ACA Preventive Drug List Effective January 1, 2021

Recommendations by United States Preventive Services Task Force (USPSTF), Health Resources and Services Administration (HRSA), and Advisory Committee on Immunization Practices (ACIP, adopted by the Centers for Disease Control)

Under the Affordable Care Act (ACA) some medications may have limited or $0 cost-sharing; examples of categories of medications that may be subject to limited or $0 cost share include aspirin, breast cancer preventive, fluoride supplements, folic acid supplements, iron supplements, tobacco cessation, immunizations (see covered vaccines on list below), bowel preparation for colonoscopy, and some contraceptive medications and devices.

The drugs listed below are grouped into broad categories. Each category includes an alphabetical list of drugs. Please verify with your plan if a generic drug must be tried before the brand version of a drug is filled. Please refer to your benefit materials for coverage details and the plan website for current information as this list will be reviewed periodically and is subject to change.

Medications are subject to formulary coverage. The Essential Formulary is a closed formulary and may not cover all versions of medications listed. Please refer to your formulary guide. The formulary document will indicate which medications are covered in the ACA column.

Generic prescription drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand. Brand prescription drugs are shown in all capital letters followed by the generic name. Generic medicines are available for many of the brand-name drugs listed though may not be available in all strengths.

ASPIRIN sodium fluoride chew tab 0.5 mg f (from 1.1 mg aspirin chew tab 81 mg naf) aspirin tab delayed release 81 mg sodium fluoride chew tab 1 mg f (from 2.2 mg naf) sodium fluoride soln 0.125 mg/drop f BOWEL PREPARATION (0.275 mg/drop naf) sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml peg 3350-kcl-sod bicarb-nacl for soln 420 gm naf) (Nulytely/flavor pack) peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely) FOLIC ACID SUPPLEMENTS folic acid cap 0.8 mg BREAST CANCER PRIMARY PREVENTION folic acid tab 400 mcg folic acid tab 800 mcg anastrazole tab (Arimidex) raloxifene hcl tab 60 mg (Evista) tamoxifen citrate tab 10 mg (base equivalent) HUMAN IMMUNODEFICIENCY VIRUS tamoxifen citrate tab 20 mg (base equivalent) PREEXPOSURE PROPHYLAXIS (HIV PREP) FLUORIDE emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg (Truvada) Dental Products & Combinations sodium fluoride cream 1.1% (Prevident 5000 plus) IRON SUPPLEMENTS sodium fluoride gel 1.1% (0.5% f) (Prevident carbonyl iron susp 15 mg/1.25ml (elemental iron) fluoride) FERROUS SULFATE – ferrous sulfate liquid sodium fluoride paste 1.1% (Prevident 5000 boost) 220 mg/5ml (44 mg/5ml elemental fe) sodium fluoride rinse 0.2% (Prevident) ferrous sulfate elixir 220 mg/5ml (44 mg/5ml sodium fluoride-potassium nitrate paste 1.1-5% elemental fe) (Prevident 5000 sensi) ferrous sulfate soln 75 mg/ml (15 mg/ml elemental stannous fluoride conc 0.63% fe) stannous fluoride gel 0.4% FERROUS SULFATE – ferrous sulfate syrup 300 mg/5ml (60 mg/5ml elemental fe) Supplements & Combinations IRON UP – polysaccharide iron complex liquid 15 mg/0.5ml (fe equiv) sodium fluoride chew tab 0.25 mg f (from 0.55 mg NOVAFERRUM PEDIATRIC DROP – polysaccharide naf) iron complex liquid 15 mg/ml (fe equiv) SINGLE AGENT STATINS FLUAD QUADRIVALENT – influenza vac type a&b lovastatin tab 20 mg surface ant adj quad pref syr 0.5 ml lovastatin tab 40 mg FLUARIX QUADRIVALENT – influenza virus vac split pravastatin sodium tab 10 mg quadrivalent susp pref syr 0.5ml pravastatin sodium tab 20 mg (Pravachol) FLUBLOK QUADRIVALENT – influenza vac recomb pravastatin sodium tab 40 mg (Pravachol) ha quad pf soln pref syr 0.5 ml pravastatin sodium tab 80 mg (Pravachol) FLUCELVAX QUADRIVALENT – influenza vac tissue- cultured subunit quadrivalent im susp TOBACCO CESSATION FLULAVAL QUADRIVALENT – influenza virus vaccine generic OTC nicotine gum, lozenges, patches split quadrivalent im inj generic Rx nicotine gum, lozenges, patches FLULAVAL QUADRIVALENT – influenza virus vac split quadrivalent susp pref syr 0.5ml bupropion hcl (smoking deterrent) tab er 12hr FLUZONE HIGH-DOSE PF – influenza virus vac split 150 mg CHANTIX – varenicline tartrate tab 0.5 mg (base high-dose pf susp pref syr 0.5ml equiv) FLUZONE HIGH-DOSE PF – influenza vac split high- CHANTIX – varenicline tartrate tab 1 mg (base equiv) dose quad pf susp pref syr 0.7 ml CHANTIX CONTINUING MONTH – varenicline tartrate FLUZONE QUADRIVALENT – influenza virus vaccine tab 1 mg (base equiv) split quadrivalent im inj CHANTIX STARTING MONTH PACK – varenicline FLUZONE QUADRIVALENT – influenza virus vaccine tartrate tab 0.5 mg x 11 & tab 1 mg x 42 pack split quadrivalent inj 0.5 ml NICOTINE TRANSDERMAL SYSTEM – nicotine td FLUZONE QUADRIVALENT – influenza virus vac split patch 24 hr kit 21-14-7 mg/24hr quadrivalent susp pref syr 0.25 ml NICOTROL INHALER – nicotine inhaler system 10 mg FLUZONE QUADRIVALENT – influenza virus vac split (4 mg delivered) quadrivalent susp pref syr 0.5ml NICOTROL NS – nicotine nasal spray 10 mg/ml GARDASIL 9 – human papillomavirus (hpv) 9-valent (0.5 mg/spray) recomb vac im susp GARDASIL 9 – human papillomavirus (hpv) 9-valent recomb vac susp pref syr VACCINES HAVRIX – hepatitis a vaccine inj susp 720 el ACTHIB – haemophilus b polysaccharide conjugate unit/0.5ml vaccine for inj HAVRIX – hepatitis a vaccine inj susp 1440 el unit/ml ADACEL – tet tox-diph-acell pertuss ad inj 5-2-15.5 lf- HEPLISAV-B – hepatitis b vaccine recomb adjuvanted lf-mcg/0.5ml pref syr 20 mcg/0.5ml AFLURIA QUADRIVALENT – influenza virus vaccine HIBERIX – haemophilus b polysaccharide conjugate split quadrivalent im inj vac for inj 10 mcg AFLURIA QUADRIVALENT – influenza virus vac split INFANRIX – diph, acellular pert & tet tox inj 25 lf- quadrivalent susp pref syr 0.25 ml 58 mcg-10 lf/0.5ml AFLURIA QUADRIVALENT – influenza virus vac split IPOL INACTIVATED IPV – poliovirus vaccine, ipv quadrivalent susp pref syr 0.5ml injection BEXSERO – meningococcal vac b (recomb omv KINRIX – diph-tetanus tox ad-acell pert & polio virus, adjuv) inj prefilled syringe ipv vac inj BOOSTRIX – tet tox-diph-acell pertuss ad inj 5-2.5- M-M-R II – measles-mumps-rubella virus vaccines for 18.5 lf-lf-mcg/0.5ml inj soln DAPTACEL – diph, acellular pert & tet tox inj 15 lf- MENACTRA – meningococcal (a, c, y, and w-135) 23 mcg-5 lf/0.5ml conjugate vaccine inj DIPHTHERIA/TETANUS TOXOID – diphtheria-tetanus MENVEO – meningococcal (a, c, y, and w-135) oligo tox adsorbed (dt) im inj 25-5 unit/0.5ml conj vac for inj ENGERIX-B – hepatitis b vaccine (recombinant) PEDIARIX – diph-tetanus tox-acell pert-hepatitis b- 10 mcg/0.5ml polio ipv vac inj ENGERIX-B – hepatitis b vaccine (recombinant) PEDVAX HIB – haemophilus b polysaccharide conj 20 mcg/ml vac im susp 7.5 mcg/0.5 ml ENGERIX-B – hepatitis b vaccine (recombinant) susp PENTACEL – diph-ac per-tet tox ad-poliov-haemoph b 10 mcg/0.5ml poly vac for im susp ENGERIX-B – hepatitis b vaccine (recombinant) susp PNEUMOVAX 23 – pneumococcal vaccine polyvalent 20 mcg/ml inj 25 mcg/0.5ml FLUAD – influenza vac type a&b surface ant adj susp PNEUMOVAX 23/1 DOSE – pneumococcal vaccine pref syr 0.5 ml polyvalent inj 25 mcg/0.5ml

Generic Drugs = bold Brand Drugs = ALL CAPITAL LETTERS © Prime Therapeutics LLC 06/21 Product names listed are the property of their respective owners. Page 2 of 8 VACCINES (CONTINUED) PREVNAR 13 – pneumococcal 13-valent conjugate vaccine inj PROQUAD – measles-mumps-rubella-varicella virus vaccines for susp QUADRACEL – diph-tetanus tox ad-acell pert & polio virus, ipv vac inj RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp 10 mcg/ml RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp 40 mcg/ml ROTARIX – rotavirus vaccine, live for oral susp ROTATEQ – rotavirus vaccine, live oral pentavalent soln SHINGRIX – zoster vac recombinant adjuvanted for im inj 50 mcg/0.5ml TDVAX – tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml TENIVAC – tetanus-diphtheria toxoids (td) inj 5-2 lfu TRUMENBA – meningococcal group b vac (recomb) im susp prefilled syr TWINRIX – hep a-hep b vaccine susp pref syr 720- 20 elu-mcg/ml VAQTA – hepatitis a vaccine inj susp 25 unit/0.5ml VAQTA – hepatitis a vaccine inj susp 50 unit/ml VARIVAX – varicella virus vac live for subcutaneous inj 1350 pfu/0.5ml ZOSTAVAX – zoster vaccine live for subcutaneous susp 19400 unit/0.65ml

Generic Drugs = bold Brand Drugs = ALL CAPITAL LETTERS © Prime Therapeutics LLC 06/21 Product names listed are the property of their respective owners. Page 3 of 8 Recommendation on Contraceptives by Health Resources and Services Administration (HRSA)

Eligible benefit plans include coverage under the Affordable Care Act for the following contraceptives to be covered at $0. To determine cost share for medications not listed below, log onto your account at MyPrime.com. Please refer to your benefit materials for coverage details and the plan website for current information as this publication is subject to change. This list will be reviewed periodically and is subject to change.

Generic prescription drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand. Brand prescription drugs are shown in all capital letters followed by the generic name. Generic medicines are available for many of the brand-name drugs listed though may not be available in all strengths.

CONTRACEPTIVES Sponge TODAY SPONGE – nonoxynol-9 vaginal sponge Barrier Method Types 1000 mg Cervical Caps FEMCAP – cervical cap 22 mm Emergency Method Types FEMCAP – cervical cap 26 mm Emergency Ella FEMCAP – cervical cap 30 mm ELLA – ulipristal acetate tab 30 mg Diaphragms Emergency Progestin CAYA – diaphragm arc-spring OMNIFLEX DIAPHRAGM – diaphragms Aftera - levonorgestrel tab 1.5 mg (Plan B One- WIDE-SEAL SILICONE DIAPHR – diaphragm wide Step) seal 60 mm Econtra Ez - levonorgestrel tab 1.5 mg (Plan B WIDE-SEAL SILICONE DIAPHR – diaphragm wide One-Step) seal 65 mm Econtra One-Step - levonorgestrel tab 1.5 mg (Plan WIDE-SEAL SILICONE DIAPHR – diaphragm wide B One-Step) seal 70 mm levonorgestrel tab 1.5 mg (Plan B One-Step) WIDE-SEAL SILICONE DIAPHR – diaphragm wide My Choice - levonorgestrel tab 1.5 mg (Plan B One- seal 75 mm Step) WIDE-SEAL SILICONE DIAPHR – diaphragm wide My Way - levonorgestrel tab 1.5 mg (Plan B One- seal 80 mm Step) WIDE-SEAL SILICONE DIAPHR – diaphragm wide New Day - levonorgestrel tab 1.5 mg (Plan B One- seal 85 mm Step) WIDE-SEAL SILICONE DIAPHR – diaphragm wide Opcicon One-Step - levonorgestrel tab 1.5 mg seal 90 mm (Plan B One-Step) WIDE-SEAL SILICONE DIAPHR – diaphragm wide Option 2 - levonorgestrel tab 1.5 mg (Plan B One- seal 95 mm Step) Preventeza - levonorgestrel tab 1.5 mg (Plan B Female Condom One-Step) React - levonorgestrel tab 1.5 mg (Plan B One- FC FEMALE CONDOM – condoms - female Step) FC2 FEMALE CONDOM – condoms - female Take Action - levonorgestrel tab 1.5 mg (Plan B One-Step) Spermicide ENCARE – nonoxynol-9 vaginal suppos 100 mg Hormonal Method Types OPTIONS GYNOL II VAGINAL – nonoxynol-9 gel 3% SHUR-SEAL – nonoxynol-9 gel 2% Injectable Progestin VCF VAGINAL CONTRACEPTIVE – nonoxynol-9 film medroxyprogesterone acetate im susp 150 mg/ml 28% (Depo-provera contrac) VCF VAGINAL CONTRACEPTIVE – nonoxynol-9 medroxyprogesterone acetate im susp prefilled syr foam 12.5% 150 mg/ml (Depo-provera contrac) VCF Vaginal Contraceptive gel - nonoxynol-9 gel 4%

Generic Drugs = bold Brand Drugs = ALL CAPITAL LETTERS © Prime Therapeutics LLC 06/21 Product names listed are the property of their respective owners. Page 4 of 8 CONTRACEPTIVES Cyred - desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg Oral Combined Cyred Eq - desogestrel & ethinyl estradiol tab Afirmelle - levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg 0.1 mg-20 mcg Dasetta 1/35 - norethindrone & ethinyl estradiol tab Altavera - levonorgestrel & ethinyl estradiol tab 1 mg-35 mcg 0.15 mg-30 mcg Dasetta 7/7/7 - norethindrone-eth estradiol tab 0.5- Alyacen 1/35 - norethindrone & ethinyl estradiol 35/0.75-35/1-35 mg-mcg tab 1 mg-35 mcg Delyla - levonorgestrel & ethinyl estradiol tab Alyacen 7/7/7 - norethindrone-eth estradiol tab 0.5- 0.1 mg-20 mcg 35/0.75-35/1-35 mg-mcg desogest-eth estrad & eth estrad tab 0.15-0.02/ Apri - desogestrel & ethinyl estradiol tab 0.15 mg- 0.01 mg(21/5) (Mircette) 30 mcg desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg Aranelle - norethindrone-eth estradiol tab 0.5-35/1- drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz) 35/0.5-35 mg-mcg drospirenone-ethinyl estradiol tab 3-0.03 mg Aubra - levonorgestrel & ethinyl estradiol tab (Yasmin 28) 0.1 mg-20 mcg drospirenone-ethinyl estrad-levomefolate tab 3- Aubra Eq - levonorgestrel & ethinyl estradiol tab 0.02-0.451 mg (Beyaz) 0.1 mg-20 mcg drospirenone-ethinyl estrad-levomefolate tab 3- Aurovela 1/20 - norethindrone ace & ethinyl 0.03-0.451 mg (Safyral) estradiol tab 1 mg-20 mcg (Loestrin 1/20- Elinest - norgestrel & ethinyl estradiol tab 0.3 mg- 21) 30 mcg Aurovela 1.5/30 - norethindrone ace & ethinyl Emoquette - desogestrel & ethinyl estradiol tab estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21) 0.15 mg-30 mcg Aurovela 24 Fe - norethindrone ace-ethinyl Enpresse-28 - levonorgestrel-eth estra tab 0.05- estradiol-fe tab 1 mg-20 mcg (24) 30/0.075-40/0.125-30mg-mcg Aurovela Fe 1.5/30 - norethindrone ace & Enskyce - desogestrel & ethinyl estradiol tab ethinyl estradiol-fe tab 1.5 mg-30 mcg 0.15 mg-30 mcg (Loestrin Fe 1.5/30) Estarylla - norgestimate & ethinyl estradiol tab Aviane - levonorgestrel & ethinyl estradiol tab 0.25 mg-35 mcg 0.1 mg-20 mcg ethynodiol diacetate & ethinyl estradiol tab 1 mg- Ayuna - levonorgestrel & ethinyl estradiol tab 35 mcg 0.15 mg-30 mcg ethynodiol diacetate & ethinyl estradiol tab 1 mg- Azurette - desogest-eth estrad & eth estrad tab 50 mcg 0.15-0.02/0.01 mg(21/5) (Mircette) Falmina - levonorgestrel & ethinyl estradiol tab Balziva - norethindrone & ethinyl estradiol tab 0.1 mg-20 mcg 0.4 mg-35 mcg Femynor - norgestimate & ethinyl estradiol tab Bekyree - desogest-eth estrad & eth estrad tab 0.25 mg-35 mcg 0.15-0.02/0.01 mg(21/5) (Mircette) Gianvi - drospirenone-ethinyl estradiol tab 3- Blisovi 24 Fe - norethindrone ace-ethinyl estradiol- 0.02 mg (Yaz) fe tab 1 mg-20 mcg (24) Hailey 1.5/30 - norethindrone ace & ethinyl Blisovi Fe 1.5/30 - norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21) estradiol-fe tab 1.5 mg-30 mcg (Loestrin Fe Hailey 24 Fe - norethindrone ace-ethinyl estradiol- 1.5/30) fe tab 1 mg-20 mcg (24) Briellyn - norethindrone & ethinyl estradiol tab Isibloom - desogestrel & ethinyl estradiol tab 0.4 mg-35 mcg 0.15 mg-30 mcg Caziant - desogest-ethin est tab 0.1-0.025/0.125- Jasmiel - drospirenone-ethinyl estradiol tab 3- 0.025/0.15-0.025mg-mg 0.02 mg (Yaz) Chateal - levonorgestrel & ethinyl estradiol tab Juleber - desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg 0.15 mg-30 mcg Chateal Eq - levonorgestrel & ethinyl estradiol tab Junel 1/20 - norethindrone ace & ethinyl estradiol 0.15 mg-30 mcg tab 1 mg-20 mcg (Loestrin 1/20-21) Cryselle-29 - norgestrel & ethinyl estradiol tab Junel 1.5/30 - norethindrone ace & ethinyl estradiol 0.3 mg-30 mcg tab 1.5 mg-30 mcg (Loestrin 1.5/30-21) Cyclafem 1/35 - norethindrone & ethinyl estradiol Junel Fe 1.5/30 - norethindrone ace & ethinyl tab 1 mg-35 mcg estradiol-fe tab 1.5 mg-30 mcg (Loestrin Fe Cyclafem 7/7/7 - norethindrone-eth estradiol tab 1.5/30) 0.5-35/0.75-35/1-35 mg-mcg Generic Drugs = bold Brand Drugs = ALL CAPITAL LETTERS © Prime Therapeutics LLC 06/21 Product names listed are the property of their respective owners. Page 5 of 8 CONTRACEPTIVES Mibelas 24 Fe - norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24) (Minastrin 24 Fe) Oral Combined (continued) Microgestin 1/20 - norethindrone ace & ethinyl Junel Fe 24 - norethindrone ace-ethinyl estradiol-fe estradiol tab 1 mg-20 mcg (Loestrin 1/20-21) tab 1 mg-20 mcg (24) Microgestin 1.5/30 - norethindrone ace & ethinyl Kaitlib Fe - norethindrone & ethinyl estradiol-fe estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21) chew tab 0.8 mg-25 mcg (Generess Fe) Microgestin Fe 1.5/30 - norethindrone ace & ethinyl Kalliga - desogestrel & ethinyl estradiol tab estradiol-fe tab 1.5 mg-30 mcg (Loestrin Fe 0.15 mg-30 mcg 1.5/30) Kariva - desogest-eth estrad & eth estrad tab 0.15- Mili - norgestimate & ethinyl estradiol tab 0.25 mg- 0.02/0.01 mg(21/5) (Mircette) 35 mcg Kelnor 1/35 - ethynodiol diacetate & ethinyl Mono-Linyah - norgestimate & ethinyl estradiol tab estradiol tab 1 mg-35 mcg 0.25 mg-35 mcg Kelnor 1/50 - ethynodiol diacetate & ethinyl Necon 0.5/35-28 - norethindrone & ethinyl estradiol estradiol tab 1 mg-50 mcg tab 0.5 mg-35 mcg Kurvelo - levonorgestrel & ethinyl estradiol tab Nikki - drospirenone-ethinyl estradiol tab 3- 0.15 mg-30 mcg 0.02 mg (Yaz) Larin 1/20 - norethindrone ace & ethinyl estradiol norethindrone ace & ethinyl estradiol tab 1 mg- tab 1 mg-20 mcg (Loestrin 1/20-21) 20 mcg (Loestrin 1/20-21) Larin 1.5/30 - norethindrone ace & ethinyl estradiol norethindrone ace & ethinyl estradiol tab 1.5 mg- tab 1.5 mg-30 mcg (Loestrin 1.5/30-21) 30 mcg (Loestrin 1.5/30-21) Larin 24 Fe - norethindrone ace-ethinyl estradiol-fe norethindrone & ethinyl estradiol-fe chew tab tab 1 mg-20 mcg (24) 0.4 mg-35 mcg Larin Fe 1.5/30 - norethindrone ace & ethinyl norethindrone & ethinyl estradiol-fe chew tab estradiol-fe tab 1.5 mg-30 mcg (Loestrin Fe 0.8 mg-25 mcg (Generess Fe) 1.5/30) norethindrone ace-ethinyl estradiol-fe tab 1 mg- Larissia - levonorgestrel & ethinyl estradiol tab 20 mcg (24) 0.1 mg-20 mcg norethindrone ace & ethinyl estradiol-fe tab Layolis Fe - norethindrone & ethinyl estradiol-fe 1.5 mg-30 mcg (Loestrin Fe 1.5/30) chew tab 0.8 mg-25 mcg (Generess Fe) norethindrone ace-eth estradiol-fe chew tab 1 mg- Leena - norethindrone-eth estradiol tab 0.5-35/1- 20 mcg (24) (Minastrin 24 Fe) 35/0.5-35 mg-mcg norgestimate & ethinyl estradiol tab 0.25 mg- Lessina - levonorgestrel & ethinyl estradiol tab 35 mcg 0.1 mg-20 mcg norgestimate-eth estrad tab 0.18-25/0.215-25/0.25- Levonest - levonorgestrel-eth estra tab 0.05- 25 mg-mcg 30/0.075-40/0.125-30mg-mcg Nortrel 0.5/35 (28) - norethindrone & ethinyl levonorgestrel & ethinyl estradiol tab 0.1 mg- estradiol tab 0.5 mg-35 mcg 20 mcg Nortrel 1/35 - norethindrone & ethinyl estradiol tab levonorgestrel & ethinyl estradiol tab 0.15 mg- 1 mg-35 mcg 30 mcg Nortrel 7/7/7 - norethindrone-eth estradiol tab 0.5- levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125- 35/0.75-35/1-35 mg-mcg 30mg-mcg Ocella - drospirenone-ethinyl estradiol tab 3- Levora 0.15/30-28 - levonorgestrel & ethinyl 0.03 mg (Yasmin 28) estradiol tab 0.15 mg-30 mcg Orsythia - levonorgestrel & ethinyl estradiol tab Lillow - levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg 0.15 mg-30 mcg Philith - norethindrone & ethinyl estradiol tab Loryna - drospirenone-ethinyl estradiol tab 3- 0.4 mg-35 mcg 0.02 mg (Yaz) Pimtrea - desogest-eth estrad & eth estrad tab Low-Ogestrel - norgestrel & ethinyl estradiol tab 0.15-0.02/0.01 mg(21/5) (Mircette) 0.3 mg-30 mcg Pirmella 1/35 - norethindrone & ethinyl estradiol Lo-Zumandimine - drospirenone-ethinyl estradiol tab 1 mg-35 mcg tab 3-0.02 mg (Yaz) Pirmella 7/7/7 - norethindrone-eth estradiol tab 0.5- Lutera - levonorgestrel & ethinyl estradiol tab 35/0.75-35/1-35 mg-mcg 0.1 mg-20 mcg Portia-28 - levonorgestrel & ethinyl estradiol tab Marlissa - levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg 0.15 mg-30 mcg Previfem - norgestimate & ethinyl estradiol tab Melodetta 24 Fe - norethindrone ace-eth estradiol- 0.25 mg-35 mcg fe chew tab 1 mg-20 mcg (24) (Minastrin 24 Fe) Generic Drugs = bold Brand Drugs = ALL CAPITAL LETTERS © Prime Therapeutics LLC 06/21 Product names listed are the property of their respective owners. Page 6 of 8 CONTRACEPTIVES Oral Combined (continued) Oral Extended Continuous Reclipsen - desogestrel & ethinyl estradiol tab Amethia - levonorg-eth est tab 0.15-0.03mg(84) & 0.15 mg-30 mcg eth est tab 0.01mg(7) (Seasonique) Simliya - desogest-eth estrad & eth estrad tab 0.15- Amethia Lo - levonorg-eth est tab 0.1-0.02mg(84) & 0.02/0.01 mg(21/5) (Mircette) eth est tab 0.01mg(7) (Loseasonique) Sprintec 28 - norgestimate & ethinyl estradiol tab Amethyst - levonorgestrel-ethinyl estradiol 0.25 mg-35 mcg (continuous) tab 90-20 mcg Sronyx - levonorgestrel & ethinyl estradiol tab Ashlyna - levonorg-eth est tab 0.15-0.03mg(84) & 0.1 mg-20 mcg eth est tab 0.01mg(7) (Seasonique) Syeda - drospirenone-ethinyl estradiol tab 3- Camrese - levonorg-eth est tab 0.15-0.03mg(84) & 0.03 mg (Yasmin 28) eth est tab 0.01mg(7) (Seasonique) Tarina 24 Fe - norethindrone ace-ethinyl estradiol- Camrese Lo - levonorg-eth est tab 0.1-0.02mg(84) fe tab 1 mg-20 mcg (24) & eth est tab 0.01mg(7) (Loseasonique) Tilia Fe - norethindrone ac-ethinyl estrad-fe tab 1- Daysee - levonorg-eth est tab 0.15-0.03mg(84) & 20/1-30/1-35 mg-mcg (Estrostep Fe) eth est tab 0.01mg(7) (Seasonique) Tri-Legest Fe - norethindrone ac-ethinyl estrad-fe Fayosim - levonor-eth est tab 0.15-0.02/0.025/ tab 1-20/1-30/1-35 mg-mcg (Estrostep Fe) 0.03 mg ð est 0.01 mg (Quartette) Tri-Lo-Estarylla - norgestimate-eth estrad tab 0.18- Jaimiess - levonorg-eth est tab 0.15-0.03mg(84) & 25/0.215-25/0.25-25 mg-mcg eth est tab 0.01mg(7) (Seasonique) Tri-Lo-Marzia - norgestimate-eth estrad tab 0.18- levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 25/0.215-25/0.25-25 mg-mcg 0.01mg(7) (Loseasonique) Tri-Lo-Mili - norgestimate-eth estrad tab 0.18- levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 25/0.215-25/0.25-25 mg-mcg 0.01mg(7) (Seasonique) Tri-Lo-Sprintec - norgestimate-eth estrad tab 0.18- levonor-eth est tab 0.15-0.02/0.025/0.03 mg ð 25/0.215-25/0.25-25 mg-mcg est 0.01 mg (Quartette) Trivora-28 - levonorgestrel-eth estra tab 0.05- levonorgestrel-ethinyl estradiol (continuous) tab 30/0.075-40/0.125-30mg-mcg 90-20 mcg Tri-Vylibra Lo - norgestimate-eth estrad tab 0.18- Lojaimiess - levonorg-eth est tab 0.1-0.02mg(84) & 25/0.215-25/0.25-25 mg-mcg eth est tab 0.01mg(7) (Loseasonique) Tydemy - drospirenone-ethinyl estrad- Rivelsa - levonor-eth est tab 0.15-0.02/0.025/0.03 levomefolate tab 3-0.03-0.451 mg (Safyral) mg ð est 0.01 mg (Quartette) Velivet - desogest-ethin est tab 0.1-0.025/0.125- Simpesse - levonorg-eth est tab 0.15-0.03mg(84) & 0.025/0.15-0.025mg-mg eth est tab 0.01mg(7) (Seasonique) Vienva - levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg Oral Progestin Viorele - desogest-eth estrad & eth estrad tab 0.15- Camila - norethindrone tab 0.35 mg (Ortho 0.02/0.01 mg(21/5) (Mircette) Micronor) Volnea - desogest-eth estrad & eth estrad tab 0.15- Deblitane - norethindrone tab 0.35 mg (Ortho 0.02/0.01 mg(21/5) (Mircette) Micronor) Vyfemla - norethindrone & ethinyl estradiol tab Errin - norethindrone tab 0.35 mg (Ortho Micronor) 0.4 mg-35 mcg Heather - norethindrone tab 0.35 mg (Ortho Vylibra - norgestimate & ethinyl estradiol tab Micronor) 0.25 mg-35 mcg Incassia - norethindrone tab 0.35 mg (Ortho Wera - norethindrone & ethinyl estradiol tab Micronor) 0.5 mg-35 mcg Jencycla - norethindrone tab 0.35 mg (Ortho Wymzya Fe - norethindrone & ethinyl estradiol-fe Micronor) chew tab 0.4 mg-35 mcg Lyza - norethindrone tab 0.35 mg (Ortho Micronor) Zarah - drospirenone-ethinyl estradiol tab 3- Nora-Be - norethindrone tab 0.35 mg (Ortho 0.03 mg (Yasmin 28) Micronor) Zovia 1/35E - ethynodiol diacetate & ethinyl norethindrone tab 0.35 mg (Ortho Micronor) estradiol tab 1 mg-35 mcg Norlyda - norethindrone tab 0.35 mg (Ortho Zumandimine - drospirenone-ethinyl estradiol tab Micronor) 3-0.03 mg (Yasmin 28) Norlyroc - norethindrone tab 0.35 mg (Ortho Micronor)

Generic Drugs = bold Brand Drugs = ALL CAPITAL LETTERS © Prime Therapeutics LLC 06/21 Product names listed are the property of their respective owners. Page 7 of 8 CONTRACEPTIVES Oral Progestin (continued) Sharobel - norethindrone tab 0.35 mg (Ortho Micronor) Tulana - norethindrone tab 0.35 mg (Ortho Micronor)

Transdermal Combined XULANE – norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr

Vaginal Combined NUVARING – etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr

Generic Drugs = bold Brand Drugs = ALL CAPITAL LETTERS © Prime Therapeutics LLC 06/21 Product names listed are the property of their respective owners. Page 8 of 8