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2018 Rx4 Traditional Annual Changes

Effective January 1, 2018

Para visualizarlo en español, haga clic aquí. To view your full Drug List, click here.

Welcome to Humana

The enclosed formulary, or Drug List, changes are effective January 1, 2018. Please visit Humana.com and log in to MyHumana– your personal, secure online account – on or after your renewal date to view specific prescription medicine benefits, including copayments or cost-share, limitations and exclusions. You also can refer to your Certificate of Coverage/Insurance or Summary Plan Description/Policy of Insurance.

If you have questions: • Prospective members: Call the Customer Care number listed in your enrollment materials • Current members: Call the number on the back of your Humana member ID card

How to read your annual Drug List changes

Some covered medicines may have additional requirements or limits on coverage. Talk to your doctor or healthcare provider if your medicine has an additional requirement. These requirements and limits may include:

Coverage status (CVG): Certain medicines that were previously not covered under your plan benefits will be added to your Drug List for 2018, while other medicines that may have been covered in the past will be removed. Please note that if you fill or refill any medicine that is not covered under your plan benefits, you may have to pay the full cost of your prescription. + CVG (addition); CVG (no change); - CVG (removal)

Prior authorization (PA): Some medicines need to be approved in advance to be covered under your pharmacy plan. For these medicines to be covered, your doctor must get approval or prior authorization from Humana. Your plan benefits won’t cover this medicine without prior authorization. Should you get the medicine first without the prior authorization, it would cost the full price. + PA (addition); +PA* (addition applies only to new prescriptions); PA (no change); - PA (removal)

Quantity limits (QL): You may have a limit on how much you can get of some medicines at one time. These limits can be placed on some medicines because of safety or healthcare concerns and help prevent misuse of these medicines. + QL (addition); QL (no change); - QL (removal)

Step therapy (ST): Sometimes more than one medicine works to treat a health condition. Some medicines may cost less but still work for you. Before a prescription is filled for a medicine that costs more, you may be asked to try at least one other medicine first. + ST (addition); +ST* (addition applies only to new prescriptions); ST (no change); - ST (removal)

Humana.com

GCHJBLZEN 1017 Page 1 of 23 Drug Name Formulary Status Alternatives acetaminophen-caffeine-dihydrocodeine CVG, -Tier (3/4), acetaminophen-caffeine- QL dihydrocodeine ; hydrocodone- acetaminophen tablet; oxycodone- acetaminophen tablet acetylcysteine capsule -CVG Consult Your Physician Afluria 2016-2017 (PF) intramuscular -CVG Consult Your Physician Afluria 2016-2017 intramuscular -CVG Consult Your Physician Afluria Quad 2016-2017 (PF) intramuscular syringe -CVG Consult Your Physician Afluria Quad 2016-2017 intramuscular suspension -CVG Consult Your Physician Airshield effervescent tablet -CVG Consult Your Physician AK-Poly-Bac eye ointment CVG, -Tier (1/2) polymyxin B sulfate-trimethoprim eye drops Aldara topical packet CVG, +Tier (4/2), Consult Your Physician QL alendronate oral CVG, +Tier (3/2), Consult Your Physician QL Alkeran tablet CVG, -Tier (2/3), Consult Your Physician QL alogliptin tablet CVG, +ST, QL Januvia tablet; Tradjenta tablet alogliptin-metformin tablet CVG, +ST, QL Janumet tablet; Janumet XR tablet,extended release; Jentadueto tablet; Jentadueto XR tablet, extended release; alogliptin-pioglitazone tablet CVG, +ST, QL Januvia tablet; Tradjenta tablet; Onglyza tablet; Nesina tablet; pioglitazone tablet Alomide eye drops CVG, +ST cromolyn eye drops; azelastine eye drops; Pazeo eye drops; olopatadine eye drops; epinastine eye drops Alprazolam Intensol oral concentrate CVG, -Tier (1/2) buspirone tablet alprazolam tablet CVG, -Tier (1/2), buspirone tablet QL Alprolix intravenous solution CVG, +PA Consult Your Physician ALZ tablet,extended release -CVG Consult Your Physician Ambien CR tablet,extended release CVG, +Tier (3/2), Consult Your Physician ST, QL amlodipine-valsartan tablet CVG, +Tier (3/2), Consult Your Physician -ST, QL amoxicillin ER tablet,extended release 24hr mphase CVG, -Tier (2/3) amoxicillin tablet; ampicillin capsule; dicloxacillin capsule Analpram-HC rectal cream CVG, -Tier (3/4) Consult Your Physician Androderm 24 hour patch CVG, -ST, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal pump; AndroGel transdermal gel packet AndroGel transdermal gel packet CVG, -ST, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet

GCHJBLZEN 1017 Page 2 of 23 Drug Name Formulary Status Alternatives AndroGel transdermal gel packet CVG, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet AndroGel transdermal gel pump CVG, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet AndroGel transdermal gel pump CVG, -ST, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet Anti-Allergy Formula tablet -CVG Consult Your Physician Apatate oral -CVG Consult Your Physician Arginaid Extra oral liquid -CVG Consult Your Physician Arginaid oral packet -CVG Consult Your Physician aspirin-caffeine-dihydrocodeine capsule CVG, -Tier (3/4), hydrocodone-acetaminophen tablet; QL oxycodone-acetaminophen tablet; hydrocodone-ibuprofen tablet astaxanthin capsule -CVG Consult Your Physician Atabex EC tablet,delayed release CVG, -Tier (1/2) Trinatal GT tablet; Prenatal Plus DHA oral pack; Prenatal 19 chewable tablet Atralin topical gel CVG, -ST, +PA tretinoin topical gel; adapalene atropine eye drops CVG, -Tier (1/2) cyclopentolate eye drops Atrovent CVG, +Tier (3/2), Consult Your Physician QL Auvi-Q ,auto-injector CVG, +Tier (4/3), Consult Your Physician PA, +QL Auvi-Q injection,auto-injector CVG, +Tier (4/3), Consult Your Physician PA, QL Avita topical cream CVG, +PA tretinoin topical cream; tretinoin topical gel; adapalene lotion Avita topical gel CVG, +PA tretinoin topical cream; tretinoin topical gel; adapalene lotion Avodart capsule CVG, +Tier (3/2), Consult Your Physician ST, QL Axiron transderm solution in metered pump CVG, -ST, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet Azilect tablet CVG, -Tier (3/4), pramipexole tablet; ropinirole tablet; PA selegiline tablet B-12 Compliance injection kit CVG, -Tier (1/2) Consult Your Physician BabyBIG intravenous solution CVG, -PA Consult Your Physician Baby's Only Dairy oral powder -CVG Consult Your Physician Baby's Only Org LactoRelief oral powder -CVG Consult Your Physician Baby's Only Organic Dairy oral powder -CVG Consult Your Physician Baby's Only Organic Dairy Whey oral powder -CVG Consult Your Physician Baby's Only Organic Soy oral powder -CVG Consult Your Physician Balanced Nutritional oral liquid -CVG Consult Your Physician Balanced Nutritional Plus oral liquid -CVG Consult Your Physician

GCHJBLZEN 1017 Page 3 of 23 Drug Name Formulary Status Alternatives Basaglar KwikPen subcutaneous CVG, +ST, -PA Lantus subcutaneous solution; Lantus Solostar subcutaneous insulin pen; Toujeo SoloStar subcutaneous insulin pen; Levemir FlexTouch subcutaneous insulin pen; Tresiba FlexTouch U-100 subcutaneous insulin pen Beef-Potatoes-Peas oral liquid -CVG Consult Your Physician Benecalorie oral liquid -CVG Consult Your Physician betamethasone dipropionate lotion CVG, -Tier (2/3) triamcinolone acetonide lotion; mometasone topical solution; hydrocortisone lotion betamethasone dipropionate topical cream CVG, -Tier (2/3) triamcinolone acetonide topical cream; mometasone topical cream; betamethasone valerate topical cream; hydrocortisone topical cream; betamethasone dipropionate topical ointment CVG, -Tier (2/3) triamcinolone acetonide topical ointment; mometasone topical ointment; betamethasone valerate topical ointment; hydrocortisone topical ointment; Betapace AF tablet CVG, -Tier (3/4) Sotalol AF tablet Betapace tablet CVG, -Tier (3/4) sotalol tablet; Sorine tablet Beyaz tablet CVG, -Tier (2/3) Safyral tablet Bifera Rx tablet CVG, -Tier (2/3) FE C Plus tablet; Poly-Iron 150 Forte capsule; Ferrocite Plus tablet Bioflex tablet -CVG Consult Your Physician Biotalan Clear oral liquid -CVG Consult Your Physician Biotin 100+10 tablet -CVG Consult Your Physician Biotin Plus Keratin tablet -CVG Consult Your Physician Boost Breeze Nutritional oral liquid -CVG Consult Your Physician Boost Calorie Smart oral liquid -CVG Consult Your Physician Boost Compact oral liquid -CVG Consult Your Physician Boost High Protein oral liquid -CVG Consult Your Physician Boost Kid Essentials oral liquid -CVG Consult Your Physician Boost Kid Essentials with Fiber oral liquid -CVG Consult Your Physician Boost oral liquid -CVG Consult Your Physician Boost Plus oral liquid -CVG Consult Your Physician Boost Pudding -CVG Consult Your Physician Boost VHC oral liquid -CVG Consult Your Physician Brain Might-DHA-Co Q10 tablet -CVG Consult Your Physician Breakfast Essentials oral liquid -CVG Consult Your Physician Bright Beginnings Soy oral liquid -CVG Consult Your Physician buprenorphine HCl sublingual tablet CVG, +Tier (3/2), Consult Your Physician PA, QL butalbital-acetaminophen tablet CVG, -Tier (2/3), tramadol tablet; tramadol- QL acetaminophen tablet butalbital-acetaminophen-caffeine capsule CVG, -Tier (2/3), butalbital-acetaminophen-caffeine QL tablet; tramadol tablet; tramadol- acetaminophen tablet

GCHJBLZEN 1017 Page 4 of 23 Drug Name Formulary Status Alternatives butalbital-acetaminophen-caffeine-codeine capsule CVG, +Tier (3/2), Consult Your Physician QL calcitriol oral solution CVG, -Tier (2/3) ergocalciferol (vitamin D2) capsule; Vitamin D2 capsule; calcitriol capsule calcium acetate capsule CVG, +Tier (3/2) Consult Your Physician calcium acetate tablet CVG, +Tier (3/2) Consult Your Physician Capacet capsule CVG, -Tier (2/3), butalbital-acetaminophen-caffeine QL tablet; tramadol tablet; tramadol- acetaminophen tablet Capex CVG, -Tier (2/3) triamcinolone acetonide lotion; mometasone topical solution; betamethasone valerate lotion; hydrocortisone lotion; captopril-hydrochlorothiazide tablet CVG, +Tier (3/2) Consult Your Physician carbidopa tablet CVG, -Tier (3/4) carbidopa-levodopa tablet; carbidopa- levodopa ER tablet,extended release; carbidopa-levodopa-entacapone tablet Chewables Multivitamins-A,B,D,E,K,Zn tablet -CVG Consult Your Physician Children's Omega-3 with dha-epa chewable tablet -CVG Consult Your Physician choline dihydrogen citrate tablet -CVG Consult Your Physician ciclopirox topical suspension CVG, -Tier (2/3) clotrimazole topical solution; ketoconazole topical cream; nystatin topical cream CLA capsule -CVG Consult Your Physician clindamycin-tretinoin topical gel CVG, +ST Onexton topical gel; Acanya topical gel with pump; sulfacetamide sodium (acne) lotion (suspension); clindamycin-benzoyl peroxide topical gel; clozapine tablet CVG, +Tier (3/2) Consult Your Physician Clozaril tablet CVG, +Tier (4/2) Consult Your Physician C-Nate DHA capsule CVG, -Tier (2/3) Trinatal GT tablet; Prenatal Plus DHA oral pack; Prenatal 19 chewable tablet coconut oil capsule -CVG Consult Your Physician Collagen Plus Vitamin C capsule -CVG Consult Your Physician Compleat oral liquid -CVG Consult Your Physician Compleat Pediatric oral liquid -CVG Consult Your Physician Compleat Pediatric Reduced Calorie oral liquid -CVG Consult Your Physician Complete Nutrition oral liquid -CVG Consult Your Physician Complete Nutrition Plus oral liquid -CVG Consult Your Physician Complete Nutritional Drink oral liquid -CVG Consult Your Physician Core Essentials oral liquid -CVG Consult Your Physician Core Essentials Peptide oral liquid -CVG Consult Your Physician Cormax scalp solution CVG, -Tier (2/4) triamcinolone acetonide lotion; mometasone topical solution; betamethasone valerate lotion; hydrocortisone lotion; Coromega oral packet -CVG Consult Your Physician

GCHJBLZEN 1017 Page 5 of 23 Drug Name Formulary Status Alternatives Curosurf intratracheal suspension CVG, -Tier (3/4) Consult Your Physician Cyclomydril eye drops CVG, -Tier (2/3) cyclopentolate eye drops; atropine eye drops; tropicamide eye drops cyclopentolate eye drops CVG, +Tier (3/1) Consult Your Physician Cystagon capsule CVG, -Tier (3/4) Consult Your Physician Cystex Cranberry oral liquid -CVG Consult Your Physician Cytotine oral liquid -CVG Consult Your Physician Cytra-2 oral solution -CVG Virt-Phos 250 Neutral tablet; Phospha 250 Neutral tablet Cytra-K oral solution -CVG Virt-Phos 250 Neutral tablet; Phospha 250 Neutral tablet Daflonex-XL tablet -CVG Consult Your Physician dapsone tablet CVG, -Tier (2/3) Consult Your Physician Desoxyn tablet CVG, -Tier (3/4), Metadate ER tablet,extended QL release; Vyvanse capsule; dextroamphetamine-amphetamine tablet Dexamethasone Intensol Drops (concentrate) CVG, -Tier (2/4) methylprednisolone tablet; prednisone tablet; dexamethasone tablet; hydrocortisone tablet; Dexedrine tablet CVG, -Tier (3/4), dextroamphetamine tablet +ST, QL Diabetic Support Formula tablet -CVG Consult Your Physician diclofenac eye drops CVG, +Tier (2/1), Consult Your Physician +QL diclofenac topical drops CVG, -Tier (3/4), meloxicam tablet; ibuprofen tablet; PA naproxen tablet; diclofenac sodium tablet,delayed release; diclofenac topical gel CVG, -Tier (2/3), meloxicam tablet; ibuprofen tablet; -ST, +PA naproxen tablet; diclofenac sodium tablet,delayed release; Dilatrate-SR capsule,extended release CVG, -Tier (2/3) isosorbide mononitrate tablet; isosorbide mononitrate ER tablet,extended release 24 hr; isosorbide dinitrate tablet Dolophine tablet CVG, -Tier (2/3), methadone tablet; morphine ER QL tablet,extended release; fentanyl doxepin topical cream CVG, +PA triamcinolone acetonide topical cream; mometasone topical cream; fluticasone topical cream; betamethasone dipropionate topical cream; clobetasol topical cream doxycycline hyclate capsule CVG, +Tier (3/2) Consult Your Physician doxycycline hyclate capsule CVG, +Tier (3/2), Consult Your Physician QL doxycycline hyclate tablet CVG, +Tier (3/2) Consult Your Physician doxycycline hyclate tablet,delayed release CVG, -Tier (3/4), doxycycline hyclate capsule; +ST, QL minocycline capsule; Solodyn tablet,extended release

GCHJBLZEN 1017 Page 6 of 23 Drug Name Formulary Status Alternatives doxycycline hyclate tablet,delayed release CVG, +ST, QL doxycycline hyclate capsule; minocycline capsule; Solodyn tablet,extended release doxycycline monohydrate capsule CVG, +ST, QL doxycycline hyclate capsule; minocycline capsule; Solodyn tablet,extended release doxycycline monohydrate capsule,immediate - delay CVG, +ST, QL doxycycline hyclate capsule; release minocycline capsule; Solodyn tablet,extended release doxycycline monohydrate tablet CVG, -Tier (2/3) doxycycline hyclate capsule; minocycline capsule; Solodyn tablet,extended release drospirenone-ethinyl estradiol-levomefolate tablet CVG, +Tier (2/1) Consult Your Physician Dry Eye Formula capsule -CVG Consult Your Physician Dry Eye Omega Benefits capsule -CVG Consult Your Physician Dry Eye Omega Benefits oral liquid -CVG Consult Your Physician Duocal oral powder -CVG Consult Your Physician Duragesic transdermal patch CVG, +Tier (4/2), Consult Your Physician QL dutasteride capsule CVG, +Tier (3/2), Consult Your Physician QL Dyzbac tablet -CVG Consult Your Physician EC Matrixx tablet -CVG Consult Your Physician Effient tablet CVG, -Tier (2/3), clopidogrel tablet; Brilinta tablet +ST, QL Egg-Pro oral powder -CVG Consult Your Physician Eliphos tablet CVG, +Tier (3/2) Consult Your Physician Elon Matrix Complete tablet -CVG Consult Your Physician Embeda capsule, extend release, oral only CVG, -Tier (2/4), morphine ER tablet,extended release; +ST, QL fentanyl transdermal patch; Xtampza ER capsule sprinkle Emend capsule CVG, -Tier (3/4), aprepitant capsule PA, QL Emend capsules in a dose pack CVG, -Tier (3/4), aprepitant capsule; aprepitant PA, QL capsules in a dose pack Enfagrow Next Step oral liquid -CVG Consult Your Physician Enfagrow Toddler Next Step Non-GMO oral powder -CVG Consult Your Physician Enfagrow Toddler Next Step oral powder -CVG Consult Your Physician Ensure Active Clear oral liquid -CVG Consult Your Physician Ensure Active Heart Health oral liquid -CVG Consult Your Physician Ensure Active High Protein oral liquid -CVG Consult Your Physician Ensure Active Light oral liquid -CVG Consult Your Physician Ensure Active Muscle Health oral liquid -CVG Consult Your Physician Ensure Active Protein-Muscle oral liquid -CVG Consult Your Physician Ensure Compact oral liquid -CVG Consult Your Physician Ensure Complete oral liquid -CVG Consult Your Physician Ensure Enlive oral liquid -CVG Consult Your Physician Ensure High Protein oral liquid -CVG Consult Your Physician

GCHJBLZEN 1017 Page 7 of 23 Drug Name Formulary Status Alternatives Ensure High Protein-Muscle oral liquid -CVG Consult Your Physician Ensure Muscle Health oral liquid -CVG Consult Your Physician Ensure oral liquid -CVG Consult Your Physician Ensure oral powder -CVG Consult Your Physician Ensure Original oral liquid -CVG Consult Your Physician Ensure Plus oral liquid -CVG Consult Your Physician Ensure Pudding -CVG Consult Your Physician EO28 Splash oral liquid -CVG Consult Your Physician epinephrine injection,auto-injector CVG, -Tier (2/3), epinephrine injection,auto-injector QL epinephrine injection,auto-injector CVG, +Tier (3/2), Consult Your Physician +QL EpiPen 2-Pak injection,auto-injector CVG, -Tier (2/3), epinephrine injection,auto-injector +ST, QL EpiPen injection,auto-injector CVG, -Tier (2/3), epinephrine injection,auto-injector +ST, QL Epivir HBV oral solution CVG, -Tier (3/4), lamivudine tablet QL Escavite chewable tablet -CVG Consult Your Physician Escavite D chew tablet,immediate - delayed rel -CVG Consult Your Physician Escavite LQ oral drops -CVG Consult Your Physician Estro Vital Nutrients X-Str tablet -CVG Consult Your Physician Estroblend tablet -CVG Consult Your Physician EstroNatural tablet -CVG Consult Your Physician Estroplus tablet -CVG Consult Your Physician Evoxac capsule CVG, -Tier (3/4) cevimeline capsule Evzio injection,auto-injector CVG, +PA, QL Narcan nasal spray Exforge tablet CVG, +Tier (3/2), Consult Your Physician ST, QL Eye Omega Advantage capsule -CVG Consult Your Physician EZ Flu 16-17(Fluzon Quad Ped)(PF) intramuscular -CVG Consult Your Physician syringe kit EZ Flu 2016-17 (Afluria) (PF) intramuscular syringe kit -CVG Consult Your Physician EZ Flu 2016-17 (Fluvirin) (PF) intramuscular syringe kit -CVG Consult Your Physician ezetimibe tablet CVG, -Tier (2/3), simvastatin tablet; lovastatin tablet; ST, QL atorvastatin tablet FaBB tablet -CVG Consult Your Physician Fabior topical foam CVG, -ST, +PA tretinoin topical gel; adapalene lotion; clindamycin-benzoyl peroxide topical gel famotidine oral suspension CVG, -Tier (2/3) ranitidine tablet; famotidine tablet fentanyl transdermal patch CVG, +Tier (3/2), Consult Your Physician QL Fibersource HN oral liquid -CVG Consult Your Physician Flax, Fish and Borage Oil capsule -CVG Consult Your Physician Flector transdermal 12 hour patch CVG, -Tier (3/4), meloxicam tablet; ibuprofen tablet; PA, QL naproxen tablet; diclofenac sodium tablet,delayed release; GCHJBLZEN 1017 Page 8 of 23 Drug Name Formulary Status Alternatives Flexgen tablet -CVG Consult Your Physician Fluad 2016-2017 (65 yr and up) (PF) intramuscular -CVG Consult Your Physician syringe Fluarix Quad 2016-2017 (PF) intramuscular syringe -CVG Consult Your Physician Flublok 2016-2017 (PF) intramuscular solution -CVG Consult Your Physician Flucelvax Quad 2016-2017 (PF) intramuscular syringe -CVG Consult Your Physician fludrocortisone tablet CVG, -Tier (1/2) Consult Your Physician Flulaval Quad 2016-2017 (PF) intramuscular syringe -CVG Consult Your Physician Flulaval Quad 2016-2017 intramuscular suspension -CVG Consult Your Physician Flumist Quad 2016-2017 nasal spray syringe -CVG Consult Your Physician fluorometholone eye drops,suspension CVG, +Tier (3/2) Consult Your Physician fluphenazine oral concentrate CVG, -Tier (1/2) Consult Your Physician fluphenazine oral CVG, -Tier (1/2) Consult Your Physician fluphenazine tablet CVG, -Tier (1/3) thioridazine tablet; trifluoperazine tablet; fluphenazine oral elixir Flura-Drops oral +CVG Consult Your Physician Fluvirin 2016-2017 (PF) intramuscular syringe -CVG Consult Your Physician Fluvirin 2016-2017 intramuscular suspension -CVG Consult Your Physician Fluzone High-Dose 2016-2017 (PF) intramuscular -CVG Consult Your Physician syringe Fluzone Intraderm Quad 2016-17 (PF) intradermal -CVG Consult Your Physician syringe Fluzone Quad 2016-2017 (PF) intramuscular suspension -CVG Consult Your Physician Fluzone Quad 2016-2017 (PF) intramuscular syringe -CVG Consult Your Physician Fluzone Quad 2016-2017 intramuscular suspension -CVG Consult Your Physician Fluzone Quad Pedi 2016-17 (PF) intramuscular syringe -CVG Consult Your Physician FML Liquifilm eye drops,suspension CVG, +Tier (3/2), Consult Your Physician ST Folbee Plus tablet CVG, +Tier (3/2) Consult Your Physician Fortesta transdermal gel pump CVG, -ST, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet Gerber Good Start Grow Non-GMO oral powder -CVG Consult Your Physician Gleostine capsule CVG, -Tier (3/4), Consult Your Physician QL GlucaGen HypoKit Injection CVG, +Tier (3/2) Consult Your Physician GlycoTrol capsule -CVG Consult Your Physician Glydo mucous membrane jelly in applicator CVG, -Tier (2/3) Consult Your Physician Gmate Lancing Device CVG, +Tier (3/1) Consult Your Physician griseofulvin microsize oral suspension CVG, +Tier (3/2) Consult Your Physician Hair, Skin and Nails Advanced tablet -CVG Consult Your Physician Hair, Skin, and Nails with Biotin chewable tablet -CVG Consult Your Physician Hair-Skin-Nails (vit C-biotin) chewable tablet -CVG Consult Your Physician Hemangeol oral solution CVG, -Tier (3/4) Consult Your Physician Hematogen Forte capsule CVG, +Tier (2/1) Consult Your Physician

GCHJBLZEN 1017 Page 9 of 23 Drug Name Formulary Status Alternatives HemeTab tablet CVG, -Tier (2/3) FE C Plus tablet; Poly-Iron 150 Forte capsule; Ferrocite Plus tablet HepaGam B injection solution CVG, -PA Consult Your Physician Hi-Cal oral liquid -CVG Consult Your Physician High-Protein Nutritional Shake oral liquid -CVG Consult Your Physician HyProst capsule -CVG Consult Your Physician Icar-C Plus tablet CVG, -Tier (2/3) FE C Plus tablet; Poly-Iron 150 Forte capsule; Ferrocite Plus tablet Ictotest tablet (non-oral) -CVG Consult Your Physician imiquimod topical cream packet CVG, +Tier (3/2), Consult Your Physician QL Infasurf intratracheal suspension CVG, -Tier (3/4) Consult Your Physician Ingrezza capsule CVG, PA, +QL Consult Your Physician Integra F capsule CVG, -Tier (2/3) FE C Plus tablet; Poly-Iron 150 Forte capsule; Ferrocite Plus tablet Integra Plus capsule CVG, -Tier (2/3) FE C Plus tablet; Poly-Iron 150 Forte capsule; Ferrocite Plus tablet Intrinsi B12-Folate tablet -CVG Consult Your Physician ipratropium bromide nasal spray CVG, -Tier (1/2), Consult Your Physician QL ISOCHRON tablet,extended release CVG, -Tier (2/3) isosorbide mononitrate tablet; isosorbide mononitrate ER tablet,extended release 24 hr; isosorbide dinitrate tablet Isosource 1.5 Cal liquid for tube feed -CVG Consult Your Physician Isosource HN liquid for tube feed -CVG Consult Your Physician Jevity 1 Cal oral liquid -CVG Consult Your Physician Jevity 1.2 Cal oral liquid -CVG Consult Your Physician Jevity 1.5 Cal oral liquid -CVG Consult Your Physician K-Effervescent tablet CVG, -Tier (2/3) potassium chloride ER tablet,extended release(part/cryst); Klor-Con M20 tablet,extended release; Klor-Con Sprinkle capsule,extended release Kids Omega-3 with DHA chewable tablet -CVG Consult Your Physician Klofensaid II topical drops CVG, -Tier (3/4) meloxicam tablet; ibuprofen tablet; naproxen tablet; diclofenac sodium tablet,delayed release; Klor-Con M15 tablet,extended release CVG, +Tier (2/1) Consult Your Physician Klor-Con/EF effervescent tablet CVG, -Tier (2/3) potassium chloride ER tablet,extended release(part/cryst); Klor-Con M20 tablet,extended release; Klor-Con Sprinkle capsule,extended release K-Pax Immune Booster oral powder -CVG Consult Your Physician K-PAX oral powder -CVG Consult Your Physician lamotrigine tablets in a dose pack CVG, +Tier (3/1) Consult Your Physician Lanoxin tablet CVG, -Tier (2/3), Consult Your Physician QL

GCHJBLZEN 1017 Page 10 of 23 Drug Name Formulary Status Alternatives Lanoxin tablet CVG, -Tier (2/3) Consult Your Physician Leukeran tablet CVG, -Tier (3/4), Consult Your Physician QL leuprolide subcutaneous kit CVG, -Tier (3/4), leuprolide subcutaneous solution PA, QL Levemir FlexTouch subcutaneous insulin pen CVG, -Tier (2/3) Lantus subcutaneous solution; Lantus Solostar subcutaneous insulin pen; Toujeo SoloStar subcutaneous insulin pen Levemir subcutaneous solution CVG, -Tier (2/3) Lantus subcutaneous solution; Lantus Solostar subcutaneous insulin pen; Toujeo SoloStar subcutaneous insulin pen levorphanol tartrate tablet CVG, -Tier (3/4), morphine immediate release tablet; QL oxycodone tablet; hydromorphone tablet levothyroxine tablet CVG, -Tier (1/2) Consult Your Physician Levoxyl tablet CVG, -Tier (1/2) Consult Your Physician lidocaine mucosal jelly CVG, -Tier (2/3) Consult Your Physician lidocaine mucous membrane jelly in applicator CVG, -Tier (2/3) Consult Your Physician lidocaine topical ointment CVG, -Tier (3/4), lidocaine mucosal jelly; lidocaine- +PA prilocaine topical cream lidocaine-prilocaine topical cream CVG, -Tier (2/3) Consult Your Physician lidocaine-prilocaine topical kit CVG, -Tier (2/4) Consult Your Physician linezolid oral suspension CVG, +Tier (4/3), Consult Your Physician QL linezolid tablet CVG, +Tier (4/3), Consult Your Physician QL Lipotriad Dry Eye capsule,delayed release -CVG Consult Your Physician Liquid Hope oral -CVG Consult Your Physician Liquid Nutrition oral -CVG Consult Your Physician Liquid Nutrition Plus oral -CVG Consult Your Physician Lister-V capsule -CVG Consult Your Physician L-Methyl-MC tablet -CVG Consult Your Physician lomustine capsule CVG, -Tier (3/4), Consult Your Physician QL Lorazepam Intensol oral concentrate CVG, -Tier (1/2), buspirone tablet QL Lovaza capsule CVG, -ST, +PA, QL gemfibrozil tablet; fenofibrate tablet; fenofibrate micronized capsule Lukaid GLA for Asthma oral -CVG Consult Your Physician MAXIMUM DAILY GREEN tablet -CVG Consult Your Physician Mebolex tablet -CVG Consult Your Physician Megavite Golden Years 55+ tablet -CVG Consult Your Physician Megavite tablet -CVG Consult Your Physician melphalan tablet CVG, -Tier (2/3), Consult Your Physician QL

GCHJBLZEN 1017 Page 11 of 23 Drug Name Formulary Status Alternatives memantine tablets in a dose pack CVG, +Tier (3/2), Consult Your Physician QL Mestinon tablet CVG, +Tier (4/3) Consult Your Physician Metafolbic tablet -CVG Consult Your Physician metaproterenol tablet CVG, -Tier (1/3) Consult Your Physician methadone tablet CVG, -Tier (2/3), Consult Your Physician QL metoprolol tartrate tablet CVG, +Tier (2/1) Consult Your Physician Metrogel Vaginal CVG, +Tier (4/3) Consult Your Physician Minitran transdermal 24 hour patch CVG, +Tier (3/2), Consult Your Physician QL minocycline ER tablet,extended release 24 hr CVG, +ST, -PA, QL doxycycline hyclate capsule; minocycline capsule; Solodyn tablet,extended release Minus Weight Plus Energy capsule -CVG Consult Your Physician Mondoxyne NL capsule CVG, -Tier (3/4), doxycycline hyclate capsule; +ST, QL minocycline capsule; Solodyn tablet,extended release Monogen oral powder -CVG Consult Your Physician Morgidox capsule CVG, +Tier (4/2), Consult Your Physician QL Morgidox capsule CVG, +Tier (4/2) Consult Your Physician Multi-Vit with Fluoride and Iron oral drops -CVG Consult Your Physician Mvc-Fluoride chewable tablet -CVG Consult Your Physician MyKidz Iron Fluoride oral suspension -CVG Consult Your Physician Myleran tablet CVG, -Tier (2/4), Consult Your Physician QL Mynatal capsule CVG, -Tier (1/2) Trinatal GT tablet; Prenatal Plus DHA oral pack; Prenatal 19 chewable tablet Mynephrocaps capsule CVG, +Tier (3/2) Consult Your Physician MyoCalm tablet -CVG Consult Your Physician Mytesi tablet,delayed release CVG, -Tier (3/4), Consult Your Physician PA, QL naloxone injection syringe CVG, +Tier (4/2) Consult Your Physician Namenda Titration Pak tablets in a dose pack CVG, +Tier (3/2), Consult Your Physician ST, QL naproxen oral suspension CVG, -Tier (2/3) meloxicam tablet; naproxen tablet; ibuprofen tablet Natesto nasal gel pump CVG, -ST, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet Natrol Omega-3 chewable tablet -CVG Consult Your Physician Neosporin GU Irrigant CVG, -Tier (3/4) Consult Your Physician Nephro-Vite Rx tablet +CVG Consult Your Physician Neptazane tablet CVG, -Tier (2/3) Consult Your Physician Nestabs DHA oral pack CVG, -Tier (2/3) Trinatal GT tablet; Prenatal Plus DHA oral pack; Prenatal 19 chewable tablet Neulasta subcutaneous syringe CVG, PA, +QL Consult Your Physician

GCHJBLZEN 1017 Page 12 of 23 Drug Name Formulary Status Alternatives Neurepa capsule -CVG Consult Your Physician Nicadan ZX tablet -CVG Consult Your Physician Nicaprin tablet -CVG Consult Your Physician nifedipine capsule CVG, +Tier (3/2) Consult Your Physician nitroglycerin sublingual tablet CVG, -Tier (1/3) Consult Your Physician Nitrostat sublingual tablet CVG, -Tier (1/3) Consult Your Physician Norinyl 1+50 (28) tablet CVG, -Tier (2/3) Necon 0.5/35 (28) tablet; Alyacen 1/35 (28) tablet; Gildagia tablet No-Stick Glucose strips -CVG Consult Your Physician Nourish oral liquid -CVG Consult Your Physician NP Thyroid tablet CVG, -Tier (1/3) Consult Your Physician Nutra Pro High Protein oral powder -CVG Consult Your Physician Nutrafit oral liquid -CVG Consult Your Physician Nutrafit Plus oral liquid -CVG Consult Your Physician Nutrament oral liquid -CVG Consult Your Physician Nutri-Drink oral liquid -CVG Consult Your Physician Nutrition Plus oral liquid -CVG Consult Your Physician Nutritional Drink oral liquid -CVG Consult Your Physician Nutritional Drink Plus oral liquid -CVG Consult Your Physician Nutritional Shake oral liquid -CVG Consult Your Physician Nutritional Shake Plus oral liquid -CVG Consult Your Physician Nutritional Supplement (lactose-free) oral liquid -CVG Consult Your Physician Nutritional Supplement oral liquid -CVG Consult Your Physician Nutritional Supplement Plus oral liquid -CVG Consult Your Physician O-Cal FA tablet CVG, -Tier (1/2) Trinatal GT tablet; Prenatal Plus DHA oral pack; Prenatal 19 chewable tablet O-Cal Prenatal tablet CVG, -Tier (1/2) Trinatal GT tablet; Prenatal Plus DHA oral pack; Prenatal 19 chewable tablet Ocean Blue Prenatal DHA capsule -CVG Consult Your Physician Ocuflox eye drops CVG, +Tier (3/2) Consult Your Physician ofloxacin eye drops CVG, +Tier (3/2) Consult Your Physician olopatadine eye drops CVG, -ST Consult Your Physician olopatadine eye drops CVG, +Tier (3/2), Consult Your Physician -ST Olux-E topical foam CVG, -Tier (3/4), ST triamcinolone acetonide topical cream; mometasone topical cream; betamethasone valerate topical cream; hydrocortisone topical cream; Omega-3 + Vitamin D3 chewable tablet -CVG Consult Your Physician omega-3 acid ethyl esters capsule CVG, +PA, QL gemfibrozil tablet; fenofibrate tablet; fenofibrate micronized capsule Omega-3 Fish Oil capsule -CVG Consult Your Physician omega3-dha-epa-other omega3s-fish oil chewable -CVG Consult Your Physician tablet Omnipred eye drops,suspension CVG, +Tier (3/2), Consult Your Physician ST One Daily tablet -CVG Consult Your Physician

GCHJBLZEN 1017 Page 13 of 23 Drug Name Formulary Status Alternatives One Daily Women's Metabolism tablet -CVG Consult Your Physician Opana ER tablet, crush resistant, ext. rel. CVG, -Tier (2/4), morphine ER tablet,extended +ST, QL release; fentanyl transdermal patch; Xtampza ER capsule sprinkle Orange Chicken-Carrots-Brown Rice oral liquid -CVG Consult Your Physician Orap tablet CVG, +Tier (3/2) Consult Your Physician Organic PediaSmart oral powder -CVG Consult Your Physician Ostera tablet -CVG Consult Your Physician oxycodone-acetaminophen oral solution CVG, -Tier (2/3), hydrocodone-acetaminophen tablet; QL oxycodone-acetaminophen tablet; hydrocodone-ibuprofen tablet Pancrelipase 5000 capsule,delayed release CVG, -Tier (2/4) Creon capsule,delayed release; Zenpep capsule,delayed release Pandel topical cream CVG, -Tier (3/4) triamcinolone acetonide topical cream; mometasone topical cream; betamethasone valerate topical cream; hydrocortisone topical cream; Patanol eye drops CVG, +Tier (3/2), Consult Your Physician ST Pediasure Enteral oral liquid -CVG Consult Your Physician PediaSure Enteral with Fiber 1.0 oral liquid -CVG Consult Your Physician PediaSure oral liquid -CVG Consult Your Physician PediaSure Shake Mix oral powder -CVG Consult Your Physician Pediasure Sidekicks Clear oral liquid -CVG Consult Your Physician PediaSure Sidekicks oral liquid -CVG Consult Your Physician PediaSure with Fiber oral liquid -CVG Consult Your Physician Pediatric Balanced Nutrition oral liquid -CVG Consult Your Physician Pediatric Drink With Fiber oral liquid -CVG Consult Your Physician Pentasa capsule,controlled release CVG, +PA, QL sulfasalazine tablet; sulfasalazine tablet,delayed release; Lialda tablet,delayed release; Apriso capsule,extended release; Phlexy-Vits oral packet -CVG Consult Your Physician Phoslyra oral solution CVG, +ST calcium acetate capsule; Renvela tablet; Auryxia tablet; Renvela oral powder packet; pimozide tablet CVG, +Tier (3/2) Consult Your Physician PoDiaPN capsule -CVG Consult Your Physician Portagen oral powder -CVG Consult Your Physician potassium bicarbonate and chloride effervescent tablet CVG, -Tier (2/3) potassium chloride ER tablet,extended release(part/cryst); Klor-Con M20 tablet,extended release; Klor-Con Sprinkle capsule,extended release potassium bicarbonate-citric acid effervescent tablet CVG, -Tier (1/3) potassium chloride ER tablet,extended release(part/cryst); Klor-Con M20 tablet,extended release; Klor-Con Sprinkle capsule,extended release

GCHJBLZEN 1017 Page 14 of 23 Drug Name Formulary Status Alternatives potassium chloride ER tablet,extended release(part/ CVG, +Tier (2/1) Consult Your Physician cryst) Pred Forte eye drops,suspension CVG, +Tier (3/2), Consult Your Physician ST prednisolone acetate eye drops,suspension CVG, +Tier (3/2) Consult Your Physician prednisolone oral solution CVG, -Tier (2/3) prednisolone sodium phosphate oral solution; prednisone oral solution; prednisolone oral solution PreNata chewable tablet CVG, -Tier (1/3) Trinatal GT tablet; Prenatal Plus DHA oral pack; Prenatal 19 chewable tablet Proctofoam HC CVG, -Tier (3/4) Consult Your Physician Procto-Pak topical cream perineal applicator CVG, -Tier (2/4) Consult Your Physician Prosight with Lutein capsule -CVG Consult Your Physician Prostate PQ tablet -CVG Consult Your Physician Protein Nutritional Shake oral liquid -CVG Consult Your Physician Protopic topical ointment CVG, -Tier (3/4) triamcinolone acetonide topical ointment; mometasone topical ointment; tacrolimus topical ointment; Elidel topical cream; Proxeed Plus oral powder packet -CVG Consult Your Physician Prudoxin topical cream CVG, +PA triamcinolone acetonide topical cream; mometasone topical cream; fluticasone topical cream; betamethasone dipropionate topical cream; clobetasol topical cream pyridostigmine bromide tablet CVG, -Tier (2/3) donepezil tablet; donepezil tablet dissolved on the tongue Qudexy XR capsule sprinkle,extended release CVG, -Tier (3/4), lamotrigine tablet; topiramate ST, QL tablet; divalproex tablet,delayed release quetiapine ER tablet,extended release 24 hr CVG, +Tier (4/3), Consult Your Physician PA, QL Quflora Pediatric chewable tablet -CVG Consult Your Physician Quflora Pediatric Drops oral -CVG Consult Your Physician Quinoa-Kale-Hemp oral liquid -CVG Consult Your Physician Qutenza topical kit CVG, -PA, QL Consult Your Physician Rajani tablet CVG, +Tier (2/1) Consult Your Physician rasagiline tablet CVG, -Tier (3/4), pramipexole tablet; ropinirole tablet; PA selegiline tablet Rayos tablet,delayed release CVG, +ST methylprednisolone tablet; prednisone tablet; dexamethasone tablet; hydrocortisone tablet; Red Wine Complex capsule -CVG Consult Your Physician Red Wine Extract capsule -CVG Consult Your Physician Red Wine Extract Plus capsule -CVG Consult Your Physician Refissa topical cream +CVG, +PA tretinoin topical cream; tretinoin topical gel Re-Gen oral liquid -CVG Consult Your Physician

GCHJBLZEN 1017 Page 15 of 23 Drug Name Formulary Status Alternatives Renal Caps capsule CVG, +Tier (3/2) Consult Your Physician Rena-Vite Rx tablet CVG, +Tier (3/2) Consult Your Physician Reno Caps capsule CVG, +Tier (3/2) Consult Your Physician RepHresh Pro-B capsule -CVG Consult Your Physician Resource 2.0 oral liquid -CVG Consult Your Physician Resource Thickenup Dairy oral liquid -CVG Consult Your Physician resveratrol-quercetin tablet -CVG Consult Your Physician resveratrol-r.wine-bioflav-grape sd-p.cusp.-C-pomg -CVG Consult Your Physician capsule Retaine OM3 capsule -CVG Consult Your Physician Retavase intravenous kit CVG, +PA Consult Your Physician Retin-A topical cream CVG, -Tier (3/4), tretinoin topical cream; tretinoin +PA topical gel; adapalene lotion Retin-A topical cream CVG, -Tier (3/4), tretinoin topical gel; adapalene +PA lotion Retin-A topical gel CVG, -Tier (3/4), tretinoin topical gel; adapalene +PA lotion Retin-A topical gel CVG, -Tier (3/4), tretinoin topical cream; tretinoin +PA topical gel; adapalene lotion Revia tablet CVG, +Tier (3/2) Consult Your Physician Rheumatrex tablets in a dose pack CVG, -Tier (2/3) methotrexate sodium tablet Rifater tablet CVG, -Tier (2/3) rifampin capsule Riomet oral solution CVG, -Tier (3/4), metformin tablet; metformin ER QL tablet,extended release 24 hr Salmon-Oats-Squash oral liquid -CVG Consult Your Physician ScandiCal oral powder -CVG Consult Your Physician Scandishake (Lactose Free) packet -CVG Consult Your Physician Scandishake oral powder -CVG Consult Your Physician Scandishake packet -CVG Consult Your Physician Sea-Omega capsule -CVG Consult Your Physician Seroquel XR tablet,extended release CVG, +Tier (4/3), Consult Your Physician PA, QL Se-Tan Plus capsule CVG, -Tier (2/3) FE C Plus tablet; Poly-Iron 150 Forte capsule; Ferrocite Plus tablet Similac Go and Grow Non-GMO oral powder -CVG Consult Your Physician Similac Go and Grow oral powder -CVG Consult Your Physician Similac Go and Grow Sensitive oral powder -CVG Consult Your Physician Sotylize oral solution CVG, -Tier (3/4) sotalol tablet; Sotalol AF tablet; Sorine tablet South African Hoodia Plus Cap capsule -CVG Consult Your Physician Sprix nasal spray CVG, -ST, +PA, QL ketorolac tablet; meloxicam tablet; hydromorphone tablet Stages Men's Multi-Vitamin tablet -CVG Consult Your Physician Striant buccal system,sustained release CVG, -Tier (3/4), testosterone cypionate -ST, +PA intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet Super Omega-3 capsule -CVG Consult Your Physician GCHJBLZEN 1017 Page 16 of 23 Drug Name Formulary Status Alternatives Suprane liquid CVG, -Tier (3/4) Consult Your Physician Survanta intratracheal suspension CVG, -Tier (3/4) Consult Your Physician Synalgos-DC capsule CVG, -Tier (3/4), hydrocodone-acetaminophen tablet; QL oxycodone-acetaminophen tablet; hydrocodone-ibuprofen tablet Tandem Plus capsule CVG, -Tier (2/3) FE C Plus tablet; Poly-Iron 150 Forte capsule; Ferrocite Plus tablet Targadox tablet CVG, +ST, QL doxycycline hyclate capsule; minocycline capsule; Solodyn tablet,extended release Tart Cherry capsule -CVG Consult Your Physician tazarotene topical cream CVG, -ST, +PA Consult Your Physician Tazorac topical cream CVG, -ST, +PA Consult Your Physician Tazorac topical gel CVG, -ST, +PA adapalene topical gel; tretinoin topical gel telmisartan tablet CVG, -ST, QL Consult Your Physician Tencon tablet CVG, -Tier (2/3), tramadol tablet; tramadol- QL acetaminophen tablet terbinafine HCl tablet +CVG, QL Consult Your Physician terbutaline tablet CVG, -Tier (2/3) Consult Your Physician Testim transdermal gel CVG, -ST, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet testosterone transderm solution in metered pump CVG, -ST, +PA, QL Consult Your Physician testosterone transdermal gel CVG, -ST, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet testosterone transdermal gel packet CVG, -ST, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet testosterone transdermal gel pump CVG, -ST, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet TexaVite LQ oral drops -CVG Consult Your Physician Theochron tablet,extended release CVG, -Tier (1/2) Consult Your Physician theophylline oral elixir CVG, -Tier (2/3) Consult Your Physician theophylline oral solution CVG, -Tier (2/3) Consult Your Physician Thera Tears Nutrition capsule -CVG Consult Your Physician Thermazene topical cream CVG, -Tier (2/3) silver sulfadiazine topical cream ThickenUp Apple Honey oral liquid -CVG Consult Your Physician ThickenUp Apple Nectar oral liquid -CVG Consult Your Physician Thickenup Cranberry Honey oral liquid -CVG Consult Your Physician Thickenup Cranberry Nectar oral liquid -CVG Consult Your Physician ThickenUp Orange Honey oral liquid -CVG Consult Your Physician ThickenUp Orange Nectar oral liquid -CVG Consult Your Physician

GCHJBLZEN 1017 Page 17 of 23 Drug Name Formulary Status Alternatives thiothixene capsule CVG, -Tier (2/3) Consult Your Physician Thrombate III intravenous solution CVG, +PA Consult Your Physician Tindamax tablet CVG, +Tier (3/2) Consult Your Physician tinidazole tablet CVG, +Tier (3/2) Consult Your Physician TL Icon capsule CVG, +Tier (2/1) Consult Your Physician TL-ICare capsule -CVG Consult Your Physician Tolak topical cream CVG, -Tier (3/4) fluorouracil topical solution Tonalin CLA capsule -CVG Consult Your Physician topiramate XR capsule sprinkle,ext.release 24 hr CVG, -Tier (3/4), lamotrigine tablet; topiramate ST, QL tablet; divalproex tablet,delayed release Tozal capsule -CVG Consult Your Physician tramadol ER tablet,extended release 24 hr CVG, +Tier (3/2), Consult Your Physician ST, QL Tresiba FlexTouch U-100 subcutaneous insulin pen CVG, -Tier (2/3) Lantus subcutaneous solution; Lantus Solostar subcutaneous insulin pen; Toujeo SoloStar subcutaneous insulin pen Tresiba FlexTouch U-200 subcutaneous insulin pen CVG, -Tier (2/3) Lantus subcutaneous solution; Lantus Solostar subcutaneous insulin pen; Toujeo SoloStar subcutaneous insulin pen tretinoin (emollient) topical cream +CVG, +PA tretinoin topical cream; tretinoin topical gel tretinoin topical cream CVG, +PA tretinoin topical cream; adapalene lotion tretinoin topical cream CVG, +PA Consult Your Physician tretinoin topical gel CVG, +PA Consult Your Physician tretinoin topical gel CVG, +PA tretinoin topical gel; adapalene lotion tretinoin topical gel CVG, +PA tretinoin topical cream; adapalene lotion TRETIN-X topical cream CVG, -Tier (3/4), tretinoin topical cream; tretinoin -ST, +PA topical gel; adapalene lotion Trezix capsule CVG, -Tier (3/4), acetaminophen-caffeine- QL dihydrocodeine tablet; hydrocodone- acetaminophen tablet; oxycodone- acetaminophen tablet triamcinolone acetonide topical aerosol CVG, -Tier (3/4), triamcinolone acetonide topical ST cream; mometasone topical cream; betamethasone valerate topical cream; hydrocortisone topical cream; Trigels-F Forte capsule CVG, +Tier (2/1) Consult Your Physician Trinate tablet CVG, -Tier (1/2) Trinatal GT tablet; Prenatal Plus DHA oral pack; Prenatal 19 chewable tablet Triphrocaps capsule CVG, +Tier (3/2) Consult Your Physician

GCHJBLZEN 1017 Page 18 of 23 Drug Name Formulary Status Alternatives Tri-Tabs DHA oral pack CVG, -Tier (2/3) Trinatal GT tablet; Prenatal Plus DHA oral pack; Prenatal 19 chewable tablet Trombonex capsule -CVG Consult Your Physician Trombonex-D capsule -CVG Consult Your Physician TwoCal HN oral liquid -CVG Consult Your Physician Tyzine nasal drops CVG, -Tier (2/3) Consult Your Physician Tyzine nasal spray CVG, -Tier (2/3) Consult Your Physician Uceris rectal foam CVG, -Tier (3/4), "hydrocortisone PA ; Colocort enema" Ultra Men's Pack oral pack -CVG Consult Your Physician Ultra Omega-3 capsule -CVG Consult Your Physician Ultram ER tablet,extended release CVG, +Tier (3/2), Consult Your Physician -ST, QL Ultramino oral powder -CVG Consult Your Physician Ultresa capsule,delayed release CVG, -Tier (3/4), Creon capsule,delayed release; ST Zenpep capsule,delayed release Urinozinc Prostate Formula capsule -CVG Consult Your Physician UTI-Stat oral liquid -CVG Consult Your Physician valacyclovir tablet CVG, -Tier (2/4), Consult Your Physician QL valproic acid capsule CVG, +Tier (2/1) Consult Your Physician Valtrex tablet CVG, -Tier (3/4), famciclovir tablet; acyclovir tablet; QL valacyclovir tablet Vandazole vaginal gel CVG, -Tier (2/3) clindamycin capsule Vasoflex capsule -CVG Consult Your Physician Vasoflex Forte capsule -CVG Consult Your Physician Vasoflex tablet -CVG Consult Your Physician Veltin topical gel CVG, +Tier (4/3), Consult Your Physician ST verapamil ER (PM) capsule 24hr pellet CT,ext.release CVG, +Tier (3/2), Consult Your Physician QL Verdrocet tablet CVG, +Tier (3/2), Consult Your Physician QL Verelan PM capsule, extended release CVG, +Tier (3/2), Consult Your Physician QL Vesicare tablet CVG, +ST, QL oxybutynin chloride ER tablet,extended release 24 hr; Toviaz tablet,extended release; Myrbetriq tablet,extended release; tolterodine ER capsule,extended release 24 hr; trospium ER capsule,extended release 24 hr Vibramycin capsule CVG, +Tier (3/2), Consult Your Physician QL Vigraplex tablet -CVG Consult Your Physician Virt Nate tablet CVG, -Tier (1/2) Trinatal GT tablet; Prenatal Plus DHA oral pack; Prenatal 19 chewable tablet

GCHJBLZEN 1017 Page 19 of 23 Drug Name Formulary Status Alternatives Virt-Caps capsule CVG, +Tier (3/2) Consult Your Physician Virt-Nate tablet CVG, -Tier (1/2) Trinatal GT tablet; Prenatal Plus DHA oral pack; Prenatal 19 chewable tablet Virt-Vite Plus tablet CVG, +Tier (3/2) Consult Your Physician Vital High Nitrogen oral packet -CVG Consult Your Physician Vital-D Rx tablet CVG, +Tier (3/2) Consult Your Physician VitaMed Md Plus Rx oral pack CVG, -Tier (2/3) Trinatal GT tablet; Prenatal Plus DHA oral pack; Prenatal 19 chewable tablet Vitamin D3 Complete tablet -CVG Consult Your Physician Vogelxo transdermal gel CVG, -ST, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet Vogelxo transdermal gel packet CVG, -ST, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet Vogelxo transdermal gel pump CVG, -ST, +PA, QL testosterone cypionate intramuscular oil; AndroGel transdermal gel pump; AndroGel transdermal gel packet Vol-Care Rx tablet CVG, +Tier (3/2) Consult Your Physician Vol-Nate tablet CVG, -Tier (1/2) Trinatal GT tablet; Prenatal Plus DHA oral pack; Prenatal 19 chewable tablet Voltaren topical gel CVG, -Tier (2/3), Consult Your Physician +PA VP-Vite Rx tablet CVG, +Tier (3/2) Consult Your Physician Wellbaby DHA-Vitamin D3 oral drops -CVG Consult Your Physician Xanax tablet CVG, +Tier (3/2), Consult Your Physician QL Xartemis XR tablet extended release, oral only CVG, +ST, QL hydrocodone-acetaminophen tablet; oxycodone-acetaminophen tablet Xodol 10/300 tablet CVG, -Tier (2/3), hydrocodone-acetaminophen tablet; QL oxycodone-acetaminophen tablet; hydrocodone-ibuprofen tablet Xodol 5/300 tablet CVG, -Tier (2/3), hydrocodone-acetaminophen tablet; QL oxycodone-acetaminophen tablet; hydrocodone-ibuprofen tablet Xodol 7.5/300 tablet CVG, -Tier (2/3), hydrocodone-acetaminophen tablet; QL oxycodone-acetaminophen tablet; hydrocodone-ibuprofen tablet Xtampza ER capsule sprinkle CVG, +Tier (4/2), Consult Your Physician -ST, QL Xydra EF capsule -CVG Consult Your Physician Zetia tablet CVG, -Tier (2/3), ezetimibe tablet +ST, QL

GCHJBLZEN 1017 Page 20 of 23 Drug Name Formulary Status Alternatives Ziana topical gel CVG, +ST Onexton topical gel; Acanya topical gel with pump; sulfacetamide sodium (acne) lotion (suspension); clindamycin-benzoyl peroxide topical gel; Zohydro ER capsule, oral only,extended release CVG, +ST, -PA, QL morphine ER tablet,extended release; fentanyl transdermal patch; Xtampza ER capsule sprinkle zolpidem ER tablet,extended release,multiphase CVG, +Tier (3/2), Consult Your Physician ST, QL Zonalon topical cream CVG, +PA triamcinolone acetonide topical cream; mometasone topical cream; fluticasone topical cream; betamethasone dipropionate topical cream; clobetasol topical cream Zubsolv sublingual tablet CVG, +Tier (3/2), Consult Your Physician PA, QL Zytaze capsule -CVG Consult Your Physician Zyvox oral suspension CVG, +Tier (4/3), Consult Your Physician QL Zyvox tablet CVG, +Tier (4/3), Consult Your Physician QL

Humana Plans are offered by the Family of Insurance and Health Plan Companies including Humana Medical Plan, Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Health Plans of Michigan, Inc., Humana Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc. License # 00235-0008, Humana Wisconsin Health Organization Insurance Corporation, or Humana Health Plan of Texas, Inc. – A Health Maintenance Organization or insured by Humana Health Insurance Company of Florida, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Insurance Company, Humana Insurance Company of Kentucky, Emphesys Insurance Company, or Humana Insurance of Puerto Rico, Inc. License # 00187-0009 or administered by Humana Insurance Company or Humana Health Plan, Inc. For Arizona Residents: Offered by Humana Health Plan, Inc. or insured by Emphesys Insurance Company or insured or administered by Humana Insurance Company or Humana Health Plan, Inc. Please refer to your Benefit Plan Document (Certificate of Coverage/Insurance or Summary Plan Description) for more information on the company providing your benefits. Our health benefit plans have limitations and exclusions.

Humana.com

GCHJBLZEN 1017 Page 21 of 23 Discrimination is Against the Law

Humana Inc. and its subsidiaries (“Humana”) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Humana does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Humana provides: • Free auxiliary aids and services, such as qualified sign language interpreters, video remote interpretation, and written information in other formats to people with disabilities when such auxiliary aids and services are necessary to ensure an equal opportunity to participate. • Free language services to people whose primary language is not English when those services are necessary to provide meaningful access, such as translated documents or oral interpretation.

If you need these services, call the number on your ID card or send an email to [email protected], or if you use a TTY, call 711.

If you believe that Humana has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Discrimination Grievances P.O. Box 14618 Lexington, KY 40512 - 4618

If you need help filing a grievance, call the number on your ID card, or if you use a TTY, call 711.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800–368–1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

GCHJBLZEN 1017 Page 22 of 23 Multi-Language Interpreter Services English: ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call the number on your ID card (TTY: 711). Español (Spanish): ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al número que figura en su tarjeta de identificación (TTY: 711). (Chinese): TTY 711 繁體中文 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電會員卡上的電話號碼 （ ： ）。 Tiếng Việt (Vietnamese): CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số điện thoại ghi trên thẻ ID của quý vị (TTY: 711). (Korean): ID 한국어 주의 : 한국어를 사용하시는 경우 , 언어 지원 서비스를 무료로 이용하실 수 있습니다 . 카드에 적혀 있는 (TTY: 711) 번호로 전화해 주십시오 . Tagalog (Tagalog – Filipino): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tawagan ang numero na nasa iyong ID card (TTY: 711). Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Наберите номер, указанный на вашей карточке-удостоверении (телетайп: 711). Kreyòl Ayisyen (French Creole): ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele nimewo ki sou kat idantite manm ou (TTY: 711). Français (French): ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le numéro figurant sur votre carte de membre (ATS : 711). Polski (Polish): UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Proszę zadzwonić pod numer podany na karcie identyfikacyjnej (TTY: 711). Português (Portuguese): ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para o número presente em seu cartão de identificação (TTY: 711). Italiano (Italian): ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero che appare sulla tessera identificativa (TTY: 711). Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Wählen Sie die Nummer, die sich auf Ihrer Versicherungskarte befindet (TTY: 711). (Japanese): ID 日本語 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。お手持ちの (TTY 711) カードに記載されている電話番号までご連絡ください ： 。 :(Farsi) فارسی توجه: اگر به زبان فارسی گفتگو می کنید، تسهیالت زبانی بصورت رایگان برای شما فراھم می باشد. با شماره تلفن روی کارت شناسایی تان تماس بگیرید (TTY: 711).

:(Arabic) العربية ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم الهاتف الموجود على بطاقة الهوية الخاصة بك )رقم هاتف الصم والبكم: 711). GCHJBLZEN 1017 Page 23 of 23