Your 2017 Three-Tier Prescription Drug List effective January 1, 2017 Connecticut Advantage Three-Tier Please read: This document contains information about commonly prescribed medications. This Prescription Drug List (PDL) is accurate as of January 1, 2017 and is subject to change after this date. The next anticipated update will be in July 2017. Your estimated coverage and copay/co-insurance may vary based on the benefit plan you choose and the effective date of the plan. For additional information: Call the toll-free member phone number on your health plan ID card.

Visit myuhc.com® • Locate a participating retail pharmacy by ZIP code. • Look up possible lower-cost medication alternatives. • Compare medication pricing and options.

1 Your Prescription Drug List This Prescription Drug List (PDL) outlines covered medications for certain conditions and organizes them into cost levels, also known as tiers. An important part of the PDL is giving you choices so you and your doctor can choose the best course of treatment for you. Go to myuhc.com® for complete drug information Since the PDL may change, we encourage you to visit our website, myuhc.com. This website is the best source for up-to-date information about the medications your pharmacy benefit covers, possible lower-cost options, and cost comparisons. To view PDL information without logging on to the member portal, visit myuhc.com and select “Pharmacy Information” under “Links and Tools.”

2 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. Drugs are listed by common categories class. They are placed into cost levels known as tiers. It includes both brand and generic prescription medications approved by the U.S. 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. Please look at your benefit plan documents provided by your employer or health plan to see what medications are covered under your plan. You may also log on 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 Prescription Drug List? Bring your PDL with you when you see your doctor. When choosing a medication, you and your doctor should consult this guide. It will help you and your doctor choose the most cost-effective prescription drugs. This guide will also help you know if a medication has special programs that apply to it. When a Prescription Drug Product is excluded from coverage, you or your representative may request an exception to gain access to the excluded 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.

3 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 or 3, 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 Lower-cost drugs. Use Tier 1 drugs for the lowest Lowest Cost Some brands and generics out‑of-pocket costs. are also included.

Tier 2 Preferred brands. Use Tier 2 drugs, instead of Mid-range Cost Tier 3 to help reduce your out-of-pocket costs.

Tier 3 Higher cost brands and Many Tier 3 drugs have Highest Cost generics. lower‑cost options in Tier 1 or 2. Ask your doctor if they could work for you.

Please note: Some plans may not have any tiers. 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. When does the Prescription Drug List 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 be excluded from coverage 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.

4 Programs and Limits Your benefit plan determines how these medications are covered and may differ than what is noted in the PDL. Call the number for Member Services listed on your ID card if you have any questions about your prescription drug coverage.

Health Care Reform (HCR) 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.

Supply Limit – Amount of medication covered per copayment or in a specific time period.

Step Therapy – Trial of a lower cost medication is required before a higher cost medication is covered.

*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 visit myuhc.com or call the toll-free member phone number on your health plan ID card. Why are some medications excluded from coverage? Medications may be excluded from coverage under your pharmacy benefit when it works the same or similar as another prescription medication or an over-the-counter (OTC) medication. There may be other medication options available. Should I talk to my doctor about over-the-counter (OTC) medications? An over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your doctor about available OTC options.

5 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. Visit myuhc.com to make sure. Are you taking a specialty medication? Specialty medications are high-cost and may be used to treat rare or complex conditions. 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 UHCSpecialtyRx.com or call the toll-free phone number on your health plan ID card to learn more.

6 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 on to myuhc.com for the following pharmacy information and tools: • Pharmacy benefit and coverage information • Possible lower-cost medication options • Medication interactions and side effects • Participating retail pharmacies by zip code • Your prescription history

And, if Mail Service is included in your pharmacy benefit, you can also: • Refill prescriptions • Check the status of your order • Set-up e-mail reminders for refills • Manage your account

For more information Call the toll-free member phone number on your health plan ID card. Or, visit myuhc.com® Where else can I go for information? HealthCareLane.com includes short videos to help you learn more about UnitedHealthcare benefits and health insurance information. UHCTV.com is a fun and easy way to learn about health terms and other health-related topics.

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.

All branded medications are trademarks or registered trademarks of their respective owners.

© 2016 United HealthCare Services, Inc. All rights reserved. Created January, 2017. 2017 Prescription Drug List – Connecticut Advantage Three-Tier 1/17 7 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy 1ST BASE CRE Tier 3 X 2-DEOXY-D POW -GLUCOSE Tier 3 5-METHYLTETR POW Tier 3 X 5-METHYLTETR POW CALCIUM Tier 3 X 8-MOP CAP 10MG Tier 2 A-LIPOIC POW ACID Tier 3 X A.A.G.C KIT CRE TERODERM Tier 3 X A/G PRO TAB Tier 3 ABACA/LAMIVU TAB 600-300 Tier 1 X ABACAV/LAMIV TAB /ZIDOVUD Tier 1 X ABACAVIR TAB 300MG Tier 1 X ABILIFY TAB 10MG Tier 3 X X ABILIFY TAB 15MG Tier 3 X X ABILIFY TAB 20MG Tier 3 X X ABILIFY TAB 2MG Tier 3 X X ABILIFY TAB 30MG Tier 3 X X ABILIFY TAB 5MG Tier 3 X X ABILIFY DISC TAB 10MG Tier 3 X ABSORICA CAP 10MG Tier 3 X X ABSORICA CAP 20MG Tier 3 X X ABSORICA CAP 25MG Tier 3 X X ABSORICA CAP 30MG Tier 3 X X ABSORICA CAP 35MG Tier 3 X X ABSORICA CAP 40MG Tier 3 X X ABSTRAL SUB 100MCG Tier 3 X X X ABSTRAL SUB 200MCG Tier 3 X X X ABSTRAL SUB 300MCG Tier 3 X X X ABSTRAL SUB 400MCG Tier 3 X X X ABSTRAL SUB 600MCG Tier 3 X X X ABSTRAL SUB 800MCG Tier 3 X X X ACAMPRO CAL TAB 333MG Tier 1 ACANYA GEL 1.2-2.5% Tier 3 X X ACARBOSE TAB 100MG Tier 1 ACARBOSE TAB 25MG Tier 1 ACARBOSE TAB 50MG Tier 1 ACCOLATE TAB 10MG Tier 3 X ACCOLATE TAB 20MG Tier 3 X ACCU-CHEK KIT AVA CONN Tier 1 X 8 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ACCU-CHEK KIT AVIVA PL Tier 1 X ACCU-CHEK KIT COMPACT Tier 1 X ACCU-CHEK KIT FASTCLIX Tier 1 ACCU-CHEK KIT MLTICLIX Tier 1 ACCU-CHEK KIT NANO Tier 1 X ACCU-CHEK KIT SOFTCLIX Tier 1 ACCU-CHEK LIQ ACT/GLUC Tier 1 ACCU-CHEK LIQ SMART Tier 1 ACCU-CHEK MIS ADAPTER Tier 3 ACCU-CHEK MIS AVIVA Tier 3 X ACCU-CHEK MIS BATTERY Tier 3 ACCU-CHEK MIS CLIP Tier 3 ACCU-CHEK MIS MLTICLIX Tier 1 ACCU-CHEK MIS SPRT COM Tier 3 ACCU-CHEK SOL Tier 1 ACCU-CHEK SOL COMPACT Tier 1 ACCU-CHEK TES ACTIVE Tier 3 X X ACCU-CHEK TES AVIVA Tier 3 X X ACCU-CHEK TES AVIVA PL Tier 3 X X ACCU-CHEK TES COMPACT Tier 3 X X ACCU-CHEK TES DRUM Tier 3 X X ACCU-CHEK TES SMART Tier 3 X X ACCU-CK COMF TES CURVE Tier 3 X X ACCUPRIL TAB 10MG Tier 3 ACCUPRIL TAB 20MG Tier 3 ACCUPRIL TAB 40MG Tier 3 ACCUPRIL TAB 5MG Tier 3 ACCURETIC TAB 10-12.5 Tier 3 ACCURETIC TAB 20-12.5 Tier 3 ACCURETIC TAB 20-25MG Tier 3 ACCUTREND SOL GLUCOSE Tier 1 ACCUTREND TES GLUCOSE Tier 3 X X ACE ACD/ALUM SOL 2% OTIC Tier 1 ACEBUTOLOL CAP 200MG Tier 1 ACEBUTOLOL CAP 400MG Tier 1 ACEON TAB 4MG Tier 3 ACEON TAB 8MG Tier 3 ACETASOL HC SOL OTIC Tier 2 9 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ACETAZOLAMID CAP 500MG ER Tier 1 ACETAZOLAMID TAB 125MG Tier 1 ACETAZOLAMID TAB 250MG Tier 1 ACETIC ACID SOL 2% OTIC Tier 1 ACETYLCYST SOL 10% Tier 1 ACETYLCYST SOL 20% Tier 1 ACIDO LACTOB POW 10BU/GM Tier 3 X ACIDO LACTOB POW 1BU/GM Tier 3 X ACIDOPHILUS POW LACTOBAC Tier 3 X ACIPHEX TAB 20MG Tier 3 X X ACIPHEX SPR CAP 10MG Tier 3 X X ACIPHEX SPR CAP 5MG Tier 3 X X ACITRETIN CAP 10MG Tier 1 ACITRETIN CAP 17.5MG Tier 1 ACITRETIN CAP 25MG Tier 1 ACLOVATE CRE 0.05% Tier 3 ACTEMRA INJ 162/0.9 Tier 3 X X X X ACTICLATE TAB 150MG Tier 3 X ACTICLATE TAB 75MG Tier 3 X ACTIGALL CAP 300MG Tier 3 ACTIMMUNE INJ 2MU/0.5 Tier 2 X X X ACTIQ LOZ 1200MCG Tier 3 X X X ACTIQ LOZ 1600MCG Tier 3 X X X ACTIQ LOZ 200MCG Tier 3 X X X ACTIQ LOZ 400MCG Tier 3 X X X ACTIQ LOZ 600MCG Tier 3 X X X ACTIQ LOZ 800MCG Tier 3 X X X ACTIVE MEDIC KIT SPECIMEN Tier 1 ACTIVE OB CAP Tier 3 ACTIVE-PREP CRE KIT I Tier 3 X ACTIVE-PREP CRE KIT II Tier 3 X ACTIVE-PREP CRE KIT III Tier 3 X ACTIVE-PREP CRE KIT IV Tier 3 X ACTIVE-PREP CRE KIT V Tier 3 X ACTIVELLA TAB 0.5-0.1 Tier 3 ACTIVELLA TAB 1-0.5MG Tier 3 ACTONEL TAB 150MG Tier 3 X ACTONEL TAB 30MG Tier 3 10 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ACTONEL TAB 35MG Tier 3 X ACTONEL TAB 5MG Tier 3 ACTOPLUS MET TAB 15-500MG Tier 3 X ACTOPLUS MET TAB 15-850MG Tier 3 X ACTOPLUS MET TAB XR Tier 3 X ACTOPLUS MET TAB XR Tier 3 X ACTOS TAB 15MG Tier 3 X X ACTOS TAB 30MG Tier 3 X X ACTOS TAB 45MG Tier 3 X X ACULAR SOL 0.5% OP Tier 3 ACULAR LS SOL 0.4% Tier 3 ACUNOL TAB 600MG Tier 3 ACUVAIL SOL 0.45% Tier 3 X X ACYCLOVIR CAP 200MG Tier 1 ACYCLOVIR OIN 5% Tier 3 X X X ACYCLOVIR SUS 200/5ML Tier 1 ACYCLOVIR TAB 400MG Tier 1 ACYCLOVIR TAB 800MG Tier 1 ACZONE GEL 5% Tier 3 X ACZONE GEL 7.5% Tier 3 X ADA SHA Tier 3 X X ADALAT CC TAB 30MG ER Tier 3 ADALAT CC TAB 60MG ER Tier 3 ADALAT CC TAB 90MG ER Tier 3 ADAPALENE CRE 0.1% Tier 3 X X ADAPALENE GEL 0.1% Tier 3 X X ADAPALENE GEL 0.3% Tier 3 X X ADAPALENE GEL PMP 0.3% Tier 3 X X ADAPALENE LOT 0.1% Tier 3 X X ADAPTADERM CRE Tier 3 X ADAPTADERM GEL Tier 3 ADASUVE INH 10MG Tier 3 ADCIRCA TAB 20MG Tier 3 X X X ADDERALL TAB 10MG Tier 3 X X ADDERALL TAB 12.5MG Tier 3 X X ADDERALL TAB 15MG Tier 3 X X ADDERALL TAB 20MG Tier 3 X X ADDERALL TAB 30MG Tier 3 X X 11 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ADDERALL TAB 5MG Tier 3 X X ADDERALL TAB 7.5MG Tier 3 X X ADDERALL XR CAP 10MG Tier 2 X ADDERALL XR CAP 15MG Tier 2 X ADDERALL XR CAP 20MG Tier 2 X ADDERALL XR CAP 25MG Tier 2 X ADDERALL XR CAP 30MG Tier 2 X ADDERALL XR CAP 5MG Tier 2 X ADDYI TAB 100MG Tier 3 X X ADEFOV DIPIV TAB 10MG Tier 1 X ADEMETIONINE POW DISULFAT Tier 3 X ADEMPAS TAB 0.5MG Tier 2 X X X ADEMPAS TAB 1.5MG Tier 2 X X X ADEMPAS TAB 1MG Tier 2 X X X ADEMPAS TAB 2.5MG Tier 2 X X X ADEMPAS TAB 2MG Tier 2 X X X ADENOSINE POW Tier 3 X ADENOSINE-5 POW MONOPHOS Tier 3 X ADENOSINE-5 POW TRIPHOSP Tier 3 X ADLT ASA LOW TAB 81MG EC HCR Preventive ADOXA CAP 150MG Tier 3 X ADOXA TAB 100MG Tier 3 X ADOXA TAB 50MG Tier 3 X ADOXA TAB 75MG Tier 3 X ADOXA PAK 1/ TAB 100MG Tier 3 X ADOXA PAK 1/ TAB 150MG Tier 3 X ADOXA PAK 2/ TAB 100MG Tier 3 X ADRENACLICK INJ 0.15MG Tier 3 X X ADRENACLICK INJ 0.3MG Tier 3 X X ADRENALIN SOL 1:1000 Tier 2 ADV LANCING MIS DEVICE Tier 3 ADVAIR DISKU AER 100/50 Tier 3 X ADVAIR DISKU AER 250/50 Tier 3 X ADVAIR DISKU AER 500/50 Tier 3 X ADVAIR HFA AER 115/21 Tier 3 X ADVAIR HFA AER 230/21 Tier 3 X ADVAIR HFA AER 45/21 Tier 3 X

12 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ADVANCED BAS CRE PLUS Tier 3 X ADVANCED DNA KIT COLLECTI Tier 1 ADVATE INJ 1000UNIT Tier 3 X X X ADVATE INJ 1500UNIT Tier 3 X X X ADVATE INJ 2000UNIT Tier 3 X X X ADVATE INJ 250UNIT Tier 3 X X X ADVATE INJ 3000UNIT Tier 3 X X X ADVATE INJ 4000UNIT Tier 3 X X X ADVATE INJ 500UNIT Tier 3 X X X ADVERA LIQ CHOCOLAT Tier 3 ADVERA LIQ VANILLA Tier 3 ADVICOR TAB 1000-20 Tier 3 X ADVICOR TAB 1000-40 Tier 3 X ADVICOR TAB 500-20MG Tier 3 X ADVICOR TAB 750-20MG Tier 3 X ADYNOVATE INJ 1000UNIT Tier 3 X X X ADYNOVATE INJ 2000UNIT Tier 3 X X X ADYNOVATE INJ 250UNIT Tier 3 X X X ADYNOVATE INJ 500UNIT Tier 3 X X X ADZENYS XR TAB 12.5MG Tier 3 X X ADZENYS XR TAB 15.7 MG Tier 3 X X ADZENYS XR TAB 18.8MG Tier 3 X X ADZENYS XR TAB 3.1MG Tier 3 X X ADZENYS XR TAB 6.3MG Tier 3 X X ADZENYS XR TAB 9.4MG Tier 3 X X AERCHMBR PLS MIS FLOW-VU Tier 3 AERCHMBR PLS MIS LRG MASK Tier 3 AERCHMBR PLS MIS SM MASK Tier 3 AEROCHAMBER MIS PLUS Tier 3 AEROSPAN AER 80MCG Tier 3 X AFEDITAB TAB 30MG CR Tier 1 AFEDITAB TAB 60MG CR Tier 1 AFINITOR TAB 10MG Tier 2 X X X AFINITOR TAB 2.5MG Tier 2 X X X AFINITOR TAB 5MG Tier 2 X X X AFINITOR TAB 7.5MG Tier 2 X X X AFINITOR DIS TAB 2MG Tier 2 X X X AFINITOR DIS TAB 3MG Tier 2 X X X 13 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy AFINITOR DIS TAB 5MG Tier 2 X X X AFREZZA POW Tier 3 X X AFREZZA POW 4& 8UNIT Tier 3 X X AFREZZA POW 4& 8UNIT Tier 3 X X AFREZZA POW 4UNIT Tier 3 X X X AFREZZA POW 8&12UNIT Tier 3 X X X AFSTYLA KIT 1000UNIT Tier 3 X X AFSTYLA KIT 2000UNIT Tier 3 X X AFSTYLA KIT 250UNIT Tier 3 X X AFSTYLA KIT 3000UNIT Tier 3 X X AFSTYLA KIT 500UNIT Tier 3 X X AFTERA TAB 1.5MG HCR Preventive AGGRENOX CAP 25-200MG Tier 3 AGRYLIN CAP 0.5MG Tier 3 AIF #2 DRUG CRE PREP KIT Tier 1 X AIF #3 DRUG CRE PREP KIT Tier 3 X AIRSHIELD CHW IMMUNITY Tier 3 AIRSHIELD TAB Tier 3 AK-POLY-BAC OIN OP Tier 1 AKTEN GEL 3.5% Tier 3 AKYNZEO CAP Tier 3 X ALA SCALP LOT 2% Tier 3 ALASKAN RED POW ALGAE Tier 3 X ALBA-DERM CRE Tier 3 X ALBENZA TAB 200MG Tier 2 X ALBUTEROL NEB 0.083% Tier 1 ALBUTEROL NEB 0.5% Tier 1 ALBUTEROL NEB 0.63MG/3 Tier 1 ALBUTEROL NEB 1.25MG/3 Tier 1 ALBUTEROL SYP 2MG/5ML Tier 1 ALBUTEROL TAB 2MG Tier 1 ALBUTEROL TAB 4MG Tier 1 ALBUTEROL TAB 4MG ER Tier 1 ALBUTEROL TAB 8MG ER Tier 1 ALCAINE SOL 0.5% OP Tier 3 ALCLOMETASON CRE 0.05% Tier 1 ALCLOMETASON OIN 0.05% Tier 1

14 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ALCOH-GLOVE PAD CONTOURE Tier 3 ALCOH-WIPE PAD 12"X12" Tier 3 ALCOHOL PAD 70% Tier 3 ALCOHOL PREP PAD Tier 3 ALCOHOL PREP PAD 70% Tier 1 ALCOHOL PREP PAD 70% Tier 3 ALCOHOL PREP PAD MED 70% Tier 3 ALCOHOL SWAB PAD Tier 3 ALDACTAZIDE TAB 25/25 Tier 3 ALDACTAZIDE TAB 50/50 Tier 2 ALDACTONE TAB 100MG Tier 3 ALDACTONE TAB 25MG Tier 3 ALDACTONE TAB 50MG Tier 3 ALDARA CRE 5% Tier 3 X ALECENSA CAP 150MG Tier 3 X X X ALENDRONATE SOL 70/75ML Tier 1 ALENDRONATE TAB 10MG Tier 1 X ALENDRONATE TAB 35MG Tier 1 X ALENDRONATE TAB 40MG Tier 1 X ALENDRONATE TAB 5MG Tier 1 X ALENDRONATE TAB 70MG Tier 1 X ALFERON N INJ 5MU/ML Tier 2 X ALFUZOSIN TAB 10MG ER Tier 1 ALINIA SUS 100/5ML Tier 2 X ALINIA TAB 500MG Tier 2 X ALKERAN TAB 2MG Tier 2 X ALLO-PAX CRE 5-5% Tier 3 X ALLOPURINOL TAB 100MG Tier 1 ALLOPURINOL TAB 300MG Tier 1 ALLZITAL TAB 25-325MG Tier 3 X X ALMOTRIP MAL TAB 12.5MG Tier 3 X ALMOTRIP MAL TAB 6.25MG Tier 3 X ALMOTRIPTAN TAB 12.5MG Tier 3 X ALMOTRIPTAN TAB 6.25MG Tier 3 X ALOCRIL SOL 2% Tier 3 ALOE VERA OIL Tier 3 X ALOE VERA POW Tier 3 X ALOE VERA POW 200:1 Tier 3 X 15 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ALOE VERA POW FRZE DRD Tier 3 X ALOE VERA POW LEAF Tier 3 X ALOG/PIOGLIP TAB 12.5-15 Tier 3 X X ALOG/PIOGLIP TAB 12.5-30 Tier 3 X X ALOG/PIOGLIT TAB 12.5-45 Tier 3 X X ALOG/PIOGLIT TAB 25-15MG Tier 3 X X ALOG/PIOGLIT TAB 25-30MG Tier 3 X X ALOG/PIOGLIT TAB 25-45MG Tier 3 X X ALOGLIPTIN TAB 12.5MG Tier 3 X X ALOGLIPTIN TAB 25MG Tier 3 X X ALOGLIPTIN TAB 6.25MG Tier 3 X X ALOGLIPTIN/ TAB METFORM Tier 3 X X ALOGLIPTIN/ TAB METFORM Tier 3 X X ALOMIDE SOL 0.1% OP Tier 3 ALORA DIS 0.025MG Tier 3 X ALORA DIS 0.05MG Tier 3 X ALORA DIS 0.075MG Tier 3 X ALORA DIS 0.1MG Tier 3 X ALOSETRON TAB 0.5MG Tier 1 X X ALOSETRON TAB 1MG Tier 1 X X ALPAWASH OIN Tier 3 ALPHA LIPOIC POW ACID Tier 3 X ALPHAGAN P SOL 0.1% Tier 2 X ALPHAGAN P SOL 0.15% Tier 3 X ALPHANATE INJ VWF/HUM Tier 2 X ALPHANATE INJ VWF/HUM Tier 2 X ALPHANATE INJ VWF/HUM Tier 2 X ALPHANATE INJ VWF/HUM Tier 2 X ALPHANATE INJ VWF/HUM Tier 2 X ALPHANINE SD INJ 1000UNIT Tier 2 X ALPHANINE SD INJ 1500UNIT Tier 2 X ALPHANINE SD INJ 500UNIT Tier 2 X ALPHATREX GEL 0.05% Tier 1 ALPRAZOLAM CON 1 MG/ML Tier 1 ALPRAZOLAM TAB 0.25 ODT Tier 1 ALPRAZOLAM TAB 0.25MG Tier 1 ALPRAZOLAM TAB 0.5MG Tier 1 ALPRAZOLAM TAB 0.5MG ER Tier 1 16 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ALPRAZOLAM TAB 0.5MG OD Tier 1 ALPRAZOLAM TAB 0.5MG XR Tier 1 ALPRAZOLAM TAB 1MG Tier 1 ALPRAZOLAM TAB 1MG ER Tier 1 ALPRAZOLAM TAB 1MG ODT Tier 1 ALPRAZOLAM TAB 1MG XR Tier 1 ALPRAZOLAM TAB 2MG Tier 1 ALPRAZOLAM TAB 2MG ER Tier 1 ALPRAZOLAM TAB 2MG ODT Tier 1 ALPRAZOLAM TAB 2MG XR Tier 1 ALPRAZOLAM TAB 3MG ER Tier 1 ALPRAZOLAM TAB 3MG XR Tier 1 ALPROLIX INJ 1000UNIT Tier 3 X ALPROLIX INJ 2000UNIT Tier 3 X ALPROLIX INJ 250UNIT Tier 3 X ALPROLIX INJ 3000UNIT Tier 3 X ALPROLIX INJ 500UNIT Tier 3 X ALPROSTADIL POW Tier 3 X ALREX SUS 0.2% Tier 3 X ALTABAX OIN 1% Tier 3 X ALTACAINE SOL 0.5% OP Tier 1 ALTACE CAP 1.25MG Tier 3 ALTACE CAP 10MG Tier 3 ALTACE CAP 2.5MG Tier 3 ALTACE CAP 5MG Tier 3 ALTADERM CRE BASE Tier 3 X ALTAFLUOR SOL 0.25-0.4 Tier 1 ALTAFRIN SOL 10% OP Tier 1 ALTAFRIN SOL 2.5% OP Tier 1 ALTAVERA TAB HCR Preventive ALTOPREV TAB 20MG ER Tier 3 X X ALTOPREV TAB 40MG ER Tier 3 X X ALTOPREV TAB 60MG ER Tier 3 X X ALUVEA CRE 39% Tier 3 ALVESCO AER 160MCG Tier 1 X ALVESCO AER 80MCG Tier 1 X

17 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ALYACEN TAB 1/35 HCR Preventive ALYACEN TAB 7/7/7 HCR Preventive AMABELZ TAB 0.5-0.1 Tier 3 AMABELZ TAB 1-0.5MG Tier 3 AMANTADINE CAP 100MG Tier 1 AMANTADINE SYP 50MG/5ML Tier 1 AMANTADINE TAB 100MG Tier 1 AMARYL TAB 1MG Tier 3

AMARYL TAB 2MG Tier 3 AMARYL TAB 4MG Tier 3 AMBIEN TAB 10MG Tier 3 X X AMBIEN TAB 5MG Tier 3 X X AMBIEN CR TAB 12.5MG Tier 3 X X AMBIEN CR TAB 6.25MG Tier 3 X X AMCINONIDE CRE 0.1% Tier 3 AMCINONIDE LOT 0.1% Tier 3 AMCINONIDE OIN 0.1% Tier 1 AMELUZ GEL 10% Tier 3 AMERGE TAB 1MG Tier 3 X AMERGE TAB 2.5MG Tier 3 X AMETHIA TAB Tier 3 X AMETHIA LO TAB Tier 3 X AMETHYST TAB 90-20MCG Tier 3 AMICAR SOL 0.25/ML Tier 3 AMICAR TAB 1000MG Tier 3 AMICAR TAB 500MG Tier 3 AMILOR/HCTZ TAB 5-50 Tier 1 AMILORIDE TAB 5MG Tier 1 AMINA-21 CAP Tier 1 AMINO ACTION TAB Tier 1 AMINOAM CAP RMS Tier 1 AMINOBEZ POT POW Tier 1 AMINOCAPR AC SYP 25% Tier 1 AMINOCAPR AC TAB 1000MG Tier 1 AMINOCAPR AC TAB 500MG Tier 1

18 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy AMINORELIEF CAP RMS Tier 1 AMIODARONE TAB 100MG Tier 1 AMIODARONE TAB 200MG Tier 1 AMIODARONE TAB 400MG Tier 1 AMITIZA CAP 24MCG Tier 3 X X X AMITIZA CAP 8MCG Tier 3 X X X AMITRIPTYLIN CRE Tier 3 X AMITRIPTYLIN KIT 2% Tier 1 X AMITRIPTYLIN POW HCL Tier 3 X AMITRIPTYLIN TAB 100MG Tier 1 AMITRIPTYLIN TAB 10MG Tier 1 AMITRIPTYLIN TAB 150MG Tier 1 AMITRIPTYLIN TAB 25MG Tier 1 AMITRIPTYLIN TAB 50MG Tier 1 AMITRIPTYLIN TAB 75MG Tier 1 AMLOD/ATORVA TAB 10-10MG Tier 3 X X AMLOD/ATORVA TAB 10-20MG Tier 3 X X AMLOD/ATORVA TAB 10-40MG Tier 3 X X AMLOD/ATORVA TAB 10-80MG Tier 3 X X AMLOD/ATORVA TAB 2.5-10MG Tier 3 X X AMLOD/ATORVA TAB 2.5-20MG Tier 3 X X AMLOD/ATORVA TAB 2.5-40MG Tier 3 X X AMLOD/ATORVA TAB 5-10MG Tier 3 X X AMLOD/ATORVA TAB 5-20MG Tier 3 X X AMLOD/ATORVA TAB 5-40MG Tier 3 X X AMLOD/ATORVA TAB 5-80MG Tier 3 X X AMLOD/BENAZP CAP 10-20MG Tier 3 X AMLOD/BENAZP CAP 10-40MG Tier 3 X AMLOD/BENAZP CAP 2.5-10MG Tier 3 X AMLOD/BENAZP CAP 5-10MG Tier 3 X AMLOD/BENAZP CAP 5-20MG Tier 3 X AMLOD/BENAZP CAP 5-40MG Tier 3 X AMLOD/OLMESA TAB 10-20MG Tier 3 X X AMLOD/OLMESA TAB 10-40MG Tier 3 X X AMLOD/OLMESA TAB 5-20MG Tier 3 X X AMLOD/OLMESA TAB 5-40MG Tier 3 X X AMLOD/VALSAR TAB /HCTZ Tier 3 X X AMLOD/VALSAR TAB /HCTZ Tier 3 X X 19 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy AMLOD/VALSAR TAB /HCTZ Tier 3 X X AMLOD/VALSAR TAB /HCTZ Tier 3 X X AMLOD/VALSAR TAB /HCTZ Tier 3 X X AMLOD/VALSAR TAB 10-160MG Tier 1 X AMLOD/VALSAR TAB 10-320MG Tier 1 X AMLOD/VALSAR TAB 5-160MG Tier 1 X AMLOD/VALSAR TAB 5-320MG Tier 1 X AMLODIPINE TAB 10MG Tier 1 AMLODIPINE TAB 2.5MG Tier 1 AMLODIPINE TAB 5MG Tier 1 AMNESTEEM CAP 10MG Tier 3 X AMNESTEEM CAP 20MG Tier 3 X AMNESTEEM CAP 40MG Tier 3 X AMOX-POT CLA TAB ER Tier 3 X AMOX/K CLAV CHW 200MG Tier 1 AMOX/K CLAV CHW 400MG Tier 1 AMOX/K CLAV SUS 200/5ML Tier 1 AMOX/K CLAV SUS 250/5ML Tier 1 AMOX/K CLAV SUS 400/5ML Tier 1 AMOX/K CLAV SUS 600/5ML Tier 1 AMOX/K CLAV TAB 250-125 Tier 1 AMOX/K CLAV TAB 500-125 Tier 1 AMOX/K CLAV TAB 875-125 Tier 1 AMOXAPINE TAB 100MG Tier 1 AMOXAPINE TAB 150MG Tier 1 AMOXAPINE TAB 25MG Tier 1 AMOXAPINE TAB 50MG Tier 1 AMOXICILLIN CAP 250MG Tier 1 AMOXICILLIN CAP 500MG Tier 1 AMOXICILLIN CHW 125MG Tier 1 AMOXICILLIN CHW 250MG Tier 1 AMOXICILLIN SUS 125/5ML Tier 1 AMOXICILLIN SUS 200/5ML Tier 1 AMOXICILLIN SUS 250/5ML Tier 1 AMOXICILLIN SUS 250MG/5M Tier 1 AMOXICILLIN SUS 400/5ML Tier 1 AMOXICILLIN TAB 500MG Tier 1 AMOXICILLIN TAB 775MG Tier 1 20 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy AMOXICILLIN TAB 875MG Tier 1 AMPHET/DEXTR CAP 10MG ER Tier 3 X X AMPHET/DEXTR CAP 15MG ER Tier 3 X X AMPHET/DEXTR CAP 20MG ER Tier 3 X X AMPHET/DEXTR CAP 25MG ER Tier 3 X X AMPHET/DEXTR CAP 30MG ER Tier 3 X X AMPHET/DEXTR CAP 5MG ER Tier 3 X X AMPHET/DEXTR TAB 10MG Tier 1 X AMPHET/DEXTR TAB 12.5MG Tier 1 X AMPHET/DEXTR TAB 15MG Tier 1 X AMPHET/DEXTR TAB 20MG Tier 1 X AMPHET/DEXTR TAB 30MG Tier 1 X AMPHET/DEXTR TAB 5MG Tier 1 X AMPHET/DEXTR TAB 7.5MG Tier 1 X AMPHETAMINE CAP 10MG ER Tier 3 X X AMPHETAMINE CAP 15MG ER Tier 3 X X AMPHETAMINE CAP 20MG ER Tier 3 X X AMPHETAMINE CAP 25MG ER Tier 3 X X AMPHETAMINE CAP 30MG ER Tier 3 X X AMPHETAMINE CAP 5MG ER Tier 3 X X AMPICILLIN CAP 250MG Tier 1 AMPICILLIN CAP 500MG Tier 1 AMPICILLIN SUS 125/5ML Tier 1 AMPICILLIN SUS 250/5ML Tier 1 AMPYRA TAB 10MG Tier 2 X X X AMRIX CAP 15MG Tier 3 X AMRIX CAP 30MG Tier 3 X ANACAINE OIN Tier 2 ANADROL-50 TAB 50MG Tier 3 ANAFRANIL CAP 25MG Tier 3 X ANAFRANIL CAP 50MG Tier 3 X ANAFRANIL CAP 75MG Tier 3 X ANAGRELIDE CAP 0.5MG Tier 1 ANAGRELIDE CAP 1MG Tier 1 ANALPRAM KIT ADVANCED Tier 3 X ANALPRAM E KIT Tier 3 X ANALPRAM HC CRE 2.5-1% Tier 3 ANALPRAM-HC CRE 1-1% Tier 3 21 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ANALPRAM-HC CRE 1-2.5% Tier 3 ANALPRAM-HC CRE SINGLES Tier 3 ANALPRAM-HC LOT 2.5% Tier 3 ANALPRM SNGL CRE HC 2.5-1 Tier 3 ANAPROX DS TAB 550MG Tier 3 ANASEPT SPR Tier 3 ANASPAZ TAB 0.125MG Tier 2 ANASTROZOLE POW Tier 3 ANASTROZOLE TAB 1MG Tier 1 ANCOBON CAP 250MG Tier 3 ANCOBON CAP 500MG Tier 3 ANDEHIST SYP 4-60MG/5 Tier 3 ANDRODERM DIS 2MG/24HR Tier 2 X X ANDRODERM DIS 4MG/24HR Tier 2 X X ANDROGEL GEL 1.62% Tier 3 X X X ANDROGEL GEL 1.62% Tier 3 X X X ANDROGEL GEL 1.62% Tier 3 X X X ANDROGEL GEL 1%(25MG) Tier 3 X X X ANDROGEL GEL 1%(50MG) Tier 3 X X X ANDROGEL GEL PUMP 1% Tier 3 X X X ANDROID CAP 10MG Tier 3 ANDROXY TAB 10MG Tier 1 ANGELIQ TAB 0.25-0.5 Tier 3 ANGELIQ TAB 0.5-1MG Tier 3 ANHYDROUS GEL BASE Tier 3 ANORO ELLIPT AER 62.5-25 Tier 3 X ANTABUSE TAB 250MG Tier 3 ANTABUSE TAB 500MG Tier 3 ANTARA CAP 30MG Tier 3 X ANTARA CAP 90MG Tier 3 X ANTI-ALLERGY TAB Tier 1 ANTICOAG CIT SOL DEX SOL Tier 1 ANTIPY/BENZO SOL OTIC Tier 1 ANTIPY/BENZO SOL OTIC Tier 1 ANUCORT-HC SUP 25MG Tier 1 ANUSOL-HC CRE 2.5% Tier 3 ANUSOL-HC SUP 25MG Tier 3 X ANZEMET TAB 100MG Tier 3 X 22 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ANZEMET TAB 50MG Tier 3 X AP-ZEL TAB Tier 3 APAP-CAFFEIN CAP DIHYDROC Tier 3 X APAP/CODEINE SOL 120-12/5 Tier 1 X APAP/CODEINE TAB 300-15MG Tier 1 X APAP/CODEINE TAB 300-30MG Tier 1 X APAP/CODEINE TAB 300-60MG Tier 1 X APEXICON E CRE 0.05% Tier 2 X APIDRA INJ SOLOSTAR Tier 3 X X APIDRA INJ U-100 Tier 3 X X APLENZIN TAB 174MG Tier 3 X X APLENZIN TAB 348MG Tier 3 X X APLENZIN TAB 522MG Tier 3 X X APOKYN INJ 10MG/ML Tier 2 X APOMORPHINE POW HCL Tier 3 X APOTHEDERM CRE Tier 3 APOTHESAR CRE PLUS Tier 3 X APOTHESAR CRE TRANSDER Tier 3 APOTHESAR 2 CRE Tier 3 X APOTHESIL CRE Tier 3 X APP-TRIM-D CAP Tier 3 APPTRIM CAP Tier 3 APPTRIM CAP Tier 2 APPTRIM-D CAP Tier 2 APRACLONIDIN SOL 0.5% OP Tier 1 APRI TAB HCR Preventive APRISO CAP 0.375GM Tier 2 APTENSIO XR CAP 10MG Tier 3 X X X APTENSIO XR CAP 15MG Tier 3 X X X APTENSIO XR CAP 20MG Tier 3 X X X APTENSIO XR CAP 30MG Tier 3 X X X APTENSIO XR CAP 40MG Tier 3 X X X APTENSIO XR CAP 50MG Tier 3 X X X APTENSIO XR CAP 60MG Tier 3 X X X APTIOM TAB 200MG Tier 3 X APTIOM TAB 400MG Tier 3 X APTIOM TAB 600MG Tier 3 X

23 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy APTIOM TAB 800MG Tier 3 X APTIVUS CAP 250MG Tier 2 X APTIVUS SOL Tier 3 X AQUORAL AER Tier 3 AQUORAL SPR Tier 3 ARANELLE TAB HCR Preventive ARANESP INJ 100MCG Tier 2 X X ARANESP INJ 100MCG Tier 2 X X ARANESP INJ 10MCG Tier 2 X ARANESP INJ 150MCG Tier 2 X X ARANESP INJ 200MCG Tier 2 X X ARANESP INJ 200MCG Tier 2 X X ARANESP INJ 25MCG Tier 2 X X ARANESP INJ 25MCG Tier 2 X X ARANESP INJ 300MCG Tier 2 X X ARANESP INJ 300MCG Tier 2 X X ARANESP INJ 40MCG Tier 2 X X ARANESP INJ 40MCG Tier 2 X X ARANESP INJ 500MCG Tier 2 X X ARANESP INJ 60MCG Tier 2 X X ARANESP INJ 60MCG Tier 2 X X ARAVA TAB 10MG Tier 3 ARAVA TAB 20MG Tier 3 ARBINOXA SOL 4MG/5ML Tier 2 ARBINOXA TAB 4MG Tier 1 ARBUTIN POW ALPHA Tier 3 X ARCALYST INJ 220MG Tier 2 X X X ARCAPTA CAP 75MCG Tier 3 X ARGININE PAK 500MG Tier 3 ARGININE TAB 500MG Tier 1 ARICEPT TAB 10MG Tier 3 ARICEPT TAB 23MG Tier 3 X ARICEPT TAB 5MG Tier 3 ARIMIDEX TAB 1MG Tier 3 X ARIPIPRAZOLE SOL 1MG/ML Tier 3 ARIPIPRAZOLE TAB 10MG Tier 1 X ARIPIPRAZOLE TAB 10MG ODT Tier 1 X

24 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ARIPIPRAZOLE TAB 15MG Tier 1 X ARIPIPRAZOLE TAB 15MG ODT Tier 1 X ARIPIPRAZOLE TAB 20MG Tier 1 X ARIPIPRAZOLE TAB 2MG Tier 1 X ARIPIPRAZOLE TAB 30MG Tier 1 X ARIPIPRAZOLE TAB 5MG Tier 1 X ARIXTRA INJ 10/0.8ML Tier 3 X ARIXTRA INJ 2.5/0.5 Tier 3 X ARIXTRA INJ 5/0.4ML Tier 3 X ARIXTRA INJ 7.5/0.6 Tier 3 X ARMODAFINIL TAB 150MG Tier 3 X X X ARMODAFINIL TAB 200MG Tier 3 X X X ARMODAFINIL TAB 250MG Tier 3 X X X ARMODAFINIL TAB 50MG Tier 3 X X X ARMOUR THYRO TAB 120MG Tier 3 ARMOUR THYRO TAB 15MG Tier 3 ARMOUR THYRO TAB 180MG Tier 3 ARMOUR THYRO TAB 240MG Tier 3 ARMOUR THYRO TAB 300MG Tier 3 ARMOUR THYRO TAB 30MG Tier 3 ARMOUR THYRO TAB 60MG Tier 3 ARMOUR THYRO TAB 90MG Tier 3 ARNUITY ELPT INH 100MCG Tier 3 X ARNUITY ELPT INH 200MCG Tier 3 X AROMASIN TAB 25MG Tier 3 ARTHROTEC 50 TAB Tier 3 ARTHROTEC 75 TAB Tier 3 ARTISS SOL 10ML Tier 3 ARTISS SOL 2ML Tier 3 ARTISS SOL 4ML Tier 3 ARZOL SILVER MIS NITR APP Tier 3 ASA/DIPYRIDA CAP 25-200MG Tier 3 ASACOL HD TAB 800MG Tier 3 X ASCENSIA LIQ NORM CON Tier 2 ASCENSIA MIS AUTODISC Tier 3 X X ASCOCID POW Tier 3 X ASCOMP/COD CAP 30MG Tier 1 ASCORBIC ACD GRA Tier 3 X 25 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ASCORBIC ACD POW Tier 3 X ASCORBIC ACD POW Tier 3 X ASCORBIC ACD POW CASSAVE Tier 3 X ASCORBIC ACD POW FINE Tier 3 X ASHLYNA TAB Tier 3 X ASILNASAL CAP RMS Tier 1 ASMANEX 120 AER 220MCG Tier 1 X ASMANEX 14 AER 220MCG Tier 1 X ASMANEX 30 AER 110MCG Tier 1 X ASMANEX 30 AER 220MCG Tier 1 X ASMANEX 60 AER 220MCG Tier 1 X ASMANEX 7 AER 110MCG Tier 1 X ASMANEX HFA AER 100 MCG Tier 1 ASMANEX HFA AER 200 MCG Tier 1 ASPIR-81 TAB 81MG EC HCR Preventive ASPIR-LOW TAB 81MG EC HCR Preventive ASPIRIN CHW 81MG HCR Preventive ASPIRIN TAB 325MG HCR Preventive ASPIRIN TAB 325MG HCR Preventive ASPIRIN TAB 325MG EC HCR Preventive ASPIRIN TAB 81MG HCR Preventive ASPIRIN TAB 81MG EC HCR Preventive ASPIRIN 81 TAB 81MG EC HCR Preventive ASPIRIN CHIL CHW 81MG HCR Preventive ASPIRIN CHLD CHW 81MG HCR Preventive ASPIRIN LOW CHW 81MG HCR Preventive ASPIRIN LOW TAB 81MG EC HCR Preventive

26 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ASPIRIN-81 CHW 81MG HCR Preventive ASPIRTAB TAB 324MG EC HCR Preventive ASSURE CMFRT MIS 28G Tier 3 ASSURE CMFRT MIS 30G Tier 3 ASTAGRAF XL CAP 0.5MG Tier 3 X X ASTAGRAF XL CAP 1MG Tier 3 X X ASTAGRAF XL CAP 5MG Tier 3 X X ASTEPRO SPR 0.15% Tier 3 X ASTRINGYN SOL 259MG/GM Tier 3 AT LAST KIT GLUCOSE Tier 3 AT LAST MIS LANCETS Tier 3 AT LAST TES Tier 3 X ATACAND TAB 16MG Tier 3 X ATACAND TAB 32MG Tier 3 X ATACAND TAB 4MG Tier 3 X ATACAND TAB 8MG Tier 3 X ATACAND HCT TAB 16-12.5 Tier 3 X ATACAND HCT TAB 32-12.5 Tier 3 X ATACAND HCT TAB 32-25MG Tier 3 X ATELVIA TAB Tier 3 X X ATENDIA PAD 4-3% Tier 3 ATENOL/CHLOR TAB 100-25MG Tier 1 ATENOL/CHLOR TAB 50-25MG Tier 1 ATENOLOL TAB 100MG Tier 1 ATENOLOL TAB 25MG Tier 1 ATENOLOL TAB 50MG Tier 1 ATIVAN TAB 0.5MG Tier 3 X ATIVAN TAB 1MG Tier 3 X ATIVAN TAB 2MG Tier 3 X ATOPICLAIR CRE Tier 3 X ATORVASTATIN TAB 10MG Tier 1 X ATORVASTATIN TAB 20MG Tier 1 X ATORVASTATIN TAB 40MG Tier 1 X ATORVASTATIN TAB 80MG Tier 1 X ATOVAQ/PROGU TAB 250-100 Tier 3 ATOVAQ/PROGU TAB 62.5-25 Tier 3

27 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ATOVAQUONE SUS 750/5ML Tier 3 ATRALIN GEL 0.05% Tier 3 X X X ATRAPRO GEL HYDROGEL Tier 3 X ATRAPRO CP KIT Tier 3 X ATRAPRO DERM SPR Tier 3 X ATRIPLA TAB Tier 2 X ATROHIST LA TAB CR Tier 3 ATROHIST SR CAP SPRINKLE Tier 3 ATROPINE POW SULFATE Tier 3 ATROPINE SUL OIN 1% OP Tier 1 ATROPINE SUL SOL 1% OP Tier 1 ATROVENT HFA AER 17MCG Tier 3 X ATROVENT NAS SOL 0.03% Tier 3 ATROVENT NAS SOL 0.06% Tier 3 AUBAGIO TAB 14MG Tier 3 X X X AUBAGIO TAB 7MG Tier 3 X X X AUBRA TAB 0.1-0.02 HCR Preventive AUG BETAMET CRE 0.05% Tier 1 AUG BETAMET GEL 0.05% Tier 1 AUG BETAMET LOT 0.05% Tier 3 AUG BETAMET OIN 0.05% Tier 3 AUGMENTIN SUS 125/5ML Tier 3 X AUGMENTIN SUS 250/5ML Tier 3 X AUGMENTIN SUS ES-600 Tier 3 X AUGMENTIN TAB 500MG Tier 3 X AUGMENTIN TAB 875MG Tier 3 X AUGMENTIN XR TAB 12HR Tier 3 X AURORA LANCE MIS 30G Tier 3 AURORA LANCE MIS THIN 23G Tier 3 AURSTAT KIT HYDROGEL Tier 3 X AURSTAT ANTI GEL -ITCH Tier 3 X AURYXIA TAB 210MG Tier 3 AUTODISC LIQ LOW/HIGH Tier 2 AUTOJECT 2 MIS Tier 3 X AUTOLET II KIT CLINISAF Tier 3 AUTOLET LANC MIS DEVICE Tier 3 AUTOLET LITE KIT STARTER Tier 3

28 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy AUTOLET MINI MIS Tier 3 AUTOPEN MIS 1-21UNIT Tier 3 AUTOPEN MIS 2-42UNIT Tier 3 AUVI-Q INJ 0.15MG Tier 3 X X AUVI-Q INJ 0.3MG Tier 3 X X AUXIPRO CRE EMOLLIEN Tier 3 X AUXIPRO CRE VANISHIN Tier 3 X AV-PHOS 250 TAB NEUTRAL Tier 1 AVAILNEX CHW 750MG Tier 3 AVALIDE TAB 150-12.5 Tier 3 X AVALIDE TAB 300-12.5 Tier 3 X AVANDAMET TAB 4-500MG Tier 3 AVANDARYL TAB 4-1MG Tier 3 AVANDARYL TAB 4-2MG Tier 3 AVANDARYL TAB 8-4MG Tier 3 AVANDIA TAB 2MG Tier 3 X AVANDIA TAB 4MG Tier 3 X AVANDIA TAB 8MG Tier 3 X AVAPRO TAB 150MG Tier 3 X AVAPRO TAB 300MG Tier 3 X AVAPRO TAB 75MG Tier 3 X AVAR PAD 9.5-5% Tier 3 X AVAR CLEANSE EMU 10-5% Tier 1 AVAR LS LIQ 10-2% Tier 3 X AVAR LS PAD 10-2% Tier 3 X AVAR-E EMOLL CRE 10-5% Tier 3 AVAR-E GREEN CRE 10-5% Tier 3 AVAR-E LS CRE 10-2% Tier 3 AVC CRE 15% Tier 2 AVELOX TAB 400MG Tier 3 X AVELOX ABC TAB 400MG Tier 3 X AVIANE TAB HCR Preventive AVIDOXY TAB 100MG Tier 1 AVIDOXY DK KIT Tier 3 AVIPTADIL POW ACETATE Tier 3 X AVITA CRE 0.025% Tier 1 X X AVITA GEL 0.025% Tier 1 X X

29 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy AVODART CAP 0.5MG Tier 3 X X AVONEX KIT 30MCG Tier 2 X X X AVONEX PEN KIT 30MCG Tier 2 X X X AVONEX PREFL KIT 30MCG Tier 2 X X X AXERT TAB 12.5MG Tier 3 X X AXERT TAB 6.25MG Tier 3 X X AXID SOL 15MG/ML Tier 3 AXIRON SOL 30MG/ACT Tier 3 X X X AXONA POW Tier 3 AYGESTIN TAB 5MG Tier 3 AZ CREAM CRE Tier 3 X AZASAN TAB 100MG Tier 3 AZASAN TAB 75 MG Tier 3 AZASITE SOL 1% Tier 3 X AZATHIOPRINE TAB 50MG Tier 1 AZELASTINE DRO 0.05% Tier 1 X AZELASTINE SPR 0.1% Tier 3 X AZELASTINE SPR 0.15% Tier 3 X AZELEX CRE 20% Tier 3 X AZILECT TAB 0.5MG Tier 3 AZILECT TAB 1MG Tier 3 AZITHROMYCIN POW 1GM PAK Tier 1 AZITHROMYCIN SUS 100/5ML Tier 1 AZITHROMYCIN SUS 200/5ML Tier 1 AZITHROMYCIN TAB 250MG Tier 1 AZITHROMYCIN TAB 500MG Tier 1 AZITHROMYCIN TAB 600MG Tier 1 AZOPT SUS 1% OP Tier 2 X AZOR TAB 10-20MG Tier 3 X X AZOR TAB 10-40MG Tier 3 X X AZOR TAB 5-20MG Tier 3 X X AZOR TAB 5-40MG Tier 3 X X AZULFIDINE TAB 500MG Tier 3 AZULFIDINE TAB 500MG EN Tier 3 AZUPHEN MB CAP 120MG Tier 1 AZURETTE TAB 28 DAY Tier 2 AZURETTE TAB 28 DAY Tier 3 B-D UF SYRG MIS .3CC/30G Tier 2 30 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy B3/AZEL/TURM TAB FA/B6/ZN Tier 1 BACIT/POLYMY OIN OP Tier 1 BACITRACIN OIN OP Tier 1 BACLOFEN CRE Tier 3 X BACLOFEN CRE 1% Tier 1 X BACLOFEN CRE 2% Tier 3 X BACLOFEN POW Tier 3 X BACLOFEN TAB 10MG Tier 1 BACLOFEN TAB 20MG Tier 1 BACOCALMINE LIQ Tier 3 BACTRIM TAB 400-80MG Tier 3 BACTRIM DS TAB 800-160 Tier 3 BACTROBAN CRE 2% Tier 3 X BACTROBAN OIN 2% Tier 3 BACTROBAN OIN NASAL 2% Tier 2 BAL-CARE MIS DHA Tier 2 BALSALAZIDE CAP 750MG Tier 1 BALZIVA TAB Tier 3 BANZEL SUS 40MG/ML Tier 3 BANZEL TAB 200MG Tier 3 X BANZEL TAB 400MG Tier 3 X BARACLUDE SOL .05MG/ML Tier 2 X BARACLUDE TAB 0.5MG Tier 3 X BARACLUDE TAB 1MG Tier 3 X BASAGLAR INJ 100UNIT Tier 3 X BASE CRE LIPOSOME Tier 3 BASE FOR CRE SCARS Tier 3 X BASE FOR GEL SALTS Tier 3 BASE FOR GEL WOUNDS Tier 3 BASE W301 CRE Tier 3 X BAYER ASA TAB 325MG HCR Preventive BAYER BREEZE KIT 2 SYSTEM Tier 3 X BAYER BREEZE LIQ HIGH CNT Tier 2 BAYER BREEZE LIQ LOW CNTL Tier 2 BAYER BREEZE LIQ NORM CNT Tier 2 BAYER BREEZE MIS 2 TEST Tier 3 X X BAYER MICRLT MIS LANC DVC Tier 3

31 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy BAYER MICRLT MIS LANCETS Tier 3 BCAD 1 POW Tier 3 BCAD 2 POW Tier 3 BEBULIN INJ 200-1200 Tier 2 X BECONASE AQ SUS 0.042% Tier 3 X X BEE POLLEN CAP 580MG Tier 1 BEKYREE TAB Tier 2 BELBUCA MIS 150MCG Tier 3 X X X BELBUCA MIS 300MCG Tier 3 X X X BELBUCA MIS 450MCG Tier 3 X X X BELBUCA MIS 600MCG Tier 3 X X X BELBUCA MIS 750MCG Tier 3 X X X BELBUCA MIS 75MCG Tier 3 X X X BELBUCA MIS 900MCG Tier 3 X X X BELLA/OPIUM SUP 16.2-30 Tier 1 BELLA/OPIUM SUP 16.2-60 Tier 2 BELSOMRA TAB 10MG Tier 3 X X BELSOMRA TAB 15MG Tier 3 X X BELSOMRA TAB 20MG Tier 3 X X BELSOMRA TAB 5MG Tier 3 X X BENAZEP/HCTZ TAB 10-12.5 Tier 1 BENAZEP/HCTZ TAB 20-12.5 Tier 1 BENAZEP/HCTZ TAB 20-25MG Tier 1 BENAZEP/HCTZ TAB 5-6.25 Tier 1 BENAZEPRIL TAB 10MG Tier 1 BENAZEPRIL TAB 20MG Tier 1 BENAZEPRIL TAB 40MG Tier 1 BENAZEPRIL TAB 5MG Tier 1 BENEFIX INJ 1000UNIT Tier 2 X BENEFIX INJ 2000UNIT Tier 2 X BENEFIX INJ 250UNIT Tier 2 X BENEFIX INJ 3000UNIT Tier 2 X BENEFIX INJ 500UNIT Tier 2 X BENICAR TAB 20MG Tier 2 X BENICAR TAB 40MG Tier 2 X BENICAR TAB 5MG Tier 2 X BENICAR HCT TAB 20-12.5 Tier 2 X BENICAR HCT TAB 40-12.5 Tier 2 X 32 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy BENICAR HCT TAB 40-25MG Tier 2 X BENSAL HP OIN Tier 2 BENTYL CAP 10MG Tier 3 BENTYL TAB 20MG Tier 3 BENZACLIN GEL 1-5% Tier 3 X X BENZACLIN GEL 1-5%PUMP Tier 3 X X BENZALKONIUM SOL 50% Tier 1 BENZALKONIUM SOL NF Tier 2 BENZAMYCIN GEL 5-3% Tier 2 X BENZIQ GEL 5.25% Tier 3 BENZIQ LS GEL 2.75% Tier 3 BENZIQ WASH LIQ 5.25% Tier 3 BENZOIN TIN NF Tier 3 BENZOIN CMPD TIN Tier 3 BENZONATATE CAP 100MG Tier 1 BENZONATATE CAP 150MG Tier 1 X BENZONATATE CAP 200MG Tier 1 BENZTROPINE TAB 0.5MG Tier 1 BENZTROPINE TAB 1MG Tier 1 BENZTROPINE TAB 2MG Tier 1 BEPREVE DRO 1.5% Tier 3 X X BERINERT INJ 500UNIT Tier 3 X X X BESIVANCE SUS 0.6% Tier 3 BETA GLUCAN POW Tier 3 X BETADINE SOL 5% OP Tier 3 BETAGAN SOL 0.5% OP Tier 3 BETAMETH ACE POW Tier 3 X BETAMETH ACE POW MICRONIZ Tier 3 X BETAMETH DIP CRE 0.05% Tier 3 BETAMETH DIP LOT 0.05% Tier 1 BETAMETH DIP OIN 0.05% Tier 3 BETAMETH DIP POW Tier 3 X BETAMETH DIP POW MICRONIZ Tier 3 X BETAMETH DIP POW USP NF Tier 3 X BETAMETH VAL AER 0.12% Tier 3 X X BETAMETH VAL CRE 0.1% Tier 1 BETAMETH VAL LOT 0.1% Tier 1 BETAMETH VAL OIN 0.1% Tier 1 33 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy BETAMETHASON POW SOD PHOS Tier 3 X BETAMETHASON POW VALERATE Tier 3 X BETAPACE TAB 120MG Tier 3 X BETAPACE TAB 160MG Tier 3 X BETAPACE TAB 80MG Tier 3 X BETAPACE AF TAB 120MG Tier 3 BETAPACE AF TAB 160MG Tier 3 BETAPACE AF TAB 80MG Tier 3 BETASERON INJ 0.3MG Tier 2 X X X BETAXOLOL SOL 0.5% OP Tier 1 BETAXOLOL TAB 10MG Tier 1 BETAXOLOL TAB 20MG Tier 1 BETHANECHOL TAB 10MG Tier 1 BETHANECHOL TAB 25MG Tier 1 BETHANECHOL TAB 50MG Tier 1 BETHANECHOL TAB 5MG Tier 1 BETHKIS NEB 300/4ML Tier 2 X X X BETIMOL SOL 0.25% Tier 2 X BETIMOL SOL 0.5% Tier 2 X BETOPTIC-S SUS 0.25% OP Tier 3 BEVESPI AER 9-4.8MCG Tier 3 X BEXAROTENE CAP 75MG Tier 1 X X BEYAZ TAB Tier 3 X BHT POW Tier 3 BIAXIN SUS 250/5ML Tier 3 BIAXIN TAB 250MG Tier 3 BIAXIN TAB 500MG Tier 3 BICALUTAMIDE TAB 50MG Tier 1 X BIDIL TAB Tier 2 BIEST/PROGES CRE Tier 3 X BILTRICIDE TAB 600MG Tier 2 BIMATOPROST SOL 0.03% Tier 3 X X BINOSTO TAB 70MG Tier 3 X X BIO GLO TES 1MG OP Tier 1 BIO-IMMUNEX CAP Tier 1 BIO-STATIN CAP 1000000 Tier 3 BIO-STATIN CAP 500000 Tier 3 BIO-STATIN POW Tier 1 34 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy BIOFLEX TAB Tier 1 BIOPEPTIDE CRE BASE Tier 3 X BIOTIN POW Tier 3 X BIOTIN-D POW Tier 3 X BIOTUSS LIQ Tier 1 BIOTUSS LIQ PEDIATRC Tier 1 BISACODYL TAB 5MG EC HCR Preventive BISMUTH SUBC POW Tier 3 BISOPRL/HCTZ TAB 10/6.25 Tier 1 BISOPRL/HCTZ TAB 2.5/6.25 Tier 1 BISOPRL/HCTZ TAB 5-6.25MG Tier 1 BISOPROL FUM TAB 10MG Tier 1 BISOPROL FUM TAB 5MG Tier 1 BL ASPIRIN TAB 300MG HCR Preventive BL ASPIRIN TAB 325MG HCR Preventive BL ASPIRIN TAB 325MG EC HCR Preventive BL DECONGEST TAB CR Tier 1 BL DIXAPHEDR TAB 60MG Tier 1 BL FOLIC ACD TAB 400MCG Tier 1 BL TRIP ANTI OIN W/LID 4% Tier 1 BLEPH-10 SOL 10% OP Tier 3 BLEPHAMIDE OIN S.O.P. Tier 2 BLEPHAMIDE SUS OP Tier 3 BLISOVI 24 TAB FE 1/20 Tier 3 BLISOVI FE TAB 1.5/30 HCR Preventive BLISOVI FE TAB 1/20 HCR Preventive BLOOD GLUC MIS MONITOR Tier 3 BLOOD GLUCOS TES PREMIUM Tier 3 X BLOOD GLUCOS TES STRIPS Tier 3 X BONIVA TAB 150MG Tier 3 X BOOST LIQ BUT PECN Tier 3 BOOST LIQ CHOC/MLT Tier 3 BOOST LIQ CHOCOLAT Tier 3

35 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy BOOST LIQ MOCHA Tier 3 BOOST LIQ STRWBRRY Tier 3 BOOST LIQ VANILLA Tier 3 BOOST HIGH LIQ PROTEIN Tier 3 BOOST PLUS LIQ CHOCOLAT Tier 3 BOOST PLUS LIQ STRAWBER Tier 3 BOOST PLUS LIQ VANILLA Tier 3 BOOST PUDDIN MIS BUTTSCTH Tier 3 BOOST PUDDIN MIS CHOCOLAT Tier 3 BOOST PUDDIN MIS VANILLA Tier 3 BORAGE CAP Tier 3 BORIC ACID GRA Tier 3 BOSULIF TAB 100MG Tier 2 X X X X BOSULIF TAB 500MG Tier 2 X X X X BP 10-1 EMU Tier 1 BP CLEANSING EMU 10-4% Tier 1 BP FOLINATAL TAB PLUS B Tier 1 BP MULTINATL CHW PLUS Tier 1 BP MULTINATL TAB PLUS Tier 1 BRAVELLE INJ 75UNIT Tier 3 X X BREEZE 2 MIS SYSTEM Tier 3 X BREO ELLIPTA INH 100-25 Tier 3 X BREO ELLIPTA INH 200-25 Tier 3 X BREVICON TAB 0.5/35 Tier 3 BRIELLYN TAB Tier 3 BRILINTA TAB 60MG Tier 3 X X BRILINTA TAB 90MG Tier 3 X X BRIMONIDINE SOL 0.15% Tier 3 X BRIMONIDINE SOL 0.2% OP Tier 1 BRINTELLIX TAB 10MG Tier 3 X X BRINTELLIX TAB 20MG Tier 3 X X BRINTELLIX TAB 5MG Tier 3 X X BRISDELLE CAP 7.5MG Tier 3 X X BRIVIACT SOL 10MG/ML Tier 3 X BRIVIACT TAB 100MG Tier 3 X BRIVIACT TAB 10MG Tier 3 X BRIVIACT TAB 25MG Tier 3 X BRIVIACT TAB 50MG Tier 3 X 36 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy BRIVIACT TAB 75MG Tier 3 X BROM/PSE/DM SYP Tier 1 BROMFED DM SYP Tier 1 BROMFENAC POW SODIUM Tier 3 X BROMFENAC SOL 0.09% OP Tier 3 X BROMFENAC SOL 0.09% OP Tier 3 X BROMOCRIPTIN CAP 5MG Tier 1 BROMOCRIPTIN TAB 2.5MG Tier 1 BROMPHENIRAM CHW 12MG Tier 1 BROMSITE DRO 0.075% Tier 3 X BROVANA NEB 15MCG Tier 3 X BUCALSEP SOL Tier 3 BUCALSEP SPR Tier 3 BUDESONIDE CAP 3MG DR Tier 3 BUDESONIDE SUS 0.25MG/2 Tier 1 X BUDESONIDE SUS 0.5MG/2 Tier 1 X BUDESONIDE SUS 1MG/2ML Tier 1 X BUDESONIDE SUS 32MCG Tier 3 X X BUMETANIDE TAB 0.5MG Tier 1 BUMETANIDE TAB 1MG Tier 1 BUMETANIDE TAB 2MG Tier 1 BUMEX TAB 0.5MG Tier 3 BUMEX TAB 1MG Tier 3 BUMEX TAB 2MG Tier 3 BUNAVAIL MIS 2.1-0.3 Tier 3 X X X BUNAVAIL MIS 4.2-0.7 Tier 3 X X X BUNAVAIL MIS 6.3-1MG Tier 3 X X X BUPAP TAB 50-300MG Tier 3 BUPHENYL POW Tier 3 X BUPHENYL TAB 500MG Tier 3 X BUPIVACAINE POW HCL Tier 3 BUPREN/NALOX SUB 2-0.5MG Tier 3 X X X BUPREN/NALOX SUB 8-2MG Tier 3 X X X BUPRENORPHIN POW HCL Tier 3 X BUPRENORPHIN SUB 2MG Tier 1 X X BUPRENORPHIN SUB 8MG Tier 1 X X BUPROBAN TAB 150MG HCR X Preventive

37 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy BUPROPION TAB 100MG Tier 1 BUPROPION TAB 100MG ER Tier 1 BUPROPION TAB 100MG SR Tier 1 BUPROPION TAB 150MG HCR X Preventive BUPROPION TAB 150MG ER Tier 1 BUPROPION TAB 150MG SR Tier 1 BUPROPION TAB 200MG ER Tier 1 BUPROPION TAB 200MG SR Tier 1 BUPROPION TAB 75MG Tier 1 BUPROPN HCL TAB 150MG XL Tier 1 BUPROPN HCL TAB 300MG XL Tier 1 BUSPIRONE TAB 10MG Tier 1 BUSPIRONE TAB 15MG Tier 1 BUSPIRONE TAB 30MG Tier 1 BUSPIRONE TAB 5MG Tier 1 BUSPIRONE TAB 7.5MG Tier 1 BUT/APAP/CAF CAP Tier 3 X BUT/APAP/CAF CAP Tier 1 X BUT/APAP/CAF CAP CODEINE Tier 3 X X BUT/APAP/CAF CAP CODEINE Tier 1 X BUT/APAP/CAF TAB Tier 1 X BUT/ASA/CAF/ CAP COD 30MG Tier 1 BUT/ASA/CAFF CAP Tier 1 BUTAL/APAP TAB 50-325MG Tier 1 BUTISOL SOD TAB 30MG Tier 3 BUTORPHANOL SOL 10MG/ML Tier 3 X BUTRANS DIS 10MCG/HR Tier 3 X X BUTRANS DIS 15MCG/HR Tier 3 X X BUTRANS DIS 20MCG/HR Tier 3 X X BUTRANS DIS 5MCG/HR Tier 3 X X BUTRANS DIS 7.5/HR Tier 3 X X BXN MOUTHWSH SUS Tier 3 X BYDUREON INJ 2MG Tier 2 X BYDUREON PEN INJ 2MG Tier 2 X BYETTA INJ 10MCG Tier 2 X BYETTA INJ 5MCG Tier 2 X BYSTOLIC TAB 10MG Tier 2

38 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy BYSTOLIC TAB 2.5MG Tier 2 BYSTOLIC TAB 20MG Tier 2 BYSTOLIC TAB 5MG Tier 2 BYVALSON TAB 5-80MG Tier 3 X X C-NATE DHA CAP 28-1-200 Tier 3 CABERGOLINE TAB 0.5MG Tier 3 CABOMETYX TAB 20MG Tier 3 X X X CABOMETYX TAB 40MG Tier 3 X X X CABOMETYX TAB 60MG Tier 3 X X X CADUET TAB 10-10MG Tier 3 X X CADUET TAB 10-20MG Tier 3 X X CADUET TAB 10-40MG Tier 3 X X CADUET TAB 10-80MG Tier 3 X X CADUET TAB 2.5-10MG Tier 3 X X CADUET TAB 2.5-20MG Tier 3 X X CADUET TAB 2.5-40MG Tier 3 X X CADUET TAB 5-10MG Tier 3 X X CADUET TAB 5-20MG Tier 3 X X CADUET TAB 5-40MG Tier 3 X X CADUET TAB 5-80MG Tier 3 X X CAFERGOT TAB 1-100MG Tier 3 CAFFEINE CIT SOL 20MG/ML Tier 1 CAFFEINE CIT SOL 60MG/3ML Tier 1 CALAN TAB 120MG Tier 3 CALAN TAB 80MG Tier 3 CALAN SR TAB 120MG Tier 3 CALAN SR TAB 180MG Tier 3 CALAN SR TAB 240MG Tier 3 CALC ACETATE CAP 667MG Tier 1 CALC ACETATE TAB 667MG Tier 1 CALCIFOL WAF Tier 3 CALCIPOTRIEN CRE 0.005% Tier 3 X CALCIPOTRIEN OIN 0.005% Tier 3 CALCIPOTRIEN OIN BETAMETH Tier 3 X CALCIPOTRIEN SOL 0.005% Tier 1 X CALCITONIN SPR 200/ACT Tier 3 CALCITRENE OIN 0.005% Tier 3 CALCITRIOL CAP 0.25MCG Tier 1 39 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy CALCITRIOL CAP 0.5MCG Tier 1 CALCITRIOL OIN 3MCG/GM Tier 1 X CALCITRIOL SOL 1MCG/ML Tier 1 CALCIUM POW FOLINATE Tier 3 CALCIUM AA GRA CHELATE Tier 3 X CALCIUM PNV CAP Tier 3 CALCIUM-FA WAF PLUS D Tier 1 CAMBIA POW 50MG Tier 3 X X CAMILA TAB 0.35MG HCR Preventive CAMINO PRO LIQ 15PE Tier 3 CAMRESE TAB Tier 3 X CAMRESE LO TAB Tier 3 X CANASA SUP 1000MG Tier 2 CANDESA/HCTZ TAB 16-12.5 Tier 3 X CANDESA/HCTZ TAB 32-12.5 Tier 3 X CANDESA/HCTZ TAB 32-25MG Tier 3 X CANDESARTAN TAB 16MG Tier 3 X CANDESARTAN TAB 32MG Tier 3 X CANDESARTAN TAB 4MG Tier 3 X CANDESARTAN TAB 8MG Tier 3 X CANTIL TAB 25MG Tier 3 CAPACET CAP Tier 1 X CAPECITABINE TAB 150MG Tier 3 X X X CAPECITABINE TAB 500MG Tier 3 X X X CAPEX SHA 0.01% Tier 2 CAPITAL/COD SUS 120-12/5 Tier 2 X CAPRELSA TAB 100MG Tier 2 X X X CAPRELSA TAB 300MG Tier 2 X X X CAPSAICIN POW PALMITAT Tier 3 X CAPTOPR/HCTZ TAB 25-15MG Tier 1 CAPTOPR/HCTZ TAB 25-25MG Tier 1 CAPTOPR/HCTZ TAB 50-15MG Tier 1 CAPTOPR/HCTZ TAB 50-25MG Tier 1 CAPTOPRIL TAB 100MG Tier 1 CAPTOPRIL TAB 12.5MG Tier 1 CAPTOPRIL TAB 25MG Tier 1 CAPTOPRIL TAB 50MG Tier 1

40 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy CARAC CRE 0.5% Tier 2 CARAFATE SUS 1GM/10ML Tier 3 CARAFATE TAB 1GM Tier 3 CARB-O-PHILC CRE /40 Tier 1 CARB-O-PHILC GEL 40% Tier 1 CARB/LEVO TAB 10-100MG Tier 1 CARB/LEVO TAB 10-100MG Tier 1 CARB/LEVO TAB 25-100MG Tier 1 CARB/LEVO TAB 25-100MG Tier 1 CARB/LEVO TAB 25-250MG Tier 1 CARB/LEVO TAB 25-250MG Tier 1 CARB/LEVO 50 TAB /ENTACAP Tier 1 CARB/LEVO 75 TAB /ENTACAP Tier 1 CARB/LEVO ER TAB 25-100MG Tier 1 CARB/LEVO ER TAB 50-200MG Tier 1 CARB/LEVO100 TAB /ENTACAP Tier 1 CARB/LEVO125 TAB /ENTACAP Tier 1 CARB/LEVO150 TAB /ENTACAP Tier 1 CARB/LEVO200 TAB /ENTACAP Tier 1 CARBAGLU TAB 200MG Tier 2 X CARBAMAZEPIN CAP 100MG ER Tier 1 CARBAMAZEPIN CAP 200MG ER Tier 1 CARBAMAZEPIN CAP 300MG ER Tier 1 CARBAMAZEPIN CHW 100MG Tier 1 CARBAMAZEPIN POW Tier 3 X CARBAMAZEPIN SUS 100/5ML Tier 1 CARBAMAZEPIN TAB 100MGER Tier 3 CARBAMAZEPIN TAB 200MG Tier 1 CARBAMAZEPIN TAB 200MG ER Tier 3 CARBAMAZEPIN TAB 400MG ER Tier 3 CARBAPHEN 12 LIQ Tier 3 CARBAPHEN 12 SUS PED Tier 3 CARBATROL CAP 100MG Tier 3 CARBATROL CAP 200MG Tier 3 CARBATROL CAP 300MG Tier 3 CARBIDOPA TAB 25MG Tier 1 CARBIN/PSE/ SYP DM Tier 1 CARBINOXAMIN SOL 4MG/5ML Tier 1 41 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy CARBINOXAMIN TAB 4MG Tier 1 CARBOGEL GEL 940 Tier 3 CARBOHOL GEL 940 Tier 2 CARBOMER GEL AQUEOUS Tier 3 CARBOMER GEL HYDROALC Tier 3 CARDIOVID CAP PLUS Tier 3 CARDIZEM TAB 120MG Tier 3 X CARDIZEM TAB 30MG Tier 3 X CARDIZEM TAB 60MG Tier 3 X CARDIZEM CD CAP 120MG/24 Tier 3 X CARDIZEM CD CAP 180MG/24 Tier 3 X CARDIZEM CD CAP 240MG/24 Tier 3 X CARDIZEM CD CAP 300MG/24 Tier 3 X CARDIZEM CD CAP 360MG/24 Tier 3 X CARDIZEM LA TAB 120MG Tier 2 X CARDIZEM LA TAB 180MG Tier 3 X CARDIZEM LA TAB 240MG Tier 3 X CARDIZEM LA TAB 300MG/24 Tier 3 X CARDIZEM LA TAB 360MG Tier 3 X CARDIZEM LA TAB 420MG/24 Tier 3 X CARDURA TAB 1MG Tier 3 CARDURA TAB 2MG Tier 3 CARDURA TAB 4MG Tier 3 CARDURA TAB 8MG Tier 3 CARDURA XL TAB 4MG Tier 3 CARDURA XL TAB 8MG Tier 3 CAREFINE MIS 31GX8MM Tier 2 CAREFINE MIS 32GX4MM Tier 2 CAREFINE MIS 32GX5MM Tier 2 CAREFINE MIS 32GX6MM Tier 2 CAREONE ADV MIS LANCING Tier 3 CAREONE LANC MIS 28G Tier 3 CAREONE LANC MIS THIN 23G Tier 3 CARISOPR/ASA TAB 200-325 Tier 1 CARISOPRODOL TAB 250MG Tier 3 X CARISOPRODOL TAB 350MG Tier 1 CARISOPRODOL TAB ASA/COD Tier 1 CARNITINE CAP 250MG Tier 1 42 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy CARNITOR SOL 1GM/10ML Tier 3 CARNITOR SF SOL 1GM/10ML Tier 3 CARNOSINE L POW Tier 3 X CARTEOLOL SOL 1% OP Tier 1 CARTIA XT CAP 120/24HR Tier 3 CARTIA XT CAP 180/24HR Tier 3 CARTIA XT CAP 240/24HR Tier 3 CARTIA XT CAP 300/24HR Tier 3 CARTRIDGE MIS 3.15ML Tier 2 CARTRIDGE MIS IR 1000 Tier 2 CARTRIDGE MIS IR 1200 Tier 2 CARTRIDGE MIS PUMP Tier 2 CARVEDILOL TAB 12.5MG Tier 1 CARVEDILOL TAB 25MG Tier 1 CARVEDILOL TAB 3.125MG Tier 1 CARVEDILOL TAB 6.25MG Tier 1 CASCARA EXT SAGRADA Tier 1 CASODEX TAB 50MG Tier 3 X CATALYTIC TAB FORMULA Tier 3 CATAPRES TAB 0.1MG Tier 3 CATAPRES TAB 0.2MG Tier 3 CATAPRES TAB 0.3MG Tier 3 CATAPRES-TTS DIS 0.1/24HR Tier 3 CATAPRES-TTS DIS 0.2/24HR Tier 3 CATAPRES-TTS DIS 0.3/24HR Tier 3 CAVAREST GEL 1.1% Tier 1 CAVERJECT INJ 20MCG Tier 3 X CAVERJECT INJ 40MCG Tier 3 X CAVERJECT KIT 10MCG Tier 3 X CAVERJECT KIT 20MCG Tier 3 X CAVIRINSE SOL 0.2% Tier 1 CAYA DPR Tier 3 CAYSTON INH 75MG Tier 2 X X X CAZIANT PAK HCR Preventive CDP/AMITRIP TAB 10-25MG Tier 1 CDP/AMITRIP TAB 5-12.5MG Tier 1 CEDAX CAP 400MG Tier 3

43 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy CEDAX SUS 180/5ML Tier 3 CEFACLOR CAP 250MG Tier 1 CEFACLOR CAP 500MG Tier 1 CEFACLOR SUS 125/5ML Tier 3 CEFACLOR SUS 250/5ML Tier 1 CEFACLOR SUS 375/5ML Tier 3 CEFACLOR ER TAB 500MG Tier 1 CEFADROXIL CAP 500MG Tier 1 CEFADROXIL SUS 250/5ML Tier 1 CEFADROXIL SUS 500/5ML Tier 1 CEFADROXIL TAB 1GM Tier 1 CEFDINIR CAP 300MG Tier 3 CEFDINIR SUS 125/5ML Tier 2 CEFDINIR SUS 250/5ML Tier 2 CEFDITOREN TAB 200MG Tier 1 CEFDITOREN TAB 400MG Tier 1 CEFIXIME SUS 100/5ML Tier 3 CEFIXIME SUS 200/5ML Tier 3 CEFPODO PROX SUS 100/5ML Tier 1 CEFPODO PROX SUS 50MG/5ML Tier 1 CEFPODOXIME TAB 100MG Tier 1 CEFPODOXIME TAB 200MG Tier 1 CEFPROZIL SUS 125/5ML Tier 1 CEFPROZIL SUS 250/5ML Tier 1 CEFPROZIL TAB 250MG Tier 1 CEFPROZIL TAB 500MG Tier 1 CEFTIBUTEN CAP 400MG Tier 1 CEFTIBUTEN SUS 180/5ML Tier 1 CEFTIN SUS 125/5ML Tier 3 CEFTIN SUS 250/5ML Tier 3 CEFTIN TAB 250MG Tier 3 CEFTIN TAB 500MG Tier 3 CEFUROXIME TAB 250MG Tier 1 CEFUROXIME TAB 500MG Tier 1 CELA BASE CRE Tier 3 X CELEBREX CAP 100MG Tier 3 X X CELEBREX CAP 200MG Tier 3 X X CELEBREX CAP 400MG Tier 3 X X 44 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy CELEBREX CAP 50MG Tier 3 X X CELECOXIB CAP 100MG Tier 1 X CELECOXIB CAP 200MG Tier 1 X CELECOXIB CAP 400MG Tier 1 X CELECOXIB CAP 50MG Tier 1 X CELEXA TAB 10MG Tier 3 X CELEXA TAB 20MG Tier 3 X CELEXA TAB 40MG Tier 3 X CELLCEPT CAP 250MG Tier 3 X CELLCEPT SUS 200MG/ML Tier 3 X CELLCEPT TAB 500MG Tier 3 X CELONTIN CAP 300MG Tier 2 CEM-UREA SOL 45% Tier 3 CENOVIA CRE Tier 3 X CENTANY OIN 2% Tier 3 CENTANY AT KIT 2% Tier 3 X CEPHALEXIN CAP 250MG Tier 1 CEPHALEXIN CAP 500MG Tier 1 CEPHALEXIN CAP 750MG Tier 1 CEPHALEXIN SUS 125/5ML Tier 1 CEPHALEXIN SUS 250/5ML Tier 1 CEPHALEXIN TAB 250MG Tier 1 CEPHALEXIN TAB 500MG Tier 1 CERACADE EMU Tier 3 X CERDELGA CAP 84MG Tier 2 X X CERISA WASH EMU 10-1% Tier 1 CEROVEL GEL 40% Tier 1 CEROVEL LOT 40% Tier 1 CERVIDIL VAG MIS 10MG INS Tier 3 CESAMET CAP 1MG Tier 3 CETACAINE AER Tier 3 CETRAXAL SOL 0.2% Tier 3 CETROTIDE KIT 0.25MG Tier 2 X CETYL MYRIST MIS OLEATE Tier 3 X CETYL MYRIST OIL OLEATE Tier 3 X CETYL MYRIST POW 20% Tier 3 X CETYL MYRIST POW OLEATE Tier 3 X CETYL MYRIST POW OLEATE Tier 3 X 45 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy CETYLEV TAB 2.5GM Tier 3 X CETYLEV TAB 500MG Tier 3 X CEVIMELINE CAP 30MG Tier 1 CGMS MIS SOFTWARE Tier 3 CGMS CABLE MIS Tier 3 CGMS SYSTEM MIS GOLD Tier 3 X X CHANTIX PAK 0.5& 1MG HCR X Preventive CHANTIX PAK 1MG HCR X Preventive CHANTIX TAB 0.5MG HCR X Preventive CHANTIX TAB 1MG HCR X Preventive CHATEAL TAB 0.15/30 HCR Preventive CHEMET CAP 100MG Tier 2 CHEMSIL K-51 GEL Tier 3 CHEMSTRIP TES UGK Tier 3 CHEMSTRIP BG MIS LOG Tier 1 CHEMSTRIP K TES Tier 2 CHENODAL TAB 250MG Tier 3 X CHERATUSSIN SYP 100-10/5 Tier 1 CHERRY SYP Tier 3 CHILD ASA CHW 81MG HCR Preventive CHILD ASA LS CHW 81MG HCR Preventive CHLORD/CLIDI CAP 5-2.5MG Tier 1 CHLORDIAZEP CAP 10MG Tier 1 CHLORDIAZEP CAP 25MG Tier 1 CHLORDIAZEP CAP 5MG Tier 1 CHLORELLA CAP Tier 3 CHLORHEX GLU SOL 0.12% Tier 1 CHLOROFORM SOL Tier 3 X CHLOROQUINE TAB 250MG Tier 1 CHLOROQUINE TAB 500MG Tier 1 CHLOROTHIAZ TAB 250MG Tier 1 CHLOROTHIAZ TAB 500MG Tier 1

46 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy CHLORPROMAZ POW HCL Tier 3 CHLORPROMAZ TAB 100MG Tier 1 CHLORPROMAZ TAB 10MG Tier 1 CHLORPROMAZ TAB 200MG Tier 1 CHLORPROMAZ TAB 25MG Tier 1 CHLORPROMAZ TAB 50MG Tier 1 CHLORPROPAM TAB 100MG Tier 1 CHLORPROPAM TAB 250MG Tier 1 CHLORTHALID TAB 100MG Tier 1 CHLORTHALID TAB 25MG Tier 1 CHLORTHALID TAB 50MG Tier 1 CHLORZOXAZON TAB 250MG Tier 1 CHLORZOXAZON TAB 500MG Tier 1 CHO MAG TRIS LIQ 500/5ML Tier 1 CHO MAG TRIS TAB 1000MG Tier 1 CHOICE DM KIT RISK TST Tier 3 CHOICE DM LIQ VANILLA Tier 3 CHOICE DM TF LIQ UNSWEET Tier 3 CHOLAC SYP 10GM/15 Tier 1 CHOLBAM CAP 250MG Tier 2 X X X CHOLBAM CAP 50MG Tier 2 X X X CHOLECALCIF POW Tier 3 X CHOLECALCIFE CRY USP/NF Tier 3 X CHOLESTYRAM POW 4GM Tier 1 CHOLESTYRAM POW 4GM Tier 1 CHOLESTYRAM POW 4GM LITE Tier 1 CHOLESTYRAM POW 4GM LITE Tier 1 CHOLESTYRAMI POW Tier 3 X CHOLESTYRAMI POW RESIN Tier 3 X CHOR GONADOT INJ 10000UNT Tier 1 X CHRYSADERM CRE DAY Tier 3 X CHRYSADERM CRE NIGHT Tier 3 X CHRYSIN POW Tier 3 X CIALIS TAB 10MG Tier 3 X CIALIS TAB 2.5MG Tier 3 X X CIALIS TAB 20MG Tier 3 X CIALIS TAB 5MG Tier 3 X X CICLODAN CRE 0.77% Tier 1 47 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy CICLODAN SOL 8% Tier 1 CICLODAN CRE KIT 0.77% Tier 3 X CICLODAN SOL KIT 8% Tier 3 X CICLOPIROX CRE 0.77% Tier 1 CICLOPIROX GEL 0.77% Tier 1 CICLOPIROX KIT 8% Tier 1 X CICLOPIROX SHA 1% Tier 3 CICLOPIROX SOL 8% Tier 1 CICLOPIROX SUS 0.77% Tier 1 CILOSTAZOL TAB 100MG Tier 1 CILOSTAZOL TAB 50MG Tier 1 CILOXAN OIN 0.3% OP Tier 3 CILOXAN SOL 0.3% OP Tier 3 CIMETIDINE SOL 300/5ML Tier 1 CIMETIDINE TAB 200MG Tier 1 CIMETIDINE TAB 300MG Tier 1 CIMETIDINE TAB 400MG Tier 1 CIMETIDINE TAB 800MG Tier 1 CIMETIDINE TAB 400MG Tier 1 CIMZIA KIT Tier 2 X X X CIMZIA KIT STARTER Tier 2 X X X CIMZIA PREFL KIT 200MG/ML Tier 2 X X X CINRYZE SOL 500 UNIT Tier 3 X X CIPRO TAB 250MG Tier 3 CIPRO TAB 500MG Tier 3 CIPRO (10%) SUS 500MG/5 Tier 3 CIPRO (5%) SUS 250MG/5 Tier 3 CIPRO HC SUS OTIC Tier 3 CIPRO XR TAB 1000MG Tier 3 CIPRO XR TAB 500MG Tier 3 CIPRODEX SUS 0.3-0.1% Tier 2 CIPROFLOXACN SOL 0.2% Tier 1 CIPROFLOXACN SOL 0.3% OP Tier 1 CIPROFLOXACN SUS 250MG/5 Tier 3 CIPROFLOXACN SUS 500MG/5 Tier 3 CIPROFLOXACN TAB 1000MG Tier 3 CIPROFLOXACN TAB 100MG Tier 1 CIPROFLOXACN TAB 250MG Tier 1 48 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy CIPROFLOXACN TAB 500MG Tier 1 CIPROFLOXACN TAB 500MG ER Tier 3 CIPROFLOXACN TAB 750MG Tier 1 CITALOPRAM SOL 10MG/5ML Tier 1 CITALOPRAM TAB 10MG Tier 1 CITALOPRAM TAB 20MG Tier 1 CITALOPRAM TAB 40MG Tier 1 CITRANATAL CAP HARMONY Tier 3 CITRANATAL MIS 90 DHA Tier 3 CITRANATAL MIS B-CALM Tier 3 CITRANATAL PAK ASSURE Tier 3 CITRANATAL PAK DHA Tier 3 CITRANATAL TAB RX Tier 3 CITRIC ACID/ SOL SOD CITR Tier 1 CITROMA SOL CHERRY HCR Preventive CITROMA SOL LEMON HCR Preventive CITRULLINE POW (L) Tier 3 CITRULLINE POW 1000 Tier 3 CLARAVIS CAP 10MG Tier 3 X CLARAVIS CAP 20MG Tier 3 X CLARAVIS CAP 30MG Tier 3 X CLARAVIS CAP 40MG Tier 3 X CLARIFOAM EF AER 10-5% Tier 3 X CLARINEX SYP 0.5MG/ML Tier 3 X CLARINEX TAB 5MG Tier 3 X X CLARINEX-D TAB 2.5-120 Tier 3 X X CLARITHROMYC SUS 125/5ML Tier 3 CLARITHROMYC SUS 250/5ML Tier 3 CLARITHROMYC TAB 250MG Tier 1 CLARITHROMYC TAB 500MG Tier 1 CLARITHROMYC TAB 500MG ER Tier 3 CLARYS CRE Tier 3 X CLEARLAX POW HCR Preventive CLEMASTINE SYP 0.5/5ML Tier 1 CLEMASTINE TAB 2.68MG Tier 1

49 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy CLEOCIN CAP 150MG Tier 3 CLEOCIN CAP 300MG Tier 3 CLEOCIN CAP 75MG Tier 2 CLEOCIN CRE 2% VAG Tier 3 CLEOCIN SUP 100MG Tier 2 CLEOCIN PED SOL 75MG/5ML Tier 3 CLEOCIN-T GEL 1% Tier 3 X CLEOCIN-T LOT 1% Tier 3 CLEOCIN-T PAD 1% Tier 3 CLEOCIN-T SOL 1% Tier 3 CLIMARA DIS 0.025MG Tier 2 X CLIMARA DIS 0.0375MG Tier 2 X CLIMARA DIS 0.05MG Tier 2 X CLIMARA DIS 0.06MG Tier 2 X CLIMARA DIS 0.075MG Tier 2 X CLIMARA DIS 0.1MG Tier 2 X CLIMARA PRO DIS WEEKLY Tier 3 X CLINDACIN KIT ETZ 1% Tier 3 X CLINDACIN KIT PAC 1% Tier 3 X CLINDACIN MIS ETZ 1% Tier 1 CLINDACIN-P PAD 1% Tier 1 CLINDAGEL GEL 1% Tier 3 X X CLINDAMAX GEL 1% Tier 3 CLINDAMY/BEN GEL 1-5% Tier 3 X X CLINDAMY/BEN GEL 1.2-5% Tier 3 X CLINDAMYCIN AER 1% Tier 3 CLINDAMYCIN CAP 150MG Tier 1 CLINDAMYCIN CAP 300MG Tier 1 CLINDAMYCIN CAP 75MG Tier 1 CLINDAMYCIN CRE 2% VAG Tier 2 CLINDAMYCIN GEL 1% Tier 3 X CLINDAMYCIN GEL TRETINOI Tier 3 X X CLINDAMYCIN LOT 1% Tier 3 CLINDAMYCIN LOT 10MG/ML Tier 3 CLINDAMYCIN PAD 1% Tier 1 CLINDAMYCIN SOL 1% Tier 1 CLINDAMYCIN SOL 75MG/5ML Tier 3 CLINDAP-T CRE Tier 3 X 50 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy CLINDESSE CRE 2% Tier 2 CLINISTIX TES STRIPS Tier 3 CLINOIN CRE Tier 3 X CLINPRO 5000 PST 1.1% Tier 1 CLOBETASOL AER 0.05% Tier 3 X X CLOBETASOL AER 0.05% Tier 3 X X CLOBETASOL CRE 0.05% Tier 2 X CLOBETASOL GEL 0.05% Tier 2 X CLOBETASOL LOT 0.05% Tier 3 X X CLOBETASOL OIN 0.05% Tier 2 X CLOBETASOL POW PROPIONA Tier 3 X CLOBETASOL SHA 0.05% Tier 3 X X CLOBETASOL SOL 0.05% Tier 1 X CLOBETASOL SPR 0.05% Tier 1 X CLOBETASOL E CRE 0.05% Tier 2 X CLOBEX LOT 0.05% Tier 3 X X CLOBEX SHA 0.05% Tier 3 X X CLOBEX SPR 0.05% Tier 3 X CLOCORTOLONE CRE PIV 0.1% Tier 3 X X CLODAN KIT 0.05% Tier 3 X CLODAN SHA 0.05% Tier 3 X X CLODERM CRE 0.1% Tier 3 X X CLODERM CRE 0.1% PMP Tier 3 X X CLOMIPHENE TAB 50MG Tier 1 CLOMIPRAMINE CAP 25MG Tier 1 CLOMIPRAMINE CAP 50MG Tier 1 CLOMIPRAMINE CAP 75MG Tier 1 CLOMIPRAMINE POW HCL Tier 3 X CLONAZEP ODT TAB 0.125MG Tier 1 CLONAZEP ODT TAB 0.25MG Tier 1 CLONAZEP ODT TAB 0.5MG Tier 1 CLONAZEP ODT TAB 1MG Tier 1 CLONAZEP ODT TAB 2MG Tier 1 CLONAZEPAM TAB 0.5MG Tier 1 CLONAZEPAM TAB 1MG Tier 1 CLONAZEPAM TAB 2MG Tier 1 CLONIDINE DIS 0.1/24HR Tier 3 CLONIDINE DIS 0.2/24HR Tier 3 51 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy CLONIDINE DIS 0.3/24HR Tier 3 CLONIDINE TAB 0.1MG Tier 1 CLONIDINE TAB 0.1MG ER Tier 3 X CLONIDINE TAB 0.2MG Tier 1 CLONIDINE TAB 0.3MG Tier 1 CLOPIDOGREL TAB 300MG Tier 1 CLOPIDOGREL TAB 75MG Tier 1 CLORAZ DIPOT TAB 15MG Tier 1 CLORAZ DIPOT TAB 3.75MG Tier 1 CLORAZ DIPOT TAB 7.5MG Tier 1 CLORPRES TAB 0.1-15MG Tier 2 CLORPRES TAB 0.2-15MG Tier 2 CLORPRES TAB 0.3-15MG Tier 2 CLOTRIM/BETA CRE 1-0.05% Tier 1 X CLOTRIM/BETA CRE DIPROP Tier 1 X CLOTRIM/BETA LOT DIPROP Tier 1 CLOTRIMAZOLE LOZ 10MG Tier 1 CLOTRIMAZOLE TRO 10MG Tier 1 CLOVAGEL GEL Tier 3 CLOZAPINE TAB 100/ODT Tier 1 CLOZAPINE TAB 100MG Tier 1 CLOZAPINE TAB 12.5/ODT Tier 1 CLOZAPINE TAB 150/ODT Tier 1 CLOZAPINE TAB 200/ODT Tier 1 CLOZAPINE TAB 200MG Tier 1 CLOZAPINE TAB 25MG Tier 1 CLOZAPINE TAB 25MG ODT Tier 1 CLOZAPINE TAB 50MG Tier 1 CLOZARIL TAB 100MG Tier 3 CLOZARIL TAB 25MG Tier 3 CNL8 NAIL KIT Tier 3 CO Q-10 CAP 100MG Tier 1 CO Q-10 CAP 200MG Tier 1 CO Q10 CAP 200MG Tier 1 CO Q10 CAP 60MG Tier 1 CO-BALAMIN CAP Tier 3 CO-ENZY Q-10 CAP 60MG Tier 1 CO-NATAL FA TAB 29-1MG Tier 2 52 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy CO-VERATROL CAP Tier 3 COAGADEX INJ 250UNIT Tier 2 X COAGADEX INJ 500UNIT Tier 2 X COAGUCHEK MIS LANCETS Tier 3 COAL TAR SOL 20% Tier 3 COARTEM TAB 20-120MG Tier 2 COCAINE HCL SOL 4% Tier 1 CODAR AR LIQ 2-8/5ML Tier 3 CODEINE SULF TAB 15MG Tier 1 CODEINE SULF TAB 30MG Tier 1 CODEINE SULF TAB 60MG Tier 1 CODEINE/GG SOL 10-100/5 Tier 1 COENZYME Q10 CAP 100MG Tier 1 COENZYME Q10 CAP 10MG Tier 1 COENZYME Q10 CAP 200MG Tier 1 COENZYME Q10 CAP 30MG Tier 1 COENZYME Q10 CAP 50MG Tier 1 COENZYME Q10 CAP 60MG Tier 1 COENZYME Q10 CHW 60MG Tier 3 COENZYME Q10 LIQ 30MG/5ML Tier 1 COENZYME Q10 POW Tier 3 X COENZYME Q10 TAB 200MG Tier 3 COLAZAL CAP 750MG Tier 3 X COLCHICINE CAP 0.6MG Tier 3 X COLCHICINE TAB 0.6MG Tier 3 X COLCIGEL GEL Tier 3 COLCRYS TAB 0.6MG Tier 3 X COLESTID GRA 5GM Tier 3 COLESTID POW 5GM Tier 3 COLESTID TAB 1GM Tier 3 COLESTID FLA GRA 5/7.5GM Tier 3 COLESTID FLA GRA 5GM Tier 3 COLESTIPOL GRA 5GM Tier 1 COLESTIPOL GRA 5GM Tier 1 COLESTIPOL TAB 1GM Tier 1 COLISTIMETH INJ 150MG Tier 1 COLLAGENASE POW Tier 3 X COLLIGINIX MIS Tier 3 53 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy COLLODION LIQ FLEXIBLE Tier 3 COLOCORT ENE 100MG Tier 1 COLY-MYCIN M INJ 150MG Tier 3 COLY-MYCIN S SUS OTIC Tier 3 COLYTE/FLAVR SOL PACKS Tier 3 COLYTE/FLAVR SOL PACKS Tier 2 COMBIGAN SOL 0.2/0.5% Tier 2 X COMBIPATCH DIS .05/.14 Tier 3 X COMBIPATCH DIS .05/.25 Tier 3 X COMBIVENT AER 20-100 Tier 3 X COMBIVIR TAB 150-300 Tier 3 X COMETRIQ KIT 100MG Tier 2 X X X COMETRIQ KIT 140MG Tier 2 X X X COMETRIQ KIT 60MG Tier 2 X X X COMFORT MIS LANCETS Tier 3 COMFORT SET MIS 23"/17MM Tier 2 COMFORT SET MIS 31"/17MM Tier 2 COMFORT SET MIS 32"/17MM Tier 2 COMFORT SET MIS 43"/17MM Tier 2 COMFORT SHRT MIS 23"/13MM Tier 2 COMFORT SHRT MIS 31"/13MM Tier 2 COMFORT SHRT MIS 32"/13MM Tier 2 COMFORT SHRT MIS 43"/13MM Tier 2 COMFORTOUCH MIS LANCET Tier 3 COMPLEAT LIQ Tier 3 COMPLEAT LIQ CLS SYS Tier 3 COMPLEAT PED LIQ Tier 3 COMPLERA TAB Tier 3 X COMPLETE NAT PAK DHA Tier 1 COMPLETE NUT LIQ CHOCOLAT Tier 3 COMPLETE NUT LIQ PLUS/CHO Tier 3 COMPLETE NUT LIQ PLUS/STR Tier 3 COMPLETE NUT LIQ PLUS/VAN Tier 3 COMPLETE NUT LIQ STRAWBER Tier 3 COMPLETE NUT LIQ VANILLA Tier 3 COMPLETENATE CHW Tier 1 COMPRO SUP 25MG Tier 1 COMTAN TAB 200MG Tier 3 54 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy CONCENTRATE CRE Tier 3 X CONCEPT DHA CAP Tier 3 CONCEPT OB CAP Tier 3 CONCEPTROL GEL 4% HCR Preventive CONCERTA TAB 18MG Tier 2 X X CONCERTA TAB 27MG Tier 2 X X CONCERTA TAB 36MG Tier 2 X X CONCERTA TAB 54MG Tier 2 X X CONDYLOX GEL 0.5% Tier 3 CONDYLOX SOL 0.5% Tier 3 CONGESTANT TAB Tier 1 CONSTULOSE SOL 10GM/15 Tier 1 CONTOUR KIT LINK Tier 3 X CONTOUR KIT MONITOR Tier 3 X CONTOUR KIT NEXT Tier 3 X CONTOUR KIT NEXT EZ Tier 3 X CONTOUR KIT NEXT LNK Tier 3 X CONTOUR KIT NEXT USB Tier 3 X CONTOUR LIQ HIGH CNT Tier 2 CONTOUR LIQ LOW CNTL Tier 2 CONTOUR LIQ NORM CNT Tier 2 CONTOUR MIS MONITOR Tier 3 X CONTOUR SOL NEXT Tier 2 CONTOUR SOL NEXT Tier 2 CONTOUR TES BLD GLUC Tier 3 X X CONTOUR TES NEXT Tier 3 X X CONTROL HIGH SOL UNISTRIP Tier 2 CONTROL LOW SOL UNISTRIP Tier 2 CONTROL SOL LIQ HI/MID/L Tier 2 CONTROL SOL LIQ HIGH/LOW Tier 2 CONTROL SOL LIQ MID Tier 2 CONTROLRX CRE 1.1% Tier 1 CONZIP CAP 100MG Tier 3 X X CONZIP CAP 200MG Tier 3 X X CONZIP CAP 300MG Tier 3 X X COPASIL GEL Tier 3 X COPASIL GEL Tier 3 X

55 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy COPAXONE INJ 20MG/ML Tier 2 X X X COPAXONE INJ 40MG/ML Tier 2 X X X COPEGUS TAB 200MG Tier 3 X COQ-10 CAP 100MG Tier 1 COQ-10 CAP 10MG Tier 1 COQ-10 CAP 200MG Tier 1 COQ-10 CAP 30MG Tier 1 COQ-10 CAP 50MG Tier 1 COQ-10 CAP 75MG Tier 1 COQ-10 FISH CAP OIL Tier 1 COQ10 CAP 100MG Tier 1 COQ10 CAP 150MG Tier 1 COQ10 CAP 30MG Tier 1 CORDARONE TAB 200MG Tier 3 CORDRAN CRE 0.05% Tier 3 X X CORDRAN LOT 0.05% Tier 3 X X CORDRAN OIN 0.05% Tier 3 X CORDRAN 24X3 TAP 4MCG/CM Tier 3 CORDRAN 24X3 TAP SML 24IN Tier 3 CORDRAN 80X3 TAP 4MCG/CM Tier 3 COREG TAB 12.5MG Tier 3 COREG TAB 25MG Tier 3 COREG TAB 3.125MG Tier 3 COREG TAB 6.25MG Tier 3 COREG CR CAP 10MG Tier 3 X X COREG CR CAP 20MG Tier 3 X X COREG CR CAP 40MG Tier 3 X X COREG CR CAP 80MG Tier 3 X X CORGARD TAB 20MG Tier 3 CORGARD TAB 40MG Tier 3 CORGARD TAB 80MG Tier 3 CORIFACT KIT Tier 2 X CORLANOR TAB 5MG Tier 3 X X CORLANOR TAB 7.5MG Tier 3 X X CORMAX SCALP SOL 0.05% Tier 1 X CORRECT TAB 5MG EC HCR Preventive CORTANE-B DRO AQ OTIC Tier 2

56 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy CORTANE-B DRO OTIC Tier 2 CORTANE-B LOT Tier 3 CORTEF TAB 10MG Tier 3 CORTEF TAB 20MG Tier 3 CORTEF TAB 5MG Tier 3 CORTENEMA ENE 100MG Tier 3 CORTIC-ND DRO Tier 1 CORTIFOAM AER 90MG Tier 2 CORTISONE AC TAB 25MG Tier 1 CORTISPORIN CRE 0.5% Tier 2 CORTISPORIN OIN 1% Tier 3 CORTISPORIN SUS -TC OTIC Tier 3 CORTROSYN INJ 0.25MG Tier 3 CORZIDE TAB 40-5MG Tier 3 CORZIDE TAB 80-5MG Tier 3 COSENTYX INJ 150MG/ML Tier 3 X X X X COSENTYX PEN INJ 150MG/ML Tier 3 X X X X COSOPT SOL 22.3-6.8 Tier 3 COSOPT PF SOL Tier 3 X X COSYNTROPIN INJ 0.25MG Tier 1 COTELLIC TAB 20MG Tier 3 X X X COUMADIN TAB 10MG Tier 3 COUMADIN TAB 1MG Tier 3 COUMADIN TAB 2.5MG Tier 3 COUMADIN TAB 2MG Tier 3 COUMADIN TAB 3MG Tier 3 COUMADIN TAB 4MG Tier 3 COUMADIN TAB 5MG Tier 3 COUMADIN TAB 6MG Tier 3 COUMADIN TAB 7.5MG Tier 3 COVARYX TAB 1.25-2.5 Tier 1 COVARYX HS TAB Tier 1 COZAAR TAB 100MG Tier 3 COZAAR TAB 25MG Tier 3 COZAAR TAB 50MG Tier 3 CPB WC LIQ Tier 3 CREAM BASE CRE Tier 3 X CREON CAP 12000UNT Tier 2 57 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy CREON CAP 24000UNT Tier 2 CREON CAP 3000UNIT Tier 2 CREON CAP 36000UNT Tier 2 CREON CAP 6000UNIT Tier 2 CRESEMBA CAP 186 MG Tier 3 CRESTOR TAB 10MG Tier 2 X X CRESTOR TAB 20MG Tier 2 X X CRESTOR TAB 40MG Tier 2 X X CRESTOR TAB 5MG Tier 2 X X CRINONE GEL 4% VAG Tier 2 CRINONE GEL 8% VAG Tier 2 CRITICARE HN LIQ Tier 3 CRIXIVAN CAP 200MG Tier 2 X CRIXIVAN CAP 400MG Tier 2 X CROMOLYN SOD CON 100/5ML Tier 1 CROMOLYN SOD NEB 20MG/2ML Tier 1 CROMOLYN SOD SOL 4% OP Tier 1 CRUCIAL LIQ ULTRAPAK Tier 3 CRUCIAL LIQ UNFLAVOR Tier 3 CRYOSERV SOL Tier 3 CRYSELLE-28 TAB 28 TABS HCR Preventive CUPRIMINE CAP 250MG Tier 3 X X CUST LIPOTHN GEL 110 Tier 3 CUST LIPOTHN GEL 133 Tier 3 CUTIS PLUS CRE Tier 3 X CUTIVATE CRE 0.05% Tier 3 CUTIVATE LOT 0.05% Tier 3 X X CUVPOSA SOL 1MG/5ML Tier 3 CVD D3 CHW 1000UNIT HCR Preventive CVS ADVANCED TES GLUCOSE Tier 3 X CVS ADVANTAG POW /IRON Tier 3 CVS ASPIRIN TAB 325MG HCR Preventive CVS ASPIRIN TAB 325MG EC HCR Preventive CVS ASPIRIN TAB 81MG EC HCR Preventive 58 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy CVS CHLD ASA CHW 81MG HCR Preventive CVS D3 CAP 1000UNIT HCR Preventive CVS D3 CAP 400UNIT HCR Preventive CVS D3 CHW 1000 UNT HCR Preventive CVS KETONE TES CARE Tier 2 CVS L-LYSINE TAB 500MG Tier 1 CVS LANCETS MIS ORIGINAL Tier 3 CVS LANCETS MIS THIN 26G Tier 3 CVS LANCETS MIS THIN 33G Tier 3 CVS LYSINE TAB 1000MG Tier 1 CVS LYSINE TAB 500MG Tier 1 CVS NICOTINE DIS 14MG/24H HCR X Preventive CVS NICOTINE DIS 7MG/24HR HCR X Preventive CVS NICOTINE GUM 2MG CINN HCR X Preventive CVS NICOTINE GUM 2MG MINT HCR X Preventive CVS NICOTINE GUM 2MG ORIG HCR X Preventive CVS NICOTINE GUM 2MGFRUIT HCR X Preventive CVS NICOTINE GUM 4MG CINN HCR X Preventive CVS NICOTINE GUM 4MG MINT HCR X Preventive CVS NICOTINE GUM 4MG ORIG HCR X Preventive CVS NICOTINE GUM 4MGFRUIT HCR X Preventive CVS NICOTINE LOZ 2MG HCR X Preventive CVS NICOTINE LOZ 2MG MINT HCR X Preventive CVS NICOTINE LOZ 4MG MINT HCR X Preventive 59 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy CVS NTS DIS STEP 1 HCR X Preventive CVS NUTRITIO LIQ CHOCOLAT Tier 3 CVS NUTRITIO LIQ STRABERY Tier 3 CVS NUTRITIO LIQ VANILLA Tier 3 CVS PURELAX POW HCR Preventive CVS SENSITIV POW /IRON Tier 3 CVS TENDER POW /IRON Tier 3 CVS TODDLER POW INFANT Tier 3 CYANOCOBAL POW Tier 3 CYANOCOBALAM CRY Tier 3 CYCLACILLIN TAB 500MG Tier 1 CYCLAFEM TAB 1/35 HCR Preventive CYCLAFEM TAB 7/7/7 HCR Preventive CYCLESSA PAK Tier 3 CYCLOBENZAPR CRE 20MG/GM Tier 1 X CYCLOBENZAPR CRE 5% KIT Tier 1 X CYCLOBENZAPR POW Tier 3 X CYCLOBENZAPR POW HCL Tier 3 X CYCLOBENZAPR TAB 10MG Tier 1 CYCLOBENZAPR TAB 5MG Tier 1 CYCLOBENZAPR TAB 7.5MG Tier 1 CYCLOGYL SOL 0.5% OP Tier 3 CYCLOGYL SOL 1% OP Tier 3 CYCLOGYL SOL 2% OP Tier 3 CYCLOMYDRIL SOL OP Tier 3 CYCLOPENTOL SOL 1% OP Tier 1 CYCLOPENTOL SOL 2% OP Tier 1 CYCLOPENTOLA SOL 0.5% Tier 1 CYCLOPHENE CRE RAPIDPAQ Tier 3 X CYCLOPHOSPH CAP 25MG Tier 2 X CYCLOPHOSPH CAP 50MG Tier 2 X CYCLOPHOSPHA POW Tier 3 X CYCLOSERINE CAP 250MG Tier 1 CYCLOSERINE POW Tier 3 X

60 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy CYCLOSET TAB 0.8MG Tier 3 CYCLOSPORINE CAP 100MG Tier 1 X CYCLOSPORINE CAP 100MG MD Tier 1 X CYCLOSPORINE CAP 25MG Tier 1 X CYCLOSPORINE CAP 25MG MOD Tier 1 X CYCLOSPORINE CAP 50MG MOD Tier 1 X CYCLOSPORINE POW Tier 3 X CYCLOSPORINE POW A Tier 3 X CYCLOSPORINE SOL MODIFIED Tier 1 X CYMBALTA CAP 20MG Tier 3 X X CYMBALTA CAP 30MG Tier 3 X X CYMBALTA CAP 60MG Tier 3 X X CYOTIC DRO Tier 1 CYPROHEPTAD SYP 2MG/5ML Tier 1 CYPROHEPTAD TAB 4MG Tier 1 CYRED TAB HCR Preventive CYSTADANE POW Tier 2 X CYSTAGON CAP 150MG Tier 3 CYSTAGON CAP 50MG Tier 3 CYSTARAN SOL 0.44% Tier 2 X X X CYSTINE PAK 500MG Tier 3 CYTOMEL TAB 25MCG Tier 3 CYTOMEL TAB 50MCG Tier 3 CYTOMEL TAB 5MCG Tier 3 CYTOTEC TAB 100MCG Tier 3 CYTOTEC TAB 200MCG Tier 3 CYTRA K GRA CRYSTALS Tier 1 CYTRA-2 SOL Tier 1 CYTRA-3 SYP Tier 1 D 1000 CHW 1000UNIT HCR Preventive D 400 CHW 400UNIT HCR Preventive D 400 TAB 400UNIT HCR Preventive D-3 GUMMY CHW 400UNIT HCR Preventive

61 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy D-400 TAB 400UNIT HCR Preventive D-VI-SOL LIQ 400UNIT HCR Preventive D-VITA LIQ 400UNIT HCR Preventive D-VITAMIN E POW SUCCINAT Tier 3 X D.H.E. 45 INJ 1MG/ML Tier 3 X D3 CAP 1000UNIT HCR Preventive DAFLONEX-XL TAB Tier 3 DAKLINZA TAB 30MG Tier 2 X X X X DAKLINZA TAB 60MG Tier 2 X X X X DAKLINZA TAB 90MG Tier 2 X X X DALIRESP TAB 500MCG Tier 3 X X DANAZOL CAP 100MG Tier 1 DANAZOL CAP 200MG Tier 1 DANAZOL CAP 50MG Tier 1 DANTRIUM CAP 25MG Tier 3 DANTRIUM CAP 50MG Tier 3 DANTROLENE CAP 100MG Tier 1 DANTROLENE CAP 25MG Tier 1 DANTROLENE CAP 50MG Tier 1 DAPSONE TAB 100MG Tier 1 DAPSONE TAB 25MG Tier 1 DARAPRIM TAB 25MG Tier 2 X X DARIFENACIN TAB 15MG Tier 3 X DARIFENACIN TAB 7.5MG Tier 3 X DASETTA TAB 1/35 HCR Preventive DASET TA TAB 7/7/7 HCR Preventive DAYPRO TAB 600MG Tier 3 DAYSEE TAB Tier 3 X DAYTRANA DIS 10MG/9HR Tier 3 X X X DAYTRANA DIS 15MG/9HR Tier 3 X X X DAYTRANA DIS 20MG/9HR Tier 3 X X X DAYTRANA DIS 30MG/9HR Tier 3 X X X DDAVP INJ 4MCG/ML Tier 3

62 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy DDAVP SOL 0.01% Tier 3 DDAVP SPR 0.01% Tier 3 DDAVP TAB 0.1MG Tier 3 DDAVP TAB 0.2MG Tier 3 DEBACTEROL SOL 30-50% Tier 2 DEBLITANE TAB 0.35MG HCR Preventive DECON-A ELX 2-5MG/5M Tier 3 DECON-G DRO 2-1-40MG Tier 2 DECONSAL TAB L.A. Tier 1 DECONSAL SR CAP SPRINKLE Tier 1 DECONSAL-II TAB Tier 3 DEHYDROEPIAN POW MICRO Tier 3 X DELBASE OIN COMPOUND Tier 1 X DELIVRA CRE SR Tier 3 DELTA D3 TAB 400UNIT HCR Preventive DELTASONE TAB 20MG Tier 1 DELYLA TAB 0.1-0.02 HCR Preventive DELZICOL CAP 400MG Tier 3 X DEMADEX TAB 100MG Tier 3 DEMADEX TAB 10MG Tier 3 DEMADEX TAB 20MG Tier 3 DEMADEX TAB 5MG Tier 3 DEMECLOCYCL TAB 150MG Tier 1 DEMECLOCYCL TAB 300MG Tier 1 DEMEROL TAB 100MG Tier 3 DEMEROL TAB 50MG Tier 3 DEMSER CAP 250MG Tier 3 DENAVIR CRE 1% Tier 3 X DENTA 5000 CRE PLUS Tier 1 DENTA 5000 CRE PLUS 2PK Tier 1 DENTAGEL GEL 1.1% Tier 1 DEPAKENE CAP 250MG Tier 3 DEPAKENE SYP 250/5ML Tier 3 DEPAKOTE TAB 125MG DR Tier 3 X DEPAKOTE TAB 250MG DR Tier 3 X

63 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy DEPAKOTE TAB 500MG DR Tier 3 X DEPAKOTE ER TAB 250MG Tier 3 X X DEPAKOTE ER TAB 500MG Tier 3 X X DEPAKOTE SPR CAP 125MG Tier 3 X X DEPEN TITRA TAB 250MG Tier 2 DEPO-PROVERA INJ 150MG/ML Tier 3 X DEPO-PROVERA INJ 150MG/ML Tier 3 X DEPO-SQ PROV INJ 104 Tier 2 X DEPO-TESTOST INJ 100MG/ML Tier 3 DEPO-TESTOST INJ 200MG/ML Tier 3 DEPRIZINE SUS 22.4/ML Tier 3 X DEPRIZINE SUS RAPIDPAQ Tier 3 X DEQUASINE TAB Tier 3 DERMA SERUM CRE FREEDOM Tier 3 X DERMA-SMOOTH OIL /FS BODY Tier 3 X DERMA-SMOOTH OIL /FS SCLP Tier 3 DERMACINRX PAK Tier 3 DERMACINRX PAK DUOPATCH Tier 3 DERMACINRX SOL BASE Tier 3 DERMANIC TAB Tier 3 DERMASORB HC KIT 2% Tier 3 X DERMASORB TA KIT 0.1% Tier 3 X DERMASORB XM KIT 39% Tier 3 X DERMATODORON LIQ Tier 3 DERMATOP CRE 0.1% Tier 3 DERMATOP OIN 0.1% Tier 3 DERMAZENE CRE 1% Tier 1 DERMOTIC OIL 0.01% Tier 3 DESCOVY TAB 200/25 Tier 3 X DESIPRAMINE TAB 100MG Tier 1 DESIPRAMINE TAB 10MG Tier 1 DESIPRAMINE TAB 150MG Tier 1 DESIPRAMINE TAB 25MG Tier 1 DESIPRAMINE TAB 50MG Tier 1 DESIPRAMINE TAB 75MG Tier 1 DESLORATADIN TAB 2.5 ODT Tier 3 X X DESLORATADIN TAB 5MG Tier 3 X X DESLORATADIN TAB 5MG ODT Tier 3 X X 64 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy DESMOPRESSIN INJ 4MCG/ML Tier 1 DESMOPRESSIN SOL 0.01% Tier 1 DESMOPRESSIN SPR 0.01% Tier 1 DESMOPRESSIN SPR 0.01% Tier 1 DESMOPRESSIN TAB 0.1MG Tier 1 DESMOPRESSIN TAB 0.2MG Tier 1 DESO/ETHINYL TAB ESTRADIO Tier 3 DESO/ETHINYL TAB ESTRADIO HCR Preventive DESOGEN-28 TAB Tier 3 DESONATE GEL 0.05% Tier 3 X X DESONIDE CRE 0.05% Tier 3 X DESONIDE LOT 0.05% Tier 3 X DESONIDE OIN 0.05% Tier 3 X DESOWEN CRE 0.05% Tier 3 X DESOWEN LOT 0.05% Tier 3 X DESOXIMETAS CRE 0.05% Tier 1 X DESOXIMETAS CRE 0.25% Tier 1 X DESOXIMETAS GEL 0.05% Tier 3 X DESOXIMETAS OIN 0.05% Tier 3 X DESOXIMETAS OIN 0.25% Tier 3 X DESOXYN TAB 5MG Tier 3 X DESVENLAFAX TAB 100MG ER Tier 3 X DESVENLAFAX TAB 100MG ER Tier 3 X X DESVENLAFAX TAB 50MG ER Tier 3 X X DESVENLAFAX TAB 50MG ER Tier 3 X X DETROL TAB 1MG Tier 3 X DETROL TAB 2MG Tier 3 X DETROL LA CAP 2MG Tier 3 X DETROL LA CAP 4MG Tier 3 X DEXAMETH PHO SOL 0.1% OP Tier 1 DEXAMETH SOD POW PHOSPHAT Tier 3 X DEXAMETHASON CON 1MG/ML Tier 1 DEXAMETHASON ELX 0.5/5ML Tier 1 DEXAMETHASON POW Tier 3 X DEXAMETHASON POW ACETATE Tier 3 X DEXAMETHASON POW MICRONIZ Tier 3 X DEXAMETHASON SOL 0.5/5ML Tier 1

65 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy DEXAMETHASON TAB 0.5MG Tier 1 DEXAMETHASON TAB 0.75MG Tier 1 DEXAMETHASON TAB 1.5MG Tier 1 DEXAMETHASON TAB 1MG Tier 1 DEXAMETHASON TAB 2MG Tier 1 DEXAMETHASON TAB 4MG Tier 1 DEXAMETHASON TAB 6MG Tier 1 DEXCOM G4 PLATINUM Tier 3 X X DEXCOM SENSOR Tier 3 X X DEXCOM TRANSMITTER Tier 3 X X DEXEDRINE CAP 10MG CR Tier 3 X DEXEDRINE CAP 15MG CR Tier 3 X DEXEDRINE CAP 5MG CR Tier 3 X DEXEDRINE TAB 10MG Tier 3 X DEXEDRINE TAB 5MG Tier 3 X DEXERYL CRE Tier 3 X DEXILANT CAP 30MG DR Tier 3 X DEXILANT CAP 60MG DR Tier 3 X DEXMETHYLPH CAP 15MG ER Tier 3 X X X DEXMETHYLPH CAP 30MG ER Tier 3 X X X DEXMETHYLPH CAP 40MG ER Tier 3 X X X DEXMETHYLPH TAB 10MG Tier 1 X DEXMETHYLPH TAB 2.5MG Tier 1 X DEXMETHYLPH TAB 5MG Tier 1 X DEXMETHYLPHE CAP 10MG ER Tier 3 X X X DEXMETHYLPHE CAP 20MG ER Tier 3 X X X DEXMETHYLPHE CAP 5MG ER Tier 3 X X X DEXPAK PAK 10 DAY Tier 3 DEXPAK PAK 13 DAY Tier 3 DEXPAK PAK 6 DAY Tier 3 DEXTROAMPHET CAP 10MG ER Tier 3 X DEXTROAMPHET CAP 15MG ER Tier 3 X DEXTROAMPHET CAP 5MG ER Tier 3 X DEXTROAMPHET SOL 5MG/5ML Tier 1 X DEXTROAMPHET TAB 10MG Tier 3 X DEXTROAMPHET TAB 5MG Tier 3 X DEXTROMETH POW Tier 3 X DEXTROMETHOR CRY MONOHYDR Tier 3 X 66 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy DEXTROMETHOR POW HBR Tier 3 X DEXTROMETHOR POW HBR MONO Tier 3 X DHEA POW Tier 3 X DIAB GEL Tier 3 X DIAB F.D.G. GEL Tier 3 X DIABETA TAB 1.25MG Tier 3 DIABETA TAB 2.5MG Tier 3 DIABETA TAB 5MG Tier 3 DIABETIC TF LIQ Tier 3 DIABETISOURC LIQ Tier 3 DIABETISOURC LIQ AC Tier 3 DIAMOX SEQUE CAP 500MG CR Tier 3 DIASTAT ACDL GEL 12.5-20 Tier 3 X DIASTAT ACDL GEL 5-10MG Tier 3 X DIASTAT PED GEL 2.5M GEL Tier 2 X DIASTIX TES STRIPS Tier 3 DIAZEPAM CON 5MG/ML Tier 1 DIAZEPAM GEL 10MG Tier 1 X DIAZEPAM GEL 2.5MG Tier 1 X DIAZEPAM GEL 20MG Tier 1 X DIAZEPAM SOL 1MG/ML Tier 1 DIAZEPAM TAB 10MG Tier 1 DIAZEPAM TAB 2MG Tier 1 DIAZEPAM TAB 5MG Tier 1 DIBENZYLINE CAP 10MG Tier 3 X DICLEGIS TAB 10-10MG Tier 3 X DICLO/MISOPR TAB 50-0.2MG Tier 3 DICLO/MISOPR TAB 75-0.2MG Tier 3 DICLOFEN POT TAB 50MG Tier 1 DICLOFENAC GEL 1% Tier 3 X DICLOFENAC GEL 3% Tier 3 X DICLOFENAC SOL 0.1% OP Tier 1 DICLOFENAC SOL 1.5% Tier 3 X DICLOFENAC TAB 100MG ER Tier 1 DICLOFENAC TAB 25MG DR Tier 1 DICLOFENAC TAB 50MG DR Tier 1 DICLOFENAC TAB 75MG DR Tier 1 DICLOXACILL CAP 250MG Tier 1 67 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy DICLOXACILL CAP 500MG Tier 1 DICOPANOL SUS 5MG/ML Tier 3 X DICOPANOL SUS RAPIDPAQ Tier 3 X DICYCLOMINE CAP 10MG Tier 1 DICYCLOMINE SOL 10MG/5ML Tier 1 DICYCLOMINE TAB 20MG Tier 1 DIDANOSINE CAP 125MG Tier 1 X DIDANOSINE CAP 200MG Tier 1 X DIDANOSINE CAP 250MG Tier 1 X DIDANOSINE CAP 400MG Tier 1 X DIDGET KIT Tier 3 X DIFFERIN CRE 0.1% Tier 2 X X DIFFERIN GEL 0.1% Tier 2 X X DIFFERIN GEL 0.3% Tier 3 X X X DIFFERIN LOT 0.1% Tier 3 X X DIFICID TAB 200MG Tier 3 X DIFIL-G FORT LIQ 100-100 Tier 1 DIFLORASONE CRE 0.05% Tier 3 DIFLORASONE OIN 0.05% Tier 3 DIFLUCAN SUS 10MG/ML Tier 3 DIFLUCAN SUS 40MG/ML Tier 3 DIFLUCAN TAB 100MG Tier 3 DIFLUCAN TAB 150MG Tier 3 DIFLUCAN TAB 200MG Tier 3 DIFLUCAN TAB 50MG Tier 3 DIFLUNISAL TAB 500MG Tier 1 DIGESTODORON LIQ Tier 3 DIGITEK TAB 0.125MG Tier 1 DIGITEK TAB 0.25MG Tier 1 DIGOX TAB 0.125MG Tier 1 DIGOX TAB 0.25MG Tier 1 DIGOXIN SOL 50MCG/ML Tier 1 DIGOXIN TAB 0.125MG Tier 1 DIGOXIN TAB 0.25MG Tier 1 DIHYDROCOD/ CAP ASA/CAFF Tier 1 DIHYDROERGOT INJ 1MG/ML Tier 1 DIHYDROERGOT POW MESYLATE Tier 3 DIHYDROERGOT SPR 4MG/ML Tier 1 68 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy DILANTIN CAP 100MG Tier 3 DILANTIN CAP 30MG Tier 3 DILANTIN CHW 50MG Tier 3 DILANTIN-125 SUS 125/5ML Tier 3 DILATRATE SR CAP 40MG Tier 3 DILAUDID LIQ 1MG/ML Tier 3 DILAUDID TAB 2MG Tier 3 DILAUDID TAB 4MG Tier 3 DILAUDID TAB 8MG Tier 3 DILT-XR CAP 120MG Tier 1 DILT-XR CAP 180MG Tier 1 DILT-XR CAP 240MG Tier 1 DILTIAZEM CAP 120MG CD Tier 3 DILTIAZEM CAP 120MG ER Tier 3 DILTIAZEM CAP 120MG ER Tier 1 DILTIAZEM CAP 120MG ER Tier 1 DILTIAZEM CAP 120MG/24 Tier 3 DILTIAZEM CAP 180MG CD Tier 3 DILTIAZEM CAP 180MG ER Tier 3 DILTIAZEM CAP 180MG ER Tier 1 DILTIAZEM CAP 180MG/24 Tier 3 DILTIAZEM CAP 240MG CD Tier 3 DILTIAZEM CAP 240MG ER Tier 3 DILTIAZEM CAP 240MG ER Tier 1 DILTIAZEM CAP 240MG/24 Tier 3 DILTIAZEM CAP 300MG CD Tier 3 DILTIAZEM CAP 300MG ER Tier 3 DILTIAZEM CAP 300MG/24 Tier 3 DILTIAZEM CAP 360MG CD Tier 3 DILTIAZEM CAP 360MG ER Tier 3 DILTIAZEM CAP 360MG ER Tier 3 DILTIAZEM CAP 360MG/24 Tier 3 DILTIAZEM CAP 420MG/24 Tier 3 DILTIAZEM CAP 60MG ER Tier 1 DILTIAZEM CAP 90MG ER Tier 1 DILTIAZEM TAB 120MG Tier 1 DILTIAZEM TAB 30MG Tier 1 DILTIAZEM TAB 60MG Tier 1 69 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy DILTIAZEM TAB 90MG Tier 1 DILTIAZEM ER TAB 180MG Tier 3 DILTIAZEM ER TAB 240MG Tier 3 DILTIAZEM ER TAB 300MG Tier 3 DILTIAZEM ER TAB 360MG Tier 3 DILTIAZEM ER TAB 420MG Tier 3 DIMERCAPT-1- POW SULF NA Tier 3 X DIMERCAPTOSU POW ACID Tier 3 X DIMETHYL SOL SULFOXID Tier 3 DIOVAN TAB 160MG Tier 3 X X DIOVAN TAB 320MG Tier 3 X X DIOVAN TAB 40MG Tier 3 X X DIOVAN TAB 80MG Tier 3 X X DIOVAN HCT TAB 160-12.5 Tier 3 X X DIOVAN HCT TAB 160-25MG Tier 3 X X DIOVAN HCT TAB 320-12.5 Tier 3 X X DIOVAN HCT TAB 320-25MG Tier 3 X X DIOVAN HCT TAB 80/12.5 Tier 3 X X DIPENTOCAINE CRE 5-5-2% Tier 3 X DIPENTUM CAP 250MG Tier 3 DIPHEN/ATROP LIQ 2.5/5 Tier 1 DIPHEN/ATROP TAB 2.5MG Tier 1 DIPROLENE LOT 0.05% Tier 3 DIPROLENE OIN 0.05% Tier 3 DIPROLENE AF CRE 0.05% Tier 3 DIPYRIDAMOLE TAB 25MG Tier 1 DIPYRIDAMOLE TAB 50MG Tier 1 DIPYRIDAMOLE TAB 75MG Tier 1 DISALCID TAB 500MG Tier 3 X DISALCID TAB 750MG Tier 3 X DISCUS LIQ COMPOSIT Tier 3 DISOPYRAMIDE CAP 100MG Tier 1 DISOPYRAMIDE CAP 150MG Tier 1 DISULFIRAM TAB 250MG Tier 1 DISULFIRAM TAB 500MG Tier 1 DITROPAN XL TAB 10MG Tier 3 DITROPAN XL TAB 15MG Tier 3 DITROPAN XL TAB 5MG Tier 3 70 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy DIURIL SUS 250/5ML Tier 2 DIUSCREEN ME KIT COLLECTI Tier 3 DIVALPROEX CAP 125MG Tier 3 DIVALPROEX TAB 125MG DR Tier 1 DIVALPROEX TAB 250MG DR Tier 1 DIVALPROEX TAB 250MG ER Tier 1 DIVALPROEX TAB 500MG DR Tier 1 DIVALPROEX TAB 500MG ER Tier 1 DIVIGEL GEL 0.25MG Tier 3 DIVIGEL GEL 0.5MG Tier 3 DIVIGEL GEL 1MG/GM Tier 3 DIVISTA CAP Tier 3 DL-3-HYDROXY POW ACID NA Tier 3 X DL-PA-500 CAP 500MG Tier 3 DMPS POW Tier 3 X DMR ANTIGEN THERAPY Tier 3 DNA COLLECT KIT Tier 3 DNA COLLECT KIT MEDICATE Tier 3 DOC OMEGA POW Tier 3 DOFETILIDE CAP 125MCG Tier 1 DOFETILIDE CAP 250MCG Tier 1 DOFETILIDE CAP 500MCG Tier 1 DOLOPHINE TAB 10MG Tier 3 X DOLOPHINE TAB 5MG Tier 3 X DONEPEZIL TAB 10MG Tier 1 DONEPEZIL TAB 10MG ODT Tier 1 DONEPEZIL TAB 5MG Tier 1 DONEPEZIL TAB 5MG ODT Tier 1 DONEPEZIL TAB HCL 23MG Tier 3 X DORAL TAB 15MG Tier 3 DORYX TAB 200MG Tier 3 X DORYX TAB 50MG Tier 3 X DORYX MPC TAB 120MG Tier 3 X DORZOL/TIMOL SOL 22.3-6.8 Tier 3 DORZOLAMIDE SOL 2% OP Tier 1 DOTHELLE DHA CAP Tier 3 DOUBLE PM SOL Tier 3 X DOVONEX CRE 0.005% Tier 3 X 71 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy DOXAZOSIN TAB 1MG Tier 1 DOXAZOSIN TAB 2MG Tier 1 DOXAZOSIN TAB 4MG Tier 1 DOXAZOSIN TAB 8MG Tier 1 DOXEPIN HCL CAP 100MG Tier 1 DOXEPIN HCL CAP 10MG Tier 1 DOXEPIN HCL CAP 150MG Tier 1 DOXEPIN HCL CAP 25MG Tier 1 DOXEPIN HCL CAP 50MG Tier 1 DOXEPIN HCL CAP 75MG Tier 1 DOXEPIN HCL CON 10MG/ML Tier 1 DOXEPIN HCL CRE 5% Tier 1 DOXERCALCIF CAP 0.5MCG Tier 1 DOXERCALCIF CAP 1MCG Tier 1 DOXERCALCIF CAP 2.5MCG Tier 1 DOXYCYC MONO CAP 100MG Tier 1 DOXYCYC MONO CAP 150MG Tier 3 X DOXYCYC MONO CAP 50MG Tier 1 DOXYCYC MONO CAP 75MG Tier 3 X DOXYCYC MONO TAB 100MG Tier 1 DOXYCYC MONO TAB 150MG Tier 1 DOXYCYC MONO TAB 50MG Tier 1 DOXYCYC MONO TAB 75MG Tier 1 DOXYCYCL HYC CAP 100MG Tier 3 DOXYCYCL HYC CAP 50MG Tier 1 DOXYCYCL HYC TAB 100MG Tier 3 DOXYCYCL HYC TAB 100MG DR Tier 3 X DOXYCYCL HYC TAB 150MG DR Tier 3 X DOXYCYCL HYC TAB 200MG DR Tier 3 X DOXYCYCL HYC TAB 50MG DR Tier 3 X DOXYCYCL HYC TAB 75MG DR Tier 3 X DOXYCYCLINE CAP 40MG Tier 3 X DOXYCYCLINE POW HYCLATE Tier 3 DOXYCYCLINE SUS 25MG/5ML Tier 3 DOXYCYCLINE TAB 20MG Tier 1 DRISDOL CAP 50000UNT Tier 3 DRITHO-CREME CRE HP 1% Tier 2 DRONABINOL CAP 10MG Tier 1 72 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy DRONABINOL CAP 2.5MG Tier 1 DRONABINOL CAP 5MG Tier 1 DROSPIR/ETHI TAB 3-0.03MG Tier 3 DROSPIRE/ETH TAB ESTR/LEV Tier 3 X DROSPIRENONE TAB ETHY EST Tier 3 DROXIA CAP 200MG Tier 2 X DROXIA CAP 300MG Tier 2 X DROXIA CAP 400MG Tier 2 X DRYSOL SOL 20% Tier 3 DUAC GEL 1.2-5% Tier 3 X X DUAVEE TAB 0.45-20 Tier 3 DUCODYL TAB 5MG EC HCR Preventive DUET DHA MIS BALANCED Tier 3 DUET DHA 400 MIS 25-1-400 Tier 3 DUETACT TAB 30-2MG Tier 3 X DUETACT TAB 30-4MG Tier 3 X DULERA AER 100-5MCG Tier 3 X X DULERA AER 200-5MCG Tier 3 X X DULOXETINE CAP 20MG Tier 3 X DULOXETINE CAP 30MG Tier 3 X DULOXETINE CAP 40MG Tier 3 X X DULOXETINE CAP 60MG Tier 3 X DULOXETINE POW HCL Tier 3 X DUOPA SUS 4.63-20 Tier 3 X DURACHOL CAP 1-3775IU Tier 3 DURAGESIC DIS 100MCG/H Tier 3 X X DURAGESIC DIS 12MCG/HR Tier 3 X X DURAGESIC DIS 25MCG/HR Tier 3 X X DURAGESIC DIS 50MCG/HR Tier 3 X X DURAGESIC DIS 75MCG/HR Tier 3 X X DURAXIN CAP Tier 1 DUREZOL EMU 0.05% Tier 3 DUTAST/TAMSU CAP 0.5-0.4 Tier 3 X DUTASTERIDE CAP 0.5MG Tier 3 X DUTOPROL TAB 100-12.5 Tier 2 X DUTOPROL TAB 25-12.5 Tier 2 X DUTOPROL TAB 50-12.5 Tier 2 X

73 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy DYANAVEL XR SUS 2.5MG/ML Tier 3 X X DYAZIDE CAP 37.5-25 Tier 3 DYMISTA SPR 137-50 Tier 3 X X DYNAMIC KIT Tier 1 DYNAMIC PLUS KIT PAK Tier 3 DYRENIUM CAP 100MG Tier 3 DYRENIUM CAP 50MG Tier 3 E-Z SPACER MIS Tier 3 E-Z SPACER MIS BODY GRD Tier 3 E-Z-CAT DRY PAK Tier 3 E-Z-DISK TAB 700MG Tier 3 E-Z-DOSE ENE Tier 2 E-Z-HD SUS 98% Tier 3 E-Z-PAQUE SUS 60% Tier 2 E-Z-PAQUE SUS 96% Tier 2 E-Z-PASTE CRE 60% Tier 2 E.E.S. 400 TAB 400MG Tier 3 X E.E.S. GRAN SUS 200/5ML Tier 3 EASIVENT MIS Tier 3 EASIVENT MIS MASK LG Tier 3 EASIVENT MIS MASK SM Tier 3 EASIVENT MIS MASK MED Tier 3 EASYGEL GEL 0.4% Tier 1 EASYGEL GEL 0.4%CHRY Tier 1 EASYGEL GEL 0.4%CITR Tier 1 EASYGEL GEL 0.4%MINT Tier 1 EASYMAX SOL HIGH Tier 2 EASYMAX SOL LOW Tier 2 EASYMAX SOL NORMAL Tier 2 EASYMAX TES Tier 3 X EASYMAX 15 SOL LEVEL 1 Tier 2 EASYMAX 15 SOL LEVEL 2 Tier 2 EASYMAX 15 TES Tier 3 X EASYMAX L KIT SYSTEM Tier 3 EASYMAX L MIS SYSTEM Tier 3 EASYMAX N KIT SYSTEM Tier 3 EASYMAX N MIS SYSTEM Tier 3 EASYMAX NG KIT SYSTEM Tier 3 74 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy EASYMAX NG MIS SYSTEM Tier 3 EASYMAX V KIT SYSTEM Tier 3 EASYMAX V MIS SYSTEM Tier 3 EASYMAX V2 KIT SYSTEM Tier 3 EASYMAX V2 MIS SYSTEM Tier 3 EASYPLS R13N KIT SYSTEM Tier 3 EASYPLUS TES BLD GLUC Tier 3 X EASYPLUS V KIT SYSTEM Tier 3 EC-NAPROSYN TAB 375MG Tier 3 EC-NAPROSYN TAB 500MG Tier 3 ECONAZOLE CRE 1% Tier 3 X ECONTRA EZ TAB 1.5MG HCR Preventive ECOZA AER 1% Tier 3 X X ECPIRIN TAB 325MG EC HCR Preventive ECZEMOL TAB Tier 3 ED CYTE F TAB Tier 3 ED-FLEX CAP Tier 1 ED-SPAZ TAB 0.125MG Tier 1 EDARBI TAB 40MG Tier 3 X EDARBI TAB 80MG Tier 3 X EDARBYCLOR TAB 40-12.5 Tier 3 X EDARBYCLOR TAB 40-25MG Tier 3 X EDECRIN TAB 25MG Tier 3 EDEX KIT 10MCG Tier 3 X EDEX KIT 20MCG Tier 3 X EDEX KIT 40MCG Tier 3 X EDLUAR SUB 10MG Tier 3 X X EDLUAR SUB 5MG Tier 3 X X EDURANT TAB 25MG Tier 2 X EEMT TAB 1.25-2.5 Tier 1 EEMT HS TAB Tier 1 EFFER-K TAB 10MEQ Tier 2 EFFER-K TAB 20MEQ Tier 2 EFFER-K TAB 25MEQ EF Tier 1 EFFEXOR XR CAP 150MG Tier 3 X EFFEXOR XR CAP 37.5MG Tier 3 X

75 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy EFFEXOR XR CAP 75MG Tier 3 X EFFIENT TAB 10MG Tier 3 X EFFIENT TAB 5MG Tier 3 X EFUDEX CRE 5% Tier 3 EGRIFTA SOL 1MG Tier 3 X X EGRIFTA SOL 2MG Tier 3 X ELAVIL TAB 25MG Tier 3 ELDEPRYL CAP 5MG Tier 3 ELESTAT DRO 0.05% Tier 3 X X ELESTRIN GEL 0.06% Tier 3 ELETONE CRE Tier 3 X ELETONE CRE TWINPACK Tier 3 X ELIDEL CRE 1% Tier 3 X X ELIGARD INJ 22.5MG Tier 3 X X ELIGARD INJ 30MG Tier 3 X X ELIGARD INJ 45MG Tier 3 X X ELIGARD INJ 7.5MG Tier 3 X X ELIMITE CRE 5% Tier 3 ELINEST TAB HCR Preventive ELIPHOS TAB 667MG Tier 1 ELIQUIS TAB 2.5MG Tier 3 X ELIQUIS TAB 5MG Tier 3 X ELITE-OB TAB Tier 3 ELIXOPHYLLIN ELX 80/15ML Tier 3 ELLA TAB 30MG HCR X Preventive ELMIRON CAP 100MG Tier 2 ELOCON CRE 0.1% Tier 3 ELOCON LOT 0.1% Tier 3 ELOCON OIN 0.1% Tier 3 ELOCTATE INJ 1000UNIT Tier 3 X X ELOCTATE INJ 1500UNIT Tier 3 X X ELOCTATE INJ 2000UNIT Tier 3 X X ELOCTATE INJ 250UNIT Tier 3 X X ELOCTATE INJ 3000UNIT Tier 3 X X ELOCTATE INJ 500UNIT Tier 3 X X ELOCTATE INJ 750UNIT Tier 3 X X

76 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy EMADINE SOL 0.05% OP Tier 3 X EMBEDA CAP 100-4MG Tier 3 X X X EMBEDA CAP 20-0.8MG Tier 3 X X X EMBEDA CAP 30-1.2MG Tier 3 X X X EMBEDA CAP 50-2MG Tier 3 X X X EMBEDA CAP 60-2.4MG Tier 3 X X X EMBEDA CAP 80-3.2MG Tier 3 X X X EMBRACE MIS Tier 3 EMBRACE SOL LOW Tier 2 EMBRACE TES BLD GLUC Tier 3 X EMCYT CAP 140MG Tier 2 X EMEND CAP 125MG Tier 2 X EMEND CAP 40MG Tier 2 X EMEND CAP 80MG Tier 2 X EMEND PAK 80 & 125 Tier 2 X EMEND SUS 125MG Tier 2 X EMLA CRE 2.5-2.5% Tier 3 EMOLIVAN CRE Tier 3 X EMOLLIENT CRE Tier 3 X EMOLLIENT CRE BASE Tier 3 X EMOQUETTE TAB HCR Preventive EMSAM DIS 12MG/24H Tier 3 EMSAM DIS 6MG/24HR Tier 3 EMSAM DIS 9MG/24HR Tier 3 EMTRIVA CAP 200MG Tier 2 X EMTRIVA SOL 10MG/ML Tier 2 X EMULSION SB EMU Tier 3 X EMVERM CHW 100MG Tier 3 X EMVOREN CRE Tier 3 X EN GENTLEASE POW FUSS/GAS Tier 3 EN GENTLEASE POW LIPIL Tier 3 ENABLEX TAB 15MG Tier 3 X ENABLEX TAB 7.5MG Tier 3 X ENALAPR/HCTZ TAB 10-25MG Tier 1 ENALAPR/HCTZ TAB 5-12.5MG Tier 1 ENALAPRIL TAB 10MG Tier 1 ENALAPRIL TAB 2.5MG Tier 1

77 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ENALAPRIL TAB 20MG Tier 1 ENALAPRIL TAB 5MG Tier 1 ENBRACE HR CAP Tier 3 ENBREL INJ 25/0.5ML Tier 3 X X X X ENBREL INJ 25MG Tier 3 X X X X ENBREL INJ 50MG/ML Tier 3 X X X X ENBREL SRCLK INJ 50MG/ML Tier 3 X X X X ENDOCET TAB 10-325MG Tier 1 X ENDOCET TAB 2.5-325 Tier 1 X ENDOCET TAB 5-325MG Tier 1 X ENDOCET TAB 7.5-325 Tier 1 X ENDOMETRIN SUP 100MG Tier 3 ENFA LACTOFR LIQ LIPIL Tier 3 ENFA NUTRAMI CON LIPIL Tier 3 ENFA NUTRAMI LIQ LIPIL Tier 3 ENFA NUTRAMI POW LIPIL Tier 3 ENFA PREGEST LIQ LIPIL Tier 3 ENFA PROSOBE CON LIPIL Tier 3 ENFA PROSOBE CON SENSITIV Tier 3 ENFA PROSOBE LIQ LIPIL Tier 3 ENFA PROSOBE LIQ SENSITIV Tier 3 ENFAGROW LIQ PREMIUM Tier 3 ENFAGROW POW GENTLEAS Tier 3 ENFAGROW POW PREMIUM Tier 3 ENFAGROW POW SOY Tier 3 ENFAGROW POW TODDLER Tier 3 ENFAGROW NEX POW STEP Tier 3 ENFAMIL LIQ ENFACARE Tier 3 ENFAMIL LIQ GENTLEAS Tier 3 ENFAMIL LIQ INFANT Tier 3 ENFAMIL LIQ PREMATUR Tier 3 ENFAMIL LIQ REGULINE Tier 3 ENFAMIL POW ENFACARE Tier 3 ENFAMIL POW ENSPIRE Tier 3 ENFAMIL POW GENTLEAS Tier 3 ENFAMIL POW INFANT Tier 3 ENFAMIL POW NEWBORN Tier 3 ENFAMIL POW REGULINE Tier 3 78 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ENFAMIL AR LIQ LIPIL Tier 3 ENFAMIL AR LIQ SPIT-UP Tier 3 ENFAMIL AR POW SPIT-UP Tier 3 ENFAMIL ENFA POW LIPIL Tier 3 ENFAMIL FOR LIQ SUPPLEME Tier 3 ENFAMIL FOR POW SUPPLEME Tier 3 ENFAMIL GENT POW FUSS/GAS Tier 3 ENFAMIL HUMA LIQ FORTIFIE Tier 3 ENFAMIL HUMA POW FORTIFIE Tier 3 ENFAMIL LIPI LIQ ENFACARE Tier 3 ENFAMIL LIPI LIQ GENTLEAS Tier 3 ENFAMIL LIPI LIQ PREMATUR Tier 3 ENFAMIL LIPI LIQ W/IRON Tier 3 ENFAMIL PREM CON INFANT Tier 3 ENFAMIL PREM CON LIPIL Tier 3 ENFAMIL PREM LIQ INFANT Tier 3 ENFAMIL PREM LIQ LIPIL Tier 3 ENFAMIL PREM LIQ NEWBORN Tier 3 ENFAMIL PREM POW INFANT Tier 3 ENFAMIL PREM POW LIPIL Tier 3 ENFAMIL PREM POW NEWBORN Tier 3 ENFAMIL SOY POW PROSOBEE Tier 3 ENFAPORT LIQ Tier 3 ENJUVIA TAB 0.3MG Tier 3 ENJUVIA TAB 0.45MG Tier 3 ENJUVIA TAB 0.625MG Tier 3 ENJUVIA TAB 0.9MG Tier 3 ENLITE MIS SERTER Tier 2 ENLITE GLUCO MIS SENSOR Tier 3 X X ENOVARX CRE 2.5% Tier 3 X ENOXAPARIN INJ 100MG/ML Tier 3 X ENOXAPARIN INJ 120/0.8 Tier 3 X ENOXAPARIN INJ 150MG/ML Tier 3 X ENOXAPARIN INJ 30/0.3ML Tier 3 X ENOXAPARIN INJ 300/3ML Tier 3 X ENOXAPARIN INJ 40/0.4ML Tier 3 X ENOXAPARIN INJ 60/0.6ML Tier 3 X ENOXAPARIN INJ 80/0.8ML Tier 3 X 79 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ENPRESSE-28 TAB HCR Preventive ENSKYCE TAB HCR Preventive ENSTILAR AER Tier 3 X ENTACAPONE TAB 200MG Tier 1 ENTECAVIR TAB 0.5MG Tier 3 X ENTECAVIR TAB 1MG Tier 3 X ENTERAGAM POW 5GM Tier 3 ENTEREG CAP 12MG Tier 3 ENTERO VU SUS 24% Tier 3 ENTOCORT EC CAP 3MG DR Tier 3 X ENTRESTO TAB 24-26MG Tier 3 X X ENTRESTO TAB 49-51MG Tier 3 X X ENTRESTO TAB 97-103MG Tier 3 X X ENTTY EMU SPRAY Tier 3 X ENULOSE SOL 10GM/15 Tier 1 ENVARSUS XR TAB 0.75MG Tier 3 X X ENVARSUS XR TAB 1MG Tier 3 X X ENVARSUS XR TAB 4MG Tier 3 X X EPANED SOL 1MG/ML Tier 3 X EPANED SOL 1MG/ML Tier 3 EPCLUSA TAB 400-100 Tier 2 X X X EPICERAM EMU Tier 3 X EPIDUO GEL 0.1-2.5% Tier 3 X EPIDUO FORTE GEL 0.3-2.5% Tier 3 X X EPIFOAM AER 1% Tier 2 EPINASTINE DRO 0.05% Tier 3 X X EPINEPHR HCL SOL 2% OP Tier 1 EPINEPHRINE INJ 0.15MG Tier 3 X X EPINEPHRINE INJ 0.3MG Tier 3 X X EPIPEN 2-PAK INJ 0.3MG Tier 2 X EPIPEN-JR INJ 2-PAK Tier 2 X EPISONE CRE Tier 1 EPITOL TAB 200MG Tier 1 EPIVIR SOL 10MG/ML Tier 3 X EPIVIR TAB 150MG Tier 3 X EPIVIR TAB 300MG Tier 3 X

80 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy EPIVIR HBV SOL 5MG/ML Tier 2 X EPIVIR HBV TAB 100MG Tier 3 X EPLERENONE TAB 25MG Tier 3 EPLERENONE TAB 50MG Tier 3 EPOGEN INJ 10000/ML Tier 2 X X EPOGEN INJ 2000/ML Tier 2 X X EPOGEN INJ 20000/ML Tier 2 X X EPOGEN INJ 3000/ML Tier 2 X X EPOGEN INJ 4000/ML Tier 2 X X EPROSART MES TAB 600MG Tier 3 X EPZICOM TAB 600-300 Tier 3 X EQ ASPIRIN TAB 325MG HCR Preventive EQ ASPIRIN TAB 325MG EC HCR Preventive EQ CHILD ASA CHW 81MG HCR Preventive EQ CLEARLAX POW HCR Preventive EQ NICOTINE DIS 14MG/24H HCR X Preventive EQ NICOTINE DIS 21MG/24H HCR X Preventive EQ NICOTINE DIS 7MG/24HR HCR X Preventive EQ NICOTINE GUM 2MG CINN HCR X Preventive EQ NICOTINE GUM 2MG MINT HCR X Preventive EQ NICOTINE GUM 2MG ORIG HCR X Preventive EQ NICOTINE GUM 2MGFRUIT HCR X Preventive EQ NICOTINE GUM 4MG CINN HCR X Preventive EQ NICOTINE GUM 4MG MINT HCR X Preventive EQ NICOTINE GUM 4MG ORIG HCR X Preventive

81 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy EQ NICOTINE GUM 4MG REF HCR X Preventive EQ NICOTINE GUM 4MG STRT HCR X Preventive EQ NICOTINE GUM 4MGFRUIT HCR X Preventive EQ NICOTINE LOZ 2MG CHER HCR X Preventive EQ NICOTINE LOZ 2MG MINT HCR X Preventive EQ NICOTINE LOZ 4MG CHRY HCR X Preventive EQ NICOTINE LOZ 4MG MINT HCR X Preventive EQL ASPIRIN TAB 325MG HCR Preventive EQL ASPIRIN TAB 325MG EC HCR Preventive EQL ASPIRIN TAB 81MG EC HCR Preventive EQL CHLD ASA CHW 81MG HCR Preventive EQL CLEARLAX POW HCR Preventive EQL GENTLE TAB LAXATIVE HCR Preventive EQL LAXATIVE TAB 5MG EC HCR Preventive EQL NICOTINE GUM 2MG HCR X Preventive EQL NICOTINE GUM 2MG REF HCR X Preventive EQL NICOTINE GUM 2MG STRT HCR X Preventive EQL NICOTINE GUM 4MG HCR X Preventive EQL NICOTINE GUM 4MG REF HCR X Preventive EQL NICOTINE GUM 4MG STRT HCR X Preventive

82 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy EQL NICOTINE LOZ 2MG HCR X Preventive EQL NICOTINE LOZ 2MG MINT HCR X Preventive EQL NICOTINE LOZ 4MG CHRY HCR X Preventive EQL NICOTINE LOZ 4MG MINT HCR X Preventive EQUETRO CAP 100MG Tier 3 EQUETRO CAP 200MG Tier 3 EQUETRO CAP 300MG Tier 3 ERGOLOID MES TAB 1MG ORAL Tier 1 ERGOMAR SUB 2MG Tier 2 ERIVEDGE CAP 150MG Tier 2 X X X ERRIN TAB 0.35MG HCR Preventive ERTACZO CRE 2% Tier 3 X ERY PAD 2% Tier 1 ERY-TAB TAB 250MG EC Tier 2 ERY-TAB TAB 333MG EC Tier 2 ERY-TAB TAB 500MG EC Tier 2 ERY/BENZOYL GEL 5-3% Tier 1 X ERYGEL GEL 2% Tier 3 ERYPED SUS 200/5ML Tier 3 ERYPED SUS 400/5ML Tier 3 ERYSIDORON LIQ #1 Tier 3 ERYTHROCIN TAB 250MG Tier 2 ERYTHROM ETH SUS 200/5ML Tier 1 ERYTHROM ETH TAB 400MG Tier 1 ERYTHROMYCIN CAP 250MG EC Tier 1 ERYTHROMYCIN GEL 2% Tier 1 ERYTHROMYCIN OIN 5MG/GM Tier 1 ERYTHROMYCIN OIN OP Tier 1 ERYTHROMYCIN PAD 2% Tier 1 ERYTHROMYCIN SOL 2% Tier 1 ERYTHROMYCIN TAB 250MG BS Tier 1 ERYTHROMYCIN TAB 500MG BS Tier 1 ESBRIET CAP 267MG Tier 2 X X X ESCAVITE CHW Tier 3 83 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ESCITALOPRAM SOL 5MG/5ML Tier 3 ESCITALOPRAM TAB 10MG Tier 1 ESCITALOPRAM TAB 20MG Tier 1 ESCITALOPRAM TAB 5MG Tier 1 ESGIC CAP Tier 3 X ESGIC TAB Tier 3 X ESSENTRA MIS 9X9" Tier 3 EST ESTROGEN TAB MTEST Tier 1 EST ESTROGEN TAB MTEST HS Tier 1 ESTARYLLA TAB 0.25-35 HCR Preventive ESTAZOLAM TAB 1MG Tier 1 ESTAZOLAM TAB 2MG Tier 1 ESTRA/NORETH TAB 0.5-0.1 Tier 3 ESTRA/NORETH TAB 1-0.5MG Tier 3 ESTRACE TAB 0.5MG Tier 3 ESTRACE TAB 1MG Tier 3 ESTRACE TAB 2MG Tier 3 ESTRACE VAG CRE 0.1MG/GM Tier 3 ESTRADIOL DIS 0.025MG Tier 1 X ESTRADIOL DIS 0.025MG Tier 3 X X ESTRADIOL DIS 0.0375MG Tier 1 X ESTRADIOL DIS 0.0375MG Tier 3 X X ESTRADIOL DIS 0.05MG Tier 1 X ESTRADIOL DIS 0.05MG Tier 3 X X ESTRADIOL DIS 0.06MG Tier 1 X ESTRADIOL DIS 0.075MG Tier 1 X ESTRADIOL DIS 0.075MG Tier 3 X X ESTRADIOL DIS 0.1MG Tier 1 X ESTRADIOL DIS 0.1MG Tier 3 X X ESTRADIOL TAB 0.5MG Tier 1 ESTRADIOL TAB 1MG Tier 1 ESTRADIOL TAB 2MG Tier 1 ESTRING MIS 2MG Tier 2 X ESTRIOL POW Tier 3 ESTRIOL POW MICRONIZ Tier 3 ESTRIOL ULT POW MICRONIZ Tier 3 ESTRO SUPPRT TAB ES Tier 1

84 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ESTRO VITAL TAB NUTRIENT Tier 1 ESTROG/MTEST TAB 1.25-2.5 Tier 1 ESTROGEL GEL Tier 3 X ESTROPIPATE TAB 0.75MG Tier 1 ESTROPIPATE TAB 1.5MG Tier 1 ESTROPIPATE TAB 3MG Tier 1 ESTROSTEP FE TAB Tier 3 ESZOPICLONE TAB 1MG Tier 3 X ESZOPICLONE TAB 2MG Tier 3 X ESZOPICLONE TAB 3MG Tier 3 X ETHACRYNIC TAB ACD 25MG Tier 3 ETHAMBUTOL TAB 100MG Tier 1 ETHAMBUTOL TAB 400MG Tier 1 ETHOSUXIMIDE CAP 250MG Tier 1 ETHOSUXIMIDE POW Tier 3 ETHOSUXIMIDE SOL 250/5ML Tier 1 ETHYL CHLOR AER FINE PIN Tier 1 ETHYL CHLOR AER FN STRM Tier 1 ETHYL CHLOR AER MED JET Tier 1 ETHYL CHLOR AER MED STRM Tier 1 ETHYL CHLOR AER MIST Tier 1 ETHYL CHLOR AER SPRAY Tier 1 ETHYNODIOL TAB 1-50 HCR Preventive ETIDRON DISD TAB 200MG Tier 1 ETIDRON DISD TAB 400MG Tier 1 ETODOLAC CAP 200MG Tier 1 ETODOLAC CAP 300MG Tier 1 ETODOLAC TAB 400MG Tier 1 ETODOLAC TAB 500MG Tier 1 ETODOLAC ER TAB 400MG Tier 1 ETODOLAC ER TAB 500MG Tier 1 ETODOLAC ER TAB 600MG Tier 1 ETOPOSIDE CAP 50MG Tier 1 X ETOPOSIDE POW Tier 3 X EURAX CRE 10% Tier 2 EURAX LOT 10% Tier 3 EVAMIST SPR 1.53MG Tier 2

85 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy EVEKEO TAB 10MG Tier 3 X X EVEKEO TAB 5MG Tier 3 X X EVICEL KIT 2ML Tier 3 EVICEL KIT 5ML Tier 3 EVISTA TAB 60MG HCR X Preventive EVITHROM SOL 800-1200 Tier 3 EVOCLIN AER 1% Tier 3 EVOTAZ TAB 300-150 Tier 2 X EVOXAC CAP 30MG Tier 3 EVZIO INJ Tier 3 X X X EX-LAX ULTRA TAB 5MG EC HCR Preventive EXACTECH TES Tier 3 X X EXACTECH TES R-S-G Tier 3 X X EXACTUSS LIQ Tier 3 EXALGO TAB 12MG Tier 3 X X X EXALGO TAB 16MG Tier 3 X X X EXALGO TAB 32MG Tier 3 X X X EXALGO TAB 8MG Tier 3 X X X EXELDERM CRE 1% Tier 3 EXELDERM SOL 1% Tier 3 EXELON CAP 1.5MG Tier 3 EXELON CAP 3MG Tier 3 EXELON CAP 4.5MG Tier 3 EXELON CAP 6MG Tier 3 EXELON DIS 13.3/24 Tier 3 X EXELON DIS 4.6MG/24 Tier 3 X EXELON DIS 9.5MG/24 Tier 3 X EXEMESTANE TAB 25MG Tier 3 EXFORGE TAB 10-160MG Tier 3 X X EXFORGE TAB 10-320MG Tier 3 X X EXFORGE TAB 5-160MG Tier 3 X X EXFORGE TAB 5-320MG Tier 3 X X EXFORGEH/10- TAB 160-12.5 Tier 3 X X EXFORGEH/10- TAB 160-25 Tier 3 X X EXFORGEH/10- TAB 320-25 Tier 3 X X EXFORGEH/5- TAB 160-12.5 Tier 3 X X

86 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy EXFORGEH/5- TAB 160-25 Tier 3 X X EXJADE TAB 125MG Tier 2 X X EXJADE TAB 250MG Tier 2 X X EXJADE TAB 500MG Tier 2 X X EXODERM LOT 25-1% Tier 1 EXOTIC-HC DRO OTIC Tier 1 EXTARDOL CRE Tier 3 X EXTAVIA INJ 0.3MG Tier 3 X X X X EXTINA AER 2% Tier 3 X EXTRA-VIRT CAP PLUS DHA Tier 3 EZIDE TAB 50MG Tier 1 F.A.A. LIQ Tier 3 FA-8 CAP 800MCG HCR Preventive FA-8 TAB 0.8MG HCR Preventive FABIOR AER 0.1% Tier 3 X X X FACTIVE TAB 320MG Tier 3 FAGRON LS CRE PLUS Tier 3 X FAGRON LS CRE ULTRA Tier 3 X FALESSA KIT Tier 3 X FALLBACK TAB 1.5MG HCR Preventive FALMINA TAB HCR Preventive FAMCICLOVIR TAB 125MG Tier 3 X FAMCICLOVIR TAB 250MG Tier 3 X FAMCICLOVIR TAB 500MG Tier 3 X FAMOTIDINE SUS 40MG/5ML Tier 1 FAMVIR TAB 125MG Tier 3 X FAMVIR TAB 250MG Tier 3 X FAMVIR TAB 500MG Tier 3 X FANAPT PAK Tier 3 X FANAPT TAB 10MG Tier 3 X FANAPT TAB 12MG Tier 3 X FANAPT TAB 1MG Tier 3 X FANAPT TAB 2MG Tier 3 X FANAPT TAB 4MG Tier 3 X

87 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy FANAPT TAB 6MG Tier 3 X FANAPT TAB 8MG Tier 3 X FANATREX SUS 25MG/ML Tier 3 X X FARESTON TAB 60MG Tier 2 X FARXIGA TAB 10MG Tier 3 X X FARXIGA TAB 5MG Tier 3 X X FARYDAK CAP 10MG Tier 3 X X X FARYDAK CAP 15MG Tier 3 X X X FARYDAK CAP 20MG Tier 3 X X X FASTCLIX MIS LANCETS Tier 1 FAZACLO TAB 100 ODT Tier 3 FAZACLO TAB 12.5 ODT Tier 3 FAZACLO TAB 150 ODT Tier 3 FAZACLO TAB 200 ODT Tier 3 FAZACLO TAB 25MG ODT Tier 3 FBL KIT CRE 15-4-5% Tier 3 X FC FEMALE MIS CONDOM HCR Preventive FEIBA INJ Tier 2 X FEIBA NF INJ Tier 2 X FELBAMATE SUS 600/5ML Tier 1 FELBAMATE TAB 400MG Tier 1 FELBAMATE TAB 600MG Tier 1 FELBATOL SUS 600/5ML Tier 3 X X FELBATOL TAB 400MG Tier 3 X X FELBATOL TAB 600MG Tier 3 X X FELDENE CAP 10MG Tier 3 FELDENE CAP 20MG Tier 3 FELODIPINE TAB 10MG ER Tier 1 FELODIPINE TAB 2.5MG ER Tier 1 FELODIPINE TAB 5MG ER Tier 1 FEM PH GEL Tier 3 FEMARA TAB 2.5MG Tier 3 X FEMCAP MIS 22MM HCR Preventive FEMCON FE CHW Tier 3 FEMHRT TAB 0.5-2.5 Tier 3

88 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy FEMININE LAX TAB 5MG EC HCR Preventive FEMRING MIS 0.05/24H Tier 3 X FEMRING MIS 0.1MG/24 Tier 3 X FEMYNOR TAB 0.25-35 HCR Preventive FENOFIBRATE CAP 130MG Tier 3 X FENOFIBRATE CAP 134MG Tier 3 X FENOFIBRATE CAP 150MG Tier 3 X FENOFIBRATE CAP 200MG Tier 3 X FENOFIBRATE CAP 43MG Tier 3 X FENOFIBRATE CAP 50MG Tier 3 X FENOFIBRATE CAP 67MG Tier 3 X FENOFIBRATE TAB 120MG Tier 3 X FENOFIBRATE TAB 145MG Tier 3 X FENOFIBRATE TAB 160MG Tier 3 FENOFIBRATE TAB 40MG Tier 3 X FENOFIBRATE TAB 48MG Tier 3 X FENOFIBRATE TAB 54MG Tier 3 FENOFIBRIC CAP 135MG DR Tier 3 X FENOFIBRIC CAP 45MG DR Tier 3 X FENOFIBRIC TAB 105MG Tier 3 X FENOFIBRIC TAB 35MG Tier 3 X FENOGLIDE TAB 120MG Tier 3 X FENOGLIDE TAB 40MG Tier 3 X FENOPROFEN CAP 200MG Tier 1 FENOPROFEN CAP 400MG Tier 1 FENOPROFEN TAB 600MG Tier 1 FENORTHO CAP 200MG Tier 1 FENORTHO CAP 400MG Tier 1 FENTANYL DIS 100MCG/H Tier 3 X FENTANYL DIS 12MCG/HR Tier 3 X FENTANYL DIS 25MCG/HR Tier 3 X FENTANYL DIS 37.5MCG Tier 3 X X FENTANYL DIS 50MCG/HR Tier 3 X FENTANYL DIS 62.5MCG Tier 3 X X FENTANYL DIS 75MCG/HR Tier 3 X FENTANYL DIS 87.5MCG Tier 3 X X

89 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy FENTANYL POW CITRATE Tier 3 X FENTANYL OT LOZ 1200MCG Tier 3 X X FENTANYL OT LOZ 1600MCG Tier 3 X X FENTANYL OT LOZ 200MCG Tier 3 X X FENTANYL OT LOZ 400MCG Tier 3 X X FENTANYL OT LOZ 600MCG Tier 3 X X FENTANYL OT LOZ 800MCG Tier 3 X X FENTORA TAB 100MCG Tier 3 X X X FENTORA TAB 200MCG Tier 3 X X X FENTORA TAB 400MCG Tier 3 X X X FENTORA TAB 600MCG Tier 3 X X X FENTORA TAB 800MCG Tier 3 X X X FERRIPROX SOL 100MG/ML Tier 2 X X FERRIPROX TAB 500MG Tier 3 X X FETZIMA CAP 120MG Tier 3 X X FETZIMA CAP 20MG Tier 3 X X FETZIMA CAP 40MG Tier 3 X X FETZIMA CAP 80MG Tier 3 X X FETZIMA CAP TITRATIO Tier 3 X X FEXMID TAB 7.5MG Tier 3 FIBERSOUR HN LIQ CLS SYS Tier 3 FIBERSOUR HN LIQ VANILLA Tier 3 FIBERSOURCE LIQ CLS SYS Tier 3 FIBRICOR TAB 105MG Tier 3 X FIBRICOR TAB 35MG Tier 3 X FINACEA AER 15% Tier 3 FINACEA GEL 15% Tier 3 FINASTERIDE TAB 5MG Tier 1 FINGERSTIX MIS LANCETS Tier 3 FIORICET CAP Tier 3 X FIORICET CAP CODEINE Tier 3 X X FIORINAL CAP Tier 3 FIORINAL/COD CAP 30MG Tier 3 FIRAZYR INJ 30MG/3ML Tier 3 X X X FIRMAGON INJ 120MG Tier 3 X FIRMAGON INJ 80MG Tier 3 X FIRST DUKES SUS MOUTHWSH Tier 3 X FIRST-BACLOF SUS 1 Tier 3 X 90 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy FIRST-BACLOF SUS 5 KIT Tier 3 X FIRST-MARYS SUS MOUTHWSH Tier 3 X FIRST-METRON SUS 100MG/ML Tier 3 X FIRST-METRON SUS 50MG/ML Tier 3 X FIRST-MOUTHW SUS BLM Tier 3 X FIRST-OMEPRA SUS 2MG/ML Tier 3 X FIRST-TESTOS CRE MC 2% Tier 3 X FIRST-TESTOS OIN 2% Tier 3 X FITALITE CRE BASE Tier 3 X FLAGYL CAP 375MG Tier 3 FLAGYL TAB 250MG Tier 3 FLAGYL TAB 500MG Tier 3 FLAREX SUS 0.1% OP Tier 2 FLAVOR BLEND SUS Tier 3 FLAVOR PLUS LIQ Tier 3 FLAVOR SWEET SYP Tier 3 FLAVOR SWEET SYP S/F Tier 3 FLAVOXATE TAB 100MG Tier 1 FLECAINIDE TAB 100MG Tier 1 FLECAINIDE TAB 150MG Tier 1 FLECAINIDE TAB 50MG Tier 1 FLECTOR DIS 1.3% Tier 3 X FLEET LAXATI TAB 5MG EC HCR Preventive FLEXGEN TAB Tier 1 FLEXICHAMBER MIS Tier 3 FLEXICHAMBER MIS MASK LRG Tier 2 FLEXICHAMBER MIS MASK SM Tier 2 FLEXLINK MIS PLS/10MM Tier 2 FLEXLINK MIS PLUS/6MM Tier 2 FLEXLINK MIS PLUS/8MM Tier 2 FLOMAX CAP 0.4MG Tier 3 X FLORIVA DRO 0.25MG Tier 3 FLORIVA DRO PLUS Tier 3 FLOVENT DISK AER 100MCG Tier 3 X FLOVENT DISK AER 250MCG Tier 3 X FLOVENT DISK AER 50MCG Tier 3 X FLOVENT HFA AER 110MCG Tier 3 X

91 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy FLOVENT HFA AER 220MCG Tier 3 X FLOVENT HFA AER 44MCG Tier 3 X FLOW-EZE MIS VENTED Tier 3 FLOWTUSS SOL 2.5-200 Tier 3 X X FLOXIN SOL 0.3% Tier 3 X FLUCAINE SOL 0.25-0.5 Tier 1 FLUCONAZOLE SUS 10MG/ML Tier 1 FLUCONAZOLE SUS 40MG/ML Tier 1 FLUCONAZOLE TAB 100MG Tier 1 FLUCONAZOLE TAB 150MG Tier 1 FLUCONAZOLE TAB 200MG Tier 1 FLUCONAZOLE TAB 50MG Tier 1 FLUCYTOSINE CAP 250MG Tier 1 FLUCYTOSINE CAP 500MG Tier 1 FLUDROCORT TAB 0.1MG Tier 1 FLUMADINE TAB 100MG Tier 3 FLUNISOLIDE SPR 0.025% Tier 3 FLUOCIN ACET CRE 0.01% Tier 3 X FLUOCIN ACET CRE 0.025% Tier 3 X FLUOCIN ACET OIL 0.01% Tier 1 FLUOCIN ACET OIL 0.01% SC Tier 3 FLUOCIN ACET OIL 0.01%BDY Tier 3 X FLUOCIN ACET OIL BODY Tier 3 X FLUOCIN ACET OIL EAR0.01% Tier 1 FLUOCIN ACET OIL SCALP Tier 3 FLUOCIN ACET OIN 0.025% Tier 1 X FLUOCIN ACET SOL 0.01% Tier 3 X FLUOCINONIDE CRE -E 0.05% Tier 1 FLUOCINONIDE CRE 0.05% Tier 1 FLUOCINONIDE CRE 0.1% Tier 3 X X FLUOCINONIDE GEL 0.05% Tier 1 FLUOCINONIDE OIN 0.05% Tier 1 FLUOCINONIDE SOL 0.05% Tier 1 FLUOR-A-DAY CHW 0.25MG F Tier 3 FLUOR-A-DAY CHW 0.5MG F Tier 3 FLUOR-A-DAY CHW 1MG F Tier 3 FLUOR-A-DAY DRO 0.125MG HCR Preventive

92 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy FLUOR-I-STRI TES 1MG OP Tier 1 FLUORABON DRO HCR Preventive FLUORACAINE SOL OP Tier 3 FLUORE-BENOX SOL 0.25-0.4 Tier 1 FLUORESCEIN/ SOL PROPARAC Tier 1 FLUORIDE CHW 0.25MG F HCR Preventive FLUORIDE CHW 0.5MG F HCR Preventive FLUORIDE CHW 1MG F HCR Preventive FLUORIDEX GEL 1.1% Tier 1 FLUORIDEX GEL SENSITIV Tier 3 FLUORIDEX GEL WHITENIN Tier 1 FLUORIDEX DD PST SENSITIV Tier 1 FLUORITAB CHW 0.25MG F HCR Preventive FLUORITAB CHW 0.5MG F HCR Preventive FLUORITAB CHW 1MG F HCR Preventive FLUORITAB CHW 2.2MG HCR Preventive FLUORITAB DRO 0.125MG HCR Preventive FLUOROMETHOL SUS 0.1% OP Tier 1 FLUOROPLEX CRE 1% Tier 3 FLUOROURACIL CRE 0.5% Tier 3 X FLUOROURACIL CRE 5% Tier 1 FLUOROURACIL DRO 2% Tier 1 X FLUOROURACIL DRO 5% Tier 1 X FLUOROURACIL POW Tier 3 X FLUOROURACIL POW USP/NF Tier 3 X FLUOROURACIL SOL 2% Tier 1 X FLUOROURACIL SOL 5% Tier 1 X FLUOXETINE CAP 10MG Tier 1 FLUOXETINE CAP 10MG Tier 1 FLUOXETINE CAP 20MG Tier 1

93 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy FLUOXETINE CAP 20MG Tier 1 FLUOXETINE CAP 40MG Tier 1 FLUOXETINE CAP 90MG DR Tier 1 X FLUOXETINE POW HCL Tier 3 X FLUOXETINE SOL 20MG/5ML Tier 1 FLUOXETINE TAB 10MG Tier 1 FLUOXETINE TAB 10MG Tier 3 FLUOXETINE TAB 20MG Tier 1 FLUOXETINE TAB 20MG Tier 3 FLUOXETINE TAB 60MG Tier 3 FLUPHENAZINE CON 5MG/ML Tier 1 FLUPHENAZINE ELX 2.5/5ML Tier 1 FLUPHENAZINE TAB 10MG Tier 1 FLUPHENAZINE TAB 1MG Tier 1 FLUPHENAZINE TAB 2.5MG Tier 1 FLUPHENAZINE TAB 5MG Tier 1 FLURA-DROPS DRO 0.125MG HCR Preventive FLURA-DROPS DRO 0.25MG F HCR Preventive FLURA-SAFE SOL Tier 3 FLURANDRENOL CRE 0.05% Tier 3 X X FLURANDRENOL LOT 0.05% Tier 3 X X FLURAZEPAM CAP 15MG Tier 1 FLURAZEPAM CAP 30MG Tier 1 FLURBIPROFEN POW Tier 3 X FLURBIPROFEN SOL 0.03% OP Tier 1 FLURBIPROFEN TAB 100MG Tier 1 FLURBIPROFEN TAB 50MG Tier 1 FLUROX SOL OP Tier 1 FLUTAMIDE CAP 125MG Tier 1 X FLUTICASONE CRE 0.05% Tier 1 FLUTICASONE LOT 0.05% Tier 3 X X FLUTICASONE OIN 0.005% Tier 1 FLUTICASONE POW PROPIONA Tier 3 X X FLUTICASONE SPR 50MCG Tier 3 X FLUVASTATIN CAP 20MG Tier 1 X FLUVASTATIN CAP 40MG Tier 1 X

94 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy FLUVASTATIN TAB 80MG ER Tier 3 X X FLUVOXAMINE CAP 100MG ER Tier 3 X FLUVOXAMINE CAP 150MG ER Tier 3 X FLUVOXAMINE TAB 100MG Tier 1 FLUVOXAMINE TAB 25MG Tier 1 FLUVOXAMINE TAB 50MG Tier 1 FML OIN 0.1% OP Tier 2 FML FORTE SUS 0.25% OP Tier 2 FML LIQUIFLM SUS 0.1% OP Tier 3 FOAMIL LIQ Tier 3 X FOCALGIN 90 MIS DHA Tier 3 FOCALGIN CA MIS Tier 3 FOCALIN TAB 10MG Tier 3 X FOCALIN TAB 2.5MG Tier 3 X FOCALIN TAB 5MG Tier 3 X FOCALIN XR CAP 10MG Tier 3 X X X FOCALIN XR CAP 15MG Tier 3 X X X FOCALIN XR CAP 20MG Tier 3 X X X FOCALIN XR CAP 25MG Tier 3 X X X FOCALIN XR CAP 30MG Tier 3 X X X FOCALIN XR CAP 35MG Tier 3 X X X FOCALIN XR CAP 40MG Tier 3 X X X FOCALIN XR CAP 5MG Tier 3 X X X FOLCAL DHA CAP Tier 3 FOLCAPS CAP OMEGA 3 Tier 2 FOLET DHA PAK Tier 3 FOLET ONE CAP 38-1-225 Tier 3 FOLIC ACID POW Tier 3 FOLIC ACID TAB 1000MCG Tier 1 FOLIC ACID TAB 1MG Tier 1 FOLIC ACID TAB 400MCG HCR Preventive FOLIC ACID TAB 800MCG HCR Preventive FOLIVANE-OB CAP Tier 3 FOLLISTIM AQ INJ 300UNIT Tier 3 X X FOLLISTIM AQ INJ 600UNIT Tier 3 X X FOLLISTIM AQ INJ 75UNIT Tier 3 X X

95 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy FOLLISTIM AQ INJ 900UNIT Tier 3 X X FONDAPARINUX INJ 10/0.8ML Tier 3 X FONDAPARINUX INJ 2.5/0.5 Tier 3 X FONDAPARINUX INJ 5/0.4ML Tier 3 X FONDAPARINUX INJ 7.5/0.6 Tier 3 X FOOD COLOR LIQ BLUE Tier 3 FORA GD50 MIS MONITOR Tier 3 FORA GD50 TES Tier 3 X FORA TEST N' MIS GO Tier 3 FORADIL CAP AEROLIZE Tier 3 X FORANE SOL Tier 2 FORFIVO XL TAB 450MG Tier 3 X X FORMA-RAY SOL 20% Tier 2 FORMADON SOL Tier 3 FORMALDEHYDE SOL 10% Tier 1 FORMALDEHYDE SOL 37% Tier 3 FORTAMET TAB 1000MG Tier 3 X X FORTAMET TAB 500MG Tier 3 X X FORTEO SOL 600/2.4 Tier 2 X X FORTESTA GEL 10MG/ACT Tier 3 X X X FORTICAL SPR 200/ACT Tier 3 FORTIGAN CAP Tier 1 FORTISCARE KIT SYSTEM Tier 3 FORTISCARE SOL CNTL HI Tier 2 FORTISCARE SOL CNTL LOW Tier 2 FORTISCARE SOL CNTL NML Tier 2 FORTISCARE TES BLD GLUC Tier 3 X FOSAMAX TAB 70MG Tier 3 X FOSAMAX + D TAB 70-2800 Tier 3 FOSAMAX + D TAB 70-5600 Tier 3 FOSINOP/HCTZ TAB 10/12.5 Tier 1 FOSINOP/HCTZ TAB 20/12.5 Tier 1 FOSINOPRIL TAB 10MG Tier 1 FOSINOPRIL TAB 20MG Tier 1 FOSINOPRIL TAB 40MG Tier 1 FOSRENOL CHW 1000MG Tier 3 FOSRENOL CHW 500MG Tier 3 FOSRENOL CHW 750MG Tier 3 96 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy FOSRENOL POW 1000MG Tier 3 FOSRENOL POW 750MG Tier 3 FOSTEUM CAP Tier 3 FOSTEUM PLUS CAP Tier 3 FOVEX CAP Tier 3 FP CEPA GEL Tier 3 FP DERM CRE Tier 3 X FP DERM GEL Tier 3 FP ENHANCING CRE Tier 3 X FP NATURAL CRE Tier 3 X FP PLUS CRE Tier 3 X FP SILO GEL Tier 3 FP SUPREME CRE Tier 3 X FP ULTRA CRE Tier 3 X FRAGMIN INJ 10000/ML Tier 3 X FRAGMIN INJ 12500UNT Tier 3 X FRAGMIN INJ 15000UNT Tier 3 X FRAGMIN INJ 18000UNT Tier 3 X FRAGMIN INJ 2500/0.2 Tier 3 X FRAGMIN INJ 5000/0.2 Tier 3 X FRAGMIN INJ 7500/0.3 Tier 3 X FRAGMIN INJ 95000UNT Tier 3 FREEDOM CRE DERMA-D Tier 3 X FREEDOM CRE DERMA-N Tier 3 X FREEDOM CRE ULTRAPEN Tier 3 X FREEDOM GEL CEPAPRO Tier 3 X FREEDOM GEL SET Tier 3 FREEDOM GEL SILOMAC Tier 3 X FREEDOM HRT CRE ULTRA Tier 3 X FREESTYLE MIS UNISTICK Tier 3 FREESTYLE TES PREC NEO Tier 3 X X FROVA TAB 2.5MG Tier 3 X FROVATRIPTAN TAB 2.5MG Tier 3 X FRST-HYDRCRT GEL 10% Tier 2 X FUL-GLO TES 0.6MG OP Tier 2 FUL-GLO TES 1MG OP Tier 1 FULYZAQ TAB 125MG Tier 3 X X X FURADANTIN SUS 25MG/5ML Tier 3 97 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy FUROSEMIDE SOL 10MG/ML Tier 1 FUROSEMIDE SOL 8MG/ML Tier 1 FUROSEMIDE TAB 20MG Tier 1 FUROSEMIDE TAB 40MG Tier 1 FUROSEMIDE TAB 80MG Tier 1 FUZEON INJ 90MG Tier 2 X FYAVOLV TAB 0.5-2.5 Tier 3 FYAVOLV TAB 1-5 Tier 3 FYCOMPA SUS 0.5MG/ML Tier 3 X FYCOMPA TAB 10MG Tier 3 X FYCOMPA TAB 12MG Tier 3 X FYCOMPA TAB 2MG Tier 3 X FYCOMPA TAB 4MG Tier 3 X FYCOMPA TAB 6MG Tier 3 X FYCOMPA TAB 8MG Tier 3 X G TUSSIN AC LIQ 100-10/5 Tier 1 G-PREPROTEIN LIQ Tier 3 GA POW Tier 3 GA DIET POW Tier 3 GABADONE CAP Tier 3 GABADONE CAP Tier 2 GABAPENTIN CAP 100MG Tier 1 GABAPENTIN CAP 300MG Tier 1 GABAPENTIN CAP 400MG Tier 1 GABAPENTIN POW Tier 3 X GABAPENTIN SOL 250/5ML Tier 1 GABAPENTIN TAB 600MG Tier 1 GABAPENTIN TAB 800MG Tier 1 GABITRIL TAB 12MG Tier 2 GABITRIL TAB 16MG Tier 2 GABITRIL TAB 2MG Tier 3 GABITRIL TAB 4MG Tier 3 GALANTAMINE CAP 16MG ER Tier 1 GALANTAMINE CAP 24MG ER Tier 1 GALANTAMINE CAP 8MG ER Tier 1 GALANTAMINE SOL 4MG/ML Tier 1 GALANTAMINE TAB 12MG Tier 1 GALANTAMINE TAB 4MG Tier 1 98 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy GALANTAMINE TAB 8MG Tier 1 GALZIN CAP 25MG Tier 3 GALZIN CAP 50MG Tier 3 GANIRELIX AC INJ Tier 3 X GAPEAUM CRE BUDIBAC Tier 3 X GASTROCROM CON 100/5ML Tier 3 GASTROGRAFIN SOL 66-10% Tier 3 GATIFLOXACIN SOL 0.5% Tier 3 X GATTEX KIT 5MG Tier 2 X X X GAVILAX POW HCR Preventive GAVILYTE-C SOL HCR Preventive GAVILYTE-G SOL HCR Preventive GAVILYTE-H KIT Tier 1 GAVILYTE-N SOL FLAV PK HCR Preventive GEBAUERS SPR AER /STRETCH Tier 3 GEL-KAM CON 0.63% Tier 3 GELFILM MIS OP Tier 2 GELNIQUE GEL 10% Tier 3 X GELNIQUE GEL 3% Tier 3 X GEMFIBROZIL TAB 600MG Tier 1 GENADUR KIT Tier 3 X GENADUR LIQ Tier 3 X GENE-XENE TAB 15MG Tier 1 GENE-XENE TAB 3.75MG Tier 1 GENE-XENE TAB 7.5MG Tier 1 GENERESS FE CHW Tier 3 X GENERLAC SOL 10GM/15 Tier 1 GENGRAF CAP 100MG Tier 1 X GENGRAF CAP 25MG Tier 1 X GENGRAF CAP 50MG Tier 1 X GENGRAF SOL 100MG/ML Tier 1 X GENOTROPIN INJ 0.2MG Tier 3 X X X X GENOTROPIN INJ 0.4MG Tier 3 X X X X GENOTROPIN INJ 0.6MG Tier 3 X X X X

99 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy GENOTROPIN INJ 0.8MG Tier 3 X X X X GENOTROPIN INJ 1.2MG Tier 3 X X X X GENOTROPIN INJ 1.4MG Tier 3 X X X X GENOTROPIN INJ 1.6MG Tier 3 X X X X GENOTROPIN INJ 1.8MG Tier 3 X X X X GENOTROPIN INJ 12MG Tier 3 X X X X GENOTROPIN INJ 1MG Tier 3 X X X X GENOTROPIN INJ 2MG Tier 3 X X X X GENOTROPIN INJ 5MG Tier 3 X X X X GENSTRIP 50 TES Tier 3 X GENTAK OIN 0.3% OP Tier 1 GENTAMICIN CRE 0.1% Tier 1 GENTAMICIN OIN 0.1% Tier 1 GENTAMICIN OIN 0.3% OP Tier 1 GENTAMICIN SOL 0.3% OP Tier 1 GENTLE LAXAT TAB 5MG EC HCR Preventive GENTLE-LET MIS 26G Tier 3 GENTLE-LET MIS 28G Tier 3 GENTLE-LET MIS LANCETS Tier 3 GENTLE-LET MIS PLATFORM Tier 3 GENTLELAX POW HCR Preventive GENVOYA TAB Tier 3 X X GEODON CAP 20MG Tier 3 X X GEODON CAP 40MG Tier 3 X X GEODON CAP 60MG Tier 3 X X GEODON CAP 80MG Tier 3 X X GERM DEFENSE TAB LEM-LIME Tier 3 GERM DEFENSE TAB ORANGE Tier 3 GERM DEFENSE TAB PM Tier 3 GG/CODEINE SOL 100-10/5 Tier 1 GIANVI TAB 3-0.02MG Tier 3 GIAZO TAB 1.1GM Tier 3 X GILDAGIA TAB 0.4-35 Tier 3 GILDESS TAB 1.5/30 Tier 3 GILDESS TAB 1/20 Tier 3 GILDESS 24 TAB FE 1/20 Tier 3

100 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy GILDESS FE TAB 1.5/30 HCR Preventive GILDESS FE TAB 1/20 HCR Preventive GILENYA CAP 0.5MG Tier 3 X X X GILOTRIF TAB 20MG Tier 3 X X X GILOTRIF TAB 30MG Tier 3 X X X GILOTRIF TAB 40MG Tier 3 X X X GILPHEX TR TAB 10-388MG Tier 3 GILTUSS LIQ Tier 3 GILTUSS PED LIQ Tier 3 GILTUSS TR TAB Tier 3 GINSENG POW AMERICAN Tier 3 X GINSENG ROOT POW Tier 3 X GLATOPA INJ 20MG/ML Tier 3 X X X X GLEEVEC TAB 100MG Tier 3 X X X X GLEEVEC TAB 400MG Tier 3 X X X X GLEOSTINE CAP 100MG Tier 3 X GLEOSTINE CAP 10MG Tier 3 X GLEOSTINE CAP 40MG Tier 3 X GLEOSTINE CAP 5MG Tier 3 X GLIMEPIRIDE TAB 1MG Tier 1 GLIMEPIRIDE TAB 2MG Tier 1 GLIMEPIRIDE TAB 4MG Tier 1 GLIP/METFORM TAB 2.5-250M Tier 3 GLIP/METFORM TAB 2.5-500M Tier 3 GLIP/METFORM TAB 5-500MG Tier 3 GLIPIZIDE POW Tier 3 GLIPIZIDE TAB 10MG Tier 1 GLIPIZIDE TAB 5MG Tier 1 GLIPIZIDE ER TAB 10MG Tier 1 GLIPIZIDE ER TAB 2.5MG Tier 1 GLIPIZIDE ER TAB 5MG Tier 1 GLIPIZIDE XL TAB 10MG Tier 1 GLIPIZIDE XL TAB 2.5MG Tier 1 GLIPIZIDE XL TAB 5MG Tier 1 GLONOIN DRO HOMACCOR Tier 3 GLUC CONTROL SOL LEVEL 1 Tier 2

101 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy GLUC CONTROL SOL LEVEL 2 Tier 2 GLUCAGEN INJ HYPOKIT Tier 2 X GLUCAGON KIT 1MG Tier 2 X GLUCOCARD 01 TES SENSOR Tier 3 X GLUCOCARD 01 TEST STRIPS Tier 3 X GLUCOCARD TES VITAL Tier 3 X GLUCOLET 2 MIS LANCING Tier 3 GLUCOPHAGE TAB 1000MG Tier 3 GLUCOPHAGE TAB 500MG Tier 3 GLUCOPHAGE TAB 500MG XR Tier 3 X GLUCOPHAGE TAB 750MG XR Tier 3 X GLUCOPHAGE TAB 850MG Tier 3 GLUCOSE CONT LIQ HIGH/LOW Tier 2 GLUCOSE CONT SOL PRECISIO Tier 2 GLUCOTROL TAB 10MG Tier 3 GLUCOTROL TAB 5MG Tier 3 GLUCOTROL XL TAB 10MG Tier 3 GLUCOTROL XL TAB 2.5MG Tier 3 GLUCOTROL XL TAB 5MG Tier 3 GLUCOVANCE TAB 2.5-500 Tier 3 GLUCOVANCE TAB 5-500MG Tier 3 GLUMETZA TAB 1000MG Tier 3 X X GLUMETZA TAB 500MG Tier 3 X X GLUTAMINE CAP 500MG Tier 3 GLUTAMINE POW Tier 3 X GLUTARALDEHY SOL 25% Tier 3 GLUTATHIONE POW Tier 3 X GLUTATHIONE POW REDUCED Tier 3 X GLYB/METFORM TAB 1.25-250 Tier 1 GLYB/METFORM TAB 2.5-500 Tier 1 GLYB/METFORM TAB 5-500MG Tier 1 GLYBURID MCR TAB 1.5MG Tier 1 GLYBURID MCR TAB 3MG Tier 1 GLYBURID MCR TAB 6MG Tier 1 GLYBURIDE POW Tier 3 GLYBURIDE TAB 1.25MG Tier 1 GLYBURIDE TAB 2.5MG Tier 1 GLYBURIDE TAB 5MG Tier 1 102 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy GLYCERIN LIQ Tier 2 GLYCERIN LIQ Tier 3 GLYCERINE LIQ Tier 3 GLYCEROL LIQ FORMAL Tier 3 GLYCOLAX POW 3350 NF HCR Preventive GLYCOPYRROL TAB 1MG Tier 1 GLYCOPYRROL TAB 2MG Tier 1 GLYNASE TAB 1.5MG Tier 3 GLYNASE TAB 3MG Tier 3 GLYNASE TAB 6MG Tier 3 GLYSET TAB 100MG Tier 3 GLYSET TAB 25MG Tier 3 GLYSET TAB 50MG Tier 3 GLYTROL LIQ ULTRAPAK Tier 3 GLYXAMBI TAB 10-5 MG Tier 3 X X GLYXAMBI TAB 25-5 MG Tier 3 X X GMATE BLOOD TES GLUCOSE Tier 3 X GMATE CONTRO SOL LEVEL 2 Tier 2 GMATE LANCET MIS 30G Tier 3 GMATE LANCIN MIS DEVICE Tier 3 GMATE ORIGIN MIS GLUC SYS Tier 3 X GMATE SMART KIT METER Tier 3 X GMATE SMART KIT STARTER Tier 3 X GMATE VOICE MIS GLUC SYS Tier 3 X GNP ALCOHOL PAD SWABS Tier 3 GNP ALLERGY ELX CHILDREN Tier 1 GNP ASPIRIN CHW 81MG HCR Preventive GNP ASPIRIN TAB 325MG HCR Preventive GNP ASPIRIN TAB 325MG EC HCR Preventive GNP ASPIRIN TAB 81MG EC HCR Preventive GNP ASPIRIN TAB LT.COAT HCR Preventive GNP BISA-LAX TAB 5MG EC HCR Preventive

103 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy GNP CLEARLAX POW HCR Preventive GNP DECONGES TAB ADV.FORM Tier 1 GNP DIPHEDRY CAP 25MG Tier 1 GNP DIPHEDRY TAB 60MG Tier 1 GNP DIXAPHED TAB 12 HR Tier 1 GNP HYDROCOR LOT 1% Tier 1 GNP HYDROCOR OIN 1% W/ALO Tier 1 GNP LAXATIVE TAB 5MG EC HCR Preventive GNP NICOTINE DIS 21MG/24H HCR X Preventive GNP NICOTINE GUM 2MG MINT HCR X Preventive GNP NICOTINE GUM 2MG ORIG HCR X Preventive GNP NICOTINE GUM 4MG MINT HCR X Preventive GNP NICOTINE GUM 4MG ORIG HCR X Preventive GNP NICOTINE LOZ 2MG MINT HCR X Preventive GNP NICOTINE LOZ 4MG MINT HCR X Preventive GNP NICOTINE LOZ MINI 2MG HCR X Preventive GNP SUPHEDRI TAB PLUS Tier 1 GNP VIT D TAB 1000UNIT HCR Preventive GOLY TELY SOL Tier 3 GOLY TELY SOL Tier 2 GOLYTELY SOL PINEAPPL Tier 3 GONAL-F INJ 1050UNIT Tier 2 X GONAL-F INJ 450UNIT Tier 2 X GONAL-F RFF INJ 300/0.5 Tier 2 X GONAL-F RFF INJ 450/0.75 Tier 2 X GONAL-F RFF INJ 75UNIT Tier 2 X GONAL-F RFF INJ 900/1.5 Tier 2 X GONITRO POW 400MCG Tier 3 X GOOD START CON SOY/IRON Tier 3 104 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy GOOD START CON W/IRON Tier 3 GOOD START LIQ SOY/IRON Tier 3 GOOD START LIQ W/IRON Tier 3 GOOD START POW NATURAL Tier 3 GOOD START POW SOY PLS2 Tier 3 GOOD START POW SOY/IRON Tier 3 GOOD START POW W/IRON Tier 3 GOOD START 2 CON W/IRON Tier 3 GOOD START 2 LIQ W/IRON Tier 3 GOOD START 2 POW SOY/IRON Tier 3 GOOD START 2 POW W/IRON Tier 3 GORDOFILM SOL Tier 2 GORDONS UREA OIN 40% Tier 3 GRALISE TAB 300MG Tier 3 X X GRALISE TAB 600MG Tier 3 X X GRALISE STAR MIS 300/600 Tier 3 X X GRANISETRON TAB 1MG Tier 3 X GRANIX INJ 300/0.5 Tier 3 X X GRANIX INJ 480/0.8 Tier 3 X X GRANULEX AER Tier 3 GRASTEK SUB 2800BAU Tier 3 X X GREEN GLO MIS 1.5MG Tier 1 GRIFULVIN V TAB 500MG Tier 3 GRIS-PEG TAB 125MG Tier 3 GRIS-PEG TAB 250MG Tier 3 GRISEOFULVIN SUS 125/5ML Tier 1 GRISEOFULVIN TAB MICR 500 Tier 1 GRISEOFULVIN TAB ULTR 125 Tier 1 GRISEOFULVIN TAB ULTR 250 Tier 1 GRX HICORT SUP 25MG Tier 1 GUAIATUSSIN SYP 100-10/5 Tier 1 GUAIFENESIN SYP 100-10/5 Tier 1 GUANFACINE TAB 1MG Tier 1 GUANFACINE TAB 1MG ER Tier 3 X GUANFACINE TAB 2MG Tier 1 GUANFACINE TAB 2MG ER Tier 3 X GUANFACINE TAB 3MG ER Tier 3 X GUANFACINE TAB 4MG ER Tier 3 X 105 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy GUANIDINE TAB 125MG Tier 3 GUARDIAN MIS TRANSMTR Tier 3 X X GUARDIAN RT KIT Tier 3 X X GUARDIAN RT KIT STARTER Tier 3 X X GUARDIAN RT KIT SYST PED Tier 3 X X GUARDIAN RT KIT SYSTEM Tier 3 X X GUARDIAN RT MIS CHARGER Tier 3 GUARDIAN RT MIS REPL PED Tier 3 X X GUARDIAN RT MIS REPLACE Tier 3 X X GUARDIAN RT MIS SOFTWARE Tier 3 GUARDIAN RT MIS SYSTEM Tier 3 X X GUARDIAN RT MIS TST PLUG Tier 3 GYNAZOLE-1 CRE 2% Tier 3 GYNOL II GEL 3% HCR Preventive H.P. ACTHAR INJ 80UNIT Tier 3 X X X X H20 GEL BASE GEL Tier 3 H2Q CAP 100MG Tier 1 H2Q POW 200MG/GM Tier 3 X HAEMOLANCE MIS LOW FLOW Tier 3 HAEMOLANCE MIS RETRACT Tier 3 HALAC KIT Tier 1 HALCION TAB 0.25MG Tier 3 HALOBETASOL CRE 0.05% Tier 1 X HALOBETASOL OIN 0.05% Tier 1 X HALOG CRE 0.1% Tier 3 X X HALOG OIN 0.1% Tier 3 X X HALOPERIDOL CON 2MG/ML Tier 1 HALOPERIDOL TAB 0.5MG Tier 1 HALOPERIDOL TAB 10MG Tier 1 HALOPERIDOL TAB 1MG Tier 1 HALOPERIDOL TAB 20MG Tier 1 HALOPERIDOL TAB 2MG Tier 1 HALOPERIDOL TAB 5MG Tier 1 HALOTIN CRE 1% Tier 3 HARVONI TAB 90-400MG Tier 2 X X X HC BUTYRATE CRE 0.1% Tier 1 HC BUTYRATE CRE 0.1% Tier 3 X X

106 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy HC BUTYRATE OIN 0.1% Tier 1 HC BUTYRATE SOL 0.1% Tier 1 HC PRAMOXINE CRE 1-1% Tier 1 HC PRAMOXINE CRE 2.5-1% Tier 1 HC PRAMOXINE CRE 2.5-1% Tier 1 HC VALERATE CRE 0.2% Tier 3 X HC VALERATE OIN 0.2% Tier 3 X HC/ACET ACID SOL OTIC Tier 1 HCU COOLER LIQ Tier 3 HCY 1 POW Tier 3 HCY 1 DIET POW Tier 3 HCY 2 POW Tier 3 HEATHER TAB 0.35MG HCR Preventive HECTOROL CAP 0.5MCG Tier 3 HECTOROL CAP 1MCG Tier 3 HECTOROL CAP 2.5MCG Tier 3 HELIXATE FS INJ 1000UNIT Tier 3 X X X HELIXATE FS INJ 2000UNIT Tier 3 X X X HELIXATE FS INJ 250UNIT Tier 3 X X X HELIXATE FS INJ 3000UNIT Tier 3 X X X HELIXATE FS INJ 500UNIT Tier 3 X X X HEMANGEOL SOL 4.28/ML Tier 3 X HEMATINIC/FA TAB Tier 1 HEMENATAL OB MIS + DHA Tier 2 HEMENATAL OB TAB 28-6-1MG Tier 2 HEMMOREX-HC SUP 25MG Tier 1 HEMMOREX-HC SUP 30MG Tier 1 HEMOCYTE-F TAB Tier 1 HEMOFIL M INJ 1000UNIT Tier 2 X HEMOFIL M INJ 1700UNIT Tier 2 X HEMOFIL M INJ 250UNIT Tier 2 X HEMOFIL M INJ 500UNIT Tier 2 X HEMOFIL M SOL Tier 2 X HEMOFIL M SOL 801-1500 Tier 2 X HEMORRHOIDAL SUP -HC 25MG Tier 1 HEPARIN LOCK INJ 100/ML Tier 1 HEPARIN LOCK INJ 10UNT/ML Tier 1

107 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy HEPARIN SOD INJ 1000/ML Tier 1 HEPARIN SOD INJ 10000/ML Tier 1 HEPARIN SOD INJ 10000/ML Tier 1 HEPARIN SOD INJ 20000/ML Tier 1 HEPARIN SOD INJ 5000/0.5 Tier 1 HEPARIN SOD INJ 5000/ML Tier 1 HEPARIN SOD INJ 5000U Tier 1 HEPSERA TAB 10MG Tier 3 X HETLIOZ CAP 20MG Tier 3 X X X HEXALEN CAP 50MG Tier 2 X HEXAPEPTIDE POW ACETYL Tier 3 X HEXAPEPTIDE SOL ACETYL Tier 3 X HIPREX TAB 1GM Tier 3 HM ASPIRIN CHW 81MG HCR Preventive HM ASPIRIN TAB 325MG HCR Preventive HM CLEARLAX POW HCR Preventive HM LAXATIVE TAB 5MG HCR Preventive HM LAXATIVE TAB 5MG EC HCR Preventive HM NICOTINE DIS 14MG/24H HCR X Preventive HM NICOTINE DIS 21MG/24H HCR X Preventive HM NICOTINE GUM 2MG MINT HCR X Preventive HM NICOTINE GUM 4MG MINT HCR X Preventive HM NICOTINE LOZ 2MG MINT HCR X Preventive HM NICOTINE LOZ 4MG MINT HCR X Preventive HOMATROPAIRE SOL 5% OP Tier 1 HOMATROPINE SOL 5% OP Tier 1 HOME PAP KIT Tier 3 X HORIZANT TAB 300MG Tier 3 X X HORIZANT TAB 600MG Tier 3 X X 108 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy HPR AER Tier 3 X HPR PLUS AER Tier 3 X HPR PLUS CRE Tier 3 X HPR PLUS KIT Tier 3 X HPR PLUS MB KIT HYDROGEL Tier 3 X HUMALOG INJ 100/ML Tier 1 X HUMALOG INJ 100/ML Tier 2 X HUMALOG KWIK INJ 100/ML Tier 2 X HUMALOG KWIK INJ 200/ML Tier 2 X HUMALOG MIX INJ 50/50 Tier 1 X HUMALOG MIX INJ 50/50KWP Tier 2 X HUMALOG MIX INJ 75/25KWP Tier 2 X HUMALOG MIX SUS 75/25 Tier 1 X HUMAPEN MIS LUXURA Tier 3 HUMATE-P SOL 2400UNIT Tier 2 X HUMATE-P SOL 250-600 Tier 2 X HUMATE-P SOL 500-1200 Tier 2 X HUMATROPE INJ 12MG Tier 3 X X X X HUMATROPE INJ 24MG Tier 3 X X X X HUMATROPE INJ 5MG Tier 3 X X X X HUMATROPE INJ 6MG Tier 3 X X X X HUMATROPEN MIS FOR 12MG Tier 3 X HUMATROPEN MIS FOR 24MG Tier 3 X HUMATROPEN MIS FOR 6MG Tier 3 X HUMIBID L.A. TAB 600MG Tier 3 HUMIBID SPRI CAP 300MG Tier 3 HUMIBID-DM TAB Tier 3 HUMIRA INJ 10MG/0.2 Tier 2 X X X HUMIRA KIT 20MG/0.4 Tier 2 X X X HUMIRA KIT 40MG/0.8 Tier 2 X X X HUMIRA PEDIA INJ CROHNS Tier 2 X X X HUMIRA PEN INJ 40MG/0.8 Tier 2 X X X HUMIRA PEN INJ CROHNS Tier 2 X X X HUMIRA PEN INJ PSORIASI Tier 2 X X X HUMULIN INJ 70/30 Tier 1 X HUMULIN INJ 70/30KWP Tier 2 X HUMULIN N INJ U-100 Tier 1 X HUMULIN N INJ U-100KWP Tier 2 X 109 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy HUMULIN R INJ U-100 Tier 1 X HUMULIN R INJ U-500 Tier 1 X HUMULIN R INJ U-500 Tier 2 HURRISEAL SOL Tier 3 HYALUCIL-0.5 CRE Tier 3 X H YA LU C I L- 4 C R E Tier 3 X HYALURONATE GEL 0.2% Tier 1 HYALURONATE POW SODIUM Tier 3 X HYALURONIC POW SODIUM Tier 3 X HYALURONIDAS POW Tier 3 X HYCAMTIN CAP 0.25MG Tier 2 X X X HYCAMTIN CAP 1MG Tier 2 X X X HYCET SOL 7.5-325 Tier 3 X HYCOFENIX SOL Tier 3 X X HYD POL/CPM SUS 10-8/5ML Tier 3 X HYDR/CPM/PSE LIQ 5-4-60MG Tier 2 X HYDRALAZINE TAB 100MG Tier 1 HYDRALAZINE TAB 10MG Tier 1 HYDRALAZINE TAB 25MG Tier 1 HYDRALAZINE TAB 50MG Tier 1 HYDREA CAP 500MG Tier 3 X HYDRO 35 AER Tier 3 HYDRO 40 AER FOAM Tier 3 HYDRO/CHLOR/ LIQ 5-4-60MG Tier 2 X HYDROC/HOMAT TAB 5-1.5MG Tier 1 HYDROCHLOROT CAP 12.5MG Tier 1 HYDROCHLOROT TAB 12.5MG Tier 1 HYDROCHLOROT TAB 25MG Tier 1 HYDROCHLOROT TAB 50MG Tier 1 HYDROCO/APAP SOL 7.5-325 Tier 3 X HYDROCO/APAP TAB 10-300MG Tier 3 X X HYDROCO/APAP TAB 10-325MG Tier 1 X HYDROCO/APAP TAB 2.5-325 Tier 1 HYDROCO/APAP TAB 5-300MG Tier 3 X X HYDROCO/APAP TAB 5-325MG Tier 1 X HYDROCO/APAP TAB 7.5-300 Tier 3 X X HYDROCO/APAP TAB 7.5-325 Tier 1 X HYDROCOD/HOM SYP 5-1.5/5 Tier 1 110 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy HYDROCOD/IBU TAB 10-200MG Tier 1 HYDROCOD/IBU TAB 2.5-200 Tier 1 HYDROCOD/IBU TAB 5-200MG Tier 1 HYDROCOD/IBU TAB 7.5-200 Tier 1 HYDROCODONE CRY BITARTRA Tier 3 X HYDROCODONE POW BITARTRA Tier 3 X HYDROCODONE SOL 10-325MG Tier 1 X HYDROCORT CRE 1% Tier 1 HYDROCORT CRE 2.5% Tier 1 HYDROCORT ENE 100MG Tier 1 HYDROCORT LOT 2.5% Tier 1 HYDROCORT OIN 1% Tier 1 HYDROCORT OIN 2.5% Tier 1 HYDROCORT TAB 10MG Tier 1 HYDROCORT TAB 20MG Tier 1 HYDROCORT TAB 5MG Tier 1 HYDROCORT AC SUP 25MG Tier 1 HYDROCORT AC SUP 30MG Tier 1 HYDROCORT/ CRE IODOQUIN Tier 1 HYDROCORT/ KIT PRAMOXIN Tier 1 X HYDROCORT/AB OIN 1% Tier 1 HYDROCORTISO CRE 2.5% Tier 1 HYDROGEL GEL Tier 1 HYDROMET SYP 5-1.5/5 Tier 1 HYDROMORPHON LIQ 1MG/ML Tier 1 HYDROMORPHON POW HCL Tier 3 X HYDROMORPHON SUP 3MG Tier 1 HYDROMORPHON TAB 12MG ER Tier 3 X X X HYDROMORPHON TAB 16MG ER Tier 3 X X X HYDROMORPHON TAB 2MG Tier 1 HYDROMORPHON TAB 32MG ER Tier 3 X X X HYDROMORPHON TAB 4MG Tier 1 HYDROMORPHON TAB 8MG Tier 1 HYDROMORPHON TAB 8MG ER Tier 3 X X X HYDROPHEN SYP Tier 1 HYDROPHILIC OIN Tier 3 X HYDROQUINONE POW Tier 3 X HYDROSORTISO OIN ABSORBAS Tier 3 X 111 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy HYDROUS CRE EMULSIFI Tier 3 X HYDROXYCHLOR TAB 200MG Tier 1 HYDROXYUREA CAP 500MG Tier 1 X HYDROXYUREA POW Tier 3 X HYDROXYZ HCL SYP 10MG/5ML Tier 1 HYDROXYZ HCL TAB 10MG Tier 1 HYDROXYZ HCL TAB 25MG Tier 1 HYDROXYZ HCL TAB 50MG Tier 1 HYDROXYZ PAM CAP 100MG Tier 1 HYDROXYZ PAM CAP 25MG Tier 1 HYDROXYZ PAM CAP 50MG Tier 1 HYLATOPIC AER PLUS Tier 3 X HYLATOPIC CRE PLUS Tier 3 X HYLATOPIC LOT PLUS Tier 3 X HYLIRA GEL 0.2% Tier 2 HYLIRA LOT 0.1% Tier 3 HYOLEV MB TAB 81MG Tier 1 HYOPHEN TAB Tier 1 HYOSCYAMINE DRO 0.125/ML Tier 1 HYOSCYAMINE ELX 0.125/5 Tier 1 HYOSCYAMINE SUB 0.125MG Tier 1 HYOSCYAMINE TAB 0.125MG Tier 1 HYOSCYAMINE TAB 0.125MG Tier 1 HYOSCYAMINE TAB 0.375 ER Tier 1 HYOSCYAMINE TAB 0.375 SR Tier 1 HYOSYNE DRO 0.125/ML Tier 1 HYOSYNE ELX 0.125/5 Tier 1 HYPER-SAL NEB 7% Tier 2 HYPERSAL NEB 3.5% Tier 2 HYPERSAL NEB 7% Tier 2 HYPERTENSA CAP Tier 3 HYPERTENSA CAP Tier 2 HYPO NEEDLE MIS 18GX1" Tier 2 HYSINGLA ER TAB 100 MG Tier 3 X X X HYSINGLA ER TAB 120 MG Tier 3 X X X HYSINGLA ER TAB 20 MG Tier 3 X X X HYSINGLA ER TAB 30 MG Tier 3 X X X HYSINGLA ER TAB 40 MG Tier 3 X X X 112 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy HYSINGLA ER TAB 60 MG Tier 3 X X X HYSINGLA ER TAB 80 MG Tier 3 X X X HYZAAR TAB 100-12.5 Tier 3 HYZAAR TAB 100-25 Tier 3 HYZAAR TAB 50-12.5 Tier 3 IBANDRONATE TAB 150MG Tier 3 X IBRANCE CAP 100MG Tier 3 X X X IBRANCE CAP 125MG Tier 3 X X X IBRANCE CAP 75MG Tier 3 X X X IBUDONE TAB 10-200MG Tier 1 IBUDONE TAB 5-200MG Tier 1 IBUPROFEN CRE 10% Tier 1 X IBUPROFEN POW Tier 3 X IBUPROFEN TAB 400MG Tier 1 IBUPROFEN TAB 600MG Tier 1 IBUPROFEN TAB 800MG Tier 1 ICLUSIG TAB 15MG Tier 3 X X X ICLUSIG TAB 45MG Tier 3 X X X IDELVION SOL 1000UNIT Tier 3 X IDELVION SOL 2000UNIT Tier 3 X IDELVION SOL 250UNIT Tier 3 X IDELVION SOL 500UNIT Tier 3 X ILEVRO DRO 0.3% OP Tier 3 X X ILOTYCIN OIN OP Tier 1 IMATINIB MES TAB 100MG Tier 3 X X X X IMATINIB MES TAB 400MG Tier 3 X X X X IMBRUVICA CAP 140MG Tier 2 X X X IMIPRAM HCL TAB 10MG Tier 1 IMIPRAM HCL TAB 25MG Tier 1 IMIPRAM HCL TAB 50MG Tier 1 IMIPRAM PAM CAP 100MG Tier 1 IMIPRAM PAM CAP 125MG Tier 1 IMIPRAM PAM CAP 150MG Tier 1 IMIPRAM PAM CAP 75MG Tier 1 IMIPRAMINE POW HCL Tier 3 X IMIQUIMOD CRE 5% Tier 3 X IMITREX INJ 4MG/0.5 Tier 3 X X IMITREX INJ 4MG/0.5 Tier 3 X X 113 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy IMITREX INJ 6MG/0.5 Tier 3 X X IMITREX INJ 6MG/0.5 Tier 3 X X IMITREX INJ 6MG/0.5 Tier 3 X X IMITREX SPR 20MG/ACT Tier 3 X IMITREX SPR 5MG/ACT Tier 3 X IMITREX TAB 100MG Tier 3 X X IMITREX TAB 25MG Tier 3 X X IMITREX TAB 50MG Tier 3 X X IMPACT LIQ Tier 3 IMPACT LIQ CHOCOLAT Tier 3 IMPACT 1.5 LIQ Tier 3 IMPACT GLUTA LIQ Tier 3 IMPACT/FIBER LIQ Tier 3 IMPAVIDO CAP 50MG Tier 2 X X IMURAN TAB 50MG Tier 3 IN TOUCH MIS Tier 1 INATAL ADV TAB Tier 2 INATAL ADV TAB Tier 1 INATAL GT TAB Tier 2 INATAL ULTRA TAB Tier 2 INATAL ULTRA TAB Tier 1 INCRELEX INJ 40MG/4ML Tier 2 X X INCRUSE ELPT INH 62.5MCG Tier 2 X INDAPAMIDE TAB 1.25MG Tier 1 INDAPAMIDE TAB 2.5MG Tier 1 INDERAL LA CAP 120MG Tier 3 INDERAL LA CAP 160MG Tier 3 INDERAL LA CAP 60MG Tier 3 INDERAL LA CAP 80MG Tier 3 INDERAL XL CAP 120MG Tier 3 INDERAL XL CAP 80MG Tier 3 INDIOMIN MB CAP 120MG Tier 3 INDOCIN SUP 50MG Tier 3 INDOCIN SUS 25MG/5ML Tier 3 INDOMETHACIN CAP 25MG Tier 1 INDOMETHACIN CAP 50MG Tier 1 INDOMETHACIN CAP 75MG ER Tier 1 INFANATE CAP BALANCE Tier 3 114 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy INFANATE CAP PLUS Tier 3 INFANT FRMLA POW /IRON Tier 3 INFUSION SET MIS 23" Tier 2 INFUSION SET MIS 23" 13MM Tier 2 INFUSION SET MIS 23" 17MM Tier 2 INFUSION SET MIS 23" 6MM Tier 2 INFUSION SET MIS 23" 8MM Tier 2 INFUSION SET MIS 23" 9MM Tier 2 INFUSION SET MIS 23"/6MM Tier 2 INFUSION SET MIS 23"/9MM Tier 2 INFUSION SET MIS 24" Tier 2 INFUSION SET MIS 24" 6MM Tier 2 INFUSION SET MIS 24" 9MM Tier 2 INFUSION SET MIS 31" Tier 2 INFUSION SET MIS 31" 6MM Tier 2 INFUSION SET MIS 31" 9MM Tier 2 INFUSION SET MIS 32" 8MM Tier 2 INFUSION SET MIS 42" 6MM Tier 2 INFUSION SET MIS 42" 9MM Tier 2 INFUSION SET MIS 43" Tier 2 INFUSION SET MIS 43" 13MM Tier 2 INFUSION SET MIS 43" 17MM Tier 2 INFUSION SET MIS 43" 6MM Tier 2 INFUSION SET MIS 43" 8MM Tier 2 INFUSION SET MIS 43" 9MM Tier 2 INFUSION SET MIS 43"/6MM Tier 2 INFUSION SET MIS 43"/9MM Tier 2 INLYTA TAB 1MG Tier 3 X X X INLYTA TAB 5MG Tier 3 X X X INNOPRAN XL CAP 120MG Tier 3 INNOPRAN XL CAP 80MG Tier 3 INNOPRAX-5 CRE Tier 3 X INOVA KIT 4% Tier 3 INOVA KIT 8% Tier 3 INOVA 4/1 KIT ACNE CON Tier 3 INOVA 8/2 KIT ACNE CON Tier 3 INSPIRACHAMB MIS LARGE Tier 3 INSPIRACHAMB MIS MEDIUM Tier 3 115 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy INSPIRACHAMB MIS MOUTHPCE Tier 3 INSPIRACHAMB MIS SMALL Tier 3 INSPIREASE MIS BAGS Tier 2 INSPIREASE MIS DD SYST Tier 3 INSPIREASE MIS MOUTHPCE Tier 2 INSPIREASE MIS RES BAG Tier 2 INSPRA TAB 25MG Tier 3 INSPRA TAB 50MG Tier 3 INST BRKFAST LIQ BERRY Tier 3 INST BRKFAST LIQ CHOCOLAT Tier 3 INST BRKFAST LIQ ORANGE Tier 3 INST BRKFAST LIQ PLUS Tier 3 INST BRKFAST LIQ STRAWBER Tier 3 INST BRKFAST LIQ VANILLA Tier 3 INSULIN SYRG MIS 0.3/29G Tier 2 INSULIN SYRG MIS 0.3/30G Tier 2 INSULIN SYRG MIS 0.3/30G Tier 2 INSULIN SYRG MIS 0.3/31G Tier 2 INSULIN SYRG MIS 0.5/28G Tier 2 INSULIN SYRG MIS 0.5/29G Tier 2 INSULIN SYRG MIS 0.5/30G Tier 2 INSULIN SYRG MIS 0.5/30G Tier 2 INSULIN SYRG MIS 0.5/30G Tier 2 INSULIN SYRG MIS 0.5/31G Tier 2 INSULIN SYRG MIS 1ML/28G Tier 2 INSULIN SYRG MIS 1ML/29G Tier 2 INSULIN SYRG MIS 1ML/30G Tier 2 INSULIN SYRG MIS 1ML/30G Tier 2 INSULIN SYRG MIS 1ML/31G Tier 2 INTELENCE TAB 100MG Tier 2 X INTELENCE TAB 200MG Tier 2 X INTELENCE TAB 25MG Tier 2 X INTERMEZZO SUB 1.75MG Tier 3 X X INTERMEZZO SUB 3.5MG Tier 3 X X INTRON A INJ 10MU Tier 3 X X INTRON A INJ 18MU Tier 3 X X INTRON A INJ 18MU Tier 3 X X INTRON A INJ 25MU Tier 3 X X 116 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy INTRON A INJ 50MU Tier 3 X X INTROVALE TAB HCR X Preventive INTUNIV TAB 1MG Tier 3 X X INTUNIV TAB 2MG Tier 3 X X INTUNIV TAB 3MG Tier 3 X X INTUNIV TAB 4MG Tier 3 X X INVEGA TAB 1.5MG Tier 3 X X INVEGA TAB 3MG Tier 3 X X INVEGA TAB 6MG Tier 3 X X INVEGA TAB 9MG Tier 3 X X INVIRASE CAP 200MG Tier 2 X INVIRASE TAB 500MG Tier 2 X INVOKAMET TAB 150-1000 Tier 2 X INVOKAMET TAB 150-500 Tier 2 X INVOKAMET TAB 50-1000 Tier 2 X INVOKAMET TAB 50-500MG Tier 2 X INVOKAMET XR TAB 150-1000 Tier 2 INVOKAMET XR TAB 150-500 Tier 2 INVOKAMET XR TAB 50-1000 Tier 2 INVOKAMET XR TAB 50-500MG Tier 2 INVOKANA TAB 100MG Tier 3 X X INVOKANA TAB 300MG Tier 3 X X IODINE SOL STRONG Tier 2 IODINE TIN 2% Tier 1 IOPHEN C-NR LIQ 100-10/5 Tier 1 IOPIDINE SOL 0.5% OP Tier 3 IOPIDINE SOL 1% OP Tier 3 IPRATROPIUM SOL 0.02%INH Tier 1 IPRATROPIUM SPR 0.03% Tier 1 IPRATROPIUM SPR 0.06% Tier 1 IPRATROPIUM/ SOL ALBUTER Tier 3 IRBESAR/HCTZ TAB 150-12.5 Tier 1 X IRBESAR/HCTZ TAB 300-12.5 Tier 1 X IRBESARTAN TAB 150MG Tier 1 X IRBESARTAN TAB 300MG Tier 1 X IRBESARTAN TAB 75MG Tier 1 X IRESSA TAB 250MG Tier 3 X X

117 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ISENTRESS CHW 100MG Tier 2 X ISENTRESS CHW 25MG Tier 2 X ISENTRESS POW 100MG Tier 2 X ISENTRESS TAB 400MG Tier 2 X ISO ATROPINE SOL 1% OP Tier 3 ISOCAL LIQ Tier 3 ISOCAL HN LIQ Tier 3 ISOCAL HN LIQ PLUS Tier 3 ISOFLURANE SOL Tier 1 ISOLEUCINE PAK 50MG Tier 3 ISOLEUCINE POW 1000 Tier 3 ISOMETH/APAP CAP DICHLOR Tier 1 ISOMETH/CAFF TAB /APAP Tier 1 ISONIAZID SYP 50MG/5ML Tier 1 ISONIAZID TAB 100MG Tier 1 ISONIAZID TAB 300MG Tier 1 ISOPROTEREN AER 131MCG Tier 1 ISOPTO CARP SOL 1% OP Tier 3 ISOPTO CARP SOL 2% OP Tier 3 ISOPTO CARP SOL 4% OP Tier 3 ISORDIL TAB 40MG Tier 2 ISORDIL TAB 5MG Tier 3 ISOSORB DIN TAB 10MG Tier 1 ISOSORB DIN TAB 20MG Tier 1 ISOSORB DIN TAB 30MG Tier 1 ISOSORB DIN TAB 40MG ER Tier 1 ISOSORB DIN TAB 5MG Tier 1 ISOSORB MONO TAB 10MG Tier 1 ISOSORB MONO TAB 120MG ER Tier 1 ISOSORB MONO TAB 20MG Tier 1 ISOSORB MONO TAB 30MG ER Tier 1 ISOSORB MONO TAB 60MG ER Tier 1 ISOSOURCE LIQ Tier 3 ISOSOURCE LIQ 1.5 CAL Tier 3 ISOSOURCE LIQ CLS SYS Tier 3 ISOSOURCE LIQ VHN VANL Tier 3 ISOSOURCE HN LIQ Tier 3 ISOXSUPRINE TAB 10MG Tier 1 118 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ISOXSUPRINE TAB HCL 20MG Tier 1 ISRADIPINE CAP 2.5MG Tier 1 ISRADIPINE CAP 5MG Tier 1 ISTALOL SOL 0.5% OP Tier 3 ITRACONAZOLE CAP 100MG Tier 1 X IVERMECTIN TAB 3MG Tier 1 IXINITY INJ 1000UNIT Tier 3 X X X IXINITY INJ 1500UNIT Tier 3 X X X IXINITY INJ 500UNIT Tier 3 X X X JADENU TAB 180MG Tier 2 X X JADENU TAB 360MG Tier 2 X X JADENU TAB 90MG Tier 2 X X JAKAFI TAB 10MG Tier 2 X X X JAKAFI TAB 15MG Tier 2 X X X JAKAFI TAB 20MG Tier 2 X X X JAKAFI TAB 25MG Tier 2 X X X JAKAFI TAB 5MG Tier 2 X X X JALYN CAP Tier 3 X JANTOVEN TAB 10MG Tier 1 JANTOVEN TAB 1MG Tier 1 JANTOVEN TAB 2.5MG Tier 1 JANTOVEN TAB 2MG Tier 1 JANTOVEN TAB 3MG Tier 1 JANTOVEN TAB 4MG Tier 1 JANTOVEN TAB 5MG Tier 1 JANTOVEN TAB 6MG Tier 1 JANTOVEN TAB 7.5MG Tier 1 JANUMET TAB 50-1000 Tier 3 X X JANUMET TAB 50-500MG Tier 3 X X JANUMET XR TAB 100-1000 Tier 3 X X JANUMET XR TAB 50-1000 Tier 3 X X JANUMET XR TAB 50-500MG Tier 3 X X JANUVIA TAB 100MG Tier 3 X X JANUVIA TAB 25MG Tier 3 X X JANUVIA TAB 50MG Tier 3 X X JARDIANCE TAB 10MG Tier 2 X X JARDIANCE TAB 25MG Tier 2 X X

119 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy JENCYCLA TAB 0.35MG HCR Preventive JENTADUETO TAB 2.5-1000 Tier 2 X JENTADUETO TAB 2.5-500 Tier 2 X JENTADUETO TAB 2.5-850 Tier 2 X JENTADUETO TAB XR Tier 3 X JENTADUETO TAB XR Tier 3 X JEVANTIQUE L TAB 0.5-2.5 Tier 3 JINTELI TAB 1MG-5MCG Tier 3 JOLESSA TAB HCR X Preventive JOLIVETTE TAB 0.35MG HCR Preventive JUBLIA SOL 10% Tier 3 X X X JULEBER TAB HCR Preventive JUNEL 1.5/30 TAB Tier 3 JUNEL 1/20 TAB Tier 3 JUNEL FE TAB 1.5/30 HCR Preventive JUNEL FE TAB 1/20 HCR Preventive JUNEL FE 24 TAB 1/20 Tier 3 JUXTAPID CAP 10MG Tier 3 X X X X JUXTAPID CAP 20MG Tier 3 X X X X JUXTAPID CAP 30MG Tier 3 X X X X JUXTAPID CAP 40MG Tier 3 X X X X JUXTAPID CAP 5MG Tier 3 X X X X JUXTAPID CAP 60MG Tier 3 X X X X K CITRATE SOL CITR ACD Tier 1 K-EFFERVESCE TAB 25MEQ EF Tier 1 K-PHOS TAB Tier 2 K-PHOS TAB NEUTRAL Tier 3 K-PHOS TAB NO 2 Tier 2 K-PRIME TAB 25MEQ EF Tier 1 K-SOL SOL 10% Tier 1 K-SOL SOL 20% Tier 1 K-TAB TAB 10MEQ CR Tier 3 K-TAB TAB 20MEQ Tier 3

120 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy K-TAB TAB 8MEQ CR Tier 3 K-VESCENT TAB 25MEQ EF Tier 1 K.B.G.L IN CRE TERODERM Tier 3 X K/NA CITRATE SOL CITR ACD Tier 1 KADIAN CAP 100MG ER Tier 3 X X X KADIAN CAP 10MG ER Tier 3 X X X KADIAN CAP 200MG ER Tier 3 X X X KADIAN CAP 20MG ER Tier 3 X X X KADIAN CAP 30MG ER Tier 3 X X X KADIAN CAP 40MG ER Tier 3 X X X KADIAN CAP 50MG ER Tier 3 X X X KADIAN CAP 60MG ER Tier 3 X X X KADIAN CAP 80MG ER Tier 3 X X X KAITLIB FE CHW Tier 3 X KALETRA SOL Tier 2 X KALETRA TAB 100-25MG Tier 2 X KALETRA TAB 200-50MG Tier 2 X KALYDECO PAK 50MG Tier 2 X X X KALYDECO PAK 75MG Tier 2 X X X KALYDECO TAB 150MG Tier 2 X X X KAMINOS TAB Tier 1 KAPVAY TAB 0.1 MG Tier 3 X KARBINAL ER SUS 4MG/5ML Tier 3 X KARIDIUM DRO 0.125MG HCR Preventive KARIGEL GEL 0.5% Tier 1 KARIGEL-N GEL 1.1% Tier 1 KARIVA TAB 28 DAY Tier 3 KAYEXALATE POW Tier 3 KAZANO 12.5- TAB 1000MG Tier 2 X KAZANO 12.5- TAB 500MG Tier 2 X KEFLEX CAP 250MG Tier 3 KEFLEX CAP 500MG Tier 3 KEFLEX CAP 750MG Tier 3 KELNOR TAB 1/35 HCR Preventive KENALOG AER SPRAY Tier 3 X KEPPRA SOL 100MG/ML Tier 3 X X

121 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy KEPPRA TAB 1000MG Tier 3 X X KEPPRA TAB 250MG Tier 3 X X KEPPRA TAB 500MG Tier 3 X X KEPPRA TAB 750MG Tier 3 X X KEPPRA XR TAB 500MG Tier 3 X X KEPPRA XR TAB 750MG Tier 3 X X KERAGEL GEL WOUND Tier 3 X KERALAC CRE 47% Tier 3 X KERALYT GEL 6% Tier 3 KERALYT KIT SCALP 6% Tier 3 X KERLONE TAB 10MG Tier 3 KERLONE TAB 20MG Tier 3 KERR TRIPLE MIS DYE SWAB Tier 2 KERYDIN SOL 5% Tier 3 X X X KETAMINE HCL POW Tier 3 X KETEK TAB 300MG Tier 3 KETEK TAB 400MG Tier 3 KETO-DIASTIX TES Tier 3 KETOCARE TES Tier 2 KETOCONAZOLE AER 2% Tier 3 X KETOCONAZOLE CRE 2% Tier 1 KETOCONAZOLE SHA 2% Tier 1 KETOCONAZOLE TAB 200MG Tier 1 KETODAN AER 2% Tier 3 X KETODAN KIT 2% Tier 3 X KETOPHENE CRE RAPIDPAQ Tier 3 X KETOPROFEN CAP 200MG ER Tier 1 KETOPROFEN CAP 50MG Tier 1 KETOPROFEN CAP 75MG Tier 1 KETOPROFEN CRE 10% Tier 3 X KETOPROFEN CRE 5% KIT Tier 3 X KETOPROFEN POW Tier 3 X KETOPROFEN POW MICRONIZ Tier 3 X KETOPROFEN POW ULT MICR Tier 3 X KETOROLAC GEL 2% Tier 3 X KETOROLAC POW TROMETHA Tier 3 X KETOROLAC SOL 0.4% Tier 1 KETOROLAC SOL 0.5% Tier 1 122 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy KETOROLAC TAB 10MG Tier 1 KETOSTIX TES Tier 2 KETOSTIX TES STRIP Tier 2 KEVEYIS TAB 50MG Tier 2 X X X KEY OMEGA POW Tier 3 KHEDEZLA TAB 100MG ER Tier 3 X KHEDEZLA TAB 50MG ER Tier 3 X X KIMIDESS TAB Tier 2 KINERET INJ Tier 3 X X X KIONEX POW Tier 1 KIONEX SUS 15GM/60 Tier 1 KITABIS PAK NEB 300/5ML Tier 3 X X X X KLARON LOT 10% Tier 3 KLOFENSAID SOL II Tier 3 X KLONOPIN TAB 0.5MG Tier 3 KLONOPIN TAB 1MG Tier 3 KLONOPIN TAB 2MG Tier 3 KLOR-CON POW 20MEQ Tier 1 KLOR-CON 10 TAB 10MEQ ER Tier 1 KLOR-CON 8 TAB 8MEQ ER Tier 1 KLOR-CON M10 TAB 10MEQ ER Tier 1 KLOR-CON M15 TAB 15MEQ ER Tier 3 KLOR-CON M20 TAB 20MEQ ER Tier 1 KLOR-CON SPR CAP 10MEQ Tier 1 KLOR-CON SPR CAP 8MEQ Tier 1 KLOR-CON/25 POW 25MEQ Tier 1 KLOR-CON/EF TAB 25MEQ FR Tier 1 KLS ASPIRIN TAB 325MG EC HCR Preventive KLS ASPIRIN TAB 81MG EC HCR Preventive KLS QUIT2 GUM 2MG HCR X Preventive KLS QUIT2 LOZ 2MG HCR X Preventive KLS QUIT4 GUM 4MG HCR X Preventive KLS QUIT4 LOZ 4MG HCR X Preventive

123 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy KOATE-DVI INJ 1000UNIT Tier 2 X KOATE-DVI INJ 250UNIT Tier 2 X KOATE-DVI INJ 500UNIT Tier 2 X KOGENATE FS INJ 1000/BS Tier 2 X KOGENATE FS INJ 1000UNIT Tier 2 X KOGENATE FS INJ 2000/BS Tier 2 X KOGENATE FS INJ 2000UNIT Tier 2 X KOGENATE FS INJ 250/BS Tier 2 X KOGENATE FS INJ 250UNIT Tier 2 X KOGENATE FS INJ 3000/BS Tier 2 X KOGENATE FS INJ 3000UNIT Tier 2 X KOGENATE FS INJ 500/BS Tier 2 X KOGENATE FS INJ 500UNIT Tier 2 X KOMBIGLYZE TAB 2.5-1000 Tier 2 X KOMBIGLYZE TAB 5-1000MG Tier 2 X KOMBIGLYZE TAB 5-500MG Tier 2 X KORLYM TAB 300MG Tier 3 X X KOSHR PRENAT TAB 30-1MG Tier 3 KOVALTRY INJ 1000UNIT Tier 2 X KOVALTRY INJ 2000UNIT Tier 2 X KOVALTRY INJ 250UNIT Tier 2 X KOVALTRY INJ 3000UNIT Tier 2 X KOVALTRY INJ 500UNIT Tier 2 X KP ASPIRIN TAB 81MG EC HCR Preventive KP BISACODYL TAB 5MG EC HCR Preventive KRISGEL 100 GEL Tier 3 KRISTALOSE PAK 10GM Tier 3 KRISTALOSE PAK 20GM Tier 3 KROGER TES Tier 3 X X KROGER BGM KIT Tier 3 X KUDZU ROOT POW Tier 3 X KURVELO TAB 0.15/30 HCR Preventive KUVAN POW 100MG Tier 2 X X X KUVAN POW 500MG Tier 2 X X X KUVAN TAB 100MG Tier 2 X X X

124 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy KYNAMRO INJ 200MG/ML Tier 3 X X X X L-ARGININE CAP 500MG Tier 1 L-ARGININE- CAP 500 Tier 1 L-CARNITINE CAP 250MG Tier 1 L-CARNITINE LIQ Tier 3 L-CARNITINE TAB 250MG Tier 3 L-CARNOSINE POW Tier 3 X L-CITRULLINE CAP 600MG Tier 3 L-CITRULLINE CAP 600MG Tier 3 L-CITRULLINE POW Tier 3 L-CYSTINE POW Tier 3 L-GLUT/CHOL/ TAB INOSITOL Tier 3 L-GLUTAMINE POW Tier 3 X L-GLUTATHION CRY Tier 3 X L-ISOLEUCINE POW Tier 3 X L-LYSINE TAB 1000MG Tier 1 L-LYSINE TAB 1000MG Tier 1 L-LYSINE TAB 500MG Tier 1 L-LYSINE ACE TAB 500MG Tier 3 L-LYSINE HCL CAP 500MG Tier 3 L-LYSINE HCL TAB 500MG Tier 1 L-TYROSINE CAP 500MG Tier 1 LABETALOL TAB 100MG Tier 1 LABETALOL TAB 200MG Tier 1 LABETALOL TAB 300MG Tier 1 LACRISERT MIS 5MG OP Tier 2 LACTULOSE SOL 10GM/15 Tier 1 LACTULOSE SOL 10GM/15 Tier 1 LACTULOSE SOL 20GM/30 Tier 1 LACTULOSE SYP 10GM/15 Tier 1 LAMICTAL CHW 25MG Tier 3 X X LAMICTAL CHW 5MG Tier 3 X X LAMICTAL KIT START 35 Tier 3 X X LAMICTAL KIT START 49 Tier 3 X X LAMICTAL KIT START 98 Tier 3 X X LAMICTAL TAB 100MG Tier 3 X X LAMICTAL TAB 150MG Tier 3 X X LAMICTAL TAB 200MG Tier 3 X X 125 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy LAMICTAL TAB 25MG Tier 3 X X LAMICTAL ODT KIT Tier 3 X X LAMICTAL ODT KIT Tier 3 X X LAMICTAL ODT KIT Tier 3 X X LAMICTAL ODT TAB 100MG Tier 3 X X LAMICTAL ODT TAB 200MG Tier 3 X X LAMICTAL ODT TAB 25MG Tier 3 X X LAMICTAL ODT TAB 50MG Tier 3 X X LAMICTAL XR KIT Tier 3 X X LAMICTAL XR KIT Tier 3 X X LAMICTAL XR KIT Tier 3 X X LAMICTAL XR TAB 100MG Tier 3 X X LAMICTAL XR TAB 200MG Tier 3 X X LAMICTAL XR TAB 250MG Tier 3 X X LAMICTAL XR TAB 25MG Tier 3 X X LAMICTAL XR TAB 300MG Tier 3 X X LAMICTAL XR TAB 50MG Tier 3 X X LAMISIL GRA 125MG Tier 3 X LAMISIL GRA 187.5MG Tier 3 X LAMISIL TAB 250MG Tier 3 X LAMIVUD/ZIDO TAB 150-300 Tier 1 X LAMIVUDINE SOL 10MG/ML Tier 1 X LAMIVUDINE TAB 100MG Tier 1 X LAMIVUDINE TAB 150MG Tier 1 X LAMIVUDINE TAB 300MG Tier 1 X LAMOTRIG ODT KIT 25/50MG Tier 3 X X LAMOTRIG ODT KIT 50/100MG Tier 3 X X LAMOTRIGINE CHW 25MG Tier 1 LAMOTRIGINE CHW 5MG Tier 1 LAMOTRIGINE KIT ODT Tier 3 X X LAMOTRIGINE TAB 100MG Tier 1 LAMOTRIGINE TAB 100MG Tier 3 X LAMOTRIGINE TAB 100MG ER Tier 3 X X LAMOTRIGINE TAB 150MG Tier 1 LAMOTRIGINE TAB 200MG Tier 1 LAMOTRIGINE TAB 200MG Tier 3 X LAMOTRIGINE TAB 200MG ER Tier 3 X X LAMOTRIGINE TAB 250MG ER Tier 3 X X 126 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy LAMOTRIGINE TAB 25MG Tier 1 LAMOTRIGINE TAB 25MG ER Tier 3 X X LAMOTRIGINE TAB 25MG ODT Tier 3 X LAMOTRIGINE TAB 300MG ER Tier 3 X X LAMOTRIGINE TAB 50MG ER Tier 3 X X LAMOTRIGINE TAB 50MG ODT Tier 3 X LANCET ALTER MIS SITE 26G Tier 3 LANCET CARRY MIS CASE Tier 3 LANCET SUPER MIS THIN 30G Tier 3 LANCET ULTRA MIS 28G Tier 3 LANCET ULTRA MIS THIN 28G Tier 3 LANCETS MIS 23G Tier 3 LANCETS MIS 28G Tier 3 LANCETS MICR MIS THIN 33G Tier 3 LANCETS THIN MIS Tier 3 LANCETS ULTR MIS THIN 28G Tier 3 LANCETS ULTR MIS THIN 30G Tier 3 LANCING DEVI MIS Tier 3 LANOLIN OIN Tier 1 LANOLIN ANHY OIN Tier 3 LANOXIN TAB 0.0625MG Tier 3 LANOXIN TAB 0.125MG Tier 3 LANOXIN TAB 0.1875MG Tier 3 LANOXIN TAB 0.25MG Tier 3 LANSOPR/AMOX MIS /CLARITH Tier 3 X X LANSOPRAZOLE SUS 3MG/ML Tier 3 X LANTUS INJ 100/ML Tier 3 X LANTUS INJ SOLOSTAR Tier 3 X LARIN TAB 1.5/30 Tier 3 LARIN TAB 1/20 Tier 3 LARIN 24 TAB FE 1/20 Tier 3 LARIN FE TAB 1.5/30 HCR Preventive LARIN FE TAB 1/20 HCR Preventive LARISSIA TAB HCR Preventive LASIX TAB 20MG Tier 3

127 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy LASIX TAB 40MG Tier 3 LASIX TAB 80MG Tier 3 LASTACAFT SOL 0.25% Tier 3 X LATANOPROST SOL 0.005% Tier 1 LATRIX SUS 50% Tier 2 LATRIX XM EMU 45% Tier 2 LATUDA TAB 120MG Tier 3 X LATUDA TAB 20MG Tier 3 X LATUDA TAB 40MG Tier 3 X LATUDA TAB 60MG Tier 3 X LATUDA TAB 80MG Tier 3 X LAVARE WOUND GEL WASH Tier 1 LAXACLEAR POW HCR Preventive LAXATIVE TAB 5MG EC HCR Preventive LAXATIVE POL POW GLYCOL HCR Preventive LAYOLIS FE CHW Tier 3 X LAZANDA SPR 100MCG Tier 3 X X LAZANDA SPR 300MCG Tier 3 X X LAZANDA SPR 400MCG Tier 3 X X LB LANCET MIS 28G Tier 3 LB LANCING MIS DEVICE Tier 3 LECITHIN GEL Tier 3 LECITHIN GRA Tier 1 LEENA TAB HCR Preventive LEFLUNOMIDE TAB 10MG Tier 1 LEFLUNOMIDE TAB 20MG Tier 1 LEG-GESIC SUS Tier 3 LENVIMA CAP 10 MG Tier 3 X X X LENVIMA CAP 14 MG Tier 3 X X X LENVIMA CAP 18 MG Tier 3 X X LENVIMA CAP 20 MG Tier 3 X X X LENVIMA CAP 24 MG Tier 3 X X X LENVIMA CAP 8 MG Tier 3 X X LESCOL CAP 20MG Tier 3 X

128 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy LESCOL CAP 40MG Tier 3 X LESCOL XL TAB 80MG Tier 3 X X LESSINA TAB HCR Preventive LETAIRIS TAB 10MG Tier 2 X X X LETAIRIS TAB 5MG Tier 2 X X X LETROZOLE TAB 2.5MG Tier 1 LETS KIT Tier 1 X LEU-FREE LIQ COOLER Tier 3 LEUCINE PAK 100MG Tier 3 LEUCOVOR CA TAB 10MG Tier 1 LEUCOVOR CA TAB 15MG Tier 1 LEUCOVOR CA TAB 25MG Tier 1 LEUCOVOR CA TAB 5MG Tier 1 LEUCOVORIN POW CALCIUM Tier 3 LEUKERAN TAB 2MG Tier 2 X LEUKINE INJ 250MCG Tier 2 X LEUPROLIDE INJ 1MG/0.2 Tier 1 X X LEUPROLIDE POW ACETATE Tier 3 X X LEVACET TAB Tier 3 LEVALBUTEROL AER 45/ACT Tier 3 X LEVALBUTEROL NEB 0.31MG Tier 3 X X LEVALBUTEROL NEB 0.63MG Tier 3 X X LEVALBUTEROL NEB 1.25/0.5 Tier 3 X X LEVALBUTEROL NEB 1.25MG Tier 3 X X LEVAQUIN SOL 25MG/ML Tier 3 LEVAQUIN TAB 250MG Tier 3 LEVAQUIN TAB 500MG Tier 3 LEVAQUIN TAB 750MG Tier 3 LEVBID TAB 0.375 ER Tier 3 LEVEMIR INJ Tier 1 X LEVEMIR INJ FLEXPEN Tier 1 X LEVEMIR INJ FLEXTOUC Tier 1 X LEVETIRACETA SOL 100MG/ML Tier 1 LEVETIRACETA SOL 500/5ML Tier 1 LEVETIRACETA TAB 1000MG Tier 1 LEVETIRACETA TAB 250MG Tier 1 LEVETIRACETA TAB 500MG Tier 1

129 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy LEVETIRACETA TAB 500MG ER Tier 3 LEVETIRACETA TAB 750MG Tier 1 LEVETIRACETA TAB 750MG ER Tier 3 LEVITRA TAB 10MG Tier 3 X LEVITRA TAB 2.5MG Tier 3 X LEVITRA TAB 20MG Tier 3 X LEVITRA TAB 5MG Tier 3 X LEVO-ETH EST TAB 90-20MCG Tier 3 LEVO-T TAB 100MCG Tier 1 LEVO-T TAB 112MCG Tier 1 LEVO-T TAB 125MCG Tier 1 LEVO-T TAB 137MCG Tier 1 LEVO-T TAB 150MCG Tier 1 LEVO-T TAB 175MCG Tier 1 LEVO-T TAB 200 MCG Tier 1 LEVO-T TAB 25MCG Tier 1 LEVO-T TAB 300 MCG Tier 1 LEVO-T TAB 50MCG Tier 1 LEVO-T TAB 75MCG Tier 1 LEVO-T TAB 88MCG Tier 1 LEVOBUNOLOL SOL 0.5% OP Tier 1 LEVOCARNITIN SOL 1GM/10ML Tier 1 LEVOCETIRIZI SOL 2.5/5ML Tier 3 LEVOCETIRIZI TAB 5MG Tier 1 X LEVOFLOXACIN SOL 0.5% Tier 1 LEVOFLOXACIN SOL 25MG/ML Tier 1 LEVOFLOXACIN TAB 250MG Tier 1 LEVOFLOXACIN TAB 500MG Tier 1 LEVOFLOXACIN TAB 750MG Tier 1 LEVOMEFOLATE CAP DHA Tier 2 LEVOMEFOLATE POW GLUCOSAM Tier 3 X LEVONEST TAB HCR Preventive LEVONOR/ETHI TAB HCR Preventive LEVONOR/ETHI TAB 0.1-0.02 HCR Preventive

130 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy LEVONOR/ETHI TAB ESTRADIO HCR Preventive LEVONOR/ETHI TAB ESTRADIO HCR X Preventive LEVONOR/ETHI TAB ESTRADIO Tier 3 X LEVONOR/ETHI TAB ESTRADIO Tier 3 X LEVONOR/ETHI TAB ESTRADIO HCR X Preventive LEVONORGESTR TAB 1.5MG HCR Preventive LEVORA-28 TAB 0.15/30 HCR Preventive LEVORPHANOL TAB 2MG Tier 1 LEVOTHYROXIN TAB 100MCG Tier 1 LEVOTHYROXIN TAB 112MCG Tier 1 LEVOTHYROXIN TAB 125MCG Tier 1 LEVOTHYROXIN TAB 137MCG Tier 1 LEVOTHYROXIN TAB 150MCG Tier 1 LEVOTHYROXIN TAB 175MCG Tier 1 LEVOTHYROXIN TAB 200MCG Tier 1 LEVOTHYROXIN TAB 25MCG Tier 1 LEVOTHYROXIN TAB 300MCG Tier 1 LEVOTHYROXIN TAB 50MCG Tier 1 LEVOTHYROXIN TAB 75MCG Tier 1 LEVOTHYROXIN TAB 88MCG Tier 1 LEVOXYL TAB 100MCG Tier 3 LEVOXYL TAB 112MCG Tier 3 LEVOXYL TAB 125MCG Tier 3 LEVOXYL TAB 137MCG Tier 3 LEVOXYL TAB 150MCG Tier 3 LEVOXYL TAB 175MCG Tier 3 LEVOXYL TAB 200MCG Tier 3 LEVOXYL TAB 25MCG Tier 3 LEVOXYL TAB 50MCG Tier 3 LEVOXYL TAB 75MCG Tier 3 LEVOXYL TAB 88MCG Tier 3 LEVSIN TAB 0.125MG Tier 3 LEVSIN/SL SUB 0.125MG Tier 3 LEVULAN KERA SOL 20% Tier 3 131 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy LEXAPRO SOL 5MG/5ML Tier 3 X LEXAPRO TAB 10MG Tier 3 X LEXAPRO TAB 20MG Tier 3 X LEXAPRO TAB 5MG Tier 3 X LEXIVA SUS 50MG/ML Tier 2 X LEXIVA TAB 700MG Tier 2 X LEXUSS 210 LIQ 2-10/5ML Tier 1 LIALDA TAB 1.2GM Tier 2 LIBERTY TES Tier 3 X LIBRAX CAP 5-2.5MG Tier 3 X LIDO/PRILOCN CRE 2.5-2.5% Tier 1 LIDOCAINE CRE 10% Tier 1 X LIDOCAINE CRE 5% Tier 1 X LIDOCAINE CRE TETRACAI Tier 3 LIDOCAINE GEL 2% JELLY Tier 1 LIDOCAINE OIN 5% Tier 1 X LIDOCAINE OIN PAK 5% Tier 1 X LIDOCAINE PAD 5% Tier 3 X LIDOCAINE SOL 2% VISC Tier 1 LIDOCAINE SOL 4% Tier 1 LIDOCAINE SOL 4% Tier 1 LIDOCAINE-PR CRE Tier 3 X LIDOCAINE-PR CRE Tier 1 X LIDOCAINE-PR CRE Tier 3 X LIDODERM DIS 5% Tier 3 X X LIDOPIN CRE 3.25% Tier 3 LIDOPROFEN CRE 5-5-2% Tier 3 X LIDOVEX CRE 3.75% Tier 3 LIDOVIR OIN 4-4% Tier 3 X LIFESCAN MIS UNISTIK2 Tier 1 LIMBREL CAP 250MG Tier 3 LIMBREL CAP 500MG Tier 3 LIMBREL250 CAP 250-50MG Tier 3 LIMBREL500 CAP 500-50MG Tier 3 LINDANE LOT 1% Tier 1 X LINDANE SHA 1% Tier 1 X LINEZOLID SUS 100/5ML Tier 1 X LINEZOLID TAB 600MG Tier 1 X 132 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy LINK ASSIST MIS ACCU-CHK Tier 3 LINZESS CAP 145MCG Tier 2 X X LINZESS CAP 290MCG Tier 2 X X LIOTHYRONINE TAB 25MCG Tier 3 LIOTHYRONINE TAB 50MCG Tier 3 LIOTHYRONINE TAB 5MCG Tier 3 LIPISTART POW Tier 3 LIPITOR TAB 10MG Tier 3 X X LIPITOR TAB 20MG Tier 3 X X LIPITOR TAB 40MG Tier 3 X X LIPITOR TAB 80MG Tier 3 X X LIPO CREAM CRE BASE Tier 3 X LIPODERM HMW GEL PCCA Tier 3 LIPOFEN CAP 150MG Tier 3 X LIPOFEN CAP 50MG Tier 3 X LIPOGEL CR GEL BASE Tier 3 LIPOIC ACID POW Tier 3 X LIPOPEN CRE Tier 2 X LIPOPEN CRE ANHYDRO Tier 3 X LIPOPEN CRE PLUS Tier 3 X LIPOPEN CRE ULTRA Tier 3 X LIPOSOMAL CRE HEAVY Tier 3 X LIPOSOMAL CRE REGULAR Tier 3 X LIPOZYME CRE Tier 3 LISINOP/HCTZ TAB 10-12.5 Tier 1 LISINOP/HCTZ TAB 20-12.5 Tier 1 LISINOP/HCTZ TAB 20-25MG Tier 1 LISINOPRIL TAB 10MG Tier 1 LISINOPRIL TAB 2.5MG Tier 1 LISINOPRIL TAB 20MG Tier 1 LISINOPRIL TAB 30MG Tier 1 LISINOPRIL TAB 40MG Tier 1 LISINOPRIL TAB 5MG Tier 1 LISSAMINE GR TES 1.5MG Tier 1 LISTER-V CAP Tier 3 LITHATE CAP Tier 3 LITHIUM SOL 8MEQ/5ML Tier 1 LITHIUM CARB CAP 150MG Tier 1 133 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy LITHIUM CARB CAP 300MG Tier 1 LITHIUM CARB CAP 600MG Tier 1 LITHIUM CARB TAB 300MG Tier 1 LITHIUM CARB TAB 300MG ER Tier 1 LITHIUM CARB TAB 450MG ER Tier 1 LITHOBID TAB 300MG CR Tier 3 LITHOSTAT TAB 250MG Tier 3 LIVALO TAB 1MG Tier 3 X X LIVALO TAB 2MG Tier 3 X X LIVALO TAB 4MG Tier 3 X X LMD POW Tier 3 LMD DIET POW Tier 3 LO LOESTRIN TAB Tier 3 LO-DOSE ASA TAB 81MG EC HCR Preventive LOCOID CRE 0.1% Tier 3 LOCOID LOT 0.1% Tier 3 X X LOCOID OIN 0.1% Tier 3 LOCOID SOL 0.1% Tier 3 LOCOID LIPO CRE 0.1% Tier 3 X X LODINE TAB 400MG Tier 3 X LODOSYN TAB 25MG Tier 3 X LOESTRIN TAB 1/20-21 Tier 3 LOESTRIN 21 TAB 1.5/30 Tier 3 LOESTRIN FE TAB 1.5/30 Tier 3 LOESTRIN FE TAB 1/20 Tier 3 LOFENE TAB 2.5MG Tier 1 LOFIBRA CAP 134MG Tier 3 X LOFIBRA CAP 200MG Tier 3 X LOFIBRA CAP 67MG Tier 3 X LOFIBRA TAB 160MG Tier 3 X LOFIBRA TAB 54MG Tier 3 X LOKARA LOT 0.05% Tier 3 X LOMEDIA 24 TAB FE Tier 3 LOMOTIL TAB 2.5MG Tier 3 LOMUSTINE CAP 100MG Tier 1 X LOMUSTINE CAP 10MG Tier 1 X LOMUSTINE CAP 40MG Tier 1 X

134 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy LONSURF TAB 15-6.14 Tier 3 X X X LONSURF TAB 20-8.19 Tier 3 X X X LOPID TAB 600MG Tier 3 LOPREEZA TAB 0.5-0.1 Tier 3 LOPREEZA TAB 1-0.5MG Tier 3 LOPRESS HCT TAB 50-25MG Tier 3 LOPRESSOR TAB 100MG Tier 3 LOPRESSOR TAB 50MG Tier 3 LOPROX CRE 0.77% Tier 3 X LOPROX KIT 0.77% Tier 3 X LOPROX SHA 1% Tier 3 X LORAZEPAM CON 2MG/ML Tier 1 LORAZEPAM TAB 0.5MG Tier 1 LORAZEPAM TAB 1MG Tier 1 LORAZEPAM TAB 2MG Tier 1 LORCET TAB 5-325MG Tier 1 X LORCET HD TAB 10-325MG Tier 1 X LORCET PLUS TAB 7.5-325 Tier 1 X LORTAB ELX 10-300MG Tier 3 LORTAB TAB 10-325MG Tier 1 X LORTAB TAB 5-325MG Tier 1 X LORTAB TAB 7.5-325 Tier 1 X LORYNA TAB 3-0.02MG Tier 3 LORZONE TAB 375MG Tier 3 X X LORZONE TAB 750MG Tier 3 X X LOSARTAN POT TAB 100MG Tier 1 LOSARTAN POT TAB 25MG Tier 1 LOSARTAN POT TAB 50MG Tier 1 LOSARTAN/HCT TAB 100-12.5 Tier 1 LOSARTAN/HCT TAB 100-25 Tier 1 LOSARTAN/HCT TAB 50-12.5 Tier 1 LOSEASONIQUE TAB Tier 3 X LOTEMAX GEL 0.5% Tier 3 X LOTEMAX OIN 0.5% Tier 3 LOTEMAX SUS 0.5% Tier 3 X LOTENSIN TAB 20MG Tier 3 LOTENSIN TAB 40MG Tier 3 LOTENSIN HCT TAB 10-12.5 Tier 3 135 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy LOTENSIN HCT TAB 20-12.5 Tier 3 LOTENSIN HCT TAB 20-25MG Tier 3 LOTREL CAP 10-20MG Tier 3 X LOTREL CAP 10-40MG Tier 3 X LOTREL CAP 2.5-10MG Tier 3 X LOTREL CAP 5-10MG Tier 3 X LOTREL CAP 5-20MG Tier 3 X LOTREL CAP 5-40MG Tier 3 X LOTRISONE CRE Tier 3 X LOTRONEX TAB 0.5MG Tier 3 X X X LOTRONEX TAB 1MG Tier 3 X X X LOUTREX CRE Tier 3 LOVASTATIN TAB 10MG Tier 1 LOVASTATIN TAB 20MG Tier 1 LOVASTATIN TAB 40MG Tier 1 LOVAZA CAP 1GM Tier 3 X X LOVENOX INJ 100MG/ML Tier 3 X LOVENOX INJ 120/0.8 Tier 3 X LOVENOX INJ 150MG/ML Tier 3 X LOVENOX INJ 30/0.3ML Tier 3 X LOVENOX INJ 300/3ML Tier 3 X LOVENOX INJ 40/0.4ML Tier 3 X LOVENOX INJ 60/0.6ML Tier 3 X LOVENOX INJ 80/0.8ML Tier 3 X LOW-OGESTREL TAB HCR Preventive LOXAPINE CAP 10MG Tier 1 LOXAPINE CAP 25MG Tier 1 LOXAPINE CAP 50MG Tier 1 LOXAPINE CAP 5MG Tier 1 LOZI-FLUR LOZ 1MG F Tier 2 LUBRAJEL NP GEL Tier 3 LUDENT CHW 0.25MG F HCR Preventive LUDENT CHW 0.5MG F HCR Preventive LUDENT CHW 1MG F HCR Preventive

136 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy LUGOLS SOL STRONG Tier 1 LUKAID GLA EMU 1GM/ML Tier 2 LUMIGAN SOL 0.01% Tier 2 LUNESTA TAB 1MG Tier 3 X X LUNESTA TAB 2MG Tier 3 X X LUNESTA TAB 3MG Tier 3 X X LURIDE DRO 0.5MG/ML HCR Preventive LUTERA TAB HCR Preventive LUXAMEND CRE Tier 3 LUXIQ AER 0.12% Tier 3 X X LUZU CRE 1% Tier 3 X X LYCELLE GEL Tier 3 LYNPARZA CAP 50MG Tier 3 X X X LYRICA CAP 100MG Tier 3 X X LYRICA CAP 150MG Tier 3 X X LYRICA CAP 200MG Tier 3 X X LYRICA CAP 225MG Tier 3 X X LYRICA CAP 25MG Tier 3 X X LYRICA CAP 300MG Tier 3 X X LYRICA CAP 50MG Tier 3 X X LYRICA CAP 75MG Tier 3 X X LYRICA SOL 20MG/ML Tier 3 X X LYSINE TAB 1000MG Tier 1 LYSIPLEX TAB PLUS Tier 1 LYSODREN TAB 500MG Tier 2 X LYSTEDA TAB 650MG Tier 3 X LYZA TAB 0.35MG HCR Preventive M-VIT TAB 27-1MG Tier 1 MACNATAL CN CAP DHA Tier 2 MACROBID CAP 100MG Tier 3 MACRODANTIN CAP 100MG Tier 3 MACRODANTIN CAP 25MG Tier 3 MACRODANTIN CAP 50MG Tier 3 MAG CITRATE SOL HCR Preventive

137 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy MAG CITRATE SOL CHERRY HCR Preventive MAG CITRATE SOL GRAPE HCR Preventive MAG CITRATE SOL LEMON HCR Preventive MAGNEBIND TAB 400 Tier 2 MAGNESIUM POW BISGLYCI Tier 3 MAGNESIUM POW GLYCINAT Tier 3 MAGNESIUM AA POW CHELATE Tier 3 X MALARONE TAB 250-100 Tier 3 MALARONE TAB 62.5-25 Tier 3 MALATHION LOT 0.5% Tier 1 MAPROTILINE TAB 25MG Tier 1 MAPROTILINE TAB 50MG Tier 1 MAPROTILINE TAB 75MG Tier 1 MARGESIC CAP Tier 1 X MARINOL CAP 10MG Tier 3 MARINOL CAP 2.5MG Tier 3 MARINOL CAP 5MG Tier 3 MARLISSA TAB 0.15/30 HCR Preventive MARNATAL-F CAP Tier 3 MARPLAN TAB 10MG Tier 3 MARTEN-TAB TAB 50-325MG Tier 1 MASK VORTEX/ MIS BABY DUC Tier 2 MASK VORTEX/ MIS DUCK Tier 2 MASK VORTEX/ MIS FROG Tier 2 MASK VORTEX/ MIS LADY BUG Tier 2 MATULANE CAP 50MG Tier 2 X MATZIM LA TAB 180MG/24 Tier 3 MATZIM LA TAB 240MG/24 Tier 3 MATZIM LA TAB 300MG/24 Tier 3 MATZIM LA TAB 360MG/24 Tier 3 MATZIM LA TAB 420MG/24 Tier 3 MAVIK TAB 1MG Tier 3 MAVIK TAB 2MG Tier 3 MAVIK TAB 4MG Tier 3

138 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy MAXALT TAB 10MG Tier 3 X X MAXALT TAB 5MG Tier 3 X X MAXALT-MLT TAB 10MG Tier 3 X X MAXALT-MLT TAB 5MG Tier 3 X X MAXIDEX SUS 0.1% OP Tier 2 MAXITROL OIN 0.1% OP Tier 3 MAXITROL SUS 0.1% OP Tier 3 MAXZIDE TAB 75-50 Tier 3 MAXZIDE-25 TAB Tier 3 MB HYDROGEL KIT Tier 3 X MCT PROCAL POW Tier 3 MD-GASTROVIE SOL 66-10% Tier 1 MDL ANTIHIST ELX 12.5/5ML Tier 1 ME/NAPHOS/MB TAB HYO 1 Tier 1 MECLOFEN SOD CAP 100MG Tier 1 MECLOFEN SOD CAP 50MG Tier 1 MED 12HR REL TAB 6-120 CR Tier 1 MED CIT MAGN SOL Tier 1 MEDCATED DNA KIT COLLECT Tier 3 MEDERMA CRE SPF 30 Tier 3 X MEDI-10 CAP Tier 3 MEDI-DERM CRE -RX Tier 3 MEDIDERM CRE Tier 3 X MEDISENSE LIQ GLUC-KET Tier 2 MEDISENSE LIQ GLUC/KET Tier 2 MEDROL TAB 16MG Tier 3 MEDROL TAB 2MG Tier 2 MEDROL TAB 32MG Tier 3 MEDROL TAB 4MG Tier 3 MEDROL TAB 4MG Tier 3 MEDROL TAB 8MG Tier 3 MEDROX-RX OIN Tier 3 MEDROXYPR AC INJ 150MG/ML HCR X Preventive MEDROXYPR AC INJ 150MG/ML HCR X Preventive MEDROXYPR AC TAB 10MG Tier 1 MEDROXYPR AC TAB 2.5MG Tier 1

139 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy MEDROXYPR AC TAB 5MG Tier 1 MEFENAM ACID CAP 250MG Tier 3 MEFENAMIC POW ACID Tier 3 X MEFLOQUINE TAB 250MG Tier 1 MEGACE ES SUS 625/5ML Tier 3 MEGACE ORAL SUS 40MG/ML Tier 3 MEGESTROL SUS 625MG/5M Tier 3 MEGESTROL AC SUS 40MG/ML Tier 1 MEGESTROL AC TAB 20MG Tier 1 MEGESTROL AC TAB 40MG Tier 1 MEIJER MIS LANCETS Tier 3 MEKINIST TAB 0.5MG Tier 2 X X X MEKINIST TAB 2MG Tier 2 X X X MELATONIN POW Tier 3 X MELOXICAM POW Tier 3 X MELOXICAM SUS 7.5/5ML Tier 1 MELOXICAM TAB 15MG Tier 1 MELOXICAM TAB 7.5MG Tier 1 MEMANT TITRA PAK 5-10MG Tier 1 MEMANTINE TAB HCL 10MG Tier 1 MEMANTINE TAB HCL 5MG Tier 1 MEMANTINE HC SOL 2MG/ML Tier 3 MENEST TAB 0.3MG Tier 3 MENEST TAB 0.625MG Tier 3 MENEST TAB 1.25MG Tier 3 MENEST TAB 2.5MG Tier 3 MENOPUR INJ 75UNIT Tier 3 X MENOSTAR DIS 14MCG Tier 3 X MENTAX CRE 1% Tier 3 MEPER/PROMET CAP 50-25MG Tier 3 MEPERIDINE SOL 50MG/5ML Tier 1 MEPERIDINE TAB 100MG Tier 1 MEPERIDINE TAB 50MG Tier 1 MEPHYTON TAB 5MG Tier 2 X MEPROBAMATE TAB 200MG Tier 1 MEPROBAMATE TAB 400MG Tier 1 MEPRON SUS Tier 3 X MERCAPTOPUR TAB 50MG Tier 1 X 140 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy MERCAPTOPURI POW Tier 3 X MERCAPTOPURI POW Tier 3 X MERCAPTOPURI POW MONOHYDR Tier 3 X MERITENE POW CHOCOLAT Tier 3 MERITENE POW VANILLA Tier 3 MESALAMINE ENE 4GM Tier 1 MESALAMINE KIT 4GM Tier 1 X MESALAMINE TAB 800MG DR Tier 3 X MESNEX TAB 400MG Tier 3 X MESTINON SYP 60MG/5ML Tier 2 MESTINON TAB 60MG Tier 3 MESTINON TAB TIMESPAN Tier 3 METADATE TAB 20MG ER Tier 1 X METADATE CD CAP 10MG Tier 2 X X METADATE CD CAP 20MG Tier 2 X X METADATE CD CAP 30MG Tier 2 X X METADATE CD CAP 40MG Tier 2 X X METADATE CD CAP 50MG Tier 2 X X METADATE CD CAP 60MG Tier 2 X X METAPROTEREN SYP 10MG/5ML Tier 1 METAPROTEREN TAB 10MG Tier 1 METAPROTEREN TAB 20MG Tier 1 METAXALL TAB 800MG Tier 3 METAXALONE TAB 400MG Tier 3 METAXALONE TAB 800MG Tier 3 METFORMIN TAB 1000MG Tier 1 METFORMIN TAB 1000MG Tier 3 X X METFORMIN TAB 500MG Tier 1 METFORMIN TAB 500MG ER Tier 1 METFORMIN TAB 500MG ER Tier 3 X X METFORMIN TAB 500MG ER Tier 3 X X METFORMIN TAB 750MG ER Tier 1 METFORMIN TAB 850MG Tier 1 METFORMIN ER TAB 1000MG Tier 3 X X METHADONE CON 10MG/ML Tier 1 X METHADONE POW Tier 3 X METHADONE SOL 10MG/5ML Tier 1 X METHADONE SOL 5MG/5ML Tier 1 X 141 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy METHADONE TAB 10MG Tier 1 X METHADONE TAB 40MG Tier 1 X METHADONE TAB 5MG Tier 1 X METHADOSE CON 10MG/ML Tier 1 X METHADOSE TAB 40MG Tier 1 X METHADOSE SF CON 10MG/ML Tier 1 X METHAMPHETAM TAB 5MG Tier 1 X METHAZEL CAP Tier 3 METHAZOLAMID TAB 25MG Tier 1 METHAZOLAMID TAB 50MG Tier 1 METHENAM HIP TAB 1GM Tier 1 METHENAM MAN TAB 1000MG Tier 1 METHENAM MAN TAB 1GM Tier 1 METHENAM MAN TAB 500MG Tier 1 METHERGINE TAB 0.2MG Tier 1 METHIMAZOLE TAB 10MG Tier 1 METHIMAZOLE TAB 5MG Tier 1 METHIONINE CAP 200MG Tier 3 METHIONINE POW Tier 3 METHITEST TAB 10MG Tier 2 METHLPHENIDA CHW 2.5MG Tier 3 X METHOCARBAM TAB 500MG Tier 1 METHOCARBAM TAB 750MG Tier 1 METHOTREXATE POW Tier 3 METHOTREXATE TAB 2.5MG Tier 1 METHOXSALEN CAP 10MG Tier 1 METHSCOPOLAM TAB 2.5MG Tier 1 METHSCOPOLAM TAB 5MG Tier 1 METHYCLOTHIA TAB 5MG Tier 1 METHYL POW FOLATE Tier 3 METHYL SALIC LIQ Tier 1 METHYLCOBALA POW Tier 3 X METHYLCOBALA POW PREMIUM Tier 3 X METHYLD/HCTZ TAB 250/15 Tier 1 METHYLD/HCTZ TAB 250/25 Tier 1 METHYLDOPA TAB 250MG Tier 1 METHYLDOPA TAB 500MG Tier 1 METHYLERGON TAB 0.2MG Tier 1 142 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy METHYLIN CHW 10MG Tier 3 X METHYLIN CHW 2.5MG Tier 3 X METHYLIN CHW 5MG Tier 3 X METHYLIN SOL 10MG/5ML Tier 3 X METHYLIN SOL 5MG/5ML Tier 3 X METHYLPHENID CAP 10MG Tier 3 X X X METHYLPHENID CAP 20MG Tier 3 X X X METHYLPHENID CAP 20MG ER Tier 3 X X X METHYLPHENID CAP 30MG Tier 3 X X X METHYLPHENID CAP 30MG ER Tier 3 X X X METHYLPHENID CAP 40MG Tier 3 X X X METHYLPHENID CAP 40MG ER Tier 3 X X X METHYLPHENID CAP 50MG Tier 3 X X X METHYLPHENID CAP 60MG Tier 3 X X X METHYLPHENID CHW 10MG Tier 3 X METHYLPHENID CHW 5MG Tier 3 X METHYLPHENID SOL 10MG/5ML Tier 1 X METHYLPHENID SOL 5MG/5ML Tier 1 X METHYLPHENID TAB 10MG Tier 1 X METHYLPHENID TAB 10MG ER Tier 1 X METHYLPHENID TAB 18MG ER Tier 3 X X X METHYLPHENID TAB 18MG ER Tier 3 X X X METHYLPHENID TAB 20MG Tier 1 X METHYLPHENID TAB 20MG ER Tier 1 X METHYLPHENID TAB 20MG SR Tier 1 X METHYLPHENID TAB 27MG ER Tier 3 X X X METHYLPHENID TAB 27MG ER Tier 3 X X X METHYLPHENID TAB 36MG ER Tier 3 X X X METHYLPHENID TAB 36MG ER Tier 3 X X X METHYLPHENID TAB 54MG ER Tier 3 X X X METHYLPHENID TAB 54MG ER Tier 3 X X X METHYLPHENID TAB 5MG Tier 1 X METHYLPRED POW ACETATE Tier 3 METHYLPRED TAB 16MG Tier 1 METHYLPRED TAB 32MG Tier 1 METHYLPRED TAB 4MG Tier 1 METHYLPRED TAB 4MG Tier 1 METHYLPRED TAB 8MG Tier 1 143 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy METHYLTESTOS CAP 10MG Tier 1 METIPRANOLOL SOL 0.3% OPH Tier 1 METOCLOPRAM SOL 5MG/5ML Tier 1 METOCLOPRAM TAB 10MG Tier 1 METOCLOPRAM TAB 5MG Tier 1 METOCLOPRAM TAB 5MG ODT Tier 3 X METOCLOPRAMI TAB 10MG ODT Tier 3 X METOLAZONE TAB 10MG Tier 1 METOLAZONE TAB 2.5MG Tier 1 METOLAZONE TAB 5MG Tier 1 METOPIRONE CAP 250MG Tier 2 METOPRL/HCTZ TAB 100-25MG Tier 1 METOPRL/HCTZ TAB 100-50MG Tier 1 METOPRL/HCTZ TAB 50-25MG Tier 1 METOPRO/HCTZ TAB 25-12.5 Tier 3 X X METOPROL TAR TAB 100MG Tier 1 METOPROL TAR TAB 25MG Tier 1 METOPROL TAR TAB 50MG Tier 1 METOPROLOL TAB 100MG ER Tier 3 METOPROLOL TAB 200MG ER Tier 3 METOPROLOL TAB 25MG ER Tier 3 METOPROLOL TAB 37.5MG Tier 3 X METOPROLOL TAB 50MG ER Tier 3 METOPROLOL TAB 75MG Tier 3 X METOZOLV ODT TAB 5MG Tier 3 X METROCREAM CRE 0.75% Tier 3 METROGEL GEL 1% Tier 3 X METROGEL-VAG GEL 0.75% Tier 3 X METROLOTION LOT 0.75% Tier 3 METRONIDAZOL CAP 375MG Tier 1 METRONIDAZOL CRE 0.75% Tier 1 METRONIDAZOL GEL 0.75% Tier 1 METRONIDAZOL GEL 0.75%VAG Tier 1 METRONIDAZOL GEL 1% Tier 3 X METRONIDAZOL LOT 0.75% Tier 1 METRONIDAZOL TAB 250MG Tier 1 METRONIDAZOL TAB 500MG Tier 1 MEVACOR TAB 40MG Tier 3 144 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy MEXILETINE CAP 150MG Tier 1 MEXILETINE CAP 200MG Tier 1 MEXILETINE CAP 250MG Tier 1 MIACALCIN INJ 200/ML Tier 3 MIACALCIN SPR 200/ACT Tier 3 MICARDIS TAB 20MG Tier 3 X X MICARDIS TAB 40MG Tier 3 X X MICARDIS TAB 80MG Tier 3 X X MICARDIS HCT TAB 40/12.5 Tier 3 X X MICARDIS HCT TAB 80-25MG Tier 3 X X MICARDIS HCT TAB 80/12.5 Tier 3 X X MICONAZOLE POW NITRATE Tier 3 MICONAZOLE 3 SUP 200MG Tier 1 MICORT-HC CRE 2.5% Tier 3 X MICRGSTIN 24 TAB FE 1/20 Tier 3 MICRO-K CAP 10MEQ CR Tier 3 MICRO-K CAP 8MEQ CR Tier 3 MICRODERM CRE BASE Tier 3 X MICROGESTIN TAB 1.5/30 Tier 3 MICROGESTIN TAB 1/20 Tier 3 MICROGESTIN TAB FE 1/20 HCR Preventive MICROGESTIN TAB FE1.5/30 HCR Preventive MICROLET MIS LANCETS Tier 3 MICROZIDE CAP 12.5MG Tier 3 MIDAZOLAM POW Tier 3 MIDAZOLAM SYP 2MG/ML Tier 1 MIDODRINE TAB 10MG Tier 1 MIDODRINE TAB 2.5MG Tier 1 MIDODRINE TAB 5MG Tier 1 MIGERGOT SUP 2/100 Tier 3 MIGLITOL TAB 100MG Tier 1 MIGLITOL TAB 25MG Tier 1 MIGLITOL TAB 50MG Tier 1 MIGRANAL SPR 4MG/ML Tier 3 X MILLIPRED SOL 10MG/5ML Tier 3 MILLIPRED TAB 5MG Tier 2

145 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy MILLIPRED DP PAK 5MG Tier 2 MILLIPRED DP PAK 5MG Tier 2 MILTAB #1 TAB Tier 3 MIMVEY TAB 1-0.5MG Tier 3 MIMVEY LO TAB 0.5-0.1 Tier 3 MINASTRIN 24 CHW FE Tier 3 X MINERAL OIL HEAVY Tier 1 MINI LANCING MIS DEVICE Tier 3 MINILINK RT KIT REPLACE Tier 3 MINILINK RT KIT STARTER Tier 3 MINILINK RT MIS TRANSMIT Tier 3 MINIMED PUMP MIS RES 3ML Tier 2 MINIPRESS CAP 1MG Tier 3 MINIPRESS CAP 2MG Tier 3 MINIPRESS CAP 5MG Tier 3 MINIPRIN LOW TAB 81MG EC HCR Preventive MINITRAN DIS 0.1MG/HR Tier 1 MINITRAN DIS 0.2MG/HR Tier 1 MINITRAN DIS 0.4MG/HR Tier 1 MINITRAN DIS 0.6MG/HR Tier 1 MINIVELLE DIS 0.025 MG Tier 3 X MINIVELLE DIS 0.0375MG Tier 3 X MINIVELLE DIS 0.05MG Tier 3 X MINIVELLE DIS 0.075MG Tier 3 X MINIVELLE DIS 0.1MG Tier 3 X MINOCIN CAP 100MG Tier 3 X MINOCIN CAP 50MG Tier 3 X MINOCIN CAP 75MG Tier 3 X MINOCIN KIT 100MG Tier 3 X MINOCIN KIT 50MG Tier 3 X MINOCYCLINE CAP 100MG Tier 1 MINOCYCLINE CAP 50MG Tier 1 MINOCYCLINE CAP 75MG Tier 1 MINOCYCLINE TAB 100MG Tier 3 MINOCYCLINE TAB 135MG ER Tier 3 MINOCYCLINE TAB 45MG ER Tier 3 MINOCYCLINE TAB 50MG Tier 3

146 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy MINOCYCLINE TAB 75MG Tier 3 MINOCYCLINE TAB 90MG ER Tier 3 MINOXIDIL POW Tier 3 X MINOXIDIL TAB 10MG Tier 1 MINOXIDIL TAB 2.5MG Tier 1 MIO INF SET MIS 18"/6MM Tier 2 MIO INF SET MIS 23"/6MM Tier 2 MIO INF SET MIS 32"/6MM Tier 2 MIO INF SET MIS 32"/9MM Tier 2 MIRAPEX TAB 0.125MG Tier 3 MIRAPEX TAB 0.25MG Tier 3 MIRAPEX TAB 0.5MG Tier 3 MIRAPEX TAB 0.75MG Tier 3 MIRAPEX TAB 1.5MG Tier 3 MIRAPEX TAB 1MG Tier 3 MIRAPEX ER TAB 0.375MG Tier 3 X MIRAPEX ER TAB 0.75MG Tier 3 X MIRAPEX ER TAB 1.5MG Tier 3 X MIRAPEX ER TAB 2.25MG Tier 3 X MIRAPEX ER TAB 3.75MG Tier 3 X MIRAPEX ER TAB 3MG Tier 3 X MIRAPEX ER TAB 4.5MG Tier 3 X MIRCETTE TAB 28 DAY Tier 3 MIRTAZAPINE TAB 15MG Tier 1 MIRTAZAPINE TAB 15MG ODT Tier 1 MIRTAZAPINE TAB 30MG Tier 1 MIRTAZAPINE TAB 30MG ODT Tier 1 MIRTAZAPINE TAB 45MG Tier 1 MIRTAZAPINE TAB 45MG ODT Tier 1 MIRTAZAPINE TAB 7.5MG Tier 1 MIRVASO GEL 0.33% Tier 3 X MISOPROSTOL TAB 100MCG Tier 1 MISOPROSTOL TAB 200MCG Tier 1 MITIGARE CAP 0.6MG Tier 2 MITOMYCIN POW Tier 3 X MITOMYCIN C POW Tier 3 X MITOSOL KIT 0.2MG Tier 3 MMA/PA LIQ COOLER Tier 3 147 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy MOBIC SUS 7.5/5ML Tier 3 MOBIC TAB 15MG Tier 3 MOBIC TAB 7.5MG Tier 3 MODAFINIL TAB 100MG Tier 3 X X MODAFINIL TAB 200MG Tier 3 X X MODERIBA PAK 1000/DAY Tier 3 X X MODERIBA PAK 1200/DAY Tier 3 X X MODERIBA PAK 600/DAY Tier 3 X X MODERIBA PAK 800/DAY Tier 3 X X MODERIBA TAB 200MG Tier 3 X X MODICON TAB 0.5/35 Tier 3 MODULEN IBD POW Tier 3 MOEXIPR/HCTZ TAB 15-12.5 Tier 1 MOEXIPR/HCTZ TAB 15-25MG Tier 1 MOEXIPR/HCTZ TAB 7.5-12.5 Tier 1 MOEXIPRIL TAB 15MG Tier 1 MOEXIPRIL TAB 7.5MG Tier 1 MOLINDONE TAB HCL 10MG Tier 3 MOLINDONE TAB HCL 25MG Tier 3 MOLINDONE TAB HCL 5MG Tier 3 MOMETASONE CRE 0.1% Tier 1 MOMETASONE OIN 0.1% Tier 1 MOMETASONE POW Tier 3 X MOMETASONE SOL 0.1% Tier 1 MOMETASONE SPR 50MCG Tier 3 X X MONDOXYNE NL CAP 100MG Tier 1 MONDOXYNE NL CAP 50MG Tier 1 MONDOXYNE NL CAP 75MG Tier 3 X MONO-LINYAH TAB 0.25-35 HCR Preventive MONOBENZONE POW Tier 3 X MONOCLATE-P INJ 1000UNIT Tier 2 X MONOCLATE-P INJ 1500UNIT Tier 2 X MONODOX CAP 100MG Tier 3 X MONODOX CAP 75MG Tier 3 X MONONESSA TAB HCR Preventive MONONINE INJ 1000UNIT Tier 2 X

148 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy MONSELS FERR SOL SUBSULF Tier 1 MONTELUKAST CHW 4MG Tier 1 MONTELUKAST CHW 5MG Tier 1 MONTELUKAST GRA 4MG Tier 3 MONTELUKAST TAB 10MG Tier 1 MONUROL PAK GRANULES Tier 3 MORCIN CRE Tier 3 MORCOMINE SYP Tier 1 MORGIDOX CAP 1X100MG Tier 3 MORGIDOX CAP 1X50MG Tier 1 MORGIDOX CAP 2X100MG Tier 3 MORGIDOX KIT 1X100MG Tier 3 X MORGIDOX KIT 2X100MG Tier 3 X MORPHINE POW SULFATE Tier 3 X MORPHINE SUL CAP 100MG ER Tier 3 X X X MORPHINE SUL CAP 10MG ER Tier 3 X X X MORPHINE SUL CAP 120MG ER Tier 3 X X X MORPHINE SUL CAP 20MG ER Tier 3 X X X MORPHINE SUL CAP 30MG ER Tier 3 X X X MORPHINE SUL CAP 30MG ER Tier 3 X X X MORPHINE SUL CAP 45MG ER Tier 3 X X X MORPHINE SUL CAP 50MG ER Tier 3 X X X MORPHINE SUL CAP 60MG ER Tier 3 X X X MORPHINE SUL CAP 60MG ER Tier 3 X X X MORPHINE SUL CAP 75MG ER Tier 3 X X X MORPHINE SUL CAP 80MG ER Tier 3 X X X MORPHINE SUL CAP 90MG ER Tier 3 X X X MORPHINE SUL SOL 100/5ML Tier 1 MORPHINE SUL SOL 10MG/5ML Tier 1 MORPHINE SUL SOL 20MG/5ML Tier 1 MORPHINE SUL SUP 10MG Tier 3 MORPHINE SUL SUP 20MG Tier 1 MORPHINE SUL SUP 30MG Tier 1 MORPHINE SUL SUP 5MG Tier 1 MORPHINE SUL TAB 100MG ER Tier 1 X MORPHINE SUL TAB 15MG Tier 1 MORPHINE SUL TAB 15MG ER Tier 1 X MORPHINE SUL TAB 200MG ER Tier 1 X 149 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy MORPHINE SUL TAB 30MG Tier 1 MORPHINE SUL TAB 30MG ER Tier 1 X MORPHINE SUL TAB 60MG ER Tier 1 X MOUTH WASH LIQ GP Tier 3 MOUTHWASH LIQ AF Tier 3 MOUTHWASH LIQ OM Tier 3 MOVANTIK TAB 12.5MG Tier 2 X X MOVANTIK TAB 25MG Tier 2 X X MOVIPREP SOL Tier 3 X MOXATAG TAB 775MG Tier 3 MOXEZA SOL 0.5% Tier 3 MOXIFLOXACIN TAB 400MG Tier 3 MOZOBIL INJ Tier 2 X MS CONTIN TAB 100MG CR Tier 3 X X X MS CONTIN TAB 15MG CR Tier 3 X X X MS CONTIN TAB 200MG CR Tier 3 X X X MS CONTIN TAB 30MG CR Tier 3 X X X MS CONTIN TAB 60MG CR Tier 3 X X X MSUD COOLER LIQ Tier 3 MSUD COOLER LIQ 20 Tier 3 MUCOLOX LIQ Tier 3 MULT-VIT/FL CHW 0.5MG Tier 1 MULTAQ TAB 400MG Tier 3 X MULTI-DRUG KIT DIUSCREE Tier 3 MULTI-VIT/FE DRO /FL 0.25 Tier 1 MULTI-VIT/FL DRO /FE 0.25 Tier 1 MULTI-VIT/FL DRO 0.25MG Tier 1 MULTI-VIT/FL DRO 0.5MG/ML Tier 1 MULTIUSE CRE BASE Tier 3 X MULTIVIT/FL CHW 0.25MG Tier 1 MULTIVIT/FL CHW 0.5MG Tier 1 MULTIVIT/FL CHW 1MG Tier 1 MUPIROCIN CRE 2% Tier 3 X MUPIROCIN OIN 2% Tier 1 MUPIROCIN CA CRE 2% Tier 3 X MUSE SUP 1000MCG Tier 3 X MUSE SUP 125MCG Tier 3 X MUSE SUP 250MCG Tier 3 X 150 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy MUSE SUP 500MCG Tier 3 X MVC-FLUORIDE CHW 0.25MG Tier 1 MVC-FLUORIDE CHW 0.5MG Tier 1 MVC-FLUORIDE CHW 1MG Tier 1 MY WAY TAB 1.5MG HCR Preventive MYALEPT INJ 11.3MG Tier 3 X X X MYAMBUTOL TAB 100MG Tier 3 MYAMBUTOL TAB 400MG Tier 3 MYCOBUTIN CAP 150MG Tier 3 MYCOPHENOLAT CAP 250MG Tier 1 X MYCOPHENOLAT SUS 200MG/ML Tier 1 X MYCOPHENOLAT TAB 500MG Tier 1 X MYCOPHENOLIC TAB 180MG DR Tier 1 X MYCOPHENOLIC TAB 360MG DR Tier 1 X MYDRIACYL SOL 1% OP Tier 3 MYFORTIC TAB 180MG Tier 3 X MYFORTIC TAB 360MG Tier 3 X MYKIDZ IRON SUS FL Tier 3 MYLERAN TAB 2MG Tier 2 X MYNATAL CAP Tier 2 MYNATAL TAB Tier 2 MYNATAL TAB ADVANCE Tier 2 MYNATAL PLUS TAB Tier 1 MYNATAL-Z TAB Tier 2 MYNATE 90 TAB PLUS Tier 1 MYORISAN CAP 10MG Tier 3 X MYORISAN CAP 20MG Tier 3 X MYORISAN CAP 30MG Tier 3 X MYORISAN CAP 40MG Tier 3 X MYRBETRIQ TAB 25MG Tier 3 X MYRBETRIQ TAB 50MG Tier 3 X MYSOLINE TAB 250MG Tier 2 X X MYSOLINE TAB 50MG Tier 2 X X MYTESI TAB 125MG Tier 3 X X X MYZILRA TAB HCR Preventive N-ACETYL-L- CAP CYSTEINE Tier 1

151 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy NA HYDROXIDE SOL 10% Tier 1 NABUMETONE POW Tier 3 X NABUMETONE TAB 500MG Tier 1 NABUMETONE TAB 750MG Tier 1 NADOLOL TAB 20MG Tier 1 NADOLOL TAB 40MG Tier 1 NADOLOL TAB 80MG Tier 1 NADOLOL/BEND TAB 40-5MG Tier 1 NADOLOL/BEND TAB 80-5MG Tier 1 NAFRINSE CHW 1MG F HCR Preventive NAFRINSE DRO 0.125MG HCR Preventive NAFRINSE SOL DAILY Tier 2 NAFRINSE DLY SOL /NEUTRAL Tier 2 NAFRINSE WK SOL 0.2% Tier 3 NAFTIFINE CRE HCL 1% Tier 3 X NAFTIFINE CRE HCL 2% Tier 3 X NAFTIN CRE 1% Tier 3 X NAFTIN CRE 2% Tier 3 X NAFTIN GEL 1% Tier 3 X NAFTIN GEL 2% Tier 3 X NALFON CAP 400MG Tier 3 NALOXONE INJ 0.4MG/ML Tier 1 NALOXONE INJ 0.4MG/ML Tier 1 NALOXONE INJ 0.4MG/ML Tier 1 NALOXONE INJ 1MG/ML Tier 1 NALTREXONE TAB 50MG Tier 1 NAMENDA SOL 10MG/5ML Tier 3 NAMENDA TAB 10MG Tier 3 NAMENDA TAB 5-10MG Tier 3 NAMENDA TAB 5MG Tier 3 NAMENDA XR CAP 14MG Tier 3 X NAMENDA XR CAP 21MG Tier 3 X NAMENDA XR CAP 28MG Tier 3 X NAMENDA XR CAP 7MG Tier 3 X NAMENDA XR CAP TITRATIO Tier 3 X NAMZARIC CAP Tier 3 X

152 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy NAMZARIC CAP 14-10MG Tier 3 X NAMZARIC CAP 21-10MG Tier 3 X NAMZARIC CAP 28-10MG Tier 3 X NAMZARIC CAP 7-10MG Tier 3 X NAN POW Tier 3 NAPHAZOLINE SOL 0.1% OP Tier 1 NAPRELAN TAB 375MG CR Tier 3 X NAPRELAN TAB 500MG CR Tier 3 X NAPRELAN TAB 750MG CR Tier 3 X NAPROSYN SUS 125/5ML Tier 3 NAPROSYN TAB 500MG Tier 3 NAPROXEN CRE Tier 3 X NAPROXEN CRE 10% Tier 1 X NAPROXEN SUS 125/5ML Tier 1 NAPROXEN TAB 250MG Tier 1 NAPROXEN TAB 375MG Tier 1 NAPROXEN TAB 500MG Tier 1 NAPROXEN DR TAB 375MG Tier 1 NAPROXEN DR TAB 500MG Tier 1 NAPROXEN SOD TAB 275MG Tier 1 NAPROXEN SOD TAB 375MG Tier 3 X NAPROXEN SOD TAB 375MG CR Tier 3 X NAPROXEN SOD TAB 500MG CR Tier 3 X NAPROXEN SOD TAB 550MG Tier 1 NARATRIPTAN TAB 1MG Tier 1 X NARATRIPTAN TAB 2.5MG Tier 1 X NARCAN SPR Tier 3 X X NARDIL TAB 15MG Tier 3 NASCOBAL SPR 500MCG Tier 3 NASONEX SPR 50MCG/AC Tier 3 X X NATACHEW CHW Tier 3 NATACREAM CRE Tier 3 X NATACYN SUS 5% OP Tier 3 NATALVIT TAB 75-1MG Tier 2 NATAZIA TAB HCR Preventive NATEGLINIDE TAB 120MG Tier 3 X NATEGLINIDE TAB 60MG Tier 3 X

153 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy NATELLE ONE CAP Tier 3 NATESTO GEL 5.5MG Tier 3 X X X NATPARA INJ 100MCG Tier 3 X X X NATPARA INJ 25MCG Tier 3 X X X NATPARA INJ 50MCG Tier 3 X X X NATPARA INJ 75MCG Tier 3 X X X NATROBA SUS 0.9% Tier 3 X NATURA-LAX POW 3350 NF HCR Preventive NATURAL CRE Tier 3 X NATURE THROI TAB 162.5MG Tier 3 NATURE-THROI TAB 113.75MG Tier 3 NATURE-THROI TAB 130MG Tier 3 NATURE-THROI TAB 146.25MG Tier 3 NATURE-THROI TAB 16.25MG Tier 3 NATURE-THROI TAB 195MG Tier 3 NATURE-THROI TAB 260MG Tier 3 NATURE-THROI TAB 32.5MG Tier 3 NATURE-THROI TAB 325MG Tier 3 NATURE-THROI TAB 48.75MG Tier 3 NATURE-THROI TAB 65MG Tier 3 NATURE-THROI TAB 81.25MG Tier 3 NATURE-THROI TAB 97.5MG Tier 3 NAZIREX CRE Tier 3 X NEBUPENT INH 300MG Tier 2 NEBUSAL NEB 3% Tier 1 NEBUSAL NEB 6% Tier 3 NECON TAB 0.5/35 HCR Preventive NECON TAB 1/35 HCR Preventive NECON TAB 1/50-28 HCR Preventive NECON TAB 10/11-28 HCR Preventive NECON TAB 7/7/7 HCR Preventive NEEDLES 22G X 1 1/2" Tier 3 NEEVO DHA CAP 27-1.13 Tier 3

154 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy NEFAZODONE TAB 100MG Tier 1 NEFAZODONE TAB 150MG Tier 1 NEFAZODONE TAB 200MG Tier 1 NEFAZODONE TAB 250MG Tier 1 NEFAZODONE TAB 50MG Tier 1 NEO-POLYCIN OIN HC 1%OP Tier 1 NEO-POLYCIN OIN OP Tier 1 NEO-SYNALAR CRE Tier 3 X X NEO-SYNALAR KIT Tier 3 X NEO/BAC/POLY OIN OP Tier 1 NEO/POLY/BAC OIN /HC 1%OP Tier 1 NEO/POLY/DEX OIN 0.1% OP Tier 1 NEO/POLY/DEX SUS 0.1% OP Tier 1 NEO/POLY/GRA SOL OP Tier 1 NEO/POLY/HC SOL 1% OTIC Tier 1 NEO/POLY/HC SUS 1% OTIC Tier 1 NEO/POLY/HC SUS OP Tier 1 NEOMYCIN TAB 500MG Tier 1 NEORAL CAP 100MG Tier 3 X NEORAL CAP 25MG Tier 3 X NEORAL SOL 100MG/ML Tier 3 X NEOSALUS AER Tier 3 X NEOSALUS CRE Tier 3 X NEOSALUS LOT Tier 3 X NEOSALUS CP CRE Tier 3 X NEOSPORIN SOL OP Tier 3 NEOTUSS PLUS LIQ Tier 3 NEPTAZANE TAB 25MG Tier 3 NEPTAZANE TAB 50MG Tier 3 NESINA TAB 12.5MG Tier 2 X NESINA TAB 25MG Tier 2 X NESINA TAB 6.25MG Tier 2 X NESTABS TAB Tier 3 NESTABS ABC MIS Tier 3 NESTABS DHA PAK Tier 3 NESTLE FLAVO PAK EX-STR Tier 3 NEUAC GEL 1.2-5% Tier 3 X NEUAC KIT 1.2-5% Tier 3 X 155 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy NEULASTA INJ 6MG/0.6M Tier 3 X NEULASTA KIT 6MG/0.6M Tier 3 X NEUMEGA INJ 5MG Tier 2 X NEUPOGEN INJ 300/0.5 Tier 3 X X NEUPOGEN INJ 300MCG Tier 3 X X NEUPOGEN INJ 480/0.8 Tier 3 X X NEUPOGEN INJ 480MCG Tier 3 X X NEUPRO DIS 1MG/24HR Tier 3 NEUPRO DIS 2MG/24HR Tier 3 NEUPRO DIS 3MG/24HR Tier 3 NEUPRO DIS 4MG/24HR Tier 3 NEUPRO DIS 6MG/24HR Tier 3 NEUPRO DIS 8MG/24HR Tier 3 NEUREPA CAP Tier 3 NEURONTIN CAP 100MG Tier 3 X X NEURONTIN CAP 300MG Tier 3 X X NEURONTIN CAP 400MG Tier 3 X X NEURONTIN SOL 250/5ML Tier 3 X X NEURONTIN TAB 600MG Tier 3 X X NEURONTIN TAB 800MG Tier 3 X X NEUTEK 2TEK SOL CONTROL Tier 2 NEUTEK 2TEK TES STRIPS Tier 3 X NEUTRAGARD GEL 1.1% Tier 1 NEUTRASAL POW Tier 3 NEVANAC SUS 0.1% Tier 3 X NEVIRAPINE SUS 50MG/5ML Tier 1 X NEVIRAPINE TAB 100MG Tier 1 X X NEVIRAPINE TAB 200MG Tier 1 X NEVIRAPINE TAB 400MG ER Tier 3 X X NEWGEN TAB 32-1MG Tier 3 NEXA PLUS CAP Tier 3 NEXAVAR TAB 200MG Tier 2 X X X NEXIUM GRA 10MG DR Tier 3 X X X NEXIUM GRA 2.5MG DR Tier 3 X X X NEXIUM GRA 20MG DR Tier 3 X X X NEXIUM GRA 40MG DR Tier 3 X X X NEXIUM GRA 5MG DR Tier 3 X X

156 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy NEXT CHOICE TAB 1.5MG HCR Preventive NIACIN POW USP/NF Tier 3 NIACIN ER TAB 1000MG Tier 3 NIACIN ER TAB 500MG Tier 3 NIACIN ER TAB 750MG Tier 3 NIACINAMIDE POW Tier 3 X NIACOR TAB 500MG Tier 3 NIASPAN TAB 1000 ER Tier 2 NIASPAN TAB 500MG ER Tier 2 NIASPAN TAB 750MG ER Tier 2 NICADAN TAB Tier 3 NICADAN ZX TAB Tier 3 NICARDIPINE CAP 20MG Tier 1 NICARDIPINE CAP 30MG Tier 1 NICAZEL TAB Tier 3 NICAZEL TAB FORTE Tier 3 NICODERM CQ DIS 14MG/24H HCR X Preventive NICODERM CQ DIS 21MG/24H HCR X Preventive NICODERM CQ DIS 7MG/24HR HCR X Preventive NICOMIDE TAB Tier 3 NICORELIEF GUM 2MG MINT HCR X Preventive NICORELIEF GUM 2MG ORIG HCR X Preventive NICORELIEF GUM 4MG MINT HCR X Preventive NICORELIEF GUM 4MG ORIG HCR X Preventive NICORETTE GUM 2MG CINN HCR X Preventive NICORETTE GUM 2MG MINT HCR X Preventive NICORETTE GUM 2MG ORIG HCR X Preventive NICORETTE GUM 2MGFRUIT HCR X Preventive

157 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy NICORETTE GUM 4MG CINN HCR X Preventive NICORETTE GUM 4MG MINT HCR X Preventive NICORETTE GUM 4MG ORIG HCR X Preventive NICORETTE GUM 4MGFRUIT HCR X Preventive NICORETTE LOZ 2MG CHRY HCR X Preventive NICORETTE LOZ 2MG MINT HCR X Preventive NICORETTE LOZ 2MG ORIG HCR X Preventive NICORETTE LOZ 4MG CHRY HCR X Preventive NICORETTE LOZ 4MG MINT HCR X Preventive NICORETTE LOZ 4MG ORIG HCR X Preventive NICORETTE ST GUM 2MG MINT HCR X Preventive NICORETTE ST GUM 2MG ORIG HCR X Preventive NICORETTE ST GUM 4MG ORIG HCR X Preventive NICOTINAMIDE POW Tier 3 X NICOTINAMIDE POW ADENINE Tier 3 X NICOTINE DIS 14MG/24H HCR X Preventive NICOTINE DIS 21MG/24H HCR X Preventive NICOTINE DIS 7MG/24HR HCR X Preventive NICOTINE GUM 2MGFRUIT HCR X Preventive NICOTINE GUM 4MG HCR X Preventive NICOTINE LOZ 2MG CHRY HCR X Preventive

158 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy NICOTINE LOZ 2MG MINT HCR X Preventive NICOTINE LOZ 4MG CHRY HCR X Preventive NICOTINE LOZ 4MG CINN HCR X Preventive NICOTINE LOZ 4MG MINT HCR X Preventive NICOTINE LOZ MINI 2MG HCR X Preventive NICOTINE POL GUM 2MG HCR X Preventive NICOTINE POL GUM 2MG CINN HCR X Preventive NICOTINE POL GUM 2MG MINT HCR X Preventive NICOTINE POL GUM 2MG ORIG HCR X Preventive NICOTINE POL GUM 2MG REF HCR X Preventive NICOTINE POL GUM 2MG STRT HCR X Preventive NICOTINE POL GUM 2MGFRUIT HCR X Preventive NICOTINE POL GUM 4MG HCR X Preventive NICOTINE POL GUM 4MG CINN HCR X Preventive NICOTINE POL GUM 4MG MINT HCR X Preventive NICOTINE POL GUM 4MG ORIG HCR X Preventive NICOTINE POL GUM 4MG REF HCR X Preventive NICOTINE POL GUM 4MG STRT HCR X Preventive NICOTINE POL GUM 4MGFRUIT HCR X Preventive NICOTINE POL LOZ 2MG CHRY HCR X Preventive

159 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy NICOTINE POL LOZ 2MG CINN HCR X Preventive NICOTINE POL LOZ 2MG MINT HCR X Preventive NICOTINE POL LOZ 4MG CHRY HCR X Preventive NICOTINE POL LOZ 4MG CINN HCR X Preventive NICOTINE POL LOZ 4MG MINT HCR X Preventive NICOTINE SYS KIT TRANSDER HCR X Preventive NICOTINE TD DIS 14MG/24H HCR X Preventive NICOTINE TD DIS 21MG/24H HCR X Preventive NICOTINE TD DIS 7MG/24HR HCR X Preventive NICOTROL INH HCR X Preventive NICOTROL NS SPR 10MG/ML HCR X Preventive NIFEDICAL XL TAB 30MG Tier 1 NIFEDICAL XL TAB 60MG Tier 1 NIFEDIPINE CAP 10MG Tier 1 NIFEDIPINE CAP 20MG Tier 1 NIFEDIPINE TAB 30MG ER Tier 1 NIFEDIPINE TAB 30MG ER Tier 1 NIFEDIPINE TAB 60MG ER Tier 1 NIFEDIPINE TAB 60MG ER Tier 1 NIFEDIPINE TAB 90MG ER Tier 1 NIFEDIPINE TAB 90MG ER Tier 1 NIKKI TAB 3-0.02MG Tier 3 NILANDRON TAB 150MG Tier 3 X NILUTAMIDE TAB 150MG Tier 3 X NIMODIPINE CAP 30MG Tier 1 NINLARO CAP 2.3MG Tier 3 X X X NINLARO CAP 3MG Tier 3 X X X NINLARO CAP 4MG Tier 3 X X X NISOLDIPINE TAB 17MG ER Tier 3 160 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy NISOLDIPINE TAB 20MG Tier 3 NISOLDIPINE TAB 25.5MG Tier 3 NISOLDIPINE TAB 30MG Tier 3 NISOLDIPINE TAB 34MG ER Tier 3 NISOLDIPINE TAB 40MG Tier 3 NISOLDIPINE TAB 8.5MG ER Tier 3 NITEBITE BAR CHOCFUDG Tier 3 NITEBITE BAR PBUTTER Tier 3 NITRIC ACID LIQ Tier 3 X NITRO-BID OIN 2% Tier 2 NITRO-DUR DIS 0.1MG/HR Tier 3 NITRO-DUR DIS 0.2MG/HR Tier 3 NITRO-DUR DIS 0.3MG/HR Tier 3 NITRO-DUR DIS 0.4MG/HR Tier 3 NITRO-DUR DIS 0.6MG/HR Tier 3 NITRO-DUR DIS 0.8MG/HR Tier 3 NITRO-TIME CAP 2.5MG CR Tier 1 NITRO-TIME CAP 6.5MG CR Tier 1 NITRO-TIME CAP 9MG CR Tier 1 NITROFUR MAC CAP 100MG Tier 1 NITROFUR MAC CAP 25MG Tier 1 NITROFUR MAC CAP 50MG Tier 1 NITROFURANTN CAP 100MG Tier 1 NITROFURANTN SUS 25MG/5ML Tier 1 NITROFURANZO OIN 0.2% Tier 1 NITROGLYCER AER 400MCG Tier 3 X NITROGLYCER CAP 2.5MG ER Tier 1 NITROGLYCER CAP 6.5MG ER Tier 1 NITROGLYCER CAP 9MG ER Tier 1 NITROGLYCER DIS 0.1MG/HR Tier 1 NITROGLYCER DIS 0.2MG/HR Tier 1 NITROGLYCER DIS 0.4MG/HR Tier 1 NITROGLYCER DIS 0.4MG/HR Tier 1 NITROGLYCER DIS 0.6MG/HR Tier 1 NITROGLYCERI SUB 0.6MG Tier 1 NITROGLYCERN SUB 0.3MG Tier 1 NITROGLYCERN SUB 0.4MG Tier 1 NITROGLYCRN SPR 0.4MG Tier 3 X X 161 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy NITROGLYCRN SPR LINGUAL Tier 3 X X NITROLINGUAL SPR PUMPSPRA Tier 3 X X NITROMIST AER 400MCG Tier 3 X NITROSTAT SUB 0.3MG Tier 3 NITROSTAT SUB 0.4MG Tier 3 NITROSTAT SUB 0.6MG Tier 3 NIVA-PLUS TAB Tier 3 NIVATOPIC CRE PLUS Tier 3 X NIZATIDINE SOL 15MG/ML Tier 3 NIZORAL SHA 2% Tier 3 NOCLOT-50 SOL ACD-A Tier 3 NODOLOR CAP Tier 1 NOR-QD TAB 0.35MG Tier 3 NORA-BE TAB 0.35MG HCR Preventive NORCO TAB 10-325MG Tier 3 X NORCO TAB 5-325MG Tier 3 X NORCO TAB 7.5-325 Tier 3 X NORDIPEN 5 MIS DEVICE Tier 3 X NORDIPEN DEL MIS SYSTEM Tier 3 X NORDITROPIN INJ 10/1.5ML Tier 3 X X X X NORDITROPIN INJ 15/1.5ML Tier 3 X X X X NORDITROPIN INJ 30/3ML Tier 3 X X X X NORDITROPIN INJ 5/1.5ML Tier 3 X X X X NORE/ETH/FER CHW 0.4MG-35 Tier 3 NORETH/ETHIN CHW FE Tier 3 X NORETH/ETHIN TAB 0.5-2.5 Tier 3 NORETH/ETHIN TAB 1/20 Tier 3 NORETH/ETHIN TAB 1MG-5MCG Tier 3 NORETH/ETHIN TAB FE 1/20 HCR Preventive NORETH/ETHIN TAB FE 1/20 Tier 3 NORETHIN ACE TAB 5MG Tier 1 NORETHINDRON TAB 0.35MG HCR Preventive NORGEST/ETHI TAB 0.25/35 HCR Preventive NORGEST/ETHI TAB ESTRADIO Tier 1

162 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy NORGEST/ETHI TAB ESTRADIO HCR Preventive NORINYL TAB 1/35 Tier 3 NORINYL TAB 1+50-28 Tier 3 NORITATE CRE 1% Tier 3 X NORLYROC TAB 0.35MG HCR Preventive NORPACE CAP 100MG Tier 3 NORPACE CAP 100MG CR Tier 2 NORPACE CAP 150MG Tier 3 NORPACE CAP 150MG CR Tier 2 NORPRAMIN TAB 100MG Tier 3 NORPRAMIN TAB 10MG Tier 3 NORPRAMIN TAB 150MG Tier 3 NORPRAMIN TAB 25MG Tier 3 NORPRAMIN TAB 50MG Tier 3 NORPRAMIN TAB 75MG Tier 3 NORTHERA CAP 100MG Tier 3 X X X NORTHERA CAP 200MG Tier 3 X X X NORTHERA CAP 300MG Tier 3 X X X NORTREL TAB 0.5/35 HCR Preventive NORTREL TAB 1/35 HCR Preventive NORTREL TAB 7/7/7 HCR Preventive NORTRIPTYLIN CAP 10MG Tier 1 NORTRIPTYLIN CAP 25MG Tier 1 NORTRIPTYLIN CAP 50MG Tier 1 NORTRIPTYLIN CAP 75MG Tier 1 NORTRIPTYLIN SOL 10MG/5ML Tier 1 NORTUSS-DE DRO Tier 1 NORTUSS-EX LIQ 200-20/5 Tier 1 NORVASC TAB 10MG Tier 3 NORVASC TAB 2.5MG Tier 3 NORVASC TAB 5MG Tier 3 NORVIR CAP 100MG Tier 2 X NORVIR SOL 80MG/ML Tier 2 X NORVIR TAB 100MG Tier 2 X 163 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy NOURILITE CRE Tier 3 X NOURISIL GEL Tier 3 X NOURIVAN CRE ANTIOX Tier 3 X NOVAREL INJ 10000UNT Tier 1 X NOVASOURCE LIQ PULMONAR Tier 3 NOVOCLAIR CRE Tier 3 X NOVOEIGHT INJ 1000UNIT Tier 2 X X NOVOEIGHT INJ 1500UNIT Tier 2 X X NOVOEIGHT INJ 2000UNIT Tier 2 X X NOVOEIGHT INJ 250UNIT Tier 2 X X NOVOEIGHT INJ 3000UNIT Tier 2 X X NOVOEIGHT INJ 500UNIT Tier 2 X X NOVOFINE MIS 30GX8MM Tier 2 NOVOFINE MIS 32GX6MM Tier 2 NOVOFINE AUT MIS 30GX8MM Tier 2 NOVOFINE PLS MIS 32GX4MM Tier 2 NOVOLIN INJ 70/30 Tier 3 X X NOVOLIN N INJ RELION Tier 3 X NOVOLIN N INJ U-100 Tier 3 X X NOVOLIN R INJ RELION Tier 3 X NOVOLIN R INJ U-100 Tier 3 X X NOVOLIN70/30 INJ RELION Tier 3 X NOVOLOG INJ 100/ML Tier 3 X X NOVOLOG INJ FLEXPEN Tier 3 X X NOVOLOG INJ PENFILL Tier 3 X X NOVOLOG MIX INJ 70/30 Tier 3 X X NOVOLOG MIX INJ FLEXPEN Tier 3 X X NOVOPEN ECHO MIS Tier 3 NOVOSEVEN RT INJ 1MG Tier 2 X NOVOSEVEN RT INJ 2MG Tier 2 X NOVOSEVEN RT INJ 5MG Tier 2 X NOVOSEVEN RT INJ 8MG Tier 2 X NOVOTWIST MIS 30GX8MM Tier 2 NOVOTWIST MIS 32GX5MM Tier 2 NOXAFIL SUS 40MG/ML Tier 2 NOXAFIL TAB 100MG Tier 2 NOXI-K CRE Tier 3 X NP #2 DRUG CRE PREP KIT Tier 3 X 164 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy NP THYROID TAB 15MG Tier 1 NP THYROID TAB 30MG Tier 1 NP THYROID TAB 60MG Tier 1 NP THYROID TAB 90MG Tier 1 NUCORT LOT 2% Tier 3 NUCYNTA TAB 100MG Tier 3 X NUCYNTA TAB 50MG Tier 3 X NUCYNTA TAB 75MG Tier 3 X NUCYNTA ER TAB 100MG Tier 3 X X NUCYNTA ER TAB 150MG Tier 3 X X NUCYNTA ER TAB 200MG Tier 3 X X NUCYNTA ER TAB 250MG Tier 3 X X NUCYNTA ER TAB 50MG Tier 3 X X NUEDEXTA CAP 20-10MG Tier 2 NULEV TAB 0.125MG Tier 3 NULYTELY SOL FLAV PKS Tier 3 NUPLAZID TAB 17MG Tier 3 X X NUTR DRINK LIQ ADVANCED Tier 3 NUTR DRINK LIQ PLUS Tier 3 NUTRAMIGEN CON DHA/ARA Tier 3 NUTRAMIGEN POW ENFLORA Tier 3 NUTREN LIQ JR/FIBER Tier 3 NUTREN LIQ JUNIOR Tier 3 NUTREN LIQ PULMONAR Tier 3 NUTREN 1.0 LIQ /FIB UNF Tier 3 NUTREN 1.0 LIQ /FIBER Tier 3 NUTREN 1.0 LIQ ULTRAPAK Tier 3 NUTREN 1.0 LIQ UNFLAVOR Tier 3 NUTREN 1.5 LIQ FIBER Tier 3 NUTREN 1.5 LIQ ULTRAPAK Tier 3 NUTREN 1.5 LIQ UNFLAV Tier 3 NUTREN 2.0 LIQ VANILLA Tier 3 NUTREN RENAL LIQ Tier 3 NUTRESTORE PAK 5GM Tier 3 NUTRI DRINK LIQ CHOCOLAT Tier 3 NUTRI DRINK LIQ PLUS Tier 3 NUTRI DRINK LIQ STRWBER Tier 3 NUTRI DRINK LIQ VANILLA Tier 3 165 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy NUTRI-DRINK LIQ + CHOCOL Tier 3 NUTRI-DRINK LIQ + VANILA Tier 3 NUTRI-DRINK LIQ CHOCOLAT Tier 3 NUTRI-DRINK LIQ VANILLA Tier 3 NUTRIDOX KIT Tier 3 NUTRIHEAL LIQ VANILLA Tier 3 NUTRIRENAL LIQ Tier 3 NUTRITIONAL LIQ SUPPLEME Tier 3 NUTRIVENT LIQ Tier 3 NUTRIVENT LIQ 1.5 VAN Tier 3 NUTROPIN AQ INJ 10MG/2ML Tier 2 X X X NUTROPIN AQ INJ 20MG/2ML Tier 2 X X X NUTROPIN AQ INJ NUSPIN 5 Tier 2 X X X NUVAIL SOL 16% Tier 3 NUVARING MIS HCR Preventive NUVESSA GEL 1.3% Tier 3 X NUVIGIL TAB 150MG Tier 3 X X X NUVIGIL TAB 200MG Tier 3 X X X NUVIGIL TAB 250MG Tier 3 X X X NUVIGIL TAB 50MG Tier 3 X X X NUVYA CRE Tier 3 X NUWIQ INJ 1000UNIT Tier 3 X X NUWIQ INJ 2000UNIT Tier 3 X X NUWIQ INJ 250UNIT Tier 3 X X NUWIQ INJ 500UNIT Tier 3 X X NUWIQ KIT 1000UNIT Tier 2 X NUWIQ KIT 2000UNIT Tier 2 X NUWIQ KIT 250UNIT Tier 2 X NUWIQ KIT 500UNIT Tier 2 X NYAMYC POW 100000 Tier 1 NYMALIZE SOL 60/20ML Tier 2 NYSTAT/TRIAM CRE Tier 3 X NYSTAT/TRIAM OIN Tier 3 X NYSTATIN CRE 100000 Tier 1 NYSTATIN OIN 100000 Tier 1 NYSTATIN POW Tier 1 NYSTATIN POW 100000 Tier 1

166 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy NYSTATIN SUS 100000 Tier 1 NYSTATIN TAB 500000 Tier 1 NYSTOP POW 100000 Tier 1 O-CAL TAB PRENATAL Tier 2 O-CAL FA TAB Tier 2 OA 1 POW Tier 3 OA 1 DIET POW Tier 3 OA 2 POW Tier 3 OA 2 DIET POW Tier 3 OB COMPLETE CAP GOLD Tier 3 OB COMPLETE CAP ONE Tier 3 OB COMPLETE CAP PETITE Tier 3 OB COMPLETE TAB Tier 3 OB COMPLETE TAB PREMIER Tier 3 OB COMPLETE/ CAP DHA Tier 3 OBIZUR INJ 500 UNIT Tier 3 X OBREDON SOL 2.5-200 Tier 3 X X OBSTETRIX PAK DHA Tier 2 OBSTETRIX EC TAB Tier 3 OBSTETRX ONE CAP 38-1-225 Tier 3 OCALIVA TAB 10MG Tier 3 X X X X OCALIVA TAB 5MG Tier 3 X X X X OCCLUSADERM GEL PCCA Tier 3 OCCLUVAN OIN Tier 3 X OCELLA TAB 3-0.03MG Tier 3 OCTREOTIDE INJ 1000MCG Tier 1 X X OCTREOTIDE INJ 100MCG Tier 1 X X OCTREOTIDE INJ 200MCG Tier 1 X X OCTREOTIDE INJ 500MCG Tier 1 X X OCTREOTIDE INJ 50MCG/ML Tier 1 X X OCUFEN SOL 0.03% OP Tier 3 OCUFLOX DRO 0.3% OP Tier 3 ODEFSEY TAB Tier 3 X ODOMZO CAP 200MG Tier 3 X X X OFEV CAP 100MG Tier 3 X X X OFEV CAP 150MG Tier 3 X X X OFLOXACIN DRO 0.3% OP Tier 1 OFLOXACIN DRO 0.3%OTIC Tier 1 167 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy OFLOXACIN TAB 300MG Tier 1 OFLOXACIN TAB 400MG Tier 1 OGESTREL TAB Tier 3 OLANZA/FLUOX CAP 12-25MG Tier 3 X OLANZA/FLUOX CAP 12-50MG Tier 3 X OLANZA/FLUOX CAP 3-25MG Tier 3 X OLANZA/FLUOX CAP 6-25MG Tier 3 X OLANZA/FLUOX CAP 6-50MG Tier 3 X OLANZAPINE TAB 10MG Tier 1 X OLANZAPINE TAB 10MG ODT Tier 3 X OLANZAPINE TAB 15MG Tier 1 X OLANZAPINE TAB 15MG ODT Tier 3 X OLANZAPINE TAB 2.5MG Tier 1 X OLANZAPINE TAB 20MG Tier 1 X OLANZAPINE TAB 20MG ODT Tier 3 X OLANZAPINE TAB 5MG Tier 1 X OLANZAPINE TAB 5MG ODT Tier 3 X OLANZAPINE TAB 7.5MG Tier 1 X OLEPTRO TAB 24HR150 Tier 3 X X OLEPTRO TAB 24HR300 Tier 3 X X OLM MED/AMLO TAB /HCTZ Tier 3 X X OLM MED/AMLO TAB /HCTZ Tier 3 X X OLM MED/AMLO TAB /HCTZ Tier 3 X X OLM MED/AMLO TAB /HCTZ Tier 3 X X OLM MED/AMLO TAB /HCTZ Tier 3 X X OLM MED/HCTZ TAB 20-12.5 Tier 3 X X OLM MED/HCTZ TAB 40-12.5 Tier 3 X X OLM MED/HCTZ TAB 40-25MG Tier 3 X X OLMESA MEDOX TAB 20MG Tier 3 X X OLMESA MEDOX TAB 40MG Tier 3 X X OLMESA MEDOX TAB 5MG Tier 3 X X OLOPATADINE DRO 0.1% Tier 3 X OLOPATADINE SPR 0.6% Tier 3 X OLUX AER 0.05% Tier 3 X X OLUX-E AER 0.05% Tier 3 X X OLYSIO CAP 150MG Tier 3 X X X X OMECLAMOX- MIS PAK Tier 3 X OMEGA-3 FISH CAP 300MG Tier 1 168 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy OMEGA-3-ACID CAP 1GM Tier 3 X OMEPRA/BICAR POW 20-1680 Tier 3 X X OMEPRA/BICAR POW 40-1680 Tier 3 X X OMEPRAZOLE CAP 10MG Tier 1 OMEPRAZOLE CAP 20MG Tier 1 OMEPRAZOLE CAP 40MG Tier 1 OMEPRAZOLE + SUS SYRSPEND Tier 3 X OMNARIS SPR Tier 3 X X OMNIFLEX DPR HCR Preventive OMNIPRED SUS 1% OP Tier 3 OMNITROPE INJ 10/1.5ML Tier 3 X X X X OMNITROPE INJ 5.8MG Tier 3 X X X X OMNITROPE INJ 5/1.5ML Tier 3 X X X X OMNITROPE 5 MIS DEVICE Tier 3 X ON CALL MIS LANCETS Tier 3 ON CALL TES EXPRESS Tier 3 X ON CALL EXPR KIT SYSTEM Tier 3 ON CALL EXPR MIS METER Tier 3 ON CALL EXPR SOL GLUCOSE Tier 2 ON CALL LANC MIS DEVICE Tier 3 ON CALL PLUS KIT METER Tier 3 ON CALL PLUS KIT MONITOR Tier 3 ON CALL PLUS MIS LANC DEV Tier 3 ON CALL PLUS MIS LANCETS Tier 3 ON CALL PLUS MIS METER Tier 3 ON CALL PLUS SOL CONTROL Tier 2 ON CALL PLUS TES BLD GLUC Tier 3 X ON CALL VIVD KIT METER Tier 3 ON CALL VIVD KIT MONITOR Tier 3 ON CALL VIVD MIS METER Tier 3 ON CALL VIVD SOL CONTROL Tier 2 ON CALL VIVD TES BLD GLUC Tier 3 X ONDANSETRON SOL 4MG/5ML Tier 1 ONDANSETRON TAB 24MG Tier 1 ONDANSETRON TAB 4MG Tier 1 ONDANSETRON TAB 4MG ODT Tier 1 ONDANSETRON TAB 8MG Tier 1

169 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ONDANSETRON TAB 8MG ODT Tier 1 ONETOUCH KIT ULT MINI Tier 1 ONETOUCH KIT ULTRA 2 Tier 1 ONETOUCH KIT ULTRALNK Tier 1 ONETOUCH KIT VERIO Tier 1 ONETOUCH KIT VERIO IQ Tier 1 ONETOUCH MIS 30G Tier 1 ONETOUCH MIS COMBO Tier 1 ONETOUCH MIS LANC DEV Tier 1 ONETOUCH MIS LANC DEV Tier 1 ONETOUCH MIS LANCETS Tier 1 ONETOUCH MIS REMOTE Tier 3 ONETOUCH SOL ULT CONT Tier 1 ONETOUCH SOL VERIO Tier 1 ONETOUCH SOL VERIO-HI Tier 1 ONETOUCH TES ULTRA BL Tier 1 X ONETOUCH TES VERIO Tier 1 X ONETOUCH FP MIS LANCETS Tier 1 ONETOUCH US MIS LANCETS Tier 1 ONETOUCH VER KIT SYNC Tier 1 ONEXTON GEL 1.2-3.75 Tier 3 X X ONFI SUS 2.5MG/ML Tier 3 X ONFI TAB 10MG Tier 3 X ONFI TAB 20MG Tier 3 X ONGLYZA TAB 2.5MG Tier 2 X ONGLYZA TAB 5MG Tier 2 X ONMEL TAB 200MG Tier 3 X X ONZETRA XSAI MIS 11MG Tier 3 X X OPANA TAB 10MG Tier 3 X OPANA TAB 5MG Tier 3 X OPANA ER TAB 10MG Tier 2 X X OPANA ER TAB 15MG Tier 2 X X OPANA ER TAB 20MG Tier 2 X X OPANA ER TAB 30MG Tier 2 X X OPANA ER TAB 40MG Tier 2 X X OPANA ER TAB 5MG Tier 2 X X OPANA ER TAB 7.5MG Tier 2 X X

170 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy OPCICON TAB 1.5MG HCR Preventive OPIUM TIN 10MG/ML Tier 1 OPSUMIT TAB 10MG Tier 2 X X X OPTIHALER MIS Tier 3 OPTIUM KIT BL GLUC Tier 3 X OPTIUM MIS SYSTEM Tier 3 X OPTIUM TES Tier 3 X X OPTIUMEZ TES Tier 3 X X OPTIVAR DRO 0.05% Tier 3 X X OPTUMRX KIT METER Tier 3 OPTUMRX KIT SYSTEM Tier 3 OPTUMRX TES BLD GLUC Tier 3 X OPTUMRX CONT SOL LEVEL1/2 Tier 2 ORA-BLEND SUS Tier 3 ORA-BLEND SF SUS Tier 3 ORA-PLUS LIQ Tier 3 ORA-SWEET SYP Tier 2 ORA-SWEET SF SYP Tier 3 ORACEA CAP 40MG Tier 3 ORACIT SOL Tier 2 ORAL MIX LIQ SUSPENDI Tier 3 ORAL MIX SF LIQ Tier 3 ORAL SUSPEND LIQ Tier 3 ORAL SYRUP LIQ FLAVORED Tier 3 ORAL SYRUP LIQ SF Tier 3 ORALAIR SUB 300 IR Tier 3 X X ORALAIR ADLT SUB 300 IR Tier 3 X X ORALAIR CHLD PAK SAMPLE Tier 3 ORALAIR CHLD SUB 100 IR Tier 3 X X ORALONE PST 0.1% Tier 1 ORAP TAB 1MG Tier 3 ORAP TAB 2MG Tier 3 ORAPRED ODT TAB 10MG Tier 3 ORAPRED ODT TAB 15MG Tier 3 ORAPRED ODT TAB 30MG Tier 3 ORENCIA INJ 125MG/ML Tier 3 X X X X ORENCIA CLCK INJ 125MG/ML Tier 3 X X X

171 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ORENITRAM TAB 0.125MG Tier 3 X X X ORENITRAM TAB 0.25MG Tier 3 X X X ORENITRAM TAB 1MG Tier 3 X X X ORENITRAM TAB 2.5MG Tier 3 X X X ORFADIN CAP 10MG Tier 3 X X ORFADIN CAP 20MG Tier 3 X X ORFADIN CAP 2MG Tier 3 X X ORFADIN CAP 5MG Tier 3 X X ORFADIN SUS 4MG/ML Tier 3 X X ORKAMBI TAB 100-125 Tier 3 X X ORKAMBI TAB 200-125 Tier 3 X X X ORNITHINE CAP 500MG Tier 1 ORPHENADRINE POW CITRATE Tier 3 X ORPHENADRINE TAB 100MG ER Tier 3 ORSYTHIA TAB HCR Preventive ORTHO EVRA DIS WEEK Tier 3 X ORTHO MICRON TAB 0.35MG Tier 3 ORTHO TRI- TAB CYCLEN Tier 3 ORTHO TRI- TAB CYCLN LO Tier 3 X ORTHO-CEPT TAB 28 Tier 3 ORTHO-CYCLEN TAB 0.25/35 Tier 3 ORTHO-EST TAB 0.625 Tier 1 ORTHO-EST TAB 1.25 Tier 1 ORTHO-NOVUM TAB 1/35 Tier 3 ORTHO-NOVUM TAB 7/7/7 Tier 3 OSCIMIN SUB 0.125MG Tier 1 OSCIMIN TAB 0.125MG Tier 1 OSCIMIN TAB 0.125MG Tier 1 OSCIMIN SR TAB 0.375MG Tier 1 OSCION CLNSR LOT 6% Tier 3 OSENI TAB 12.5-15 Tier 2 X OSENI TAB 12.5-30 Tier 2 X OSENI TAB 12.5-45 Tier 2 X OSENI TAB 25-15MG Tier 2 X OSENI TAB 25-30MG Tier 2 X OSENI TAB 25-45MG Tier 2 X OSMOPREP TAB 1.5GM Tier 3

172 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy OSPHENA TAB 60MG Tier 3 OSTIGEN MIS 350MG Tier 3 OTEZLA TAB 10/20/30 Tier 3 X X X X OTEZLA TAB 30MG Tier 3 X X X X OTIC CARE DRO Tier 1 OTICIN HC DRO Tier 2 OTO-END 10 SOL Tier 1 OTOMAX-HC DRO Tier 1 OTOVEL DRO Tier 3 X OTOZIN DRO Tier 1 OTREXUP INJ 10MG Tier 3 X X OTREXUP INJ 12.5/0.4 Tier 3 X X OTREXUP INJ 15MG Tier 3 X X OTREXUP INJ 17.5/0.4 Tier 3 X X OTREXUP INJ 20MG Tier 3 X X OTREXUP INJ 22.5/0.4 Tier 3 X X OTREXUP INJ 25MG Tier 3 X X OTREXUP INJ 7.5/0.4 Tier 3 X X OVACE PLUS CRE 10% Tier 3 OVACE PLUS GEL 10% WASH Tier 3 OVACE PLUS LIQ 10% WASH Tier 3 OVACE PLUS LOT 9.8% Tier 3 X OVACE PLUS SHA 10% Tier 3 OVACE WASH LIQ 10% Tier 3 OVCON-35 TAB Tier 3 OVIDE LOT 0.5% Tier 3 OVIDREL INJ Tier 3 X OXANDRIN TAB 10MG Tier 3 OXANDRIN TAB 2.5MG Tier 3 OXANDROLONE TAB 10MG Tier 3 OXANDROLONE TAB 2.5MG Tier 3 OXAPROZIN TAB 600MG Tier 1 OXAYDO TAB 5MG Tier 3 X X OXAYDO TAB 7.5MG Tier 3 X X OXAZEPAM CAP 10MG Tier 1 OXAZEPAM CAP 15MG Tier 1 OXAZEPAM CAP 30MG Tier 1 OXCARBAZEPIN SUS 300MG/5M Tier 1 173 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy OXCARBAZEPIN TAB 150MG Tier 1 OXCARBAZEPIN TAB 300MG Tier 1 OXCARBAZEPIN TAB 600MG Tier 1 OXICONAZOLE CRE NITRATE Tier 3 X X X OXISTAT CRE 1% Tier 3 X X X OXISTAT LOT 1% Tier 3 X OXSORALEN LOT 1% Tier 3 OXSORALEN-UL CAP 10MG Tier 2 OXTELLAR XR TAB 150MG Tier 3 X X OXTELLAR XR TAB 300MG Tier 3 X X OXTELLAR XR TAB 600MG Tier 3 X X OXYBUTYNIN SYP 5MG/5ML Tier 1 OXYBUTYNIN TAB 10MG ER Tier 3 OXYBUTYNIN TAB 15MG ER Tier 3 OXYBUTYNIN TAB 5MG Tier 1 OXYBUTYNIN TAB 5MG ER Tier 3 OXYCOD/APAP TAB 10-325MG Tier 1 X OXYCOD/APAP TAB 2.5-325 Tier 1 X OXYCOD/APAP TAB 5-325MG Tier 1 X OXYCOD/APAP TAB 7.5-325 Tier 1 X OXYCOD/ASA TAB Tier 1 OXYCOD/IBU TAB 5-400MG Tier 1 OXYCODONE CAP 5MG Tier 1 OXYCODONE CON 100/5ML Tier 1 OXYCODONE CON 20MG/ML Tier 1 OXYCODONE POW HCL Tier 3 X OXYCODONE SOL 5MG/5ML Tier 1 OXYCODONE TAB 10MG Tier 1 OXYCODONE TAB 10MG ER Tier 3 X X X OXYCODONE TAB 15MG Tier 1 OXYCODONE TAB 15MG ER Tier 3 X X X OXYCODONE TAB 20MG Tier 1 OXYCODONE TAB 20MG ER Tier 3 X X X OXYCODONE TAB 30MG Tier 1 OXYCODONE TAB 30MG ER Tier 3 X X X OXYCODONE TAB 40MG ER Tier 3 X X X OXYCODONE TAB 5MG Tier 1 OXYCODONE TAB 60MG ER Tier 3 X X X 174 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy OXYCODONE TAB 80MG ER Tier 3 X X X OXYCODONE/ SOL APAP Tier 1 X OXYCONTIN TAB 10MG CR Tier 3 X X X OXYCONTIN TAB 15MG CR Tier 3 X X X OXYCONTIN TAB 20MG CR Tier 3 X X X OXYCONTIN TAB 30MG CR Tier 3 X X X OXYCONTIN TAB 40MG CR Tier 3 X X X OXYCONTIN TAB 60MG CR Tier 3 X X X OXYCONTIN TAB 80MG CR Tier 3 X X X OXYMORPHONE TAB 10MG ER Tier 3 X X X OXYMORPHONE TAB 15MG ER Tier 3 X X X OXYMORPHONE TAB 20MG ER Tier 3 X X X OXYMORPHONE TAB 30MG ER Tier 3 X X X OXYMORPHONE TAB 40MG ER Tier 3 X X X OXYMORPHONE TAB 5MG ER Tier 3 X X X OXYMORPHONE TAB 7.5MG ER Tier 3 X X X OXYMORPHONE TAB HCL 10MG Tier 3 X OXYMORPHONE TAB HCL 5MG Tier 3 X P-SILOXAN DS CRE Tier 3 X PA CLA CAP 1000MG Tier 3 PACERONE TAB 100MG Tier 3 PACERONE TAB 200MG Tier 1 PACERONE TAB 400MG Tier 3 PAIN EASE AER MD STRM Tier 3 PAIN EASE AER MIST Tier 3 PAIN RELIEF PAD PATCH Tier 3 PAIRE OB MIS Tier 3 PALIPERIDONE TAB ER 1.5MG Tier 3 X PALIPERIDONE TAB ER 3MG Tier 3 X PALIPERIDONE TAB ER 6MG Tier 3 X PALIPERIDONE TAB ER 9MG Tier 3 X PAMELOR CAP 10MG Tier 3 PAMELOR CAP 25MG Tier 3 PAMELOR CAP 50MG Tier 3 PAMELOR CAP 75MG Tier 3 PAMINE TAB 2.5MG Tier 3 PAMINE FQ KIT Tier 3 PANCREAZE CAP Tier 3 175 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy PANCREAZE CAP 10500UNT Tier 3 X PANCREAZE CAP 16800UNT Tier 3 X PANCREAZE CAP 21000UNT Tier 3 X PANCREAZE CAP 4200UNIT Tier 3 X PANCRELIPASE CAP 5000UNIT Tier 1 PANDEL CRE 0.1% Tier 3 PANRETIN GEL 0.1% Tier 3 PANTOPRAZOLE TAB 20MG Tier 1 PANTOPRAZOLE TAB 40MG Tier 1 PAPAVERINE POW HCL Tier 3 X PARADIGM MIS UPGRADE Tier 3 PARADIGM QR MIS POLY 24" Tier 2 PARADIGM QR MIS POLY 42" Tier 2 PARADIGM REA MIS TRANSMIT Tier 3 PARADIGM RES MIS 1.8ML Tier 2 PARADIGM RES MIS 3ML Tier 2 PARADIGM SOF MIS -SET 24" Tier 2 PARADIGM SOF MIS -SET 42" Tier 2 PARAFON FORT TAB 500MG Tier 3 PAREGORIC TIN 2MG/5ML Tier 1 PAREMYD SOL 1-0.25% Tier 3 PARICALCITOL CAP 1 MCG Tier 1 PARICALCITOL CAP 2 MCG Tier 1 PARICALCITOL CAP 4 MCG Tier 1 PARLODEL TAB 2.5MG Tier 3 X PARNATE TAB 10MG Tier 3 PAROEX SOL 0.12% Tier 1 PAROMOMYCIN CAP 250MG Tier 1 PAROXETIN ER TAB 12.5MG Tier 3 X PAROXETIN ER TAB 37.5MG Tier 3 X PAROXETINE TAB 10MG Tier 1 PAROXETINE TAB 20MG Tier 1 PAROXETINE TAB 25MG ER Tier 3 X PAROXETINE TAB 30MG Tier 1 PAROXETINE TAB 40MG Tier 1 PASER GRA 4GM Tier 3 PATADAY SOL 0.2% Tier 3 X X PATANASE SPR 0.6% Tier 3 X 176 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy PATANOL SOL 0.1% OP Tier 3 X X PAXIL SUS 10MG/5ML Tier 3 PAXIL TAB 10MG Tier 3 PAXIL TAB 20MG Tier 3 PAXIL TAB 30MG Tier 3 PAXIL TAB 40MG Tier 3 PAXIL CR TAB 12.5MG Tier 3 X PAXIL CR TAB 25MG Tier 3 X PAXIL CR TAB 37.5MG Tier 3 X PAZEO DRO 0.7% Tier 3 X X PCA INJECTOR MIS Tier 3 X PCCA ACACIA SYP BASE Tier 3 PCCA ALADERM CRE BASE Tier 3 X PCCA BASE CRE 7542 Tier 3 X PCCA COBASE OIN #1 Tier 3 PCCA COSMETI CRE HRT BASE Tier 2 X PCCA CUSTOM CRE LIPO-MAX Tier 3 PCCA EMOLLIE CRE BASE Tier 3 X PCCA LIPODER CRE BASE Tier 2 X PCCA LIPODER CRE BASE Tier 3 X PCCA LIPOSOM CRE DRY Tier 3 PCCA LIPOSOM CRE NORMAL Tier 3 PCCA LIPOSOM CRE OILY Tier 3 PCCA LIPOSOM CRE SENSITIV Tier 3 PCCA MVC CRE BASE Tier 3 X PCCA SWEET SYP -SF Tier 3 PCCA SYRUP SYP VEHICLE Tier 3 PCCA VANISH CRE BASE Tier 3 X PCCA VANISHI CRE LIGHT Tier 3 X PCCA VANPEN CRE BASE Tier 3 X PCCA-PLUS SUS Tier 3 PCE TAB 333MG EC Tier 3 PCE TAB 500MG EC Tier 3 PCP 100 KIT Tier 3 X PE/GUAIFENES DRO 1.5-20MG Tier 1 PEDIA D-VITE DRO 400UNIT HCR Preventive PEDIADERM AF KIT COMPLETE Tier 3 X

177 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy PEDIADERM HC KIT Tier 3 PEDIADERM TA KIT Tier 3 X PEDIAPRED SOL 6.7/5ML Tier 2 PEDIPAK PAK Tier 3 PEG 3350 POW HCR Preventive PEG 3350 POW Tier 2 PEG 3350 SOL ELECTROL HCR Preventive PEG-3350 SOL ELECTROL HCR Preventive PEG-3350/KCL SOL /SODIUM HCR Preventive PEG-INTRON KIT 120 RP Tier 3 X X X PEG-INTRON KIT 120MCG Tier 3 X X X PEG-INTRON KIT 150 RP Tier 3 X X X PEG-INTRON KIT 150MCG Tier 3 X X X PEG-INTRON KIT 50MCG Tier 3 X X X PEG-INTRON KIT 50MCG RP Tier 3 X X X PEG-INTRON KIT 80MCG Tier 3 X X X PEG-INTRON KIT 80MCG RP Tier 3 X X X PEG-PREP KIT Tier 1 PEG3350 POW HCR Preventive PEGANONE TAB 250MG Tier 2 PEGASYS INJ Tier 2 X X X PEGASYS INJ 180MCG/M Tier 2 X X X PEGASYS INJ PROCLICK Tier 2 X X X PEGASYS INJ PROCLICK Tier 2 X X X PEGINTRON KIT 120MCG Tier 3 X X X PEGINTRON KIT 150MCG Tier 3 X X X PEGINTRON KIT 50MCG Tier 3 X X X PEGINTRON KIT 80MCG Tier 3 X X X PEGYLAX POW Tier 3 PEMOLINE POW Tier 3 X PEN NEEDLE MIS 29GX1/2" Tier 2 PEN NEEDLES MIS 29GX1/2" Tier 2 PEN NEEDLES MIS 29GX12MM Tier 2 PEN NEEDLES MIS 30GX5/16 Tier 2 178 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy PEN NEEDLES MIS 31GX1/4" Tier 2 PEN NEEDLES MIS 31GX3/16 Tier 2 PEN NEEDLES MIS 31GX5/16 Tier 2 PEN NEEDLES MIS 31GX5MM Tier 2 PEN NEEDLES MIS 31GX6MM Tier 2 PEN NEEDLES MIS 31GX8MM Tier 2 PEN NEEDLES MIS 32GX4MM Tier 2 PENCREAM CRE Tier 3 X PENDERM CRE Tier 3 X PENICILLN VK SOL 125/5ML Tier 1 PENICILLN VK SOL 250/5ML Tier 1 PENICILLN VK TAB 250MG Tier 1 PENICILLN VK TAB 500MG Tier 1 PENLAC SOL 8% Tier 3 X PENLET II KIT BLOOD Tier 1 PENLET II MIS REPL CAP Tier 1 PENNSAID SOL 2% Tier 3 X PENTAPHENE CRE Tier 3 X PENTASA CAP 250MG CR Tier 3 X PENTASA CAP 500MG CR Tier 3 X PENTAZ/NALOX TAB 50-0.5MG Tier 1 PENTOXIFYL POW Tier 3 X PENTOXIFYLLI TAB 400MG ER Tier 1 PEPCID SUS 40MG/5ML Tier 3 PEPTAMEN LIQ PREBIO1 Tier 3 PEPTAMEN LIQ UNFLAVOR Tier 3 PEPTAMEN 1.5 LIQ Tier 3 PEPTAMEN AF LIQ UNFLAVOR Tier 3 PEPTAMEN JR LIQ 1 CAL Tier 3 PEPTAMEN JR LIQ CHOCOLAT Tier 3 PEPTAMEN JR LIQ UNFLAVRD Tier 3 PEPTAMEN JUN POW VANILLA Tier 3 PEPTAMEN OS LIQ 1.5/VAN Tier 3 PEPTAMEN OS LIQ CHOCOLAT Tier 3 PEPTAMEN OS LIQ VANILLA Tier 3 PEPTAMEN VHP LIQ ULTRAPAK Tier 3 PEPTAMEN VHP LIQ UNFLAVOR Tier 3 PEPTAMEN VHP LIQ VANILLA Tier 3 179 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy PEPTINEX 1.5 LIQ VANILLA Tier 3 PEPTINEX DT LIQ Tier 3 PEPTINEX DT LIQ /FIBER Tier 3 PEPTINEX DT LIQ PREBIOTC Tier 3 PEPTINEX DT LIQ VANILLA Tier 3 PERCOCET TAB 10-325MG Tier 3 X X PERCOCET TAB 2.5-325 Tier 3 X X PERCOCET TAB 5-325MG Tier 3 X X PERCOCET TAB 7.5-325 Tier 3 X X PERCURA CAP Tier 3 PERFOROMIST NEB 20MCG Tier 3 X PERGOLIDE POW MESYLATE Tier 3 X PERIDEX SOL 0.12% Tier 3 PERINDOPRIL TAB 2MG Tier 3 PERINDOPRIL TAB 4MG Tier 3 PERINDOPRIL TAB 8MG Tier 3 PERIOGARD SOL 0.12% Tier 1 PERMETHRIN CRE 5% Tier 1 PERPHEN/AMIT TAB 2-10MG Tier 1 PERPHEN/AMIT TAB 2-25MG Tier 1 PERPHEN/AMIT TAB 4-10MG Tier 1 PERPHEN/AMIT TAB 4-25MG Tier 1 PERPHEN/AMIT TAB 4-50MG Tier 1 PERPHENAZINE TAB 16MG Tier 1 PERPHENAZINE TAB 2MG Tier 1 PERPHENAZINE TAB 4MG Tier 1 PERPHENAZINE TAB 8MG Tier 1 PERSANTINE TAB 25MG Tier 3 PERSANTINE TAB 50MG Tier 3 PERSANTINE TAB 75MG Tier 3 PERTZYE CAP Tier 3 X PERTZYE CAP Tier 3 X PERTZYE CAP Tier 3 X PETN TAB 80MG Tier 1 PETROLATUM OIN WHITE Tier 3 PETROLATUM OIN YELLOW Tier 3 PEXEVA TAB 10MG Tier 3 X X PEXEVA TAB 20MG Tier 3 X X 180 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy PEXEVA TAB 30MG Tier 3 X X PEXEVA TAB 40MG Tier 3 X X PFCB CRE Tier 3 X PFD 1 POW Tier 3 PFD 2 POW Tier 3 PHARMABASE CRE ANTIOXID Tier 3 X PHARMABASE CRE COSMETIC Tier 3 X PHARMABASE CRE HEAVY Tier 3 X PHARMABASE CRE LIGHT Tier 3 X PHARMABASE CRE VAGINAL Tier 3 X PHENADOZ SUP 12.5MG Tier 1 PHENADOZ SUP 25MG Tier 1 PHENAZO TAB 200MG Tier 1 PHENAZOPYRID TAB 100MG Tier 1 PHENAZOPYRID TAB 200MG Tier 1 PHENELZINE TAB 15MG Tier 1 PHENERGAN SUP 12.5MG Tier 1 PHENERGAN SUP 25MG Tier 1 PHENERGAN SUP 50MG Tier 1 PHENOBARB ELX 20/5ML Tier 1 PHENOBARB ELX 20MG/5ML Tier 1 PHENOBARB SOL 20MG/5ML Tier 1 PHENOBARB TAB 100MG Tier 1 PHENOBARB TAB 15MG Tier 1 PHENOBARB TAB 16.2MG Tier 1 PHENOBARB TAB 30MG Tier 1 PHENOBARB TAB 32.4MG Tier 1 PHENOBARB TAB 60MG Tier 1 PHENOBARB TAB 64.8MG Tier 1 PHENOBARB TAB 97.2MG Tier 1 PHENOXYBENZA CAP 10MG Tier 1 PHENYL-FREE POW 1 Tier 3 PHENYLALANIN PAK 50MG Tier 3 PHENYLBUTYRA POW SODIUM Tier 1 X PHENYLEPHRIN SOL 10% OP Tier 1 PHENYLEPHRIN SOL 2.5% OP Tier 1 PHENYLPROPAN POW HCL Tier 3 X PHENYTEK CAP 200MG Tier 3 181 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy PHENYTEK CAP 300MG Tier 3 PHENYTOIN CHW 50MG Tier 3 PHENYTOIN SUS 125/5ML Tier 1 PHENYTOIN EX CAP 100MG Tier 1 PHENYTOIN EX CAP 200MG Tier 1 PHENYTOIN EX CAP 300MG Tier 1 PHILITH TAB 0.4-35 Tier 3 PHOS-FLUR GEL 1.1% Tier 1 PHOSLO CAP 667MG Tier 3 PHOSLYRA SOL Tier 3 PHOSPHA 250 TAB NEUTRAL Tier 1 PHOSPHASAL TAB Tier 1 PHOSPHATIDYL POW 20% Tier 3 X PHOSPHOLINE SOL 0.125%OP Tier 2 PHYTOBASE CRE Tier 2 X PHYTOBASE CRE Tier 3 X PICATO GEL 0.015% Tier 3 X PICATO GEL 0.05% Tier 3 X PICODERM CRE Tier 3 X PILOCARPINE SOL 1% OP Tier 1 PILOCARPINE SOL 2% OP Tier 1 PILOCARPINE SOL 4% OP Tier 1 PILOCARPINE TAB 5MG Tier 1 PILOCARPINE TAB 7.5MG Tier 1 PIMOZIDE TAB 1MG Tier 2 PIMOZIDE TAB 2MG Tier 2 PIMTREA TAB Tier 3 PINDOLOL TAB 10MG Tier 1 PINDOLOL TAB 5MG Tier 1 PINE BARK EX POW 95% Tier 3 X PINNACAINE DRO 20% OTIC Tier 3 PIOGLIT/GLIM TAB 30-2MG Tier 1 X PIOGLIT/GLIM TAB 30-4MG Tier 1 X PIOGLITA/MET TAB 15-500MG Tier 3 X PIOGLITA/MET TAB 15-850MG Tier 3 X PIOGLITAZONE TAB 15MG Tier 1 X PIOGLITAZONE TAB 30MG Tier 1 X PIOGLITAZONE TAB 45MG Tier 1 X 182 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy PIRMELLA TAB 1/35 HCR Preventive PIRMELL A TAB 7/7/7 HCR Preventive PIROXICAM CAP 10MG Tier 1 PIROXICAM CAP 20MG Tier 1 PIROXICAM POW Tier 3 X PLACEBO #00 CAP Tier 2 PLAN B TAB 1.5MG HCR Preventive PLAQUENIL TAB 200MG Tier 3 PLAVIX TAB 300MG Tier 3 X PLAVIX TAB 75MG Tier 3 X PLEGRIDY INJ Tier 3 X X X X PLEGRIDY INJ PEN Tier 3 X X X X PLEGRIDY INJ STARTER Tier 3 X X X X PLEGRIDY PEN INJ STARTER Tier 3 X X X X PLETAL TAB 100MG Tier 3 PLETAL TAB 50MG Tier 3 PLEXION CRE 9.8-4.8% Tier 3 X PLEXION LIQ 9.8-4.8% Tier 3 X PLEXION LOT 9.8-4.8% Tier 3 X PLEXION CLTH PAD 9.8-4.8% Tier 3 X PLIAGLIS CRE 7-7% Tier 3 PLO GEL MEDIFLO Tier 3 PLO MEDIFLO KIT KIT Tier 3 PLO TRANSDER CRE Tier 3 PLO20 BASE GEL Tier 3 PNA-HRT BASE CRE Tier 3 X PNEUMODORON LIQ Tier 3 PNV FE FUM TAB DOC/FA Tier 3 PNV FOLIC AC TAB + IRON Tier 3 PNV OB+DHA PAK Tier 3 PNV PRENATAL TAB PLUS Tier 3 PNV TABS TAB 29-1MG Tier 3 PNV-DHA CAP Tier 3 PNV-DHA CAP DOCUSATE Tier 3 PNV-OMEGA CAP Tier 3

183 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy PNV-SELECT TAB Tier 3 PNV-TOTAL CAP Tier 2 PNV-VP-U CAP 106.5-1 Tier 2 PODOCON SOL 25% Tier 1 PODOFILOX SOL 0.5% Tier 1 POLIBAR ACB KIT 96% Tier 3 POLIBAR PLUS SUS 105% Tier 2 POLY-VI-FLOR CHW 0.25MG Tier 3 POLY-VI-FLOR CHW 0.5MG Tier 3 POLY-VI-FLOR CHW 1MG Tier 3 POLY-VI-FLOR CHW W/IRON Tier 3 POLY-VI-FLOR SUS /IRON Tier 3 POLY-VI-FLOR SUS 0.25/ML Tier 3 POLYCIN OIN OP Tier 1 POLYETH GLYC OIN 8000 Tier 3 POLYETH GLYC POW 3350 NF Tier 3 POLYETH GLYC POW 3350 NF Tier 3 POLYETH GLYC POW 3350 NF HCR Preventive POLYETH GLYC POW 3350-GRX HCR Preventive POLYFIN 24" MIS INFUSION Tier 2 POLYFIN 42" MIS INFUSION Tier 2 POLYFIN 42" MIS QR INFUS Tier 2 POLYFIN 60" MIS TUBING Tier 2 POLYMYXIN B/ SOL TRIMETHP Tier 1 POLYOX POW WSR-301 Tier 3 X POLYPEG OIN BASE Tier 3 POLYSORBATE LIQ 80 Tier 3 POLYSORBATE LIQ 80 Tier 2 POLYTRIM SOL OP Tier 3 POMALYST CAP 1MG Tier 3 X X X POMALYST CAP 2MG Tier 3 X X X POMALYST CAP 3MG Tier 3 X X X POMALYST CAP 4MG Tier 3 X X X PONSTEL CAP 250MG Tier 3 PORTAGEN POW Tier 3

184 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy PORTIA-28 TAB HCR Preventive POT CHLORIDE CAP 10MEQ CR Tier 1 POT CHLORIDE CAP 10MEQ ER Tier 1 POT CHLORIDE CAP 8MEQ ER Tier 1 POT CHLORIDE POW 20MEQ Tier 1 POT CHLORIDE SOL 10% Tier 1 POT CHLORIDE SOL 10% SF Tier 1 POT CHLORIDE SOL 20% Tier 1 POT CHLORIDE TAB 10MEQ CR Tier 1 POT CHLORIDE TAB 10MEQ ER Tier 1 POT CHLORIDE TAB 20MEQ ER Tier 1 POT CHLORIDE TAB 25MEQ EF Tier 1 POT CHLORIDE TAB 8MEQ ER Tier 1 POT CHLORIDE TAB 8MEQ SR Tier 1 POT CITRATE TAB 1080MG Tier 1 POT CITRATE TAB 1620MG Tier 1 POT CITRATE TAB 540MG ER Tier 1 POT CITRATE- PAK CIT ACID Tier 1 POT CL MICRO TAB 10MEQ CR Tier 1 POT CL MICRO TAB 10MEQ ER Tier 1 POT CL MICRO TAB 20MEQ ER Tier 1 POT HYDROXID SOL 5% Tier 2 POT PHOSPHAT GRA DIBASIC Tier 3 POT/CHLORIDE TAB 25MEQ EF Tier 1 POTABA CAP 500MG Tier 3 POTASSIUM TAB 25MEQ EF Tier 1 POTIGA TAB 200MG Tier 3 X POTIGA TAB 300MG Tier 3 X POTIGA TAB 400MG Tier 3 X POTIGA TAB 50MG Tier 3 X POWDERLAX POW HCR Preventive PR CREAM KIT Tier 3 X PR NATAL 400 PAK Tier 1 PR NATAL 400 PAK EC Tier 1 PR NATAL 430 PAK Tier 3 PR NATAL 430 PAK EC Tier 3

185 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy PRACASIL TM- CRE PLUS Tier 3 X PRADAXA CAP 110MG Tier 2 X PRADAXA CAP 150MG Tier 2 X PRADAXA CAP 75MG Tier 2 X PRALUENT INJ 150MG/ML Tier 2 X X X X PRALUENT INJ 150MG/ML Tier 2 X X X X PRALUENT INJ 75MG/ML Tier 2 X X X X PRALUENT INJ 75MG/ML Tier 2 X X X X PRAMCORT CRE 1-1% Tier 1 PRAMIPEXOLE TAB 0.125MG Tier 1 PRAMIPEXOLE TAB 0.25MG Tier 1 PRAMIPEXOLE TAB 0.375MG Tier 3 X PRAMIPEXOLE TAB 0.5MG Tier 1 PRAMIPEXOLE TAB 0.75 ER Tier 3 X PRAMIPEXOLE TAB 0.75MG Tier 1 PRAMIPEXOLE TAB 1.5MG Tier 1 PRAMIPEXOLE TAB 1.5MG ER Tier 3 X PRAMIPEXOLE TAB 1MG Tier 1 PRAMIPEXOLE TAB 2.25MG Tier 3 X PRAMIPEXOLE TAB 3.75MG Tier 3 X PRAMIPEXOLE TAB 3MG Tier 3 X PRAMIPEXOLE TAB 4.5MG Tier 3 X PRAMOSONE CRE 1-1% Tier 1 PRAMOSONE CRE 1-2.5% Tier 3 PRAMOSONE CRE 1% Tier 1 PRAMOSONE LOT 1% Tier 2 PRAMOSONE LOT 2.5% Tier 2 PRAMOSONE OIN 1% Tier 2 PRAMOSONE OIN 2.5% Tier 3 PRAMOSONE E CRE 1-2.5% Tier 3 X PRAMOTIC DRO 1-0.1% Tier 3 PRAMOX GEL 1% Tier 1 PRANDIMET TAB 1-500MG Tier 3 PRANDIMET TAB 2-500MG Tier 3 PRANDIN TAB 0.5MG Tier 3 X PRANDIN TAB 1MG Tier 3 X PRANDIN TAB 2MG Tier 3 X PRAVACHOL TAB 20MG Tier 3 186 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy PRAVACHOL TAB 40MG Tier 3 PRAVACHOL TAB 80MG Tier 3 PRAVASTATIN TAB 10MG Tier 1 PRAVASTATIN TAB 20MG Tier 1 PRAVASTATIN TAB 40MG Tier 1 PRAVASTATIN TAB 80MG Tier 1 PRAZOSIN HCL CAP 1MG Tier 1 PRAZOSIN HCL CAP 2MG Tier 1 PRAZOSIN HCL CAP 5MG Tier 1 PRE PROTEIN TAB Tier 1 PREC NEO SYS KIT FREESTYL Tier 3 X PRECISION KIT LINK Tier 3 X PRECISION KIT XTRA Tier 3 X PRECISION LIQ CONTROL Tier 2 PRECISION LIQ GLUC/KET Tier 2 PRECISION LIQ NRML/MID Tier 2 PRECISION MIS QID Tier 3 X PRECISION MIS SOF-TACT Tier 3 X PRECISION MIS XTRA Tier 3 X PRECISION TES PCX Tier 3 X X PRECISION TES PCX PLUS Tier 3 X X PRECISION TES QID Tier 3 X X PRECISION TES SOF-TACT Tier 3 X X PRECISION TES XTRA Tier 3 X X PRECISION PT TES OF CARE Tier 3 X X PRECISN XTRA TES KETONE Tier 3 PRECOSE TAB 100MG Tier 3 PRECOSE TAB 25MG Tier 3 PRECOSE TAB 50MG Tier 3 PRED FORTE SUS 1% OP Tier 3 PRED MILD SUS 0.12% OP Tier 2 PRED SOD PHO SOL 1% OP Tier 1 PRED SOD PHO SOL 5MG/5ML Tier 1 PRED-G SUS OP Tier 3 PRED-G S.O.P OIN OP Tier 3 PREDNICARBAT CRE 0.1% Tier 1 PREDNICARBAT OIN 0.1% Tier 1 PREDNISOLONE SOL 15MG/5ML Tier 1 187 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy PREDNISOLONE SOL 15MG/5ML Tier 1 PREDNISOLONE SOL 25MG/5ML Tier 1 PREDNISOLONE SUS 1% OP Tier 1 PREDNISOLONE SYP 15MG/5ML Tier 1 PREDNISOLONE TAB 10MG ODT Tier 1 PREDNISOLONE TAB 15MG ODT Tier 1 PREDNISOLONE TAB 30MG ODT Tier 1 PREDNISONE CON 5MG/ML Tier 1 PREDNISONE PAK 10MG Tier 1 PREDNISONE PAK 10MG Tier 1 PREDNISONE PAK 5MG Tier 1 PREDNISONE PAK 5MG Tier 1 PREDNISONE SOL 5MG/5ML Tier 1 PREDNISONE TAB 10MG Tier 1 PREDNISONE TAB 1MG Tier 1 PREDNISONE TAB 2.5MG Tier 1 PREDNISONE TAB 20MG Tier 1 PREDNISONE TAB 50MG Tier 1 PREDNISONE TAB 5MG Tier 1 PREFERA OB TAB Tier 3 PREFERA OB TAB Tier 3 PREFERAOB CAP ONE Tier 3 PREFERAOB MIS +DHA Tier 3 PREFEST TAB Tier 2 PREGESTIMIL POW Tier 3 PREGNENOLONE POW Tier 3 X PREGNENOLONE POW MICRONIZ Tier 3 X PREGNYL INJ 10000UNT Tier 1 X PREMARIN TAB 0.3MG Tier 3 PREMARIN TAB 0.45MG Tier 3 PREMARIN TAB 0.625MG Tier 3 PREMARIN TAB 0.9MG Tier 3 PREMARIN TAB 1.25MG Tier 3 PREMARIN VAG CRE 0.625MG Tier 3 PREMPHASE TAB Tier 3 PREMPRO TAB .625-2.5 Tier 3 PREMPRO TAB 0.3-1.5 Tier 3 PREMPRO TAB 0.45-1.5 Tier 3 188 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy PREMPRO TAB 0.625-5 Tier 3 PRENA 1 TRUE MIS Tier 3 PRENA1 CHW Tier 3 PRENA1 PEARL CAP Tier 3 PRENAISSANCE CAP Tier 2 PRENAISSANCE CAP BALANCE Tier 2 PRENAISSANCE CAP PLUS Tier 2 PRENAISSANCE MIS HARMONY Tier 3 PRENAISSANCE PAK 90 DHA Tier 3 PRENAISSANCE PAK DHA Tier 3 PRENAISSANCE PAK PROMISE Tier 3 PRENAISSANCE TAB NEXT Tier 2 PRENAISSANCE TAB NEXT-B Tier 3 PRENAT PLUS TAB 27-1MG Tier 3 PRENATA CHW 29-1MG Tier 3 PRENATABS FA TAB Tier 1 PRENATABS RX TAB Tier 1 PRENATAL MIS COMPLEAT Tier 3 PRENATAL TAB 27-1MG Tier 3 PRENATAL TAB PLUS Tier 3 PRENATAL 19 CHW 29-1MG Tier 3 PRENATAL 19 CHW TAB Tier 1 PRENATAL 19 TAB Tier 1 PRENATAL 19 TAB 29-1MG Tier 3 PRENATAL VIT TAB LOW IRON Tier 3 PRENATAL-U CAP 106.5-1 Tier 2 PRENATAL+FE TAB 29-1MG Tier 3 PRENATE CAP ENHANCE Tier 3 PRENATE CAP ESSENT Tier 3 PRENATE CAP ESSENTIA Tier 3 PRENATE CAP PIXIE Tier 3 PRENATE CAP RESTORE Tier 3 PRENATE CHW 0.6-0.4 Tier 3 PRENATE TAB ELITE Tier 3 PRENATE TAB ELITE Tier 3 PRENATE AM TAB 1MG Tier 3 PRENATE DHA CAP Tier 3 PRENATE DHA CAP Tier 3 189 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy PRENATE MINI CAP Tier 3 PRENATE MINI CAP Tier 3 PRENATE STAR TAB 20-1MG Tier 3 PREP PADS PAD Tier 3 PREPIDIL GEL 0.5MG/3G Tier 3 PREPLUS TAB 27-1MG Tier 3 PREPOPIK PAK Tier 3 PREPROTEIN LIQ Tier 3 PREPROTEIN LIQ 20 Tier 3 PREQUE 10 TAB Tier 3 PRESERA AER Tier 3 X PRESTALIA TAB 14-10MG Tier 3 X X PRESTALIA TAB 3.5-2.5 Tier 3 X X PRESTALIA TAB 7-5MG Tier 3 X X PRETAB TAB 29-1MG Tier 3 PREVACID TAB 15MG STB Tier 3 X X X PREVACID TAB 30MG STB Tier 3 X X X PREVALITE POW 4GM Tier 1 PREVALITE POW 4GM PK Tier 1 PREVDNT 5000 PST 1.1% Tier 3 PREVIDENT CRE 5000 PLS Tier 3 PREVIDENT GEL 1.1% Tier 3 PREVIDENT GEL 1.1% BER Tier 3 PREVIDENT GEL 1.1% CHR Tier 3 PREVIDENT GEL 1.1% MIN Tier 3 PREVIDENT PST 5000 BST Tier 3 PREVIDENT PST 5000 SEN Tier 3 PREVIDENT SOL 0.2% Tier 3 PREVIDENT SOL RINSE Tier 3 PREVIFEM TAB HCR Preventive PREVPAC MIS Tier 3 X X PREZCOBIX TAB 800-150 Tier 2 X PREZISTA SUS 100MG/ML Tier 2 X PREZISTA TAB 150MG Tier 2 X PREZISTA TAB 600MG Tier 2 X PREZISTA TAB 75MG Tier 2 X PREZISTA TAB 800MG Tier 2 X

190 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy PRIFTIN TAB 150MG Tier 2 PRILOSEC POW 10MG Tier 3 X PRILOSEC POW 2.5MG Tier 3 X PRIMAQUINE TAB 26.3MG Tier 1 PRIMIDONE TAB 250MG Tier 1 PRIMIDONE TAB 50MG Tier 1 PRIMLEV TAB 10-300MG Tier 3 X PRIMLEV TAB 5-300MG Tier 3 X PRIMLEV TAB 7.5-300 Tier 3 X PRIMSOL SOL 50MG/5ML Tier 3 PRINIVIL TAB 10MG Tier 3 PRINIVIL TAB 20MG Tier 3 PRINIVIL TAB 5MG Tier 3 PRISTIQ TAB 100MG Tier 3 X PRISTIQ TAB 25MG Tier 3 X PRISTIQ TAB 50MG Tier 3 X PRO DNA KIT KIT Tier 3 PRO-CAL POW Tier 3 PROAIR HFA AER Tier 3 X PROAIR RESPI AER Tier 3 X PROBALANCE LIQ ULTRAPAK Tier 3 PROBALANCE LIQ VANILLA Tier 3 PROBEN/COLCH TAB 500-0.5 Tier 1 PROBENECID TAB 500MG Tier 1 PROCARDIA CAP 10MG Tier 3 PROCARDIA XL TAB 30MG CR Tier 3 PROCARDIA XL TAB 60MG CR Tier 3 PROCARDIA XL TAB 90MG CR Tier 3 PROCENTRA SOL 5MG/5ML Tier 3 X PROCHLORPER SUP 25MG Tier 1 PROCHLORPER TAB 10MG Tier 1 PROCHLORPER TAB 5MG Tier 1 PROCORT CRE Tier 3 X PROCRIT INJ 10000/ML Tier 2 X X PROCRIT INJ 2000/ML Tier 2 X X PROCRIT INJ 20000/ML Tier 2 X X PROCRIT INJ 3000/ML Tier 2 X X PROCRIT INJ 4000/ML Tier 2 X X 191 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy PROCRIT INJ 40000/ML Tier 2 X X PROCTO-MED CRE HC 2.5% Tier 1 PROCTO-PAK CRE 1% Tier 1 PROCTOCORT CRE 1% Tier 3 X PROCTOCORT SUP 30MG Tier 3 X PROCTOFOAM AER HC 1% Tier 2 PROCTOSOL HC CRE 2.5% Tier 1 PROCTOZONE CRE -HC 2.5% Tier 1 PROCYSBI CAP 25MG Tier 3 X X X PROCYSBI CAP 75MG Tier 3 X X X PRODRIN TAB Tier 3 X PRODUCT3232A POW Tier 3 PROFERRIN- TAB FORTE Tier 3 PROFILNINE INJ 1000UNIT Tier 2 X PROFILNINE INJ 1500UNIT Tier 2 X PROFILNINE INJ 500UNIT Tier 2 X PROGESTERONE CAP 100MG Tier 3 PROGESTERONE CAP 200MG Tier 3 PROGESTERONE CRE 10% KIT Tier 3 X PROGESTERONE INJ 50MG/ML Tier 1 PROGESTERONE POW MICRONIZ Tier 3 PROGESTERONE SUP VGS 100 Tier 3 X PROGESTERONE SUP VGS 200 Tier 3 X PROGESTERONE SUP VGS 25 Tier 3 X PROGESTERONE SUP VGS 400 Tier 3 X PROGESTERONE SUP VGS 50 Tier 3 X PROGLYCEM SUS 50MG/ML Tier 3 PROGRAF CAP 0.5MG Tier 3 X PROGRAF CAP 1MG Tier 3 X PROGRAF CAP 5MG Tier 3 X PROLENSA SOL 0.07% Tier 3 X X PROMACTA TAB 12.5MG Tier 3 X X PROMACTA TAB 25MG Tier 3 X X PROMACTA TAB 50MG Tier 3 X X PROMACTA TAB 75MG Tier 3 X X PROMACTIN AA SUS PLUS Tier 3 PROMETH VC SYP PLAIN Tier 1 PROMETH VC/ SYP CODEINE Tier 1 192 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy PROMETH/COD SYP 6.25-10 Tier 1 PROMETH/PE SYP 6.25-5/5 Tier 3 PROMETH/PE SYP 6.25-5/5 Tier 1 PROMETH/PE/ SYP CODEINE Tier 1 PROMETHAZINE CRY HCL Tier 3 X PROMETHAZINE POW HCL Tier 3 X PROMETHAZINE SOL 6.25/5ML Tier 1 PROMETHAZINE SUP 12.5MG Tier 1 PROMETHAZINE SUP 25MG Tier 1 PROMETHAZINE SUP 50MG Tier 1 PROMETHAZINE SYP 6.25/5ML Tier 1 PROMETHAZINE SYP DM Tier 1 PROMETHAZINE TAB 12.5MG Tier 1 PROMETHAZINE TAB 25MG Tier 1 PROMETHAZINE TAB 50MG Tier 1 PROMETHEGAN SUP 12.5MG Tier 1 PROMETHEGAN SUP 25MG Tier 1 PROMETHEGAN SUP 50MG Tier 1 PROMETRIUM CAP 100MG Tier 3 PROMETRIUM CAP 200MG Tier 3 PROMISEB CRE Tier 3 PROMISEB KIT COMPLETE Tier 3 X PROPAFENONE CAP 225MG ER Tier 3 PROPAFENONE CAP 325MG ER Tier 3 PROPAFENONE CAP 425MG SR Tier 3 PROPAFENONE TAB 150MG Tier 1 PROPAFENONE TAB 225MG Tier 1 PROPAFENONE TAB 300MG Tier 1 PROPANTHELIN TAB 15MG Tier 1 PROPARACAINE SOL 0.5% OP Tier 1 PROPRAN/HCTZ TAB 40/25 Tier 1 PROPRAN/HCTZ TAB 80/25 Tier 1 PROPRANOLOL CAP 120MG ER Tier 3 PROPRANOLOL CAP 160MG ER Tier 3 PROPRANOLOL CAP 60MG ER Tier 3 PROPRANOLOL CAP 80MG ER Tier 3 PROPRANOLOL SOL 20MG/5ML Tier 1 PROPRANOLOL SOL 40MG/5ML Tier 1 193 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy PROPRANOLOL TAB 10MG Tier 1 PROPRANOLOL TAB 20MG Tier 1 PROPRANOLOL TAB 40MG Tier 1 PROPRANOLOL TAB 60MG Tier 1 PROPRANOLOL TAB 80MG Tier 1 PROPYLENE GL SOL Tier 3 PROPYLTHIOUR TAB 50MG Tier 1 PROS-TECH CAP PLUS Tier 1 PROSCAR TAB 5MG Tier 3 PROSTAGLAND POW E1 Tier 3 X PROSTIN E2 SUP 20MG Tier 3 PROT COOKIE MIS OATRAISN Tier 3 PROTEIN TAB 975MG Tier 3 PROTEINEX LIQ Tier 3 PROTEINEX LIQ P100 Tier 1 PROTEINEX TAB Tier 1 PROTEINEX-18 LIQ BLK/CHER Tier 3 PROTEINEX-18 LIQ LEM/LIME Tier 3 PROTEOLYTIC TAB FORMULA Tier 3 PROTONIX PAK Tier 3 X X PROTONIX TAB 20MG Tier 3 X PROTONIX TAB 40MG Tier 3 X PROTOPIC OIN 0.03% Tier 3 X X X PROTOPIC OIN 0.1% Tier 3 X X X PROTRIPTYLIN TAB 10MG Tier 1 PROTRIPTYLIN TAB 5MG Tier 1 PROVENTIL AER HFA Tier 3 X PROVERA TAB 10MG Tier 3 PROVERA TAB 2.5MG Tier 3 PROVERA TAB 5MG Tier 3 PROVIDA DHA CAP Tier 3 PROVIDA OB CAP Tier 3 PROVIGIL TAB 100MG Tier 3 X X X PROVIGIL TAB 200MG Tier 3 X X X PROZAC CAP 10MG Tier 3 X PROZAC CAP 20MG Tier 3 X PROZAC CAP 40MG Tier 3 X PROZAC WEEKL CAP 90MG Tier 3 X 194 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy PROZENA PAD 4% Tier 3 PRUCLAIR CRE Tier 3 X PRUDOXIN CRE 5% Tier 1 PRUMYX CRE Tier 3 X PRVDNT 5000 PST ENAML PR Tier 3 PSORCON CRE 0.05% Tier 3 PSORIZIDE TAB FORTE Tier 2 PSS SAFE LAN MIS Tier 3 PSS SEL LANC MIS Tier 3 PSS SEL PLAT MIS Tier 3 PULMICORT INH 180MCG Tier 3 X PULMICORT INH 90MCG Tier 3 X PULMICORT SUS 0.25MG/2 Tier 3 X PULMICORT SUS 0.5MG/2 Tier 3 X PULMICORT SUS 1MG/2ML Tier 3 X PULMONA CAP Tier 2 PULMOSAL NEB 7% Tier 1 PULMOZYME SOL 1MG/ML Tier 2 X X X PUMP REMOTE MIS PROGRAM Tier 3 PURAMINO POW DHA/ARA Tier 3 PURAMINO POW TODDLER Tier 3 PUREFE OB CAP PLUS Tier 3 PURIFIED LIQ WATER Tier 3 PURIXAN SUS 20MG/ML Tier 3 X X PX ASPIRIN TAB 325MG HCR Preventive PX ASPIRIN TAB 325MG EC HCR Preventive PX LANCETS MIS ULT THIN Tier 3 PYLERA CAP Tier 3 X PYRAZINAMIDE TAB 500MG Tier 1 PYRIDIUM TAB 100MG Tier 3 PYRIDIUM TAB 200MG Tier 3 PYRIDOSTIGM TAB 60MG Tier 1 PYRIDOSTIGMI TAB ER 180MG Tier 1 PYROGALL ACD OIN Tier 2 Q-BID-LA TAB 600MG Tier 1 Q-DERM CRE Tier 3 X

195 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy Q-GEL FORTE CAP 30MG Tier 1 Q-GEL MEGA CAP 100MG Tier 1 Q-GEL ULTRA CAP 60MG Tier 1 Q2 ORAL CLEA KIT SYSTEM Tier 3 Q4 ORAL CLEA KIT SYSTEM Tier 3 QBRELIS SOL 1MG/ML Tier 3 X QC ALCOHOL PAD SWABS Tier 3 QC ASPIRIN TAB 325MG HCR Preventive QC ASPIRIN TAB 325MG EC HCR Preventive QC CHILD ASA CHW 81MG HCR Preventive QC LANCETS MIS 28G Tier 3 QC LANCETS MIS 30G Tier 3 QC LANCING MIS DEVICE Tier 3 QC LAXATIVE TAB 5MG EC HCR Preventive QC NICOTINE GUM 4MG HCR X Preventive QNAPRIL/HCTZ TAB 10-12.5 Tier 3 QNAPRIL/HCTZ TAB 20-12.5 Tier 3 QNAPRIL/HCTZ TAB 20-25MG Tier 3 QNASL AER 80MCG Tier 3 X X QNASL CHILD SPR 40MCG Tier 3 X QUALAQUIN CAP 324MG Tier 3 X QUARTETTE TAB Tier 3 X X QUASENSE TAB HCR X Preventive QUAZEPAM TAB 15MG Tier 1 QUDEXY XR CAP 100/24HR Tier 3 X X QUDEXY XR CAP 150/24HR Tier 3 X X QUDEXY XR CAP 200/24HR Tier 3 X X QUDEXY XR CAP 25/24HR Tier 3 X X QUDEXY XR CAP 50/24HR Tier 3 X X QUESTRAN POW 4GM Tier 3 QUESTRAN POW 4GM Tier 3 QUESTRAN POW 4GM LITE Tier 3 QUETIAPINE TAB 100MG Tier 1

196 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy QUETIAPINE TAB 150MG ER Tier 3 X QUETIAPINE TAB 200MG Tier 1 QUETIAPINE TAB 200MG ER Tier 3 X QUETIAPINE TAB 25MG Tier 1 QUETIAPINE TAB 300MG Tier 1 QUETIAPINE TAB 300MG ER Tier 3 X QUETIAPINE TAB 400MG Tier 1 QUETIAPINE TAB 400MG ER Tier 3 X QUETIAPINE TAB 50MG Tier 1 QUETIAPINE TAB 50MG ER Tier 3 X QUFLORA PED CHW 0.25MG Tier 3 QUFLORA PED CHW 0.5MG Tier 3 QUFLORA PED CHW 1MG Tier 3 QUFLORA PED DRO 0.25MG Tier 3 QUFLORA PED DRO 0.5MG/ML Tier 3 QUICK-SERTER MIS INS DEV Tier 2 QUICK-SET MIS 18"/6MM Tier 2 QUICK-SET MIS 23"/6MM Tier 2 QUICK-SET MIS 23"/9MM Tier 2 QUICK-SET MIS 32"/6MM Tier 2 QUICK-SET MIS 32"/9MM Tier 2 QUICK-SET MIS 43"/6MM Tier 2 QUICK-SET MIS 43"/9MM Tier 2 QUILLICHEW CHW 20MG ER Tier 3 X X X QUILLICHEW CHW 30MG ER Tier 3 X X X QUILLICHEW CHW 40MG ER Tier 3 X X X QUILLIVANT SUS 25MG/5ML Tier 3 X X X QUINAPRIL TAB 10MG Tier 1 QUINAPRIL TAB 20MG Tier 1 QUINAPRIL TAB 40MG Tier 1 QUINAPRIL TAB 5MG Tier 1 QUINIDINE GL TAB 324MG CR Tier 1 QUINIDINE GL TAB 324MG ER Tier 1 QUINIDINE SU TAB 200MG Tier 1 QUINIDINE SU TAB 300MG Tier 1 QUINIDINE SU TAB 300MG ER Tier 1 QUININE SULF CAP 324MG Tier 1 X QUINTET MIS SYSTEM Tier 3 197 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy QUINTET TES BLD GLUC Tier 3 X QUINTET AC MIS SYSTEM Tier 3 QUINTET AC TES BLD GLUC Tier 3 X QUINTET CONT SOL HGH/NORM Tier 2 QUINZYME TAB 90MG Tier 3 QUTENZA KIT 8% 1-PCH Tier 3 X QUTENZA KIT 8% 2-PCH Tier 3 X QVAR AER 40MCG Tier 1 X QVAR AER 80MCG Tier 1 X R-NATAL OB CAP 20-1-320 Tier 3 RA ALCOHOL PAD SWABS Tier 3 RA ASPIRIN CHW 81MG HCR Preventive RA ASPIRIN TAB 325MG HCR Preventive RA ASPIRIN TAB 325MG EC HCR Preventive RA ASPIRIN TAB 81MG EC HCR Preventive RA BEE POLLE CHW 500MG Tier 1 RA CHILD ASA CHW 81MG HCR Preventive RA E-ZJECT MIS 28G Tier 3 RA E-ZJECT MIS 33G Tier 3 RA E-ZJECT MIS THIN 26G Tier 3 RA E-ZJECT MIS THIN 28G Tier 3 RA E-ZJECT MIS ULT THIN Tier 3 RA EFFERVESC TAB FORMULA Tier 3 RA GLUCOSE MIS MONITOR Tier 3 RA L-LYSINE TAB 1000MG Tier 1 RA L-LYSINE TAB 500MG Tier 1 RA LAXATIVE POW HCR Preventive RA LAXATIVE TAB 5MG EC HCR Preventive RA NICOTINE DIS 14MG/24H HCR X Preventive RA NICOTINE DIS 21MG/24H HCR X Preventive

198 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy RA NICOTINE DIS 7MG/24HR HCR X Preventive RA NICOTINE GUM 2MG HCR X Preventive RA NICOTINE GUM 2MG CINN HCR X Preventive RA NICOTINE GUM 2MG MINT HCR X Preventive RA NICOTINE GUM 2MGFRUIT HCR X Preventive RA NICOTINE GUM 4MG HCR X Preventive RA NICOTINE GUM 4MG FRUT HCR X Preventive RA NICOTINE GUM 4MG MINT HCR X Preventive RA NICOTINE LOZ 2MG MINT HCR X Preventive RA NICOTINE LOZ 4MG MINT HCR X Preventive RA NUTRITION LIQ CHOCOLAT Tier 3 RA NUTRITION LIQ STRAWBRY Tier 3 RA NUTRITION LIQ VANILLA Tier 3 RA PEN NEEDL MIS 31GX3/16 Tier 2 RA TRUE2GO KIT Tier 3 RA TRUETEST TES Tier 3 X RABEPRAZOLE TAB 20MG Tier 3 X RADIAGEL GEL Tier 3 X RADIAGEL GEL Tier 2 X RADIAPLEXRX GEL Tier 3 X RADIOGARDASE CAP 0.5GM Tier 3 RAGWITEK SUB Tier 3 X X RAJANI TAB Tier 3 X RALOXIFENE TAB 60MG HCR Preventive RAMIPRIL CAP 1.25MG Tier 1 RAMIPRIL CAP 10MG Tier 1 RAMIPRIL CAP 2.5MG Tier 1 RAMIPRIL CAP 5MG Tier 1 RANEXA TAB 1000MG Tier 2 199 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy RANEXA TAB 500MG Tier 2 RANITIDINE SYP 150/10ML Tier 1 RANITIDINE SYP 15MG/ML Tier 1 RANITIDINE SYP 75MG/5ML Tier 1 RAPAFLO CAP 4MG Tier 3 RAPAFLO CAP 8MG Tier 3 RAPAMUNE SOL 1MG/ML Tier 2 X RAPAMUNE TAB 0.5MG Tier 3 X RAPAMUNE TAB 1MG Tier 3 X RAPAMUNE TAB 2MG Tier 3 X RAPID GEL RX GEL Tier 3 RAPID-D INF MIS 24"/10MM Tier 2 RAPID-D INF MIS 24"/6MM Tier 2 RAPID-D INF MIS 24"/8MM Tier 2 RAPID-D INF MIS 31"/10MM Tier 2 RAPID-D INF MIS 31"/6MM Tier 2 RAPID-D INF MIS 31"/8MM Tier 2 RAPID-D INF MIS 43"/10MM Tier 2 RAPID-D INF MIS 43"/6MM Tier 2 RAPID-D INF MIS 43"/8MM Tier 2 RAPID-D LINK MIS TRANSFER Tier 2 RASPBERRY SYP Tier 1 RASUVO INJ 10MG Tier 3 X X RASUVO INJ 12.5MG Tier 3 X X RASUVO INJ 15MG Tier 3 X X RASUVO INJ 17.5MG Tier 3 X X RASUVO INJ 20MG Tier 3 X RASUVO INJ 20MG Tier 3 X X RASUVO INJ 22.5MG Tier 3 X X RASUVO INJ 25MG Tier 3 X X RASUVO INJ 27.5MG Tier 3 X X RASUVO INJ 30MG Tier 3 X X RASUVO INJ 7.5MG Tier 3 X X RAVICTI LIQ 1.1GM/ML Tier 3 X X X RAYALDEE CAP 30MCG Tier 3 X X RAYOS TAB 1MG Tier 3 X RAYOS TAB 2MG Tier 3 X RAYOS TAB 5MG Tier 3 X 200 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy RAZADYNE TAB 12MG Tier 3 RAZADYNE TAB 4MG Tier 3 RAZADYNE TAB 8MG Tier 3 RAZADYNE ER CAP 16MG Tier 3 RAZADYNE ER CAP 24MG Tier 3 RAZADYNE ER CAP 8MG Tier 3 REA LO 39 CRE 39% Tier 1 REA LO 40 CRE 40% Tier 1 REA LO 40 LOT 40% Tier 1 REACT TAB 1.5MG HCR Preventive READI-CAT 2 SUS 2.1% Tier 2 READI-CAT 2 SUS BANANA Tier 2 READI-CAT 2 SUS BERRY Tier 2 READI-CAT 2 SUS MOCHACCI Tier 2 REAL-TIME KIT Tier 3 REBETOL CAP 200MG Tier 3 X REBETOL SOL 40MG/ML Tier 2 X REBIF INJ 22/0.5 Tier 3 X X X X REBIF INJ 44/0.5 Tier 3 X X X X REBIF REBIDO INJ 22/0.5 Tier 3 X X X X REBIF REBIDO INJ 44/0.5 Tier 3 X X X X REBIF REBIDO INJ TITRATN Tier 3 X X X X REBIF TITRTN INJ PACK Tier 3 X X X X RECLIPSEN TAB HCR Preventive RECOMBINATE INJ Tier 3 X X X RECOMBINATE INJ Tier 3 X X X RECOMBINATE INJ 220-400 Tier 3 X X X RECOMBINATE INJ 401-800 Tier 3 X X X RECOMBINATE INJ 801-1240 Tier 3 X X X RECOTHROM SOL 20000UNT Tier 3 RECOTHROM SOL 5000UNIT Tier 3 RECTACORT-HC SUP 25MG Tier 1 RECTIV OIN 0.4% Tier 3 X REDICHEW RX CHW Tier 3 REGLAN TAB 10MG Tier 3 REGLAN TAB 5MG Tier 3

201 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy REGRANEX GEL 0.01% Tier 2 X X REJUVACARE CRE PLUS Tier 3 X RELAGARD GEL Tier 3 RELENZA MIS DISKHALE Tier 3 X RELHIST CHW Tier 2 RELION TES ULTIMA Tier 3 X RELION BLOOD TES GLUCOSE Tier 3 X X RELION KETON TES Tier 2 RELION LANCE MIS THIN 26G Tier 3 RELION ULTIM KIT SYSTEM Tier 3 RELISTOR INJ 12/0.6ML Tier 3 X RELISTOR INJ 8/0.4ML Tier 3 X RELISTOR TAB 150MG Tier 3 X X RELNATE DHA CAP Tier 2 RELPAX TAB 20MG Tier 2 X RELPAX TAB 40MG Tier 2 X REMAXAZON PAD Tier 3 REMERON TAB 15MG Tier 3 REMERON TAB 30MG Tier 3 REMERON TAB 45MG Tier 3 REMERON SLTB TAB 15MG Tier 3 REMERON SLTB TAB 30MG Tier 3 REMERON SLTB TAB 45MG Tier 3 REMEVEN CRE 50% Tier 2 RENAGEL TAB 400MG Tier 3 RENAGEL TAB 800MG Tier 3 RENASTART POW Tier 3 RENVELA PAK 0.8GM Tier 2 RENVELA PAK 2.4GM Tier 2 RENVELA TAB 800MG Tier 2 REPAGLINIDE TAB 0.5MG Tier 3 X REPAGLINIDE TAB 1-500MG Tier 3 REPAGLINIDE TAB 1MG Tier 3 X REPAGLINIDE TAB 2-500MG Tier 3 REPAGLINIDE TAB 2MG Tier 3 X REPATHA INJ 140MG/ML Tier 3 X X X X REPATHA PUSH INJ 420/3.5 Tier 3 X X X REPATHA SURE INJ 140MG/ML Tier 3 X X X X 202 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy REPLETE LIQ /FIBER Tier 3 REPLETE LIQ ULTRAPAK Tier 3 REPREXAIN TAB 10-200MG Tier 1 REPREXAIN TAB 5-200MG Tier 1 REQUIP TAB 0.25MG Tier 3 REQUIP TAB 0.5MG Tier 3 REQUIP TAB 1MG Tier 3 REQUIP TAB 2MG Tier 3 REQUIP TAB 3MG Tier 3 REQUIP TAB 4MG Tier 3 REQUIP TAB 5MG Tier 3 REQUIP XL TAB 12MG Tier 3 X REQUIP XL TAB 2MG Tier 3 X REQUIP XL TAB 4MG Tier 3 X REQUIP XL TAB 6MG Tier 3 X REQUIP XL TAB 8MG Tier 3 X RESCRIPTOR TAB 100 MG Tier 2 X RESCRIPTOR TAB 200MG Tier 2 X RESCULA SOL 0.15% Tier 3 X X RESERPINE TAB 0.1MG Tier 1 RESERPINE TAB 0.25MG Tier 1 RESOURCE KID LIQ CR STRAW Tier 3 RESOURCE KID LIQ FR VAN Tier 3 RESOURCE KID LIQ SW CHOC Tier 3 RESOURCE KID LIQ W/FIBER Tier 3 RESOURCE SUP LIQ CHOCOLAT Tier 3 RESOURCE SUP LIQ STRAWBER Tier 3 RESOURCE SUP LIQ VANILLA Tier 3 RESPA-BR TAB 11MG Tier 3 RESPALOR LIQ Tier 3 RESTASIS EMU 0.05% Tier 3 X X RESTASIS MUL EMU 0.05% Tier 3 X X RESTORA RX CAP 60-1.25 Tier 3 RESTORIL CAP 15MG Tier 3 RESTORIL CAP 22.5MG Tier 3 RESTORIL CAP 30MG Tier 3 RESTORIL CAP 7.5MG Tier 3 RESVERATROL POW Tier 3 X 203 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy RESVERATROL POW +98% Tier 3 X RESVERATROL POW 98% Tier 3 X RETIN-A CRE 0.025% Tier 3 X X RETIN-A CRE 0.05% Tier 3 X X RETIN-A CRE 0.1% Tier 3 X X RETIN-A GEL 0.01% Tier 3 X X RETIN-A GEL 0.025% Tier 3 X X RETIN-A MICR GEL 0.04% Tier 3 X X X RETIN-A MICR GEL 0.04%PMP Tier 3 X X X RETIN-A MICR GEL 0.08% Tier 3 X X X RETIN-A MICR GEL 0.1% Tier 3 X X X RETIN-A MICR GEL 0.1%PUMP Tier 3 X X X RETINALDEHYD POW Tier 3 X RETINOIC ACD POW Tier 3 X X RETINOIC ACD POW ALL TRAN Tier 3 X X RETROVIR CAP 100MG Tier 3 X RETROVIR SYP 50MG/5ML Tier 3 X REVATIO SUS 10MG/ML Tier 3 X X X REVATIO TAB 20MG Tier 3 X X X X REVEAL KIT MONITOR Tier 3 REVEAL TES BLD GLUC Tier 3 X REVIA TAB 50MG Tier 3 REVLIMID CAP 10MG Tier 2 X X X REVLIMID CAP 15MG Tier 2 X X X REVLIMID CAP 2.5MG Tier 2 X X X REVLIMID CAP 20MG Tier 2 X X X REVLIMID CAP 25MG Tier 2 X X X REVLIMID CAP 5MG Tier 2 X X X REXULTI TAB 0.25MG Tier 3 X X REXULTI TAB 0.5MG Tier 3 X X REXULTI TAB 1MG Tier 3 X X REXULTI TAB 2MG Tier 3 X X REXULTI TAB 3MG Tier 3 X X REXULTI TAB 4MG Tier 3 X X REYATAZ CAP 150MG Tier 2 X REYATAZ CAP 200MG Tier 2 X REYATAZ CAP 300MG Tier 2 X REYATAZ POW 50MG Tier 2 X 204 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy REZIRA SOL 60-5/5ML Tier 3 REZYST IM CHW Tier 3 RHEOSPRAY LIQ Tier 3 X RHEUMADORON LIQ 102A Tier 3 RHEUMATE CAP Tier 3 RHEUMATREX TAB 2.5MG Tier 2 RHINOCORT SUS AQUA Tier 3 X X RIASTAP SOL 1GM Tier 3 X RIBAPAK PAK 1000/DAY Tier 3 X X RIBAPAK PAK 1200/DAY Tier 3 X X RIBAPAK PAK 600/DAY Tier 3 X X RIBAPAK PAK 800/DAY Tier 3 X X RIBASPHERE CAP 200MG Tier 1 X RIBASPHERE TAB 200MG Tier 1 X RIBASPHERE TAB 400MG Tier 1 X RIBASPHERE TAB 600MG Tier 1 X RIBATAB PAK 1000/DAY Tier 1 X RIBATAB TAB 1200/DAY Tier 1 X RIBATAB TAB 800/DAY Tier 1 X RIBAVIRIN CAP 200MG Tier 1 X RIBAVIRIN POW Tier 3 X RIBAVIRIN TAB 200MG Tier 1 X RIDAURA CAP 3MG Tier 3 RIFABUTIN CAP 150MG Tier 1 RIFADIN CAP 150MG Tier 3 RIFADIN CAP 300MG Tier 3 RIFAMATE CAP Tier 3 RIFAMPIN CAP 150MG Tier 1 RIFAMPIN CAP 300MG Tier 1 RIFATER TAB Tier 2 RIGHTSOURCE MIS METER Tier 3 RILUTEK TAB 50MG Tier 3 RILUZOLE TAB 50MG Tier 1 RIMANTADINE TAB 100MG Tier 1 RIOMET SOL Tier 3 RIOMET SOL 500/5ML Tier 3 RISEDRON SOD TAB 35MG DR Tier 3 X X RISEDRONATE TAB 150MG Tier 3 X 205 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy RISEDRONATE TAB 30MG Tier 3 RISEDRONATE TAB 35MG Tier 3 X RISEDRONATE TAB 5MG Tier 3 RISPERDAL SOL 1MG/ML Tier 3 X RISPERDAL TAB 0.25MG Tier 3 X RISPERDAL TAB 0.5MG Tier 3 X RISPERDAL TAB 1MG Tier 3 X RISPERDAL TAB 2MG Tier 3 X RISPERDAL TAB 3MG Tier 3 X RISPERDAL TAB 4MG Tier 3 X RISPERDAL M TAB 0.5MG Tier 3 X RISPERDAL M TAB 1MG Tier 3 X RISPERDAL M TAB 2MG Tier 3 X RISPERDAL M TAB 3MG Tier 3 X RISPERDAL M TAB 4MG Tier 3 X RISPERIDONE SOL 1MG/ML Tier 1 RISPERIDONE TAB 0.25 ODT Tier 1 RISPERIDONE TAB 0.25MG Tier 1 RISPERIDONE TAB 0.5MG Tier 1 RISPERIDONE TAB 0.5MG OD Tier 1 RISPERIDONE TAB 1MG Tier 1 RISPERIDONE TAB 1MG ODT Tier 1 RISPERIDONE TAB 2MG Tier 1 RISPERIDONE TAB 2MG ODT Tier 1 RISPERIDONE TAB 3MG Tier 1 RISPERIDONE TAB 3MG ODT Tier 1 RISPERIDONE TAB 4MG Tier 1 RISPERIDONE TAB 4MG ODT Tier 1 RITALIN TAB 10MG Tier 3 X RITALIN TAB 20MG Tier 3 X RITALIN TAB 5MG Tier 3 X RITALIN LA CAP 10MG Tier 3 X X X RITALIN LA CAP 20MG Tier 3 X X X RITALIN LA CAP 30MG Tier 3 X X X RITALIN LA CAP 40MG Tier 3 X X X RITALIN LA CAP 60MG Tier 3 X X X RIVASTIGMINE CAP 1.5MG Tier 1 RIVASTIGMINE CAP 3MG Tier 1 206 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy RIVASTIGMINE CAP 4.5MG Tier 1 RIVASTIGMINE CAP 6MG Tier 1 RIVASTIGMINE DIS 13.3/24 Tier 3 RIVASTIGMINE DIS 4.6MG/24 Tier 3 RIVASTIGMINE DIS 9.5MG/24 Tier 3 RIXUBIS INJ 1000UNIT Tier 2 X RIXUBIS INJ 2000UNIT Tier 2 X RIXUBIS INJ 250 UNIT Tier 2 X RIXUBIS INJ 3000UNIT Tier 2 X RIXUBIS INJ 500UNIT Tier 2 X RIZATRIPTAN TAB 10MG Tier 3 X RIZATRIPTAN TAB 10MG ODT Tier 1 X RIZATRIPTAN TAB 5MG Tier 3 X RIZATRIPTAN TAB 5MG ODT Tier 1 X ROBAXIN TAB 500MG Tier 3 ROBAXIN-750 TAB 750MG Tier 3 ROBINUL TAB 1MG Tier 3 ROBINUL FORT TAB 2MG Tier 3 ROCALTROL CAP 0.25MCG Tier 3 ROCALTROL CAP 0.5MCG Tier 3 ROCALTROL SOL 1MCG/ML Tier 3 ROPINIROLE TAB 0.25MG Tier 1 ROPINIROLE TAB 0.5MG Tier 1 ROPINIROLE TAB 12MG ER Tier 3 X ROPINIROLE TAB 1MG Tier 1 ROPINIROLE TAB 2MG Tier 1 ROPINIROLE TAB 2MG ER Tier 3 X ROPINIROLE TAB 3MG Tier 1 ROPINIROLE TAB 4MG Tier 1 ROPINIROLE TAB 4MG ER Tier 3 X ROPINIROLE TAB 5MG Tier 1 ROPINIROLE TAB 6MG ER Tier 3 X ROPINIROLE TAB 8MG ER Tier 3 X ROSADAN CRE 0.75% Tier 1 ROSADAN GEL 0.75% Tier 1 ROSADAN KIT 0.75% Tier 3 X ROSADAN KIT 0.75% Tier 3 X ROSANIL EMU CLEANSER Tier 1 207 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ROSE GLO TES 1.5MG Tier 3 ROSUVASTATIN TAB 10MG Tier 1 X ROSUVASTATIN TAB 20MG Tier 1 X ROSUVASTATIN TAB 40MG Tier 1 X ROSUVASTATIN TAB 5MG Tier 1 X ROWASA KIT 4GM Tier 3 X ROWEEPRA TAB 500MG Tier 1 ROXICODONE TAB 15MG Tier 3 ROXICODONE TAB 30MG Tier 3 ROXICODONE TAB 5MG Tier 3 ROZEREM TAB 8MG Tier 3 X X RUCONEST INJ 2100UNIT Tier 3 X X X RULAVITE DHA CAP Tier 3 RX-SPECIMEN KIT COLLECTI Tier 3 RYTARY CAP 145MG Tier 3 X RYTARY CAP 195MG Tier 3 X RYTARY CAP 245MG Tier 3 X RYTARY CAP 95MG Tier 3 X RYTHMOL TAB 150MG Tier 3 RYTHMOL TAB 225MG Tier 3 RYTHMOL SR CAP 225MG Tier 3 RYTHMOL SR CAP 325MG Tier 3 RYTHMOL SR CAP 425MG Tier 3 SABRIL POW 500MG Tier 2 X SABRIL TAB 500MG Tier 2 X SAFE-T-LANCE MIS 21G Tier 3 SAFE-T-LANCE MIS 25G Tier 3 SAFE-T-LANCE MIS HI FLOW Tier 3 SAFE-T-LANCE MIS LOW FLOW Tier 3 SAFE-T-LANCE MIS NOR FLOW Tier 3 SAFE-T-PRO MIS LANCETS Tier 1 SAFE-T-PRO MIS PLUS Tier 1 SAFTY NEEDLE MIS 18GX1.5" Tier 2 SAFTY NEEDLE MIS 18GX1" Tier 2 SAFTY NEEDLE MIS 19GX1.5" Tier 2 SAFTY NEEDLE MIS 19GX1" Tier 2 SAFTY NEEDLE MIS 20GX1.5" Tier 2 SAFTY NEEDLE MIS 20GX1" Tier 2 208 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy SAFTY NEEDLE MIS 21GX1.5" Tier 2 SAFTY NEEDLE MIS 21GX1" Tier 2 SAFTY NEEDLE MIS 22GX1.5" Tier 2 SAFTY NEEDLE MIS 22GX1" Tier 2 SAFTY NEEDLE MIS 23GX1" Tier 2 SAFTY NEEDLE MIS 25GX1" Tier 2 SAFTY NEEDLE MIS 25GX5/8" Tier 2 SAFYRAL TAB Tier 3 X SAIZEN INJ 5MG Tier 3 X X X X SAIZEN INJ 8.8MG Tier 3 X X X X SALACYN CRE 6% Tier 1 SALACYN LOT 6% Tier 1 SALAGEN TAB 5MG Tier 3 SALAGEN TAB 7.5MG Tier 3 SALICYLIC AER 6% Tier 1 SALICYLIC AC CRE 6% Tier 1 SALICYLIC AC GEL 6% Tier 1 SALICYLIC AC LIQ 26% Tier 1 SALICYLIC AC LOT 6% Tier 1 SALIVAMAX POW Tier 3 SALIVATE RX POW Tier 3 SALSALATE TAB 500MG Tier 1 SALSALATE TAB 750MG Tier 1 SALT DURABLE CRE Tier 3 X SALT STABLE CRE Tier 3 X SALT STABLE CRE LS ADV Tier 3 X SALVAX AER 6% Tier 3 SALVAX DUO KIT PLUS Tier 3 SAMSCA TAB 15MG Tier 2 X X SAMSCA TAB 30MG Tier 2 X X SANARE CRE ADVANCED Tier 3 X SANARE SCAR CRE THERAPY Tier 3 X SANCUSO DIS 3.1MG Tier 3 X X SANDIMMUNE CAP 100MG Tier 3 X SANDIMMUNE CAP 25MG Tier 3 X SANDIMMUNE SOL 100MG/ML Tier 3 X SANDOSTATIN INJ 1000MCG Tier 3 X X SANDOSTATIN INJ 100MCG Tier 3 X X 209 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy SANDOSTATIN INJ 200MCG Tier 3 X X SANDOSTATIN INJ 500MCG Tier 3 X X SANDOSTATIN INJ 50MCG/ML Tier 3 X X SANTYL OIN 250/GM Tier 3 SAPHRIS SUB 10MG Tier 3 X SAPHRIS SUB 2.5MG Tier 3 SAPHRIS SUB 5MG Tier 3 X SARAFEM TAB 10MG Tier 3 SARAFEM TAB 20MG Tier 3 SAVAYSA TAB 15MG Tier 3 X SAVAYSA TAB 30MG Tier 3 X SAVAYSA TAB 60MG Tier 3 X SAVELLA MIS TITR PAK Tier 3 X SAVELLA TAB 100MG Tier 3 X SAVELLA TAB 12.5MG Tier 3 X SAVELLA TAB 25MG Tier 3 X SAVELLA TAB 50MG Tier 3 X SCALACORT LOT 2% Tier 1 SCALACORT DK KIT Tier 3 SCANDICAL POW Tier 3 SCANDISHAKE POW VANILLA Tier 3 SCAR CARE CRE Tier 3 X SCARCIN CRE Tier 3 X SE-NATAL 19 CHW Tier 1 SE-NATAL 19 TAB Tier 1 SE-TAN DHA CAP Tier 1 SEASONIQUE TAB Tier 3 X SEB-PREV LIQ WASH Tier 1 SECONAL CAP 100MG Tier 3 SECONAL SOD CAP 100MG Tier 3 SECTRAL CAP 200MG Tier 3 SECTRAL CAP 400MG Tier 3 SEDANARE CRE Tier 3 X SEEBRI NEOHA CAP 15.6MCG Tier 2 X SELECT-LITE KIT DEV/LANC Tier 3 SELECT-OB CHW Tier 3 SELECT-OB CHW Tier 3 SELECT-OB+ PAK DHA Tier 3 210 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy SELEGILINE CAP 5MG Tier 1 SELEGILINE TAB 5MG Tier 1 SELENIUM SUL LOT 2.5% Tier 1 SELENIUM SUL SHA 2.25% Tier 3 SELZENTRY TAB 150MG Tier 2 X X SELZENTRY TAB 300MG Tier 2 X X SEMPREX-D CAP 8-60MG Tier 3 SEN-SERTER MIS Tier 2 SENSIPAR TAB 30MG Tier 3 X SENSIPAR TAB 60MG Tier 3 X SENSIPAR TAB 90MG Tier 3 X SENTRA AM CAP Tier 3 SENTRA AM CAP Tier 2 SENTRA PM CAP Tier 3 SENTRA PM CAP Tier 2 SERAQUA LIQ Tier 3 SEREVENT DIS AER 50MCG Tier 3 X SERMORELIN POW ACETATE Tier 3 X SERNIVO SPR Tier 3 X X SEROQUEL TAB 100MG Tier 3 X SEROQUEL TAB 200MG Tier 3 X SEROQUEL TAB 25MG Tier 3 X SEROQUEL TAB 300MG Tier 3 X SEROQUEL TAB 400MG Tier 3 X SEROQUEL TAB 50MG Tier 3 X SEROQUEL XR TAB 150MG Tier 3 X SEROQUEL XR TAB 200MG Tier 3 X SEROQUEL XR TAB 300MG Tier 3 X SEROQUEL XR TAB 400MG Tier 3 X SEROQUEL XR TAB 50MG Tier 3 X SEROSTIM INJ 4MG Tier 3 X X X SEROSTIM INJ 5MG Tier 3 X X X SEROSTIM INJ 6MG Tier 3 X X X SEROTONIN POW HCL Tier 3 X SERTRALINE CON 20MG/ML Tier 1 SERTRALINE TAB 100MG Tier 1 SERTRALINE TAB 25MG Tier 1 SERTRALINE TAB 50MG Tier 1 211 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy SETLAKIN TAB HCR X Preventive SEVOFLURANE SOL Tier 1 SF GEL 1.1% Tier 1 SF 5000 PLUS CRE 1.1% Tier 1 SFROWASA ENE 4GM Tier 3 SHAROBEL TAB 0.35MG HCR Preventive SHOHLS SOL MODIFIED Tier 2 SHUR-SEAL GEL 2% HCR Preventive SIGNIFOR INJ 0.3MG/ML Tier 2 X X X SIGNIFOR INJ 0.6MG/ML Tier 2 X X X SIGNIFOR INJ 0.9MG/ML Tier 2 X X X SIL-SERTER MIS INS DEV Tier 2 SILDENAFIL TAB 20MG Tier 1 X X X SILENOR TAB 3MG Tier 3 X X SILENOR TAB 6MG Tier 3 X X SILHOUETTE MIS 13MM Tier 2 SILHOUETTE MIS 17MM Tier 2 SILHOUETTE MIS 18"/13MM Tier 2 SILHOUETTE MIS 23" SET Tier 2 SILHOUETTE MIS 32"/13MM Tier 2 SILHOUETTE MIS 32"/17MM Tier 2 SILHOUETTE MIS 43" SET Tier 2 SILHOUETTE MIS COMBO Tier 2 SILHOUETTE MIS FULL SET Tier 2 SILOMAC GEL ULTRA Tier 3 SILOSOME CRE TRANSDER Tier 3 SILPROTEX CRE PLUS Tier 3 X SILVADENE CRE 1% Tier 3 SILVER NITRA OIN 10% Tier 1 SILVER NITRA SOL 0.5% Tier 1 SILVER NITRA SOL 10% Tier 1 SILVER NITRA SOL 25% Tier 1 SILVER NITRA SOL 50% Tier 1 SILVER SULFA CRE 1% Tier 1 SIMBRINZA SUS 1-0.2% Tier 3 X X

212 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy SIMCOR TAB 1000-20 Tier 3 X SIMCOR TAB 1000-40 Tier 3 X SIMCOR TAB 500-20MG Tier 3 X SIMCOR TAB 500-40MG Tier 3 X SIMCOR TAB 750-20MG Tier 3 X SIMPLE SYP Tier 1 SIMPLGEL 30 GEL Tier 3 SIMPONI INJ 100MG/ML Tier 2 X X X SIMPONI INJ 100MG/ML Tier 2 X X X SIMPONI INJ 50/0.5ML Tier 2 X X X SIMPONI INJ 50/0.5ML Tier 2 X X X SIMVASTATIN TAB 10MG Tier 1 SIMVASTATIN TAB 20MG Tier 1 SIMVASTATIN TAB 40MG Tier 1 SIMVASTATIN TAB 5MG Tier 1 SIMVASTATIN TAB 80MG Tier 1 SINEMET TAB 10-100MG Tier 3 SINEMET TAB 25-100MG Tier 3 SINEMET TAB 25-250MG Tier 3 SINEMET CR TAB 25-100MG Tier 3 SINEMET CR TAB 50-200MG Tier 3 SINGLE-LET MIS 23G Tier 3 SINGULAIR CHW 4MG Tier 3 X SINGULAIR CHW 5MG Tier 3 X SINGULAIR GRA 4MG Tier 3 SINGULAIR TAB 10MG Tier 3 X SIROLIMUS POW Tier 3 X SIROLIMUS TAB 0.5MG Tier 1 X SIROLIMUS TAB 1MG Tier 1 X SIROLIMUS TAB 2MG Tier 1 X SIRTURO TAB 100MG Tier 2 SITAVIG TAB 50MG Tier 3 X X SIVEXTRO TAB 200MG Tier 3 X SKELAXIN TAB 800MG Tier 3 X SKLICE LOT 0.5% Tier 3 X SKYY DERM CRE Tier 3 X SM ALCOHOL PAD PREP Tier 3

213 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy SM ASPIRIN CHW 81MG HCR Preventive SM ASPIRIN TAB 325MG HCR Preventive SM ASPIRIN TAB 325MG EC HCR Preventive SM ASPIRIN TAB 81MG EC HCR Preventive SM CHILD ASA CHW 81MG HCR Preventive SM CLEARLAX POW HCR Preventive SM FOLIC ACD TAB 400MCG HCR Preventive SM GENTLE TAB LAXATIVE HCR Preventive SM INSULIN SYRINGE Tier 2 SM L-LYSINE TAB 500MG Tier 1 SM LAXATIVE TAB 5MG EC HCR Preventive SM NICOTINE DIS 14MG/24H HCR X Preventive SM NICOTINE DIS 21MG HCR X Preventive SM NICOTINE DIS 21MG/24H HCR X Preventive SM NICOTINE DIS 7MG/24HR HCR X Preventive SM NICOTINE GUM 2MG HCR X Preventive SM NICOTINE GUM 2MG MINT HCR X Preventive SM NICOTINE GUM 4MG HCR X Preventive SM NICOTINE GUM 4MG MINT HCR X Preventive SM NICOTINE LOZ 2MG MINT HCR X Preventive SM NICOTINE LOZ 4MG MINT HCR X Preventive

214 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy SMOOTH LAX POW HCR Preventive SMZ-TMP SUS 200-40/5 Tier 1 SMZ-TMP TAB 400-80MG Tier 1 SMZ-TMP DS TAB 800-160 Tier 1 SMZ/TMP DS TAB 800-160 Tier 1 SNAP PUMP MIS CONTROLL Tier 3 SOD CHLORIDE GRA Tier 3 SOD CHLORIDE NEB 0.9% Tier 1 SOD CITRATE SOL CITR ACD Tier 1 SOD FLUORIDE CHW 0.25MG F HCR Preventive SOD FLUORIDE CHW 0.5MG F HCR Preventive SOD FLUORIDE CHW 1.1MG HCR Preventive SOD FLUORIDE CHW 1MG F HCR Preventive SOD FLUORIDE CHW 2.2MG HCR Preventive SOD FLUORIDE DRO 0.5MG/ML HCR Preventive SOD FLUORIDE SOL 0.2% Tier 1 SOD FLUORIDE TAB 0.5MG F Tier 1 SOD FLUORIDE TAB 1MG F Tier 1 SOD POLY SUL POW Tier 1 SOD POLY SUL SUS 15GM/60 Tier 1 SOD POLY SUL SUS 30/120ML Tier 1 SOD POLY SUL SUS 50/200ML Tier 1 SOD SUL/SULF CRE 10-2% Tier 1 SOD SUL/SULF CRE 10-5% Tier 1 SOD SUL/SULF CRE 9.8-4.8% Tier 3 X SOD SUL/SULF EMU 10-5% Tier 1 SOD SUL/SULF EMU 10-5% Tier 1 SOD SUL/SULF GEL 10-5% Tier 1 SOD SUL/SULF KIT Tier 3 X SOD SUL/SULF LIQ 10-2% Tier 1 X SOD SUL/SULF LIQ 9-4.5% Tier 1 SOD SUL/SULF LIQ 9.8-4.8% Tier 3 X

215 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy SOD SUL/SULF LIQ WASH Tier 1 SOD SUL/SULF LOT 10-5% Tier 1 SOD SUL/SULF LOT 9.8-4.8% Tier 3 X SOD SUL/SULF PAD 10-4% Tier 1 SOD SUL/SULF SUS 10-5% Tier 1 SOD SUL/SULF SUS 8-4% Tier 1 SOD SULFACET GEL 10% Tier 1 SOD SULFACET SHA 10% Tier 1 SOD SULFACET SOL 10% OP Tier 1 SODIUM POW BICARBON Tier 3 SODIUM POW CHLORIDE Tier 3 SODIUM BUTYR POW Tier 3 X SODIUM CHLOR NEB 10% Tier 1 SODIUM CHLOR NEB 3% Tier 1 SODIUM CHLOR NEB 7% Tier 1 SODIUM SULFA LIQ 10% WASH Tier 1 SODIUM SULFA LIQ 10% WASH Tier 1 SOF-SENSOR MIS Tier 3 X X SOF-SERTER MIS INS DEV Tier 2 SOF-SET 24" KIT INFUSION Tier 2 SOF-SET 24" KIT MICRO QR Tier 2 SOF-SET 24" KIT ULTIM QR Tier 2 SOF-SET 42" KIT INFUSION Tier 2 SOF-SET 42" KIT MICRO QR Tier 2 SOF-SET 42" KIT ULTIM QR Tier 2 SOFT TOUCH MIS LANCETS Tier 1 SOFTCLIX MIS LANCETS Tier 1 SOJOURN SOL Tier 1 SOLARAZE GEL 3% W/W Tier 3 X SOLODYN TAB 105MG Tier 3 SOLODYN TAB 115MG Tier 3 SOLODYN TAB 55MG Tier 3 SOLODYN TAB 65MG Tier 3 SOLODYN TAB 80MG Tier 3 SOLTAMOX SOL 10MG/5ML Tier 3 X SOLU-K GEL Tier 3 SOLUPAK PAK Tier 3 X SOLVIL POW Tier 3 216 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy SOLYDRA LIQ Tier 3 SOMA TAB 250MG Tier 3 X SOMA TAB 350MG Tier 3 SOMATULINE INJ 120/.5ML Tier 3 X SOMATULINE INJ 60/0.2ML Tier 3 X SOMATULINE INJ 90/0.3ML Tier 3 X SOMAVERT INJ 10MG Tier 3 X X X SOMAVERT INJ 15MG Tier 3 X X X SOMAVERT INJ 20MG Tier 3 X X X SOMAVERT INJ 25MG Tier 3 X X X SOMAVERT INJ 30MG Tier 3 X X X SONATA CAP 10MG Tier 3 X SONATA CAP 5MG Tier 3 X SOOLANTRA CRE 1% Tier 3 X X SORIATANE CAP 10MG Tier 3 SORIATANE CAP 17.5MG Tier 3 SORIATANE CAP 25MG Tier 3 SORILUX AER 0.005% Tier 3 X X SOTALOL AF TAB 120MG Tier 1 SOTALOL AF TAB 160MG Tier 1 SOTALOL AF TAB 80MG Tier 1 SOTALOL HCL TAB 120MG Tier 1 SOTALOL HCL TAB 160MG Tier 1 SOTALOL HCL TAB 240MG Tier 1 SOTALOL HCL TAB 80MG Tier 1 SOTYLIZE SOL 5MG/ML Tier 3 X SOVALDI TAB 400MG Tier 2 X X X X SOY INFANT POW FRMLA/FE Tier 3 SPECIMEN KIT COLLECTI Tier 3 SPECTRACEF TAB 400MG Tier 3 SPEEDGEL RX GEL Tier 3 SPINOSAD SUS 0.9% Tier 3 SPIRA-WASH GEL BASE Tier 3 X SPIRIVA AER 1.25MCG Tier 3 X X SPIRIVA CAP HANDIHLR Tier 3 X SPIRIVA SPR 2.5MCG Tier 3 X SPIRONO/HCTZ TAB 25/25 Tier 1 SPIRONOLACT POW Tier 3 X 217 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy SPIRONOLACT TAB 100MG Tier 1 SPIRONOLACT TAB 25MG Tier 1 SPIRONOLACT TAB 50MG Tier 1 SPORANOX CAP 100MG Tier 3 X SPORANOX CAP PULSEPAK Tier 3 X SPORANOX SOL 10MG/ML Tier 2 X SPRINTEC 28 TAB 28 DAY HCR Preventive SPRITAM TAB 1000MG Tier 3 X X SPRITAM TAB 250MG Tier 3 X X SPRITAM TAB 500MG Tier 3 X X SPRITAM TAB 750MG Tier 3 X X SPRIX SPR 15.75MG Tier 3 SPRYCEL TAB 100MG Tier 3 X X X X SPRYCEL TAB 140MG Tier 3 X X X X SPRYCEL TAB 20MG Tier 3 X X X X SPRYCEL TAB 50MG Tier 3 X X X X SPRYCEL TAB 70MG Tier 3 X X X X SPRYCEL TAB 80MG Tier 3 X X X X SPS SUS 15GM/60 Tier 1 SRONYX TAB HCR Preventive SS 10-2 SOL 10-2% Tier 1 X SSD CRE 1% Tier 1 SSKI SOL 1GM/ML Tier 3 SSS CRE 10%-5% Tier 1 SSS 10-5 AER 10-5% Tier 1 ST JOSEPH CHW LOW 81MG HCR Preventive STALEVO 100 TAB Tier 3 STALEVO 125 TAB Tier 3 STALEVO 150 TAB Tier 3 STALEVO 200 TAB Tier 3 STALEVO 50 TAB Tier 3 STALEVO 75 TAB Tier 3 STARLIX TAB 120MG Tier 3 X STARLIX TAB 60MG Tier 3 X STAVUDINE CAP 15MG Tier 1 X

218 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy STAVUDINE CAP 20MG Tier 1 X STAVUDINE CAP 30MG Tier 1 X STAVUDINE CAP 40MG Tier 1 X STAVUDINE SOL 1MG/ML Tier 1 X STAXYN TAB 10MG Tier 3 X X STELARA INJ 45MG/0.5 Tier 2 X X X STELARA INJ 90MG/ML Tier 2 X X X STENDRA TAB 100MG Tier 3 X STENDRA TAB 200MG Tier 3 X STENDRA TAB 50MG Tier 3 X STERA BASE CRE Tier 3 X STERYMINE GEL Tier 3 STIM LAXAT TAB 5MG EC HCR Preventive STIMATE SOL 1.5MG/ML Tier 3 STIOLTO AER 2.5-2.5 Tier 3 X X STIVARGA TAB 40MG Tier 2 X X X STOP SMOKING GUM 2MG MINT HCR X Preventive STOP SMOKING GUM 2MG ORIG HCR X Preventive STOP SMOKING GUM 4MG HCR X Preventive STOP SMOKING LOZ 2MG HCR X Preventive STOP SMOKING LOZ 2MG MINT HCR X Preventive STOP SMOKING LOZ 4MG MINT HCR X Preventive STRATTERA CAP 100MG Tier 3 X STRATTERA CAP 10MG Tier 3 X STRATTERA CAP 18MG Tier 3 X STRATTERA CAP 25MG Tier 3 X STRATTERA CAP 40MG Tier 3 X STRATTERA CAP 60MG Tier 3 X STRATTERA CAP 80MG Tier 3 X STRENSIQ INJ 18/0.45 Tier 2 X X X STRENSIQ INJ 28/0.7ML Tier 2 X X X STRENSIQ INJ 40MG/ML Tier 2 X X X

219 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy STRENSIQ INJ 80/0.8ML Tier 2 X X X STRIANT MIS 30MG Tier 3 X X STRIBILD TAB Tier 3 X X STRIVERDI AER 2.5MCG Tier 2 X STROMECTOL TAB 3MG Tier 3 SUBDUE LIQ CHOC/ALM Tier 3 SUBDUE LIQ ORNG/VAN Tier 3 SUBDUE LIQ REDI-FED Tier 3 SUBDUE LIQ UNFLAVRD Tier 3 SUBDUE PLUS LIQ UNFLAVRD Tier 3 SUBOXONE MIS 12-3MG Tier 3 X X X SUBOXONE MIS 2-0.5MG Tier 3 X X X SUBOXONE MIS 4-1MG Tier 3 X X X SUBOXONE MIS 8-2MG Tier 3 X X X SUBSYS SPR 100MCG Tier 3 X X X SUBSYS SPR 1200MCG Tier 3 X X X SUBSYS SPR 1600MCG Tier 3 X X X SUBSYS SPR 200MCG Tier 3 X X X SUBSYS SPR 400MCG Tier 3 X X X SUBSYS SPR 600MCG Tier 3 X X X SUBSYS SPR 800MCG Tier 3 X X X SUCCIMER DMS POW Tier 3 X SUCLEAR KIT Tier 3 SUCRAID SOL 8500/ML Tier 2 X SUCRALFATE TAB 1GM Tier 1 SUL SOD/SULF LIQ 10-2% Tier 1 X SUL SOD/SULF PAD 10-4% Tier 1 SULAR TAB 17MG Tier 3 SULAR TAB 34MG Tier 3 SULAR TAB 8.5MG Tier 3 SULF LIME SOL Tier 3 SULF/PRED NA SOL OP Tier 1 SULF/SUNSCRN KIT 9-4.5% Tier 1 X SULFACET SOD OIN 10% OP Tier 1 SULFACET SOD SOL 10% OP Tier 1 SULFACETAMID LOT 10% Tier 1 SULFACETAMID SUS 10% Tier 1 SULFACLEANSE SUS 8-4% Tier 1 220 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy SULFADIAZINE TAB 500MG Tier 1 SULFADIMETHO POW Tier 3 X SULFAMYLON CRE 85MG/GM Tier 3 SULFAMYLON PAK 5% Tier 3 SULFASALAZIN TAB 500MG Tier 1 SULFASALAZIN TAB 500MG DR Tier 1 SULFATRIM PD SUS 200-40/5 Tier 1 SULFOAM SHA 2% Tier 3 SULFZIX POW Tier 3 SULINDAC TAB 150MG Tier 1 SULINDAC TAB 200MG Tier 1 SUMADAN KIT Tier 3 X SUMADAN WASH LIQ 9-4.5% Tier 3 X SUMADAN XLT KIT 9-4.5% Tier 3 X SUMATRIPTAN INJ 4MG/0.5 Tier 1 X SUMATRIPTAN INJ 4MG/0.5 Tier 1 X SUMATRIPTAN INJ 6MG/0.5 Tier 1 X SUMATRIPTAN INJ 6MG/0.5 Tier 1 X SUMATRIPTAN INJ 6MG/0.5 Tier 1 X SUMATRIPTAN INJ 6MG/0.5 Tier 1 X SUMATRIPTAN SPR 20MG/ACT Tier 3 X SUMATRIPTAN SPR 5MG/ACT Tier 3 X SUMATRIPTAN TAB 100MG Tier 1 X SUMATRIPTAN TAB 25MG Tier 1 X SUMATRIPTAN TAB 50MG Tier 1 X SUMAVEL DOSE INJ 4MG/0.5 Tier 3 X X SUMAVEL DOSE INJ 6MG/0.5 Tier 3 X X SUMAXIN PAD 10-4% Tier 3 SUMAXIN CP KIT Tier 3 X SUMAXIN TS SUS 8-4% Tier 3 X SUMAXIN WASH LIQ 9-4% Tier 3 SUPER THIN MIS LANCETS Tier 3 SUPRACIL CRE Tier 3 X SUPRANE INH Tier 2 SUPRANE SOL Tier 2 SUPRAX CAP 400MG Tier 3 SUPRAX CHW 100MG Tier 3 SUPRAX CHW 200MG Tier 3 221 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy SUPRAX SUS 100/5ML Tier 3 SUPRAX SUS 200/5ML Tier 3 SUPRAX SUS 500/5ML Tier 3 SUPREME CRE Tier 3 X SUPREME TES Tier 3 X SUPREME II LIQ HIGH/LOW Tier 2 SUPREP BOWEL SOL PREP Tier 3 SURE-T MIS 23"/6MM Tier 2 SURE-T MIS 23"/8MM Tier 2 SURESTEP SOL CONTROL Tier 1 SURESTEP GLU SOL Tier 1 SURESTEP GLU SOL HIGH/LOW Tier 1 SURESTEP PRO KIT LINEARIT Tier 1 SURESTEP PRO TES HIGH CON Tier 1 SURESTEP PRO TES LOW CON Tier 1 SURESTEP PRO TES NORM CON Tier 1 SURMONTIL CAP 100MG Tier 3 SURMONTIL CAP 25MG Tier 3 SURMONTIL CAP 50MG Tier 3 SURVANTA INH Tier 3 SUSPENSION SUS VEHICLE Tier 3 SUSTIVA CAP 200MG Tier 2 X SUSTIVA CAP 50MG Tier 2 X SUSTIVA TAB 600MG Tier 2 X SUTENT CAP 12.5MG Tier 2 X X X SUTENT CAP 25MG Tier 2 X X X SUTENT CAP 37.5MG Tier 2 X X X SUTENT CAP 50MG Tier 2 X X X SW CLEARLAX POW HCR Preventive SW NICOTINE GUM 2MG MINT HCR X Preventive SW NICOTINE GUM 4MG HCR X Preventive SW NICOTINE LOZ 2MG MINT HCR X Preventive SW NICOTINE LOZ 4MG MINT HCR X Preventive SYEDA TAB 3-0.03MG Tier 3 222 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy SYLATRON KIT 200MCG Tier 2 X X X SYLATRON KIT 300MCG Tier 2 X X X SYLATRON KIT 600MCG Tier 2 X X X SYMAX DUOTAB TAB Tier 3 SYMAX-SL SUB 0.125MG Tier 1 SYMAX-SR TAB 0.375MG Tier 1 SYMBICORT AER 160-4.5 Tier 3 X SYMBICORT AER 80-4.5 Tier 3 X SYMBYAX CAP 12-25MG Tier 3 X SYMBYAX CAP 12-50MG Tier 3 X SYMBYAX CAP 3-25MG Tier 3 X SYMBYAX CAP 6-25MG Tier 3 X SYMBYAX CAP 6-50MG Tier 3 X SYMLINPEN 60 INJ 1000MCG Tier 3 X SYMLNPEN 120 INJ 1000MCG Tier 3 SYNALAR CRE 0.025% Tier 3 X X SYNALAR KIT 0.025% Tier 3 X SYNALAR KIT 0.025% Tier 3 X SYNALAR OIN 0.025% Tier 3 X X SYNALAR SOL 0.01% Tier 3 X X SYNALAR TS KIT 0.01% Tier 3 X SYNALGOS-DC CAP Tier 3 SYNAPRYN SUS 10MG/ML Tier 3 X SYNAREL SOL 2MG/ML Tier 2 SYNERA DIS 70-70MG Tier 3 SYNERDERM EMU Tier 3 SYNJARDY TAB Tier 2 X SYNJARDY TAB 12.5-500 Tier 2 X SYNJARDY TAB 5-1000MG Tier 2 X SYNJARDY TAB 5-500MG Tier 2 X SYNTHROID TAB 100MCG Tier 2 SYNTHROID TAB 112MCG Tier 2 SYNTHROID TAB 125MCG Tier 2 SYNTHROID TAB 137MCG Tier 2 SYNTHROID TAB 150MCG Tier 2 SYNTHROID TAB 175MCG Tier 2 SYNTHROID TAB 200MCG Tier 2 SYNTHROID TAB 25MCG Tier 2 223 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy SYNTHROID TAB 300MCG Tier 2 SYNTHROID TAB 50MCG Tier 2 SYNTHROID TAB 75MCG Tier 2 SYNTHROID TAB 88MCG Tier 2 SYNVEXIA TC CRE 4-1% Tier 3 SYPRINE CAP 250MG Tier 3 X X SYRPALTA SYP Tier 3 SYRPALTA SYP Tier 1 SYRPALTA SYP CLEAR Tier 1 SYRSPEND SF LIQ Tier 3 SYRSPEND SF SUS PH4 Tier 3 SYRUP SYP VEHICLE Tier 3 SYRUP SF SYP VEHICLE Tier 3 T:30 INFUSIO MIS SET Tier 2 T:FLEX 4.8ML MIS CARTRDGE Tier 2 T:SLIM 3ML MIS CARTRDGE Tier 2 T:SLIM G4 MIS CARTRDGE Tier 2 T.R.U.E. TES Tier 3 TABLOID TAB 40MG Tier 2 X TABRADOL SUS 1MG/ML Tier 3 X TABRADOL SUS RAPIDPAQ Tier 3 X TACLONEX OIN Tier 3 X X TACLONEX SUS Tier 3 X TACROLIMUS CAP 0.5MG Tier 1 X TACROLIMUS CAP 1MG Tier 1 X TACROLIMUS CAP 5MG Tier 1 X TACROLIMUS OIN 0.03% Tier 1 X X TACROLIMUS OIN 0.1% Tier 1 X X TACROLIMUS POW Tier 3 X TACROLIMUS POW MONOHYD Tier 3 X TAFINLAR CAP 50MG Tier 2 X X X TAFINLAR CAP 75MG Tier 2 X X X TAGITOL V SUS 40% Tier 2 TAGRISSO TAB 40MG Tier 3 X X X TAGRISSO TAB 80MG Tier 3 X X X TAKE ACTION TAB 1.5MG HCR Preventive TALTZ INJ 80MG/ML Tier 3 X X X X

224 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy TALTZ INJ 80MG/ML Tier 3 X X X X TAMIFLU CAP 30MG Tier 3 X TAMIFLU CAP 45MG Tier 3 X TAMIFLU CAP 75MG Tier 3 X TAMIFLU SUS 6MG/ML Tier 3 X TAMOXIFEN POW CITRATE Tier 2 X TAMOXIFEN TAB 10MG Tier 1 TAMOXIFEN TAB 20MG HCR Preventive TAMSULOSIN CAP 0.4MG Tier 1 TANDEM F CAP Tier 3 TANZEUM INJ 30MG Tier 3 X TANZEUM INJ 50MG Tier 3 X TAPAZOLE TAB 10MG Tier 3 TAPAZOLE TAB 5MG Tier 3 TARCEVA TAB 100MG Tier 2 X X X TARCEVA TAB 150MG Tier 2 X X X TARCEVA TAB 25MG Tier 2 X X X TARGRETIN CAP 75MG Tier 2 X TARGRETIN GEL 1% Tier 3 X X TARINA FE TAB 1/20 HCR Preventive TARKA TAB 1-240 CR Tier 3 TARKA TAB 2-180 CR Tier 3 TARKA TAB 2-240 CR Tier 3 TARKA TAB 4-240 CR Tier 3 TARON GRA CRYSTALS Tier 1 TARON-BC MIS Tier 2 TARON-C DHA CAP Tier 3 TARON-PREX CAP Tier 3 TASIGNA CAP 150MG Tier 2 X X X X TASIGNA CAP 200MG Tier 2 X X X X TASMAR TAB 100MG Tier 3 X TAURINE CAP 500MG Tier 1 TAYTULLA CAP Tier 3 X TAZORAC CRE 0.05% Tier 3 X X TAZORAC CRE 0.1% Tier 3 X X TAZORAC GEL 0.05% Tier 3 X X

225 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy TAZORAC GEL 0.1% Tier 3 X X TAZTIA XT CAP 120MG/24 Tier 3 TAZTIA XT CAP 180MG/24 Tier 3 TAZTIA XT CAP 240MG/24 Tier 3 TAZTIA XT CAP 300MG/24 Tier 3 TAZTIA XT CAP 360MG/24 Tier 3 TBC AER Tier 1 TDC MAX CRE Tier 3 TDM SOLUTION SOL Tier 3 TECFIDERA CAP 120MG Tier 2 X X X TECFIDERA CAP 240MG Tier 2 X X X TECFIDERA MIS STARTER Tier 2 X X X TECHLITE MIS LANCETS Tier 3 TECHNIVIE TAB Tier 3 X X TEGADERM AG PAD 2"X2" Tier 3 TEGADERM AG PAD 4"X5" Tier 3 TEGADERM AG PAD 4"X8" Tier 3 TEGADERM AG PAD 8"X8" Tier 3 TEGRETOL SUS 100/5ML Tier 3 TEGRETOL TAB 200MG Tier 3 TEGRETOL-XR TAB 100MG Tier 3 TEGRETOL-XR TAB 200MG Tier 3 TEGRETOL-XR TAB 400MG Tier 3 TEKTURNA TAB 150MG Tier 3 X TEKTURNA TAB 300MG Tier 3 X TEKTURNA HCT TAB 150-12.5 Tier 3 X TEKTURNA HCT TAB 150-25MG Tier 3 X TEKTURNA HCT TAB 300-12.5 Tier 3 X TEKTURNA HCT TAB 300-25MG Tier 3 X TELMIS/AMLOD TAB 40-10MG Tier 3 X X TELMIS/AMLOD TAB 40-5MG Tier 3 X X TELMIS/AMLOD TAB 80-10MG Tier 3 X X TELMIS/AMLOD TAB 80-5MG Tier 3 X X TELMISA/HCTZ TAB 40-12.5 Tier 3 X TELMISA/HCTZ TAB 80-12.5 Tier 3 X TELMISA/HCTZ TAB 80-25MG Tier 3 X TELMISARTAN TAB 20MG Tier 3 X TELMISARTAN TAB 40MG Tier 3 X 226 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy TELMISARTAN TAB 80MG Tier 3 X TEMAZEPAM CAP 15MG Tier 1 TEMAZEPAM CAP 22.5MG Tier 1 TEMAZEPAM CAP 30MG Tier 1 TEMAZEPAM CAP 7.5MG Tier 1 TEMODAR CAP 100MG Tier 3 X X TEMODAR CAP 140MG Tier 3 X X TEMODAR CAP 180MG Tier 3 X X TEMODAR CAP 20MG Tier 3 X X TEMODAR CAP 250MG Tier 3 X X TEMODAR CAP 5MG Tier 3 X X TEMOVATE CRE 0.05% Tier 3 X TEMOVATE GEL 0.05% Tier 3 X TEMOVATE OIN 0.05% Tier 3 X TEMOVATE SOL 0.05% Tier 3 X TEMOVATE E CRE 0.05%EML Tier 3 X TEMOZOLOMIDE CAP 100MG Tier 1 X X TEMOZOLOMIDE CAP 140MG Tier 1 X X TEMOZOLOMIDE CAP 180MG Tier 1 X X TEMOZOLOMIDE CAP 20MG Tier 1 X X TEMOZOLOMIDE CAP 250MG Tier 1 X X TEMOZOLOMIDE CAP 5MG Tier 1 X X TENCON TAB 50-325MG Tier 1 TENEX TAB 1MG Tier 3 TENEX TAB 2MG Tier 3 TENORETIC TAB 100 Tier 3 X TENORETIC TAB 50 Tier 3 X TENORMIN TAB 100MG Tier 3 X TENORMIN TAB 25MG Tier 3 X TENORMIN TAB 50MG Tier 3 X TERAZOL 3 CRE 0.8% Tier 3 TERAZOL 7 CRE 0.4% Tier 3 TERAZOSIN CAP 10MG Tier 1 TERAZOSIN CAP 1MG Tier 1 TERAZOSIN CAP 2MG Tier 1 TERAZOSIN CAP 5MG Tier 1 TERBINAFINE TAB 250MG Tier 1 X TERBUTALINE POW SULFATE Tier 3 227 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy TERBUTALINE TAB 2.5MG Tier 1 TERBUTALINE TAB 5MG Tier 1 TERCONAZOLE CRE 0.4% Tier 1 TERCONAZOLE CRE 0.8% Tier 1 TERCONAZOLE SUP 80MG Tier 1 TERODERM CRE Tier 3 X TERRELL SOL Tier 1 TERSI FOAM AER 2.25% Tier 3 TESSALON PER CAP 100MG Tier 3 TEST PLUG MIS Tier 3 TESTIM GEL 1%(50MG) Tier 2 X X TESTOST CYP INJ 100MG/ML Tier 1 TESTOST CYP INJ 200MG/ML Tier 1 TESTOST ENAN INJ 200MG/ML Tier 1 TESTOSTERONE CRY YAM Tier 3 TESTOSTERONE GEL 1%(25MG) Tier 3 X X X TESTOSTERONE GEL 1%(50MG) Tier 3 X X X TESTOSTERONE GEL 10MG/ACT Tier 3 X X X TESTOSTERONE GEL PUMP 1% Tier 3 X X X TESTOSTERONE INJ 250MG/ML Tier 3 TESTOSTERONE POW Tier 3 TESTOSTERONE POW CYPIONAT Tier 3 TESTOSTERONE POW ENANTHAT Tier 3 TESTOSTERONE POW SOY Tier 3 TESTRED CAP 10MG Tier 3 TETCAINE SOL 0.5% OP Tier 1 TETRABENAZIN TAB 12.5MG Tier 1 X TETRABENAZIN TAB 25MG Tier 1 X TETRACAINE SOL 0.5% OP Tier 1 TETRACYCLINE CAP 250MG Tier 3 TETRACYCLINE CAP 500MG Tier 3 TETRAMEX SPR 2-1-3% Tier 3 TETRAVISC SOL 0.5% OP Tier 1 TETRAVISC SOL FORTE Tier 1 TEXACORT SOL 2.5% Tier 2 TGQ 15DM/5PE SYP H/2CPM Tier 1 TGQ 30/ SYP 150/15 Tier 1 TGQ 30/PSE/3 SYP BRM/15DM Tier 1 228 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy TGQ 50PSE/3 SYP BRM/30DM Tier 1 TGT ASPIRIN CHW 81MG HCR Preventive TGT ASPIRIN CHW CHILD HCR Preventive TGT ASPIRIN TAB 325MG HCR Preventive TGT ASPIRIN TAB 81MG HCR Preventive TGT ASPIRIN TAB 81MG EC HCR Preventive TGT LANCET MIS 23G Tier 3 TGT LANCET MIS 28G Tier 3 TGT LANCET MIS 30G Tier 3 TGT LANCET MIS ALTERNAT Tier 3 TGT LANCING MIS ADV DEV Tier 3 TGT LANCING MIS DEVICE Tier 3 TGT NICOTINE DIS 14MG/24H HCR X Preventive TGT NICOTINE DIS 21MG/24H HCR X Preventive TGT NICOTINE DIS 7MG/24HR HCR X Preventive TGT NICOTINE GUM 2MG MINT HCR X Preventive TGT NICOTINE GUM 2MG ORIG HCR X Preventive TGT NICOTINE GUM 2MGFRUIT HCR X Preventive TGT NICOTINE GUM 4MG HCR X Preventive TGT NICOTINE GUM 4MG MINT HCR X Preventive TGT NICOTINE GUM 4MG ORIG HCR X Preventive TGT NICOTINE LOZ 2MG CHRY HCR X Preventive TGT NICOTINE LOZ 2MG MINT HCR X Preventive TGT NICOTINE LOZ 4MG CHRY HCR X Preventive 229 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy TGT NICOTINE LOZ 4MG MINT HCR X Preventive THALAMUS SUB COMPOSIT Tier 3 THALOMID CAP 100MG Tier 2 X X X THALOMID CAP 150MG Tier 2 X X X THALOMID CAP 200MG Tier 2 X X X THALOMID CAP 50MG Tier 2 X X X THE ELIMINAT CAP Tier 3 THEO-24 CAP 100MG CR Tier 3 THEO-24 CAP 200MG CR Tier 3 THEO-24 CAP 300MG CR Tier 3 THEO-24 CAP 400MG ER Tier 3 THEOCHRON TAB 100MG CR Tier 1 THEOCHRON TAB 200MG CR Tier 1 THEOCHRON TAB 300MG CR Tier 1 THEOPHYLLINE SOL 80/15ML Tier 1 THEOPHYLLINE TAB 100MG CR Tier 1 THEOPHYLLINE TAB 100MG ER Tier 1 THEOPHYLLINE TAB 200MG CR Tier 1 THEOPHYLLINE TAB 200MG ER Tier 1 THEOPHYLLINE TAB 300MG ER Tier 1 THEOPHYLLINE TAB 400MG ER Tier 1 THEOPHYLLINE TAB 450MG ER Tier 1 THEOPHYLLINE TAB 600MG ER Tier 1 THERA-FLUR-N DRO 1.1% Tier 3 THERAMINE CAP Tier 3 THERAMINE CAP Tier 2 THERAMINE POW PLUS Tier 3 THERATEARS CAP NUTR Tier 3 THIN LANCETS MIS Tier 3 THINLETS GP MIS 26G Tier 3 THIOGUANINE POW Tier 3 X THIOLA TAB 100MG Tier 3 X THIORIDAZINE TAB 100MG Tier 1 THIORIDAZINE TAB 10MG Tier 1 THIORIDAZINE TAB 25MG Tier 1 THIORIDAZINE TAB 50MG Tier 1 THIOTEPA POW Tier 3 X

230 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy THIOTHIXENE CAP 10MG Tier 1 THIOTHIXENE CAP 1MG Tier 1 THIOTHIXENE CAP 2MG Tier 1 THIOTHIXENE CAP 5MG Tier 1 THRIVE GUM 2MG MINT HCR X Preventive THRIVITE 19 TAB Tier 3 THRIVITE RX TAB 29-1MG Tier 3 THROMBIN KIT 5000UNIT Tier 3 THROMBIN-JMI KIT 20000UNT Tier 3 THROMBIN-JMI KIT 5000UNIT Tier 3 THROMBOGEN KIT 10000UNT Tier 3 THROMBOGEN SOL 10000UNT Tier 3 THROMBOGEN SOL 1000UNIT Tier 3 THYROLAR-1 TAB 60MG Tier 3 THYROLAR-1/2 TAB 30MG Tier 3 THYROLAR-1/4 TAB 15MG Tier 3 THYROLAR-2 TAB 120MG Tier 3 THYROLAR-3 TAB 180MG Tier 3 TIAGABINE TAB 2MG Tier 1 TIAGABINE TAB 4MG Tier 1 TIAZAC CAP 120MG/24 Tier 3 TIAZAC CAP 180MG/24 Tier 3 TIAZAC CAP 240MG/24 Tier 3 TIAZAC CAP 300MG/24 Tier 3 TIAZAC CAP 360MG/24 Tier 3 TIAZAC CAP 420MG/24 Tier 3 TICLOPIDINE TAB 250MG Tier 1 TIGAN CAP 300MG Tier 3 TIGHTENING CRE BASE Tier 3 X TIKOSYN CAP 125MCG Tier 3 TIKOSYN CAP 250MCG Tier 3 TIKOSYN CAP 500MCG Tier 3 TILIA FE TAB Tier 3 TIMOLOL GEL SOL 0.25% OP Tier 1 TIMOLOL GEL SOL 0.5% OP Tier 1 TIMOLOL MAL SOL 0.25% OP Tier 1 TIMOLOL MAL SOL 0.5% OP Tier 1

231 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy TIMOLOL MAL TAB 10MG Tier 1 TIMOLOL MAL TAB 20MG Tier 1 TIMOLOL MAL TAB 5MG Tier 1 TIMOPTIC SOL 0.25% OP Tier 3 TIMOPTIC SOL 0.5% OP Tier 3 TIMOPTIC OCU SOL 0.25% OP Tier 3 TIMOPTIC OCU SOL 0.25% OP Tier 2 TIMOPTIC OCU SOL 0.5% OP Tier 2 TIMOPTIC-XE SOL 0.25% OP Tier 3 TIMOPTIC-XE SOL 0.5% OP Tier 3 TINDAMAX TAB 250MG Tier 3 TINDAMAX TAB 500MG Tier 3 TINIDAZOLE TAB 250MG Tier 3 TINIDAZOLE TAB 500MG Tier 3 TIROSINT CAP 100MCG Tier 3 X TIROSINT CAP 112MCG Tier 3 X TIROSINT CAP 125MCG Tier 3 X TIROSINT CAP 137MCG Tier 3 X TIROSINT CAP 13MCG Tier 3 X TIROSINT CAP 150MCG Tier 3 X TIROSINT CAP 25MCG Tier 3 X TIROSINT CAP 50MCG Tier 3 X TIROSINT CAP 75MCG Tier 3 X TIROSINT CAP 88MCG Tier 3 X TISSEEL SOL Tier 3 TISSEEL VH KIT 10ML Tier 3 TISSEEL VH KIT 2ML Tier 3 TISSEEL VH KIT 4ML Tier 3 TIVICAY TAB 10MG Tier 3 X TIVICAY TAB 25MG Tier 3 X TIVICAY TAB 50MG Tier 3 X TIVORBEX CAP 20MG Tier 3 X TIVORBEX CAP 40MG Tier 3 X TIZANIDINE CAP 2MG Tier 3 TIZANIDINE CAP 4MG Tier 3 TIZANIDINE CAP 6MG Tier 3 TIZANIDINE KIT COMFORT Tier 3 X TIZANIDINE POW HCL Tier 3 X 232 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy TIZANIDINE TAB 2MG Tier 1 TIZANIDINE TAB 4MG Tier 1 TL FOLATE TAB Tier 3 TL TRISEB CRE Tier 3 TL-CARE DHA CAP 27-1-500 Tier 3 TL-FLUORIVIT CHW Tier 3 TL-ICARE CAP Tier 3 TL-SELECT CAP Tier 2 TOBI NEB 300/5ML Tier 3 X X X X TOBI PODHALR CAP 28MG Tier 3 X X X TOBRA/DEXAME SUS 0.3-0.1% Tier 3 TOBRADEX OIN 0.3-0.1% Tier 3 TOBRADEX SUS 0.3-0.1% Tier 3 TOBRADEX ST SUS 0.3-0.05 Tier 3 X X TOBRAMYCIN NEB 300/5ML Tier 3 X X X X TOBRAMYCIN SOL 0.3% OP Tier 1 TOBREX OIN 0.3% OP Tier 3 TOBREX SOL 0.3% OP Tier 3 TOCOPHEROL LIQ ALPHA Tier 3 X TOCOPHEROLS POW 30% Tier 3 X TOCOPHERYL POW SUCCINAT Tier 3 X TODAY SPONGE MIS HCR Preventive TOFRANIL TAB 10MG Tier 3 TOFRANIL TAB 25MG Tier 3 TOFRANIL TAB 50MG Tier 3 TOFRANIL-PM CAP 100MG Tier 3 TOFRANIL-PM CAP 125MG Tier 3 TOFRANIL-PM CAP 150MG Tier 3 TOFRANIL-PM CAP 75MG Tier 3 TOLAK CRE 4% Tier 3 X TOLAZAMIDE TAB 250MG Tier 1 TOLAZAMIDE TAB 500MG Tier 1 TOLBUTAMIDE TAB 500MG Tier 1 TOLCAPONE TAB 100MG Tier 1 TOLMETIN SOD CAP 400MG Tier 3 TOLMETIN SOD TAB 200MG Tier 3 TOLMETIN SOD TAB 600MG Tier 3

233 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy TOLTERODINE CAP 2MG ER Tier 3 X TOLTERODINE CAP 4MG ER Tier 3 X TOLTERODINE TAB 1MG Tier 3 X TOLTERODINE TAB 2MG Tier 3 X TOMMY GEL GEL Tier 3 TOPAMAX TAB 100MG Tier 3 X X TOPAMAX TAB 200MG Tier 3 X X TOPAMAX TAB 25MG Tier 3 X X TOPAMAX TAB 50MG Tier 3 X X TOPAMAX SPR CAP 15MG Tier 3 X X TOPAMAX SPR CAP 25MG Tier 3 X X TOPEX TOPCAL SPR ANESTHET Tier 3 TOPICORT CRE 0.05% Tier 3 X TOPICORT CRE 0.25% Tier 3 X TOPICORT GEL 0.05% Tier 3 X TOPICORT OIN 0.05% Tier 3 X TOPICORT OIN 0.25% Tier 3 X TOPICORT SPR 0.25% Tier 3 X TOPIRAMATE CAP 15MG Tier 1 TOPIRAMATE CAP 25MG Tier 1 TOPIRAMATE CAP ER 100MG Tier 3 X X TOPIRAMATE CAP ER 150MG Tier 3 X X TOPIRAMATE CAP ER 200MG Tier 3 X X TOPIRAMATE CAP ER 25MG Tier 3 X X TOPIRAMATE CAP ER 50MG Tier 3 X X TOPIRAMATE TAB 100MG Tier 1 TOPIRAMATE TAB 200MG Tier 1 TOPIRAMATE TAB 25MG Tier 1 TOPIRAMATE TAB 50MG Tier 1 TOPROL XL TAB 100MG Tier 3 TOPROL XL TAB 200MG Tier 3 TOPROL XL TAB 25MG Tier 3 TOPROL XL TAB 50MG Tier 3 TORSEMIDE TAB 100MG Tier 1 TORSEMIDE TAB 10MG Tier 1 TORSEMIDE TAB 20MG Tier 1 TORSEMIDE TAB 5MG Tier 1 TOUJEO SOLO INJ 300IU/ML Tier 3 X X 234 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy TOVIAZ TAB 4MG Tier 3 TOVIAZ TAB 8MG Tier 3 TOXICOL SALV KIT COLLECT Tier 3 TOZAL CAP Tier 3 TRACLEER TAB 125MG Tier 2 X X X TRACLEER TAB 62.5MG Tier 2 X X X TRADJENTA TAB 5MG Tier 2 X TRAMADL/APAP TAB 37.5-325 Tier 1 X TRAMADOL CRE 5% Tier 1 X TRAMADOL CRE 8% KIT Tier 1 X TRAMADOL HCL CAP 150MG ER Tier 1 TRAMADOL HCL CAP ER 100MG Tier 3 X X TRAMADOL HCL CAP ER 200MG Tier 3 X X TRAMADOL HCL CAP ER 300MG Tier 3 X X TRAMADOL HCL POW Tier 3 X TRAMADOL HCL TAB 100MG ER Tier 3 X TRAMADOL HCL TAB 100MG ER Tier 3 X X TRAMADOL HCL TAB 200MG ER Tier 3 X TRAMADOL HCL TAB 200MG ER Tier 3 X X TRAMADOL HCL TAB 300MG ER Tier 3 X TRAMADOL HCL TAB 300MG ER Tier 3 X X TRAMADOL HCL TAB 50MG Tier 1 TRANDO/VERAP TAB 1-240 CR Tier 3 TRANDO/VERAP TAB 1-240 ER Tier 3 TRANDO/VERAP TAB 2-180 CR Tier 3 TRANDO/VERAP TAB 2-180 ER Tier 3 TRANDO/VERAP TAB 2-240 CR Tier 3 TRANDO/VERAP TAB 2-240 ER Tier 3 TRANDO/VERAP TAB 4-240 ER Tier 3 TRANDOLAPRIL TAB 1MG Tier 1 TRANDOLAPRIL TAB 2MG Tier 1 TRANDOLAPRIL TAB 4MG Tier 1 TRANEX ACID TAB 650MG Tier 3 X TRANS-PEN CRE Tier 3 TRANSDERM-SC DIS 1MG Tier 3 TRANSDERMAL CRE PAIN BAS Tier 3 TRANSMITTER MIS TAPE Tier 3 TRANXENE T TAB 3.75MG Tier 3 235 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy TRANXENE T TAB 7.5MG Tier 3 TRANYLCYPROM TAB 10MG Tier 1 TRANZGEL GEL Tier 3 TRAVATAN Z DRO 0.004% Tier 2 X TRAVOPROST DRO 0.004% Tier 3 X TRAZODONE TAB 100MG Tier 1 TRAZODONE TAB 150MG Tier 1 TRAZODONE TAB 300MG Tier 1 TRAZODONE TAB 50MG Tier 1 TRECATOR TAB 250MG Tier 2 TRENTAL TAB 400MG Tier 3 TRESIBA FLEX INJ 100UNIT Tier 3 X X TRESIBA FLEX INJ 200UNIT Tier 3 X X TRETIN-X CRE 0.0375% Tier 3 X X X TRETIN-X CRE 0.075% Tier 3 X X TRETIN-X CRE KIT 0.05% Tier 3 X X X TRETINOIN CAP 10MG Tier 3 X X TRETINOIN CRE 0.025% Tier 1 X X TRETINOIN CRE 0.05% Tier 1 X X TRETINOIN CRE 0.1% Tier 1 X X TRETINOIN GEL 0.01% Tier 1 X X TRETINOIN GEL 0.025% Tier 1 X X TRETINOIN GEL 0.04% Tier 3 X X X TRETINOIN GEL 0.04%PMP Tier 3 X X X TRETINOIN GEL 0.05% Tier 3 X X X TRETINOIN GEL 0.1% Tier 3 X X X TRETINOIN GEL 0.1%PUMP Tier 3 X X X TRETINOIN POW Tier 3 X X TRETTEN INJ Tier 3 X TREXALL TAB 10MG Tier 2 TREXALL TAB 15MG Tier 2 TREXALL TAB 5MG Tier 2 TREXALL TAB 7.5MG Tier 2 TREXIMET TAB 10-60MG Tier 3 X TREXIMET TAB 85-500MG Tier 3 X X TREZIX CAP Tier 3 X TRI-CHLOR LIQ 80% Tier 2

236 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy TRI-ESTARYLL TAB HCR Preventive TRI-LEGEST TAB FE Tier 3 TRI-LINYAH TAB HCR Preventive TRI-LO TAB ESTARYLL Tier 1 TRI-LO- TAB MARZIA Tier 1 TRI-LO- TAB SPRINTEC Tier 1 TRI-NORINYL TAB 28 Tier 3 TRI-PREVIFEM TAB HCR Preventive TRI-SPRINTEC TAB HCR Preventive TRI-TABS DHA MIS Tier 3 TRI-VI-FLOR SUS 0.25/ML Tier 3 TRI-VI-FLOR SUS 0.5MG/ML Tier 3 TRI-VI-FLORO SUS 0.25/ML Tier 3 TRI-VI-FLORO SUS 0.5MG/ML Tier 3 TRI-VIT/FE DRO /FL 0.25 Tier 1 TRI-VIT/FL DRO 0.25MG Tier 1 TRI-VIT/FL DRO 0.5MG Tier 1 TRI-VIT/FLUO DRO 0.25MG Tier 1 TRI-VIT/FLUO DRO 0.5MG Tier 1 TRI-VITA/FL DRO 0.25MG Tier 1 TRIADVANCE TAB Tier 1 TRIAMCIN/ORA PST 0.1% Tier 1 TRIAMCINOLON AER SPRAY Tier 1 TRIAMCINOLON CRE 0.025% Tier 1 TRIAMCINOLON CRE 0.1% Tier 1 TRIAMCINOLON CRE 0.5% Tier 1 TRIAMCINOLON LOT 0.025% Tier 1 TRIAMCINOLON LOT 0.1% Tier 1 TRIAMCINOLON OIN 0.025% Tier 1 TRIAMCINOLON OIN 0.1% Tier 1 TRIAMCINOLON OIN 0.5% Tier 1 TRIAMCINOLON POW Tier 3 X TRIAMCINOLON POW ACETONID Tier 3 X TRIAMCINOLON POW DIACETAT Tier 3 X

237 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy TRIAMCINOLON POW HEXACETO Tier 3 X TRIAMCINOLON PST 0.1% Tier 1 TRIAMT/HCTZ CAP 37.5-25 Tier 1 TRIAMT/HCTZ CAP 50-25MG Tier 1 TRIAMT/HCTZ CAP 50/25 Tier 1 TRIAMT/HCTZ TAB 37.5-25 Tier 1 TRIAMT/HCTZ TAB 75-50MG Tier 1 TRIANEX OIN 0.05% Tier 3 X TRIAZOLAM TAB 0.125MG Tier 1 TRIAZOLAM TAB 0.25MG Tier 1 TRIBENZOR20- TAB 5-12.5MG Tier 3 X X TRIBENZOR40- TAB 10-12.5 Tier 3 X X TRIBENZOR40- TAB 10-25MG Tier 3 X X TRIBENZOR40- TAB 5-12.5MG Tier 3 X X TRIBENZOR40- TAB 5-25MG Tier 3 X X TRICARE CHW PRENATAL Tier 3 TRICARE PAK PRENATAL Tier 3 TRICARE TAB PRENATAL Tier 3 TRICARE PRE CAP 27-1-500 Tier 3 TRICITRASOL CON Tier 3 TRICITRATES SOL Tier 1 TRICOR TAB 145MG Tier 3 X TRICOR TAB 48MG Tier 3 X TRIDERM CRE 0.1% Tier 1 TRIDERMA CRE FORTE Tier 3 X TRIDESILON CRE 0.05% Tier 3 X TRIFERIC SOL Tier 3 TRIFLUOPERAZ TAB 10MG Tier 1 TRIFLUOPERAZ TAB 1MG Tier 1 TRIFLUOPERAZ TAB 2MG Tier 1 TRIFLUOPERAZ TAB 5MG Tier 1 TRIFLURIDINE SOL 1% OP Tier 1 TRIGLIDE TAB 160MG Tier 3 X TRIHEXYPHEN ELX 0.4MG/ML Tier 1 TRIHEXYPHEN TAB 2MG Tier 1 TRIHEXYPHEN TAB 5MG Tier 1 TRILEPTAL SUS 300MG/5M Tier 3 X X TRILEPTAL TAB 150MG Tier 3 X X 238 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy TRILEPTAL TAB 300MG Tier 3 X X TRILEPTAL TAB 600MG Tier 3 X X TRILIPIX CAP 135MG Tier 3 X TRILIPIX CAP 45MG Tier 3 X TRILYTE SOL HCR Preventive TRIMETHOBENZ CAP 300MG Tier 1 TRIMETHOPRIM SOL POLYMYXN Tier 1 TRIMETHOPRIM TAB 100MG Tier 1 TRIMIPRAMINE CAP 100MG Tier 3 TRIMIPRAMINE CAP 25MG Tier 3 TRIMIPRAMINE CAP 50MG Tier 3 TRINATAL GT TAB Tier 2 TRINATAL RX TAB 1 Tier 1 TRINATE TAB Tier 1 TRINESSA TAB HCR Preventive TRINESSA LO TAB Tier 1 TRINTELLIX TAB 10MG Tier 3 X X TRINTELLIX TAB 20MG Tier 3 X X TRINTELLIX TAB 5MG Tier 3 X X TRIPLE PMB SOL Tier 3 X TRIPLE PMK SOL Tier 3 X TRISEON CRE Tier 3 X TRISTART DHA CAP Tier 3 TRIUMEQ TAB Tier 2 X TRIVEEN-DUO PAK DHA Tier 2 TRIVEEN-PRX CAP RNF Tier 2 TRIVORA-28 TAB HCR Preventive TRIZIVIR TAB Tier 3 X TROKENDI XR CAP 100MG Tier 3 X X TROKENDI XR CAP 200MG Tier 3 X X TROKENDI XR CAP 25MG Tier 3 X X TROKENDI XR CAP 50MG Tier 3 X X TROMBONEX CAP Tier 3 TROPAZONE LOT Tier 3 X TROPICAMIDE SOL 0.5% OP Tier 1

239 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy TROPICAMIDE SOL 1% OP Tier 1 TROSPIUM CHL CAP 60MG ER Tier 3 X TROSPIUM CL TAB 20MG Tier 3 X TRUE METRIX KIT AIR Tier 3 TRUE METRIX KIT METER Tier 3 TRUE METRIX MIS AIR Tier 3 TRUE METRIX SOL LEVEL 1 Tier 2 TRUE METRIX SOL LEVEL 2 Tier 2 TRUE METRIX SOL LEVEL 3 Tier 2 TRUE METRIX TES Tier 3 X TRUE METRIX TES GLUCOSE Tier 3 X TRUE2GO KIT Tier 3 TRUECONTROL LIQ LEVEL 0 Tier 2 TRUECONTROL LIQ LEVEL 1 Tier 2 TRUEDRAW MIS LANC DEV Tier 3 TRUERESULT KIT Tier 3 TRUERESULT KIT MONITOR Tier 3 TRUETEST LIQ LEVEL 1 Tier 2 TRUETEST LIQ LEVEL 2 Tier 2 TRUETEST LIQ LEVEL 3 Tier 2 TRUETEST TES Tier 3 X TRUETEST TES BLD GLUC Tier 3 X TRUETRACK KIT SYSTEM Tier 3 TRUETRACK MIS BLD GLC Tier 3 TRUETRACK TES Tier 3 X TRUETRACK TES BLD GLUC Tier 3 X TRULICITY INJ 0.75/0.5 Tier 3 X X TRULICITY INJ 1.5/0.5 Tier 3 X X TRUPLUS LANC MIS 26G Tier 3 TRUPLUS LANC MIS 28G Tier 3 TRUPLUS LANC MIS 30G Tier 3 TRUPLUS LANC MIS 33G Tier 3 TRUSOPT SOL 2% OP Tier 3 TRUVADA TAB 100-150 Tier 3 X TRUVADA TAB 133-200 Tier 3 X TRUVADA TAB 167-250 Tier 3 X TRUVADA TAB 200-300 Tier 3 X TRYPTOPHAN CAP 500MG Tier 3 240 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy TUDORZA PRES AER 400/ACT Tier 2 X TURPENTINE SOL SPIRITS Tier 3 TUSNEL CAP Tier 3 TUSSICAPS CAP 10-8MG Tier 3 TUSSICAPS CAP 5-4MG Tier 3 TUSSIGON TAB 5-1.5MG Tier 1 TUSSIONEX SUS 10-8/5ML Tier 3 X TUZISTRA XR SUS Tier 3 X X TWYNSTA TAB 40-10MG Tier 3 X X TWYNSTA TAB 40-5MG Tier 3 X X TWYNSTA TAB 80-10MG Tier 3 X X TWYNSTA TAB 80-5MG Tier 3 X X TYBOST TAB 150MG Tier 2 X TYKERB TAB 250MG Tier 2 X X X TYLENOL/COD TAB #3 Tier 3 X TYLENOL/COD TAB #4 Tier 3 X TYR COOLER LIQ 20 Tier 3 TYR COOLER LIQ RED Tier 3 TYROS 1 POW Tier 3 TYROS 2 POW Tier 3 TYROSINE CAP 500MG Tier 1 TYROSINE PAK 1000MG Tier 3 TYVASO SOL 0.6MG/ML Tier 2 X X TYVASO REFIL SOL 0.6MG/ML Tier 2 X X TYVASO START SOL 0.6MG/ML Tier 2 X X TYZEKA TAB 600MG Tier 3 X TYZINE PED DRO 0.05% Tier 3 U-BASE CRE Tier 3 X U-MILD SHA Tier 3 X X UBIDECARENON POW Tier 3 X UBIQUINOL POW Tier 3 X UBIQUINOL POW 30% Tier 3 X UCD TRIO POW Tier 3 UCERIS AER 2MG/ACT Tier 3 X UCERIS TAB 9MG Tier 3 ULESFIA LOT 5% Tier 3 ULORIC TAB 40MG Tier 3 X X ULORIC TAB 80MG Tier 3 X X 241 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ULTANE SOL Tier 3 ULTILET ALCH PAD SWAB Tier 1 ULTILET OPER MIS DEVICE Tier 3 ULTIMA KIT MONITOR Tier 3 X ULTIMA TES Tier 3 X ULTIMATECARE CAP ONE Tier 1 ULTIMATECARE CAP ONE NF Tier 1 ULTRA ENERGY TAB Tier 3 ULTRA THIN MIS LANC 26G Tier 3 ULTRA THIN MIS LANC 28G Tier 3 ULTRA THIN MIS LANC 30G Tier 3 ULTRA THIN MIS LANCETS Tier 3 ULTRACAL LIQ Tier 3 ULTRACAL HN LIQ PLUS Tier 3 ULTRACET TAB 37.5-325 Tier 3 X ULTRADERM CRE Tier 3 X ULTRAFLEX MIS 12"/6MM Tier 2 ULTRAFLEX MIS 24"/10MM Tier 2 ULTRAFLEX MIS 24"/6MM Tier 2 ULTRAFLEX MIS 24"/8MM Tier 2 ULTRAFLEX MIS 31"/10MM Tier 2 ULTRAFLEX MIS 31"/6MM Tier 2 ULTRAFLEX MIS 31"/8MM Tier 2 ULTRAFLEX MIS 43"/10MM Tier 2 ULTRAFLEX MIS 43"/8MM Tier 2 ULTRAM TAB 50MG Tier 3 ULTRAM ER TAB 100MG Tier 3 X ULTRAM ER TAB 200MG Tier 3 X ULTRAM ER TAB 300MG Tier 3 X ULTRAVATE CRE 0.05% Tier 3 X ULTRAVATE LOT 0.05% Tier 3 X X ULTRAVATE OIN 0.05% Tier 3 X ULTRAVATE X KIT 0.05-10% Tier 3 X ULTRAVATE X KIT 0.05-10% Tier 3 X ULTRESA CAP 13800UNT Tier 3 X ULTRESA CAP 20700UNT Tier 3 X ULTRESA CAP 23000UNT Tier 3 X UMECTA EMU Tier 3 X 242 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy UMECTA MOUSS AER 40% Tier 3 X UMECTA NAIL SUS FILM Tier 3 X UMECTA PD EMU 40-0.3% Tier 3 X UMECTA PD SUS 40-0.3% Tier 3 X UNFINE PNTP MIS 32GX4MM Tier 2 UNIFINE PNTP MIS 29GX1/2" Tier 2 UNIFINE PNTP MIS 29GX12MM Tier 2 UNIFINE PNTP MIS 31GX3/16 Tier 2 UNIFINE PNTP MIS 31GX5/16 Tier 2 UNIFINE PNTP MIS 31GX5MM Tier 2 UNIFINE PNTP MIS 31GX6MM Tier 2 UNIFINE PNTP MIS 31GX8MM Tier 2 UNILET EX II MIS 28G Tier 3 UNILET EXCEL MIS 23G Tier 3 UNILET G.P MIS SUPR 23G Tier 3 UNILET G.P. MIS 21G Tier 3 UNILET LANCT MIS 30G Tier 3 UNILET LANCT MIS 33G Tier 3 UNILET SUPER MIS 23G Tier 3 UNISTIK 1 MIS 2.4MM Tier 3 UNISTIK 1 MIS 3.0MM Tier 3 UNISTIK 2 MIS 1.8MM Tier 3 UNISTIK 2 MIS 2.4MM Tier 3 UNISTIK 2 MIS EXTRA Tier 3 UNISTIK 2 MIS SUPER Tier 3 UNISTIK 3 MIS 1.8MM Tier 3 UNISTIK II MIS LANCETS Tier 1 UNISTRIP1 TES GENERIC Tier 3 X X UNITH DIRECT TAB 100MCG Tier 1 UNITH DIRECT TAB 112MCG Tier 1 UNITH DIRECT TAB 125MCG Tier 1 UNITH DIRECT TAB 150MCG Tier 1 UNITH DIRECT TAB 175MCG Tier 1 UNITH DIRECT TAB 200MCG Tier 1 UNITH DIRECT TAB 25MCG Tier 1 UNITH DIRECT TAB 300MCG Tier 1 UNITH DIRECT TAB 50MCG Tier 1 UNITH DIRECT TAB 75MCG Tier 1 243 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy UNITH DIRECT TAB 88MCG Tier 1 UNITHROID TAB 100MCG Tier 1 UNITHROID TAB 112MCG Tier 1 UNITHROID TAB 125MCG Tier 1 UNITHROID TAB 137MCG Tier 1 UNITHROID TAB 150MCG Tier 1 UNITHROID TAB 175MCG Tier 1 UNITHROID TAB 200MCG Tier 1 UNITHROID TAB 25MCG Tier 1 UNITHROID TAB 300MCG Tier 1 UNITHROID TAB 50MCG Tier 1 UNITHROID TAB 75MCG Tier 1 UNITHROID TAB 88MCG Tier 1 UPTRAVI TAB 1000MCG Tier 3 X X X UPTRAVI TAB 1200MCG Tier 3 X X X UPTRAVI TAB 1400MCG Tier 3 X X X UPTRAVI TAB 1600MCG Tier 3 X X X UPTRAVI TAB 200/800 Tier 3 X X X UPTRAVI TAB 200MCG Tier 3 X X X UPTRAVI TAB 400MCG Tier 3 X X X UPTRAVI TAB 600MCG Tier 3 X X X UPTRAVI TAB 800MCG Tier 3 X X X UR N-C TAB Tier 1 URAMAXIN AER 20% Tier 3 URAMAXIN CRE 45% Tier 3 URAMAXIN GEL 45% Tier 3 URAMAXIN LOT 45% Tier 3 URAMAXIN GT GEL 45% Tier 3 X URAMAXIN GT KIT 45% Tier 3 X URAMIT MB CAP 118MG Tier 1 URE-K CRE 50% Tier 1 UREA CRE 39% Tier 1 UREA CRE 40% Tier 1 UREA CRE 45% Tier 1 UREA CRE 47% Tier 1 X UREA CRE 50% Tier 1 UREA EMU 50% Tier 1 UREA GEL 40% Tier 1 244 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy UREA LOT 40% Tier 1 UREA LOT 45% Tier 1 UREA POW Tier 3 UREA SUS 50% Tier 1 UREA 40% SUS NAIL Tier 1 UREA HYDRATI AER 35% Tier 1 UREA NAIL GEL 45% Tier 1 UREA NAIL KIT Tier 1 UREA NAIL MIS 50% Tier 1 UREA TOPICAL SUS 40% Tier 1 UREA-C40 LOT 40% Tier 1 URECHOLINE TAB 10MG Tier 3 URECHOLINE TAB 25MG Tier 3 URECHOLINE TAB 50MG Tier 3 URECHOLINE TAB 5MG Tier 3 URELLE TAB Tier 1 URETRON D/S TAB Tier 1 URIBEL CAP 118MG Tier 3 URIMAR-T TAB Tier 2 URIN D/S TAB Tier 1 URINX MEDIC KIT SPECIMEN Tier 3 URO-458 TAB Tier 1 URO-BLUE TAB 81.6MG Tier 1 URO-L TAB 81MG Tier 1 URO-MP CAP 118MG Tier 1 UROAV-81 TAB Tier 1 UROAV-B CAP Tier 1 UROCIT-K 10 TAB Tier 3 UROCIT-K 15 TAB Tier 3 UROCIT-K 5 TAB Tier 3 UROGESIC- TAB BLUE Tier 3 UROLET MB TAB Tier 1 UROPHEN MB TAB 81.6MG Tier 1 UROXATRAL TAB 10MG Tier 3 URSO 250 TAB 250MG Tier 3 URSO FORTE TAB 500MG Tier 3 URSODIOL CAP 300MG Tier 1 URSODIOL TAB 250MG Tier 1 245 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy URSODIOL TAB 500MG Tier 1 URYL TAB Tier 2 USTELL CAP Tier 1 UTA CAP 120MG Tier 3 UTIBRON CAP NEOHALER Tier 2 X UTICAP CAP Tier 1 UTIRA-C TAB Tier 1 UTOPIC CRE 41% Tier 3 X UTRONA-C TAB Tier 1 V-MAX CRE Tier 3 X V-R ALC PREP PAD SWABS Tier 1 VACUSTIM KIT BLACK Tier 3 X VAGIFEM TAB 10MCG Tier 2 VALACYCLOVIR TAB 1GM Tier 3 X VALACYCLOVIR TAB 500MG Tier 3 X VALCHLOR GEL 0.016% Tier 2 X X X VALCYTE SOL 50MG/ML Tier 3 VALCYTE TAB 450MG Tier 3 X X VALGANCICLOV SOL 50MG/ML Tier 1 VALGANCICLOV TAB 450MG Tier 1 X VALIDERM CRE Tier 3 X VALINE PAK 50MG Tier 3 VALINE 1000 POW Tier 3 VALIUM TAB 10MG Tier 3 X VALIUM TAB 2MG Tier 3 X VALIUM TAB 5MG Tier 3 X VALPROIC ACD CAP 250MG Tier 1 VALPROIC ACD SOL 250/5ML Tier 1 VALPROIC ACD SYP 250/5ML Tier 1 VALSART/HCTZ TAB 160-12.5 Tier 1 X VALSART/HCTZ TAB 160-25MG Tier 1 X VALSART/HCTZ TAB 320-12.5 Tier 1 X VALSART/HCTZ TAB 320-25MG Tier 1 X VALSART/HCTZ TAB 80-12.5 Tier 1 X VALSARTAN TAB 160MG Tier 3 X VALSARTAN TAB 320MG Tier 3 X VALSARTAN TAB 40MG Tier 3 X VALSARTAN TAB 80MG Tier 3 X 246 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy VALTREX TAB 1GM Tier 3 X X VALTREX TAB 500MG Tier 3 X X VANACHOL CAP Tier 3 VANATOL LQ SOL Tier 1 X VANCOCIN HCL CAP 250MG Tier 3 X VANCOMYCIN CAP 125MG Tier 1 X VANCOMYCIN CAP 250MG Tier 1 X VANCOMYCIN SUS +SYRSPEN Tier 3 X VANCOMYCN 25 SOL 25MG/ML Tier 3 X VANCOMYCN 50 SOL 50MG/ML Tier 3 X VANDAZOLE GEL 0.75% Tier 2 VANIBASE CRE Tier 3 X VANISH-PEN CRE Tier 3 X VANISHING CRE Tier 3 X VANISHING CRE BOTANCAL Tier 3 X VANOS CRE 0.1% Tier 3 X X VANOXIDE-HC LOT 5-0.5% Tier 3 VARIBAR PST PUDDING Tier 3 VARIBAR HONE SUS 40% Tier 3 VARIBAR NECT SUS 40% Tier 3 VARIBAR THIN SUS HONEY Tier 3 VARIBAR THIN SUS LIQUID Tier 3 VARUBI TAB 90MG Tier 2 X VASCEPA CAP 0.5GM Tier 3 X X VASCEPA CAP 1GM Tier 3 X VASCUDERM GEL HYDROGEL Tier 3 X VASCUDERM KIT STASIS Tier 3 X VASERETIC TAB 10-25MG Tier 3 X VASOFLEX CAP Tier 3 VASOFLEX CAP FORTE Tier 1 VASOFLEX TAB Tier 1 VASOFLEX HD TAB Tier 1 VASOTEC TAB 10MG Tier 3 X VASOTEC TAB 2.5MG Tier 3 X VASOTEC TAB 20MG Tier 3 X VASOTEC TAB 5MG Tier 3 X VAYACOG CAP Tier 3 VAYARIN CAP Tier 3 247 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy VCF VAGINAL AER CONTRACP HCR Preventive VCF VAGINAL GEL CONTRACE HCR Preventive VCF VAGINAL MIS CONTRACP HCR Preventive VECAMYL TAB 2.5MG Tier 3 X X VECTICAL OIN 3MCG/GM Tier 3 X VELIVET PAK HCR Preventive VELPHORO CHW 500MG Tier 2 VELTASSA POW 16.8GM Tier 3 X X VELTASSA POW 25.2GM Tier 3 X X VELTASSA POW 8.4GM Tier 3 X X VELTIN GEL Tier 3 X X VELTRIX CRE 4-1% Tier 3 VEMAVITE- CAP PRX 2 Tier 3 VEMLIDY TAB 25MG Tier 3 X VENA-BAL MIS DHA Tier 2 VENCLEXTA TAB 100MG Tier 3 X X X VENCLEXTA TAB 10MG Tier 3 X X X VENCLEXTA TAB 50MG Tier 3 X X X VENCLEXTA TAB START PK Tier 3 X X VENLAFAXINE CAP 150MG ER Tier 1 VENLAFAXINE CAP 37.5 ER Tier 1 VENLAFAXINE CAP 75MG ER Tier 1 VENLAFAXINE TAB 100MG Tier 1 VENLAFAXINE TAB 150MG ER Tier 3 X X VENLAFAXINE TAB 225MG ER Tier 3 X X VENLAFAXINE TAB 25MG Tier 1 VENLAFAXINE TAB 37.5 ER Tier 3 X X VENLAFAXINE TAB 37.5MG Tier 1 VENLAFAXINE TAB 50MG Tier 1 VENLAFAXINE TAB 75MG Tier 1 VENLAFAXINE TAB 75MG ER Tier 3 X X VENTAVIS SOL 10MCG/ML Tier 2 X X VENTAVIS SOL 20MCG/ML Tier 2 X X VENTOLIN HFA AER Tier 2 X

248 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy VERAMYST SPR 27.5MCG Tier 3 X X VERAPAMIL CAP 100MG ER Tier 3 VERAPAMIL CAP 120MG ER Tier 1 VERAPAMIL CAP 120MG SR Tier 1 VERAPAMIL CAP 180MG ER Tier 1 VERAPAMIL CAP 180MG SR Tier 1 VERAPAMIL CAP 200MG ER Tier 3 VERAPAMIL CAP 240MG ER Tier 1 VERAPAMIL CAP 240MG SR Tier 1 VERAPAMIL CAP 300MG ER Tier 3 VERAPAMIL CAP 360MG SR Tier 1 VERAPAMIL TAB 120MG Tier 1 VERAPAMIL TAB 120MG ER Tier 1 VERAPAMIL TAB 180MG ER Tier 1 VERAPAMIL TAB 240MG ER Tier 1 VERAPAMIL TAB 40MG Tier 1 VERAPAMIL TAB 80MG Tier 1 VERCOLATE TAB 5MG EC HCR Preventive VERDESO AER 0.05% Tier 3 X X VERDROCET TAB 2.5-325 Tier 1 VEREGEN OIN 15% Tier 3 X VERELAN CAP 120MG SR Tier 3 VERELAN CAP 180MG SR Tier 3 VERELAN CAP 240MG SR Tier 3 VERELAN CAP 360MG SR Tier 3 VERELAN PM CAP 100MG ER Tier 3 VERELAN PM CAP 200MG ER Tier 3 VERELAN PM CAP 300MG ER Tier 3 VERIO FLEX KIT ONETOUCH Tier 1 VERIPRED 20 SOL 20MG/5ML Tier 3 VERRUNEX CRE Tier 3 X VERSABASE GEL Tier 3 VERSACLOZ SUS 50MG/ML Tier 3 X VERSAFREE SYP Tier 3 VERSAPLUS SYP Tier 3 VERSAPRO CRE Tier 3 X VERSAPRO GEL Tier 3

249 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy VERSAPRO SHA Tier 3 X X VERSATILE CRE BASE Tier 3 X VERSATILE CRE RICH BSE Tier 3 X VERSIGEL CRE Tier 3 X VESICARE TAB 10MG Tier 3 X VESICARE TAB 5MG Tier 3 X VESTURA TAB 3-0.02MG Tier 3 VEXOL SUS 1% OP Tier 2 VFEND SUS 40MG/ML Tier 3 VFEND TAB 200MG Tier 3 X VFEND TAB 50MG Tier 3 X VHC 2.25 LIQ VANILLA Tier 3 VIAGRA TAB 100MG Tier 3 X VIAGRA TAB 25MG Tier 3 X VIAGRA TAB 50MG Tier 3 X VIBERZI TAB 100MG Tier 3 X X VIBERZI TAB 75MG Tier 3 X X VIBRAMYCIN CAP 100MG Tier 3 VIBRAMYCIN SUS 25MG/5ML Tier 3 VIBRAMYCIN SYP 50MG/5ML Tier 3 VICODIN TAB 5-300MG Tier 3 X X VICODIN ES TAB 7.5-300 Tier 3 X X VICODIN HP TAB 10-300MG Tier 3 X X VICOPROFEN TAB 7.5-200 Tier 3 VICTOZA INJ 18MG/3ML Tier 2 X VICTOZA INJ 18MG/3ML Tier 3 X VICTRELIS CAP 200MG Tier 3 X X X VIDEX SOL 2GM Tier 2 X VIDEX SOL 4GM Tier 2 X VIDEX EC CAP 125MG Tier 3 X VIDEX EC CAP 200MG Tier 3 X VIDEX EC CAP 250MG Tier 3 X VIDEX EC CAP 400MG Tier 3 X VIEKIRA PAK TAB Tier 3 X X X X VIEKIRA XR TAB Tier 3 X X X VIENVA TAB 0.1-20 HCR Preventive VIGAMOX DRO 0.5% Tier 3

250 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy VIIBRYD KIT Tier 3 X VIIBRYD KIT STARTER Tier 3 VIIBRYD TAB 10MG Tier 3 X VIIBRYD TAB 20MG Tier 3 X VIIBRYD TAB 40MG Tier 3 X VIMPAT SOL 10MG/ML Tier 3 X VIMPAT TAB 100MG Tier 3 X VIMPAT TAB 150MG Tier 3 X VIMPAT TAB 200MG Tier 3 X VIMPAT TAB 50MG Tier 3 X VINATE DHA CAP 27-1.13 Tier 3 VINATE II TAB Tier 1 VINATE M TAB Tier 1 VINATE ONE TAB Tier 1 VIOKACE TAB Tier 3 X VIOKACE TAB 20880 Tier 3 X VIORELE TAB Tier 3 VIRACEPT TAB 250MG Tier 2 X VIRACEPT TAB 625MG Tier 2 X VIRAMUNE SUS 50MG/5ML Tier 3 X VIRAMUNE TAB 200MG Tier 3 X X VIRAMUNE XR TAB 100MG Tier 3 X X VIRAMUNE XR TAB 400MG Tier 3 X X VIRAZOLE INH 6GM Tier 2 VIREAD POW 40MG/GM Tier 3 X VIREAD TAB 150MG Tier 2 X VIREAD TAB 200MG Tier 2 X VIREAD TAB 250MG Tier 2 X VIREAD TAB 300MG Tier 2 X VIROPTIC SOL 1% OP Tier 3 VIRT NATE TAB Tier 3 VIRT NATE TAB 28-1MG Tier 3 VIRT-ADVANCE TAB 90-1MG Tier 2 VIRT-C DHA CAP Tier 3 VIRT-CARE CAP ONE Tier 2 VIRT-NATE CAP DHA Tier 3 VIRT-PHOS TAB 250 NEUT Tier 1 VIRT-PN TAB Tier 3 251 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy VIRT-PN DHA CAP Tier 3 VIRT-PN PLUS CAP Tier 3 VIRT-SELECT CAP Tier 3 VIRT-VITE GT TAB 90-1MG Tier 2 VIRTPREX CAP Tier 3 VIRTRATE-2 SOL Tier 1 VIRTRATE-2 SOL 500-334 Tier 1 VIRTRATE-3 SOL Tier 1 VIRTRATE-K SOL Tier 1 VIRTRATE-K SOL 1100-334 Tier 1 VIRTUSSIN AC SOL 100-10/5 Tier 1 VISTARIL CAP 25MG Tier 3 VISTARIL CAP 50MG Tier 3 VISTOGARD PAK 10GM Tier 2 X X VIT A/C/D/FL DRO 0.25MG Tier 1 VIT D CHILD CHW 1000UNIT HCR Preventive VITA-PREN TAB Tier 3 VITAFOL CAP ULTRA Tier 3 VITAFOL CHW GUMMIES Tier 3 VITAFOL FE+ CAP Tier 3 VITAFOL-NANO TAB Tier 3 VITAFOL-OB PAK +DHA Tier 3 VITAFOL-OB TAB 65-1MG Tier 3 VITAFOL-ONE CAP Tier 3 VITAJOULE POW Tier 3 VITAMEDMD CAP ONE RX Tier 3 VITAMEDMD MIS PLUS RX Tier 3 VITAMIN C POW Tier 3 X VITAMIN D CAP 1000UNIT HCR Preventive VITAMIN D CAP 400UNIT HCR Preventive VITAMIN D CAP 50000UNT Tier 1 VITAMIN D CHW 400UNIT HCR Preventive VITAMIN D DRO 400UNIT HCR Preventive

252 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy VITAMIN D TAB 1000UNIT HCR Preventive VITAMIN D TAB 400UNIT HCR Preventive VITAMIN D-3 TAB 1000UNIT HCR Preventive VITAMIN D2 TAB 400UNIT HCR Preventive VITAMIN D3 CAP 1000UNIT HCR Preventive VITAMIN D3 CAP 400UNIT HCR Preventive VITAMIN D3 CHW 1000UNIT HCR Preventive VITAMIN D3 CHW 400UNIT HCR Preventive VITAMIN D3 DRO 400UNIT HCR Preventive VITAMIN D3 LIQ Tier 3 X VITAMIN D3 POW Tier 3 X VITAMIN D3 POW Tier 3 X VITAMIN D3 TAB 1000UNIT HCR Preventive VITAMIN D3 TAB 400UNIT HCR Preventive VITAMIN E LIQ Tier 3 X VITAMIN E LIQ ACETATE Tier 3 X VITAMIN E POW ACETATE Tier 3 X VITAMIN E POW SUCCINAT Tier 3 X VITAMIN K2 POW 0.2% Tier 3 X VITAPEARL CAP Tier 3 VITAPRO POW Tier 3 VITATRUE MIS Tier 3 VITEKTA TAB 150MG Tier 2 X VITEKTA TAB 85MG Tier 2 X VITUZ SOL 5-4MG Tier 3 X X VIVA DHA CAP Tier 3 VIVELLE-DOT DIS 0.025MG Tier 2 X VIVELLE-DOT DIS 0.0375MG Tier 2 X VIVELLE-DOT DIS 0.05MG Tier 2 X 253 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy VIVELLE-DOT DIS 0.075MG Tier 2 X VIVELLE-DOT DIS 0.1MG Tier 2 X VIVID PAL KIT METER Tier 3 VIVID PAL MIS METER Tier 3 VIVLODEX CAP 10MG Tier 3 X X VIVLODEX CAP 5MG Tier 3 X X VIVONEX RTF LIQ Tier 3 VOGELXO GEL 1%(50MG) Tier 3 X X X VOGELXO GEL PUMP 1% Tier 3 X X X VOL-NATE TAB Tier 3 VOL-PLUS TAB Tier 3 VOL-TAB RX TAB Tier 3 VOLTAREN GEL 1% Tier 2 VOLTAREN-XR TAB 100MG Tier 3 VOLUMEN SUS 0.1% Tier 2 VONVENDI INJ 1300UNIT Tier 3 X VONVENDI INJ 650UNIT Tier 3 X VOPAC CRE 10-2% Tier 3 X VOPAC 5 CRE 5% Tier 3 X VOPAC GB CRE 5-2-5% Tier 3 X VOPAC KT CRE 5-5-2% Tier 3 X VORICONAZOLE SUS 40MG/ML Tier 1 VORICONAZOLE TAB 200MG Tier 1 X VORICONAZOLE TAB 50MG Tier 1 X VORTEX VALVE MIS CHAMBER Tier 2 VOSPIRE ER TAB 4MG Tier 3 VOSPIRE ER TAB 8MG Tier 3 VOTRIENT TAB 200MG Tier 2 X X X VP-CH PLUS CAP Tier 3 VP-CH-PNV CAP Tier 3 VP-CH-PNV CAP Tier 2 VP-GGR-B6 TAB PRENATAL Tier 2 VP-GSTN CAP Tier 1 VP-HEME OB MIS + DHA Tier 3 VP-HEME OB TAB Tier 3 VP-HEME ONE CAP Tier 3 VP-HEME-OB TAB 28-6-1MG Tier 3 VP-PNV-DHA CAP Tier 3 254 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy VP-ZEL TAB Tier 3 VP-ZEL TAB Tier 1 VRAYLAR CAP 1.5-3MG Tier 3 X X VRAYLAR CAP 1.5MG Tier 3 X X VRAYLAR CAP 3MG Tier 3 X X VRAYLAR CAP 4.5MG Tier 3 X X VRAYLAR CAP 6MG Tier 3 X X VUSION OIN Tier 3 X VYFEMLA TAB 0.4-35 Tier 3 VYTORIN TAB 10-10MG Tier 3 X VYTORIN TAB 10-20MG Tier 3 X VYTORIN TAB 10-40MG Tier 3 X VYTORIN TAB 10-80MG Tier 3 X VYVANSE CAP 10MG Tier 2 X VYVANSE CAP 20MG Tier 2 X X VYVANSE CAP 30MG Tier 2 X X VYVANSE CAP 40MG Tier 2 X X VYVANSE CAP 50MG Tier 2 X X VYVANSE CAP 60MG Tier 2 X X VYVANSE CAP 70MG Tier 2 X X WARFARIN TAB 10MG Tier 1 WARFARIN TAB 1MG Tier 1 WARFARIN TAB 2.5MG Tier 1 WARFARIN TAB 2MG Tier 1 WARFARIN TAB 3MG Tier 1 WARFARIN TAB 4MG Tier 1 WARFARIN TAB 5MG Tier 1 WARFARIN TAB 6MG Tier 1 WARFARIN TAB 7.5MG Tier 1 WATCHHALER MIS Tier 3 WELCHOL PAK 3.75GM Tier 2 WELCHOL TAB 625MG Tier 2 WELLBUTRIN TAB 100MG Tier 3 X WELLBUTRIN TAB 100MG SR Tier 3 X WELLBUTRIN TAB 150MG SR Tier 3 X WELLBUTRIN TAB 200MG SR Tier 3 X WELLBUTRIN TAB 75MG Tier 3 X WELLBUTRIN TAB XL 150MG Tier 3 X 255 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy WELLBUTRIN TAB XL 300MG Tier 3 X WERA TAB 0.5/35 HCR Preventive WESTCORT OIN 0.2% Tier 3 X WESTHROID TAB 130MG Tier 3 WESTHROID TAB 195MG Tier 3 WESTHROID TAB 32.5MG Tier 3 WESTHROID TAB 65MG Tier 3 WESTHROID TAB 97.5MG Tier 3 WHEAT GERM OIL Tier 3 WHEY PROTEIN POW COOKIES Tier 3 WIDE-SEAL DPR KIT 60 HCR Preventive WIDE-SEAL DPR KIT 65 HCR Preventive WIDE-SEAL DPR KIT 70 HCR Preventive WIDE-SEAL DPR KIT 75 HCR Preventive WIDE-SEAL DPR KIT 80 HCR Preventive WIDE-SEAL DPR KIT 85 HCR Preventive WIDE-SEAL DPR KIT 90 HCR Preventive WIDE-SEAL DPR KIT 95 HCR Preventive WILATE INJ Tier 2 X WILATE INJ Tier 2 X WILATE INJ Tier 2 X WILATE INJ Tier 2 X WND POW Tier 3 WND 1 POW Tier 3 WND 2 POW Tier 3 WOMANS LAXAT TAB 5MG EC HCR Preventive WOMENS LAXAT TAB 5MG EC HCR Preventive WOUND CARE CRE Tier 3 X WOUND WASH GEL BASE Tier 3 256 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy WP THYROID TAB 113.75MG Tier 3 WP THYROID TAB 130MG Tier 3 WP THYROID TAB 16.25MG Tier 3 WP THYROID TAB 32.5MG Tier 3 WP THYROID TAB 48.75MG Tier 3 WP THYROID TAB 65MG Tier 3 WP THYROID TAB 81.25MG Tier 3 WP THYROID TAB 97.5MG Tier 3 WYMZYA FE CHW 0.4MG-35 Tier 3 XALATAN SOL 0.005% Tier 3 XALKORI CAP 200MG Tier 2 X X X XALKORI CAP 250MG Tier 2 X X X XANAX TAB 0.25MG Tier 3 X XANAX TAB 0.5MG Tier 3 X XANAX TAB 1MG Tier 3 X XANAX TAB 2MG Tier 3 X XANAX XR TAB 0.5MG Tier 3 X XANAX XR TAB 1MG Tier 3 X XANAX XR TAB 2MG Tier 3 X XANAX XR TAB 3MG Tier 3 X XARELTO TAB 10MG Tier 2 X XARELTO TAB 15MG Tier 2 X XARELTO TAB 20MG Tier 2 X XARELTO STAR TAB 15/20MG Tier 2 XARTEMIS XR TAB 7.5-325 Tier 3 X X XCEL 100 CRE Tier 3 X XELJANZ TAB 5MG Tier 3 X X X X XELJANZ XR TAB 11MG Tier 3 X X X XELODA TAB 150MG Tier 1 X X XELODA TAB 500MG Tier 1 X X XEMATOP CRE BASE Tier 3 X XENAZINE TAB 12.5MG Tier 3 X X XENAZINE TAB 25MG Tier 3 X X XERAC-AC SOL 6.25% Tier 2 XERESE CRE 5-1% Tier 3 X XIFAXAN TAB 200MG Tier 3 X X XIFAXAN TAB 550MG Tier 3 X X XIGDUO XR TAB 10-1000 Tier 3 X X 257 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy XIGDUO XR TAB 10-500MG Tier 3 X X XIGDUO XR TAB 5-1000MG Tier 3 X X XIGDUO XR TAB 5-500MG Tier 3 X X XIIDRA DRO 5% Tier 3 X XIZFLUS POW Tier 3 XODOL TAB 10-300MG Tier 3 X X XODOL TAB 5-300MG Tier 3 X X XODOL TAB 7.5-300 Tier 3 X X XOLEGEL GEL 2% Tier 3 XOLEGEL KIT COREPAK Tier 3 XOLEGEL DUO/ KIT HEAD&SHD Tier 3 XOLEGEL DUO/ KIT XOLEX Tier 3 XOPENEX NEB 0.31MG Tier 3 X X XOPENEX NEB 0.63MG Tier 3 X X XOPENEX NEB 1.25/3ML Tier 3 X X XOPENEX CONC NEB 1.25/0.5 Tier 3 X X XOPENEX HFA AER Tier 3 X XTAMPZA ER CAP 13.5MG Tier 3 X X XTAMPZA ER CAP 18MG Tier 3 X X XTAMPZA ER CAP 27MG Tier 3 X X XTAMPZA ER CAP 36MG Tier 3 X X XTAMPZA ER CAP 9MG Tier 3 X X XTANDI CAP 40MG Tier 3 X X X X XULANE DIS 150-35 HCR Preventive XURIDEN POW 2GM Tier 2 X X X XYLOCAINE SOL 4% Tier 3 XYLON TAB 10-200MG Tier 1 XYNTHA INJ 1000UNIT Tier 3 X X X XYNTHA INJ 2000UNIT Tier 3 X X X XYNTHA INJ 250UNIT Tier 3 X X X XYNTHA INJ 500UNIT Tier 3 X X X XYNTHA SOLOF INJ 1000UNIT Tier 3 X X X XYNTHA SOLOF INJ 2000UNIT Tier 3 X X X XYNTHA SOLOF INJ 3000UNIT Tier 3 X X X XYNTHA SOLOF INJ 500UNIT Tier 3 X X X XYNTHA SOLOF KIT 250UNIT Tier 3 X X X XYREM SOL 500MG/ML Tier 3 X X X

258 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy XYZAL SOL Tier 3 XYZAL SOL 2.5/5ML Tier 3 XYZAL TAB 5MG Tier 3 X YASMIN 28 TAB 3-0.03MG HCR Preventive YAZ TAB 3-0.02MG Tier 2 YOSPRALA TAB 325-40MG Tier 3 X YOSPRALA TAB 81-40MG Tier 3 X YUVAFEM TAB 10MCG Tier 3 X ZACARE KIT KIT 4% Tier 3 ZACARE KIT KIT 8% Tier 3 ZACLIR LOT 8% Tier 1 ZAFIRLUKAST TAB 10MG Tier 1 X ZAFIRLUKAST TAB 20MG Tier 1 X ZALEPLON CAP 10MG Tier 1 X ZALEPLON CAP 5MG Tier 1 X ZAMICET SOL 10-325MG Tier 1 X ZANAFLEX CAP 2MG Tier 3 ZANAFLEX CAP 4MG Tier 3 ZANAFLEX CAP 6MG Tier 3 ZANAFLEX TAB 4MG Tier 3 ZARAH TAB 3-0.03MG Tier 3 ZARONTIN CAP 250MG Tier 3 ZARONTIN SOL 250/5ML Tier 3 ZARXIO INJ 300/0.5 Tier 2 X ZARXIO INJ 480/0.8 Tier 2 X ZATEAN-CH CAP Tier 2 ZATEAN-PN CAP DHA Tier 3 ZATEAN-PN CAP PLUS Tier 3 ZATEAN-PN TAB Tier 3 ZAVESCA CAP 100MG Tier 3 X ZAZOLE CRE 0.8% Tier 1 ZAZOLE SUP 80MG Tier 1 ZEBETA TAB 10MG Tier 3 ZEBETA TAB 5MG Tier 3 ZEBUTAL CAP Tier 1 X ZECUITY PAD 6.5MG/4H Tier 3 X X ZEGERID POW 20-1680 Tier 3 X X

259 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ZEGERID POW 40-1680 Tier 3 X X ZELAPAR TAB 1.25MG Tier 3 ZELBORAF TAB 240MG Tier 2 X X X ZEMBRACE SYM INJ 3/0.5ML Tier 3 X X ZEMPLAR CAP 1MCG Tier 3 ZEMPLAR CAP 2MCG Tier 3 ZENATANE CAP 10MG Tier 3 X ZENATANE CAP 20MG Tier 3 X ZENATANE CAP 30MG Tier 3 X ZENATANE CAP 40MG Tier 3 X ZENCHENT TAB Tier 3 ZENCHENT FE CHW 0.4MG-35 Tier 3 ZENCIA LIQ 9-4% Tier 1 ZENPEP CAP 10000UNT Tier 2 ZENPEP CAP 15000UNT Tier 2 ZENPEP CAP 20000UNT Tier 2 ZENPEP CAP 25000UNT Tier 2 ZENPEP CAP 3000UNIT Tier 2 ZENPEP CAP 40000UNT Tier 2 ZENPEP CAP 5000UNIT Tier 2 ZENZEDI TAB 10MG Tier 3 X X ZENZEDI TAB 15MG Tier 3 X X ZENZEDI TAB 2.5MG Tier 3 X X ZENZEDI TAB 20MG Tier 3 X X ZENZEDI TAB 30MG Tier 3 X X ZENZEDI TAB 5MG Tier 3 X X ZENZEDI TAB 7.5MG Tier 3 X X ZEPATIER TAB 50-100MG Tier 3 X X X X ZERIT CAP 15MG Tier 3 X ZERIT CAP 20MG Tier 3 X ZERIT CAP 30MG Tier 3 X ZERIT CAP 40MG Tier 3 X ZERIT SOL 1MG/ML Tier 3 X ZESTORETIC TAB 10-12.5 Tier 3 X ZESTORETIC TAB 20-12.5 Tier 3 X ZESTORETIC TAB 20-25MG Tier 3 X ZESTRIL TAB 10MG Tier 3 X ZESTRIL TAB 2.5MG Tier 3 X 260 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ZESTRIL TAB 20MG Tier 3 X ZESTRIL TAB 30MG Tier 3 X ZESTRIL TAB 40MG Tier 3 X ZESTRIL TAB 5MG Tier 3 X ZETIA TAB 10MG Tier 3 X ZETONNA AER 37MCG Tier 3 X ZIAC TAB 10/6.25 Tier 3 ZIAC TAB 2.5/6.25 Tier 3 ZIAC TAB 5-6.25MG Tier 3 ZIAGEN SOL 20MG/ML Tier 2 X ZIAGEN TAB 300MG Tier 3 X ZIANA GEL Tier 3 X X ZIDOVUDINE CAP 100MG Tier 1 X ZIDOVUDINE SYP 50MG/5ML Tier 1 X ZIDOVUDINE TAB 300MG Tier 1 X ZINBRYTA INJ 150MG/ML Tier 3 X X X X ZIOPTAN DRO 0.0015% Tier 3 X X ZIPRASIDONE CAP 20MG Tier 3 X ZIPRASIDONE CAP 40MG Tier 3 X ZIPRASIDONE CAP 60MG Tier 3 X ZIPRASIDONE CAP 80MG Tier 3 X ZIPSOR CAP 25MG Tier 3 X ZIRGAN GEL 0.15% Tier 3 X ZITHRANOL SHA 1% Tier 3 ZITHRANOL-RR CRE 1.2% Tier 3 ZITHROMAX POW 1GM PAK Tier 3 ZITHROMAX SUS 100/5ML Tier 3 ZITHROMAX SUS 200/5ML Tier 3 ZITHROMAX TAB 250MG Tier 3 ZITHROMAX TAB 500MG Tier 3 ZITHROMAX TAB 600MG Tier 3 ZITHROMAX TAB TRI-PAK Tier 3 ZITHROMAX TAB Z-PAK Tier 3 ZMAX SUS 2GM Tier 3 ZOCOR TAB 10MG Tier 3 ZOCOR TAB 20MG Tier 3 ZOCOR TAB 40MG Tier 3 ZOCOR TAB 5MG Tier 3 261 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ZOCOR TAB 80MG Tier 3 ZOE SCRIPTS CRE IDEALBAS Tier 3 X ZOFRAN SOL 4MG/5ML Tier 3 ZOFRAN TAB 4MG Tier 3 ZOFRAN TAB 4MG ODT Tier 3 ZOFRAN TAB 8MG Tier 3 ZOFRAN TAB 8MG ODT Tier 3 ZOHYDRO ER CAP 10MG Tier 3 X X X ZOHYDRO ER CAP 15MG Tier 3 X X X ZOHYDRO ER CAP 20MG Tier 3 X X X ZOHYDRO ER CAP 30MG Tier 3 X X X ZOHYDRO ER CAP 40MG Tier 3 X X X ZOHYDRO ER CAP 50MG Tier 3 X X X ZOLATE CAP Tier 3 ZOLINZA CAP 100MG Tier 2 X X ZOLMITRIPTAN TAB 2.5 MG Tier 3 X ZOLMITRIPTAN TAB 2.5MG Tier 3 X ZOLMITRIPTAN TAB 5MG Tier 3 X ZOLMITRIPTAN TAB 5MG Tier 3 X ZOLOFT CON 20MG/ML Tier 3 X ZOLOFT TAB 100MG Tier 3 X ZOLOFT TAB 25MG Tier 3 X ZOLOFT TAB 50MG Tier 3 X ZOLPIDEM TAB 10MG Tier 1 X ZOLPIDEM TAB 5MG Tier 1 X ZOLPIDEM ER TAB 12.5MG Tier 3 X X ZOLPIDEM ER TAB 6.25MG Tier 3 X X ZOLPIDEM TAR SUB 1.75MG Tier 3 X X ZOLPIDEM TAR SUB 3.5MG Tier 3 X X ZOLPIMIST SPR 5MG Tier 3 X X ZOMACTON INJ 10MG Tier 3 X X X X ZOMACTON INJ 5MG Tier 3 X X X X ZOMIG SPR 2.5MG Tier 3 X ZOMIG TAB 2.5MG Tier 3 X ZOMIG TAB 5MG Tier 3 X ZOMIG NASAL SPR 5MG Tier 3 X ZOMIG ZMT TAB 2.5 MG Tier 3 X ZOMIG ZMT TAB 5MG Tier 3 X 262 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ZONALON CRE 5% Tier 3 ZONATUSS CAP 150MG Tier 1 X ZONEGRAN CAP 100MG Tier 3 X X ZONEGRAN CAP 25MG Tier 3 X X ZONISAMIDE CAP 100MG Tier 1 ZONISAMIDE CAP 25MG Tier 1 ZONISAMIDE CAP 50MG Tier 1 ZONTIVITY TAB 2.08MG Tier 3 X ZORBTIVE INJ 8.8MG Tier 3 X X X ZORTRESS TAB 0.25MG Tier 3 X ZORTRESS TAB 0.5MG Tier 3 X ZORTRESS TAB 0.75MG Tier 3 X ZORVOLEX CAP 18MG Tier 3 X ZORVOLEX CAP 35MG Tier 3 X ZOVIA 1/35E TAB HCR Preventive ZOVIA 1/50E TAB HCR Preventive ZOVIRAX CAP 200MG Tier 3 ZOVIRAX CRE 5% Tier 3 X X ZOVIRAX OIN 5% Tier 3 X X X ZOVIRAX SUS 200/5ML Tier 3 ZOVIRAX TAB 400MG Tier 3 ZOVIRAX TAB 800MG Tier 3 ZUBSOLV SUB 1.4-0.36 Tier 2 X X ZUBSOLV SUB 11.4-2.9 Tier 2 X ZUBSOLV SUB 2.9-0.71 Tier 2 X ZUBSOLV SUB 5.7-1.4 Tier 2 X X ZUBSOLV SUB 8.6-2.1 Tier 2 X X ZUPLENZ MIS 4MG Tier 3 X X ZUPLENZ MIS 8MG Tier 3 X X ZURAMPIC TAB 200MG Tier 3 X X X ZUTRIPRO LIQ 60-4-5MG Tier 3 X X ZYCLARA CRE 3.75% Tier 3 X X ZYCLARA PUMP CRE 2.5% Tier 3 X X ZYCLARA PUMP CRE 3.75% Tier 3 X X ZYDELIG TAB 100MG Tier 3 X X X ZYDELIG TAB 150MG Tier 3 X X X

263 Benefit Prior Supply Step Product Name Specialty Tier Authorization Limit Therapy ZYFLO TAB 600MG Tier 3 X ZYFLO CR TAB 600MG Tier 3 X X ZYKADIA CAP 150MG Tier 3 X X X ZYLET SUS 0.5-0.3% Tier 3 ZYLOPRIM TAB 100MG Tier 3 ZYLOPRIM TAB 300MG Tier 3 ZYMAXID SOL 0.5% Tier 3 X ZYPREXA TAB 10MG Tier 3 X X ZYPREXA TAB 15MG Tier 3 X X ZYPREXA TAB 2.5MG Tier 3 X X ZYPREXA TAB 20MG Tier 3 X X ZYPREXA TAB 5MG Tier 3 X X ZYPREXA TAB 7.5MG Tier 3 X X ZYPREXA ZYDI TAB 10MG Tier 3 X X ZYPREXA ZYDI TAB 15MG Tier 3 X X ZYPREXA ZYDI TAB 20MG Tier 3 X X ZYPREXA ZYDI TAB 5MG Tier 3 X X ZYTIGA TAB 250MG Tier 2 X X X ZYVODOL CRE Tier 3 X ZYVOX SUS 100MG/5M Tier 3 X ZYVOX TAB 600MG Tier 3 X X

264