulators - Drugs to PIOGLITAZONE HCL TAB 45 MG (BASE PIOGLITAZONE TAB 45MG Tier 1 X Regulate Blood Sugar EQUIV) Blood Glucose Regulators - Drugs to PRANDIN TAB 0.5MG REPAGLINIDE TAB 0.5 MG Tier 3 X Regulate Blood Sugar Blood Glucose Regulators - Drugs to PRANDIN TAB 1MG REPAGLINIDE TAB 1 MG Tier 3 X Regulate Blood Sugar Blood Glucose Regulators - Drugs to PRANDIN TAB 2MG REPAGLINIDE TAB 2 MG Tier 3 X Regulate Blood Sugar Blood Glucose Regulators - Drugs to PRECOSE TAB 100MG ACARBOSE TAB 100 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to PRECOSE TAB 25MG ACARBOSE TAB 25 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to PRECOSE TAB 50MG ACARBOSE TAB 50 MG Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to PROGLYCEM SUS 50MG/ML DIAZOXIDE SUSP 50 MG/ML Tier 3 Regulate Blood Sugar Blood Glucose Regulators - Drugs to REPAGLINIDE TAB 0.5MG REPAGLINIDE TAB 0.5 MG Tier 2 X Regulate Blood Sugar Blood Glucose Regulators - Drugs to REPAGLINIDE-METFORMIN HCL TAB REPAGLINIDE TAB 1-500MG Tier 3 Regulate Blood Sugar 1-500 MG Blood Glucose Regulators - Drugs to REPAGLINIDE TAB 1MG REPAGLINIDE TAB 1 MG Tier 2 X Regulate Blood Sugar Blood Glucose Regulators - Drugs to REPAGLINIDE-METFORMIN HCL TAB REPAGLINIDE TAB 2-500MG Tier 3 Regulate Blood Sugar 2-500 MG Blood Glucose Regulators - Drugs to REPAGLINIDE TAB 2MG REPAGLINIDE TAB 2 MG Tier 2 X Regulate Blood Sugar Blood Glucose Regulators - Drugs to METFORMIN HCL ORAL SOLN 500 RIOMET SOL Tier 3 Regulate Blood Sugar MG/5ML Blood Glucose Regulators - Drugs to METFORMIN HCL ORAL SOLN 500 RIOMET SOL 500/5ML Tier 3 Regulate Blood Sugar MG/5ML Blood Glucose Regulators - Drugs to INSULIN GLARGINE-LIXISENATIDE SOL SOLIQUA INJ 100/33 Tier 2 X X Regulate Blood Sugar PEN-INJ 100-33 UNIT-MCG/ML Blood Glucose Regulators - Drugs to STARLIX TAB 120MG NATEGLINIDE TAB 120 MG Tier 3 X Regulate Blood Sugar Blood Glucose Regulators - Drugs to STARLIX TAB 60MG NATEGLINIDE TAB 60 MG Tier 3 X Regulate Blood Sugar Blood Glucose Regulators - Drugs to SYMLINPEN 60 INJ PRAMLINTIDE ACETATE PEN-INJ 1500 Tier 3 X Regulate Blood Sugar 1000MCG MCG/1.5ML (1000 MCG/ML) Blood Glucose Regulators - Drugs to SYMLNPEN 120 INJ PRAMLINTIDE ACETATE PEN-INJ 2700 Tier 3 X Regulate Blood Sugar 1000MCG MCG/2.7ML (1000 MCG/ML) Blood Glucose Regulators - Drugs to EMPAGLIFLOZIN-METFORMIN HCL TAB SYNJARDY TAB Tier 2 X Regulate Blood Sugar 12.5-1000 MG Blood Glucose Regulators - Drugs to EMPAGLIFLOZIN-METFORMIN HCL TAB SYNJARDY TAB 12.5-500 Tier 2 X Regulate Blood Sugar 12.5-500 MG Blood Glucose Regulators - Drugs to EMPAGLIFLOZIN-METFORMIN HCL TAB SYNJARDY TAB 5-1000MG Tier 2 X Regulate Blood Sugar 5-1000 MG Blood Glucose Regulators - Drugs to EMPAGLIFLOZIN-METFORMIN HCL TAB SYNJARDY TAB 5-500MG Tier 2 X Regulate Blood Sugar 5-500 MG Blood Glucose Regulators - Drugs to EMPAGLIFLOZIN-METFORMIN HCL TAB SYNJARDY XR TAB Tier 2 X Regulate Blood Sugar SR 24HR 12.5-1000 MG Blood Glucose Regulators - Drugs to EMPAGLIFLOZIN-METFORMIN HCL TAB SYNJARDY XR TAB 10-1000 Tier 2 X Regulate Blood Sugar SR 24HR 10-1000 MG Blood Glucose Regulators - Drugs to EMPAGLIFLOZIN-METFORMIN HCL TAB SYNJARDY XR TAB 25-1000 Tier 2 X Regulate Blood Sugar SR 24HR 25-1000 MG Blood Glucose Regulators - Drugs to SYNJARDY XR TAB EMPAGLIFLOZIN-METFORMIN HCL TAB Tier 2 X Regulate Blood Sugar 5-1000MG SR 24HR 5-1000 MG Blood Glucose Regulators - Drugs to ALBIGLUTIDE FOR SOLN PEN-INJECTOR TANZEUM INJ 30MG Tier 2 X Regulate Blood Sugar 30 MG Blood Glucose Regulators - Drugs to ALBIGLUTIDE FOR SOLN PEN-INJECTOR TANZEUM INJ 50MG Tier 2 X Regulate Blood Sugar 50 MG Blood Glucose Regulators - Drugs to TOLAZAMIDE TAB 250MG TOLAZAMIDE TAB 250 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to TOLAZAMIDE TAB 500MG TOLAZAMIDE TAB 500 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to TOLBUTAMIDE TAB 500MG TOLBUTAMIDE TAB 500 MG Tier 1 Regulate Blood Sugar Blood Glucose Regulators - Drugs to TRADJENTA TAB 5MG LINAGLIPTIN TAB 5 MG Tier 2 X Regulate Blood Sugar Blood Glucose Regulators - Drugs to INSULIN DEGLUDEC SOLN PEN- TRESIBA FLEX INJ 100UNIT Tier 3 X X Regulate Blood Sugar INJECTOR 100 UNIT/ML Blood Glucose Regulators - Drugs to INSULIN DEGLUDEC SOLN PEN- TRESIBA FLEX INJ 200UNIT Tier 3 X X Regulate Blood Sugar INJECTOR 200 UNIT/ML Blood Glucose Regulators - Drugs to DULAGLUTIDE SOLN PEN-INJECTOR 0.75 TRULICITY INJ 0.75/0.5 Tier 3 X Regulate Blood Sugar MG/0.5ML Blood Glucose Regulators - Drugs to DULAGLUTIDE SOLN PEN-INJECTOR 1.5 TRULICITY INJ 1.5/0.5 Tier 3 X Regulate Blood Sugar MG/0.5ML

68 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Blood Glucose Regulators - Drugs to LIRAGLUTIDE SOLN PEN-INJECTOR 18 VICTOZA INJ 18MG/3ML Tier 2 X Regulate Blood Sugar MG/3ML (6 MG/ML) Blood Glucose Regulators - Drugs to LIRAGLUTIDE SOLN PEN-INJECTOR 18 VICTOZA INJ 18MG/3ML Tier 3 X Regulate Blood Sugar MG/3ML (6 MG/ML) Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR RAHF-PFM Expanders - Drugs to Treat Blood ADVATE INJ 1000UNIT Tier 4 X X X FOR INJ 1000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR RAHF-PFM Expanders - Drugs to Treat Blood ADVATE INJ 1500UNIT Tier 4 X X X FOR INJ 1500 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR RAHF-PFM Expanders - Drugs to Treat Blood ADVATE INJ 2000UNIT Tier 4 X X X FOR INJ 2000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR RAHF-PFM Expanders - Drugs to Treat Blood ADVATE INJ 250UNIT Tier 4 X X X FOR INJ 250 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR RAHF-PFM Expanders - Drugs to Treat Blood ADVATE INJ 3000UNIT Tier 4 X X X FOR INJ 3000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR RAHF-PFM Expanders - Drugs to Treat Blood ADVATE INJ 4000UNIT Tier 4 X X X FOR INJ 4000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR RAHF-PFM Expanders - Drugs to Treat Blood ADVATE INJ 500UNIT Tier 4 X X X FOR INJ 500 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACT RCMB SINGLE Expanders - Drugs to Treat Blood AFSTYLA KIT 1000UNIT Tier 3 X X CHAIN FOR INJ KIT 1000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACT RCMB SINGLE Expanders - Drugs to Treat Blood AFSTYLA KIT 2000UNIT Tier 3 X X CHAIN FOR INJ KIT 2000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACT RCMB SINGLE Expanders - Drugs to Treat Blood AFSTYLA KIT 250UNIT Tier 3 X X CHAIN FOR INJ KIT 250 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACT RCMB SINGLE Expanders - Drugs to Treat Blood AFSTYLA KIT 500UNIT Tier 3 X X CHAIN FOR INJ KIT 500 UNIT Disorders Blood Products/Modifiers/Volume ASPIRIN-DIPYRIDAMOLE CAP SR 12HR Expanders - Drugs to Treat Blood AGGRENOX CAP 25-200MG Tier 3 25-200 MG Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood AGRYLIN CAP 0.5MG ANAGRELIDE HCL CAP 0.5 MG Tier 3 Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR/VWF Expanders - Drugs to Treat Blood ALPHANATE INJ VWF/HUM Tier 2 X (HUMAN) FOR INJ 250 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR/VWF Expanders - Drugs to Treat Blood ALPHANATE INJ VWF/HUM Tier 2 X (HUMAN) FOR INJ 500 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR/VWF Expanders - Drugs to Treat Blood ALPHANATE INJ VWF/HUM Tier 2 X (HUMAN) FOR INJ 1000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR/VWF Expanders - Drugs to Treat Blood ALPHANATE INJ VWF/HUM Tier 2 X (HUMAN) FOR INJ 1500 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR/VWF Expanders - Drugs to Treat Blood ALPHANATE INJ VWF/HUM Tier 2 X (HUMAN) FOR INJ 2000 UNIT Disorders Blood Products/Modifiers/Volume ALPHANINE SD INJ COAGULATION FACTOR IX FOR INJ 1000 Expanders - Drugs to Treat Blood Tier 2 X 1000UNIT UNIT Disorders Blood Products/Modifiers/Volume ALPHANINE SD INJ COAGULATION FACTOR IX FOR INJ 1500 Expanders - Drugs to Treat Blood Tier 2 X 1500UNIT UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX FOR INJ 500 Expanders - Drugs to Treat Blood ALPHANINE SD INJ 500UNIT Tier 2 X UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX (RECOMB) Expanders - Drugs to Treat Blood ALPROLIX INJ 1000UNIT Tier 3 X (RFIXFC) FOR INJ 1000 UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX (RECOMB) Expanders - Drugs to Treat Blood ALPROLIX INJ 2000UNIT Tier 3 X (RFIXFC) FOR INJ 2000 UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX (RECOMB) Expanders - Drugs to Treat Blood ALPROLIX INJ 250UNIT Tier 3 X (RFIXFC) FOR INJ 250 UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX (RECOMB) Expanders - Drugs to Treat Blood ALPROLIX INJ 3000UNIT Tier 3 X (RFIXFC) FOR INJ 3000 UNIT Disorders

69 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Blood Products/Modifiers/Volume COAGULATION FACTOR IX (RECOMB) Expanders - Drugs to Treat Blood ALPROLIX INJ 4000UNIT Tier 3 (RFIXFC) FOR INJ 4000 UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX (RECOMB) Expanders - Drugs to Treat Blood ALPROLIX INJ 500UNIT Tier 3 X (RFIXFC) FOR INJ 500 UNIT Disorders Blood Products/Modifiers/Volume AMINOCAPROIC ACID ORAL SOLN 0.25 Expanders - Drugs to Treat Blood AMICAR SOL 0.25/ML Tier 3 GM/ML Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood AMICAR TAB 1000MG AMINOCAPROIC ACID TAB 1000 MG Tier 3 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood AMICAR TAB 500MG AMINOCAPROIC ACID TAB 500 MG Tier 3 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood ANAGRELIDE CAP 0.5MG ANAGRELIDE HCL CAP 0.5 MG Tier 1 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood ANAGRELIDE CAP 1MG ANAGRELIDE HCL CAP 1 MG Tier 1 Disorders Blood Products/Modifiers/Volume *ANTICOAGULANT CITRATE DEXTROSE Expanders - Drugs to Treat Blood ANTICOAG CIT SOL DEX SOL Tier 1 SOLUTION A** Disorders Blood Products/Modifiers/Volume ANTICOAGULNT SOL SOD ANTICOAGULANT SODIUM CITRATE Expanders - Drugs to Treat Blood Tier 3 CITR SOLN 4% Disorders Blood Products/Modifiers/Volume DARBEPOETIN ALFA SOLN INJ 100 MCG/ Expanders - Drugs to Treat Blood ARANESP INJ 100MCG Tier 2 X X ML Disorders Blood Products/Modifiers/Volume DARBEPOETIN ALFA SOLN PREFILLED Expanders - Drugs to Treat Blood ARANESP INJ 100MCG Tier 2 X X SYRINGE 100 MCG/0.5ML Disorders Blood Products/Modifiers/Volume DARBEPOETIN ALFA SOLN PREFILLED Expanders - Drugs to Treat Blood ARANESP INJ 10MCG Tier 2 X X SYRINGE 10 MCG/0.4ML Disorders Blood Products/Modifiers/Volume DARBEPOETIN ALFA SOLN PREFILLED Expanders - Drugs to Treat Blood ARANESP INJ 150MCG Tier 2 X X SYRINGE 150 MCG/0.3ML Disorders Blood Products/Modifiers/Volume DARBEPOETIN ALFA SOLN INJ 200 MCG/ Expanders - Drugs to Treat Blood ARANESP INJ 200MCG Tier 2 X X ML Disorders Blood Products/Modifiers/Volume DARBEPOETIN ALFA SOLN PREFILLED Expanders - Drugs to Treat Blood ARANESP INJ 200MCG Tier 2 X X SYRINGE 200 MCG/0.4ML Disorders Blood Products/Modifiers/Volume DARBEPOETIN ALFA SOLN INJ 25 MCG/ Expanders - Drugs to Treat Blood ARANESP INJ 25MCG Tier 2 X X ML Disorders Blood Products/Modifiers/Volume DARBEPOETIN ALFA SOLN PREFILLED Expanders - Drugs to Treat Blood ARANESP INJ 25MCG Tier 2 X X SYRINGE 25 MCG/0.42ML Disorders Blood Products/Modifiers/Volume DARBEPOETIN ALFA SOLN INJ 300 MCG/ Expanders - Drugs to Treat Blood ARANESP INJ 300MCG Tier 2 X X ML Disorders Blood Products/Modifiers/Volume DARBEPOETIN ALFA SOLN PREFILLED Expanders - Drugs to Treat Blood ARANESP INJ 300MCG Tier 2 X X SYRINGE 300 MCG/0.6ML Disorders Blood Products/Modifiers/Volume DARBEPOETIN ALFA SOLN INJ 40 MCG/ Expanders - Drugs to Treat Blood ARANESP INJ 40MCG Tier 2 X X ML Disorders Blood Products/Modifiers/Volume DARBEPOETIN ALFA SOLN PREFILLED Expanders - Drugs to Treat Blood ARANESP INJ 40MCG Tier 2 X X SYRINGE 40 MCG/0.4ML Disorders Blood Products/Modifiers/Volume DARBEPOETIN ALFA SOLN PREFILLED Expanders - Drugs to Treat Blood ARANESP INJ 500MCG Tier 2 X X SYRINGE 500 MCG/ML Disorders Blood Products/Modifiers/Volume DARBEPOETIN ALFA SOLN INJ 60 MCG/ Expanders - Drugs to Treat Blood ARANESP INJ 60MCG Tier 2 X X ML Disorders Blood Products/Modifiers/Volume DARBEPOETIN ALFA SOLN PREFILLED Expanders - Drugs to Treat Blood ARANESP INJ 60MCG Tier 2 X X SYRINGE 60 MCG/0.3ML Disorders Blood Products/Modifiers/Volume FONDAPARINUX SODIUM Expanders - Drugs to Treat Blood ARIXTRA INJ 10/0.8ML Tier 4 X SUBCUTANEOUS INJ 10 MG/0.8ML Disorders Blood Products/Modifiers/Volume FONDAPARINUX SODIUM Expanders - Drugs to Treat Blood ARIXTRA INJ 2.5/0.5 Tier 4 X SUBCUTANEOUS INJ 2.5 MG/0.5ML Disorders

70 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Blood Products/Modifiers/Volume FONDAPARINUX SODIUM Expanders - Drugs to Treat Blood ARIXTRA INJ 5/0.4ML Tier 4 X SUBCUTANEOUS INJ 5 MG/0.4ML Disorders Blood Products/Modifiers/Volume FONDAPARINUX SODIUM Expanders - Drugs to Treat Blood ARIXTRA INJ 7.5/0.6 Tier 4 X SUBCUTANEOUS INJ 7.5 MG/0.6ML Disorders Blood Products/Modifiers/Volume ASA/DIPYRIDA CAP 25- ASPIRIN-DIPYRIDAMOLE CAP ER 12HR Expanders - Drugs to Treat Blood Tier 3 200MG 25-200 MG Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood ASTRINGYN SOL 259MG/GM FERRIC SUBSULFATE SOLN 259 MG/GM Tier 3 Disorders Blood Products/Modifiers/Volume FACTOR IX COMPLEX FOR INJ 200-1200 Expanders - Drugs to Treat Blood BEBULIN INJ 200-1200 Tier 2 X UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX Expanders - Drugs to Treat Blood BENEFIX INJ 1000UNIT Tier 2 X (RECOMBINANT) FOR INJ KIT 1000 UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX Expanders - Drugs to Treat Blood BENEFIX INJ 2000UNIT Tier 2 X (RECOMBINANT) FOR INJ KIT 2000 UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX Expanders - Drugs to Treat Blood BENEFIX INJ 250UNIT Tier 2 X (RECOMBINANT) FOR INJ KIT 250 UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX Expanders - Drugs to Treat Blood BENEFIX INJ 3000UNIT Tier 2 X (RECOMBINANT) FOR INJ KIT 3000 UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX Expanders - Drugs to Treat Blood BENEFIX INJ 500UNIT Tier 2 X (RECOMBINANT) FOR INJ KIT 500 UNIT Disorders Blood Products/Modifiers/Volume BETRIXABAN MALEATE CAP 40 MG Expanders - Drugs to Treat Blood BEVYXXA CAP 40MG Tier 3 X (BASE EQUIVALENT) Disorders Blood Products/Modifiers/Volume BETRIXABAN MALEATE CAP 80 MG Expanders - Drugs to Treat Blood BEVYXXA CAP 80MG Tier 3 X (BASE EQUIVALENT) Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood BRILINTA TAB 60MG TICAGRELOR TAB 60 MG Tier 3 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood BRILINTA TAB 90MG TICAGRELOR TAB 90 MG Tier 3 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood CILOSTAZOL TAB 100MG CILOSTAZOL TAB 100 MG Tier 1 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood CILOSTAZOL TAB 50MG CILOSTAZOL TAB 50 MG Tier 1 Disorders Blood Products/Modifiers/Volume CLOPIDOGREL POW CLOPIDOGREL BISULFATE (BULK) Expanders - Drugs to Treat Blood Tier 3 BISULFAT POWDER Disorders Blood Products/Modifiers/Volume CLOPIDOGREL BISULFATE TAB 300 MG Expanders - Drugs to Treat Blood CLOPIDOGREL TAB 300MG Tier 1 (BASE EQUIV) Disorders Blood Products/Modifiers/Volume CLOPIDOGREL BISULFATE TAB 75 MG Expanders - Drugs to Treat Blood CLOPIDOGREL TAB 75MG Tier 1 (BASE EQUIV) Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR X (HUMAN) FOR Expanders - Drugs to Treat Blood COAGADEX INJ 250UNIT Tier 4 X INJ 250 UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR X (HUMAN) FOR Expanders - Drugs to Treat Blood COAGADEX INJ 500UNIT Tier 4 X INJ 500 UNIT Disorders Blood Products/Modifiers/Volume FACTOR XIII CONCENTRATE (HUMAN) Expanders - Drugs to Treat Blood CORIFACT KIT Tier 2 X FOR INJ KIT 1000-1600 UNIT Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood COUMADIN TAB 10MG WARFARIN SODIUM TAB 10 MG Tier 3 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood COUMADIN TAB 1MG WARFARIN SODIUM TAB 1 MG Tier 3 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood COUMADIN TAB 2.5MG WARFARIN SODIUM TAB 2.5 MG Tier 3 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood COUMADIN TAB 2MG WARFARIN SODIUM TAB 2 MG Tier 3 Disorders

71 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood COUMADIN TAB 3MG WARFARIN SODIUM TAB 3 MG Tier 3 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood COUMADIN TAB 4MG WARFARIN SODIUM TAB 4 MG Tier 3 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood COUMADIN TAB 5MG WARFARIN SODIUM TAB 5 MG Tier 3 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood COUMADIN TAB 6MG WARFARIN SODIUM TAB 6 MG Tier 3 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood COUMADIN TAB 7.5MG WARFARIN SODIUM TAB 7.5 MG Tier 3 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood DIPYRIDAMOLE TAB 25MG DIPYRIDAMOLE TAB 25 MG Tier 1 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood DIPYRIDAMOLE TAB 50MG DIPYRIDAMOLE TAB 50 MG Tier 1 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood DIPYRIDAMOLE TAB 75MG DIPYRIDAMOLE TAB 75 MG Tier 1 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood ELIQUIS TAB 2.5MG APIXABAN TAB 2.5 MG Tier 3 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood ELIQUIS TAB 5MG APIXABAN TAB 5 MG Tier 3 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood ELIQUIS ST P TAB 5MG APIXABAN TAB 5 MG Tier 3 X Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (RECOMB) Expanders - Drugs to Treat Blood ELOCTATE INJ 1000UNIT Tier 4 X X RFVIIIFC FOR INJ 1000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (RECOMB) Expanders - Drugs to Treat Blood ELOCTATE INJ 1500UNIT Tier 4 X X RFVIIIFC FOR INJ 1500 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (RECOMB) Expanders - Drugs to Treat Blood ELOCTATE INJ 2000UNIT Tier 4 X X RFVIIIFC FOR INJ 2000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (RECOMB) Expanders - Drugs to Treat Blood ELOCTATE INJ 250UNIT Tier 4 X X RFVIIIFC FOR INJ 250 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (RECOMB) Expanders - Drugs to Treat Blood ELOCTATE INJ 3000UNIT Tier 4 X X RFVIIIFC FOR INJ 3000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (RECOMB) Expanders - Drugs to Treat Blood ELOCTATE INJ 4000UNIT Tier 4 X X RFVIIIFC FOR INJ 4000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (RECOMB) Expanders - Drugs to Treat Blood ELOCTATE INJ 5000UNIT Tier 4 X X RFVIIIFC FOR INJ 5000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (RECOMB) Expanders - Drugs to Treat Blood ELOCTATE INJ 500UNIT Tier 4 X X RFVIIIFC FOR INJ 500 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (RECOMB) Expanders - Drugs to Treat Blood ELOCTATE INJ 6000UNIT Tier 4 X X RFVIIIFC FOR INJ 6000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (RECOMB) Expanders - Drugs to Treat Blood ELOCTATE INJ 750UNIT Tier 4 X X RFVIIIFC FOR INJ 750 UNIT Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood ENOXAPARIN INJ 100MG/ML ENOXAPARIN SODIUM INJ 100 MG/ML Tier 2 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood ENOXAPARIN INJ 120/0.8 ENOXAPARIN SODIUM INJ 120 MG/0.8ML Tier 2 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood ENOXAPARIN INJ 150MG/ML ENOXAPARIN SODIUM INJ 150 MG/ML Tier 2 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood ENOXAPARIN INJ 30/0.3ML ENOXAPARIN SODIUM INJ 30 MG/0.3ML Tier 2 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood ENOXAPARIN INJ 300/3ML ENOXAPARIN SODIUM INJ 300 MG/3ML Tier 2 X Disorders

72 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood ENOXAPARIN INJ 40/0.4ML ENOXAPARIN SODIUM INJ 40 MG/0.4ML Tier 2 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood ENOXAPARIN INJ 60/0.6ML ENOXAPARIN SODIUM INJ 60 MG/0.6ML Tier 2 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood ENOXAPARIN INJ 80/0.8ML ENOXAPARIN SODIUM INJ 80 MG/0.8ML Tier 2 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood EPOGEN INJ 10000/ML EPOETIN ALFA INJ 10000 UNIT/ML Tier 2 X X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood EPOGEN INJ 2000/ML EPOETIN ALFA INJ 2000 UNIT/ML Tier 2 X X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood EPOGEN INJ 20000/ML EPOETIN ALFA INJ 20000 UNIT/ML Tier 2 X X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood EPOGEN INJ 3000/ML EPOETIN ALFA INJ 3000 UNIT/ML Tier 2 X X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood EPOGEN INJ 4000/ML EPOETIN ALFA INJ 4000 UNIT/ML Tier 2 X X Disorders Blood Products/Modifiers/Volume THROMBIN (HUMAN) TOPICAL SOLN Expanders - Drugs to Treat Blood EVITHROM SOL 800-1200 Tier 3 800-1200 UNIT/ML Disorders Blood Products/Modifiers/Volume *ANTIINHIBITOR COAGULANT COMPLEX Expanders - Drugs to Treat Blood FEIBA INJ Tier 2 X FOR INJ** Disorders Blood Products/Modifiers/Volume FONDAPARINUX INJ FONDAPARINUX SODIUM Expanders - Drugs to Treat Blood Tier 2 X 10/0.8ML SUBCUTANEOUS INJ 10 MG/0.8ML Disorders Blood Products/Modifiers/Volume FONDAPARINUX SODIUM Expanders - Drugs to Treat Blood FONDAPARINUX INJ 2.5/0.5 Tier 2 X SUBCUTANEOUS INJ 2.5 MG/0.5ML Disorders Blood Products/Modifiers/Volume FONDAPARINUX SODIUM Expanders - Drugs to Treat Blood FONDAPARINUX INJ 5/0.4ML Tier 2 X SUBCUTANEOUS INJ 5 MG/0.4ML Disorders Blood Products/Modifiers/Volume FONDAPARINUX SODIUM Expanders - Drugs to Treat Blood FONDAPARINUX INJ 7.5/0.6 Tier 2 X SUBCUTANEOUS INJ 7.5 MG/0.6ML Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood FRAGMIN INJ 10000/ML DALTEPARIN SODIUM INJ 10000 UNIT/ML Tier 3 X Disorders Blood Products/Modifiers/Volume DALTEPARIN SODIUM INJ 12500 Expanders - Drugs to Treat Blood FRAGMIN INJ 12500UNT Tier 3 X UNIT/0.5ML Disorders Blood Products/Modifiers/Volume DALTEPARIN SODIUM INJ 15000 Expanders - Drugs to Treat Blood FRAGMIN INJ 15000UNT Tier 3 X UNIT/0.6ML Disorders Blood Products/Modifiers/Volume DALTEPARIN SODIUM INJ 18000 Expanders - Drugs to Treat Blood FRAGMIN INJ 18000UNT Tier 3 X UNIT/0.72ML Disorders Blood Products/Modifiers/Volume DALTEPARIN SODIUM INJ 2500 Expanders - Drugs to Treat Blood FRAGMIN INJ 2500/0.2 Tier 3 X UNIT/0.2ML Disorders Blood Products/Modifiers/Volume DALTEPARIN SODIUM INJ 5000 Expanders - Drugs to Treat Blood FRAGMIN INJ 5000/0.2 Tier 3 X UNIT/0.2ML Disorders Blood Products/Modifiers/Volume DALTEPARIN SODIUM INJ 7500 Expanders - Drugs to Treat Blood FRAGMIN INJ 7500/0.3 Tier 3 X UNIT/0.3ML Disorders Blood Products/Modifiers/Volume DALTEPARIN SODIUM INJ 95000 Expanders - Drugs to Treat Blood FRAGMIN INJ 95000UNT Tier 3 UNIT/3.8ML Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (HUMAN) FOR Expanders - Drugs to Treat Blood HEMOFIL M INJ 1000UNIT Tier 2 X INJ 1000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (HUMAN) FOR Expanders - Drugs to Treat Blood HEMOFIL M INJ 1700UNIT Tier 2 X INJ 1700 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (HUMAN) FOR Expanders - Drugs to Treat Blood HEMOFIL M INJ 250UNIT Tier 2 X INJ 250 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (HUMAN) FOR Expanders - Drugs to Treat Blood HEMOFIL M INJ 500UNIT Tier 2 X INJ 500 UNIT Disorders

73 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Blood Products/Modifiers/Volume HEPARIN SODIUM (PORCINE) INJ 1000 Expanders - Drugs to Treat Blood HEPARIN SOD INJ 1000/ML Tier 1 UNIT/ML Disorders Blood Products/Modifiers/Volume HEPARIN SODIUM (PORCINE) INJ 10000 Expanders - Drugs to Treat Blood HEPARIN SOD INJ 10000/ML Tier 1 UNIT/ML Disorders Blood Products/Modifiers/Volume HEPARIN SODIUM (PORCINE) PF INJ Expanders - Drugs to Treat Blood HEPARIN SOD INJ 10000/ML Tier 1 5000 UNIT/0.5ML Disorders Blood Products/Modifiers/Volume HEPARIN SODIUM (PORCINE) INJ 20000 Expanders - Drugs to Treat Blood HEPARIN SOD INJ 20000/ML Tier 1 UNIT/ML Disorders Blood Products/Modifiers/Volume HEPARIN SODIUM (PORCINE) PF INJ Expanders - Drugs to Treat Blood HEPARIN SOD INJ 5000/0.5 Tier 1 5000 UNIT/0.5ML Disorders Blood Products/Modifiers/Volume HEPARIN SODIUM (PORCINE) INJ 5000 Expanders - Drugs to Treat Blood HEPARIN SOD INJ 5000/ML Tier 1 UNIT/ML Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR/VWF Expanders - Drugs to Treat Blood HUMATE-P SOL 2400UNIT Tier 2 X (HUMAN) FOR INJ 1000-2400 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR/VWF Expanders - Drugs to Treat Blood HUMATE-P SOL 250-600 Tier 2 X (HUMAN) FOR INJ 250-600 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR/VWF Expanders - Drugs to Treat Blood HUMATE-P SOL 500-1200 Tier 2 X (HUMAN) FOR INJ 500-1200 UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX (RECOMB) Expanders - Drugs to Treat Blood IDELVION SOL 1000UNIT Tier 3 X (RIX-FP) FOR INJ 1000 UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX (RECOMB) Expanders - Drugs to Treat Blood IDELVION SOL 2000UNIT Tier 3 X (RIX-FP) FOR INJ 2000 UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX (RECOMB) Expanders - Drugs to Treat Blood IDELVION SOL 250UNIT Tier 3 X (RIX-FP) FOR INJ 250 UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX (RECOMB) Expanders - Drugs to Treat Blood IDELVION SOL 500UNIT Tier 3 X (RIX-FP) FOR INJ 500 UNIT Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood JANTOVEN TAB 10MG WARFARIN SODIUM TAB 10 MG Tier 1 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood JANTOVEN TAB 1MG WARFARIN SODIUM TAB 1 MG Tier 1 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood JANTOVEN TAB 2.5MG WARFARIN SODIUM TAB 2.5 MG Tier 1 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood JANTOVEN TAB 2MG WARFARIN SODIUM TAB 2 MG Tier 1 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood JANTOVEN TAB 3MG WARFARIN SODIUM TAB 3 MG Tier 1 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood JANTOVEN TAB 4MG WARFARIN SODIUM TAB 4 MG Tier 1 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood JANTOVEN TAB 5MG WARFARIN SODIUM TAB 5 MG Tier 1 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood JANTOVEN TAB 6MG WARFARIN SODIUM TAB 6 MG Tier 1 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood JANTOVEN TAB 7.5MG WARFARIN SODIUM TAB 7.5 MG Tier 1 Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (HUMAN) FOR Expanders - Drugs to Treat Blood KOATE INJ 1000UNIT Tier 2 X INJ 1000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (HUMAN) FOR Expanders - Drugs to Treat Blood KOATE INJ 250UNIT Tier 2 X INJ 250 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (HUMAN) FOR Expanders - Drugs to Treat Blood KOATE INJ 500 UNIT Tier 2 X INJ 500 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (HUMAN) FOR Expanders - Drugs to Treat Blood KOATE-DVI INJ 1000UNIT Tier 2 X INJ 1000 UNIT Disorders

74 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (HUMAN) FOR Expanders - Drugs to Treat Blood KOATE-DVI INJ 250UNIT Tier 2 X INJ 250 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (HUMAN) FOR Expanders - Drugs to Treat Blood KOATE-DVI INJ 500UNIT Tier 2 X INJ 500 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood KOGENATE FS INJ 1000/BS Tier 2 X (RECOMBINANT) FOR INJ KIT 1000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood KOGENATE FS INJ 1000UNIT Tier 2 X (RECOMBINANT) FOR INJ KIT 1000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood KOGENATE FS INJ 2000/BS Tier 2 X (RECOMBINANT) FOR INJ KIT 2000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood KOGENATE FS INJ 2000UNIT Tier 2 X (RECOMBINANT) FOR INJ KIT 2000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood KOGENATE FS INJ 250/BS Tier 2 X (RECOMBINANT) FOR INJ KIT 250 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood KOGENATE FS INJ 250UNIT Tier 2 X (RECOMBINANT) FOR INJ KIT 250 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood KOGENATE FS INJ 3000/BS Tier 2 X (RECOMBINANT) FOR INJ KIT 3000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood KOGENATE FS INJ 3000UNIT Tier 2 X (RECOMBINANT) FOR INJ KIT 3000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood KOGENATE FS INJ 500/BS Tier 2 X (RECOMBINANT) FOR INJ KIT 500 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood KOGENATE FS INJ 500UNIT Tier 2 X (RECOMBINANT) FOR INJ KIT 500 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood KOVALTRY INJ 1000UNIT Tier 2 X (RECOMBINANT) FOR INJ 1000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood KOVALTRY INJ 2000UNIT Tier 2 X (RECOMBINANT) FOR INJ 2000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood KOVALTRY INJ 250UNIT Tier 2 X (RECOMBINANT) FOR INJ 250 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood KOVALTRY INJ 3000UNIT Tier 2 X (RECOMBINANT) FOR INJ 3000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood KOVALTRY INJ 500UNIT Tier 2 X (RECOMBINANT) FOR INJ 500 UNIT Disorders Blood Products/Modifiers/Volume SARGRAMOSTIM LYOPHILIZED FOR INJ Expanders - Drugs to Treat Blood LEUKINE INJ 250MCG Tier 2 X 250 MCG Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood LOVENOX INJ 100MG/ML ENOXAPARIN SODIUM INJ 100 MG/ML Tier 3 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood LOVENOX INJ 120/0.8 ENOXAPARIN SODIUM INJ 120 MG/0.8ML Tier 3 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood LOVENOX INJ 150MG/ML ENOXAPARIN SODIUM INJ 150 MG/ML Tier 3 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood LOVENOX INJ 30/0.3ML ENOXAPARIN SODIUM INJ 30 MG/0.3ML Tier 3 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood LOVENOX INJ 300/3ML ENOXAPARIN SODIUM INJ 300 MG/3ML Tier 3 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood LOVENOX INJ 40/0.4ML ENOXAPARIN SODIUM INJ 40 MG/0.4ML Tier 3 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood LOVENOX INJ 60/0.6ML ENOXAPARIN SODIUM INJ 60 MG/0.6ML Tier 3 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood LOVENOX INJ 80/0.8ML ENOXAPARIN SODIUM INJ 80 MG/0.8ML Tier 3 X Disorders

75 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood LYSTEDA TAB 650MG TRANEXAMIC ACID TAB 650 MG Tier 3 X Disorders Blood Products/Modifiers/Volume MONOCLATE-P INJ ANTIHEMOPHILIC FACTOR (HUMAN) FOR Expanders - Drugs to Treat Blood Tier 2 X 1000UNIT INJ KIT 1000 UNIT Disorders Blood Products/Modifiers/Volume MONOCLATE-P INJ ANTIHEMOPHILIC FACTOR (HUMAN) FOR Expanders - Drugs to Treat Blood Tier 2 X 1500UNIT INJ KIT 1500 UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX FOR INJ 1000 Expanders - Drugs to Treat Blood MONONINE INJ 1000UNIT Tier 2 X UNIT Disorders Blood Products/Modifiers/Volume MONSELS FERR SOL Expanders - Drugs to Treat Blood *FERRIC SUBSULFATE SOLN** Tier 1 SUBSULF Disorders Blood Products/Modifiers/Volume PLERIXAFOR SUBCUTANEOUS INJ 24 Expanders - Drugs to Treat Blood MOZOBIL INJ Tier 2 X MG/1.2ML (20 MG/ML) Disorders Blood Products/Modifiers/Volume PEGFILGRASTIM SOLN PREFILLED Expanders - Drugs to Treat Blood NEULASTA INJ 6MG/0.6M Tier 4 X SYRINGE 6 MG/0.6ML Disorders Blood Products/Modifiers/Volume *ANTICOAGULANT CITRATE DEXTROSE Expanders - Drugs to Treat Blood NOCLOT-50 SOL ACD-A Tier 3 SOLUTION A** Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood NOVOEIGHT INJ 1000UNIT Tier 4 X (RECOMBINANT) FOR INJ 1000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood NOVOEIGHT INJ 1500UNIT Tier 4 X (RECOMBINANT) FOR INJ 1500 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood NOVOEIGHT INJ 2000UNIT Tier 4 X (RECOMBINANT) FOR INJ 2000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood NOVOEIGHT INJ 250UNIT Tier 4 X (RECOMBINANT) FOR INJ 250 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood NOVOEIGHT INJ 3000UNIT Tier 4 X (RECOMBINANT) FOR INJ 3000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood NOVOEIGHT INJ 500UNIT Tier 4 X (RECOMBINANT) FOR INJ 500 UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR VIIA (RECOMB) Expanders - Drugs to Treat Blood NOVOSEVEN RT INJ 1MG Tier 2 X FOR INJ 1 MG (1000 MCG) Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR VIIA (RECOMB) Expanders - Drugs to Treat Blood NOVOSEVEN RT INJ 2MG Tier 2 X FOR INJ 2 MG (2000 MCG) Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR VIIA (RECOMB) Expanders - Drugs to Treat Blood NOVOSEVEN RT INJ 5MG Tier 2 X FOR INJ 5 MG (5000 MCG) Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR VIIA (RECOMB) Expanders - Drugs to Treat Blood NOVOSEVEN RT INJ 8MG Tier 2 X FOR INJ 8 MG (8000 MCG) Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (BDD-RFVIII) Expanders - Drugs to Treat Blood NUWIQ INJ 1000UNIT Tier 4 X FOR INJ 1000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (BDD-RFVIII) Expanders - Drugs to Treat Blood NUWIQ INJ 2000UNIT Tier 4 X FOR INJ 2000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (BDD-RFVIII) Expanders - Drugs to Treat Blood NUWIQ INJ 2500UNIT Tier 4 X FOR INJ 2500 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (BDD-RFVIII) Expanders - Drugs to Treat Blood NUWIQ INJ 250UNIT Tier 4 X FOR INJ 250 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (BDD-RFVIII) Expanders - Drugs to Treat Blood NUWIQ INJ 3000UNIT Tier 4 X FOR INJ 3000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (BDD-RFVIII) Expanders - Drugs to Treat Blood NUWIQ INJ 4000UNIT Tier 4 X FOR INJ 4000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (BDD-RFVIII) Expanders - Drugs to Treat Blood NUWIQ INJ 500UNIT Tier 4 X FOR INJ 500 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (BDD-RFVIII) Expanders - Drugs to Treat Blood NUWIQ KIT 1000UNIT Tier 4 X FOR INJ KIT 1000 UNIT Disorders

76 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (BDD-RFVIII) Expanders - Drugs to Treat Blood NUWIQ KIT 2000UNIT Tier 4 X FOR INJ KIT 2000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (BDD-RFVIII) Expanders - Drugs to Treat Blood NUWIQ KIT 2500UNIT Tier 4 X FOR INJ KIT 2500 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (BDD-RFVIII) Expanders - Drugs to Treat Blood NUWIQ KIT 250UNIT Tier 4 X FOR INJ KIT 250 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (BDD-RFVIII) Expanders - Drugs to Treat Blood NUWIQ KIT 3000UNIT Tier 4 X FOR INJ KIT 3000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (BDD-RFVIII) Expanders - Drugs to Treat Blood NUWIQ KIT 4000UNIT Tier 4 X FOR INJ KIT 4000 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR (BDD-RFVIII) Expanders - Drugs to Treat Blood NUWIQ KIT 500UNIT Tier 4 X FOR INJ KIT 500 UNIT Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood PLETAL TAB 100MG CILOSTAZOL TAB 100 MG Tier 3 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood PLETAL TAB 50MG CILOSTAZOL TAB 50 MG Tier 3 Disorders Blood Products/Modifiers/Volume DABIGATRAN ETEXILATE MESYLATE Expanders - Drugs to Treat Blood PRADAXA CAP 110MG Tier 2 X CAP 110 MG (ETEXILATE BASE EQ) Disorders Blood Products/Modifiers/Volume DABIGATRAN ETEXILATE MESYLATE Expanders - Drugs to Treat Blood PRADAXA CAP 150MG Tier 2 X CAP 150 MG (ETEXILATE BASE EQ) Disorders Blood Products/Modifiers/Volume DABIGATRAN ETEXILATE MESYLATE Expanders - Drugs to Treat Blood PRADAXA CAP 75MG Tier 2 X CAP 75 MG (ETEXILATE BASE EQ) Disorders Blood Products/Modifiers/Volume PRASUGREL HCL TAB 10 MG (BASE Expanders - Drugs to Treat Blood PRASUGREL TAB 10MG Tier 3 X EQUIV) Disorders Blood Products/Modifiers/Volume PRASUGREL HCL TAB 5 MG (BASE Expanders - Drugs to Treat Blood PRASUGREL TAB 5MG Tier 3 X EQUIV) Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood PROCRIT INJ 10000/ML EPOETIN ALFA INJ 10000 UNIT/ML Tier 2 X X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood PROCRIT INJ 2000/ML EPOETIN ALFA INJ 2000 UNIT/ML Tier 2 X X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood PROCRIT INJ 20000/ML EPOETIN ALFA INJ 20000 UNIT/ML Tier 2 X X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood PROCRIT INJ 3000/ML EPOETIN ALFA INJ 3000 UNIT/ML Tier 2 X X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood PROCRIT INJ 4000/ML EPOETIN ALFA INJ 4000 UNIT/ML Tier 2 X X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood PROCRIT INJ 40000/ML EPOETIN ALFA INJ 40000 UNIT/ML Tier 2 X X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood PROFILNINE INJ 1000UNIT FACTOR IX COMPLEX FOR INJ 1000 UNIT Tier 2 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood PROFILNINE INJ 1500UNIT FACTOR IX COMPLEX FOR INJ 1500 UNIT Tier 2 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood PROFILNINE INJ 500UNIT FACTOR IX COMPLEX FOR INJ 500 UNIT Tier 2 X Disorders Blood Products/Modifiers/Volume ELTROMBOPAG OLAMINE TAB 12.5 MG Expanders - Drugs to Treat Blood PROMACTA TAB 12.5MG Tier 4 X X (BASE EQUIV) Disorders Blood Products/Modifiers/Volume ELTROMBOPAG OLAMINE TAB 25 MG Expanders - Drugs to Treat Blood PROMACTA TAB 25MG Tier 4 X X (BASE EQUIV) Disorders Blood Products/Modifiers/Volume ELTROMBOPAG OLAMINE TAB 50 MG Expanders - Drugs to Treat Blood PROMACTA TAB 50MG Tier 4 X X (BASE EQUIV) Disorders Blood Products/Modifiers/Volume ELTROMBOPAG OLAMINE TAB 75 MG Expanders - Drugs to Treat Blood PROMACTA TAB 75MG Tier 4 X X (BASE EQUIV) Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood RECOMBINATE INJ Tier 4 X X X (RECOMBINANT) FOR INJ 1241-1800 UNIT Disorders 77 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood RECOMBINATE INJ (RECOMBINANT) FOR INJ 1801-2400 Tier 4 X X X Disorders UNIT Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood RECOMBINATE INJ 220-400 Tier 4 X X X (RECOMBINANT) FOR INJ 220-400 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood RECOMBINATE INJ 401-800 Tier 4 X X X (RECOMBINANT) FOR INJ 401-800 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood RECOMBINATE INJ 801-1240 Tier 4 X X X (RECOMBINANT) FOR INJ 801-1240 UNIT Disorders Blood Products/Modifiers/Volume RECOTHROM SOL THROMBIN (RECOMBINANT) FOR SOLN Expanders - Drugs to Treat Blood Tier 3 20000UNT 20000 UNIT Disorders Blood Products/Modifiers/Volume RECOTHROM SOL THROMBIN (RECOMBINANT) FOR SOLN Expanders - Drugs to Treat Blood Tier 3 5000UNIT 5000 UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX Expanders - Drugs to Treat Blood RIXUBIS INJ 1000UNIT Tier 2 X (RECOMBINANT) FOR INJ 1000 UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX Expanders - Drugs to Treat Blood RIXUBIS INJ 2000UNIT Tier 2 X (RECOMBINANT) FOR INJ 2000 UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX Expanders - Drugs to Treat Blood RIXUBIS INJ 250 UNIT Tier 2 X (RECOMBINANT) FOR INJ 250 UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX Expanders - Drugs to Treat Blood RIXUBIS INJ 3000UNIT Tier 2 X (RECOMBINANT) FOR INJ 3000 UNIT Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR IX Expanders - Drugs to Treat Blood RIXUBIS INJ 500UNIT Tier 2 X (RECOMBINANT) FOR INJ 500 UNIT Disorders Blood Products/Modifiers/Volume EDOXABAN TOSYLATE TAB 15 MG (BASE Expanders - Drugs to Treat Blood SAVAYSA TAB 15MG Tier 3 X EQUIVALENT) Disorders Blood Products/Modifiers/Volume EDOXABAN TOSYLATE TAB 30 MG (BASE Expanders - Drugs to Treat Blood SAVAYSA TAB 30MG Tier 3 X EQUIVALENT) Disorders Blood Products/Modifiers/Volume EDOXABAN TOSYLATE TAB 60 MG (BASE Expanders - Drugs to Treat Blood SAVAYSA TAB 60MG Tier 3 X EQUIVALENT) Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood THROMBIN KIT 5000UNIT THROMBIN FOR SOLN KIT 5000 UNIT Tier 3 Disorders Blood Products/Modifiers/Volume THROMBIN-JMI KIT Expanders - Drugs to Treat Blood THROMBIN FOR SOLN KIT 20000 UNIT Tier 3 20000UNT Disorders Blood Products/Modifiers/Volume THROMBIN-JMI KIT Expanders - Drugs to Treat Blood THROMBIN FOR SOLN KIT 5000 UNIT Tier 3 5000UNIT Disorders Blood Products/Modifiers/Volume THROMBOGEN KIT Expanders - Drugs to Treat Blood THROMBIN FOR SOLN KIT 10000 UNIT Tier 3 10000UNT Disorders Blood Products/Modifiers/Volume THROMBOGEN SOL Expanders - Drugs to Treat Blood THROMBIN FOR SOLN 10000 UNIT Tier 3 10000UNT Disorders Blood Products/Modifiers/Volume THROMBOGEN SOL Expanders - Drugs to Treat Blood THROMBIN FOR SOLN 1000 UNIT Tier 3 1000UNIT Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood TRANEX ACID TAB 650MG TRANEXAMIC ACID TAB 650 MG Tier 2 X Disorders Blood Products/Modifiers/Volume COAGULATION FACTOR XIII A-SUBUNIT Expanders - Drugs to Treat Blood TRETTEN INJ Tier 3 X FOR INJ 2000-3125 UNIT Disorders Blood Products/Modifiers/Volume ANTICOAGULANT SODIUM CITRATE Expanders - Drugs to Treat Blood TRICITRASOL CON Tier 3 CONCENTRATE 46.7% Disorders Blood Products/Modifiers/Volume VON WILLEBRAND FACTOR Expanders - Drugs to Treat Blood VONVENDI INJ 1300UNIT Tier 2 X (RECOMBINANT) FOR INJ 1300 UNIT Disorders Blood Products/Modifiers/Volume VON WILLEBRAND FACTOR Expanders - Drugs to Treat Blood VONVENDI INJ 650UNIT Tier 2 X (RECOMBINANT) FOR INJ 650 UNIT Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood WARFARIN TAB 10MG WARFARIN SODIUM TAB 10 MG Tier 1 Disorders

78 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood WARFARIN TAB 1MG WARFARIN SODIUM TAB 1 MG Tier 1 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood WARFARIN TAB 2.5MG WARFARIN SODIUM TAB 2.5 MG Tier 1 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood WARFARIN TAB 2MG WARFARIN SODIUM TAB 2 MG Tier 1 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood WARFARIN TAB 3MG WARFARIN SODIUM TAB 3 MG Tier 1 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood WARFARIN TAB 4MG WARFARIN SODIUM TAB 4 MG Tier 1 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood WARFARIN TAB 5MG WARFARIN SODIUM TAB 5 MG Tier 1 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood WARFARIN TAB 6MG WARFARIN SODIUM TAB 6 MG Tier 1 Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood WARFARIN TAB 7.5MG WARFARIN SODIUM TAB 7.5 MG Tier 1 Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR/VWF Expanders - Drugs to Treat Blood WILATE INJ Tier 2 X (HUMAN) FOR INJ 500-500 UNIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR/VWF Expanders - Drugs to Treat Blood WILATE INJ Tier 2 X (HUMAN) FOR INJ 500-500 UNIT KIT Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR/VWF Expanders - Drugs to Treat Blood WILATE INJ Tier 2 X (HUMAN) FOR INJ 1000-1000 UNIT KIT Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood XARELTO TAB 10MG RIVAROXABAN TAB 10 MG Tier 2 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood XARELTO TAB 15MG RIVAROXABAN TAB 15 MG Tier 2 X Disorders Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood XARELTO TAB 20MG RIVAROXABAN TAB 20 MG Tier 2 X Disorders Blood Products/Modifiers/Volume XARELTO STAR TAB RIVAROXABAN TAB STARTER THERAPY Expanders - Drugs to Treat Blood Tier 2 15/20MG PACK 15 MG & 20 MG Disorders Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood XYNTHA INJ 1000UNIT RECOMBINANT PAF FOR INJ KIT 1000 Tier 4 X X X Disorders UNIT Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood XYNTHA INJ 2000UNIT RECOMBINANT PAF FOR INJ KIT 2000 Tier 4 X X X Disorders UNIT Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood XYNTHA INJ 250UNIT RECOMBINANT PAF FOR INJ KIT 250 Tier 4 X X X Disorders UNIT Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood XYNTHA INJ 500UNIT RECOMBINANT PAF FOR INJ KIT 500 Tier 4 X X X Disorders UNIT Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR XYNTHA SOLOF INJ Expanders - Drugs to Treat Blood RECOMBINANT PAF FOR INJ KIT 1000 Tier 4 X X X 1000UNIT Disorders UNIT Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR XYNTHA SOLOF INJ Expanders - Drugs to Treat Blood RECOMBINANT PAF FOR INJ KIT 2000 Tier 4 X X X 2000UNIT Disorders UNIT Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR XYNTHA SOLOF INJ Expanders - Drugs to Treat Blood RECOMBINANT PAF FOR INJ KIT 3000 Tier 4 X X X 3000UNIT Disorders UNIT Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood XYNTHA SOLOF INJ 500UNIT RECOMBINANT PAF FOR INJ KIT 500 Tier 4 X X X Disorders UNIT Blood Products/Modifiers/Volume ANTIHEMOPHILIC FACTOR Expanders - Drugs to Treat Blood XYNTHA SOLOF KIT 250UNIT RECOMBINANT PAF FOR INJ KIT 250 Tier 4 X X X Disorders UNIT Blood Products/Modifiers/Volume FILGRASTIM-SNDZ SOLN PREFILLED Expanders - Drugs to Treat Blood ZARXIO INJ 300/0.5 Tier 2 X SYRINGE 300 MCG/0.5ML Disorders Blood Products/Modifiers/Volume FILGRASTIM-SNDZ SOLN PREFILLED Expanders - Drugs to Treat Blood ZARXIO INJ 480/0.8 Tier 2 X SYRINGE 480 MCG/0.8ML Disorders

79 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Blood Products/Modifiers/Volume VORAPAXAR SULFATE TAB 2.08 MG Expanders - Drugs to Treat Blood ZONTIVITY TAB 2.08MG Tier 3 X (BASE EQUIVALENT) Disorders Cardiovascular Agents - Drugs to Treat ACCUPRIL TAB 10MG QUINAPRIL HCL TAB 10 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ACCUPRIL TAB 20MG QUINAPRIL HCL TAB 20 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ACCUPRIL TAB 40MG QUINAPRIL HCL TAB 40 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ACCUPRIL TAB 5MG QUINAPRIL HCL TAB 5 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat QUINAPRIL-HYDROCHLOROTHIAZIDE ACCURETIC TAB 10-12.5 Tier 3 Heart and Circulation Conditions TAB 10-12.5 MG Cardiovascular Agents - Drugs to Treat QUINAPRIL-HYDROCHLOROTHIAZIDE ACCURETIC TAB 20-12.5 Tier 3 Heart and Circulation Conditions TAB 20-12.5 MG Cardiovascular Agents - Drugs to Treat QUINAPRIL-HYDROCHLOROTHIAZIDE ACCURETIC TAB 20-25MG Tier 3 Heart and Circulation Conditions TAB 20-25 MG Cardiovascular Agents - Drugs to Treat ACEBUTOLOL CAP 200MG ACEBUTOLOL HCL CAP 200 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ACEBUTOLOL CAP 400MG ACEBUTOLOL HCL CAP 400 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ACEON TAB 4MG PERINDOPRIL ERBUMINE TAB 4 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ACEON TAB 8MG PERINDOPRIL ERBUMINE TAB 8 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ACETAZOLAMID CAP ACETAZOLAMIDE CAP ER 12HR 500 MG Tier 1 Heart and Circulation Conditions 500MG ER Cardiovascular Agents - Drugs to Treat ACETAZOLAMID TAB 125MG ACETAZOLAMIDE TAB 125 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ACETAZOLAMID TAB 250MG ACETAZOLAMIDE TAB 250 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ADALAT CC TAB 30MG ER NIFEDIPINE TAB ER 24HR 30 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ADALAT CC TAB 30MG ER NIFEDIPINE TAB SR 24HR 30 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ADALAT CC TAB 60MG ER NIFEDIPINE TAB ER 24HR 60 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ADALAT CC TAB 90MG ER NIFEDIPINE TAB ER 24HR 90 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ADRENALIN SOL 1:1000 EPINEPHRINE HCL NASAL SOLN 0.1% Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat AFEDITAB TAB 30MG CR NIFEDIPINE TAB ER 24HR 30 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat AFEDITAB TAB 60MG CR NIFEDIPINE TAB ER 24HR 60 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat SPIRONOLACTONE & ALDACTAZIDE TAB 25/25 Tier 3 Heart and Circulation Conditions HYDROCHLOROTHIAZIDE TAB 25-25 MG Cardiovascular Agents - Drugs to Treat SPIRONOLACTONE & ALDACTAZIDE TAB 50/50 Tier 2 Heart and Circulation Conditions HYDROCHLOROTHIAZIDE TAB 50-50 MG Cardiovascular Agents - Drugs to Treat ALDACTONE TAB 100MG SPIRONOLACTONE TAB 100 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ALDACTONE TAB 25MG SPIRONOLACTONE TAB 25 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ALDACTONE TAB 50MG SPIRONOLACTONE TAB 50 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ALTACE CAP 1.25MG RAMIPRIL CAP 1.25 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ALTACE CAP 10MG RAMIPRIL CAP 10 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ALTACE CAP 2.5MG RAMIPRIL CAP 2.5 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ALTACE CAP 5MG RAMIPRIL CAP 5 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat AMILORIDE & HYDROCHLOROTHIAZIDE AMILOR/HCTZ TAB 5-50 Tier 1 Heart and Circulation Conditions TAB 5-50 MG Cardiovascular Agents - Drugs to Treat AMILORIDE TAB 5MG AMILORIDE HCL TAB 5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat AMIODARONE TAB 100MG AMIODARONE HCL TAB 100 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat AMIODARONE TAB 200MG AMIODARONE HCL TAB 200 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat AMIODARONE TAB 400MG AMIODARONE HCL TAB 400 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat AMLOD/BENAZP CAP 10- AMLODIPINE BESYLATE-BENAZEPRIL Tier 1 Heart and Circulation Conditions 20MG HCL CAP 10-20 MG Cardiovascular Agents - Drugs to Treat AMLOD/BENAZP CAP 10- AMLODIPINE BESYLATE-BENAZEPRIL Tier 1 Heart and Circulation Conditions 40MG HCL CAP 10-40 MG

80 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Cardiovascular Agents - Drugs to Treat AMLOD/BENAZP CAP 2.5- AMLODIPINE BESYLATE-BENAZEPRIL Tier 1 Heart and Circulation Conditions 10MG HCL CAP 2.5-10 MG Cardiovascular Agents - Drugs to Treat AMLOD/BENAZP CAP AMLODIPINE BESYLATE-BENAZEPRIL Tier 1 Heart and Circulation Conditions 5-10MG HCL CAP 5-10 MG Cardiovascular Agents - Drugs to Treat AMLOD/BENAZP CAP AMLODIPINE BESYLATE-BENAZEPRIL Tier 1 Heart and Circulation Conditions 5-20MG HCL CAP 5-20 MG Cardiovascular Agents - Drugs to Treat AMLOD/BENAZP CAP AMLODIPINE BESYLATE-BENAZEPRIL Tier 1 Heart and Circulation Conditions 5-40MG HCL CAP 5-40 MG Cardiovascular Agents - Drugs to Treat AMLOD/VALSAR TAB 10- AMLODIPINE BESYLATE-VALSARTAN TAB Tier 2 Heart and Circulation Conditions 160MG 10-160 MG Cardiovascular Agents - Drugs to Treat AMLOD/VALSAR TAB 10- AMLODIPINE BESYLATE-VALSARTAN TAB Tier 2 Heart and Circulation Conditions 320MG 10-320 MG Cardiovascular Agents - Drugs to Treat AMLOD/VALSAR TAB AMLODIPINE BESYLATE-VALSARTAN TAB Tier 2 Heart and Circulation Conditions 5-160MG 5-160 MG Cardiovascular Agents - Drugs to Treat AMLOD/VALSAR TAB AMLODIPINE BESYLATE-VALSARTAN TAB Tier 2 Heart and Circulation Conditions 5-320MG 5-320 MG Cardiovascular Agents - Drugs to Treat AMLODIPINE TAB 10MG AMLODIPINE BESYLATE TAB 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat AMLODIPINE TAB 2.5MG AMLODIPINE BESYLATE TAB 2.5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat AMLODIPINE TAB 5MG AMLODIPINE BESYLATE TAB 5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ATACAND TAB 16MG CANDESARTAN CILEXETIL TAB 16 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ATACAND TAB 32MG CANDESARTAN CILEXETIL TAB 32 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ATACAND TAB 4MG CANDESARTAN CILEXETIL TAB 4 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ATACAND TAB 8MG CANDESARTAN CILEXETIL TAB 8 MG Tier 3 Heart and Circulation Conditions CANDESARTAN CILEXETIL- Cardiovascular Agents - Drugs to Treat ATACAND HCT TAB 16-12.5 HYDROCHLOROTHIAZIDE TAB 16-12.5 Tier 3 Heart and Circulation Conditions MG CANDESARTAN CILEXETIL- Cardiovascular Agents - Drugs to Treat ATACAND HCT TAB 32-12.5 HYDROCHLOROTHIAZIDE TAB 32-12.5 Tier 3 Heart and Circulation Conditions MG Cardiovascular Agents - Drugs to Treat CANDESARTAN CILEXETIL- ATACAND HCT TAB 32-25MG Tier 3 Heart and Circulation Conditions HYDROCHLOROTHIAZIDE TAB 32-25 MG Cardiovascular Agents - Drugs to Treat ATENOL/CHLOR TAB 100- ATENOLOL & CHLORTHALIDONE TAB Tier 1 Heart and Circulation Conditions 25MG 100-25 MG Cardiovascular Agents - Drugs to Treat ATENOL/CHLOR TAB 50- ATENOLOL & CHLORTHALIDONE TAB Tier 1 Heart and Circulation Conditions 25MG 50-25 MG Cardiovascular Agents - Drugs to Treat ATENOLOL TAB 100MG ATENOLOL TAB 100 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ATENOLOL TAB 25MG ATENOLOL TAB 25 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ATENOLOL TAB 50MG ATENOLOL TAB 50 MG Tier 1 Heart and Circulation Conditions HCR Cardiovascular Agents - Drugs to Treat ATORVASTATIN CALCIUM TAB 10 MG ATORVASTATIN TAB 10MG Preventive X Heart and Circulation Conditions (BASE EQUIVALENT) Care HCR Cardiovascular Agents - Drugs to Treat ATORVASTATIN CALCIUM TAB 20 MG ATORVASTATIN TAB 20MG Preventive X Heart and Circulation Conditions (BASE EQUIVALENT) Care Cardiovascular Agents - Drugs to Treat ATORVASTATIN CALCIUM TAB 40 MG ATORVASTATIN TAB 40MG Tier 1 X Heart and Circulation Conditions (BASE EQUIVALENT) Cardiovascular Agents - Drugs to Treat ATORVASTATIN CALCIUM TAB 80 MG ATORVASTATIN TAB 80MG Tier 1 X Heart and Circulation Conditions (BASE EQUIVALENT) Cardiovascular Agents - Drugs to Treat IRBESARTAN-HYDROCHLOROTHIAZIDE AVALIDE TAB 150-12.5 Tier 3 Heart and Circulation Conditions TAB 150-12.5 MG Cardiovascular Agents - Drugs to Treat IRBESARTAN-HYDROCHLOROTHIAZIDE AVALIDE TAB 300-12.5 Tier 3 Heart and Circulation Conditions TAB 300-12.5 MG Cardiovascular Agents - Drugs to Treat AVAPRO TAB 150MG IRBESARTAN TAB 150 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat AVAPRO TAB 300MG IRBESARTAN TAB 300 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat AVAPRO TAB 75MG IRBESARTAN TAB 75 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat BENAZEPRIL & HYDROCHLOROTHIAZIDE BENAZEP/HCTZ TAB 10-12.5 Tier 1 Heart and Circulation Conditions TAB 10-12.5 MG Cardiovascular Agents - Drugs to Treat BENAZEPRIL & HYDROCHLOROTHIAZIDE BENAZEP/HCTZ TAB 20-12.5 Tier 1 Heart and Circulation Conditions TAB 20-12.5 MG Cardiovascular Agents - Drugs to Treat BENAZEP/HCTZ TAB 20- BENAZEPRIL & HYDROCHLOROTHIAZIDE Tier 1 Heart and Circulation Conditions 25MG TAB 20-25 MG Cardiovascular Agents - Drugs to Treat BENAZEPRIL & HYDROCHLOROTHIAZIDE BENAZEP/HCTZ TAB 5-6.25 Tier 1 Heart and Circulation Conditions TAB 5-6.25 MG Cardiovascular Agents - Drugs to Treat BENAZEPRIL TAB 10MG BENAZEPRIL HCL TAB 10 MG Tier 1 Heart and Circulation Conditions

81 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Cardiovascular Agents - Drugs to Treat BENAZEPRIL TAB 20MG BENAZEPRIL HCL TAB 20 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat BENAZEPRIL TAB 40MG BENAZEPRIL HCL TAB 40 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat BENAZEPRIL TAB 5MG BENAZEPRIL HCL TAB 5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat BETAPACE AF TAB 120MG SOTALOL HCL (AFIB/AFL) TAB 120 MG Tier 4 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat BETAPACE AF TAB 160MG SOTALOL HCL (AFIB/AFL) TAB 160 MG Tier 4 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat BETAPACE AF TAB 80MG SOTALOL HCL (AFIB/AFL) TAB 80 MG Tier 4 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat BETAXOLOL TAB 10MG BETAXOLOL HCL TAB 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat BETAXOLOL TAB 20MG BETAXOLOL HCL TAB 20 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ISOSORBIDE DINITRATE-HYDRALAZINE BIDIL TAB Tier 2 Heart and Circulation Conditions HCL TAB 20-37.5 MG BISOPROLOL & Cardiovascular Agents - Drugs to Treat BISOPRL/HCTZ TAB 10/6.25 HYDROCHLOROTHIAZIDE TAB 10-6.25 Tier 1 Heart and Circulation Conditions MG BISOPROLOL & Cardiovascular Agents - Drugs to Treat BISOPRL/HCTZ TAB 2.5/6.25 HYDROCHLOROTHIAZIDE TAB 2.5-6.25 Tier 1 Heart and Circulation Conditions MG Cardiovascular Agents - Drugs to Treat BISOPRL/HCTZ TAB BISOPROLOL & Tier 1 Heart and Circulation Conditions 5-6.25MG HYDROCHLOROTHIAZIDE TAB 5-6.25 MG Cardiovascular Agents - Drugs to Treat BISOPROL FUM TAB 10MG BISOPROLOL FUMARATE TAB 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat BISOPROL FUM TAB 5MG BISOPROLOL FUMARATE TAB 5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat BUMETANIDE TAB 0.5MG BUMETANIDE TAB 0.5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat BUMETANIDE TAB 1MG BUMETANIDE TAB 1 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat BUMETANIDE TAB 2MG BUMETANIDE TAB 2 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat BUMEX TAB 0.5MG BUMETANIDE TAB 0.5 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat BUMEX TAB 1MG BUMETANIDE TAB 1 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat BUMEX TAB 2MG BUMETANIDE TAB 2 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NEBIVOLOL HCL TAB 10 MG (BASE BYSTOLIC TAB 10MG Tier 2 Heart and Circulation Conditions EQUIVALENT) Cardiovascular Agents - Drugs to Treat NEBIVOLOL HCL TAB 2.5 MG (BASE BYSTOLIC TAB 2.5MG Tier 2 Heart and Circulation Conditions EQUIVALENT) Cardiovascular Agents - Drugs to Treat NEBIVOLOL HCL TAB 20 MG (BASE BYSTOLIC TAB 20MG Tier 2 Heart and Circulation Conditions EQUIVALENT) Cardiovascular Agents - Drugs to Treat NEBIVOLOL HCL TAB 5 MG (BASE BYSTOLIC TAB 5MG Tier 2 Heart and Circulation Conditions EQUIVALENT) Cardiovascular Agents - Drugs to Treat BYVALSON TAB 5-80MG NEBIVOLOL-VALSARTAN TAB 5-80 MG Tier 2 X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CALAN TAB 120MG VERAPAMIL HCL TAB 120 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CALAN TAB 80MG VERAPAMIL HCL TAB 80 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CALAN SR TAB 120MG VERAPAMIL HCL TAB CR 120 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CALAN SR TAB 180MG VERAPAMIL HCL TAB CR 180 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CALAN SR TAB 240MG VERAPAMIL HCL TAB CR 240 MG Tier 3 Heart and Circulation Conditions CANDESARTAN CILEXETIL- Cardiovascular Agents - Drugs to Treat CANDESA/HCTZ TAB 16-12.5 HYDROCHLOROTHIAZIDE TAB 16-12.5 Tier 3 Heart and Circulation Conditions MG CANDESARTAN CILEXETIL- Cardiovascular Agents - Drugs to Treat CANDESA/HCTZ TAB 32-12.5 HYDROCHLOROTHIAZIDE TAB 32-12.5 Tier 3 Heart and Circulation Conditions MG Cardiovascular Agents - Drugs to Treat CANDESA/HCTZ TAB 32- CANDESARTAN CILEXETIL- Tier 3 Heart and Circulation Conditions 25MG HYDROCHLOROTHIAZIDE TAB 32-25 MG Cardiovascular Agents - Drugs to Treat CANDESARTAN TAB 16MG CANDESARTAN CILEXETIL TAB 16 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CANDESARTAN TAB 32MG CANDESARTAN CILEXETIL TAB 32 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CANDESARTAN TAB 4MG CANDESARTAN CILEXETIL TAB 4 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CANDESARTAN TAB 8MG CANDESARTAN CILEXETIL TAB 8 MG Tier 3 Heart and Circulation Conditions

82 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Cardiovascular Agents - Drugs to Treat CAPTOPR/HCTZ TAB 25- CAPTOPRIL & HYDROCHLOROTHIAZIDE Tier 1 Heart and Circulation Conditions 15MG TAB 25-15 MG Cardiovascular Agents - Drugs to Treat CAPTOPR/HCTZ TAB 25- CAPTOPRIL & HYDROCHLOROTHIAZIDE Tier 1 Heart and Circulation Conditions 25MG TAB 25-25 MG Cardiovascular Agents - Drugs to Treat CAPTOPR/HCTZ TAB 50- CAPTOPRIL & HYDROCHLOROTHIAZIDE Tier 1 Heart and Circulation Conditions 15MG TAB 50-15 MG Cardiovascular Agents - Drugs to Treat CAPTOPR/HCTZ TAB 50- CAPTOPRIL & HYDROCHLOROTHIAZIDE Tier 1 Heart and Circulation Conditions 25MG TAB 50-25 MG Cardiovascular Agents - Drugs to Treat CAPTOPRIL TAB 100MG CAPTOPRIL TAB 100 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CAPTOPRIL TAB 12.5MG CAPTOPRIL TAB 12.5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CAPTOPRIL TAB 25MG CAPTOPRIL TAB 25 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CAPTOPRIL TAB 50MG CAPTOPRIL TAB 50 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CARDURA TAB 1MG DOXAZOSIN MESYLATE TAB 1 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CARDURA TAB 2MG DOXAZOSIN MESYLATE TAB 2 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CARDURA TAB 4MG DOXAZOSIN MESYLATE TAB 4 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CARDURA TAB 8MG DOXAZOSIN MESYLATE TAB 8 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS CAP ER CARTIA XT CAP 120/24HR Tier 2 Heart and Circulation Conditions 24HR 120 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS CAP ER CARTIA XT CAP 180/24HR Tier 2 Heart and Circulation Conditions 24HR 180 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS CAP ER CARTIA XT CAP 240/24HR Tier 2 Heart and Circulation Conditions 24HR 240 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS CAP ER CARTIA XT CAP 300/24HR Tier 2 Heart and Circulation Conditions 24HR 300 MG Cardiovascular Agents - Drugs to Treat CARVEDILOL TAB 12.5MG CARVEDILOL TAB 12.5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CARVEDILOL TAB 25MG CARVEDILOL TAB 25 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CARVEDILOL TAB 3.125MG CARVEDILOL TAB 3.125 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CARVEDILOL TAB 6.25MG CARVEDILOL TAB 6.25 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CATAPRES TAB 0.1MG CLONIDINE HCL TAB 0.1 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CATAPRES TAB 0.2MG CLONIDINE HCL TAB 0.2 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CATAPRES TAB 0.3MG CLONIDINE HCL TAB 0.3 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CLONIDINE HCL TD PATCH WEEKLY 0.1 CATAPRES-TTS DIS 0.1/24HR Tier 3 Heart and Circulation Conditions MG/24HR Cardiovascular Agents - Drugs to Treat CATAPRES-TTS DIS CLONIDINE HCL TD PATCH WEEKLY 0.2 Tier 3 Heart and Circulation Conditions 0.2/24HR MG/24HR Cardiovascular Agents - Drugs to Treat CLONIDINE HCL TD PATCH WEEKLY 0.3 CATAPRES-TTS DIS 0.3/24HR Tier 3 Heart and Circulation Conditions MG/24HR Cardiovascular Agents - Drugs to Treat CHLOROTHIAZ TAB 250MG CHLOROTHIAZIDE TAB 250 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CHLOROTHIAZ TAB 500MG CHLOROTHIAZIDE TAB 500 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CHLORTHALID TAB 25MG CHLORTHALIDONE TAB 25 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CHLORTHALID TAB 50MG CHLORTHALIDONE TAB 50 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CHOLESTYRAMINE POWDER 4 GM/ CHOLESTYRAM POW 4GM Tier 1 Heart and Circulation Conditions DOSE Cardiovascular Agents - Drugs to Treat CHOLESTYRAMINE POWDER PACKETS CHOLESTYRAM POW 4GM Tier 1 Heart and Circulation Conditions 4 GM Cardiovascular Agents - Drugs to Treat CHOLESTYRAM POW 4GM CHOLESTYRAMINE LIGHT POWDER 4 Tier 1 Heart and Circulation Conditions LITE GM/DOSE Cardiovascular Agents - Drugs to Treat CHOLESTYRAM POW 4GM CHOLESTYRAMINE LIGHT POWDER Tier 1 Heart and Circulation Conditions LITE PACKETS 4 GM Cardiovascular Agents - Drugs to Treat CHOLESTYRAMI POW CHOLESTYRAMINE (BULK) POWDER Tier 3 X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CHOLESTYRAMI POW RESIN CHOLESTYRAMINE (BULK) POWDER Tier 3 X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CLONIDINE HCL TD PATCH WEEKLY 0.1 CLONIDINE DIS 0.1/24HR Tier 3 Heart and Circulation Conditions MG/24HR Cardiovascular Agents - Drugs to Treat CLONIDINE HCL TD PATCH WEEKLY 0.2 CLONIDINE DIS 0.2/24HR Tier 3 Heart and Circulation Conditions MG/24HR Cardiovascular Agents - Drugs to Treat CLONIDINE HCL TD PATCH WEEKLY 0.3 CLONIDINE DIS 0.3/24HR Tier 3 Heart and Circulation Conditions MG/24HR

83 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Cardiovascular Agents - Drugs to Treat CLONIDINE TAB 0.1MG CLONIDINE HCL TAB 0.1 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CLONIDINE TAB 0.2MG CLONIDINE HCL TAB 0.2 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CLONIDINE TAB 0.3MG CLONIDINE HCL TAB 0.3 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CLONIDINE & CHLORTHALIDONE TAB CLORPRES TAB 0.1-15MG Tier 2 Heart and Circulation Conditions 0.1-15 MG Cardiovascular Agents - Drugs to Treat CLONIDINE & CHLORTHALIDONE TAB CLORPRES TAB 0.2-15MG Tier 2 Heart and Circulation Conditions 0.2-15 MG Cardiovascular Agents - Drugs to Treat CLONIDINE & CHLORTHALIDONE TAB CLORPRES TAB 0.3-15MG Tier 2 Heart and Circulation Conditions 0.3-15 MG Cardiovascular Agents - Drugs to Treat COLESTID GRA 5GM COLESTIPOL HCL GRANULES 5 GM Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat COLESTIPOL HCL GRANULE PACKETS COLESTID POW 5GM Tier 3 Heart and Circulation Conditions 5 GM Cardiovascular Agents - Drugs to Treat COLESTID TAB 1GM COLESTIPOL HCL TAB 1 GM Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat COLESTIPOL HCL GRANULE PACKETS COLESTID FLA GRA 5/7.5GM Tier 3 Heart and Circulation Conditions 5 GM Cardiovascular Agents - Drugs to Treat COLESTID FLA GRA 5GM COLESTIPOL HCL GRANULES 5 GM Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat COLESTIPOL HCL GRANULE PACKETS COLESTIPOL GRA 5GM Tier 1 Heart and Circulation Conditions 5 GM Cardiovascular Agents - Drugs to Treat COLESTIPOL GRA 5GM COLESTIPOL HCL GRANULES 5 GM Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat COLESTIPOL TAB 1GM COLESTIPOL HCL TAB 1 GM Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat COREG TAB 12.5MG CARVEDILOL TAB 12.5 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat COREG TAB 25MG CARVEDILOL TAB 25 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat COREG TAB 3.125MG CARVEDILOL TAB 3.125 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat COREG TAB 6.25MG CARVEDILOL TAB 6.25 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CORGARD TAB 20MG NADOLOL TAB 20 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CORGARD TAB 40MG NADOLOL TAB 40 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CORGARD TAB 80MG NADOLOL TAB 80 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat IVABRADINE HCL TAB 5 MG (BASE CORLANOR TAB 5MG Tier 3 X X Heart and Circulation Conditions EQUIV) Cardiovascular Agents - Drugs to Treat IVABRADINE HCL TAB 7.5 MG (BASE CORLANOR TAB 7.5MG Tier 3 X X Heart and Circulation Conditions EQUIV) Cardiovascular Agents - Drugs to Treat NADOLOL & BENDROFLUMETHIAZIDE CORZIDE TAB 40-5MG Tier 3 Heart and Circulation Conditions TAB 40-5 MG Cardiovascular Agents - Drugs to Treat NADOLOL & BENDROFLUMETHIAZIDE CORZIDE TAB 80-5MG Tier 3 Heart and Circulation Conditions TAB 80-5 MG Cardiovascular Agents - Drugs to Treat COZAAR TAB 100MG LOSARTAN POTASSIUM TAB 100 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat COZAAR TAB 25MG LOSARTAN POTASSIUM TAB 25 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat COZAAR TAB 50MG LOSARTAN POTASSIUM TAB 50 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DEMADEX TAB 10MG TORSEMIDE TAB 10 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DEMADEX TAB 20MG TORSEMIDE TAB 20 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DEMADEX TAB 5MG TORSEMIDE TAB 5 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DEMSER CAP 250MG METYROSINE CAP 250 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DIAMOX SEQUE CAP 500MG ACETAZOLAMIDE CAP ER 12HR 500 MG Tier 3 Heart and Circulation Conditions CR Cardiovascular Agents - Drugs to Treat DIGITEK TAB 0.125MG DIGOXIN TAB 125 MCG (0.125 MG) Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DIGITEK TAB 0.25MG DIGOXIN TAB 250 MCG (0.25 MG) Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DIGOX TAB 0.125MG DIGOXIN TAB 125 MCG (0.125 MG) Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DIGOX TAB 0.25MG DIGOXIN TAB 250 MCG (0.25 MG) Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DIGOXIN SOL 50MCG/ML DIGOXIN ORAL SOLN 0.05 MG/ML Tier 1 Heart and Circulation Conditions

84 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Cardiovascular Agents - Drugs to Treat DIGOXIN TAB 0.125MG DIGOXIN TAB 125 MCG (0.125 MG) Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DIGOXIN TAB 0.25MG DIGOXIN TAB 250 MCG (0.25 MG) Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DILATRATE SR CAP 40MG ISOSORBIDE DINITRATE CAP ER 40 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS CAP ER DILTIAZEM CAP 120MG CD Tier 2 Heart and Circulation Conditions 24HR 120 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS CAP ER DILTIAZEM CAP 120MG ER Tier 2 Heart and Circulation Conditions 24HR 120 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM CAP 120MG ER DILTIAZEM HCL CAP ER 24HR 120 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DILTIAZEM CAP 120MG ER DILTIAZEM HCL CAP ER 12HR 120 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE DILTIAZEM CAP 120MG ER Tier 2 Heart and Circulation Conditions BEADS CAP ER 24HR 120 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE DILTIAZEM CAP 120MG/24 Tier 2 Heart and Circulation Conditions BEADS CAP ER 24HR 120 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS CAP ER DILTIAZEM CAP 180MG CD Tier 2 Heart and Circulation Conditions 24HR 180 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS CAP ER DILTIAZEM CAP 180MG ER Tier 2 Heart and Circulation Conditions 24HR 180 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM CAP 180MG ER DILTIAZEM HCL CAP ER 24HR 180 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE DILTIAZEM CAP 180MG ER Tier 2 Heart and Circulation Conditions BEADS CAP ER 24HR 180 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE DILTIAZEM CAP 180MG/24 Tier 2 Heart and Circulation Conditions BEADS CAP ER 24HR 180 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS CAP ER DILTIAZEM CAP 240MG CD Tier 2 Heart and Circulation Conditions 24HR 240 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS CAP ER DILTIAZEM CAP 240MG ER Tier 2 Heart and Circulation Conditions 24HR 240 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM CAP 240MG ER DILTIAZEM HCL CAP ER 24HR 240 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE DILTIAZEM CAP 240MG ER Tier 2 Heart and Circulation Conditions BEADS CAP ER 24HR 240 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE DILTIAZEM CAP 240MG/24 Tier 2 Heart and Circulation Conditions BEADS CAP ER 24HR 240 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS CAP ER DILTIAZEM CAP 300MG CD Tier 2 Heart and Circulation Conditions 24HR 300 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS CAP ER DILTIAZEM CAP 300MG ER Tier 2 Heart and Circulation Conditions 24HR 300 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE DILTIAZEM CAP 300MG ER Tier 2 Heart and Circulation Conditions BEADS CAP ER 24HR 300 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE DILTIAZEM CAP 300MG/24 Tier 2 Heart and Circulation Conditions BEADS CAP ER 24HR 300 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS CAP ER DILTIAZEM CAP 360MG CD Tier 2 Heart and Circulation Conditions 24HR 360 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS CAP ER DILTIAZEM CAP 360MG ER Tier 2 Heart and Circulation Conditions 24HR 360 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE DILTIAZEM CAP 360MG ER Tier 2 Heart and Circulation Conditions BEADS CAP ER 24HR 360 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE DILTIAZEM CAP 360MG/24 Tier 2 Heart and Circulation Conditions BEADS CAP ER 24HR 360 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE DILTIAZEM CAP 420MG/24 Tier 2 Heart and Circulation Conditions BEADS CAP ER 24HR 420 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM CAP 60MG ER DILTIAZEM HCL CAP ER 12HR 60 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DILTIAZEM CAP 90MG ER DILTIAZEM HCL CAP ER 12HR 90 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DILTIAZEM TAB 120MG DILTIAZEM HCL TAB 120 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DILTIAZEM TAB 30MG DILTIAZEM HCL TAB 30 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DILTIAZEM TAB 60MG DILTIAZEM HCL TAB 60 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DILTIAZEM TAB 90MG DILTIAZEM HCL TAB 90 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS TAB ER DILTIAZEM ER TAB 180MG Tier 2 Heart and Circulation Conditions 24HR 180 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS TAB ER DILTIAZEM ER TAB 240MG Tier 2 Heart and Circulation Conditions 24HR 240 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS TAB ER DILTIAZEM ER TAB 300MG Tier 2 Heart and Circulation Conditions 24HR 300 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS TAB ER DILTIAZEM ER TAB 360MG Tier 2 Heart and Circulation Conditions 24HR 360 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS TAB ER DILTIAZEM ER TAB 420MG Tier 2 Heart and Circulation Conditions 24HR 420 MG

85 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Cardiovascular Agents - Drugs to Treat DILT-XR CAP 120MG DILTIAZEM HCL CAP ER 24HR 120 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DILT-XR CAP 180MG DILTIAZEM HCL CAP ER 24HR 180 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DILT-XR CAP 240MG DILTIAZEM HCL CAP ER 24HR 240 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DISOPYRAMIDE PHOSPHATE CAP 100 DISOPYRAMIDE CAP 100MG Tier 1 Heart and Circulation Conditions MG Cardiovascular Agents - Drugs to Treat DISOPYRAMIDE PHOSPHATE CAP 150 DISOPYRAMIDE CAP 150MG Tier 1 Heart and Circulation Conditions MG Cardiovascular Agents - Drugs to Treat DIURIL SUS 250/5ML CHLOROTHIAZIDE SUSP 250 MG/5ML Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DOFETILIDE CAP 125MCG DOFETILIDE CAP 125 MCG (0.125 MG) Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DOFETILIDE CAP 250MCG DOFETILIDE CAP 250 MCG (0.25 MG) Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DOFETILIDE CAP 500MCG DOFETILIDE CAP 500 MCG (0.5 MG) Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DOXAZOSIN TAB 1MG DOXAZOSIN MESYLATE TAB 1 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DOXAZOSIN TAB 2MG DOXAZOSIN MESYLATE TAB 2 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DOXAZOSIN TAB 4MG DOXAZOSIN MESYLATE TAB 4 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DOXAZOSIN TAB 8MG DOXAZOSIN MESYLATE TAB 8 MG Tier 1 Heart and Circulation Conditions TRIAMTERENE & Cardiovascular Agents - Drugs to Treat DYAZIDE CAP 37.5-25 HYDROCHLOROTHIAZIDE CAP 37.5-25 Tier 3 Heart and Circulation Conditions MG Cardiovascular Agents - Drugs to Treat DYRENIUM CAP 100MG TRIAMTERENE CAP 100 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DYRENIUM CAP 50MG TRIAMTERENE CAP 50 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat EDARBI TAB 40MG AZILSARTAN MEDOXOMIL TAB 40 MG Tier 3 X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat EDARBI TAB 80MG AZILSARTAN MEDOXOMIL TAB 80 MG Tier 3 X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat AZILSARTAN MEDOXOMIL- EDARBYCLOR TAB 40-12.5 Tier 3 X Heart and Circulation Conditions CHLORTHALIDONE TAB 40-12.5 MG Cardiovascular Agents - Drugs to Treat AZILSARTAN MEDOXOMIL- EDARBYCLOR TAB 40-25MG Tier 3 X Heart and Circulation Conditions CHLORTHALIDONE TAB 40-25 MG Cardiovascular Agents - Drugs to Treat EDECRIN TAB 25MG ETHACRYNIC ACID TAB 25 MG Tier 4 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ENALAPR/HCTZ TAB 10- ENALAPRIL MALEATE & Tier 1 Heart and Circulation Conditions 25MG HYDROCHLOROTHIAZIDE TAB 10-25 MG Cardiovascular Agents - Drugs to Treat ENALAPR/HCTZ TAB ENALAPRIL MALEATE & Tier 1 Heart and Circulation Conditions 5-12.5MG HYDROCHLOROTHIAZIDE TAB 5-12.5 MG Cardiovascular Agents - Drugs to Treat ENALAPRIL TAB 10MG ENALAPRIL MALEATE TAB 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ENALAPRIL TAB 2.5MG ENALAPRIL MALEATE TAB 2.5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ENALAPRIL TAB 20MG ENALAPRIL MALEATE TAB 20 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ENALAPRIL TAB 5MG ENALAPRIL MALEATE TAB 5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ENTRESTO TAB 24-26MG SACUBITRIL-VALSARTAN TAB 24-26 MG Tier 3 X X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ENTRESTO TAB 49-51MG SACUBITRIL-VALSARTAN TAB 49-51 MG Tier 3 X X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ENTRESTO TAB 97-103MG SACUBITRIL-VALSARTAN TAB 97-103 MG Tier 3 X X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ENALAPRIL MALEATE FOR ORAL SOLN EPANED SOL 1MG/ML Tier 3 X Heart and Circulation Conditions 1 MG/ML Cardiovascular Agents - Drugs to Treat ENALAPRIL MALEATE ORAL SOLN 1 EPANED SOL 1MG/ML Tier 3 X Heart and Circulation Conditions MG/ML Cardiovascular Agents - Drugs to Treat EPLERENONE TAB 25MG EPLERENONE TAB 25 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat EPLERENONE TAB 50MG EPLERENONE TAB 50 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat EPROSART MES TAB 600MG EPROSARTAN MESYLATE TAB 600 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ETHACRYNIC TAB ACD ETHACRYNIC ACID TAB 25 MG Tier 3 Heart and Circulation Conditions 25MG Cardiovascular Agents - Drugs to Treat EZETIM/SIMVA TAB 10-10MG EZETIMIBE-SIMVASTATIN TAB 10-10 MG Tier 3 X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat EZETIM/SIMVA TAB 10-20MG EZETIMIBE-SIMVASTATIN TAB 10-20 MG Tier 3 X Heart and Circulation Conditions

86 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Cardiovascular Agents - Drugs to Treat EZETIM/SIMVA TAB 10- EZETIMIBE-SIMVASTATIN TAB 10-40 MG Tier 3 X Heart and Circulation Conditions 40MG Cardiovascular Agents - Drugs to Treat EZETIM/SIMVA TAB 10- EZETIMIBE-SIMVASTATIN TAB 10-80 MG Tier 3 X Heart and Circulation Conditions 80MG Cardiovascular Agents - Drugs to Treat EZETIMIBE TAB 10MG EZETIMIBE TAB 10 MG Tier 3 X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat EZIDE TAB 50MG HYDROCHLOROTHIAZIDE TAB 50 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat FELODIPINE TAB 10MG ER FELODIPINE TAB ER 24HR 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat FELODIPINE TAB 2.5MG ER FELODIPINE TAB ER 24HR 2.5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat FELODIPINE TAB 5MG ER FELODIPINE TAB ER 24HR 5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat FENOFIBRATE TAB 160 FENOFIBRATE TAB 160 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat FENOFIBRATE TAB 160MG FENOFIBRATE TAB 160 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat FENOFIBRATE TAB 54MG FENOFIBRATE TAB 54 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat FLECAINIDE TAB 100MG FLECAINIDE ACETATE TAB 100 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat FLECAINIDE TAB 150MG FLECAINIDE ACETATE TAB 150 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat FLECAINIDE TAB 50MG FLECAINIDE ACETATE TAB 50 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat SIMVASTATIN SUSP 20 MG/5ML (4 MG/ FLOLIPID SUS 20MG/5ML Tier 3 X Heart and Circulation Conditions ML) Cardiovascular Agents - Drugs to Treat SIMVASTATIN SUSP 40 MG/5ML (8 MG/ FLOLIPID SUS 40MG/5ML Tier 3 X Heart and Circulation Conditions ML) Cardiovascular Agents - Drugs to Treat FLUVASTATIN CAP 20MG FLUVASTATIN SODIUM CAP 20 MG Tier 1 X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat FLUVASTATIN CAP 40MG FLUVASTATIN SODIUM CAP 40 MG Tier 1 X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat FLUVASTATIN SODIUM TAB ER 24 HR FLUVASTATIN TAB 80MG ER Tier 3 X X Heart and Circulation Conditions 80 MG FOSINOPRIL SODIUM & Cardiovascular Agents - Drugs to Treat FOSINOP/HCTZ TAB 10/12.5 HYDROCHLOROTHIAZIDE TAB 10-12.5 Tier 1 Heart and Circulation Conditions MG FOSINOPRIL SODIUM & Cardiovascular Agents - Drugs to Treat FOSINOP/HCTZ TAB 20/12.5 HYDROCHLOROTHIAZIDE TAB 20-12.5 Tier 1 Heart and Circulation Conditions MG Cardiovascular Agents - Drugs to Treat FOSINOPRIL TAB 10MG FOSINOPRIL SODIUM TAB 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat FOSINOPRIL TAB 20MG FOSINOPRIL SODIUM TAB 20 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat FOSINOPRIL TAB 40MG FOSINOPRIL SODIUM TAB 40 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat FUROSEMIDE SOL 10MG/ML FUROSEMIDE ORAL SOLN 10 MG/ML Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat FUROSEMIDE SOL 8MG/ML FUROSEMIDE ORAL SOLN 8 MG/ML Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat FUROSEMIDE TAB 20MG FUROSEMIDE TAB 20 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat FUROSEMIDE TAB 40MG FUROSEMIDE TAB 40 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat FUROSEMIDE TAB 80MG FUROSEMIDE TAB 80 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat GEMFIBROZIL TAB 600MG GEMFIBROZIL TAB 600 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat GUANFACINE TAB 1MG GUANFACINE HCL TAB 1 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat GUANFACINE TAB 2MG GUANFACINE HCL TAB 2 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat HYDRALAZINE TAB 100MG HYDRALAZINE HCL TAB 100 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat HYDRALAZINE TAB 10MG HYDRALAZINE HCL TAB 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat HYDRALAZINE TAB 25MG HYDRALAZINE HCL TAB 25 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat HYDRALAZINE TAB 50MG HYDRALAZINE HCL TAB 50 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat HYDROCHLOROT CAP HYDROCHLOROTHIAZIDE CAP 12.5 MG Tier 1 Heart and Circulation Conditions 12.5MG Cardiovascular Agents - Drugs to Treat HYDROCHLOROT TAB HYDROCHLOROTHIAZIDE TAB 12.5 MG Tier 1 Heart and Circulation Conditions 12.5MG Cardiovascular Agents - Drugs to Treat HYDROCHLOROT TAB 25MG HYDROCHLOROTHIAZIDE TAB 25 MG Tier 1 Heart and Circulation Conditions

87 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Cardiovascular Agents - Drugs to Treat HYDROCHLOROT TAB 50MG HYDROCHLOROTHIAZIDE TAB 50 MG Tier 1 Heart and Circulation Conditions LOSARTAN POTASSIUM & Cardiovascular Agents - Drugs to Treat HYZAAR TAB 100-12.5 HYDROCHLOROTHIAZIDE TAB 100-12.5 Tier 3 Heart and Circulation Conditions MG LOSARTAN POTASSIUM & Cardiovascular Agents - Drugs to Treat HYZAAR TAB 100-25 HYDROCHLOROTHIAZIDE TAB 100-25 Tier 3 Heart and Circulation Conditions MG LOSARTAN POTASSIUM & Cardiovascular Agents - Drugs to Treat HYZAAR TAB 50-12.5 HYDROCHLOROTHIAZIDE TAB 50-12.5 Tier 3 Heart and Circulation Conditions MG Cardiovascular Agents - Drugs to Treat INDAPAMIDE TAB 1.25MG INDAPAMIDE TAB 1.25 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat INDAPAMIDE TAB 2.5MG INDAPAMIDE TAB 2.5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PROPRANOLOL HCL SUSTAINED- INDERAL XL CAP 120MG Tier 3 Heart and Circulation Conditions RELEASE BEADS CAP ER 24HR 120 MG Cardiovascular Agents - Drugs to Treat PROPRANOLOL HCL SUSTAINED- INDERAL XL CAP 80MG Tier 3 Heart and Circulation Conditions RELEASE BEADS CAP ER 24HR 80 MG Cardiovascular Agents - Drugs to Treat PROPRANOLOL HCL SUSTAINED- INNOPRAN XL CAP 120MG Tier 3 Heart and Circulation Conditions RELEASE BEADS CAP ER 24HR 120 MG Cardiovascular Agents - Drugs to Treat PROPRANOLOL HCL SUSTAINED- INNOPRAN XL CAP 120MG Tier 3 Heart and Circulation Conditions RELEASE BEADS CAP SR 24HR 120 MG Cardiovascular Agents - Drugs to Treat PROPRANOLOL HCL SUSTAINED- INNOPRAN XL CAP 80MG Tier 3 Heart and Circulation Conditions RELEASE BEADS CAP ER 24HR 80 MG Cardiovascular Agents - Drugs to Treat INSPRA TAB 25MG EPLERENONE TAB 25 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat INSPRA TAB 50MG EPLERENONE TAB 50 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat IRBESARTAN-HYDROCHLOROTHIAZIDE IRBESAR/HCTZ TAB 150-12.5 Tier 1 Heart and Circulation Conditions TAB 150-12.5 MG Cardiovascular Agents - Drugs to Treat IRBESAR/HCTZ TAB 300- IRBESARTAN-HYDROCHLOROTHIAZIDE Tier 1 Heart and Circulation Conditions 12.5 TAB 300-12.5 MG Cardiovascular Agents - Drugs to Treat IRBESARTAN TAB 150MG IRBESARTAN TAB 150 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat IRBESARTAN TAB 300MG IRBESARTAN TAB 300 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat IRBESARTAN TAB 75MG IRBESARTAN TAB 75 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ISOPROTERENOL HCL INHAL AEROSOL ISOPROTEREN AER 131MCG Tier 1 Heart and Circulation Conditions SOLN 131 MCG/ACT (2.5 MG/ML) Cardiovascular Agents - Drugs to Treat ISORDIL TAB 40MG ISOSORBIDE DINITRATE TAB 40 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ISORDIL TAB 5MG ISOSORBIDE DINITRATE TAB 5 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ISOSORB DIN TAB 10MG ISOSORBIDE DINITRATE TAB 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ISOSORB DIN TAB 20MG ISOSORBIDE DINITRATE TAB 20 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ISOSORB DIN TAB 30MG ISOSORBIDE DINITRATE TAB 30 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ISOSORB DIN TAB 40MG ER ISOSORBIDE DINITRATE TAB ER 40 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ISOSORB DIN TAB 5MG ISOSORBIDE DINITRATE TAB 5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ISOSORB MONO TAB 10MG ISOSORBIDE MONONITRATE TAB 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ISOSORB MONO TAB 120MG ISOSORBIDE MONONITRATE TAB ER Tier 1 Heart and Circulation Conditions ER 24HR 120 MG Cardiovascular Agents - Drugs to Treat ISOSORB MONO TAB 20MG ISOSORBIDE MONONITRATE TAB 20 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ISOSORB MONO TAB 30MG ISOSORBIDE MONONITRATE TAB ER Tier 1 Heart and Circulation Conditions ER 24HR 30 MG Cardiovascular Agents - Drugs to Treat ISOSORB MONO TAB 60MG ISOSORBIDE MONONITRATE TAB ER Tier 1 Heart and Circulation Conditions ER 24HR 60 MG Cardiovascular Agents - Drugs to Treat ISOXSUPRINE TAB 10MG ISOXSUPRINE HCL TAB 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ISOXSUPRINE TAB HCL ISOXSUPRINE HCL TAB 20 MG Tier 1 Heart and Circulation Conditions 20MG Cardiovascular Agents - Drugs to Treat ISRADIPINE CAP 2.5MG ISRADIPINE CAP 2.5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ISRADIPINE CAP 5MG ISRADIPINE CAP 5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LOMITAPIDE MESYLATE CAP 10 MG JUXTAPID CAP 10MG Tier 3 X X X X Heart and Circulation Conditions (BASE EQUIV) Cardiovascular Agents - Drugs to Treat LOMITAPIDE MESYLATE CAP 20 MG JUXTAPID CAP 20MG Tier 3 X X X X Heart and Circulation Conditions (BASE EQUIV)

88 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Cardiovascular Agents - Drugs to Treat LOMITAPIDE MESYLATE CAP 30 MG JUXTAPID CAP 30MG Tier 3 X X X X Heart and Circulation Conditions (BASE EQUIV) Cardiovascular Agents - Drugs to Treat LOMITAPIDE MESYLATE CAP 40 MG JUXTAPID CAP 40MG Tier 3 X X X X Heart and Circulation Conditions (BASE EQUIV) Cardiovascular Agents - Drugs to Treat LOMITAPIDE MESYLATE CAP 5 MG (BASE JUXTAPID CAP 5MG Tier 3 X X X X Heart and Circulation Conditions EQUIV) Cardiovascular Agents - Drugs to Treat LOMITAPIDE MESYLATE CAP 60 MG JUXTAPID CAP 60MG Tier 3 X X X X Heart and Circulation Conditions (BASE EQUIV) Cardiovascular Agents - Drugs to Treat KEVEYIS TAB 50MG DICHLORPHENAMIDE TAB 50 MG Tier 2 X X X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat MIPOMERSEN SODIUM SOLN PREFILLED KYNAMRO INJ 200MG/ML Tier 4 X X X X Heart and Circulation Conditions SYRINGE 200 MG/ML Cardiovascular Agents - Drugs to Treat LABETALOL TAB 100MG LABETALOL HCL TAB 100 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LABETALOL TAB 200MG LABETALOL HCL TAB 200 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LABETALOL TAB 300MG LABETALOL HCL TAB 300 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LANOXIN TAB 0.0625MG DIGOXIN TAB 62.5 MCG (0.0625 MG) Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LANOXIN TAB 0.125MG DIGOXIN TAB 125 MCG (0.125 MG) Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LANOXIN TAB 0.1875MG DIGOXIN TAB 187.5 MCG (0.1875 MG) Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LANOXIN TAB 0.25MG DIGOXIN TAB 250 MCG (0.25 MG) Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LASIX TAB 20MG FUROSEMIDE TAB 20 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LASIX TAB 40MG FUROSEMIDE TAB 40 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LASIX TAB 80MG FUROSEMIDE TAB 80 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LISINOPRIL & HYDROCHLOROTHIAZIDE LISINOP/HCTZ TAB 10-12.5 Tier 1 Heart and Circulation Conditions TAB 10-12.5 MG Cardiovascular Agents - Drugs to Treat LISINOPRIL & HYDROCHLOROTHIAZIDE LISINOP/HCTZ TAB 20-12.5 Tier 1 Heart and Circulation Conditions TAB 20-12.5 MG Cardiovascular Agents - Drugs to Treat LISINOPRIL & HYDROCHLOROTHIAZIDE LISINOP/HCTZ TAB 20-25MG Tier 1 Heart and Circulation Conditions TAB 20-25 MG Cardiovascular Agents - Drugs to Treat LISINOPRIL TAB 10MG LISINOPRIL TAB 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LISINOPRIL TAB 2.5MG LISINOPRIL TAB 2.5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LISINOPRIL TAB 20MG LISINOPRIL TAB 20 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LISINOPRIL TAB 30MG LISINOPRIL TAB 30 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LISINOPRIL TAB 40MG LISINOPRIL TAB 40 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LISINOPRIL TAB 5MG LISINOPRIL TAB 5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LOPID TAB 600MG GEMFIBROZIL TAB 600 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat METOPROLOL & LOPRESS HCT TAB 50-25MG Tier 3 Heart and Circulation Conditions HYDROCHLOROTHIAZIDE TAB 50-25 MG Cardiovascular Agents - Drugs to Treat LOPRESSOR TAB 100MG METOPROLOL TARTRATE TAB 100 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LOPRESSOR TAB 50MG METOPROLOL TARTRATE TAB 50 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LOSARTAN POT TAB 100MG LOSARTAN POTASSIUM TAB 100 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LOSARTAN POT TAB 25MG LOSARTAN POTASSIUM TAB 25 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LOSARTAN POT TAB 50MG LOSARTAN POTASSIUM TAB 50 MG Tier 1 Heart and Circulation Conditions LOSARTAN POTASSIUM & Cardiovascular Agents - Drugs to Treat LOSARTAN/HCT TAB 100- HYDROCHLOROTHIAZIDE TAB 100-12.5 Tier 1 Heart and Circulation Conditions 12.5 MG LOSARTAN POTASSIUM & Cardiovascular Agents - Drugs to Treat LOSARTAN/HCT TAB 100-25 HYDROCHLOROTHIAZIDE TAB 100-25 Tier 1 Heart and Circulation Conditions MG LOSARTAN POTASSIUM & Cardiovascular Agents - Drugs to Treat LOSARTAN/HCT TAB 50-12.5 HYDROCHLOROTHIAZIDE TAB 50-12.5 Tier 1 Heart and Circulation Conditions MG Cardiovascular Agents - Drugs to Treat LOTENSIN TAB 20MG BENAZEPRIL HCL TAB 20 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat LOTENSIN TAB 40MG BENAZEPRIL HCL TAB 40 MG Tier 3 Heart and Circulation Conditions

89 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Cardiovascular Agents - Drugs to Treat BENAZEPRIL & HYDROCHLOROTHIAZIDE LOTENSIN HCT TAB 10-12.5 Tier 3 Heart and Circulation Conditions TAB 10-12.5 MG Cardiovascular Agents - Drugs to Treat BENAZEPRIL & HYDROCHLOROTHIAZIDE LOTENSIN HCT TAB 20-12.5 Tier 3 Heart and Circulation Conditions TAB 20-12.5 MG Cardiovascular Agents - Drugs to Treat LOTENSIN HCT TAB 20- BENAZEPRIL & HYDROCHLOROTHIAZIDE Tier 3 Heart and Circulation Conditions 25MG TAB 20-25 MG Cardiovascular Agents - Drugs to Treat AMLODIPINE BESYLATE-BENAZEPRIL LOTREL CAP 10-20MG Tier 3 Heart and Circulation Conditions HCL CAP 10-20 MG Cardiovascular Agents - Drugs to Treat AMLODIPINE BESYLATE-BENAZEPRIL LOTREL CAP 10-40MG Tier 3 Heart and Circulation Conditions HCL CAP 10-40 MG Cardiovascular Agents - Drugs to Treat AMLODIPINE BESYLATE-BENAZEPRIL LOTREL CAP 5-10MG Tier 3 Heart and Circulation Conditions HCL CAP 5-10 MG Cardiovascular Agents - Drugs to Treat AMLODIPINE BESYLATE-BENAZEPRIL LOTREL CAP 5-20MG Tier 3 Heart and Circulation Conditions HCL CAP 5-20 MG HCR Cardiovascular Agents - Drugs to Treat LOVASTATIN TAB 10MG LOVASTATIN TAB 10 MG Preventive Heart and Circulation Conditions Care HCR Cardiovascular Agents - Drugs to Treat LOVASTATIN TAB 20MG LOVASTATIN TAB 20 MG Preventive Heart and Circulation Conditions Care HCR Cardiovascular Agents - Drugs to Treat LOVASTATIN TAB 40MG LOVASTATIN TAB 40 MG Preventive Heart and Circulation Conditions Care Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS TAB ER MATZIM LA TAB 180MG/24 Tier 2 Heart and Circulation Conditions 24HR 180 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS TAB ER MATZIM LA TAB 240MG/24 Tier 2 Heart and Circulation Conditions 24HR 240 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS TAB ER MATZIM LA TAB 300MG/24 Tier 2 Heart and Circulation Conditions 24HR 300 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS TAB ER MATZIM LA TAB 360MG/24 Tier 2 Heart and Circulation Conditions 24HR 360 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL COATED BEADS TAB ER MATZIM LA TAB 420MG/24 Tier 2 Heart and Circulation Conditions 24HR 420 MG Cardiovascular Agents - Drugs to Treat MAVIK TAB 1MG TRANDOLAPRIL TAB 1 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat MAVIK TAB 2MG TRANDOLAPRIL TAB 2 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat TRIAMTERENE & MAXZIDE TAB 75-50 Tier 3 Heart and Circulation Conditions HYDROCHLOROTHIAZIDE TAB 75-50 MG TRIAMTERENE & Cardiovascular Agents - Drugs to Treat MAXZIDE-25 TAB HYDROCHLOROTHIAZIDE TAB 37.5-25 Tier 3 Heart and Circulation Conditions MG Cardiovascular Agents - Drugs to Treat METHYCLOTHIA TAB 5MG METHYCLOTHIAZIDE TAB 5 MG Tier 1 Heart and Circulation Conditions METHYLDOPA & Cardiovascular Agents - Drugs to Treat METHYLD/HCTZ TAB 250/15 HYDROCHLOROTHIAZIDE TAB 250-15 Tier 1 Heart and Circulation Conditions MG METHYLDOPA & Cardiovascular Agents - Drugs to Treat METHYLD/HCTZ TAB 250/25 HYDROCHLOROTHIAZIDE TAB 250-25 Tier 1 Heart and Circulation Conditions MG Cardiovascular Agents - Drugs to Treat METHYLDOPA TAB 250MG METHYLDOPA TAB 250 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat METHYLDOPA TAB 500MG METHYLDOPA TAB 500 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat METOLAZONE TAB 10MG METOLAZONE TAB 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat METOLAZONE TAB 2.5MG METOLAZONE TAB 2.5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat METOLAZONE TAB 5MG METOLAZONE TAB 5 MG Tier 1 Heart and Circulation Conditions METOPROLOL & Cardiovascular Agents - Drugs to Treat METOPRL/HCTZ TAB 100- HYDROCHLOROTHIAZIDE TAB 100-25 Tier 1 Heart and Circulation Conditions 25MG MG METOPROLOL & Cardiovascular Agents - Drugs to Treat METOPRL/HCTZ TAB 100- HYDROCHLOROTHIAZIDE TAB 100-50 Tier 1 Heart and Circulation Conditions 50MG MG Cardiovascular Agents - Drugs to Treat METOPRL/HCTZ TAB 50- METOPROLOL & Tier 1 Heart and Circulation Conditions 25MG HYDROCHLOROTHIAZIDE TAB 50-25 MG Cardiovascular Agents - Drugs to Treat METOPROL SUC TAB METOPROLOL SUCCINATE TAB ER 24HR Tier 2 Heart and Circulation Conditions 100MG ER 100 MG (TARTRATE EQUIV) Cardiovascular Agents - Drugs to Treat METOPROL SUC TAB METOPROLOL SUCCINATE TAB ER 24HR Tier 2 Heart and Circulation Conditions 200MG ER 200 MG (TARTRATE EQUIV) Cardiovascular Agents - Drugs to Treat METOPROL SUC TAB 25MG METOPROLOL SUCCINATE TAB ER 24HR Tier 1 Heart and Circulation Conditions ER 25 MG (TARTRATE EQUIV) Cardiovascular Agents - Drugs to Treat METOPROL SUC TAB 50MG METOPROLOL SUCCINATE TAB ER 24HR Tier 2 Heart and Circulation Conditions ER 50 MG (TARTRATE EQUIV) Cardiovascular Agents - Drugs to Treat METOPROL TAR TAB 100MG METOPROLOL TARTRATE TAB 100 MG Tier 1 Heart and Circulation Conditions

90 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Cardiovascular Agents - Drugs to Treat METOPROL TAR TAB 25MG METOPROLOL TARTRATE TAB 25 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat METOPROL TAR TAB 50MG METOPROLOL TARTRATE TAB 50 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat METOPROLOL TAB 100MG METOPROLOL SUCCINATE TAB ER 24HR Tier 2 Heart and Circulation Conditions ER 100 MG (TARTRATE EQUIV) Cardiovascular Agents - Drugs to Treat METOPROLOL TAB 200MG METOPROLOL SUCCINATE TAB ER 24HR Tier 2 Heart and Circulation Conditions ER 200 MG (TARTRATE EQUIV) Cardiovascular Agents - Drugs to Treat METOPROLOL SUCCINATE TAB ER 24HR METOPROLOL TAB 25MG ER Tier 1 Heart and Circulation Conditions 25 MG (TARTRATE EQUIV) Cardiovascular Agents - Drugs to Treat METOPROLOL SUCCINATE TAB ER 24HR METOPROLOL TAB 50MG ER Tier 2 Heart and Circulation Conditions 50 MG (TARTRATE EQUIV) Cardiovascular Agents - Drugs to Treat MEVACOR TAB 40MG LOVASTATIN TAB 40 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat MEXILETINE CAP 150MG MEXILETINE HCL CAP 150 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat MEXILETINE CAP 200MG MEXILETINE HCL CAP 200 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat MEXILETINE CAP 250MG MEXILETINE HCL CAP 250 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat MICROZIDE CAP 12.5MG HYDROCHLOROTHIAZIDE CAP 12.5 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat MIDODRINE TAB 10MG MIDODRINE HCL TAB 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat MIDODRINE TAB 2.5MG MIDODRINE HCL TAB 2.5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat MIDODRINE TAB 5MG MIDODRINE HCL TAB 5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat MINIPRESS CAP 1MG PRAZOSIN HCL CAP 1 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat MINIPRESS CAP 2MG PRAZOSIN HCL CAP 2 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat MINIPRESS CAP 5MG PRAZOSIN HCL CAP 5 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NITROGLYCERIN TD PATCH 24HR 0.1 MINITRAN DIS 0.1MG/HR Tier 1 Heart and Circulation Conditions MG/HR Cardiovascular Agents - Drugs to Treat NITROGLYCERIN TD PATCH 24HR 0.2 MINITRAN DIS 0.2MG/HR Tier 1 Heart and Circulation Conditions MG/HR Cardiovascular Agents - Drugs to Treat NITROGLYCERIN TD PATCH 24HR 0.4 MINITRAN DIS 0.4MG/HR Tier 1 Heart and Circulation Conditions MG/HR Cardiovascular Agents - Drugs to Treat NITROGLYCERIN TD PATCH 24HR 0.6 MINITRAN DIS 0.6MG/HR Tier 1 Heart and Circulation Conditions MG/HR Cardiovascular Agents - Drugs to Treat MINOXIDIL TAB 10MG MINOXIDIL TAB 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat MINOXIDIL TAB 2.5MG MINOXIDIL TAB 2.5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat MOEXIPRIL-HYDROCHLOROTHIAZIDE MOEXIPR/HCTZ TAB 15-12.5 Tier 1 Heart and Circulation Conditions TAB 15-12.5 MG Cardiovascular Agents - Drugs to Treat MOEXIPR/HCTZ TAB 15- MOEXIPRIL-HYDROCHLOROTHIAZIDE Tier 1 Heart and Circulation Conditions 25MG TAB 15-25 MG Cardiovascular Agents - Drugs to Treat MOEXIPRIL-HYDROCHLOROTHIAZIDE MOEXIPR/HCTZ TAB 7.5-12.5 Tier 1 Heart and Circulation Conditions TAB 7.5-12.5 MG Cardiovascular Agents - Drugs to Treat MOEXIPRIL TAB 15MG MOEXIPRIL HCL TAB 15 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat MOEXIPRIL TAB 7.5MG MOEXIPRIL HCL TAB 7.5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DRONEDARONE HCL TAB 400 MG (BASE MULTAQ TAB 400MG Tier 3 X Heart and Circulation Conditions EQUIVALENT) Cardiovascular Agents - Drugs to Treat NADOLOL TAB 20MG NADOLOL TAB 20 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NADOLOL TAB 40MG NADOLOL TAB 40 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NADOLOL TAB 80MG NADOLOL TAB 80 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NADOLOL/BEND TAB 40- NADOLOL & BENDROFLUMETHIAZIDE Tier 1 Heart and Circulation Conditions 5MG TAB 40-5 MG Cardiovascular Agents - Drugs to Treat NADOLOL/BEND TAB 80- NADOLOL & BENDROFLUMETHIAZIDE Tier 1 Heart and Circulation Conditions 5MG TAB 80-5 MG Cardiovascular Agents - Drugs to Treat NIACIN TAB ER 1000 MG NIACIN ER TAB 1000MG Tier 3 Heart and Circulation Conditions (ANTIHYPERLIPIDEMIC) Cardiovascular Agents - Drugs to Treat NIACIN TAB ER 500 MG NIACIN ER TAB 500MG Tier 3 Heart and Circulation Conditions (ANTIHYPERLIPIDEMIC) Cardiovascular Agents - Drugs to Treat NIACIN TAB ER 750 MG NIACIN ER TAB 750MG Tier 3 Heart and Circulation Conditions (ANTIHYPERLIPIDEMIC) Cardiovascular Agents - Drugs to Treat NIACIN (ANTIHYPERLIPIDEMIC) TAB 500 NIACOR TAB 500MG Tier 2 Heart and Circulation Conditions MG Cardiovascular Agents - Drugs to Treat NIACIN (ANTIHYPERLIPIDEMIC) TAB 500 NIACOR TAB 500MG Tier 1 Heart and Circulation Conditions MG

91 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Cardiovascular Agents - Drugs to Treat NIACIN TAB ER 1000 MG NIASPAN TAB 1000 ER Tier 2 Heart and Circulation Conditions (ANTIHYPERLIPIDEMIC) Cardiovascular Agents - Drugs to Treat NIACIN TAB ER 500 MG NIASPAN TAB 500MG ER Tier 2 Heart and Circulation Conditions (ANTIHYPERLIPIDEMIC) Cardiovascular Agents - Drugs to Treat NIACIN TAB ER 750 MG NIASPAN TAB 750MG ER Tier 2 Heart and Circulation Conditions (ANTIHYPERLIPIDEMIC) Cardiovascular Agents - Drugs to Treat NICARDIPINE CAP 20MG NICARDIPINE HCL CAP 20 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NICARDIPINE CAP 30MG NICARDIPINE HCL CAP 30 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NIFEDIPINE TAB ER 24HR OSMOTIC NIFEDICAL XL TAB 30MG Tier 1 Heart and Circulation Conditions RELEASE 30 MG Cardiovascular Agents - Drugs to Treat NIFEDIPINE TAB ER 24HR OSMOTIC NIFEDICAL XL TAB 60MG Tier 1 Heart and Circulation Conditions RELEASE 60 MG Cardiovascular Agents - Drugs to Treat NIFEDIPINE CAP 10MG NIFEDIPINE CAP 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NIFEDIPINE CAP 20MG NIFEDIPINE CAP 20 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NIFEDIPINE TAB 30MG ER NIFEDIPINE TAB ER 24HR 30 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NIFEDIPINE TAB ER 24HR OSMOTIC NIFEDIPINE TAB 30MG ER Tier 1 Heart and Circulation Conditions RELEASE 30 MG Cardiovascular Agents - Drugs to Treat NIFEDIPINE TAB 60MG ER NIFEDIPINE TAB ER 24HR 60 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NIFEDIPINE TAB ER 24HR OSMOTIC NIFEDIPINE TAB 60MG ER Tier 1 Heart and Circulation Conditions RELEASE 60 MG Cardiovascular Agents - Drugs to Treat NIFEDIPINE TAB 90MG ER NIFEDIPINE TAB ER 24HR 90 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NIFEDIPINE TAB ER 24HR OSMOTIC NIFEDIPINE TAB 90MG ER Tier 1 Heart and Circulation Conditions RELEASE 90 MG Cardiovascular Agents - Drugs to Treat NIMODIPINE CAP 30MG NIMODIPINE CAP 30 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NISOLDIPINE TAB 17MG ER NISOLDIPINE TAB ER 24HR 17 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NISOLDIPINE TAB 20MG ER NISOLDIPINE TAB ER 24HR 20 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NISOLDIPINE TAB 25.5MG NISOLDIPINE TAB ER 24HR 25.5 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NISOLDIPINE TAB 30MG ER NISOLDIPINE TAB ER 24HR 30 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NISOLDIPINE TAB 34MG ER NISOLDIPINE TAB ER 24HR 34 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NISOLDIPINE TAB 40MG ER NISOLDIPINE TAB ER 24HR 40 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NISOLDIPINE TAB 8.5MG ER NISOLDIPINE TAB ER 24HR 8.5 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NITRO-BID OIN 2% NITROGLYCERIN OINT 2% Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NITROGLYCERIN TD PATCH 24HR 0.1 NITRO-DUR DIS 0.1MG/HR Tier 3 Heart and Circulation Conditions MG/HR Cardiovascular Agents - Drugs to Treat NITROGLYCERIN TD PATCH 24HR 0.2 NITRO-DUR DIS 0.2MG/HR Tier 3 Heart and Circulation Conditions MG/HR Cardiovascular Agents - Drugs to Treat NITROGLYCERIN TD PATCH 24HR 0.3 NITRO-DUR DIS 0.3MG/HR Tier 3 Heart and Circulation Conditions MG/HR Cardiovascular Agents - Drugs to Treat NITROGLYCERIN TD PATCH 24HR 0.4 NITRO-DUR DIS 0.4MG/HR Tier 3 Heart and Circulation Conditions MG/HR Cardiovascular Agents - Drugs to Treat NITROGLYCERIN TD PATCH 24HR 0.6 NITRO-DUR DIS 0.6MG/HR Tier 3 Heart and Circulation Conditions MG/HR Cardiovascular Agents - Drugs to Treat NITROGLYCERIN TD PATCH 24HR 0.8 NITRO-DUR DIS 0.8MG/HR Tier 3 Heart and Circulation Conditions MG/HR Cardiovascular Agents - Drugs to Treat NITROGLYCERIN LINGUAL AEROSOL NITROGLYCER AER 400MCG Tier 3 X Heart and Circulation Conditions 400 MCG/SPRAY Cardiovascular Agents - Drugs to Treat NITROGLYCER CAP 2.5MG NITROGLYCERIN CAP ER 2.5 MG Tier 1 Heart and Circulation Conditions ER Cardiovascular Agents - Drugs to Treat NITROGLYCER CAP 6.5MG NITROGLYCERIN CAP ER 6.5 MG Tier 1 Heart and Circulation Conditions ER Cardiovascular Agents - Drugs to Treat NITROGLYCER CAP 9MG ER NITROGLYCERIN CAP ER 9 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NITROGLYCER DIS 0.1MG/ NITROGLYCERIN TD PATCH 24HR 0.1 Tier 1 Heart and Circulation Conditions HR MG/HR Cardiovascular Agents - Drugs to Treat NITROGLYCER DIS 0.2MG/ NITROGLYCERIN TD PATCH 24HR 0.2 Tier 1 Heart and Circulation Conditions HR MG/HR Cardiovascular Agents - Drugs to Treat NITROGLYCER DIS 0.4MG/ NITROGLYCERIN TD PATCH 24HR 0.4 Tier 1 Heart and Circulation Conditions HR MG/HR Cardiovascular Agents - Drugs to Treat NITROGLYCER DIS 0.6MG/ NITROGLYCERIN TD PATCH 24HR 0.6 Tier 1 Heart and Circulation Conditions HR MG/HR Cardiovascular Agents - Drugs to Treat NITROGLYCERI SUB 0.6MG NITROGLYCERIN SL TAB 0.6 MG Tier 1 Heart and Circulation Conditions

92 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Cardiovascular Agents - Drugs to Treat NITROGLYCERN SUB 0.3MG NITROGLYCERIN SL TAB 0.3 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NITROGLYCERN SUB 0.4MG NITROGLYCERIN SL TAB 0.4 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NITROGLYCERIN LINGUAL AEROSOL NITROMIST AER 400MCG Tier 3 X Heart and Circulation Conditions 400 MCG/SPRAY Cardiovascular Agents - Drugs to Treat NITROSTAT SUB 0.3MG NITROGLYCERIN SL TAB 0.3 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NITROSTAT SUB 0.4MG NITROGLYCERIN SL TAB 0.4 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NITROSTAT SUB 0.6MG NITROGLYCERIN SL TAB 0.6 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NITRO-TIME CAP 2.5MG CR NITROGLYCERIN CAP ER 2.5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NITRO-TIME CAP 6.5MG CR NITROGLYCERIN CAP ER 6.5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NITRO-TIME CAP 9MG CR NITROGLYCERIN CAP ER 9 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DISOPYRAMIDE PHOSPHATE CAP 100 NORPACE CAP 100MG Tier 3 Heart and Circulation Conditions MG Cardiovascular Agents - Drugs to Treat DISOPYRAMIDE PHOSPHATE CAP SR NORPACE CAP 100MG CR Tier 2 Heart and Circulation Conditions 12HR 100 MG Cardiovascular Agents - Drugs to Treat DISOPYRAMIDE PHOSPHATE CAP 150 NORPACE CAP 150MG Tier 3 Heart and Circulation Conditions MG Cardiovascular Agents - Drugs to Treat DISOPYRAMIDE PHOSPHATE CAP ER NORPACE CAP 150MG CR Tier 2 Heart and Circulation Conditions 12HR 150 MG Cardiovascular Agents - Drugs to Treat NORTHERA CAP 100MG DROXIDOPA CAP 100 MG Tier 4 X X X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NORTHERA CAP 200MG DROXIDOPA CAP 200 MG Tier 4 X X X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NORTHERA CAP 300MG DROXIDOPA CAP 300 MG Tier 4 X X X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NORVASC TAB 10MG AMLODIPINE BESYLATE TAB 10 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NORVASC TAB 2.5MG AMLODIPINE BESYLATE TAB 2.5 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NORVASC TAB 5MG AMLODIPINE BESYLATE TAB 5 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NYMALIZE SOL 30/10ML NIMODIPINE ORAL SOLN 60 MG/20ML Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat NYMALIZE SOL 60/20ML NIMODIPINE ORAL SOLN 60 MG/20ML Tier 2 Heart and Circulation Conditions OLMESARTAN MEDOXOMIL- Cardiovascular Agents - Drugs to Treat OLM MED/HCTZ TAB 20-12.5 HYDROCHLOROTHIAZIDE TAB 20-12.5 Tier 2 X Heart and Circulation Conditions MG OLMESARTAN MEDOXOMIL- Cardiovascular Agents - Drugs to Treat OLM MED/HCTZ TAB 40-12.5 HYDROCHLOROTHIAZIDE TAB 40-12.5 Tier 2 X Heart and Circulation Conditions MG Cardiovascular Agents - Drugs to Treat OLM MED/HCTZ TAB 40- OLMESARTAN MEDOXOMIL- Tier 2 X Heart and Circulation Conditions 25MG HYDROCHLOROTHIAZIDE TAB 40-25 MG Cardiovascular Agents - Drugs to Treat OLMESA MEDOX TAB 20MG OLMESARTAN MEDOXOMIL TAB 20 MG Tier 2 X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat OLMESA MEDOX TAB 40MG OLMESARTAN MEDOXOMIL TAB 40 MG Tier 2 X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat OLMESA MEDOX TAB 5MG OLMESARTAN MEDOXOMIL TAB 5 MG Tier 2 X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat OMEGA-3-ACID ETHYL ESTERS CAP 1 OMEGA-3-ACID CAP 1GM Tier 3 X Heart and Circulation Conditions GM Cardiovascular Agents - Drugs to Treat PACERONE TAB 100MG AMIODARONE HCL TAB 100 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PACERONE TAB 200MG AMIODARONE HCL TAB 200 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PACERONE TAB 400MG AMIODARONE HCL TAB 400 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PENTOXIFYLLI TAB 400MG PENTOXIFYLLINE TAB ER 400 MG Tier 1 Heart and Circulation Conditions ER Cardiovascular Agents - Drugs to Treat PERINDOPRIL TAB 2MG PERINDOPRIL ERBUMINE TAB 2 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PERINDOPRIL TAB 4MG PERINDOPRIL ERBUMINE TAB 4 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PERINDOPRIL TAB 8MG PERINDOPRIL ERBUMINE TAB 8 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PHENOXYBENZA CAP 10MG PHENOXYBENZAMINE HCL CAP 10 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PINDOLOL TAB 10MG PINDOLOL TAB 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PINDOLOL TAB 5MG PINDOLOL TAB 5 MG Tier 1 Heart and Circulation Conditions

93 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Cardiovascular Agents - Drugs to Treat ALIROCUMAB SUBCUTANEOUS SOLN PRALUENT INJ 150MG/ML Tier 2 X X X X Heart and Circulation Conditions PEN-INJECTOR 150 MG/ML Cardiovascular Agents - Drugs to Treat ALIROCUMAB SUBCUTANEOUS SOLN PRALUENT INJ 150MG/ML Tier 2 X X X X Heart and Circulation Conditions PREFILLED SYRINGE 150 MG/ML Cardiovascular Agents - Drugs to Treat ALIROCUMAB SUBCUTANEOUS SOLN PRALUENT INJ 75MG/ML Tier 2 X X X X Heart and Circulation Conditions PEN-INJECTOR 75 MG/ML Cardiovascular Agents - Drugs to Treat ALIROCUMAB SUBCUTANEOUS SOLN PRALUENT INJ 75MG/ML Tier 2 X X X X Heart and Circulation Conditions PREFILLED SYRINGE 75 MG/ML Cardiovascular Agents - Drugs to Treat PRAVACHOL TAB 20MG PRAVASTATIN SODIUM TAB 20 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PRAVACHOL TAB 40MG PRAVASTATIN SODIUM TAB 40 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PRAVACHOL TAB 80MG PRAVASTATIN SODIUM TAB 80 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PRAVASTATIN TAB 10MG PRAVASTATIN SODIUM TAB 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PRAVASTATIN TAB 20MG PRAVASTATIN SODIUM TAB 20 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PRAVASTATIN TAB 40MG PRAVASTATIN SODIUM TAB 40 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PRAVASTATIN TAB 80MG PRAVASTATIN SODIUM TAB 80 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PRAZOSIN HCL CAP 1MG PRAZOSIN HCL CAP 1 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PRAZOSIN HCL CAP 2MG PRAZOSIN HCL CAP 2 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PRAZOSIN HCL CAP 5MG PRAZOSIN HCL CAP 5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat CHOLESTYRAMINE LIGHT POWDER 4 PREVALITE POW 4GM Tier 1 Heart and Circulation Conditions GM/DOSE Cardiovascular Agents - Drugs to Treat CHOLESTYRAMINE LIGHT POWDER PREVALITE POW 4GM PK Tier 1 Heart and Circulation Conditions PACKETS 4 GM Cardiovascular Agents - Drugs to Treat PRINIVIL TAB 10MG LISINOPRIL TAB 10 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PRINIVIL TAB 20MG LISINOPRIL TAB 20 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PRINIVIL TAB 5MG LISINOPRIL TAB 5 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PROCARDIA CAP 10MG NIFEDIPINE CAP 10 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PROCARDIA XL TAB 30MG NIFEDIPINE TAB ER 24HR OSMOTIC Tier 3 Heart and Circulation Conditions CR RELEASE 30 MG Cardiovascular Agents - Drugs to Treat PROCARDIA XL TAB 60MG NIFEDIPINE TAB ER 24HR OSMOTIC Tier 3 Heart and Circulation Conditions CR RELEASE 60 MG Cardiovascular Agents - Drugs to Treat PROCARDIA XL TAB 90MG NIFEDIPINE TAB ER 24HR OSMOTIC Tier 3 Heart and Circulation Conditions CR RELEASE 90 MG Cardiovascular Agents - Drugs to Treat PROPAFENONE CAP 225MG PROPAFENONE HCL CAP ER 12HR 225 Tier 3 Heart and Circulation Conditions ER MG Cardiovascular Agents - Drugs to Treat PROPAFENONE CAP 325MG PROPAFENONE HCL CAP ER 12HR 325 Tier 3 Heart and Circulation Conditions ER MG Cardiovascular Agents - Drugs to Treat PROPAFENONE CAP 425MG PROPAFENONE HCL CAP ER 12HR 425 Tier 3 Heart and Circulation Conditions ER MG Cardiovascular Agents - Drugs to Treat PROPAFENONE CAP 425MG PROPAFENONE HCL CAP ER 12HR 425 Tier 3 Heart and Circulation Conditions SR MG Cardiovascular Agents - Drugs to Treat PROPAFENONE TAB 150MG PROPAFENONE HCL TAB 150 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PROPAFENONE TAB 225MG PROPAFENONE HCL TAB 225 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PROPAFENONE TAB 300MG PROPAFENONE HCL TAB 300 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PROPRANOLOL & PROPRAN/HCTZ TAB 40/25 Tier 1 Heart and Circulation Conditions HYDROCHLOROTHIAZIDE TAB 40-25 MG Cardiovascular Agents - Drugs to Treat PROPRANOLOL & PROPRAN/HCTZ TAB 80/25 Tier 1 Heart and Circulation Conditions HYDROCHLOROTHIAZIDE TAB 80-25 MG Cardiovascular Agents - Drugs to Treat PROPRANOLOL CAP 120MG PROPRANOLOL HCL CAP ER 24HR 120 Tier 2 Heart and Circulation Conditions ER MG Cardiovascular Agents - Drugs to Treat PROPRANOLOL CAP 160MG PROPRANOLOL HCL CAP ER 24HR 160 Tier 2 Heart and Circulation Conditions ER MG Cardiovascular Agents - Drugs to Treat PROPRANOLOL CAP 60MG PROPRANOLOL HCL CAP ER 24HR 60 Tier 2 Heart and Circulation Conditions ER MG Cardiovascular Agents - Drugs to Treat PROPRANOLOL CAP 80MG PROPRANOLOL HCL CAP ER 24HR 80 Tier 2 Heart and Circulation Conditions ER MG Cardiovascular Agents - Drugs to Treat PROPRANOLOL SOL PROPRANOLOL HCL ORAL SOLN 20 Tier 1 Heart and Circulation Conditions 20MG/5ML MG/5ML Cardiovascular Agents - Drugs to Treat PROPRANOLOL SOL PROPRANOLOL HCL ORAL SOLN 40 Tier 1 Heart and Circulation Conditions 40MG/5ML MG/5ML Cardiovascular Agents - Drugs to Treat PROPRANOLOL TAB 10MG PROPRANOLOL HCL TAB 10 MG Tier 1 Heart and Circulation Conditions

94 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Cardiovascular Agents - Drugs to Treat PROPRANOLOL TAB 20MG PROPRANOLOL HCL TAB 20 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PROPRANOLOL TAB 40MG PROPRANOLOL HCL TAB 40 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PROPRANOLOL TAB 60MG PROPRANOLOL HCL TAB 60 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PROPRANOLOL TAB 80MG PROPRANOLOL HCL TAB 80 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat QBRELIS SOL 1MG/ML LISINOPRIL ORAL SOLN 1 MG/ML Tier 3 X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat QUINAPRIL-HYDROCHLOROTHIAZIDE QNAPRIL/HCTZ TAB 10-12.5 Tier 2 Heart and Circulation Conditions TAB 10-12.5 MG Cardiovascular Agents - Drugs to Treat QUINAPRIL-HYDROCHLOROTHIAZIDE QNAPRIL/HCTZ TAB 20-12.5 Tier 2 Heart and Circulation Conditions TAB 20-12.5 MG Cardiovascular Agents - Drugs to Treat QNAPRIL/HCTZ TAB 20- QUINAPRIL-HYDROCHLOROTHIAZIDE Tier 2 Heart and Circulation Conditions 25MG TAB 20-25 MG Cardiovascular Agents - Drugs to Treat CHOLESTYRAMINE POWDER PACKETS QUESTRAN POW 4GM Tier 3 Heart and Circulation Conditions 4 GM Cardiovascular Agents - Drugs to Treat CHOLESTYRAMINE POWDER 4 GM/ QUESTRAN POW 4GM Tier 3 Heart and Circulation Conditions DOSE Cardiovascular Agents - Drugs to Treat CHOLESTYRAMINE LIGHT POWDER 4 QUESTRAN POW 4GM LITE Tier 3 Heart and Circulation Conditions GM/DOSE Cardiovascular Agents - Drugs to Treat QUINAPRIL TAB 10MG QUINAPRIL HCL TAB 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat QUINAPRIL TAB 20MG QUINAPRIL HCL TAB 20 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat QUINAPRIL TAB 40MG QUINAPRIL HCL TAB 40 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat QUINAPRIL TAB 5MG QUINAPRIL HCL TAB 5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat QUINIDINE GL TAB 324MG QUINIDINE GLUCONATE TAB ER 324 MG Tier 1 Heart and Circulation Conditions CR Cardiovascular Agents - Drugs to Treat QUINIDINE GL TAB 324MG QUINIDINE GLUCONATE TAB ER 324 MG Tier 1 Heart and Circulation Conditions ER Cardiovascular Agents - Drugs to Treat QUINIDINE SU TAB 200MG QUINIDINE SULFATE TAB 200 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat QUINIDINE SU TAB 300MG QUINIDINE SULFATE TAB 300 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat RAMIPRIL CAP 1.25MG RAMIPRIL CAP 1.25 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat RAMIPRIL CAP 10MG RAMIPRIL CAP 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat RAMIPRIL CAP 2.5MG RAMIPRIL CAP 2.5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat RAMIPRIL CAP 5MG RAMIPRIL CAP 5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat RANEXA TAB 1000MG RANOLAZINE TAB ER 12HR 1000 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat RANEXA TAB 500MG RANOLAZINE TAB ER 12HR 500 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat RECTIV OIN 0.4% NITROGLYCERIN OINT 0.4% Tier 3 X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat EVOLOCUMAB SUBCUTANEOUS SOLN REPATHA INJ 140MG/ML Tier 4 X X X X Heart and Circulation Conditions PREFILLED SYRINGE 140 MG/ML Cardiovascular Agents - Drugs to Treat EVOLOCUMAB SUBCUTANEOUS SOLN REPATHA PUSH INJ 420/3.5 Tier 3 X X X X Heart and Circulation Conditions CARTRIDGE/INFUSOR 420 MG/3.5ML Cardiovascular Agents - Drugs to Treat REPATHA SURE INJ 140MG/ EVOLOCUMAB SUBCUTANEOUS SOLN Tier 4 X X X X Heart and Circulation Conditions ML AUTO-INJECTOR 140 MG/ML Cardiovascular Agents - Drugs to Treat ROSUVASTATIN TAB 10MG ROSUVASTATIN CALCIUM TAB 10 MG Tier 2 X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ROSUVASTATIN TAB 20MG ROSUVASTATIN CALCIUM TAB 20 MG Tier 2 X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ROSUVASTATIN TAB 40MG ROSUVASTATIN CALCIUM TAB 40 MG Tier 2 X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ROSUVASTATIN TAB 5MG ROSUVASTATIN CALCIUM TAB 5 MG Tier 2 X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat RYTHMOL TAB 225MG PROPAFENONE HCL TAB 225 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat PROPAFENONE HCL CAP ER 12HR 225 RYTHMOL SR CAP 225MG Tier 3 Heart and Circulation Conditions MG Cardiovascular Agents - Drugs to Treat PROPAFENONE HCL CAP ER 12HR 325 RYTHMOL SR CAP 325MG Tier 3 Heart and Circulation Conditions MG Cardiovascular Agents - Drugs to Treat PROPAFENONE HCL CAP ER 12HR 425 RYTHMOL SR CAP 425MG Tier 3 Heart and Circulation Conditions MG Cardiovascular Agents - Drugs to Treat SECTRAL CAP 200MG ACEBUTOLOL HCL CAP 200 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat SECTRAL CAP 400MG ACEBUTOLOL HCL CAP 400 MG Tier 3 Heart and Circulation Conditions

95 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy HCR Cardiovascular Agents - Drugs to Treat SIMVASTATIN TAB 10MG SIMVASTATIN TAB 10 MG Preventive Heart and Circulation Conditions Care HCR Cardiovascular Agents - Drugs to Treat SIMVASTATIN TAB 20MG SIMVASTATIN TAB 20 MG Preventive Heart and Circulation Conditions Care HCR Cardiovascular Agents - Drugs to Treat SIMVASTATIN TAB 40MG SIMVASTATIN TAB 40 MG Preventive Heart and Circulation Conditions Care HCR Cardiovascular Agents - Drugs to Treat SIMVASTATIN TAB 5MG SIMVASTATIN TAB 5 MG Preventive Heart and Circulation Conditions Care Cardiovascular Agents - Drugs to Treat SIMVASTATIN TAB 80MG SIMVASTATIN TAB 80 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat SOTALOL AF TAB 120MG SOTALOL HCL (AFIB/AFL) TAB 120 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat SOTALOL AF TAB 160MG SOTALOL HCL (AFIB/AFL) TAB 160 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat SOTALOL AF TAB 80MG SOTALOL HCL (AFIB/AFL) TAB 80 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat SOTALOL HCL TAB 120MG SOTALOL HCL TAB 120 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat SOTALOL HCL TAB 160MG SOTALOL HCL TAB 160 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat SOTALOL HCL TAB 240MG SOTALOL HCL TAB 240 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat SOTALOL HCL TAB 80MG SOTALOL HCL TAB 80 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat SOTALOL HCL ORAL SOLUTION 5 MG/ SOTYLIZE SOL 5MG/ML Tier 3 X Heart and Circulation Conditions ML Cardiovascular Agents - Drugs to Treat SPIRONOLACTONE & SPIRONO/HCTZ TAB 25/25 Tier 1 Heart and Circulation Conditions HYDROCHLOROTHIAZIDE TAB 25-25 MG Cardiovascular Agents - Drugs to Treat SPIRONOLACT TAB 100MG SPIRONOLACTONE TAB 100 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat SPIRONOLACT TAB 25MG SPIRONOLACTONE TAB 25 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat SPIRONOLACT TAB 50MG SPIRONOLACTONE TAB 50 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat SULAR TAB 17MG NISOLDIPINE TAB ER 24HR 17 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat SULAR TAB 17MG NISOLDIPINE TAB SR 24HR 17 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat SULAR TAB 34MG NISOLDIPINE TAB ER 24HR 34 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat SULAR TAB 8.5MG NISOLDIPINE TAB ER 24HR 8.5 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat TRANDOLAPRIL-VERAPAMIL HCL TAB ER TARKA TAB 1-240 CR Tier 3 Heart and Circulation Conditions 1-240 MG Cardiovascular Agents - Drugs to Treat TRANDOLAPRIL-VERAPAMIL HCL TAB ER TARKA TAB 2-180 CR Tier 3 Heart and Circulation Conditions 2-180 MG Cardiovascular Agents - Drugs to Treat TRANDOLAPRIL-VERAPAMIL HCL TAB TARKA TAB 2-240 CR Tier 3 Heart and Circulation Conditions CR 2-240 MG Cardiovascular Agents - Drugs to Treat TRANDOLAPRIL-VERAPAMIL HCL TAB TARKA TAB 4-240 CR Tier 3 Heart and Circulation Conditions CR 4-240 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE TAZTIA XT CAP 120MG/24 Tier 2 Heart and Circulation Conditions BEADS CAP ER 24HR 120 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE TAZTIA XT CAP 180MG/24 Tier 2 Heart and Circulation Conditions BEADS CAP ER 24HR 180 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE TAZTIA XT CAP 240MG/24 Tier 2 Heart and Circulation Conditions BEADS CAP ER 24HR 240 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE TAZTIA XT CAP 300MG/24 Tier 2 Heart and Circulation Conditions BEADS CAP ER 24HR 300 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE TAZTIA XT CAP 360MG/24 Tier 2 Heart and Circulation Conditions BEADS CAP ER 24HR 360 MG Cardiovascular Agents - Drugs to Treat ALISKIREN FUMARATE TAB 150 MG TEKTURNA TAB 150MG Tier 3 X Heart and Circulation Conditions (BASE EQUIVALENT) Cardiovascular Agents - Drugs to Treat ALISKIREN FUMARATE TAB 300 MG TEKTURNA TAB 300MG Tier 3 X Heart and Circulation Conditions (BASE EQUIVALENT) Cardiovascular Agents - Drugs to Treat TEKTURNA HCT TAB 150- ALISKIREN-HYDROCHLOROTHIAZIDE Tier 3 X Heart and Circulation Conditions 12.5 TAB 150-12.5 MG Cardiovascular Agents - Drugs to Treat TEKTURNA HCT TAB 150- ALISKIREN-HYDROCHLOROTHIAZIDE Tier 3 X Heart and Circulation Conditions 25MG TAB 150-25 MG Cardiovascular Agents - Drugs to Treat TEKTURNA HCT TAB 300- ALISKIREN-HYDROCHLOROTHIAZIDE Tier 3 X Heart and Circulation Conditions 12.5 TAB 300-12.5 MG Cardiovascular Agents - Drugs to Treat TEKTURNA HCT TAB 300- ALISKIREN-HYDROCHLOROTHIAZIDE Tier 3 X Heart and Circulation Conditions 25MG TAB 300-25 MG Cardiovascular Agents - Drugs to Treat TELMISARTAN-HYDROCHLOROTHIAZIDE TELMISA/HCTZ TAB 40-12.5 Tier 2 Heart and Circulation Conditions TAB 40-12.5 MG

96 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Cardiovascular Agents - Drugs to Treat TELMISARTAN-HYDROCHLOROTHIAZIDE TELMISA/HCTZ TAB 80-12.5 Tier 2 Heart and Circulation Conditions TAB 80-12.5 MG Cardiovascular Agents - Drugs to Treat TELMISA/HCTZ TAB 80- TELMISARTAN-HYDROCHLOROTHIAZIDE Tier 2 Heart and Circulation Conditions 25MG TAB 80-25 MG Cardiovascular Agents - Drugs to Treat TELMISARTAN TAB 20MG TELMISARTAN TAB 20 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat TELMISARTAN TAB 40MG TELMISARTAN TAB 40 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat TELMISARTAN TAB 80MG TELMISARTAN TAB 80 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat TENEX TAB 1MG GUANFACINE HCL TAB 1 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat TENEX TAB 2MG GUANFACINE HCL TAB 2 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE TIAZAC CAP 120MG/24 Tier 3 Heart and Circulation Conditions BEADS CAP ER 24HR 120 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE TIAZAC CAP 180MG/24 Tier 3 Heart and Circulation Conditions BEADS CAP ER 24HR 180 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE TIAZAC CAP 240MG/24 Tier 3 Heart and Circulation Conditions BEADS CAP ER 24HR 240 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE TIAZAC CAP 300MG/24 Tier 3 Heart and Circulation Conditions BEADS CAP ER 24HR 300 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE TIAZAC CAP 360MG/24 Tier 3 Heart and Circulation Conditions BEADS CAP ER 24HR 360 MG Cardiovascular Agents - Drugs to Treat DILTIAZEM HCL EXTENDED RELEASE TIAZAC CAP 420MG/24 Tier 3 Heart and Circulation Conditions BEADS CAP SR 24HR 420 MG Cardiovascular Agents - Drugs to Treat TIKOSYN CAP 125MCG DOFETILIDE CAP 125 MCG (0.125 MG) Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat TIKOSYN CAP 250MCG DOFETILIDE CAP 250 MCG (0.25 MG) Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat TIKOSYN CAP 500MCG DOFETILIDE CAP 500 MCG (0.5 MG) Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat TIMOLOL MAL TAB 10MG TIMOLOL MALEATE TAB 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat TIMOLOL MAL TAB 20MG TIMOLOL MALEATE TAB 20 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat TIMOLOL MAL TAB 5MG TIMOLOL MALEATE TAB 5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat METOPROLOL SUCCINATE TAB ER 24HR TOPROL XL TAB 100MG Tier 3 Heart and Circulation Conditions 100 MG (TARTRATE EQUIV) Cardiovascular Agents - Drugs to Treat METOPROLOL SUCCINATE TAB ER 24HR TOPROL XL TAB 200MG Tier 3 Heart and Circulation Conditions 200 MG (TARTRATE EQUIV) Cardiovascular Agents - Drugs to Treat METOPROLOL SUCCINATE TAB ER 24HR TOPROL XL TAB 25MG Tier 3 Heart and Circulation Conditions 25 MG (TARTRATE EQUIV) Cardiovascular Agents - Drugs to Treat METOPROLOL SUCCINATE TAB ER 24HR TOPROL XL TAB 50MG Tier 3 Heart and Circulation Conditions 50 MG (TARTRATE EQUIV) Cardiovascular Agents - Drugs to Treat TORSEMIDE TAB 100MG TORSEMIDE TAB 100 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat TORSEMIDE TAB 10MG TORSEMIDE TAB 10 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat TORSEMIDE TAB 20MG TORSEMIDE TAB 20 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat TORSEMIDE TAB 5MG TORSEMIDE TAB 5 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat TRANDO/VERAP TAB 1-240 TRANDOLAPRIL-VERAPAMIL HCL TAB ER Tier 3 Heart and Circulation Conditions ER 1-240 MG Cardiovascular Agents - Drugs to Treat TRANDO/VERAP TAB 2-180 TRANDOLAPRIL-VERAPAMIL HCL TAB ER Tier 3 Heart and Circulation Conditions ER 2-180 MG Cardiovascular Agents - Drugs to Treat TRANDO/VERAP TAB 2-240 TRANDOLAPRIL-VERAPAMIL HCL TAB ER Tier 3 Heart and Circulation Conditions ER 2-240 MG Cardiovascular Agents - Drugs to Treat TRANDO/VERAP TAB 4-240 TRANDOLAPRIL-VERAPAMIL HCL TAB ER Tier 3 Heart and Circulation Conditions ER 4-240 MG Cardiovascular Agents - Drugs to Treat TRANDOLAPRIL TAB 1MG TRANDOLAPRIL TAB 1 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat TRANDOLAPRIL TAB 2MG TRANDOLAPRIL TAB 2 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat TRANDOLAPRIL TAB 4MG TRANDOLAPRIL TAB 4 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat TRENTAL TAB 400MG PENTOXIFYLLINE TAB 400MG Tier 3 Heart and Circulation Conditions TRIAMTERENE & Cardiovascular Agents - Drugs to Treat TRIAMT/HCTZ CAP 37.5-25 HYDROCHLOROTHIAZIDE CAP 37.5-25 Tier 1 Heart and Circulation Conditions MG Cardiovascular Agents - Drugs to Treat TRIAMTERENE & TRIAMT/HCTZ CAP 50-25MG Tier 1 Heart and Circulation Conditions HYDROCHLOROTHIAZIDE CAP 50-25 MG TRIAMTERENE & Cardiovascular Agents - Drugs to Treat TRIAMT/HCTZ TAB 37.5-25 HYDROCHLOROTHIAZIDE TAB 37.5-25 Tier 1 Heart and Circulation Conditions MG

97 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Cardiovascular Agents - Drugs to Treat TRIAMTERENE & TRIAMT/HCTZ TAB 75-50MG Tier 1 Heart and Circulation Conditions HYDROCHLOROTHIAZIDE TAB 75-50 MG Cardiovascular Agents - Drugs to Treat OMEGA-3-ACID ETHYL ESTERS CAP 1 TRIKLO CAP 1GM Tier 3 X Heart and Circulation Conditions GM Cardiovascular Agents - Drugs to Treat VALSART/HCTZ TAB 160- VALSARTAN-HYDROCHLOROTHIAZIDE Tier 1 Heart and Circulation Conditions 12.5 TAB 160-12.5 MG Cardiovascular Agents - Drugs to Treat VALSART/HCTZ TAB 160- VALSARTAN-HYDROCHLOROTHIAZIDE Tier 1 Heart and Circulation Conditions 25MG TAB 160-25 MG Cardiovascular Agents - Drugs to Treat VALSART/HCTZ TAB 320- VALSARTAN-HYDROCHLOROTHIAZIDE Tier 1 Heart and Circulation Conditions 12.5 TAB 320-12.5 MG Cardiovascular Agents - Drugs to Treat VALSART/HCTZ TAB 320- VALSARTAN-HYDROCHLOROTHIAZIDE Tier 1 Heart and Circulation Conditions 25MG TAB 320-25 MG Cardiovascular Agents - Drugs to Treat VALSARTAN-HYDROCHLOROTHIAZIDE VALSART/HCTZ TAB 80-12.5 Tier 1 Heart and Circulation Conditions TAB 80-12.5 MG Cardiovascular Agents - Drugs to Treat VALSARTAN TAB 160MG VALSARTAN TAB 160 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VALSARTAN TAB 320MG VALSARTAN TAB 320 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VALSARTAN TAB 40MG VALSARTAN TAB 40 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VALSARTAN TAB 80MG VALSARTAN TAB 80 MG Tier 2 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VASCEPA CAP 0.5GM ICOSAPENT ETHYL CAP 0.5 GM Tier 3 X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VASCEPA CAP 1GM ICOSAPENT ETHYL CAP 1 GM Tier 3 X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VECAMYL TAB 2.5MG MECAMYLAMINE HCL TAB 2.5 MG Tier 3 X X Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERAPAMIL CAP 100MG ER VERAPAMIL HCL CAP ER 24HR 100 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERAPAMIL CAP 120MG ER VERAPAMIL HCL CAP ER 24HR 120 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERAPAMIL CAP 120MG SR VERAPAMIL HCL CAP ER 24HR 120 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERAPAMIL CAP 180MG ER VERAPAMIL HCL CAP ER 24HR 180 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERAPAMIL CAP 180MG SR VERAPAMIL HCL CAP ER 24HR 180 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERAPAMIL CAP 200MG ER VERAPAMIL HCL CAP ER 24HR 200 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERAPAMIL CAP 240MG ER VERAPAMIL HCL CAP ER 24HR 240 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERAPAMIL CAP 240MG SR VERAPAMIL HCL CAP ER 24HR 240 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERAPAMIL CAP 300MG ER VERAPAMIL HCL CAP ER 24HR 300 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERAPAMIL CAP 360MG SR VERAPAMIL HCL CAP ER 24HR 360 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERAPAMIL TAB 120MG VERAPAMIL HCL TAB 120 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERAPAMIL TAB 120MG ER VERAPAMIL HCL TAB ER 120 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERAPAMIL TAB 180MG ER VERAPAMIL HCL TAB ER 180 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERAPAMIL TAB 240MG ER VERAPAMIL HCL TAB ER 240 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERAPAMIL TAB 40MG VERAPAMIL HCL TAB 40 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERAPAMIL TAB 80MG VERAPAMIL HCL TAB 80 MG Tier 1 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERELAN CAP 120MG SR VERAPAMIL HCL CAP ER 24HR 120 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERELAN CAP 180MG SR VERAPAMIL HCL CAP ER 24HR 180 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERELAN CAP 240MG SR VERAPAMIL HCL CAP ER 24HR 240 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERELAN CAP 360MG SR VERAPAMIL HCL CAP ER 24HR 360 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat VERELAN PM CAP 100MG VERAPAMIL HCL CAP ER 24HR 100 MG Tier 3 Heart and Circulation Conditions ER Cardiovascular Agents - Drugs to Treat VERELAN PM CAP 200MG VERAPAMIL HCL CAP ER 24HR 200 MG Tier 3 Heart and Circulation Conditions ER Cardiovascular Agents - Drugs to Treat VERELAN PM CAP 300MG VERAPAMIL HCL CAP ER 24HR 300 MG Tier 3 Heart and Circulation Conditions ER Cardiovascular Agents - Drugs to Treat COLESEVELAM HCL PACKET FOR SUSP WELCHOL PAK 3.75GM Tier 2 Heart and Circulation Conditions 3.75 GM Cardiovascular Agents - Drugs to Treat WELCHOL TAB 625MG COLESEVELAM HCL TAB 625 MG Tier 2 Heart and Circulation Conditions

98 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Cardiovascular Agents - Drugs to Treat ZEBETA TAB 10MG BISOPROLOL FUMARATE TAB 10 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ZEBETA TAB 5MG BISOPROLOL FUMARATE TAB 5 MG Tier 3 Heart and Circulation Conditions BISOPROLOL & Cardiovascular Agents - Drugs to Treat ZIAC TAB 10/6.25 HYDROCHLOROTHIAZIDE TAB 10-6.25 Tier 3 Heart and Circulation Conditions MG BISOPROLOL & Cardiovascular Agents - Drugs to Treat ZIAC TAB 2.5/6.25 HYDROCHLOROTHIAZIDE TAB 2.5-6.25 Tier 3 Heart and Circulation Conditions MG Cardiovascular Agents - Drugs to Treat BISOPROLOL & ZIAC TAB 5-6.25MG Tier 3 Heart and Circulation Conditions HYDROCHLOROTHIAZIDE TAB 5-6.25 MG Cardiovascular Agents - Drugs to Treat ZOCOR TAB 10MG SIMVASTATIN TAB 10 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ZOCOR TAB 20MG SIMVASTATIN TAB 20 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ZOCOR TAB 40MG SIMVASTATIN TAB 40 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ZOCOR TAB 5MG SIMVASTATIN TAB 5 MG Tier 3 Heart and Circulation Conditions Cardiovascular Agents - Drugs to Treat ZOCOR TAB 80MG SIMVASTATIN TAB 80 MG Tier 3 Heart and Circulation Conditions Central Nervous System Agents - Drugs AMPHETAMINE-DEXTROAMPHETAMINE ADDERALL XR CAP 10MG Tier 2 X to Treat Nerve Conditions CAP ER 24HR 10 MG Central Nervous System Agents - Drugs AMPHETAMINE-DEXTROAMPHETAMINE ADDERALL XR CAP 15MG Tier 2 X to Treat Nerve Conditions CAP ER 24HR 15 MG Central Nervous System Agents - Drugs AMPHETAMINE-DEXTROAMPHETAMINE ADDERALL XR CAP 20MG Tier 2 X to Treat Nerve Conditions CAP ER 24HR 20 MG Central Nervous System Agents - Drugs AMPHETAMINE-DEXTROAMPHETAMINE ADDERALL XR CAP 25MG Tier 2 X to Treat Nerve Conditions CAP ER 24HR 25 MG Central Nervous System Agents - Drugs AMPHETAMINE-DEXTROAMPHETAMINE ADDERALL XR CAP 30MG Tier 2 X to Treat Nerve Conditions CAP ER 24HR 30 MG Central Nervous System Agents - Drugs AMPHETAMINE-DEXTROAMPHETAMINE ADDERALL XR CAP 5MG Tier 2 X to Treat Nerve Conditions CAP ER 24HR 5 MG Central Nervous System Agents - Drugs ADDYI TAB 100MG FLIBANSERIN TAB 100 MG Tier 3 X X to Treat Nerve Conditions Central Nervous System Agents - Drugs ADIPEX-P CAP 37.5MG PHENTERMINE HCL CAP 37.5 MG Tier 3 X to Treat Nerve Conditions Central Nervous System Agents - Drugs ADIPEX-P TAB 37.5MG PHENTERMINE HCL TAB 37.5 MG Tier 3 X to Treat Nerve Conditions Central Nervous System Agents - Drugs AMPHETAMINE-DEXTROAMPHETAMINE AMPHET/DEXTR TAB 10MG Tier 1 X to Treat Nerve Conditions TAB 10 MG Central Nervous System Agents - Drugs AMPHET/DEXTR TAB AMPHETAMINE-DEXTROAMPHETAMINE Tier 1 X to Treat Nerve Conditions 12.5MG TAB 12.5 MG Central Nervous System Agents - Drugs AMPHETAMINE-DEXTROAMPHETAMINE AMPHET/DEXTR TAB 15MG Tier 1 X to Treat Nerve Conditions TAB 15 MG Central Nervous System Agents - Drugs AMPHETAMINE-DEXTROAMPHETAMINE AMPHET/DEXTR TAB 20MG Tier 1 X to Treat Nerve Conditions TAB 20 MG Central Nervous System Agents - Drugs AMPHETAMINE-DEXTROAMPHETAMINE AMPHET/DEXTR TAB 30MG Tier 1 X to Treat Nerve Conditions TAB 30 MG Central Nervous System Agents - Drugs AMPHETAMINE-DEXTROAMPHETAMINE AMPHET/DEXTR TAB 5MG Tier 1 X to Treat Nerve Conditions TAB 5 MG Central Nervous System Agents - Drugs AMPHETAMINE-DEXTROAMPHETAMINE AMPHET/DEXTR TAB 7.5MG Tier 1 X to Treat Nerve Conditions TAB 7.5 MG Central Nervous System Agents - Drugs AMPYRA TAB 10MG DALFAMPRIDINE TAB SR 12HR 10 MG Tier 2 X X X to Treat Nerve Conditions Central Nervous System Agents - Drugs ATOMOXETINE HCL CAP 100 MG (BASE ATOMOXETINE CAP 100MG Tier 3 X to Treat Nerve Conditions EQUIV) Central Nervous System Agents - Drugs ATOMOXETINE HCL CAP 10 MG (BASE ATOMOXETINE CAP 10MG Tier 3 X to Treat Nerve Conditions EQUIV) Central Nervous System Agents - Drugs ATOMOXETINE HCL CAP 18 MG (BASE ATOMOXETINE CAP 18MG Tier 3 X to Treat Nerve Conditions EQUIV) Central Nervous System Agents - Drugs ATOMOXETINE HCL CAP 25 MG (BASE ATOMOXETINE CAP 25MG Tier 3 X to Treat Nerve Conditions EQUIV) Central Nervous System Agents - Drugs ATOMOXETINE HCL CAP 40 MG (BASE ATOMOXETINE CAP 40MG Tier 3 X to Treat Nerve Conditions EQUIV) Central Nervous System Agents - Drugs ATOMOXETINE HCL CAP 60 MG (BASE ATOMOXETINE CAP 60MG Tier 3 X to Treat Nerve Conditions EQUIV) Central Nervous System Agents - Drugs ATOMOXETINE HCL CAP 80 MG (BASE ATOMOXETINE CAP 80MG Tier 3 X to Treat Nerve Conditions EQUIV) Central Nervous System Agents - Drugs AUBAGIO TAB 14MG TERIFLUNOMIDE TAB 14 MG Tier 3 X X X to Treat Nerve Conditions Central Nervous System Agents - Drugs AUBAGIO TAB 7MG TERIFLUNOMIDE TAB 7 MG Tier 3 X X X to Treat Nerve Conditions Central Nervous System Agents - Drugs AUSTEDO TAB 12MG DEUTETRABENAZINE TAB 12 MG Tier 2 X X X to Treat Nerve Conditions Central Nervous System Agents - Drugs AUSTEDO TAB 6MG DEUTETRABENAZINE TAB 6 MG Tier 2 X X X to Treat Nerve Conditions

99 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Central Nervous System Agents - Drugs AUSTEDO TAB 9MG DEUTETRABENAZINE TAB 9 MG Tier 2 X X X to Treat Nerve Conditions Central Nervous System Agents - Drugs INTERFERON BETA-1A FOR IM INJ KIT AVONEX KIT 30MCG Tier 2 X X X to Treat Nerve Conditions 30MCG (33MCG(6.6 MU)/VIAL) Central Nervous System Agents - Drugs INTERFERON BETA-1A IM AUTO- AVONEX PEN KIT 30MCG Tier 2 X X X to Treat Nerve Conditions INJECTOR KIT 30 MCG/0.5ML Central Nervous System Agents - Drugs INTERFERON BETA-1A IM PREFILLED AVONEX PREFL KIT 30MCG Tier 2 X X X to Treat Nerve Conditions SYRINGE KIT 30 MCG/0.5ML Central Nervous System Agents - Drugs BELVIQ TAB 10MG LORCASERIN HCL TAB 10 MG Tier 3 X to Treat Nerve Conditions Central Nervous System Agents - Drugs BELVIQ XR TAB 20MG LORCASERIN HCL TAB ER 24HR 20 MG Tier 3 X to Treat Nerve Conditions Central Nervous System Agents - Drugs BENZPHETAMIN TAB 50MG BENZPHETAMINE HCL TAB 50 MG Tier 1 X to Treat Nerve Conditions Central Nervous System Agents - Drugs BENZPHETMINE TAB 25MG BENZPHETAMINE HCL TAB 25 MG Tier 1 X to Treat Nerve Conditions Central Nervous System Agents - Drugs INTERFERON BETA-1B FOR INJ KIT 0.3 BETASERON INJ 0.3MG Tier 2 X X X to Treat Nerve Conditions MG Central Nervous System Agents - Drugs CAFFEINE CIT SOL 20MG/ CAFFEINE CITRATE ORAL SOLN 60 Tier 1 to Treat Nerve Conditions ML MG/3ML (10 MG/ML BASE EQUIV) Central Nervous System Agents - Drugs CAFFEINE CIT SOL CAFFEINE CITRATE ORAL SOLN 60 Tier 1 to Treat Nerve Conditions 60MG/3ML MG/3ML (10 MG/ML BASE EQUIV) Central Nervous System Agents - Drugs METHYLPHENIDATE HCL TAB ER CONCERTA TAB 18MG Tier 2 X X to Treat Nerve Conditions OSMOTIC RELEASE (OSM) 18 MG Central Nervous System Agents - Drugs METHYLPHENIDATE HCL TAB ER CONCERTA TAB 27MG Tier 2 X X to Treat Nerve Conditions OSMOTIC RELEASE (OSM) 27 MG Central Nervous System Agents - Drugs METHYLPHENIDATE HCL TAB ER CONCERTA TAB 36MG Tier 2 X X to Treat Nerve Conditions OSMOTIC RELEASE (OSM) 36 MG Central Nervous System Agents - Drugs METHYLPHENIDATE HCL TAB ER CONCERTA TAB 54MG Tier 2 X X to Treat Nerve Conditions OSMOTIC RELEASE (OSM) 54 MG Central Nervous System Agents - Drugs NALTREXONE HCL-BUPROPION HCL TAB CONTRAVE TAB 8-90MG Tier 3 X to Treat Nerve Conditions SR 12HR 8-90 MG Central Nervous System Agents - Drugs NALTREXONE HCL-BUPROPION HCL TAB CONTRAVE TAB 8-90MG Tier 3 X to Treat Nerve Conditions ER 12HR 8-90 MG Central Nervous System Agents - Drugs GLATIRAMER ACETATE SOLN PREFILLED COPAXONE INJ 20MG/ML Tier 2 X X X to Treat Nerve Conditions SYRINGE 20 MG/ML Central Nervous System Agents - Drugs GLATIRAMER ACETATE SOLN PREFILLED COPAXONE INJ 40MG/ML Tier 2 X X X to Treat Nerve Conditions SYRINGE 40 MG/ML Central Nervous System Agents - Drugs DESOXYN TAB 5MG METHAMPHETAMINE HCL TAB 5 MG Tier 3 X to Treat Nerve Conditions Central Nervous System Agents - Drugs DEXTROAMPHETAMINE SULFATE CAP DEXEDRINE CAP 10MG CR Tier 4 X to Treat Nerve Conditions ER 24HR 10 MG Central Nervous System Agents - Drugs DEXTROAMPHETAMINE SULFATE CAP DEXEDRINE CAP 15MG CR Tier 4 X to Treat Nerve Conditions ER 24HR 15 MG Central Nervous System Agents - Drugs DEXTROAMPHETAMINE SULFATE CAP DEXEDRINE CAP 5MG CR Tier 4 X to Treat Nerve Conditions ER 24HR 5 MG Central Nervous System Agents - Drugs DEXTROAMPHETAMINE SULFATE TAB DEXEDRINE TAB 10MG Tier 3 X to Treat Nerve Conditions 10 MG Central Nervous System Agents - Drugs DEXTROAMPHETAMINE SULFATE TAB DEXEDRINE TAB 5MG Tier 3 X to Treat Nerve Conditions 5 MG Central Nervous System Agents - Drugs DEXMETHYLPH TAB 10MG DEXMETHYLPHENIDATE HCL TAB 10 MG Tier 1 X to Treat Nerve Conditions Central Nervous System Agents - Drugs DEXMETHYLPH TAB 2.5MG DEXMETHYLPHENIDATE HCL TAB 2.5 MG Tier 1 X to Treat Nerve Conditions Central Nervous System Agents - Drugs DEXMETHYLPH TAB 5MG DEXMETHYLPHENIDATE HCL TAB 5 MG Tier 1 X to Treat Nerve Conditions Central Nervous System Agents - Drugs DEXTROAMPHET CAP 10MG DEXTROAMPHETAMINE SULFATE CAP Tier 3 X to Treat Nerve Conditions ER ER 24HR 10 MG Central Nervous System Agents - Drugs DEXTROAMPHET CAP 15MG DEXTROAMPHETAMINE SULFATE CAP Tier 3 X to Treat Nerve Conditions ER ER 24HR 15 MG Central Nervous System Agents - Drugs DEXTROAMPHET CAP 5MG DEXTROAMPHETAMINE SULFATE CAP Tier 3 X to Treat Nerve Conditions ER ER 24HR 5 MG Central Nervous System Agents - Drugs DEXTROAMPHET SOL DEXTROAMPHETAMINE SULFATE ORAL Tier 1 X to Treat Nerve Conditions 5MG/5ML SOLUTION 5 MG/5ML Central Nervous System Agents - Drugs DEXTROAMPHETAMINE SULFATE TAB DEXTROAMPHET TAB 10MG Tier 3 X to Treat Nerve Conditions 10 MG Central Nervous System Agents - Drugs DEXTROAMPHETAMINE SULFATE TAB DEXTROAMPHET TAB 5MG Tier 3 X to Treat Nerve Conditions 5 MG Central Nervous System Agents - Drugs DIETHYLPROP TAB 25MG DIETHYLPROPION HCL TAB 25 MG Tier 1 X to Treat Nerve Conditions Central Nervous System Agents - Drugs DIETHYLPROPION HCL TAB ER 24HR DIETHYLPROP TAB 75MG ER Tier 1 X to Treat Nerve Conditions 75 MG Central Nervous System Agents - Drugs DULOXETINE HCL ENTERIC COATED DULOXETINE CAP 20MG Tier 3 X to Treat Nerve Conditions PELLETS CAP 20 MG (BASE EQ) Central Nervous System Agents - Drugs DULOXETINE HCL ENTERIC COATED DULOXETINE CAP 30MG Tier 3 X to Treat Nerve Conditions PELLETS CAP 30 MG (BASE EQ) Central Nervous System Agents - Drugs DULOXETINE HCL ENTERIC COATED DULOXETINE CAP 60MG Tier 3 X to Treat Nerve Conditions PELLETS CAP 60 MG (BASE EQ)

100 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Central Nervous System Agents - Drugs FOCALIN TAB 10MG DEXMETHYLPHENIDATE HCL TAB 10 MG Tier 3 X to Treat Nerve Conditions Central Nervous System Agents - Drugs FOCALIN TAB 2.5MG DEXMETHYLPHENIDATE HCL TAB 2.5 MG Tier 3 X to Treat Nerve Conditions Central Nervous System Agents - Drugs FOCALIN TAB 5MG DEXMETHYLPHENIDATE HCL TAB 5 MG Tier 3 X to Treat Nerve Conditions Central Nervous System Agents - Drugs FINGOLIMOD HCL CAP 0.5 MG (BASE GILENYA CAP 0.5MG Tier 3 X X X to Treat Nerve Conditions EQUIV) Central Nervous System Agents - Drugs GUANFACINE HCL TAB ER 24HR 1 MG GUANFACINE TAB 1MG ER Tier 2 X to Treat Nerve Conditions (BASE EQUIV) Central Nervous System Agents - Drugs GUANFACINE HCL TAB ER 24HR 2 MG GUANFACINE TAB 2MG ER Tier 2 X to Treat Nerve Conditions (BASE EQUIV) Central Nervous System Agents - Drugs GUANFACINE HCL TAB ER 24HR 3 MG GUANFACINE TAB 3MG ER Tier 2 X to Treat Nerve Conditions (BASE EQUIV) Central Nervous System Agents - Drugs GUANFACINE HCL TAB ER 24HR 4 MG GUANFACINE TAB 4MG ER Tier 2 X to Treat Nerve Conditions (BASE EQUIV) Central Nervous System Agents - Drugs HETLIOZ CAP 20MG TASIMELTEON CAPSULE 20 MG Tier 4 X X X to Treat Nerve Conditions Central Nervous System Agents - Drugs VALBENAZINE TOSYLATE CAP 40 MG INGREZZA CAP 40MG Tier 3 X X X to Treat Nerve Conditions (BASE EQUIV) Central Nervous System Agents - Drugs VALBENAZINE TOSYLATE CAP 80 MG INGREZZA CAP 80MG Tier 3 X X X to Treat Nerve Conditions (BASE EQUIV) Central Nervous System Agents - Drugs ISOMETH/APAP CAP ISOMETHEPTENE-DICHLORAL- Tier 1 to Treat Nerve Conditions DICHLOR ACETAMINOPHEN CAP 65-100-325 MG Central Nervous System Agents - Drugs LOMAIRA TAB 8MG PHENTERMINE HCL TAB 8 MG Tier 3 X to Treat Nerve Conditions Central Nervous System Agents - Drugs LYRICA CAP 100MG PREGABALIN CAP 100 MG Tier 3 X X to Treat Nerve Conditions Central Nervous System Agents - Drugs LYRICA CAP 150MG PREGABALIN CAP 150 MG Tier 3 X X to Treat Nerve Conditions Central Nervous System Agents - Drugs LYRICA CAP 200MG PREGABALIN CAP 200 MG Tier 3 X X to Treat Nerve Conditions Central Nervous System Agents - Drugs LYRICA CAP 225MG PREGABALIN CAP 225 MG Tier 3 X X to Treat Nerve Conditions Central Nervous System Agents - Drugs LYRICA CAP 25MG PREGABALIN CAP 25 MG Tier 3 X X to Treat Nerve Conditions Central Nervous System Agents - Drugs LYRICA CAP 300MG PREGABALIN CAP 300 MG Tier 3 X X to Treat Nerve Conditions Central Nervous System Agents - Drugs LYRICA CAP 50MG PREGABALIN CAP 50 MG Tier 3 X X to Treat Nerve Conditions Central Nervous System Agents - Drugs LYRICA CAP 75MG PREGABALIN CAP 75 MG Tier 3 X X to Treat Nerve Conditions Central Nervous System Agents - Drugs LYRICA SOL 20MG/ML PREGABALIN SOLN 20 MG/ML Tier 3 X X to Treat Nerve Conditions Central Nervous System Agents - Drugs METADATE TAB 20MG ER METHYLPHENIDATE HCL TAB ER 20 MG Tier 3 X X to Treat Nerve Conditions Central Nervous System Agents - Drugs METHAMPHETAM TAB 5MG METHAMPHETAMINE HCL TAB 5 MG Tier 1 X to Treat Nerve Conditions Central Nervous System Agents - Drugs METHLPHENIDA CHW METHYLPHENIDATE HCL CHEW TAB Tier 3 X to Treat Nerve Conditions 2.5MG 2.5 MG Central Nervous System Agents - Drugs METHYLPHENIDATE HCL CHEW TAB 10 METHYLIN CHW 10MG Tier 3 X to Treat Nerve Conditions MG Central Nervous System Agents - Drugs METHYLPHENIDATE HCL CHEW TAB METHYLIN CHW 2.5MG Tier 3 X to Treat Nerve Conditions 2.5 MG Central Nervous System Agents - Drugs METHYLPHENIDATE HCL CHEW TAB 5 METHYLIN CHW 5MG Tier 3 X to Treat Nerve Conditions MG Central Nervous System Agents - Drugs METHYLPHENIDATE HCL SOLN 10 METHYLIN SOL 10MG/5ML Tier 3 X to Treat Nerve Conditions MG/5ML Central Nervous System Agents - Drugs METHYLPHENIDATE HCL SOLN 5 METHYLIN SOL 5MG/5ML Tier 3 X to Treat Nerve Conditions MG/5ML Central Nervous System Agents - Drugs METHYLPHENIDATE HCL CAP ER 10 MG METHYLPHENID CAP 10MG Tier 2 X X to Treat Nerve Conditions (CD) Central Nervous System Agents - Drugs METHYLPHENIDATE HCL CAP ER 20 MG METHYLPHENID CAP 20MG Tier 2 X X to Treat Nerve Conditions (CD) Central Nervous System Agents - Drugs METHYLPHENID CAP 20MG METHYLPHENIDATE HCL CAP ER 24HR Tier 2 X X to Treat Nerve Conditions ER 20 MG (LA) Central Nervous System Agents - Drugs METHYLPHENIDATE HCL CAP ER 30 MG METHYLPHENID CAP 30MG Tier 2 X X to Treat Nerve Conditions (CD) Central Nervous System Agents - Drugs METHYLPHENID CAP 30MG METHYLPHENIDATE HCL CAP ER 24HR Tier 2 X X to Treat Nerve Conditions ER 30 MG (LA) Central Nervous System Agents - Drugs METHYLPHENIDATE HCL CAP ER 40 MG METHYLPHENID CAP 40MG Tier 2 X X to Treat Nerve Conditions (CD) Central Nervous System Agents - Drugs METHYLPHENID CAP 40MG METHYLPHENIDATE HCL CAP ER 24HR Tier 2 X X to Treat Nerve Conditions ER 40 MG (LA) Central Nervous System Agents - Drugs METHYLPHENIDATE HCL CAP ER 50 MG METHYLPHENID CAP 50MG Tier 2 X X to Treat Nerve Conditions (CD) Central Nervous System Agents - Drugs METHYLPHENIDATE HCL CAP ER 60 MG METHYLPHENID CAP 60MG Tier 2 X X to Treat Nerve Conditions (CD)

101 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Central Nervous System Agents - Drugs METHYLPHENID CAP 60MG METHYLPHENIDATE HCL CAP ER 24HR Tier 2 X to Treat Nerve Conditions LA 60 MG (LA) Central Nervous System Agents - Drugs METHYLPHENIDATE HCL CHEW TAB 10 METHYLPHENID CHW 10MG Tier 3 X to Treat Nerve Conditions MG Central Nervous System Agents - Drugs METHYLPHENIDATE HCL CHEW TAB 5 METHYLPHENID CHW 5MG Tier 3 X to Treat Nerve Conditions MG Central Nervous System Agents - Drugs METHYLPHENID SOL METHYLPHENIDATE HCL SOLN 10 Tier 1 X to Treat Nerve Conditions 10MG/5ML MG/5ML Central Nervous System Agents - Drugs METHYLPHENID SOL METHYLPHENIDATE HCL SOLN 5 Tier 1 X to Treat Nerve Conditions 5MG/5ML MG/5ML Central Nervous System Agents - Drugs METHYLPHENID TAB 10MG METHYLPHENIDATE HCL TAB 10 MG Tier 1 X to Treat Nerve Conditions Central Nervous System Agents - Drugs METHYLPHENID TAB 10MG METHYLPHENIDATE HCL TAB ER 10 MG Tier 3 X X to Treat Nerve Conditions ER Central Nervous System Agents - Drugs METHYLPHENID TAB 20MG METHYLPHENIDATE HCL TAB 20 MG Tier 1 X to Treat Nerve Conditions Central Nervous System Agents - Drugs METHYLPHENID TAB 20MG METHYLPHENIDATE HCL TAB ER 20 MG Tier 3 X X to Treat Nerve Conditions ER Central Nervous System Agents - Drugs METHYLPHENID TAB 5MG METHYLPHENIDATE HCL TAB 5 MG Tier 1 X to Treat Nerve Conditions Central Nervous System Agents - Drugs ISOMETHEPTENE-DICHLORAL- NODOLOR CAP Tier 1 to Treat Nerve Conditions ACETAMINOPHEN CAP 65-100-325 MG Central Nervous System Agents - Drugs DEXTROMETHORPHAN HBR-QUINIDINE NUEDEXTA CAP 20-10MG Tier 2 X to Treat Nerve Conditions SULFATE CAP 20-10 MG Central Nervous System Agents - Drugs PHENDIMETRAZ CAP PHENDIMETRAZINE TARTRATE CAP ER Tier 1 X to Treat Nerve Conditions 105MG ER 24HR 105 MG Central Nervous System Agents - Drugs PHENDIMETRAZINE TARTRATE TAB 35 PHENDIMETRAZ TAB 35MG Tier 1 X to Treat Nerve Conditions MG Central Nervous System Agents - Drugs PHENTERMINE CAP 15MG PHENTERMINE HCL CAP 15 MG Tier 1 X to Treat Nerve Conditions Central Nervous System Agents - Drugs PHENTERMINE CAP 30MG PHENTERMINE HCL CAP 30 MG Tier 1 X to Treat Nerve Conditions Central Nervous System Agents - Drugs PHENTERMINE CAP 37.5MG PHENTERMINE HCL CAP 37.5 MG Tier 1 X to Treat Nerve Conditions Central Nervous System Agents - Drugs PHENTERMINE TAB 37.5MG PHENTERMINE HCL TAB 37.5 MG Tier 1 X to Treat Nerve Conditions Central Nervous System Agents - Drugs PEGINTERFERON BETA-1A SOLN PLEGRIDY INJ Tier 4 X X X to Treat Nerve Conditions PREFILLED SYRINGE 125 MCG/0.5ML Central Nervous System Agents - Drugs PEGINTERFERON BETA-1A SOLN PEN- PLEGRIDY INJ PEN Tier 4 X X X to Treat Nerve Conditions INJECTOR 125 MCG/0.5ML Central Nervous System Agents - Drugs PEGINTERFERON BETA-1A SOLN PREF PLEGRIDY INJ STARTER Tier 4 X X X to Treat Nerve Conditions SYR 63 & 94 MCG/0.5ML PACK Central Nervous System Agents - Drugs PEGINTERFERON BETA-1A SOLN PEN-INJ PLEGRIDY PEN INJ STARTER Tier 4 X X X to Treat Nerve Conditions 63 & 94 MCG/0.5ML PACK Central Nervous System Agents - Drugs DEXTROAMPHETAMINE SULFATE ORAL PROCENTRA SOL 5MG/5ML Tier 3 X to Treat Nerve Conditions SOLUTION 5 MG/5ML Central Nervous System Agents - Drugs PHENTERMINE HCL-TOPIRAMATE CAP QSYMIA CAP 11.25-69 Tier 3 X to Treat Nerve Conditions ER 24HR 11.25-69 MG Central Nervous System Agents - Drugs PHENTERMINE HCL-TOPIRAMATE CAP QSYMIA CAP 15-92MG Tier 3 X to Treat Nerve Conditions ER 24HR 15-92 MG Central Nervous System Agents - Drugs PHENTERMINE HCL-TOPIRAMATE CAP QSYMIA CAP 3.75-23 Tier 3 X to Treat Nerve Conditions ER 24HR 3.75-23 MG Central Nervous System Agents - Drugs PHENTERMINE HCL-TOPIRAMATE CAP QSYMIA CAP 7.5-46MG Tier 3 X to Treat Nerve Conditions ER 24HR 7.5-46 MG Central Nervous System Agents - Drugs INTERFERON BETA-1A SOLN PREF SYR REBIF INJ 22/0.5 Tier 4 X X X X to Treat Nerve Conditions 22 MCG/0.5ML (12MU/ML) Central Nervous System Agents - Drugs INTERFERON BETA-1A SOLN PREF SYR REBIF INJ 44/0.5 Tier 4 X X X X to Treat Nerve Conditions 44 MCG/0.5ML (24MU/ML) Central Nervous System Agents - Drugs INTERFERON BETA-1A SOLN AUTO-INJ REBIF REBIDO INJ 22/0.5 Tier 4 X X X X to Treat Nerve Conditions 22 MCG/0.5ML (12MU/ML) Central Nervous System Agents - Drugs INTERFERON BETA-1A SOLN AUTO-INJ REBIF REBIDO INJ 44/0.5 Tier 4 X X X X to Treat Nerve Conditions 44 MCG/0.5ML (24MU/ML) Central Nervous System Agents - Drugs INTERFERON BETA-1A AUTO-INJ 6X8.8 REBIF REBIDO INJ TITRATN Tier 4 X X X X to Treat Nerve Conditions MCG/0.2ML & 6X22 MCG/0.5ML Central Nervous System Agents - Drugs INTERFERON BETA-1A PREF SYR 6X8.8 REBIF TITRTN INJ PACK Tier 4 X X X X to Treat Nerve Conditions MCG/0.2ML & 6X22 MCG/0.5ML Central Nervous System Agents - Drugs REGIMEX TAB 25MG BENZPHETAMINE HCL TAB 25 MG Tier 1 X to Treat Nerve Conditions Central Nervous System Agents - Drugs RILUTEK TAB 50MG RILUZOLE TAB 50 MG Tier 3 to Treat Nerve Conditions Central Nervous System Agents - Drugs RILUZOLE TAB 50MG RILUZOLE TAB 50 MG Tier 1 to Treat Nerve Conditions Central Nervous System Agents - Drugs RITALIN TAB 10MG METHYLPHENIDATE HCL TAB 10 MG Tier 3 X to Treat Nerve Conditions Central Nervous System Agents - Drugs RITALIN TAB 20MG METHYLPHENIDATE HCL TAB 20 MG Tier 3 X to Treat Nerve Conditions Central Nervous System Agents - Drugs RITALIN TAB 5MG METHYLPHENIDATE HCL TAB 5 MG Tier 3 X to Treat Nerve Conditions

102 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Central Nervous System Agents - Drugs MILNACIPRAN HCL TAB 12.5 MG (5) & 25 SAVELLA MIS TITR PAK Tier 3 X to Treat Nerve Conditions MG (8) & 50 MG (42) PAK Central Nervous System Agents - Drugs SAVELLA TAB 100MG MILNACIPRAN HCL TAB 100 MG Tier 3 X to Treat Nerve Conditions Central Nervous System Agents - Drugs SAVELLA TAB 12.5MG MILNACIPRAN HCL TAB 12.5 MG Tier 3 X to Treat Nerve Conditions Central Nervous System Agents - Drugs SAVELLA TAB 25MG MILNACIPRAN HCL TAB 25 MG Tier 3 X to Treat Nerve Conditions Central Nervous System Agents - Drugs SAVELLA TAB 50MG MILNACIPRAN HCL TAB 50 MG Tier 3 X to Treat Nerve Conditions Central Nervous System Agents - Drugs DIMETHYL FUMARATE CAPSULE TECFIDERA CAP 120MG Tier 2 X X X to Treat Nerve Conditions DELAYED RELEASE 120 MG Central Nervous System Agents - Drugs DIMETHYL FUMARATE CAPSULE TECFIDERA CAP 240MG Tier 2 X X X to Treat Nerve Conditions DELAYED RELEASE 240 MG Central Nervous System Agents - Drugs DIMETHYL FUMARATE CAPSULE DR TECFIDERA MIS STARTER Tier 2 X X X to Treat Nerve Conditions STARTER PACK 120 MG & 240 MG Central Nervous System Agents - Drugs TETRABENAZIN TAB 12.5MG TETRABENAZINE TAB 12.5 MG Tier 2 X X to Treat Nerve Conditions Central Nervous System Agents - Drugs TETRABENAZIN TAB 25MG TETRABENAZINE TAB 25 MG Tier 2 X X to Treat Nerve Conditions Central Nervous System Agents - Drugs LISDEXAMFETAMINE DIMESYLATE CAP VYVANSE CAP 10MG Tier 2 X X to Treat Nerve Conditions 10 MG Central Nervous System Agents - Drugs LISDEXAMFETAMINE DIMESYLATE CAP VYVANSE CAP 20MG Tier 2 X X to Treat Nerve Conditions 20 MG Central Nervous System Agents - Drugs LISDEXAMFETAMINE DIMESYLATE CAP VYVANSE CAP 30MG Tier 2 X X to Treat Nerve Conditions 30 MG Central Nervous System Agents - Drugs LISDEXAMFETAMINE DIMESYLATE CAP VYVANSE CAP 40MG Tier 2 X X to Treat Nerve Conditions 40 MG Central Nervous System Agents - Drugs LISDEXAMFETAMINE DIMESYLATE CAP VYVANSE CAP 50MG Tier 2 X X to Treat Nerve Conditions 50 MG Central Nervous System Agents - Drugs LISDEXAMFETAMINE DIMESYLATE CAP VYVANSE CAP 60MG Tier 2 X X to Treat Nerve Conditions 60 MG Central Nervous System Agents - Drugs LISDEXAMFETAMINE DIMESYLATE CAP VYVANSE CAP 70MG Tier 2 X X to Treat Nerve Conditions 70 MG Central Nervous System Agents - Drugs LISDEXAMFETAMINE DIMESYLATE VYVANSE CHW 10MG Tier 2 X X to Treat Nerve Conditions CHEW TAB 10 MG Central Nervous System Agents - Drugs LISDEXAMFETAMINE DIMESYLATE VYVANSE CHW 20MG Tier 2 X X to Treat Nerve Conditions CHEW TAB 20 MG Central Nervous System Agents - Drugs LISDEXAMFETAMINE DIMESYLATE VYVANSE CHW 30MG Tier 2 X X to Treat Nerve Conditions CHEW TAB 30 MG Central Nervous System Agents - Drugs LISDEXAMFETAMINE DIMESYLATE VYVANSE CHW 40MG Tier 2 X X to Treat Nerve Conditions CHEW TAB 40 MG Central Nervous System Agents - Drugs LISDEXAMFETAMINE DIMESYLATE VYVANSE CHW 50MG Tier 2 X X to Treat Nerve Conditions CHEW TAB 50 MG Central Nervous System Agents - Drugs LISDEXAMFETAMINE DIMESYLATE VYVANSE CHW 60MG Tier 2 X X to Treat Nerve Conditions CHEW TAB 60 MG Central Nervous System Agents - Drugs DACLIZUMAB SOLN PREFILLED SYRINGE ZINBRYTA INJ 150MG/ML Tier 3 X X X to Treat Nerve Conditions 150 MG/ML Dental and Oral Agents - Drugs to Treat AQUORAL AER *ARTIFICIAL SALIVA - AERO SOLN*** Tier 3 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat BOCASAL POW *ARTIFICIAL SALIVA - PACKET*** Tier 3 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat CAVAREST GEL 1.1% SODIUM FLUORIDE GEL 1.1% (0.5% F) Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat CEVIMELINE CAP 30MG CEVIMELINE HCL CAP 30 MG Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat CHLORHEXIDINE GLUCONATE SOLN CHLORHEX GLU SOL 0.12% Tier 1 Mouth and Throat Conditions 0.12% Dental and Oral Agents - Drugs to Treat CLINPRO 5000 PST 1.1% SODIUM FLUORIDE PASTE 1.1% Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat SULFURIC ACID-SULFONATED DEBACTEROL SOL 30-50% Tier 2 Mouth and Throat Conditions PHENOLICS SOLN 30-50% Dental and Oral Agents - Drugs to Treat DENTA 5000 CRE PLUS SODIUM FLUORIDE CREAM 1.1% Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat DENTA 5000 CRE PLUS 2PK SODIUM FLUORIDE CREAM 1.1% Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat DENTAGEL GEL 1.1% SODIUM FLUORIDE GEL 1.1% (0.5% F) Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat EASYGEL GEL 0.4% STANNOUS FLUORIDE GEL 0.4% Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat EASYGEL GEL 0.4%CHRY STANNOUS FLUORIDE GEL 0.4% Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat EASYGEL GEL 0.4%CITR STANNOUS FLUORIDE GEL 0.4% Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat EASYGEL GEL 0.4%MINT STANNOUS FLUORIDE GEL 0.4% Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat EVOXAC CAP 30MG CEVIMELINE HCL CAP 30 MG Tier 3 Mouth and Throat Conditions

103 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Dental and Oral Agents - Drugs to Treat SODIUM FLUORIDE-POTASSIUM NITRATE FLUORID SENS PST 1.1-5% Tier 1 Mouth and Throat Conditions PASTE 1.1-5% Dental and Oral Agents - Drugs to Treat FLUORIDEX CON DLY REN STANNOUS FLUORIDE CONC 0.63% Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat FLUORIDEX GEL 1.1% SODIUM FLUORIDE GEL 1.1% (0.5% F) Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat SODIUM FLUORIDE-POTASSIUM NITRATE FLUORIDEX GEL SENSITIV Tier 3 Mouth and Throat Conditions GEL 1.1-5% Dental and Oral Agents - Drugs to Treat FLUORIDEX GEL WHITENIN SODIUM FLUORIDE GEL 1.1% (0.5% F) Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat FLUORIDEX PST 1.1% SODIUM FLUORIDE PASTE 1.1% Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat FLUORIDEX DD PST SODIUM FLUORIDE-POTASSIUM NITRATE Tier 1 Mouth and Throat Conditions SENSITIV PASTE 1.1-5% Dental and Oral Agents - Drugs to Treat GEL-KAM CON 0.63% STANNOUS FLUORIDE CONC 0.63% Tier 3 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat KARIGEL GEL 0.5% SODIUM FLUORIDE GEL 1.1% (0.5% F) Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat KARIGEL-N GEL 1.1% SODIUM FLUORIDE GEL 1.1% (0.5% F) Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat SODIUM FLUORIDE-PHOSPHORIC ACID NAFRINSE SOL DAILY Tier 2 Mouth and Throat Conditions FOR SOLN 1 MG/5ML (F EQUIV) Dental and Oral Agents - Drugs to Treat NAFRINSE DLY SOL / SODIUM FLUORIDE FOR SOLN RINSE Tier 2 Mouth and Throat Conditions NEUTRAL 0.05% Dental and Oral Agents - Drugs to Treat SODIUM FLUORIDE FOR SOLN RINSE NAFRINSE WK SOL 0.2% Tier 3 Mouth and Throat Conditions 0.2% Dental and Oral Agents - Drugs to Treat NEUTRAGARD GEL 1.1% SODIUM FLUORIDE GEL 1.1% (0.5% F) Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat NEUTRASAL POW *ARTIFICIAL SALIVA - PACKET*** Tier 3 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat TRIAMCINOLONE ACETONIDE DENTAL ORALONE DENT PST 0.1% Tier 1 Mouth and Throat Conditions PASTE 0.1% Dental and Oral Agents - Drugs to Treat CHLORHEXIDINE GLUCONATE SOLN PAROEX SOL 0.12% Tier 1 Mouth and Throat Conditions 0.12% Dental and Oral Agents - Drugs to Treat CHLORHEXIDINE GLUCONATE SOLN PERIDEX SOL 0.12% Tier 3 Mouth and Throat Conditions 0.12% Dental and Oral Agents - Drugs to Treat CHLORHEXIDINE GLUCONATE SOLN PERIOGARD SOL 0.12% Tier 1 Mouth and Throat Conditions 0.12% Dental and Oral Agents - Drugs to Treat PHOS-FLUR GEL 1.1% SODIUM FLUORIDE GEL 1.1% (0.5% F) Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat PILOCARPINE TAB 5MG PILOCARPINE HCL TAB 5 MG Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat PILOCARPINE TAB 7.5MG PILOCARPINE HCL TAB 7.5 MG Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat PREVDNT 5000 PST 1.1% SODIUM FLUORIDE PASTE 1.1% Tier 3 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat SODIUM FLUORIDE-POTASSIUM NITRATE PREVDNT 5000 PST 1.1-5% Tier 3 Mouth and Throat Conditions PASTE 1.1-5% Dental and Oral Agents - Drugs to Treat PREVIDENT CRE 5000 PLS SODIUM FLUORIDE CREAM 1.1% Tier 3 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat PREVIDENT GEL 1.1% SODIUM FLUORIDE GEL 1.1% (0.5% F) Tier 3 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat PREVIDENT GEL 1.1% BER SODIUM FLUORIDE GEL 1.1% (0.5% F) Tier 3 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat PREVIDENT GEL 1.1% CHR SODIUM FLUORIDE GEL 1.1% (0.5% F) Tier 3 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat PREVIDENT GEL 1.1% MIN SODIUM FLUORIDE GEL 1.1% (0.5% F) Tier 3 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat PREVIDENT PST 5000 BST SODIUM FLUORIDE PASTE 1.1% Tier 3 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat PREVIDENT SOL 0.2% SODIUM FLUORIDE RINSE 0.2% Tier 3 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat SALAGEN TAB 5MG PILOCARPINE HCL TAB 5 MG Tier 3 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat SALAGEN TAB 7.5MG PILOCARPINE HCL TAB 7.5 MG Tier 3 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat SALIVAMAX POW *ARTIFICIAL SALIVA - PACKET*** Tier 3 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat SALIVATE RX POW *ARTIFICIAL SALIVA - PACKET*** Tier 3 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat SF GEL 1.1% SODIUM FLUORIDE GEL 1.1% (0.5% F) Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat SF 5000 PLUS CRE 1.1% SODIUM FLUORIDE CREAM 1.1% Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat SOD FLUORIDE SOL 0.2% SODIUM FLUORIDE RINSE 0.2% Tier 1 Mouth and Throat Conditions Dental and Oral Agents - Drugs to Treat THERA-FLUR-N DRO 1.1% SODIUM FLUORIDE GEL 1.1% (0.5% F) Tier 3 Mouth and Throat Conditions

104 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Dental and Oral Agents - Drugs to Treat TOPEX TOPCAL AER BENZOCAINE MOUTH/THROAT Tier 3 Mouth and Throat Conditions ANESTHET AEROSOL 20% Dental and Oral Agents - Drugs to Treat TRIAMCINOLON PST DEN TRIAMCINOLONE ACETONIDE DENTAL Tier 1 Mouth and Throat Conditions 0.1% PASTE 0.1% Dermatological Agents - Drugs to Treat 8-MOP CAP 10MG METHOXSALEN CAP 10 MG Tier 2 Skin Conditions Dermatological Agents - Drugs to Treat ACITRETIN CAP 10MG ACITRETIN CAP 10 MG Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat ACITRETIN CAP 17.5MG ACITRETIN CAP 17.5 MG Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat ACITRETIN CAP 25MG ACITRETIN CAP 25 MG Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat ACZONE GEL 5% DAPSONE GEL 5% Tier 3 X Skin Conditions Dermatological Agents - Drugs to Treat ACZONE GEL 7.5% DAPSONE GEL 7.5% Tier 3 X Skin Conditions Dermatological Agents - Drugs to Treat ALDARA CRE 5% IMIQUIMOD CREAM 5% Tier 3 X Skin Conditions Dermatological Agents - Drugs to Treat ALUVEA CRE 39% UREA CREAM 39% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat AMELUZ GEL 10% AMINOLEVULINIC ACID HCL GEL 10% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat AMNESTEEM CAP 10MG ISOTRETINOIN CAP 10 MG Tier 2 X Skin Conditions Dermatological Agents - Drugs to Treat AMNESTEEM CAP 20MG ISOTRETINOIN CAP 20 MG Tier 2 X Skin Conditions Dermatological Agents - Drugs to Treat AMNESTEEM CAP 40MG ISOTRETINOIN CAP 40 MG Tier 2 X Skin Conditions Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR AVAR CLEANSE EMU 10-5% Tier 1 Skin Conditions EMULSION 10-5% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR AVAR-E EMOLL CRE 10-5% Tier 3 Skin Conditions CREAM 10-5% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR AVAR-E GREEN CRE 10-5% Tier 3 Skin Conditions CREAM 10-5% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR AVAR-E LS CRE 10-2% Tier 3 Skin Conditions CREAM 10-2% Dermatological Agents - Drugs to Treat AZELEX CRE 20% AZELAIC ACID CREAM 20% Tier 3 X Skin Conditions Dermatological Agents - Drugs to Treat SALICYLIC ACID & BENZOIC ACID OINT BENSAL HP OIN Tier 2 Skin Conditions 3-6% Dermatological Agents - Drugs to Treat BENZ PER- HC LOT 5-0.5% BENZOYL PEROXIDE-HC LOTION 5-0.5% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat BENZ PEROXID GEL 6.5% BENZOYL PEROXIDE GEL 6.5% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat BENZOYL PEROXIDE-ERYTHROMYCIN BENZAMYCIN GEL 5-3% Tier 2 X Skin Conditions GEL 5-3% Dermatological Agents - Drugs to Treat BENZIQ GEL 5.25% BENZOYL PEROXIDE GEL 5.25 % Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat BENZIQ LS GEL 2.75% BENZOYL PEROXIDE GEL 2.75% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat BENZIQ WASH LIQ 5.25% BENZOYL PEROXIDE LIQ 5.25% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR BP 10-1 EMU Tier 1 Skin Conditions EMULSION 10-1% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM-SULFUR IN BP CLEANSING EMU 10-4% Tier 1 Skin Conditions UREA EMULSION 10-4% Dermatological Agents - Drugs to Treat CALCIPOTRIEN CRE 0.005% CALCIPOTRIENE CREAM 0.005% Tier 2 X Skin Conditions Dermatological Agents - Drugs to Treat CALCIPOTRIEN OIN 0.005% CALCIPOTRIENE OINT 0.005% Tier 2 Skin Conditions Dermatological Agents - Drugs to Treat CALCIPOTRIEN OIN CALCIPOTRIENE-BETAMETHASONE Tier 3 X Skin Conditions BETAMETH DIPROPIONATE OINT 0.005-0.064% Dermatological Agents - Drugs to Treat CALCIPOTRIENE SOLN 0.005% (50 MCG/ CALCIPOTRIEN SOL 0.005% Tier 1 X Skin Conditions ML) Dermatological Agents - Drugs to Treat CALCITRENE OIN 0.005% CALCIPOTRIENE OINT 0.005% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat CALCITRIOL OIN 3MCG/GM CALCITRIOL OINT 3 MCG/GM Tier 1 X Skin Conditions Dermatological Agents - Drugs to Treat CARAC CRE 0.5% FLUOROURACIL CREAM 0.5% Tier 2 Skin Conditions Dermatological Agents - Drugs to Treat CEM-UREA SOL 45% UREA SOLN 45% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR CERISA WASH EMU 10-1% Tier 1 Skin Conditions EMULSION 10-1% Dermatological Agents - Drugs to Treat CEROVEL LOT 40% UREA LOTION 40% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat CLARAVIS CAP 10MG ISOTRETINOIN CAP 10 MG Tier 2 X Skin Conditions

105 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Dermatological Agents - Drugs to Treat CLARAVIS CAP 20MG ISOTRETINOIN CAP 20 MG Tier 2 X Skin Conditions Dermatological Agents - Drugs to Treat CLARAVIS CAP 30MG ISOTRETINOIN CAP 30 MG Tier 2 X Skin Conditions Dermatological Agents - Drugs to Treat CLARAVIS CAP 40MG ISOTRETINOIN CAP 40 MG Tier 2 X Skin Conditions Dermatological Agents - Drugs to Treat CLINDAMYCIN PHOSPH-BENZOYL CLINDAMY/BEN GEL 1.2-5% Tier 3 X Skin Conditions PEROXIDE (REFRIG) GEL 1.2 (1)-5% Dermatological Agents - Drugs to Treat CLOTRIMAZOLE W/ BETAMETHASONE CLOTRIM/BETA CRE 1-0.05% Tier 1 X Skin Conditions CREAM 1-0.05% Dermatological Agents - Drugs to Treat CLOTRIMAZOLE W/ BETAMETHASONE CLOTRIM/BETA CRE DIPROP Tier 1 X Skin Conditions CREAM 1-0.05% Dermatological Agents - Drugs to Treat CLOTRIMAZOLE W/ BETAMETHASONE CLOTRIM/BETA LOT DIPROP Tier 1 Skin Conditions LOTION 1-0.05% Dermatological Agents - Drugs to Treat COAL TAR SOL 20% COAL TAR SOLN 20% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat CONDYLOX GEL 0.5% PODOFILOX GEL 0.5% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat CONDYLOX SOL 0.5% PODOFILOX SOLN 0.5% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat HYDROCORTISONE-PRAMOXINE- CORTANE-B LOT Tier 3 Skin Conditions CHLOROXYLENOL LOT 10-10-1MG/ML Dermatological Agents - Drugs to Treat NEOMYCIN-POLYMYXIN-HC CRM 3.5 CORTISPORIN CRE 0.5% Tier 2 Skin Conditions MG/GM-10000 UNT/GM-0.5% Dermatological Agents - Drugs to Treat BACITRACIN-POLYMYXIN-NEOMYCIN HC CORTISPORIN OIN 1% Tier 3 Skin Conditions OINT 1% Dermatological Agents - Drugs to Treat SECUKINUMAB SUBCUTANEOUS SOLN COSENTYX INJ 150MG/ML Tier 3 X X X X Skin Conditions PREFILLED SYRINGE 150 MG/ML Dermatological Agents - Drugs to Treat SECUKINUMAB SUBCUTANEOUS SOLN COSENTYX INJ 300DOSE Tier 3 X X X X Skin Conditions PREFILLED SYRINGE 150 MG/ML Dermatological Agents - Drugs to Treat COSENTYX PEN INJ 150MG/ SECUKINUMAB SUBCUTANEOUS SOLN Tier 3 X X X X Skin Conditions ML AUTO-INJECTOR 150 MG/ML Dermatological Agents - Drugs to Treat COSENTYX PEN INJ SECUKINUMAB SUBCUTANEOUS SOLN Tier 3 X X X X Skin Conditions 300DOSE AUTO-INJECTOR 150 MG/ML Dermatological Agents - Drugs to Treat DERMABASE CRE *EMOLLIENT - CREAM** Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat DERMAZENE CRE 1% IODOQUINOL-HC CREAM 1% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat DICLOFENAC SODIUM (ACTINIC DICLOFENAC GEL 3% Tier 3 X X Skin Conditions KERATOSES) GEL 3% Dermatological Agents - Drugs to Treat DOVONEX CRE 0.005% CALCIPOTRIENE CREAM 0.005% Tier 3 X Skin Conditions Dermatological Agents - Drugs to Treat DOXEPIN HCL CRE 5% DOXEPIN HCL CREAM 5% Tier 1 X X Skin Conditions Dermatological Agents - Drugs to Treat DUPILUMAB SUBCUTANEOUS SOLN DUPIXENT INJ 300/2ML Tier 3 X X X X Skin Conditions PREFILLED SYRINGE 300 MG/2ML Dermatological Agents - Drugs to Treat EFUDEX CRE 5% FLUOROURACIL CREAM 5% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat ELIDEL CRE 1% PIMECROLIMUS CREAM 1% Tier 3 X X Skin Conditions Dermatological Agents - Drugs to Treat CALCIPOTRIENE-BETAMETHASONE ENSTILAR AER Tier 4 X Skin Conditions DIPROPIONATE FOAM 0.005-0.064% Dermatological Agents - Drugs to Treat EPIFOAM AER 1% PRAMOXINE-HC AEROSOL FOAM 1-1% Tier 2 Skin Conditions Dermatological Agents - Drugs to Treat BENZOYL PEROXIDE-ERYTHROMYCIN ERY/BENZOYL GEL 5-3% Tier 1 X Skin Conditions GEL 5-3% Dermatological Agents - Drugs to Treat EUCRISA OIN 2% CRISABOROLE OINT 2% Tier 3 X X Skin Conditions Dermatological Agents - Drugs to Treat FINACEA AER 15% AZELAIC ACID FOAM 15% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat FINACEA GEL 15% AZELAIC ACID GEL 15% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat FLUOROPLEX CRE 1% FLUOROURACIL CREAM 1% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat FLUOROURACIL CRE 0.5% FLUOROURACIL CREAM 0.5% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat FLUOROURACIL CRE 5% FLUOROURACIL CREAM 5% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat FLUOROURACIL SOL 2% FLUOROURACIL SOLN 2% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat FLUOROURACIL SOL 5% FLUOROURACIL SOLN 5% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat SALICYLIC & LACTIC ACIDS SOLN 16.7- GORDOFILM SOL Tier 2 Skin Conditions 16.7% Dermatological Agents - Drugs to Treat GORDONS UREA OIN 40% UREA OINTMENT 40% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat HALOBETASOL PROP OINT 0.05% & HALAC KIT Tier 1 Skin Conditions AMMONIUM LACTATE LOT 12% KIT

106 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Dermatological Agents - Drugs to Treat HC PRAMOXINE CRE 2.5-1% PRAMOXINE-HC CREAM 1-2.5% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat HYALURONATE SODIUM (EMOLLIENT) HYALURONATE GEL 0.2% Tier 1 Skin Conditions GEL 0.2% Dermatological Agents - Drugs to Treat UREA IN LACTIC ACID VEHICLE FOAM HYDRO 35 AER Tier 3 Skin Conditions 35% Dermatological Agents - Drugs to Treat HYDRO 40 AER FOAM UREA FOAM 40% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat HYDROCORT/ CRE IODOQUINOL-HC CREAM 1% Tier 1 Skin Conditions IODOQUIN Dermatological Agents - Drugs to Treat HYALURONATE SODIUM (EMOLLIENT) HYLIRA GEL 0.2% Tier 2 Skin Conditions GEL 0.2% Dermatological Agents - Drugs to Treat HYALURONATE SODIUM (EMOLLIENT) HYLIRA LOT 0.1% Tier 3 Skin Conditions LOTION 0.1% Dermatological Agents - Drugs to Treat IMIQUIMOD CRE 5% IMIQUIMOD CREAM 5% Tier 1 X Skin Conditions Dermatological Agents - Drugs to Treat *BENZOYL PEROXIDE PAD 4% & VITAMIN INOVA KIT 4% Tier 3 Skin Conditions E TOPICAL 5% KIT*** Dermatological Agents - Drugs to Treat *BENZOYL PEROXIDE PAD 8% & VITAMIN INOVA KIT 8% Tier 3 Skin Conditions E TOPICAL 5% KIT*** Dermatological Agents - Drugs to Treat *BENZOYL PEROX PAD 4% & SALICYLIC INOVA 4/1 KIT ACNE CON Tier 3 Skin Conditions AC PAD 1% & VIT E 5% KIT* Dermatological Agents - Drugs to Treat *BENZOYL PEROX PAD 8% & SALICYLIC INOVA 8/2 KIT ACNE CON Tier 3 Skin Conditions AC PAD 2% & VIT E 5% KIT* Dermatological Agents - Drugs to Treat ISOTRETINOIN CAP 10MG ISOTRETINOIN CAP 10 MG Tier 2 X Skin Conditions Dermatological Agents - Drugs to Treat ISOTRETINOIN CAP 20MG ISOTRETINOIN CAP 20 MG Tier 2 X Skin Conditions Dermatological Agents - Drugs to Treat ISOTRETINOIN CAP 30MG ISOTRETINOIN CAP 30 MG Tier 2 X Skin Conditions Dermatological Agents - Drugs to Treat ISOTRETINOIN CAP 40MG ISOTRETINOIN CAP 40 MG Tier 2 X Skin Conditions Dermatological Agents - Drugs to Treat KERALYT GEL 6% SALICYLIC ACID GEL 6% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM LOTION 10% KLARON LOT 10% Tier 3 Skin Conditions (ACNE) Dermatological Agents - Drugs to Treat LATRIX SUS 50% UREA SUSPENSION 50% Tier 2 Skin Conditions Dermatological Agents - Drugs to Treat UREA IN ZINC UNDECYLENATE-LACTIC LATRIX XM EMU 45% Tier 2 Skin Conditions ACID VEHICLE EMULSION 45% Dermatological Agents - Drugs to Treat AMINOLEVULINIC ACID HCL FOR SOLN LEVULAN KERA SOL 20% Tier 3 Skin Conditions 20% (STICK APPLICATOR) Dermatological Agents - Drugs to Treat CLOTRIMAZOLE W/ BETAMETHASONE LOTRISONE CRE Tier 3 X Skin Conditions CREAM 1-0.05% Dermatological Agents - Drugs to Treat *ANTISEBORRHEIC PRODUCTS MISC - LOUTREX CRE Tier 3 Skin Conditions CREAM*** Dermatological Agents - Drugs to Treat METHOXSALEN CAP 10MG METHOXSALEN RAPID CAP 10 MG Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat METHYL SALIC LIQ *METHYL SALICYLATE LIQUID** Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat MEZPAROX HC CRE 1-2.5% PRAMOXINE-HC CREAM 1-2.5% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat BRIMONIDINE TARTRATE GEL 0.33% MIRVASO GEL 0.33% Tier 3 X Skin Conditions (BASE EQUIVALENT) Dermatological Agents - Drugs to Treat MYORISAN CAP 10MG ISOTRETINOIN CAP 10 MG Tier 2 X Skin Conditions Dermatological Agents - Drugs to Treat MYORISAN CAP 20MG ISOTRETINOIN CAP 20 MG Tier 2 X Skin Conditions Dermatological Agents - Drugs to Treat MYORISAN CAP 30MG ISOTRETINOIN CAP 30 MG Tier 2 X Skin Conditions Dermatological Agents - Drugs to Treat MYORISAN CAP 40MG ISOTRETINOIN CAP 40 MG Tier 2 X Skin Conditions Dermatological Agents - Drugs to Treat CLINDAMYCIN PHOSPH-BENZOYL NEUAC GEL 1.2-5% Tier 3 X Skin Conditions PEROXIDE (REFRIG) GEL 1.2 (1)-5% Dermatological Agents - Drugs to Treat OSCION CLNSR LOT 6% BENZOYL PEROXIDE LOTION 6% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat OVACE PLUS CRE 10% SULFACETAMIDE SODIUM CREAM 10% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat OVACE PLUS GEL 10% SULFACETAMIDE SODIUM CLEANSING Tier 3 Skin Conditions WASH GEL 10% Dermatological Agents - Drugs to Treat OVACE PLUS LIQ 10% WASH SULFACETAMIDE SODIUM LIQUID 10% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM SHAMPOO OVACE PLUS SHA 10% Tier 3 Skin Conditions 10% Dermatological Agents - Drugs to Treat OVACE WASH LIQ 10% SULFACETAMIDE SODIUM LIQUID 10% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat OXSORALEN-UL CAP 10MG METHOXSALEN RAPID CAP 10 MG Tier 2 Skin Conditions

107 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Dermatological Agents - Drugs to Treat PICATO GEL 0.015% INGENOL MEBUTATE GEL 0.015% Tier 3 X Skin Conditions Dermatological Agents - Drugs to Treat PICATO GEL 0.05% INGENOL MEBUTATE GEL 0.05% Tier 3 X Skin Conditions Dermatological Agents - Drugs to Treat PODOCON SOL 25% PODOPHYLLUM RESIN SOLN 25% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat PODOFILOX SOL 0.5% PODOFILOX SOLN 0.5% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat PRAMOSONE CRE 1-1% PRAMOXINE-HC CREAM 1-1% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat PRAMOSONE CRE 1-2.5% PRAMOXINE-HC CREAM 1-2.5% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat PRAMOSONE LOT 1% PRAMOXINE-HC LOTION 1-1% Tier 2 Skin Conditions Dermatological Agents - Drugs to Treat PRAMOSONE LOT 2.5% PRAMOXINE-HC LOTION 1-2.5% Tier 2 Skin Conditions Dermatological Agents - Drugs to Treat PRAMOSONE OIN 1% PRAMOXINE-HC OINT 1-1% Tier 2 Skin Conditions Dermatological Agents - Drugs to Treat PRAMOSONE OIN 2.5% PRAMOXINE-HC OINT 1-2.5% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat PRAMOX GEL 1% PRAMOXINE HCL GEL 1% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat *ANTISEBORRHEIC PRODUCTS MISC - PROMISEB CRE Tier 3 Skin Conditions CREAM*** Dermatological Agents - Drugs to Treat PRUDOXIN CRE 5% DOXEPIN HCL CREAM 5% Tier 1 X X Skin Conditions Dermatological Agents - Drugs to Treat PYROGALLOL-CHLOROBUTANOL OINT PYROGALL ACD OIN Tier 2 Skin Conditions 25-2% Dermatological Agents - Drugs to Treat REA LO 39 CRE 39% UREA CREAM 39% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat REA LO 40 CRE 40% UREA CREAM 40% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat REA LO 40 LOT 40% UREA LOTION 40% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat REGRANEX GEL 0.01% BECAPLERMIN GEL 0.01% Tier 2 X X Skin Conditions Dermatological Agents - Drugs to Treat REMEVEN CRE 50% UREA CREAM 50% Tier 2 Skin Conditions Dermatological Agents - Drugs to Treat RHOFADE CRE 1% OXYMETAZOLINE HCL CREAM 1% Tier 3 X X Skin Conditions Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR ROSANIL EMU CLEANSER Tier 1 Skin Conditions EMULSION 10-5% Dermatological Agents - Drugs to Treat SALACYN CRE 6% SALICYLIC ACID CREAM 6% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat SALACYN LOT 6% SALICYLIC ACID LOTION 6% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat SALICYLIC AER 6% SALICYLIC ACID FOAM 6% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat SALICYLIC AC CRE 6% SALICYLIC ACID CREAM 6% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat SALICYLIC AC GEL 6% SALICYLIC ACID GEL 6% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat SALICYLIC AC LIQ 26% SALICYLIC ACID SOLN 26% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat SALICYLIC AC LOT 6% SALICYLIC ACID LOTION 6% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat SALICYLIC AC SOL 26% SALICYLIC ACID SOLN 26% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat SALIMEZ CRE 6% SALICYLIC ACID CREAM 6% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat SALIMEZ FORT CRE 10% SALICYLIC ACID CREAM 10% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat SALVAX AER 6% SALICYLIC ACID FOAM 6% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat SALICYLIC ACID FOAM 6% & UREA IN SALVAX DUO KIT PLUS Tier 3 Skin Conditions LACTIC ACID FOAM 35% KIT Dermatological Agents - Drugs to Treat SANTYL OIN 250/GM COLLAGENASE OINT 250 UNIT/GM Tier 3 X Skin Conditions Dermatological Agents - Drugs to Treat *HC LOT 2% & SAL ACID-SULFUR SCALACORT DK KIT Tier 3 Skin Conditions SHAMPOO 2-2% & SHAMPOO KIT*** Dermatological Agents - Drugs to Treat SEB-PREV LIQ WASH SULFACETAMIDE SODIUM LIQUID 10% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat SELENIUM SUL LOT 2.5% SELENIUM SULFIDE LOTION 2.5% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat SELENIUM SULFIDE-PYRITHIONE ZINC IN SELENIUM SUL SHA 2.25% Tier 3 Skin Conditions UREA SHAMPOO 2.25% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR SOD SUL/SULF CRE 10-2% Tier 1 Skin Conditions CREAM 10-2%

108 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR SOD SUL/SULF CRE 10-5% Tier 1 Skin Conditions CREAM 10-5% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM-SULFUR IN SOD SUL/SULF EMU 10-5% Tier 1 Skin Conditions UREA EMULSION 10-5% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR SOD SUL/SULF EMU 10-5% Tier 1 Skin Conditions EMULSION 10-5% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM-SULFUR IN SOD SUL/SULF GEL 10-5% Tier 1 Skin Conditions UREA GEL 10-5% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR SOD SUL/SULF LIQ 9-4.5% Tier 1 Skin Conditions WASH 9-4.5% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR SOD SUL/SULF LIQ WASH Tier 1 Skin Conditions WASH 9-4% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR SOD SUL/SULF LOT 10-5% Tier 1 Skin Conditions LOTION 10-5% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR SOD SUL/SULF PAD 10-4% Tier 1 Skin Conditions CLEANSING PAD 10-4% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR SOD SUL/SULF SUS 10-5% Tier 1 Skin Conditions SUSP 10-5% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR SOD SUL/SULF SUS 8-4% Tier 1 Skin Conditions SUSP 8-4% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM CLEANSING SOD SULFACET GEL 10% Tier 1 Skin Conditions GEL 10% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM SHAMPOO SOD SULFACET SHA 10% Tier 1 Skin Conditions 10% Dermatological Agents - Drugs to Treat SODIUM SULFA LIQ 10% SULFACETAMIDE SODIUM LIQUID 10% Tier 1 Skin Conditions WASH Dermatological Agents - Drugs to Treat SODIUM SULFA LIQ 10% SULFACETAMIDE SODIUM IN Tier 1 Skin Conditions WASH BAKUCHIOL VEHICLE WASH 10% Dermatological Agents - Drugs to Treat DICLOFENAC SODIUM (ACTINIC SOLARAZE GEL 3% W/W Tier 3 X X Skin Conditions KERATOSES) GEL 3% Dermatological Agents - Drugs to Treat SOOLANTRA CRE 1% IVERMECTIN CREAM 1% Tier 3 X X Skin Conditions Dermatological Agents - Drugs to Treat SORIATANE CAP 10MG ACITRETIN CAP 10 MG Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat SORIATANE CAP 17.5MG ACITRETIN CAP 17.5 MG Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat SORIATANE CAP 25MG ACITRETIN CAP 25 MG Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR SSS CRE 10%-5% Tier 1 Skin Conditions CREAM 10-5% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR SSS 10-5 AER 10-5% Tier 1 Skin Conditions FOAM 10-5% Dermatological Agents - Drugs to Treat STELARA INJ 45MG/0.5 USTEKINUMAB INJ 45 MG/0.5ML Tier 2 X X Skin Conditions Dermatological Agents - Drugs to Treat USTEKINUMAB SOLN PREFILLED STELARA INJ 45MG/0.5 Tier 2 X X X Skin Conditions SYRINGE 45 MG/0.5ML Dermatological Agents - Drugs to Treat USTEKINUMAB SOLN PREFILLED STELARA INJ 90MG/ML Tier 2 X X X Skin Conditions SYRINGE 90 MG/ML Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR SUL SOD/SULF PAD 10-4% Tier 1 Skin Conditions CLEANSING PAD 10-4% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM LOTION 10% SULFACETAMID LOT 10% Tier 1 Skin Conditions (ACNE) Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM LOTION 10% SULFACETAMID SUS 10% Tier 1 Skin Conditions (ACNE) Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR SULFACLEANSE SUS 8-4% Tier 1 Skin Conditions SUSP 8-4% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR SULFAMEZ EMU 10-1% Tier 1 Skin Conditions EMULSION 10-1% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR SUMAXIN PAD 10-4% Tier 3 Skin Conditions CLEANSING PAD 10-4% Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR SUMAXIN WASH LIQ 9-4% Tier 3 Skin Conditions WASH 9-4% Dermatological Agents - Drugs to Treat CALCIPOTRIENE-BETAMETHASONE TACLONEX SUS Tier 3 X Skin Conditions DIPROPIONATE SUSP 0.005-0.064% Dermatological Agents - Drugs to Treat TACROLIMUS OIN 0.03% TACROLIMUS OINT 0.03% Tier 2 X X Skin Conditions Dermatological Agents - Drugs to Treat TACROLIMUS OIN 0.1% TACROLIMUS OINT 0.1% Tier 2 X X Skin Conditions Dermatological Agents - Drugs to Treat IXEKIZUMAB SUBCUTANEOUS SOLN TALTZ INJ 80MG/ML Tier 4 X X X X Skin Conditions AUTO-INJECTOR 80 MG/ML Dermatological Agents - Drugs to Treat IXEKIZUMAB SUBCUTANEOUS SOLN TALTZ INJ 80MG/ML Tier 4 X X X X Skin Conditions PREFILLED SYRINGE 80 MG/ML Dermatological Agents - Drugs to Treat TAZORAC CRE 0.05% TAZAROTENE CREAM 0.05% Tier 3 X X Skin Conditions Dermatological Agents - Drugs to Treat TAZORAC CRE 0.1% TAZAROTENE CREAM 0.1% Tier 3 X X Skin Conditions Dermatological Agents - Drugs to Treat TAZORAC GEL 0.05% TAZAROTENE GEL 0.05% Tier 3 X X Skin Conditions

109 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Dermatological Agents - Drugs to Treat TAZORAC GEL 0.1% TAZAROTENE GEL 0.1% Tier 3 X X Skin Conditions Dermatological Agents - Drugs to Treat TRYPSIN W/ CASTOR OIL & PERUVIAN TBC AER Tier 1 Skin Conditions BALSAM SPRAY Dermatological Agents - Drugs to Treat TRETINOIN CRE 0.025% TRETINOIN CREAM 0.025% Tier 3 X X Skin Conditions Dermatological Agents - Drugs to Treat TRETINOIN CRE 0.05% TRETINOIN CREAM 0.05% Tier 3 X X Skin Conditions Dermatological Agents - Drugs to Treat TRETINOIN CRE 0.1% TRETINOIN CREAM 0.1% Tier 3 X X Skin Conditions Dermatological Agents - Drugs to Treat TRI-CHLOR LIQ 80% TRICHLOROACETIC ACID LIQD 80% Tier 2 Skin Conditions Dermatological Agents - Drugs to Treat TRICHLOROACE CRY ACID TRICHLOROACETIC ACID CRYSTALS Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat TURPENTINE SOL SPIRITS TURPENTINE SPIRIT Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat *UREA IN AMMONIUM LACTATE VEHICLE URAMAXIN AER 20% Tier 3 Skin Conditions FOAM 20%*** Dermatological Agents - Drugs to Treat URAMAXIN CRE 45% UREA CREAM 45% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat URAMAXIN LOT 45% UREA LOTION 45% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat URE-39 CRE 39% UREA CREAM 39% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat UREA CRE 39% UREA CREAM 39% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat UREA CRE 40% UREA CREAM 40% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat UREA CRE 45% UREA CREAM 45% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat UREA CRE 50% UREA CREAM 50% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat UREA IN ZINC UNDECYLENATE-LACTIC UREA EMU 50% Tier 1 Skin Conditions ACID VEHICLE EMULSION 50% Dermatological Agents - Drugs to Treat UREA GEL 40% UREA GEL 40% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat UREA LOT 40% UREA LOTION 40% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat UREA LOT 45% UREA LOTION 45% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat UREA SUS 50% UREA SUSPENSION 50% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat UREA 40% SUS NAIL UREA SUSPENSION 40% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat UREA IN LACTIC ACID VEHICLE FOAM UREA HYDRATI AER 35% Tier 1 Skin Conditions 35% Dermatological Agents - Drugs to Treat UREA NAIL GEL 45% UREA GEL 45% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat UREA SUSP 40% & HYALURONATE UREA NAIL KIT Tier 1 Skin Conditions SODIUM GEL 0.2% KIT Dermatological Agents - Drugs to Treat UREA IN ZINC UNDECYLENATE-LACTIC UREA NAIL MIS 50% Tier 1 Skin Conditions ACID VEHICLE STICK 50% Dermatological Agents - Drugs to Treat UREA TOPICAL SUS 40% UREA SUSPENSION 40% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat UREA-C40 LOT 40% UREA LOTION 40% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat UREDEB CRE 39% UREA CREAM 39% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat URE-K CRE 50% UREA CREAM 50% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat UREMEZ-40 CRE 40% UREA CREAM 40% Tier 1 Skin Conditions Dermatological Agents - Drugs to Treat URESOL CRE 42.5% UREA CREAM 42.5% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat VANOXIDE-HC LOT 5-0.5% BENZOYL PEROXIDE-HC LOTION 5-0.5% Tier 3 Skin Conditions Dermatological Agents - Drugs to Treat VECTICAL OIN 3MCG/GM CALCITRIOL OINT 3 MCG/GM Tier 3 X Skin Conditions Dermatological Agents - Drugs to Treat VEREGEN OIN 15% SINECATECHINS OINT 15% Tier 3 X Skin Conditions Dermatological Agents - Drugs to Treat VOLTAREN GEL 1% DICLOFENAC SODIUM GEL 1% Tier 2 Skin Conditions Dermatological Agents - Drugs to Treat BENZOYL PEROXIDE LOTION 4% & ZACARE KIT KIT 4% Tier 3 Skin Conditions HYALURONATE SODIUM GEL 0.2% KIT Dermatological Agents - Drugs to Treat BENZOYL PEROXIDE LOTION 8% & ZACARE KIT KIT 8% Tier 3 Skin Conditions HYALURONATE SODIUM GEL 0.2% KIT Dermatological Agents - Drugs to Treat ZACLIR LOT 8% BENZOYL PEROXIDE LOTION 8% Tier 1 Skin Conditions

110 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Dermatological Agents - Drugs to Treat ZENATANE CAP 10MG ISOTRETINOIN CAP 10 MG Tier 2 X Skin Conditions Dermatological Agents - Drugs to Treat ZENATANE CAP 20MG ISOTRETINOIN CAP 20 MG Tier 2 X Skin Conditions Dermatological Agents - Drugs to Treat ZENATANE CAP 30MG ISOTRETINOIN CAP 30 MG Tier 2 X Skin Conditions Dermatological Agents - Drugs to Treat ZENATANE CAP 40MG ISOTRETINOIN CAP 40 MG Tier 2 X Skin Conditions Dermatological Agents - Drugs to Treat SULFACETAMIDE SODIUM W/ SULFUR ZENCIA LIQ 9-4% Tier 1 Skin Conditions WASH 9-4% Dermatological Agents - Drugs to Treat ZONALON CRE 5% DOXEPIN HCL CREAM 5% Tier 3 X X Skin Conditions Enzyme Replacement/Modifiers - Drugs SODIUM PHENYLBUTYRATE ORAL BUPHENYL POW Tier 3 X X to Treat Enzyme Deficiency POWDER 3 GM/TEASPOONFUL Enzyme Replacement/Modifiers - Drugs BUPHENYL TAB 500MG SODIUM PHENYLBUTYRATE TAB 500 MG Tier 3 X X to Treat Enzyme Deficiency Enzyme Replacement/Modifiers - Drugs ELIGLUSTAT TARTRATE CAP 84 MG CERDELGA CAP 84MG Tier 2 X X to Treat Enzyme Deficiency (BASE EQUIVALENT) Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR CREON CAP 12000UNT Tier 2 to Treat Enzyme Deficiency CAP 12000-38000-60000 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR CREON CAP 24000UNT Tier 2 to Treat Enzyme Deficiency CAP 24000-76000-120000 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR CREON CAP 3000UNIT Tier 2 to Treat Enzyme Deficiency CAP 3000-9500-15000 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR CREON CAP 36000UNT Tier 2 to Treat Enzyme Deficiency CAP 36000-114000-180000 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR CREON CAP 6000UNIT Tier 2 to Treat Enzyme Deficiency CAP 6000-19000-30000 UNIT Enzyme Replacement/Modifiers - Drugs *BETAINE POWDER FOR ORAL CYSTADANE POW Tier 2 X to Treat Enzyme Deficiency SOLUTION*** Enzyme Replacement/Modifiers - Drugs CYSTAGON CAP 150MG CYSTEAMINE BITARTRATE CAP 150 MG Tier 2 to Treat Enzyme Deficiency Enzyme Replacement/Modifiers - Drugs CYSTAGON CAP 50MG CYSTEAMINE BITARTRATE CAP 50 MG Tier 2 to Treat Enzyme Deficiency Enzyme Replacement/Modifiers - Drugs SAPROPTERIN DIHYDROCHLORIDE KUVAN POW 100MG Tier 2 X X X to Treat Enzyme Deficiency POWDER PACKET 100 MG Enzyme Replacement/Modifiers - Drugs SAPROPTERIN DIHYDROCHLORIDE KUVAN POW 500MG Tier 2 X X X to Treat Enzyme Deficiency POWDER PACKET 500 MG Enzyme Replacement/Modifiers - Drugs SAPROPTERIN DIHYDROCHLORIDE KUVAN TAB 100MG Tier 2 X X X to Treat Enzyme Deficiency SOLUBLE TAB 100 MG Enzyme Replacement/Modifiers - Drugs NITYR TAB 10MG NITISINONE TAB 10 MG Tier 2 X X to Treat Enzyme Deficiency Enzyme Replacement/Modifiers - Drugs NITYR TAB 2MG NITISINONE TAB 2 MG Tier 2 X to Treat Enzyme Deficiency Enzyme Replacement/Modifiers - Drugs NITYR TAB 5MG NITISINONE TAB 5 MG Tier 2 X to Treat Enzyme Deficiency Enzyme Replacement/Modifiers - Drugs OCALIVA TAB 10MG OBETICHOLIC ACID TAB 10 MG Tier 4 X X X X to Treat Enzyme Deficiency Enzyme Replacement/Modifiers - Drugs OCALIVA TAB 5MG OBETICHOLIC ACID TAB 5 MG Tier 4 X X X X to Treat Enzyme Deficiency Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR PANCREAZE CAP Tier 3 X to Treat Enzyme Deficiency CAP 2600-6200-10850 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR PANCREAZE CAP 10500UNT Tier 3 X to Treat Enzyme Deficiency CAP 10500-35500-61500 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR PANCREAZE CAP 16800UNT Tier 3 X to Treat Enzyme Deficiency CAP 16800-56800-98400 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR PANCREAZE CAP 21000UNT Tier 3 X to Treat Enzyme Deficiency CAP 21000-54700-83900 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR PANCREAZE CAP 4200UNIT Tier 3 X to Treat Enzyme Deficiency CAP 4200-14200-24600 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR PERTZYE CAP Tier 4 X to Treat Enzyme Deficiency CAP 4000-14375-15125 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR PERTZYE CAP Tier 4 X to Treat Enzyme Deficiency CAP 8000-28750-30250 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR PERTZYE CAP Tier 4 X to Treat Enzyme Deficiency CAP 16000-57500-60500 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR PERTZYE CAP Tier 4 X to Treat Enzyme Deficiency CAP 24000-86250-90750 UNIT Enzyme Replacement/Modifiers - Drugs PHENYLBUTYRA POW SODIUM PHENYLBUTYRATE ORAL Tier 1 X X to Treat Enzyme Deficiency SODIUM POWDER 3 GM/TEASPOONFUL Enzyme Replacement/Modifiers - Drugs CYSTEAMINE BITARTRATE CAP PROCYSBI CAP 25MG Tier 4 X X X to Treat Enzyme Deficiency DELAYED RELEASE 25 MG (BASE EQUIV) Enzyme Replacement/Modifiers - Drugs CYSTEAMINE BITARTRATE CAP PROCYSBI CAP 75MG Tier 4 X X X to Treat Enzyme Deficiency DELAYED RELEASE 75 MG (BASE EQUIV) Enzyme Replacement/Modifiers - Drugs GLYCEROL PHENYLBUTYRATE LIQUID RAVICTI LIQ 1.1GM/ML Tier 4 X X X X to Treat Enzyme Deficiency 1.1 GM/ML Enzyme Replacement/Modifiers - Drugs SODIUM PHENY TAB 500MG SODIUM PHENYLBUTYRATE TAB 500 MG Tier 3 X X to Treat Enzyme Deficiency

111 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Enzyme Replacement/Modifiers - Drugs ASFOTASE ALFA SUBCUTANEOUS INJ 18 STRENSIQ INJ 18/0.45 Tier 4 X X X to Treat Enzyme Deficiency MG/0.45ML Enzyme Replacement/Modifiers - Drugs ASFOTASE ALFA SUBCUTANEOUS INJ 28 STRENSIQ INJ 28/0.7ML Tier 4 X X X to Treat Enzyme Deficiency MG/0.7ML Enzyme Replacement/Modifiers - Drugs ASFOTASE ALFA SUBCUTANEOUS INJ STRENSIQ INJ 40MG/ML Tier 4 X X X to Treat Enzyme Deficiency 40 MG/ML Enzyme Replacement/Modifiers - Drugs ASFOTASE ALFA SUBCUTANEOUS INJ 80 STRENSIQ INJ 80/0.8ML Tier 4 X X X to Treat Enzyme Deficiency MG/0.8ML Enzyme Replacement/Modifiers - Drugs SUCRAID SOL 8500/ML SACROSIDASE SOLN 8500 UNIT/ML Tier 2 X to Treat Enzyme Deficiency Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) TAB VIOKACE TAB Tier 3 X to Treat Enzyme Deficiency 10440-39150-39150 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) TAB VIOKACE TAB 20880 Tier 3 X to Treat Enzyme Deficiency 20880-78300-78300 UNIT Enzyme Replacement/Modifiers - Drugs ZAVESCA CAP 100MG MIGLUSTAT CAP 100 MG Tier 3 X to Treat Enzyme Deficiency Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR ZENPEP CAP Tier 2 to Treat Enzyme Deficiency CAP 40000-126000-168000 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR ZENPEP CAP 10000UNT Tier 2 to Treat Enzyme Deficiency CAP 10000-34000-55000 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR ZENPEP CAP 15000UNT Tier 2 to Treat Enzyme Deficiency CAP 15000-51000-82000 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR ZENPEP CAP 20000UNT Tier 2 to Treat Enzyme Deficiency CAP 20000-63000-84000 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR ZENPEP CAP 20000UNT Tier 2 to Treat Enzyme Deficiency CAP 20000-68000-109000 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR ZENPEP CAP 25000UNT Tier 2 to Treat Enzyme Deficiency CAP 25000-85000-136000 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR ZENPEP CAP 3000UNIT Tier 2 to Treat Enzyme Deficiency CAP 3000-10000-16000 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR ZENPEP CAP 40000UNT Tier 2 to Treat Enzyme Deficiency CAP 40000-136000-218000 UNIT Enzyme Replacement/Modifiers - Drugs PANCRELIPASE (LIP-PROT-AMYL) DR ZENPEP CAP 5000UNIT Tier 2 to Treat Enzyme Deficiency CAP 5000-17000-27000 UNIT Gastrointestinal Agents - Drugs to Treat ACTIGALL CAP 300MG URSODIOL CAP 300 MG Tier 3 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat ALOSETRON HCL TAB 0.5 MG (BASE ALOSETRON TAB 0.5MG Tier 2 X X Bowel, Intestine and Stomach Conditions EQUIV) Gastrointestinal Agents - Drugs to Treat ALOSETRON HCL TAB 1 MG (BASE ALOSETRON TAB 1MG Tier 2 X X Bowel, Intestine and Stomach Conditions EQUIV) Gastrointestinal Agents - Drugs to Treat AMITIZA CAP 24MCG LUBIPROSTONE CAP 24 MCG Tier 3 X X X Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat AMITIZA CAP 8MCG LUBIPROSTONE CAP 8 MCG Tier 3 X X X Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat HYOSCYAMINE SULFATE TAB DISINT ANASPAZ TAB 0.125MG Tier 2 Bowel, Intestine and Stomach Conditions 0.125 MG Gastrointestinal Agents - Drugs to Treat ATROPINE POW SULFATE ATROPINE SULFATE POWDER Tier 3 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat AXID SOL 15MG/ML NIZATIDINE ORAL SOLN 15 MG/ML Tier 3 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat BELLADONNA ALKALOIDS & OPIUM BELLA/OPIUM SUP 16.2-30 Tier 1 Bowel, Intestine and Stomach Conditions SUPPOS 16.2-30 MG Gastrointestinal Agents - Drugs to Treat BELLADONNA ALKALOIDS & OPIUM BELLA/OPIUM SUP 16.2-60 Tier 2 Bowel, Intestine and Stomach Conditions SUPPOS 16.2-60 MG Gastrointestinal Agents - Drugs to Treat BENTYL CAP 10MG DICYCLOMINE HCL CAP 10 MG Tier 3 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat BENTYL TAB 20MG DICYCLOMINE HCL TAB 20 MG Tier 3 Bowel, Intestine and Stomach Conditions HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 BISACODYL TAB 5MG EC Preventive Bowel, Intestine and Stomach Conditions MG Care Gastrointestinal Agents - Drugs to Treat CARAFATE SUS 1GM/10ML SUCRALFATE SUSP 1 GM/10ML Tier 3 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat CARAFATE TAB 1GM SUCRALFATE TAB 1 GM Tier 3 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat CASCARA EXT SAGRADA CASCARA SAGRADA FL EXT 1 GM/ML Tier 1 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat CHENODAL TAB 250MG CHENODIOL TAB 250 MG Tier 3 X Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat CHLORDIAZEPOXIDE HCL-CLIDINIUM CHLORD/CLIDI CAP 5-2.5MG Tier 3 Bowel, Intestine and Stomach Conditions BROMIDE CAP 5-2.5 MG Gastrointestinal Agents - Drugs to Treat LACTULOSE (ENCEPHALOPATHY) CHOLAC SYP 10GM/15 Tier 1 Bowel, Intestine and Stomach Conditions SYRUP 10 GM/15ML Gastrointestinal Agents - Drugs to Treat CHOLBAM CAP 250MG CHOLIC ACID CAP 250 MG Tier 2 X X X Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat CHOLBAM CAP 50MG CHOLIC ACID CAP 50 MG Tier 2 X X X Bowel, Intestine and Stomach Conditions

112 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Gastrointestinal Agents - Drugs to Treat CIMETIDINE SOL 300/5ML CIMETIDINE HCL SOLN 300 MG/5ML Tier 1 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat CIMETIDINE TAB 200MG CIMETIDINE TAB 200 MG Tier 1 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat CIMETIDINE TAB 300MG CIMETIDINE TAB 300 MG Tier 1 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat CIMETIDINE TAB 400MG CIMETIDINE TAB 400 MG Tier 1 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat CIMETIDINE TAB 800MG CIMETIDINE TAB 800 MG Tier 1 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat CIMETIDINE TAB 400MG CIMETIDINE TAB 400 MG Tier 1 Bowel, Intestine and Stomach Conditions HCR Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL CLEARLAX POW Preventive Bowel, Intestine and Stomach Conditions POWDER Care Gastrointestinal Agents - Drugs to Treat PEG 3350-KCL-NA BICARB-NACL-NA COLYTE/FLAVR SOL PACKS Tier 3 Bowel, Intestine and Stomach Conditions SULFATE FOR SOLN 240 GM Gastrointestinal Agents - Drugs to Treat CONSTULOSE SOL 10GM/15 LACTULOSE SOLUTION 10 GM/15ML Tier 1 Bowel, Intestine and Stomach Conditions HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 CORRECT TAB 5MG EC Preventive Bowel, Intestine and Stomach Conditions MG Care Gastrointestinal Agents - Drugs to Treat CROMOLYN SOD CON CROMOLYN SODIUM ORAL CONC 100 Tier 1 Bowel, Intestine and Stomach Conditions 100/5ML MG/5ML Gastrointestinal Agents - Drugs to Treat GLYCOPYRROLATE ORAL SOLN 1 CUVPOSA SOL 1MG/5ML Tier 3 Bowel, Intestine and Stomach Conditions MG/5ML HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 CVS C-LAX TAB 5MG Preventive Bowel, Intestine and Stomach Conditions MG Care HCR Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL CVS PURELAX POW Preventive Bowel, Intestine and Stomach Conditions POWDER Care HCR Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL CVS PURELAX POW 3350 Preventive Bowel, Intestine and Stomach Conditions POWDER Care Gastrointestinal Agents - Drugs to Treat CYTOTEC TAB 100MCG MISOPROSTOL TAB 100 MCG Tier 3 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat CYTOTEC TAB 200MCG MISOPROSTOL TAB 200 MCG Tier 3 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat DEXLANSOPRAZOLE CAP DELAYED DEXILANT CAP 30MG DR Tier 3 X Bowel, Intestine and Stomach Conditions RELEASE 30 MG Gastrointestinal Agents - Drugs to Treat DEXLANSOPRAZOLE CAP DELAYED DEXILANT CAP 60MG DR Tier 3 X Bowel, Intestine and Stomach Conditions RELEASE 60 MG Gastrointestinal Agents - Drugs to Treat DICYCLOMINE CAP 10MG DICYCLOMINE HCL CAP 10 MG Tier 1 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat DICYCLOMINE SOL DICYCLOMINE HCL ORAL SOLN 10 Tier 1 Bowel, Intestine and Stomach Conditions 10MG/5ML MG/5ML Gastrointestinal Agents - Drugs to Treat DICYCLOMINE TAB 20MG DICYCLOMINE HCL TAB 20 MG Tier 1 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat DIPHENOXYLATE W/ ATROPINE LIQ 2.5- DIPHEN/ATROP LIQ 2.5/5 Tier 1 Bowel, Intestine and Stomach Conditions 0.025 MG/5ML Gastrointestinal Agents - Drugs to Treat DIPHENOXYLATE W/ ATROPINE TAB 2.5- DIPHEN/ATROP TAB 2.5MG Tier 1 Bowel, Intestine and Stomach Conditions 0.025 MG HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 DUCODYL TAB 5MG EC Preventive Bowel, Intestine and Stomach Conditions MG Care Gastrointestinal Agents - Drugs to Treat HYOSCYAMINE SULFATE TAB DISINT ED-SPAZ TAB 0.125MG Tier 1 Bowel, Intestine and Stomach Conditions 0.125 MG Gastrointestinal Agents - Drugs to Treat ENTEREG CAP 12MG ALVIMOPAN CAP 12 MG Tier 3 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat LACTULOSE (ENCEPHALOPATHY) ENULOSE SOL 10GM/15 Tier 1 Bowel, Intestine and Stomach Conditions SOLUTION 10 GM/15ML HCR Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL EQ CLEARLAX POW Preventive Bowel, Intestine and Stomach Conditions POWDER Care HCR Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL EQL CLEARLAX POW Preventive Bowel, Intestine and Stomach Conditions POWDER Care HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 EQL GENTLE TAB LAXATIVE Preventive Bowel, Intestine and Stomach Conditions MG Care HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 EX-LAX ULTRA TAB 5MG EC Preventive Bowel, Intestine and Stomach Conditions MG Care Gastrointestinal Agents - Drugs to Treat FAMOTIDINE SUS FAMOTIDINE FOR SUSP 40 MG/5ML Tier 1 Bowel, Intestine and Stomach Conditions 40MG/5ML HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 FEMININE LAX TAB 5MG EC Preventive Bowel, Intestine and Stomach Conditions MG Care

113 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 FLEET LAXATI TAB 5MG EC Preventive Bowel, Intestine and Stomach Conditions MG Care Gastrointestinal Agents - Drugs to Treat CROFELEMER TAB DELAYED RELEASE FULYZAQ TAB 125MG Tier 3 X X Bowel, Intestine and Stomach Conditions 125 MG Gastrointestinal Agents - Drugs to Treat GASTROCROM CON CROMOLYN SODIUM ORAL CONC 100 Tier 3 Bowel, Intestine and Stomach Conditions 100/5ML MG/5ML Gastrointestinal Agents - Drugs to Treat GATTEX KIT 5MG TEDUGLUTIDE (RDNA) FOR INJ KIT 5 MG Tier 2 X X X Bowel, Intestine and Stomach Conditions HCR Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL GAVILAX POW Preventive Bowel, Intestine and Stomach Conditions POWDER Care HCR Gastrointestinal Agents - Drugs to Treat PEG 3350-KCL-NA BICARB-NACL-NA GAVILYTE-C SOL Preventive Bowel, Intestine and Stomach Conditions SULFATE FOR SOLN 240 GM Care HCR Gastrointestinal Agents - Drugs to Treat PEG 3350-KCL-NA BICARB-NACL-NA GAVILYTE-G SOL Preventive Bowel, Intestine and Stomach Conditions SULFATE FOR SOLN 236 GM Care Gastrointestinal Agents - Drugs to Treat BISACODYL TAB & PEG 3350-KCL-SOD GAVILYTE-H KIT Tier 1 Bowel, Intestine and Stomach Conditions BICARB-NACL FOR SOLN KIT HCR Gastrointestinal Agents - Drugs to Treat PEG 3350-KCL-SOD BICARB-NACL FOR GAVILYTE-N SOL FLAV PK Preventive Bowel, Intestine and Stomach Conditions SOLN 420 GM Care Gastrointestinal Agents - Drugs to Treat LACTULOSE (ENCEPHALOPATHY) GENERLAC SOL 10GM/15 Tier 1 Bowel, Intestine and Stomach Conditions SOLUTION 10 GM/15ML HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 GENTLE LAXAT TAB 5MG EC Preventive Bowel, Intestine and Stomach Conditions MG Care HCR Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL GENTLELAX POW Preventive Bowel, Intestine and Stomach Conditions POWDER Care Gastrointestinal Agents - Drugs to Treat GLYCERIN LIQ GLYCERIN LIQUID Tier 2 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat GLYCERIN LIQ GLYCERIN LIQUID Tier 3 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat GLYCERINE LIQ GLYCERIN LIQUID Tier 3 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat GLYCEROL LIQ FORMAL GLYCERIN LIQUID Tier 3 Bowel, Intestine and Stomach Conditions HCR Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL GLYCOLAX POW 3350 NF Preventive Bowel, Intestine and Stomach Conditions POWDER Care Gastrointestinal Agents - Drugs to Treat GLYCOPYRROL TAB 1MG GLYCOPYRROLATE TAB 1 MG Tier 1 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat GLYCOPYRROL TAB 2MG GLYCOPYRROLATE TAB 2 MG Tier 1 Bowel, Intestine and Stomach Conditions HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 GNP BISA-LAX TAB 5MG EC Preventive Bowel, Intestine and Stomach Conditions MG Care HCR Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL GNP CLEARLAX POW Preventive Bowel, Intestine and Stomach Conditions POWDER Care HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 GNP LAXATIVE TAB 5MG EC Preventive Bowel, Intestine and Stomach Conditions MG Care Gastrointestinal Agents - Drugs to Treat PEG 3350-KCL-NA BICARB-NACL-NA GOLYTELY SOL Tier 3 Bowel, Intestine and Stomach Conditions SULFATE FOR SOLN 236 GM Gastrointestinal Agents - Drugs to Treat PEG 3350-KCL-NA BICARB-NACL-NA GOLYTELY SOL Tier 2 Bowel, Intestine and Stomach Conditions SULFATE PACKET 227.1 GM Gastrointestinal Agents - Drugs to Treat PEG 3350-KCL-NA BICARB-NACL-NA GOLYTELY SOL PINEAPPL Tier 3 Bowel, Intestine and Stomach Conditions SULFATE FOR SOLN 236 GM HCR Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL HM CLEARLAX POW Preventive Bowel, Intestine and Stomach Conditions POWDER Care HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 HM LAXATIVE TAB 5MG Preventive Bowel, Intestine and Stomach Conditions MG Care HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 HM LAXATIVE TAB 5MG EC Preventive Bowel, Intestine and Stomach Conditions MG Care Gastrointestinal Agents - Drugs to Treat HYOSCYAMINE DRO 0.125/ HYOSCYAMINE SULFATE SOLN 0.125 Tier 1 Bowel, Intestine and Stomach Conditions ML MG/ML Gastrointestinal Agents - Drugs to Treat HYOSCYAMINE SULFATE ELIXIR 0.125 HYOSCYAMINE ELX 0.125/5 Tier 1 Bowel, Intestine and Stomach Conditions MG/5ML Gastrointestinal Agents - Drugs to Treat HYOSCYAMINE SUB HYOSCYAMINE SULFATE TAB SL 0.125 Tier 1 Bowel, Intestine and Stomach Conditions 0.125MG MG Gastrointestinal Agents - Drugs to Treat HYOSCYAMINE SULFATE TAB DISINT HYOSCYAMINE TAB 0.125MG Tier 1 Bowel, Intestine and Stomach Conditions 0.125 MG

114 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Gastrointestinal Agents - Drugs to Treat HYOSCYAMINE TAB 0.125MG HYOSCYAMINE SULFATE TAB 0.125 MG Tier 1 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat HYOSCYAMINE SULFATE TAB ER 12HR HYOSCYAMINE TAB 0.375 ER Tier 1 Bowel, Intestine and Stomach Conditions 0.375 MG Gastrointestinal Agents - Drugs to Treat HYOSCYAMINE SULFATE TAB ER 12HR HYOSCYAMINE TAB 0.375 SR Tier 1 Bowel, Intestine and Stomach Conditions 0.375 MG Gastrointestinal Agents - Drugs to Treat HYOSCYAMINE SULFATE SOLN 0.125 HYOSYNE DRO 0.125/ML Tier 1 Bowel, Intestine and Stomach Conditions MG/ML Gastrointestinal Agents - Drugs to Treat HYOSCYAMINE SULFATE ELIXIR 0.125 HYOSYNE ELX 0.125/5 Tier 1 Bowel, Intestine and Stomach Conditions MG/5ML HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 KP BISACODYL TAB 5MG EC Preventive Bowel, Intestine and Stomach Conditions MG Care Gastrointestinal Agents - Drugs to Treat LACTULOSE ORAL CRYSTAL PACKET KRISTALOSE PAK 10GM Tier 3 Bowel, Intestine and Stomach Conditions 10 GM Gastrointestinal Agents - Drugs to Treat LACTULOSE ORAL CRYSTAL PACKET KRISTALOSE PAK 20GM Tier 3 Bowel, Intestine and Stomach Conditions 20 GM Gastrointestinal Agents - Drugs to Treat LACTULOSE SOL 10GM/15 LACTULOSE SOLUTION 10 GM/15ML Tier 1 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat LACTULOSE (ENCEPHALOPATHY) LACTULOSE SOL 10GM/15 Tier 1 Bowel, Intestine and Stomach Conditions SOLUTION 10 GM/15ML Gastrointestinal Agents - Drugs to Treat LACTULOSE SOL 20GM/30 LACTULOSE SOLUTION 10 GM/15ML Tier 1 Bowel, Intestine and Stomach Conditions HCR Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL LAXACLEAR POW Preventive Bowel, Intestine and Stomach Conditions POWDER Care HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 LAXATIVE TAB 5MG EC Preventive Bowel, Intestine and Stomach Conditions MG Care Gastrointestinal Agents - Drugs to Treat HYOSCYAMINE SULFATE TAB ER 12HR LEVBID TAB 0.375 ER Tier 3 Bowel, Intestine and Stomach Conditions 0.375 MG Gastrointestinal Agents - Drugs to Treat LEVSIN TAB 0.125MG HYOSCYAMINE SULFATE TAB 0.125 MG Tier 3 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat HYOSCYAMINE SULFATE TAB SL 0.125 LEVSIN/SL SUB 0.125MG Tier 3 Bowel, Intestine and Stomach Conditions MG Gastrointestinal Agents - Drugs to Treat LINZESS CAP 145MCG LINACLOTIDE CAP 145 MCG Tier 2 X X Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat LINZESS CAP 290MCG LINACLOTIDE CAP 290 MCG Tier 2 X X Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat LINZESS CAP 72MCG LINACLOTIDE CAP 72 MCG Tier 2 X X Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat DIPHENOXYLATE W/ ATROPINE TAB 2.5- LOMOTIL TAB 2.5MG Tier 3 Bowel, Intestine and Stomach Conditions 0.025 MG Gastrointestinal Agents - Drugs to Treat METHSCOPOLAM TAB METHSCOPOLAMINE BROMIDE TAB Tier 1 Bowel, Intestine and Stomach Conditions 2.5MG 2.5 MG Gastrointestinal Agents - Drugs to Treat METHSCOPOLAMINE BROMIDE TAB 5 METHSCOPOLAM TAB 5MG Tier 1 Bowel, Intestine and Stomach Conditions MG Gastrointestinal Agents - Drugs to Treat MINERAL OIL HEAVY MINERAL OIL Tier 1 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat MISOPROSTOL TAB MISOPROSTOL TAB 100 MCG Tier 1 Bowel, Intestine and Stomach Conditions 100MCG Gastrointestinal Agents - Drugs to Treat MISOPROSTOL TAB MISOPROSTOL TAB 200 MCG Tier 1 Bowel, Intestine and Stomach Conditions 200MCG Gastrointestinal Agents - Drugs to Treat NALOXEGOL OXALATE TAB 12.5 MG MOVANTIK TAB 12.5MG Tier 2 X X Bowel, Intestine and Stomach Conditions (BASE EQUIVALENT) Gastrointestinal Agents - Drugs to Treat NALOXEGOL OXALATE TAB 25 MG (BASE MOVANTIK TAB 25MG Tier 2 X X Bowel, Intestine and Stomach Conditions EQUIVALENT) Gastrointestinal Agents - Drugs to Treat PEG 3350-KCL-NACL-NA SULFATE-NA MOVIPREP SOL Tier 3 X Bowel, Intestine and Stomach Conditions ASCORBATE-C FOR SOLN 100 GM Gastrointestinal Agents - Drugs to Treat CROFELEMER TAB DELAYED RELEASE MYTESI TAB 125MG Tier 3 X X Bowel, Intestine and Stomach Conditions 125 MG HCR Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL NATURA-LAX POW 3350 NF Preventive Bowel, Intestine and Stomach Conditions POWDER Care Gastrointestinal Agents - Drugs to Treat ESOMEPRAZOLE MAGNESIUM FOR NEXIUM GRA 10MG DR Tier 3 X X X Bowel, Intestine and Stomach Conditions DELAYED RELEASE SUSP PACKET 10 MG Gastrointestinal Agents - Drugs to Treat ESOMEPRAZOLE MAGNESIUM FOR NEXIUM GRA 2.5MG DR Tier 3 X X X Bowel, Intestine and Stomach Conditions DELAYED RELEASE SUSP PACK 2.5 MG ESOMEPRAZOLE MAGNESIUM FOR Gastrointestinal Agents - Drugs to Treat NEXIUM GRA 20MG DR DELAYED RELEASE SUSP PACKET 20 Tier 3 X X X Bowel, Intestine and Stomach Conditions MG ESOMEPRAZOLE MAGNESIUM FOR Gastrointestinal Agents - Drugs to Treat NEXIUM GRA 40MG DR DELAYED RELEASE SUSP PACKET 40 Tier 3 X X X Bowel, Intestine and Stomach Conditions MG Gastrointestinal Agents - Drugs to Treat ESOMEPRAZOLE MAGNESIUM FOR NEXIUM GRA 5MG DR Tier 3 X X Bowel, Intestine and Stomach Conditions DELAYED RELEASE SUSP PACKET 5 MG Gastrointestinal Agents - Drugs to Treat NIZATIDINE SOL 15MG/ML NIZATIDINE ORAL SOLN 15 MG/ML Tier 2 Bowel, Intestine and Stomach Conditions

115 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Gastrointestinal Agents - Drugs to Treat HYOSCYAMINE SULFATE TAB DISINT NULEV TAB 0.125MG Tier 3 Bowel, Intestine and Stomach Conditions 0.125 MG Gastrointestinal Agents - Drugs to Treat PEG 3350-KCL-SOD BICARB-NACL FOR NULYTELY SOL FLAV PKS Tier 3 Bowel, Intestine and Stomach Conditions SOLN 420 GM Gastrointestinal Agents - Drugs to Treat AMOXICILLIN CAP-CLARITHRO TAB W/ OMECLAMOX- MIS PAK Tier 3 X Bowel, Intestine and Stomach Conditions OMEPRAZ CAP DR THERAPY PACK Gastrointestinal Agents - Drugs to Treat OMEPRAZOLE CAP DELAYED RELEASE OMEPRAZOLE CAP 10MG Tier 1 Bowel, Intestine and Stomach Conditions 10 MG Gastrointestinal Agents - Drugs to Treat OMEPRAZOLE CAP DELAYED RELEASE OMEPRAZOLE CAP 20MG Tier 1 Bowel, Intestine and Stomach Conditions 20 MG Gastrointestinal Agents - Drugs to Treat OMEPRAZOLE CAP DELAYED RELEASE OMEPRAZOLE CAP 40MG Tier 1 Bowel, Intestine and Stomach Conditions 40 MG Gastrointestinal Agents - Drugs to Treat OPIUM TINCTURE 1% (10 MG/ML) OPIUM TIN 10MG/ML Tier 1 Bowel, Intestine and Stomach Conditions (MORPHINE EQUIV) Gastrointestinal Agents - Drugs to Treat HYOSCYAMINE SULFATE TAB SL 0.125 OSCIMIN SUB 0.125MG Tier 1 Bowel, Intestine and Stomach Conditions MG Gastrointestinal Agents - Drugs to Treat OSCIMIN TAB 0.125MG HYOSCYAMINE SULFATE TAB 0.125 MG Tier 1 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat HYOSCYAMINE SULFATE TAB DISINT OSCIMIN TAB 0.125MG Tier 1 Bowel, Intestine and Stomach Conditions 0.125 MG Gastrointestinal Agents - Drugs to Treat HYOSCYAMINE SULFATE TAB ER 12HR OSCIMIN SR TAB 0.375MG Tier 1 Bowel, Intestine and Stomach Conditions 0.375 MG Gastrointestinal Agents - Drugs to Treat METHSCOPOLAMINE BROMIDE TAB PAMINE TAB 2.5MG Tier 3 Bowel, Intestine and Stomach Conditions 2.5 MG Gastrointestinal Agents - Drugs to Treat *METHSCOPOLAMINE TAB 5 MG & MISC PAMINE FQ KIT Tier 3 Bowel, Intestine and Stomach Conditions INTESTINAL FLORA REG CAP*** Gastrointestinal Agents - Drugs to Treat PANTOPRAZOLE SODIUM EC TAB 20 MG PANTOPRAZOLE TAB 20MG Tier 1 Bowel, Intestine and Stomach Conditions (BASE EQUIV) Gastrointestinal Agents - Drugs to Treat PANTOPRAZOLE SODIUM EC TAB 40 MG PANTOPRAZOLE TAB 40MG Tier 1 Bowel, Intestine and Stomach Conditions (BASE EQUIV) Gastrointestinal Agents - Drugs to Treat PAREGORIC TINCTURE 2 MG/5ML PAREGORIC TIN 2MG/5ML Tier 1 Bowel, Intestine and Stomach Conditions (MORPHINE EQUIVALENT) HCR Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL PEG 3350 POW Preventive Bowel, Intestine and Stomach Conditions POWDER Care Gastrointestinal Agents - Drugs to Treat PEG 3350 POW POLYETHYLENE GLYCOL 3350 POWDER Tier 2 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat PEG 3350 POW POLYETHYLENE GLYCOL 3350 POWDER Tier 3 Bowel, Intestine and Stomach Conditions HCR Gastrointestinal Agents - Drugs to Treat PEG 3350-KCL-NA BICARB-NACL-NA PEG 3350 SOL ELECTROL Preventive Bowel, Intestine and Stomach Conditions SULFATE FOR SOLN 240 GM Care HCR Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL PEG3350 POW Preventive Bowel, Intestine and Stomach Conditions POWDER Care HCR Gastrointestinal Agents - Drugs to Treat PEG 3350-KCL-NA BICARB-NACL-NA PEG-3350 SOL ELECTROL Preventive Bowel, Intestine and Stomach Conditions SULFATE FOR SOLN 236 GM Care HCR Gastrointestinal Agents - Drugs to Treat PEG-3350/KCL SOL / PEG 3350-KCL-SOD BICARB-NACL FOR Preventive Bowel, Intestine and Stomach Conditions SODIUM SOLN 420 GM Care Gastrointestinal Agents - Drugs to Treat BISACODYL TAB & PEG 3350-KCL-SOD PEG-PREP KIT Tier 1 Bowel, Intestine and Stomach Conditions BICARB-NACL FOR SOLN KIT Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL PEGYLAX POW Tier 2 Bowel, Intestine and Stomach Conditions POWDER Gastrointestinal Agents - Drugs to Treat PEPCID SUS 40MG/5ML FAMOTIDINE FOR SUSP 40 MG/5ML Tier 3 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat POLY GLYCOL LIQ 1450 POLYETHYLENE GLYCOL 1450 LIQUID Tier 3 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat POLYETH GLYC OIN 8000 POLYETHYLENE GLYCOL 8000 OINT Tier 3 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat POLYETH GLYC POW 3350 POLYETHYLENE GLYCOL 3350 ORAL Tier 2 Bowel, Intestine and Stomach Conditions NF POWDER Gastrointestinal Agents - Drugs to Treat POLYETH GLYC POW 3350 POLYETHYLENE GLYCOL 3350 ORAL Tier 2 Bowel, Intestine and Stomach Conditions NF PACKET HCR Gastrointestinal Agents - Drugs to Treat POLYETH GLYC POW 3350 POLYETHYLENE GLYCOL 3350 ORAL Preventive Bowel, Intestine and Stomach Conditions NF POWDER Care HCR Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL POWDERLAX POW Preventive Bowel, Intestine and Stomach Conditions POWDER Care Gastrointestinal Agents - Drugs to Treat SOD PICOSULFATE-MG OXIDE-CITRIC PREPOPIK PAK Tier 3 Bowel, Intestine and Stomach Conditions ACID PACK 10 MG-3.5 GM-12 GM LANSOPRAZOLE TAB DELAYED Gastrointestinal Agents - Drugs to Treat PREVACID TAB 15MG STB RELEASE ORALLY DISINTEGRATING 15 Tier 3 X X X Bowel, Intestine and Stomach Conditions MG LANSOPRAZOLE TAB DELAYED Gastrointestinal Agents - Drugs to Treat PREVACID TAB 30MG STB RELEASE ORALLY DISINTEGRATING 30 Tier 3 X X X Bowel, Intestine and Stomach Conditions MG

116 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Gastrointestinal Agents - Drugs to Treat PRODIGEN CAP *PROBIOTIC PRODUCT - CAP** Tier 3 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat PROPANTHELIN TAB 15MG PROPANTHELINE BROMIDE TAB 15 MG Tier 1 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat BISMUTH SUBCIT-METRONIDAZOLE- PYLERA CAP Tier 3 X Bowel, Intestine and Stomach Conditions TETRACYCLINE CAP 140-125-125 MG HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 QC LAXATIVE TAB 5MG EC Preventive Bowel, Intestine and Stomach Conditions MG Care HCR Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL RA LAXATIVE POW Preventive Bowel, Intestine and Stomach Conditions POWDER Care HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 RA LAXATIVE TAB 5MG EC Preventive Bowel, Intestine and Stomach Conditions MG Care Gastrointestinal Agents - Drugs to Treat RABEPRAZOLE TAB 20MG RABEPRAZOLE SODIUM EC TAB 20 MG Tier 3 X Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat RANITIDINE HCL SYRUP 15 MG/ML (75 RANITIDINE SYP 150/10ML Tier 1 Bowel, Intestine and Stomach Conditions MG/5ML) Gastrointestinal Agents - Drugs to Treat RANITIDINE HCL SYRUP 15 MG/ML (75 RANITIDINE SYP 15MG/ML Tier 1 Bowel, Intestine and Stomach Conditions MG/5ML) Gastrointestinal Agents - Drugs to Treat RANITIDINE HCL SYRUP 15 MG/ML (75 RANITIDINE SYP 75MG/5ML Tier 1 Bowel, Intestine and Stomach Conditions MG/5ML) Gastrointestinal Agents - Drugs to Treat METHYLNALTREXONE BROMIDE INJ 12 RELISTOR INJ 12/0.6ML Tier 4 X X Bowel, Intestine and Stomach Conditions MG/0.6ML (20 MG/ML) Gastrointestinal Agents - Drugs to Treat METHYLNALTREXONE BROMIDE INJ 8 RELISTOR INJ 8/0.4ML Tier 4 X X Bowel, Intestine and Stomach Conditions MG/0.4ML (20 MG/ML) Gastrointestinal Agents - Drugs to Treat LACTOBACILLUS CASEI-FOLIC ACID CAP RESTORA RX CAP 60-1.25 Tier 3 Bowel, Intestine and Stomach Conditions 60-1.25 MG Gastrointestinal Agents - Drugs to Treat ROBINUL TAB 1MG GLYCOPYRROLATE TAB 1 MG Tier 3 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat ROBINUL FORT TAB 2MG GLYCOPYRROLATE TAB 2 MG Tier 3 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat SOMATROPIN (NON-REFRIGERATED) SEROSTIM INJ 4MG Tier 4 X X X Bowel, Intestine and Stomach Conditions FOR SUBCUTANEOUS INJ 4 MG Gastrointestinal Agents - Drugs to Treat SOMATROPIN (NON-REFRIGERATED) SEROSTIM INJ 5MG Tier 4 X X X Bowel, Intestine and Stomach Conditions FOR SUBCUTANEOUS INJ 5 MG Gastrointestinal Agents - Drugs to Treat SOMATROPIN (NON-REFRIGERATED) SEROSTIM INJ 6MG Tier 4 X X X Bowel, Intestine and Stomach Conditions FOR SUBCUTANEOUS INJ 6 MG HCR Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL SM CLEARLAX POW Preventive Bowel, Intestine and Stomach Conditions POWDER Care HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 SM GENTLE TAB LAXATIVE Preventive Bowel, Intestine and Stomach Conditions MG Care HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 SM LAXATIVE TAB 5MG EC Preventive Bowel, Intestine and Stomach Conditions MG Care HCR Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL SMOOTH LAX POW Preventive Bowel, Intestine and Stomach Conditions POWDER Care HCR Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL SMOOTH LAX POW 3350 Preventive Bowel, Intestine and Stomach Conditions POWDER Care Gastrointestinal Agents - Drugs to Treat SODIUM POW BICARBON *SODIUM BICARBONATE POWDER** Tier 3 Bowel, Intestine and Stomach Conditions HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 STIM LAXAT TAB 5MG EC Preventive Bowel, Intestine and Stomach Conditions MG Care Gastrointestinal Agents - Drugs to Treat SUCRALFATE TAB 1GM SUCRALFATE TAB 1 GM Tier 1 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat SUPREP BOWEL SOL PREP SODIUM SULFATE-POTASSIUM SULFATE- Tier 3 Bowel, Intestine and Stomach Conditions KIT MAGNESIUM SULFATE ORAL SOLN HCR Gastrointestinal Agents - Drugs to Treat POLYETHYLENE GLYCOL 3350 ORAL SW CLEARLAX POW Preventive Bowel, Intestine and Stomach Conditions POWDER Care Gastrointestinal Agents - Drugs to Treat HYOSCYAMINE SULFATE TAB ER 0.375 SYMAX DUOTAB TAB Tier 3 Bowel, Intestine and Stomach Conditions MG (0.125 MG IR/0.25 MG ER) Gastrointestinal Agents - Drugs to Treat HYOSCYAMINE SULFATE TAB SL 0.125 SYMAX-SL SUB 0.125MG Tier 1 Bowel, Intestine and Stomach Conditions MG Gastrointestinal Agents - Drugs to Treat HYOSCYAMINE SULFATE TAB ER 12HR SYMAX-SR TAB 0.375MG Tier 1 Bowel, Intestine and Stomach Conditions 0.375 MG HCR Gastrointestinal Agents - Drugs to Treat PEG 3350-KCL-SOD BICARB-NACL FOR TRILYTE SOL Preventive Bowel, Intestine and Stomach Conditions SOLN 420 GM Care Gastrointestinal Agents - Drugs to Treat TRULANCE TAB 3MG PLECANATIDE TAB 3 MG Tier 3 X X X Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat URSO 250 TAB 250MG URSODIOL TAB 250 MG Tier 3 Bowel, Intestine and Stomach Conditions

117 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Gastrointestinal Agents - Drugs to Treat URSO FORTE TAB 500MG URSODIOL TAB 500 MG Tier 3 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat URSODIOL CAP 300MG URSODIOL CAP 300 MG Tier 1 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat URSODIOL TAB 250MG URSODIOL TAB 250 MG Tier 1 Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat URSODIOL TAB 500MG URSODIOL TAB 500 MG Tier 1 Bowel, Intestine and Stomach Conditions HCR Gastrointestinal Agents - Drugs to Treat BISACODYL TAB DELAYED RELEASE 5 VERCOLATE TAB 5MG EC Preventive Bowel, Intestine and Stomach Conditions MG Care Gastrointestinal Agents - Drugs to Treat VIBERZI TAB 100MG ELUXADOLINE TAB 100 MG Tier 4 X X Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat VIBERZI TAB 75MG ELUXADOLINE TAB 75 MG Tier 4 X X Bowel, Intestine and Stomach Conditions HCR Gastrointestinal Agents - Drugs to Treat WOMANS LAXAT TAB 5MG BISACODYL TAB DELAYED RELEASE 5 Preventive Bowel, Intestine and Stomach Conditions EC MG Care HCR Gastrointestinal Agents - Drugs to Treat WOMENS LAXAT TAB 5MG BISACODYL TAB DELAYED RELEASE 5 Preventive Bowel, Intestine and Stomach Conditions EC MG Care Gastrointestinal Agents - Drugs to Treat XENICAL CAP 120MG ORLISTAT CAP 120 MG Tier 3 X Bowel, Intestine and Stomach Conditions Gastrointestinal Agents - Drugs to Treat TELOTRISTAT ETIPRATE TAB 250 MG XERMELO TAB 250MG Tier 3 X X X Bowel, Intestine and Stomach Conditions (TELOTRISTAT ETHYL EQUIV) Gastrointestinal Agents - Drugs to Treat SOMATROPIN (NON-REFRIGERATED) ZORBTIVE INJ 8.8MG Tier 3 X X X Bowel, Intestine and Stomach Conditions FOR SUBCUTANEOUS INJ 8.8 MG Genitourinary Agents - Drugs to Treat ALFUZOSIN TAB 10MG ER ALFUZOSIN HCL TAB ER 24HR 10 MG Tier 1 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat FERRIC CITRATE TAB 1 GM (210 MG AURYXIA TAB 210MG Tier 3 Bladder, Genital and Kidney Conditions FERRIC IRON) Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOSC-METH BLUE- AZUPHEN MB CAP 120MG Tier 1 Bladder, Genital and Kidney Conditions SOD PHOS-PHEN SAL CAP 120 MG*** Genitourinary Agents - Drugs to Treat BETHANECHOL TAB 10MG BETHANECHOL CHLORIDE TAB 10 MG Tier 1 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat BETHANECHOL TAB 25MG BETHANECHOL CHLORIDE TAB 25 MG Tier 1 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat BETHANECHOL TAB 50MG BETHANECHOL CHLORIDE TAB 50 MG Tier 1 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat BETHANECHOL TAB 5MG BETHANECHOL CHLORIDE TAB 5 MG Tier 1 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat CALCIUM ACETATE (PHOSPHATE CALC ACETATE CAP 667MG Tier 1 Bladder, Genital and Kidney Conditions BINDER) CAP 667 MG (169 MG CA) Genitourinary Agents - Drugs to Treat CALCIUM ACETATE (PHOSPHATE CALC ACETATE TAB 667MG Tier 1 Bladder, Genital and Kidney Conditions BINDER) TAB 667 MG Genitourinary Agents - Drugs to Treat DOXAZOSIN MESYLATE TAB SR 24 HR 4 CARDURA XL TAB 4MG Tier 3 Bladder, Genital and Kidney Conditions MG (BASE EQUIV) Genitourinary Agents - Drugs to Treat DOXAZOSIN MESYLATE TAB SR 24 HR 8 CARDURA XL TAB 8MG Tier 3 Bladder, Genital and Kidney Conditions MG (BASE EQUIV) Genitourinary Agents - Drugs to Treat CAVERJECT INJ 20MCG ALPROSTADIL FOR INJ 20 MCG Tier 3 X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat CAVERJECT INJ 40MCG ALPROSTADIL FOR INJ 40 MCG Tier 3 X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat CAVERJECT KIT 10MCG ALPROSTADIL FOR INJ KIT 10 MCG Tier 3 X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat CAVERJECT KIT 20MCG ALPROSTADIL FOR INJ KIT 20 MCG Tier 3 X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat CIALIS TAB 10MG TADALAFIL TAB 10 MG Tier 3 X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat CIALIS TAB 2.5MG TADALAFIL TAB 2.5 MG Tier 3 X X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat CIALIS TAB 20MG TADALAFIL TAB 20 MG Tier 3 X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat CIALIS TAB 5MG TADALAFIL TAB 5 MG Tier 3 X X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat DEPEN TITRA TAB 250MG PENICILLAMINE TAB 250 MG Tier 2 X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat OXYBUTYNIN CHLORIDE TAB ER 24HR DITROPAN XL TAB 10MG Tier 3 Bladder, Genital and Kidney Conditions 10 MG Genitourinary Agents - Drugs to Treat OXYBUTYNIN CHLORIDE TAB ER 24HR DITROPAN XL TAB 15MG Tier 3 Bladder, Genital and Kidney Conditions 15 MG Genitourinary Agents - Drugs to Treat OXYBUTYNIN CHLORIDE TAB ER 24HR DITROPAN XL TAB 5MG Tier 3 Bladder, Genital and Kidney Conditions 5 MG Genitourinary Agents - Drugs to Treat DUTASTERIDE CAP 0.5MG DUTASTERIDE CAP 0.5 MG Tier 3 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat EDEX KIT 10MCG ALPROSTADIL FOR INJ KIT 10 MCG Tier 3 X Bladder, Genital and Kidney Conditions

118 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Genitourinary Agents - Drugs to Treat EDEX KIT 20MCG ALPROSTADIL FOR INJ KIT 20 MCG Tier 3 X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat EDEX KIT 40MCG ALPROSTADIL FOR INJ KIT 40 MCG Tier 3 X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat CALCIUM ACETATE (PHOSPHATE ELIPHOS TAB 667MG Tier 1 Bladder, Genital and Kidney Conditions BINDER) TAB 667 MG Genitourinary Agents - Drugs to Treat PENTOSAN POLYSULFATE SODIUM ELMIRON CAP 100MG Tier 2 Bladder, Genital and Kidney Conditions CAPS 100 MG Genitourinary Agents - Drugs to Treat FINASTERIDE TAB 5MG FINASTERIDE TAB 5 MG Tier 1 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat FLAVOXATE TAB 100MG FLAVOXATE HCL TAB 100 MG Tier 1 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat LANTHANUM CARBONATE ORAL FOSRENOL POW 1000MG Tier 3 Bladder, Genital and Kidney Conditions POWDER PACK 1000 MG (ELEMENTAL) Genitourinary Agents - Drugs to Treat LANTHANUM CARBONATE ORAL FOSRENOL POW 750MG Tier 3 Bladder, Genital and Kidney Conditions POWDER PACK 750 MG (ELEMENTAL) Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOSC-METH BLUE- HYOLEV MB TAB 81MG Tier 1 Bladder, Genital and Kidney Conditions SOD PHOS-PHEN SAL TAB 81 MG*** Genitourinary Agents - Drugs to Treat METHENAMINE-HYOSC-METH BLUE- HYOPHEN TAB Tier 1 Bladder, Genital and Kidney Conditions BENZ ACID-PHENYL SAL TAB 81.6MG Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOSCAMINE-METH INDIOMIN MB CAP 120MG Tier 3 Bladder, Genital and Kidney Conditions BLUE-SOD PHOS CAP 120 MG*** Genitourinary Agents - Drugs to Treat LANTHANUM CARBONATE CHEW TAB LANTHANUM CHW 1000MG Tier 3 Bladder, Genital and Kidney Conditions 1000 MG (ELEMENTAL) Genitourinary Agents - Drugs to Treat LANTHANUM CARBONATE CHEW TAB LANTHANUM CHW 500MG Tier 3 Bladder, Genital and Kidney Conditions 500 MG (ELEMENTAL) Genitourinary Agents - Drugs to Treat LANTHANUM CARBONATE CHEW TAB LANTHANUM CHW 750MG Tier 3 Bladder, Genital and Kidney Conditions 750 MG (ELEMENTAL) Genitourinary Agents - Drugs to Treat LEVITRA TAB 10MG VARDENAFIL HCL TAB 10 MG Tier 3 X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat LEVITRA TAB 2.5MG VARDENAFIL HCL TAB 2.5 MG Tier 3 X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat LEVITRA TAB 20MG VARDENAFIL HCL TAB 20 MG Tier 3 X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat LEVITRA TAB 5MG VARDENAFIL HCL TAB 5 MG Tier 3 X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat LITHOSTAT TAB 250MG ACETOHYDROXAMIC ACID TAB 250 MG Tier 3 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOSCAMINE-METH ME/NAPHOS/MB TAB HYO 1 Tier 1 Bladder, Genital and Kidney Conditions BLUE-SOD PHOS TAB 81.6 MG*** Genitourinary Agents - Drugs to Treat ALPROSTADIL URETHRAL PELLET 1000 MUSE SUP 1000MCG Tier 3 X Bladder, Genital and Kidney Conditions MCG Genitourinary Agents - Drugs to Treat ALPROSTADIL URETHRAL PELLET 125 MUSE SUP 125MCG Tier 3 X Bladder, Genital and Kidney Conditions MCG Genitourinary Agents - Drugs to Treat ALPROSTADIL URETHRAL PELLET 250 MUSE SUP 250MCG Tier 3 X Bladder, Genital and Kidney Conditions MCG Genitourinary Agents - Drugs to Treat ALPROSTADIL URETHRAL PELLET 500 MUSE SUP 500MCG Tier 3 X Bladder, Genital and Kidney Conditions MCG Genitourinary Agents - Drugs to Treat OXYBUTYNIN CHLORIDE SYRUP 5 OXYBUTYNIN SYP 5MG/5ML Tier 1 Bladder, Genital and Kidney Conditions MG/5ML Genitourinary Agents - Drugs to Treat OXYBUTYNIN CHLORIDE TAB ER 24HR OXYBUTYNIN TAB 10MG ER Tier 2 Bladder, Genital and Kidney Conditions 10 MG Genitourinary Agents - Drugs to Treat OXYBUTYNIN CHLORIDE TAB ER 24HR OXYBUTYNIN TAB 15MG ER Tier 2 Bladder, Genital and Kidney Conditions 15 MG Genitourinary Agents - Drugs to Treat OXYBUTYNIN TAB 5MG OXYBUTYNIN CHLORIDE TAB 5 MG Tier 1 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat OXYBUTYNIN CHLORIDE TAB ER 24HR OXYBUTYNIN TAB 5MG ER Tier 2 Bladder, Genital and Kidney Conditions 5 MG Genitourinary Agents - Drugs to Treat PHENAZO TAB 200MG PHENAZOPYRIDINE HCL TAB 200 MG Tier 1 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat PHENAZOPYRID TAB 100MG PHENAZOPYRIDINE HCL TAB 100 MG Tier 1 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat PHENAZOPYRID TAB 200MG PHENAZOPYRIDINE HCL TAB 200 MG Tier 1 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat CALCIUM ACETATE (PHOSPHATE PHOSLYRA SOL Tier 3 Bladder, Genital and Kidney Conditions BINDER) ORAL SOLN 667 MG/5ML Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOS-METH BLUE-SOD PHOSPHASAL TAB Tier 1 Bladder, Genital and Kidney Conditions PHOS-PHEN SAL TAB 81.6 MG*** Genitourinary Agents - Drugs to Treat PROSCAR TAB 5MG FINASTERIDE TAB 5 MG Tier 3 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat PYRIDIUM TAB 100MG PHENAZOPYRIDINE HCL TAB 100 MG Tier 3 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat PYRIDIUM TAB 200MG PHENAZOPYRIDINE HCL TAB 200 MG Tier 3 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat RAPAFLO CAP 4MG SILODOSIN CAP 4 MG Tier 3 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat RAPAFLO CAP 8MG SILODOSIN CAP 8 MG Tier 3 Bladder, Genital and Kidney Conditions

119 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Genitourinary Agents - Drugs to Treat RENAGEL TAB 400MG SEVELAMER HCL TAB 400 MG Tier 3 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat RENAGEL TAB 800MG SEVELAMER HCL TAB 800 MG Tier 3 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat SEVELAMER CARBONATE PACKET 0.8 RENVELA PAK 0.8GM Tier 3 Bladder, Genital and Kidney Conditions GM Genitourinary Agents - Drugs to Treat SEVELAMER CARBONATE PACKET 2.4 RENVELA PAK 2.4GM Tier 3 Bladder, Genital and Kidney Conditions GM Genitourinary Agents - Drugs to Treat RENVELA TAB 800MG SEVELAMER CARBONATE TAB 800 MG Tier 3 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat SEVELAMER CARBONATE PACKET 0.8 SEVELAMER POW 0.8GM Tier 2 Bladder, Genital and Kidney Conditions GM Genitourinary Agents - Drugs to Treat SEVELAMER CARBONATE PACKET 2.4 SEVELAMER POW 2.4GM Tier 2 Bladder, Genital and Kidney Conditions GM Genitourinary Agents - Drugs to Treat SEVELAMER TAB 800MG SEVELAMER CARBONATE TAB 800 MG Tier 2 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat SILDENAFIL TAB 100MG SILDENAFIL CITRATE TAB 100 MG Tier 3 X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat SILDENAFIL TAB 25MG SILDENAFIL CITRATE TAB 25 MG Tier 3 X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat SILDENAFIL TAB 50MG SILDENAFIL CITRATE TAB 50 MG Tier 3 X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat STENDRA TAB 100MG AVANAFIL TAB 100 MG Tier 3 X X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat STENDRA TAB 200MG AVANAFIL TAB 200 MG Tier 3 X X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat STENDRA TAB 50MG AVANAFIL TAB 50 MG Tier 3 X X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat TAMSULOSIN CAP 0.4MG TAMSULOSIN HCL CAP 0.4 MG Tier 1 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat TERAZOSIN CAP 10MG TERAZOSIN HCL CAP 10 MG Tier 1 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat TERAZOSIN CAP 1MG TERAZOSIN HCL CAP 1 MG Tier 1 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat TERAZOSIN CAP 2MG TERAZOSIN HCL CAP 2 MG Tier 1 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat TERAZOSIN CAP 5MG TERAZOSIN HCL CAP 5 MG Tier 1 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat THIOLA TAB 100MG TIOPRONIN TAB 100 MG Tier 3 X Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat FESOTERODINE FUMARATE TAB ER TOVIAZ TAB 4MG Tier 3 Bladder, Genital and Kidney Conditions 24HR 4 MG Genitourinary Agents - Drugs to Treat FESOTERODINE FUMARATE TAB ER TOVIAZ TAB 8MG Tier 3 Bladder, Genital and Kidney Conditions 24HR 8 MG Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOS-METH BLUE-SOD UR N-C TAB Tier 1 Bladder, Genital and Kidney Conditions PHOS-PHEN SAL TAB 81.6 MG*** Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOSC-METH BLUE- URAMIT MB CAP 118MG Tier 1 Bladder, Genital and Kidney Conditions SOD PHOS-PHEN SAL CAP 118 MG*** Genitourinary Agents - Drugs to Treat URECHOLINE TAB 10MG BETHANECHOL CHLORIDE TAB 10 MG Tier 3 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat URECHOLINE TAB 25MG BETHANECHOL CHLORIDE TAB 25 MG Tier 3 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat URECHOLINE TAB 50MG BETHANECHOL CHLORIDE TAB 50 MG Tier 3 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat URECHOLINE TAB 5MG BETHANECHOL CHLORIDE TAB 5 MG Tier 3 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOSC-METH BLUE- URELLE TAB Tier 1 Bladder, Genital and Kidney Conditions SOD PHOS-PHEN SAL TAB 81 MG*** Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOS-METH BLUE-SOD URETRON D/S TAB Tier 1 Bladder, Genital and Kidney Conditions PHOS-PHEN SAL TAB 81.6 MG*** Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOSC-METH BLUE- URIBEL CAP 118MG Tier 3 Bladder, Genital and Kidney Conditions SOD PHOS-PHEN SAL CAP 118 MG*** Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOSC-METH BLUE- URIMAR-T TAB Tier 2 Bladder, Genital and Kidney Conditions SOD PHOS-PHEN SAL TAB 120 MG*** Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOS-METH BLUE-SOD URIN D/S TAB Tier 1 Bladder, Genital and Kidney Conditions PHOS-PHEN SAL TAB 81.6 MG*** Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOSC-METH BLUE- URO-458 TAB Tier 1 Bladder, Genital and Kidney Conditions SOD PHOS-PHEN SAL TAB 81 MG*** Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOSC-METH BLUE- UROAV-81 TAB Tier 1 Bladder, Genital and Kidney Conditions SOD PHOS-PHEN SAL TAB 81 MG*** Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOSC-METH BLUE- UROAV-B CAP Tier 1 Bladder, Genital and Kidney Conditions SOD PHOS-PHEN SAL CAP 118 MG*** Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOSCAMINE-METH UROGESIC- TAB BLUE Tier 3 Bladder, Genital and Kidney Conditions BLUE-SOD PHOS TAB 81.6 MG*** Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOSCAMINE-METH UROLET MB TAB Tier 1 Bladder, Genital and Kidney Conditions BLUE-SOD PHOS TAB 81.6 MG*** Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOSC-METH BLUE- URO-MP CAP 118MG Tier 1 Bladder, Genital and Kidney Conditions SOD PHOS-PHEN SAL CAP 118 MG***

120 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Genitourinary Agents - Drugs to Treat METHENAMINE-HYOSC-METH BLUE- UROPHEN MB TAB 81.6MG Tier 1 Bladder, Genital and Kidney Conditions BENZ ACID-PHENYL SAL TAB 81.6MG Genitourinary Agents - Drugs to Treat UROXATRAL TAB 10MG ALFUZOSIN HCL TAB ER 24HR 10 MG Tier 4 Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOSCAMINE-METH URYL TAB Tier 2 Bladder, Genital and Kidney Conditions BLUE-SOD PHOS TAB 81.6 MG*** Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOSC-METH BLUE- USTELL CAP Tier 1 Bladder, Genital and Kidney Conditions SOD PHOS-PHEN SAL CAP 120 MG*** Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOSCAMINE-METH UTA CAP 120MG Tier 3 Bladder, Genital and Kidney Conditions BLUE-SOD PHOS CAP 120 MG*** Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOSC-METH BLUE- UTICAP CAP Tier 1 Bladder, Genital and Kidney Conditions SOD PHOS-PHEN SAL CAP 120 MG*** Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOS-METH BLUE-SOD UTIRA-C TAB Tier 1 Bladder, Genital and Kidney Conditions PHOS-PHEN SAL TAB 81.6 MG*** Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOS-METH BLUE-SOD UTRONA-C TAB Tier 1 Bladder, Genital and Kidney Conditions PHOS-PHEN SAL TAB 81.6 MG*** Genitourinary Agents - Drugs to Treat SUCROFERRIC OXYHYDROXIDE CHEW VELPHORO CHW 500MG Tier 2 Bladder, Genital and Kidney Conditions TAB 500 MG Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOSC-METH BLUE- VILAMIT MB CAP 118MG Tier 1 Bladder, Genital and Kidney Conditions SOD PHOS-PHEN SAL CAP 118 MG*** Genitourinary Agents - Drugs to Treat *METHENAMINE-HYOSC-METH BLUE- VILEVEV MB TAB 81MG Tier 1 Bladder, Genital and Kidney Conditions SOD PHOS-PHEN SAL TAB 81 MG*** Hormonal Agents, Stimulant/ ALCLOMETASONE DIPROPIONATE Replacement/Modifying (Adrenal) - ACLOVATE CRE 0.05% Tier 3 CREAM 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - ALA SCALP LOT 2% HYDROCORTISONE LOTION 2% Tier 3 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - ALA-CORT CRE 2.5% HYDROCORTISONE CREAM 2.5% Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ ALCLOMETASONE DIPROPIONATE Replacement/Modifying (Adrenal) - ALCLOMETASON CRE 0.05% Tier 1 CREAM 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ ALCLOMETASONE DIPROPIONATE OINT Replacement/Modifying (Adrenal) - ALCLOMETASON OIN 0.05% Tier 1 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ BETAMETHASONE DIPROPIONATE Replacement/Modifying (Adrenal) - ALPHATREX GEL 0.05% Tier 1 AUGMENTED GEL 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - AMCINONIDE CRE 0.1% AMCINONIDE CREAM 0.1% Tier 3 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - AMCINONIDE LOT 0.1% AMCINONIDE LOTION 0.1% Tier 3 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - AMCINONIDE OIN 0.1% AMCINONIDE OINT 0.1% Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HYDROCORTISONE ACETATE SUPPOS Replacement/Modifying (Adrenal) - ANUCORT-HC SUP 25MG Tier 2 25 MG Drugs to Regulate Hormones Hormonal Agents, Stimulant/ DIFLORASONE DIACETATE EMOLLIENT Replacement/Modifying (Adrenal) - APEXICON E CRE 0.05% Tier 2 X BASE CREAM 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ BETAMETHASONE DIPROPIONATE Replacement/Modifying (Adrenal) - AUG BETAMET CRE 0.05% Tier 1 AUGMENTED CREAM 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ BETAMETHASONE DIPROPIONATE Replacement/Modifying (Adrenal) - AUG BETAMET GEL 0.05% Tier 1 AUGMENTED GEL 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ BETAMETHASONE DIPROPIONATE Replacement/Modifying (Adrenal) - AUG BETAMET LOT 0.05% Tier 3 AUGMENTED LOTION 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ BETAMETHASONE DIPROPIONATE Replacement/Modifying (Adrenal) - AUG BETAMET OIN 0.05% Tier 3 AUGMENTED OINT 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ BETAMETHASONE DIPROPIONATE Replacement/Modifying (Adrenal) - BETAMETH DIP CRE 0.05% Tier 2 CREAM 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ BETAMETHASONE DIPROPIONATE Replacement/Modifying (Adrenal) - BETAMETH DIP LOT 0.05% Tier 1 LOTION 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ BETAMETHASONE DIPROPIONATE OINT Replacement/Modifying (Adrenal) - BETAMETH DIP OIN 0.05% Tier 2 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ BETAMETHASONE VALERATE CREAM Replacement/Modifying (Adrenal) - BETAMETH VAL CRE 0.1% Tier 1 0.1% (BASE EQUIVALENT) Drugs to Regulate Hormones

121 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ BETAMETHASONE VALERATE LOTION Replacement/Modifying (Adrenal) - BETAMETH VAL LOT 0.1% Tier 1 0.1% (BASE EQUIVALENT) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ BETAMETHASONE VALERATE OINT 0.1% Replacement/Modifying (Adrenal) - BETAMETH VAL OIN 0.1% Tier 1 (BASE EQUIVALENT) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ FLUOCINOLONE ACETONIDE SHAMPOO Replacement/Modifying (Adrenal) - CAPEX SHA 0.01% Tier 2 0.01% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ CLOBETASOL PROPIONATE CREAM Replacement/Modifying (Adrenal) - CLOBETASOL CRE 0.05% Tier 2 X 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - CLOBETASOL GEL 0.05% CLOBETASOL PROPIONATE GEL 0.05% Tier 2 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - CLOBETASOL OIN 0.05% CLOBETASOL PROPIONATE OINT 0.05% Tier 2 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - CLOBETASOL SOL 0.05% CLOBETASOL PROPIONATE SOLN 0.05% Tier 1 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ CLOBETASOL PROPIONATE SPRAY Replacement/Modifying (Adrenal) - CLOBETASOL SPR 0.05% Tier 1 X 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ CLOBETASOL PROPIONATE EMOLLIENT Replacement/Modifying (Adrenal) - CLOBETASOL E CRE 0.05% Tier 2 X BASE CREAM 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ CLOBETASOL PROPIONATE SPRAY Replacement/Modifying (Adrenal) - CLOBEX SPR 0.05% Tier 3 X 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ CLOCORTOLONE CRE PIV Replacement/Modifying (Adrenal) - CLOCORTOLONE PIVALATE CREAM 0.1% Tier 3 X X 0.1% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - CORDRAN OIN 0.05% FLURANDRENOLIDE OINT 0.05% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ CORDRAN 24X3 TAP 4MCG/ Replacement/Modifying (Adrenal) - FLURANDRENOLIDE TAPE 4 MCG/SQCM Tier 3 X CM Drugs to Regulate Hormones Hormonal Agents, Stimulant/ CORDRAN 24X3 TAP SML Replacement/Modifying (Adrenal) - FLURANDRENOLIDE TAPE 4 MCG/SQCM Tier 3 X 24IN Drugs to Regulate Hormones Hormonal Agents, Stimulant/ CORDRAN 80X3 TAP 4MCG/ Replacement/Modifying (Adrenal) - FLURANDRENOLIDE TAPE 4 MCG/SQCM Tier 3 X CM Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - CORMAX SCALP SOL 0.05% CLOBETASOL PROPIONATE SOLN 0.05% Tier 1 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - CORTEF TAB 10MG HYDROCORTISONE TAB 10 MG Tier 3 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - CORTEF TAB 20MG HYDROCORTISONE TAB 20 MG Tier 3 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - CORTEF TAB 5MG HYDROCORTISONE TAB 5 MG Tier 3 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HYDROCORTISONE ACETATE RECTAL Replacement/Modifying (Adrenal) - CORTIFOAM AER 90MG Tier 2 FOAM 10% (90 MG/DOSE) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - CORTISONE AC TAB 25MG CORTISONE ACETATE TAB 25 MG Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ FLUTICASONE PROPIONATE CREAM Replacement/Modifying (Adrenal) - CUTIVATE CRE 0.05% Tier 3 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ FLUTICASONE PROPIONATE LOTION Replacement/Modifying (Adrenal) - CUTIVATE LOT 0.05% Tier 3 X X 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - DELTASONE TAB 20MG PREDNISONE TAB 20 MG Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ DERMA-SMOOTH OIL /FS FLUOCINOLONE ACETONIDE OIL 0.01% Replacement/Modifying (Adrenal) - Tier 3 X BODY (BODY OIL) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ DERMA-SMOOTH OIL /FS FLUOCINOLONE ACETONIDE OIL 0.01% Replacement/Modifying (Adrenal) - Tier 3 SCLP (SCALP OIL) Drugs to Regulate Hormones

122 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - DERMATOP CRE 0.1% PREDNICARBATE CREAM 0.1% Tier 3 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - DERMATOP OIN 0.1% PREDNICARBATE OINT 0.1% Tier 3 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - DESONATE GEL 0.05% DESONIDE GEL 0.05% Tier 3 X X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - DESONIDE CRE 0.05% DESONIDE CREAM 0.05% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - DESONIDE LOT 0.05% DESONIDE LOTION 0.05% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - DESONIDE OIN 0.05% DESONIDE OINT 0.05% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - DESOWEN CRE 0.05% DESONIDE CREAM 0.05% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - DESOWEN LOT 0.05% DESONIDE LOTION 0.05% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - DESOXIMETAS CRE 0.05% DESOXIMETASONE CREAM 0.05% Tier 1 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - DESOXIMETAS CRE 0.25% DESOXIMETASONE CREAM 0.25% Tier 1 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - DESOXIMETAS GEL 0.05% DESOXIMETASONE GEL 0.05% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - DESOXIMETAS OIN 0.05% DESOXIMETASONE OINT 0.05% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - DESOXIMETAS OIN 0.25% DESOXIMETASONE OINT 0.25% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ DEXAMETHASON CON Replacement/Modifying (Adrenal) - DEXAMETHASONE CONC 1 MG/ML Tier 1 1MG/ML Drugs to Regulate Hormones Hormonal Agents, Stimulant/ DEXAMETHASON ELX Replacement/Modifying (Adrenal) - DEXAMETHASONE ELIXIR 0.5 MG/5ML Tier 1 0.5/5ML Drugs to Regulate Hormones Hormonal Agents, Stimulant/ DEXAMETHASON SOL Replacement/Modifying (Adrenal) - DEXAMETHASONE SOLN 0.5 MG/5ML Tier 1 0.5/5ML Drugs to Regulate Hormones Hormonal Agents, Stimulant/ DEXAMETHASON TAB Replacement/Modifying (Adrenal) - DEXAMETHASONE TAB 0.5 MG Tier 1 0.5MG Drugs to Regulate Hormones Hormonal Agents, Stimulant/ DEXAMETHASON TAB Replacement/Modifying (Adrenal) - DEXAMETHASONE TAB 0.75 MG Tier 1 0.75MG Drugs to Regulate Hormones Hormonal Agents, Stimulant/ DEXAMETHASON TAB Replacement/Modifying (Adrenal) - DEXAMETHASONE TAB 1.5 MG Tier 1 1.5MG Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - DEXAMETHASON TAB 1MG DEXAMETHASONE TAB 1 MG Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - DEXAMETHASON TAB 2MG DEXAMETHASONE TAB 2 MG Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - DEXAMETHASON TAB 4MG DEXAMETHASONE TAB 4 MG Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - DEXAMETHASON TAB 6MG DEXAMETHASONE TAB 6 MG Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ DEXAMETHASONE TAB THERAPY PACK Replacement/Modifying (Adrenal) - DEXPAK PAK 10 DAY Tier 3 1.5 MG (35) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ DEXAMETHASONE TAB THERAPY PACK Replacement/Modifying (Adrenal) - DEXPAK PAK 13 DAY Tier 3 1.5 MG (51) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ DEXAMETHASONE TAB THERAPY PACK Replacement/Modifying (Adrenal) - DEXPAK PAK 6 DAY Tier 3 1.5 MG (21) Drugs to Regulate Hormones

123 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - DIFLORASONE CRE 0.05% DIFLORASONE DIACETATE CREAM 0.05% Tier 3 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - DIFLORASONE OIN 0.05% DIFLORASONE DIACETATE OINT 0.05% Tier 3 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ BETAMETHASONE DIPROPIONATE Replacement/Modifying (Adrenal) - DIPROLENE LOT 0.05% Tier 3 AUGMENTED LOTION 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ BETAMETHASONE DIPROPIONATE Replacement/Modifying (Adrenal) - DIPROLENE OIN 0.05% Tier 3 AUGMENTED OINT 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ BETAMETHASONE DIPROPIONATE Replacement/Modifying (Adrenal) - DIPROLENE AF CRE 0.05% Tier 3 AUGMENTED CREAM 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - ELOCON CRE 0.1% MOMETASONE FUROATE CREAM 0.1% Tier 3 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ MOMETASONE FUROATE SOLUTION Replacement/Modifying (Adrenal) - ELOCON LOT 0.1% Tier 3 0.1% (LOTION) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - ELOCON OIN 0.1% MOMETASONE FUROATE OINT 0.1% Tier 3 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ FLUDROCORTISONE ACETATE TAB 0.1 Replacement/Modifying (Adrenal) - FLUDROCORT TAB 0.1MG Tier 1 MG Drugs to Regulate Hormones Hormonal Agents, Stimulant/ FLUOCINOLONE ACETONIDE CREAM Replacement/Modifying (Adrenal) - FLUOCIN ACET CRE 0.01% Tier 3 X 0.01% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ FLUOCINOLONE ACETONIDE CREAM Replacement/Modifying (Adrenal) - FLUOCIN ACET CRE 0.025% Tier 3 X 0.025% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ FLUOCINOLONE ACETONIDE OIL 0.01% Replacement/Modifying (Adrenal) - FLUOCIN ACET OIL 0.01% SC Tier 3 (SCALP OIL) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ FLUOCIN ACET OIL FLUOCINOLONE ACETONIDE OIL 0.01% Replacement/Modifying (Adrenal) - Tier 3 X 0.01%BDY (BODY OIL) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ FLUOCINOLONE ACETONIDE OIL 0.01% Replacement/Modifying (Adrenal) - FLUOCIN ACET OIL BODY Tier 3 X (BODY OIL) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ FLUOCINOLONE ACETONIDE OIL 0.01% Replacement/Modifying (Adrenal) - FLUOCIN ACET OIL SCALP Tier 3 (SCALP OIL) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ FLUOCINOLONE ACETONIDE OINT Replacement/Modifying (Adrenal) - FLUOCIN ACET OIN 0.025% Tier 2 X 0.025% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ FLUOCINOLONE ACETONIDE SOLN Replacement/Modifying (Adrenal) - FLUOCIN ACET SOL 0.01% Tier 3 X 0.01% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - FLUOCINONIDE CRE 0.05% FLUOCINONIDE CREAM 0.05% Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ FLUOCINONIDE EMULSIFIED BASE Replacement/Modifying (Adrenal) - FLUOCINONIDE CRE E 0.05% Tier 1 CREAM 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - FLUOCINONIDE GEL 0.05% FLUOCINONIDE GEL 0.05% Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - FLUOCINONIDE OIN 0.05% FLUOCINONIDE OINT 0.05% Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - FLUOCINONIDE SOL 0.05% FLUOCINONIDE SOLN 0.05% Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - FLURANDRENOL CRE 0.05% FLURANDRENOLIDE CREAM 0.05% Tier 3 X X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - FLURANDRENOL LOT 0.05% FLURANDRENOLIDE LOTION 0.05% Tier 3 X X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - FLURANDRENOL OIN 0.05% FLURANDRENOLIDE OINT 0.05% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ FLUTICASONE PROPIONATE CREAM Replacement/Modifying (Adrenal) - FLUTICASONE CRE 0.05% Tier 1 0.05% Drugs to Regulate Hormones

124 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ FLUTICASONE PROPIONATE LOTION Replacement/Modifying (Adrenal) - FLUTICASONE LOT 0.05% Tier 3 X X 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ FLUTICASONE PROPIONATE OINT Replacement/Modifying (Adrenal) - FLUTICASONE OIN 0.005% Tier 1 0.005% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HALOBETASOL PROPIONATE CREAM Replacement/Modifying (Adrenal) - HALOBETASOL CRE 0.05% Tier 2 X 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - HALOBETASOL OIN 0.05% HALOBETASOL PROPIONATE OINT 0.05% Tier 2 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - HALOG CRE 0.1% HALCINONIDE CREAM 0.1% Tier 3 X X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - HALOG OIN 0.1% HALCINONIDE OINT 0.1% Tier 3 X X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HYDROCORTISONE BUTYRATE CREAM Replacement/Modifying (Adrenal) - HC BUTYRATE CRE 0.1% Tier 1 0.1% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HYDROCORTISONE BUTYRATE OINT Replacement/Modifying (Adrenal) - HC BUTYRATE OIN 0.1% Tier 1 0.1% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HYDROCORTISONE BUTYRATE SOLN Replacement/Modifying (Adrenal) - HC BUTYRATE SOL 0.1% Tier 1 0.1% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HYDROCORTISONE VALERATE CREAM Replacement/Modifying (Adrenal) - HC VALERATE CRE 0.2% Tier 3 X 0.2% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HYDROCORTISONE VALERATE OINT Replacement/Modifying (Adrenal) - HC VALERATE OIN 0.2% Tier 3 X 0.2% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HYDROCORTISONE ACETATE SUPPOS Replacement/Modifying (Adrenal) - HEMMOREX-HC SUP 25MG Tier 2 25 MG Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HYDROCORTISONE ACETATE SUPPOS Replacement/Modifying (Adrenal) - HEMMOREX-HC SUP 30MG Tier 2 30 MG Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HEMORRHOIDAL SUP -HC HYDROCORTISONE ACETATE SUPPOS Replacement/Modifying (Adrenal) - Tier 2 25MG 25 MG Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - HYDROCORT CRE 2.5% HYDROCORTISONE CREAM 2.5% Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - HYDROCORT LOT 2.5% HYDROCORTISONE LOTION 2.5% Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - HYDROCORT OIN 1% HYDROCORTISONE OINT 1% Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - HYDROCORT OIN 2.5% HYDROCORTISONE OINT 2.5% Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - HYDROCORT TAB 10MG HYDROCORTISONE TAB 10 MG Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - HYDROCORT TAB 20MG HYDROCORTISONE TAB 20 MG Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - HYDROCORT TAB 5MG HYDROCORTISONE TAB 5 MG Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HYDROCORTISONE ACETATE SUPPOS Replacement/Modifying (Adrenal) - HYDROCORT AC SUP 25MG Tier 2 25 MG Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HYDROCORTISONE ACETATE SUPPOS Replacement/Modifying (Adrenal) - HYDROCORT AC SUP 30MG Tier 2 30 MG Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - HYDROCORT/AB OIN 1% HYDROCORTISONE OINT 1% Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HYDROSORTISO OIN Replacement/Modifying (Adrenal) - HYDROCORTISONE OINT 1% Tier 1 ABSORBAS Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HYDROCORTISONE BUTYRATE CREAM Replacement/Modifying (Adrenal) - LOCOID CRE 0.1% Tier 3 0.1% Drugs to Regulate Hormones

125 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ HYDROCORTISONE BUTYRATE OINT Replacement/Modifying (Adrenal) - LOCOID OIN 0.1% Tier 3 0.1% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HYDROCORTISONE BUTYRATE SOLN Replacement/Modifying (Adrenal) - LOCOID SOL 0.1% Tier 3 0.1% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - LOKARA LOT 0.05% DESONIDE LOTION 0.05% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - MEDROL TAB 16MG METHYLPREDNISOLONE TAB 16 MG Tier 3 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - MEDROL TAB 2MG METHYLPREDNISOLONE TAB 2 MG Tier 2 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - MEDROL TAB 32MG METHYLPREDNISOLONE TAB 32 MG Tier 3 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - MEDROL TAB 4MG METHYLPREDNISOLONE TAB 4 MG Tier 3 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ METHYLPREDNISOLONE TAB THERAPY Replacement/Modifying (Adrenal) - MEDROL TAB 4MG Tier 3 PACK 4 MG (21) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - MEDROL TAB 8MG METHYLPREDNISOLONE TAB 8 MG Tier 3 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - MERCAPTOPURI POW MERCAPTOPURINE (BULK) POWDER Tier 3 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ METHYLPRED POW METHYLPREDNISOLONE ACETATE Replacement/Modifying (Adrenal) - Tier 3 ACETATE POWDER Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - METHYLPRED TAB 16MG METHYLPREDNISOLONE TAB 16 MG Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - METHYLPRED TAB 32MG METHYLPREDNISOLONE TAB 32 MG Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - METHYLPRED TAB 4MG METHYLPREDNISOLONE TAB 4 MG Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ METHYLPREDNISOLONE TAB THERAPY Replacement/Modifying (Adrenal) - METHYLPRED TAB 4MG Tier 1 PACK 4 MG (21) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - METHYLPRED TAB 8MG METHYLPREDNISOLONE TAB 8 MG Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PREDNISOLONE SOD PHOSPHATE ORAL Replacement/Modifying (Adrenal) - MILLIPRED SOL 10MG/5ML Tier 1 SOLN 10 MG/5ML (BASE EQUIV) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - MILLIPRED TAB 5MG PREDNISOLONE TAB 5 MG Tier 2 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PREDNISOLONE TAB THERAPY PACK 5 Replacement/Modifying (Adrenal) - MILLIPRED DP PAK 5MG Tier 2 MG (48) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PREDNISOLONE TAB THERAPY PACK 5 Replacement/Modifying (Adrenal) - MILLIPRED DP PAK 5MG Tier 2 MG (21) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - MOMETASONE CRE 0.1% MOMETASONE FUROATE CREAM 0.1% Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - MOMETASONE OIN 0.1% MOMETASONE FUROATE OINT 0.1% Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ MOMETASONE FUROATE SOLUTION Replacement/Modifying (Adrenal) - MOMETASONE SOL 0.1% Tier 1 0.1% (LOTION) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - NOLIX CRE 0.05% FLURANDRENOLIDE CREAM 0.05% Tier 3 X X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - NOLIX LOT 0.05% FLURANDRENOLIDE LOTION 0.05% Tier 3 X X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HYDROCORTISONE ACETATE LOTION Replacement/Modifying (Adrenal) - NUCORT LOT 2% Tier 3 2% Drugs to Regulate Hormones

126 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ PREDNISOLONE SOD PHOS ORALLY Replacement/Modifying (Adrenal) - ORAPRED ODT TAB 10MG Tier 3 DISINTEGR TAB 10 MG (BASE EQ) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PREDNISOLONE SOD PHOS ORALLY Replacement/Modifying (Adrenal) - ORAPRED ODT TAB 15MG Tier 3 DISINTEGR TAB 15 MG (BASE EQ) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PREDNISOLONE SOD PHOS ORALLY Replacement/Modifying (Adrenal) - ORAPRED ODT TAB 30MG Tier 3 DISINTEGR TAB 30 MG (BASE EQ) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HYDROCORTISONE PROBUTATE CREAM Replacement/Modifying (Adrenal) - PANDEL CRE 0.1% Tier 3 0.1% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PREDNISOLONE SOD PHOSPH ORAL Replacement/Modifying (Adrenal) - PEDIAPRED SOL 6.7/5ML Tier 2 SOLN 6.7 MG/5ML (5 MG/5ML BASE) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PRED SOD PHO SOL PREDNISOLONE SOD PHOSPH ORAL Replacement/Modifying (Adrenal) - Tier 1 5MG/5ML SOLN 6.7 MG/5ML (5 MG/5ML BASE) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - PREDNICARBAT CRE 0.1% PREDNICARBATE CREAM 0.1% Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - PREDNICARBAT OIN 0.1% PREDNICARBATE OINT 0.1% Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PREDNISOLONE SOL PREDNISOLONE SOD PHOSPHATE ORAL Replacement/Modifying (Adrenal) - Tier 1 10MG/5ML SOLN 10 MG/5ML (BASE EQUIV) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PREDNISOLONE SOL PREDNISOLONE SYRUP 15 MG/5ML Replacement/Modifying (Adrenal) - Tier 1 15MG/5ML (USP SOLUTION EQUIVALENT) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PREDNISOLONE SOL PREDNISOLONE SOD PHOSPHATE ORAL Replacement/Modifying (Adrenal) - Tier 1 15MG/5ML SOLN 15 MG/5ML (BASE EQUIV) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PREDNISOLONE SOL PREDNISOLONE SOD PHOSPHATE ORAL Replacement/Modifying (Adrenal) - Tier 1 20MG/5ML SOLN 20 MG/5ML (BASE EQUIV) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PREDNISOLONE SOL PREDNISOLONE SODIUM PHOSPHATE Replacement/Modifying (Adrenal) - Tier 3 25MG/5ML ORAL SOLN 25 MG/5ML (BASE EQ) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PREDNISOLONE SOL PREDNISOLONE SODIUM PHOSPHATE Replacement/Modifying (Adrenal) - Tier 1 25MG/5ML ORAL SOLN 25 MG/5ML (BASE EQ) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PREDNISOLONE SYP PREDNISOLONE SYRUP 15 MG/5ML Replacement/Modifying (Adrenal) - Tier 1 15MG/5ML (USP SOLUTION EQUIVALENT) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PREDNISOLONE TAB 10MG PREDNISOLONE SOD PHOS ORALLY Replacement/Modifying (Adrenal) - Tier 1 ODT DISINTEGR TAB 10 MG (BASE EQ) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PREDNISOLONE TAB 15MG PREDNISOLONE SOD PHOS ORALLY Replacement/Modifying (Adrenal) - Tier 1 ODT DISINTEGR TAB 15 MG (BASE EQ) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PREDNISOLONE TAB 30MG PREDNISOLONE SOD PHOS ORALLY Replacement/Modifying (Adrenal) - Tier 1 ODT DISINTEGR TAB 30 MG (BASE EQ) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - PREDNISONE CON 5MG/ML PREDNISONE CONC 5 MG/ML Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PREDNISONE TAB THERAPY PACK 10 Replacement/Modifying (Adrenal) - PREDNISONE PAK 10MG Tier 1 MG (21) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PREDNISONE TAB THERAPY PACK 10 Replacement/Modifying (Adrenal) - PREDNISONE PAK 10MG Tier 1 MG (48) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PREDNISONE TAB THERAPY PACK 5 Replacement/Modifying (Adrenal) - PREDNISONE PAK 5MG Tier 1 MG (21) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ PREDNISONE TAB THERAPY PACK 5 Replacement/Modifying (Adrenal) - PREDNISONE PAK 5MG Tier 1 MG (48) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - PREDNISONE SOL 5MG/5ML PREDNISONE ORAL SOLN 5 MG/5ML Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - PREDNISONE TAB 10MG PREDNISONE TAB 10 MG Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - PREDNISONE TAB 1MG PREDNISONE TAB 1 MG Tier 1 Drugs to Regulate Hormones

127 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - PREDNISONE TAB 2.5MG PREDNISONE TAB 2.5 MG Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - PREDNISONE TAB 20MG PREDNISONE TAB 20 MG Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - PREDNISONE TAB 50MG PREDNISONE TAB 50 MG Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - PREDNISONE TAB 5MG PREDNISONE TAB 5 MG Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - PSORCON CRE 0.05% DIFLORASONE DIACETATE CREAM 0.05% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - SCALACORT LOT 2% HYDROCORTISONE LOTION 2% Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ CLOBETASOL PROPIONATE CREAM Replacement/Modifying (Adrenal) - TEMOVATE CRE 0.05% Tier 3 X 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - TEMOVATE GEL 0.05% CLOBETASOL PROPIONATE GEL 0.05% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - TEMOVATE OIN 0.05% CLOBETASOL PROPIONATE OINT 0.05% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - TEMOVATE SOL 0.05% CLOBETASOL PROPIONATE SOLN 0.05% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ CLOBETASOL PROPIONATE EMOLLIENT Replacement/Modifying (Adrenal) - TEMOVATE E CRE 0.05%EML Tier 3 X BASE CREAM 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - TEXACORT SOL 2.5% HYDROCORTISONE SOLN 2.5% Tier 2 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - TOPICORT CRE 0.05% DESOXIMETASONE CREAM 0.05% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - TOPICORT CRE 0.25% DESOXIMETASONE CREAM 0.25% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - TOPICORT GEL 0.05% DESOXIMETASONE GEL 0.05% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - TOPICORT OIN 0.05% DESOXIMETASONE OINT 0.05% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - TOPICORT OIN 0.25% DESOXIMETASONE OINT 0.25% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ TRIAMCINOLONE ACETONIDE AEROSOL Replacement/Modifying (Adrenal) - TRIAMCINOLON AER SPRAY Tier 2 SOLN 0.147 MG/GM Drugs to Regulate Hormones Hormonal Agents, Stimulant/ TRIAMCINOLONE ACETONIDE CREAM Replacement/Modifying (Adrenal) - TRIAMCINOLON CRE 0.025% Tier 1 0.025% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ TRIAMCINOLONE ACETONIDE CREAM Replacement/Modifying (Adrenal) - TRIAMCINOLON CRE 0.1% Tier 1 0.1% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ TRIAMCINOLONE ACETONIDE CREAM Replacement/Modifying (Adrenal) - TRIAMCINOLON CRE 0.5% Tier 1 0.5% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ TRIAMCINOLONE ACETONIDE LOTION Replacement/Modifying (Adrenal) - TRIAMCINOLON LOT 0.025% Tier 1 0.025% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ TRIAMCINOLONE ACETONIDE LOTION Replacement/Modifying (Adrenal) - TRIAMCINOLON LOT 0.1% Tier 1 0.1% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ TRIAMCINOLONE ACETONIDE OINT Replacement/Modifying (Adrenal) - TRIAMCINOLON OIN 0.025% Tier 1 0.025% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - TRIAMCINOLON OIN 0.1% TRIAMCINOLONE ACETONIDE OINT 0.1% Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - TRIAMCINOLON OIN 0.5% TRIAMCINOLONE ACETONIDE OINT 0.5% Tier 1 Drugs to Regulate Hormones

128 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ TRIAMCINOLONE ACETONIDE CREAM Replacement/Modifying (Adrenal) - TRIDERM CRE 0.1% Tier 1 0.1% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ TRIAMCINOLONE ACETONIDE CREAM Replacement/Modifying (Adrenal) - TRIDERM CRE 0.5% Tier 1 0.5% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - TRIDESILON CRE 0.05% DESONIDE CREAM 0.05% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HALOBETASOL PROPIONATE CREAM Replacement/Modifying (Adrenal) - ULTRAVATE CRE 0.05% Tier 3 X 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HALOBETASOL PROPIONATE LOTION Replacement/Modifying (Adrenal) - ULTRAVATE LOT 0.05% Tier 3 X X X 0.05% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Adrenal) - ULTRAVATE OIN 0.05% HALOBETASOL PROPIONATE OINT 0.05% Tier 3 X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ VERIPRED 20 SOL PREDNISOLONE SOD PHOSPHATE ORAL Replacement/Modifying (Adrenal) - Tier 1 20MG/5ML SOLN 20 MG/5ML (BASE EQUIV) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HYDROCORTISONE VALERATE OINT Replacement/Modifying (Adrenal) - WESTCORT OIN 0.2% Tier 3 X 0.2% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) - DDAVP INJ 4MCG/ML DESMOPRESSIN ACETATE INJ 4 MCG/ML Tier 3 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ DESMOPRESSIN ACETATE NASAL SOLN Replacement/Modifying (Pituitary) - DDAVP SOL 0.01% Tier 3 0.01% (REFRIGERATED) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ DESMOPRESSIN ACETATE NASAL SPRAY Replacement/Modifying (Pituitary) - DDAVP SPR 0.01% Tier 3 SOLN 0.01% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) - DDAVP TAB 0.1MG DESMOPRESSIN ACETATE TAB 0.1 MG Tier 3 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) - DDAVP TAB 0.2MG DESMOPRESSIN ACETATE TAB 0.2 MG Tier 3 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ DESMOPRESSIN INJ 4MCG/ Replacement/Modifying (Pituitary) - DESMOPRESSIN ACETATE INJ 4 MCG/ML Tier 1 ML Drugs to Regulate Hormones Hormonal Agents, Stimulant/ DESMOPRESSIN ACETATE NASAL SOLN Replacement/Modifying (Pituitary) - DESMOPRESSIN SOL 0.01% Tier 1 0.01% (REFRIGERATED) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ DESMOPRESSIN ACETATE NASAL SPRAY Replacement/Modifying (Pituitary) - DESMOPRESSIN SPR 0.01% Tier 1 SOLN 0.01% (REFRIGERATED) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ DESMOPRESSIN ACETATE NASAL SPRAY Replacement/Modifying (Pituitary) - DESMOPRESSIN SPR 0.01% Tier 1 SOLN 0.01% Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) - DESMOPRESSIN TAB 0.1MG DESMOPRESSIN ACETATE TAB 0.1 MG Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) - DESMOPRESSIN TAB 0.2MG DESMOPRESSIN ACETATE TAB 0.2 MG Tier 1 Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) - H.P. ACTHAR INJ 80UNIT CORTICOTROPIN INJ GEL 80 UNIT/ML Tier 4 X X X X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ MECASERMIN INJ 40 MG/4ML (10 MG/ Replacement/Modifying (Pituitary) - INCRELEX INJ 40MG/4ML Tier 2 X X X ML) Drugs to Regulate Hormones Hormonal Agents, Stimulant/ NUTROPIN AQ INJ Replacement/Modifying (Pituitary) - SOMATROPIN INJ 10 MG/2ML Tier 2 X X X 10MG/2ML Drugs to Regulate Hormones Hormonal Agents, Stimulant/ NUTROPIN AQ INJ Replacement/Modifying (Pituitary) - SOMATROPIN INJ 20 MG/2ML Tier 2 X X X 20MG/2ML Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) - NUTROPIN AQ INJ NUSPIN 5 SOMATROPIN INJ 5 MG/2ML Tier 2 X X X Drugs to Regulate Hormones Hormonal Agents, Stimulant/ DESMOPRESSIN ACETATE NASAL SOLN Replacement/Modifying (Pituitary) - STIMATE SOL 1.5MG/ML Tier 3 1.5 MG/ML Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Prostaglandins) KORLYM TAB 300MG MIFEPRISTONE TAB 300 MG Tier 3 X X - Drugs to Regulate Hormones

129 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL & NORETHINDRONE ACTIVELLA TAB 0.5-0.1 Tier 3 Hormones/Modifiers) - Drugs to Regulate ACETATE TAB 0.5-0.1 MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL & NORETHINDRONE ACTIVELLA TAB 1-0.5MG Tier 3 Hormones/Modifiers) - Drugs to Regulate ACETATE TAB 1-0.5 MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH TWICE WEEKLY ALORA DIS 0.025MG Tier 3 X Hormones/Modifiers) - Drugs to Regulate 0.025 MG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH TWICE WEEKLY ALORA DIS 0.05MG Tier 3 X Hormones/Modifiers) - Drugs to Regulate 0.05 MG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH TWICE WEEKLY ALORA DIS 0.075MG Tier 3 X Hormones/Modifiers) - Drugs to Regulate 0.075 MG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH TWICE WEEKLY ALORA DIS 0.1MG Tier 3 X Hormones/Modifiers) - Drugs to Regulate 0.1 MG/24HR Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL ALTAVERA TAB Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.15 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE & ETHINYL ALYACEN TAB 1/35 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE-ETH ESTRADIOL TAB ALYACEN TAB 7/7/7 Preventive Hormones/Modifiers) - Drugs to Regulate 0.5-35/0.75-35/1-35 MG-MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL & NORETHINDRONE AMABELZ TAB 0.5-0.1 Tier 2 Hormones/Modifiers) - Drugs to Regulate ACETATE TAB 0.5-0.1 MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL & NORETHINDRONE AMABELZ TAB 1-0.5MG Tier 2 Hormones/Modifiers) - Drugs to Regulate ACETATE TAB 1-0.5 MG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORG-ETH EST TAB 0.15- AMETHIA TAB Preventive Hormones/Modifiers) - Drugs to Regulate 0.03MG(84) & ETH EST TAB 0.01MG(7) Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORG-ETH EST TAB 0.1-0.02MG(84) AMETHIA LO TAB Preventive Hormones/Modifiers) - Drugs to Regulate & ETH EST TAB 0.01MG(7) Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL-ETHINYL ESTRADIOL AMETHYST TAB 90-20MCG Preventive Hormones/Modifiers) - Drugs to Regulate (CONTINUOUS) TAB 90-20 MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ANADROL-50 TAB 50MG OXYMETHOLONE TAB 50 MG Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ANDRODERM DIS TESTOSTERONE TD PATCH 24HR 2 Tier 2 X X Hormones/Modifiers) - Drugs to Regulate 2MG/24HR MG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ANDRODERM DIS TESTOSTERONE TD PATCH 24HR 4 Tier 2 X X Hormones/Modifiers) - Drugs to Regulate 4MG/24HR MG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ANDROID CAP 10MG METHYLTESTOSTERONE CAP 10 MG Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ANDROXY TAB 10MG FLUOXYMESTERONE TAB 10 MG Tier 1 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DROSPIRENONE-ESTRADIOL TAB 0.25- ANGELIQ TAB 0.25-0.5 Tier 3 Hormones/Modifiers) - Drugs to Regulate 0.5 MG Hormones

130 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DROSPIRENONE-ESTRADIOL TAB 0.5-1 ANGELIQ TAB 0.5-1MG Tier 3 Hormones/Modifiers) - Drugs to Regulate MG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DESOGESTREL & ETHINYL ESTRADIOL APRI TAB Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.15 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE-ETH ESTRADIOL TAB ARANELLE TAB Preventive Hormones/Modifiers) - Drugs to Regulate 0.5-35/1-35/0.5-35 MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORG-ETH EST TAB 0.15- ASHLYNA TAB Preventive Hormones/Modifiers) - Drugs to Regulate 0.03MG(84) & ETH EST TAB 0.01MG(7) Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL AUBRA TAB 0.1-0.02 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL AVIANE TAB Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex AYGESTIN TAB 5MG NORETHINDRONE ACETATE TAB 5 MG Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DESOGEST-ETH ESTRAD & ETH ESTRAD AZURETTE TAB 28 DAY Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.15-0.02/0.01 MG(21/5) Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE & ETHINYL BALZIVA TAB Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.4 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DESOGEST-ETH ESTRAD & ETH ESTRAD BEKYREE TAB Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.15-0.02/0.01 MG(21/5) Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DROSPIRENONE-ETHINYL ESTRAD- BEYAZ TAB Tier 3 X Hormones/Modifiers) - Drugs to Regulate LEVOMEFOLATE TAB 3-0.02-0.451 MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex *ESTRADIOL-ESTRIOL-PROGESTERONE BIEST/PROGES CRE Tier 3 Hormones/Modifiers) - Drugs to Regulate MICRONIZED CREAM (CMPD KIT)* Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE-ETHINYL BLISOVI 24 TAB FE 1/20 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1 MG-20 MCG (24) Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL BLISOVI FE TAB 1.5/30 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1.5 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL BLISOVI FE TAB 1/20 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORETHINDRONE & ETHINYL BREVICON TAB 0.5/35 Tier 3 Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.5 MG-35 MCG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE & ETHINYL BRIELLYN TAB Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.4 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex CAMILA TAB 0.35MG NORETHINDRONE TAB 0.35 MG Preventive Hormones/Modifiers) - Drugs to Regulate Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORG-ETH EST TAB 0.15- CAMRESE TAB Preventive Hormones/Modifiers) - Drugs to Regulate 0.03MG(84) & ETH EST TAB 0.01MG(7) Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORG-ETH EST TAB 0.1-0.02MG(84) CAMRESE LO TAB Preventive Hormones/Modifiers) - Drugs to Regulate & ETH EST TAB 0.01MG(7) Care Hormones

131 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DESOGEST-ETHIN EST TAB CAZIANT PAK Preventive Hormones/Modifiers) - Drugs to Regulate 0.1-0.025/0.125-0.025/0.15-0.025MG-MG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL CHATEAL TAB 0.15/30 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.15 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL-LEVONORGESTREL TD CLIMARA PRO DIS WEEKLY Tier 3 X Hormones/Modifiers) - Drugs to Regulate PATCH WEEKLY 0.045-0.015 MG/DAY Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL-NORETHINDRONE ACE TD COMBIPATCH DIS .05/.14 Tier 3 X Hormones/Modifiers) - Drugs to Regulate PTTW 0.05-0.14 MG/DAY Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL-NORETHINDRONE ACE TD COMBIPATCH DIS .05/.25 Tier 3 X Hormones/Modifiers) - Drugs to Regulate PTTW 0.05-0.25 MG/DAY Hormones Hormonal Agents, Stimulant/ ESTERIFIED ESTROGENS & Replacement/Modifying (Sex COVARYX TAB 1.25-2.5 METHYLTESTOSTERONE TAB 1.25-2.5 Tier 1 Hormones/Modifiers) - Drugs to Regulate MG Hormones Hormonal Agents, Stimulant/ ESTERIFIED ESTROGENS & Replacement/Modifying (Sex COVARYX HS TAB METHYLTESTOSTERONE TAB 0.625-1.25 Tier 1 Hormones/Modifiers) - Drugs to Regulate MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex CRINONE GEL 4% VAG PROGESTERONE VAGINAL GEL 4% Tier 3 X Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex CRINONE GEL 8% VAG PROGESTERONE VAGINAL GEL 8% Tier 3 X X Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTREL & ETHINYL ESTRADIOL CRYSELLE-28 TAB 28 TABS Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.3 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE & ETHINYL CYCLAFEM TAB 1/35 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE-ETH ESTRADIOL TAB CYCLAFEM TAB 7/7/7 Preventive Hormones/Modifiers) - Drugs to Regulate 0.5-35/0.75-35/1-35 MG-MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DESOGEST-ETHIN EST TAB CYCLESSA PAK Tier 3 Hormones/Modifiers) - Drugs to Regulate 0.1-0.025/0.125-0.025/0.15-0.025MG-MG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DESOGESTREL & ETHINYL ESTRADIOL CYRED TAB Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.15 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DANAZOL CAP 100MG DANAZOL CAP 100 MG Tier 1 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DANAZOL CAP 200MG DANAZOL CAP 200 MG Tier 1 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DANAZOL CAP 50MG DANAZOL CAP 50 MG Tier 1 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE & ETHINYL DASETTA TAB 1/35 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE-ETH ESTRADIOL TAB DASET TA TAB 7/7/7 Preventive Hormones/Modifiers) - Drugs to Regulate 0.5-35/0.75-35/1-35 MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORG-ETH EST TAB 0.15- DAYSEE TAB Preventive Hormones/Modifiers) - Drugs to Regulate 0.03MG(84) & ETH EST TAB 0.01MG(7) Care Hormones

132 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DEBLITANE TAB 0.35MG NORETHINDRONE TAB 0.35 MG Preventive Hormones/Modifiers) - Drugs to Regulate Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DELESTROGEN INJ 10MG/ ESTRADIOL VALERATE IM IN OIL 10 MG/ Tier 3 Hormones/Modifiers) - Drugs to Regulate ML ML Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DELESTROGEN INJ 20MG/ ESTRADIOL VALERATE IM IN OIL 20 MG/ Tier 3 Hormones/Modifiers) - Drugs to Regulate ML ML Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DELESTROGEN INJ 40MG/ ESTRADIOL VALERATE IM IN OIL 40 MG/ Tier 3 Hormones/Modifiers) - Drugs to Regulate ML ML Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL DELYLA TAB 0.1-0.02 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL CYPIONATE IM IN OIL 5 MG/ DEPO-ESTRADI INJ 5MG/ML Tier 3 Hormones/Modifiers) - Drugs to Regulate ML Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DEPO-PROVERA INJ 150MG/ MEDROXYPROGESTERONE ACETATE IM Tier 3 Hormones/Modifiers) - Drugs to Regulate ML SUSP 150 MG/ML Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DEPO-PROVERA INJ 150MG/ MEDROXYPROGESTERONE ACETATE IM Tier 3 Hormones/Modifiers) - Drugs to Regulate ML SUSP PREFILLED SYR 150 MG/ML Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex MEDROXYPROGESTERONE ACETATE DEPO-SQ PROV INJ 104 Preventive Hormones/Modifiers) - Drugs to Regulate SUSP PREF SYR 104 MG/0.65ML Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DEPO-TESTOST INJ 100MG/ TESTOSTERONE CYPIONATE IM INJ IN Tier 3 Hormones/Modifiers) - Drugs to Regulate ML OIL 100 MG/ML Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DEPO-TESTOST INJ 200MG/ TESTOSTERONE CYPIONATE IM INJ IN Tier 3 Hormones/Modifiers) - Drugs to Regulate ML OIL 200 MG/ML Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DESO/ETHINYL TAB DESOGESTREL & ETHINYL ESTRADIOL Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIO TAB 0.15 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DESO/ETHINYL TAB DESOGEST-ETH ESTRAD & ETH ESTRAD Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIO TAB 0.15-0.02/0.01 MG(21/5) Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DESOGESTREL & ETHINYL ESTRADIOL DESOGEN-28 TAB Tier 3 Hormones/Modifiers) - Drugs to Regulate TAB 0.15 MG-30 MCG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD GEL 0.25 MG/0.25GM DIVIGEL GEL 0.25MG Tier 3 Hormones/Modifiers) - Drugs to Regulate (0.1%) Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DIVIGEL GEL 0.5MG ESTRADIOL TD GEL 0.5 MG/0.5GM (0.1%) Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DIVIGEL GEL 1MG/GM ESTRADIOL TD GEL 1 MG/GM (0.1%) Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DROSPIR/ETHI TAB DROSPIRENONE-ETHINYL ESTRADIOL Tier 3 Hormones/Modifiers) - Drugs to Regulate 3-0.02MG TAB 3-0.02 MG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DROSPIR/ETHI TAB DROSPIRENONE-ETHINYL ESTRADIOL Preventive Hormones/Modifiers) - Drugs to Regulate 3-0.03MG TAB 3-0.03 MG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DROSPIRE/ETH TAB ESTR/ DROSPIRENONE-ETHINYL ESTRAD- Preventive X Hormones/Modifiers) - Drugs to Regulate LEV LEVOMEFOLATE TAB 3-0.02-0.451 MG Care Hormones

133 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DROSPIRENONE TAB ETHY DROSPIRENONE-ETHINYL ESTRADIOL Tier 3 Hormones/Modifiers) - Drugs to Regulate EST TAB 3-0.02 MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex CONJUGATED ESTROGENS- DUAVEE TAB 0.45-20 Tier 3 X Hormones/Modifiers) - Drugs to Regulate BAZEDOXIFENE TAB 0.45-20 MG Hormones Hormonal Agents, Stimulant/ ESTERIFIED ESTROGENS & Replacement/Modifying (Sex EEMT TAB 1.25-2.5 METHYLTESTOSTERONE TAB 1.25-2.5 Tier 1 Hormones/Modifiers) - Drugs to Regulate MG Hormones Hormonal Agents, Stimulant/ ESTERIFIED ESTROGENS & Replacement/Modifying (Sex EEMT HS TAB METHYLTESTOSTERONE TAB 0.625-1.25 Tier 1 Hormones/Modifiers) - Drugs to Regulate MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL GEL 0.06% (0.52 MG/0.87 ELESTRIN GEL 0.06% Tier 3 Hormones/Modifiers) - Drugs to Regulate GM METERED-DOSE PUMP) Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTREL & ETHINYL ESTRADIOL ELINEST TAB Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.3 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex ELLA TAB 30MG ULIPRISTAL ACETATE TAB 30 MG Preventive X Hormones/Modifiers) - Drugs to Regulate Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DESOGESTREL & ETHINYL ESTRADIOL EMOQUETTE TAB Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.15 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex PROGESTERONE VAGINAL INSERT 100 ENDOMETRIN SUP 100MG Tier 2 X Hormones/Modifiers) - Drugs to Regulate MG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL-ETH ESTRA TAB ENPRESSE-28 TAB Preventive Hormones/Modifiers) - Drugs to Regulate 0.05-30/0.075-40/0.125-30MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DESOGESTREL & ETHINYL ESTRADIOL ENSKYCE TAB Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.15 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex ERRIN TAB 0.35MG NORETHINDRONE TAB 0.35 MG Preventive Hormones/Modifiers) - Drugs to Regulate Care Hormones Hormonal Agents, Stimulant/ ESTERIFIED ESTROGENS & Replacement/Modifying (Sex EST ESTROGEN TAB MTEST METHYLTESTOSTERONE TAB 1.25-2.5 Tier 1 Hormones/Modifiers) - Drugs to Regulate MG Hormones Hormonal Agents, Stimulant/ ESTERIFIED ESTROGENS & Replacement/Modifying (Sex EST ESTROGEN TAB MTEST METHYLTESTOSTERONE TAB 0.625-1.25 Tier 1 Hormones/Modifiers) - Drugs to Regulate HS MG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTIMATE & ETHINYL ESTRADIOL ESTARYLLA TAB 0.25-35 Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.25 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL & NORETHINDRONE ESTRA/NORETH TAB 0.5-0.1 Tier 2 Hormones/Modifiers) - Drugs to Regulate ACETATE TAB 0.5-0.1 MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRA/NORETH TAB ESTRADIOL & NORETHINDRONE Tier 2 Hormones/Modifiers) - Drugs to Regulate 1-0.5MG ACETATE TAB 1-0.5 MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRACE TAB 0.5MG ESTRADIOL TAB 0.5 MG Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRACE TAB 1MG ESTRADIOL TAB 1 MG Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRACE TAB 2MG ESTRADIOL TAB 2 MG Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones

134 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRACE VAG CRE 0.01% ESTRADIOL VAGINAL CREAM 0.1 MG/GM Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL VALERATE IM IN OIL 40 MG/ ESTRAD VAL INJ 200MG/5 Tier 1 Hormones/Modifiers) - Drugs to Regulate ML Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL VALERATE IM IN OIL 20 MG/ ESTRAD VAL INJ 20MG/ML Tier 1 Hormones/Modifiers) - Drugs to Regulate ML Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH WEEKLY 0.025 ESTRADIOL DIS 0.025MG Tier 1 X Hormones/Modifiers) - Drugs to Regulate MG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH WEEKLY 0.0375 ESTRADIOL DIS 0.0375MG Tier 1 X Hormones/Modifiers) - Drugs to Regulate MG/24HR (37.5 MCG/24HR) Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH WEEKLY 0.05 ESTRADIOL DIS 0.05MG Tier 1 X Hormones/Modifiers) - Drugs to Regulate MG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH WEEKLY 0.06 ESTRADIOL DIS 0.06MG Tier 1 X Hormones/Modifiers) - Drugs to Regulate MG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH WEEKLY 0.075 ESTRADIOL DIS 0.075MG Tier 1 X Hormones/Modifiers) - Drugs to Regulate MG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH WEEKLY 0.1 ESTRADIOL DIS 0.1MG Tier 1 X Hormones/Modifiers) - Drugs to Regulate MG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TAB 0.5MG ESTRADIOL TAB 0.5 MG Tier 1 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TAB 10MCG ESTRADIOL VAGINAL TAB 10 MCG Tier 2 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TAB 1MG ESTRADIOL TAB 1 MG Tier 1 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TAB 2MG ESTRADIOL TAB 2 MG Tier 1 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL VAGINAL RING 2 MG (7.5 ESTRING MIS 2MG Tier 2 X Hormones/Modifiers) - Drugs to Regulate MCG/24HRS) Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRIOL POW ESTRIOL MICRONIZED (BULK) POWDER Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRIOL POW MICRONIZ ESTRIOL MICRONIZED (BULK) POWDER Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRIOL ULT POW ESTRIOL MICRONIZED (BULK) POWDER Tier 3 Hormones/Modifiers) - Drugs to Regulate MICRONIZ Hormones Hormonal Agents, Stimulant/ ESTERIFIED ESTROGENS & Replacement/Modifying (Sex ESTROG/MTEST TAB 1.25- METHYLTESTOSTERONE TAB 1.25-2.5 Tier 1 Hormones/Modifiers) - Drugs to Regulate 2.5 MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL GEL 0.06% (0.75 MG/1.25 GM ESTROGEL GEL Tier 3 X Hormones/Modifiers) - Drugs to Regulate METERED-DOSE PUMP) Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTROPIPATE TAB 0.75MG ESTROPIPATE TAB 0.75 MG Tier 1 Hormones/Modifiers) - Drugs to Regulate Hormones

135 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTROPIPATE TAB 1.5MG ESTROPIPATE TAB 1.5 MG Tier 1 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTROPIPATE TAB 3MG ESTROPIPATE TAB 3 MG Tier 1 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORETHINDRONE AC-ETHINYL ESTRAD- ESTROSTEP FE TAB Tier 3 Hormones/Modifiers) - Drugs to Regulate FE TAB 1-20/1-30/1-35 MG-MCG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex ETHYNODIOL DIACETATE & ETHINYL ETHY ETH EST TAB 1-35 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex ETHYNODIOL DIACETATE & ETHINYL ETHYNODIOL TAB 1-50 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-50 MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TRANSDERMAL SPRAY 1.53 EVAMIST SPR 1.53MG Tier 2 Hormones/Modifiers) - Drugs to Regulate MG/SPRAY Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex EVISTA TAB 60MG RALOXIFENE HCL TAB 60 MG Preventive Hormones/Modifiers) - Drugs to Regulate Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex *LEVONORGEST-ETH ESTRAD TAB 0.1 FALESSA KIT Preventive X Hormones/Modifiers) - Drugs to Regulate MG-20 MCG & FA TAB 1 MG KIT* Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL FALMINA TAB Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONOR-ETH EST TAB 0.15- FAYOSIM TAB Preventive Hormones/Modifiers) - Drugs to Regulate 0.02/0.025/0.03 MG Ð EST 0.01 MG Care Hormones Hormonal Agents, Stimulant/ NORETHINDRONE & ETHINYL Replacement/Modifying (Sex FEMCON FE CHW ESTRADIOL-FE CHEW TAB 0.4 MG-35 Tier 3 Hormones/Modifiers) - Drugs to Regulate MCG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORETHINDRONE ACETATE-ETHINYL FEMHRT TAB 0.5-2.5 Tier 3 Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.5 MG-2.5 MCG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL ACETATE VAGINAL RING FEMRING MIS 0.05/24H Tier 3 X Hormones/Modifiers) - Drugs to Regulate 0.05 MG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL ACETATE VAGINAL RING 0.1 FEMRING MIS 0.1MG/24 Tier 3 X Hormones/Modifiers) - Drugs to Regulate MG/24HR Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTIMATE & ETHINYL ESTRADIOL FEMYNOR TAB 0.25-35 Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.25 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORETHINDRONE ACETATE-ETHINYL FYAVOLV TAB 0.5-2.5 Tier 3 Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.5 MG-2.5 MCG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORETHINDRONE ACETATE-ETHINYL FYAVOLV TAB 1-5 Tier 3 Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-5 MCG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DROSPIRENONE-ETHINYL ESTRADIOL GIANVI TAB 3-0.02MG Tier 3 Hormones/Modifiers) - Drugs to Regulate TAB 3-0.02 MG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE & ETHINYL GILDAGIA TAB 0.4-35 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.4 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL GILDESS TAB 1.5/30 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1.5 MG-30 MCG Care Hormones

136 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL GILDESS TAB 1/20 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE-ETHINYL GILDESS 24 TAB FE 1/20 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1 MG-20 MCG (24) Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL GILDESS FE TAB 1.5/30 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1.5 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL GILDESS FE TAB 1/20 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex HEATHER TAB 0.35MG NORETHINDRONE TAB 0.35 MG Preventive Hormones/Modifiers) - Drugs to Regulate Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex INTRAROSA SUP 6.5MG PRASTERONE VAGINAL INSERT 6.5 MG Tier 3 X X Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL INTROVALE TAB Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL (91-DAY) TAB 0.15-0.03 MG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DESOGESTREL & ETHINYL ESTRADIOL ISIBLOOM TAB 0.15-30 Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.15 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex JENCYCLA TAB 0.35MG NORETHINDRONE TAB 0.35 MG Preventive Hormones/Modifiers) - Drugs to Regulate Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORETHINDRONE ACETATE-ETHINYL JEVANTIQUE L TAB 0.5-2.5 Tier 3 Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.5 MG-2.5 MCG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORETHINDRONE ACETATE-ETHINYL JINTELI TAB 1MG-5MCG Tier 3 Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-5 MCG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL JOLESSA TAB Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL (91-DAY) TAB 0.15-0.03 MG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex JOLIVETTE TAB 0.35MG NORETHINDRONE TAB 0.35 MG Preventive Hormones/Modifiers) - Drugs to Regulate Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DESOGESTREL & ETHINYL ESTRADIOL JULEBER TAB Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.15 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL JUNEL 1.5/30 TAB Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1.5 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL JUNEL 1/20 TAB Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL JUNEL FE TAB 1.5/30 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1.5 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL JUNEL FE TAB 1/20 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE-ETHINYL JUNEL FE 24 TAB 1/20 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1 MG-20 MCG (24) Care Hormones Hormonal Agents, Stimulant/ NORETHINDRONE & ETHINYL HCR Replacement/Modifying (Sex KAITLIB FE CHW ESTRADIOL-FE CHEW TAB 0.8 MG-25 Preventive Hormones/Modifiers) - Drugs to Regulate MCG Care Hormones

137 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DESOGEST-ETH ESTRAD & ETH ESTRAD KARIVA TAB 28 DAY Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.15-0.02/0.01 MG(21/5) Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex ETHYNODIOL DIACETATE & ETHINYL KELNOR TAB 1/35 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DESOGEST-ETH ESTRAD & ETH ESTRAD KIMIDESS TAB Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.15-0.02/0.01 MG(21/5) Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL KURVELO TAB 0.15/30 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.15 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL LARIN TAB 1.5/30 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1.5 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL LARIN TAB 1/20 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE-ETHINYL LARIN 24 TAB FE 1/20 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1 MG-20 MCG (24) Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL LARIN FE TAB 1.5/30 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1.5 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL LARIN FE TAB 1/20 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL LARISSIA TAB Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ NORETHINDRONE & ETHINYL HCR Replacement/Modifying (Sex LAYOLIS FE CHW ESTRADIOL-FE CHEW TAB 0.8 MG-25 Preventive Hormones/Modifiers) - Drugs to Regulate MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE-ETH ESTRADIOL TAB LEENA TAB Preventive Hormones/Modifiers) - Drugs to Regulate 0.5-35/1-35/0.5-35 MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL LESSINA TAB Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVO-ETH EST TAB 90- LEVONORGESTREL-ETHINYL ESTRADIOL Preventive Hormones/Modifiers) - Drugs to Regulate 20MCG (CONTINUOUS) TAB 90-20 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL-ETH ESTRA TAB LEVONEST TAB Preventive Hormones/Modifiers) - Drugs to Regulate 0.05-30/0.075-40/0.125-30MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL-ETH ESTRA TAB LEVONOR/ETHI TAB Preventive Hormones/Modifiers) - Drugs to Regulate 0.05-30/0.075-40/0.125-30MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL LEVONOR/ETHI TAB 0.1-0.02 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONOR/ETHI TAB LEVONORGESTREL & ETHINYL Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIO ESTRADIOL TAB 0.15 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONOR/ETHI TAB LEVONORGESTREL & ETHINYL Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIO ESTRADIOL (91-DAY) TAB 0.15-0.03 MG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONOR/ETHI TAB LEVONORG-ETH EST TAB 0.1-0.02MG(84) Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIO & ETH EST TAB 0.01MG(7) Care Hormones

138 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONOR/ETHI TAB LEVONORG-ETH EST TAB 0.15- Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIO 0.03MG(84) & ETH EST TAB 0.01MG(7) Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONOR/ETHI TAB LEVONOR-ETH EST TAB 0.15- Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIO 0.02/0.025/0.03 MG Ð EST 0.01 MG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL LEVORA-28 TAB 0.15/30 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.15 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL LILLOW TAB 0.15/30 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.15 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHIN-ETH ESTRADIOL-FE TAB 1 LO LOESTRIN TAB Preventive Hormones/Modifiers) - Drugs to Regulate MG-10 MCG (24)/10 MCG (2) Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL LOESTRIN TAB 1/20-21 Tier 3 Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-20 MCG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL LOESTRIN 21 TAB 1.5/30 Tier 3 Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1.5 MG-30 MCG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL LOESTRIN FE TAB 1.5/30 Tier 3 Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1.5 MG-30 MCG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL LOESTRIN FE TAB 1/20 Tier 3 Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1 MG-20 MCG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE-ETHINYL LOMEDIA 24 TAB FE Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1 MG-20 MCG (24) Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL & NORETHINDRONE LOPREEZA TAB 0.5-0.1 Tier 2 Hormones/Modifiers) - Drugs to Regulate ACETATE TAB 0.5-0.1 MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL & NORETHINDRONE LOPREEZA TAB 1-0.5MG Tier 2 Hormones/Modifiers) - Drugs to Regulate ACETATE TAB 1-0.5 MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DROSPIRENONE-ETHINYL ESTRADIOL LORYNA TAB 3-0.02MG Tier 3 Hormones/Modifiers) - Drugs to Regulate TAB 3-0.02 MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex LEVONORG-ETH EST TAB 0.1-0.02MG(84) LOSEASONIQUE TAB Tier 3 Hormones/Modifiers) - Drugs to Regulate & ETH EST TAB 0.01MG(7) Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTREL & ETHINYL ESTRADIOL LOW-OGESTREL TAB Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.3 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL LUTERA TAB Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LYZA TAB 0.35MG NORETHINDRONE TAB 0.35 MG Preventive Hormones/Modifiers) - Drugs to Regulate Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL MARLISSA TAB 0.15/30 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.15 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex MEDROXYPR AC INJ MEDROXYPROGESTERONE ACETATE IM Preventive Hormones/Modifiers) - Drugs to Regulate 150MG/ML SUSP 150 MG/ML Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex MEDROXYPR AC INJ MEDROXYPROGESTERONE ACETATE IM Preventive Hormones/Modifiers) - Drugs to Regulate 150MG/ML SUSP PREFILLED SYR 150 MG/ML Care Hormones

139 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ Replacement/Modifying (Sex MEDROXYPROGESTERONE ACETATE MEDROXYPR AC TAB 10MG Tier 1 Hormones/Modifiers) - Drugs to Regulate TAB 10 MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex MEDROXYPROGESTERONE ACETATE MEDROXYPR AC TAB 2.5MG Tier 1 Hormones/Modifiers) - Drugs to Regulate TAB 2.5 MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex MEDROXYPROGESTERONE ACETATE MEDROXYPR AC TAB 5MG Tier 1 Hormones/Modifiers) - Drugs to Regulate TAB 5 MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex MEGESTROL ACETATE SUSP 625 MEGACE ES SUS 625/5ML Tier 3 Hormones/Modifiers) - Drugs to Regulate MG/5ML Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex MEGACE ORAL SUS 40MG/ MEGESTROL ACETATE SUSP 40 MG/ML Tier 3 Hormones/Modifiers) - Drugs to Regulate ML Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex MEGESTROL SUS MEGESTROL ACETATE SUSP 625 Tier 3 Hormones/Modifiers) - Drugs to Regulate 625MG/5M MG/5ML Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex MEGESTROL AC SUS 40MG/ MEGESTROL ACETATE SUSP 40 MG/ML Tier 1 Hormones/Modifiers) - Drugs to Regulate ML Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex MEGESTROL AC TAB 20MG MEGESTROL ACETATE TAB 20 MG Tier 1 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex MEGESTROL AC TAB 40MG MEGESTROL ACETATE TAB 40 MG Tier 1 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE-ETH ESTRADIOL- MELODETTA CHW 24 FE Preventive X Hormones/Modifiers) - Drugs to Regulate FE CHEW TAB 1 MG-20 MCG (24) Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex MENEST TAB 0.3MG ESTERIFIED ESTROGENS TAB 0.3 MG Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex MENEST TAB 0.625MG ESTERIFIED ESTROGENS TAB 0.625 MG Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex MENEST TAB 1.25MG ESTERIFIED ESTROGENS TAB 1.25 MG Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH WEEKLY 14 MENOSTAR DIS 14MCG Tier 3 X Hormones/Modifiers) - Drugs to Regulate MCG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex METHYLTESTOSTERONE ORAL TAB 10 METHITEST TAB 10MG Tier 2 Hormones/Modifiers) - Drugs to Regulate MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex METHYLTESTOS CAP 10MG METHYLTESTOSTERONE CAP 10 MG Tier 2 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE-ETH ESTRADIOL- MIBELAS 24 CHW FE Preventive X Hormones/Modifiers) - Drugs to Regulate FE CHEW TAB 1 MG-20 MCG (24) Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE-ETHINYL MICRGSTIN 24 TAB FE 1/20 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1 MG-20 MCG (24) Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL MICROGESTIN TAB 1.5/30 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1.5 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL MICROGESTIN TAB 1/20 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-20 MCG Care Hormones

140 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL MICROGESTIN TAB FE 1/20 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL MICROGESTIN TAB FE1.5/30 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1.5 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL & NORETHINDRONE MIMVEY TAB 1-0.5MG Tier 2 Hormones/Modifiers) - Drugs to Regulate ACETATE TAB 1-0.5 MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL & NORETHINDRONE MIMVEY LO TAB 0.5-0.1 Tier 2 Hormones/Modifiers) - Drugs to Regulate ACETATE TAB 0.5-0.1 MG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE-ETH ESTRADIOL- MINASTRIN 24 CHW FE Preventive X Hormones/Modifiers) - Drugs to Regulate FE CHEW TAB 1 MG-20 MCG (24) Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH TWICE WEEKLY MINIVELLE DIS 0.025MG Tier 3 X Hormones/Modifiers) - Drugs to Regulate 0.025 MG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH TWICE WEEKLY MINIVELLE DIS 0.0375MG Tier 3 X Hormones/Modifiers) - Drugs to Regulate 0.0375 MG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH TWICE WEEKLY MINIVELLE DIS 0.05MG Tier 3 X Hormones/Modifiers) - Drugs to Regulate 0.05 MG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH TWICE WEEKLY MINIVELLE DIS 0.075MG Tier 3 X Hormones/Modifiers) - Drugs to Regulate 0.075 MG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH TWICE WEEKLY MINIVELLE DIS 0.1MG Tier 3 X Hormones/Modifiers) - Drugs to Regulate 0.1 MG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DESOGEST-ETH ESTRAD & ETH ESTRAD MIRCETTE TAB 28 DAY Tier 3 Hormones/Modifiers) - Drugs to Regulate TAB 0.15-0.02/0.01 MG(21/5) Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORETHINDRONE & ETHINYL MODICON TAB 0.5/35 Tier 3 Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.5 MG-35 MCG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTIMATE & ETHINYL ESTRADIOL MONO-LINYAH TAB 0.25-35 Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.25 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTIMATE & ETHINYL ESTRADIOL MONONESSA TAB Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.25 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL-ETH ESTRA TAB MYZILRA TAB Preventive Hormones/Modifiers) - Drugs to Regulate 0.05-30/0.075-40/0.125-30MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex ESTRADIOL VALERATE-DIENOGEST TAB NATAZIA TAB Preventive Hormones/Modifiers) - Drugs to Regulate 3 MG /2-2 MG/2-3 MG/1 MG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE & ETHINYL NECON TAB 0.5/35 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.5 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE & ETHINYL NECON TAB 1/35 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE & MESTRANOL TAB 1 NECON TAB 1/50-28 Preventive Hormones/Modifiers) - Drugs to Regulate MG-50 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE-ETH ESTRADIOL TAB NECON TAB 10/11-28 Preventive Hormones/Modifiers) - Drugs to Regulate 0.5-35/1-35 MG-MCG (10/11) Care Hormones

141 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE-ETH ESTRADIOL TAB NECON TAB 7/7/7 Preventive Hormones/Modifiers) - Drugs to Regulate 0.5-35/0.75-35/1-35 MG-MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DROSPIRENONE-ETHINYL ESTRADIOL NIKKI TAB 3-0.02MG Tier 3 Hormones/Modifiers) - Drugs to Regulate TAB 3-0.02 MG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORA-BE TAB 0.35MG NORETHINDRONE TAB 0.35 MG Preventive Hormones/Modifiers) - Drugs to Regulate Care Hormones Hormonal Agents, Stimulant/ NORETHINDRONE & ETHINYL HCR Replacement/Modifying (Sex NORE/ETH/FER CHW ESTRADIOL-FE CHEW TAB 0.4 MG-35 Preventive Hormones/Modifiers) - Drugs to Regulate 0.4MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ NORETHINDRONE & ETHINYL HCR Replacement/Modifying (Sex NORETH/ETHIN CHW FE ESTRADIOL-FE CHEW TAB 0.8 MG-25 Preventive Hormones/Modifiers) - Drugs to Regulate MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETH/ETHIN CHW FE NORETHINDRONE ACE-ETH ESTRADIOL- Preventive X Hormones/Modifiers) - Drugs to Regulate 1/20 FE CHEW TAB 1 MG-20 MCG (24) Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORETHINDRONE ACETATE-ETHINYL NORETH/ETHIN TAB 0.5-2.5 Tier 3 Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.5 MG-2.5 MCG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL NORETH/ETHIN TAB 1/20 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORETH/ETHIN TAB 1MG- NORETHINDRONE ACETATE-ETHINYL Tier 3 Hormones/Modifiers) - Drugs to Regulate 5MCG ESTRADIOL TAB 1 MG-5 MCG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL NORETH/ETHIN TAB FE 1/20 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE-ETHINYL NORETH/ETHIN TAB FE 1/20 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1 MG-20 MCG (24) Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORETHIN ACE TAB 5MG NORETHINDRONE ACETATE TAB 5 MG Tier 1 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRON TAB NORETHINDRONE TAB 0.35 MG Preventive Hormones/Modifiers) - Drugs to Regulate 0.35MG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTIMATE & ETHINYL ESTRADIOL NORGEST/ETHI TAB 0.25/35 Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.25 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGEST/ETHI TAB NORGESTIMATE-ETH ESTRAD TAB 0.18- Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIO 25/0.215-25/0.25-25 MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGEST/ETHI TAB NORGESTIMATE-ETH ESTRAD TAB 0.18- Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIO 35/0.215-35/0.25-35 MG-MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORETHINDRONE & ETHINYL NORINYL TAB 1/35 Tier 3 Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-35 MCG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORLYDA TAB 0.35MG NORETHINDRONE TAB 0.35 MG Preventive Hormones/Modifiers) - Drugs to Regulate Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORLYROC TAB 0.35MG NORETHINDRONE TAB 0.35 MG Preventive Hormones/Modifiers) - Drugs to Regulate Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NOR-QD TAB 0.35MG NORETHINDRONE TAB 0.35 MG Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones

142 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE & ETHINYL NORTREL TAB 0.5/35 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.5 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE & ETHINYL NORTREL TAB 1/35 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE-ETH ESTRADIOL TAB NORTREL TAB 7/7/7 Preventive Hormones/Modifiers) - Drugs to Regulate 0.5-35/0.75-35/1-35 MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex ETONOGESTREL-ETHINYL ESTRADIOL NUVARING MIS Preventive Hormones/Modifiers) - Drugs to Regulate VA RING 0.120-0.015 MG/24HR Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DROSPIRENONE-ETHINYL ESTRADIOL OCELLA TAB 3-0.03MG Preventive Hormones/Modifiers) - Drugs to Regulate TAB 3-0.03 MG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTREL & ETHINYL ESTRADIOL OGESTREL TAB Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.5 MG-50 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL ORSYTHIA TAB Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ORTHO MICRON TAB NORETHINDRONE TAB 0.35 MG Tier 3 Hormones/Modifiers) - Drugs to Regulate 0.35MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORGESTIMATE-ETH ESTRAD TAB 0.18- ORTHO TRI- TAB CYCLEN Tier 3 Hormones/Modifiers) - Drugs to Regulate 35/0.215-35/0.25-35 MG-MCG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ORTHO-CYCLEN TAB NORGESTIMATE & ETHINYL ESTRADIOL Tier 3 Hormones/Modifiers) - Drugs to Regulate 0.25/35 TAB 0.25 MG-35 MCG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORETHINDRONE & ETHINYL ORTHO-NOVUM TAB 1/35 Tier 3 Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-35 MCG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORETHINDRONE-ETH ESTRADIOL TAB ORTHO - NOVUM TAB 7/7/7 Tier 3 Hormones/Modifiers) - Drugs to Regulate 0.5-35/0.75-35/1-35 MG-MCG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex OSPHENA TAB 60MG OSPEMIFENE TAB 60 MG Tier 3 X Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORETHINDRONE & ETHINYL OVCON-35 TAB Tier 3 Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.4 MG-35 MCG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex OXANDRIN TAB 10MG OXANDROLONE TAB 10 MG Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex OXANDRIN TAB 2.5MG OXANDROLONE TAB 2.5 MG Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex OXANDROLONE TAB 10MG OXANDROLONE TAB 10 MG Tier 2 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex OXANDROLONE TAB 2.5MG OXANDROLONE TAB 2.5 MG Tier 2 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE & ETHINYL PHILITH TAB 0.4-35 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.4 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DESOGEST-ETH ESTRAD & ETH ESTRAD PIMTREA TAB Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.15-0.02/0.01 MG(21/5) Care Hormones

143 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE & ETHINYL PIRMELLA TAB 1/35 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE-ETH ESTRADIOL TAB PIRMELL A TAB 7/7/7 Preventive Hormones/Modifiers) - Drugs to Regulate 0.5-35/0.75-35/1-35 MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL PORTIA-28 TAB Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.15 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TAB 1 MG(15)/ESTRAD- PREFEST TAB Tier 2 Hormones/Modifiers) - Drugs to Regulate NORGESTIMATE TAB 1-0.09MG(15) Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex PREMARIN TAB 0.3MG ESTROGENS, CONJUGATED TAB 0.3 MG Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTROGENS, CONJUGATED TAB 0.45 PREMARIN TAB 0.45MG Tier 3 Hormones/Modifiers) - Drugs to Regulate MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTROGENS, CONJUGATED TAB 0.625 PREMARIN TAB 0.625MG Tier 3 Hormones/Modifiers) - Drugs to Regulate MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex PREMARIN TAB 0.9MG ESTROGENS, CONJUGATED TAB 0.9 MG Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTROGENS, CONJUGATED TAB 1.25 PREMARIN TAB 1.25MG Tier 3 Hormones/Modifiers) - Drugs to Regulate MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex PREMARIN VAG CRE ESTROGENS, CONJUGATED VAGINAL Tier 3 Hormones/Modifiers) - Drugs to Regulate 0.625MG CREAM 0.625 MG/GM Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex CONJ EST 0.625(14)/CONJ EST- PREMPHASE TAB Tier 3 Hormones/Modifiers) - Drugs to Regulate MEDROXYPRO AC TAB 0.625-5MG(14) Hormones Hormonal Agents, Stimulant/ CONJUGATED ESTROGEN- Replacement/Modifying (Sex PREMPRO TAB .625-2.5 MEDROXYPROGEST ACETATE TAB Tier 3 Hormones/Modifiers) - Drugs to Regulate 0.625-2.5 MG Hormones Hormonal Agents, Stimulant/ CONJUGATED ESTROGEN- Replacement/Modifying (Sex PREMPRO TAB 0.3-1.5 MEDROXYPROGEST ACETATE TAB 0.3- Tier 3 Hormones/Modifiers) - Drugs to Regulate 1.5 MG Hormones Hormonal Agents, Stimulant/ CONJUGATED ESTROGEN- Replacement/Modifying (Sex PREMPRO TAB 0.45-1.5 MEDROXYPROGEST ACETATE TAB 0.45- Tier 3 Hormones/Modifiers) - Drugs to Regulate 1.5 MG Hormones Hormonal Agents, Stimulant/ CONJUGATED ESTROGEN- Replacement/Modifying (Sex PREMPRO TAB 0.625-5 MEDROXYPROGEST ACETATE TAB Tier 3 Hormones/Modifiers) - Drugs to Regulate 0.625-5 MG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTIMATE & ETHINYL ESTRADIOL PREVIFEM TAB Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.25 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex PROGESTERONE CAP PROGESTERONE MICRONIZED CAP 100 Tier 2 Hormones/Modifiers) - Drugs to Regulate 100MG MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex PROGESTERONE CAP PROGESTERONE MICRONIZED CAP 200 Tier 2 Hormones/Modifiers) - Drugs to Regulate 200MG MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex PROGESTERONE INJ 50MG/ PROGESTERONE IM IN OIL 50 MG/ML Tier 1 Hormones/Modifiers) - Drugs to Regulate ML Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex PROGESTERONE POW PROGESTERONE MICRONIZED (BULK) Tier 3 Hormones/Modifiers) - Drugs to Regulate MICRONIZ POWDER Hormones

144 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ Replacement/Modifying (Sex PROGESTERONE MICRONIZED CAP 100 PROMETRIUM CAP 100MG Tier 3 Hormones/Modifiers) - Drugs to Regulate MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex PROGESTERONE MICRONIZED CAP 200 PROMETRIUM CAP 200MG Tier 3 Hormones/Modifiers) - Drugs to Regulate MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex MEDROXYPROGESTERONE ACETATE PROVERA TAB 10MG Tier 3 Hormones/Modifiers) - Drugs to Regulate TAB 10 MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex MEDROXYPROGESTERONE ACETATE PROVERA TAB 2.5MG Tier 3 Hormones/Modifiers) - Drugs to Regulate TAB 2.5 MG Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex MEDROXYPROGESTERONE ACETATE PROVERA TAB 5MG Tier 3 Hormones/Modifiers) - Drugs to Regulate TAB 5 MG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONOR-ETH EST TAB 0.15- QUARTETTE TAB Preventive Hormones/Modifiers) - Drugs to Regulate 0.02/0.025/0.03 MG Ð EST 0.01 MG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL QUASENSE TAB Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL (91-DAY) TAB 0.15-0.03 MG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DROSPIRENONE-ETHINYL ESTRAD- RAJANI TAB Preventive X Hormones/Modifiers) - Drugs to Regulate LEVOMEFOLATE TAB 3-0.02-0.451 MG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex RALOXIFENE TAB 60MG RALOXIFENE HCL TAB 60 MG Preventive Hormones/Modifiers) - Drugs to Regulate Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DESOGESTREL & ETHINYL ESTRADIOL RECLIPSEN TAB Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.15 MG-30 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONOR-ETH EST TAB 0.15- RIVELSA TAB Preventive Hormones/Modifiers) - Drugs to Regulate 0.02/0.025/0.03 MG Ð EST 0.01 MG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DROSPIRENONE-ETHINYL ESTRAD- SAFYRAL TAB Preventive X Hormones/Modifiers) - Drugs to Regulate LEVOMEFOLATE TAB 3-0.03-0.451 MG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex LEVONORG-ETH EST TAB 0.15- SEASONIQUE TAB Tier 3 Hormones/Modifiers) - Drugs to Regulate 0.03MG(84) & ETH EST TAB 0.01MG(7) Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL SETLAKIN TAB Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL (91-DAY) TAB 0.15-0.03 MG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex SHAROBEL TAB 0.35MG NORETHINDRONE TAB 0.35 MG Preventive Hormones/Modifiers) - Drugs to Regulate Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTIMATE & ETHINYL ESTRADIOL SPRINTEC 28 TAB 28 DAY Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.25 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL SRONYX TAB Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex TESTOSTERONE BUCCAL STRIANT MIS 30MG Tier 3 X X Hormones/Modifiers) - Drugs to Regulate MUCOADHESIVE SYSTEM 30 MG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DROSPIRENONE-ETHINYL ESTRADIOL SYEDA TAB 3-0.03MG Preventive Hormones/Modifiers) - Drugs to Regulate TAB 3-0.03 MG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE & ETHINYL TARINA FE TAB 1/20 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE TAB 1 MG-20 MCG Care Hormones

145 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE ACE-ETHINYL TAYTULLA CAP Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL-FE CAP 1 MG-20 MCG (24) Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex TESTOSTERONE TD GEL 50 MG/5GM TESTIM GEL 1%(50MG) Tier 2 X X Hormones/Modifiers) - Drugs to Regulate (1%) Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex TESTOST CYP INJ 100MG/ TESTOSTERONE CYPIONATE IM INJ IN Tier 1 Hormones/Modifiers) - Drugs to Regulate ML OIL 100 MG/ML Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex TESTOST CYP INJ 200MG/ TESTOSTERONE CYPIONATE IM INJ IN Tier 1 Hormones/Modifiers) - Drugs to Regulate ML OIL 200 MG/ML Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex TESTOST ENAN INJ 200MG/ TESTOSTERONE ENANTHATE IM INJ IN Tier 1 Hormones/Modifiers) - Drugs to Regulate ML OIL 200 MG/ML Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex TESTOSTERONE MICRONIZED (BULK) TESTOSTERONE CRY YAM Tier 3 Hormones/Modifiers) - Drugs to Regulate CRYSTALS Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex TESTOSTERONE POW TESTOSTERONE (BULK) POWDER Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex TESTOSTERONE POW TESTOSTERONE CYPIONATE (BULK) Tier 3 Hormones/Modifiers) - Drugs to Regulate CYPIONAT POWDER Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex TESTOSTERONE POW TESTOSTERONE ENANTHATE (BULK) Tier 3 Hormones/Modifiers) - Drugs to Regulate ENANTHAT POWDER Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex TESTOSTERONE POW SOY TESTOSTERONE (BULK) POWDER Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex TESTRED CAP 10MG METHYLTESTOSTERONE CAP 10 MG Tier 3 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE AC-ETHINYL ESTRAD- TILIA FE TAB Preventive Hormones/Modifiers) - Drugs to Regulate FE TAB 1-20/1-30/1-35 MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTIMATE-ETH ESTRAD TAB 0.18- TRI FEMYNOR TAB Preventive Hormones/Modifiers) - Drugs to Regulate 35/0.215-35/0.25-35 MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTIMATE-ETH ESTRAD TAB 0.18- TRI-ESTARYLL TAB Preventive Hormones/Modifiers) - Drugs to Regulate 35/0.215-35/0.25-35 MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE AC-ETHINYL ESTRAD- TRI-LEGEST TAB FE Preventive Hormones/Modifiers) - Drugs to Regulate FE TAB 1-20/1-30/1-35 MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTIMATE-ETH ESTRAD TAB 0.18- TRI-LINYAH TAB Preventive Hormones/Modifiers) - Drugs to Regulate 35/0.215-35/0.25-35 MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTIMATE-ETH ESTRAD TAB 0.18- TRI-LO TAB ESTARYLL Preventive Hormones/Modifiers) - Drugs to Regulate 25/0.215-25/0.25-25 MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTIMATE-ETH ESTRAD TAB 0.18- TRI-LO- TAB MARZIA Preventive Hormones/Modifiers) - Drugs to Regulate 25/0.215-25/0.25-25 MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTIMATE-ETH ESTRAD TAB 0.18- TRI-LO- TAB SPRINTEC Preventive Hormones/Modifiers) - Drugs to Regulate 25/0.215-25/0.25-25 MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTIMATE-ETH ESTRAD TAB 0.18- TRINESSA TAB Preventive Hormones/Modifiers) - Drugs to Regulate 35/0.215-35/0.25-35 MG-MCG Care Hormones

146 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTIMATE-ETH ESTRAD TAB 0.18- TRINESSA LO TAB Preventive Hormones/Modifiers) - Drugs to Regulate 25/0.215-25/0.25-25 MG-MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex NORETHINDRONE-ETH ESTRADIOL TAB TRI-NORINYL TAB 28 Tier 3 Hormones/Modifiers) - Drugs to Regulate 0.5-35/1-35/0.5-35 MG-MCG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTIMATE-ETH ESTRAD TAB 0.18- TRI-PREVIFEM TAB Preventive Hormones/Modifiers) - Drugs to Regulate 35/0.215-35/0.25-35 MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTIMATE-ETH ESTRAD TAB 0.18- TRI-SPRINTEC TAB Preventive Hormones/Modifiers) - Drugs to Regulate 35/0.215-35/0.25-35 MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL-ETH ESTRA TAB TRIVORA-28 TAB Preventive Hormones/Modifiers) - Drugs to Regulate 0.05-30/0.075-40/0.125-30MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTIMATE-ETH ESTRAD TAB 0.18- TRI-VYLIBRA TAB Preventive Hormones/Modifiers) - Drugs to Regulate 35/0.215-35/0.25-35 MG-MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DESOGEST-ETHIN EST TAB VELIVET PAK Preventive Hormones/Modifiers) - Drugs to Regulate 0.1-0.025/0.125-0.025/0.15-0.025MG-MG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex DROSPIRENONE-ETHINYL ESTRADIOL VESTURA TAB 3-0.02MG Tier 3 Hormones/Modifiers) - Drugs to Regulate TAB 3-0.02 MG Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex LEVONORGESTREL & ETHINYL VIENVA TAB 0.1-20 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.1 MG-20 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DESOGEST-ETH ESTRAD & ETH ESTRAD VIORELE TAB Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.15-0.02/0.01 MG(21/5) Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH TWICE WEEKLY VIVELLE-DOT DIS 0.025MG Tier 2 X Hormones/Modifiers) - Drugs to Regulate 0.025 MG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH TWICE WEEKLY VIVELLE-DOT DIS 0.0375MG Tier 2 X Hormones/Modifiers) - Drugs to Regulate 0.0375 MG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH TWICE WEEKLY VIVELLE-DOT DIS 0.05MG Tier 2 X Hormones/Modifiers) - Drugs to Regulate 0.05 MG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH TWICE WEEKLY VIVELLE-DOT DIS 0.075MG Tier 2 X Hormones/Modifiers) - Drugs to Regulate 0.075 MG/24HR Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex ESTRADIOL TD PATCH TWICE WEEKLY VIVELLE-DOT DIS 0.1MG Tier 2 X Hormones/Modifiers) - Drugs to Regulate 0.1 MG/24HR Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE & ETHINYL VYFEMLA TAB 0.4-35 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.4 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORGESTIMATE & ETHINYL ESTRADIOL VYLIBRA TAB 0.25-35 Preventive Hormones/Modifiers) - Drugs to Regulate TAB 0.25 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE & ETHINYL WERA TAB 0.5/35 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.5 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ NORETHINDRONE & ETHINYL HCR Replacement/Modifying (Sex WYMZYA FE CHW 0.4MG-35 ESTRADIOL-FE CHEW TAB 0.4 MG-35 Preventive Hormones/Modifiers) - Drugs to Regulate MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORELGESTROMIN-ETHINYL XULANE DIS 150-35 Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TD PTWK 150-35 MCG/24HR Care Hormones

147 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DROSPIRENONE-ETHINYL ESTRADIOL YASMIN 28 TAB 3-0.03MG Preventive Hormones/Modifiers) - Drugs to Regulate TAB 3-0.03 MG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DROSPIRENONE-ETHINYL ESTRADIOL YAZ TAB 3-0.02MG Preventive Hormones/Modifiers) - Drugs to Regulate TAB 3-0.02 MG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Sex YUVAFEM TAB 10MCG ESTRADIOL VAGINAL TAB 10 MCG Tier 2 Hormones/Modifiers) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex DROSPIRENONE-ETHINYL ESTRADIOL ZARAH TAB 3-0.03MG Preventive Hormones/Modifiers) - Drugs to Regulate TAB 3-0.03 MG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex NORETHINDRONE & ETHINYL ZENCHENT TAB Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 0.4 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ NORETHINDRONE & ETHINYL HCR Replacement/Modifying (Sex ZENCHENT FE CHW 0.4MG- ESTRADIOL-FE CHEW TAB 0.4 MG-35 Preventive Hormones/Modifiers) - Drugs to Regulate 35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex ETHYNODIOL DIACETATE & ETHINYL ZOVIA 1/35E TAB Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-35 MCG Care Hormones Hormonal Agents, Stimulant/ HCR Replacement/Modifying (Sex ETHYNODIOL DIACETATE & ETHINYL ZOVIA 1/50E TAB Preventive Hormones/Modifiers) - Drugs to Regulate ESTRADIOL TAB 1 MG-50 MCG Care Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - CYTOMEL TAB 25MCG LIOTHYRONINE SODIUM TAB 25 MCG Tier 3 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - CYTOMEL TAB 50MCG LIOTHYRONINE SODIUM TAB 50 MCG Tier 3 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - CYTOMEL TAB 5MCG LIOTHYRONINE SODIUM TAB 5 MCG Tier 3 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVO-T TAB 100MCG LEVOTHYROXINE SODIUM TAB 100 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVO-T TAB 112MCG LEVOTHYROXINE SODIUM TAB 112 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVO-T TAB 125MCG LEVOTHYROXINE SODIUM TAB 125 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVO-T TAB 137MCG LEVOTHYROXINE SODIUM TAB 137 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVO-T TAB 150MCG LEVOTHYROXINE SODIUM TAB 150 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVO-T TAB 175MCG LEVOTHYROXINE SODIUM TAB 175 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVO-T TAB 200 MCG LEVOTHYROXINE SODIUM TAB 200 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVO-T TAB 25MCG LEVOTHYROXINE SODIUM TAB 25 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVO-T TAB 300 MCG LEVOTHYROXINE SODIUM TAB 300 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVO-T TAB 50MCG LEVOTHYROXINE SODIUM TAB 50 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVO-T TAB 75MCG LEVOTHYROXINE SODIUM TAB 75 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVO-T TAB 88MCG LEVOTHYROXINE SODIUM TAB 88 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ LEVOTHYROXIN TAB Replacement/Modifying (Thyroid) - LEVOTHYROXINE SODIUM TAB 100 MCG Tier 1 100MCG Drugs to Replace Thyroid Hormones

148 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ LEVOTHYROXIN TAB Replacement/Modifying (Thyroid) - LEVOTHYROXINE SODIUM TAB 112 MCG Tier 1 112MCG Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ LEVOTHYROXIN TAB Replacement/Modifying (Thyroid) - LEVOTHYROXINE SODIUM TAB 125 MCG Tier 1 125MCG Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ LEVOTHYROXIN TAB Replacement/Modifying (Thyroid) - LEVOTHYROXINE SODIUM TAB 137 MCG Tier 1 137MCG Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ LEVOTHYROXIN TAB Replacement/Modifying (Thyroid) - LEVOTHYROXINE SODIUM TAB 150 MCG Tier 1 150MCG Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ LEVOTHYROXIN TAB Replacement/Modifying (Thyroid) - LEVOTHYROXINE SODIUM TAB 175 MCG Tier 1 175MCG Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ LEVOTHYROXIN TAB Replacement/Modifying (Thyroid) - LEVOTHYROXINE SODIUM TAB 200 MCG Tier 1 200MCG Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVOTHYROXIN TAB 25MCG LEVOTHYROXINE SODIUM TAB 25 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ LEVOTHYROXIN TAB Replacement/Modifying (Thyroid) - LEVOTHYROXINE SODIUM TAB 300 MCG Tier 1 300MCG Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVOTHYROXIN TAB 50MCG LEVOTHYROXINE SODIUM TAB 50 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVOTHYROXIN TAB 75MCG LEVOTHYROXINE SODIUM TAB 75 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVOTHYROXIN TAB 88MCG LEVOTHYROXINE SODIUM TAB 88 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVOXYL TAB 100MCG LEVOTHYROXINE SODIUM TAB 100 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVOXYL TAB 112MCG LEVOTHYROXINE SODIUM TAB 112 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVOXYL TAB 125MCG LEVOTHYROXINE SODIUM TAB 125 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVOXYL TAB 137MCG LEVOTHYROXINE SODIUM TAB 137 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVOXYL TAB 150MCG LEVOTHYROXINE SODIUM TAB 150 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVOXYL TAB 175MCG LEVOTHYROXINE SODIUM TAB 175 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVOXYL TAB 200MCG LEVOTHYROXINE SODIUM TAB 200 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVOXYL TAB 25MCG LEVOTHYROXINE SODIUM TAB 25 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVOXYL TAB 50MCG LEVOTHYROXINE SODIUM TAB 50 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVOXYL TAB 75MCG LEVOTHYROXINE SODIUM TAB 75 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LEVOXYL TAB 88MCG LEVOTHYROXINE SODIUM TAB 88 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LIOTHYRONINE TAB 25MCG LIOTHYRONINE SODIUM TAB 25 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LIOTHYRONINE TAB 50MCG LIOTHYRONINE SODIUM TAB 50 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - LIOTHYRONINE TAB 5MCG LIOTHYRONINE SODIUM TAB 5 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - SYNTHROID TAB 100MCG LEVOTHYROXINE SODIUM TAB 100 MCG Tier 2 Drugs to Replace Thyroid Hormones

149 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - SYNTHROID TAB 112MCG LEVOTHYROXINE SODIUM TAB 112 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - SYNTHROID TAB 125MCG LEVOTHYROXINE SODIUM TAB 125 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - SYNTHROID TAB 137MCG LEVOTHYROXINE SODIUM TAB 137 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - SYNTHROID TAB 150MCG LEVOTHYROXINE SODIUM TAB 150 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - SYNTHROID TAB 175MCG LEVOTHYROXINE SODIUM TAB 175 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - SYNTHROID TAB 200MCG LEVOTHYROXINE SODIUM TAB 200 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - SYNTHROID TAB 25MCG LEVOTHYROXINE SODIUM TAB 25 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - SYNTHROID TAB 300MCG LEVOTHYROXINE SODIUM TAB 300 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - SYNTHROID TAB 50MCG LEVOTHYROXINE SODIUM TAB 50 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - SYNTHROID TAB 75MCG LEVOTHYROXINE SODIUM TAB 75 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - SYNTHROID TAB 88MCG LEVOTHYROXINE SODIUM TAB 88 MCG Tier 2 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - THYROLAR-1 TAB 60MG LIOTRIX (T3-T4) TAB 60 MG (12.5-50 MCG) Tier 3 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - THYROLAR-1/2 TAB 30MG LIOTRIX (T3-T4) TAB 30 MG (6.25-25 MCG) Tier 3 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - THYROLAR-1/4 TAB 15MG LIOTRIX (T3-T4) TAB 15 MG (3.1-12.5 MCG) Tier 3 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ LIOTRIX (T3-T4) TAB 120 MG (25-100 Replacement/Modifying (Thyroid) - THYROLAR-2 TAB 120MG Tier 3 MCG) Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ LIOTRIX (T3-T4) TAB 180 MG (37.5-150 Replacement/Modifying (Thyroid) - THYROLAR-3 TAB 180MG Tier 3 MCG) Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITH DIRECT TAB 100MCG LEVOTHYROXINE SODIUM TAB 100 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITH DIRECT TAB 112MCG LEVOTHYROXINE SODIUM TAB 112 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITH DIRECT TAB 125MCG LEVOTHYROXINE SODIUM TAB 125 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITH DIRECT TAB 150MCG LEVOTHYROXINE SODIUM TAB 150 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITH DIRECT TAB 175MCG LEVOTHYROXINE SODIUM TAB 175 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITH DIRECT TAB 200MCG LEVOTHYROXINE SODIUM TAB 200 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITH DIRECT TAB 25MCG LEVOTHYROXINE SODIUM TAB 25 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITH DIRECT TAB 300MCG LEVOTHYROXINE SODIUM TAB 300 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITH DIRECT TAB 50MCG LEVOTHYROXINE SODIUM TAB 50 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITH DIRECT TAB 75MCG LEVOTHYROXINE SODIUM TAB 75 MCG Tier 1 Drugs to Replace Thyroid Hormones

150 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITH DIRECT TAB 88MCG LEVOTHYROXINE SODIUM TAB 88 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITHROID TAB 100MCG LEVOTHYROXINE SODIUM TAB 100 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITHROID TAB 112MCG LEVOTHYROXINE SODIUM TAB 112 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITHROID TAB 125MCG LEVOTHYROXINE SODIUM TAB 125 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITHROID TAB 137MCG LEVOTHYROXINE SODIUM TAB 137 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITHROID TAB 150MCG LEVOTHYROXINE SODIUM TAB 150 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITHROID TAB 175MCG LEVOTHYROXINE SODIUM TAB 175 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITHROID TAB 200MCG LEVOTHYROXINE SODIUM TAB 200 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITHROID TAB 25MCG LEVOTHYROXINE SODIUM TAB 25 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITHROID TAB 300MCG LEVOTHYROXINE SODIUM TAB 300 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITHROID TAB 50MCG LEVOTHYROXINE SODIUM TAB 50 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITHROID TAB 75MCG LEVOTHYROXINE SODIUM TAB 75 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) - UNITHROID TAB 88MCG LEVOTHYROXINE SODIUM TAB 88 MCG Tier 1 Drugs to Replace Thyroid Hormones Hormonal Agents, Suppressant (Adrenal) LYSODREN TAB 500MG MITOTANE TAB 500 MG Tier 2 - Drugs to Regulate Hormones Hormonal Agents, Suppressant CINACALCET HCL TAB 30 MG (BASE (Parathyroid) - Drugs to Regulate SENSIPAR TAB 30MG Tier 4 X EQUIV) Hormones Hormonal Agents, Suppressant CINACALCET HCL TAB 60 MG (BASE (Parathyroid) - Drugs to Regulate SENSIPAR TAB 60MG Tier 4 X EQUIV) Hormones Hormonal Agents, Suppressant CINACALCET HCL TAB 90 MG (BASE (Parathyroid) - Drugs to Regulate SENSIPAR TAB 90MG Tier 4 X EQUIV) Hormones Hormonal Agents, Suppressant CABERGOLINE TAB 0.5MG CABERGOLINE TAB 0.5 MG Tier 2 (Pituitary) - Drugs to Regulate Hormones Hormonal Agents, Suppressant TESAMORELIN ACETATE FOR INJ 1 MG EGRIFTA SOL 1MG Tier 4 X X (Pituitary) - Drugs to Regulate Hormones (BASE EQUIV) Hormonal Agents, Suppressant LEUPROLIDE ACETATE (3 MONTH) FOR ELIGARD INJ 22.5MG Tier 3 X (Pituitary) - Drugs to Regulate Hormones SUBCUTANEOUS INJ KIT 22.5MG Hormonal Agents, Suppressant LEUPROLIDE ACETATE (4 MONTH) FOR ELIGARD INJ 30MG Tier 3 X (Pituitary) - Drugs to Regulate Hormones SUBCUTANEOUS INJ KIT 30 MG Hormonal Agents, Suppressant LEUPROLIDE ACETATE (6 MONTH) FOR ELIGARD INJ 45MG Tier 3 X (Pituitary) - Drugs to Regulate Hormones SUBCUTANEOUS INJ KIT 45 MG Hormonal Agents, Suppressant LEUPROLIDE ACETATE FOR ELIGARD INJ 7.5MG Tier 3 X (Pituitary) - Drugs to Regulate Hormones SUBCUTANEOUS INJ KIT 7.5 MG Hormonal Agents, Suppressant DEGARELIX ACETATE FOR INJ 120 MG FIRMAGON INJ 120MG Tier 3 X (Pituitary) - Drugs to Regulate Hormones (BASE EQUIV) Hormonal Agents, Suppressant DEGARELIX ACETATE FOR INJ 80 MG FIRMAGON INJ 80MG Tier 3 X (Pituitary) - Drugs to Regulate Hormones (BASE EQUIV) Hormonal Agents, Suppressant LEUPROLIDE INJ 1MG/0.2 LEUPROLIDE ACETATE INJ KIT 5 MG/ML Tier 1 X (Pituitary) - Drugs to Regulate Hormones Hormonal Agents, Suppressant OCTREOTIDE ACETATE INJ 1000 MCG/ OCTREOTIDE INJ 1000MCG Tier 1 X X (Pituitary) - Drugs to Regulate Hormones ML (1 MG/ML) Hormonal Agents, Suppressant OCTREOTIDE ACETATE INJ 100 MCG/ML OCTREOTIDE INJ 100MCG Tier 1 X X (Pituitary) - Drugs to Regulate Hormones (0.1 MG/ML) Hormonal Agents, Suppressant OCTREOTIDE ACETATE INJ 200 MCG/ML OCTREOTIDE INJ 200MCG Tier 1 X X (Pituitary) - Drugs to Regulate Hormones (0.2 MG/ML) Hormonal Agents, Suppressant OCTREOTIDE ACETATE INJ 500 MCG/ML OCTREOTIDE INJ 500MCG Tier 1 X X (Pituitary) - Drugs to Regulate Hormones (0.5 MG/ML) Hormonal Agents, Suppressant OCTREOTIDE INJ 50MCG/ OCTREOTIDE ACETATE INJ 50 MCG/ML Tier 1 X X (Pituitary) - Drugs to Regulate Hormones ML (0.05 MG/ML)

151 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Suppressant PASIREOTIDE DIASPARTATE INJ 0.3 MG/ SIGNIFOR INJ 0.3MG/ML Tier 2 X X X (Pituitary) - Drugs to Regulate Hormones ML (BASE EQUIV) Hormonal Agents, Suppressant PASIREOTIDE DIASPARTATE INJ 0.6 MG/ SIGNIFOR INJ 0.6MG/ML Tier 2 X X X (Pituitary) - Drugs to Regulate Hormones ML (BASE EQUIV) Hormonal Agents, Suppressant PASIREOTIDE DIASPARTATE INJ 0.9 MG/ SIGNIFOR INJ 0.9MG/ML Tier 2 X X X (Pituitary) - Drugs to Regulate Hormones ML (BASE EQUIV) Hormonal Agents, Suppressant LANREOTIDE ACETATE EXTENDED SOMATULINE INJ 120/.5ML Tier 4 X (Pituitary) - Drugs to Regulate Hormones RELEASE INJ 120 MG/0.5ML Hormonal Agents, Suppressant LANREOTIDE ACETATE EXTENDED SOMATULINE INJ 60/0.2ML Tier 4 X (Pituitary) - Drugs to Regulate Hormones RELEASE INJ 60 MG/0.2ML Hormonal Agents, Suppressant LANREOTIDE ACETATE EXTENDED SOMATULINE INJ 90/0.3ML Tier 4 X (Pituitary) - Drugs to Regulate Hormones RELEASE INJ 90 MG/0.3ML Hormonal Agents, Suppressant PEGVISOMANT FOR INJ 10 MG (AS SOMAVERT INJ 10MG Tier 3 X X X (Pituitary) - Drugs to Regulate Hormones PROTEIN) Hormonal Agents, Suppressant PEGVISOMANT FOR INJ 15 MG (AS SOMAVERT INJ 15MG Tier 3 X X X (Pituitary) - Drugs to Regulate Hormones PROTEIN) Hormonal Agents, Suppressant PEGVISOMANT FOR INJ 20 MG (AS SOMAVERT INJ 20MG Tier 3 X X X (Pituitary) - Drugs to Regulate Hormones PROTEIN) Hormonal Agents, Suppressant PEGVISOMANT FOR INJ 25 MG (AS SOMAVERT INJ 25MG Tier 3 X X X (Pituitary) - Drugs to Regulate Hormones PROTEIN) Hormonal Agents, Suppressant PEGVISOMANT FOR INJ 30 MG (AS SOMAVERT INJ 30MG Tier 3 X X X (Pituitary) - Drugs to Regulate Hormones PROTEIN) Hormonal Agents, Suppressant NAFARELIN ACETATE NASAL SOLN 2 SYNAREL SOL 2MG/ML Tier 2 (Pituitary) - Drugs to Regulate Hormones MG/ML (200 MCG/ACT) (BASE EQ) Hormonal Agents, Suppressant (Thyroid) ARMOUR THYRO TAB THYROID TAB 120 MG (2 GRAIN) Tier 3 - Drugs to Suppress Thyroid Hormones 120MG Hormonal Agents, Suppressant (Thyroid) ARMOUR THYRO TAB 15MG THYROID TAB 15 MG (1/4 GRAIN) Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) ARMOUR THYRO TAB THYROID TAB 180 MG (3 GRAIN) Tier 3 - Drugs to Suppress Thyroid Hormones 180MG Hormonal Agents, Suppressant (Thyroid) ARMOUR THYRO TAB THYROID TAB 240 MG (4 GRAIN) Tier 3 - Drugs to Suppress Thyroid Hormones 240MG Hormonal Agents, Suppressant (Thyroid) ARMOUR THYRO TAB THYROID TAB 300 MG (5 GRAIN) Tier 3 - Drugs to Suppress Thyroid Hormones 300MG Hormonal Agents, Suppressant (Thyroid) ARMOUR THYRO TAB 30MG THYROID TAB 30 MG (1/2 GRAIN) Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) ARMOUR THYRO TAB 60MG THYROID TAB 60 MG (1 GRAIN) Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) ARMOUR THYRO TAB 90MG THYROID TAB 90 MG (1 1/2 GRAIN) Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) DINOPROSTONE VAGINAL INSERTS 10 CERVIDIL VAG MIS 10MG INS Tier 3 - Drugs to Suppress Thyroid Hormones MG Hormonal Agents, Suppressant (Thyroid) LEVO/LIOTHYR TAB 120MG THYROID TAB 120 MG (2 GRAIN) Tier 1 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) LEVO/LIOTHYR TAB 15MG THYROID TAB 15 MG (1/4 GRAIN) Tier 1 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) LEVO/LIOTHYR TAB 30MG THYROID TAB 30 MG (1/2 GRAIN) Tier 1 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) LEVO/LIOTHYR TAB 60MG THYROID TAB 60 MG (1 GRAIN) Tier 1 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) LEVO/LIOTHYR TAB 90MG THYROID TAB 90 MG (1 1/2 GRAIN) Tier 1 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) METHIMAZOLE TAB 10MG METHIMAZOLE TAB 10 MG Tier 1 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) METHIMAZOLE TAB 5MG METHIMAZOLE TAB 5 MG Tier 1 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) NATURE THROI TAB THYROID TAB 162.5 MG (2 1/2 GRAIN) Tier 3 - Drugs to Suppress Thyroid Hormones 162.5MG Hormonal Agents, Suppressant (Thyroid) NATURE-THROI TAB THYROID TAB 113.75 MG Tier 3 - Drugs to Suppress Thyroid Hormones 113.75MG Hormonal Agents, Suppressant (Thyroid) NATURE-THROI TAB 130MG THYROID TAB 130 MG Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) NATURE-THROI TAB THYROID TAB 146.25 MG Tier 3 - Drugs to Suppress Thyroid Hormones 146.25MG Hormonal Agents, Suppressant (Thyroid) NATURE-THROI TAB THYROID TAB 16.25 MG Tier 3 - Drugs to Suppress Thyroid Hormones 16.25MG Hormonal Agents, Suppressant (Thyroid) NATURE-THROI TAB 195MG THYROID TAB 195 MG Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) NATURE-THROI TAB 260MG THYROID TAB 260 MG Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) NATURE-THROI TAB 32.5MG THYROID TAB 32.5 MG Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) NATURE-THROI TAB 325MG THYROID TAB 325 MG (5 GRAIN) Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) NATURE-THROI TAB THYROID TAB 48.75 MG (3/4 GRAIN) Tier 3 - Drugs to Suppress Thyroid Hormones 48.75MG Hormonal Agents, Suppressant (Thyroid) NATURE-THROI TAB 65MG THYROID TAB 65 MG Tier 3 - Drugs to Suppress Thyroid Hormones

152 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Hormonal Agents, Suppressant (Thyroid) NATURE-THROI TAB THYROID TAB 81.25 MG Tier 3 - Drugs to Suppress Thyroid Hormones 81.25MG Hormonal Agents, Suppressant (Thyroid) NATURE-THROI TAB 97.5MG THYROID TAB 97.5 MG Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) NP THYROID TAB 120MG THYROID TAB 120 MG (2 GRAIN) Tier 1 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) NP THYROID TAB 15MG THYROID TAB 15 MG (1/4 GRAIN) Tier 1 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) NP THYROID TAB 30MG THYROID TAB 30 MG (1/2 GRAIN) Tier 1 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) NP THYROID TAB 60MG THYROID TAB 60 MG (1 GRAIN) Tier 1 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) NP THYROID TAB 90MG THYROID TAB 90 MG (1 1/2 GRAIN) Tier 1 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) DINOPROSTONE CERVICAL GEL 0.5 PREPIDIL GEL 0.5MG/3G Tier 3 - Drugs to Suppress Thyroid Hormones MG/3GM Hormonal Agents, Suppressant (Thyroid) PROPYLTHIOUR TAB 50MG PROPYLTHIOURACIL TAB 50 MG Tier 1 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) DINOPROSTONE VAGINAL SUPPOS 20 PROSTIN E2 SUP 20MG Tier 3 - Drugs to Suppress Thyroid Hormones MG Hormonal Agents, Suppressant (Thyroid) TAPAZOLE TAB 10MG METHIMAZOLE TAB 10 MG Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) TAPAZOLE TAB 5MG METHIMAZOLE TAB 5 MG Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) WESTHROID TAB 130MG THYROID TAB 130 MG Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) WESTHROID TAB 195MG THYROID TAB 195 MG Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) WESTHROID TAB 32.5MG THYROID TAB 32.5 MG Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) WESTHROID TAB 65MG THYROID TAB 65 MG Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) WESTHROID TAB 97.5MG THYROID TAB 97.5 MG Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) WP THYROID TAB 113.75MG THYROID TAB 113.75 MG Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) WP THYROID TAB 130MG THYROID TAB 130 MG Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) WP THYROID TAB 16.25MG THYROID TAB 16.25 MG Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) WP THYROID TAB 32.5MG THYROID TAB 32.5 MG Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) WP THYROID TAB 48.75MG THYROID TAB 48.75 MG (3/4 GRAIN) Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) WP THYROID TAB 65MG THYROID TAB 65 MG Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) WP THYROID TAB 81.25MG THYROID TAB 81.25 MG Tier 3 - Drugs to Suppress Thyroid Hormones Hormonal Agents, Suppressant (Thyroid) WP THYROID TAB 97.5MG THYROID TAB 97.5 MG Tier 3 - Drugs to Suppress Thyroid Hormones METHOTREXATE SOLN PF AUTO- Immunological Agents RASUVO INJ 12.5MG Tier 3 X X INJECTOR 12.5 MG/0.25ML METHOTREXATE SOLN PF AUTO- Immunological Agents RASUVO INJ 15MG Tier 3 X X INJECTOR 15 MG/0.3ML METHOTREXATE SOLN PF AUTO- Immunological Agents RASUVO INJ 17.5MG Tier 3 X X INJECTOR 17.5 MG/0.35ML METHOTREXATE SOLN PF AUTO- Immunological Agents RASUVO INJ 20MG Tier 3 X X INJECTOR 20 MG/0.4ML METHOTREXATE SOLN PF AUTO- Immunological Agents RASUVO INJ 22.5MG Tier 3 X X INJECTOR 22.5 MG/0.45ML METHOTREXATE SOLN PF AUTO- Immunological Agents RASUVO INJ 25MG Tier 3 X X INJECTOR 25 MG/0.5ML METHOTREXATE SOLN PF AUTO- Immunological Agents RASUVO INJ 27.5MG Tier 3 X X INJECTOR 27.5 MG/0.55ML METHOTREXATE SOLN PF AUTO- Immunological Agents RASUVO INJ 30MG Tier 3 X X INJECTOR 30 MG/0.6ML METHOTREXATE SOLN PF AUTO- Immunological Agents RASUVO INJ 7.5MG Tier 3 X X INJECTOR 7.5 MG/0.15ML Immunological Agents - Drugs that TOCILIZUMAB SUBCUTANEOUS SOLN Stimulate or Suppress the Immune ACTEMRA INJ 162/0.9 Tier 3 X X X X PREFILLED SYRINGE 162 MG/0.9ML System Immunological Agents - Drugs that INTERFERON GAMMA-1B INJ 100 Stimulate or Suppress the Immune ACTIMMUNE INJ 2MU/0.5 Tier 2 X X X MCG/0.5ML (2000000 UNIT/0.5ML) System Immunological Agents - Drugs that INTERFERON ALFA-N3 INJ 5000000 Stimulate or Suppress the Immune ALFERON N INJ 5MU/ML Tier 2 X UNIT/ML System

153 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Immunological Agents - Drugs that Stimulate or Suppress the Immune ARAVA TAB 10MG LEFLUNOMIDE TAB 10 MG Tier 3 System Immunological Agents - Drugs that Stimulate or Suppress the Immune ARAVA TAB 20MG LEFLUNOMIDE TAB 20 MG Tier 3 System Immunological Agents - Drugs that Stimulate or Suppress the Immune ARCALYST INJ 220MG RILONACEPT FOR INJ 220 MG Tier 2 X X X System Immunological Agents - Drugs that Stimulate or Suppress the Immune AZASAN TAB 100MG AZATHIOPRINE TAB 100 MG Tier 3 System Immunological Agents - Drugs that Stimulate or Suppress the Immune AZASAN TAB 75 MG AZATHIOPRINE TAB 75 MG Tier 3 System Immunological Agents - Drugs that Stimulate or Suppress the Immune AZATHIOPRINE TAB 50MG AZATHIOPRINE TAB 50 MG Tier 1 System Immunological Agents - Drugs that BELIMUMAB SUBCUTANEOUS Stimulate or Suppress the Immune BENLYSTA INJ 200MG/ML Tier 2 X X X SOLUTION AUTO-INJECTOR 200 MG/ML System Immunological Agents - Drugs that BELIMUMAB SUBCUTANEOUS Stimulate or Suppress the Immune BENLYSTA INJ 200MG/ML SOLUTION PREFILLED SYRINGE 200 Tier 2 X X X System MG/ML Immunological Agents - Drugs that C1 ESTERASE INHIBITOR (HUMAN) FOR Stimulate or Suppress the Immune BERINERT INJ 500UNIT Tier 2 X X X IV INJ KIT 500 UNIT System Immunological Agents - Drugs that CERTOLIZUMAB PEGOL FOR INJ KIT 2 X Stimulate or Suppress the Immune CIMZIA KIT Tier 2 X X X 200 MG System Immunological Agents - Drugs that CERTOLIZUMAB PEGOL INJ KIT 6 X 200 Stimulate or Suppress the Immune CIMZIA KIT STARTER Tier 2 X X X MG/ML System Immunological Agents - Drugs that CIMZIA PREFL KIT 200MG/ CERTOLIZUMAB PEGOL INJ KIT 2 X 200 Stimulate or Suppress the Immune Tier 2 X X X ML MG/ML System Immunological Agents - Drugs that C1 ESTERASE INHIBITOR (HUMAN) FOR Stimulate or Suppress the Immune CINRYZE SOL 500 UNIT Tier 3 X X X IV INJ 500 UNIT System Immunological Agents - Drugs that Stimulate or Suppress the Immune CYCLOSPORINE CAP 100MG CYCLOSPORINE CAP 100 MG Tier 1 X System Immunological Agents - Drugs that CYCLOSPORINE CAP Stimulate or Suppress the Immune CYCLOSPORINE MODIFIED CAP 100 MG Tier 1 X 100MG MD System Immunological Agents - Drugs that Stimulate or Suppress the Immune CYCLOSPORINE CAP 25MG CYCLOSPORINE CAP 25 MG Tier 1 X System Immunological Agents - Drugs that CYCLOSPORINE CAP 25MG Stimulate or Suppress the Immune CYCLOSPORINE MODIFIED CAP 25 MG Tier 1 X MOD System Immunological Agents - Drugs that CYCLOSPORINE CAP 50MG Stimulate or Suppress the Immune CYCLOSPORINE MODIFIED CAP 50 MG Tier 1 X MOD System Immunological Agents - Drugs that CYCLOSPORINE SOL CYCLOSPORINE MODIFIED ORAL SOLN Stimulate or Suppress the Immune Tier 1 MODIFIED 100 MG/ML System Immunological Agents - Drugs that ETANERCEPT SUBCUTANEOUS SOLN Stimulate or Suppress the Immune ENBREL INJ 25/0.5ML Tier 4 X X X X PREFILLED SYRINGE 25 MG/0.5ML System Immunological Agents - Drugs that ETANERCEPT FOR SUBCUTANEOUS INJ Stimulate or Suppress the Immune ENBREL INJ 25MG Tier 4 X X X X 25 MG System Immunological Agents - Drugs that ETANERCEPT SUBCUTANEOUS SOLN Stimulate or Suppress the Immune ENBREL INJ 50MG/ML Tier 4 X X X X PREFILLED SYRINGE 50 MG/ML System Immunological Agents - Drugs that ETANERCEPT SUBCUTANEOUS Stimulate or Suppress the Immune ENBREL MINI INJ 50MG/ML Tier 3 X X X SOLUTION CARTRIDGE 50 MG/ML System Immunological Agents - Drugs that ENBREL SRCLK INJ 50MG/ ETANERCEPT SUBCUTANEOUS Stimulate or Suppress the Immune Tier 4 X X X X ML SOLUTION AUTO-INJECTOR 50 MG/ML System Immunological Agents - Drugs that ICATIBANT ACETATE INJ 30 MG/3ML Stimulate or Suppress the Immune FIRAZYR INJ 30MG/3ML Tier 4 X X X (BASE EQUIVALENT) System Immunological Agents - Drugs that Stimulate or Suppress the Immune GENGRAF CAP 100MG CYCLOSPORINE MODIFIED CAP 100 MG Tier 1 X System

154 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Immunological Agents - Drugs that Stimulate or Suppress the Immune GENGRAF CAP 25MG CYCLOSPORINE MODIFIED CAP 25 MG Tier 1 X System Immunological Agents - Drugs that Stimulate or Suppress the Immune GENGRAF CAP 50MG CYCLOSPORINE MODIFIED CAP 50 MG Tier 1 X System Immunological Agents - Drugs that CYCLOSPORINE MODIFIED ORAL SOLN Stimulate or Suppress the Immune GENGRAF SOL 100MG/ML Tier 1 100 MG/ML System Immunological Agents - Drugs that C1 ESTERASE INHIBITOR (HUMAN) FOR Stimulate or Suppress the Immune HAEGARDA INJ 2000UNIT Tier 2 X X X SUBCUTANEOUS INJ 2000 UNIT System Immunological Agents - Drugs that C1 ESTERASE INHIBITOR (HUMAN) FOR Stimulate or Suppress the Immune HAEGARDA INJ 3000UNIT Tier 2 X X X SUBCUTANEOUS INJ 3000 UNIT System Immunological Agents - Drugs that ADALIMUMAB PREFILLED SYRINGE KIT Stimulate or Suppress the Immune HUMIRA INJ 10MG/0.2 Tier 2 X X X 10 MG/0.2ML System Immunological Agents - Drugs that ADALIMUMAB PREFILLED SYRINGE KIT Stimulate or Suppress the Immune HUMIRA KIT 20MG/0.4 Tier 2 X X X 20 MG/0.4ML System Immunological Agents - Drugs that ADALIMUMAB PREFILLED SYRINGE KIT Stimulate or Suppress the Immune HUMIRA KIT 40MG/0.8 Tier 2 X X X 40 MG/0.8ML System Immunological Agents - Drugs that ADALIMUMAB PREFILLED SYRINGE KIT Stimulate or Suppress the Immune HUMIRA PEDIA INJ CROHNS Tier 2 X X X 40 MG/0.8ML System Immunological Agents - Drugs that ADALIMUMAB PEN-INJECTOR KIT 40 Stimulate or Suppress the Immune HUMIRA PEN INJ 40MG/0.8 Tier 2 X X X MG/0.8ML System Immunological Agents - Drugs that ADALIMUMAB PEN-INJECTOR KIT 40 Stimulate or Suppress the Immune HUMIRA PEN INJ CROHNS Tier 2 X X X MG/0.8ML System Immunological Agents - Drugs that ADALIMUMAB PEN-INJECTOR KIT 40 Stimulate or Suppress the Immune HUMIRA PEN INJ PSORIASI Tier 2 X X X MG/0.8ML System Immunological Agents - Drugs that SARILUMAB SUBCUTANEOUS SOLN Stimulate or Suppress the Immune KEVZARA INJ 150/1.14 Tier 3 X X X X PREFILLED SYRINGE 150 MG/1.14ML System Immunological Agents - Drugs that SARILUMAB SUBCUTANEOUS SOLN Stimulate or Suppress the Immune KEVZARA INJ 200/1.14 Tier 3 X X X X PREFILLED SYRINGE 200 MG/1.14ML System Immunological Agents - Drugs that ANAKINRA SUBCUTANEOUS SOLN Stimulate or Suppress the Immune KINERET INJ Tier 3 X X X PREFILLED SYRINGE 100 MG/0.67ML System Immunological Agents - Drugs that Stimulate or Suppress the Immune LEFLUNOMIDE TAB 10MG LEFLUNOMIDE TAB 10 MG Tier 1 System Immunological Agents - Drugs that Stimulate or Suppress the Immune LEFLUNOMIDE TAB 20MG LEFLUNOMIDE TAB 20 MG Tier 1 System Immunological Agents - Drugs that Stimulate or Suppress the Immune METHOTREXATE POW METHOTREXATE POWDER Tier 3 System Immunological Agents - Drugs that METHOTREXATE SODIUM TAB 2.5 MG Stimulate or Suppress the Immune METHOTREXATE TAB 2.5MG Tier 1 (BASE EQUIV) System Immunological Agents - Drugs that MYCOPHENOLAT CAP MYCOPHENOLATE MOFETIL CAP 250 Stimulate or Suppress the Immune Tier 1 X 250MG MG System Immunological Agents - Drugs that MYCOPHENOLAT SUS MYCOPHENOLATE MOFETIL FOR ORAL Stimulate or Suppress the Immune Tier 1 200MG/ML SUSP 200 MG/ML System Immunological Agents - Drugs that MYCOPHENOLAT TAB Stimulate or Suppress the Immune MYCOPHENOLATE MOFETIL TAB 500 MG Tier 1 X 500MG System Immunological Agents - Drugs that MYCOPHENOLIC TAB MYCOPHENOLATE SODIUM TAB DR 180 Stimulate or Suppress the Immune Tier 2 X 180MG DR MG (MYCOPHENOLIC ACID EQUIV) System Immunological Agents - Drugs that MYCOPHENOLIC TAB MYCOPHENOLATE SODIUM TAB DR 360 Stimulate or Suppress the Immune Tier 2 X 360MG DR MG (MYCOPHENOLIC ACID EQUIV) System Immunological Agents - Drugs that ABATACEPT SUBCUTANEOUS SOLN Stimulate or Suppress the Immune ORENCIA INJ 125MG/ML Tier 4 X X X X PREFILLED SYRINGE 125 MG/ML System Immunological Agents - Drugs that ABATACEPT SUBCUTANEOUS SOLN Stimulate or Suppress the Immune ORENCIA INJ 50/0.4 Tier 4 X X X PREFILLED SYRINGE 50 MG/0.4ML System

155 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Immunological Agents - Drugs that ABATACEPT SUBCUTANEOUS SOLN Stimulate or Suppress the Immune ORENCIA INJ 87.5/0.7 Tier 4 X X X PREFILLED SYRINGE 87.5 MG/0.7ML System Immunological Agents - Drugs that ORENCIA CLCK INJ 125MG/ ABATACEPT SUBCUTANEOUS SOLN Stimulate or Suppress the Immune Tier 4 X X X X ML AUTO-INJECTOR 125 MG/ML System Immunological Agents - Drugs that APREMILAST TAB STARTER THERAPY Stimulate or Suppress the Immune OTEZLA TAB 10/20/30 Tier 4 X X X PACK 10 MG & 20 MG & 30 MG System Immunological Agents - Drugs that Stimulate or Suppress the Immune OTEZLA TAB 30MG APREMILAST TAB 30 MG Tier 4 X X X System Immunological Agents - Drugs that Stimulate or Suppress the Immune RAPAMUNE SOL 1MG/ML SIROLIMUS ORAL SOLN 1 MG/ML Tier 2 X System Immunological Agents - Drugs that METHOTREXATE SOLN PF AUTO- Stimulate or Suppress the Immune RASUVO INJ 10MG Tier 3 X X INJECTOR 10 MG/0.2ML System Immunological Agents - Drugs that METHOTREXATE SODIUM TAB 2.5 MG Stimulate or Suppress the Immune RHEUMATREX TAB 2.5MG Tier 2 (ANTIRHEUMATIC) System Immunological Agents - Drugs that Stimulate or Suppress the Immune RIDAURA CAP 3MG AURANOFIN CAP 3 MG Tier 3 System Immunological Agents - Drugs that SANDIMMUNE SOL 100MG/ Stimulate or Suppress the Immune CYCLOSPORINE ORAL SOLN 100 MG/ML Tier 3 ML System Immunological Agents - Drugs that BRODALUMAB SUBCUTANEOUS SOLN Stimulate or Suppress the Immune SILIQ INJ 210/1.5 Tier 3 X X X PREFILLED SYRINGE 210 MG/1.5ML System Immunological Agents - Drugs that GOLIMUMAB SUBCUTANEOUS SOLN Stimulate or Suppress the Immune SIMPONI INJ 100MG/ML Tier 2 X X X PREFILLED SYRINGE 100 MG/ML System Immunological Agents - Drugs that GOLIMUMAB SUBCUTANEOUS SOLN Stimulate or Suppress the Immune SIMPONI INJ 100MG/ML Tier 2 X X X AUTO-INJECTOR 100 MG/ML System Immunological Agents - Drugs that GOLIMUMAB SUBCUTANEOUS SOLN Stimulate or Suppress the Immune SIMPONI INJ 50/0.5ML Tier 2 X X X PREFILLED SYRINGE 50 MG/0.5ML System Immunological Agents - Drugs that GOLIMUMAB SUBCUTANEOUS SOLN Stimulate or Suppress the Immune SIMPONI INJ 50/0.5ML Tier 2 X X X AUTO-INJECTOR 50 MG/0.5ML System Immunological Agents - Drugs that Stimulate or Suppress the Immune SIROLIMUS TAB 0.5MG SIROLIMUS TAB 0.5 MG Tier 1 X System Immunological Agents - Drugs that Stimulate or Suppress the Immune SIROLIMUS TAB 1MG SIROLIMUS TAB 1 MG Tier 1 X System Immunological Agents - Drugs that Stimulate or Suppress the Immune SIROLIMUS TAB 2MG SIROLIMUS TAB 2 MG Tier 1 X System Immunological Agents - Drugs that Stimulate or Suppress the Immune TACROLIMUS CAP 0.5MG TACROLIMUS CAP 0.5 MG Tier 1 X System Immunological Agents - Drugs that Stimulate or Suppress the Immune TACROLIMUS CAP 1MG TACROLIMUS CAP 1 MG Tier 1 X System Immunological Agents - Drugs that Stimulate or Suppress the Immune TACROLIMUS CAP 5MG TACROLIMUS CAP 5 MG Tier 1 X System Immunological Agents - Drugs that GUSELKUMAB SOLN PREFILLED Stimulate or Suppress the Immune TREMFYA INJ 100MG/ML Tier 2 X X X SYRINGE 100 MG/ML System Immunological Agents - Drugs that METHOTREXATE SODIUM TAB 10 MG Stimulate or Suppress the Immune TREXALL TAB 10MG Tier 2 (BASE EQUIV) System Immunological Agents - Drugs that METHOTREXATE SODIUM TAB 15 MG Stimulate or Suppress the Immune TREXALL TAB 15MG Tier 2 (BASE EQUIV) System Immunological Agents - Drugs that METHOTREXATE SODIUM TAB 5 MG Stimulate or Suppress the Immune TREXALL TAB 5MG Tier 2 (BASE EQUIV) System Immunological Agents - Drugs that METHOTREXATE SODIUM TAB 7.5 MG Stimulate or Suppress the Immune TREXALL TAB 7.5MG Tier 2 (BASE EQUIV) System Immunological Agents - Drugs that Stimulate or Suppress the Immune XATMEP SOL 2.5MG/ML METHOTREXATE ORAL SOLN 2.5 MG/ML Tier 3 X X System

156 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Immunological Agents - Drugs that TOFACITINIB CITRATE TAB 5 MG (BASE Stimulate or Suppress the Immune XELJANZ TAB 5MG Tier 3 X X X X EQUIVALENT) System Immunological Agents - Drugs that TOFACITINIB CITRATE TAB ER 24HR 11 Stimulate or Suppress the Immune XELJANZ XR TAB 11MG Tier 3 X X X X MG (BASE EQUIVALENT) System Immunological Agents - Drugs that Stimulate or Suppress the Immune ZORTRESS TAB 0.25MG EVEROLIMUS TAB 0.25 MG Tier 3 X System Immunological Agents - Drugs that Stimulate or Suppress the Immune ZORTRESS TAB 0.5MG EVEROLIMUS TAB 0.5 MG Tier 3 X System Immunological Agents - Drugs that Stimulate or Suppress the Immune ZORTRESS TAB 0.75MG EVEROLIMUS TAB 0.75 MG Tier 3 X System Inflammatory Bowel Disease Agents *HC-PRAMOXINE EMOL CREAM 2.5-1% & - Drugs to Treat Inflammatory Bowel ANALPRAM E KIT Tier 3 X PRAMOXINE WIPE 1% KIT*** Disease Inflammatory Bowel Disease Agents HYDROCORTISONE ACETATE W/ - Drugs to Treat Inflammatory Bowel ANALPRAM HC CRE 2.5-1% Tier 3 PRAMOXINE RECTAL CREAM 2.5-1% Disease Inflammatory Bowel Disease Agents HYDROCORTISONE ACETATE W/ - Drugs to Treat Inflammatory Bowel ANALPRAM-HC CRE 1-1% Tier 3 PRAMOXINE RECTAL CREAM 1-1% Disease Inflammatory Bowel Disease Agents HYDROCORTISONE ACETATE W/ - Drugs to Treat Inflammatory Bowel ANALPRAM-HC LOT 2.5% Tier 3 PRAMOXINE RECTAL LOTN 2.5-1% Disease Inflammatory Bowel Disease Agents ANALPRM SNGL CRE HC HYDROCORTISONE ACETATE W/ - Drugs to Treat Inflammatory Bowel Tier 3 2.5-1 PRAMOXINE RECTAL CREAM 2.5-1% Disease Inflammatory Bowel Disease Agents HYDROCORTISONE RECTAL CREAM - Drugs to Treat Inflammatory Bowel ANUSOL-HC CRE 2.5% Tier 3 2.5% Disease Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel APRISO CAP 0.375GM MESALAMINE CAP ER 24HR 0.375 GM Tier 2 Disease Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel AZULFIDINE TAB 500MG SULFASALAZINE TAB 500 MG Tier 3 Disease Inflammatory Bowel Disease Agents SULFASALAZINE TAB DELAYED - Drugs to Treat Inflammatory Bowel AZULFIDINE TAB 500MG EN Tier 3 RELEASE 500 MG Disease Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel BALSALAZIDE CAP 750MG BALSALAZIDE DISODIUM CAP 750 MG Tier 1 Disease Inflammatory Bowel Disease Agents BUDESONIDE DELAYED RELEASE - Drugs to Treat Inflammatory Bowel BUDESONIDE CAP 3MG DR Tier 2 PARTICLES CAP 3 MG Disease Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel CANASA SUP 1000MG MESALAMINE SUPPOS 1000 MG Tier 2 Disease Inflammatory Bowel Disease Agents HYDROCORTISONE ENEMA 100 - Drugs to Treat Inflammatory Bowel COLOCORT ENE 100MG Tier 1 MG/60ML Disease Inflammatory Bowel Disease Agents HYDROCORTISONE ENEMA 100 - Drugs to Treat Inflammatory Bowel CORTENEMA ENE 100MG Tier 3 MG/60ML Disease Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel DIPENTUM CAP 250MG OLSALAZINE SODIUM CAP 250 MG Tier 3 Disease Inflammatory Bowel Disease Agents HYDROCORTISONE ACETATE W/ - Drugs to Treat Inflammatory Bowel HC PRAMOXINE CRE 1-1% Tier 1 PRAMOXINE RECTAL CREAM 1-1% Disease Inflammatory Bowel Disease Agents HYDROCORTISONE ACETATE W/ - Drugs to Treat Inflammatory Bowel HC PRAMOXINE CRE 2.5-1% Tier 1 PRAMOXINE RECTAL CREAM 2.5-1% Disease Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel HYDROCORT CRE 1% HYDROCORTISONE RECTAL CREAM 1% Tier 1 Disease Inflammatory Bowel Disease Agents HYDROCORTISONE ENEMA 100 - Drugs to Treat Inflammatory Bowel HYDROCORT ENE 100MG Tier 1 MG/60ML Disease Inflammatory Bowel Disease Agents HYDROCORTISONE RECTAL CREAM - Drugs to Treat Inflammatory Bowel HYDROCORTISO CRE 2.5% Tier 1 2.5% Disease Inflammatory Bowel Disease Agents MESALAMINE TAB DELAYED RELEASE - Drugs to Treat Inflammatory Bowel LIALDA TAB 1.2GM Tier 2 1.2 GM Disease

157 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel MESALAMINE ENE 4GM MESALAMINE ENEMA 4 GM Tier 1 Disease Inflammatory Bowel Disease Agents *MESALAMINE RECTAL ENEMA 4 GM & - Drugs to Treat Inflammatory Bowel MESALAMINE KIT 4GM Tier 1 X CLEANSER WIPE KIT** Disease Inflammatory Bowel Disease Agents HYDROCORTISONE ACETATE W/ - Drugs to Treat Inflammatory Bowel PRAMCORT CRE 1-1% Tier 1 PRAMOXINE RECTAL CREAM 1-1% Disease Inflammatory Bowel Disease Agents HYDROCORTISONE ACETATE W/ - Drugs to Treat Inflammatory Bowel PROCTOFOAM AER HC 1% Tier 2 PRAMOXINE RECTAL FOAM 1-1% Disease Inflammatory Bowel Disease Agents HYDROCORTISONE RECTAL CREAM - Drugs to Treat Inflammatory Bowel PROCTO-MED CRE HC 2.5% Tier 1 2.5% Disease Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel PROCTO-PAK CRE 1% HYDROCORTISONE RECTAL CREAM 1% Tier 1 Disease Inflammatory Bowel Disease Agents HYDROCORTISONE RECTAL CREAM - Drugs to Treat Inflammatory Bowel PROCTOSOL HC CRE 2.5% Tier 1 2.5% Disease Inflammatory Bowel Disease Agents HYDROCORTISONE RECTAL CREAM - Drugs to Treat Inflammatory Bowel PROCTOZONE CRE -HC 2.5% Tier 1 2.5% Disease Inflammatory Bowel Disease Agents *MESALAMINE RECTAL ENEMA 4 GM & - Drugs to Treat Inflammatory Bowel ROWASA KIT 4GM Tier 4 X CLEANSER WIPE KIT** Disease Inflammatory Bowel Disease Agents MESALAMINE SULFITE-FREE (SF) ENEMA - Drugs to Treat Inflammatory Bowel SFROWASA ENE 4GM Tier 4 4 GM/60ML Disease Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel SULFASALAZIN TAB 500MG SULFASALAZINE TAB 500 MG Tier 1 Disease Inflammatory Bowel Disease Agents SULFASALAZIN TAB 500MG SULFASALAZINE TAB DELAYED - Drugs to Treat Inflammatory Bowel Tier 1 DR RELEASE 500 MG Disease Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel UCERIS AER 2MG/ACT BUDESONIDE RECTAL FOAM 2 MG/ACT Tier 2 Disease Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel UCERIS TAB 9MG BUDESONIDE TAB ER 24HR 9 MG Tier 3 Disease Metabolic Bone Disease Agents - Drugs ACTONEL TAB 150MG RISEDRONATE SODIUM TAB 150 MG Tier 3 X to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs ACTONEL TAB 30MG RISEDRONATE SODIUM TAB 30 MG Tier 3 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs ACTONEL TAB 35MG RISEDRONATE SODIUM TAB 35 MG Tier 3 X to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs ACTONEL TAB 5MG RISEDRONATE SODIUM TAB 5 MG Tier 3 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs ALENDRONATE SOL ALENDRONATE SODIUM ORAL SOLN 70 Tier 1 to Treat Bone Conditions 70/75ML MG/75ML Metabolic Bone Disease Agents - Drugs ALENDRONATE TAB 10MG ALENDRONATE SODIUM TAB 10 MG Tier 1 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs ALENDRONATE TAB 35MG ALENDRONATE SODIUM TAB 35 MG Tier 1 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs ALENDRONATE TAB 40MG ALENDRONATE SODIUM TAB 40 MG Tier 1 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs ALENDRONATE TAB 5MG ALENDRONATE SODIUM TAB 5 MG Tier 1 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs ALENDRONATE TAB 70MG ALENDRONATE SODIUM TAB 70 MG Tier 1 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs IBANDRONATE SODIUM TAB 150 MG BONIVA TAB 150MG Tier 3 X to Treat Bone Conditions (BASE EQUIVALENT) Metabolic Bone Disease Agents - Drugs CALCITONIN (SALMON) NASAL SOLN CALCITONIN SPR 200/ACT Tier 2 to Treat Bone Conditions 200 UNIT/ACT Metabolic Bone Disease Agents - Drugs CALCITRIOL CAP 0.25MCG CALCITRIOL CAP 0.25 MCG Tier 1 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs CALCITRIOL CAP 0.5MCG CALCITRIOL CAP 0.5 MCG Tier 1 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs CALCITRIOL SOL 1MCG/ML CALCITRIOL ORAL SOLN 1 MCG/ML Tier 1 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs DOXERCALCIF CAP 0.5MCG DOXERCALCIFEROL CAP 0.5 MCG Tier 1 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs DOXERCALCIF CAP 1MCG DOXERCALCIFEROL CAP 1 MCG Tier 1 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs DOXERCALCIF CAP 2.5MCG DOXERCALCIFEROL CAP 2.5 MCG Tier 1 to Treat Bone Conditions

158 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Metabolic Bone Disease Agents - Drugs ETIDRON DISD TAB 200MG ETIDRONATE DISODIUM TAB 200 MG Tier 1 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs ETIDRON DISD TAB 400MG ETIDRONATE DISODIUM TAB 400 MG Tier 1 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs TERIPARATIDE (RECOMBINANT) INJ 600 FORTEO SOL 600/2.4 Tier 3 X X to Treat Bone Conditions MCG/2.4ML Metabolic Bone Disease Agents - Drugs CALCITONIN (SALMON) NASAL SOLN FORTICAL SPR 200/ACT Tier 3 to Treat Bone Conditions 200 UNIT/ACT Metabolic Bone Disease Agents - Drugs FOSAMAX TAB 70MG ALENDRONATE SODIUM TAB 70 MG Tier 3 to Treat Bone Conditions ALENDRONATE SODIUM- Metabolic Bone Disease Agents - Drugs FOSAMAX + D TAB 70-2800 CHOLECALCIFEROL TAB 70-2800 MG- Tier 3 to Treat Bone Conditions UNIT ALENDRONATE SODIUM- Metabolic Bone Disease Agents - Drugs FOSAMAX + D TAB 70-5600 CHOLECALCIFEROL TAB 70-5600 MG- Tier 3 to Treat Bone Conditions UNIT Metabolic Bone Disease Agents - Drugs HECTOROL CAP 0.5MCG DOXERCALCIFEROL CAP 0.5 MCG Tier 3 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs HECTOROL CAP 1MCG DOXERCALCIFEROL CAP 1 MCG Tier 3 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs HECTOROL CAP 2.5MCG DOXERCALCIFEROL CAP 2.5 MCG Tier 3 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs IBANDRONATE SODIUM TAB 150 MG IBANDRONATE TAB 150MG Tier 2 X to Treat Bone Conditions (BASE EQUIVALENT) Metabolic Bone Disease Agents - Drugs MIACALCIN INJ 200/ML CALCITONIN (SALMON) INJ 200 UNIT/ML Tier 3 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs CALCITONIN (SALMON) NASAL SOLN MIACALCIN SPR 200/ACT Tier 3 to Treat Bone Conditions 200 UNIT/ACT PARATHYROID HORMONE Metabolic Bone Disease Agents - Drugs NATPARA INJ 100MCG (RECOMBINANT) FOR INJ CARTRIDGE Tier 4 X X X to Treat Bone Conditions 100 MCG PARATHYROID HORMONE Metabolic Bone Disease Agents - Drugs NATPARA INJ 25MCG (RECOMBINANT) FOR INJ CARTRIDGE Tier 4 X X X to Treat Bone Conditions 25 MCG PARATHYROID HORMONE Metabolic Bone Disease Agents - Drugs NATPARA INJ 50MCG (RECOMBINANT) FOR INJ CARTRIDGE Tier 4 X X X to Treat Bone Conditions 50 MCG PARATHYROID HORMONE Metabolic Bone Disease Agents - Drugs NATPARA INJ 75MCG (RECOMBINANT) FOR INJ CARTRIDGE Tier 4 X X X to Treat Bone Conditions 75 MCG Metabolic Bone Disease Agents - Drugs PARICALCITOL CAP 1 MCG PARICALCITOL CAP 1 MCG Tier 1 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs PARICALCITOL CAP 2 MCG PARICALCITOL CAP 2 MCG Tier 1 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs PARICALCITOL CAP 4 MCG PARICALCITOL CAP 4 MCG Tier 1 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs RISEDRONATE TAB 150MG RISEDRONATE SODIUM TAB 150 MG Tier 3 X to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs RISEDRONATE TAB 30MG RISEDRONATE SODIUM TAB 30 MG Tier 3 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs RISEDRONATE TAB 35MG RISEDRONATE SODIUM TAB 35 MG Tier 3 X to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs RISEDRONATE TAB 5MG RISEDRONATE SODIUM TAB 5 MG Tier 3 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs ROCALTROL CAP 0.25MCG CALCITRIOL CAP 0.25 MCG Tier 3 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs ROCALTROL CAP 0.5MCG CALCITRIOL CAP 0.5 MCG Tier 3 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs ROCALTROL SOL 1MCG/ML CALCITRIOL ORAL SOLN 1 MCG/ML Tier 3 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs ABALOPARATIDE SUBCUTANEOUS SOLN TYMLOS INJ Tier 3 X X to Treat Bone Conditions PEN-INJECTOR 3120 MCG/1.56ML Metabolic Bone Disease Agents - Drugs ZEMPLAR CAP 1MCG PARICALCITOL CAP 1 MCG Tier 3 to Treat Bone Conditions Metabolic Bone Disease Agents - Drugs ZEMPLAR CAP 2MCG PARICALCITOL CAP 2 MCG Tier 3 to Treat Bone Conditions Miscellaneous Therapeutic Agents 2-DEOXY-D POW -GLUCOSE 2-DEOXY-D-GLUCOSE POWDER Tier 3 Miscellaneous Therapeutic Agents ADAPTADERM GEL *GEL BASE - GEL** Tier 3 AERCHMBR PLS MIS FLOW- *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents Tier 3 VU CHAMBERS - DEVICE*** AERCHMBR PLS MIS LRG *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents Tier 3 MASK CHAMBERS - DEVICE*** AERCHMBR PLS MIS SM *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents Tier 3 MASK CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents AEROCHAMBER MIS PLUS Tier 3 CHAMBERS - DEVICE*** ALCOH-GLOVE PAD Miscellaneous Therapeutic Agents *ALCOHOL SWABS*** Tier 3 CONTOURE

159 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Miscellaneous Therapeutic Agents ALCOHOL PAD 70% *ALCOHOL SWABS*** Tier 3 Miscellaneous Therapeutic Agents ALCOHOL PREP PAD *ALCOHOL SWABS*** Tier 3 Miscellaneous Therapeutic Agents ALCOHOL PREP PAD 70% *ALCOHOL SWABS*** Tier 1 Miscellaneous Therapeutic Agents ALCOHOL PREP PAD 70% *ALCOHOL SWABS*** Tier 3 ALCOHOL PREP PAD MED Miscellaneous Therapeutic Agents *ALCOHOL SWABS*** Tier 3 70% Miscellaneous Therapeutic Agents ALCOHOL SWAB PAD *ALCOHOL SWABS*** Tier 3 Miscellaneous Therapeutic Agents ALCOHOL SWAB PAD 70% *ALCOHOL SWABS*** Tier 3 Miscellaneous Therapeutic Agents ALCOH-WIPE MIS 12"X12" *ALCOHOL SHEETS*** Tier 3 Miscellaneous Therapeutic Agents ALPAWASH OIN POLYETHYLENE GLYCOL OINTMENT Tier 3 Miscellaneous Therapeutic Agents AMINOAM CAP RMS *AMINO ACIDS CAP*** Tier 1 Miscellaneous Therapeutic Agents AMINORELIEF CAP RMS *AMINO ACIDS CAP*** Tier 1 Miscellaneous Therapeutic Agents ANASEPT SPR SODIUM HYPOCHLORITE LIQUID 0.057% Tier 3 Miscellaneous Therapeutic Agents ANHYDROUS GEL BASE *GEL BASE - GEL** Tier 3 Miscellaneous Therapeutic Agents APOTHEDERM CRE *TRANSDERMAL BASE CREAM** Tier 3 APOTHESAR CRE Miscellaneous Therapeutic Agents *TRANSDERMAL BASE CREAM** Tier 3 TRANSDER *FIBRIN SEALANT COMPONENT Miscellaneous Therapeutic Agents ARTISS SOL 10ML Tier 3 SOLUTION*** *FIBRIN SEALANT COMPONENT Miscellaneous Therapeutic Agents ARTISS SOL 2ML Tier 3 SOLUTION*** *FIBRIN SEALANT COMPONENT Miscellaneous Therapeutic Agents ARTISS SOL 4ML Tier 3 SOLUTION*** Miscellaneous Therapeutic Agents AT LAST KIT GLUCOSE *BLOOD GLUCOSE MONITORING KIT*** Tier 3 Miscellaneous Therapeutic Agents AT LAST TES GLUCOSE BLOOD TEST STRIP Tier 3 X Miscellaneous Therapeutic Agents AUTOJECT 2 MIS *INJECTION DEVICE - MISC*** Tier 3 X *PHARMACEUTICAL EXCIPIENTS (BULK) Miscellaneous Therapeutic Agents BACOCALMINE LIQ Tier 3 LIQUID** Miscellaneous Therapeutic Agents BASE CRE LIPOSOME *CREAM BASE LIPOSOMIC** Tier 3 INSULIN SYRINGE/NEEDLE U-100 0.3 ML Miscellaneous Therapeutic Agents B-D UF SYRG MIS .3CC/30G Tier 2 30 X 1/2" Miscellaneous Therapeutic Agents BENZOIN TIN NF BENZOIN TINCTURE Tier 3 Miscellaneous Therapeutic Agents BENZOIN CMPD TIN BENZOIN COMPOUND TINCTURE Tier 1 Miscellaneous Therapeutic Agents BENZONATATE CAP 100MG BENZONATATE CAP 100 MG Tier 1 Miscellaneous Therapeutic Agents BENZONATATE CAP 200MG BENZONATATE CAP 200 MG Tier 1 BUTYLATED HYDROXYTOLUENE Miscellaneous Therapeutic Agents BHT POW Tier 3 POWDER Miscellaneous Therapeutic Agents BISMUTH SUBC POW BISMUTH SUBCARBONATE POWDER Tier 3 *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents BLOOD GLUC MIS MONITOR Tier 3 DEVICES*** BLOOD GLUCOS TES Miscellaneous Therapeutic Agents GLUCOSE BLOOD TEST STRIP Tier 3 X PREMIUM BLOOD GLUCOS TES Miscellaneous Therapeutic Agents GLUCOSE BLOOD TEST STRIP Tier 3 X STRIPS Miscellaneous Therapeutic Agents BORIC ACID GRA BORIC ACID GRANULES Tier 3 Miscellaneous Therapeutic Agents CARBOGEL GEL 940 *CARBOMER GEL BASE** Tier 3 Miscellaneous Therapeutic Agents CARBOHOL GEL 940 *CARBOMER GEL BASE** Tier 2 Miscellaneous Therapeutic Agents CARBOMER GEL AQUEOUS *CARBOMER GEL BASE** Tier 3 CARBOMER GEL Miscellaneous Therapeutic Agents *CARBOMER GEL BASE** Tier 3 HYDROALC DHA-EPA-VIT B6-B12-FOLIC ACID CAP Miscellaneous Therapeutic Agents CARDIOVID CAP PLUS Tier 3 240-360-20-0.5-0.8 MG INSULIN PEN NEEDLE 31 G X 8 MM (1/3" Miscellaneous Therapeutic Agents CAREFINE MIS 31GX8MM Tier 2 OR 5/16") INSULIN PEN NEEDLE 32 G X 4 MM Miscellaneous Therapeutic Agents CAREFINE MIS 32GX4MM Tier 2 (5/32") INSULIN PEN NEEDLE 32 G X 5 MM (1/5" Miscellaneous Therapeutic Agents CAREFINE MIS 32GX5MM Tier 2 OR 3/16") Miscellaneous Therapeutic Agents CAREFINE MIS 32GX6MM INSULIN PEN NEEDLE 32 G X 6 MM (1/4") Tier 2 Miscellaneous Therapeutic Agents CARETOUCH MIS 31GX5MM INSULIN PEN NEEDLE 31 G X 5 MM (3/16") Tier 2 Miscellaneous Therapeutic Agents CARETOUCH MIS 31GX6MM INSULIN PEN NEEDLE 31 G X 6 MM (1/4") Tier 2 INSULIN PEN NEEDLE 31 G X 8 MM (1/3" Miscellaneous Therapeutic Agents CARETOUCH MIS 31GX8MM Tier 2 OR 5/16") INSULIN PEN NEEDLE 32 G X 4 MM Miscellaneous Therapeutic Agents CARETOUCH MIS 32GX4MM Tier 2 (5/32") INSULIN PEN NEEDLE 32 G X 5 MM (1/5" Miscellaneous Therapeutic Agents CARETOUCH MIS 32GX5MM Tier 2 OR 3/16") Miscellaneous Therapeutic Agents CARETOUCH PAD ALCOHOL *ALCOHOL SWABS*** Tier 3 Miscellaneous Therapeutic Agents CAYA DPR *DIAPHRAGM ARC-SPRING*** Tier 3 Miscellaneous Therapeutic Agents CHEMSIL K-51 GEL *GEL BASE - GEL** Tier 3 *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents CHEMSTRIP BG MIS LOG Tier 1 MISC.*** Miscellaneous Therapeutic Agents CHERRY SYP CHERRY SYRUP Tier 3 Miscellaneous Therapeutic Agents CHOICE DM KIT RISK TST *BLOOD GLUCOSE MONITORING KIT*** Tier 3 Miscellaneous Therapeutic Agents CITRULLINE POW (L) CITRULLINE (BULK) POWDER Tier 3

160 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Miscellaneous Therapeutic Agents CLOVAGEL GEL *GEL BASE - GEL** Tier 3 Miscellaneous Therapeutic Agents COLCIGEL GEL *HOMEOPATHIC PRODUCTS - GEL** Tier 3 Miscellaneous Therapeutic Agents COLLODION LIQ FLEXIBLE COLLODION FLEXIBLE Tier 3 *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents CONTOUR KIT NEXT Tier 2 DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents CONTOUR KIT NEXT EZ Tier 2 DEVICE*** Miscellaneous Therapeutic Agents CONTOUR TES NEXT GLUCOSE BLOOD TEST STRIP Tier 2 X Miscellaneous Therapeutic Agents CONTOUR NEXT KIT ONE *BLOOD GLUCOSE MONITORING KIT*** Tier 2 Miscellaneous Therapeutic Agents CORN SYP CORN SYRUP Tier 3 Miscellaneous Therapeutic Agents CORTROSYN INJ 0.25MG COSYNTROPIN FOR INJ 0.25 MG Tier 3 Miscellaneous Therapeutic Agents COSYNTROPIN INJ 0.25MG COSYNTROPIN FOR INJ 0.25 MG Tier 1 Miscellaneous Therapeutic Agents CRYOSERV SOL *DIMETHYL SULFOXIDE - SOLUTION*** Tier 3 Miscellaneous Therapeutic Agents CUST LIPOTHN GEL 110 *GEL BASE - GEL** Tier 3 Miscellaneous Therapeutic Agents CUST LIPOTHN GEL 133 *GEL BASE - GEL** Tier 3 CVS ADVANCED TES Miscellaneous Therapeutic Agents GLUCOSE BLOOD TEST STRIP Tier 3 X GLUCOSE Miscellaneous Therapeutic Agents CYCLOSPORINE POW CYCLOSPORINE (BULK) POWDER Tier 3 Miscellaneous Therapeutic Agents CYCLOSPORINE POW A CYCLOSPORINE (BULK) POWDER Tier 3 Miscellaneous Therapeutic Agents DELIVRA CRE SR *TRANSDERMAL BASE CREAM** Tier 3 Miscellaneous Therapeutic Agents DERMACINRX SOL BASE *EXTERNAL VEHICLES - SOLUTION*** Tier 3 DERMASHIELD GEL Miscellaneous Therapeutic Agents *GEL BASE - GEL** Tier 3 HYDROGEL Miscellaneous Therapeutic Agents DERMATODORON LIQ *HOMEOPATHIC PRODUCTS - LIQUID** Tier 3 Miscellaneous Therapeutic Agents DIGESTODORON LIQ *HOMEOPATHIC PRODUCTS - LIQUID** Tier 3 Miscellaneous Therapeutic Agents DIMETHYL SOL SULFOXID *DIMETHYL SULFOXIDE - SOLUTION*** Tier 3 Miscellaneous Therapeutic Agents DISCUS LIQ COMPOSIT *HOMEOPATHIC PRODUCTS - LIQUID** Tier 3 Miscellaneous Therapeutic Agents DRYSOL SOL 20% ALUMINUM CHLORIDE SOLN 20% Tier 3 *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents EASIVENT MIS Tier 3 CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents EASIVENT MIS MASK LG Tier 3 CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents EASIVENT MIS MASK SM Tier 3 CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents EASIVENT MIS MASK MED Tier 3 CHAMBERS - DEVICE*** Miscellaneous Therapeutic Agents EASYMAX TES GLUCOSE BLOOD TEST STRIP Tier 3 X Miscellaneous Therapeutic Agents EASYMAX 15 TES GLUCOSE BLOOD TEST STRIP Tier 3 X *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents EASYMAX L KIT SYSTEM Tier 3 DEVICE*** *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents EASYMAX L MIS SYSTEM Tier 3 DEVICES*** *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents EASYMAX N KIT SYSTEM Tier 3 DEVICE*** *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents EASYMAX N MIS SYSTEM Tier 3 DEVICES*** *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents EASYMAX NG KIT SYSTEM Tier 3 DEVICE*** *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents EASYMAX NG MIS SYSTEM Tier 3 DEVICES*** *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents EASYMAX V KIT SYSTEM Tier 3 DEVICE*** *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents EASYMAX V MIS SYSTEM Tier 3 DEVICES*** *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents EASYMAX V2 KIT SYSTEM Tier 3 DEVICE*** *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents EASYMAX V2 MIS SYSTEM Tier 3 DEVICES*** *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents EASYPLS R13N KIT SYSTEM Tier 3 DEVICE*** Miscellaneous Therapeutic Agents EASYPLUS TES BLD GLUC GLUCOSE BLOOD TEST STRIP Tier 3 X *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents EASYPLUS V KIT SYSTEM Tier 3 DEVICE*** *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents EMBRACE MIS Tier 3 DEVICES*** Miscellaneous Therapeutic Agents EMBRACE TES BLD GLUC GLUCOSE BLOOD TEST STRIP Tier 3 X *DERMATOLOGICAL PRODUCTS MISC - Miscellaneous Therapeutic Agents EPISONE CRE Tier 1 CREAM** ERGOLOID MES TAB 1MG Miscellaneous Therapeutic Agents ERGOLOID MESYLATES TAB 1 MG Tier 1 ORAL Miscellaneous Therapeutic Agents ERYSIDORON LIQ #1 *HOMEOPATHIC PRODUCTS - LIQUID** Tier 3 Miscellaneous Therapeutic Agents ESSENTRA MIS 9X9" ISOPROPYL ALCOHOL WIPES 70% Tier 3 Miscellaneous Therapeutic Agents ETHOSUXIMIDE POW ETHOSUXIMIDE (BULK) POWDER Tier 3 *FIBRIN SEALANT COMPONENT KIT 2 Miscellaneous Therapeutic Agents EVICEL KIT 2ML Tier 3 ML***

161 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy *FIBRIN SEALANT COMPONENT KIT 5 Miscellaneous Therapeutic Agents EVICEL KIT 5ML Tier 3 ML*** *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents E-Z SPACER MIS Tier 3 CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents E-Z SPACER MIS BODY GRD Tier 3 CHAMBERS - DEVICE*** Miscellaneous Therapeutic Agents FE PYROPHOSP POW *BULK CHEMICALS - POWDER** Tier 3 X Miscellaneous Therapeutic Agents FLAVOR BLEND SUS *ORAL VEHICLES - SUSP*** Tier 3 Miscellaneous Therapeutic Agents FLAVOR PLUS LIQ *ORAL VEHICLES*** Tier 3 Miscellaneous Therapeutic Agents FLAVOR SWEET SYP *ORAL VEHICLES - SYRUP*** Tier 3 Miscellaneous Therapeutic Agents FLAVOR SWEET SYP S/F *ORAL VEHICLES - SYRUP*** Tier 3 *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents FLEXICHAMBER MIS Tier 3 CHAMBERS - DEVICE*** FLEXICHAMBER MIS MASK *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents Tier 2 LRG CHAMBER SUPPLIES - MASKS*** FLEXICHAMBER MIS MASK *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents Tier 2 SM CHAMBER SUPPLIES - MASKS*** DYE FDC BLUE 1 (BRILLIANT BLUE FCF) Miscellaneous Therapeutic Agents FOOD COLOR LIQ BLUE Tier 3 - LIQUID *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents FORA GD50 MIS MONITOR Tier 3 DEVICES*** Miscellaneous Therapeutic Agents FORA GD50 TES GLUCOSE BLOOD TEST STRIP Tier 3 X *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents FORA TEST N' MIS GO Tier 3 DEVICES*** Miscellaneous Therapeutic Agents FORANE SOL ISOFLURANE INHAL SOLN Tier 2 Miscellaneous Therapeutic Agents FORMADON SOL FORMALDEHYDE SOLUTION 10% Tier 3 Miscellaneous Therapeutic Agents FORMALDEHYDE SOL 10% FORMALDEHYDE SOLUTION 10% Tier 1 Miscellaneous Therapeutic Agents FORMALDEHYDE SOL 37% FORMALDEHYDE SOLUTION 37% Tier 3 Miscellaneous Therapeutic Agents FORMA-RAY SOL 20% FORMALDEHYDE SOLUTION 20% Tier 2 *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents FORTISCARE KIT SYSTEM Tier 3 DEVICE*** Miscellaneous Therapeutic Agents FORTISCARE TES BLD GLUC GLUCOSE BLOOD TEST STRIP Tier 3 X Miscellaneous Therapeutic Agents FP CEPA GEL *GEL BASE - GEL** Tier 3 Miscellaneous Therapeutic Agents FP DERM GEL *GEL BASE - GEL** Tier 3 Miscellaneous Therapeutic Agents FP SILO GEL *GEL BASE - GEL** Tier 3 Miscellaneous Therapeutic Agents FREEDOM GEL CEPAPRO *GEL BASE - GEL** Tier 3 Miscellaneous Therapeutic Agents FREEDOM GEL SET *GEL BASE - GEL** Tier 3 Miscellaneous Therapeutic Agents FREEDOM GEL SILOMAC *GEL BASE - GEL** Tier 3 Miscellaneous Therapeutic Agents GENSTRIP 50 TES GLUCOSE BLOOD TEST STRIP Tier 3 X Miscellaneous Therapeutic Agents GLONOIN DRO HOMACCOR *HOMEOPATHIC PRODUCTS - LIQUID** Tier 3 Miscellaneous Therapeutic Agents GLUTARALDEHY SOL 25% GLUTARAL SOLN 25% Tier 3 Miscellaneous Therapeutic Agents GNP ALCOHOL PAD SWABS *ALCOHOL SWABS*** Tier 3 Miscellaneous Therapeutic Agents H20 GEL BASE GEL *GEL BASE - GEL** Tier 3 HEPARIN SODIUM (PORCINE) LOCK Miscellaneous Therapeutic Agents HEPARIN LOCK INJ 100/ML Tier 1 FLUSH IV SOLN 100 UNIT/ML HEPARIN LOCK INJ 10UNT/ HEPARIN SODIUM (PORCINE) LOCK Miscellaneous Therapeutic Agents Tier 1 ML FLUSH IV SOLN 10 UNIT/ML Miscellaneous Therapeutic Agents HM STERILE PAD ALCHOL *ALCOHOL SWABS*** Tier 3 *DENTAL DESENSITIZING PRODUCT - Miscellaneous Therapeutic Agents HURRISEAL SOL Tier 3 SOLUTION*** Miscellaneous Therapeutic Agents HYDROGEL GEL *CARBOMER GEL BASE** Tier 1 Miscellaneous Therapeutic Agents HYPO NEEDLE MIS 18GX1" NEEDLE (DISP) 18 X 1" Tier 2 *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents IN TOUCH MIS Tier 1 MISC.*** *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents INSPIRACHAMB MIS LARGE Tier 3 CHAMBERS - DEVICE*** INSPIRACHAMB MIS *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents Tier 3 MEDIUM CHAMBERS - DEVICE*** INSPIRACHAMB MIS *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents Tier 3 MOUTHPCE CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents INSPIRACHAMB MIS SMALL Tier 3 CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents INSPIREASE MIS DD SYST Tier 3 CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents INSPIREASE MIS RES BAG Tier 2 CHAMBER SUPPLIES - BAGS*** INSULIN SYRINGE/NEEDLE U-100 0.3 ML Miscellaneous Therapeutic Agents INSULIN SYR MIS 0.3/31G Tier 2 31 X 15/64" INSULIN SYRINGE/NEEDLE U-100 0.3 ML Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.3/29G Tier 2 29 X 1/2" INSULIN SYRINGE/NEEDLE U-100 0.3 ML Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.3/30G Tier 2 30 X 5/16" INSULIN SYRINGE/NEEDLE U-100 0.3 ML Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.3/30G Tier 2 30 X 1/2" INSULIN SYRINGE/NEEDLE U-100 0.3 ML Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.3/31G Tier 2 31 X 5/16"

162 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy INSULIN SYRINGE/NEEDLE U-100 0.3 ML Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.3ML/30 Tier 2 30 X 5/16" INSULIN SYRINGE/NEEDLE U-100 0.3 ML Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.3ML/31 Tier 2 31 X 5/16" INSULIN SYRINGE/NEEDLE U-100 1/2 ML Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.5/28G Tier 2 28 X 1/2" INSULIN SYRINGE/NEEDLE U-100 1/2 ML Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.5/29G Tier 2 29 X 1/2" INSULIN SYRINGE/NEEDLE U-100 1/2 ML Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.5/30G Tier 2 30 X 5/16" INSULIN SYRINGE/NEEDLE U-100 1/2 ML Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.5/30G Tier 2 30 X 1/2" INSULIN SYRINGE/NEEDLE U-100 1/2 ML Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.5/30G Tier 2 30 X 3/8" INSULIN SYRINGE/NEEDLE U-100 1/2 ML Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.5/31G Tier 2 31 X 5/16" INSULIN SYRINGE/NEEDLE U-100 1/2 ML Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.5/31G Tier 2 31 X 15/64" INSULIN SYRINGE/NEEDLE U-100 1/2 ML Miscellaneous Therapeutic Agents INSULIN SYRG MIS 1/2ML/30 Tier 2 30 X 5/16" INSULIN SYRINGE/NEEDLE U-100 1/2 ML Miscellaneous Therapeutic Agents INSULIN SYRG MIS 1/2ML/31 Tier 2 31 X 5/16" INSULIN SYRINGE/NEEDLE U-100 1 ML Miscellaneous Therapeutic Agents INSULIN SYRG MIS 1ML/28G Tier 2 28 X 1/2" INSULIN SYRINGE/NEEDLE U-100 1 ML Miscellaneous Therapeutic Agents INSULIN SYRG MIS 1ML/29G Tier 2 29 X 1/2" INSULIN SYRINGE/NEEDLE U-100 1 ML Miscellaneous Therapeutic Agents INSULIN SYRG MIS 1ML/30G Tier 2 30 X 5/16" INSULIN SYRINGE/NEEDLE U-100 1 ML Miscellaneous Therapeutic Agents INSULIN SYRG MIS 1ML/30G Tier 2 30 X 1/2" INSULIN SYRINGE/NEEDLE U-100 1 ML Miscellaneous Therapeutic Agents INSULIN SYRG MIS 1ML/31G Tier 2 31 X 5/16" IODINE SOLUTION STRONG 5% Miscellaneous Therapeutic Agents IODINE SOL STRONG Tier 2 (LUGOL' S) Miscellaneous Therapeutic Agents ISOFLURANE SOL ISOFLURANE INHAL SOLN Tier 1 Miscellaneous Therapeutic Agents KERAMATRIX MIS 10X10CM *WOUND DRESSINGS - SHEET*** Tier 3 Miscellaneous Therapeutic Agents KERAMATRIX MIS 5X5CM *WOUND DRESSINGS - SHEET*** Tier 3 Miscellaneous Therapeutic Agents KRISGEL 100 GEL KRISGEL 100 GEL Tier 3 Miscellaneous Therapeutic Agents LANOLIN OIN LANOLIN Tier 1 Miscellaneous Therapeutic Agents LANOLIN ANHY OIN LANOLIN ANHYDROUS Tier 3 L-ASPARAGINE POW Miscellaneous Therapeutic Agents *BULK CHEMICALS - POWDER** Tier 3 X MONOHYDR Miscellaneous Therapeutic Agents LAVARE WOUND GEL WASH *WOUND CLEANSERS - GEL** Tier 1 Miscellaneous Therapeutic Agents L-CITRULLINE POW CITRULLINE (BULK) POWDER Tier 3 Miscellaneous Therapeutic Agents L- CYSTINE POW CYSTINE POWDER Tier 3 PREMIUM LECITHIN ORGANOGEL BASE Miscellaneous Therapeutic Agents LECITHIN GEL Tier 3 GEL Miscellaneous Therapeutic Agents LECITHIN GRA LECITHIN GRANULES Tier 1 Miscellaneous Therapeutic Agents LIBERTY TES GLUCOSE BLOOD TEST STRIP Tier 3 X Miscellaneous Therapeutic Agents LIPODERM HMW GEL PCCA *GEL BASE - GEL** Tier 3 Miscellaneous Therapeutic Agents LIPOGEL CR GEL BASE *GEL BASE - GEL** Tier 3 Miscellaneous Therapeutic Agents LIPOZYME CRE *CREAM BASE LIPOSOMIC** Tier 3 Miscellaneous Therapeutic Agents LUBRAJEL NP GEL *GEL BASE - GEL** Tier 3 Miscellaneous Therapeutic Agents LUXAMEND CRE *WOUND DRESSINGS - CREAM*** Tier 3 MAGNESIUM GLYCINATE (BULK) Miscellaneous Therapeutic Agents MAGNESIUM POW BISGLYCI Tier 3 POWDER MAGNESIUM POW MAGNESIUM GLYCINATE (BULK) Miscellaneous Therapeutic Agents Tier 3 GLYCINAT POWDER MASK VORTEX/ MIS BABY *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents Tier 2 DUC CHAMBER SUPPLIES - MASKS*** *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents MASK VORTEX/ MIS DUCK Tier 2 CHAMBER SUPPLIES - MASKS*** *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents MASK VORTEX/ MIS FROG Tier 2 CHAMBER SUPPLIES - MASKS*** MASK VORTEX/ MIS LADY *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents Tier 2 BUG CHAMBER SUPPLIES - MASKS*** METHYLERGONOVINE MALEATE TAB Miscellaneous Therapeutic Agents METHERGINE TAB 0.2MG Tier 1 0.2 MG METHYLERGONOVINE MALEATE TAB Miscellaneous Therapeutic Agents METHYLERGON TAB 0.2MG Tier 1 0.2 MG MITOMYCIN FOR OPHTH SOLN KIT 0.2 Miscellaneous Therapeutic Agents MITOSOL KIT 0.2MG Tier 3 MG Miscellaneous Therapeutic Agents MORCIN CRE *HOMEOPATHIC PRODUCTS - CREAM** Tier 3 *MOUTHWASH COMPOUNDING BASE - Miscellaneous Therapeutic Agents MOUTH WASH LIQ GP Tier 3 LIQUID*** *MOUTHWASH COMPOUNDING BASE - Miscellaneous Therapeutic Agents MOUTHWASH LIQ AF Tier 3 LIQUID***

163 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy *MOUTHWASH COMPOUNDING BASE - Miscellaneous Therapeutic Agents MOUTHWASH LIQ OM Tier 3 LIQUID*** *PHARMACEUTICAL EXCIPIENTS (BULK) Miscellaneous Therapeutic Agents MUCOLOX LIQ Tier 3 LIQUID** METRELEPTIN FOR SUBCUTANEOUS INJ Miscellaneous Therapeutic Agents MYALEPT INJ 11.3MG Tier 3 X X X 11.3 MG Miscellaneous Therapeutic Agents NA HYDROXIDE SOL 10% SODIUM HYDROXIDE SOLUTION 10% Tier 1 Miscellaneous Therapeutic Agents NEEDLES 22G X 1 1/2" NEEDLE (DISP) 22 X 1-1/2" Tier 3 Miscellaneous Therapeutic Agents NEUTEK 2TEK TES STRIPS GLUCOSE BLOOD TEST STRIP Tier 3 X INSULIN PEN NEEDLE 30 G X 8 MM (1/3" Miscellaneous Therapeutic Agents NOVOFINE MIS 30GX8MM Tier 2 OR 5/16") Miscellaneous Therapeutic Agents NOVOFINE MIS 32GX6MM INSULIN PEN NEEDLE 32 G X 6 MM (1/4") Tier 2 NOVOFINE AUT MIS INSULIN PEN NEEDLE 30 G X 8 MM (1/3" Miscellaneous Therapeutic Agents Tier 2 30GX8MM OR 5/16") NOVOFINE PLS MIS INSULIN PEN NEEDLE 32 G X 4 MM Miscellaneous Therapeutic Agents Tier 2 32GX4MM (5/32") INSULIN PEN NEEDLE 30 G X 8 MM (1/3" Miscellaneous Therapeutic Agents NOVOTWIST MIS 30GX8MM Tier 2 OR 5/16") INSULIN PEN NEEDLE 32 G X 5 MM (1/5" Miscellaneous Therapeutic Agents NOVOTWIST MIS 32GX5MM Tier 2 OR 3/16") *DERMATOLOGICAL PRODUCTS MISC - Miscellaneous Therapeutic Agents NUVAIL SOL 16% Tier 3 SOLUTION** Miscellaneous Therapeutic Agents OCCLUSADERM GEL PCCA *GEL BASE - GEL** Tier 3 HCR Miscellaneous Therapeutic Agents OMNIFLEX DPR *DIAPHRAGMS*** Preventive Care Miscellaneous Therapeutic Agents ON CALL TES EXPRESS GLUCOSE BLOOD TEST STRIP Tier 3 X *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents ON CALL EXPR KIT SYSTEM Tier 3 DEVICE*** *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents ON CALL EXPR MIS METER Tier 3 DEVICES*** *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents ON CALL PLUS KIT METER Tier 3 DEVICE*** ON CALL PLUS KIT *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents Tier 3 MONITOR DEVICE*** *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents ON CALL PLUS MIS METER Tier 3 DEVICES*** ON CALL PLUS TES BLD Miscellaneous Therapeutic Agents GLUCOSE BLOOD TEST STRIP Tier 3 X GLUC *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents ON CALL VIVD KIT METER Tier 3 DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents ON CALL VIVD KIT MONITOR Tier 3 DEVICE*** *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents ON CALL VIVD MIS METER Tier 3 DEVICES*** ON CALL VIVD TES BLD Miscellaneous Therapeutic Agents GLUCOSE BLOOD TEST STRIP Tier 3 X GLUC *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents ONETOUCH KIT ULT MINI Tier 1 DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents ONETOUCH KIT ULTRA 2 Tier 1 DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents ONETOUCH KIT ULTRALNK Tier 1 DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents ONETOUCH KIT VERIO Tier 1 DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents ONETOUCH KIT VERIO FL Tier 1 DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents ONETOUCH KIT VERIO IQ Tier 1 DEVICE*** *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents ONETOUCH MIS REMOTE Tier 3 SUPPLIES*** Miscellaneous Therapeutic Agents ONETOUCH TES ULTRA BL GLUCOSE BLOOD TEST STRIP Tier 1 X Miscellaneous Therapeutic Agents ONETOUCH TES VERIO GLUCOSE BLOOD TEST STRIP Tier 1 X *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents ONETOUCH VER KIT SYNC Tier 1 DEVICE*** *RESPIRATORY THERAPY SUPPLIES - Miscellaneous Therapeutic Agents OPTICHAMBER MIS Tier 3 MISC** *RESPIRATORY THERAPY SUPPLIES - Miscellaneous Therapeutic Agents OPTICHAMBER/ MIS MASK Tier 3 MISC** OPTICHAMBER/ MIS MASK *RESPIRATORY THERAPY SUPPLIES - Miscellaneous Therapeutic Agents Tier 3 SM MISC** *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents OPTIHALER MIS Tier 3 CHAMBERS - DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents OPTUMRX KIT METER Tier 3 DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents OPTUMRX KIT SYSTEM Tier 3 DEVICE*** Miscellaneous Therapeutic Agents OPTUMRX TES BLD GLUC GLUCOSE BLOOD TEST STRIP Tier 3 X 164 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Miscellaneous Therapeutic Agents ORA-BLEND SUS *ORAL VEHICLES - SUSP*** Tier 3 Miscellaneous Therapeutic Agents ORA-BLEND SF SUS *ORAL VEHICLES - SUSP*** Tier 3 Miscellaneous Therapeutic Agents ORA-PLUS LIQ *ORAL VEHICLES*** Tier 3 Miscellaneous Therapeutic Agents ORA-SWEET SYP *ORAL VEHICLES - SYRUP*** Tier 2 Miscellaneous Therapeutic Agents ORA-SWEET SF SYP *ORAL VEHICLES - SYRUP*** Tier 3 Miscellaneous Therapeutic Agents PCCA ACACIA SYP BASE ACACIA SYRUP Tier 3 Miscellaneous Therapeutic Agents PCCA COBASE OIN #1 COBASE #1 OINTMENT BASE Tier 3 PCCA CUSTOM CRE LIPO- Miscellaneous Therapeutic Agents *CREAM BASE LIPOSOMIC** Tier 3 MAX Miscellaneous Therapeutic Agents PCCA LIPOSOM CRE DRY *CREAM BASE LIPOSOMIC** Tier 3 PCCA LIPOSOM CRE Miscellaneous Therapeutic Agents *CREAM BASE LIPOSOMIC** Tier 3 NORMAL Miscellaneous Therapeutic Agents PCCA LIPOSOM CRE OILY *CREAM BASE LIPOSOMIC** Tier 3 PCCA LIPOSOM CRE Miscellaneous Therapeutic Agents *CREAM BASE LIPOSOMIC** Tier 3 SENSITIV Miscellaneous Therapeutic Agents PCCA SWEET SYP -SF *ORAL VEHICLES - SYRUP*** Tier 3 Miscellaneous Therapeutic Agents PCCA SYRUP SYP VEHICLE *ORAL VEHICLES - SYRUP*** Tier 3 Miscellaneous Therapeutic Agents PCCA-PLUS SUS *ORAL VEHICLES - SUSP*** Tier 3 Miscellaneous Therapeutic Agents PEN NEEDLE MIS 29GX1/2" INSULIN PEN NEEDLE 29 G X 12.7 MM Tier 2 Miscellaneous Therapeutic Agents PEN NEEDLES MIS 29GX1/2" INSULIN PEN NEEDLE 29 G X 12 MM (1/2") Tier 2 PEN NEEDLES MIS Miscellaneous Therapeutic Agents INSULIN PEN NEEDLE 29 G X 12 MM (1/2") Tier 2 29GX12MM INSULIN PEN NEEDLE 30 G X 8 MM (1/3" Miscellaneous Therapeutic Agents PEN NEEDLES MIS 30GX5/16 Tier 2 OR 5/16") Miscellaneous Therapeutic Agents PEN NEEDLES MIS 31GX1/4" INSULIN PEN NEEDLE 31 G X 6 MM (1/4") Tier 2 Miscellaneous Therapeutic Agents PEN NEEDLES MIS 31GX3/16 INSULIN PEN NEEDLE 31 G X 5 MM (3/16") Tier 2 INSULIN PEN NEEDLE 31 G X 8 MM (1/3" Miscellaneous Therapeutic Agents PEN NEEDLES MIS 31GX5/16 Tier 2 OR 5/16") PEN NEEDLES MIS Miscellaneous Therapeutic Agents INSULIN PEN NEEDLE 31 G X 5 MM (3/16") Tier 2 31GX5MM PEN NEEDLES MIS Miscellaneous Therapeutic Agents INSULIN PEN NEEDLE 31 G X 6 MM (1/4") Tier 2 31GX6MM PEN NEEDLES MIS INSULIN PEN NEEDLE 31 G X 8 MM (1/3" Miscellaneous Therapeutic Agents Tier 2 31GX8MM OR 5/16") PEN NEEDLES MIS INSULIN PEN NEEDLE 32 G X 4 MM Miscellaneous Therapeutic Agents Tier 2 32GX4MM (5/32") PEN NEEDLES MIS INSULIN PEN NEEDLE 32 G X 4 MM Miscellaneous Therapeutic Agents Tier 2 32GX5/32 (5/32") Miscellaneous Therapeutic Agents PENTIPS MIS 29GX12MM INSULIN PEN NEEDLE 29 G X 12 MM (1/2") Tier 2 Miscellaneous Therapeutic Agents PENTIPS MIS 31GX5MM INSULIN PEN NEEDLE 31 G X 5 MM (3/16") Tier 2 INSULIN PEN NEEDLE 31 G X 8 MM (1/3" Miscellaneous Therapeutic Agents PENTIPS MIS 31GX8MM Tier 2 OR 5/16") INSULIN PEN NEEDLE 32 G X 4 MM Miscellaneous Therapeutic Agents PENTIPS MIS 32GX4MM Tier 2 (5/32") Miscellaneous Therapeutic Agents PETROLATUM GEL WHITE WHITE PETROLATUM GEL Tier 1 Miscellaneous Therapeutic Agents PETROLATUM OIN WHITE WHITE PETROLATUM OINTMENT Tier 3 Miscellaneous Therapeutic Agents PETROLATUM OIN YELLOW PETROLATUM OINTMENT Tier 3 PHOTREXA/PHO SOL VISC RIBOFLAV 0.146% & RIBOFLAV-DEXTRAN Miscellaneous Therapeutic Agents Tier 3 KIT 0.146-20% OP SOL PREF SYR Miscellaneous Therapeutic Agents PLACEBO #00 CAP *PLACEBO - CAP** Tier 2 PREMIUM LECITHIN ORGANOGEL BASE Miscellaneous Therapeutic Agents PLO GEL MEDIFLO Tier 3 GEL PREMIUM LECITHIN ORGANOGEL BASE Miscellaneous Therapeutic Agents PLO MEDIFLO KIT KIT Tier 3 KIT Miscellaneous Therapeutic Agents PLO TRANSDER CRE *TRANSDERMAL BASE CREAM** Tier 3 PREMIUM LECITHIN ORGANOGEL BASE Miscellaneous Therapeutic Agents PLO20 BASE GEL Tier 3 GEL Miscellaneous Therapeutic Agents PNEUMODORON LIQ *HOMEOPATHIC PRODUCTS - LIQUID** Tier 3 Miscellaneous Therapeutic Agents POLYMAC GEL PROGEL *GEL BASE - GEL** Tier 3 Miscellaneous Therapeutic Agents POLYOX POW WSR-301 *BULK CHEMICALS - POWDER** Tier 3 X Miscellaneous Therapeutic Agents POLYPEG OIN BASE POLYETHYLENE GLYCOL OINTMENT Tier 3 Miscellaneous Therapeutic Agents POLYSORBATE LIQ 80 POLYSORBATE 80 LIQ Tier 3 Miscellaneous Therapeutic Agents POLYSORBATE LIQ 80 POLYSORBATE 80 LIQ Tier 2 Miscellaneous Therapeutic Agents POT HYDROXID SOL 5% POTASSIUM HYDROXIDE SOLUTION 5% Tier 2 Miscellaneous Therapeutic Agents PREP PADS PAD *ALCOHOL SWABS*** Tier 3 Miscellaneous Therapeutic Agents PROPYLENE GL SOL PROPYLENE GLYCOL Tier 3 Miscellaneous Therapeutic Agents PURIFIED LIQ WATER *DISTILLED WATER*** Tier 3 Miscellaneous Therapeutic Agents QC ALCOHOL PAD SWABS *ALCOHOL SWABS*** Tier 3 *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents QUINTET MIS SYSTEM Tier 3 DEVICES*** Miscellaneous Therapeutic Agents QUINTET TES BLD GLUC GLUCOSE BLOOD TEST STRIP Tier 3 X *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents QUINTET AC MIS SYSTEM Tier 3 DEVICES*** Miscellaneous Therapeutic Agents QUINTET AC TES BLD GLUC GLUCOSE BLOOD TEST STRIP Tier 3 X Miscellaneous Therapeutic Agents RA ALCOHOL PAD SWABS *ALCOHOL SWABS*** Tier 3

165 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents RA GLUCOSE MIS MONITOR Tier 3 DEVICES*** RA PEN NEEDL MIS Miscellaneous Therapeutic Agents INSULIN PEN NEEDLE 31 G X 5 MM (3/16") Tier 2 31GX3/16 *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents RA TRUE2GO KIT Tier 3 DEVICE*** Miscellaneous Therapeutic Agents RA TRUETEST TES GLUCOSE BLOOD TEST STRIP Tier 3 X Miscellaneous Therapeutic Agents RADIOGARDASE CAP 0.5GM PRUSSIAN BLUE INSOLUBLE CAP 0.5 GM Tier 3 Miscellaneous Therapeutic Agents RAPID GEL RX GEL *HOMEOPATHIC PRODUCTS - GEL** Tier 3 Miscellaneous Therapeutic Agents RASPBERRY SYP RASPBERRY SYRUP Tier 1 Miscellaneous Therapeutic Agents RELION TES ULTIMA GLUCOSE BLOOD TEST STRIP Tier 3 X *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents RELION ULTIM KIT SYSTEM Tier 3 DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents REVEAL KIT MONITOR Tier 3 DEVICE*** Miscellaneous Therapeutic Agents REVEAL TES BLD GLUC GLUCOSE BLOOD TEST STRIP Tier 3 X Miscellaneous Therapeutic Agents RHEUMADORON LIQ 102A *HOMEOPATHIC PRODUCTS - LIQUID** Tier 3 *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents RIGHTSOURCE MIS METER Tier 3 DEVICES*** C1 ESTERASE INHIBITOR Miscellaneous Therapeutic Agents RUCONEST INJ 2100UNIT Tier 3 X X X (RECOMBINANT) FOR IV INJ 2100 UNIT Miscellaneous Therapeutic Agents SAFTY NEEDLE MIS 18GX1" NEEDLE (DISP) 18 X 1" Tier 2 Miscellaneous Therapeutic Agents SAFTY NEEDLE MIS 18GX1.5" NEEDLE (DISP) 18 X 1-1/2" Tier 2 Miscellaneous Therapeutic Agents SAFTY NEEDLE MIS 19GX1" NEEDLE (DISP) 19 X 1" Tier 2 Miscellaneous Therapeutic Agents SAFTY NEEDLE MIS 19GX1.5" NEEDLE (DISP) 19 X 1-1/2" Tier 2 Miscellaneous Therapeutic Agents SAFTY NEEDLE MIS 20GX1" NEEDLE (DISP) 20 X 1" Tier 2 SAFTY NEEDLE MIS Miscellaneous Therapeutic Agents NEEDLE (DISP) 20 X 1-1/2" Tier 2 20GX1.5" Miscellaneous Therapeutic Agents SAFTY NEEDLE MIS 21GX1" NEEDLE (DISP) 21 X 1" Tier 2 Miscellaneous Therapeutic Agents SAFTY NEEDLE MIS 21GX1.5" NEEDLE (DISP) 21 X 1-1/2" Tier 2 Miscellaneous Therapeutic Agents SAFTY NEEDLE MIS 22GX1" NEEDLE (DISP) 22 X 1" Tier 2 SAFTY NEEDLE MIS Miscellaneous Therapeutic Agents NEEDLE (DISP) 22 X 1-1/2" Tier 2 22GX1.5" Miscellaneous Therapeutic Agents SAFTY NEEDLE MIS 23GX1" NEEDLE (DISP) 23 X 1" Tier 2 Miscellaneous Therapeutic Agents SAFTY NEEDLE MIS 25GX1" NEEDLE (DISP) 25 X 1" Tier 2 SAFTY NEEDLE MIS Miscellaneous Therapeutic Agents NEEDLE (DISP) 25 X 5/8" Tier 2 25GX5/8" LIRAGLUTIDE (WEIGHT MANAGEMENT) Miscellaneous Therapeutic Agents SAXENDA INJ 6MG/ML Tier 3 X SOLN PEN-INJECTOR 18 MG/3ML Miscellaneous Therapeutic Agents SERAQUA LIQ *SERUM BASE - LIQUID*** Tier 3 Miscellaneous Therapeutic Agents SEVOFLURANE SOL SEVOFLURANE INHAL SOLN Tier 1 Miscellaneous Therapeutic Agents SHARP CONTAI MIS *SHARPS CONTAINER - MISC*** Tier 3 Miscellaneous Therapeutic Agents SIL-K PAD MIS LARGE *WOUND DRESSINGS - MISC*** Tier 3 Miscellaneous Therapeutic Agents SIL-K PAD MIS MEDIUM *WOUND DRESSINGS - MISC*** Tier 3 Miscellaneous Therapeutic Agents SIL-K PAD MIS SMALL *WOUND DRESSINGS - MISC*** Tier 3 Miscellaneous Therapeutic Agents SILOMAC GEL ULTRA *GEL BASE - GEL** Tier 3 Miscellaneous Therapeutic Agents SILOSOME CRE TRANSDER *TRANSDERMAL BASE CREAM** Tier 3 Miscellaneous Therapeutic Agents SIMPLE SYP SIMPLE - SYRUP Tier 1 Miscellaneous Therapeutic Agents SIMPLGEL 30 GEL *GEL BASE - GEL** Tier 3 Miscellaneous Therapeutic Agents SIROLIMUS POW SIROLIMUS (BULK) POWDER Tier 3 X Miscellaneous Therapeutic Agents SM ALCOHOL PAD PREP *ALCOHOL SWABS*** Tier 3 INSULIN SYRINGE/NEEDLE U-100 0.3 ML Miscellaneous Therapeutic Agents SM INSULIN SYRINGE Tier 2 29 X 1/2" SOD PYROPHOS POW Miscellaneous Therapeutic Agents *BULK CHEMICALS - POWDER** Tier 3 X ANHYDROU Miscellaneous Therapeutic Agents SOJOURN SOL SEVOFLURANE INHAL SOLN Tier 1 Miscellaneous Therapeutic Agents SOLU-K GEL *GEL BASE - GEL** Tier 3 Miscellaneous Therapeutic Agents SOLVATECH SUS PLUS *ORAL VEHICLES - SUSP*** Tier 3 Miscellaneous Therapeutic Agents SOLVATECH SYP SWEET SF *ORAL VEHICLES - SYRUP*** Tier 3 Miscellaneous Therapeutic Agents SOLYDRA LIQ *OIL BASE - LIQUID*** Tier 3 Miscellaneous Therapeutic Agents SPEEDGEL RX GEL *HOMEOPATHIC PRODUCTS - GEL** Tier 3 Miscellaneous Therapeutic Agents SSKI SOL 1GM/ML POTASSIUM IODIDE SOLN 1 GM/ML Tier 3 Miscellaneous Therapeutic Agents SUPRANE INH DESFLURANE INHAL SOLN Tier 2 Miscellaneous Therapeutic Agents SUPRANE SOL DESFLURANE INHAL SOLN Tier 2 Miscellaneous Therapeutic Agents SUPREME TES GLUCOSE BLOOD TEST STRIP Tier 3 X SURESTEP PRO KIT *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents Tier 1 LINEARIT MISC.*** Miscellaneous Therapeutic Agents SUSPENSION SUS VEHICLE *ORAL VEHICLES - SUSP*** Tier 3 Miscellaneous Therapeutic Agents SYRPALTA SYP *ORAL VEHICLES - SYRUP*** Tier 3 Miscellaneous Therapeutic Agents SYRPALTA SYP SIMPLE - SYRUP Tier 1 Miscellaneous Therapeutic Agents SYRPALTA SYP CLEAR SIMPLE - SYRUP Tier 1 Miscellaneous Therapeutic Agents SYRSPEND SF LIQ *ORAL VEHICLES*** Tier 3 Miscellaneous Therapeutic Agents SYRSPEND SF SUS PH4 *ORAL VEHICLES FOR SUSP*** Tier 3 Miscellaneous Therapeutic Agents SYRUP SYP VEHICLE *ORAL VEHICLES - SYRUP*** Tier 3 Miscellaneous Therapeutic Agents SYRUP SF SYP VEHICLE *ORAL VEHICLES - SYRUP*** Tier 3 166 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Miscellaneous Therapeutic Agents TACROLIMUS POW TACROLIMUS (BULK) POWDER Tier 3 X TACROLIMUS POW Miscellaneous Therapeutic Agents TACROLIMUS (BULK) POWDER Tier 3 X MONOHYD Miscellaneous Therapeutic Agents TDC MAX CRE *TRANSDERMAL BASE CREAM** Tier 3 Miscellaneous Therapeutic Agents TDM SOLUTION SOL *EXTERNAL VEHICLES - SOLUTION*** Tier 3 Miscellaneous Therapeutic Agents TEGADERM AG PAD 2"X2" *WOUND DRESSINGS - PADS*** Tier 3 Miscellaneous Therapeutic Agents TEGADERM AG PAD 4"X5" *WOUND DRESSINGS - PADS*** Tier 3 Miscellaneous Therapeutic Agents TEGADERM AG PAD 4"X8" *WOUND DRESSINGS - PADS*** Tier 3 Miscellaneous Therapeutic Agents TEGADERM AG PAD 8"X8" *WOUND DRESSINGS - PADS*** Tier 3 Miscellaneous Therapeutic Agents TERRELL SOL ISOFLURANE INHAL SOLN Tier 1 Miscellaneous Therapeutic Agents TESSALON PER CAP 100MG BENZONATATE CAP 100 MG Tier 3 *DERMATOLOGICAL PRODUCTS MISC - Miscellaneous Therapeutic Agents TETRIX CRE Tier 3 CREAM** Miscellaneous Therapeutic Agents THALAMUS SUB COMPOSIT *HOMEOPATHIC PRODUCTS - SL TAB** Tier 3 Miscellaneous Therapeutic Agents THIOTEPA POW THIOTEPA (BULK) POWDER Tier 3 X *FIBRIN SEALANT COMPONENT KIT 10 Miscellaneous Therapeutic Agents TISSEEL KIT 10ML Tier 3 ML*** *FIBRIN SEALANT COMPONENT KIT 2 Miscellaneous Therapeutic Agents TISSEEL KIT 2ML Tier 3 ML*** *FIBRIN SEALANT COMPONENT KIT 4 Miscellaneous Therapeutic Agents TISSEEL KIT 4ML Tier 3 ML*** *FIBRIN SEALANT COMPONENT Miscellaneous Therapeutic Agents TISSEEL SOL Tier 3 SOLUTION*** *FIBRIN SEALANT COMPONENT KIT 10 Miscellaneous Therapeutic Agents TISSEEL VH KIT 10ML Tier 3 ML*** *FIBRIN SEALANT COMPONENT KIT 2 Miscellaneous Therapeutic Agents TISSEEL VH KIT 2ML Tier 3 ML*** *FIBRIN SEALANT COMPONENT KIT 4 Miscellaneous Therapeutic Agents TISSEEL VH KIT 4ML Tier 3 ML*** Miscellaneous Therapeutic Agents TOMMY GEL GEL *GEL BASE - GEL** Tier 3 TRANSDERMAL CRE PAIN Miscellaneous Therapeutic Agents *TRANSDERMAL BASE CREAM** Tier 3 BAS Miscellaneous Therapeutic Agents TRANZGEL GEL *HOMEOPATHIC PRODUCTS - GEL** Tier 3 *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents TRUE METRIX KIT AIR Tier 3 DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents TRUE METRIX KIT METER Tier 3 DEVICE*** *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents TRUE METRIX MIS AIR Tier 3 DEVICES*** TRUE METRIX TES Miscellaneous Therapeutic Agents GLUCOSE BLOOD TEST STRIP Tier 3 X GLUCOSE *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents TRUE2GO KIT Tier 3 DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents TRUERESULT KIT Tier 3 DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents TRUERESULT KIT MONITOR Tier 3 DEVICE*** Miscellaneous Therapeutic Agents TRUETEST TES GLUCOSE BLOOD TEST STRIP Tier 3 X Miscellaneous Therapeutic Agents TRUETEST TES BLD GLUC GLUCOSE BLOOD TEST STRIP Tier 3 X *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents TRUETRACK KIT SYSTEM Tier 3 DEVICE*** *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents TRUETRACK MIS BLD GLC Tier 3 DEVICES*** Miscellaneous Therapeutic Agents TRUETRACK TES GLUCOSE BLOOD TEST STRIP Tier 3 X Miscellaneous Therapeutic Agents TRUETRACK TES BLD GLUC GLUCOSE BLOOD TEST STRIP Tier 3 X Miscellaneous Therapeutic Agents TRYPTOPHAN CAP 500MG TRYPTOPHAN CAP 500 MG Tier 3 Miscellaneous Therapeutic Agents ULTANE SOL SEVOFLURANE INHAL SOLN Tier 3 Miscellaneous Therapeutic Agents ULTILET ALCH PAD SWAB *ALCOHOL SWABS*** Tier 1 *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents ULTILET OPER MIS DEVICE Tier 3 DEVICES**** Miscellaneous Therapeutic Agents ULTIMA TES GLUCOSE BLOOD TEST STRIP Tier 3 X INSULIN PEN NEEDLE 32 G X 4 MM Miscellaneous Therapeutic Agents UNFINE PNTP MIS 32GX4MM Tier 2 (5/32") Miscellaneous Therapeutic Agents UNIFINE PNTP MIS 29GX1/2" INSULIN PEN NEEDLE 29 G X 12 MM (1/2") Tier 2 UNIFINE PNTP MIS Miscellaneous Therapeutic Agents INSULIN PEN NEEDLE 29 G X 12 MM (1/2") Tier 2 29GX12MM Miscellaneous Therapeutic Agents UNIFINE PNTP MIS 31GX3/16 INSULIN PEN NEEDLE 31 G X 5 MM (3/16") Tier 2 INSULIN PEN NEEDLE 31 G X 8 MM (1/3" Miscellaneous Therapeutic Agents UNIFINE PNTP MIS 31GX5/16 Tier 2 OR 5/16") UNIFINE PNTP MIS Miscellaneous Therapeutic Agents INSULIN PEN NEEDLE 31 G X 5 MM (3/16") Tier 2 31GX5MM UNIFINE PNTP MIS Miscellaneous Therapeutic Agents INSULIN PEN NEEDLE 31 G X 6 MM (1/4") Tier 2 31GX6MM UNIFINE PNTP MIS INSULIN PEN NEEDLE 31 G X 8 MM (1/3" Miscellaneous Therapeutic Agents Tier 2 31GX8MM OR 5/16") Miscellaneous Therapeutic Agents UREA POW UREA POWDER Tier 3

167 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Miscellaneous Therapeutic Agents VENELEX OIN *BALSAM PERU-CASTOR OIL OINT*** Tier 3 *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents VERIO FLEX KIT ONETOUCH Tier 1 DEVICE*** Miscellaneous Therapeutic Agents VERSABASE GEL VERSABASE GEL Tier 3 Miscellaneous Therapeutic Agents VERSAFREE SYP *ORAL VEHICLES - SYRUP*** Tier 3 Miscellaneous Therapeutic Agents VERSAPLUS SYP *ORAL VEHICLES - SYRUP*** Tier 3 Miscellaneous Therapeutic Agents VERSAPRO GEL *GEL BASE - GEL** Tier 3 *BLOOD GLUCOSE MONITORING KIT W/ Miscellaneous Therapeutic Agents VIVID PAL KIT METER Tier 3 DEVICE*** *BLOOD GLUCOSE MONITORING Miscellaneous Therapeutic Agents VIVID PAL MIS METER Tier 3 DEVICES*** VORTEX VALVE MIS *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents Tier 2 CHAMBER CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING Miscellaneous Therapeutic Agents WATCHHALER MIS Tier 3 CHAMBERS - DEVICE*** HCR Miscellaneous Therapeutic Agents WIDE-SEAL DPR KIT 60 DIAPHRAGM WIDE SEAL 60 MM Preventive Care HCR Miscellaneous Therapeutic Agents WIDE-SEAL DPR KIT 65 DIAPHRAGM WIDE SEAL 65 MM Preventive Care HCR Miscellaneous Therapeutic Agents WIDE-SEAL DPR KIT 70 DIAPHRAGM WIDE SEAL 70 MM Preventive Care HCR Miscellaneous Therapeutic Agents WIDE-SEAL DPR KIT 75 DIAPHRAGM WIDE SEAL 75 MM Preventive Care HCR Miscellaneous Therapeutic Agents WIDE-SEAL DPR KIT 80 DIAPHRAGM WIDE SEAL 80 MM Preventive Care HCR Miscellaneous Therapeutic Agents WIDE-SEAL DPR KIT 85 DIAPHRAGM WIDE SEAL 85 MM Preventive Care HCR Miscellaneous Therapeutic Agents WIDE-SEAL DPR KIT 90 DIAPHRAGM WIDE SEAL 90 MM Preventive Care HCR Miscellaneous Therapeutic Agents WIDE-SEAL DPR KIT 95 DIAPHRAGM WIDE SEAL 95 MM Preventive Care Miscellaneous Therapeutic Agents WOUND WASH GEL BASE *GEL BASE - GEL** Tier 3 Not Specified ACCU-CHEK KIT FASTCLIX *LANCETS KIT*** Tier 1 Not Specified ACCU-CHEK KIT MLTICLIX *LANCETS KIT*** Tier 1 Not Specified ACCU-CHEK KIT SOFTCLIX *LANCETS KIT*** Tier 1 *BLOOD GLUCOSE CALIBRATION - Not Specified ACCU-CHEK LIQ GUIDE Tier 1 LIQUID*** *BLOOD GLUCOSE CALIBRATION - Not Specified ACCU-CHEK LIQ SMART Tier 1 LIQUID*** Not Specified ACCU-CHEK MIS MLTICLIX *LANCETS*** Tier 1 *BLOOD GLUCOSE CALIBRATION - Not Specified ACCU-CHEK SOL Tier 1 LIQUID*** *BLOOD GLUCOSE CALIBRATION - Not Specified ACCU-CHEK SOL COMPACT Tier 1 LIQUID*** *BLOOD GLUCOSE CALIBRATION - Not Specified ACCUTREND SOL GLUCOSE Tier 1 LIQUID*** Not Specified ADV LANCING MIS DEVICE *LANCET DEVICES*** Tier 3 HCR Not Specified AFTERA TAB 1.5MG LEVONORGESTREL TAB 1.5 MG Preventive Care BROMPHENIRAMINE & Not Specified ANDEHIST SYP 4-60MG/5 PSEUDOEPHEDRINE SYRUP 4-60 Tier 3 MG/5ML Not Specified ASSURE CMFRT MIS 28G *LANCETS*** Tier 3 Not Specified ASSURE CMFRT MIS 30G *LANCETS*** Tier 3 Not Specified AT LAST MIS LANCETS *LANCETS*** Tier 3 Not Specified AURORA LANCE MIS 30G *LANCETS*** Tier 3 AURORA LANCE MIS THIN Not Specified *LANCETS*** Tier 3 23G Not Specified AUTOLET II KIT CLINISAF *LANCETS KIT*** Tier 3 Not Specified AUTOLET LANC MIS DEVICE *LANCET DEVICES*** Tier 3 Not Specified AUTOLET LITE KIT STARTER *LANCETS KIT*** Tier 3 Not Specified AUTOLET MINI MIS *LANCET DEVICES*** Tier 3 Not Specified AUTOPEN MIS 1-21UNIT INJECTION DEVICE FOR INSULIN Tier 3 Not Specified AUTOPEN MIS 2-42UNIT INJECTION DEVICE FOR INSULIN Tier 3 BAYER BREEZE LIQ HIGH *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 2 CNT LIQUID - HIGH*** BAYER BREEZE LIQ LOW *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 2 CNTL LIQUID - LOW***

168 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy BAYER BREEZE LIQ NORM *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 2 CNT LIQUID - NORMAL*** BAYER MICRLT MIS LANC Not Specified *LANCET DEVICES*** Tier 3 DVC BAYER MICRLT MIS Not Specified *LANCETS*** Tier 3 LANCETS CAREONE ADV MIS Not Specified *LANCET DEVICES*** Tier 3 LANCING Not Specified CAREONE LANC MIS 28G *LANCETS*** Tier 3 CAREONE LANC MIS THIN Not Specified *LANCETS*** Tier 3 23G Not Specified CARETOUCH MIS EJECTOR *LANCET DEVICES*** Tier 3 Not Specified CARETOUCH MIS TWIST 28 *LANCETS*** Tier 3 Not Specified CARETOUCH MIS TWIST 30 *LANCETS*** Tier 3 Not Specified CARETOUCH MIS TWIST 33 *LANCETS*** Tier 3 *URINE GLUCOSE-KETONES TEST Not Specified CHEMSTRIP TES UGK Tier 3 STRIPS*** Not Specified CHEMSTRIP K TES ACETONE (URINE) TEST STRIP Tier 2 GUAIFENESIN-CODEINE SOLN 100-10 Not Specified CHERATUSSIN SYP 100-10/5 Tier 1 MG/5ML HCR Not Specified CITROMA SOL CHERRY MAGNESIUM CITRATE SOLN Preventive Care HCR Not Specified CITROMA SOL LEMON MAGNESIUM CITRATE SOLN Preventive Care Not Specified COAGUCHEK MIS LANCETS *LANCETS*** Tier 3 GUAIFENESIN-CODEINE SOLN 100-10 Not Specified CODEINE/GG SOL 100-10/5 Tier 1 MG/5ML GUAIFENESIN-CODEINE SOLN 100-10 Not Specified CODEINE/GG SOL 10-100/5 Tier 1 MG/5ML Not Specified COMFORT MIS LANCETS *LANCETS*** Tier 3 COMFORTOUCH MIS Not Specified *LANCETS*** Tier 3 LANCET HCR Not Specified CONCEPTROL GEL 4% NONOXYNOL-9 GEL 4% Preventive Care *BLOOD GLUCOSE CALIBRATION - Not Specified CONTOUR LIQ HIGH CNT Tier 2 LIQUID - HIGH*** *BLOOD GLUCOSE CALIBRATION - Not Specified CONTOUR LIQ LOW CNTL Tier 2 LIQUID - LOW*** *BLOOD GLUCOSE CALIBRATION - Not Specified CONTOUR LIQ NORM CNT Tier 2 LIQUID - NORMAL*** *BLOOD GLUCOSE CALIBRATION - Not Specified CONTOUR SOL NEXT Tier 2 LIQUID - NORMAL*** *BLOOD GLUCOSE CALIBRATION - Not Specified CONTOUR SOL NEXT Tier 2 LIQUID - LOW*** CONTROL HIGH SOL *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 2 UNISTRIP LIQUID - HIGH*** CONTROL LOW SOL *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 2 UNISTRIP LIQUID - LOW*** *BLOOD GLUCOSE CALIBRATION - Not Specified CONTROL SOL LIQ HI/MID/L Tier 2 LIQUID*** CONTROL SOL LIQ HIGH/ *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 2 LOW LIQUID*** *BLOOD GLUCOSE CALIBRATION - Not Specified CONTROL SOL LIQ MID Tier 2 LIQUID*** HCR CHOLECALCIFEROL CHEW TAB 1000 Not Specified CVD D3 CHW 1000UNIT Preventive UNIT Care HCR Not Specified CVS D3 CAP 1000UNIT CHOLECALCIFEROL CAP 1000 UNIT Preventive Care HCR Not Specified CVS D3 CAP 400UNIT CHOLECALCIFEROL CAP 400 UNIT Preventive Care HCR CHOLECALCIFEROL CHEW TAB 1000 Not Specified CVS D3 CHW 1000 UNT Preventive UNIT Care *URINE GLUCOSE-KETONES TEST Not Specified CVS KETONE TES CARE Tier 2 STRIPS*** CVS LANCETS MIS Not Specified *LANCETS*** Tier 3 ORIGINAL Not Specified CVS LANCETS MIS THIN 26G *LANCETS*** Tier 3 Not Specified CVS LANCETS MIS THIN 33G *LANCETS*** Tier 3 Not Specified CVS LANCING MIS DEVICE *LANCET DEVICES*** Tier 3

169 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy HCR CVS NICOTINE GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive CINN Care HCR CVS NICOTINE GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive MINT Care HCR CVS NICOTINE GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive ORIG Care HCR CVS NICOTINE GUM Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive 2MGFRUIT Care HCR CVS NICOTINE GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive CINN Care HCR CVS NICOTINE GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive MINT Care HCR CVS NICOTINE GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive ORIG Care HCR CVS NICOTINE GUM Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive 4MGFRUIT Care HCR Not Specified CVS NICOTINE LOZ 2MG NICOTINE POLACRILEX LOZENGE 2 MG Preventive Care HCR CVS NICOTINE LOZ 2MG Not Specified NICOTINE POLACRILEX LOZENGE 2 MG Preventive MINT Care HCR CVS NICOTINE LOZ 4MG Not Specified NICOTINE POLACRILEX LOZENGE 4 MG Preventive MINT Care Not Specified CYCLACILLIN TAB 500MG CYCLACILLIN TAB 500 MG Tier 1 HCR CHOLECALCIFEROL CHEW TAB 400 Not Specified D 400 CHW 400UNIT Preventive UNIT Care HCR Not Specified D 400 TAB 400UNIT CHOLECALCIFEROL TAB 400 UNIT Preventive Care HCR Not Specified D3 CAP 1000UNIT CHOLECALCIFEROL CAP 1000 UNIT Preventive Care HCR CHOLECALCIFEROL CHEW TAB 400 Not Specified D-3 GUMMY CHW 400UNIT Preventive UNIT Care HCR Not Specified DELTA D3 TAB 400UNIT CHOLECALCIFEROL TAB 400 UNIT Preventive Care GLUCOSE URINE TEST-(GLUCOSE Not Specified DIASTIX TES STRIPS Tier 3 OXIDASE) STRIP DOXYLAMINE-PYRIDOXINE TAB Not Specified DICLEGIS TAB 10-10MG Tier 3 X DELAYED RELEASE 10-10 MG DICLOFENAC GEL 1% & MENTHOL- Not Specified DICLOPR KIT 1-10-30% Tier 3 METHYL SAL CREAM 10-30% KIT ANTIGEN SERUM (MIXED) {DMR USE Not Specified DMR ANTIGEN THERAPY Tier 3 ONLY} HCR CHOLECALCIFEROL ORAL LIQUID 400 Not Specified D-VI-SOL LIQ 400UNIT Preventive UNIT/ML Care HCR CHOLECALCIFEROL ORAL LIQUID 400 Not Specified D-VITA LIQ 400UNIT Preventive UNIT/ML Care *BLOOD GLUCOSE CALIBRATION - Not Specified EASYMAX SOL HIGH Tier 2 LIQUID - HIGH*** *BLOOD GLUCOSE CALIBRATION - Not Specified EASYMAX SOL LOW Tier 2 LIQUID - LOW*** *BLOOD GLUCOSE CALIBRATION - Not Specified EASYMAX SOL NORM/LOW Tier 2 LIQUID*** *BLOOD GLUCOSE CALIBRATION - Not Specified EASYMAX SOL NORMAL Tier 2 LIQUID - NORMAL*** *BLOOD GLUCOSE CALIBRATION - Not Specified EASYMAX 15 SOL LEVEL 1 Tier 2 LIQUID*** *BLOOD GLUCOSE CALIBRATION - Not Specified EASYMAX 15 SOL LEVEL 2 Tier 2 LIQUID*** *BLOOD GLUCOSE CALIBRATION - Not Specified EASYMAX 15 SOL LEVEL1-2 Tier 2 LIQUID*** HCR Not Specified ECONTRA EZ TAB 1.5MG LEVONORGESTREL TAB 1.5 MG Preventive Care 170 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy *BLOOD GLUCOSE CALIBRATION - Not Specified EMBRACE SOL LOW Tier 2 LIQUID - LOW*** Not Specified EPINEPHR HCL SOL 2% OP EPINEPHRINE HCL OPHTH SOLN 2% Tier 1 HCR EQ NICOTINE GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive CINN Care HCR EQ NICOTINE GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive MINT Care HCR EQ NICOTINE GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive ORIG Care HCR EQ NICOTINE GUM Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive 2MGFRUIT Care HCR EQ NICOTINE GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive CINN Care HCR EQ NICOTINE GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive MINT Care HCR EQ NICOTINE GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive ORIG Care HCR Not Specified EQ NICOTINE GUM 4MG REF NICOTINE POLACRILEX GUM 4 MG Preventive Care HCR EQ NICOTINE GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive STRT Care HCR EQ NICOTINE GUM Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive 4MGFRUIT Care HCR EQ NICOTINE LOZ 2MG Not Specified NICOTINE POLACRILEX LOZENGE 2 MG Preventive CHER Care HCR Not Specified EQ NICOTINE LOZ 2MG CINN NICOTINE POLACRILEX LOZENGE 2 MG Preventive Care HCR Not Specified EQ NICOTINE LOZ 2MG MINT NICOTINE POLACRILEX LOZENGE 2 MG Preventive Care HCR EQ NICOTINE LOZ 4MG Not Specified NICOTINE POLACRILEX LOZENGE 4 MG Preventive CHRY Care HCR Not Specified EQ NICOTINE LOZ 4MG CINN NICOTINE POLACRILEX LOZENGE 4 MG Preventive Care HCR Not Specified EQ NICOTINE LOZ 4MG MINT NICOTINE POLACRILEX LOZENGE 4 MG Preventive Care HCR Not Specified EQL NICOTINE GUM 2MG NICOTINE POLACRILEX GUM 2 MG Preventive Care HCR Not Specified EQL NICOTINE GUM 4MG NICOTINE POLACRILEX GUM 4 MG Preventive Care HCR Not Specified EQL NICOTINE LOZ 2MG NICOTINE POLACRILEX LOZENGE 2 MG Preventive Care HCR EQL NICOTINE LOZ 2MG Not Specified NICOTINE POLACRILEX LOZENGE 2 MG Preventive MINT Care HCR EQL NICOTINE LOZ 4MG Not Specified NICOTINE POLACRILEX LOZENGE 4 MG Preventive CHRY Care HCR EQL NICOTINE LOZ 4MG Not Specified NICOTINE POLACRILEX LOZENGE 4 MG Preventive MINT Care HCR Not Specified FALLBACK TAB 1.5MG LEVONORGESTREL TAB 1.5 MG Preventive Care Not Specified FASTCLIX MIS LANCETS *LANCETS*** Tier 1 HCR Not Specified FC FEMALE MIS CONDOM *CONDOMS - FEMALE*** Preventive Care HCR Not Specified FEMCAP MIS 22MM PLACEHOLDER DNU Preventive Care Not Specified FINGERSTIX MIS LANCETS *LANCETS*** Tier 3

171 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Not Specified FLOW-EZE MIS VENTED HYPODERMIC NEEDLES (DISPOSABLE) Tier 1 *BLOOD GLUCOSE CALIBRATION - Not Specified FORTISCARE SOL CNTL HI Tier 2 LIQUID - HIGH*** FORTISCARE SOL CNTL *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 2 LOW LIQUID - LOW*** FORTISCARE SOL CNTL *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 2 NML LIQUID - NORMAL*** Not Specified FREESTYLE MIS UNISTICK *LANCETS*** Tier 3 GUAIFENESIN-CODEINE SOLN 100-10 Not Specified G TUSSIN AC LIQ 100-10/5 Tier 1 MG/5ML Not Specified GENTLE-LET MIS 26G *LANCETS*** Tier 3 Not Specified GENTLE-LET MIS 28G *LANCETS*** Tier 3 Not Specified GENTLE-LET MIS LANCETS *LANCETS*** Tier 3 Not Specified GENTLE-LET MIS PLATFORM *LANCETS MISC.*** Tier 3 GUAIFENESIN-CODEINE SOLN 100-10 Not Specified GG/CODEINE SOL Tier 1 MG/5ML GUAIFENESIN-CODEINE SOLN 100-10 Not Specified GG/CODEINE SOL 100-10/5 Tier 1 MG/5ML GLUC CONTROL SOL LEVEL *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 2 1 LIQUID*** GLUC CONTROL SOL LEVEL *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 2 2 LIQUID*** GLUCOCARD 01 TES Not Specified GLUCOSE BLOOD TEST STRIPS Tier 3 X SENSOR GLUCOCARD 01 TEST Not Specified GLUCOSE BLOOD TEST STRIPS Tier 3 X STRIPS Not Specified GLUCOCARD TES VITAL GLUCOSE BLOOD TEST STRIPS Tier 3 X GLUCOSE CONT LIQ HIGH/ *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 2 LOW LIQUID*** GLUCOSE CONT SOL *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 2 PRECISIO LIQUID*** HCR GNP NICOTINE GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive MINT Care HCR GNP NICOTINE GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive ORIG Care HCR GNP NICOTINE GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive MINT Care HCR GNP NICOTINE GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive ORIG Care HCR GNP NICOTINE LOZ 2MG Not Specified NICOTINE POLACRILEX LOZENGE 2 MG Preventive MINT Care HCR GNP NICOTINE LOZ 4MG Not Specified NICOTINE POLACRILEX LOZENGE 4 MG Preventive MINT Care HCR GNP NICOTINE LOZ MINI Not Specified NICOTINE POLACRILEX LOZENGE 2 MG Preventive 2MG Care HCR Not Specified GNP VIT D TAB 1000UNIT CHOLECALCIFEROL TAB 1000 UNIT Preventive Care GUAIFENESIN-CODEINE SOLN 100-10 Not Specified GUAIATUSSIN SYP 100-10/5 Tier 1 MG/5ML GUAIFENESIN-CODEINE SOLN 100-10 Not Specified GUAIFENESIN SYP 100-10/5 Tier 1 MG/5ML HCR Not Specified GYNOL II GEL 3% NONOXYNOL-9 GEL 3% Preventive Care HAEMOLANCE MIS LOW Not Specified *LANCETS*** Tier 3 FLOW HAEMOLANCE MIS Not Specified *LANCETS*** Tier 3 RETRACT HCR HM NICOTINE GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive MINT Care HCR HM NICOTINE GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive MINT Care HCR HM NICOTINE LOZ 2MG Not Specified NICOTINE POLACRILEX LOZENGE 2 MG Preventive MINT Care HCR HM NICOTINE LOZ 4MG Not Specified NICOTINE POLACRILEX LOZENGE 4 MG Preventive MINT Care Not Specified HUMAPEN MIS LUXURA INJECTION DEVICE FOR INSULIN Tier 3 172 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Not Specified HYDROMORPHON SUP 3MG HYDROMORPHONE HCL SUPPOS 3 MG Tier 1 Not Specified IMPAVIDO CAP 50MG MILTEFOSINE CAP 50 MG Tier 2 X X GUAIFENESIN-CODEINE SOLN 100-10 Not Specified IOPHEN C-NR LIQ 100-10/5 Tier 1 MG/5ML Not Specified KETOCARE TES ACETONE (URINE) TEST STRIP Tier 2 *URINE GLUCOSE-KETONES TEST Not Specified KETO-DIASTIX TES Tier 3 STRIPS*** Not Specified KETOSTIX TES STRIP ACETONE (URINE) TEST STRIP Tier 2 HCR Not Specified KLS QUIT2 GUM 2MG NICOTINE POLACRILEX GUM 2 MG Preventive Care HCR Not Specified KLS QUIT2 LOZ 2MG NICOTINE POLACRILEX LOZENGE 2 MG Preventive Care HCR Not Specified KLS QUIT4 GUM 4MG NICOTINE POLACRILEX GUM 4 MG Preventive Care HCR Not Specified KLS QUIT4 LOZ 4MG NICOTINE POLACRILEX LOZENGE 4 MG Preventive Care LANCET ALTER MIS SITE Not Specified *LANCETS*** Tier 3 26G Not Specified LANCET CARRY MIS CASE *LANCETS MISC.*** Tier 3 LANCET SUPER MIS THIN Not Specified *LANCETS*** Tier 3 30G Not Specified LANCET ULTRA MIS 28G *LANCETS*** Tier 3 LANCET ULTRA MIS THIN Not Specified *LANCETS*** Tier 3 28G Not Specified LANCETS MIS 23G *LANCETS*** Tier 3 Not Specified LANCETS MIS 28G *LANCETS*** Tier 3 LANCETS MICR MIS THIN Not Specified *LANCETS*** Tier 3 33G LANCETS SUPR MIS THIN Not Specified *LANCETS*** Tier 3 28G Not Specified LANCETS THIN MIS *LANCETS*** Tier 3 LANCETS ULTR MIS THIN Not Specified *LANCETS*** Tier 3 28G Not Specified LANCING DEVI MIS *LANCET DEVICES*** Tier 3 Not Specified LB LANCET MIS 28G *LANCETS*** Tier 3 Not Specified LB LANCING MIS DEVICE *LANCET DEVICES*** Tier 3 HCR Not Specified LEVONORGESTR TAB 1.5MG LEVONORGESTREL TAB 1.5 MG Preventive Care Not Specified LIFESCAN MIS UNISTIK2 *LANCETS*** Tier 1 HCR Not Specified MAG CITRATE SOL MAGNESIUM CITRATE SOLN Preventive Care HCR Not Specified MAG CITRATE SOL CHERRY MAGNESIUM CITRATE SOLN Preventive Care HCR Not Specified MAG CITRATE SOL GRAPE MAGNESIUM CITRATE SOLN Preventive Care HCR Not Specified MAG CITRATE SOL LEMON MAGNESIUM CITRATE SOLN Preventive Care *BLOOD GLUCOSE CALIBRATION - Not Specified MEDISENSE LIQ GLUC/KET Tier 2 LIQUID*** *BLOOD GLUCOSE CALIBRATION - Not Specified MEDISENSE LIQ GLUC-KET Tier 2 LIQUID*** Not Specified MEIJER MIS LANCETS *LANCETS*** Tier 3 Not Specified MICROLET MIS LANCETS *LANCETS*** Tier 3 Not Specified MICROLET MIS NEXT *LANCET DEVICES*** Tier 3 Not Specified MINI LANCING MIS DEVICE *LANCET DEVICES*** Tier 3 Not Specified MM LANCING MIS DEVICE *LANCET DEVICES*** Tier 3 Not Specified MM TWIST MIS LANCETS *LANCETS*** Tier 3 Not Specified MOBILE LANCE MIS 30G *LANCETS*** Tier 3 Not Specified MORPHINE SUL SUP 10MG MORPHINE SULFATE SUPPOS 10 MG Tier 3 Not Specified MORPHINE SUL SUP 20MG MORPHINE SULFATE SUPPOS 20 MG Tier 1 Not Specified MORPHINE SUL SUP 30MG MORPHINE SULFATE SUPPOS 30 MG Tier 1 Not Specified MORPHINE SUL SUP 5MG MORPHINE SULFATE SUPPOS 5 MG Tier 1 HCR Not Specified MY CHOICE TAB 1.5MG LEVONORGESTREL TAB 1.5 MG Preventive Care HCR Not Specified MY WAY TAB 1.5MG LEVONORGESTREL TAB 1.5 MG Preventive Care

173 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy NEUTEK 2TEK SOL *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 2 CONTROL LIQUID*** HCR Not Specified NEXT CHOICE TAB 1.5MG LEVONORGESTREL TAB 1.5 MG Preventive Care HCR Not Specified NICORELIEF GUM 2MG MINT NICOTINE POLACRILEX GUM 2 MG Preventive Care HCR Not Specified NICORELIEF GUM 2MG ORIG NICOTINE POLACRILEX GUM 2 MG Preventive Care HCR Not Specified NICORELIEF GUM 4MG MINT NICOTINE POLACRILEX GUM 4 MG Preventive Care HCR Not Specified NICORELIEF GUM 4MG ORIG NICOTINE POLACRILEX GUM 4 MG Preventive Care HCR Not Specified NICORETTE GUM 2MG NICOTINE POLACRILEX GUM 2 MG Preventive Care HCR Not Specified NICORETTE GUM 2MG CINN NICOTINE POLACRILEX GUM 2 MG Preventive Care HCR Not Specified NICORETTE GUM 2MG MINT NICOTINE POLACRILEX GUM 2 MG Preventive Care HCR Not Specified NICORETTE GUM 2MG ORIG NICOTINE POLACRILEX GUM 2 MG Preventive Care HCR Not Specified NICORETTE GUM 2MGFRUIT NICOTINE POLACRILEX GUM 2 MG Preventive Care HCR Not Specified NICORETTE GUM 4MG NICOTINE POLACRILEX GUM 4 MG Preventive Care HCR Not Specified NICORETTE GUM 4MG CINN NICOTINE POLACRILEX GUM 4 MG Preventive Care HCR Not Specified NICORETTE GUM 4MG MINT NICOTINE POLACRILEX GUM 4 MG Preventive Care HCR Not Specified NICORETTE GUM 4MG ORIG NICOTINE POLACRILEX GUM 4 MG Preventive Care HCR Not Specified NICORETTE GUM 4MGFRUIT NICOTINE POLACRILEX GUM 4 MG Preventive Care HCR Not Specified NICORETTE LOZ 2MG CHRY NICOTINE POLACRILEX LOZENGE 2 MG Preventive Care HCR Not Specified NICORETTE LOZ 2MG MINT NICOTINE POLACRILEX LOZENGE 2 MG Preventive Care HCR Not Specified NICORETTE LOZ 2MG ORIG NICOTINE POLACRILEX LOZENGE 2 MG Preventive Care HCR Not Specified NICORETTE LOZ 4MG CHRY NICOTINE POLACRILEX LOZENGE 4 MG Preventive Care HCR Not Specified NICORETTE LOZ 4MG MINT NICOTINE POLACRILEX LOZENGE 4 MG Preventive Care HCR Not Specified NICORETTE LOZ 4MG ORIG NICOTINE POLACRILEX LOZENGE 4 MG Preventive Care HCR NICORETTE ST GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive MINT Care HCR NICORETTE ST GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive ORIG Care HCR NICORETTE ST GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive ORIG Care HCR Not Specified NICOTINE GUM 2MG NICOTINE POLACRILEX GUM 2 MG Preventive Care HCR Not Specified NICOTINE GUM 2MGFRUIT NICOTINE POLACRILEX GUM 2 MG Preventive Care

174 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy HCR Not Specified NICOTINE GUM 4MG NICOTINE POLACRILEX GUM 4 MG Preventive Care HCR Not Specified NICOTINE LOZ 2MG CHRY NICOTINE POLACRILEX LOZENGE 2 MG Preventive Care HCR Not Specified NICOTINE LOZ 2MG MINT NICOTINE POLACRILEX LOZENGE 2 MG Preventive Care HCR Not Specified NICOTINE LOZ 4MG CHRY NICOTINE POLACRILEX LOZENGE 4 MG Preventive Care HCR Not Specified NICOTINE LOZ 4MG CINN NICOTINE POLACRILEX LOZENGE 4 MG Preventive Care HCR Not Specified NICOTINE LOZ 4MG MINT NICOTINE POLACRILEX LOZENGE 4 MG Preventive Care HCR Not Specified NICOTINE LOZ MINI 2MG NICOTINE POLACRILEX LOZENGE 2 MG Preventive Care HCR Not Specified NICOTINE POL GUM 2MG NICOTINE POLACRILEX GUM 2 MG Preventive Care HCR NICOTINE POL GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive CINN Care HCR NICOTINE POL GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive MINT Care HCR NICOTINE POL GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive ORIG Care HCR NICOTINE POL GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive REF Care HCR NICOTINE POL GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive STRT Care HCR NICOTINE POL GUM Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive 2MGFRUIT Care HCR Not Specified NICOTINE POL GUM 4MG NICOTINE POLACRILEX GUM 4 MG Preventive Care HCR NICOTINE POL GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive CINN Care HCR NICOTINE POL GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive MINT Care HCR NICOTINE POL GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive ORIG Care HCR NICOTINE POL GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive REF Care HCR NICOTINE POL GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive STRT Care HCR NICOTINE POL GUM Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive 4MGFRUIT Care HCR NICOTINE POL LOZ 2MG Not Specified NICOTINE POLACRILEX LOZENGE 2 MG Preventive CHRY Care HCR NICOTINE POL LOZ 2MG Not Specified NICOTINE POLACRILEX LOZENGE 2 MG Preventive CINN Care HCR NICOTINE POL LOZ 2MG Not Specified NICOTINE POLACRILEX LOZENGE 2 MG Preventive MINT Care HCR NICOTINE POL LOZ 4MG Not Specified NICOTINE POLACRILEX LOZENGE 4 MG Preventive CHRY Care HCR NICOTINE POL LOZ 4MG Not Specified NICOTINE POLACRILEX LOZENGE 4 MG Preventive CINN Care

175 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy HCR NICOTINE POL LOZ 4MG Not Specified NICOTINE POLACRILEX LOZENGE 4 MG Preventive MINT Care Not Specified NOVOPEN ECHO MIS INJECTION DEVICE FOR INSULIN Tier 3 Not Specified ON CALL MIS LANCETS *LANCETS*** Tier 3 ON CALL EXPR SOL *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 2 GLUCOSE LIQUID*** Not Specified ON CALL LANC MIS DEVICE *LANCET DEVICES*** Tier 3 ON CALL PLUS MIS LANC Not Specified *LANCET DEVICES*** Tier 3 DEV ON CALL PLUS MIS Not Specified *LANCETS*** Tier 3 LANCETS ON CALL PLUS SOL *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 2 CONTROL LIQUID*** ON CALL VIVD SOL *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 2 CONTROL LIQUID*** Not Specified ONETOUCH MIS 30G *LANCETS*** Tier 1 Not Specified ONETOUCH MIS COMBO *LANCETS*** Tier 1 Not Specified ONETOUCH MIS LANC DEV *LANCETS MISC.*** Tier 1 Not Specified ONETOUCH MIS LANC DEV *LANCET DEVICES*** Tier 1 Not Specified ONETOUCH MIS LANCETS *LANCETS*** Tier 1 *BLOOD GLUCOSE CALIBRATION - Not Specified ONETOUCH SOL ULT CONT Tier 1 LIQUID*** *BLOOD GLUCOSE CALIBRATION - Not Specified ONETOUCH SOL VERIO Tier 1 LIQUID*** *BLOOD GLUCOSE CALIBRATION - Not Specified ONETOUCH SOL VERIO-HI Tier 1 LIQUID - HIGH*** ONETOUCH FP MIS Not Specified *LANCETS*** Tier 1 LANCETS ONETOUCH US MIS Not Specified *LANCETS*** Tier 1 LANCETS HCR Not Specified OPCICON TAB 1.5MG LEVONORGESTREL TAB 1.5 MG Preventive Care HCR Not Specified OPTION 2 TAB 1.5MG LEVONORGESTREL TAB 1.5 MG Preventive Care OPTUMRX CONT SOL *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 2 LEVEL1/2 LIQUID*** PD TEST NDC BRAND W/ Not Specified PD TEST GPI Tier 3 GENERIC 1 PD TEST NDC BRAND W/ Not Specified PD TEST GPI Tier 3 GENERIC 2 PD TEST NDC GENERIC W/ Not Specified PD TEST GPI Tier 1 MAC 1 PD TEST NDC GENERIC W/ Not Specified PD TEST GPI Tier 1 MAC 2 PD TEST NDC GENERIC W/O Not Specified PD TEST GPI Tier 1 MAC 1 PD TEST NDC GENERIC W/O Not Specified PD TEST GPI Tier 1 MAC 2 HCR CHOLECALCIFEROL ORAL LIQUID 400 Not Specified PEDIA D-VITE DRO 400UNIT Preventive UNIT/ML Care Not Specified PENLET II KIT BLOOD *LANCETS KIT*** Tier 1 Not Specified PENLET II MIS REPL CAP *LANCETS MISC.*** Tier 1 PENTAERYTHRITOL TETRANITRATE TAB Not Specified PETN TAB 80MG Tier 1 80 MG HCR Not Specified PLAN B TAB 1.5MG LEVONORGESTREL TAB 1.5 MG Preventive Care *BLOOD GLUCOSE CALIBRATION - Not Specified PRECISION LIQ CONTROL Tier 2 LIQUID*** *BLOOD GLUCOSE CALIBRATION - Not Specified PRECISION LIQ GLUC/KET Tier 2 LIQUID*** *BLOOD GLUCOSE CALIBRATION - Not Specified PRECISION LIQ NRML/MID Tier 2 LIQUID*** Not Specified PRECISN XTRA TES KETONE KETONE BLOOD TEST STRIP Tier 3 PRENATAL DHA PAK 27-1- *PRENATAL W/O A W/FE FUM-FA TAB Not Specified Tier 3 250 27-1 MG & DHA CAP 250 MG*** Not Specified PSS SAFE LAN MIS *LANCETS*** Tier 3 Not Specified PSS SEL LANC MIS *LANCETS*** Tier 3 Not Specified PSS SEL PLAT MIS *LANCETS MISC.*** Tier 3 Not Specified PX LANCETS MIS ULT THIN *LANCETS*** Tier 3 Not Specified QC LANCETS MIS 28G *LANCETS*** Tier 3 Not Specified QC LANCETS MIS 30G *LANCETS*** Tier 3 Not Specified QC LANCING MIS DEVICE *LANCET DEVICES*** Tier 3

176 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy HCR Not Specified QC NICOTINE GUM 4MG NICOTINE POLACRILEX GUM 4 MG Preventive Care QUINTET CONT SOL HGH/ *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 2 NORM LIQUID*** Not Specified RA E-ZJECT MIS 28G *LANCETS*** Tier 3 Not Specified RA E-ZJECT MIS 33G *LANCETS*** Tier 3 Not Specified RA E-ZJECT MIS THIN 26G *LANCETS*** Tier 3 Not Specified RA E-ZJECT MIS THIN 28G *LANCETS*** Tier 3 Not Specified RA E-ZJECT MIS ULT THIN *LANCETS*** Tier 3 HCR Not Specified RA NICOTINE GUM 2MG NICOTINE POLACRILEX GUM 2 MG Preventive Care HCR RA NICOTINE GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive CINN Care HCR RA NICOTINE GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive MINT Care HCR RA NICOTINE GUM Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive 2MGFRUIT Care HCR Not Specified RA NICOTINE GUM 4MG NICOTINE POLACRILEX GUM 4 MG Preventive Care HCR RA NICOTINE GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive FRUT Care HCR RA NICOTINE GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive MINT Care HCR Not Specified RA NICOTINE LOZ 2MG MINT NICOTINE POLACRILEX LOZENGE 2 MG Preventive Care HCR Not Specified RA NICOTINE LOZ 4MG MINT NICOTINE POLACRILEX LOZENGE 4 MG Preventive Care HCR Not Specified REACT TAB 1.5MG LEVONORGESTREL TAB 1.5 MG Preventive Care Not Specified RELION KETON TES ACETONE (URINE) TEST STRIP Tier 2 RELION LANCE MIS THIN Not Specified *LANCETS*** Tier 3 26G *SILICONE PATCH & VITAMIN E-SILICONE Not Specified REXASIL KIT Tier 3 LIQUID KIT** GUAIFENESIN-CODEINE SOLN 100-10 Not Specified ROBAFEN AC SOL 100-10/5 Tier 1 MG/5ML Not Specified SAFE-T-LANCE MIS 21G *LANCETS*** Tier 3 Not Specified SAFE-T-LANCE MIS 25G *LANCETS*** Tier 3 Not Specified SAFE-T-LANCE MIS HI FLOW *LANCETS*** Tier 3 SAFE-T-LANCE MIS LOW Not Specified *LANCETS*** Tier 3 FLOW SAFE-T-LANCE MIS NOR Not Specified *LANCETS*** Tier 3 FLOW Not Specified SAFE-T-PRO MIS LANCETS *LANCETS*** Tier 1 Not Specified SAFE-T-PRO MIS PLUS *LANCETS*** Tier 1 Not Specified SELECT-LITE KIT DEV/LANC *LANCETS KIT*** Tier 3 HCR Not Specified SHUR-SEAL GEL 2% NONOXYNOL-9 GEL 2% Preventive Care Not Specified SINGLE-LET MIS 23G *LANCETS*** Tier 3 HCR Not Specified SM NICOTINE GUM 2MG NICOTINE POLACRILEX GUM 2 MG Preventive Care HCR SM NICOTINE GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive MINT Care HCR Not Specified SM NICOTINE GUM 4MG NICOTINE POLACRILEX GUM 4 MG Preventive Care HCR SM NICOTINE GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive MINT Care HCR SM NICOTINE LOZ 2MG Not Specified NICOTINE POLACRILEX LOZENGE 2 MG Preventive MINT Care HCR SM NICOTINE LOZ 4MG Not Specified NICOTINE POLACRILEX LOZENGE 4 MG Preventive MINT Care 177 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Not Specified SOFT TOUCH MIS LANCETS *LANCETS*** Tier 1 Not Specified SOFTCLIX MIS LANCETS *LANCETS*** Tier 1 HCR STOP SMOKING GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive MINT Care HCR STOP SMOKING GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive ORIG Care HCR Not Specified STOP SMOKING GUM 4MG NICOTINE POLACRILEX GUM 4 MG Preventive Care HCR Not Specified STOP SMOKING LOZ 2MG NICOTINE POLACRILEX LOZENGE 2 MG Preventive Care HCR STOP SMOKING LOZ 2MG Not Specified NICOTINE POLACRILEX LOZENGE 2 MG Preventive MINT Care HCR STOP SMOKING LOZ 4MG Not Specified NICOTINE POLACRILEX LOZENGE 4 MG Preventive MINT Care Not Specified SUPER THIN MIS LANCETS *LANCETS*** Tier 3 *BLOOD GLUCOSE CALIBRATION - Not Specified SUPREME II LIQ HIGH/LOW Tier 2 LIQUID*** *BLOOD GLUCOSE CALIBRATION - Not Specified SURESTEP SOL CONTROL Tier 1 LIQUID*** *BLOOD GLUCOSE CALIBRATION - Not Specified SURESTEP GLU SOL Tier 1 LIQUID*** SURESTEP GLU SOL HIGH/ *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 1 LOW LIQUID*** SURESTEP PRO TES HIGH *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 1 CON LIQUID - HIGH*** SURESTEP PRO TES LOW *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 1 CON LIQUID - LOW*** SURESTEP PRO TES NORM *BLOOD GLUCOSE CALIBRATION - Not Specified Tier 1 CON LIQUID - NORMAL*** HCR SW NICOTINE GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive MINT Care HCR Not Specified SW NICOTINE GUM 4MG NICOTINE POLACRILEX GUM 4 MG Preventive Care HCR SW NICOTINE LOZ 2MG Not Specified NICOTINE POLACRILEX LOZENGE 2 MG Preventive MINT Care HCR SW NICOTINE LOZ 4MG Not Specified NICOTINE POLACRILEX LOZENGE 4 MG Preventive MINT Care Not Specified T Tier 1 HCR Not Specified TAKE ACTION TAB 1.5MG LEVONORGESTREL TAB 1.5 MG Preventive Care Not Specified TECHLITE MIS LANCETS *LANCETS*** Tier 3 Not Specified TGT LANCET MIS 23G *LANCETS*** Tier 3 Not Specified TGT LANCET MIS 28G *LANCETS*** Tier 3 Not Specified TGT LANCET MIS 30G *LANCETS*** Tier 3 Not Specified TGT LANCET MIS ALTERNAT *LANCETS*** Tier 3 Not Specified TGT LANCING MIS ADV DEV *LANCET DEVICES*** Tier 3 Not Specified TGT LANCING MIS DEVICE *LANCET DEVICES*** Tier 3 HCR TGT NICOTINE GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive MINT Care HCR TGT NICOTINE GUM 2MG Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive ORIG Care HCR TGT NICOTINE GUM Not Specified NICOTINE POLACRILEX GUM 2 MG Preventive 2MGFRUIT Care HCR Not Specified TGT NICOTINE GUM 4MG NICOTINE POLACRILEX GUM 4 MG Preventive Care HCR TGT NICOTINE GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive MINT Care HCR TGT NICOTINE GUM 4MG Not Specified NICOTINE POLACRILEX GUM 4 MG Preventive ORIG Care HCR TGT NICOTINE LOZ 2MG Not Specified NICOTINE POLACRILEX LOZENGE 2 MG Preventive CHRY Care 178 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy HCR TGT NICOTINE LOZ 2MG Not Specified NICOTINE POLACRILEX LOZENGE 2 MG Preventive MINT Care HCR TGT NICOTINE LOZ 4MG Not Specified NICOTINE POLACRILEX LOZENGE 4 MG Preventive CHRY Care HCR TGT NICOTINE LOZ 4MG Not Specified NICOTINE POLACRILEX LOZENGE 4 MG Preventive MINT Care Not Specified THIN LANCETS MIS *LANCETS*** Tier 3 Not Specified THINLETS GP MIS 26G *LANCETS*** Tier 3 HCR Not Specified THRIVE GUM 2MG MINT NICOTINE POLACRILEX GUM 2 MG Preventive Care HCR NONOXYNOL-9 VAGINAL SPONGE 1000 Not Specified TODAY SPONGE MIS Preventive MG Care *BLOOD GLUCOSE CALIBRATION - Not Specified TRUE METRIX SOL LEVEL 1 Tier 2 LIQUID - LOW*** *BLOOD GLUCOSE CALIBRATION - Not Specified TRUE METRIX SOL LEVEL 2 Tier 2 LIQUID - NORMAL*** *BLOOD GLUCOSE CALIBRATION - Not Specified TRUE METRIX SOL LEVEL 3 Tier 2 LIQUID - HIGH*** *BLOOD GLUCOSE CALIBRATION - Not Specified TRUECONTROL LIQ LEVEL 0 Tier 2 LIQUID*** *BLOOD GLUCOSE CALIBRATION - Not Specified TRUECONTROL LIQ LEVEL 1 Tier 2 LIQUID*** Not Specified TRUEDRAW MIS LANC DEV *LANCET DEVICES*** Tier 3 *BLOOD GLUCOSE CALIBRATION - Not Specified TRUETEST LIQ LEVEL 1 Tier 2 LIQUID*** *BLOOD GLUCOSE CALIBRATION - Not Specified TRUETEST LIQ LEVEL 2 Tier 2 LIQUID*** *BLOOD GLUCOSE CALIBRATION - Not Specified TRUETEST LIQ LEVEL 3 Tier 2 LIQUID*** Not Specified TRUPLUS LANC MIS 26G *LANCETS*** Tier 3 Not Specified TRUPLUS LANC MIS 28G *LANCETS*** Tier 3 Not Specified TRUPLUS LANC MIS 30G *LANCETS*** Tier 3 Not Specified TRUPLUS LANC MIS 33G *LANCETS*** Tier 3 Not Specified ULTRA THIN MIS LANC 26G *LANCETS*** Tier 3 Not Specified ULTRA THIN MIS LANC 28G *LANCETS*** Tier 3 Not Specified ULTRA THIN MIS LANC 30G *LANCETS*** Tier 3 Not Specified ULTRA THIN MIS LANCETS *LANCETS*** Tier 3 Not Specified UNILET EX II MIS 28G *LANCETS*** Tier 3 Not Specified UNILET EXCEL MIS 23G *LANCETS*** Tier 3 Not Specified UNILET G.P MIS SUPR 23G *LANCETS*** Tier 3 Not Specified UNILET G.P. MIS 21G *LANCETS*** Tier 3 Not Specified UNILET LANCT MIS 30G *LANCETS*** Tier 3 Not Specified UNILET LANCT MIS 33G *LANCETS*** Tier 3 Not Specified UNILET SUPER MIS 23G *LANCETS*** Tier 3 Not Specified UNISTIK 1 MIS 2.4MM *LANCETS MISC.*** Tier 3 Not Specified UNISTIK 1 MIS 3.0MM *LANCETS MISC.*** Tier 3 Not Specified UNISTIK 2 MIS 1.8MM *LANCETS MISC.*** Tier 3 Not Specified UNISTIK 2 MIS 2.4MM *LANCETS MISC.*** Tier 3 Not Specified UNISTIK 2 MIS EXTRA *LANCETS MISC.*** Tier 3 Not Specified UNISTIK 2 MIS SUPER *LANCETS MISC.*** Tier 3 Not Specified UNISTIK 3 MIS 1.8MM *LANCETS MISC.*** Tier 3 Not Specified UNISTIK II MIS LANCETS *LANCETS*** Tier 1 HCR VCF VAGINAL AER Not Specified NONOXYNOL-9 FOAM 12.5% Preventive CONTRACP Care HCR VCF VAGINAL GEL Not Specified NONOXYNOL-9 GEL 4% Preventive CONTRACE Care HCR VCF VAGINAL MIS Not Specified NONOXYNOL-9 FILM 28% Preventive CONTRACP Care GUAIFENESIN-CODEINE SOLN 100-10 Not Specified VIRTUSSIN AC SOL 100-10/5 Tier 1 MG/5ML URIDINE TRIACETATE ORAL GRANULES Not Specified VISTOGARD PAK 10GM Tier 2 X X PACKET 10 GM HCR CHOLECALCIFEROL CHEW TAB 1000 Not Specified VIT D CHILD CHW 1000UNIT Preventive UNIT Care HCR Not Specified VITAMIN D CAP 1000UNIT CHOLECALCIFEROL CAP 1000 UNIT Preventive Care

179 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy HCR Not Specified VITAMIN D CAP 400UNIT CHOLECALCIFEROL CAP 400 UNIT Preventive Care HCR CHOLECALCIFEROL CHEW TAB 400 Not Specified VITAMIN D CHW 400UNIT Preventive UNIT Care HCR CHOLECALCIFEROL ORAL LIQUID 400 Not Specified VITAMIN D DRO 400UNIT Preventive UNIT/ML Care HCR Not Specified VITAMIN D TAB 1000UNIT CHOLECALCIFEROL TAB 1000 UNIT Preventive Care HCR Not Specified VITAMIN D TAB 400UNIT CHOLECALCIFEROL TAB 400 UNIT Preventive Care HCR Not Specified VITAMIN D3 CAP 1000UNIT CHOLECALCIFEROL CAP 1000 UNIT Preventive Care HCR CHOLECALCIFEROL CHEW TAB 1000 Not Specified VITAMIN D3 CHW 1000UNIT Preventive UNIT Care HCR CHOLECALCIFEROL CHEW TAB 400 Not Specified VITAMIN D3 CHW 400UNIT Preventive UNIT Care HCR CHOLECALCIFEROL ORAL LIQUID 400 Not Specified VITAMIN D3 DRO 400UNIT Preventive UNIT/ML Care HCR Not Specified VITAMIN D3 TAB 1000UNIT CHOLECALCIFEROL TAB 1000 UNIT Preventive Care HCR Not Specified VITAMIN D3 TAB 400UNIT CHOLECALCIFEROL TAB 400 UNIT Preventive Care HCR Not Specified VITAMIN D-3 TAB 1000UNIT CHOLECALCIFEROL TAB 1000 UNIT Preventive Care ALUMINUM CHLORIDE IN ALCOHOL Not Specified XERAC-AC SOL 6.25% Tier 2 SOLUTION 6.25% URIDINE TRIACETATE ORAL GRANULES Not Specified XURIDEN POW 2GM Tier 2 X X X PACKET 2 GM Ophthalmic Agents - Drugs to Treat Eye KETOROLAC TROMETHAMINE OPHTH ACULAR SOL 0.5% OP Tier 3 Conditions SOLN 0.5% Ophthalmic Agents - Drugs to Treat Eye KETOROLAC TROMETHAMINE OPHTH ACULAR LS SOL 0.4% Tier 3 Conditions SOLN 0.4% Ophthalmic Agents - Drugs to Treat Eye AKTEN GEL 3.5% LIDOCAINE HCL OPHTH GEL 3.5% Tier 3 Conditions Ophthalmic Agents - Drugs to Treat Eye ALCAINE SOL 0.5% OP PROPARACAINE HCL OPHTH SOLN 0.5% Tier 3 Conditions Ophthalmic Agents - Drugs to Treat Eye ALOCRIL SOL 2% NEDOCROMIL SODIUM OPHTH SOLN 2% Tier 3 Conditions Ophthalmic Agents - Drugs to Treat Eye LODOXAMIDE TROMETHAMINE OPHTH ALOMIDE SOL 0.1% OP Tier 3 Conditions SOLN 0.1% Ophthalmic Agents - Drugs to Treat Eye BRIMONIDINE TARTRATE OPHTH SOLN ALPHAGAN P SOL 0.1% Tier 2 X Conditions 0.1% Ophthalmic Agents - Drugs to Treat Eye BRIMONIDINE TARTRATE OPHTH SOLN ALPHAGAN P SOL 0.15% Tier 3 X Conditions 0.15% Ophthalmic Agents - Drugs to Treat Eye LOTEPREDNOL ETABONATE OPHTH ALREX SUS 0.2% Tier 3 X Conditions SUSP 0.2% Ophthalmic Agents - Drugs to Treat Eye ALTACAINE SOL 0.5% OP TETRACAINE HCL OPHTH SOLN 0.5% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye ALTAFRIN SOL 10% OP PHENYLEPHRINE HCL OPHTH SOLN 10% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye PHENYLEPHRINE HCL OPHTH SOLN ALTAFRIN SOL 2.5% OP Tier 1 Conditions 2.5% Ophthalmic Agents - Drugs to Treat Eye APRACLONIDIN SOL 0.5% APRACLONIDINE HCL OPHTH SOLN 0.5% Tier 1 Conditions OP (BASE EQUIVALENT) Ophthalmic Agents - Drugs to Treat Eye ATROPINE SUL OIN 1% OP ATROPINE SULFATE OPHTH OINT 1% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye ATROPINE SUL SOL 1% OP ATROPINE SULFATE OPHTH SOLN 1% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye AZELASTINE DRO 0.05% AZELASTINE HCL OPHTH SOLN 0.05% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye AZOPT SUS 1% OP BRINZOLAMIDE OPHTH SUSP 1% Tier 2 X Conditions Ophthalmic Agents - Drugs to Treat Eye BACIT/POLYMY OIN OP BACITRACIN-POLYMYXIN B OPHTH OINT Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye BETAGAN SOL 0.5% OP LEVOBUNOLOL HCL OPHTH SOLN 0.5% Tier 3 Conditions

180 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Ophthalmic Agents - Drugs to Treat Eye BETAXOLOL SOL 0.5% OP BETAXOLOL HCL OPHTH SOLN 0.5% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye BETIMOL SOL 0.25% TIMOLOL OPHTH SOLN 0.25% Tier 2 X Conditions Ophthalmic Agents - Drugs to Treat Eye BETIMOL SOL 0.5% TIMOLOL OPHTH SOLN 0.5% Tier 2 X Conditions Ophthalmic Agents - Drugs to Treat Eye BETOPTIC-S SUS 0.25% OP BETAXOLOL HCL OPHTH SUSP 0.25% Tier 3 Conditions Ophthalmic Agents - Drugs to Treat Eye SULFACETAMIDE SODIUM- BLEPHAMIDE OIN S.O.P. Tier 2 Conditions PREDNISOLONE OPHTH OINT 10-0.2% Ophthalmic Agents - Drugs to Treat Eye SULFACETAMIDE SODIUM- BLEPHAMIDE SUS OP Tier 3 Conditions PREDNISOLONE OPHTH SUSP 10-0.2% Ophthalmic Agents - Drugs to Treat Eye BRIMONIDINE TARTRATE OPHTH SOLN BRIMONIDINE SOL 0.15% Tier 2 X Conditions 0.15% Ophthalmic Agents - Drugs to Treat Eye BRIMONIDINE TARTRATE OPHTH SOLN BRIMONIDINE SOL 0.2% OP Tier 1 Conditions 0.2% Ophthalmic Agents - Drugs to Treat Eye BROMFENAC SODIUM OPHTH SOLN BROMFENAC SOL 0.09% OP Tier 3 Conditions 0.09% (BASE EQUIVALENT) Ophthalmic Agents - Drugs to Treat Eye CARTEOLOL SOL 1% OP CARTEOLOL HCL OPHTH SOLN 1% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye BRIMONIDINE TARTRATE-TIMOLOL COMBIGAN SOL 0.2/0.5% Tier 2 X Conditions MALEATE OPHTH SOLN 0.2-0.5% Ophthalmic Agents - Drugs to Treat Eye DORZOLAMIDE HCL-TIMOLOL MALEATE COSOPT SOL 22.3-6.8 Tier 3 Conditions OPHTH SOLN 22.3-6.8 MG/ML Ophthalmic Agents - Drugs to Treat Eye CROMOLYN SOD SOL 4% OP CROMOLYN SODIUM OPHTH SOLN 4% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye CYCLOPENTOLATE HCL OPHTH SOLN CYCLOGYL SOL 0.5% OP Tier 3 Conditions 0.5% Ophthalmic Agents - Drugs to Treat Eye CYCLOPENTOLATE HCL OPHTH SOLN CYCLOGYL SOL 1% OP Tier 3 Conditions 1% Ophthalmic Agents - Drugs to Treat Eye CYCLOPENTOLATE HCL OPHTH SOLN CYCLOGYL SOL 2% OP Tier 3 Conditions 2% Ophthalmic Agents - Drugs to Treat Eye CYCLOPENTOLATE W/ PHENYLEPHRINE CYCLOMYDRIL SOL OP Tier 3 Conditions OPHTH SOLN 0.2-1% Ophthalmic Agents - Drugs to Treat Eye CYCLOPENTOLATE HCL OPHTH SOLN CYCLOPENTOL SOL 1% OP Tier 1 Conditions 1% Ophthalmic Agents - Drugs to Treat Eye CYCLOPENTOLATE HCL OPHTH SOLN CYCLOPENTOL SOL 2% OP Tier 1 Conditions 2% Ophthalmic Agents - Drugs to Treat Eye CYCLOPENTOLATE HCL OPHTH SOLN CYCLOPENTOLA SOL 0.5% Tier 1 Conditions 0.5% Ophthalmic Agents - Drugs to Treat Eye CYSTEAMINE HCL OPHTH SOLN 0.44% CYSTARAN SOL 0.44% Tier 2 X X X Conditions (BASE EQUIVALENT) Ophthalmic Agents - Drugs to Treat Eye DEXAMETH PHO SOL 0.1% DEXAMETHASONE SODIUM PHOSPHATE Tier 1 Conditions OP OPHTH SOLN 0.1% Ophthalmic Agents - Drugs to Treat Eye DICLOFENAC SOL 0.1% OP DICLOFENAC SODIUM OPHTH SOLN 0.1% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye DORZOL/TIMOL SOL 22.3- DORZOLAMIDE HCL-TIMOLOL MALEATE Tier 2 Conditions 6.8 OPHTH SOLN 22.3-6.8 MG/ML Ophthalmic Agents - Drugs to Treat Eye DORZOLAMIDE SOL 2% OP DORZOLAMIDE HCL OPHTH SOLN 2% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye DIFLUPREDNATE OPHTH EMULSION DUREZOL EMU 0.05% Tier 3 Conditions 0.05% Ophthalmic Agents - Drugs to Treat Eye FLUOROMETHOLONE ACETATE OPHTH FLAREX SUS 0.1% OP Tier 2 Conditions SUSP 0.1% Ophthalmic Agents - Drugs to Treat Eye FLUOROMETHOL SUS 0.1% FLUOROMETHOLONE OPHTH SUSP 0.1% Tier 1 Conditions OP Ophthalmic Agents - Drugs to Treat Eye FLURBIPROFEN SOL 0.03% FLURBIPROFEN SODIUM OPHTH SOLN Tier 1 Conditions OP 0.03% Ophthalmic Agents - Drugs to Treat Eye FML OIN 0.1% OP FLUOROMETHOLONE OPHTH OINT 0.1% Tier 2 Conditions Ophthalmic Agents - Drugs to Treat Eye FLUOROMETHOLONE OPHTH SUSP FML FORTE SUS 0.25% OP Tier 2 Conditions 0.25% Ophthalmic Agents - Drugs to Treat Eye FML LIQUIFLM SUS 0.1% OP FLUOROMETHOLONE OPHTH SUSP 0.1% Tier 3 Conditions Ophthalmic Agents - Drugs to Treat Eye GELFILM MIS OP GELATIN ADSORBABLE OPHTH FILM Tier 2 Conditions Ophthalmic Agents - Drugs to Treat Eye HOMATROPAIRE SOL 5% OP HOMATROPINE HBR OPHTH SOLN 5% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye HOMATROPINE SOL 5% OP HOMATROPINE HBR OPHTH SOLN 5% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye APRACLONIDINE HCL OPHTH SOLN 0.5% IOPIDINE SOL 0.5% OP Tier 3 Conditions (BASE EQUIVALENT) Ophthalmic Agents - Drugs to Treat Eye APRACLONIDINE HCL OPHTH SOLN 1% IOPIDINE SOL 1% OP Tier 3 Conditions (BASE EQUIVALENT) Ophthalmic Agents - Drugs to Treat Eye ISOPTO CARP SOL 1% OP PILOCARPINE HCL OPHTH SOLN 1% Tier 3 Conditions Ophthalmic Agents - Drugs to Treat Eye ISOPTO CARP SOL 2% OP PILOCARPINE HCL OPHTH SOLN 2% Tier 3 Conditions

181 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Ophthalmic Agents - Drugs to Treat Eye ISOPTO CARP SOL 4% OP PILOCARPINE HCL OPHTH SOLN 4% Tier 3 Conditions Ophthalmic Agents - Drugs to Treat Eye TIMOLOL MALEATE OPHTH SOLN 0.5% ISTALOL SOL 0.5% OP Tier 3 Conditions (ONCE-DAILY) Ophthalmic Agents - Drugs to Treat Eye KETOROLAC TROMETHAMINE OPHTH KETOROLAC SOL 0.4% Tier 1 Conditions SOLN 0.4% Ophthalmic Agents - Drugs to Treat Eye KETOROLAC TROMETHAMINE OPHTH KETOROLAC SOL 0.5% Tier 1 Conditions SOLN 0.5% Ophthalmic Agents - Drugs to Treat Eye LACRISERT MIS 5MG OP *ARTIFICIAL TEAR OPHTH INSERT*** Tier 2 Conditions Ophthalmic Agents - Drugs to Treat Eye LASTACAFT SOL 0.25% ALCAFTADINE OPHTH SOLN 0.25% Tier 3 X Conditions Ophthalmic Agents - Drugs to Treat Eye LATANOPROST SOL 0.005% LATANOPROST OPHTH SOLN 0.005% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye LEVOBUNOLOL SOL 0.5% LEVOBUNOLOL HCL OPHTH SOLN 0.5% Tier 1 Conditions OP Ophthalmic Agents - Drugs to Treat Eye LOTEPREDNOL ETABONATE OPHTH LOTEMAX OIN 0.5% Tier 3 Conditions OINT 0.5% Ophthalmic Agents - Drugs to Treat Eye LOTEPREDNOL ETABONATE OPHTH LOTEMAX SUS 0.5% Tier 3 X Conditions SUSP 0.5% Ophthalmic Agents - Drugs to Treat Eye LUMIGAN SOL 0.01% BIMATOPROST OPHTH SOLN 0.01% Tier 2 Conditions Ophthalmic Agents - Drugs to Treat Eye MAXIDEX SUS 0.1% OP DEXAMETHASONE OPHTH SUSP 0.1% Tier 2 Conditions Ophthalmic Agents - Drugs to Treat Eye NEOMYCIN-POLYMYXIN- MAXITROL OIN 0.1% OP Tier 3 Conditions DEXAMETHASONE OPHTH OINT 0.1% Ophthalmic Agents - Drugs to Treat Eye NEOMYCIN-POLYMYXIN- MAXITROL SUS 0.1% OP Tier 3 Conditions DEXAMETHASONE OPHTH SUSP 0.1% Ophthalmic Agents - Drugs to Treat Eye METHAZOLAMID TAB 25MG METHAZOLAMIDE TAB 25 MG Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye METHAZOLAMID TAB 50MG METHAZOLAMIDE TAB 50 MG Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye METIPRANOLOL SOL 0.3% METIPRANOLOL OPHTH SOLN 0.3% Tier 1 Conditions OPH Ophthalmic Agents - Drugs to Treat Eye NEOMYCIN-BACITRAC ZN-POLYMYX NEO/BAC/POLY OIN OP Tier 1 Conditions 5(3.5)MG-400UNT-10000UNT OP OIN Ophthalmic Agents - Drugs to Treat Eye NEO/POLY/BAC OIN /HC BACITRACIN-POLYMYXIN-NEOMYCIN-HC Tier 1 Conditions 1%OP OPHTH OINT 1% Ophthalmic Agents - Drugs to Treat Eye NEOMYCIN-BACITRAC ZN-POLYMYX NEO/POLY/BAC OIN OP Tier 1 Conditions 5(3.5)MG-400UNT-10000UNT OP OIN Ophthalmic Agents - Drugs to Treat Eye NEOMYCIN-POLYMYXIN- NEO/POLY/DEX OIN 0.1% OP Tier 1 Conditions DEXAMETHASONE OPHTH OINT 0.1% Ophthalmic Agents - Drugs to Treat Eye NEOMYCIN-POLYMYXIN- NEO/POLY/DEX SUS 0.1% OP Tier 1 Conditions DEXAMETHASONE OPHTH SUSP 0.1% Ophthalmic Agents - Drugs to Treat Eye NEOMYCIN-POLYMY-GRAMICID OP SOL NEO/POLY/GRA SOL OP Tier 1 Conditions 1.75-10000-0.025MG-UNT-MG/ML Ophthalmic Agents - Drugs to Treat Eye NEOMYCIN-POLYMYXIN-HC OPHTH NEO/POLY/HC SUS OP Tier 1 Conditions SUSP Ophthalmic Agents - Drugs to Treat Eye BACITRACIN-POLYMYXIN-NEOMYCIN-HC NEO-POLYCIN OIN HC 1%OP Tier 1 Conditions OPHTH OINT 1% Ophthalmic Agents - Drugs to Treat Eye NEOMYCIN-BACITRAC ZN-POLYMYX NEO-POLYCIN OIN OP Tier 1 Conditions 5(3.5)MG-400UNT-10000UNT OP OIN Ophthalmic Agents - Drugs to Treat Eye NEOMYCIN-POLYMY-GRAMICID OP SOL NEOSPORIN SOL OP Tier 3 Conditions 1.75-10000-0.025MG-UNT-MG/ML Ophthalmic Agents - Drugs to Treat Eye NEPTAZANE TAB 25MG METHAZOLAMIDE TAB 25 MG Tier 3 Conditions Ophthalmic Agents - Drugs to Treat Eye NEPTAZANE TAB 50MG METHAZOLAMIDE TAB 50 MG Tier 3 Conditions Ophthalmic Agents - Drugs to Treat Eye NEVANAC SUS 0.1% NEPAFENAC OPHTH SUSP 0.1% Tier 3 Conditions Ophthalmic Agents - Drugs to Treat Eye FLURBIPROFEN SODIUM OPHTH SOLN OCUFEN SOL 0.03% OP Tier 3 Conditions 0.03% Ophthalmic Agents - Drugs to Treat Eye PREDNISOLONE ACETATE OPHTH SUSP OMNIPRED SUS 1% OP Tier 3 Conditions 1% Ophthalmic Agents - Drugs to Treat Eye PHENYLEPHRIN SOL 10% PHENYLEPHRINE HCL OPHTH SOLN 10% Tier 1 Conditions OP Ophthalmic Agents - Drugs to Treat Eye PHENYLEPHRIN SOL 2.5% PHENYLEPHRINE HCL OPHTH SOLN Tier 1 Conditions OP 2.5% Ophthalmic Agents - Drugs to Treat Eye PHOSPHOLINE SOL ECHOTHIOPHATE IODIDE OPHTH FOR Tier 2 Conditions 0.125%OP SOLN 0.125% Ophthalmic Agents - Drugs to Treat Eye PILOCARPINE SOL 1% OP PILOCARPINE HCL OPHTH SOLN 1% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye PILOCARPINE SOL 2% OP PILOCARPINE HCL OPHTH SOLN 2% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye PILOCARPINE SOL 4% OP PILOCARPINE HCL OPHTH SOLN 4% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye POLYCIN OIN OP BACITRACIN-POLYMYXIN B OPHTH OINT Tier 1 Conditions

182 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Ophthalmic Agents - Drugs to Treat Eye POLYMYXIN B/ SOL POLYMYXIN B-TRIMETHOPRIM OPHTH Tier 1 Conditions TRIMETHP SOLN 10000 UNIT/ML-0.1% Ophthalmic Agents - Drugs to Treat Eye POLYMYXIN B-TRIMETHOPRIM OPHTH POLYTRIM SOL OP Tier 3 Conditions SOLN 10000 UNIT/ML-0.1% Ophthalmic Agents - Drugs to Treat Eye PREDNISOLONE ACETATE OPHTH SUSP PRED FORTE SUS 1% OP Tier 3 Conditions 1% Ophthalmic Agents - Drugs to Treat Eye PREDNISOLONE ACETATE OPHTH SUSP PRED MILD SUS 0.12% OP Tier 2 Conditions 0.12% Ophthalmic Agents - Drugs to Treat Eye PREDNISOLONE SODIUM PHOSPHATE PRED SOD PHO SOL 1% OP Tier 1 Conditions OPHTH SOLN 1% Ophthalmic Agents - Drugs to Treat Eye GENTAMICIN-PREDNISOLONE ACE PRED-G SUS OP Tier 3 Conditions OPHTH SUSP 0.3-1% Ophthalmic Agents - Drugs to Treat Eye GENTAMICIN-PREDNISOLONE ACE PRED-G S.O.P OIN OP Tier 3 Conditions OPHTH OINT 0.3-0.6% Ophthalmic Agents - Drugs to Treat Eye PREDNISOLONE ACETATE OPHTH SUSP PREDNISOLONE SUS 1% OP Tier 1 Conditions 1% Ophthalmic Agents - Drugs to Treat Eye PROPARACAINE SOL 0.5% PROPARACAINE HCL OPHTH SOLN 0.5% Tier 1 Conditions OP Ophthalmic Agents - Drugs to Treat Eye UNOPROSTONE ISOPROPYL OPHTH RESCULA SOL 0.15% Tier 3 X X Conditions SOLN 0.15% Ophthalmic Agents - Drugs to Treat Eye CYCLOSPORINE (OPHTH) EMULSION RESTASIS EMU 0.05% Tier 3 X X Conditions 0.05% SULFACETAMIDE SODIUM- Ophthalmic Agents - Drugs to Treat Eye SULF/PRED NA SOL OP PREDNISOLONE OPHTH SOLN 10- Tier 1 Conditions 0.23(0.25)% Ophthalmic Agents - Drugs to Treat Eye TETCAINE SOL 0.5% OP TETRACAINE HCL OPHTH SOLN 0.5% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye TETRACAINE SOL 0.5% OP TETRACAINE HCL OPHTH SOLN 0.5% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye TETRAVISC SOL 0.5% OP TETRACAINE HCL OPHTH SOLN 0.5% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye TETRAVISC SOL FORTE TETRACAINE HCL OPHTH SOLN 0.5% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye TIMOLOL MALEATE OPHTH GEL TIMOLOL GEL SOL 0.25% OP Tier 1 Conditions FORMING SOLN 0.25% Ophthalmic Agents - Drugs to Treat Eye TIMOLOL MALEATE OPHTH GEL TIMOLOL GEL SOL 0.5% OP Tier 1 Conditions FORMING SOLN 0.5% Ophthalmic Agents - Drugs to Treat Eye TIMOLOL MAL SOL 0.25% OP TIMOLOL MALEATE OPHTH SOLN 0.25% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye TIMOLOL MAL SOL 0.5% OP TIMOLOL MALEATE OPHTH SOLN 0.5% Tier 1 Conditions Ophthalmic Agents - Drugs to Treat Eye TIMOLOL MALEATE OPHTH SOLN 0.5% TIMOLOL MALE SOL 0.5% Tier 3 Conditions (ONCE-DAILY) Ophthalmic Agents - Drugs to Treat Eye TIMOPTIC SOL 0.25% OP TIMOLOL MALEATE OPHTH SOLN 0.25% Tier 3 Conditions Ophthalmic Agents - Drugs to Treat Eye TIMOPTIC SOL 0.5% OP TIMOLOL MALEATE OPHTH SOLN 0.5% Tier 3 Conditions Ophthalmic Agents - Drugs to Treat Eye TIMOPTIC OCU SOL 0.25% TIMOLOL MALEATE PRESERVATIVE FREE Tier 3 Conditions OP OPHTH SOLN 0.25% Ophthalmic Agents - Drugs to Treat Eye TIMOLOL MALEATE PRESERVATIVE FREE TIMOPTIC OCU SOL 0.5% OP Tier 2 Conditions OPHTH SOLN 0.5% Ophthalmic Agents - Drugs to Treat Eye TIMOLOL MALEATE OPHTH GEL TIMOPTIC-XE SOL 0.25% OP Tier 3 Conditions FORMING SOLN 0.25% Ophthalmic Agents - Drugs to Treat Eye TIMOLOL MALEATE OPHTH GEL TIMOPTIC-XE SOL 0.5% OP Tier 3 Conditions FORMING SOLN 0.5% Ophthalmic Agents - Drugs to Treat Eye TOBRA/DEXAME SUS 0.3- TOBRAMYCIN-DEXAMETHASONE Tier 2 Conditions 0.1% OPHTH SUSP 0.3-0.1% Ophthalmic Agents - Drugs to Treat Eye TOBRAMYCIN-DEXAMETHASONE TOBRADEX SUS 0.3-0.1% Tier 3 Conditions OPHTH SUSP 0.3-0.1% Ophthalmic Agents - Drugs to Treat Eye TRAVOPROST OPHTH SOLN 0.004% TRAVATAN Z DRO 0.004% Tier 2 X Conditions (BENZALKONIUM FREE) (BAK FREE) Ophthalmic Agents - Drugs to Treat Eye TRAVOPROST DRO 0.004% TRAVOPROST OPHTH SOLN 0.004% Tier 3 X Conditions Ophthalmic Agents - Drugs to Treat Eye TRIMETHOPRIM SOL POLYMYXIN B-TRIMETHOPRIM OPHTH Tier 1 Conditions POLYMYXN SOLN 10000 UNIT/ML-0.1% Ophthalmic Agents - Drugs to Treat Eye TRUSOPT SOL 2% OP DORZOLAMIDE HCL OPHTH SOLN 2% Tier 3 Conditions Ophthalmic Agents - Drugs to Treat Eye VEXOL SUS 1% OP RIMEXOLONE OPHTH SUSP 1% Tier 2 Conditions Ophthalmic Agents - Drugs to Treat Eye XALATAN SOL 0.005% LATANOPROST OPHTH SOLN 0.005% Tier 3 Conditions Ophthalmic Agents - Drugs to Treat Eye XIIDRA DRO 5% LIFITEGRAST OPHTH SOLN 5% Tier 3 X X Conditions Ophthalmic Agents - Drugs to Treat Eye ZIOPTAN DRO 0.0015% TAFLUPROST OPHTH SOLN 0.0015% Tier 3 X X Conditions Ophthalmic Agents - Drugs to Treat Eye LOTEPREDNOL ETABONATE- ZYLET SUS 0.5-0.3% Tier 3 Conditions TOBRAMYCIN OPHTH SUSP 0.5-0.3%

183 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Otic Agents - Drugs to Treat Ear ACE ACD/ALUM SOL 2% ACETIC ACID 2% IN ALUMINUM ACETATE Tier 1 Conditions OTIC OTIC SOLN Otic Agents - Drugs to Treat Ear HYDROCORTISONE W/ ACETIC ACID ACETASOL HC SOL OTIC Tier 2 Conditions OTIC SOLN 1-2% Otic Agents - Drugs to Treat Ear ACETIC ACID SOL 2% OTIC ACETIC ACID OTIC SOLN 2% Tier 1 Conditions Otic Agents - Drugs to Treat Ear CIPROFLOXACIN HCL OTIC SOLN 0.2% CETRAXAL SOL 0.2% Tier 3 Conditions (BASE EQUIVALENT) Otic Agents - Drugs to Treat Ear CIPROFLOXACIN-HYDROCORTISONE CIPRO HC SUS OTIC Tier 3 Conditions OTIC SUSP 0.2-1% Otic Agents - Drugs to Treat Ear CIPROFLOXACIN-DEXAMETHASONE CIPRODEX SUS 0.3-0.1% Tier 3 Conditions OTIC SUSP 0.3-0.1% Otic Agents - Drugs to Treat Ear CIPROFLOXACIN HCL OTIC SOLN 0.2% CIPROFLOXACN SOL 0.2% Tier 1 Conditions (BASE EQUIVALENT) Otic Agents - Drugs to Treat Ear NEOMYCIN-COLISTIN-HC-THONZONIUM COLY-MYCIN S SUS OTIC Tier 3 Conditions OTIC SUSP 3.3-3-10-0.5 MG/ML Otic Agents - Drugs to Treat Ear PRAMOXINE-HC-CHLOROXYLENOL CORTANE-B DRO AQ OTIC Tier 2 Conditions AQUEOUS OTIC SOLN 10-10-1 MG/ML Otic Agents - Drugs to Treat Ear PRAMOXINE-HC-CHLOROXYLENOL OTIC CORTANE-B DRO OTIC Tier 2 Conditions SOLN 10-10-1 MG/ML Otic Agents - Drugs to Treat Ear PRAMOXINE-HC-CHLOROXYLENOL OTIC CORTIC-ND DRO Tier 1 Conditions SOLN 10-10-1 MG/ML Otic Agents - Drugs to Treat Ear PRAMOXINE-HC-CHLOROXYLENOL OTIC CYOTIC DRO Tier 1 Conditions SOLN 10-10-1 MG/ML Otic Agents - Drugs to Treat Ear FLUOCINOLONE ACETONIDE (OTIC) OIL DERMOTIC OIL 0.01% Tier 3 Conditions 0.01% Otic Agents - Drugs to Treat Ear PRAMOXINE-HC-CHLOROXYLENOL OTIC EXOTIC-HC DRO OTIC Tier 1 Conditions SOLN 10-10-1 MG/ML Otic Agents - Drugs to Treat Ear FLUOCINOLONE ACETONIDE (OTIC) OIL FLUOCIN ACET OIL 0.01% Tier 1 Conditions 0.01% Otic Agents - Drugs to Treat Ear FLUOCIN ACET OIL FLUOCINOLONE ACETONIDE (OTIC) OIL Tier 1 Conditions EAR0.01% 0.01% Otic Agents - Drugs to Treat Ear HYDROCORTISONE W/ ACETIC ACID HC/ACET ACID SOL OTIC Tier 1 Conditions OTIC SOLN 1-2% Otic Agents - Drugs to Treat Ear NEOMYCIN-POLYMYXIN-HC OTIC SOLN NEO/POLY/HC SOL 1% OTIC Tier 1 Conditions 1% Otic Agents - Drugs to Treat Ear NEOMYCIN-POLYMYXIN-HC OTIC SUSP NEO/POLY/HC SUS 1% OTIC Tier 1 Conditions 3.5 MG/ML-10000 UNIT/ML-1% Otic Agents - Drugs to Treat Ear PRAMOXINE-HC-CHLOROXYLENOL OTIC OTICIN HC DRO Tier 2 Conditions SOLN 10-10-1 MG/ML Otic Agents - Drugs to Treat Ear PRAMOXINE-HC-CHLOROXYLENOL OTIC OTOMAX-HC DRO Tier 1 Conditions SOLN 10-10-1 MG/ML Otic Agents - Drugs to Treat Ear PRAMOXINE-CHLOROXYLENOL OTIC PRAMOTIC DRO 1-0.1% Tier 3 Conditions LIQUID 1-0.1% Respiratory Tract Agents - Drugs to ACETYLCYSTEINE EFFERVESCENT TAB Treat Allergies, Cough, Cold and Lung CETYLEV TAB 2.5GM Tier 3 2.5 GM Conditions Respiratory Tract Agents - Drugs to ACETYLCYSTEINE EFFERVESCENT TAB Treat Allergies, Cough, Cold and Lung CETYLEV TAB 500MG Tier 3 500 MG Conditions Respiratory Tract Agents - Drugs to IODINE SOLUTION STRONG (LUGOL'S) Treat Allergies, Cough, Cold and Lung IODINE SOL STRONG Tier 3 (BULK) Conditions Respiratory Tract Agents - Drugs to IODINE SOLUTION STRONG (LUGOL'S) Treat Allergies, Cough, Cold and Lung LUGOLS SOL Tier 2 (BULK) Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ACCOLATE TAB 10MG ZAFIRLUKAST TAB 10 MG Tier 3 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ACCOLATE TAB 20MG ZAFIRLUKAST TAB 20 MG Tier 3 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ACETYLCYST SOL 10% ACETYLCYSTEINE INHAL SOLN 10% Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ACETYLCYST SOL 20% ACETYLCYSTEINE INHAL SOLN 20% Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ADCIRCA TAB 20MG TADALAFIL TAB 20 MG (PAH) Tier 4 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ADEMPAS TAB 0.5MG RIOCIGUAT TAB 0.5 MG Tier 2 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ADEMPAS TAB 1.5MG RIOCIGUAT TAB 1.5 MG Tier 2 X X X and Lung Conditions

184 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ADEMPAS TAB 1MG RIOCIGUAT TAB 1 MG Tier 2 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ADEMPAS TAB 2.5MG RIOCIGUAT TAB 2.5 MG Tier 2 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ADEMPAS TAB 2MG RIOCIGUAT TAB 2 MG Tier 2 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - FLUTICASONE-SALMETEROL AER Drugs to Treat Allergies, Cough, Cold ADVAIR DISKU AER 100/50 Tier 3 X POWDER BA 100-50 MCG/DOSE and Lung Conditions Respiratory Tract/Pulmonary Agents - FLUTICASONE-SALMETEROL AER Drugs to Treat Allergies, Cough, Cold ADVAIR DISKU AER 250/50 Tier 3 X POWDER BA 250-50 MCG/DOSE and Lung Conditions Respiratory Tract/Pulmonary Agents - FLUTICASONE-SALMETEROL AER Drugs to Treat Allergies, Cough, Cold ADVAIR DISKU AER 500/50 Tier 3 X POWDER BA 500-50 MCG/DOSE and Lung Conditions Respiratory Tract/Pulmonary Agents - FLUTICASONE-SALMETEROL INHAL Drugs to Treat Allergies, Cough, Cold ADVAIR HFA AER 115/21 Tier 3 X AEROSOL 115-21 MCG/ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - FLUTICASONE-SALMETEROL INHAL Drugs to Treat Allergies, Cough, Cold ADVAIR HFA AER 230/21 Tier 3 X AEROSOL 230-21 MCG/ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - FLUTICASONE-SALMETEROL INHAL Drugs to Treat Allergies, Cough, Cold ADVAIR HFA AER 45/21 Tier 3 X AEROSOL 45-21 MCG/ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - FLUNISOLIDE HFA INHAL AEROSOL 80 Drugs to Treat Allergies, Cough, Cold AEROSPAN AER 80MCG Tier 3 X MCG/ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - ALBUTEROL SULFATE SOLN NEBU Drugs to Treat Allergies, Cough, Cold ALBUTEROL NEB 0.083% Tier 1 0.083% (2.5 MG/3ML) and Lung Conditions Respiratory Tract/Pulmonary Agents - ALBUTEROL SULFATE SOLN NEBU 0.5% Drugs to Treat Allergies, Cough, Cold ALBUTEROL NEB 0.5% Tier 1 (5 MG/ML) and Lung Conditions Respiratory Tract/Pulmonary Agents - ALBUTEROL SULFATE SOLN NEBU 0.63 Drugs to Treat Allergies, Cough, Cold ALBUTEROL NEB 0.63MG/3 Tier 1 MG/3ML (BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - ALBUTEROL SULFATE SOLN NEBU 1.25 Drugs to Treat Allergies, Cough, Cold ALBUTEROL NEB 1.25MG/3 Tier 1 MG/3ML (BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ALBUTEROL SYP 2MG/5ML ALBUTEROL SULFATE SYRUP 2 MG/5ML Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ALBUTEROL TAB 2MG ALBUTEROL SULFATE TAB 2 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ALBUTEROL TAB 4MG ALBUTEROL SULFATE TAB 4 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - ALBUTEROL SULFATE TAB ER 12HR 4 Drugs to Treat Allergies, Cough, Cold ALBUTEROL TAB 4MG ER Tier 1 MG and Lung Conditions Respiratory Tract/Pulmonary Agents - ALBUTEROL SULFATE TAB ER 12HR 8 Drugs to Treat Allergies, Cough, Cold ALBUTEROL TAB 8MG ER Tier 1 MG and Lung Conditions Respiratory Tract/Pulmonary Agents - CICLESONIDE INHAL AEROSOL 160 Drugs to Treat Allergies, Cough, Cold ALVESCO AER 160MCG Tier 1 X MCG/ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - CICLESONIDE INHAL AEROSOL 80 MCG/ Drugs to Treat Allergies, Cough, Cold ALVESCO AER 80MCG Tier 1 X ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - UMECLIDINIUM-VILANTEROL AERO Drugs to Treat Allergies, Cough, Cold ANORO ELLIPT AER 62.5-25 Tier 3 X POWD BA 62.5-25 MCG/INH and Lung Conditions Respiratory Tract/Pulmonary Agents - CARBINOXAMINE MALEATE SOLN 4 Drugs to Treat Allergies, Cough, Cold ARBINOXA SOL 4MG/5ML Tier 2 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ARBINOXA TAB 4MG CARBINOXAMINE MALEATE TAB 4 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - INDACATEROL MALEATE INHAL Drugs to Treat Allergies, Cough, Cold ARCAPTA CAP 75MCG Tier 3 X POWDER CAP 75 MCG (BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - FLUTICASONE FUROATE AEROSOL Drugs to Treat Allergies, Cough, Cold ARNUITY ELPT INH 100MCG Tier 3 X POWDER BREATH ACTIV 100 MCG/ACT and Lung Conditions

185 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Respiratory Tract/Pulmonary Agents - FLUTICASONE FUROATE AEROSOL Drugs to Treat Allergies, Cough, Cold ARNUITY ELPT INH 200MCG Tier 3 X POWDER BREATH ACTIV 200 MCG/ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - MOMETASONE FUROATE INHAL POWD Drugs to Treat Allergies, Cough, Cold ASMANEX 120 AER 220MCG Tier 1 X 220 MCG/INH (BREATH ACTIVATED) and Lung Conditions Respiratory Tract/Pulmonary Agents - MOMETASONE FUROATE INHAL POWD Drugs to Treat Allergies, Cough, Cold ASMANEX 14 AER 220MCG Tier 1 X 220 MCG/INH (BREATH ACTIVATED) and Lung Conditions Respiratory Tract/Pulmonary Agents - MOMETASONE FUROATE INHAL POWD Drugs to Treat Allergies, Cough, Cold ASMANEX 30 AER 110MCG Tier 1 X 110 MCG/INH (BREATH ACTIVATED) and Lung Conditions Respiratory Tract/Pulmonary Agents - MOMETASONE FUROATE INHAL POWD Drugs to Treat Allergies, Cough, Cold ASMANEX 30 AER 220MCG Tier 1 X 220 MCG/INH (BREATH ACTIVATED) and Lung Conditions Respiratory Tract/Pulmonary Agents - MOMETASONE FUROATE INHAL POWD Drugs to Treat Allergies, Cough, Cold ASMANEX 60 AER 220MCG Tier 1 X 220 MCG/INH (BREATH ACTIVATED) and Lung Conditions Respiratory Tract/Pulmonary Agents - MOMETASONE FUROATE INHAL POWD Drugs to Treat Allergies, Cough, Cold ASMANEX 7 AER 110MCG Tier 1 X 110 MCG/INH (BREATH ACTIVATED) and Lung Conditions Respiratory Tract/Pulmonary Agents - ASMANEX HFA AER 100 MOMETASONE FUROATE INHAL Drugs to Treat Allergies, Cough, Cold Tier 1 X MCG AEROSOL SUSPENSION 100 MCG/ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - ASMANEX HFA AER 200 MOMETASONE FUROATE INHAL Drugs to Treat Allergies, Cough, Cold Tier 1 X MCG AEROSOL SUSPENSION 200 MCG/ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - IPRATROPIUM BROMIDE HFA INHAL Drugs to Treat Allergies, Cough, Cold ATROVENT HFA AER 17MCG Tier 3 X AEROSOL 17 MCG/ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - AZELASTINE HCL NASAL SPRAY 0.1% Drugs to Treat Allergies, Cough, Cold AZELASTINE SPR 0.1% Tier 3 (137 MCG/SPRAY) and Lung Conditions Respiratory Tract/Pulmonary Agents - GLYCOPYRROLATE-FORMOTEROL Drugs to Treat Allergies, Cough, Cold BEVESPI AER 9-4.8MCG Tier 2 X FUMARATE AEROSOL 9-4.8 MCG/ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - PHENYLEPHRINE W/ DM-GG LIQD 10-15- Drugs to Treat Allergies, Cough, Cold BIOTUSS LIQ Tier 1 300 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - PHENYLEPHRINE W/ DM-GG LIQD 2.5-5- Drugs to Treat Allergies, Cough, Cold BIOTUSS LIQ PEDIATRC Tier 1 50 MG/ML and Lung Conditions Respiratory Tract/Pulmonary Agents - FLUTICASONE FUROATE-VILANTEROL Drugs to Treat Allergies, Cough, Cold BREO ELLIPTA INH 100-25 Tier 3 X AERO POWD BA 100-25 MCG/INH and Lung Conditions Respiratory Tract/Pulmonary Agents - FLUTICASONE FUROATE-VILANTEROL Drugs to Treat Allergies, Cough, Cold BREO ELLIPTA INH 200-25 Tier 3 X AERO POWD BA 200-25 MCG/INH and Lung Conditions Respiratory Tract/Pulmonary Agents - PSEUDOEPHED-BROMPHEN-DM SYRUP Drugs to Treat Allergies, Cough, Cold BROM/PSE/DM SYP Tier 1 30-2-10 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - PSEUDOEPHED-BROMPHEN-DM SYRUP Drugs to Treat Allergies, Cough, Cold BROMFED DM SYP Tier 1 30-2-10 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - BROMPHENIRAM CHW BROMPHENIRAMINE TANNATE CHEW Drugs to Treat Allergies, Cough, Cold Tier 1 12MG TAB 12 MG and Lung Conditions Respiratory Tract/Pulmonary Agents - ARFORMOTEROL TARTRATE SOLN Drugs to Treat Allergies, Cough, Cold BROVANA NEB 15MCG Tier 3 X NEBU 15 MCG/2ML (BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - BUDESONIDE INHALATION SUSP 0.25 Drugs to Treat Allergies, Cough, Cold BUDESONIDE SUS 0.25MG/2 Tier 2 X MG/2ML and Lung Conditions Respiratory Tract/Pulmonary Agents - BUDESONIDE INHALATION SUSP 0.5 Drugs to Treat Allergies, Cough, Cold BUDESONIDE SUS 0.5MG/2 Tier 2 X MG/2ML and Lung Conditions Respiratory Tract/Pulmonary Agents - BUDESONIDE INHALATION SUSP 1 Drugs to Treat Allergies, Cough, Cold BUDESONIDE SUS 1MG/2ML Tier 2 X MG/2ML and Lung Conditions Respiratory Tract/Pulmonary Agents - PHENYLEPH-CHLORPHEN- Drugs to Treat Allergies, Cough, Cold CARBAPHEN 12 LIQ CARBETAPENTANE LIQD 10-4-27.5 Tier 3 and Lung Conditions MG/5ML Respiratory Tract/Pulmonary Agents - PHENYLEPH-CHLORPHEN- Drugs to Treat Allergies, Cough, Cold CARBAPHEN 12 SUS PED CARBETAPENTANE SUSP 2.5-1.25-7.5 Tier 3 and Lung Conditions MG/ML Respiratory Tract/Pulmonary Agents - CARBINOXAMIN SOL CARBINOXAMINE MALEATE SOLN 4 Drugs to Treat Allergies, Cough, Cold Tier 1 4MG/5ML MG/5ML and Lung Conditions

186 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold CARBINOXAMIN TAB 4MG CARBINOXAMINE MALEATE TAB 4 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - AZTREONAM LYSINE FOR INHAL SOLN Drugs to Treat Allergies, Cough, Cold CAYSTON INH 75MG Tier 2 X X X 75 MG (BASE EQUIVALENT) and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold CLEMASTINE TAB 2.68MG CLEMASTINE FUMARATE TAB 2.68 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - CHLORPHENIRAMINE W/ CODEINE Drugs to Treat Allergies, Cough, Cold CODAR AR LIQ 2-8/5ML Tier 3 LIQUID 2-8 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - IPRATROPIUM-ALBUTEROL INHAL Drugs to Treat Allergies, Cough, Cold COMBIVENT AER 20-100 Tier 3 X AEROSOL SOLN 20-100 MCG/ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - CROMOLYN SOD NEB CROMOLYN SODIUM SOLN NEBU 20 Drugs to Treat Allergies, Cough, Cold Tier 1 20MG/2ML MG/2ML and Lung Conditions Respiratory Tract/Pulmonary Agents - CYPROHEPTAD SYP CYPROHEPTADINE HCL SYRUP 2 Drugs to Treat Allergies, Cough, Cold Tier 1 2MG/5ML MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold CYPROHEPTAD TAB 4MG CYPROHEPTADINE HCL TAB 4 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold DALIRESP TAB 500MCG ROFLUMILAST TAB 500 MCG Tier 3 X X and Lung Conditions Respiratory Tract/Pulmonary Agents - BROMPHENIRAMINE & PHENYLEPHRINE Drugs to Treat Allergies, Cough, Cold DECON-A ELX 2-5MG/5M Tier 3 ELIXIR 2-5 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - PHENYLEPHRINE-BROMPHENIRAMINE- Drugs to Treat Allergies, Cough, Cold DECON-G DRO 2-1-40MG Tier 2 GUAIFENESIN LIQD 2-1-40 MG/ML and Lung Conditions Respiratory Tract/Pulmonary Agents - DYPHYLLINE-GUAIFENESIN LIQD 100-100 Drugs to Treat Allergies, Cough, Cold DIFIL-G FORT LIQ 100-100 Tier 1 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - DIPHENHYDRAM ELX DIPHENHYDRAMINE HCL ELIXIR 12.5 Drugs to Treat Allergies, Cough, Cold Tier 1 12.5/5ML MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ELIXOPHYLLIN ELX 80/15ML THEOPHYLLINE ELIXIR 80 MG/15ML Tier 3 and Lung Conditions Respiratory Tract/Pulmonary Agents - EPINEPHRINE SOLUTION AUTO- Drugs to Treat Allergies, Cough, Cold EPINEPHRINE INJ 0.15MG Tier 2 X INJECTOR 0.15 MG/0.3ML (1:2000) and Lung Conditions Respiratory Tract/Pulmonary Agents - EPINEPHRINE SOLUTION AUTO- Drugs to Treat Allergies, Cough, Cold EPINEPHRINE INJ 0.3MG Tier 2 X INJECTOR 0.3 MG/0.3ML (1:1000) and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ESBRIET CAP 267MG PIRFENIDONE CAP 267 MG Tier 2 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ESBRIET TAB 267MG PIRFENIDONE TAB 267 MG Tier 2 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ESBRIET TAB 801MG PIRFENIDONE TAB 801 MG Tier 2 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - PHENYLEPHRINE W/ DM-GG LIQD 10-28- Drugs to Treat Allergies, Cough, Cold EXACTUSS LIQ Tier 3 388 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - FLUTICASONE PROPIONATE AER POW Drugs to Treat Allergies, Cough, Cold FLOVENT DISK AER 100MCG Tier 3 X BA 100 MCG/BLISTER and Lung Conditions Respiratory Tract/Pulmonary Agents - FLUTICASONE PROPIONATE AER POW Drugs to Treat Allergies, Cough, Cold FLOVENT DISK AER 250MCG Tier 3 X BA 250 MCG/BLISTER and Lung Conditions Respiratory Tract/Pulmonary Agents - FLUTICASONE PROPIONATE AER POW Drugs to Treat Allergies, Cough, Cold FLOVENT DISK AER 50MCG Tier 3 X BA 50 MCG/BLISTER and Lung Conditions Respiratory Tract/Pulmonary Agents - FLUTICASONE PROPIONATE HFA INHAL Drugs to Treat Allergies, Cough, Cold FLOVENT HFA AER 110MCG Tier 3 X AER 110 MCG/ACT (125/VALVE) and Lung Conditions Respiratory Tract/Pulmonary Agents - FLUTICASONE PROPIONATE HFA INHAL Drugs to Treat Allergies, Cough, Cold FLOVENT HFA AER 220MCG Tier 3 X AER 220 MCG/ACT (250/VALVE) and Lung Conditions Respiratory Tract/Pulmonary Agents - FLUTICASONE PROPIONATE HFA INHAL Drugs to Treat Allergies, Cough, Cold FLOVENT HFA AER 44MCG Tier 3 X AERO 44 MCG/ACT (50/VALVE) and Lung Conditions Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Respiratory Tract/Pulmonary Agents - FLUNISOLIDE NASAL SOLN 25 MCG/ACT Drugs to Treat Allergies, Cough, Cold FLUNISOLIDE SPR 0.025% Tier 3 (0.025%) and Lung Conditions Respiratory Tract/Pulmonary Agents - FLUTICASONE INH FLUTICASONE-SALMETEROL AER Drugs to Treat Allergies, Cough, Cold Tier 2 X SALMETER POWDER BA 55-14 MCG/ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - FLUTICASONE INH FLUTICASONE-SALMETEROL AER Drugs to Treat Allergies, Cough, Cold Tier 2 X SALMETER POWDER BA 113-14 MCG/ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - FLUTICASONE INH FLUTICASONE-SALMETEROL AER Drugs to Treat Allergies, Cough, Cold Tier 2 X SALMETER POWDER BA 232-14 MCG/ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - FLUTICASONE PROPIONATE NASAL Drugs to Treat Allergies, Cough, Cold FLUTICASONE SPR 50MCG Tier 2 X SUSP 50 MCG/ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - PHENYLEPHRINE-GUAIFENESIN TAB 10- Drugs to Treat Allergies, Cough, Cold GILPHEX TR TAB 10-388MG Tier 3 388 MG and Lung Conditions Respiratory Tract/Pulmonary Agents - PHENYLEPHRINE W/ DM-GG LIQD 10-28- Drugs to Treat Allergies, Cough, Cold GILTUSS LIQ Tier 3 388 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - PHENYLEPHRINE W/ DM-GG LIQD 2.5- Drugs to Treat Allergies, Cough, Cold GILTUSS PED LIQ Tier 3 7.5 - 88 MG/ML and Lung Conditions Respiratory Tract/Pulmonary Agents - PHENYLEPHRINE W/ DM-GG TAB 10-28- Drugs to Treat Allergies, Cough, Cold GILTUSS TR TAB Tier 3 388 MG and Lung Conditions Respiratory Tract/Pulmonary Agents - TIMOTHY GRASS POLLEN ALLERGEN Drugs to Treat Allergies, Cough, Cold GRASTEK SUB 2800BAU Tier 3 X X EXT TAB SL 2800 BAU and Lung Conditions Respiratory Tract/Pulmonary Agents - HYD POL/CPM SUS 10- HYDROCOD POLST-CHLORPHEN POLST Drugs to Treat Allergies, Cough, Cold Tier 3 X X 8/5ML ER SUSP 10-8 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - HYDR/CPM/PSE LIQ 5-4- PSEUDOEPH-CHLORPHEN W/ Drugs to Treat Allergies, Cough, Cold Tier 2 X X 60MG HYDROCODONE SOLN 60-4-5 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - HYDRO/CHLOR/ LIQ 5-4- PSEUDOEPH-CHLORPHEN W/ Drugs to Treat Allergies, Cough, Cold Tier 2 X X 60MG HYDROCODONE SOLN 60-4-5 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - HYDROC/HOMAT TAB HYDROCODONE W/ HOMATROPINE TAB Drugs to Treat Allergies, Cough, Cold Tier 1 X 5-1.5MG 5-1.5 MG and Lung Conditions Respiratory Tract/Pulmonary Agents - HYDROCOD/HOM SYP HYDROCODONE W/ HOMATROPINE Drugs to Treat Allergies, Cough, Cold Tier 1 X 5-1.5/5 SYRUP 5-1.5 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - HYDROCODONE W/ HOMATROPINE Drugs to Treat Allergies, Cough, Cold HYDROMET SYP 5-1.5/5 Tier 1 X SYRUP 5-1.5 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold HYPERSAL NEB 3.5% SODIUM CHLORIDE SOLN NEBU 3.5% Tier 2 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold HYPERSAL NEB 7% SODIUM CHLORIDE SOLN NEBU 7% Tier 2 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold HYPER-SAL NEB 7% SODIUM CHLORIDE SOLN NEBU 7% Tier 2 and Lung Conditions Respiratory Tract/Pulmonary Agents - UMECLIDINIUM BR AERO POWD BREATH Drugs to Treat Allergies, Cough, Cold INCRUSE ELPT INH 62.5MCG Tier 2 X ACT 62.5 MCG/INH (BASE EQ) and Lung Conditions Respiratory Tract/Pulmonary Agents - IPRATROPIUM SOL IPRATROPIUM BROMIDE INHAL SOLN Drugs to Treat Allergies, Cough, Cold Tier 1 0.02%INH 0.02% and Lung Conditions Respiratory Tract/Pulmonary Agents - IPRATROPIUM BROMIDE NASAL SOLN Drugs to Treat Allergies, Cough, Cold IPRATROPIUM SPR 0.03% Tier 1 0.03% (21 MCG/SPRAY) and Lung Conditions Respiratory Tract/Pulmonary Agents - IPRATROPIUM BROMIDE NASAL SOLN Drugs to Treat Allergies, Cough, Cold IPRATROPIUM SPR 0.06% Tier 1 0.06% (42 MCG/SPRAY) and Lung Conditions Respiratory Tract/Pulmonary Agents - IPRATROPIUM/ SOL IPRATROPIUM-ALBUTEROL NEBU SOLN Drugs to Treat Allergies, Cough, Cold Tier 1 ALBUTER 0.5-2.5(3) MG/3ML and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold KALYDECO PAK 50MG IVACAFTOR PACKET 50 MG Tier 2 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold KALYDECO PAK 75MG IVACAFTOR PACKET 75 MG Tier 2 X X X and Lung Conditions

188 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold KALYDECO TAB 150MG IVACAFTOR TAB 150 MG Tier 2 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold LETAIRIS TAB 10MG AMBRISENTAN TAB 10 MG Tier 2 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold LETAIRIS TAB 5MG AMBRISENTAN TAB 5 MG Tier 2 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - LEVALBUTEROL AER 45/ LEVALBUTEROL TARTRATE INHAL Drugs to Treat Allergies, Cough, Cold Tier 3 X ACT AEROSOL 45 MCG/ACT (BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - LEVOCETIRIZINE DIHYDROCHLORIDE Drugs to Treat Allergies, Cough, Cold LEVOCETIRIZI SOL 2.5/5ML Tier 3 SOLN 2.5 MG/5ML (0.5 MG/ML) and Lung Conditions Respiratory Tract/Pulmonary Agents - LEVOCETIRIZINE DIHYDROCHLORIDE Drugs to Treat Allergies, Cough, Cold LEVOCETIRIZI TAB 5MG Tier 1 TAB 5 MG and Lung Conditions Respiratory Tract/Pulmonary Agents - CHLORPHENIRAMINE W/ CODEINE Drugs to Treat Allergies, Cough, Cold LEXUSS 210 LIQ 2-10/5ML Tier 1 LIQUID 2-10 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - DIPHENHYDRAMINE HCL ELIXIR 12.5 Drugs to Treat Allergies, Cough, Cold MDL ANTIHIST ELX 12.5/5ML Tier 1 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - METAPROTEREN SYP METAPROTERENOL SULFATE SYRUP 10 Drugs to Treat Allergies, Cough, Cold Tier 1 10MG/5ML MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold METAPROTEREN TAB 10MG METAPROTERENOL SULFATE TAB 10 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold METAPROTEREN TAB 20MG METAPROTERENOL SULFATE TAB 20 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - MONTELUKAST SODIUM CHEW TAB 4 Drugs to Treat Allergies, Cough, Cold MONTELUKAST CHW 4MG Tier 1 MG (BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - MONTELUKAST SODIUM CHEW TAB 5 Drugs to Treat Allergies, Cough, Cold MONTELUKAST CHW 5MG Tier 1 MG (BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - MONTELUKAST SODIUM ORAL Drugs to Treat Allergies, Cough, Cold MONTELUKAST GRA 4MG Tier 2 GRANULES PACKET 4 MG (BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - MONTELUKAST SODIUM TAB 10 MG Drugs to Treat Allergies, Cough, Cold MONTELUKAST TAB 10MG Tier 1 (BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold NEBUSAL NEB 3% SODIUM CHLORIDE SOLN NEBU 3% Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold NEBUSAL NEB 6% SODIUM CHLORIDE SOLN NEBU 6% Tier 3 and Lung Conditions Respiratory Tract/Pulmonary Agents - PHENYLEPHRINE-CHLORPHEN-DM Drugs to Treat Allergies, Cough, Cold NEOTUSS PLUS LIQ Tier 3 LIQUID 7.5-4-30 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - PHENYLEPHRINE W/ DM-GG LIQD 2.5-5- Drugs to Treat Allergies, Cough, Cold NORTUSS-DE DRO Tier 1 50 MG/ML and Lung Conditions Respiratory Tract/Pulmonary Agents - DEXTROMETHORPHAN-GUAIFENESIN Drugs to Treat Allergies, Cough, Cold NORTUSS-EX LIQ 200-20/5 Tier 1 LIQUID 20-200 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - HYDROCODONE-GUAIFENESIN SOLN Drugs to Treat Allergies, Cough, Cold OBREDON SOL 2.5-200 Tier 3 X X X 2.5-200 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - NINTEDANIB ESYLATE CAP 100 MG Drugs to Treat Allergies, Cough, Cold OFEV CAP 100MG Tier 4 X X X (BASE EQUIVALENT) and Lung Conditions Respiratory Tract/Pulmonary Agents - NINTEDANIB ESYLATE CAP 150 MG Drugs to Treat Allergies, Cough, Cold OFEV CAP 150MG Tier 4 X X X (BASE EQUIVALENT) and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold OLOPATADINE SPR 0.6% OLOPATADINE HCL NASAL SOLN 0.6% Tier 3 X and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold OPSUMIT TAB 10MG MACITENTAN TAB 10 MG Tier 2 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - *GRASS MIXED POLLEN EXT TAB SL 300 Drugs to Treat Allergies, Cough, Cold ORALAIR SUB 300 IR Tier 3 X X IR (INDEX OF REACTIVITY)* and Lung Conditions

189 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Respiratory Tract/Pulmonary Agents - *GRASS MIXED POLLEN EXT TAB SL 300 Drugs to Treat Allergies, Cough, Cold ORALAIR ADLT SUB 300 IR Tier 3 X X IR (INDEX OF REACTIVITY)* and Lung Conditions Respiratory Tract/Pulmonary Agents - ORALAIR CHLD PAK *GRASS MIXED POLLEN TAB SL Drugs to Treat Allergies, Cough, Cold Tier 3 SAMPLE THERPAK 100 (3) IR & 300 (6) IR* and Lung Conditions Respiratory Tract/Pulmonary Agents - *GRASS MIXED POLLEN EXT TAB SL 100 Drugs to Treat Allergies, Cough, Cold ORALAIR CHLD SUB 100 IR Tier 3 X X IR (INDEX OF REACTIVITY)* and Lung Conditions Respiratory Tract/Pulmonary Agents - TREPROSTINIL DIOLAMINE TAB CR 0.125 Drugs to Treat Allergies, Cough, Cold ORENITRAM TAB 0.125MG Tier 3 X X X MG (BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - TREPROSTINIL DIOLAMINE TAB CR 0.25 Drugs to Treat Allergies, Cough, Cold ORENITRAM TAB 0.25MG Tier 3 X X X MG (BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - TREPROSTINIL DIOLAMINE TAB CR 1 MG Drugs to Treat Allergies, Cough, Cold ORENITRAM TAB 1MG Tier 3 X X X (BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - TREPROSTINIL DIOLAMINE TAB CR 2.5 Drugs to Treat Allergies, Cough, Cold ORENITRAM TAB 2.5MG Tier 3 X X X MG (BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - TREPROSTINIL DIOLAMINE TAB ER 5 MG Drugs to Treat Allergies, Cough, Cold ORENITRAM TAB 5MG Tier 3 X X X (BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - LUMACAFTOR-IVACAFTOR TAB 100-125 Drugs to Treat Allergies, Cough, Cold ORKAMBI TAB 100-125 Tier 2 X X X MG and Lung Conditions Respiratory Tract/Pulmonary Agents - LUMACAFTOR-IVACAFTOR TAB 200-125 Drugs to Treat Allergies, Cough, Cold ORKAMBI TAB 200-125 Tier 2 X X X MG and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold PATANASE SPR 0.6% OLOPATADINE HCL NASAL SOLN 0.6% Tier 3 X and Lung Conditions Respiratory Tract/Pulmonary Agents - PE/GUAIFENES DRO 1.5- PHENYLEPHRINE-GUAIFENESIN LIQD 7.5- Drugs to Treat Allergies, Cough, Cold Tier 1 20MG 100 MG/5ML (1.5-20 MG/ML) and Lung Conditions Respiratory Tract/Pulmonary Agents - FORMOTEROL FUMARATE SOLN NEBU Drugs to Treat Allergies, Cough, Cold PERFOROMIST NEB 20MCG Tier 3 X 20 MCG/2ML and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold PHENADOZ SUP 12.5MG PROMETHAZINE HCL SUPPOS 12.5 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold PHENADOZ SUP 25MG PROMETHAZINE HCL SUPPOS 25 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold PHENERGAN SUP 12.5MG PROMETHAZINE HCL SUPPOS 12.5 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold PHENERGAN SUP 25MG PROMETHAZINE HCL SUPPOS 25 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold PHENERGAN SUP 50MG PROMETHAZINE HCL SUPPOS 50 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - ALBUTEROL SULFATE INHAL AERO 108 Drugs to Treat Allergies, Cough, Cold PROAIR HFA AER Tier 3 X MCG/ACT (90MCG BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - ALBUTEROL SULFATE AER POW BA 108 Drugs to Treat Allergies, Cough, Cold PROAIR RESPI AER Tier 3 X MCG/ACT (90 MCG BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - PROMETHAZINE & PHENYLEPHRINE Drugs to Treat Allergies, Cough, Cold PROMETH VC SOL PLAIN Tier 1 SYRUP 6.25-5 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - PROMETH VC/ SYP PROMETHAZINE-PHENYLEPHRINE- Drugs to Treat Allergies, Cough, Cold Tier 1 X CODEINE CODEINE SYRUP 6.25-5-10 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - PROMETHAZINE W/ CODEINE SYRUP Drugs to Treat Allergies, Cough, Cold PROMETH/COD SYP 6.25-10 Tier 1 X 6.25-10 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - PROMETHAZINE & PHENYLEPHRINE Drugs to Treat Allergies, Cough, Cold PROMETH/PE SYP 6.25-5/5 Tier 1 SYRUP 6.25-5 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - PROMETH/PE/ SYP PROMETHAZINE-PHENYLEPHRINE- Drugs to Treat Allergies, Cough, Cold Tier 1 X CODEINE CODEINE SYRUP 6.25-5-10 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - PROMETHAZINE SOL PROMETHAZINE HCL SYRUP 6.25 Drugs to Treat Allergies, Cough, Cold Tier 1 6.25/5ML MG/5ML and Lung Conditions

190 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Respiratory Tract/Pulmonary Agents - PROMETHAZINE SUP Drugs to Treat Allergies, Cough, Cold PROMETHAZINE HCL SUPPOS 12.5 MG Tier 1 12.5MG and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold PROMETHAZINE SUP 25MG PROMETHAZINE HCL SUPPOS 25 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold PROMETHAZINE SUP 50MG PROMETHAZINE HCL SUPPOS 50 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - PROMETHAZINE SYP PROMETHAZINE HCL SYRUP 6.25 Drugs to Treat Allergies, Cough, Cold Tier 1 6.25/5ML MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - PROMETHAZINE-DM SYRUP 6.25-15 Drugs to Treat Allergies, Cough, Cold PROMETHAZINE SYP DM Tier 1 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - PROMETHAZINE TAB Drugs to Treat Allergies, Cough, Cold PROMETHAZINE HCL TAB 12.5 MG Tier 1 12.5MG and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold PROMETHAZINE TAB 25MG PROMETHAZINE HCL TAB 25 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold PROMETHAZINE TAB 50MG PROMETHAZINE HCL TAB 50 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - PROMETHEGAN SUP Drugs to Treat Allergies, Cough, Cold PROMETHAZINE HCL SUPPOS 12.5 MG Tier 1 12.5MG and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold PROMETHEGAN SUP 25MG PROMETHAZINE HCL SUPPOS 25 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold PROMETHEGAN SUP 50MG PROMETHAZINE HCL SUPPOS 50 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - ALBUTEROL SULFATE INHAL AERO 108 Drugs to Treat Allergies, Cough, Cold PROVENTIL AER HFA Tier 3 X MCG/ACT (90MCG BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - BUDESONIDE INHAL AERO POWD 180 Drugs to Treat Allergies, Cough, Cold PULMICORT INH 180MCG Tier 3 X X MCG/ACT (BREATH ACTIVATED) and Lung Conditions Respiratory Tract/Pulmonary Agents - BUDESONIDE INHAL AERO POWD 90 Drugs to Treat Allergies, Cough, Cold PULMICORT INH 90MCG Tier 3 X X MCG/ACT (BREATH ACTIVATED) and Lung Conditions Respiratory Tract/Pulmonary Agents - BUDESONIDE INHALATION SUSP 0.25 Drugs to Treat Allergies, Cough, Cold PULMICORT SUS 0.25MG/2 Tier 3 X MG/2ML and Lung Conditions Respiratory Tract/Pulmonary Agents - BUDESONIDE INHALATION SUSP 0.5 Drugs to Treat Allergies, Cough, Cold PULMICORT SUS 0.5MG/2 Tier 3 X MG/2ML and Lung Conditions Respiratory Tract/Pulmonary Agents - BUDESONIDE INHALATION SUSP 1 Drugs to Treat Allergies, Cough, Cold PULMICORT SUS 1MG/2ML Tier 3 X MG/2ML and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold PULMOSAL NEB 7% SODIUM CHLORIDE SOLN NEBU 7% Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold PULMOZYME SOL 1MG/ML DORNASE ALFA INHAL SOLN 1 MG/ML Tier 2 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold Q-BID-LA TAB 600MG GUAIFENESIN TAB ER 12HR 600 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - BECLOMETHASONE DIPROP INHAL Drugs to Treat Allergies, Cough, Cold QVAR AER 40MCG Tier 1 X AERO SOLN 40 MCG/ACT (50/VALVE) and Lung Conditions Respiratory Tract/Pulmonary Agents - BECLOMETHASONE DIPROP INHAL Drugs to Treat Allergies, Cough, Cold QVAR AER 80MCG Tier 1 X AERO SOLN 80 MCG/ACT (100/VALVE) and Lung Conditions Respiratory Tract/Pulmonary Agents - SHORT RAGWEED POLLEN ALLERGEN Drugs to Treat Allergies, Cough, Cold RAGWITEK SUB Tier 3 X X EXTRACT TAB SL 12 AMB A 1-U and Lung Conditions Respiratory Tract/Pulmonary Agents - BROMPHEN TAN-PHENYLEPH TAN Drugs to Treat Allergies, Cough, Cold RELHIST CHW Tier 2 CHEW TAB 6-15 MG and Lung Conditions Respiratory Tract/Pulmonary Agents - BROMPHENIRAMINE MALEATE TAB SR Drugs to Treat Allergies, Cough, Cold RESPA-BR TAB 11MG Tier 3 12HR 11 MG and Lung Conditions Respiratory Tract/Pulmonary Agents - SILDENAFIL CITRATE FOR SUSPENSION Drugs to Treat Allergies, Cough, Cold REVATIO SUS 10MG/ML Tier 4 X X X 10 MG/ML and Lung Conditions

191 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Respiratory Tract/Pulmonary Agents - PSEUDOEPHEDRINE W/ HYDROCODONE Drugs to Treat Allergies, Cough, Cold REZIRA SOL 60-5/5ML Tier 3 SOLN 60-5 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - ACRIVASTINE & PSEUDOEPHEDRINE Drugs to Treat Allergies, Cough, Cold SEMPREX-D CAP 8-60MG Tier 3 CAP 8-60 MG and Lung Conditions Respiratory Tract/Pulmonary Agents - SALMETEROL XINAFOATE AER POW BA Drugs to Treat Allergies, Cough, Cold SEREVENT DIS AER 50MCG Tier 3 X 50 MCG/DOSE (BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold SILDENAFIL TAB 20MG SILDENAFIL CITRATE TAB 20 MG Tier 1 X X and Lung Conditions Respiratory Tract/Pulmonary Agents - MONTELUKAST SODIUM ORAL Drugs to Treat Allergies, Cough, Cold SINGULAIR GRA 4MG Tier 3 GRANULES PACKET 4 MG (BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold SOD CHLORIDE NEB 0.9% SODIUM CHLORIDE SOLN NEBU 0.9% Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold SODIUM CHLOR NEB 10% SODIUM CHLORIDE SOLN NEBU 10% Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold SODIUM CHLOR NEB 3% SODIUM CHLORIDE SOLN NEBU 3% Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold SODIUM CHLOR NEB 7% SODIUM CHLORIDE SOLN NEBU 7% Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - TIOTROPIUM BROMIDE MONOHYDRATE Drugs to Treat Allergies, Cough, Cold SPIRIVA AER 1.25MCG Tier 3 X INHAL AEROSOL 1.25 MCG/ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - TIOTROPIUM BROMIDE MONOHYDRATE Drugs to Treat Allergies, Cough, Cold SPIRIVA CAP HANDIHLR Tier 3 X INHAL CAP 18 MCG (BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - TIOTROPIUM BROMIDE MONOHYDRATE Drugs to Treat Allergies, Cough, Cold SPIRIVA SPR 2.5MCG Tier 3 X INHAL AEROSOL 2.5 MCG/ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - OLODATEROL HCL INHAL AEROSOL Drugs to Treat Allergies, Cough, Cold STRIVERDI AER 2.5MCG Tier 2 X SOLN 2.5 MCG/ACT (BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - BUDESONIDE-FORMOTEROL FUMARATE Drugs to Treat Allergies, Cough, Cold SYMBICORT AER 160-4.5 Tier 3 X DIHYD AEROSOL 160-4.5 MCG/ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - BUDESONIDE-FORMOTEROL FUMARATE Drugs to Treat Allergies, Cough, Cold SYMBICORT AER 80-4.5 Tier 3 X DIHYD AEROSOL 80-4.5 MCG/ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - TERBUTALINE POW Drugs to Treat Allergies, Cough, Cold TERBUTALINE SULFATE POWDER Tier 3 SULFATE and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold TERBUTALINE TAB 2.5MG TERBUTALINE SULFATE TAB 2.5 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold TERBUTALINE TAB 5MG TERBUTALINE SULFATE TAB 5 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - PHENYLEPHRINE-CHLORPHEN-DM Drugs to Treat Allergies, Cough, Cold TGQ 15DM/5PE SYP H/2CPM Tier 1 SYRUP 5-2-15 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - PSEUDOEPHEDRINE W/ DM-GG SYRUP Drugs to Treat Allergies, Cough, Cold TGQ 30/ SYP 150/15 Tier 1 30-15-150 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - TGQ 30/PSE/3 SYP PSEUDOEPHED-BROMPHEN-DM SYRUP Drugs to Treat Allergies, Cough, Cold Tier 1 BRM/15DM 30-3-15 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold THEO-24 CAP 100MG CR THEOPHYLLINE CAP ER 24HR 100 MG Tier 3 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold THEO-24 CAP 200MG CR THEOPHYLLINE CAP ER 24HR 200 MG Tier 3 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold THEO-24 CAP 300MG CR THEOPHYLLINE CAP ER 24HR 300 MG Tier 3 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold THEO-24 CAP 400MG ER THEOPHYLLINE CAP ER 24HR 400 MG Tier 3 and Lung Conditions Respiratory Tract/Pulmonary Agents - THEOCHRON TAB 100MG Drugs to Treat Allergies, Cough, Cold THEOPHYLLINE TAB ER 12HR 100 MG Tier 1 CR and Lung Conditions

192 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Respiratory Tract/Pulmonary Agents - THEOCHRON TAB 200MG Drugs to Treat Allergies, Cough, Cold THEOPHYLLINE TAB ER 12HR 200 MG Tier 1 CR and Lung Conditions Respiratory Tract/Pulmonary Agents - THEOCHRON TAB 300MG Drugs to Treat Allergies, Cough, Cold THEOPHYLLINE TAB ER 12HR 300 MG Tier 1 CR and Lung Conditions Respiratory Tract/Pulmonary Agents - THEOPHYLLINE SOL Drugs to Treat Allergies, Cough, Cold THEOPHYLLINE SOLN 80 MG/15ML Tier 1 80/15ML and Lung Conditions Respiratory Tract/Pulmonary Agents - THEOPHYLLINE TAB 100MG Drugs to Treat Allergies, Cough, Cold THEOPHYLLINE TAB ER 12HR 100 MG Tier 1 CR and Lung Conditions Respiratory Tract/Pulmonary Agents - THEOPHYLLINE TAB 100MG Drugs to Treat Allergies, Cough, Cold THEOPHYLLINE TAB ER 12HR 100 MG Tier 1 ER and Lung Conditions Respiratory Tract/Pulmonary Agents - THEOPHYLLINE TAB 200MG Drugs to Treat Allergies, Cough, Cold THEOPHYLLINE TAB ER 12HR 200 MG Tier 1 CR and Lung Conditions Respiratory Tract/Pulmonary Agents - THEOPHYLLINE TAB 200MG Drugs to Treat Allergies, Cough, Cold THEOPHYLLINE TAB ER 12HR 200 MG Tier 1 ER and Lung Conditions Respiratory Tract/Pulmonary Agents - THEOPHYLLINE TAB 300MG Drugs to Treat Allergies, Cough, Cold THEOPHYLLINE TAB ER 12HR 300 MG Tier 1 ER and Lung Conditions Respiratory Tract/Pulmonary Agents - THEOPHYLLINE TAB 400MG Drugs to Treat Allergies, Cough, Cold THEOPHYLLINE TAB ER 24HR 400 MG Tier 1 ER and Lung Conditions Respiratory Tract/Pulmonary Agents - THEOPHYLLINE TAB 450MG Drugs to Treat Allergies, Cough, Cold THEOPHYLLINE TAB ER 12HR 450 MG Tier 1 ER and Lung Conditions Respiratory Tract/Pulmonary Agents - THEOPHYLLINE TAB 600MG Drugs to Treat Allergies, Cough, Cold THEOPHYLLINE TAB ER 24HR 600 MG Tier 1 ER and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold TRACLEER TAB 125MG BOSENTAN TAB 125 MG Tier 2 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold TRACLEER TAB 32MG BOSENTAN TAB FOR ORAL SUSP 32 MG Tier 2 X X and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold TRACLEER TAB 62.5MG BOSENTAN TAB 62.5 MG Tier 2 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - TUDORZA PRES AER 400/ ACLIDINIUM BROMIDE AEROSOL POWD Drugs to Treat Allergies, Cough, Cold Tier 2 X ACT BREATH ACTIVATED 400 MCG/ACT and Lung Conditions Respiratory Tract/Pulmonary Agents - HYDROCOD POLST-CHLORPHEN POLST Drugs to Treat Allergies, Cough, Cold TUSSICAPS CAP 10-8MG Tier 3 CAP ER 12HR 10-8 MG and Lung Conditions Respiratory Tract/Pulmonary Agents - HYDROCOD POLST-CHLORPHEN POLST Drugs to Treat Allergies, Cough, Cold TUSSICAPS CAP 5-4MG Tier 3 CAP ER 12HR 5-4 MG and Lung Conditions Respiratory Tract/Pulmonary Agents - HYDROCODONE W/ HOMATROPINE TAB Drugs to Treat Allergies, Cough, Cold TUSSIGON TAB 5-1.5MG Tier 1 X 5-1.5 MG and Lung Conditions Respiratory Tract/Pulmonary Agents - HYDROCOD POLST-CHLORPHEN POLST Drugs to Treat Allergies, Cough, Cold TUSSIONEX SUS 10-8/5ML Tier 3 X X ER SUSP 10-8 MG/5ML and Lung Conditions Respiratory Tract/Pulmonary Agents - TREPROSTINIL INHALATION SOLUTION Drugs to Treat Allergies, Cough, Cold TYVASO SOL 0.6MG/ML Tier 2 X X 0.6 MG/ML and Lung Conditions Respiratory Tract/Pulmonary Agents - TYVASO REFIL SOL 0.6MG/ TREPROSTINIL INHALATION SOLUTION Drugs to Treat Allergies, Cough, Cold Tier 2 X X ML 0.6 MG/ML and Lung Conditions Respiratory Tract/Pulmonary Agents - TYVASO START SOL 0.6MG/ TREPROSTINIL INHALATION SOLUTION Drugs to Treat Allergies, Cough, Cold Tier 2 X X ML 0.6 MG/ML and Lung Conditions Respiratory Tract/Pulmonary Agents - TETRAHYDROZOLINE HCL NASAL SOLN Drugs to Treat Allergies, Cough, Cold TYZINE PED DRO 0.05% Tier 3 0.05% and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold UPTRAVI TAB 1000MCG SELEXIPAG TAB 1000 MCG Tier 3 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold UPTRAVI TAB 1200MCG SELEXIPAG TAB 1200 MCG Tier 3 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold UPTRAVI TAB 1400MCG SELEXIPAG TAB 1400 MCG Tier 3 X X X and Lung Conditions

193 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold UPTRAVI TAB 1600MCG SELEXIPAG TAB 1600 MCG Tier 3 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - SELEXIPAG TAB THERAPY PACK 200 Drugs to Treat Allergies, Cough, Cold UPTRAVI TAB 200/800 Tier 3 X X X MCG (140) & 800 MCG (60) and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold UPTRAVI TAB 200MCG SELEXIPAG TAB 200 MCG Tier 3 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold UPTRAVI TAB 400MCG SELEXIPAG TAB 400 MCG Tier 3 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold UPTRAVI TAB 600MCG SELEXIPAG TAB 600 MCG Tier 3 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold UPTRAVI TAB 800MCG SELEXIPAG TAB 800 MCG Tier 3 X X X and Lung Conditions Respiratory Tract/Pulmonary Agents - ILOPROST INHALATION SOLUTION 10 Drugs to Treat Allergies, Cough, Cold VENTAVIS SOL 10MCG/ML Tier 2 X X MCG/ML and Lung Conditions Respiratory Tract/Pulmonary Agents - ILOPROST INHALATION SOLUTION 20 Drugs to Treat Allergies, Cough, Cold VENTAVIS SOL 20MCG/ML Tier 2 X X MCG/ML and Lung Conditions Respiratory Tract/Pulmonary Agents - ALBUTEROL SULFATE INHAL AERO 108 Drugs to Treat Allergies, Cough, Cold VENTOLIN HFA AER Tier 2 X MCG/ACT (90MCG BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - ALBUTEROL SULFATE TAB ER 12HR 4 Drugs to Treat Allergies, Cough, Cold VOSPIRE ER TAB 4MG Tier 3 MG and Lung Conditions Respiratory Tract/Pulmonary Agents - ALBUTEROL SULFATE TAB ER 12HR 8 Drugs to Treat Allergies, Cough, Cold VOSPIRE ER TAB 8MG Tier 3 MG and Lung Conditions Respiratory Tract/Pulmonary Agents - LEVALBUTEROL TARTRATE INHAL Drugs to Treat Allergies, Cough, Cold XOPENEX HFA AER Tier 3 X AEROSOL 45 MCG/ACT (BASE EQUIV) and Lung Conditions Respiratory Tract/Pulmonary Agents - LEVOCETIRIZINE DIHYDROCHLORIDE Drugs to Treat Allergies, Cough, Cold XYZAL SOL Tier 3 SOLN 2.5 MG/5ML (0.5 MG/ML) and Lung Conditions Respiratory Tract/Pulmonary Agents - LEVOCETIRIZINE DIHYDROCHLORIDE Drugs to Treat Allergies, Cough, Cold XYZAL SOL 2.5/5ML Tier 3 SOLN 2.5 MG/5ML (0.5 MG/ML) and Lung Conditions Respiratory Tract/Pulmonary Agents - LEVOCETIRIZINE DIHYDROCHLORIDE Drugs to Treat Allergies, Cough, Cold XYZAL TAB 5MG Tier 3 TAB 5 MG and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ZAFIRLUKAST TAB 10MG ZAFIRLUKAST TAB 10 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ZAFIRLUKAST TAB 20MG ZAFIRLUKAST TAB 20 MG Tier 1 and Lung Conditions Respiratory Tract/Pulmonary Agents - CICLESONIDE NASAL AEROSOL SOLN Drugs to Treat Allergies, Cough, Cold ZETONNA AER 37MCG Tier 3 X 37 MCG/ACT (50 MCG/VALVE) and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ZILEUTON ER TAB 600MG ZILEUTON TAB ER 12HR 600 MG Tier 3 X and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ZYFLO TAB 600MG ZILEUTON TAB 600 MG Tier 3 X and Lung Conditions Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold ZYFLO CR TAB 600MG ZILEUTON TAB ER 12HR 600 MG Tier 4 X and Lung Conditions Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle BACLOFEN TAB 10MG BACLOFEN TAB 10 MG Tier 1 and Joint Conditions Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle BACLOFEN TAB 20MG BACLOFEN TAB 20 MG Tier 1 and Joint Conditions Skeletal Muscle Relaxants - Drugs to CARISOPR/ASA TAB 200- CARISOPRODOL W/ ASPIRIN TAB 200- Treat Pain, Inflammation, and Muscle Tier 1 325 325 MG and Joint Conditions Skeletal Muscle Relaxants - Drugs to CARISOPRODOL TAB Treat Pain, Inflammation, and Muscle CARISOPRODOL TAB 350 MG Tier 1 350MG and Joint Conditions Skeletal Muscle Relaxants - Drugs to CHLORZOXAZON TAB Treat Pain, Inflammation, and Muscle CHLORZOXAZONE TAB 500 MG Tier 1 500MG and Joint Conditions

194 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle CYCLOBENZAPR TAB 10MG CYCLOBENZAPRINE HCL TAB 10 MG Tier 1 and Joint Conditions Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle CYCLOBENZAPR TAB 5MG CYCLOBENZAPRINE HCL TAB 5 MG Tier 1 and Joint Conditions Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle CYCLOBENZAPR TAB 7.5MG CYCLOBENZAPRINE HCL TAB 7.5 MG Tier 1 and Joint Conditions Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle DANTRIUM CAP 25MG DANTROLENE SODIUM CAP 25 MG Tier 3 and Joint Conditions Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle DANTRIUM CAP 50MG DANTROLENE SODIUM CAP 50 MG Tier 3 and Joint Conditions Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle DANTROLENE CAP 100MG DANTROLENE SODIUM CAP 100 MG Tier 1 and Joint Conditions Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle DANTROLENE CAP 25MG DANTROLENE SODIUM CAP 25 MG Tier 1 and Joint Conditions Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle DANTROLENE CAP 50MG DANTROLENE SODIUM CAP 50 MG Tier 1 and Joint Conditions Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle FEXMID TAB 7.5MG CYCLOBENZAPRINE HCL TAB 7.5 MG Tier 3 and Joint Conditions Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle METAXALL TAB 800MG METAXALONE TAB 800 MG Tier 3 and Joint Conditions Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle METAXALONE TAB 400MG METAXALONE TAB 400 MG Tier 3 and Joint Conditions Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle METAXALONE TAB 800MG METAXALONE TAB 800 MG Tier 3 and Joint Conditions Skeletal Muscle Relaxants - Drugs to METHOCARBAM TAB Treat Pain, Inflammation, and Muscle METHOCARBAMOL TAB 500 MG Tier 1 500MG and Joint Conditions Skeletal Muscle Relaxants - Drugs to METHOCARBAM TAB Treat Pain, Inflammation, and Muscle METHOCARBAMOL TAB 750 MG Tier 1 750MG and Joint Conditions Skeletal Muscle Relaxants - Drugs to ORPHENADRINE TAB ORPHENADRINE CITRATE TAB ER 12HR Treat Pain, Inflammation, and Muscle Tier 2 100MG ER 100 MG and Joint Conditions Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle PARAFON FORT TAB 500MG CHLORZOXAZONE TAB 500 MG Tier 3 and Joint Conditions Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle ROBAXIN TAB 500MG METHOCARBAMOL TAB 500 MG Tier 3 and Joint Conditions Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle ROBAXIN-750 TAB 750MG METHOCARBAMOL TAB 750 MG Tier 3 and Joint Conditions Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle SOMA TAB 350MG CARISOPRODOL TAB 350 MG Tier 3 and Joint Conditions Skeletal Muscle Relaxants - Drugs to TIZANIDINE HCL CAP 2 MG (BASE Treat Pain, Inflammation, and Muscle TIZANIDINE CAP 2MG Tier 3 EQUIVALENT) and Joint Conditions Skeletal Muscle Relaxants - Drugs to TIZANIDINE HCL CAP 4 MG (BASE Treat Pain, Inflammation, and Muscle TIZANIDINE CAP 4MG Tier 3 EQUIVALENT) and Joint Conditions Skeletal Muscle Relaxants - Drugs to TIZANIDINE HCL CAP 6 MG (BASE Treat Pain, Inflammation, and Muscle TIZANIDINE CAP 6MG Tier 3 EQUIVALENT) and Joint Conditions Skeletal Muscle Relaxants - Drugs to TIZANIDINE HCL TAB 2 MG (BASE Treat Pain, Inflammation, and Muscle TIZANIDINE TAB 2MG Tier 1 EQUIVALENT) and Joint Conditions Skeletal Muscle Relaxants - Drugs to TIZANIDINE HCL TAB 4 MG (BASE Treat Pain, Inflammation, and Muscle TIZANIDINE TAB 4MG Tier 1 EQUIVALENT) and Joint Conditions Skeletal Muscle Relaxants - Drugs to TIZANIDINE HCL CAP 2 MG (BASE Treat Pain, Inflammation, and Muscle ZANAFLEX CAP 2MG Tier 3 EQUIVALENT) and Joint Conditions Skeletal Muscle Relaxants - Drugs to TIZANIDINE HCL CAP 4 MG (BASE Treat Pain, Inflammation, and Muscle ZANAFLEX CAP 4MG Tier 3 EQUIVALENT) and Joint Conditions

195 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Skeletal Muscle Relaxants - Drugs to TIZANIDINE HCL CAP 6 MG (BASE Treat Pain, Inflammation, and Muscle ZANAFLEX CAP 6MG Tier 3 EQUIVALENT) and Joint Conditions Skeletal Muscle Relaxants - Drugs to TIZANIDINE HCL TAB 4 MG (BASE Treat Pain, Inflammation, and Muscle ZANAFLEX TAB 4MG Tier 3 EQUIVALENT) and Joint Conditions Sleep Disorder Agents - Drugs for ARMODAFINIL TAB 150MG ARMODAFINIL TAB 150 MG Tier 3 X X Sedation and Sleep Sleep Disorder Agents - Drugs for ARMODAFINIL TAB 200MG ARMODAFINIL TAB 200 MG Tier 3 X X Sedation and Sleep Sleep Disorder Agents - Drugs for ARMODAFINIL TAB 250MG ARMODAFINIL TAB 250 MG Tier 3 X X Sedation and Sleep Sleep Disorder Agents - Drugs for ARMODAFINIL TAB 50MG ARMODAFINIL TAB 50 MG Tier 3 X X Sedation and Sleep Sleep Disorder Agents - Drugs for BELSOMRA TAB 10MG SUVOREXANT TAB 10 MG Tier 3 X X Sedation and Sleep Sleep Disorder Agents - Drugs for BELSOMRA TAB 15MG SUVOREXANT TAB 15 MG Tier 3 X X Sedation and Sleep Sleep Disorder Agents - Drugs for BELSOMRA TAB 20MG SUVOREXANT TAB 20 MG Tier 3 X X Sedation and Sleep Sleep Disorder Agents - Drugs for BELSOMRA TAB 5MG SUVOREXANT TAB 5 MG Tier 3 X X Sedation and Sleep Sleep Disorder Agents - Drugs for BUTISOL SOD TAB 30MG BUTABARBITAL SODIUM TAB 30 MG Tier 3 Sedation and Sleep Sleep Disorder Agents - Drugs for ESZOPICLONE TAB 1MG ESZOPICLONE TAB 1 MG Tier 2 X Sedation and Sleep Sleep Disorder Agents - Drugs for ESZOPICLONE TAB 2MG ESZOPICLONE TAB 2 MG Tier 2 X Sedation and Sleep Sleep Disorder Agents - Drugs for ESZOPICLONE TAB 3MG ESZOPICLONE TAB 3 MG Tier 2 X Sedation and Sleep Sleep Disorder Agents - Drugs for FLURAZEPAM CAP 15MG FLURAZEPAM HCL CAP 15 MG Tier 1 Sedation and Sleep Sleep Disorder Agents - Drugs for FLURAZEPAM CAP 30MG FLURAZEPAM HCL CAP 30 MG Tier 1 Sedation and Sleep Sleep Disorder Agents - Drugs for MODAFINIL TAB 100MG MODAFINIL TAB 100 MG Tier 3 X X Sedation and Sleep Sleep Disorder Agents - Drugs for MODAFINIL TAB 200MG MODAFINIL TAB 200 MG Tier 3 X X Sedation and Sleep Sleep Disorder Agents - Drugs for RESTORIL CAP 15MG TEMAZEPAM CAP 15 MG Tier 3 Sedation and Sleep Sleep Disorder Agents - Drugs for RESTORIL CAP 22.5MG TEMAZEPAM CAP 22.5 MG Tier 3 Sedation and Sleep Sleep Disorder Agents - Drugs for RESTORIL CAP 30MG TEMAZEPAM CAP 30 MG Tier 3 Sedation and Sleep Sleep Disorder Agents - Drugs for RESTORIL CAP 7.5MG TEMAZEPAM CAP 7.5 MG Tier 3 Sedation and Sleep Sleep Disorder Agents - Drugs for ROZEREM TAB 8MG RAMELTEON TAB 8 MG Tier 3 X X Sedation and Sleep Sleep Disorder Agents - Drugs for SECONAL SOD CAP 100MG SECOBARBITAL SODIUM CAP 100 MG Tier 3 Sedation and Sleep Sleep Disorder Agents - Drugs for SONATA CAP 10MG ZALEPLON CAP 10 MG Tier 3 X Sedation and Sleep Sleep Disorder Agents - Drugs for SONATA CAP 5MG ZALEPLON CAP 5 MG Tier 3 X Sedation and Sleep Sleep Disorder Agents - Drugs for TEMAZEPAM CAP 15MG TEMAZEPAM CAP 15 MG Tier 1 Sedation and Sleep Sleep Disorder Agents - Drugs for TEMAZEPAM CAP 22.5MG TEMAZEPAM CAP 22.5 MG Tier 1 Sedation and Sleep Sleep Disorder Agents - Drugs for TEMAZEPAM CAP 30MG TEMAZEPAM CAP 30 MG Tier 1 Sedation and Sleep Sleep Disorder Agents - Drugs for TEMAZEPAM CAP 7.5MG TEMAZEPAM CAP 7.5 MG Tier 1 Sedation and Sleep Sleep Disorder Agents - Drugs for SODIUM OXYBATE ORAL SOLUTION 500 XYREM SOL 500MG/ML Tier 3 X X X Sedation and Sleep MG/ML Sleep Disorder Agents - Drugs for ZALEPLON CAP 10MG ZALEPLON CAP 10 MG Tier 1 X Sedation and Sleep Sleep Disorder Agents - Drugs for ZALEPLON CAP 5MG ZALEPLON CAP 5 MG Tier 1 X Sedation and Sleep Sleep Disorder Agents - Drugs for ZOLPIDEM TAB 10MG ZOLPIDEM TARTRATE TAB 10 MG Tier 1 X Sedation and Sleep Sleep Disorder Agents - Drugs for ZOLPIDEM TAB 5MG ZOLPIDEM TARTRATE TAB 5 MG Tier 1 X Sedation and Sleep Sleep Disorder Agents - Drugs for ZOLPIDEM TARTRATE ORAL SPRAY 5 ZOLPIMIST SPR 5MG Tier 3 X X Sedation and Sleep MG/ACT Therapeutic Nutrients/Minerals/ *PRENATAL W/O A W/FE CBN-FA-DHA Electrolytes - Drugs to Treat Vitamin, ACTIVE OB CAP Tier 3 CAP 20-1-320 MG*** Mineral and Body Fluid Deficiencies

196 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Therapeutic Nutrients/Minerals/ POTASSIUM AMINOBENZOATE PACKET Electrolytes - Drugs to Treat Vitamin, AMINOBEZ POT POW Tier 1 2 GM Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ DSS-IRON Electrolytes - Drugs to Treat Vitamin, ATABEX EC TAB 29-1MG Tier 3 CARBONYL-FA TAB DR 29-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POT PHOS MONOBASIC W/SOD PHOS DI Electrolytes - Drugs to Treat Vitamin, AV-PHOS 250 TAB NEUTRAL Tier 1 & MONOBAS TAB 155-852-130MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/FE POLY-NA FERED-FA TAB Electrolytes - Drugs to Treat Vitamin, BAL-CARE MIS DHA Tier 2 27-1 & OMEGA CAP DR 430MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/ CALCIUM CARBONATE- Electrolytes - Drugs to Treat Vitamin, BP FOLINATAL TAB PLUS B Tier 1 B6-B12-FA TAB 1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O A VIT W/ FE FUM-FA TAB Electrolytes - Drugs to Treat Vitamin, BP MULTINATL CHW PLUS Tier 1 CHEW 40-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O A VIT W/ FE FUMARATE- Electrolytes - Drugs to Treat Vitamin, BP MULTINATL TAB PLUS Tier 1 FA TAB 30-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ CA CARB-FOLIC ACID-VIT D-B6-B12- Electrolytes - Drugs to Treat Vitamin, CALCIFOL WAF Tier 3 BORON-MAG WAFER 1342-1.6 MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O VIT A W/ FE FUM-FA- Electrolytes - Drugs to Treat Vitamin, CALCIUM PNV CAP Tier 3 OMEGA 3 CAP 28-1-250 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ CA CARB-FOLIC ACID-VIT D-B6-B12- Electrolytes - Drugs to Treat Vitamin, CALCIUM-FA WAF PLUS D Tier 1 BORON-MAG WAFER 1342-1 MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, CARBAGLU TAB 200MG CARGLUMIC ACID TAB 200 MG Tier 2 X X Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ LEVOCARNITINE ORAL SOLN 1 Electrolytes - Drugs to Treat Vitamin, CARNITOR SOL 1GM/10ML Tier 3 GM/10ML (10%) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, CARNITOR TAB 330MG LEVOCARNITINE TAB 330 MG Tier 3 Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ CARNITOR SF SOL LEVOCARNITINE ORAL SOLN 1 Electrolytes - Drugs to Treat Vitamin, Tier 3 1GM/10ML GM/10ML (10%) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, CHEMET CAP 100MG SUCCIMER CAP 100 MG Tier 2 Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ CITRANATAL CAP *PRENAT W/O A W/FE FUM-FE CBN-DSS- Electrolytes - Drugs to Treat Vitamin, Tier 3 HARMONY FA-DHA CAP 27-1-260 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FECBN-FEGL-DSS-FA Electrolytes - Drugs to Treat Vitamin, CITRANATAL MIS Tier 3 TAB 90 &DHA CAP 300MG PAK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FECBN-FEGL-DSS-FA Electrolytes - Drugs to Treat Vitamin, CITRANATAL MIS 90 DHA Tier 3 TAB 90 &DHA CAP 300MG PAK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FECBN-FEGLU-FA Electrolytes - Drugs to Treat Vitamin, CITRANATAL MIS B-CALM Tier 3 TAB 20-1 MG & VIT B6 TAB PAK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FECBN-FEGL-DSS-FA Electrolytes - Drugs to Treat Vitamin, CITRANATAL PAK ASSURE Tier 3 TAB & DHA CAP 300 MG PACK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FECBN-FEGL-DSS-FA Electrolytes - Drugs to Treat Vitamin, CITRANATAL PAK DHA Tier 3 TAB & DHA CAP 250 MG PACK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ DSS-FE CBN-FE Electrolytes - Drugs to Treat Vitamin, CITRANATAL TAB BLOOM Tier 3 GLUC-FA TAB 90-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O A W/ FE CARBONYL-FE Electrolytes - Drugs to Treat Vitamin, CITRANATAL TAB RX Tier 3 GLUC-DSS-FA TAB 27-1MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUM-FA-OMEGA 3 Electrolytes - Drugs to Treat Vitamin, C-NATE DHA CAP 28-1-200 Tier 3 CAP 28-1-200 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT-FE BIS-FE PROT SUCC-FA-CA Electrolytes - Drugs to Treat Vitamin, COMPLETE NAT PAK DHA Tier 1 TAB & OMEGA 3 CAP 250 PK** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA Electrolytes - Drugs to Treat Vitamin, COMPLETENATE CHW Tier 1 CHEW TAB 29-1 MG*** Mineral and Body Fluid Deficiencies

197 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, CO-NATAL FA TAB 29-1MG Tier 2 29-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/FE FUM-FE POLY -FA- Electrolytes - Drugs to Treat Vitamin, CONCEPT DHA CAP Tier 3 OMEGA 3 CAP 53.5-38-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O A W/FE FUM-FE POLY- Electrolytes - Drugs to Treat Vitamin, CONCEPT OB CAP Tier 3 FA CAP 130-92.4-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ CYANOCOBALAMIN POWDER (FOR Electrolytes - Drugs to Treat Vitamin, CYANOCOBAL POW Tier 3 COMPOUNDING) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, CYANOCOBALAM CRY CYANOCOBALAMIN CRYSTALS Tier 3 Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CITRATE & CITRIC ACID Electrolytes - Drugs to Treat Vitamin, CYTRA K GRA CRYSTALS Tier 1 POWDER PACK 3300-1002 MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/FE FUM-FE POLY -FA- Electrolytes - Drugs to Treat Vitamin, DOTHELLE DHA CAP Tier 3 OMEGA 3 CAP 53.5-38-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/FE POLY-NA FERED-FA TAB Electrolytes - Drugs to Treat Vitamin, DUET DHA MIS BALANCED Tier 3 25-1 & OMEGA CAP 267 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/FE POLY-NA FERED-FA TAB Electrolytes - Drugs to Treat Vitamin, DUET DHA 400 MIS 25-1-400 Tier 3 25-1 & OMEGA CAP 400 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM BICARBONATE-CITRIC ACID Electrolytes - Drugs to Treat Vitamin, EFFER-K TAB 10MEQ Tier 2 EFFER TAB 10 MEQ Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM BICARBONATE-CITRIC ACID Electrolytes - Drugs to Treat Vitamin, EFFER-K TAB 20MEQ Tier 2 EFFER TAB 20 MEQ Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM BICARBONATE EFFER TAB Electrolytes - Drugs to Treat Vitamin, EFFER-K TAB 25MEQ EF Tier 1 25 MEQ Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ IRON CARBONYL-FA Electrolytes - Drugs to Treat Vitamin, ELITE-OB TAB Tier 3 TAB 50-1.25 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE GLY CYS-FA- Electrolytes - Drugs to Treat Vitamin, ENBRACE HR CAP Tier 3 OMEGA 3 FATTY ACIDS CAP*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, ERGOCAL CAP 2500UNIT ERGOCALCIFEROL CAP 2500 UNIT Tier 3 Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ FL- Electrolytes - Drugs to Treat Vitamin, ESCAVITE CHW Tier 3 FE CHEW TAB 0.25-7.5 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ DEFERASIROX TAB FOR ORAL SUSP Electrolytes - Drugs to Treat Vitamin, EXJADE TAB 125MG Tier 2 X X 125 MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ DEFERASIROX TAB FOR ORAL SUSP Electrolytes - Drugs to Treat Vitamin, EXJADE TAB 250MG Tier 2 X X 250 MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ DEFERASIROX TAB FOR ORAL SUSP Electrolytes - Drugs to Treat Vitamin, EXJADE TAB 500MG Tier 2 X X 500 MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O VIT A W/ FE FUM-DOC- Electrolytes - Drugs to Treat Vitamin, EXTRA-VIRT CAP PLUS DHA Tier 3 FA-DHA CAP 29-1.25-350 MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ HCR Electrolytes - Drugs to Treat Vitamin, FA-8 CAP 800MCG FOLIC ACID CAP 0.8 MG Preventive Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ HCR Electrolytes - Drugs to Treat Vitamin, FA-8 TAB 0.8MG FOLIC ACID TAB 800 MCG Preventive Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, FERRIPROX SOL 100MG/ML DEFERIPRONE ORAL SOLN 100 MG/ML Tier 2 X X Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, FERRIPROX TAB 500MG DEFERIPRONE TAB 500 MG Tier 4 X X Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ SODIUM FLUORIDE-VITAMIN D LIQD Electrolytes - Drugs to Treat Vitamin, FLORIVA DRO 0.25MG Tier 3 DROPS 0.25 MG/ML-400 UNIT/ML Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, FLORIVA DRO PLUS Tier 3 FLUORIDE SOLN 0.25 MG/ML*** Mineral and Body Fluid Deficiencies

198 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Therapeutic Nutrients/Minerals/ HCR SODIUM FLUORIDE SOLN 0.25 MG/0.6ML Electrolytes - Drugs to Treat Vitamin, FLUORABON DRO Preventive (FROM 0.55 MG/0.6ML NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ FLUOR-A-DAY CHW 0.25MG SODIUM FLUORIDE-XYLITOL CHEW TAB Electrolytes - Drugs to Treat Vitamin, Tier 3 F 0.55 (0.25 MG F)-236.79 MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ SODIUM FLUORIDE-XYLITOL CHEW TAB Electrolytes - Drugs to Treat Vitamin, FLUOR-A-DAY CHW 1MG F Tier 3 2.2 (1 MG F)-236.79 MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ HCR SODIUM FLUORIDE SOLN 0.125 MG/ Electrolytes - Drugs to Treat Vitamin, FLUOR-A-DAY DRO 0.125MG Preventive DROP F (0.275 MG/DROP NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ HCR SODIUM FLUORIDE CHEW TAB 0.25 MG F Electrolytes - Drugs to Treat Vitamin, FLUORIDE CHW 0.25MG F Preventive (FROM 0.55 MG NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ HCR SODIUM FLUORIDE CHEW TAB 0.5 MG F Electrolytes - Drugs to Treat Vitamin, FLUORIDE CHW 0.5MG F Preventive (FROM 1.1 MG NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ HCR SODIUM FLUORIDE CHEW TAB 1 MG F Electrolytes - Drugs to Treat Vitamin, FLUORIDE CHW 1MG F Preventive (FROM 2.2 MG NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ HCR SODIUM FLUORIDE CHEW TAB 0.25 MG F Electrolytes - Drugs to Treat Vitamin, FLUORITAB CHW 0.25MG F Preventive (FROM 0.55 MG NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ HCR SODIUM FLUORIDE CHEW TAB 0.5 MG F Electrolytes - Drugs to Treat Vitamin, FLUORITAB CHW 0.5MG F Preventive (FROM 1.1 MG NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ HCR SODIUM FLUORIDE CHEW TAB 1 MG F Electrolytes - Drugs to Treat Vitamin, FLUORITAB CHW 1MG F Preventive (FROM 2.2 MG NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ HCR SODIUM FLUORIDE CHEW TAB 1 MG F Electrolytes - Drugs to Treat Vitamin, FLUORITAB CHW 2.2MG Preventive (FROM 2.2 MG NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ HCR SODIUM FLUORIDE SOLN 0.125 MG/ Electrolytes - Drugs to Treat Vitamin, FLUORITAB DRO 0.125MG Preventive DROP F (0.275 MG/DROP NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ HCR FLURA-DROPS DRO 0.25MG SODIUM FLUORIDE SOLN 0.25 MG/DROP Electrolytes - Drugs to Treat Vitamin, Preventive F F (FROM 0.55 MG/DROP NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FECBN-FEGL-DSS-FA Electrolytes - Drugs to Treat Vitamin, FOCALGIN 90 MIS DHA Tier 3 TAB 90 &DHA CAP 300MG PAK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FECBN-FEGL-DSS-FA Electrolytes - Drugs to Treat Vitamin, FOCALGIN CA MIS Tier 3 TAB & DHA CAP 300 MG PACK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O VIT A W/ FE FUM-DSS- Electrolytes - Drugs to Treat Vitamin, FOLCAL DHA CAP Tier 3 FA-DHA CAP 27-1.25-300 MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE CBN-FE ASP GLYC- Electrolytes - Drugs to Treat Vitamin, FOLCAPS CAP OMEGA 3 Tier 2 FA-OMEGA 3 CAP 27-1MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/FECBN-BISG-METHYLF-DSS Electrolytes - Drugs to Treat Vitamin, FOLET DHA PAK Tier 3 TAB DR & DHA CAP PAK*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FECBN-BISG- Electrolytes - Drugs to Treat Vitamin, FOLET ONE CAP 38-1-225 Tier 3 METHYLF-DSS-DHA CAP 38-1-225 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, FOLIC ACID POW FOLIC ACID POWDER Tier 3 Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, FOLIC ACID TAB 1000MCG FOLIC ACID TAB 1 MG Tier 1 Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, FOLIC ACID TAB 1MG FOLIC ACID TAB 1 MG Tier 1 Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ HCR Electrolytes - Drugs to Treat Vitamin, FOLIC ACID TAB 400MCG FOLIC ACID TAB 400 MCG Preventive Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ HCR Electrolytes - Drugs to Treat Vitamin, FOLIC ACID TAB 800MCG FOLIC ACID TAB 800 MCG Preventive Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ *PRENATAL W/O A W/FE FUM-FE POLY- Electrolytes - Drugs to Treat Vitamin, FOLIVANE-OB CAP Tier 3 FA CAP 130-92.4-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ ZINC ACETATE CAP 25 MG (ELEMENTAL Electrolytes - Drugs to Treat Vitamin, GALZIN CAP 25MG Tier 3 ZINC) Mineral and Body Fluid Deficiencies

199 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Therapeutic Nutrients/Minerals/ ZINC ACETATE CAP 50 MG (ELEMENTAL Electrolytes - Drugs to Treat Vitamin, GALZIN CAP 50MG Tier 3 ZINC) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ FERROUS FUMARATE-FOLIC ACID TAB Electrolytes - Drugs to Treat Vitamin, HEMATINIC/FA TAB Tier 1 324-1 MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT-FE POLY CMPLX-FE HEME Electrolytes - Drugs to Treat Vitamin, HEMENATAL OB MIS + DHA Tier 2 POLY-FA TAB & OMEGA 3 CAP PCK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ HEMENATAL OB TAB 28-6- *PRENAT VIT-FE POLY CMPLX-FE HEME Electrolytes - Drugs to Treat Vitamin, Tier 2 1MG POLY-FA TAB 28-6-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ FERROUS FUMARATE-FOLIC ACID TAB Electrolytes - Drugs to Treat Vitamin, HEMOCYTE-F TAB Tier 1 324-1 MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ DSS-IRON Electrolytes - Drugs to Treat Vitamin, INATAL ADV TAB Tier 2 CARBONYL-FA TAB 90-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ DSS-IRON Electrolytes - Drugs to Treat Vitamin, INATAL GT TAB Tier 2 CARBONYL-FA TAB 90-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ DSS-IRON Electrolytes - Drugs to Treat Vitamin, INATAL ULTRA TAB Tier 2 CARBONYL-FA TAB 90-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O A W/FE CBN-DSS-FA- Electrolytes - Drugs to Treat Vitamin, INFANATE CAP BALANCE Tier 3 DHA CAP 29-1-265 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, JADENU TAB 180MG DEFERASIROX TAB 180 MG Tier 2 X X Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, JADENU TAB 360MG DEFERASIROX TAB 360 MG Tier 2 X X Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, JADENU TAB 90MG DEFERASIROX TAB 90 MG Tier 2 X X Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ DEFERASIROX GRANULES PACKET 180 Electrolytes - Drugs to Treat Vitamin, JADENU SPRKL GRA 180MG Tier 2 X X MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ DEFERASIROX GRANULES PACKET 360 Electrolytes - Drugs to Treat Vitamin, JADENU SPRKL GRA 360MG Tier 2 X X MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ DEFERASIROX GRANULES PACKET 90 Electrolytes - Drugs to Treat Vitamin, JADENU SPRKL GRA 90MG Tier 2 X X MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CITRATE & CITRIC ACID Electrolytes - Drugs to Treat Vitamin, K CITRATE SOL CITR ACD Tier 1 SOLN 1100-334 MG/5ML Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ HCR SODIUM FLUORIDE SOLN 0.125 MG/ Electrolytes - Drugs to Treat Vitamin, KARIDIUM DRO 0.125MG Preventive DROP F (0.275 MG/DROP NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ *SODIUM POLYSTYRENE SULFONATE Electrolytes - Drugs to Treat Vitamin, KAYEXALATE POW Tier 3 POWDER** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ K-EFFERVESCE TAB 25MEQ POTASSIUM BICARBONATE EFFER TAB Electrolytes - Drugs to Treat Vitamin, Tier 1 EF 25 MEQ Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *SODIUM POLYSTYRENE SULFONATE Electrolytes - Drugs to Treat Vitamin, KIONEX POW Tier 1 POWDER** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ SODIUM POLYSTYRENE SULFONATE Electrolytes - Drugs to Treat Vitamin, KIONEX SUS 15GM/60 Tier 1 ORAL SUSP 15 GM/60ML Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CHLORIDE POWDER Electrolytes - Drugs to Treat Vitamin, KLOR-CON PAK 20MEQ Tier 1 PACKET 20 MEQ Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CHLORIDE POWDER Electrolytes - Drugs to Treat Vitamin, KLOR-CON POW 20MEQ Tier 1 PACKET 20 MEQ Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ KLOR-CON 10 TAB 10MEQ Electrolytes - Drugs to Treat Vitamin, POTASSIUM CHLORIDE TAB ER 10 MEQ Tier 1 ER Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CHLORIDE TAB ER 8 MEQ Electrolytes - Drugs to Treat Vitamin, KLOR-CON 8 TAB 8MEQ ER Tier 1 (600 MG) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CHLORIDE KLOR-CON M10 TAB 10MEQ Electrolytes - Drugs to Treat Vitamin, MICROENCAPSULATED CRYS ER TAB Tier 1 ER Mineral and Body Fluid Deficiencies 10 MEQ

200 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Therapeutic Nutrients/Minerals/ POTASSIUM CHLORIDE KLOR-CON M15 TAB 15MEQ Electrolytes - Drugs to Treat Vitamin, MICROENCAPSULATED CRYS ER TAB Tier 3 ER Mineral and Body Fluid Deficiencies 15 MEQ Therapeutic Nutrients/Minerals/ POTASSIUM CHLORIDE KLOR-CON M20 TAB 20MEQ Electrolytes - Drugs to Treat Vitamin, MICROENCAPSULATED CRYS ER TAB Tier 1 ER Mineral and Body Fluid Deficiencies 20 MEQ Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, KLOR-CON SPR CAP 10MEQ POTASSIUM CHLORIDE CAP ER 10 MEQ Tier 1 Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, KLOR-CON SPR CAP 8MEQ POTASSIUM CHLORIDE CAP ER 8 MEQ Tier 1 Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CHLORIDE POWDER Electrolytes - Drugs to Treat Vitamin, KLOR-CON/25 POW 25MEQ Tier 1 PACKET 25 MEQ Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ KLOR-CON/EF TAB 25MEQ POTASSIUM BICARBONATE EFFER TAB Electrolytes - Drugs to Treat Vitamin, Tier 1 FR 25 MEQ Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ IRON CARBONYL-FA Electrolytes - Drugs to Treat Vitamin, KOSHR PRENAT TAB 30-1MG Tier 3 TAB 30-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM PHOSPHATE MONOBASIC Electrolytes - Drugs to Treat Vitamin, K-PHOS TAB Tier 2 TAB 500 MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POT PHOS MONOBASIC W/SOD PHOS DI Electrolytes - Drugs to Treat Vitamin, K-PHOS TAB NEUTRAL Tier 3 & MONOBAS TAB 155-852-130MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM & SODIUM ACID Electrolytes - Drugs to Treat Vitamin, K-PHOS TAB NO 2 Tier 2 PHOSPHATES TAB 305-700 MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM BICARBONATE EFFER TAB Electrolytes - Drugs to Treat Vitamin, K-PRIME TAB 25MEQ EF Tier 1 25 MEQ Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, K-TAB TAB 10MEQ CR POTASSIUM CHLORIDE TAB CR 10 MEQ Tier 3 Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CHLORIDE TAB ER 20 MEQ Electrolytes - Drugs to Treat Vitamin, K-TAB TAB 20MEQ Tier 3 (1500 MG) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CHLORIDE TAB ER 8 MEQ Electrolytes - Drugs to Treat Vitamin, K-TAB TAB 8MEQ CR Tier 3 (600 MG) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM BICARBONATE EFFER TAB Electrolytes - Drugs to Treat Vitamin, K-VESCENT TAB 25MEQ EF Tier 1 25 MEQ Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ LEVOCARNITIN SOL LEVOCARNITINE ORAL SOLN 1 Electrolytes - Drugs to Treat Vitamin, Tier 1 1GM/10ML GM/10ML (10%) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, LEVOCARNITIN TAB 330MG LEVOCARNITINE TAB 330 MG Tier 1 Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/FE FUM-L METHYLFOLATE- Electrolytes - Drugs to Treat Vitamin, LEVOMEFOLATE CAP DHA Tier 2 FA-DHA CAP 27-1.13-0.4 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ SODIUM FLUORIDE LOZENGE 1 MG F Electrolytes - Drugs to Treat Vitamin, LOZI-FLUR LOZ 1MG F Tier 2 (FROM 2.2 MG NAF) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ HCR SODIUM FLUORIDE CHEW TAB 0.25 MG F Electrolytes - Drugs to Treat Vitamin, LUDENT CHW 0.25MG F Preventive (FROM 0.55 MG NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ HCR SODIUM FLUORIDE CHEW TAB 0.5 MG F Electrolytes - Drugs to Treat Vitamin, LUDENT CHW 0.5MG F Preventive (FROM 1.1 MG NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ HCR SODIUM FLUORIDE CHEW TAB 1 MG F Electrolytes - Drugs to Treat Vitamin, LUDENT CHW 1MG F Preventive (FROM 2.2 MG NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ HCR SODIUM FLUORIDE SOLN 0.5 MG/ML F Electrolytes - Drugs to Treat Vitamin, LURIDE DRO 0.5MG/ML Preventive (FROM 1.1 MG/ML NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ *PRENATAL W/O A W/FE CBN-DSS-FA- Electrolytes - Drugs to Treat Vitamin, MACNATAL CN CAP DHA Tier 2 DHA CAP 28-1-250 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ MAGNESIUM-CALCIUM-FOLIC ACID TAB Electrolytes - Drugs to Treat Vitamin, MAGNEBIND TAB 400 Tier 2 400-200-1 MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O VIT A W/ FE POLYSAC Electrolytes - Drugs to Treat Vitamin, MARNATAL-F CAP Tier 3 CMPLX-FA CAP 60-1 MG*** Mineral and Body Fluid Deficiencies

201 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, MEPHYTON TAB 5MG PHYTONADIONE TAB 5 MG Tier 2 X Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, MICRO-K CAP 10MEQ CR POTASSIUM CHLORIDE CAP ER 10 MEQ Tier 3 Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, MICRO-K CAP 8MEQ CR POTASSIUM CHLORIDE CAP ER 8 MEQ Tier 3 Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ MULTI VIT/FL DRO 0.5MG/ *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, Tier 1 ML FLUORIDE SOLN 0.5 MG/ML*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ FL- Electrolytes - Drugs to Treat Vitamin, MULTI-VIT/FE DRO /FL 0.25 Tier 1 FE DROPS 0.25-10 MG/ML** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, MULTIVIT/FL CHW 0.25MG Tier 1 FLUORIDE CHEW TAB 0.25 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, MULTIVIT/FL CHW 0.25MG Tier 3 FLUORIDE CHEW TAB 0.25 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, MULTIVIT/FL CHW 0.5MG Tier 1 FLUORIDE CHEW TAB 0.5 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, MULTIVIT/FL CHW 0.5MG Tier 3 FLUORIDE CHEW TAB 0.5 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, MULTIVIT/FL CHW 1MG Tier 1 FLUORIDE CHEW TAB 1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, MULTIVIT/FL CHW 1MG Tier 3 FLUORIDE CHEW TAB 1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, MULTIVIT/FL DRO 0.25MG Tier 1 FLUORIDE SOLN 0.25 MG/ML*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, MULTIVIT/FL SOL 0.5MG/ML Tier 1 FLUORIDE SOLN 0.5 MG/ML*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ FL- Electrolytes - Drugs to Treat Vitamin, MULTI-VIT/FL DRO /FE 0.25 Tier 1 FE DROPS 0.25-10 MG/ML** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, MULTI-VIT/FL DRO 0.25MG Tier 1 FLUORIDE SOLN 0.25 MG/ML*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ MULTI-VIT/FL DRO 0.5MG/ *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, Tier 1 ML FLUORIDE SOLN 0.5 MG/ML*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ FL- Electrolytes - Drugs to Treat Vitamin, MULTIVIT/FL/ DRO FE 0.25 Tier 1 FE DROPS 0.25-10 MG/ML** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, MULT-VIT/FL CHW 0.5MG Tier 1 FLUORIDE CHEW TAB 0.5 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ MVC-FLUORIDE CHW *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, Tier 1 0.25MG FLUORIDE CHEW TAB 0.25 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, MVC-FLUORIDE CHW 0.5MG Tier 1 FLUORIDE CHEW TAB 0.5 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, MVC-FLUORIDE CHW 1MG Tier 1 FLUORIDE CHEW TAB 1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, M-VIT TAB 27-1MG Tier 1 27-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC VITAMINS ACD FLUORIDE & Electrolytes - Drugs to Treat Vitamin, MYKIDZ IRON SUS FL Tier 3 FE SUSP 0.25-10 MG/2ML*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL MULTIVITAMINS & MINERALS Electrolytes - Drugs to Treat Vitamin, MYNATAL CAP Tier 2 W/ IRON & FA CAP 1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ DSS-IRON Electrolytes - Drugs to Treat Vitamin, MYNATAL TAB Tier 2 CARBONYL-FA TAB 90-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ DSS-IRON Electrolytes - Drugs to Treat Vitamin, MYNATAL TAB ADVANCE Tier 2 CARBONYL-FA TAB 90-1 MG*** Mineral and Body Fluid Deficiencies

202 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, MYNATAL PLUS TAB Tier 1 65-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, MYNATAL-Z TAB Tier 2 65-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ DSS-FE FUMARATE- Electrolytes - Drugs to Treat Vitamin, MYNATE 90 TAB PLUS Tier 1 FA TAB ER 90-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, N -ACET YL- L- CAP CYSTEINE ACETYLCYSTEINE CAP 600 MG Tier 1 Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ HCR SODIUM FLUORIDE CHEW TAB 1 MG F Electrolytes - Drugs to Treat Vitamin, NAFRINSE CHW 1MG F Preventive (FROM 2.2 MG NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ HCR SODIUM FLUORIDE SOLN 0.125 MG/ Electrolytes - Drugs to Treat Vitamin, NAFRINSE DRO 0.125MG Preventive DROP F (0.275 MG/DROP NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ CYANOCOBALAMIN NASAL SPRAY 500 Electrolytes - Drugs to Treat Vitamin, NASCOBAL SPR 500MCG Tier 3 MCG/0.1ML Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUM-FE Electrolytes - Drugs to Treat Vitamin, NATACHEW CHW Tier 3 BISGLYCIN-FA CHEW TAB 28-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, NATALVIT TAB 75-1MG Tier 2 75-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O VIT A W/ FE FUM-FA- Electrolytes - Drugs to Treat Vitamin, NATELLE ONE CAP Tier 3 OMEGA 3 CAP 28-1-250 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FEFUM-METHYLFOL- Electrolytes - Drugs to Treat Vitamin, NEEVO DHA CAP 27-1.13 Tier 3 OMEGAS CAP 27-1.13 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/O VIT A W/ FE Electrolytes - Drugs to Treat Vitamin, NESTABS TAB Tier 3 BISGLYCINATE-FA TAB 32-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O VIT A W/FE POLYSAC- Electrolytes - Drugs to Treat Vitamin, NESTABS ABC MIS Tier 3 FA-CA TAB & OMEGA 3 CAP*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/ FE BISGLYC-FA TAB Electrolytes - Drugs to Treat Vitamin, NESTABS DHA PAK Tier 3 32-1 MG & OMEGA CAP PACK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/O VIT A W/ FE Electrolytes - Drugs to Treat Vitamin, NEWGEN TAB 32-1MG Tier 3 BISGLYCINATE-FA TAB 32-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O VIT A W/ FE FUM-DOC- Electrolytes - Drugs to Treat Vitamin, NEXA PLUS CAP Tier 3 FA-DHA CAP 29-1.25-350 MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, NIACIN POW USP/NF *NIACIN ORAL POWDER*** Tier 3 Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *NIACINAMIDE W/ ZN-CU-METHYLFOL- Electrolytes - Drugs to Treat Vitamin, NICOMIDE TAB Tier 3 SE-CR TAB 750-27-2-0.5 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, NIVA-PLUS TAB Tier 3 27-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FEFUM-METHYLFOL- Electrolytes - Drugs to Treat Vitamin, OB COMPLETE CAP Tier 3 FA-OMEGA CAP 27-1-385 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FECBN-METHFOL-FA- Electrolytes - Drugs to Treat Vitamin, OB COMPLETE CAP GOLD Tier 3 DHA CAP 27.5-1-200 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O A W/FECBN-FE ASP Electrolytes - Drugs to Treat Vitamin, OB COMPLETE CAP ONE Tier 3 GLYC-FA-FISH CAP 50-1-476 MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FECBN-FEASPGLYC- Electrolytes - Drugs to Treat Vitamin, OB COMPLETE CAP PETITE Tier 3 FA-OMEGA CAP 35-5-1-200 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ IRON CARBONYL-FA Electrolytes - Drugs to Treat Vitamin, OB COMPLETE TAB Tier 3 TAB 50-1.25 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ OB COMPLETE TAB *PRENATAL VIT W/ FE CBN-FE ASP GLYC- Electrolytes - Drugs to Treat Vitamin, Tier 3 PREMIER FA TAB 30-20-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/ IRON CBN-FE ASP GLYC-FA- Electrolytes - Drugs to Treat Vitamin, OB COMPLETE/ CAP DHA Tier 3 OMEGA CAP 30-10-1-200 MG* Mineral and Body Fluid Deficiencies

203 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Therapeutic Nutrients/Minerals/ *PRENAT W/FECBN-FA-DSS TAB 29-1 MG Electrolytes - Drugs to Treat Vitamin, OBSTETRIX PAK DHA Tier 2 & OMEGA 3 CAP 387 MG PAK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ DSS-IRON Electrolytes - Drugs to Treat Vitamin, OBSTETRIX EC TAB Tier 3 CARBONYL-FA TAB 29-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ OBSTETRX ONE CAP 38- *PRENAT W/O A W/FECBN-BISG- Electrolytes - Drugs to Treat Vitamin, Tier 3 1-225 METHYLF-DSS-DHA CAP 38-1-225 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, O-CAL TAB PRENATAL Tier 2 15-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, O-CAL FA TAB Tier 2 27-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ SODIUM CITRATE & CITRIC ACID SOLN Electrolytes - Drugs to Treat Vitamin, ORACIT SOL Tier 2 490-640 MG/5ML Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ SOD PHOS MONO-SOD PHOS DI TABS Electrolytes - Drugs to Treat Vitamin, OSMOPREP TAB 1.5GM Tier 3 1.102-0.398 GM(1.5GM NA PHOS) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ PHOSPHA 250 TAB POT PHOS MONOBASIC W/SOD PHOS DI Electrolytes - Drugs to Treat Vitamin, Tier 1 NEUTRAL & MONOBAS TAB 155-852-130MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ PHOSPHO-TRIN TAB 250 POT PHOS MONOBASIC W/SOD PHOS DI Electrolytes - Drugs to Treat Vitamin, Tier 1 NEUT & MONOBAS TAB 155-852-130MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ DSS-FE FUMARATE- Electrolytes - Drugs to Treat Vitamin, PNV FE FUM TAB DOC/FA Tier 3 FA TAB 29-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, PNV FOLIC AC TAB + IRON Tier 3 27-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FECBN-FEGL-DSS-FA Electrolytes - Drugs to Treat Vitamin, PNV OB+DHA PAK Tier 3 TAB & DHA CAP 250 MG PACK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, PNV PRENATAL TAB PLUS Tier 3 27-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ IRON CARBONYL-FA Electrolytes - Drugs to Treat Vitamin, PNV TABS TAB 29-1MG Tier 3 TAB 29-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FEFUM-METHFOL-FA- Electrolytes - Drugs to Treat Vitamin, PNV-DHA CAP Tier 3 DHA CAP 27-0.6-0.4-300 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O VIT A W/ FE FUM-DSS- Electrolytes - Drugs to Treat Vitamin, PNV-DHA CAP DOCUSATE Tier 3 FA-DHA CAP 27-1.25-300 MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/ FE FUMERATE- Electrolytes - Drugs to Treat Vitamin, PNV-OMEGA CAP Tier 3 METHYLFOLATE-FA-OMEGA 3 CAP*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUM- Electrolytes - Drugs to Treat Vitamin, PNV-SELECT TAB METHYLFOLATE-FA TAB 27-0.6-0.4 Tier 3 Mineral and Body Fluid Deficiencies MG*** Therapeutic Nutrients/Minerals/ *PRENAT W/ FE CBN-FE BISGLYC-FA- Electrolytes - Drugs to Treat Vitamin, PNV-TOTAL CAP Tier 2 FISH OIL CAP 35-5-1.2 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O A VIT W/ FE FUMARATE- Electrolytes - Drugs to Treat Vitamin, PNV-VP-U CAP 106.5-1 Tier 2 FA CAP 106.5-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PED MULTIPLE VIT W/ FLUORIDE Electrolytes - Drugs to Treat Vitamin, POLY-VI-FLOR CHW 0.25MG Tier 3 BIPHASIC CHEW TAB 0.25 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PED MULTIPLE VIT W/ FLUORIDE Electrolytes - Drugs to Treat Vitamin, POLY-VI-FLOR CHW 0.5MG Tier 3 BIPHASIC CHEW TAB 0.5 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PED MULTIPLE VIT W/ FLUORIDE Electrolytes - Drugs to Treat Vitamin, POLY-VI-FLOR CHW 1MG Tier 3 BIPHASIC CHEW TAB 1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PED MULTIPLE VIT W/ FL-FE BIPHASIC Electrolytes - Drugs to Treat Vitamin, POLY-VI-FLOR CHW W/IRON Tier 3 CHEW TAB 0.5-10 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PED MULTIPLE VITAMIN W/ FL-FE Electrolytes - Drugs to Treat Vitamin, POLY-VI-FLOR SUS /IRON Tier 3 BIPHASIC SUSP 0.25-7 MG/ML** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PED MULTIPLE VIT W/ FLUORIDE Electrolytes - Drugs to Treat Vitamin, POLY-VI-FLOR SUS 0.25/ML Tier 3 BIPHASIC SUSP 0.25 MG/ML*** Mineral and Body Fluid Deficiencies

204 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Therapeutic Nutrients/Minerals/ POT CHLORIDE CAP 10MEQ Electrolytes - Drugs to Treat Vitamin, POTASSIUM CHLORIDE CAP ER 10 MEQ Tier 1 ER Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POT CHLORIDE CAP 8MEQ Electrolytes - Drugs to Treat Vitamin, POTASSIUM CHLORIDE CAP ER 8 MEQ Tier 1 ER Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CHLORIDE POWDER Electrolytes - Drugs to Treat Vitamin, POT CHLORIDE POW 20MEQ Tier 1 PACKET 20 MEQ Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CHLORIDE ORAL SOLN 10% Electrolytes - Drugs to Treat Vitamin, POT CHLORIDE SOL 10% Tier 1 (20 MEQ/15ML) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CHLORIDE ORAL SOLN 20% Electrolytes - Drugs to Treat Vitamin, POT CHLORIDE SOL 20% Tier 1 (40 MEQ/15ML) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POT CHLORIDE TAB 10MEQ Electrolytes - Drugs to Treat Vitamin, POTASSIUM CHLORIDE TAB ER 10 MEQ Tier 1 CR Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POT CHLORIDE TAB 10MEQ Electrolytes - Drugs to Treat Vitamin, POTASSIUM CHLORIDE TAB ER 10 MEQ Tier 1 ER Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CHLORIDE POT CHLORIDE TAB 10MEQ Electrolytes - Drugs to Treat Vitamin, MICROENCAPSULATED CRYS ER TAB Tier 1 ER Mineral and Body Fluid Deficiencies 10 MEQ Therapeutic Nutrients/Minerals/ POTASSIUM CHLORIDE POT CHLORIDE TAB 20MEQ Electrolytes - Drugs to Treat Vitamin, MICROENCAPSULATED CRYS ER TAB Tier 1 ER Mineral and Body Fluid Deficiencies 20 MEQ Therapeutic Nutrients/Minerals/ POT CHLORIDE TAB 20MEQ POTASSIUM CHLORIDE TAB ER 20 MEQ Electrolytes - Drugs to Treat Vitamin, Tier 1 ER (1500 MG) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POT CHLORIDE TAB 25MEQ POT BICARBONATE & CHLORIDE EFFER Electrolytes - Drugs to Treat Vitamin, Tier 1 EF TAB 25 MEQ Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POT CHLORIDE TAB 8MEQ POTASSIUM CHLORIDE TAB ER 8 MEQ Electrolytes - Drugs to Treat Vitamin, Tier 1 ER (600 MG) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POT CHLORIDE TAB 8MEQ POTASSIUM CHLORIDE TAB ER 8 MEQ Electrolytes - Drugs to Treat Vitamin, Tier 1 SR (600 MG) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CITRATE TAB ER 10 MEQ Electrolytes - Drugs to Treat Vitamin, POT CITRATE TAB 1080MG Tier 1 (1080 MG) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CITRATE TAB ER 15 MEQ Electrolytes - Drugs to Treat Vitamin, POT CITRATE TAB 1620MG Tier 1 (1620 MG) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POT CITRATE TAB 540MG POTASSIUM CITRATE TAB ER 5 MEQ Electrolytes - Drugs to Treat Vitamin, Tier 1 ER (540 MG) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CITRATE & CITRIC ACID Electrolytes - Drugs to Treat Vitamin, POT CITRATE- PAK CIT ACID Tier 1 POWDER PACK 3300-1002 MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CHLORIDE POT CL MICRO TAB 10MEQ Electrolytes - Drugs to Treat Vitamin, MICROENCAPSULATED CRYS ER TAB Tier 1 CR Mineral and Body Fluid Deficiencies 10 MEQ Therapeutic Nutrients/Minerals/ POTASSIUM CHLORIDE POT CL MICRO TAB 10MEQ Electrolytes - Drugs to Treat Vitamin, MICROENCAPSULATED CRYS ER TAB Tier 1 ER Mineral and Body Fluid Deficiencies 10 MEQ Therapeutic Nutrients/Minerals/ POTASSIUM CHLORIDE POT CL MICRO TAB 20MEQ Electrolytes - Drugs to Treat Vitamin, MICROENCAPSULATED CRYS ER TAB Tier 1 ER Mineral and Body Fluid Deficiencies 20 MEQ Therapeutic Nutrients/Minerals/ POT PHOSPHAT GRA POTASSIUM PHOSPHATE DIBASIC Electrolytes - Drugs to Treat Vitamin, Tier 3 DIBASIC GRANULES Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POT/CHLORIDE TAB 25MEQ POT BICARBONATE & CHLORIDE EFFER Electrolytes - Drugs to Treat Vitamin, Tier 1 EF TAB 25 MEQ Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM AMINOBENZOATE CAP 500 Electrolytes - Drugs to Treat Vitamin, POTABA CAP 500MG Tier 3 MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM BICARBONATE EFFER TAB Electrolytes - Drugs to Treat Vitamin, POTASSIUM TAB 25MEQ EF Tier 1 25 MEQ Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT-FE BIS-FE PROT SUCC-FA-CA Electrolytes - Drugs to Treat Vitamin, PR NATAL 400 PAK Tier 1 TAB & OMEGA 3 CAP 400 PK** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT-FE BIS-FE PROT SUCC-FA-CA Electrolytes - Drugs to Treat Vitamin, PR NATAL 400 PAK EC Tier 1 TAB & OMEGA CAP DR 400 PK* Mineral and Body Fluid Deficiencies

205 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Therapeutic Nutrients/Minerals/ *PRENAT-FE BIS-FE PROT SUCC-FA-CA Electrolytes - Drugs to Treat Vitamin, PR NATAL 430 PAK Tier 2 TAB & OMEGA 3 CAP 430 PK** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT-FE BIS-FE PROT SUCC-FA-CA Electrolytes - Drugs to Treat Vitamin, PR NATAL 430 PAK EC Tier 2 TAB & OMEGA CAP DR 430 PK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT VIT-FE POLY CMPLX-FE HEME Electrolytes - Drugs to Treat Vitamin, PREFERA OB TAB Tier 3 POLY-FA TAB 34-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT-FE POLY CMPLX-FE HEME Electrolytes - Drugs to Treat Vitamin, PREFERAOB CAP ONE Tier 3 POLY-FA-DHA CAP 22-6-1-200 MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT-FE POLY CMPLX 28MG-FE Electrolytes - Drugs to Treat Vitamin, PREFERAOB MIS +DHA Tier 3 HEME POLY-FA TAB&DHA CAP PACK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FE CHEL-FA TAB 30- Electrolytes - Drugs to Treat Vitamin, PRENA 1 TRUE MIS Tier 3 1.4 MG & DHA CAP 300MG PK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/ B2-B6-B12-D3-FOLIC ACID Electrolytes - Drugs to Treat Vitamin, PRENA1 CHW Tier 3 CHEW TAB 1.4 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/OA W/FEFUM-NA FERED-FA- Electrolytes - Drugs to Treat Vitamin, PRENA1 PEARL CAP Tier 3 DHA CAP ER 30-1.4-200 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O VIT A W/ FE FUM-DSS- Electrolytes - Drugs to Treat Vitamin, PRENAISSANCE CAP Tier 2 FA-DHA CAP 29-1.25-325 MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ PRENAISSANCE CAP *PRENATAL W/O VIT A W/ FE CBN-DSS- Electrolytes - Drugs to Treat Vitamin, Tier 2 BALANCE FA-DHA CAP 30-1-260 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O A W/FE CBN-DSS-FA- Electrolytes - Drugs to Treat Vitamin, PRENAISSANCE CAP PLUS Tier 2 DHA CAP 28-1-250 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ PRENAISSANCE MIS *PRENAT W/FE POLY-NA FERED-FA TAB Electrolytes - Drugs to Treat Vitamin, Tier 3 HARMONY 27-1 & OMEGA CAP DR 380MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/ CALCIUM-VIT B6-FA- Electrolytes - Drugs to Treat Vitamin, PRENAISSANCE TAB NEXT Tier 2 GINGER TAB 1.2 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/ CALCIUM-VIT B6-FA- Electrolytes - Drugs to Treat Vitamin, PRENAISSANCE TAB NEXT-B Tier 3 GINGER TAB 1.22 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, PRENAT PLUS TAB 27-1MG Tier 3 27-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O A VIT W/ FE FUM-FA TAB Electrolytes - Drugs to Treat Vitamin, PRENATA CHW 29-1MG Tier 3 CHEW 29-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ IRON CARBONYL-FA Electrolytes - Drugs to Treat Vitamin, PRENATABS RX TAB Tier 1 TAB 29-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A FEFUM-FA TAB 27-1 MG Electrolytes - Drugs to Treat Vitamin, PRENATAL MIS COMPLEAT Tier 3 & FISH OIL CHEW CAP PAK** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, PRENATAL TAB 27-1MG Tier 3 27-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, PRENATAL TAB PLUS Tier 3 27-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA Electrolytes - Drugs to Treat Vitamin, PRENATAL 19 CHW 29-1MG Tier 3 CHEW TAB 29-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA Electrolytes - Drugs to Treat Vitamin, PRENATAL 19 CHW TAB Tier 1 CHEW TAB 29-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ DSS-FE FUMARATE- Electrolytes - Drugs to Treat Vitamin, PRENATAL 19 TAB Tier 1 FA TAB 29-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ DSS-FE FUMARATE- Electrolytes - Drugs to Treat Vitamin, PRENATAL 19 TAB 29-1MG Tier 3 FA TAB 29-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ PRENATAL PLS MIS MV + *PRENAT W/ FE FUM-FA TAB 27-1 MG & Electrolytes - Drugs to Treat Vitamin, Tier 3 DHA OMEGA 3 CAP 312 MG PAK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ PRENATAL VIT TAB LOW *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, Tier 3 IRON 27-1 MG*** Mineral and Body Fluid Deficiencies

206 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ IRON CARBONYL-FA Electrolytes - Drugs to Treat Vitamin, PRENATAL+FE TAB 29-1MG Tier 3 TAB 29-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O A VIT W/ FE FUMARATE- Electrolytes - Drugs to Treat Vitamin, PRENATAL-U CAP 106.5-1 Tier 2 FA CAP 106.5-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FEFUM-METHFOL-FA- Electrolytes - Drugs to Treat Vitamin, PRENATE CAP ENHANCE Tier 3 DHA CAP 28-0.6-0.4-400 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FEASPG-METHFOL- Electrolytes - Drugs to Treat Vitamin, PRENATE CAP ESSENT Tier 3 FA-DHA CAP 18-0.6-0.4-300 MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FEASP-METHYLF-FA- Electrolytes - Drugs to Treat Vitamin, PRENATE CAP ESSENTIA Tier 3 OMEG CAP 29-0.6-0.4-340 MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FEASPG-METHFOL- Electrolytes - Drugs to Treat Vitamin, PRENATE CAP PIXIE Tier 3 FA-DHA CAP 10-0.6-0.4-200 MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FEFUM-METHFOL-FA- Electrolytes - Drugs to Treat Vitamin, PRENATE CAP RESTORE Tier 3 DHA CAP 27-0.6-0.4-400 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT MV & MIN W/ Electrolytes - Drugs to Treat Vitamin, PRENATE CHW 0.6-0.4 L-METHYLFOLATE-FA CHEW TAB 0.6-0.4 Tier 3 Mineral and Body Fluid Deficiencies MG*** Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUM- Electrolytes - Drugs to Treat Vitamin, PRENATE TAB ELITE METHYLFOLATE-FA TAB 26-0.6-0.4 Tier 3 Mineral and Body Fluid Deficiencies MG*** Therapeutic Nutrients/Minerals/ *PRENATAL W/ FE ASP GLY-L Electrolytes - Drugs to Treat Vitamin, PRENATE TAB ELITE Tier 3 METHYLFOL-FA TAB 20-0.6-0.4 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/ CALCIUM-VIT B6-VIT B12- Electrolytes - Drugs to Treat Vitamin, PRENATE AM TAB 1MG Tier 3 FA-GINGER TAB 1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FEFUM-METHFOL-FA- Electrolytes - Drugs to Treat Vitamin, PRENATE DHA CAP Tier 3 DHA CAP 28-0.6-0.4-300 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FEASPG-METHFOL- Electrolytes - Drugs to Treat Vitamin, PRENATE DHA CAP Tier 3 FA-DHA CAP 18-0.6-0.4-300 MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FECBN-METHYLF-FA- Electrolytes - Drugs to Treat Vitamin, PRENATE MINI CAP Tier 3 DHA CAP 29-0.6-0.4-350 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/OA W/FECB-FEASP-METH- Electrolytes - Drugs to Treat Vitamin, PRENATE MINI CAP Tier 3 FA-DHA CAP 18-0.6-0.4-350 MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE ASPARTO Electrolytes - Drugs to Treat Vitamin, PRENATE STAR TAB 20-1MG Tier 3 GLYCINATE-FA TAB 20-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, PREPLUS TAB 27-1MG Tier 3 27-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL MV W/FE CARBONYL-DSS- Electrolytes - Drugs to Treat Vitamin, PREQUE 10 TAB Tier 3 FA-DHA TAB 15-25-0.5-50 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, PRETAB TAB 29-1MG Tier 3 29-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ HCR *PRENAT W/O A W/FEASP-METHLF-FA- Electrolytes - Drugs to Treat Vitamin, PRIMACARE CAP Preventive OMEG CAP 30-0.75-0.25-470MG* Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ IRON HEME POLYPEPTIDE-FOLIC ACID Electrolytes - Drugs to Treat Vitamin, PROFERRIN- TAB FORTE Tier 3 TAB 12-1 MG (FE EQUIV) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FE FUM-FE POLY-FA- Electrolytes - Drugs to Treat Vitamin, PROVIDA DHA CAP Tier 3 DHA CAP 16-16-1.25-110 MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O A W/FE FUM-FE POLY- Electrolytes - Drugs to Treat Vitamin, PROVIDA OB CAP Tier 3 FA CAP 20-20-1.25 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O A W/FE FUM-FE POLY- Electrolytes - Drugs to Treat Vitamin, PUREFE OB CAP PLUS Tier 3 FA CAP 162.115.2-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, QUFLORA PED CHW 0.25MG Tier 3 FLUORIDE CHEW TAB 0.25 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, QUFLORA PED CHW 0.5MG Tier 3 FLUORIDE CHEW TAB 0.5 MG*** Mineral and Body Fluid Deficiencies

207 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, QUFLORA PED CHW 1MG Tier 3 FLUORIDE CHEW TAB 1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, QUFLORA PED DRO 0.25MG Tier 3 FLUORIDE SOLN 0.25 MG/ML*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ QUFLORA PED DRO 0.5MG/ *PEDIATRIC MULTIPLE VITAMINS W/ Electrolytes - Drugs to Treat Vitamin, Tier 3 ML FLUORIDE SOLN 0.5 MG/ML*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/ B2-B6-B12-D3-FOLIC ACID Electrolytes - Drugs to Treat Vitamin, REDICHEW RX CHW Tier 3 CHEW TAB 1.4 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUM-FA-OMEGA 3 Electrolytes - Drugs to Treat Vitamin, RELNATE DHA CAP Tier 2 CAP 28-1-200 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O A W/FE CBN-FA-DHA Electrolytes - Drugs to Treat Vitamin, R-NATAL OB CAP 20-1-320 Tier 3 CAP 20-1-320 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FEFUM-METHFOL-FA- Electrolytes - Drugs to Treat Vitamin, RULAVITE DHA CAP Tier 3 DHA CAP 27-0.6-0.4-300 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, SAMSCA TAB 15MG TOLVAPTAN TAB 15 MG Tier 2 X X Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, SAMSCA TAB 30MG TOLVAPTAN TAB 30 MG Tier 2 X X Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE POLYSAC CMPLX- Electrolytes - Drugs to Treat Vitamin, SELECT-OB CHW Tier 3 FA CHEW TAB 29-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/ FEPOLYCMPLX- Electrolytes - Drugs to Treat Vitamin, SELECT-OB CHW METHYLFOL-FA CHEW TAB 29-0.6-0.4 Tier 3 Mineral and Body Fluid Deficiencies MG** Therapeutic Nutrients/Minerals/ *PRENATAL MV W/FE POLY-FA CHW 29-1 Electrolytes - Drugs to Treat Vitamin, SELECT-OB+ PAK DHA Tier 3 MG & DHA CAP 250 MG PAK * Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA Electrolytes - Drugs to Treat Vitamin, SE-NATAL 19 CHW Tier 1 CHEW TAB 29-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ DSS-FE FUMARATE- Electrolytes - Drugs to Treat Vitamin, SE-NATAL 19 TAB Tier 1 FA TAB 29-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ SODIUM CITRATE & CITRIC ACID SOLN Electrolytes - Drugs to Treat Vitamin, SHOHLS SOL MODIFIED Tier 2 500-334 MG/5ML Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ HCR Electrolytes - Drugs to Treat Vitamin, SM FOLIC ACD TAB 400MCG FOLIC ACID TAB 400 MCG Preventive Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, SOD CHLORIDE GRA SODIUM CHLORIDE GRANULES Tier 3 Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ SODIUM CITRATE & CITRIC ACID SOLN Electrolytes - Drugs to Treat Vitamin, SOD CITRATE SOL CITR ACD Tier 1 500-334 MG/5ML Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ HCR SOD FLUORIDE CHW SODIUM FLUORIDE CHEW TAB 0.25 MG F Electrolytes - Drugs to Treat Vitamin, Preventive 0.25MG F (FROM 0.55 MG NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ HCR SOD FLUORIDE CHW 0.5MG SODIUM FLUORIDE CHEW TAB 0.5 MG F Electrolytes - Drugs to Treat Vitamin, Preventive F (FROM 1.1 MG NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ HCR SODIUM FLUORIDE CHEW TAB 0.5 MG F Electrolytes - Drugs to Treat Vitamin, SOD FLUORIDE CHW 1.1MG Preventive (FROM 1.1 MG NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ HCR SODIUM FLUORIDE CHEW TAB 1 MG F Electrolytes - Drugs to Treat Vitamin, SOD FLUORIDE CHW 1MG F Preventive (FROM 2.2 MG NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ HCR SODIUM FLUORIDE CHEW TAB 1 MG F Electrolytes - Drugs to Treat Vitamin, SOD FLUORIDE CHW 2.2MG Preventive (FROM 2.2 MG NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ HCR SOD FLUORIDE DRO 0.5MG/ SODIUM FLUORIDE SOLN 0.5 MG/ML F Electrolytes - Drugs to Treat Vitamin, Preventive ML (FROM 1.1 MG/ML NAF) Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ SODIUM FLUORIDE TAB 0.5 MG F (FROM Electrolytes - Drugs to Treat Vitamin, SOD FLUORIDE TAB 0.5MG F Tier 1 1.1 MG NAF) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ SODIUM FLUORIDE TAB 1 MG F (FROM Electrolytes - Drugs to Treat Vitamin, SOD FLUORIDE TAB 1MG F Tier 1 2.2 MG NAF) Mineral and Body Fluid Deficiencies

208 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Therapeutic Nutrients/Minerals/ *SODIUM POLYSTYRENE SULFONATE Electrolytes - Drugs to Treat Vitamin, SOD POLY SUL POW Tier 1 POWDER** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ SOD POLY SUL SUS SODIUM POLYSTYRENE SULFONATE Electrolytes - Drugs to Treat Vitamin, Tier 1 15GM/60 ORAL SUSP 15 GM/60ML Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ SOD POLY SUL SUS SODIUM POLYSTYRENE SULFONATE Electrolytes - Drugs to Treat Vitamin, Tier 1 30/120ML RECTAL SUSP 30 GM/120ML Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ SOD POLY SUL SUS SODIUM POLYSTYRENE SULFONATE Electrolytes - Drugs to Treat Vitamin, Tier 1 50/200ML RECTAL SUSP 30 GM/120ML Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, SODIUM POW CHLORIDE SODIUM CHLORIDE POWDER Tier 3 Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ SODIUM POLYSTYRENE SULFONATE Electrolytes - Drugs to Treat Vitamin, SPS SUS 15GM/60 Tier 1 ORAL SUSP 15 GM/60ML Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, SYPRINE CAP 250MG TRIENTINE HCL CAP 250 MG Tier 3 X X Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CITRATE & CITRIC ACID Electrolytes - Drugs to Treat Vitamin, TARON GRA CRYSTALS Tier 1 POWDER PACK 3300-1002 MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/ FE CBNYL-FA TAB Electrolytes - Drugs to Treat Vitamin, TARON-BC MIS Tier 2 20-1 MG & VIT B6 TAB PAK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/FE FUM-FE POLY -FA- Electrolytes - Drugs to Treat Vitamin, TARON-C DHA CAP Tier 3 OMEGA 3 CAP 53.5-38-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O VIT A W/ FE FUM-DSS- Electrolytes - Drugs to Treat Vitamin, TARON-PREX CAP Tier 3 FA-DHA CAP 30-1.2-265 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ DSS-FE FUMARATE- Electrolytes - Drugs to Treat Vitamin, THRIVITE 19 TAB Tier 3 FA TAB 29-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ IRON CARBONYL-FA Electrolytes - Drugs to Treat Vitamin, THRIVITE RX TAB 29-1MG Tier 3 TAB 29-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUM- Electrolytes - Drugs to Treat Vitamin, TL FOLATE TAB METHYLFOLATE-FA TAB 27-0.5-0.5 Tier 3 Mineral and Body Fluid Deficiencies MG*** Therapeutic Nutrients/Minerals/ *PRENATAL W/FE FUMARATE-FA-DSS- Electrolytes - Drugs to Treat Vitamin, TL-CARE DHA CAP 27-1-500 Tier 3 FISH OIL CAP 27-1-500 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC MULTIPLE VITAMINS W/ FL- Electrolytes - Drugs to Treat Vitamin, TL-FLUORIVIT CHW Tier 3 FE CHEW TAB 0.25-7.5 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O VIT A W/ FE FUM-DSS- Electrolytes - Drugs to Treat Vitamin, TL-SELECT CAP Tier 2 FA-DHA CAP 29-1.25-325 MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ DSS-IRON Electrolytes - Drugs to Treat Vitamin, TRIADVANCE TAB Tier 1 CARBONYL-FA TAB 90-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O VIT A W/ FE PYROPHOS- Electrolytes - Drugs to Treat Vitamin, TRICARE CHW PRENATAL Tier 3 METHYLF CHEW TAB 4.5-1 MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FEPYRO-MFOL CHW Electrolytes - Drugs to Treat Vitamin, TRICARE PAK PRENATAL Tier 3 4.5-1 MG & DHA CAP 150 THPK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, TRICARE TAB PRENATAL Tier 3 27-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/FE FUMARATE-FA-DSS- Electrolytes - Drugs to Treat Vitamin, TRICARE PRE CAP 27-1-500 Tier 3 FISH OIL CAP 27-1-500 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ TRICARE PREN CAP DHA *PRENATAL MULTIVITAMINS & MINERALS Electrolytes - Drugs to Treat Vitamin, Tier 3 ONE W/IRON & FA CAP 0.8 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POT & SOD CITRATES W/ CIT AC SOLN Electrolytes - Drugs to Treat Vitamin, TRICITRATES SOL Tier 1 550-500-334 MG/5ML Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, TRIENTINE CAP 250MG TRIENTINE HCL CAP 250 MG Tier 1 X X Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ DSS-IRON Electrolytes - Drugs to Treat Vitamin, TRINATAL GT TAB Tier 2 CARBONYL-FA TAB 90-1 MG*** Mineral and Body Fluid Deficiencies

209 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, TRINATAL RX TAB 1 Tier 1 60-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, TRINATE TAB Tier 1 28-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FECBN-METHYLF-FA- Electrolytes - Drugs to Treat Vitamin, TRISTART DHA CAP Tier 3 DHA CAP 31-0.6-0.4-200 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FECBN-METHYLF-FA- Electrolytes - Drugs to Treat Vitamin, TRISTART ONE CAP 35-1-215 Tier 3 DHA CAP 35-1-215 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/ FE BISGLYC-FA TAB Electrolytes - Drugs to Treat Vitamin, TRI-TABS DHA MIS Tier 3 32-1 MG & OMEGA CAP PACK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT-FE BIS-FE PROT SUCC-FA-CA Electrolytes - Drugs to Treat Vitamin, TRIVEEN-DUO PAK DHA Tier 2 TAB & OMEGA 3 CAP 400 PK** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O VIT A W/ FE FUM-DSS- Electrolytes - Drugs to Treat Vitamin, TRIVEEN-PRX CAP RNF Tier 2 FA-DHA CAP 26-1.2-300 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PED VIT ACD & L-METHYLFOL W/ FL Electrolytes - Drugs to Treat Vitamin, TRI-VI-FLOR SUS 0.25/ML Tier 3 BIPHASIC SUSP 0.25 MG/ML*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PED VIT ACD & L-METHYLFOL W/ FL Electrolytes - Drugs to Treat Vitamin, TRI-VI-FLOR SUS 0.5MG/ML Tier 3 BIPHASIC SUSP 0.5 MG/ML*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PED VIT ACD & L-METHYLFOL W/ FL Electrolytes - Drugs to Treat Vitamin, TRI-VI-FLORO SUS 0.25/ML Tier 3 BIPHASIC SUSP 0.25 MG/ML*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ TRI-VI-FLORO SUS 0.5MG/ *PED VIT ACD & L-METHYLFOL W/ FL Electrolytes - Drugs to Treat Vitamin, Tier 3 ML BIPHASIC SUSP 0.5 MG/ML*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC VITAMINS ACD FLUORIDE & Electrolytes - Drugs to Treat Vitamin, TRI-VIT/FE DRO /FL 0.25 Tier 1 FE DROPS 0.25-10 MG/ML*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC VITAMINS ACD W/ FLUORIDE Electrolytes - Drugs to Treat Vitamin, TRI-VIT/FL DRO 0.25MG Tier 1 SOLN 0.25 MG/ML*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC VITAMINS ACD W/ FLUORIDE Electrolytes - Drugs to Treat Vitamin, TRI-VIT/FL DRO 0.5MG Tier 1 SOLN 0.5 MG/ML*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC VITAMINS ACD W/ FLUORIDE Electrolytes - Drugs to Treat Vitamin, TRI-VIT/FLUO DRO 0.25MG Tier 1 SOLN 0.25 MG/ML*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC VITAMINS ACD W/ FLUORIDE Electrolytes - Drugs to Treat Vitamin, TRI-VIT/FLUO DRO 0.5MG Tier 1 SOLN 0.5 MG/ML*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE CBN-FE ASP GLYC- Electrolytes - Drugs to Treat Vitamin, ULTIMATECARE CAP ONE Tier 1 FA-OMEGA 3 CAP 27-1MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/FE CBNYL-FE ASP GLYC- Electrolytes - Drugs to Treat Vitamin, ULTIMATECARE CAP ONE NF Tier 1 FA-DSS-OMEGA CAP 20-7-1 MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CITRATE TAB ER 10 MEQ Electrolytes - Drugs to Treat Vitamin, UROCIT-K 10 TAB Tier 3 (1080 MG) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CITRATE TAB ER 15 MEQ Electrolytes - Drugs to Treat Vitamin, UROCIT-K 15 TAB Tier 3 (1620 MG) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CITRATE TAB ER 5 MEQ Electrolytes - Drugs to Treat Vitamin, UROCIT-K 5 TAB Tier 3 (540 MG) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ PATIROMER SORBITEX CALCIUM FOR Electrolytes - Drugs to Treat Vitamin, VELTASSA POW 16.8GM Tier 3 X X SUSP PACKET 16.8 GM (BASE EQ) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ PATIROMER SORBITEX CALCIUM FOR Electrolytes - Drugs to Treat Vitamin, VELTASSA POW 25.2GM Tier 3 X X SUSP PACKET 25.2 GM (BASE EQ) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ PATIROMER SORBITEX CALCIUM FOR Electrolytes - Drugs to Treat Vitamin, VELTASSA POW 8.4GM Tier 3 X X SUSP PACKET 8.4 GM (BASE EQ) Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O VIT A W/ FE FUM-DSS- Electrolytes - Drugs to Treat Vitamin, VEMAVITE- CAP PRX 2 Tier 3 FA-DHA CAP 27-1.25-300 MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/FE POLY-NA FERED-FA TAB Electrolytes - Drugs to Treat Vitamin, VENA-BAL MIS DHA Tier 2 27-1 & OMEGA CAP DR 430MG* Mineral and Body Fluid Deficiencies

210 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FEFUM-METHYLFOL- Electrolytes - Drugs to Treat Vitamin, VINATE DHA CAP 27-1.13 Tier 3 OMEGAS CAP 27-1.13 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE BISGLYCINATE Electrolytes - Drugs to Treat Vitamin, VINATE II TAB Tier 1 CHELATE-FA TAB 29-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ SEL-FE FUMARATE-FA Electrolytes - Drugs to Treat Vitamin, VINATE M TAB Tier 1 TAB 27-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, VINATE ONE TAB Tier 1 60-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, VIRT NATE TAB Tier 3 28-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, VIRT NATE TAB 28-1MG Tier 3 28-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ DSS-IRON Electrolytes - Drugs to Treat Vitamin, VIRT-ADVANCE TAB 90-1MG Tier 2 CARBONYL-FA TAB 90-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/FE FUM-FE POLY -FA- Electrolytes - Drugs to Treat Vitamin, VIRT-C DHA CAP Tier 3 OMEGA 3 CAP 53.5-38-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUM-FA-OMEGA 3 Electrolytes - Drugs to Treat Vitamin, VIRT-NATE CAP DHA Tier 3 CAP 28-1-200 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POT PHOS MONOBASIC W/SOD PHOS DI Electrolytes - Drugs to Treat Vitamin, VIRT-PHOS TAB 250 NEUT Tier 1 & MONOBAS TAB 155-852-130MG Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUM- Electrolytes - Drugs to Treat Vitamin, VIRT-PN TAB METHYLFOLATE-FA TAB 27-0.6-0.4 Tier 3 Mineral and Body Fluid Deficiencies MG*** Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FEFUM-METHFOL-FA- Electrolytes - Drugs to Treat Vitamin, VIRT-PN DHA CAP Tier 3 DHA CAP 27-0.6-0.4-300 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/ FE FUMERATE- Electrolytes - Drugs to Treat Vitamin, VIRT-PN PLUS CAP Tier 3 METHYLFOLATE-FA-OMEGA 3 CAP*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O VIT A W/ FE FUM-DSS- Electrolytes - Drugs to Treat Vitamin, VIRTPREX CAP Tier 3 FA-DHA CAP 26-1.2-300 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ SODIUM CITRATE & CITRIC ACID SOLN Electrolytes - Drugs to Treat Vitamin, VIRTRATE-2 SOL Tier 1 500-334 MG/5ML Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ SODIUM CITRATE & CITRIC ACID SOLN Electrolytes - Drugs to Treat Vitamin, VIRTRATE-2 SOL 500-334 Tier 1 500-334 MG/5ML Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POT & SOD CITRATES W/ CIT AC SOLN Electrolytes - Drugs to Treat Vitamin, VIRTRATE-3 SOL Tier 1 550-500-334 MG/5ML Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ POTASSIUM CITRATE & CITRIC ACID Electrolytes - Drugs to Treat Vitamin, VIRTRATE-K SOL 1100-334 Tier 1 SOLN 1100-334 MG/5ML Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O VIT A W/ FE FUM-DSS- Electrolytes - Drugs to Treat Vitamin, VIRT-SELECT CAP Tier 3 FA-DHA CAP 29-1.25-325 MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ DSS-IRON Electrolytes - Drugs to Treat Vitamin, VIRT-VITE GT TAB 90-1MG Tier 2 CARBONYL-FA TAB 90-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PEDIATRIC VITAMINS ACD W/ FLUORIDE Electrolytes - Drugs to Treat Vitamin, VIT A/C/D/FL DRO 0.25MG Tier 1 SOLN 0.25 MG/ML*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/FE POLY-METHYLFOL-FA- Electrolytes - Drugs to Treat Vitamin, VITAFOL CAP ULTRA Tier 3 DHA CAP 29-0.6-0.4-200 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT VIT W/ FE PHOS-FA-OMEGA Electrolytes - Drugs to Treat Vitamin, VITAFOL CHW GUMMIES Tier 3 CHEW TAB 3.33-0.333-34.8 MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT-FEPOLY-METHOL-FA-DHA CAP Electrolytes - Drugs to Treat Vitamin, VITAFOL FE+ CAP Tier 3 90-1-200 MG & DSS 50MG CAP* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O A W/ FEFUM-L Electrolytes - Drugs to Treat Vitamin, VITAFOL-NANO TAB Tier 3 METHYLFOL-FA TAB 18-0.6-0.4 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL MV W/FE FUM-FA TAB 65-1 Electrolytes - Drugs to Treat Vitamin, VITAFOL-OB PAK +DHA Tier 3 MG & DHA CAP 250 MG PACK * Mineral and Body Fluid Deficiencies

211 Tier Prior Supply Step Therapeutic Class Label Name Generic Name Specialty Value Authorization Limit Therapy Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, VITAFOL-OB TAB 65-1MG Tier 3 65-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL MV W/ FE POLYSAC CMPLX- Electrolytes - Drugs to Treat Vitamin, VITAFOL-ONE CAP Tier 3 FA-DHA CAP 29-1-200 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FEFUM-METHFOL-FA- Electrolytes - Drugs to Treat Vitamin, VITAMEDMD CAP ONE RX Tier 3 DHA CAP 30-0.6-0.4-200 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/ FE CHELATE-L Electrolytes - Drugs to Treat Vitamin, VITAMEDMD MIS PLUS RX Tier 3 METHYLFOL-FA TAB & DHA CAP PK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, VITAMIN D CAP 50000UNT ERGOCALCIFEROL CAP 50000 UNIT Tier 1 Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ HCR Electrolytes - Drugs to Treat Vitamin, VITAMIN D2 TAB 400UNIT ERGOCALCIFEROL TAB 400 UNIT Preventive Mineral and Body Fluid Deficiencies Care Therapeutic Nutrients/Minerals/ *PRENAT W/OA W/FEFUM-NA FERED-FA- Electrolytes - Drugs to Treat Vitamin, VITAPEARL CAP Tier 3 DHA CAP ER 30-1.4-200 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ DOCUSATE-IRON-FA Electrolytes - Drugs to Treat Vitamin, VITA-PREN TAB Tier 3 TAB 65-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FE CHEL-FA TAB 30- Electrolytes - Drugs to Treat Vitamin, VITATRUE MIS Tier 3 1.4 MG & DHA CAP 300MG PK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUM-FA-OMEGA 3 Electrolytes - Drugs to Treat Vitamin, VIVA DHA CAP Tier 3 CAP 28-1-200 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, VOL-NATE TAB Tier 3 28-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUMARATE-FA TAB Electrolytes - Drugs to Treat Vitamin, VOL-PLUS TAB Tier 3 27-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ IRON CARBONYL-FA Electrolytes - Drugs to Treat Vitamin, VOL-TAB RX TAB Tier 3 TAB 29-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O A W/FE CBN-DSS-FA- Electrolytes - Drugs to Treat Vitamin, VP-CH PLUS CAP Tier 3 DHA CAP 29-1-265 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O VIT A W/ FE CBN-DSS- Electrolytes - Drugs to Treat Vitamin, VP-CH-PNV CAP Tier 3 FA-DHA CAP 30-1-260 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/ CALCIUM-VIT B6-FA- Electrolytes - Drugs to Treat Vitamin, VP-GGR-B6 TAB PRENATAL Tier 2 GINGER TAB 1.2 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT-FE POLY CMPLX-FE HEME Electrolytes - Drugs to Treat Vitamin, VP-HEME OB MIS + DHA Tier 3 POLY-FA TAB & OMEGA 3 CAP PCK* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT VIT-FE POLY CMPLX-FE HEME Electrolytes - Drugs to Treat Vitamin, VP-HEME OB TAB Tier 3 POLY-FA TAB 28-6-1 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT-FE POLY CMPLX-FE HEME Electrolytes - Drugs to Treat Vitamin, VP-HEME ONE CAP Tier 3 POLY-FA-DHA CAP 22-6-1-200 MG* Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL VIT W/ FE FUM-FA-OMEGA 3 Electrolytes - Drugs to Treat Vitamin, VP-PNV-DHA CAP Tier 3 CAP 28-1-215.8 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ Electrolytes - Drugs to Treat Vitamin, WHEAT GERM OIL *WHEAT GERM - OIL*** Tier 3 Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENATAL W/O A W/FE CBN-DSS-FA- Electrolytes - Drugs to Treat Vitamin, ZATEAN-CH CAP Tier 2 DHA CAP 27-1-250 MG*** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/FEFUM-METHFOL-FA- Electrolytes - Drugs to Treat Vitamin, ZATEAN-PN CAP DHA Tier 3 DHA CAP 27-0.6-0.4-300 MG** Mineral and Body Fluid Deficiencies Therapeutic Nutrients/Minerals/ *PRENAT W/O A W/ FE FUMERATE- Electrolytes - Drugs to Treat Vitamin, ZATEAN-PN CAP PLUS Tier 3 METHYLFOLATE-FA-OMEGA 3 CAP*** Mineral and Body Fluid Deficiencies