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Quantity Limit Program October 2021

The Quantity Limit Program encourages safe medication use. The chart below lists quantity limits for medications on Blue Cross Blue Shield of Michigan’s Clinical, Closed, Custom and Custom Select Drug Lists, Blue Cross and Blue Care Network’s Preferred Drug List and Blue Care Network’s Closed, Custom and Custom Select Drug Lists. The quantities are consistent with the Food and Drug Administration’s approved dosing guidelines.

All opioids are limited to a 90 morphine milligram equivalent per day.

Note: Some member limits may be slightly different. Please see your benefit information for your specific limits.

Key SC = subcutaneous, mg = milligram, gm = gram, mcg = microgram, ml = milliliter, IU = international unit Not covered: You may be responsible for the full cost of the medication. Not applicable: Quantity limits may not apply.

Sample Abilify MyCite = brand name (aripiprazole) = generic name

Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Abilify MyCite Not covered Not covered 1 tablet per day Not covered Not covered (aripiprazole)

Absorica Not covered Not covered 5 capsules per day Not covered Not covered (isotretinoin)

Absorica LD Not covered Not covered 5 capsules per day Not covered Not covered (isotretinoin)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 1 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Accolate 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (zafirlukast) Accrufer 2 tablets per day 2 tablets per day Not covered 2 tablets per day 2 tablets per day (ferric maltol) Accutane 5 capsules per day 5 capsules per day 5 capsules per day 5 capsules per day 5 capsules per day (isotretinoin) Aciphex sprinkle 2 capsules per day Not covered Not covered Not covered 2 capsules per day (rabeprazole) Actemra 4 packages (4 syringes) 4 packages (4 syringes) 4 packages (4 syringes) 4 packages (4 syringes) 4 packages (4 syringes) (tocilizumab) per 30 days per 30 days per 30 days per 30 days per 30 days Acthar Gel 4 vials (20 ml) per 30 days Not covered 4 vials (20 ml) per 30 days 4 vials (20 ml) per 30 days Not covered (repository corticotropin) Actiq 4 lollipops per day 4 lollipops per day 4 lollipops per day 4 lollipops per day 4 lollipops per day (fentanyl citrate) Actonel 5mg, 30mg 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (risedronate) Actonel 35mg 4 tablets per 30 days 4 tablets per 30 days 4 tablets per 30 days 4 tablets per 30 days 4 tablets per 30 days (risedronate) Actonel 150mg 1 tablet per 30 days 1 tablet per 30 days 1 tablet per 30 days 1 tablet per 30 days 1 tablet per 30 days (risedronate) Aczone 5% 90 grams per 30 days Not covered 90 grams per 30 days 90 grams per 30 days Not covered (dapsone)

Adacel 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill

* Limited to a 15 day supply ** Limited to a 30 day supply Page 2 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Adcirca 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (tadalafil) Adderall 5, 7.5, 10, 12.5, 15mg 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (amphetamine + dextroamphetamine) Adderall 20mg (amphetamine + 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day dextroamphetamine) Adderall 30mg (amphetamine + 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day dextroamphetamine) Adderall XR (amphetamine + 2 capsules per day 2 capsules per day 2 capsules per day 2 capsules per day 2 capsules per day dextroamphetamine) Addyi 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered (fibanserin) Adempas 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day (riociguat) Adhansia XR (methylphenidate extended- Not covered Not covered 1 capsule per day Not covered Not covered release) Advair Diskus 1 box (60 blisters) 1 box (60 blisters) 1 box (60 blisters) 1 box (60 blisters) 1 box (60 blisters) (fluticasone propionate + per 30 days per 30 days per 30 days per 30 days per 30 days salmeterol)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 3 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Advair HFA (fluticasone propionate + 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days salmeterol) Adzenys ER (amphetamine extended- 15 ml (18.8mg) per day Not covered 15 ml (18.8mg) per day 15 ml (18.8mg) per day Not covered release) Adzenys XR-ODT (amphetamine extended- 2 tablets per day Not covered 2 tablets per day 2 tablets per day Not covered release) Aemcolo 12 tablets per 90 days Not covered 12 tablets per 90 days 12 tablets per 90 days Not covered (rifamycin) Afinitor, Disperz 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* () Aimovig 1 autoinjector / syringe 1 autoinjector / syringe 1 autoinjector / syringe 1 autoinjector / syringe 1 autoinjector / syringe () (1 pack) per 30 days (1 pack) per 30 days (1 pack) per 30 days (1 pack) per 30 days (1 pack) per 30 days AirDuo Respiclick 1 inhaler per 30 days 1 inhaler per 30 days Not covered 1 inhaler per 30 days 1 inhaler per 30 days (fluticasone +salmeterol) Ajovy 1 syringe (1 pack) 1 syringe (1 pack) 1 syringe (1 pack) 1 syringe (1 pack) 1 syringe (1 pack) (-vfrm) per 30 days per 30 days per 30 days per 30 days per 30 days Aklief Not covered Not covered 45 grams per 30 days Not covered Not covered (trifarotene) Akynzeo 4 capsules per 30 days 4 capsules per 30 days Not covered 4 capsules per 30 days 4 capsules per 30 days (etupitant + palonosetron) Albenza 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (albendazole) Aldara 1 packet per day 1 packet per day 1 packet per day 1 packet per day 1 packet per day (imiquimod)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 4 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Alecensa 8 capsules per day 8 capsules per day 8 capsules per day 8 capsules per day 8 capsules per day (alectinib) Alkindi Sprinkle 3 capsules per day 3 capsules per day Not covered 3 capsules per day 3 capsules per day (hydrocortisone) Altreno 1 tube (45 grams) 1 tube (45 grams) 1 tube (45 grams) 1 tube (45 grams) 1 tube (45 grams) (tretinoin) per 30 days per 30 days per 30 days per 30 days per 30 days Alunbrig starter pack 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days (brigatinib) Alunbrig 30mg 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (brigatinib) Alunbrig 90mg, 180mg 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (brigatinib) Alvesco Not covered Not covered 2 inhalers per Rx Not covered Not covered (ciclesonide) Ambien 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (zolpidem tartrate) Ambien CR 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (zolpidem tartrate) Amerge 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days (naratriptan) Amitiza 2 capsules per day 2 capsules per day Not covered 2 capsules per day 2 capsules per day (lubiprostone) Ampyra 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (dalfampridine)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 5 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Amzeeq 1 can per 30 days Not covered 1 can per 30 days 1 can per 30 days Not covered (minocycline) Androderm 1 patch per day 1 patch per day 1 patch per day 1 patch per day 1 patch per day (testosterone) AndroGel packet 1% 90 packets (225 gm) 90 packets (225 gm) 90 packets (225 gm) 90 packets (225 gm) 90 packets (225 gm) (2.5gm/day) per 30 days per 30 days per 30 days per 30 days per 30 days (testosterone) AndroGel packet 1% 60 packets (300 gm) 60 packets (300 gm) 60 packets (300 gm) 60 packets (300 gm) 60 packets (300 gm) (5gm/day) per 30 days per 30 days per 30 days per 30 days per 30 days (testosterone) AndroGel packet 1.62% 30 packets (38 gm) 30 packets (38 gm) 30 packets (38 gm) 30 packets (38 gm) 30 packets (38 gm) (1.25gm/day) per 30 days per 30 days per 30 days per 30 days per 30 days (testosterone) AndroGel packet 1.62% 60 packets (150 gm) 60 packets (150 gm) 60 packets (150 gm) 60 packets (150 gm) 60 packets (150 gm) (2.5gm/day) per 30 days per 30 days per 30 days per 30 days per 30 days (testosterone) AndroGel pump 1% 4 bottles (300 gm) 4 bottles (300 gm) 4 bottles (300 gm) 4 bottles (300 gm) 4 bottles (300 gm) (testosterone) per 30 days per 30 days per 30 days per 30 days per 30 days AndroGel pump 1.62% 2 bottles (150 gm) 2 bottles (150 gm) 2 bottles (150 gm) 2 bottles (150 gm) 2 bottles (150 gm) (testosterone) per 30 days per 30 days per 30 days per 30 days per 30 days Android 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered (methyltestosterone) Annovera (segesterone acetate + ethinyl Not covered Not covered 1 ring per 30 days Not covered Not covered ) Anoro Ellipta 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days (umeclidinium + vilanterol)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 6 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Aptensio XR (methylphenidate extended- 1 capsule per day Not covered 1 capsule per day 1 capsule per day Not covered release) Aptiom 200mg, 400mg 1 tablet per day Not covered Not covered 1 tablet per day Not covered (eslicarbazepine acetate) Aptiom 600mg, 800mg 2 tablets per day Not covered Not covered 2 tablets per day Not covered (eslicarbazepine acetate) Arakoda 1 carton (16 tablets) 1 carton (16 tablets) 1 carton (16 tablets) 1 carton (16 tablets) 1 carton (16 tablets) (tafenoquine) per 30 days per 30 days per 30 days per 30 days per 30 days Arazlo Not covered Not covered 45 grams per 30 days Not covered Not covered (tazarotene) Arcalyst 4 vials per 30 days 4 vials per 30 days 4 vials per 30 days 4 vials per 30 days 4 vials per 30 days (rilonacept) Arcapta Neohaler 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day (indacaterol) Aricept 23mg 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered (donepezil) Arikayce 1 kit (28 vials) per 28 days 1 kit (28 vials) per 28 days 1 kit (28 vials) per 28 days 1 kit (28 vials) per 28 days 1 kit (28 vials) per 28 days (amikacin) Arimidex 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (anastrozole) Aristada 441, 662, 882mg 1 syringe per 30 days 1 syringe per 30 days 1 syringe per 30 days 1 syringe per 30 days 1 syringe per 30 days (aripiprazole lauroxil) Aristada 1,064mg 1 syringe per 60 days 1 syringe per 60 days 1 syringe per 60 days 1 syringe per 60 days 1 syringe per 60 days (aripiprazole lauroxil)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 7 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List ArmonAir Respiclick 1 inhaler per 30 days Not covered 1 inhaler per 30 days 1 inhaler per 30 days Not covered (fluticasone propionate) Arnuity Ellipta 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days (fluticasone furoate) Aromasin 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (exemestane) Asmanex 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days (mometasone furoate) Asmanex HFA 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days (mometasone furoate) Astelin 2 (30 ml bottles) per 30 days 2 (30 ml bottles) per 30 days 2 (30 ml bottles) per 30 days 2 (30 ml bottles) per 30 days 2 (30 ml bottles) per 30 days (azelastine) Astepro 2 (30 ml bottles) per 30 days Not covered 2 (30 ml bottles) per 30 days Not covered Not covered (azelastine) Atelvia 4 tablets per 30 days 4 tablets per 30 days 4 tablets per 30 days 4 tablets per 30 days 4 tablets per 30 days (risedronate) Atrovent HFA 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days (ipratropium bromide) Atrovent nasal 21mcg 2 (30 ml bottles) per 30 days 2 (30 ml bottles) per 30 days 2 (30 ml bottles) per 30 days 2 (30 ml bottles) per 30 days 2 (30 ml bottles) per 30 days (ipratropium bromide) Atrovent nasal 42mcg 3 (15 ml bottles) per 30 days 3 (15 ml bottles) per 30 days 3 (15 ml bottles) per 30 days 3 (15 ml bottles) per 30 days 3 (15 ml bottles) per 30 days (ipratropium bromide) Aubagio 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (teriflunomide)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 8 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Austedo 6mg 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (deutetrabenazine) Austedo 9mg, 12mg 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (deutetrabenazine) Avandia 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (rosiglitazone maleate) Avinza 1 capsule per day Not covered 1 capsule per day 1 capsule per day Not covered (morphine) Avonex 4 syringes / pens 4 syringes / pens 4 syringes / pens 4 syringes / pens 4 syringes / pens (interferon beta 1a) per 28 days per 28 days per 28 days per 28 days per 28 days Axert 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days (almotriptan) Axiron 2 bottles (180 ml) per 30 days Not covered 2 bottles (180 ml) per 30 days 2 bottles (180 ml) per 30 days Not covered (testosterone) Ayvakit 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* (avapritinib) Azstarys (serdexmethylphenidate + 1 tablet per day Not covered Not covered 1 tablet per day Not covered dexmethylphenidate) Bafiertam 4 capsules per day Not covered 4 capsules per day 4 capsules per day Not covered (monomethyl fumarate) Balversa 3mg 90 tablets per 30 days* 90 tablets per 30 days* Not covered 90 tablets per 30 days* 90 tablets per 30 days* (erdafitinib) Balversa 4mg 60 tablets per 30 days* 60 tablets per 30 days* Not covered 60 tablets per 30 days* 60 tablets per 30 days* (erdafitinib)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 9 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Balversa 5mg 30 tablets per 30 days* 30 tablets per 30 days* Not covered 30 tablets per 30 days* 30 tablets per 30 days* (erdafitinib) Banzel 200mg tablet 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (rufinamide) Banzel 400mg tablet 8 tablets per day 8 tablets per day 8 tablets per day 8 tablets per day 8 tablets per day (rufinamide) Baqsimi 8 units per 30 days 8 units per 30 days 8 units per 30 days; 8 units per 30 days 8 units per 30 days; () 16 units per 365 days 16 units per 365 days 16 units per 365 days 16 units per 365 days 16 units per 365 days Beconase AQ 2 (25 gm bottles) per 30 days Not covered Not covered Not covered Not covered (beclomethasone dipropionate) Belbuca 2 films per day** Not covered 2 films per day** 2 films per day** Not covered (buprenorphine) Belsomra 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered () Benlysta 4 syringes per 28 days 4 syringes per 28 days 4 syringes per 28 days 4 syringes per 28 days 4 syringes per 28 days (belimumab) Benznidazole 12.5mg 12 tablets per day 12 tablets per day 12 tablets per day 12 tablets per day 12 tablets per day (benznidazole) Benznidazole 100mg 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (benznidazole) Betaseron 14 syringes per 28 days 14 syringes per 28 days 14 syringes per 28 days 14 syringes per 28 days 14 syringes per 28 days (interferon beta 1b) Bethkis 56 ampules per 56 rolling 56 ampules per 56 rolling 56 ampules per 56 rolling Not covered Not covered (tobramycin) days days days

* Limited to a 15 day supply ** Limited to a 30 day supply Page 10 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Bevespi Aerosphere (glycopyrrolate + formoterol 1 inhaler per 30 days Not covered 1 inhaler per 30 days 1 inhaler per 30 days Not covered fumarate) Bevyxxa 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (betrixaban) Bijuva 1 capsule per day Not covered 1 capsule per day 1 capsule per day Not covered (estradiol + ) Biktarvy (bictegravir + emtricitabine + 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day tenofovir alafenamide) Binosto 4 tablets per 30 days Not covered 4 tablets per 30 days 4 tablets per 30 days Not covered (alendronate) Boniva 150mg 1 tablet per 30 days 1 tablet per 30 days 1 tablet per 30 days 1 tablet per 30 days 1 tablet per 30 days (ibandronate) Bonjesta (doxylamine succinate + 2 tablets per day Not covered 2 tablets per day 2 tablets per day Not covered pyridoxine extended-release) Boostrix / Boostrix TDAP 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill vaccine Bosulif 100mg 90 tablets per 30 days* 90 tablets per 30 days* 90 tablets per 30 days* 90 tablets per 30 days* 90 tablets per 30 days* (bosutinib) Bosulif 400mg, 500mg 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* (bosutinib)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 11 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Bowel preparation medications (Bisacodyl 2 fills per 365 days 2 fills per 365 days 2 fills per 365 days 2 fills per 365 days 2 fills per 365 days Magnesium Citrate Magnesium hydroxide Phosphate laxative) Bowel preparation medications 1 fill per 365 days 1 fill per 365 days 1 fill per 365 days 1 fill per 365 days 1 fill per 365 days (generic polyethylene glycol 3350 products) Braftovi 50mg 1 carton 1 carton 1 carton 1 carton 1 carton (2 bottles of 60 capsules) (2 bottles of 60 capsules) (2 bottles of 60 capsules) (2 bottles of 60 capsules) (2 bottles of 60 capsules) (encorafenib) per 30 days per 30 days per 30 days per 30 days per 30 days Braftovi 75mg 1 carton 1 carton 1 carton 1 carton 1 carton (2 bottles of 90 capsules) (2 bottles of 90 capsules) (2 bottles of 90 capsules) (2 bottles of 90 capsules) (2 bottles of 90 capsules) (encorafenib) per 30 days per 30 days per 30 days per 30 days per 30 days Breo Ellipta 1 inhaler (60 blisters) 1 inhaler (60 blisters) 1 inhaler (60 blisters) 1 inhaler (60 blisters) 1 inhaler (60 blisters) (fluticasone furoate + vilanterol) per 30 days per 30 days per 30 days per 30 days per 30 days Breztri Aerosphere (budesonide + glycopyrrolate + 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days formoterol fumarate) Brilinta 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (ticagrelor) Brisdelle 1 capsule per day Not covered 1 capsule per day 1 capsule per day Not covered (paroxetine mesylate) Briviact oral solution 20 ml per day 20 ml per day 20 ml per day 20 ml per day 20 ml per day (brivaracetam) Briviact tablet 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (brivaracetam)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 12 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Bronchitol 4 inhalers per 28 days 4 inhalers per 28 days 4 inhalers per 28 days 4 inhalers per 28 days 4 inhalers per 28 days (mannitol) Brovana 2 vials (4 mL) per day 2 vials (4 ml) per day Not covered 2 vials (4 ml) per day 2 vials (4 ml) per day (arformoterol tartrate) Brukinsa 120 capsules per 30 days* 120 capsules per 30 days* 120 capsules per 30 days* 120 capsules per 30 days* 120 capsules per 30 days* (zanubrutinib) Bryhali 1 tube per 30 days 1 tube per 30 days 1 tube per 30 days 1 tube per 30 days 1 tube per 30 days (halobetasol propionate) Bunavail 2 films per day 2 films per day Not covered 2 films per day 2 films per day (buprenorphine + naloxone) Buphenyl tablet 40 tablets per day 40 tablets per day 40 tablets per day 40 tablets per day 40 tablets per day (sodium phenylbutyrate) butalbital + acetaminophen 4 grams of APAP per day 4 grams of APAP per day 4 grams of APAP per day 4 grams of APAP per day 4 grams of APAP per day + caffeine + codeine butalbital + aspirin + caffeine + codeine Limited to 30 day supply Limited to 30 day supply Limited to 30 day supply Limited to 30 day supply Limited to 30 day supply (Fiorinal w/codeine, Ascomp per fill per fill per fill per fill per fill w/codeine, Butalbital compound w/codeine) Butrans 4 patches per 28 days** 4 patches per 28 days** 4 patches per 28 days** 4 patches per 28 days** 4 patches per 28 days** (buprenorphine) Bydureon Not covered Not covered 4 syringes / vials per 30 days Not covered Not covered () Byetta Not covered Not covered 1 pen per 30 days Not covered Not covered (exenatide) Bystolic 2.5, 5, 10mg 2 tablets per day 2 tablets per day Not covered 2 tablets per day 2 tablets per day (nebivolol)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 13 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Cablivi 1 vial (kit) per day 1 vial (kit) per day 1 vial (kit) per day 1 vial (kit) per day 1 vial (kit) per day (caplacizumab-yhdp) Cabometyx 20mg, 60mg 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* (cabozantinib) Cabometyx 40mg 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* (cabozantinib) Caduet 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (amlodipine + atorvastatin) Cafergot 40 tablets per 30 days 40 tablets per 30 days 40 tablets per 30 days 40 tablets per 30 days 40 tablets per 30 days (ergotamine tartrate + caffeine) Calquence 120 capsules per 30 days* 120 capsules per 30 days* Not covered 120 capsules per 30 days* 120 capsules per 30 days* (acalabrutinib) Cambia Not covered Not covered 9 packets per 30 days Not covered Not covered (diclofenac) Caplyta 1 tablet per day 1 tablet per day Not covered 1 tablet per day 1 tablet per day (lumateperone) Caprelsa 100mg 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* (vandetanib) Caprelsa 300mg 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* (vandetanib) Caverject 12 vials / units per 30 days Not covered 12 vials / units per 30 days 6 units per 28 days Not covered (alprostadil) Cayston 1 kit per 28 days 1 kit per 28 days 1 kit per 28 days 1 kit (84 vials) per 42 days 1 kit (84 vials) per 42 days (aztreonam)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 14 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Cequa 1 box (60 vials) per 30 days Not covered 1 box (60 vials) per 30 days 1 box (60 vials) per 30 days Not covered (cyclosporine) Cerdelga 56 capsules per 30 days 56 capsules per 30 days 56 capsules per 30 days 56 capsules per 30 days 56 capsules per 30 days (eliglustat) Chantix 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (varenicline) Chicken pox vaccine 0.5 ml per Rx 0.5 ml per Rx 0.5 ml per Rx 0.5 ml per Rx 0.5 ml per Rx (Varivax) Cholbam 8 capsules per day 8 capsules per day 8 capsules per day 8 capsules per day 8 capsules per day (cholic acid) 2 vials per 30 days, 2 vials per 30 days, Not applicable Not covered Not applicable chorionic gonadotropin 6 vials per 365 days 6 vials per 365 days Cialis 12 tablets per 30 days Not covered 12 tablets per 30 days 6 tablets per 28 days Not covered (tadalafil) Cimduo (lamivudine + tenofovir 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day disoproxil fumarate) Cimzia starter kit 2 starter kits per 365 days 2 starter kits per 365 days 2 starter kits per 365 days 2 starter kits per 365 days 2 starter kits per 365 days (certolizumab) Cimzia 2 packages (4 syringes) 2 packages (4 syringes) 2 packages (4 syringes) 2 packages (4 syringes) 2 packages (4 syringes) (certolizumab) per 30 days / 2 kits in 30 days per 30 days/ 2 kits in 30 days per 30 days / 2 kits in 30 days per 30 days/ 2 kits in 30 days per 30 days / 2 kits in 30 days Clarinex / Clarinex Reditab 1 tablet per day Not covered 1 tablet per day Not covered Not covered (desloratadine) Clarinex D (desloratadine + 2 tablets per day Not covered 2 tablets per day Not covered Not covered pseudoephedrine)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 15 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Clomid Not applicable 30 tablets per 365 days Not applicable Not applicable 30 tablets per 365 days (clomiphene) Coartem 24 tablets per Rx 24 tablets per Rx 24 tablets per Rx 24 tablets per Rx 24 tablets per Rx (artemether-lumefantrine) Cometriq 4 cards (1 box) per 30 days* 4 cards (1 box) per 30 days* 4 cards (1 box) per 30 days* 4 cards (1 box) per 30 days* 4 cards (1 box) per 30 days* (cabozantinib) Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply codeine for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for each subsequent fill for each subsequent fill for each subsequent fill for each subsequent fill for each subsequent fill Combivent Respimat (ipratropium bromide + 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days albuterol)

Combunox Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply (oxycodone + ibuprofen) for each subsequent fill for each subsequent fill for each subsequent fill for each subsequent fill for each subsequent fill Complera (emtricitabine + rilpivirine + 1 tablet per day 1 tablet per day Not covered 1 tablet per day 1 tablet per day tenofovir disoproxil fumarate) Concerta 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (methylphenidate) Consensi Not covered Not covered 1 tablet per day Not covered Not covered (amlodipine and celecoxib) Contrave (naltrexone + bupropion 4 tablets per day Not covered 4 tablets per day 4 tablets per day Not covered extended-release)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 16 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Copaxone 20mg 1 syringe per day 1 syringe per day 1 syringe per day 1 syringe per day 1 syringe per day (glatiramer acetate) Copaxone 40mg 12 syringes per 30 days 12 syringes per 30 days 12 syringes per 30 days 12 syringes per 30 days 12 syringes per 30 days (glatiramer acetate) Copiktra 1 carton (56 capsules) 1 carton (56 capsules) 1 carton (56 capsules) 1 carton (56 capsules) 1 carton (56 capsules) (duvelisib) per 30 days per 30 days per 30 days per 30 days per 30 days Coreg CR 1 capsule per day Not covered 1 capsule per day 1 capsule per day Not covered (carvedilol) Corlanor solution 4 cartons (112 pouches) 4 cartons (112 pouches) 4 cartons (112 pouches) 4 cartons (112 pouches) 4 cartons (112 pouches) (ivabradiene) per 30 days per 30 days per 30 days per 30 days per 30 days Corlanor tablet 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (ivabradiene) Cotellic 63 tablets per 28 days 63 tablets per 28 days 63 tablets per 28 days 63 tablets per 28 days 63 tablets per 28 days (cobimetinib) Cotempla XR-ODT (methylphenidate extended- Not covered Not covered 2 tablets per day Not covered Not covered release) Cresemba 70 capsules per 30 days 70 capsules per 30 days 70 capsules per 30 days 70 capsules per 30 days 70 capsules per 30 days (isavuconazonium sulfate) Crestor 1.5 tablets per day 1.5 tablets per day 1.5 tablets per day 1.5 tablets per day 1.5 tablets per day (rosuvastatin) Cycloset 6 tablets per day 6 tablets per day 6 tablets per day 6 tablets per day 6 tablets per day ( mesylate) Cystadrops 4 bottles per 30 days 4 bottles per 30 days Not covered 4 bottles per 30 days 4 bottles per 30 days (cysteamine)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 17 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Cystaran 4 bottles (60 ml) per 30 days 4 bottles (60 ml) per 30 days 4 bottles (60 ml) per 30 days 4 bottles (60 ml) per 30 days 4 bottles (60 ml) per 30 days (cysteamine) Daliresp 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (roflumilast) Dalmane 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day (flurazepam) Daurismo 25mg 90 tablets per 30 days* 90 tablets per 30 days* 90 tablets per 30 days* 90 tablets per 30 days* 90 tablets per 30 days* (glasdegib) Daurismo 100mg 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* (glasdegib) Daytrana 1 patch per day 1 patch per day 1 patch per day 1 patch per day 1 patch per day (methylphenidate) Dayvigo 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day () Delstrigo (doravirine + lamivudine + 1 tablet per day 1 tablet per day Not covered 1 tablet per day 1 tablet per day tenofovir disoproxil fumarate) Depen 8 tablets per day 8 tablets per day 8 tablets per day 8 tablets per day 8 tablets per day (penicillamine) Descovy 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (emtricitabine + tenofovir) Desoxyn 5 tablets per day 5 tablets per day 5 tablets per day 5 tablets per day 5 tablets per day (methamphetamine) desvenlafaxine ER 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered

Dexcom G5 Receiver, 1 receiver per 365 days 1 receiver per 365 days 1 receiver per 365 days 1 receiver per 365 days 1 receiver per 365 days Dexcom G6 Receiver

* Limited to a 15 day supply ** Limited to a 30 day supply Page 18 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List

Dexcom G6 Sensor 3 units per 30 days 3 units per 30 days 3 units per 30 days 3 units per 30 days 3 units per 30 days

Dexcom G6 Transmitter 4 units per 365 days 4 units per 365 days 4 units per 365 days 4 units per 365 days 4 units per 365 days

Dexedrine 4 tablets / capsules per day 4 tablets / capsules per day 4 tablets / capsules per day 4 tablets / capsules per day 4 tablets / capsules per day (dextroamphetamine) D.H.E. 45 6 vials per 30 days 6 vials per 30 days 6 vials per 30 days 6 vials per 30 days 6 vials per 30 days (dihydroergotamine) Diacomit 3,000 mg per day 3,000 mg per day Not covered 3,000 mg per day 3,000 mg per day (stiripentol) Dibenzyline 12 capsules per day 12 capsules per day 12 capsules per day 12 capsules per day 12 capsules per day (phenoxybenzamine) Diclegis (doxylamine succinate + 4 tablets per day Not covered 4 tablets per day 4 tablets per day Not covered pyridoxine) Dificid suspension 1 bottle (150 ml) per 30 days 1 bottle (150 ml) per 30 days 1 bottle (150 ml) per 30 days 1 bottle (150 ml) per 30 days 1 bottle (150 ml) per 30 days (fidaxomicin) Dificid tablet 20 tablets per 30 days 20 tablets per 30 days 20 tablets per 30 days 20 tablets per 30 days 20 tablets per 30 days (fidaxomicin) Doptelet 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (avatrombopag) Dovato 1 tablet per day 1 tablet per day Not covered 1 tablet per day 1 tablet per day (dolutegravir + lamivudine) Doxepin cream 1 tube per 365 days 1 tube per 365 days 1 tube per 365 days 1 tube per 365 days 1 tube per 365 days (Prudoxin, Zonalon)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 19 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Duexis Not covered Not covered 3 tablets per day Not covered Not covered (ibuprofen + famotidine) Dulera (mometasone furoate + 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days formoterol fumarate) Duobrii 1 tube per 30 days 1 tube per 30 days 1 tube per 30 days 1 tube per 30 days 1 tube per 30 days (halobetasol + tazarotene) Duopa 4 cartons (2800ml) 4 cartons (2800ml) 4 cartons (2800ml) 4 cartons (2800ml) 4 cartons (2800ml) (carbidopa + levodopa) per 30 days per 30 days per 30 days per 30 days per 30 days Dupixent 2 syringes per 30 days 2 syringes per 30 days 2 syringes per 30 days 2 syringes per 30 days 2 syringes per 30 days (dupliumab) Duragesic 12, 25, 50, 75 100mcg/hr 10 patches per 30 days** 10 patches per 30 days** 10 patches per 30 days** 10 patches per 30 days** 10 patches per 30 days** (fentanyl) Duragesic 37.5, 62.5, 87.5mcg/hr 10 patches per 30 days** Not covered 10 patches per 30 days** 10 patches per 30 days** Not covered (fentanyl) Duzallo 1 tablet per day Not covered Not covered 1 tablet per day Not covered (lesinurad + allopurinol) Dyanavel XR (amphetamine extended- 8 ml per day Not covered 8 ml per day 8 ml per day Not covered release) Dymista 1 bottle (23 gm) per 30 days Not covered 1 bottle (23 gm) per 30 days Not covered Not covered (azelastine + fluticasone) Ecoza 1 bottle per 30 days Not covered Not covered 1 bottle per 30 days Not covered (econazole)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 20 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Edarbi 1 tablet per day 1 tablet per day Not covered 1 tablet per day 1 tablet per day (azilsartan medoxomil) Edarbyclor (azilsartan medoxomil + 1 tablet per day 1 tablet per day Not covered 1 tablet per day 1 tablet per day chlorthalidone) Edex 12 units per 30 days Not covered 12 units per 30 days 12 units per 30 days Not covered (alprostadil) Edluar 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered (zolpidem) Edurant 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (rilpivirine) Effient 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (prasugrel) Egrifta 1mg 2 vials per day Not covered 2 vials per day 2 vials per day Not covered (tesamorelin) Egrifta 2mg 1 vial per day Not covered 1 vial per day 1 vial per day Not covered (tesamorelin) Elepsia XR (levetiracetam extended- 2 tablets per day Not covered Not covered 2 tablets per day Not covered release) Eliquis starter pack 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days (apixaban) Eliquis 74 tablets per 30 days 74 tablets per 30 days 74 tablets per 30 days 74 tablets per 30 days 74 tablets per 30 days (apixaban) 194 tablets per 90 days 194 tablets per 90 days 194 tablets per 90 days 194 tablets per 90 days 194 tablets per 90 days Ella 2 tablets per 30 days 2 tablets per 30 days 2 tablets per 30 days 2 tablets per 30 days 2 tablets per 30 days (ulipristal acetate)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 21 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Emend 40mg, 80mg 4 capsules per 30 days 4 capsules per 30 days 4 capsules per 30 days 4 capsules per 30 days 4 capsules per 30 days (aprepitant) Emend 125mg 2 capsules per 30 days 2 capsules per 30 days 2 capsules per 30 days 2 capsules per 30 days 2 capsules per 30 days (aprepitant) Emend oral suspension 6 packets per 30 days 6 packets per 30 days 6 packets per 30 days 6 packets per 30 days 6 packets per 30 days (aprepitant) Emend Trifold pack 2 packs (6 capsules) 2 packs (6 capsules) 2 packs (6 capsules) 2 packs (6 capsules) 2 packs (6 capsules) (aprepitant) per 30 days per 30 days per 30 days per 30 days per 30 days 1 carton (3 syringes) 1 carton (3 syringes) 1 carton (3 syringes) 1 carton (3 syringes) 1 carton (3 syringes) Emgality 100mg per 30 days; per 30 days; per 30 days; per 30 days; per 30 days; (-gnlm) 4 cartons (12 syringes) 4 cartons (12 syringes) 4 cartons (12 syringes) 4 cartons (12 syringes) 4 cartons (12 syringes) per 365 days per 365 days per 365 days per 365 days per 365 days Emgality 120mg 1 pen / syringe per 30 days 1 pen / syringe per 30 days 1 pen / syringe per 30 days 1 pen / syringe per 30 days 1 pen / syringe per 30 days (galcanezumab-gnlm) Empaveli 5.4 ml per day 5.4 ml per day Not covered 5.4 ml per day 5.4 ml per day (pegcetacoplan) Emsam 1 patch per day 1 patch per day 1 patch per day 1 patch per day 1 patch per day (selegiline) Emverm 6 tablets per 30 days Not covered 6 tablets per 30 days 6 tablets per 30 days Not covered (mebendazole) Enablex 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered (darifenacin) Enbrel 25mg 8 syringes / vials per 30 days 8 syringes / vials per 30 days 8 syringes / vials per 30 days 8 syringes / vials per 30 days 8 syringes / vials per 30 days (etanercept)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 22 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Enbrel 50mg 4 syringes / vials per 30 days 4 syringes / vials per 30 days 4 syringes / vials per 30 days 4 syringes / vials per 30 days 4 syringes / vials per 30 days (etanercept) Endari 6 packets per day 6 packets per day 6 packets per day 6 packets per day 6 packets per day (l-glutamine) Engerix B vaccine, 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill 10mcg/0.5ml Engerix B vaccine, 1 ml per fill 1 ml per fill 1 ml per fill 1 ml per fill 1 ml per fill 20mcg/ml Enspryng 1 syringe (120 mg) 1 syringe (120 mg) 1 syringe (120 mg) 1 syringe (120 mg) 1 syringe (120 mg) (satralizumab) per 30 days per 30 days per 30 days per 30 days per 30 days Enstilar (calcipotriene + betamethasone 7 cans per 30 days Not covered 7 cans per 30 days 7 cans per 30 days Not covered dipropionate) Entresto 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day ( + valsartan) Epclusa 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (sofosbuvir + velpatasvir) Epidiolex 20 ml per day 20 ml per day 20 ml per day 20 ml per day 20 ml per day (cannabidiol) (6 bottles per month) (6 bottles per month) (6 bottles per month) (6 bottles per month) (6 bottles per month) Epiduo Forte 1 pump per 30 days Not covered Not covered 1 pump per 30 days Not covered (adapalene + benzoyl peroxide) epinephrine auto-injector 4 injections per Rx, 4 injections per Rx, 4 injections per Rx, 4 injections per Rx, 4 injections per Rx, (EpiPen, EpiPen Jr.) 8 injections per 365 days 8 injections per 365 days 8 injections per 365 days 8 injections per 365 days 8 injections per 365 days Ergomar 20 tablets per 30 days Not covered 20 tablets per 30 days 20 tablets per 30 days Not covered (ergotamine tartrate tablets)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 23 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Erivedge 30 capsules per 30 days* 30 capsules per 30 days* 30 capsules per 30 days* 30 capsules per 30 days* 30 capsules per 30 days* (vismodegib) Erleada 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (apalutamide) Esbriet 267mg 9 capsules / tablets per day 9 capsules / tablets per day 9 capsules / tablets per day 9 capsules / tablets per day 9 capsules / tablets per day (pirfenidone) Esbriet 801mg 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day (pirfenidone) Esgic 4 grams of APAP per day 4 grams of APAP per day 4 grams of APAP per day 4 grams of APAP per day 4 grams of APAP per day (butalbital + acetaminophen) Eucrisa 1 tube per Rx Not covered 1 tube per Rx 1 tube per Rx Not covered (crisaborole) Evekeo 60 mg per day Not covered 60 mg per day 60 mg per day Not covered (amphetamine sulfate) Evista 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (raloxifene) Evotaz 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (atazanavir + cobicistat) Evrysdi 3 bottles (240 ml) per 30 days 3 bottles (240 ml) per 30 days 3 bottles (240 ml) per 30 days 3 bottles (240 ml) per 30 days 3 bottles (240 ml) per 30 days (risdiplam) Exalgo 1 tablet per day** Not covered 1 tablet per day** 1 tablet per day** Not covered (hydromorphone) Exjade Limited to 15 day supply Limited to 15 day supply Limited to 15 day supply Limited to 15 day supply Limited to 15 day supply (deferasirox) per fill per fill per fill per fill per fill Exservan 1 carton (60 pouches) 1 carton (60 pouches) 1 carton (60 pouches) 1 carton (60 pouches) Not covered (riluzole) per 30 days per 30 days per 30 days per 30 days

* Limited to a 15 day supply ** Limited to a 30 day supply Page 24 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Extavia 14 vials / kits per 30 days 14 vials / kits per 30 days Not covered 14 vials / kits per 30 days 14 vials / kits per 30 days (interferon beta 1b) Fabior 1 canister per 30 days Not covered 1 canister per 30 days 1 canister per 30 days Not covered (tazarotene) Farxiga 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (dapagliflozin) Farydak 6 capsules per 21 days 6 capsules per 21 days 6 capsules per 21 days 6 capsules per 21 days 6 capsules per 21 days (panobinostat) Fasenra pen 1 pen per 30 days 1 pen per 30 days 1 pen per 30 days 1 pen per 30 days 1 pen per 30 days (benralizumab)

Female Condom 6 units per 30 days 6 units per 30 days 6 units per 30 days 6 units per 30 days 6 units per 30 days

Fenoprofen 200mg 16 capsules per day Not covered Not covered 16 capsules per day Not covered

Fenoprofen 400mg 8 capsules per day Not covered Not covered 8 capsules per day Not covered

Fenoprofen 600mg 5 tablets per day 5 tablets per day 5 tablets per day 5 tablets per day 5 tablets per day

Fenortho 200mg 16 capsules per day Not covered Not covered 16 capsules per day Not covered (fenoprofen) Fentora 4 buccal tablets per day Not covered Not covered 4 buccal tablets per day Not covered (fentanyl citrate) Ferriprox oral solution 90 ml per day 90 ml per day 90 ml per day 90 ml per day 90 ml per day (deferiprone)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 25 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Ferriprox tablet 9 tablets per day 9 tablets per day 9 tablets per day 9 tablets per day 9 tablets per day (deferiprone) Fetzima 1 capsule per day Not covered 1 capsule per day 1 capsule per day Not covered (levomilnacipran) Fetzima titration pack 1 pack per 365 days Not covered 1 pack per 365 days 1 pack per 365 days Not covered (levomilnacipran) Finacea Foam 1 can per 30 days Not covered 1 can per 30 days 1 can per 30 days Not covered (azelaic acid) Fintepla 1 bottle (360 ml) per 30 days 1 bottle (360 ml) per 30 days Not covered 1 bottle (360 ml) per 30 days 1 bottle (360 ml) per 30 days (fenfluramine) Fioricet 4 grams of APAP per day 4 grams of APAP per day 4 grams of APAP per day 4 grams of APAP per day 4 grams of APAP per day (butalbital + acetaminophen) Fioricet with Codeine (butalbital + acetaminophen + 4 grams of APAP per day 4 grams of APAP per day 4 grams of APAP per day 4 grams of APAP per day 4 grams of APAP per day codeine) Firazyr 12 syringes (36 ml) 12 syringes (36 ml) 12 syringes (36 ml) 12 syringes (36 ml) 12 syringes (36 ml) () per 30 days per 30 days per 30 days per 30 days per 30 days Firvanq 1 gram per day 1 gram per day Not covered 1 gram per day 1 gram per day (vancomycin) Flector patch 2 patches per day Not covered 2 patches per day 2 patches per day Not covered (diclofenac) Flonase 1 (16 gm bottle) per 30 days 1 (16 gm bottle) per 30 days 1 (16 gm bottle) per 30 days Not covered 1 (16 gm bottle) per 30 days (fluticasone) Flovent Diskus 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days (fluticasone propionate)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 26 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Flovent HFA 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days (fluticasone propionate) Flu vaccines 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill (Afluria, Quad; Fluad; Flublok, ≥ 9 yrs old ≥ 9 yrs old ≥ 9 yrs old ≥ 9 yrs old ≥ 9 yrs old Quad; Flucelvax Quad; 1 vaccine per 180 days 1 vaccine per 180 days 1 vaccine per 180 days 1 vaccine per 180 days 1 vaccine per 180 days Flucelvax Quad; Flulaval) 2 nasal spray syringes 2 nasal spray syringes 2 nasal spray syringes 2 nasal spray syringes 2 nasal spray syringes Flumist per 6 months per 6 months per 6 months per 6 months per 6 months 0.7 ml per fill 0.7 ml per fill 0.7 ml per fill 0.7 ml per fill 0.7 ml per fill Fluzone HD ≥ 65 years old ≥ 65 years old ≥ 65 years old ≥ 65 years old ≥ 65 years old fluticasone-salmeterol 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days inhalation powder Focalin 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day (dexmethylphenidate) Focalin XR 2 capsules per day 2 capsules per day 2 capsules per day 2 capsules per day 2 capsules per day (dexmethylphenidate) Follistim AQ cartridge 45 cartridges (19 ml) 45 cartridges (19 ml) Not applicable Not covered Not applicable 300IU per 365 days per 365 days (follitropin beta) Follistim AQ cartridge 24 cartridges (19 ml) 24 cartridges (19 ml) 600IU Not applicable Not covered Not applicable per 365 days per 365 days (follitropin beta) Follistim AQ cartridge 15 cartridges (18 ml) 15 cartridges (18 ml) 900IU Not applicable Not covered Not applicable per 365 days per 365 days (follitropin beta)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 27 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Forfivo XL Not covered Not covered 1 tablet per day Not covered Not covered (bupropion) Forteo 1 pen per 30 days 1 pen per 30 days 1 pen per 30 days 1 pen per 30 days 1 pen per 30 days () Fortesta 2 canisters (120 gm) 2 canisters (120 gm) 2 canisters (120 gm) Not covered Not covered (testosterone) per 30 days per 30 days per 30 days Fosamax 5, 10, 40mg 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (alendronate) Fosamax 35mg, 70mg 4 tablets per 30 days 4 tablets per 30 days 4 tablets per 30 days 4 tablets per 30 days 4 tablets per 30 days (alendronate) Fosamax solution 4 bottles (300 ml) per 30 days 4 bottles (300 ml) per 30 days 4 bottles (300 ml) per 30 days 4 bottles (300 ml) per 30 days 4 bottles (300 ml) per 30 days (alendronate) Fosamax Plus D 4 tablets per 30 days Not covered 4 tablets per 30 days 4 tablets per 30 days Not covered (alendronate + vitamin D) Fotivda 21 capsules per 30 days 21 capsules per 30 days Not covered 21 capsules per 30 days 21 capsules per 30 days (tivozanib) Freestyle Libre 14 day reader, 1 reader per 365 days 1 reader per 365 days 1 reader per 365 days 1 reader per 365 days 1 reader per 365 days Freestyle Libre 2 14 day reader Freestyle Libre Sensor, 4 units per 30 days 4 units per 30 days 4 units per 30 days 4 units per 30 days 4 units per 30 days Freestyle Libre 2 Sensor Frova 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days (frovatriptan)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 28 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Fulphila 2 syringes per 30 days 2 syringes per 30 days 2 syringes per 30 days 2 syringes per 30 days 2 syringes per 30 days (pegfilgrastim-jmdb) Fycompa oral suspension 2 bottles (680 ml) per 30 days 2 bottles (680 ml) per 30 days 2 bottles (680 ml) per 30 days 2 bottles (680 ml) per 30 days 2 bottles (680 ml) per 30 days (perampanel) Fycompa tablet 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (perampanel) Galafold 1 wallet pack (14 capsules) 1 wallet pack (14 capsules) 1 wallet pack (14 capsules) 1 wallet pack (14 capsules) 1 wallet pack (14 capsules) (migalastat) per 28 days per 28 days per 28 days per 28 days per 28 days Gardasil / Gardasil 9 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill vaccine Gattex 1 vial per day 1 vial per day 1 vial per day 1 vial per day 1 vial per day () Gavreto 120 capsules per 30 days* 120 capsules per 30 days* 120 capsules per 30 days* 120 capsules per 30 days* 120 capsules per 30 days* (pralsetinib) Gelnique sachet 1 sachet per day Not covered 1 sachet per day 1 sachet per day Not covered (oxybutynin) Gemtesa Not covered Not covered 1 tablet per day Not covered Not covered (vibegron) Genvoya (elvitegravir + cobicstat + 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day emtricitabine + tenofovir alafenamide) Giazo 6 tablets per day 6 tablets per day 6 tablets per day 6 tablets per day 6 tablets per day (balsalazide)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 29 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Gilenya 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day (fingolimod) Gilotrif 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (afatinib) Glassia (alpha-1 Proteinase Inhibitor 9 vials per 30 days 9 vials per 30 days 9 vials per 30 days 9 vials per 30 days 9 vials per 30 days (Human)) Glatopa 1 syringe per day 1 syringe per day 1 syringe per day 1 syringe per day 1 syringe per day (glatiramer acetate) Gloperba Not covered Not covered 150 ml per 30 days Not covered Not covered (colchicine) Glucometer (Contour, Contour Next EZ, Contour Next, Contour Next 1 meter per 365 days 1 meter per 365 days 1 meter per 365 days 1 meter per 365 days 1 meter per 365 days One, One Touch Ultra 2, One Touch Verio Flex, One Touch Verio Reflect) Glyxambi 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (empagliflozin + linagliptin) Gonal-f 450 units 7 vials per 30 days, 7 vials per 30 days, Not applicable Not applicable Not applicable (follitropin alfa) 21 vials per 365 days 21 vials per 365 days Gonal-f 1,050 units 4 vials per 30 days, 4 vials per 30 days, Not applicable Not applicable Not applicable (follitropin alfa) 12 vials per 365 days 12 vials per 365 days Gonal-f RFF 75 units 10 vials per 30 days, 10 vials per 30 days, Not applicable Not applicable Not applicable (follitropin alfa) 30 vials per 365 days 30 vials per 365 days

* Limited to a 15 day supply ** Limited to a 30 day supply Page 30 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Gonal-f RFF Pen 300 units 15 cartridges per 30 days, 15 cartridges per 30 days, Not applicable Not applicable Not applicable (follitropin alfa) 45 cartridges per 365 days 45 cartridges per 365 days Gonal-f RFF Pen 450 units 10 cartridges per 30 days, 10 cartridges per 30 days, Not applicable Not applicable Not applicable (follitropin alfa) 30 cartridges per 365 days 30 cartridges per 365 days Gonal-f RFF Pen 900 units 5 cartridges per 30 days, 5 cartridges per 30 days, Not applicable Not applicable Not applicable (follitropin alfa) 15 cartridges per 365 days 15 cartridges per 365 days Gralise starter pack 78 tablets per 365 days Not covered 78 tablets per 365 days 78 tablets per 365 days Not covered (gabapentin) Gralise 3 tablets per day Not covered 3 tablets per day 3 tablets per day Not covered (gabapentin) Grastek (timothy grass pollen allergen 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered extract) Gvoke Syringe / Hypopen 8 units per 30 days, 8 units per 30 days, 8 units per 30 days, 8 units per 30 days, 8 units per 30 days, (glucagon) 16 units per 365 days 16 units per 365 days 16 units per 365 days 16 units per 365 days 16 units per 365 days Gynol II 1 package (81 grams) 1 package (81 grams) 1 package (81 grams) 1 package (81 grams) 1 package (81 grams) (nonoxinol 9) per 30 days per 30 days per 30 days per 30 days per 30 days Haegarda 2,000mg 16 vials per 30 days 16 vials per 30 days 16 vials per 30 days 16 vials per 30 days 16 vials per 30 days (C1 Esterase Inhibitor) Haegarda 3,000mg 8 vials per 30 days 8 vials per 30 days 8 vials per 30 days 8 vials per 30 days 8 vials per 30 days (C1 Esterase Inhibitor) Halcion 0.125mg 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (triazolam) Halcion 0.25mg 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (triazolam)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 31 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Harvoni pellet 2 packets per day 2 packets per day 2 packets per day 2 packets per day 2 packets per day (ledipasvir + sofosbuvir) Harvoni tablet 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered (ledipasvir + sofosbuvir)

Havrix vaccine 720 units 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill

Havrix vaccine 1,440 units 1 ml per fill 1 ml per fill 1 ml per fill 1 ml per fill 1 ml per fill

Hemangeol 3 bottles per 30 days Not covered 3 bottles per 30 days 3 bottles per 30 days Not covered (propranolol) Hetlioz 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day (tasimelteon) Hetlioz LQ 48ml bottle 2 bottles per 30 days 2 bottles per 30 days 2 bottles per 30 days 2 bottles per 30 days 2 bottles per 30 days (tasimelteon) Hetlioz LQ 158ml bottle 1 bottle per 30 days 1 bottle per 30 days 1 bottle per 30 days 1 bottle per 30 days 1 bottle per 30 days (tasimelteon) Horizant 2 tablets per day Not covered 2 tablets per day 2 tablets per day Not covered (gabapentin enacarbil) Humira 10mg, 20mg 1 package (2 syringes) 1 package (2 syringes) 1 package (2 syringes) 1 package (2 syringes) 1 package (2 syringes) (adalimumab) per 30 days per 30 days per 30 days per 30 days per 30 days Humira 40mg 2 packages (4 syringes/pens) 2 packages (4 syringes/pens) 2 packages (4 syringes/pens) 2 packages (4 syringes/pens) 2 packages (4 syringes/pens) (adalimumab) per 30 days per 30 days per 30 days per 30 days per 30 days Humira 80mg 1 package (3 syringes) 1 package (3 syringes) 1 package (3 syringes) 1 package (3 syringes) 1 package (3 syringes) (adalimumab) per 30 days per 30 days per 30 days per 30 days per 30 days

* Limited to a 15 day supply ** Limited to a 30 day supply Page 32 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Humira 80mg-40mg 2 kits per 365 days 2 kits per 365 days 2 kits per 365 days 2 kits per 365 days 2 kits per 365 days (adalimumab) Humira Crohn’s kit 1 kit (6 syringes) 1 kit (6 syringes) 1 kit (6 syringes) 1 kit (6 syringes) 1 kit (6 syringes) (adalimumab) per 365 days per 365 days per 365 days per 365 days per 365 days Humira Pen starter pack 2 packages per 365 days 2 packages per 365 days 2 packages per 365 days 2 packages per 365 days 2 packages per 365 days (adalimumab) Humira Psoriasis kit 1 kit (4 syringes) 1 kit (4 syringes) 1 kit (4 syringes) 1 kit (4 syringes) 1 kit (4 syringes) (adalimumab) per 365 days per 365 days per 365 days per 365 days per 365 days Hycet Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply (hydrocodone bitartrate + for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply acetaminophen) for each subsequent fill for each subsequent fill for each subsequent fill for each subsequent fill for each subsequent fill hydrocodone / acetaminophen, oxycodone / 4 grams acetaminophen 4 grams acetaminophen 4 grams acetaminophen 4 grams acetaminophen 4 grams acetaminophen acetaminophen, per day, per day, per day, per day, per day, codeine / acetaminophen (Limited to a 5 day supply for (Limited to a 5 day supply for (Limited to a 5 day supply for (Limited to a 5 day supply for (Limited to a 5 day supply for (Capital with Codeine, Endocet, the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for Lorcet, Lortab, Margesic #3, each subsequent fill) each subsequent fill) each subsequent fill) each subsequent fill) each subsequent fill) Norco, Percocet, Tylenol with Codeine, Verdrocdet, Vicodin, Xodol) hydrocodone + ibuprofen Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply (Ibudone, Reprexain, Xylon 10) for each subsequent fill for each subsequent fill for each subsequent fill for each subsequent fill for each subsequent fill hydromorphone Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply (Dilaudid) for each subsequent fill for each subsequent fill for each subsequent fill for each subsequent fill for each subsequent fill

* Limited to a 15 day supply ** Limited to a 30 day supply Page 33 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Hysingla ER (hydrocodone extended- 1 tablet per day** Not covered 1 tablet per day** 1 tablet per day** Not covered release) Ibrance 21 tablets / capsules 21 tablets / capsules 21 tablets / capsules 21 tablets / capsules 21 tablets / capsules (palbociclib) per 30 days per 30 days per 30 days per 30 days per 30 days Iclusig 15mg 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* (ponatinib) Iclusig 10mg, 30mg, 45mg 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* (ponatinib) Idhifa 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (enasidenib) Imbruvica capsule 120 capsules per 30 days* 120 capsules per 30 days* 120 capsules per 30 days* 120 capsules per 30 days* 120 capsules per 30 days* (ibrutinib) Imbruvica tablet 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (ibrutinib) Imcivree 9 ml per 30 days 9 ml per 30 days 9 ml per 30 days 9 ml per 30 days 9 ml per 30 days (setmelanotide) Imitrex injection 12 units per 30 days 12 units per 30 days 12 units per 30 days 12 units per 30 days 12 units per 30 days (sumatriptan) Imitrex nasal spray 12 units per 30 days 12 units per 30 days 12 units per 30 days 12 units per 30 days 12 units per 30 days (sumatriptan) Imitrex tablet 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days (sumatriptan) Impavido 84 capsules per 30 days 84 capsules per 30 days 84 capsules per 30 days 84 capsules per 30 days 84 capsules per 30 days (miltefosine)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 34 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Inbrija 60 count 5 cartons per 30 days 5 cartons per 30 days 5 cartons per 30 days 5 cartons per 30 days 5 cartons per 30 days (levodopa) Incruse Ellipta 1 inhaler per 30 days Not covered 1 inhaler per 30 days 1 inhaler per 30 days Not covered (umeclidinium) Indocin suppository 4 suppositories per day 4 suppositories per day 4 suppositories per day 4 suppositories per day 4 suppositories per day (indomethacin) Ingrezza 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day (valbenazine) Ingrezza titration pack 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days (valbenazine) Inlyta 1mg 180 tablets per 30 days* 180 tablets per 30 days* 180 tablets per 30 days* 180 tablets per 30 days* 180 tablets per 30 days* (axitinib) Inlyta 5mg 120 tablets per 30 days* 120 tablets per 30 days* 120 tablets per 30 days* 120 tablets per 30 days* 120 tablets per 30 days* (axitinib) Inqovi 5 tablets (1 blister card) 5 tablets (1 blister card) 5 tablets (1 blister card) 5 tablets (1 blister card) 5 tablets (1 blister card) (decitabine + cedazuridine) per 28 days per 28 days per 28 days per 28 days per 28 days Inrebic 120 capsules per 30 days* 120 capsules per 30 days* Not covered 120 capsules per 30 days* 120 capsules per 30 days* (fedratinib) Needles and Not applicable 200 per 30 days Not applicable 200 syringes per Rx 200 syringes per Rx Syringes Intermezzo 60 tablets per 90 days Not covered 60 tablets per 90 days 60 tablets per 90 days Not covered (zolpidem) Intuniv 2 tablet per day 2 tablet per day 2 tablet per day 2 tablet per day 2 tablet per day (guanfacine) Invega 1.5mg, 3mg, 9mg 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (paliperidone)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 35 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Invega 6mg 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (paliperidone) Invega Trinza 4 kits per 365 days 4 kits per 365 days 4 kits per 365 days 4 kits per 365 days 4 kits per 365 days (paliperidone palmitate) Inveltys 1 bottle per 30 days Not covered 1 bottle per 30 days 1 bottle per 30 days Not covered (loteprednol) Invokamet 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (canagliflozin + metformin) Invokamet XR (canagliflozin + metformin 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day extended-release) Invokana 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (canagliflozin) Iressa 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (gefitinib) Isturisa 1mg, 5mg 4 tablets per day 4 tablets per day Not covered 4 tablets per day 4 tablets per day (osilodrostat) Isturisa 10mg 6 tablets per day 6 tablets per day Not covered 6 tablets per day 6 tablets per day (osilodrostat) ivermectin 20 tablets per 365 days 20 tablets per 365 days 20 tablets per 365 days 20 tablets per 365 days 20 tablets per 365 days (Stromectol) Jadenu packet Limited to 15 day supply Limited to 15 day supply Not covered Not covered Not covered (deferasirox) per fill per fill Jadenu tablet Limited to 15 day supply Limited to 15 day supply Limited to 15 day supply Not covered Not covered (deferasirox) per fill per fill per fill Jakafi 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* (ruxolitinib)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 36 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Jalyn 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day (dutasteride + tamsulosin) Janumet 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (sitagliptin + metformin) Janumet XR 50/1,000mg 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (sitagliptin + metformin) Janumet XR 50/500mg, 100/1,000mg 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (sitagliptin + metformin) Januvia 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (sitagliptin) Jardiance 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (empagliflozin) Jatenzo 158mg, 198mg 4 capsules per day Not covered 4 capsules per day 4 capsules per day Not covered (testosterone) Jatenzo 237mg 2 capsules per day Not covered 2 capsules per day 2 capsules per day Not covered (testosterone) Jentadueto 2 tablets per day Not covered Not covered 2 tablets per day Not covered (linagliptin + metformin) Jentadueto XR 2.5/1,000mg (linagliptin + metformin 2 tablets per day Not covered Not covered 2 tablets per day Not covered extended-release) Jentadueto XR 5/1,000mg (linagliptin + metformin 1 tablet per day Not covered Not covered 1 tablet per day Not covered extended-release)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 37 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Jornay PM 1 capsule per day Not covered 1 capsule per day 1 capsule per day Not covered (methylphenidate) Juluca 1 tablet per day 1 tablet per day Not covered 1 tablet per day 1 tablet per day (dolutegravir + rilpivirine) Juxtapid 20mg 3 capsules per day Not covered 3 capsules per day 3 capsules per day Not covered (lomitapide) Juxtapid 5,10, 30, 40, 60mg 1 capsule per day Not covered 1 capsule per day 1 capsule per day Not covered (lomitapide) Jynarque 15mg, 30mg 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (tolvaptan) Jynarque 45, 60, 90mg 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (tolvaptan) Kadian 1 capsule per day** 1 capsule per day** 1 capsule per day** 1 capsule per day** 1 capsule per day** (morphine) Kalydeco granule 2 packets per day 2 packets per day 2 packets per day 2 packets per day 2 packets per day (ivacaftor) Kalydeco tablet 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (ivacaftor) Kapvay 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (clonidine extended-release) Karbinal ER 3 bottles (1,440 ml) 3 bottles (1,440 ml) 3 bottles (1,440 ml) Not covered Not covered (carbinoxamine extended- per 30 days per 30 days per 30 days release) Katerzia 2 bottles (300mg) 2 bottles (300mg) Not covered Not covered Not covered (amlodipine) per 30 days per 30 days

* Limited to a 15 day supply ** Limited to a 30 day supply Page 38 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Kenalog Spray 1 can per 365 days 1 can per 365 days 1 can per 365 days 1 can per 365 days 1 can per 365 days (triamcinolone acetonide) Kerendia 1 tablet per day 1 tablet per day Not covered 1 tablet per day 1 tablet per day (finerenone) Kesimpta 4 pens / injectors per 28 days 4 pens / injectors per 28 days 4 pens / injectors per 28 days 4 pens / injectors per 28 days 4 pens / injectors per 28 days (ofatumumab) Ketoprofen 25mg 4 capsules per day 4 capsules per day 4 capsules per day 4 capsules per day 4 capsules per day (ketoprofen) Keveyis 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (dichlorphenamide) Kevzara 2 syringes (1 pack) 2 syringes (1 pack) 2 syringes (1 pack) 2 syringes (1 pack) 2 syringes (1 pack) (sarilumab) per 28 days per 28 days per 28 days per 28 days per 28 days Khedezla ER 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered (desvenlafaxine) Kineret 1 syringe per day 1 syringe per day 1 syringe per day 1 syringe per day 1 syringe per day (anakinra) Kisqali 63 tablets per 30 days 63 tablets per 30 days Not covered 63 tablets per 30 days 63 tablets per 30 days (ribociclib) Kisqali Femara Co-pack 91 tablets per 30 days 91 tablets per 30 days Not covered 91 tablets per 30 days 91 tablets per 30 days (ribociclib + letrozole) Klisyri 5 packets per 30 days 5 packets per 30 days Not covered 5 packets per 30 days 5 packets per 30 days (tirbanibulin) Kloxxado 4 doses per fill 4 doses per fill Not covered 4 doses per fill 4 doses per fill (naloxone) Korlym 4 tablets per day 4 tablets per day Not covered 4 tablets per day 4 tablets per day (mifepristone)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 39 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Koselugo 6 capsules per day 6 capsules per day 6 capsules per day 6 capsules per day 6 capsules per day (selumetinib) Krintafel 2 tablets per Rx 2 tablets per Rx 2 tablets per Rx 2 tablets per Rx 2 tablets per Rx (tafenoquine) Kynmobi 5 cartons (150 films) 5 cartons (150 films) 5 cartons (150 films) 5 cartons (150 films) 5 cartons (150 films) (apomorphine) per 30 days per 30 days per 30 days per 30 days per 30 days Kynmobi titration pack 1 kit per 365 days 1 kit per 365 days Not covered 1 kit per 365 days 1 kit per 365 days (apomorphine) Kytril 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (granisetron) Lampit 30mg 720 tablets per 365 days 720 tablets per 365 days Not covered 720 tablets per 365 days 720 tablets per 365 days (nifurtimox) Lampit 120mg 450 tablets per 365 days 450 tablets per 365 days Not covered 450 tablets per 365 days 450 tablets per 365 days (nifurtimox) Lancets 300 units per 30 days 300 units per 30 days 300 units per 30 days 300 units per 30 days 300 units per 30 days Lenvima 4mg, 10mg 1 capsule per day* 1 capsule per day* 1 capsule per day* 1 capsule per day* 1 capsule per day* (lenvatinib) Lenvima 8mg, 14mg, 20mg 2 capsules per day* 2 capsules per day* 2 capsules per day* 2 capsules per day* 2 capsules per day* (lenvatinib) Lenvima 12mg, 18mg, 24mg 3 capsules per day* 3 capsules per day* 3 capsules per day* 3 capsules per day* 3 capsules per day* (lenvatinib) Lescol 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day (fluvastatin)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 40 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Lescol XL 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (fluvastatin) Letairis 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day () Levitra 12 tablets per 30 days Not covered 12 tablets per 30 days 6 tablets per 28 days Not covered (vardenafil) levonorgestrel 2 tablets per 30 days 2 tablets per 30 days 2 tablets per 30 days 2 tablets per 30 days 2 tablets per 30 days (Plan B) (emergency OC) 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply levorphanol for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for each subsequent fill for each subsequent fill for each subsequent fill for each subsequent fill for each subsequent fill Lialda 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (mesalamine) Licart Not covered Not covered 2 patches per day Not covered Not covered (diclofenac epolamine) Linzess 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day (linaclotide) Lipitor 1.5 tablets per day 1.5 tablets per day 1.5 tablets per day 1.5 tablets per day 1.5 tablets per day (atorvastatin) Livalo 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (pitavastatin) Lokelma 5gm 3 boxes (90 packets) 3 boxes (90 packets) 3 boxes (90 packets) 3 boxes (90 packets) 3 boxes (90 packets) (sodium zirconium cyclosilicate) per 30 days per 30 days per 30 days per 30 days per 30 days Lokelma 10gm 1 box (30 packets ) 1 box (30 packets ) 1 box (30 packets ) 1 box (30 packets ) 1 box (30 packets ) (sodium zirconium cyclosilicate) per 30 days per 30 days per 30 days per 30 days per 30 days

* Limited to a 15 day supply ** Limited to a 30 day supply Page 41 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Long acting opioids + Limited to a 30 day supply Limited to a 30 day supply Limited to a 30 day supply Limited to a 30 day supply Limited to a 30 day supply narcotics per fill per fill per fill per fill per fill Brand and generic Long acting opioids + narcotic combination Limited to a 30 day supply Limited to a 30 day supply Limited to a 30 day supply Limited to a 30 day supply Limited to a 30 day supply products per fill per fill per fill per fill per fill Brand and generic Lonhala Magnair starter pack 1 starter pack per 365 days 1 starter pack per 365 days 1 starter pack per 365 days 1 starter pack per 365 days 1 starter pack per 365 days (glycopyrrolate) Lonhala Magnair refill pack 2 vials per day 2 vials per day 2 vials per day 2 vials per day 2 vials per day (glycopyrrolate) Lonsurf 100 tablets per 30 days 100 tablets per 30 days 100 tablets per 30 days 100 tablets per 30 days 100 tablets per 30 days (trifluridine + tipiracil) Lorbrena 25mg 90 tablets per 30 days* 90 tablets per 30 days* 90 tablets per 30 days* 90 tablets per 30 days* 90 tablets per 30 days* (lorlatinib) Lorbrena 100mg 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* (lorlatinib) LoSeasonique (levonorgestrel + ethinyl 1 blister pack per 91 days 1 blister pack per 91 days 1 blister pack per 91 days 1 blister pack per 91 days 1 blister pack per 91 days estradiol) Lotemax SM 1 bottle per 30 days Not covered 1 bottle per 30 days 1 bottle per 30 days Not covered (loteprednol etabonate) Lotronex 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (alosetron)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 42 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Lovaza 4 capsules per day 4 capsules per day 4 capsules per day 4 capsules per day 4 capsules per day (omega-3-ccid ethyl esters) Lucemyra 224 tablets per 30 days 224 tablets per 30 days Not covered 224 tablets per 30 days 224 tablets per 30 days (lofexidine) Lumakras 8 tablets per day* 8 tablets per day* Not covered 8 tablets per day* 8 tablets per day* (sotorasib) Lunesta 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (eszopiclone) Lupkynis 6 tablets per day 6 tablets per day Not covered 6 tablets per day 6 tablets per day (voclosporin) Luzu 1 tube per 30 days Not covered 1 tube per 30 days 1 tube per 30 days Not covered (luliconazole) Lynparza tablet 120 tablets per 30 days* 120 tablets per 30 days* 120 tablets per 30 days* 120 tablets per 30 days* 120 tablets per 30 days* (olaparib) Lyrica capsule 3 capsules per day 3 capsules per day 3 capsules per day 3 capsules per day 3 capsules per day (pregabalin) Lyrica solution 2 bottles (946 ml) per 30 days 2 bottles (946 ml) per 30 days 2 bottles (946 ml) per 30 days 2 bottles (946 ml) per 30 days 2 bottles (946 ml) per 30 days (pregabalin) Lyrica CR 82.5, 165mg 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered (pregabalin extended-release) Lyrica CR 330mg 2 tablets per day Not covered 2 tablets per day 2 tablets per day Not covered (pregabalin extended-release) Lysteda 30 tablets per 28 days 30 tablets per 28 days 30 tablets per 28 days 30 tablets per 28 days 30 tablets per 28 days (tranexamic acid)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 43 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Mavenclad 2 boxes per 365 days 2 boxes per 365 days 2 boxes per 365 days 2 boxes per 365 days 2 boxes per 365 days (cladribine) Mavyret 3 tablets per day 3 tablets per day Not covered 3 tablets per day 3 tablets per day (glecaprevir + pibrentasvir) Mayzent starter pack 2 packs per 365 days 2 packs per 365 days 2 packs per 365 days 2 packs per 365 days 2 packs per 365 days (siponimod) Mayzent 0.25mg 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (siponimod) Mayzent 2mg 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (siponimod) Maxalt / Maxalt MLT 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days (rizatriptan) Measles, Mumps, Rubella vaccine 0.5 ml per Rx 0.5 ml per Rx 0.5 ml per Rx 0.5 ml per Rx 0.5 ml per Rx (MMR II) Mekinist 0.5mg 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day (trametinib) Mekinist 2mg 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (trametinib) Mektovi 6 tablets per day 6 tablets per day 6 tablets per day 6 tablets per day 6 tablets per day (binimetinib) Menactra vaccine 0.5 ml per fill 0.5ml per fill 0.5 ml per fill 0.5ml per fill 0.5 ml per fill Meningococcal B vaccine 0.5 ml per Rx 0.5 ml per Rx 0.5 ml per Rx 0.5 ml per Rx 0.5 ml per Rx (Trumenba, Bexsero)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 44 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Menveo (Meningococcal conjugate 1 kit per Rx 1 kit per Rx 1 kit per Rx 1 kit per Rx 1 kit per Rx vaccine) meperidine Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply (Demerol) for each subsequent fill for each subsequent fill for each subsequent fill for each subsequent fill for each subsequent fill Metadate CD 10, 20, 30mg 3 capsules per day 3 capsules per day 3 capsules per day 3 capsules per day 3 capsules per day (methylphenidate) Metadate CD 40, 50, 60mg 2 capsules per day 2 capsules per day 2 capsules per day 2 capsules per day 2 capsules per day (methylphenidate) Methadone Limited to a 30 day supply Limited to a 30 day supply Limited to a 30 day supply Limited to a 30 day supply Limited to a 30 day supply (Diskets, Dolophine, per fill per fill per fill per fill per fill Methadose) Methergine 6 tablets per day 6 tablets per day 6 tablets per day 6 tablets per day 6 tablets per day (methylergonovine) Methitest 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (methyltestosterone) Methylin tablet 2.5, 5, 10mg 7 tablets per day 7 tablets per day 7 tablets per day 7 tablets per day 7 tablets per day (methylphenidate) Methylin chew tablet 2.5, 5, 10mg 7 tablets per day Not covered 7 tablets per day 7 tablets per day Not covered (methylphenidate) Methylin solution 80 mg per day 80 mg per day 80 mg per day 80 mg per day 80 mg per day (methylphenidate) Methylin ER 10, 20mg (methylphenidate extended- 6 tablets per day 6 tablets per day 6 tablets per day 6 tablets per day 6 tablets per day release)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 45 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Methylphenidate ER 72mg (methylphenidate extended- 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day release) Mevacor 10mg, 20mg 1.5 tablets per day 1.5 tablets per day 1.5 tablets per day 1.5 tablets per day 1.5 tablets per day (lovastatin) Mevacor 40mg 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (lovastatin) Migranal 8 ampules per Rx 8 ampules per Rx 8 ampules per Rx 8 ampules per Rx 8 ampules per Rx (dihydroergotamine) Mirapex ER 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered (pramipexole extended-release) Mircera (methoxy polyethylene glycol- 2 syringes per 30 days Not covered Not covered 2 syringes per 30 days Not covered epoetin beta) Molindone 5mg 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered

Molindone 10mg, 20mg 9 tablets per day Not covered 9 tablets per day 9 tablets per day Not covered Morphine ER Limited to 30 day supply Limited to 30 day supply Limited to 30 day supply Limited to 30 day supply Limited to 30 day supply (Arymo ER, Morphine Sulfate, per fill per fill per fill per fill per fill Morphine Sulfate CR) Motegrity 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered (prucalopride) Movantik 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered (naloxegol) MS Contin 4 tablets per day** 4 tablets per day** 4 tablets per day** 4 tablets per day** 4 tablets per day** (morphine)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 46 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List MSIR Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply (morphine) for each subsequent fill for each subsequent fill for each subsequent fill for each subsequent fill for each subsequent fill Multaq 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (dronedarone) Muse 12 pouches per 30 days Not covered 12 pouches per 30 days 6 units per 28 days Not covered (alprostadil) Myalept 1 vial per day 1 vial per day 1 vial per day 1 vial per day 1 vial per day () Mycapssa 112 capsules (4 wallets) 112 capsules (4 wallets) Not covered Not covered Not covered (octreotide) per 28 days per 28 days Mydayis (amphetamine + 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day dextroamphetamine) Myfembree (relugolix + estradiol + 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day norethindrone acetate) Myrbetriq granules 10 ml per day 10 ml per day Not covered 10 ml per day 10 ml per day (mirabegron extended-release) Myrbetriq tablet 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (mirabegron extended-release) Mytesi 2 tablets per day 2 tablets per day Not covered 2 tablets per day 2 tablets per day (crofelemer delayed-release) Naftin 1 bottle per 30 days Not covered 1 bottle per 30 days 1 bottle per 30 days Not covered (naftifine) Nalfon 400mg 8 capsules per day 8 capsules per day Not covered 8 capsules per day 8 capsules per day (fenoprofen)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 47 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Nalfon 600mg 5 tablets per day 5 tablets per day Not covered 5 tablets per day 5 tablets per day (fenoprofen) Namenda titration pack 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days (memantine) Namenda XR 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day (memantine extended-release) Namenda XR titration pack 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days (memantine extended-release) Namzaric 1 capsule per day Not covered 1 capsule per day 1 capsule per day Not covered (memantine + donepezil) Namzaric titration pack 1 pack (28 capsules) 1 pack (28 capsules) 1 pack (28 capsules) Not covered Not covered (memantine + donepezil) per 365 days per 365 days per 365 days Narcan 2 cartons (4 doses) per fill 2 cartons (4 doses) per fill 2 cartons (4 doses) per fill 2 cartons (4 doses) per fill 2 cartons (4 doses) per fill (naloxone hydrochloride) Nasalide 3 (25 ml bottles) per 30 days Not covered 3 (25 ml bottles) per 30 days Not covered Not covered (flunisolide) Nasonex 2 bottle (17 gm) per 30 days Not covered 2 bottle (17 gm) per 30 days Not covered Not covered (mometasone furoate) Natesto 3 bottles per 30 days Not covered 3 bottles per 30 days 3 bottles per 30 days Not covered (testosterone) Natpara 2 cartridges per 30 days 2 cartridges per 30 days 2 cartridges per 30 days 2 cartridges per 30 days 2 cartridges per 30 days () Nayzilam 5 boxes (10 nasal spray units) 5 boxes (10 nasal spray units) 5 boxes (10 nasal spray units) 5 boxes (10 nasal spray units) 5 boxes (10 nasal spray units) (midazolam) per 30 days per 30 days per 30 days per 30 days per 30 days

* Limited to a 15 day supply ** Limited to a 30 day supply Page 48 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Nerlynx 180 tablets per 30 days* 180 tablets per 30 days* 180 tablets per 30 days* 180 tablets per 30 days* 180 tablets per 30 days* (neratinib) Neulasta 2 syringes per 30 days 2 syringes per 30 days Not covered 2 syringes per 30 days 2 syringes per 30 days (pegfilgrastim) Neupro 1 patch per day Not covered 1 patch per day 1 patch per day Not covered (rotigotine) Nexavar (sorafenib) 120 tablets per 30 days* 120 tablets per 30 days* 120 tablets per 30 days* 120 tablets per 30 days* 120 tablets per 30 days* Nexletol 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (bempedoic acid) Nexlizet 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (bempedoic acid) Nicorette gum / lozenges 770 pieces per 30 days 770 pieces per 30 days 770 pieces per 30 days 770 pieces per 30 days 770 pieces per 30 days (nicotine) Nicotine patch 1 patch per day 1 patch per day 1 patch per day 1 patch per day 1 patch per day (nicotine) Nicotrol inhaler 3 packages per 30 days 3 packages per 30 days 3 packages per 30 days 3 packages per 30 days 3 packages per 30 days (nicotine) Nicotrol NS nasal spray 40 ml (4 bottles) per 30 days 40 ml (4 bottles) per 30 days 40 ml (4 bottles) per 30 days 40 ml (4 bottles) per 30 days 40 ml (4 bottles) per 30 days (nicotine) Nilandron 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (Nilutamide) Ninlaro 3 capsules per 30 days 3 capsules per 30 days 3 capsules per 30 days 3 capsules per 30 days 3 capsules per 30 days (ixazomib)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 49 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Nivestym 2 vials per day 2 vials per day 2 vials per day 2 vials per day 2 vials per day (filgrastim) Nocdurna 1 carton 1 carton 1 carton Not covered Not covered (desmopressin acetate) (30 tablets per 30 days) (30 tablets per 30 days) (30 tablets per 30 days) Noctiva 1 bottle per 30 days Not covered Not covered 1 bottle per 30 days Not covered (desmopressin acetate) Northera 100mg, 200mg 3 capsules per day Not covered 3 capsules per day 3 capsules per day Not covered (droxidopa) Northera 300mg 6 capsules per day Not covered 6 capsules per day 6 capsules per day Not covered (droxidopa) Nourianz 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (istradefylline) Noxafil 99 tablets per 30 days 99 tablets per 30 days 99 tablets per 30 days 99 tablets per 30 days 99 tablets per 30 days (posaconazole delayed-release) Nubeqa 120 tablets per 30 days* 120 tablets per 30 days* 120 tablets per 30 days* 120 tablets per 30 days* 120 tablets per 30 days* (darolutamide) Nucala 3 auto-injectors per 30 days 3 auto-injectors per 30 days 3 auto-injectors per 30 days 3 auto-injectors per 30 days 3 auto-injectors per 30 days (mepolizumab) 6 tablets per day, 6 tablets per day, 6 tablets per day, 6 tablets per day, Nucynta (Limited to 5 day supply for (Limited to 5 day supply for (Limited to 5 day supply for (Limited to 5 day supply for Not covered (tapentadol) the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for each subsequent fill) each subsequent fill) each subsequent fill) each subsequent fill) Nucynta ER 2 tablets per day** 2 tablets per day** Not covered 2 tablets per day** 2 tablets per day** (tapentadol) Nuedexta (dextromethorphan HBr + 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day quinidine)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 50 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Nuplazid 1 tablet / capsule per day 1 tablet / capsule per day 1 tablet / capsule per day 1 tablet / capsule per day 1 tablet / capsule per day (pimavanserin) Nurtec ODT 8 tablets per 30 days Not covered 8 tablets per 30 days 8 tablets per 30 days Not covered () Nuvaring 1 vaginal ring per 28 days 1 vaginal ring per 28 days 1 vaginal ring per 28 days 1 vaginal ring per 28 days 1 vaginal ring per 28 days (etonogestrel + ethinyl estradiol) Nuvigil 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (armodafinil) Nuzyra tablet 30 tablets per 10 days 30 tablets per 10 days 30 tablets per 10 days 30 tablets per 10 days 30 tablets per 10 days (omadacycline) Nymalize 30mg/5ml 630 mls per 21 days, 630 mls per 21 days, 630 mls per 21 days, 630 mls per 21 days, 630 mls per 21 days, (nimodipine) 1260 mls per 365 days 1260 mls per 365 days 1260 mls per 365 days 1260 mls per 365 days 1260 mls per 365 days Nymalize 60mg/10ml 1260 ml per 21 days, 1260 ml per 21 days, 1260 ml per 21 days, 1260 ml per 21 days, 1260 ml per 21 days, (nimodipine) 2520 ml per 265 days 2520 ml per 265 days 2520 ml per 265 days 2520 ml per 265 days 2520 ml per 265 days Nyvepria 2 syringes per 30 days 2 syringes per 30 days 2 syringes per 30 days 2 syringes per 30 days 2 syringes per 30 days (pegfilgrastim-apgf) Obredon 240 ml per 30 days Not covered 240 ml per 30 days 240 ml per 30 days Not covered (hydrocodone + guaifenisin) Ocaliva 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (obeticholic acid) Odactra (house dust mite allergan 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered extract) Odefsey (emtricitabine + rilpivirine + 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day tenofovir)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 51 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Odomzo 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* (sonidegib) Ofev 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (nintedanib) Olumiant 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (baricitinib) Omnaris 1 bottle (13 gm) per 30 days Not covered Not covered Not covered Not covered (ciclesonide)

Omnipod Dash Pods 4 packs (20 units) per 30 days 4 packs (20 units) per 30 days 4 packs (20 units) per 30 days 4 packs (20 units) per 30 days 4 packs (20 units) per 30 days Onexton (clindamycin + benzoyl Not covered Not covered 1 bottle per 30 days Not covered Not covered peroxide) Onfi 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day (clobazam) Onfi oral suspension 16 ml (40mg) per day 16 ml (40mg) per day 16 ml (40mg) per day 16 ml (40mg) per day 16 ml (40mg) per day (clobazam) Ongentys 1 capsule per day 1 capsule per day Not covered 1 capsule per day 1 capsule per day (opicapone) Onureg 14 tablets per 30 days 14 tablets per 30 days 14 tablets per 30 days 14 tablets per 30 days 14 tablets per 30 days (azacitidine) Onzetra Xsail 1 kit per 30 days Not covered 1 kit per 30 days Not covered 1 kit per 30 days (sumatriptan) 6 tablets per day 6 tablets per day 6 tablets per day Opana (Limited to 5 day supply for (Limited to 5 day supply for (Limited to 5 day supply for Not covered Not covered (oxymorphone) the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for each subsequent fill) each subsequent fill) each subsequent fill)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 52 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Opana ER (oxymorphone extended- 4 tablets per day** 4 tablets per day** 4 tablets per day** 4 tablets per day** 4 tablets per day** release) Opium + Belladonna Limited to 30 day supply Limited to 30 day supply Limited to 30 day supply Limited to 30 day supply Limited to 30 day supply alkaloids per fill per fill per fill per fill per fill Opsumit 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day () Oralair (mixed grass pollens allergens 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered extract) Oravig 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered (miconazole) Orencia 4 syringes per 30 days 4 syringes per 30 days 4 syringes per 30 days 4 syringes per 30 days 4 syringes per 30 days (abatacept) Orenitram 9 tablets per day 9 tablets per day 9 tablets per day 9 tablets per day 9 tablets per day (treprostinil) Orgovyx 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (relugolix) Oriahnn 1 carton (56 capsules) 1 carton (56 capsules) 1 carton (56 capsules) 1 carton (56 capsules) 1 carton (56 capsules) (elagolix+estradiol+norethindron per 28 days per 28 days per 28 days per 28 days per 28 days e acetate & elagolix) Orilissa 150mg 1 carton (28 tablets) 1 carton (28 tablets) 1 carton (28 tablets) 1 carton (28 tablets) 1 carton (28 tablets) (elagolix) per 30 days per 30 days per 30 days per 30 days per 30 days Orilissa 200mg 1 carton (56 tablets) 1 carton (56 tablets) 1 carton (56 tablets) 1 carton (56 tablets) 1 carton (56 tablets) (elagolix) per 30 days per 30 days per 30 days per 30 days per 30 days

* Limited to a 15 day supply ** Limited to a 30 day supply Page 53 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Orkambi granules 56 packets per 30 days 56 packets per 30 days 56 packets per 30 days 56 packets per 30 days 56 packets per 30 days (lumacaftor + ivacaftor) Orkambi tablet 112 tablets per 30 days 112 tablets per 30 days 112 tablets per 30 days 112 tablets per 30 days 112 tablets per 30 days (lumacaftor + ivacaftor) Orladeyo 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day (berotralstat) Ortho Evra (ethinyl estradiol + 3 patches per 28 days 3 patches per 28 days 3 patches per 28 days 3 patches per 28 days 3 patches per 28 days norelgestromin) Ortikos Not covered Not covered 1 capsule per day Not covered Not covered (budesonide) Oseni Not covered Not covered 1 tablet per day Not covered Not covered (alogliptin + pioglitazone) Osmolex ER Not covered Not covered 1 capsule per day Not covered Not covered (amantadine) Osmolex ER therapy pack Not covered Not covered 1 pack per 30 days Not covered Not covered (amantadine) Otezla 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (apremilast) Otrexup 4 injections per 30 days Not covered Not covered 4 injections per 30 days Not covered (methotrexate) Ovidrel 2 syringes per 30 days, 2 syringes per 30 days, Not applicable Not applicable Not applicable (choriogonadotropin alfa i) 6 syringes per 365 days 6 syringes per 365 days Oxaydo Not covered Not covered 6 tablets per day Not covered Not covered (oxycodone HCl)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 54 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Oxbryta 3 tablets per day 3 tablets per day Not covered 3 tablets per day 3 tablets per day (voxelotor) 4 cartons (28 vials) 4 cartons (28 vials) 4 cartons (28 vials) 4 cartons (28 vials) 4 cartons (28 vials) Oxervate per 30 days, per 30 days, per 30 days, per 30 days, per 30 days, (cenegermin-bkbj) (Limited to 8 cartons (56 vials) (Limited to 8 cartons (56 vials) (Limited to 8 cartons (56 vials) (Limited to 8 cartons (56 vials) (Limited to 8 cartons (56 vials) per 60 days) per 60 days) per 60 days) per 60 days) per 60 days) Oxistat 1 bottle per 30 days Not covered 1 bottle per 30 days 1 bottle per 30 days Not covered (oxiconazole) Oxtellar XR 150mg, 300mg (oxcarbazepine extended- 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered release) Oxtellar XR 600mg (oxcarbazepine extended- 4 tablets per day Not covered 4 tablets per day 4 tablets per day Not covered release) 6 tablets per day, 6 tablets per day, 6 tablets per day, 6 tablets per day, 6 tablets per day, oxycodone (Limited to 5 day supply for (Limited to 5 day supply for (Limited to 5 day supply for (Limited to 5 day supply for (Limited to 5 day supply for (immediate release) the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for each subsequent fill) each subsequent fill) each subsequent fill) each subsequent fill) each subsequent fill) 150 ml per 30 days, 150 ml per 30 days, 150 ml per 30 days, 150 ml per 30 days, 150 ml per 30 days, oxycodone oral (Limited to 5 day supply for (Limited to 5 day supply for (Limited to 5 day supply for (Limited to 5 day supply for (Limited to 5 day supply for concentrate 20mg/ml the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for each subsequent fill) each subsequent fill) each subsequent fill) each subsequent fill) each subsequent fill) 2400 ml per 30 days, 2400 ml per 30 days, 2400 ml per 30 days, 2400 ml per 30 days, 2400 ml per 30 days, oxycodone oral solution (Limited to 5 day supply for (Limited to 5 day supply for (Limited to 5 day supply for (Limited to 5 day supply for (Limited to 5 day supply for 1 mg/ml the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for each subsequent fill) each subsequent fill) each subsequent fill) each subsequent fill) each subsequent fill) Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply oxycodone + ibuprofen for the 1st fill, 30 day supply Not covered for the 1st fill, 30 day supply for the 1st fill, 30 day supply Not covered for each subsequent fill for each subsequent fill for each subsequent fill

* Limited to a 15 day supply ** Limited to a 30 day supply Page 55 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Oxycontin 2 tablets per day** 2 tablets per day** 2 tablets per day** 2 tablets per day** 2 tablets per day** (oxycodone extended-release) Ozempic 6 ml per 30 days 6 ml per 30 days 6 ml per 30 days 6 ml per 30 days 6 ml per 30 days () Ozobax 5 bottles (2400mL) 5 bottles (2400mL) Not covered Not covered Not covered (baclofen) per 30 days per 30 days Palforzia packet 1 kit per 30 days 1 kit per 30 days 1 kit per 30 days 1 kit per 30 days 1 kit per 30 days (peanut arachis hypogaea) Palynziq 2.5mg 8 injections per 30 days 8 injections per 30 days 8 injections per 30 days 8 injections per 30 days 8 injections per 30 days (pegvaliase-pqpz) Palynziq 10mg 1 injection per day 1 injection per day 1 injection per day 1 injection per day 1 injection per day (pegvaliase-pqpz) Palynziq 20mg 2 injections per day 2 injections per day 2 injections per day 2 injections per day 2 injections per day (pegvaliase-pqpz) Patanase 1 bottle (30 gm) per 30 days Not covered 1 bottle (30 gm) per 30 days 1 bottle (30 gm) per 30 days Not covered (olopatadine) Pazeo 2 bottles per 30 days 2 bottles per 30 days Not covered 2 bottles per 30 days 2 bottles per 30 days (olopatadine hydrochloride) Pegasys 4 syringes / vials / pens 4 syringes / vials / pens 4 syringes / vials / pens 4 syringes / vials / pens 4 syringes / vials / pens (peginterferon alfa-2a) per 30 days per 30 days per 30 days per 30 days per 30 days Peg-intron 4 vials / redipens per 30 days 4 vials / redipens per 30 days 4 vials / redipens per 30 days 4 vials / redipens per 30 days 4 vials / redipens per 30 days (peginterferon alfa-2b) Pennsaid 2% 2 bottles per 30 days Not covered Not covered 2 bottles per 30 days Not covered (diclofenac sodium)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 56 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Pemazyre 14 tablets per 30 days 14 tablets per 30 days 14 tablets per 30 days 14 tablets per 30 days 14 tablets per 30 days (pemigatinib) pentazocine + naloxone Limit to 30 day supply per fill Limit to 30 day supply per fill Limit to 30 day supply per fill Limit to 30 day supply per fill Limit to 30 day supply per fill

Percodan Limited to a 5 day supply for Limited to a 5 day supply for Limited to a 5 day supply for Limited to a 5 day supply for Limited to a 5 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for (aspirin + oxycodone) each subsequent fill each subsequent fill each subsequent fill each subsequent fill each subsequent fill Perforomist 2 vials (4 ml) per day 2 vials (4 ml) per day 2 vials (4 ml) per day 2 vials (4 ml) per day 2 vials (4 ml) per day (formoterol fumarate dihydrate) Perseris 2 syringes per 30 days 2 syringes per 30 days Not covered 2 syringes per 30 days 2 syringes per 30 days () Pexeva 1 tablet per day 1 tablet per day Not covered 1 tablet per day 1 tablet per day (paroxetine mesylate) Picato 1 carton per 90 days 1 carton per 90 days 1 carton per 90 days 1 carton per 90 days 1 carton per 90 days (ingenol mebutate) Pifeltro 1 tablet per day 1 tablet per day Not covered 1 tablet per day 1 tablet per day (doravirine)

Piqray 200mg 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (alpelisib)

Piqray 250mg, 300mg 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (alpelisib)

Plegridy 1 carton (2 syringes) 1 carton (2 syringes) 1 carton (2 syringes) 1 carton (2 syringes) 1 carton (2 syringes) (peginterferon beta- 1a) per 30 days per 30 days per 30 days per 30 days per 30 days

* Limited to a 15 day supply ** Limited to a 30 day supply Page 57 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Plegridy starter pack 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days (peginterferon beta- 1a)

0.5 ml per fill, 0.5 ml per fill, 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill Pneumovax 23 vaccine 1 fill per 2 years 1 fill per 2 years Polio vaccine 0.5 ml per Rx 0.5 ml per Rx 0.5 ml per Rx 0.5 ml per Rx 0.5 ml per Rx (Ipol) Pomalyst 21 capsules per 30 days 21 capsules per 30 days 21 capsules per 30 days 21 capsules per 30 days 21 capsules per 30 days (pomalidomide) Ponvory starter pack 1 pack per 365 days Not covered 1 pack per 365 days 1 pack per 365 days Not covered (ponesimod) Ponvory 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered (ponesimod) Pradaxa 2 capsules per day 2 capsules per day Not covered 2 capsules per day 2 capsules per day (dabigatran) Praluent 2 doses per 30 days 2 doses per 30 days Not covered 2 doses per 30 days 2 doses per 30 days (alirocumab) Pravachol 1.5 tablets per day 1.5 tablets per day 1.5 tablets per day 1.5 tablets per day 1.5 tablets per day (pravastatin) Pregnyl 2 vials per 30 days, 2 vials per 30 days, Not applicable Not covered Not applicable (chorionic gonadotropin) 6 vials per 365 days 6 vials per 365 days Prestalia (perindopril arginine + 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered amlodipine)

Pretomanid 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day

* Limited to a 15 day supply ** Limited to a 30 day supply Page 58 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Prevacid Not applicable 2 capsules per day Not applicable Not covered 2 capsules per day (lansoprazole) 0.5 ml per fill, 0.5 ml per fill, 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill Prevnar 13 vaccine 1 fill per 2 years 1 fill per 2 years Prevymis 28 tablets (1 carton) 28 tablets (1 carton) 28 tablets (1 carton) 28 tablets (1 carton) 28 tablets (1 carton) (letermovir) per 30 days per 30 days per 30 days per 30 days per 30 days Prezcobix 1 tablet per day 1 tablet per day Not covered 1 tablet per day 1 tablet per day (darunavir + cobicistat) Prilosec Not applicable 2 capsules per day Not applicable Not covered 2 capsules per day (omeprazole) Pristiq 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (desvenlafaxine) ProAir HFA 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days (albuterol sulfate) Procentra 60 mL (60 mg) per day 60 mL (60 mg) per day 60 mL (60 mg) per day 60 mL (60 mg) per day 60 mL (60 mg) per day (dextroamphetamine) Procysbi 25mg 2 capsules per day Not covered Not covered 2 capsules per day Not covered (cysteamine bitartrate) Procysbi packet 2 cartons per 30 days Not covered Not covered 2 cartons per 30 days Not covered (cysteamine bitartrate) Prosom 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (estazolam) Protonix Not applicable 2 tablets per day Not applicable Not covered 2 tablets per day (pantoprazole)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 59 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Proventil HFA 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days (albuterol sulfate) Provigil 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (modafinil) Prozac 60mg 1 tablet per day 1 tablet per day 1 tablet per day Not applicable Not applicable (fluoxetine) Prozac Weekly 4 capsules per 30 days 4 capsules per 30 days 4 capsules per 30 days Not applicable Not applicable (fluoxetine) Pulmicort Flexhaler 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days (budesonide) Qbrelis 40 ml per day Not covered 40 ml per day 40 ml per day Not covered (lisinopril) Qbrexza 1 box (30 pouches) 1 box (30 pouches) 1 box (30 pouches) Not covered Not covered (glycopyrronium cloth) per 30 days per 30 days per 30 days Qelbree 2 capsules per day 2 capsules per day Not covered 2 capsules per day 2 capsules per day (viloxazine) Qinlock 3 tablets per day 3 tablets per day Not covered 3 tablets per day 3 tablets per day (ripretinib) Qnasl 1 canister per 30 days Not covered Not covered Not covered Not covered (beclomethasone) Qsymia 1 capsule per day Not covered 1 capsule per day 1 capsule per day Not covered (phentermine + topiramate) Qtern 1 tablet per day 1 tablet per day Not covered 1 tablet per day 1 tablet per day (dapagliflozin + saxagliptin)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 60 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Quartette (levonorgestrel + ethinyl 1 blister pack per 91 days 1 blister pack per 91 days 1 blister pack per 91 days 1 blister pack per 91 days 1 blister pack per 91 days estradiol) Qudexy XR 25, 50, 100, 150mg 1 capsule per day Not covered 1 capsule per day 1 capsule per day Not covered (topiramate) Qudexy XR 200mg 2 capsules per day Not covered 2 capsules per day 2 capsules per day Not covered (topiramate) Quillichew ER 20mg (methylphenidate extended- 60 mg per day Not covered 60 mg per day 60mg per day Not covered release) Quillichew ER 30mg (methylphenidate extended- 60 mg per day Not covered 60 mg per day 60mg per day Not covered release) Quillichew ER 40mg (methylphenidate extended- 60 mg per day Not covered 60 mg per day 60mg per day Not covered release) Quillivant XR (methylphenidate extended- 12ml (60mg) per day Not covered 12ml (60mg) per day 12ml (60mg) per day Not covered release) Qvar RediHaler 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days 2 inhalers per 30 days (beclomethasone dipropionate) Ragwitek (short ragweed pollen allergen 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered extract) Rapaflo 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day (silodosin)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 61 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Rasuvo 4 injections per 30 days Not covered 4 injections per 30 days 4 injections per 30 days Not covered (methotrexate) Ravicti 525 ml per 30 days 525 ml per 30 days 525 ml per 30 days 525 ml per 30 days 525 ml per 30 days (glycerol phenylbutyrate) Rayaldee 2 capsules per day Not covered 2 capsules per day 2 capsules per day Not covered (calcifediol extended-release) Rayos 3 tablets per day Not covered 3 tablets per day 3 tablets per day Not covered (prednisone delayed-release) Rebif 12 syringes / 12 syringes / pens 12 syringes / pens 12 syringes / pens 12 syringes / pens (interferon beta 1a) pens per 30 days per 30 days per 30 days per 28 days per 30 days Rebif titration pack 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days (interferon beta 1a) Rebif Rebidose 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days (interferon beta 1a) Recombivax HB vaccine, 1 ml per fill 1 ml per fill 1 ml per fill 1 ml per fill 1 ml per fill 10mcg/ml Recombivax HB vaccine, 1 ml per fill 1 ml per fill 1 ml per fill 1 ml per fill 1 ml per fill 40mcg/ml Rectiv 1 tube (30 gm) per 30 days 1 tube (30 gm) per 30 days 1 tube (30 gm) per 30 days 1 tube (30 gm) per Rx 1 tube (30 gm) per Rx (nitroglycerin) RediTrex 4 syringes per 30 days Not covered Not covered 4 syringes per 30 days Not covered (methotrexate) Regranex 3 tubes (45 gm) per 150 days 3 tubes (45 gm) per 150 days 3 tubes (45 gm) per 150 days 3 tubes (45 gm) per 150 days 3 tubes (45 gm) per 150 days (becaplermin)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 62 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Relenza 2 inhalers per 180 days 2 inhalers per 180 days 2 inhalers per 180 days 2 inhalers per 180 days 2 inhalers per 180 days (zanamivir) Relexxii 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (methylphenidate) Relistor tablet 3 tablets per day Not covered 3 tablets per day 3 tablets per day Not covered (methylnaltrexone) Relpax 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days (eletriptan) Repatha 3 injections per 30 days 3 injections per 30 days 3 injections per 30 days 3 injections per 30 days 3 injections per 30 days (evolocumab) Repatha Pushtronex 1 injector per 30 days 1 injector per 30 days Not covered 1 injector per 30 days 1 injector per 30 days (evolocumab) Restoril 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day (temazepam) Retevmo 40mg 180 capsules per 30 days* 180 capsules per 30 days* 180 capsules per 30 days* 180 capsules per 30 days* 180 capsules per 30 days* (selpercatinib) Retevmo 80mg 120 capsules per 30 days* 120 capsules per 30 days* 120 capsules per 30 days* 120 capsules per 30 days* 120 capsules per 30 days* (selpercatinib) Revatio 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day (sildenafil citrate) Revatio suspension 112ml bottle 2 bottles per 30 days 2 bottles per 30 days 2 bottles per 30 days 2 bottles per 30 days 2 bottles per 30 days (sildenafil)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 63 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Revcovi 48 vials per 30 days 48 vials per 30 days 48 vials per 30 days 48 vials per 30 days 48 vials per 30 days (elapegademase-lvlr) Revlimid 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day (lenalidomide) Rexulti 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered (brexpiprazole) Reyvow 8 tablets per 30 days 8 tablets per 30 days 8 tablets per 30 days 8 tablets per 30 days 8 tablets per 30 days (lasmiditan) Rhopressa 2 (2.5ml) bottles per 30 days Not covered Not covered 2 (2.5ml) bottles per 30 days Not covered (netarsudil) Rinvoq 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (upadacitinib) Riomet ER 1 bottle (473 ml) per 30 days Not covered 1 bottle (473 ml) per 30 days 1 bottle (473 ml) per 30 days Not covered (metformin extended-release) Ritalin 7 tablets per day 7 tablets per day 7 tablets per day 7 tablets per day 7 tablets per day (methylphenidate) Ritalin LA 10, 20, 30mg (methylphenidate extened- 4 capsules per day 4 capsules per day 4 capsules per day 4 capsules per day 4 capsules per day release) Ritalin LA 40mg (methylphenidate extened- 3 capsules per day 3 capsules per day 3 capsules per day 3 capsules per day 3 capsules per day release) Ritalin LA 60mg (methylphenidate extened- 2 capsules per day 2 capsules per day 2 capsules per day 2 capsules per day 2 capsules per day release)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 64 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List RMS Limited to a 5 day supply for Limited to a 5 day supply for Limited to a 5 day supply for Limited to a 5 day supply for Limited to a 5 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for (morphine) each subsequent fill each subsequent fill each subsequent fill each subsequent fill each subsequent fill Rocklatan 2 (2.5ml) bottles per 30 days 2 (2.5ml) bottles per 30 days Not covered 2 (2.5ml) bottles per 30 days 2 (2.5ml) bottles per 30 days (netarsudil + latanoprost)

Rotarix vaccine 1 ml per fill 1 ml per fill 1 ml per fill 1 ml per fill 1 ml per fill

Roxanol Limited to a 5 day supply for Limited to a 5 day supply for Limited to a 5 day supply for Limited to a 5 day supply for Limited to a 5 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for (morphine) each subsequent fill each subsequent fill each subsequent fill each subsequent fill each subsequent fill Roxicet Limited to a 5 day supply for Limited to a 5 day supply for Limited to a 5 day supply for Limited to a 5 day supply for Limited to a 5 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for (oxycodone + acetaminophen) each subsequent fill each subsequent fill each subsequent fill each subsequent fill each subsequent fill Rozerem 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (ramelteon) Rozlytrek 90 capsules per 30 days* 90 capsules per 30 days* 90 capsules per 30 days* 90 capsules per 30 days* 90 capsules per 30 days* (entrectinib) Rubraca 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (rucaparib) Ruconest (C1 esterase inhibitor, 2 doses (4 vials) per 30 days 2 doses (4 vials) per 30 days 2 doses (4 vials) per 30 days 2 doses (4 vials) per 30 days 2 doses (4 vials) per 30 days [recombinant]) Rukobia 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (fostemsavir) Ruzurgi 10 tablets per day 10 tablets per day 10 tablets per day 10 tablets per day 10 tablets per day (alfampridine) Rybelsus 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (semaglutide)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 65 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Rydapt 8 capsules per day 8 capsules per day 8 capsules per day 8 capsules per day 8 capsules per day (midostaurin) Rytary (carbidopa + levodopa 12 capsules per day Not covered 12 capsules per day 12 capsules per day Not covered extended-release) Sabril powder 6 packs per day 6 packs per day 6 packs per day 6 packs per day 6 packs per day (vigabatrin) Sabril tablet 6 tablets per day 6 tablets per day 6 tablets per day 6 tablets per day 6 tablets per day (vigabatrin) Samsca 15mg 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (tolvaptan) Samsca 30mg 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (tolvaptan) Sanctura 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (trospium) Sanctura XL (trospium chloride extended- 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day release) Sancuso 4 patches per 30 days 4 patches per 30 days 4 patches per 30 days 4 patches per 30 days 4 patches per 30 days (granisetron extended-release) Saphris 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (asenapine) Savaysa 1 tablet per day 1 tablet per day Not covered 1 tablet per day 1 tablet per day (edoxaban) Savella 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (milnacipran)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 66 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Savella titration pack 1 pack per 180 days 1 pack per 180 days 1 pack per 180 days 1 pack per 180 days 1 pack per 180 days (milnacipran) Saxenda 5 pens per 30 days Not covered 5 pens per 30 days 5 pens per 30 days Not covered () Seasonale / Jolessa /

Quasense 1 blister pack per 91 days 1 blister pack per 91 days 1 blister pack per 91 days 1 blister pack per 91 days 1 blister pack per 91 days (levonorgestrel + ethinyl estradiol) Seasonique (levonorgestrel + ethinyl 1 blister pack per 91 days 1 blister pack per 91 days 1 blister pack per 91 days 1 blister pack per 91 days 1 blister pack per 91 days estradiol) Secuado 1 patch per day 1 patch per day 1 patch per day 1 patch per day 1 patch per day (asenapine) Seebri Neohaler 2 capsules per day Not covered 2 capsules per day 2 capsules per day Not covered (glycopyrrolate) Segluromet 2.5/500mg 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (vertugliflozin + metformin) Segluromet 2.5/1,000, 7.5/500, 7.5/1,000 mg 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (vertugliflozin + metformin) Serevent Diskus 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days (salmeterol xinafoate) Seroquel XR 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (quetiapine fumarate) Shingrix (zoster vaccine recombinant, 2 vial kits per 720 days 2 vial kits per 720 days 2 vial kits per 720 days 2 vial kits per 720 days 2 vial kits per 720 days adjuvanted)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 67 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Short acting immediate Limited to a 5 day supply Limited to a 5 day Limited to a 5 day supply Limited to a 5 day Limited to a 5 day supply for the 1st fill, supply for the 1st fill, for the 1st fill, supply for the 1st fill, for the 1st fill, release opioids + narcotics 30 day supply for each 30 day supply for each 30 day supply for each 30 day supply for each 30 day supply for each Brand and generic subsequent fill subsequent fill subsequent fill subsequent fill subsequent fill Short acting immediate Limited to a 5 day supply Limited to a 5 day Limited to a 5 day supply Limited to a 5 day Limited to a 5 day supply release opioids + narcotics for the 1st fill, supply for the 1st fill, for the 1st fill, supply for the 1st fill, for the 1st fill, combination products 30 day supply for each 30 day supply for each 30 day supply for each 30 day supply for each 30 day supply for each Brand and generic subsequent fill subsequent fill subsequent fill subsequent fill subsequent fill Signifor 2 ampules per day 2 ampules per day 2 ampules per day 2 ampules per day 2 ampules per day (pasireotide) Signifor LAR 1 kit per 30 days Not covered Not covered 1 kit per 30 days Not covered (pasireotide) Silenor 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered (doxepin) Siliq 1 carton (2 syringes) 1 carton (2 syringes) 1 carton (2 syringes) 1 carton (2 syringes) 1 carton (2 syringes) (brodalumab) per 30 days per 30 days per 30 days per 30 days per 30 days

Simplicity Inserter 1 inserter per 365 days 1 inserter per 365 days 1 inserter per 365 days 1 inserter per 365 days 1 inserter per 365 days

Simplicity 2 Unit 2 packs (10 units) per 30 days 2 packs (10 units) per 30 days 2 packs (10 units) per 30 days 2 packs (10 units) per 30 days 2 packs (10 units) per 30 days

Simponi 1 syringe per 30 days 1 syringe per 30 days 1 syringe per 30 days 1 syringe per 30 days 1 syringe per 30 days (golimumab) Singulair packet 1 packet per day 1 packet per day 1 packet per day 1 packet per day 1 packet per day (montelukast) Singulair tablet 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (montelukast)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 68 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Sirturo 20mg 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (bedaquiline) Sirturo 100mg 188 tablets per 168 days 188 tablets per 168 days 188 tablets per 168 days 188 tablets per 168 days 188 tablets per 168 days (bedaquiline) Sitavig 1 tablet per 30 days Not covered Not covered 1 tablet per 30 days Not covered (acyclovir) Sivextro 6 tablets per 30 days 6 tablets per 30 days 6 tablets per 30 days 6 tablets per 30 days 6 tablets per 30 days (tedizolid phosphate) Sklice 1 tube (117gm) per 30 days 1 tube (117gm) per 30 days 1 tube (117gm) per 30 days 1 tube (117gm) per 30 days 1 tube (117gm) per 30 days (ivermectin) Skyrizi 1 syringe / pen per 90 days 1 syringe / pen per 90 days 1 syringe / pen per 90 days 1 syringe / pen per 90 days 1 syringe / pen per 90 days (risankizumab-rzaa) Slynd 1 blister pack per 30 days 1 blister pack per 30 days 1 blister pack per 30 days 1 blister pack per 30 days 1 blister pack per 30 days (drospirenone) Solaraze 100 gm (1 tube) per 30 days 100 gm (1 tube) per 30 days 100 gm (1 tube) per 30 days 100 gm (1 tube) per 30 days 100 gm (1 tube) per 30 days (diclofenac sodium) Soliqua ( + 5 pens per 30 days 5 pens per 30 days 5 pens per 30 days 5 pens per 30 days 5 pens per 30 days injection) Solosec Not covered Not covered 1 unit per fill Not covered Not covered (secnidazole) Somatuline Depot 1 syringe per 30 days 1 syringe per 30 days 1 syringe per 30 days 1 syringe per 30 days 1 syringe per 30 days (lanreotide) Sonata 5mg 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day (zaleplon)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 69 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Sonata 10mg 2 capsules per day 2 capsules per day 2 capsules per day 2 capsules per day 2 capsules per day (zaleplon) Soolantra 45 gm (1 tube) per 30 days Not covered 45 gm (1 tube) per 30 days 45 gm (1 tube) per 30 days Not covered (ivermectin) Sovaldi pellet 2 packets per day 2 packets per day 2 packets per day 2 packets per day 2 packets per day (sofosbuvir) Sovaldi tablet 1 tablet per day Not covered Not covered 1 tablet per day Not covered (sofosbuvir) Spectracef 14 tablets per Rx 14 tablets per Rx 14 tablets per Rx 14 tablets per Rx 14 tablets per Rx (cefditoren pivoxil)

Spiriva Handihaler 1 box (30 capsules) 1 box (30 capsules) 1 box (30 capsules) 1 box (30 capsules) Not covered (tiotropium bromide) per 30 days per 30 days per 30 days per 30 days Spiriva Respimat 1 inhaler per 30 days 1 inhaler per 30 days Not covered 1 inhaler per 30 days 1 inhaler per 30 days (tiotropium) Spritam 250, 500, 1,000mg 2 tablets per day Not covered 2 tablets per day 2 tablets per day Not covered (levetiracetam) Spritam 750mg 4 tablets per day Not covered 4 tablets per day 4 tablets per day Not covered (levetiracetam) Sprix Not covered Not covered 5 bottles per 30 days Not covered Not covered (ketorolac tromethamine) Sprycel Limited to 15 day supply Limited to 15 day supply Limited to 15 day supply Limited to 15 day supply Limited to 15 day supply (dasatinib) per fill per fill per fill per fill per fill Stadol NS Limited to a 5 day supply for Limited to a 5 day supply for Limited to a 5 day supply for Limited to a 5 day supply for Limited to a 5 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for (butorphanol) each subsequent fill each subsequent fill each subsequent fill each subsequent fill each subsequent fill

* Limited to a 15 day supply ** Limited to a 30 day supply Page 70 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Staxyn 12 tablets per 30 days Not covered 12 tablets per 30 days 6 units per 28 days Not covered (vardenafil) Steglatro 5mg 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (ertugliflozin) Steglatro 15mg 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (ertugliflozin) Steglujan Not covered Not covered 1 tablet per day Not covered Not covered (ertugliflozin + sitagliptan) Stelara 1 syringe / vial every 56 days 1 syringe / vial every 56 days 1 syringe / vial every 56 days 1 syringe / vial every 56 days 1 syringe / vial every 56 days (ustekinumab) Stendra 12 tablets per 30 days Not covered 12 tablets per 30 days 6 units per 28 days Not covered (avanafil) Stiolto Respimat (tiotropium bromide + 1 inhaler per 30 days 1 inhaler per 30 days Not covered 1 inhaler per 30 days 1 inhaler per 30 days olodaterol) Stivarga 84 tablets per 30 days 84 tablets per 30 days 84 tablets per 30 days 84 tablets per 30 days 84 tablets per 30 days (regorafenib) Strattera 2 capsules per day 2 capsules per day 2 capsules per day 2 capsules per day 2 capsules per day (atomoxetine) Strensiq 18, 28, 40mg 24 vials per 30 days 24 vials per 30 days 24 vials per 30 days 24 vials per 30 days 24 vials per 30 days (asfotase alfa) Strensiq 80mg 48 vials per 30 days 48 vials per 30 days 48 vials per 30 days 48 vials per 30 days 48 vials per 30 days (asfotase alfa)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 71 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Stribild (elvitegravir + cobicistat + 1 tablet per day 1 tablet per day Not covered 1 tablet per day 1 tablet per day emtricitabine + tenofovir disoproxil fumarate) Striverdi Respimat 1 inhaler per 30 days Not covered 1 inhaler per 30 days 1 inhaler per 30 days Not covered (olodaterol) Suboxone 3 films / tablets per day 3 films / tablets per day 3 films / tablets per day 3 films / tablets per day 3 films / tablets per day (buprenorphine + naloxone) Subutex 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day (buprenorphine) Subsys 4 sprays per day Not covered Not covered 4 sprays per day Not covered (fentanyl) Sucraid 4 bottles (472 ml) per 30 days 4 bottles (472 ml) per 30 days 4 bottles (472 ml) per 30 days 4 bottles (472 ml) per 30 days 4 bottles (472 ml) per 30 days (sacrosidase) Sunosi 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (solriamfetol) Sutab (sodium sulfate + magnesium 2 fills per 365 days Not covered Not covered 2 fills per 365 days Not covered sulfate + potassium chloride) Sutent 30 capsules per 30 days* 30 capsules per 30 days* 30 capsules per 30 days* 30 capsules per 30 days* 30 capsules per 30 days* (sunitinib) Sylatron 4 vials per 30 days 4 vials per 30 days 4 vials per 30 days 4 vials per 28 days 4 vials per 28 days (peginterferon alfa-2b) Symbicort 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days (budesonide + formoterol)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 72 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Symdeko 1 carton (56 tablets) 1 carton (56 tablets) 1 carton (56 tablets) 1 carton (56 tablets) 1 carton (56 tablets) (tezacaftor + ivacaftor) per 28 days per 28 days per 28 days per 28 days per 28 days Symfi (efavirenz + lamivudine + 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day tenofovir disoproxil fumarate) Symfi Lo (efavirenz + lamivudine + 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day tenofovir disoproxil fumarate) Symjepi 4 injections per rx, 4 injections per rx, 4 injections per rx, 4 injections per rx, 4 injections per rx, (epinephrine) 8 injections per 365 days 8 injections per 365 days 8 injections per 365 days 8 injections per 365 days 8 injections per 365 days Sympazan 2 films per day Not covered 2 films per day 2 films per day Not covered (clobazam) Symproic 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered (naldemedine) Symtuza (darunavir + cobicistat + 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day emtricitabine + tenofovir alafenamide) Synjardy 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (empagliflozin + metformin) Synjardy XR 5/1,000, 12.5/1,000mg 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (empagliflozin + metformin extended-release)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 73 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Synjardy XR 10/1,000, 25/1,000mg 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (empagliflozin + metformin extended-release) Synribo 20 vials per 28 days 20 vials per 28 days 20 vials per 28 days 20 vials per 28 days 20 vials per 28 days (omacetaxine) Syprine 8 capsules per day 8 capsules per day 8 capsules per day 8 capsules per day 8 capsules per day (trientine) Tabrecta 112 tablets per 28 days 112 tablets per 28 days 112 tablets per 28 days 112 tablets per 28 days 112 tablets per 28 days (capmatinib) Tafinlar 4 capsules per day 4 capsules per day 4 capsules per day 4 capsules per day 4 capsules per day (dabrafenib) Tagrisso 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* (osimertinib) Takhzyro 2 vials per 30 days 2 vials per 30 days 2 vials per 30 days 2 vials per 30 days 2 vials per 30 days (lanadelumab-flyo) Talicia (omeprazole + amoxicillin + 168 tablets per 90 days Not covered 168 tablets per 90 days 168 tablets per 90 days Not covered rifabutin) Taltz single pack 1 pack per 30 days 1 pack per 30 days 1 pack per 30 days 1 pack per 30 days 1 pack per 30 days (ixekizumab) Taltz 2 pack 2 packs per 365 days 2 packs per 365 days 2 packs per 365 days 2 packs per 365 days 2 packs per 365 days (ixekizumab) Taltz 3 pack 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days (ixekizumab)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 74 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Talzenna 0.25mg 90 tablets per 30 days* 90 tablets per 30 days* 90 tablets per 30 days* 90 tablets per 30 days* 90 tablets per 30 days* (talazoparib) Talzenna 1mg 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* (talazoparib) Tamiflu 30mg 40 capsules per 180 days 40 capsules per 180 days 40 capsules per 180 days 40 capsules per 180 days 40 capsules per 180 days (oseltamivir) Tamiflu 45mg, 75 mg 20 capsules per 180 days 20 capsules per 180 days 20 capsules per 180 days 20 capsules per 180 days 20 capsules per 180 days (oseltamivir) Tamiflu suspension 60 ml 6 bottles (360 ml) 6 bottles (360 ml) 6 bottles (360 ml) 6 bottles (360 ml) 6 bottles (360 ml) bottle per 180 days per 180 days per 180 days per 180 days8 per 180 days (oseltamivir) tamoxifen citrate 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day Tarceva Limited to 15 day supply Limited to 15 day supply Limited to 15 day supply Limited to 15 day supply Limited to 15 day supply (erlotinib) per fill per fill per fill per fill per fill Targretin capsule Limited to 15 day supply Limited to 15 day supply Limited to 15 day supply Limited to 15 day supply Limited to 15 day supply (bexarotene) per fill per fill per fill per fill per fill Tasigna 120 capsules per 30 days* 120 capsules per 30 days* 120 capsules per 30 days* 120 capsules per 30 days* 120 capsules per 30 days* (nilotinib) Tavalisse (fostamatinib disodium 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day hexahydrate) Tazverik 240 tablets per 30 days* 240 tablets per 30 days* 240 tablets per 30 days* 240 tablets per 30 days* 240 tablets per 30 days* (tazemetostat) Tecfidera starter pack (dimethyl fumarate delayed- 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days release)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 75 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Tecfidera (dimethyl fumarate delayed- 2 capsules per day 2 capsules per day 2 capsules per day 2 capsules per day 2 capsules per day release) Tegsedi 4 syringes per 30 days 4 syringes per 30 days 4 syringes per 30 days 4 syringes per 30 days 4 syringes per 30 days (inotersen) Temixys (lamivudine + tenofovir 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day disoproxil fumarate) Tepmetko 2 tablets per day* 2 tablets per day* Not covered 2 tablets per day* 2 tablets per day* (tepotinib) Teriparatide Not covered Not covered 1 pen per 30 days Not covered Not covered 620mcg/2.48ml

Test strips 300 units per 30 days 300 units per 30 days 300 units per 30 days 300 units per 30 days 300 units per 30 days

Testim 2 cartons (60 tubes) 2 cartons (60 tubes) 2 cartons (60 tubes) Not covered Not covered (testosterone) per 30 days per 30 days per 30 days Testred (methyltestosterone) 1 capsule per day Not covered 1 capsule per day 1 capsule per day Not covered Tetanus/diphtheria booster (Tenivac, Tdvax) 0.5 ml per Rx 0.5 ml per Rx 0.5 ml per Rx 0.5 ml per Rx 0.5 ml per Rx Thiola (tiopronin) 10 tablets per day 10 tablets per day 10 tablets per day 10 tablets per day 10 tablets per day Thiola EC 100mg 10 tablets per day 10 tablets per day 10 tablets per day 10 tablets per day 10 tablets per day (tiopronin delayed-release) Thiola EC 300mg 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day (tiopronin delayed-release)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 76 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Tibsovo 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* (ivosidenib) Tiglutik 2 bottles (600ml) per 30 days 2 bottles (600ml) per 30 days 2 bottles (600ml) per 30 days 2 bottles (600ml) per 30 days 2 bottles (600ml) per 30 days (riluzole) Tindamax 20 tablets per 20 days 20 tablets per 20 days 20 tablets per 20 days 20 tablets per 20 days 20 tablets per 20 days (tinidazole) Tivicay PD 6 tablets per day 6 tablets per day 6 tablets per day 6 tablets per day 6 tablets per day (dolutegravir) Tivorbex 3 capsules per day Not covered Not covered 3 capsules per day Not covered (indomethacin) Tobi 56 ampules 56 ampules 56 ampules 56 ampules 56 ampules (tobramycin) per 56 rolling days per 56 rolling days per 56 rolling days per 56 rolling days per 56 rolling days Tobi Podhaler 224 capsules 224 capsules 224 capsules Not covered Not covered (tobramycin) per 56 rolling days per 56 rolling days per 56 rolling days Today Contraceptive Sponge 6 units per 30 days 6 units per 30 days 6 units per 30 days 6 units per 30 days 6 units per 30 days (nonoxynol-9) Tolak 40 gm (1 tube) per 30 days 40 gm (1 tube) per 30 days 40 gm (1 tube) per 30 days 40 gm (1 tube) per 30 days 40 gm (1 tube) per 30 days (fluorouracil) Toradol 20 tablets per Rx 20 tablets per Rx 20 tablets per Rx 20 tablets every 26 days 20 tablets every 26 days (ketorolac) Tosymra Not covered Not covered 12 units per 30 days Not covered Not covered (sumatriptan) Toviaz 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (fesoterodine)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 77 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Tracleer 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day () Tradjenta 1 tablet per day 1 tablet per day Not covered 1 tablet per day 1 tablet per day (linagliptin) Limited to 30 day supply Limited to 30 day supply Limited to 30 day supply Limited to 30 day supply Limited to 30 day supply Tramadol ER per fill per fill per fill per fill per fill Trelegy Ellipta 30 inhalations (60 blisters) 30 inhalations (60 blisters) 30 inhalations (60 blisters) 30 inhalations (60 blisters) 30 inhalations (60 blisters) (fluticasone + umeclidinium + per 30 days per 30 days per 30 days per 30 days per 30 days vilanterol) Tremfya 8 syringes per 365 days 8 syringes per 365 days 8 syringes per 365 days 8 syringes per 365 days 8 syringes per 365 days (guselkumab) Treximet 85/500mg 12 tablets per 30 days Not covered 12 tablets per 30 days 12 tablets per 30 days Not covered (sumatriptan + naproxen) Trezix Limited to 5 day supply for the Limited to 5 day supply for the Limited to 5 day supply for the (acetaminophen + caffeine + 1st fill, 30 day supply for each Not covered 1st fill, 30 day supply for each 1st fill, 30 day supply for each Not covered dihyrdocodeine) subsequent fill subsequent fill subsequent fill Tribenzor (olmesartan + amlodipine + 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day hydrochlorothiazide) Trijardy XR 5/2.5/1000, 10/5/1000, 12.5/2.5/1000mg 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (empagliflozin + linagliptin + metformin extended-release) Trijardy XR 25/5/1000mg (empagliflozin + linagliptin + 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day metformin extended-release)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 78 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Trikafta 84 tablets (1 carton) 84 tablets (1 carton) 84 tablets (1 carton) 84 tablets (1 carton) 84 tablets (1 carton) (elexacaftor + ivacaftor + per 28 days per 28 days per 28 days per 28 days per 28 days tezacaftor) Trintellix 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (vortioxetine) Triumeq (abacavir + dolutegravir + 1 tablet per day 1 tablet per day Not covered 1 tablet per day 1 tablet per day lamivudine) Trokendi XR 2 capsules per day Not covered 2 capsules per day 2 capsules per day Not covered (topiramate extended-release) Trulicity 4 pens (2mL) per 30 days 4 pens (2mL) per 30 days 4 pens (2mL) per 30 days 4 pens (2mL) per 30 days 4 pens (2mL) per 30 days () Truseltiq 50mg, 125mg 42 capsules per 30 days 42 capsules per 30 days Not covered 42 capsules per 30 days 42 capsules per 30 days (infigratinib) Truseltiq 75mg 63 capsules per 30 days 63 capsules per 30 days Not covered 63 capsules per 30 days 63 capsules per 30 days (infigratinib) Truseltiq 100mg 21 capsules per 30 days 21 capsules per 30 days Not covered 21 capsules per 30 days 21 capsules per 30 days (infigratinib) Truvada (emtricitabine + tenofovir 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day disoproxil fumarate) Tudorza Pressair 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days 1 inhaler per 30 days (aclidinium bromide) Tukysa 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (tucatinib)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 79 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Turalio 4 capsules per day 4 capsules per day 4 capsules per day 4 capsules per day 4 capsules per day (pexidartinib) TussiCaps (hydrocodone + 14 capsules per 30 days Not covered 14 capsules per 30 days 14 capsules per 30 days Not covered chlorpheniramine) Tuzistra XR (codeine + chlorpheniramine 240 ml per 30 days Not covered 240 ml per 30 days 240 ml per 30 days Not covered extended-release)

Twinrix 1ml per fill 1ml per fill 1ml per fill 1ml per fill 1ml per fill

Tybost 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (cobicistat) Tymlos 1 unit per 30 days 1 unit per 30 days 1 unit per 30 days 1 unit per 30 days 1 unit per 30 days () Tyvaso institutional + starter kit 1 kit per 365 days 1 kit per 365 days 1 kit per 365 days 1 kit per 365 days 1 kit per 365 days (treprostinil) Tyvaso refill kit 1 kit (81.2 ml) per 30 days 1 kit (81.2 ml) per 30 days 1 kit (81.2 ml) per 30 days 1 kit (81.2 ml) per 30 days 1 kit (81.2 ml) per 30 days (treprostinil) Tyvaso vial 28 ampules (81.2 ml) 28 ampules (81.2 ml) 28 ampules (81.2 ml) 28 ampules (81.2 ml) 28 ampules (81.2 ml) (treprostinil) per 28 days per 28 days per 28 days per 28 days per 28 days Ubrelvy 10 tablets per 30 days 10 tablets per 30 days 10 tablets per 30 days 10 tablets per 30 days 10 tablets per 30 days () Uceris 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered (budesonide extended-release)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 80 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Udenyca 2 syringes per 30 days 2 syringes per 30 days Not covered 2 syringes per 30 days 2 syringes per 30 days (pegfilgrastim-cbqv) Ukoniq 4 tablets per day* 4 tablets per day* 4 tablets per day* 4 tablets per day* 4 tablets per day* (umbralisib) Uloric 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (febuxostat) Ultracet 4 grams of APAP per day 4 grams of APAP per day 4 grams of APAP per day 4 grams of APAP per day 4 grams of APAP per day (tramadol + acetaminophen)

Ultram Limited to 30 day supply Limited to 30 day supply Limited to 30 day supply Limited to 30 day supply Limited to 30 day supply (tramadol) per fill per fill per fill per fill per fill Upneeq 1 carton per 30 days 1 carton per 30 days 1 carton per 30 days 1 carton per 30 days 1 carton per 30 days (oxymetazoline hydrochloride) Uptravi starter pack 2 packs per 365 days 2 packs per 365 days 2 packs per 365 days 2 packs per 365 days 2 packs per 365 days (selexipag) Uptravi 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (selexipag) Utibron Neohaler 2 capsules per day Not covered 2 capsules per day 2 capsules per day Not covered (indacaterol + glycopyrrolate) Valchlor 2 tubes (120 gm) per 30 days 2 tubes (120 gm) per 30 days 2 tubes (120 gm) per 30 days 2 tubes (120gm) per 30 days 2 tubes (120gm) per 30 days (mechlorethamine) Valtoco 5 boxes (10 nasal spray units) 5 boxes (10 nasal spray units) 5 boxes (10 nasal spray units) 5 boxes (10 nasal spray units) 5 boxes (10 nasal spray units) (diazepam) per 30 days per 30 days per 30 days per 30 days per 30 days Vanos 240 gm per 30 days 240 gm per 30 days 240 gm per 30 days 240 gm per 30 days 240 gm per 30 days (fluocinonide)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 81 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Vaqta vaccine 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill 0.5 ml per fill Vaqta vaccine 1 ml per fill 1 ml per fill 1 ml per fill 1 ml per fill 1 ml per fill Varubi 8 tablets per 30 days Not covered 8 tablets per 30 days 8 tablets per 30 days Not covered (rolapitant) Vascepa 4 capsules per day 4 capsules per day 4 capsules per day 4 capsules per day 4 capsules per day (icosapent ethyl) VCF film 6 units per 30 days 6 units per 30 days 6 units per 30 days 6 units per 30 days 6 units per 30 days (nonoxynol-9) VCF foam 1 box (17 gm) per 30 days 1 box (17 gm) per 30 days 1 box (17 gm) per 30 days 1 box (17 gm) per 30 days 1 box (17 gm) per 30 days (nonoxynol-9) VCF gel 1 package (10 units) 1 package (10 units) 1 package (10 units) 1 package (10 units) 1 package (10 units) (nonoxynol-9) per 30 days per 30 days per 30 days per 30 days per 30 days Vecamyl 10 tablets per day Not covered 10 tablets per day 10 tablets per day Not covered (mecamylamine) Veltassa 8.4gm 2 packets per day 2 packets per day Not covered 2 packets per day 2 packets per day (patiromer) Veltassa 16.8gm, 25.2gm 1 packet per day 1 packet per day Not covered 1 packet per day 1 packet per day (patiromer) Vemlidy 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (tenofovir alafenamide) Venclexta starter pack 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days (venetoclax) Venclexta 100mg 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (venetoclax) Venclexta unit dose 10, 50mg 28 unit packs per 30 days 28 unit packs per 30 days 28 unit packs per 30 days 28 unit packs per 30 days 28 unit packs per 30 days (venetoclax)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 82 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Venclexta wallets 10, 50mg 4 wallets per 30 days 4 wallets per 30 days 4 wallets per 30 days 4 wallets per 30 days 4 wallets per 30 days (venetoclax) Ventavis 9 ampules per day 9 ampules per day 9 ampules per day 9 ampules per day 9 ampules per day (iloprost) Verquvo 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (vericiguat) Verzenio 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* (abemaciclib) Vesicare 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (solifenacin) Vesicare LS 2 bottles (300 ml) per 30 days 2 bottles (300 ml) per 30 days Not covered 2 bottles (300 ml) per 30 days 2 bottles (300 ml) per 30 days (solifenacin succinate)

Vgo20, Vgo30, Vgo40 30 units per 30 days 30 units per 30 days 30 units per 30 days 30 units per 30 days 30 units per 30 days

Vicoprofen Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply Limited to a 5 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply for the 1st fill, 30 day supply (hydrocodone + ibuprofen) for each subsequent fill for each subsequent fill for each subsequent fill for each subsequent fill for each subsequent fill Viagra 12 tablets per 30 days Not covered 12 tablets per 30 days 6 units per 28 days Not covered (sildenafil) Viberzi 2 tablets per day Not covered 2 tablets per day 2 tablets per day Not covered (eluxadoline) Victoza 3 pens (9 ml) per 30 days 3 pens (9 ml) per 30 days Not covered 3 pens (9 ml) per 30 days 3 pens (9 ml) per 30 days (liraglutide) Viibryd 1 tablet per day 1 tablet per day Not covered 1 tablet per day 1 tablet per day (vilazodone)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 83 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Viibryd titration pack 1 pack per 365 days 1 pack per 365 days Not covered 1 pack per 365 days 1 pack per 365 days (vilazodone) Vimpat 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (lacosamide) Vitrakvi 25mg 180 capsules per 30 days* 180 capsules per 30 days* 180 capsules per 30 days* 180 capsules per 30 days* 180 capsules per 30 days* (larotrectinib) Vitrakvi 100mg 60 capsules per 30 days* 60 capsules per 30 days* 60 capsules per 30 days* 60 capsules per 30 days* 60 capsules per 30 days* (larotrectinib) Vitrakvi solution 10 ml per day 10 ml per day 10 ml per day 10 ml per day 10 ml per day (larotrectinib) Vistogard 20 packets per fill 20 packets per fill 20 packets per fill 20 packets per fill 20 packets per fill (uridine triacetate) Vituz (chlorpheniramine + 240 ml per Rx Not covered 240 ml per Rx 240 ml per Rx Not covered hydrocodone) Vivlodex 1 capsule per day Not covered 1 capsule per day 1 capsule per day Not covered (meloxicam) Vizimpro 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* 30 tablets per 30 days* (dacomitinib) Vogelxo packet 2 packets per day Not covered 2 packets per day 2 packets per day Not covered (testosterone) Vogelxo pump 4 bottles (300gm) per 30 days Not covered 4 bottles (300gm) per 30 days 4 bottles (300gm) per 30 days Not covered (testosterone) Voltaren gel 4 tubes (400 gm) per 30 days 4 tubes (400 gm) per 30 days 4 tubes (400 gm) per 30 days 4 tubes (400 gm) per 30 days 4 tubes (400 gm) per 30 days (diclofenac)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 84 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Vosevi (sofosbuvir +velpatasvir + 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day voxilaprevir) Votrient Limited to a 15 day supply Limited to a 15 day supply Limited to a 15 day supply Limited to a 15 day supply Limited to a 15 day supply (pazopanib) per fill per fill per fill per fill per fill Vraylar 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day 1 capsule per day (cariprazine) Vraylar dose pack 4 packs (28 capsules) 4 packs (28 capsules) 4 packs (28 capsules) 4 packs (28 capsules) 4 packs (28 capsules) (cariprazine) per 30 days per 30 days per 30 days per 30 days per 30 days Vumerity 4 capsules per day 4 capsules per day 4 capsules per day 4 capsules per day 4 capsules per day (dimethyl fumarate) Vumerity starter pack 1 bottle per 365 days 1 bottle per 365 days 1 bottle per 365 days 1 bottle per 365 days 1 bottle per 365 days (dimethyl fumarate) Vusion (miconazole nitrate + zinc oxide 1 tube (50 gm) per 30 days Not covered 1 tube (50 gm) per 30 days 1 tube (50 gm) per 30 days Not covered + white petrolatum) Vyleesi 2 cartons (8 autoinjectors) 2 cartons (8 autoinjectors) 2 cartons (8 autoinjectors) Not covered Not covered (bremelanotide) per 30 days per 30 days per 30 days Vyndamax 1 capsule per day 1 capsule per day Not covered 1 capsule per day 1 capsule per day (tafamidis) Vyndaqel 4 capsules per day 4 capsules per day 4 capsules per day 4 capsules per day 4 capsules per day (tafamidis meglumine) Vytorin 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (ezetimibe + simvastatin) Vyvanse 1 capsule / chew tablet 1 capsule / chew tablet 1 capsule / chew tablet 1 capsule / chew tablet 1 capsule / chew tablet (lisdexamfetamine) per day per day per day per day per day

* Limited to a 15 day supply ** Limited to a 30 day supply Page 85 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Wakix 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (pitolisant) Wegovy 0.25, 0.5mg, 1mg 4 pens (2ml) per 30 days Not covered 4 pens (2ml) per 30 days 4 pens (2ml) per 30 days Not covered (semaglutide) Wegovy 1.7mg, 2.4mg 4 pens (3 ml) per 30 days Not covered 4 pens (3 ml) per 30 days 4 pens (3 ml) per 30 days Not covered (semaglutide)

Wide Seal diaphragms Not covered Not covered Not covered 1 unit per 90 days 1 unit per 90 days

Winlevi 1 tube (60 gm) per 30 days Not covered Not covered 1 tube (60 gm) per 30 days Not covered (clascoterone) Xadago 1 tablet per day 1 tablet per day Not covered 1 tablet per day 1 tablet per day (safinamide) Xalkori 60 capsules per 30 days* 60 capsules per 30 days* 60 capsules per 30 days* 60 capsules per 30 days* 60 capsules per 30 days* (crizotinib) Xarelto starter pack 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days 1 pack per 365 days (rivaroxaban) Xarelto 2.5mg, 15mg 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (rivaroxaban) Xarelto 10mg, 20mg 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (rivaroxaban) Xcopri 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (cenobamate) Xcopri 250mg, 350 mg maintenance pack 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (cenobamate)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 86 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Xcopri titration pack 3 packs per 365 days 3 packs per 365 days 3 packs per 365 days 3 packs per 365 days 3 packs per 365 days (cenobamate) Xeljanz 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (tofacitinib) Xeljanz solution 1 bottle (240 ml) per 30 days 1 bottle (240 ml) per 30 days 1 bottle (240 ml) per 30 days 1 bottle (240 ml) per 30 days 1 bottle (240 ml) per 30 days (tofacitinib) Xeljanz XR 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (tofacitinib extended-release) Xelpros 1 bottle per Rx 1 bottle per Rx Not covered 1 bottle per Rx 1 bottle per Rx (latanoprost) Xenazine 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (tetrabenazine) Xenical 3 capsules per day Not covered 3 capsules per day 3 capsules per day Not covered (orlistat) Xenleta 20 tablets per 10 days 20 tablets per 10 days 20 tablets per 10 days 20 tablets per 10 days 20 tablets per 10 days (lefamulin) Xepi 1 tube per 30 days Not covered 1 tube per 30 days 1 tube per 30 days Not covered (ozenoxacin) Xerese Not covered Not covered 1 tube per 30 days Not covered Not covered (acyclovir + hydrocortisone) Xermelo 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day (telotristat ethyl) Xhance Not covered Not covered 1 inhaler per 30 days Not covered Not covered (fluticasone propionate)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 87 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Xifaxan 200mg 9 tablets per 7 days 9 tablets per 7 days 9 tablets per 7 days 9 tablets per 7 days 9 tablets per 7 days (rifaximin) Xifaxan 550mg 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day (rifaximin) Xigduo XR 5/500, 10/500, 10/1,000mg 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (dapagliflozin + metformin) Xigduo XR 2.5/1,000, 5/1,000mg 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (dapagliflozin + metformin) Xiidra 2 vials per day Not covered 2 vials per day 2 vials per day Not covered (lifitegrast) Xofluza 40mg 4 tablets per 180 days 4 tablets per 180 days 4 tablets per 180 days 4 tablets per 180 days 4 tablets per 180 days (baloxavir marboxil) Xofluza 80mg 2 tablets per 180 days 2 tablets per 180 days 2 tablets per 180 days 2 tablets per 180 days 2 tablets per 180 days (baloxavir marboxil) Xolair 75mg 2 syringes per 30 days 2 syringes per 30 days 2 syringes per 30 days 2 syringes per 30 days 2 syringes per 30 days (omalizumab) Xolair 150mg 8 syringes per 30 days 8 syringes per 30 days 8 syringes per 30 days 8 syringes per 30 days 8 syringes per 30 days (omalizumab) Xolegel 1 tube (45 g) per 30 days Not covered Not covered 1 tube (45 g) per 30 days Not covered (ketoconazole) Xopenex HFA 2 inhalers per 30 days 2 inhalers per 30 days Not covered 2 inhalers per 30 days 2 inhalers per 30 days (levalbuterol)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 88 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Xospata 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day (gilteritinib) Xpovio 1 carton (4 blister packs) 1 carton (4 blister packs) 1 carton (4 blister packs) 1 carton (4 blister packs) Not covered (selinexor) per 30 days* per 30 days* per 30 days* per 30 days* Xtandi 40mg 120 tablets / capsules 120 tablets / capsules 120 tablets / capsules 120 tablets / capsules 120 tablets / capsules (enzalutamide) per 30 days* per 30 days* per 30 days* per 30 days* per 30 days* Xtandi 80mg 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* 60 tablets per 30 days* (enzalutamide) Xulane ethinyl estradiol + 3 patches per 28 days 3 patches per 28 days 3 patches per 28 days 3 patches per 28 days 3 patches per 28 days norelgestromin Xultophy 5 pens per 30 days 5 pens per 30 days 5 pens per 30 days 5 pens per 30 days 5 pens per 30 days ( + liraglutide) Xuriden 120 packets per 30 days 120 packets per 30 days 120 packets per 30 days 120 packets per 30 days 120 packets per 30 days (uridine triacetate) Xyosted 1 carton (4 autoinjectors) 1 carton (4 autoinjectors) 1 carton (4 autoinjectors) Not covered Not covered (testosterone enanthate) per 30 days per 30 days per 30 days Xyrem 3 bottles (540 ml) per 30 days 3 bottles (540 ml) per 30 days 3 bottles (540 ml) per 30 days 3 bottles (540 ml) per 30 days 3 bottles (540 ml) per 30 days (sodium oxybate) Xywav (calcium + magnesium + 3 bottles (540 ml) per 30 days Not covered 3 bottles (540 ml) per 30 days 3 bottles (540 ml) per 30 days Not covered potassium + sodium oxybates) Xyzal oral solution 296 ml per 30 days Not covered 296 ml per 30 days Not covered Not covered (levocetirizine)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 89 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Xyzal tablet 1 tablet per day Not covered 1 tablet per day Not covered Not covered (levocetirizine) Yonsa Not covered Not covered 120 tablets per 30 days Not covered Not covered (abiraterone acetate) Yupelri 1 vial per day 1 vial per day 1 vial per day 1 vial per day 1 vial per day (revefenacin) Zavesca 3 capsules per day 3 capsules per day 3 capsules per day 3 capsules per day 3 capsules per day (miglustat) Zegalogue 8 injections per fill, 8 injections per fill, 8 injections per fill, 8 injections per fill, 8 injections per fill, () 16 injections per 365 days 16 injections per 365 days 16 injections per 365 days 16 injections per 365 days 16 injections per 365 days Zejula 90 capsules per 30 days* 90 capsules per 30 days* 90 capsules per 30 days* 90 capsules per 30 days* 90 capsules per 30 days* (niraparib) Zelapar 2 tablets per day 2 tablets per day Not covered 2 tablets per day 2 tablets per day (selegiline) Zelboraf 240 tablets per 30 days* 240 tablets per 30 days* 240 tablets per 30 days* 240 tablets per 30 days* 240 tablets per 30 days* (vemurafenib) Zelnorm 2 capsules per day 2 capsules per day 2 capsules per day 2 capsules per day 2 capsules per day (tegaserod) Zembrace SymTouch 12 injections per 30 days 12 injections per 30 days 12 injections per 30 days 12 injections per 30 days 12 injections per 30 days (sumatriptan succinate) Zenzedi 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (dextroamphetamine) Zepatier 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (elbasvir + grazoprevir)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 90 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Zeposia starter kit 1 starter kit per 365 days Not covered 1 starter kit per 365 days 1 starter kit per 365 days Not covered (ozanimod) Zeposia 7-Day starter pack 1 starter pack per 365 days Not covered 1 starter pack per 365 days 1 starter pack per 365 days Not covered (ozanimod) Zeposia 1 tablet per day Not covered 1 tablet per day 1 tablet per day Not covered (ozanimod) Zetia 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (ezetimibe) Zetonna 1 canister per 30 days Not covered Not covered Not covered Not covered (ciclesonide) Ziextenzo 2 syringes per 30 days 2 syringes per 30 days 2 syringes per 30 days 2 syringes per 30 days 2 syringes per 30 days (pegfilgrastim-bmez) Zilxi foam Not covered Not covered 1 can (30 grams) per 30 days Not covered Not covered (minocycline) Zipsor 4 capsules per day Not covered Not covered 4 capsules per day Not covered (diclofenac) Zocor 1.5 tablets per day 1.5 tablets per day 1.5 tablets per day 1.5 tablets per day 1.5 tablets per day (simvastatin) Zofran / Zofran ODT 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (ondansetron) Zohydro ER 2 tablets per day** 2 tablets per day** 2 tablets per day** 2 tablets per day** 2 tablets per day** (hydrocodone) Zokinvy 4 capsules per day 4 capsules per day 4 capsules per day 4 capsules per day 4 capsules per day (lonafarnib)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 91 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Zoladex 1 syringe per Rx 1 syringe per Rx 1 syringe per Rx Not applicable Not applicable (goserelin acetate) Zolinza Limited to 15 day supply Limited to 15 day supply Limited to 15 day supply Limited to 15 day supply Limited to 15 day supply (vorinostat) per fill per fill per fill per fill per fill Zolpimist Not covered Not covered 2 sprays per day Not covered Not covered (zolpidem tartrate) Zomig / Zomig ZMT 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days 12 tablets per 30 days (zolmitriptan) Zomig nasal spray 12 units per 30 days 12 units per 30 days 12 units per 30 days 12 units per 30 days 12 units per 30 days (zolmitriptan) Zontivity 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day (vorapaxar) Zorvolex 3 capsules per day Not covered Not covered 3 capsules per day Not covered (diclofenac) ZTlido Not covered Not covered 3 patches per day Not covered Not covered (lidocaine) Zubsolv 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day 3 tablets per day (buprenorphine + naloxone) Zyban 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (bupropion extended-release) Zyclara cream pack 3.75% 1 packet per day Not covered 1 packet per day 1 packet per day Not covered (imiquimod) Zyclara cream pump 2.5%, 3.75% 1 bottle per 30 days Not covered 1 bottle per 30 days 1 bottle per 30 days Not covered (imiquimod)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 92 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Michigan Blue Care Network Prior Authorization and Step Therapy Coverage Criteria March 2019 Quantity limits for: BCBSM BCBSM BCBSM and BCN BCN BCN Medication Clinical, Custom, Closed Custom Select Preferred Custom, Closed Custom Select Drug Lists Drug List Drug List Drug Lists Drug List Zydelig 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day (idelalisib) Zyflo CR 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (zileuton extended-release) Zyflo 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (zileuton) Zykadia 90 capsules per 30 days* 90 capsules per 30 days* 90 capsules per 30 days* 90 capsules per 30 days* 90 capsules per 30 days* (ceritinib) Zytiga 250mg 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day 4 tablets per day (abiraterone)

* Limited to a 15 day supply ** Limited to a 30 day supply Page 93 Revised: 10-01-21 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.