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National List

Drug list — Five Tier Drug Plan

Your prescription benefit comes with a drug list, which is also called a formulary. This list is made up of brand-name and generic prescription approved by the U.S. Food & Drug Administration (FDA).

The following is a list of plan names to which this formulary may apply. Additional plans may be applicable. If you are a current Anthem member with questions about your pharmacy benefits, we're here to help. Just call us at the Pharmacy Member Services number on your ID card.

Solution PPO 1500/15/20 $5/$15/$50/$65/30% to $250 after deductible Solution PPO 2000/20/20 $5/$20/$30/$50/30% to $250 Solution PPO 2500/25/20 $5/$20/$40/$60/30% to $250 Solution PPO 3500/30/30 $5/$20/$40/$60/30% to $250 Rx ded $150 Solution PPO 4500/30/30 $5/$20/$40/$75/30% to $250 Solution PPO 5500/30/30 $5/$20/$40/$75/30% to $250 Rx ded $250 $5/$15/$25/$45/30% to $250 $5/$20/$50/$65/30% to $250 Rx ded $500 $5/$15/$30/$50/30% to $250 $5/$20/$50/$70/30% to $250 $5/$15/$40/$60/30% to $250 $5/$20/$50/$70/30% to $250 after deductible

Here are a few things to remember:

o You can view and search our current drug lists when you visit anthem.com/ca and choose Prescription Benefits. Please note: The formulary is subject to change and all previous versions of the formulary are no longer in effect.

o Additional tools and resources are available for current Anthem members to view the most up-to-date list of drugs for your plan - including drugs that have been added, generic drugs and more – by logging in at anthem.com/ca.

o Your coverage has limitations and exclusions, which means there are certain rules about what's covered by your plan and what isn't. Already a member? You can view your Certificate/Evidence of Coverage or your Summary Plan Description by logging in at anthem.com/ca and go to My Plan ->Benefits-> Plan Documents.

o You and your doctor can use this list as a guide to choose drugs that are best for you. Drugs that aren’t on this list may not be covered by your plan and may cost you more out of pocket. To help you see how the drug list works with your drug benefit, we've included some frequently asked questions (FAQ) in this document about how the list is set up and what to do if a drug you take isn't on it.

Last Updated: September 1, 2021 DMHC National Drug List Five Tier

Table of Contents

INFORMATIONAL SECTION...... 4 *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* - DRUGS FOR THE NERVOUS SYSTEM...... 11 *ALLERGENIC EXTRACTS/BIOLOGICALS MISC* - BIOLOGICAL AGENTS...... 15 *AMEBICIDES* - DRUGS FOR INFECTIONS...... 19 *AMINOGLYCOSIDES* - DRUGS FOR INFECTIONS...... 19 * - ANTI-INFLAMMATORY* - DRUGS FOR PAIN AND FEVER...... 19 *ANALGESICS - NONNARCOTIC* - DRUGS FOR PAIN AND FEVER...... 22 *ANALGESICS - OPIOID* - DRUGS FOR PAIN AND FEVER...... 25 *-ANABOLIC* - HORMONES...... 30 *ANORECTAL AND RELATED PRODUCTS* - RECTAL PREPARATIONS...... 30 *ANTACIDS* - DRUGS FOR THE STOMACH...... 31 *ANTHELMINTICS* - DRUGS FOR INFECTIONS...... 31 *ANTIANGINAL AGENTS* - DRUGS FOR THE HEART...... 31 *ANTIANXIETY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 32 *ANTIARRHYTHMICS* - DRUGS FOR THE HEART...... 33 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* - DRUGS FOR THE LUNGS...... 34 *ANTICOAGULANTS* - DRUGS FOR THE BLOOD...... 37 *ANTICONVULSANTS* - DRUGS FOR THE NERVOUS SYSTEM...... 38 *ANTIDEPRESSANTS* - DRUGS FOR THE NERVOUS SYSTEM...... 42 *ANTIDIABETICS* - HORMONES...... 45 *ANTIDIARRHEAL/PROBIOTIC AGENTS* - DRUGS FOR THE STOMACH...... 49 *ANTIDOTES AND SPECIFIC ANTAGONISTS* - DRUGS FOR OVERDOSE OR POISONING...... 50 *ANTIEMETICS* - DRUGS FOR THE STOMACH...... 51 ** - DRUGS FOR INFECTIONS...... 52 *ANTIHISTAMINES* - DRUGS FOR THE LUNGS...... 54 *ANTIHYPERLIPIDEMICS* - DRUGS FOR THE HEART...... 55 *ANTIHYPERTENSIVES* - DRUGS FOR THE HEART...... 57 *ANTI-INFECTIVE AGENTS - MISC.* - DRUGS FOR INFECTIONS...... 61 *ANTIMALARIALS* - DRUGS FOR INFECTIONS...... 65 *ANTIMYASTHENIC/CHOLINERGIC AGENTS* - DRUGS FOR NERVES AND MUSCLES...... 65 *ANTIMYCOBACTERIAL AGENTS* - DRUGS FOR INFECTIONS...... 66 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* - DRUGS FOR ...... 66 *ANTIPARKINSON AND RELATED THERAPY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 84 */ANTIMANIC AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 85 *ANTISEPTICS & DISINFECTANTS* - ANTISEPTICS AND DISINFECTANTS...... 89 *ANTIVIRALS* - DRUGS FOR INFECTIONS...... 89 *BETA BLOCKERS* - DRUGS FOR THE HEART...... 95 * CHANNEL BLOCKERS* - DRUGS FOR THE HEART...... 97 *CARDIOTONICS* - DRUGS FOR THE HEART...... 99 *CARDIOVASCULAR AGENTS - MISC.* - DRUGS FOR THE HEART...... 100 *CEPHALOSPORINS* - DRUGS FOR INFECTIONS...... 101 *CONTRACEPTIVES* - DRUGS FOR WOMEN...... 104 *CORTICOSTEROIDS* - HORMONES...... 111 *COUGH/COLD/* - DRUGS FOR THE LUNGS...... 112 *DERMATOLOGICALS* - DRUGS FOR THE SKIN...... 114 *DIAGNOSTIC PRODUCTS*...... 126 *DIGESTIVE AIDS* - DRUGS FOR THE STOMACH...... 126 *DIURETICS* - DRUGS FOR THE HEART...... 127 *ENDOCRINE AND METABOLIC AGENTS - MISC.* - HORMONES...... 128 ** - HORMONES...... 132 *FLUOROQUINOLONES* - DRUGS FOR INFECTIONS...... 133 *GASTROINTESTINAL AGENTS - MISC.* - DRUGS FOR THE STOMACH...... 134 *GENERAL * - DRUGS FOR PAIN AND FEVER...... 137 *GENITOURINARY AGENTS - MISCELLANEOUS* - DRUGS FOR THE URINARY SYSTEM...... 137 *GOUT AGENTS* - DRUGS FOR PAIN AND FEVER...... 139 *HEMATOLOGICAL AGENTS - MISC.* - DRUGS FOR THE BLOOD...... 139 *HEMATOPOIETIC AGENTS* - DRUGS FOR NUTRITION...... 142 *HEMOSTATICS* - DRUGS FOR THE BLOOD...... 143 TOC-2 *HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 145 *LAXATIVES* - DRUGS FOR THE STOMACH...... 147 *LOCAL ANESTHETICS-PARENTERAL* - DRUGS FOR PAIN AND FEVER...... 150 *MACROLIDES* - DRUGS FOR INFECTIONS...... 151 *MEDICAL DEVICES AND SUPPLIES* - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT...... 152 *MIGRAINE PRODUCTS* - DRUGS FOR THE NERVOUS SYSTEM...... 171 *MINERALS & ELECTROLYTES* - DRUGS FOR NUTRITION...... 172 *MISCELLANEOUS THERAPEUTIC CLASSES* - VITAMINS AND MINERALS...... 175 *MOUTH/THROAT/DENTAL AGENTS* - DRUGS FOR THE MOUTH AND THROAT...... 179 *MULTIVITAMINS* - DRUGS FOR NUTRITION...... 181 *MUSCULOSKELETAL THERAPY AGENTS* - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES...... 192 *NASAL AGENTS - SYSTEMIC AND TOPICAL* - DRUGS FOR THE NOSE...... 194 *NEUROMUSCULAR AGENTS* - DRUGS FOR NERVES AND MUSCLES...... 194 *NUTRIENTS* - DRUGS FOR NUTRITION...... 195 *OPHTHALMIC AGENTS* - DRUGS FOR THE EYE...... 196 *OTIC AGENTS* - DRUGS FOR THE EAR...... 203 *OXYTOCICS* - HORMONES...... 204 *PASSIVE IMMUNIZING AND TREATMENT AGENTS* - BIOLOGICAL AGENTS...... 205 *PENICILLINS* - DRUGS FOR INFECTIONS...... 205 *PROGESTINS* - HORMONES...... 206 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* - DRUGS FOR THE NERVOUS SYSTEM...... 207 *RESPIRATORY AGENTS - MISC.* - DRUGS FOR THE LUNGS...... 213 *SULFONAMIDES* - DRUGS FOR INFECTIONS...... 213 ** - DRUGS FOR INFECTIONS...... 213 *THYROID AGENTS* - HORMONES...... 214 *TOXOIDS* - BIOLOGICAL AGENTS...... 215 *ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS* - DRUGS FOR THE STOMACH...... 216 *URINARY ANTISPASMODICS* - DRUGS FOR THE URINARY SYSTEM...... 218 *VACCINES* - BIOLOGICAL AGENTS...... 219 *VAGINAL AND RELATED PRODUCTS* - DRUGS FOR WOMEN...... 221 *VASOPRESSORS* - DRUGS FOR THE HEART...... 222 *VITAMINS* - DRUGS FOR NUTRITION...... 223

TOC-3 National Drug List – Informational Section

Definitions

“$0” next to a drug means this is a preventive drug. For some members, this product may be covered at 100% with $0 cost share with a prescription from your provider if specified criteria are met.

“BRAND name drug” means a drug that is marketed under a proprietary, trademark-protected name. A BRAND name drug is listed in this formulary in all CAPITAL letters.

“Coinsurance” means a percentage of the cost of a covered health care benefit that an enrollee pays after the enrollee has paid the deductible, if a deductible applies to the health care benefit, such as the benefit.

“Copayment” means a fixed dollar amount that an enrollee pays for a covered health care benefit after the enrollee has paid the deductible, if a deductible applies to the health care benefit, such as the prescription drug benefit.

“Deductible” means the amount an enrollee pays for covered health care benefits before the enrollee’s health plan begins payment for all or part of the cost of the health care benefit under the terms of the policy.

“Dose Optimization (DO)” means dose optimization. Usually, this means you may have to switch from taking a drug twice a day to taking it once a day at a higher strength.

“Drug Tier” is a group of prescription drugs that corresponds to a specified cost sharing tier in the health plan’s prescription drug coverage. The tier in which a prescription drug is placed determines the enrollee’s portion of the cost for the drug.

“Enrollee” is a person enrolled in a health plan who is entitled to receive services from the plan. All references to enrollees in this this formulary template shall also include subscriber as defined in this section below.

“Exception request” is a request for coverage of a prescription drug. If an enrollee, his or her designee or prescribing health care provider submits an exception request for coverage of a prescription drug, the health plan must cover the prescription drug when the drug is determined to be medically necessary to treat the enrollee’s condition.

“Exigent circumstances” means when you are suffering from a medical condition that may seriously jeopardize your life, health, or ability to regain maximum function, or when you are undergoing a current course of treatment using a non-formulary drug.

“Formulary” or “prescription drug list” is the complete list of drugs preferred for use and eligible for coverage under a health plan product, and includes all drugs covered under the outpatient prescription drug benefit of the health plan product. Formulary is also known as a prescription drug list.

“Generic drug” is the same drug as its BRAND name equivalent in dosage, safety, strength, how it is taken, quality, performance, and intended use. A generic drug is listed in bold and italicized lowercase letters.

“Limited Distribution (LD)” means limited distribution. These drugs are available only through certain pharmacies or wholesalers, depending on what the manufacturer decides.

“Medically Necessary” means health care benefits needed to diagnose, treat, or prevent a medical condition or its symptoms and that meet accepted standards of medicine. Health insurance usually does not cover health care benefits that are not medically necessary.

“Nonformulary drug” is a prescription drug that is not listed on the health plan’s formulary.

“Oral (OC)” Notwithstanding any deductible, the total amount of copayments and coinsurance an insured is required to pay shall not exceed two hundred dollars ($200) for an individual prescription of up to a 30-day supply of a prescribed orally administered anticancer covered by the policy.

“Out-of-pocket costs” are copayments, coinsurance, and the applicable deductible, plus all costs for health care services that are not covered by the health plan.

“Prescribing provider” is a health care provider authorized to write a prescription to treat a medical condition for a health plan enrollee.

“Prescription” is an oral, written, or electronic order by a prescribing provider for a specific enrollee that contains the name of the prescription drug, the quantity of the prescribed drug, the date of issue, the name and contact information of the prescribing provider, the signature of the prescribing provider if the prescription is in writing, and if requested by the enrollee, the medical condition or purpose for which the drug is being prescribed.

“Prescription drug” is a drug that is prescribed by the enrollee’s prescribing provider and requires a prescription under applicable law.

“Prior Authorization (PA)” is a health plan’s requirement that the enrollee or the enrollee’s prescribing provider obtain the health plan’s authorization for a prescription drug before the health plan will cover the drug. The health plan shall grant a prior authorization when it is medically necessary for the enrollee to obtain the drug.

“Quantity limit (QL)” means a restriction on the number of doses of a prescription drug covered by a health insurance product during a specific time period, or any other limitation on the quantity of a drug that is covered.

“Specialty Drugs (SP)” means specialty drugs. Specialty drugs are used to treat difficult, long-term conditions. You may need to get this drug through a specialty pharmacy.

“Step therapy (ST)” is a process specifying the sequence in which different prescription drugs for a given medical condition and medically appropriate for a particular patient are prescribed. The health plan may require the enrollee to try one or more drugs to treat the enrollee’s medical condition before the health plan will cover a particular drug for the condition pursuant to a step therapy request. If the enrollee’s prescribing provider submits a request for step therapy exception, the health plans shall make exceptions to step therapy when the criteria is met.

“Subscriber” means the person who is responsible for payment to a plan or whose employment or other status, except for family dependency, is the basis for eligibility for membership in the plan.

Frequently Asked Questions

How do I know what drugs are covered under my benefits? This is a complete listing of all the drugs on the drug list. But, it’s possible a drug(s) on this list may not be covered, depending on your plan’s design.

Your pharmacy benefit covers prescription drugs, including Specialty Drugs, that may be administered to you as part of a doctor’s visit, home care visit, or at an outpatient Facility when they are Covered Services. Benefits that are administered to you in your provider’s office are typically covered under your medical benefit. This may include Drugs for infusion therapy, chemotherapy, blood products, certain injectables and any drug that must be administered by a Provider.

How can I find a drug on the list? (A) A prescription drug may be located by looking up the therapeutic category and class to which the drug belongs or the BRAND name or generic name of the drug in the alphabetical index; and (B) If a generic equivalent for a BRAND name drug is not available on the market or is not covered, the drug will not be separately listed by its generic name.

You can search the PDF drug list by:

o Drug name, using Ctrl + F on your keyboard, then type in the name of the drug you’re looking for. o , using the categories listed in alphabetical order.

How are drugs shown on the list? o A drug is listed alphabetically by its BRAND name and generic names in the therapeutic category and class to which it belongs; o The generic name for a BRAND name drug is included after the BRAND name in parentheses and all bold and italicized lowercase letters;

o If a generic equivalent for a BRAND name drug is both available and covered, the generic drug will be listed separately from the BRAND name drug in all bold and italicized lowercase letters; and

o If a generic drug is marketed under a proprietary, trademark-protected BRAND name, the BRAND name will be listed after the generic name in parentheses and regular typeface with the first letter of each word capitalized.

The “Under Coverage Requirements and Limits” section will indicate if you need preapproval before you can take the drug (called prior authorization or PA), or if you need to try other drugs first for your treatment (called step therapy or ST).

Note: The presence of a prescription drug on the formulary does not guarantee that your doctor will prescribe that prescription drug for a particular medical condition.

What are my options for getting my prescriptions? You have plenty of choices about how and where to get your prescription medicines, including local pharmacies in your plan, convenient home delivery or specialty pharmacies. Most plans include our home delivery program at no extra cost to you.

Current Anthem members can find out more by logging in at anthem.com/ca and choose Prescription Benefits or call 833-203-1739. For more details about your coverage, you can call the phone number on your member ID card.

What if my drug isn’t on the list? We understand that only you and your doctor know what is best for you. If you want to take a drug that’s not on the drug list, you may have to pay the full cost for it. You can also talk to your doctor or pharmacist to see if there’s another drug covered by your plan that will work just as well, or if generic or OTC drugs are an option. Only you and your doctor can decide what drugs are right for you.

If a drug you’re taking isn’t covered, your doctor can ask us to review the coverage. This process is called preapproval or prior authorization.

Your doctor can get the process started by completing an electronic Prior Authorization, calling the Member Services number on the back of your member ID card or by downloading a prior authorization form from our website and submitting it. If your request is approved, the amount you pay for the drug will depend on your plan’s benefit.

There are a few options for your doctor to start the Prior Authorization (PA) process: 1. Submit an electronic PA request by going to https://www.covermymeds.com/main/partners/anthem. 2. Log in at anthem.com/ca and choose Pharmacy. o Go to Pharmacy Resources and Search Your Drug List for your medication. o Choose the correct medication strength and form. o Scroll down to Definition of Restrictions and locate the applicable Fax Form in the table. o Your doctor completes and faxes the form to us at 844-474-3347. 3. Calling Member Services number on the back of your member ID card.

Who decides what drugs are on the list? The drugs on the list are reviewed through our Pharmacy and Therapeutics (P&T) process. In this process, a group of independent doctors, pharmacists and other health care professionals decides which drugs we include on our lists. This group meets regularly to look at new and existing drugs and recommends drugs based on how safe they are, how well they work and the value they offer our members.

What is a specialty drug and how do I get them? If you’re taking a medicine that is considered a specialty drug, you may need to use a specialty pharmacy in order for your drug to be covered. Specialty drugs come in many forms like pills, liquids, injections (shots), infusions or inhalers and may need special storage and handling. Typically benefits for specialty drugs that are self-administered will be covered under the pharmacy benefit. Benefits for specialty drugs that are administered to you in your provider’s office are typically covered under your medical benefit. If you use pharmacies that are not in the network, your medicine may not be covered and you may have to pay the full cost. For more details about your coverage, you can call the phone number on your member ID card.

Does the drug list change, and how will I know if it does? Drugs on our list are reviewed and updated on a monthly basis. Sometimes, drugs are added, removed, change tiers or have updated requirements. The changes will usually go into effect the first day of the month. But don’t worry, we’ll let you know if a drug you take is taken off the list and, in some cases, if a drug you take is moved to a higher tier.

You can always check the drug list to make sure medicines you take are still on it. You’ll find the most up-to-date drug list when you log in at anthem.com/ca.

What kind of drugs can I find on the formulary? We cover FDA-approved preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA) and California state regulations. Your doctor may need to write a prescription for these preventive services to be covered by your plan, even if they are listed as over-the-counter. The availability or coverage of these without cost-sharing may be subject to criteria established by the health plan.

We cover FDA-approved equipment and supplies for the management and treatment of -using diabetes, non-insulin-using diabetes and gestational diabetes as medically necessary. Medication encompasses insulin, insulin pumps, and oral hypoglycemic agents. Covered supplies and equipment are limited to monitors, test strips, syringes and lancets. Covered benefits also include outpatient self-management and educational services used to treat diabetes if services are provided through a program authorized by the State's Diabetes Control Project within the Bureau of Health.

What drugs can I find in each tier? We place drugs on different tiers based on how well they work to improve health, whether there are over-the-counter (OTC) options and their costs compared to other drugs used for the same type of treatment. The lower the tier, the lower your share of the cost. Here’s a breakdown of the tiers in your plan:

o Tier 1 drugs have the lowest cost share for you. These are usually generic drugs that offer the best value compared to other drugs that treat the same conditions. Some plans split Tier 1 into Tier 1a and Tier 1b:

- Tier 1a drugs have the lowest cost share. These are often generic drugs that offer the greatest value compared to others that treat the same conditions. - Tier 1b drugs have a low cost share. These are typically generic drugs that offer the greatest value compared to others that treat the same conditions.

o Tier 2 drugs have a higher cost share than Tier 1. They may be preferred brand drugs, based on how well they work and their cost compared to other drugs used for the same type of treatment. Some are generic drugs that may cost more because they’re newer to the market.

o Tier 3 drugs have a higher cost share. They often include brand and generic drugs that may cost more than drugs on lower tiers that are used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA.

o Tier 4 drugs have a higher cost share and usually include preferred specialty brand and generic drugs. They may cost more than drugs on lower tiers that are used to treat the same condition. Tier 4 may also include drugs recently approved by the FDA or specialty drugs used to treat serious, long-term health conditions and that may need special handling.

o Tier 5 drugs have the highest cost share. Drugs in this tier are non-preferred specialty brand and generic drugs. Tier 5 may also include drugs recently approved by the FDA or specialty drugs used to treat serious, long-term health conditions and that may need special handling.

How will I know how much my drug will cost? Current Anthem members can go online and with the Price a Medication Tool, get pharmacy-specific pricing from a number of local retail pharmacies in your zip code.

Note: For oral chemotherapy drugs - Notwithstanding any deductible, the total amount of copayments and coinsurance an insured is required to pay shall not exceed two hundred dollars ($200) for an individual prescription of up to a 30- day supply of a prescribed orally administered anticancer medication covered by the policy.

How does Anthem promote safety? When you go to a pharmacy, the pharmacist will get an electronic message from Anthem if a drug needs prior authorization, requires step therapy or has a limit on the amount that can be given. Here’s a closer look at all of the programs we’ve put into place to help make sure you get the care you need, while helping to keep you safe.1

Our clinical edit programs are:  Prior authorization, which requires you to get approval before taking a medicine. This helps make sure a drug is used properly and focuses on drugs that may have: — Risk of side effects. — Risk of harmful effects when taken with other drugs. — Potential for incorrect use or abuse. — Rules for use with certain conditions.  Step therapy, which requires that other drugs be tried first. It focuses on whether a drug is right for your condition.  Dose optimization, which involves changing from taking a dose twice a day to once a day, when medically appropriate. Taking fewer doses may lower your costs; a single higher dose of a drug taken once a day may cost less than a lower dose taken twice a day.  Quantity Limits impose a limit on the amount in a prescription and how often it can be refilled. — If a refill request is submitted too soon or the doctor prescribes an amount that's higher than what is allowed, the drug won't be covered at that time. — If there are medical reasons to prescribe the drug as originally dosed, the doctor can ask for review by our Prior Authorization Center.

Also, If you’re taking a medicine that is considered a specialty drug, you may need to use a specialty pharmacy in order for your drug to be covered. How does my doctor start the Prior Authorization process? If your drug is on our formulary but requires a PA or Step Therapy, there are a few options for your doctor to start the Prior Authorization (PA) process: 1. Submit an electronic PA request by going to https://www.covermymeds.com/main/partners/anthem. 2. Log in at anthem.com/ca and choose Pharmacy. o Go to Pharmacy Resources and Search Your Drug List for your medication. o Choose the correct medication strength and form. o Scroll down to Definition of Restrictions and locate the applicable Fax Form in the table. o Your doctor completes the form and faxes it to Anthem at 844-474-3347. 3. Calling Pharmacy Member Services number on the back of your member ID card.

What is Step Therapy? How does it work? Step therapy requires trying other drugs before certain medications may be covered. The pharmacy will let you know if step therapy is required and you must first try the drug or treatment included in the program. If the drug or treatment does not treat the condition well, the doctor can contact our Prior Authorization Center to ask that we approve the original drug.1

A few more notes about the exception process:

o If we fail to respond to a completed prior authorization or step therapy exception request within 72 hours of receiving a non- urgent request and 24 hours of receiving a request based on exigent circumstances, the request is deemed approved and we may not deny any subsequent requests for this medication.

o Don’t worry, if you’ve changed policies, we won’t ask you to repeat an approved step therapy request that is already being used to treat a medical condition provided that the drug is still appropriately prescribed and is considered safe and effective.

A note about opioid analgesics. The member cost share for certain abuse-deterrent opioid analgesics may be lower in some states because of laws in those states. Opioid analgesics are a type of painkiller. In response to the global opioid epidemic, the U.S. Food and Drug Administration (FDA) has encouraged drug manufacturers to develop opioids with properties that help deter their misuse and abuse.

Drug(s) may be excluded from the list based on your plan's benefit design.

1 If the Prior Authorization Center concludes the prescription claim should be denied, members and their doctors will get letters that explain the appeals and/or grievance process.

KEY Here are some terms and notes you’ll find on the drug list.

BRAND name drugs are in UPPER CASE, plain type. generic drugs are in lower case, italic bold type.

$0 = preventive drugs. For some members, this Tier 1 = drugs have the lowest cost share for you. product may be covered at 100% with $0 cost share These are usually generic drugs that offer the best with a prescription from your provider if specified value compared to other drugs that treat the same criteria are met. conditions.

DO = dose optimization. Usually, this means you may Tier 1a = drugs have the lowest cost share. These are have to switch from taking a drug twice a day to taking often generic drugs that offer the greatest value it once a day at a higher strength. compared to others that treat the same conditions.

LD = limited distribution. These drugs are available Tier 1b = drugs have a low cost share. These are only through certain pharmacies or wholesalers, typically generic drugs that offer the greatest value depending on what the manufacturer decides. compared to others that treat the same conditions.

OC = oral chemotherapy. These drugs after deductible Tier 2 = drugs have a higher cost share than Tier 1. shall not exceed $200 per an individual prescription for They may be preferred brand drugs, based on how well up to a 30 day supply. they work and their cost compared to other drugs used for the same type of treatment. Some are generic PA = prior authorization. You may need to get benefits drugs that may cost more because they’re newer to the approved before certain prescriptions can be filled. market.

QL = quantity limits. There are limits on the amount of Tier 3 = drugs have a higher cost share. They often medicine covered within a certain amount of time. include brand and generic drugs that may cost more than drugs on lower tiers that are used to treat the SP = specialty drugs. Specialty drugs are used to treat same condition. difficult, long-term conditions. You may need to get this drug through a specialty pharmacy. Tier 4 = Tier 4 drugs have a higher cost share and usually include preferred specialty brand and generic ST = step therapy. You may need to use another drugs. recommended drug first before a prescribed drug is covered. Tier 5 = Tier 5 drugs have the highest cost share. Drugs in this tier are non-preferred specialty brand and generic drugs. .

Five Tier

CURRENT AS OF 9/1/2021

Coverage Requirements and Prescription Drug Name Drug Tier Limits *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* - DRUGS FOR THE NERVOUS SYSTEM *ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS*** - DRUGS FOR ATTENTION DEFICIT DISORDER hcl er oral tablet extended release 12 hour 1 or 1b* PA; QL (4 tablets per 1 day) hcl er oral tablet extended release 24 hour 1 mg, 2 mg 1 or 1b* PA; DO guanfacine hcl er oral tablet extended release 24 hour 3 mg, 4 mg 1 or 1b* PA; QL (1 tablet per 1 day) KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR (clonidine 3 PA; QL (4 tablets per 1 day) hcl) *ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR*** - DRUGS FOR ATTENTION DEFICIT DISORDER hcl oral capsule 10 mg, 18 mg, 25 mg, 40 mg 1 or 1b* PA; DO atomoxetine hcl oral capsule 100 mg, 60 mg, 80 mg 1 or 1b* PA; QL (1 capsule per 1 day) *AMPHETAMINE MIXTURES*** - DRUGS FOR ATTENTION DEFICIT DISORDER amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 1 or 1b* PA; DO 15 mg, 5 mg amphetamine-dextroamphet er oral capsule extended release 24 hour 20 mg, 1 or 1b* PA; QL (1 capsule per 1 day) 25 mg, 30 mg amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 5 mg, 1 or 1b* PA; DO 7.5 mg amphetamine-dextroamphetamine oral tablet 20 mg 1 or 1b* PA; QL (3 tablets per 1 day) amphetamine-dextroamphetamine oral tablet 30 mg 1 or 1b* PA; QL (2 tablets per 1 day) MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 ST; QL (1 capsule per 1 day) (amphetamine-dextroamphetamine) *AMPHETAMINES*** - DRUGS FOR ATTENTION DEFICIT DISORDER ADZENYS ER ORAL SUSPENSION EXTENDED RELEASE 3 PA; QL (15 mL per 1 day) (amphetamine) ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE 3 ST; QL (1 tablet per 1 day) DISPERSIBLE (amphetamine) amphetamine er oral suspension extended release 1 or 1b* QL (15 mL per 1 day) amphetamine sulfate oral tablet 10 mg 1 or 1b* QL (6 tablets per 1 day) amphetamine sulfate oral tablet 5 mg 1 or 1b* DO dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 1 or 1b* PA; QL (4 capsules per 1 day) 15 mg dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg 1 or 1b* PA; DO dextroamphetamine sulfate oral solution 1 or 1b* PA; QL (60 mL per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 11 Coverage Requirements and Prescription Drug Name Drug Tier Limits dextroamphetamine sulfate oral tablet 10 mg 1 or 1b* PA; QL (6 tablets per 1 day) dextroamphetamine sulfate oral tablet 5 mg 1 or 1b* PA; DO DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE 3 ST; QL (8 mL per 1 day) (amphetamine) EVEKEO ODT ORAL TABLET DISPERSIBLE (amphetamine sulfate) 3 ST; QL (2 tablets per 1 day) procentra oral solution 1 or 1b* PA; QL (60 mL per 1 day) VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG (lisdexamfetamine 2 PA; DO dimesylate) VYVANSE ORAL CAPSULE 40 MG, 50 MG, 60 MG, 70 MG 2 PA; QL (1 capsule per 1 day) (lisdexamfetamine dimesylate) VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, 30 MG 2 PA; DO (lisdexamfetamine dimesylate) VYVANSE ORAL TABLET CHEWABLE 40 MG, 50 MG, 60 MG 2 PA; QL (1 tablet per 1 day) (lisdexamfetamine dimesylate) zenzedi oral tablet 10 mg, 7.5 mg 1 or 1b* PA; QL (6 tablets per 1 day) zenzedi oral tablet 15 mg 1 or 1b* PA; QL (3 tablets per 1 day) zenzedi oral tablet 2.5 mg, 5 mg 1 or 1b* PA; DO zenzedi oral tablet 20 mg, 30 mg 1 or 1b* PA; QL (2 tablets per 1 day) *ANALEPTICS*** - DRUGS FOR THE NERVOUS SYSTEM CAFCIT INTRAVENOUS SOLUTION ( citrate) 3 caffeine citrate intravenous solution 1 or 1b* caffeine citrate oral solution 1 or 1b* DOPRAM INTRAVENOUS SOLUTION (doxapram hcl) 3 *ANOREXIANT COMBINATIONS*** - DRUGS FOR THE NERVOUS SYSTEM PLENITY ORAL CAPSULE (carboxymeth-cellulose-citricac) 3 PLENITY WELCOME KIT ORAL CAPSULE (carboxymeth-cellulose- 3 citricac) QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 PA (phentermine-) *ANOREXIANTS NON-AMPHETAMINE*** - DRUGS FOR THE NERVOUS SYSTEM ADIPEX-P ORAL CAPSULE (phentermine hcl) 3 PA ADIPEX-P ORAL TABLET (phentermine hcl) 3 PA benzphetamine hcl oral tablet 25 mg 1 or 1b* benzphetamine hcl oral tablet 50 mg 1 or 1b* PA diethylpropion hcl er oral tablet extended release 24 hour 1 or 1b* PA diethylpropion hcl oral tablet 1 or 1b* PA LOMAIRA ORAL TABLET (phentermine hcl) 3 PA phendimetrazine tartrate er oral capsule extended release 24 hour 1 or 1b* PA

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 12 Coverage Requirements and Prescription Drug Name Drug Tier Limits phendimetrazine tartrate oral tablet 1 or 1b* PA phentermine hcl oral capsule 1 or 1b* PA phentermine hcl oral tablet 1 or 1b* PA *ANTI-OBESITY - GLP-1 RECEPTOR AGONISTS*** - DRUGS FOR THE NERVOUS SYSTEM SAXENDA SUBCUTANEOUS SOLUTION PEN-INJECTOR ( - 3 PA weight management) WEGOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR (- 3 PA weight management) *ANTI-OBESITY AGENT COMBINATIONS** - DRUGS FOR THE NERVOUS SYSTEM CONTRAVE ORAL TABLET EXTENDED RELEASE 12 HOUR 3 PA (naltrexone-bupropion hcl) * AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS)*** - DRUGS FOR SLEEP DISORDER SUNOSI ORAL TABLET 150 MG (solriamfetol hcl) 3 PA; QL (1 tablet per 1 day) SUNOSI ORAL TABLET 75 MG (solriamfetol hcl) 3 PA; DO *LIPASE INHIBITORS*** - DRUGS FOR THE NERVOUS SYSTEM XENICAL ORAL CAPSULE () 3 PA *STIMULANTS - MISC.*** - DRUGS FOR ATTENTION DEFICIT DISORDER ADHANSIA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 ST; QL (1 capsule per 1 day) (methylphenidate hcl) APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 3 ST; DO MG, 15 MG, 20 MG, 30 MG (methylphenidate hcl) APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 40 3 ST; QL (1 capsule per 1 day) MG, 50 MG, 60 MG (methylphenidate hcl) oral tablet 150 mg, 200 mg, 250 mg 1 or 1b* PA; QL (1 tablet per 1 day) armodafinil oral tablet 50 mg 1 or 1b* PA; QL (2 tablets per 1 day) COTEMPLA XR-ODT ORAL TABLET EXTENDED RELEASE 3 ST; QL (2 tablets per 1 day) DISPERSIBLE (methylphenidate) DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 MG/9HR 3 ST; DO (methylphenidate) DAYTRANA TRANSDERMAL PATCH 20 MG/9HR, 30 MG/9HR 3 ST; QL (1 patch per 1 day) (methylphenidate) dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 1 or 1b* PA; DO mg, 20 mg, 5 mg dexmethylphenidate hcl er oral capsule extended release 24 hour 25 mg, 30 1 or 1b* PA; QL (1 capsule per 1 day) mg, 35 mg, 40 mg dexmethylphenidate hcl oral tablet 10 mg 1 or 1b* PA; QL (2 tablets per 1 day) dexmethylphenidate hcl oral tablet 2.5 mg, 5 mg 1 or 1b* PA; DO FOCALIN ORAL TABLET 10 MG (dexmethylphenidate hcl) 3 PA; QL (2 tablets per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 13 Coverage Requirements and Prescription Drug Name Drug Tier Limits FOCALIN ORAL TABLET 2.5 MG, 5 MG (dexmethylphenidate hcl) 3 PA; DO JORNAY PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 3 ST; QL (1 capsule per 1 day) 60 MG, 80 MG (methylphenidate hcl) JORNAY PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG, 3 ST; DO 40 MG (methylphenidate hcl) METHYLIN ORAL SOLUTION 10 MG/5ML (methylphenidate hcl) 3 ST; QL (30 mL per 1 day) METHYLIN ORAL SOLUTION 5 MG/5ML (methylphenidate hcl) 3 ST; QL (60 mL per 1 day) methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 1 or 1b* PA; DO mg methylphenidate hcl er (cd) oral capsule extended release 40 mg, 50 mg, 60 1 or 1b* PA; QL (1 capsule per 1 day) mg methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 1 or 1b* PA; DO mg methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg 1 or 1b* PA; QL (2 capsules per 1 day) methylphenidate hcl er (la) oral capsule extended release 24 hour 40 mg, 60 1 or 1b* PA; QL (1 capsule per 1 day) mg methylphenidate hcl er (xr) oral capsule extended release 24 hour 10 mg, 15 1 or 1b* PA; DO mg, 20 mg, 30 mg methylphenidate hcl er (xr) oral capsule extended release 24 hour 40 mg, 50 1 or 1b* PA; QL (1 capsule per 1 day) mg, 60 mg methylphenidate hcl er oral tablet extended release 10 mg, 18 mg, 27 mg 1 or 1b* PA; DO methylphenidate hcl er oral tablet extended release 20 mg 1 or 1b* PA; QL (3 tablets per 1 day) methylphenidate hcl er oral tablet extended release 24 hour 1 or 1b* PA; DO methylphenidate hcl er oral tablet extended release 36 mg 1 or 1b* PA; QL (2 tablets per 1 day) methylphenidate hcl er oral tablet extended release 54 mg 1 or 1b* PA; QL (1 tablet per 1 day) METHYLPHENIDATE HCL ER ORAL TABLET EXTENDED RELEASE 3 ST; QL (1 tablet per 1 day) 72 MG methylphenidate hcl oral solution 10 mg/5ml 1 or 1b* PA; QL (30 mL per 1 day) methylphenidate hcl oral solution 5 mg/5ml 1 or 1b* PA; QL (60 mL per 1 day) methylphenidate hcl oral tablet 10 mg, 5 mg 1 or 1b* PA; DO methylphenidate hcl oral tablet 20 mg 1 or 1b* PA; QL (3 tablets per 1 day) methylphenidate hcl oral tablet chewable 10 mg 1 or 1b* PA; QL (3 tablets per 1 day) methylphenidate hcl oral tablet chewable 2.5 mg 1 or 1b* ST; DO methylphenidate hcl oral tablet chewable 5 mg 1 or 1b* PA; DO oral tablet 100 mg 1 or 1b* PA; DO modafinil oral tablet 200 mg 1 or 1b* PA; QL (1 tablet per 1 day) QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 3 ST; DO 20 MG (methylphenidate hcl) QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 3 ST; QL (2 tablets per 1 day) 30 MG (methylphenidate hcl)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 14 Coverage Requirements and Prescription Drug Name Drug Tier Limits QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 3 ST; QL (1 tablet per 1 day) 40 MG (methylphenidate hcl) QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED ER 3 QL (12 mL per 1 day) (methylphenidate hcl) RELEXXII ORAL TABLET EXTENDED RELEASE (methylphenidate hcl) 3 ST; QL (1 tablet per 1 day) RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 3 PA; DO 20 MG (methylphenidate hcl) RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 30 MG 3 PA; QL (2 capsules per 1 day) (methylphenidate hcl) RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 40 MG 3 PA; QL (1 capsule per 1 day) (methylphenidate hcl) RITALIN ORAL TABLET 10 MG, 5 MG (methylphenidate hcl) 3 PA; DO RITALIN ORAL TABLET 20 MG (methylphenidate hcl) 3 PA; QL (3 tablets per 1 day) *ALLERGENIC EXTRACTS/BIOLOGICALS MISC* - BIOLOGICAL AGENTS *ALLERGENIC EXTRACTS*** - BIOLOGICAL AGENTS ACACIA SUBCUTANEOUS SOLUTION 3 ACREMONIUM SUBCUTANEOUS SOLUTION 3 ALDER SUBCUTANEOUS SOLUTION 3 ALTERNARIA SUBCUTANEOUS SOLUTION 3 AMERICAN BEECH SUBCUTANEOUS SOLUTION 3 AMERICAN COCKROACH SUBCUTANEOUS SOLUTION 3 AMERICAN ELM SUBCUTANEOUS SOLUTION 3 ARIZONA CYPRESS SUBCUTANEOUS SOLUTION 3 ASPERGILLUS FUMIGATUS INJECTION SOLUTION 3 AUREOBASIDIUM PULLULANS INJECTION SOLUTION 3 AUREOBASIDIUM SUBCUTANEOUS SOLUTION 3 AUSTRALIAN PINE SUBCUTANEOUS SOLUTION 3 BAHIA SUBCUTANEOUS SOLUTION 3 BALD CYPRESS SUBCUTANEOUS SOLUTION 3 BAYBERRY (WAX MYRTLE) SUBCUTANEOUS SOLUTION 3 BERMUDA GRASS INJECTION SOLUTION 3 BERMUDA GRASS SUBCUTANEOUS SOLUTION 3 BLACK WILLOW SUBCUTANEOUS SOLUTION 3 BOTRYTIS INJECTION SOLUTION 3 BOTRYTIS SUBCUTANEOUS SOLUTION 3 BROME SUBCUTANEOUS SOLUTION 3 CALIFORNIA PEPPER SUBCUTANEOUS SOLUTION 3 CANDIDA ALBICANS EXTRACT INJECTION SOLUTION 3

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 15 Coverage Requirements and Prescription Drug Name Drug Tier Limits CANDIDA ALBICANS EXTRACT SUBCUTANEOUS SOLUTION 3 CAT HAIR EXTRACT INJECTION SOLUTION 3 CAT HAIR EXTRACT SUBCUTANEOUS SOLUTION 3 CATTLE EPITHELIUM SUBCUTANEOUS SOLUTION 3 CEDAR ELM SUBCUTANEOUS SOLUTION 3 CLADOSPORIUM CLADOSPORIOIDES INJECTION SOLUTION 3 CLADOSPORIUM CLADOSPORIOIDES INTRADERMAL SOLUTION 3 CLADOSPORIUM CLADOSPORIOIDES SUBCUTANEOUS SOLUTION 3 CLADOSPORIUM SPHAEROSPERMUM SUBCUTANEOUS SOLUTION 3 COCKLEBUR SUBCUTANEOUS SOLUTION 3 CORN POLLEN SUBCUTANEOUS SOLUTION 3 CURVULARIA SUBCUTANEOUS SOLUTION 3 DANDELION SUBCUTANEOUS SOLUTION 3 DOG EPITHELIUM SUBCUTANEOUS SOLUTION 3 DOG FENNEL SUBCUTANEOUS SOLUTION 3 DRECHSLERA SUBCUTANEOUS SOLUTION 3 EASTERN COTTONWOOD SUBCUTANEOUS SOLUTION 3 EPICOCCUM NIGRUM INJECTION SOLUTION 3 EPICOCCUM SUBCUTANEOUS SOLUTION 3 FIRE ANT SUBCUTANEOUS SOLUTION 3 FUSARIUM SUBCUTANEOUS SOLUTION 3 GERMAN COCKROACH SUBCUTANEOUS SOLUTION 3 GOLDENROD SUBCUTANEOUS SOLUTION 3 GRASS POLLEN(K-O-R-T-SWT VERN) INJECTION SOLUTION 3 GRASTEK SUBLINGUAL TABLET SUBLINGUAL (timothy grass pollen 3 PA; QL (1 tablet per 1 day) allergen) HACKBERRY SUBCUTANEOUS SOLUTION 3 HONEY BEE VENOM PROTEIN INJECTION SOLUTION 3 RECONSTITUTED (honey bee venom) HONEY BEE VENOM SUBCUTANEOUS SOLUTION RECONSTITUTED 3 HORSE EPITHELIUM SUBCUTANEOUS SOLUTION 3 JOHNSON GRASS SUBCUTANEOUS SOLUTION 3 JUNE GRASS POLLEN STANDARDIZED SUBCUTANEOUS SOLUTION 3 KAPOK SUBCUTANEOUS SOLUTION 3 KOCHIA SUBCUTANEOUS SOLUTION 3 LENSCALE SUBCUTANEOUS SOLUTION 3 MEADOW FESCUE GRASS POLLEN SUBCUTANEOUS SOLUTION 3 MELALEUCA SUBCUTANEOUS SOLUTION 3

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 16 Coverage Requirements and Prescription Drug Name Drug Tier Limits MESQUITE SUBCUTANEOUS SOLUTION 3 MITE (D. FARINAE) INJECTION SOLUTION 3 MITE (D. FARINAE) SUBCUTANEOUS SOLUTION 3 MITE (D. PTERONYSSINUS) INJECTION SOLUTION 3 MITE (D. PTERONYSSINUS) SUBCUTANEOUS SOLUTION 3 MIXED RAGWEED SUBCUTANEOUS SOLUTION 3 MIXED VESPID VENOM PROTEIN INJECTION SOLUTION 3 RECONSTITUTED MIXED VESPID VENOM PROTEIN SUBCUTANEOUS SOLUTION 3 RECONSTITUTED MOUNTAIN CEDAR SUBCUTANEOUS SOLUTION 3 MOUSE EPITHELIUM SUBCUTANEOUS SOLUTION 3 MUCOR INJECTION SOLUTION 3 MUCOR INTRADERMAL SOLUTION 3 MUCOR SUBCUTANEOUS SOLUTION 3 MUGWORT SUBCUTANEOUS SOLUTION 3 OLIVE TREE SUBCUTANEOUS SOLUTION 3 ORCHARD GRASS POLLEN SUBCUTANEOUS SOLUTION 3 PENICILLIUM NOTATUM INJECTION SOLUTION 3 PENICILLIUM NOTATUM SUBCUTANEOUS SOLUTION 3 PERENNIAL RYE GRASS POLLEN INJECTION SOLUTION 3 PHOMA EXIGUA SUBCUTANEOUS SOLUTION 3 PRIVET SUBCUTANEOUS SOLUTION 3 QUEEN PALM SUBCUTANEOUS SOLUTION 3 RABBIT EPITHELIUM SUBCUTANEOUS SOLUTION 3 RAGWITEK SUBLINGUAL TABLET SUBLINGUAL (short ragweed pollen 3 PA; QL (1 tablet per 1 day) ext) RED MAPLE SUBCUTANEOUS SOLUTION 3 RED MULBERRY SUBCUTANEOUS SOLUTION 3 RED TOP GRASS POLLEN SUBCUTANEOUS SOLUTION 3 RHIZOPUS SUBCUTANEOUS SOLUTION 3 ROUGH MARSH ELDER SUBCUTANEOUS SOLUTION 3 RUSSIAN THISTLE SUBCUTANEOUS SOLUTION 3 SACCHAROMYCES CEREVISIAE INJECTION SOLUTION 3 SACCHAROMYCES CEREVISIAE SUBCUTANEOUS SOLUTION 3 SHAGBARK HICKORY SUBCUTANEOUS SOLUTION 3 SHEEP SORREL SUBCUTANEOUS SOLUTION 3 SHORT RAGWEED POLLEN EXT SUBCUTANEOUS SOLUTION 3 SPINY PIGWEED SUBCUTANEOUS SOLUTION 3 BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 17 Coverage Requirements and Prescription Drug Name Drug Tier Limits STEMPHYLIUM SUBCUTANEOUS SOLUTION 3 SWEET GUM SUBCUTANEOUS SOLUTION 3 SWEET VERNAL GRASS POLLEN SUBCUTANEOUS SOLUTION 3 TALL RAGWEED SUBCUTANEOUS SOLUTION 3 TIMOTHY GRASS POLLEN ALLERGEN INJECTION SOLUTION 3 TIMOTHY GRASS POLLEN ALLERGEN SUBCUTANEOUS SOLUTION 3 TRICHOPHYTON MENTAGROPHYTES SUBCUTANEOUS SOLUTION 3 TRICHOPHYTON SUBCUTANEOUS SOLUTION 3 VENOMIL HONEY BEE VENOM INJECTION KIT (honey bee venom) 3 VENOMIL MIXED VESPID VENOM INJECTION SOLUTION 3 RECONSTITUTED (mixed vespid venom) VENOMIL WASP VENOM INJECTION KIT (wasp venom) 3 VENOMIL WHITE FACED HORNET INJECTION KIT (white faced hornet 3 venom) VENOMIL YELLOW HORNET VENOM INJECTION KIT (yellow hornet 3 venom) VENOMIL YELLOW JACKET VENOM INJECTION KIT (yellow jacket 3 venom) WASP VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 3 WASP VENOM PROTEIN SUBCUTANEOUS SOLUTION 3 RECONSTITUTED WESTERN JUNIPER SUBCUTANEOUS SOLUTION 3 WHITE BIRCH SUBCUTANEOUS SOLUTION 3 WHITE FACED HORNET VENOM SUBCUTANEOUS SOLUTION 3 RECONSTITUTED WHITE MULBERRY SUBCUTANEOUS SOLUTION 3 WHITE OAK SUBCUTANEOUS SOLUTION 3 WHITE PINE SUBCUTANEOUS SOLUTION 3 WHITE-FACED HORNET VENOM INJECTION SOLUTION 3 RECONSTITUTED (white faced hornet venom) YELLOW DOCK SUBCUTANEOUS SOLUTION 3 YELLOW HORNET VENOM PROTEIN INJECTION SOLUTION 3 RECONSTITUTED YELLOW HORNET VENOM PROTEIN SUBCUTANEOUS SOLUTION 3 RECONSTITUTED YELLOW JACKET VENOM PROTEIN INJECTION SOLUTION 3 RECONSTITUTED YELLOW JACKET VENOM PROTEIN SUBCUTANEOUS SOLUTION 3 RECONSTITUTED *MIXED ALLERGENIC EXTRACTS*** - BIOLOGICAL AGENTS DUST MITE MIXED ALLERGEN EXT INJECTION SOLUTION 3

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 18 Coverage Requirements and Prescription Drug Name Drug Tier Limits DUST MITE MIXED ALLERGEN EXT SUBCUTANEOUS SOLUTION 3 MIXED ASPERGILLUS SUBCUTANEOUS SOLUTION 3 MIXED FEATHERS SUBCUTANEOUS SOLUTION 3 ODACTRA SUBLINGUAL TABLET SUBLINGUAL (dust mite mixed 3 PA; QL (1 tablet per 1 day) allergen ext) ORALAIR SUBLINGUAL TABLET SUBLINGUAL (grass mix pollens 3 PA; LD; QL (1 tablet per 1 day) allergen ext) SORREL/DOCK MIX SUBCUTANEOUS SOLUTION 3 *AMEBICIDES* - DRUGS FOR INFECTIONS *AMEBICIDES*** - DRUGS FOR PARASITES SOLOSEC ORAL PACKET (secnidazole) 3 ST; QL (2 grams per 1 fill) *AMINOGLYCOSIDES* - DRUGS FOR INFECTIONS *AMINOGLYCOSIDES*** - ANTIBIOTICS amikacin sulfate injection solution 1 or 1b* gentamicin in saline intravenous solution 1 or 1b* gentamicin sulfate injection solution 1 or 1b* HUMATIN ORAL CAPSULE (paromomycin sulfate) 3 neomycin sulfate oral tablet 1 or 1a* paromomycin sulfate oral capsule 1 or 1b* streptomycin sulfate intramuscular solution reconstituted 1 or 1b* tobramycin inhalation nebulization solution 300 mg/4ml 4 SP; QL (224 mL per 28 days) tobramycin inhalation nebulization solution 300 mg/5ml 4 SP; QL (9.4 mL per 1 day) tobramycin sulfate injection solution 1 or 1b* tobramycin sulfate injection solution reconstituted 1 or 1b* QL (30 vials per 30 days) ZEMDRI INTRAVENOUS SOLUTION (plazomicin sulfate) 3 *ANALGESICS - ANTI-INFLAMMATORY* - DRUGS FOR PAIN AND FEVER *ANTIRHEUMATIC - JANUS KINASE (JAK) INHIBITORS*** - ARTHRITIS AND PAIN DRUGS RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR (upadacitinib) 4 PA; SP; QL (1 tablet per 1 day) *ANTIRHEUMATIC *** - ARTHRITIS AND PAIN DRUGS RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR ( PA; SP; QL (4 auto-injector per 28 4 (anti-rheumatic)) days) *ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES*** - ARTHRITIS AND PAIN DRUGS HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED 4 PA; SP; QL (1 kit per 365 days) SYRINGE KIT (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML 4 PA; SP; QL (2 EA per 28 days) (adalimumab)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 19 Coverage Requirements and Prescription Drug Name Drug Tier Limits HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML 4 PA; SP; QL (2 pens per 28 days) (adalimumab) PA; SP; QL (2 kits per 28 days (QL HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML 4 exception needed for maintenance (adalimumab) therapys) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR 4 PA; SP; QL (1 kit per 365 days) KIT (adalimumab) HUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS PEN- 4 PA; SP; QL (1 kit per 365 days) INJECTOR KIT (adalimumab) HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN- 4 PA; SP; QL (1 kit per 365 days) INJECTOR KIT (adalimumab) HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PEN- 4 PA; SP; QL (1 kit per 365 days) INJECTOR KIT (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 20 4 PA; SP; QL (2 EA per 28 days) MG/0.2ML, 40 MG/0.4ML (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML 4 PA; SP; QL (2 syringes per 28 days) (adalimumab) SIMPONI ARIA INTRAVENOUS SOLUTION (golimumab) 4 PA; SP SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR (golimumab) 4 PA; SP; QL (1 pen per 28 days) SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (1 syringe per 28 days) (golimumab) *CYCLOOXYGENASE 2 (COX-2) INHIBITORS*** - ARTHRITIS AND PAIN DRUGS oral capsule 100 mg, 200 mg, 50 mg 1 or 1b* ST; QL (2 capsules per 1 day) celecoxib oral capsule 400 mg 1 or 1b* ST; QL (1 capsule per 1 day) *GOLD COMPOUNDS*** - ARTHRITIS AND PAIN DRUGS RIDAURA ORAL CAPSULE (auranofin) 2 *NONSTEROIDAL ANTI-INFLAMMATORY AGENT COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS diclofenac-misoprostol oral tablet delayed release 50-0.2 mg 1 or 1b* ST; QL (4 tablets per 1 day) diclofenac-misoprostol oral tablet delayed release 75-0.2 mg 1 or 1b* ST; QL (2 tablets per 1 day) *NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)*** - ARTHRITIS AND PAIN DRUGS ANJESO INTRAVENOUS INJECTABLE (meloxicam) 3 CALDOLOR INTRAVENOUS SOLUTION (ibuprofen) 3 cataflam oral tablet 1 or 1b* DAYPRO ORAL TABLET (oxaprozin) 3 QL (2 tablets per 1 day) diclofenac potassium oral tablet 1 or 1b* diclofenac sodium er oral tablet extended release 24 hour 1 or 1b* QL (2 tablets per 1 day) diclofenac sodium oral tablet delayed release 25 mg 1 or 1b* QL (5 tablets per 1 day) diclofenac sodium oral tablet delayed release 50 mg 1 or 1b* QL (4 tablets per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 20 Coverage Requirements and Prescription Drug Name Drug Tier Limits diclofenac sodium oral tablet delayed release 75 mg 1 or 1b* QL (2 tablets per 1 day) ec-naproxen oral tablet delayed release 1 or 1b* etodolac er oral tablet extended release 24 hour 400 mg, 500 mg 1 or 1b* QL (2 tablets per 1 day) etodolac er oral tablet extended release 24 hour 600 mg 1 or 1b* QL (1 tablet per 1 day) etodolac oral capsule 200 mg 1 or 1b* QL (4 capsules per 1 day) etodolac oral capsule 300 mg 1 or 1b* QL (3 capsules per 1 day) etodolac oral tablet 1 or 1b* QL (2 tablets per 1 day) FELDENE ORAL CAPSULE (piroxicam) 3 QL (1 capsule per 1 day) fenoprofen calcium oral tablet 1 or 1b* QL (4 tablets per 1 day) flurbiprofen oral tablet 100 mg 1 or 1b* QL (3 tablets per 1 day) flurbiprofen oral tablet 50 mg 1 or 1b* QL (4 tablets per 1 day) ibu oral tablet 1 or 1a* QL (4 tablets per 1 day) ibuprofen lysine intravenous solution 1 or 1b* ibuprofen oral suspension 1 or 1a* QL (4 mL per 1 day) ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 or 1a* QL (4 tablets per 1 day) indomethacin er oral capsule extended release 1 or 1b* QL (2 capsules per 1 day) indomethacin oral capsule 25 mg 1 or 1b* QL (3 capsule per 1 day) indomethacin oral capsule 50 mg 1 or 1b* QL (4 capsule per 1 day) indomethacin sodium intravenous solution reconstituted 1 or 1b* ketoprofen er oral capsule extended release 24 hour 1 or 1b* QL (1 capsule per 1 day) ketoprofen oral capsule 50 mg 1 or 1b* ketoprofen oral capsule 75 mg 1 or 1b* QL (4 capsules per 1 day) ketorolac tromethamine injection solution 15 mg/ml 1 or 1b* QL (4 mL per 30 days) ketorolac tromethamine injection solution 30 mg/ml 1 or 1b* QL (2 mL per 30 days) ketorolac tromethamine intramuscular solution 1 or 1b* QL (2 mL per 30 days) ketorolac tromethamine oral tablet 1 or 1a* QL (20 tablets per 30 days) LODINE ORAL TABLET (etodolac) 3 QL (2 tablets per 1 day) meclofenamate sodium oral capsule 1 or 1b* QL (4 capsules per 1 day) oral capsule 1 or 1b* QL (29 capsule per 1 fill) meloxicam oral tablet 1 or 1b* QL (1 tablet per 1 day) nabumetone oral tablet 500 mg 1 or 1b* QL (4 tablets per 1 day) nabumetone oral tablet 750 mg 1 or 1b* QL (2 tablets per 1 day) naproxen oral suspension 1 or 1b* naproxen oral tablet 1 or 1b* naproxen oral tablet delayed release 1 or 1b* naproxen sodium oral tablet 275 mg 1 or 1b* QL (4 tablets per 1 day) naproxen sodium oral tablet 550 mg 1 or 1b* QL (2 tablets per 1 day) NEOPROFEN INTRAVENOUS SOLUTION (ibuprofen lysine) 3 BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 21 Coverage Requirements and Prescription Drug Name Drug Tier Limits oxaprozin oral tablet 1 or 1b* QL (2 tablets per 1 day) piroxicam oral capsule 1 or 1b* QL (1 capsule per 1 day) relafen oral tablet 500 mg 1 or 1b* QL (4 tablets per 1 day) relafen oral tablet 750 mg 1 or 1b* QL (2 tablets per 1 day) sulindac oral tablet 1 or 1b* QL (2 tablets per 1 day) *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS*** - ARTHRITIS AND PAIN DRUGS OTEZLA ORAL TABLET (apremilast) 4 PA; SP; QL (2 tablets per 1 day) OTEZLA ORAL TABLET THERAPY PACK (apremilast) 4 PA; SP; QL (1 pack per 365 days) *PYRIMIDINE SYNTHESIS INHIBITORS*** - ARTHRITIS AND PAIN DRUGS ARAVA ORAL TABLET (leflunomide) 3 leflunomide oral tablet 1 or 1b* *SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS*** - ARTHRITIS AND PAIN DRUGS PA; SP; QL (4 cartridge per 28 ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE (etanercept) 4 days) PA; SP; QL (8 injections per 28 ENBREL SUBCUTANEOUS SOLUTION (etanercept) 4 days) ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 4 PA; SP; QL (8 syringes per 28 days) MG/0.5ML (etanercept) ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 4 PA; SP; QL (4 syringes per 28 days) MG/ML (etanercept) ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED (etanercept) 4 PA; SP; QL (8 vials per 28 days) ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 4 PA; SP; QL (4 pens per 28 days) (etanercept) *ANALGESICS - NONNARCOTIC* - DRUGS FOR PAIN AND FEVER *ANALGESICS OTHER*** - ARTHRITIS AND PAIN DRUGS acetaminophen intravenous solution 1 or 1b* clonidine hcl (analgesia) epidural solution 1 or 1b* DURACLON EPIDURAL SOLUTION (clonidine hcl (analgesia)) 3 OFIRMEV INTRAVENOUS SOLUTION (acetaminophen) 3 *ANALGESICS-SEDATIVES*** - ARTHRITIS AND PAIN DRUGS bac oral tablet 1 or 1b* QL (6 tablets per 1 day) bupap oral tablet 1 or 1b* QL (6 tablets per 1 day) butalbital-acetaminophen oral capsule 1 or 1b* QL (6 capsules per 1 day) butalbital-acetaminophen oral tablet 25-325 mg 1 or 1b* QL (12 tablets per 1 day) butalbital-acetaminophen oral tablet 50-300 mg, 50-325 mg 1 or 1b* QL (6 tablets per 1 day) butalbital-apap-caffeine oral capsule 1 or 1b* QL (6 capsules per 1 day) butalbital-apap-caffeine oral tablet 1 or 1b* QL (6 tablets per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 22 Coverage Requirements and Prescription Drug Name Drug Tier Limits butalbital-aspirin-caffeine oral capsule 1 or 1b* QL (6 capsules per 1 day) esgic oral capsule 1 or 1b* QL (6 capsules per 1 day) tencon oral tablet 1 or 1b* QL (6 tablets per 1 day) zebutal oral capsule 1 or 1b* QL (6 capsules per 1 day) *SALICYLATE COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS sm aspirin tri-buffered oral tablet 1 or 1b*; $0 tri-buffered aspirin oral tablet 1 or 1b*; $0 *SALICYLATES*** - ARTHRITIS AND PAIN DRUGS adult aspirin regimen oral tablet delayed release 1 or 1a*; $0 aspirin 81 oral tablet chewable 1 or 1a*; $0 aspirin adult low dose oral tablet delayed release 1 or 1a*; $0 aspirin adult low strength oral tablet delayed release 1 or 1a*; $0 aspirin childrens oral tablet chewable 1 or 1a*; $0 aspirin ec adult low strength oral tablet delayed release 1 or 1a*; $0 aspirin ec low dose oral tablet delayed release 1 or 1a*; $0 aspirin ec low strength oral tablet delayed release 1 or 1a*; $0 aspirin ec oral tablet delayed release 1 or 1a*; $0 aspirin low dose oral tablet chewable 1 or 1a*; $0 aspirin low dose oral tablet delayed release 1 or 1a*; $0 aspirin low strength oral tablet chewable 1 or 1a*; $0 aspirin oral tablet 1 or 1a*; $0 aspirin oral tablet chewable 1 or 1a*; $0 aspirin oral tablet delayed release 1 or 1a*; $0 bayer advanced aspirin reg st oral tablet 1 or 1a*; $0 bayer aspirin ec low dose oral tablet delayed release 1 or 1a*; $0 bayer aspirin oral tablet 1 or 1a*; $0 bayer aspirin oral tablet delayed release 1 or 1a*; $0 bayer low dose oral tablet chewable 1 or 1a*; $0 bayer low dose oral tablet delayed release 1 or 1a*; $0 childrens aspirin oral tablet chewable 1 or 1a*; $0 cvs aspirin adult low dose oral tablet chewable 1 or 1a*; $0 cvs aspirin adult low strength oral tablet delayed release 1 or 1a*; $0 cvs aspirin ec oral tablet delayed release 1 or 1a*; $0 cvs aspirin low dose oral tablet delayed release 1 or 1a*; $0 cvs aspirin low strength oral tablet delayed release 1 or 1a*; $0 cvs aspirin oral tablet 1 or 1a*; $0 diflunisal oral tablet 1 or 1b*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 23 Coverage Requirements and Prescription Drug Name Drug Tier Limits ecotrin low strength oral tablet delayed release 1 or 1a*; $0 eq aspirin adult low dose oral tablet delayed release 1 or 1a*; $0 eq aspirin low dose oral tablet chewable 1 or 1a*; $0 eq aspirin oral tablet 1 or 1a*; $0 eql aspirin ec oral tablet delayed release 1 or 1a*; $0 eql aspirin low dose oral tablet chewable 1 or 1a*; $0 eql aspirin low dose oral tablet delayed release 1 or 1a*; $0 gnp adult aspirin low strength oral tablet chewable 1 or 1a*; $0 gnp aspirin low dose oral tablet delayed release 1 or 1a*; $0 gnp aspirin oral tablet 1 or 1a*; $0 gnp aspirin oral tablet delayed release 1 or 1a*; $0 goodsense aspirin adult low st oral tablet chewable 1 or 1a*; $0 goodsense aspirin adults oral tablet 1 or 1a*; $0 goodsense aspirin low dose oral tablet delayed release 1 or 1a*; $0 goodsense aspirin oral tablet 1 or 1a*; $0 goodsense aspirin oral tablet chewable 1 or 1a*; $0 goodsense aspirin oral tablet delayed release 1 or 1a*; $0 h-e-b aspirin oral tablet delayed release 1 or 1a*; $0 hm adult aspirin oral tablet 1 or 1a*; $0 hm aspirin ec low dose oral tablet delayed release 1 or 1a*; $0 hm aspirin ec oral tablet delayed release 1 or 1a*; $0 hm aspirin oral tablet 1 or 1a*; $0 hm aspirin oral tablet chewable 1 or 1a*; $0 hm aspirin oral tablet delayed release 1 or 1a*; $0 kls aspirin low dose oral tablet delayed release 1 or 1a*; $0 kp aspirin oral tablet delayed release 1 or 1a*; $0 meijer aspirin ec oral tablet delayed release 1 or 1a*; $0 px aspirin oral tablet 1 or 1a*; $0 px aspirin oral tablet chewable 1 or 1a*; $0 px enteric aspirin oral tablet delayed release 1 or 1a*; $0 qc aspirin low dose oral tablet chewable 1 or 1a*; $0 qc aspirin low dose oral tablet delayed release 1 or 1a*; $0 qc aspirin oral tablet 1 or 1a*; $0 qc aspirin oral tablet delayed release 1 or 1a*; $0 qc childrens aspirin oral tablet chewable 1 or 1a*; $0 qc enteric aspirin oral tablet delayed release 1 or 1a*; $0 ra aspirin adult low dose oral tablet chewable 1 or 1a*; $0 ra aspirin adult low strength oral tablet chewable 1 or 1a*; $0 BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 24 Coverage Requirements and Prescription Drug Name Drug Tier Limits ra aspirin childrens oral tablet chewable 1 or 1a*; $0 ra aspirin ec adult low st oral tablet delayed release 1 or 1a*; $0 ra aspirin ec oral tablet delayed release 1 or 1a*; $0 ra aspirin oral tablet 1 or 1a*; $0 ra pain relief aspirin oral tablet 1 or 1a*; $0 sb aspirin adult low strength oral tablet delayed release 1 or 1a*; $0 sb aspirin ec oral tablet delayed release 1 or 1a*; $0 sb aspirin oral tablet 1 or 1a*; $0 sb aspirin oral tablet delayed release 1 or 1a*; $0 sb childrens aspirin oral tablet chewable 1 or 1a*; $0 sb low dose asa ec oral tablet delayed release 1 or 1a*; $0 sm aspirin adult low strength oral tablet chewable 1 or 1a*; $0 sm aspirin adult low strength oral tablet delayed release 1 or 1a*; $0 sm aspirin ec low strength oral tablet delayed release 1 or 1a*; $0 sm aspirin ec oral tablet delayed release 1 or 1a*; $0 sm aspirin low dose oral tablet chewable 1 or 1a*; $0 sm aspirin oral tablet 1 or 1a*; $0 sm childrens aspirin oral tablet chewable 1 or 1a*; $0 st joseph aspirin oral tablet delayed release 1 or 1a*; $0 st joseph low dose oral tablet chewable 1 or 1a*; $0 st joseph low dose oral tablet delayed release 1 or 1a*; $0 *ANALGESICS - OPIOID* - DRUGS FOR PAIN AND FEVER *CODEINE COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS acetaminophen-codeine #2 oral tablet 1 or 1a* QL (6 tablets per 1 day) acetaminophen-codeine #3 oral tablet 1 or 1a* QL (6 tablet per 1 day) acetaminophen-codeine #4 oral tablet 1 or 1a* QL (6 tablet per 1 day) acetaminophen-codeine oral solution 1 or 1a* QL (30 mL per 1 day) acetaminophen-codeine oral tablet 300-15 mg 1 or 1a* QL (6 tablets per 1 day) acetaminophen-codeine oral tablet 300-30 mg, 300-60 mg 1 or 1a* QL (6 tablet per 1 day) ascomp-codeine oral capsule 1 or 1b* QL (6 capsule per 1 day) butalbital-apap-caff-cod oral capsule 50-300-40-30 mg 1 or 1b* QL (6 capsules per 1 day) butalbital-apap-caff-cod oral capsule 50-325-40-30 mg 1 or 1b* QL (6 capsule per 1 day) butalbital-asa-caff-codeine oral capsule 1 or 1b* QL (6 capsule per 1 day) *DIHYDROCODEINE COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS apap-caff-dihydrocodeine oral capsule 1 or 1b* QL (6 capsules per 1 day) apap-caff-dihydrocodeine oral tablet 1 or 1b* QL (6 tablets per 1 day) trezix oral capsule 1 or 1b* QL (6 capsules per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 25 Coverage Requirements and Prescription Drug Name Drug Tier Limits * COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS FENTANYL CIT--NACL EPIDURAL SOLUTION 0.4-0.2- 3 0.9 MG/200ML-% FENTANYL--NACL EPIDURAL SOLUTION 0.8-0.1667- 3 0.9 MG/200ML-% *HYDROCODONE COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS hydrocodone-acetaminophen oral solution 1 or 1b* QL (90 mL per 1 day) hydrocodone-acetaminophen oral tablet 1 or 1b* QL (6 tablets per 1 day) hydrocodone-ibuprofen oral tablet 1 or 1b* QL (5 tablets per 1 day) *OPIOID AGONISTS*** - ARTHRITIS AND PAIN DRUGS ALFENTANIL HCL INTRAVENOUS SOLUTION 3 CODEINE SULFATE ORAL TABLET 15 MG, 60 MG 3 QL (6 tablets per 1 day) codeine sulfate oral tablet 30 mg 1 or 1b* QL (6 tablets per 1 day) CONZIP ORAL CAPSULE EXTENDED RELEASE 24 HOUR ( hcl) 3 PA; QL (1 capsule per 1 day) DEMEROL INJECTION SOLUTION (meperidine hcl) 3 QL (4 mL per 1 day) DILAUDID INJECTION SOLUTION (hydromorphone hcl) 3 QL (6 mL per 1 day) DILAUDID ORAL LIQUID (hydromorphone hcl) 3 QL (24 mL per 1 day) DILAUDID ORAL TABLET (hydromorphone hcl) 3 QL (6 tablets per 1 day) DSUVIA SUBLINGUAL TABLET SUBLINGUAL (sufentanil citrate) 3 DURAGESIC-100 TRANSDERMAL PATCH 72 HOUR (fentanyl) 3 PA; QL (15 patches per 30 days) DURAGESIC-12 TRANSDERMAL PATCH 72 HOUR (fentanyl) 3 PA; QL (15 patches per 30 days) DURAGESIC-25 TRANSDERMAL PATCH 72 HOUR (fentanyl) 3 PA; QL (15 patches per 30 days) DURAGESIC-50 TRANSDERMAL PATCH 72 HOUR (fentanyl) 3 PA; QL (15 patches per 30 days) DURAGESIC-75 TRANSDERMAL PATCH 72 HOUR (fentanyl) 3 PA; QL (15 patches per 30 days) duramorph injection solution 1 or 1b* QL (6 mL per 1 day) FENTANYL CITRATE (PF) INJECTION SOLUTION 100 MCG/2ML, 250 3 MCG/5ML, 50 MCG/ML fentanyl citrate (pf) injection solution 1000 mcg/20ml, 2500 mcg/50ml, 500 1 or 1b* mcg/10ml fentanyl citrate (pf) injection solution cartridge 1 or 1b* fentanyl citrate buccal lozenge on a handle 1 or 1b* PA; QL (4 lozenge per 1 day) fentanyl citrate buccal tablet 1 or 1b* PA; QL (4 tablet per 1 day) FENTANYL CITRATE INTRAVENOUS SOLUTION 1500 MCG/30ML, 3 2500 MCG/50ML FENTANYL CITRATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 100 MCG/10ML, 1000 MCG/20ML, 20 MCG/2ML, 50 3 MCG/5ML, 500 MCG/50ML FENTANYL CITRATE PF INJECTION SOLUTION PREFILLED SYRINGE 3

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 26 Coverage Requirements and Prescription Drug Name Drug Tier Limits FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 100-0.9 MCG/10ML-%, 500-0.9 MCG/50ML-% fentanyl transdermal patch 72 hour 1 or 1b* PA; QL (15 patches per 30 days) FENTORA BUCCAL TABLET (fentanyl citrate) 3 PA; QL (4 tablet per 1 day) hydrocodone bitartrate er oral tablet er 24 hour abuse-deterrent 1 or 1b* PA; QL (1 tablet per 1 day) hydromorphone hcl er oral tablet extended release 24 hour 1 or 1b* PA; QL (1 tablet per 1 day) hydromorphone hcl injection solution 4 mg/ml 1 or 1b* QL (2 mL per 1 day) hydromorphone hcl oral liquid 1 or 1b* QL (24 mL per 1 day) hydromorphone hcl oral tablet 1 or 1b* QL (6 tablets per 1 day) HYDROMORPHONE HCL PF INJECTION SOLUTION 1 MG/ML, 2 3 QL (6 mL per 1 day) MG/ML HYDROMORPHONE HCL PF INJECTION SOLUTION 10 MG/ML 3 QL (1 injection per 30 days) HYDROMORPHONE HCL PF INJECTION SOLUTION 4 MG/ML 3 QL (2 mL per 1 day) hydromorphone hcl pf injection solution 50 mg/5ml, 500 mg/50ml 1 or 1b* QL (1 injection per 30 days) HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE 15-0.9 MG/30ML-%, 5-0.9 MG/25ML-% INFUMORPH 200 INJECTION SOLUTION (morphine sulfate 3 QL (2 vials per 30 days) microinfusion) INFUMORPH 500 INJECTION SOLUTION (morphine sulfate 3 QL (2 vials per 30 days) microinfusion) levorphanol tartrate oral tablet 1 or 1b* PA; QL (6 tablets per 1 day) meperidine hcl injection solution 1 or 1b* QL (4 mL per 1 day) meperidine hcl oral solution 1 or 1b* QL (7 days per 1 fill) meperidine hcl oral tablet 1 or 1b* QL (6 tablets per 1 day) METHADONE HCL INJECTION SOLUTION 3 PA; QL (1 mL per 1 day) methadone hcl intensol oral concentrate 1 or 1b* PA; QL (6 mL per 1 day) methadone hcl oral concentrate 1 or 1b* PA; QL (6 mL per 1 day) methadone hcl oral solution 10 mg/5ml 1 or 1b* PA; QL (30 mL per 1 day) methadone hcl oral solution 5 mg/5ml 1 or 1b* PA; QL (60 mL per 1 day) methadone hcl oral tablet 10 mg 1 or 1b* PA; QL (6 tablet per 1 day) methadone hcl oral tablet 5 mg 1 or 1b* PA; QL (6 tablets per 1 day) methadone hcl oral tablet soluble 1 or 1b* PA; QL (1 tablet per 1 day) METHADOSE ORAL CONCENTRATE 10 MG/ML (methadone hcl) 3 PA; QL (6 mL per 1 day) methadose oral tablet soluble 1 or 1b* PA; QL (1 tablet per 1 day) METHADOSE SUGAR-FREE ORAL CONCENTRATE (methadone hcl) 3 PA; QL (6 mL per 1 day) mitigo injection solution 1 or 1b* QL (2 vials per 30 days) morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml 1 or 1b* QL (6 mL per 1 day) morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml 1 or 1b* QL (6 mL per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 27 Coverage Requirements and Prescription Drug Name Drug Tier Limits MORPHINE SULFATE (PF) INJECTION SOLUTION 10 MG/ML, 2 3 QL (6 mL per 1 day) MG/ML, 4 MG/ML, 5 MG/ML, 8 MG/ML MORPHINE SULFATE (PF) INTRAVENOUS SOLUTION 3 QL (6 mL per 1 day) morphine sulfate er beads oral capsule extended release 24 hour 1 or 1b* PA; QL (1 capsule per 1 day) morphine sulfate er oral capsule extended release 24 hour 1 or 1b* PA; QL (2 capsules per 1 day) morphine sulfate er oral tablet extended release 100 mg, 200 mg 1 or 1b* PA; QL (2 tablets per 1 day) morphine sulfate er oral tablet extended release 15 mg, 30 mg, 60 mg 1 or 1b* PA; QL (3 tablet per 1 day) MORPHINE SULFATE INJECTION SOLUTION 2 MG/ML, 4 MG/ML 3 QL (6 mL per 1 day) morphine sulfate oral solution 1 or 1b* QL (30 mL per 1 day) morphine sulfate oral tablet 1 or 1b* QL (6 tablets per 1 day) MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 1-0.9 MG/ML-% NUCYNTA ORAL TABLET 100 MG (tapentadol hcl) 3 QL (181 tablets per 30 days) NUCYNTA ORAL TABLET 50 MG (tapentadol hcl) 3 QL (6 tablets per 1 day) NUCYNTA ORAL TABLET 75 MG (tapentadol hcl) 3 QL (8 tablet per 1 day) OLINVYK INTRAVENOUS SOLUTION (oliceridine fumarate) 3 OXAYDO ORAL TABLET (oxycodone hcl) 3 QL (6 tablets per 1 day) oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg, 15 mg, 20 mg, 3 PA; QL (2 tablets per 1 day) 30 mg, 40 mg, 60 mg oxycodone hcl er oral tablet er 12 hour abuse-deterrent 80 mg 3 PA; QL (2 tablet per 1 day) oxycodone hcl oral capsule 1 or 1b* QL (7 days per 1 fill) oxycodone hcl oral concentrate 100 mg/5ml 1 or 1b* QL (6 mL per 1 day) oxycodone hcl oral solution 1 or 1b* QL (30 mL per 1 day) oxycodone hcl oral tablet 1 or 1b* QL (6 tablets per 1 day) OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG, 3 PA; QL (2 tablets per 1 day) 15 MG, 20 MG, 30 MG, 40 MG (oxycodone hcl) OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 60 MG, 3 PA; QL (2 tablet per 1 day) 80 MG (oxycodone hcl) oxymorphone hcl er oral tablet extended release 12 hour 1 or 1b* PA; QL (2 tablets per 1 day) oxymorphone hcl oral tablet 10 mg 1 or 1b* QL (6 tablet per 1 day) oxymorphone hcl oral tablet 5 mg 1 or 1b* QL (6 tablets per 1 day) QDOLO ORAL SOLUTION (tramadol hcl) 3 QL (80 mL per 1 day) remifentanil hcl intravenous solution reconstituted 1 or 1b* ROXICODONE ORAL TABLET (oxycodone hcl) 3 QL (6 tablets per 1 day) SUFENTANIL CITRATE INTRAVENOUS SOLUTION 3 tramadol hcl er (biphasic) oral tablet extended release 24 hour 1 or 1b* PA; QL (1 tablet per 1 day) tramadol hcl er oral capsule extended release 24 hour 1 or 1b* PA; QL (1 capsule per 1 day) tramadol hcl er oral tablet extended release 24 hour 1 or 1b* PA; QL (1 tablet per 1 day) tramadol hcl oral tablet 100 mg 1 or 1b* QL (4 tablets per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 28 Coverage Requirements and Prescription Drug Name Drug Tier Limits tramadol hcl oral tablet 50 mg 1 or 1b* QL (8 tablet per 1 day) ULTIVA INTRAVENOUS SOLUTION RECONSTITUTED (remifentanil 3 hcl) *OPIOID COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS APADAZ ORAL TABLET (benzhydrocodone-acetaminophen) 3 QL (6 tablets per 1 day) BENZHYDROCODONE-ACETAMINOPHEN ORAL TABLET 3 QL (6 tablets per 1 day) endocet oral tablet 10-325 mg, 2.5-325 mg, 7.5-325 mg 1 or 1b* QL (6 tablets per 1 day) endocet oral tablet 5-325 mg 1 or 1b* QL (6 tablet per 1 day) oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 7.5-325 mg 1 or 1b* QL (6 tablets per 1 day) oxycodone-acetaminophen oral tablet 5-325 mg 1 or 1b* QL (6 tablet per 1 day) *OPIOID PARTIAL AGONISTS*** - ARTHRITIS AND PAIN DRUGS BELBUCA BUCCAL FILM ( hcl) 3 PA; QL (2 film per 1 day) BUNAVAIL BUCCAL FILM 4.2-0.7 MG (buprenorphine hcl-naloxone hcl) 3 QL (3 films per 1 day) BUNAVAIL BUCCAL FILM 6.3-1 MG (buprenorphine hcl-naloxone hcl) 3 QL (2 films per 1 day) BUPRENEX INJECTION SOLUTION (buprenorphine hcl) 3 QL (3 mL per 1 day) buprenorphine hcl injection solution 1 or 1b* QL (3 mL per 1 day) buprenorphine hcl sublingual tablet sublingual 2 mg 1 or 1b* QL (12 tablets per 90 days) buprenorphine hcl sublingual tablet sublingual 8 mg 1 or 1b* QL (3 tablets per 90 days) buprenorphine hcl-naloxone hcl sublingual film 12-3 mg 1 or 1b* QL (2 films per 1 day) buprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg 1 or 1b* QL (12 films per 1 day) buprenorphine hcl-naloxone hcl sublingual film 4-1 mg 1 or 1b* QL (6 films per 1 day) buprenorphine hcl-naloxone hcl sublingual film 8-2 mg 1 or 1b* QL (3 films per 1 day) buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg 1 or 1b* QL (12 tablets per 1 day) buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg 1 or 1b* QL (3 tablets per 1 day) buprenorphine transdermal patch weekly 1 or 1b* PA; QL (1 package per 28 days) butorphanol tartrate injection solution 1 mg/ml 1 or 1b* QL (8 mL per 1 day) butorphanol tartrate injection solution 2 mg/ml 1 or 1b* QL (4 mL per 1 day) butorphanol tartrate nasal solution 1 or 1b* QL (2 bottles per 30 days) BUTRANS TRANSDERMAL PATCH WEEKLY (buprenorphine) 3 PA; QL (1 package per 28 days) nalbuphine hcl injection solution 1 or 1b* QL (2 mL per 1 day) pentazocine-naloxone hcl oral tablet 1 or 1b* QL (6 tablets per 1 day) PROBUPHINE IMPLANT KIT SUBCUTANEOUS IMPLANT 3 PA; LD (buprenorphine hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7-0.18 MG 3 QL (23 tablets per 1 day) (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG 3 QL (12 tablets per 1 day) (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 11.4-2.9 MG 3 QL (1 tablet per 1 day) (buprenorphine hcl-naloxone hcl)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 29 Coverage Requirements and Prescription Drug Name Drug Tier Limits ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 2.9-0.71 MG 3 QL (5 tablets per 1 day) (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 5.7-1.4 MG 3 QL (3 tablets per 1 day) (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 8.6-2.1 MG 3 QL (2 tablets per 1 day) (buprenorphine hcl-naloxone hcl) *TRAMADOL COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS tramadol-acetaminophen oral tablet 1 or 1b* QL (8 tablet per 1 day) *ANDROGENS-ANABOLIC* - HORMONES *ANABOLIC *** - DRUGS FOR MEN oral tablet 1 or 1b* PA *ANDROGENS*** - DRUGS FOR MEN ANDRODERM TRANSDERMAL PATCH 24 HOUR () 3 PA; QL (1 patch per 1 day) oral capsule 1 or 1b* DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION (testosterone 3 PA cypionate) JATENZO ORAL CAPSULE 158 MG, 198 MG () 3 PA; QL (4 capsules per 1 day) JATENZO ORAL CAPSULE 237 MG (testosterone undecanoate) 3 PA; QL (2 capsules per 1 day) TESTOPEL IMPLANT PELLET (testosterone) 3 PA; LD intramuscular solution 1 or 1b* PA intramuscular solution 1 or 1b* PA testosterone transdermal gel 1.62 %, 12.5 mg/act (1%), 20.25 mg/act (1.62%) 1 or 1b* PA; QL (1 bottle per 30 days) testosterone transdermal gel 10 mg/act (2%) 1 or 1b* PA; QL (1 pump per 30 days) testosterone transdermal gel 20.25 mg/1.25gm (1.62%), 40.5 mg/2.5gm 1 or 1b* PA; QL (1 packet per 1 day) (1.62%), 50 mg/5gm (1%) testosterone transdermal gel 25 mg/2.5gm (1%) 1 or 1b* PA; QL (2 packet per 1 day) testosterone transdermal solution 1 or 1b* PA; QL (1 pump bottle per 30 days) *ANORECTAL AND RELATED PRODUCTS* - RECTAL PREPARATIONS *INTRARECTAL STEROIDS*** - RECTAL PREPARATIONS CORTENEMA RECTAL ENEMA (hydrocortisone) 3 CORTIFOAM EXTERNAL FOAM (hydrocortisone acetate) 3 QL (2.15 gram per 1 day) hydrocortisone rectal enema 1 or 1b* UCERIS RECTAL FOAM (budesonide) 3 QL (4.78 gm per 1 day) *NITRATE VASODILATING AGENTS*** - RECTAL PREPARATIONS RECTIV RECTAL OINTMENT (nitroglycerin) 3 QL (1 unit per 1 day) *RECTAL /STEROIDS*** - RECTAL PREPARATIONS ANALPRAM-HC EXTERNAL CREAM (hydrocortisone ace-pramoxine) 3 ANALPRAM-HC EXTERNAL LOTION (hydrocortisone ace-pramoxine) 3 BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 30 Coverage Requirements and Prescription Drug Name Drug Tier Limits hydrocortisone ace-pramoxine external cream 1-1 % 1 or 1b* PROCTOFOAM HC EXTERNAL FOAM (hydrocortisone ace-pramoxine) 3 *RECTAL LOCAL ANESTHETICS*** - RECTAL PREPARATIONS (ANORECTAL) RECTAL SUPPOSITORY 3 *RECTAL STEROIDS*** - RECTAL PREPARATIONS ANUSOL-HC EXTERNAL CREAM (hydrocortisone) 3 hydrocortisone (perianal) external cream 1 or 1b* PROCTOCORT EXTERNAL CREAM (hydrocortisone) 3 procto-med hc external cream 1 or 1b* procto-pak external cream 1 or 1b* proctozone-hc external cream 1 or 1b* *ANTACIDS* - DRUGS FOR THE STOMACH *ANTACIDS - BICARBONATE*** - DRUGS FOR ULCERS AND STOMACH ACID SODIUM BICARBONATE ORAL POWDER 3 *ANTHELMINTICS* - DRUGS FOR INFECTIONS *ANTHELMINTICS*** - DRUGS FOR PARASITES albendazole oral tablet 1 or 1b* PA; QL (4 tablets per 1 day) ALBENZA ORAL TABLET (albendazole) 3 PA; QL (4 tablets per 1 day) BENZNIDAZOLE ORAL TABLET 3 BILTRICIDE ORAL TABLET (praziquantel) 3 EMVERM ORAL TABLET CHEWABLE (mebendazole) 3 ivermectin oral tablet 1 or 1b* praziquantel oral tablet 1 or 1b* STROMECTOL ORAL TABLET (ivermectin) 3 *ANTIANGINAL AGENTS* - DRUGS FOR THE HEART *ANTIANGINALS-OTHER*** - DRUGS FOR ANGINA RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR () 3 ranolazine er oral tablet extended release 12 hour 1 or 1b* *NITRATES*** - DRUGS FOR ANGINA DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE (isosorbide 2 dinitrate) GONITRO SUBLINGUAL PACKET (nitroglycerin) 3 ISORDIL TITRADOSE ORAL TABLET (isosorbide dinitrate) 3 isosorbide dinitrate oral tablet 1 or 1b* isosorbide mononitrate er oral tablet extended release 24 hour 1 or 1b* isosorbide mononitrate oral tablet 1 or 1b* minitran transdermal patch 24 hour 1 or 1b*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 31 Coverage Requirements and Prescription Drug Name Drug Tier Limits NITRO-BID TRANSDERMAL OINTMENT (nitroglycerin) 3 NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 3 0.4 MG/HR, 0.6 MG/HR (nitroglycerin) NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR 2 (nitroglycerin) nitroglycerin in d5w intravenous solution 1 or 1b* NITROGLYCERIN INTRAVENOUS SOLUTION 3 nitroglycerin sublingual tablet sublingual 1 or 1b* nitroglycerin transdermal patch 24 hour 1 or 1b* nitroglycerin translingual solution 1 or 1b* NITROLINGUAL TRANSLINGUAL SOLUTION (nitroglycerin) 3 NITROMIST TRANSLINGUAL AEROSOL SOLUTION (nitroglycerin) 3 NITROSTAT SUBLINGUAL TABLET SUBLINGUAL (nitroglycerin) 3 *ANTIANXIETY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM *ANTIANXIETY AGENTS - MISC.*** - DRUGS FOR ANXIETY hcl oral tablet 1 or 1b* injection solution 1 or 1b* hcl intramuscular solution 1 or 1b* hydroxyzine hcl oral syrup 1 or 1b* hydroxyzine hcl oral tablet 1 or 1b* hydroxyzine pamoate oral capsule 1 or 1a* meprobamate oral tablet 1 or 1b* VISTARIL ORAL CAPSULE (hydroxyzine pamoate) 3 *BENZODIAZEPINES*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN alprazolam er oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) ALPRAZOLAM INTENSOL ORAL CONCENTRATE (alprazolam) 3 QL (4 mL per 1 day) alprazolam oral tablet 1 or 1b* QL (3 tablets per 1 day) alprazolam oral tablet dispersible 1 or 1b* QL (3 tablets per 1 day) alprazolam xr oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) chlordiazepoxide hcl oral capsule 1 or 1b* QL (4 capsules per 1 day) clorazepate dipotassium oral tablet 1 or 1b* QL (4 tablets per 1 day) diazepam injection solution 1 or 1a* diazepam intensol oral concentrate 1 or 1a* QL (8 mL per 1 day) DIAZEPAM INTRAMUSCULAR SOLUTION AUTO-INJECTOR 3 diazepam oral concentrate 1 or 1a* QL (8 mL per 1 day) diazepam oral solution 1 or 1a* diazepam oral tablet 1 or 1a* QL (4 tablets per 1 day) injection solution 1 or 1b* BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 32 Coverage Requirements and Prescription Drug Name Drug Tier Limits lorazepam intensol oral concentrate 1 or 1b* QL (3 mL per 1 day) lorazepam oral concentrate 2 mg/ml 1 or 1b* QL (3 mL per 1 day) lorazepam oral tablet 1 or 1b* QL (3 tablets per 1 day) oxazepam oral capsule 1 or 1b* QL (4 capsules per 1 day) *ANTIARRHYTHMICS* - DRUGS FOR THE HEART *ANTIARRHYTHMICS - MISC.*** - DRUGS FOR ABNORMAL HEART RHYTHMS adenosine intravenous solution 12 mg/4ml, 6 mg/2ml 1 or 1b* *ANTIARRHYTHMICS TYPE I-A*** - DRUGS FOR ABNORMAL HEART RHYTHMS disopyramide phosphate oral capsule 1 or 1b* NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 2 (disopyramide phosphate) NORPACE ORAL CAPSULE (disopyramide phosphate) 3 procainamide hcl injection solution 1 or 1b* gluconate er oral tablet extended release 1 or 1b* quinidine sulfate oral tablet 1 or 1a* *ANTIARRHYTHMICS TYPE I-B*** - DRUGS FOR ABNORMAL HEART RHYTHMS LIDOCAINE HCL (CARDIAC) INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 100 MG/10ML LIDOCAINE HCL (CARDIAC) INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 100 MG/5ML lidocaine hcl (cardiac) intravenous solution prefilled syringe 50 mg/5ml 1 or 1b* LIDOCAINE HCL (CARDIAC) PF INTRAVENOUS SOLUTION 3 lidocaine hcl (cardiac) pf intravenous solution prefilled syringe 1 or 1b* lidocaine in d5w intravenous solution 4-5 mg/ml-%, 8-5 mg/ml-% 1 or 1b* hcl oral capsule 1 or 1b* *ANTIARRHYTHMICS TYPE I-C*** - DRUGS FOR ABNORMAL HEART RHYTHMS acetate oral tablet 100 mg 1 or 1b* QL (4 tablets per 1 day) flecainide acetate oral tablet 150 mg 1 or 1b* QL (2 tablets per 1 day) flecainide acetate oral tablet 50 mg 1 or 1b* QL (3 tablets per 1 day) propafenone hcl er oral capsule extended release 12 hour 1 or 1b* propafenone hcl oral tablet 1 or 1b* RYTHMOL SR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 3 (propafenone hcl) *ANTIARRHYTHMICS TYPE III*** - DRUGS FOR ABNORMAL HEART RHYTHMS HCL IN DEXTROSE INTRAVENOUS SOLUTION 3

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 33 Coverage Requirements and Prescription Drug Name Drug Tier Limits amiodarone hcl intravenous solution 1 or 1b* amiodarone hcl oral tablet 100 mg, 400 mg 1 or 1b* amiodarone hcl oral tablet 200 mg 1 or 1b* QL (3 tablets per 1 day) TOSYLATE INJECTION SOLUTION 3 CORVERT INTRAVENOUS SOLUTION ( fumarate) 3 oral capsule 1 or 1b* ibutilide fumarate intravenous solution 1 or 1b* MULTAQ ORAL TABLET (dronedarone hcl) 3 QL (2 tablets per 1 day) NEXTERONE INTRAVENOUS SOLUTION (amiodarone hcl in dextrose) 3 pacerone oral tablet 100 mg, 400 mg 1 or 1b* pacerone oral tablet 200 mg 1 or 1b* QL (3 tablets per 1 day) *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* - DRUGS FOR THE LUNGS *ADRENERGIC COMBINATIONS*** - DRUGS FOR ASTHMA/COPD ADVAIR HFA INHALATION AEROSOL (fluticasone-salmeterol) 2 QL (1 inhaler per 30 days) ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH 2 QL (1 inhaler per 30 days) ACTIVATED (umeclidinium-vilanterol) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH 2 QL (1 inhaler per 30 days) ACTIVATED (fluticasone furoate-vilanterol) BREZTRI AEROSPHERE INHALATION AEROSOL (budeson-glycopyrrol- 3 QL (1 inhaler per 30 days) formoterol) budesonide-formoterol fumarate inhalation aerosol 1 or 1b* QL (3 inhalers per 30 days) COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 2 QL (2 inhalers per 30 days) (ipratropium-albuterol) fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 1 or 1b* QL (1 package per 30 days) mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose fluticasone-salmeterol inhalation aerosol powder breath activated 113-14 1 or 1b* QL (1 inhaler per 30 days) mcg/act, 232-14 mcg/act, 55-14 mcg/act ipratropium-albuterol inhalation solution 1 or 1b* STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION (tiotropium 2 QL (1 inhaler per 30 days) bromide-olodaterol) SYMBICORT INHALATION AEROSOL (budesonide-formoterol fumarate) 2 QL (3 inhalers per 30 days) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH 2 QL (1 inhaler per 30 days) ACTIVATED (fluticasone-umeclidin-vilant) wixela inhub inhalation aerosol powder breath activated 1 or 1b* QL (1 package per 30 days) *ANTI-INFLAMMATORY AGENTS*** - DRUGS FOR ASTHMA/COPD cromolyn sodium inhalation nebulization solution 1 or 1b* *BETA ADRENERGICS*** - DRUGS FOR ASTHMA/COPD albuterol sulfate hfa inhalation aerosol solution 1 or 1b* QL (2 inhalers per 30 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 34 Coverage Requirements and Prescription Drug Name Drug Tier Limits albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 1 or 1b* QL (360 mL per 30 days) mg/3ml, 1.25 mg/3ml albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5%, 2.5 1 or 1b* QL (60 mL per 30 days) mg/0.5ml albuterol sulfate oral syrup 1 or 1b* albuterol sulfate oral tablet 1 or 1b* arformoterol tartrate inhalation nebulization solution 1 or 1b* QL (60 vial per 30 days) BROVANA INHALATION NEBULIZATION SOLUTION (arformoterol 3 QL (60 vial per 30 days) tartrate) formoterol fumarate inhalation nebulization solution 1 or 1b* QL (120 ML per 30 days) isoproterenol hcl injection solution 1 or 1b* ISOPROTERENOL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 ISUPREL INJECTION SOLUTION (isoproterenol hcl) 3 levalbuterol hcl inhalation nebulization solution 1 or 1b* QL (90 mL per 30 days) levalbuterol tartrate inhalation aerosol 1 or 1b* QL (2 inhalers per 30 days) PERFOROMIST INHALATION NEBULIZATION SOLUTION (formoterol 3 QL (120 ML per 30 days) fumarate) PROAIR DIGIHALER INHALATION AEROSOL POWDER BREATH 3 ST; QL (2 inhalers per 30 days) ACTIVATED (albuterol sulfate) PROAIR HFA INHALATION AEROSOL SOLUTION (albuterol sulfate) 2 ST; QL (2 inhalers per 30 days) PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH 2 QL (2 inhalers per 30 days) ACTIVATED (albuterol sulfate) PROVENTIL HFA INHALATION AEROSOL SOLUTION (albuterol 3 ST; QL (2 inhalers per 30 days) sulfate) SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH 2 QL (1 inhaler per 30 days) ACTIVATED (salmeterol xinafoate) STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION (olodaterol 3 QL (1 inhaler per 30 days) hcl) terbutaline sulfate injection solution 1 or 1b* terbutaline sulfate oral tablet 1 or 1b* VENTOLIN HFA INHALATION AEROSOL SOLUTION (albuterol sulfate) 2 ST; QL (2 inhalers per 30 days) XOPENEX HFA INHALATION AEROSOL (levalbuterol tartrate) 3 QL (2 inhalers per 30 days) *BRONCHODILATORS - ANTICHOLINERGICS*** - DRUGS FOR ASTHMA/COPD ATROVENT HFA INHALATION AEROSOL SOLUTION (ipratropium 2 QL (2 inhalers per 30 days) bromide hfa) ipratropium bromide inhalation solution 1 or 1b* QL (378 ML per 30 days) LONHALA MAGNAIR REFILL KIT INHALATION SOLUTION 3 ST; QL (2 vials per 1 day) (glycopyrrolate) LONHALA MAGNAIR STARTER KIT INHALATION SOLUTION 3 ST; QL (1 kit per 365 days) (glycopyrrolate)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 35 Coverage Requirements and Prescription Drug Name Drug Tier Limits SPIRIVA HANDIHALER INHALATION CAPSULE (tiotropium bromide 2 QL (30 capsules per 30 days) monohydrate) SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION (tiotropium 2 QL (1 inhaler per 30 days) bromide monohydrate) YUPELRI INHALATION SOLUTION (revefenacin) 3 ST; QL (1 vial per 1 day) *LEUKOTRIENE RECEPTOR ANTAGONISTS*** - DRUGS FOR ASTHMA/COPD ACCOLATE ORAL TABLET () 3 QL (2 tablets per 1 day) montelukast sodium oral packet 1 or 1b* QL (1 packet per 1 day) montelukast sodium oral tablet 1 or 1b* QL (1 tablet per 1 day) montelukast sodium oral tablet chewable 1 or 1b* QL (1 tablet per 1 day) zafirlukast oral tablet 1 or 1b* QL (2 tablets per 1 day) *SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS*** - DRUGS FOR ASTHMA/COPD DALIRESP ORAL TABLET (roflumilast) 3 PA; QL (1 tablet per 1 day) * INHALANTS*** - DRUGS FOR ASTHMA/COPD ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH 2 QL (1 inhaler per 30 days) ACTIVATED (fluticasone furoate) budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml 1 or 1b* QL (120 ML per 30 days) budesonide inhalation suspension 1 mg/2ml 1 or 1b* QL (60 ML per 30 days) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST (fluticasone propionate 2 QL (1 inhaler per 30 days) (inhal)) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH 2 QL (4 inhalers per 30 days) ACTIVATED 250 MCG/BLIST (fluticasone propionate (inhal)) FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 44 MCG/ACT 2 QL (1 inhaler per 30 days) (fluticasone propionate hfa) FLOVENT HFA INHALATION AEROSOL 220 MCG/ACT (fluticasone 2 QL (2 inhalers per 30 days) propionate hfa) QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 2 QL (1 inhaler per 30 days) MCG/ACT (beclomethasone diprop hfa) QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 80 2 QL (2 inhalers per 30 days) MCG/ACT (beclomethasone diprop hfa) *XANTHINES*** - DRUGS FOR ASTHMA/COPD aminophylline intravenous solution 1 or 1b* ELIXOPHYLLIN ORAL ELIXIR (theophylline) 2 QL (112.5 mL per 1 day) THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG 2 QL (4 tablets per 1 day) (theophylline) THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG 2 QL (3 capsules per 1 day) (theophylline) THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 300 MG, 400 2 QL (2 capsules per 1 day) MG (theophylline)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 36 Coverage Requirements and Prescription Drug Name Drug Tier Limits theophylline er oral tablet extended release 12 hour 300 mg 1 or 1b* QL (2 tablets per 1 day) theophylline er oral tablet extended release 12 hour 450 mg 1 or 1b* QL (1 tablet per 1 day) theophylline er oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) THEOPHYLLINE IN D5W INTRAVENOUS SOLUTION 3 theophylline oral solution 1 or 1b* QL (112.5 mL per 1 day) *ANTICOAGULANTS* - DRUGS FOR THE BLOOD *ANTICOAGULANTS - MISC.*** - DRUGS TO PREVENT BLOOD CLOTS SODIUM CITRATE LOCK FLUSH INTRAVENOUS SOLUTION 3 SODIUM CITRATE LOCK FLUSH INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE *COUMARIN ANTICOAGULANTS*** - DRUGS TO PREVENT BLOOD CLOTS jantoven oral tablet 1 or 1a* warfarin sodium oral tablet 1 or 1a* *DIRECT FACTOR XA INHIBITORS*** - DRUGS TO PREVENT BLOOD CLOTS ELIQUIS DVT/PE STARTER PACK ORAL TABLET THERAPY PACK 2 QL (74 tablets per 30 days) (apixaban) ELIQUIS ORAL TABLET 2.5 MG (apixaban) 2 QL (2 tablets per 1 day) ELIQUIS ORAL TABLET 5 MG (apixaban) 2 QL (74 tablets per 30 days) XARELTO ORAL TABLET 10 MG, 20 MG (rivaroxaban) 2 QL (1 tablet per 1 day) XARELTO ORAL TABLET 15 MG (rivaroxaban) 2 QL (42 tablet per 1 fill) XARELTO ORAL TABLET 2.5 MG (rivaroxaban) 2 QL (2 tablets per 1 day) XARELTO STARTER PACK ORAL TABLET THERAPY PACK 2 QL (1 pack per 365 days) (rivaroxaban) *HEPARINS AND HEPARINOID-LIKE AGENTS*** - DRUGS TO PREVENT BLOOD CLOTS heparin (porcine) in nacl intravenous solution 1000-0.9 ut/500ml-%, 2000- 1 or 1b* 0.9 unit/l-% HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 12500-0.45 3 UT/250ML-%, 25000-0.45 UT/250ML-%, 25000-0.45 UT/500ML-% HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 2500-0.9 UT/500ML-%, 30000-0.9 UNIT/L-%, 500-0.9 UT/500ML-%, 5000-0.9 3 UNIT/L-%, 5000-0.9 UT/500ML-% heparin lock flush intravenous solution 1 or 1b* HEPARIN SOD (PORCINE) IN D5W INTRAVENOUS SOLUTION 100 3 UNIT/ML, 25000-5 UT/500ML-% heparin sod (porcine) in d5w intravenous solution 40-5 unit/ml-% 1 or 1b* heparin sodium (porcine) injection solution 1 or 1b*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 37 Coverage Requirements and Prescription Drug Name Drug Tier Limits HEPARIN SODIUM (PORCINE) INJECTION SOLUTION PREFILLED 3 SYRINGE heparin sodium (porcine) pf injection solution 5000 unit/0.5ml 1 or 1b* HEPARIN SODIUM (PORCINE) PF INJECTION SOLUTION 5000 3 UNIT/ML heparin sodium lock flush intravenous solution 1 or 1b* *LOW MOLECULAR WEIGHT HEPARINS*** - DRUGS TO PREVENT BLOOD CLOTS enoxaparin sodium injection solution 4 QL (30 syringes per 30 days) enoxaparin sodium subcutaneous solution 4 QL (30 syringes per 30 days) FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 4 QL (30 syringes per 30 days) 5000 UNIT/0.2ML, 7500 UNIT/0.3ML (dalteparin sodium) FRAGMIN SUBCUTANEOUS SOLUTION 95000 UNIT/3.8ML (dalteparin 4 QL (6 vials per 30 days) sodium) *SYNTHETIC HEPARINOID-LIKE AGENTS*** - DRUGS TO PREVENT BLOOD CLOTS fondaparinux sodium subcutaneous solution 4 QL (30 syringes per 30 days) *THROMBIN INHIBITORS - HIRUDIN TYPE*** - DRUGS TO PREVENT BLOOD CLOTS ANGIOMAX INTRAVENOUS SOLUTION RECONSTITUTED (bivalirudin 3 trifluoroacetate) BIVALIRUDIN RTU INTRAVENOUS SOLUTION 3 BIVALIRUDIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 *THROMBIN INHIBITORS - SELECTIVE DIRECT & REVERSIBLE*** - DRUGS TO PREVENT BLOOD CLOTS ARGATROBAN IN SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 ARGATROBAN INTRAVENOUS SOLUTION 3 *ANTICONVULSANTS* - DRUGS FOR THE NERVOUS SYSTEM *AMPA GLUTAMATE RECEPTOR ANTAGONISTS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN FYCOMPA ORAL SUSPENSION (perampanel) 3 QL (24 mL per 1 day) FYCOMPA ORAL TABLET (perampanel) 3 QL (1 tablet per 1 day) *ANTICONVULSANTS - BENZODIAZEPINES*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN clobazam oral suspension 1 or 1b* QL (16 mL per 1 day) clobazam oral tablet 1 or 1b* QL (2 tablets per 1 day) clonazepam oral tablet 1 or 1b* QL (3 tablets per 1 day) clonazepam oral tablet dispersible 1 or 1b* QL (3 tablets per 1 day) DIASTAT ACUDIAL RECTAL GEL (diazepam) 3 QL (2 syringes per 1 fill) DIASTAT PEDIATRIC RECTAL GEL (diazepam) 3 QL (2 syringes per 1 fill)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 38 Coverage Requirements and Prescription Drug Name Drug Tier Limits diazepam rectal gel 1 or 1b* QL (2 syringes per 1 fill) NAYZILAM NASAL SOLUTION (midazolam (anticonvulsant)) 3 PA; QL (50 mg per 30 days) SYMPAZAN ORAL FILM 10 MG, 20 MG (clobazam) 3 QL (2 film strips per 1 day) SYMPAZAN ORAL FILM 5 MG (clobazam) 3 QL (1 film strip per 1 day) PA; QL (10 blister packs per 30 VALTOCO 10 MG DOSE NASAL LIQUID (diazepam) 3 days) PA; QL (10 blister packs per 30 VALTOCO 15 MG DOSE NASAL LIQUID THERAPY PACK (diazepam) 3 days) PA; QL (10 blister packs per 30 VALTOCO 20 MG DOSE NASAL LIQUID THERAPY PACK (diazepam) 3 days) PA; QL (10 blister packs per 30 VALTOCO 5 MG DOSE NASAL LIQUID (diazepam) 3 days) *ANTICONVULSANTS - MISC.*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN APTIOM ORAL TABLET 200 MG, 400 MG () 3 DO APTIOM ORAL TABLET 600 MG, 800 MG (eslicarbazepine acetate) 3 QL (2 tablets per 1 day) BANZEL ORAL SUSPENSION () 3 QL (80 mL per 1 day) BANZEL ORAL TABLET 200 MG (rufinamide) 3 QL (6 tablets per 1 day) BANZEL ORAL TABLET 400 MG (rufinamide) 3 QL (8 tablets per 1 day) BRIVIACT INTRAVENOUS SOLUTION (brivaracetam) 3 BRIVIACT ORAL SOLUTION (brivaracetam) 3 QL (20 mg per 1 day) BRIVIACT ORAL TABLET 10 MG (brivaracetam) 3 BRIVIACT ORAL TABLET 100 MG, 25 MG, 50 MG, 75 MG (brivaracetam) 3 QL (2 tablets per 1 day) er oral capsule extended release 12 hour 100 mg, 200 mg 1 or 1b* QL (2 capsules per 1 day) carbamazepine er oral capsule extended release 12 hour 300 mg 1 or 1b* QL (5 capsules per 1 day) carbamazepine er oral tablet extended release 12 hour 100 mg, 200 mg 1 or 1b* QL (2 tablets per 1 day) carbamazepine er oral tablet extended release 12 hour 400 mg 1 or 1b* QL (4 tablets per 1 day) carbamazepine oral suspension 1 or 1b* QL (50 mL per 1 day) carbamazepine oral tablet 1 or 1b* QL (8 tablets per 1 day) carbamazepine oral tablet chewable 1 or 1b* QL (10 tablets per 1 day) ELEPSIA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 QL (2 tablets per 1 day) (levetiracetam) epitol oral tablet 1 or 1b* QL (8 tablets per 1 day) oral capsule 100 mg, 400 mg 1 or 1b* QL (6 capsules per 1 day) gabapentin oral capsule 300 mg 1 or 1b* QL (9 capsules per 1 day) gabapentin oral solution 1 or 1b* QL (72 mL per 1 day) gabapentin oral tablet 600 mg 1 or 1b* QL (6 tablets per 1 day) gabapentin oral tablet 800 mg 1 or 1b* QL (4 tablets per 1 day) er oral tablet extended release 24 hour 100 mg 1 or 1b* QL (4 tablets per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 39 Coverage Requirements and Prescription Drug Name Drug Tier Limits lamotrigine er oral tablet extended release 24 hour 200 mg, 250 mg, 300 mg 1 or 1b* QL (2 tablets per 1 day) lamotrigine er oral tablet extended release 24 hour 25 mg, 50 mg 1 or 1b* QL (3 tablets per 1 day) lamotrigine oral kit 1 or 1b* QL (1 kit per 35 days) lamotrigine oral tablet 1 or 1b* QL (2 tablets per 1 day) lamotrigine oral tablet chewable 25 mg 1 or 1b* QL (2 tablets per 1 day) lamotrigine oral tablet chewable 5 mg 1 or 1b* QL (4 tablets per 1 day) lamotrigine oral tablet dispersible 100 mg, 200 mg 1 or 1b* QL (2 tablets per 1 day) lamotrigine oral tablet dispersible 25 mg 1 or 1b* QL (3 tablets per 1 day) lamotrigine oral tablet dispersible 50 mg 1 or 1b* QL (4 tablets per 1 day) lamotrigine starter kit-blue oral kit 1 or 1b* QL (1 kit per 28 days) lamotrigine starter kit-green oral kit 1 or 1b* QL (1 kit per 35 days) lamotrigine starter kit-orange oral kit 1 or 1b* QL (1 kit per 35 days) levetiracetam er oral tablet extended release 24 hour 500 mg 1 or 1b* QL (6 tablets per 1 day) levetiracetam er oral tablet extended release 24 hour 750 mg 1 or 1b* QL (4 tablets per 1 day) LEVETIRACETAM IN NACL INTRAVENOUS SOLUTION 3 levetiracetam intravenous solution 1 or 1b* levetiracetam oral solution 1 or 1b* levetiracetam oral tablet 1000 mg 1 or 1b* QL (3 tablets per 1 day) levetiracetam oral tablet 250 mg 1 or 1b* QL (2 tablets per 1 day) levetiracetam oral tablet 500 mg 1 or 1b* QL (6 tablets per 1 day) levetiracetam oral tablet 750 mg 1 or 1b* QL (4 tablets per 1 day) oral suspension 1 or 1b* QL (40 mL per 1 day) oxcarbazepine oral tablet 150 mg, 300 mg 1 or 1b* QL (2 tablets per 1 day) oxcarbazepine oral tablet 600 mg 1 or 1b* QL (4 tablets per 1 day) OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 3 QL (3 tablets per 1 day) MG, 300 MG (oxcarbazepine) OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 600 3 QL (4 tablets per 1 day) MG (oxcarbazepine) oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 mg 1 or 1b* QL (3 capsule per 1 day) pregabalin oral capsule 225 mg, 300 mg, 75 mg 1 or 1b* QL (2 capsules per 1 day) pregabalin oral solution 1 or 1b* QL (30 mL per 1 day) oral tablet 1 or 1b* QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 25 MG, 3 ST; QL (1 capsule per 1 day) 50 MG (topiramate) QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 150 MG, 200 MG 3 ST; QL (2 capsules per 1 day) (topiramate) roweepra oral tablet 1 or 1b* QL (6 tablets per 1 day) rufinamide oral suspension 1 or 1b* QL (80 mL per 1 day) rufinamide oral tablet 200 mg 1 or 1b* QL (6 tablets per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 40 Coverage Requirements and Prescription Drug Name Drug Tier Limits rufinamide oral tablet 400 mg 1 or 1b* QL (8 tablets per 1 day) SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 250 3 QL (2 tablets per 1 day) MG, 500 MG (levetiracetam) SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 750 MG 3 QL (4 tablets per 1 day) (levetiracetam) subvenite oral tablet 1 or 1b* QL (2 tablets per 1 day) subvenite starter kit-blue oral kit 1 or 1b* QL (1 kit per 28 days) subvenite starter kit-green oral kit 1 or 1b* QL (1 kit per 35 days) subvenite starter kit-orange oral kit 1 or 1b* QL (1 kit per 35 days) topiramate er oral capsule er 24 hour sprinkle 100 mg, 25 mg, 50 mg 1 or 1b* QL (1 capsule per 1 day) topiramate er oral capsule er 24 hour sprinkle 150 mg, 200 mg 1 or 1b* QL (2 capsules per 1 day) topiramate oral capsule sprinkle 1 or 1b* QL (2 capsules per 1 day) topiramate oral tablet 1 or 1b* QL (2 tablets per 1 day) TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 2 QL (1 capsule per 1 day) MG, 25 MG, 50 MG (topiramate) TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 2 QL (2 capsules per 1 day) MG (topiramate) VIMPAT INTRAVENOUS SOLUTION (lacosamide) 3 VIMPAT ORAL SOLUTION (lacosamide) 3 QL (40 mL per 1 day) VIMPAT ORAL TABLET (lacosamide) 3 QL (2 tablets per 1 day) oral capsule 1 or 1b* QL (6 capsule per 1 day) *CARBAMATES*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN felbamate oral suspension 1 or 1b* felbamate oral tablet 1 or 1b* XCOPRI (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 100 & 3 QL (1 blister pack per 28 days) 150 MG (cenobamate) XCOPRI (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 50 & 3 QL (1 pack per 28 days) 200 MG (cenobamate) XCOPRI (350 MG DAILY DOSE) ORAL TABLET THERAPY PACK 3 QL (1 pack per 28 days) (cenobamate) XCOPRI ORAL TABLET 100 MG, 150 MG, 50 MG (cenobamate) 3 QL (1 tablet per 1 day) XCOPRI ORAL TABLET 200 MG (cenobamate) 3 QL (2 tablets per 1 day) XCOPRI ORAL TABLET THERAPY PACK (cenobamate) 3 QL (1 pack per 28 days) *GABA MODULATORS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN tiagabine hcl oral tablet 1 or 1b* vigabatrin oral packet 1 or 1b* LD; SP; QL (6 packets per 1 day) vigabatrin oral tablet 1 or 1b* LD; SP; QL (6 tablets per 1 day) vigadrone oral packet 1 or 1b* LD; QL (6 packets per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 41 Coverage Requirements and Prescription Drug Name Drug Tier Limits *HYDANTOINS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN CEREBYX INJECTION SOLUTION (fosphenytoin sodium) 3 DILANTIN INFATABS ORAL TABLET CHEWABLE () 3 DILANTIN ORAL CAPSULE 100 MG (phenytoin sodium extended) 3 DILANTIN ORAL CAPSULE 30 MG (phenytoin sodium extended) 2 DILANTIN ORAL SUSPENSION (phenytoin) 3 fosphenytoin sodium injection solution 1 or 1b* PHENYTEK ORAL CAPSULE (phenytoin sodium extended) 3 phenytoin infatabs oral tablet chewable 1 or 1b* phenytoin oral suspension 1 or 1b* phenytoin oral tablet chewable 1 or 1b* phenytoin sodium extended oral capsule 1 or 1b* phenytoin sodium injection solution 1 or 1b* *SUCCINIMIDES*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN CELONTIN ORAL CAPSULE (methsuximide) 3 ethosuximide oral capsule 1 or 1b* ethosuximide oral solution 1 or 1b* *VALPROIC ACID*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN divalproex sodium er oral tablet extended release 24 hour 250 mg 1 or 1b* QL (2 tablets per 1 day) divalproex sodium er oral tablet extended release 24 hour 500 mg 1 or 1b* QL (7 tablets per 1 day) divalproex sodium oral capsule delayed release sprinkle 1 or 1b* QL (8 capsules per 1 day) divalproex sodium oral tablet delayed release 125 mg, 250 mg 1 or 1b* QL (2 tablets per 1 day) divalproex sodium oral tablet delayed release 500 mg 1 or 1b* QL (7 tablets per 1 day) sodium intravenous solution 1 or 1b* valproic acid oral capsule 1 or 1b* QL (4 capsules per 1 day) valproic acid oral solution 1 or 1b* *ANTIDEPRESSANTS* - DRUGS FOR THE NERVOUS SYSTEM *ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)*** - DRUGS FOR DEPRESSION mirtazapine oral tablet 1 or 1b* mirtazapine oral tablet dispersible 1 or 1b* REMERON ORAL TABLET (mirtazapine) 3 REMERON SOLTAB ORAL TABLET DISPERSIBLE (mirtazapine) 3 *ANTIDEPRESSANTS - MISC.*** - DRUGS FOR DEPRESSION APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR 174 MG 3 ST; DO (bupropion hbr)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 42 Coverage Requirements and Prescription Drug Name Drug Tier Limits APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR 348 MG, 3 ST; QL (1 tablet per 1 day) 522 MG (bupropion hbr) bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg 1 or 1b* DO bupropion hcl er (sr) oral tablet extended release 12 hour 150 mg, 200 mg 1 or 1b* QL (2 tablets per 1 day) bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg 1 or 1b* DO bupropion hcl er (xl) oral tablet extended release 24 hour 300 mg, 450 mg 1 or 1b* QL (1 tablet per 1 day) bupropion hcl oral tablet 100 mg 1 or 1b* QL (4.5 tablet per 1 day) bupropion hcl oral tablet 75 mg 1 or 1b* DO *MONOAMINE OXIDASE INHIBITORS (MAOIS)*** - DRUGS FOR DEPRESSION EMSAM TRANSDERMAL PATCH 24 HOUR (selegiline) 3 MARPLAN ORAL TABLET (isocarboxazid) 3 QL (6 tablets per 1 day) NARDIL ORAL TABLET (phenelzine sulfate) 3 PARNATE ORAL TABLET (tranylcypromine sulfate) 3 phenelzine sulfate oral tablet 1 or 1b* tranylcypromine sulfate oral tablet 1 or 1b* *SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)*** - DRUGS FOR DEPRESSION citalopram hydrobromide oral solution 1 or 1b* QL (20 mL per 1 day) citalopram hydrobromide oral tablet 10 mg, 20 mg 1 or 1b* DO citalopram hydrobromide oral tablet 40 mg 1 or 1b* QL (1 tablet per 1 day) escitalopram oxalate oral solution 1 or 1b* QL (20 mL per 1 day) escitalopram oxalate oral tablet 10 mg, 5 mg 1 or 1b* DO escitalopram oxalate oral tablet 20 mg 1 or 1b* QL (1 tablet per 1 day) fluoxetine hcl oral capsule 10 mg 1 or 1b* DO fluoxetine hcl oral capsule 20 mg 1 or 1b* QL (4 capsules per 1 day) fluoxetine hcl oral capsule 40 mg 1 or 1b* QL (2 capsules per 1 day) fluoxetine hcl oral capsule delayed release 1 or 1b* QL (4 capsules per 28 days) fluoxetine hcl oral solution 1 or 1b* QL (20 mL per 1 day) fluoxetine hcl oral tablet 10 mg 1 or 1b* DO fluoxetine hcl oral tablet 20 mg 1 or 1b* QL (4 tablets per 1 day) FLUOXETINE HCL ORAL TABLET 60 MG 3 QL (1 tablet per 1 day) fluvoxamine maleate er oral capsule extended release 24 hour 1 or 1b* QL (2 capsules per 1 day) fluvoxamine maleate oral tablet 100 mg 1 or 1b* QL (3 tablet per 1 day) fluvoxamine maleate oral tablet 25 mg, 50 mg 1 or 1b* DO paroxetine hcl er oral tablet extended release 24 hour 12.5 mg 1 or 1b* DO paroxetine hcl er oral tablet extended release 24 hour 25 mg, 37.5 mg 1 or 1b* QL (2 tablets per 1 day) paroxetine hcl oral tablet 10 mg, 20 mg 1 or 1b* DO paroxetine hcl oral tablet 30 mg 1 or 1b* QL (2 tablets per 1 day) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 43 Coverage Requirements and Prescription Drug Name Drug Tier Limits paroxetine hcl oral tablet 40 mg 1 or 1b* QL (1.5 tablet per 1 day) PAXIL ORAL SUSPENSION (paroxetine hcl) 3 ST; QL (30 mL per 1 day) PEXEVA ORAL TABLET 10 MG, 20 MG (paroxetine mesylate) 3 ST; DO PEXEVA ORAL TABLET 30 MG (paroxetine mesylate) 3 ST; QL (2 tablets per 1 day) PEXEVA ORAL TABLET 40 MG (paroxetine mesylate) 3 ST; QL (1.5 tablet per 1 day) sertraline hcl oral concentrate 1 or 1b* QL (10 mL per 1 day) sertraline hcl oral tablet 100 mg 1 or 1b* QL (2 tablets per 1 day) sertraline hcl oral tablet 25 mg, 50 mg 1 or 1b* DO *SEROTONIN MODULATORS*** - DRUGS FOR DEPRESSION hcl oral tablet 1 or 1b* trazodone hcl oral tablet 1 or 1a* TRINTELLIX ORAL TABLET 10 MG, 5 MG (vortioxetine hbr) 3 DO TRINTELLIX ORAL TABLET 20 MG (vortioxetine hbr) 3 QL (1 tablet per 1 day) *SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)*** - DRUGS FOR DEPRESSION DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 3 ST; QL (1 tablet per 1 day) HOUR 100 MG DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 3 ST HOUR 50 MG desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg 1 or 1b* QL (1 tablet per 1 day) desvenlafaxine succinate er oral tablet extended release 24 hour 25 mg, 50 1 or 1b* DO mg duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg 1 or 1b* QL (2 capsules per 1 day) duloxetine hcl oral capsule delayed release particles 30 mg 1 or 1b* DO duloxetine hcl oral capsule delayed release particles 40 mg 1 or 1b* QL (3 capsule per 1 day) FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 ST; QL (1 capsule per 1 day) (levomilnacipran hcl) FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK 3 ST; QL (28 pack per 365 days) (levomilnacipran hcl) venlafaxine hcl er oral capsule extended release 24 hour 150 mg 1 or 1b* QL (1 capsule per 1 day) venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg, 75 mg 1 or 1b* DO venlafaxine hcl er oral tablet extended release 24 hour 150 mg, 225 mg 1 or 1b* QL (1 tablet per 1 day) venlafaxine hcl er oral tablet extended release 24 hour 37.5 mg, 75 mg 1 or 1b* DO venlafaxine hcl oral tablet 1 or 1b* QL (3 tablet per 1 day) *TRICYCLIC AGENTS*** - DRUGS FOR DEPRESSION hcl oral tablet 1 or 1a* oral tablet 100 mg 1 or 1b* QL (4 tablets per 1 day) amoxapine oral tablet 150 mg 1 or 1b* QL (2 tablets per 1 day) amoxapine oral tablet 25 mg, 50 mg 1 or 1b* DO

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 44 Coverage Requirements and Prescription Drug Name Drug Tier Limits hcl oral capsule 1 or 1b* hcl oral tablet 1 or 1b* hcl oral capsule 1 or 1b* doxepin hcl oral concentrate 1 or 1b* hcl oral tablet 1 or 1b* imipramine pamoate oral capsule 1 or 1b* NORPRAMIN ORAL TABLET (desipramine hcl) 3 hcl oral capsule 1 or 1b* nortriptyline hcl oral solution 1 or 1b* PAMELOR ORAL CAPSULE (nortriptyline hcl) 3 protriptyline hcl oral tablet 1 or 1b* maleate oral capsule 1 or 1b* *ANTIDIABETICS* - HORMONES *ALPHA-GLUCOSIDASE INHIBITORS*** - DRUGS FOR DIABETES oral tablet 1 or 1b* QL (3 tablets per 1 day) oral tablet 1 or 1b* QL (3 tablets per 1 day) PRECOSE ORAL TABLET (acarbose) 3 QL (3 tablets per 1 day) *ANTIDIABETIC - ANALOGS*** - DRUGS FOR DIABETES SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (4 pens per 30 days) ( acetate) SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (2 boxes per 30 days) (pramlintide acetate) **** - DRUGS FOR DIABETES hcl er oral tablet extended release 24 hour 1 or 1b* metformin hcl oral solution 1 or 1b* PA; QL (2 bottles per 30 days) metformin hcl oral tablet 1 or 1b* RIOMET ORAL SOLUTION (metformin hcl) 3 PA; QL (2 bottles per 30 days) *DIABETIC OTHER*** - DRUGS FOR DIABETES BAQSIMI ONE PACK NASAL POWDER () 3 QL (2 packs per 30 days) BAQSIMI TWO PACK NASAL POWDER (glucagon) 3 QL (1 pack per 30 days) oral suspension 1 or 1b* GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 2 QL (2 kits per 30 days) (glucagon hcl (rdna)) GLUCAGON EMERGENCY INJECTION KIT 1 or 1b* QL (2 kits per 30 days) GLUCAGON EMERGENCY INJECTION SOLUTION RECONSTITUTED 3 GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION AUTO- 3 QL (2 packs per 30 days) INJECTOR (glucagon) GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION AUTO- 3 QL (2 packs per 30 days) INJECTOR (glucagon)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 45 Coverage Requirements and Prescription Drug Name Drug Tier Limits GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 QL (2 packs per 30 days) (glucagon) PROGLYCEM ORAL SUSPENSION (diazoxide) 3 ZEGALOGUE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 QL (1.2 mL per 30 days) ( hcl) ZEGALOGUE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 QL (1.2 mL per 30 days) (dasiglucagon hcl) *DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS*** - DRUGS FOR DIABETES benzoate oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) JANUVIA ORAL TABLET ( phosphate) 2 ST; QL (1 tablet per 1 day) *DIPEPTIDYL PEPTIDASE-4 INHIBITOR- COMBINATIONS*** - DRUGS FOR DIABETES alogliptin-metformin hcl oral tablet 1 or 1b* ST; QL (2 tablets per 1 day) JANUMET ORAL TABLET (sitagliptin-metformin hcl) 2 ST; QL (2 tablets per 1 day) JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 2 ST; QL (1 tablet per 1 day) MG (sitagliptin-metformin hcl) JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 50-1000 2 ST; QL (2 tablets per 1 day) MG, 50-500 MG (sitagliptin-metformin hcl) * AGONISTS - ERGOT DERIVATIVES*** - DRUGS FOR DIABETES CYCLOSET ORAL TABLET ( mesylate) 3 *DPP-4 INHIBITOR- COMBINATIONS*** - DRUGS FOR DIABETES alogliptin- oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) *HUMAN INSULIN*** - DRUGS FOR DIABETES HUMALOG JUNIOR KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 QL (30 mL per 30 days) INJECTOR () HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (30 mL per 30 days) (insulin lispro) HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- 2 QL (30 mL per 30 days) INJECTOR (insulin lispro prot & lispro) HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (insulin lispro 2 QL (30 mL per 30 days) prot & lispro) HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- 2 QL (30 mL per 30 days) INJECTOR (insulin lispro prot & lispro) HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (insulin lispro 2 QL (30 mL per 30 days) prot & lispro) HUMALOG SUBCUTANEOUS SOLUTION (insulin lispro) 2 QL (30 mL per 30 days) HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE (insulin lispro) 2 QL (30 mL per 30 days) HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- 2 QL (30 mL per 30 days) INJECTOR (insulin nph isophane & regular)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 46 Coverage Requirements and Prescription Drug Name Drug Tier Limits HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (insulin nph isophane 2 QL (30 mL per 30 days) & regular) HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN- 2 QL (30 mL per 30 days) INJECTOR (insulin nph human (isophane)) HUMULIN N SUBCUTANEOUS SUSPENSION (insulin nph human 2 QL (30 mL per 30 days) (isophane)) HUMULIN R INJECTION SOLUTION (insulin regular human) 2 QL (30 mL per 30 days) HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 2 PA; QL (20 mL per 30 days) (insulin regular human) HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 PA; QL (18 mL per 30 days) INJECTOR (insulin regular human) INSULIN LISPRO (1 UNIT DIAL) SUBCUTANEOUS SOLUTION PEN- 2 QL (30 mL per 30 days) INJECTOR INSULIN LISPRO JUNIOR KWIKPEN SUBCUTANEOUS SOLUTION 2 QL (30 mL per 30 days) PEN-INJECTOR INSULIN LISPRO PROT & LISPRO SUBCUTANEOUS SUSPENSION 2 QL (30 mL per 30 days) PEN-INJECTOR INSULIN LISPRO SUBCUTANEOUS SOLUTION 2 QL (30 mL per 30 days) LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (30 mL per 30 days) () LANTUS SUBCUTANEOUS SOLUTION (insulin glargine) 2 QL (30 mL per 30 days) LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (30 mL per 30 days) () LEVEMIR SUBCUTANEOUS SOLUTION (insulin detemir) 2 QL (30 mL per 30 days) MYXREDLIN INTRAVENOUS SOLUTION (insulin regular(human) in 3 nacl) SEMGLEE SUBCUTANEOUS SOLUTION (insulin glargine) 3 QL (30 mL per 30 days) SEMGLEE SUBCUTANEOUS SOLUTION PEN-INJECTOR (insulin 3 QL (30 mL per 30 days) glargine) TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 2 QL (12 mL per 30 days) INJECTOR (insulin glargine) TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (13.5 mL per 30 days) (insulin glargine) TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (30 mL per 30 days) 100 UNIT/ML () TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 QL (18 mL per 30 days) 200 UNIT/ML (insulin degludec) TRESIBA SUBCUTANEOUS SOLUTION (insulin degludec) 2 QL (30 mL per 30 days) *INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)*** - DRUGS FOR DIABETES OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION PEN- 2 ST; QL (1 pen per 28 days) INJECTOR (semaglutide)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 47 Coverage Requirements and Prescription Drug Name Drug Tier Limits OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 2 ST; QL (2 pens per 28 days) MG/1.5ML (semaglutide) OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 4 2 ST; QL (1 unit per 28 days) MG/3ML (semaglutide) RYBELSUS ORAL TABLET 14 MG, 7 MG (semaglutide) 2 ST; QL (1 carton per 30 days) RYBELSUS ORAL TABLET 3 MG (semaglutide) 2 ST; QL (1 carton per 1 fill) TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 2 ST; QL (4 pens per 28 days) MG/0.5ML, 1.5 MG/0.5ML () TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 3 MG/0.5ML, 2 ST; QL (4 syringes per 28 days) 4.5 MG/0.5ML (dulaglutide) VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR (liraglutide) 2 ST; QL (1 box per 30 days) *INSULIN-INCRETIN MIMETIC COMBINATIONS*** - DRUGS FOR DIABETES SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR (insulin 3 ST; QL (5 pen per 25 days) glargine-) XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR (insulin 3 ST; QL (5 pen per 30 days) degludec-liraglutide) *MEGLITINIDE ANALOGUES*** - DRUGS FOR DIABETES oral tablet 1 or 1b* QL (3 tablets per 1 day) oral tablet 0.5 mg, 1 mg 1 or 1b* QL (4 tablets per 1 day) repaglinide oral tablet 2 mg 1 or 1b* QL (8 tablets per 1 day) *SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS*** - DRUGS FOR DIABETES FARXIGA ORAL TABLET ( propanediol) 2 ST; QL (1 tablet per 1 day) JARDIANCE ORAL TABLET () 2 ST; QL (1 tablet per 1 day) *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR- BIGUANIDE COMB*** - DRUGS FOR DIABETES SYNJARDY ORAL TABLET (empagliflozin-metformin hcl) 2 ST; QL (2 tablets per 1 day) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10- 2 ST; QL (2 tablets per 1 day) 1000 MG, 12.5-1000 MG, 5-1000 MG (empagliflozin-metformin hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 25- 2 ST; QL (1 tablet per 1 day) 1000 MG (empagliflozin-metformin hcl) XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 2 ST; QL (1 tablet per 1 day) MG, 10-500 MG, 5-500 MG (dapagliflozin-metformin hcl) XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 2 ST; QL (2 tablet per 1 day) MG (dapagliflozin-metformin hcl) XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 2 ST; QL (2 tablets per 1 day) MG (dapagliflozin-metformin hcl) *-BIGUANIDE COMBINATIONS*** - DRUGS FOR DIABETES -metformin hcl oral tablet 1 or 1b* ST glyburide-metformin oral tablet 1 or 1b* ST

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 48 Coverage Requirements and Prescription Drug Name Drug Tier Limits **** - DRUGS FOR DIABETES AMARYL ORAL TABLET () 3 ST glimepiride oral tablet 1 or 1b* ST glipizide er oral tablet extended release 24 hour 1 or 1a* ST glipizide oral tablet 1 or 1a* ST glipizide xl oral tablet extended release 24 hour 1 or 1a* ST GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 ST (glipizide) glyburide micronized oral tablet 1 or 1b* ST glyburide oral tablet 1 or 1b* ST GLYNASE ORAL TABLET (glyburide micronized) 3 ST oral tablet 1 or 1b* ST *SULFONYLUREA-THIAZOLIDINEDIONE COMBINATIONS*** - DRUGS FOR DIABETES DUETACT ORAL TABLET (pioglitazone hcl-glimepiride) 3 ST; QL (1 tablet per 1 day) pioglitazone hcl-glimepiride oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) *THIAZOLIDINEDIONE-BIGUANIDE COMBINATIONS*** - DRUGS FOR DIABETES ACTOPLUS MET ORAL TABLET (pioglitazone hcl-metformin hcl) 3 ST; QL (3 tablet per 1 day) pioglitazone hcl-metformin hcl oral tablet 1 or 1b* ST; QL (3 tablets per 1 day) **** - DRUGS FOR DIABETES pioglitazone hcl oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) *ANTIDIARRHEAL/PROBIOTIC AGENTS* - DRUGS FOR THE STOMACH *ANTIDIARRHEAL - CHLORIDE CHANNEL ANTAGONISTS*** - DRUGS FOR MYTESI ORAL TABLET DELAYED RELEASE (crofelemer) 3 PA; LD; QL (2 tablets per 1 day) *ANTIDIARRHEAL/PROBIOTIC COMBINATIONS*** - DRUGS FOR DIARRHEA RESTORA RX ORAL CAPSULE (lactobacillus casei-folic acid) 3 *ANTIPERISTALTIC AGENTS*** - DRUGS FOR DIARRHEA diphenoxylate-atropine oral liquid 1 or 1b* diphenoxylate-atropine oral tablet 1 or 1b* LOMOTIL ORAL TABLET (diphenoxylate-atropine) 3 loperamide hcl oral capsule 1 or 1b* MOTOFEN ORAL TABLET (difenoxin-atropine) 3

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 49 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTIDOTES AND SPECIFIC ANTAGONISTS* - DRUGS FOR OVERDOSE OR POISONING *ANTIDOTE COMBINATIONS*** - DRUGS FOR OVERDOSE OR POISONING DUODOTE INTRAMUSCULAR SOLUTION AUTO-INJECTOR (atropine- 3 pralidoxime chloride) NITHIODOTE INTRAVENOUS KIT (sodium nitrite-sod thiosulfate) 3 *ANTIDOTES - CHELATING AGENTS*** - DRUGS FOR OVERDOSE OR POISONING CHEMET ORAL CAPSULE (succimer) 3 deferasirox granules oral packet 4 PA; SP deferasirox oral packet 4 PA; SP deferasirox oral tablet 180 mg 4 SP deferasirox oral tablet 360 mg, 90 mg 4 PA; SP deferasirox oral tablet soluble 4 PA; SP deferiprone oral tablet 4 PA PENTETATE CALCIUM TRISODIUM COMBINATION SOLUTION 3 PENTETATE TRISODIUM COMBINATION SOLUTION 3 *ANTIDOTES AND SPECIFIC ANTAGONISTS*** - DRUGS FOR OVERDOSE OR POISONING ACETADOTE INTRAVENOUS SOLUTION (acetylcysteine) 3 acetylcysteine intravenous solution 1 or 1b* ANDEXXA INTRAVENOUS SOLUTION RECONSTITUTED (coag fact xa 3 inactivated-zhzo) BAL IN OIL INTRAMUSCULAR SOLUTION 3 BRIDION INTRAVENOUS SOLUTION (sugammadex sodium) 3 CALCIUM DISODIUM VERSENATE INJECTION SOLUTION 3 CYANOKIT INTRAVENOUS SOLUTION RECONSTITUTED 3 (hydroxocobalamin) deferoxamine mesylate injection solution reconstituted 4 SP DIGIFAB INTRAVENOUS SOLUTION RECONSTITUTED (digoxin 3 immune fab) fomepizole intravenous solution 1 or 1b* PRAXBIND INTRAVENOUS SOLUTION (idarucizumab) 3 PROTOPAM CHLORIDE INTRAVENOUS SOLUTION RECONSTITUTED 3 (pralidoxime chloride) PROVAYBLUE INTRAVENOUS SOLUTION (methylene blue (antidote)) 3 RADIOGARDASE ORAL CAPSULE (prussian blue insoluble) 3 SODIUM NITRITE INTRAVENOUS SOLUTION 3 PA; LD; QL (20 packets per 30 VISTOGARD ORAL PACKET (uridine triacetate) 3 days) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 50 Coverage Requirements and Prescription Drug Name Drug Tier Limits *BENZODIAZEPINE ANTAGONISTS*** - DRUGS FOR OVERDOSE OR POISONING flumazenil intravenous solution 1 or 1b* *OPIOID ANTAGONISTS*** - DRUGS FOR OVERDOSE OR POISONING naloxone hcl injection solution 1 or 1b* QL (6 vial per 90 days) naloxone hcl injection solution cartridge 1 or 1b* QL (6 syringe per 90 days) naloxone hcl injection solution prefilled syringe 1 or 1b* QL (6 syringe per 90 days) naltrexone hcl oral tablet 1 or 1b* NARCAN NASAL LIQUID (naloxone hcl) 2 QL (6 nasal spray per 90 days) *ANTIEMETICS* - DRUGS FOR THE STOMACH *5-HT3 RECEPTOR ANTAGONISTS*** - DRUGS FOR VOMITING AND ALOXI INTRAVENOUS SOLUTION (palonosetron hcl) 3 PA granisetron hcl intravenous solution 1 or 1b* granisetron hcl oral tablet 1 or 1b* QL (10 tablets per 30 days) ondansetron hcl injection solution 1 or 1b* ondansetron hcl oral solution 1 or 1b* QL (8 mL per 1 day) ondansetron hcl oral tablet 24 mg 1 or 1b* QL (8 tablet per 30 days) ondansetron hcl oral tablet 4 mg 1 or 1b* QL (48 tablets per 30 days) ondansetron hcl oral tablet 8 mg 1 or 1b* QL (24 tablets per 30 days) ondansetron oral tablet dispersible 4 mg 1 or 1b* QL (48 tablets per 30 days) ondansetron oral tablet dispersible 8 mg 1 or 1b* QL (24 tablets per 30 days) PALONOSETRON HCL INTRAVENOUS SOLUTION 0.25 MG/2ML 3 PA palonosetron hcl intravenous solution 0.25 mg/5ml 1 or 1b* PA palonosetron hcl intravenous solution prefilled syringe 1 or 1b* PA SANCUSO TRANSDERMAL PATCH (granisetron) 3 QL (4 patches per 28 days) SUSTOL SUBCUTANEOUS PREFILLED SYRINGE (granisetron) 3 ZOFRAN ORAL TABLET (ondansetron hcl) 3 QL (48 tablets per 30 days) ZUPLENZ ORAL FILM 4 MG (ondansetron) 3 QL (48 films per 30 days) ZUPLENZ ORAL FILM 8 MG (ondansetron) 3 QL (24 films per 30 days) *ANTIEMETIC COMBINATIONS*** - DRUGS FOR VOMITING AND NAUSEA AKYNZEO INTRAVENOUS SOLUTION (fosnetupitant-palonosetron) 3 PA; QL (5 vials per 30 days) AKYNZEO INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; QL (5 vials per 30 days) (fosnetupitant-palonosetron) AKYNZEO ORAL CAPSULE (netupitant-palonosetron) 3 QL (5 capsules per 25 days) BONJESTA ORAL TABLET EXTENDED RELEASE (doxylamine- 3 PA; QL (4 tablet per 1 day) pyridoxine)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 51 Coverage Requirements and Prescription Drug Name Drug Tier Limits doxylamine-pyridoxine oral tablet delayed release 1 or 1b* PA; QL (4 tablet per 1 day) *ANTIEMETICS - ANTICHOLINERGIC*** - DRUGS FOR VOMITING AND NAUSEA DIMENHYDRINATE INJECTION SOLUTION 3 hcl oral tablet 1 or 1a* meclizine hcl oral tablet chewable 1 or 1a* scopolamine transdermal patch 72 hour 1 or 1b* TIGAN INTRAMUSCULAR SOLUTION ( hcl) 3 trimethobenzamide hcl oral capsule 1 or 1b* *ANTIEMETICS - ANTIDOPAMINERGIC*** - DRUGS FOR VOMITING AND NAUSEA BARHEMSYS INTRAVENOUS SOLUTION ( (antiemetic)) 3 *ANTIEMETICS - MISCELLANEOUS*** - DRUGS FOR VOMITING AND NAUSEA oral capsule 1 or 1b* MARINOL ORAL CAPSULE (dronabinol) 3 SYNDROS ORAL SOLUTION (dronabinol) 3 */NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS*** - DRUGS FOR VOMITING AND NAUSEA aprepitant oral 1 or 1b* QL (15 capsules per 25 days) aprepitant oral capsule 125 mg 1 or 1b* QL (5 capsules per 25 days) aprepitant oral capsule 40 mg 1 or 1b* QL (1 capsule per 1 fill) aprepitant oral capsule 80 & 125 mg 1 or 1b* QL (15 capsules per 25 days) aprepitant oral capsule 80 mg 1 or 1b* QL (10 capsules per 25 days) CINVANTI INTRAVENOUS EMULSION (aprepitant) 3 PA; QL (5 vials per 30 days) EMEND ORAL SUSPENSION RECONSTITUTED (aprepitant) 3 QL (15 kit per 30 days) fosaprepitant dimeglumine intravenous solution reconstituted 1 or 1b* PA; QL (5 vial per 30 days) VARUBI (180 MG DOSE) ORAL TABLET THERAPY PACK (rolapitant 3 QL (4 capsules per 28 days) hcl) *ANTIFUNGALS* - DRUGS FOR INFECTIONS * - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS)*** - ANTIBIOTICS CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED (caspofungin 3 acetate) CASPOFUNGIN ACETATE INTRAVENOUS SOLUTION 3 RECONSTITUTED ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED (anidulafungin) 3 micafungin sodium intravenous solution reconstituted 1 or 1b* MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED (micafungin 3 sodium)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 52 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTIFUNGALS*** - DRUGS FOR ABELCET INTRAVENOUS SUSPENSION (amphotericin b lipid) 3 AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 3 (amphotericin b liposome) amphotericin b intravenous solution reconstituted 1 or 1b* ANCOBON ORAL CAPSULE (flucytosine) 3 PA flucytosine oral capsule 1 or 1b* PA microsize oral suspension 1 or 1b* griseofulvin microsize oral tablet 1 or 1b* griseofulvin ultramicrosize oral tablet 1 or 1b* nystatin oral tablet 1 or 1b* terbinafine hcl oral tablet 1 or 1b* QL (1 tablet per 1 day) *IMIDAZOLES*** - DRUGS FOR FUNGUS oral tablet 1 or 1b* QL (2 tablets per 1 day) *TRIAZOLES*** - DRUGS FOR FUNGUS CRESEMBA INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; QL (1 vial per 1 day) (isavuconazonium sulfate) CRESEMBA ORAL CAPSULE (isavuconazonium sulfate) 3 PA; QL (2 capsules per 1 day) DIFLUCAN ORAL SUSPENSION RECONSTITUTED 10 MG/ML 3 QL (40 mL per 1 day) (fluconazole) DIFLUCAN ORAL SUSPENSION RECONSTITUTED 40 MG/ML 3 QL (10 mL per 1 day) (fluconazole) DIFLUCAN ORAL TABLET 100 MG (fluconazole) 3 QL (4 tablet per 1 day) DIFLUCAN ORAL TABLET 150 MG, 200 MG (fluconazole) 3 QL (2 tablets per 1 day) DIFLUCAN ORAL TABLET 50 MG (fluconazole) 3 QL (8 tablet per 1 day) fluconazole in sodium chloride intravenous solution 1 or 1b* fluconazole oral suspension reconstituted 10 mg/ml 1 or 1b* QL (40 mL per 1 day) fluconazole oral suspension reconstituted 40 mg/ml 1 or 1b* QL (10 mL per 1 day) fluconazole oral tablet 100 mg 1 or 1b* QL (4 tablet per 1 day) fluconazole oral tablet 150 mg, 200 mg 1 or 1b* QL (2 tablets per 1 day) fluconazole oral tablet 50 mg 1 or 1b* QL (8 tablet per 1 day) itraconazole oral capsule 1 or 1b* PA; QL (4.2 capsules per 1 day) itraconazole oral solution 1 or 1b* PA; QL (20 mL per 1 day) NOXAFIL INTRAVENOUS SOLUTION (posaconazole) 3 NOXAFIL ORAL SUSPENSION (posaconazole) 3 PA; QL (20 mL per 1 day) NOXAFIL ORAL TABLET DELAYED RELEASE (posaconazole) 3 PA; QL (8 tablet per 1 day) posaconazole oral tablet delayed release 1 or 1b* PA; QL (8 tablet per 1 day) SPORANOX ORAL CAPSULE (itraconazole) 3 PA; QL (4.2 capsules per 1 day) SPORANOX ORAL SOLUTION (itraconazole) 3 PA; QL (20 mL per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 53 Coverage Requirements and Prescription Drug Name Drug Tier Limits SPORANOX PULSEPAK ORAL CAPSULE (itraconazole) 3 PA; QL (4.2 capsules per 1 day) TOLSURA ORAL CAPSULE 3 PA; QL (126 capsules per 30 days) VFEND ORAL SUSPENSION RECONSTITUTED (voriconazole) 3 PA; QL (10 mL per 1 day) VFEND ORAL TABLET 200 MG (voriconazole) 3 PA; QL (2 tablets per 1 day) VFEND ORAL TABLET 50 MG (voriconazole) 3 PA; QL (4 tablet per 1 day) voriconazole intravenous solution reconstituted 1 or 1b* voriconazole oral suspension reconstituted 1 or 1b* PA; QL (10 mL per 1 day) voriconazole oral tablet 200 mg 1 or 1b* PA; QL (2 tablets per 1 day) voriconazole oral tablet 50 mg 1 or 1b* PA; QL (4 tablet per 1 day) *ANTIHISTAMINES* - DRUGS FOR THE LUNGS *ANTIHISTAMINES - ALKYLAMINES*** - DRUGS FOR ryclora oral solution 1 or 1b* *ANTIHISTAMINES - ETHANOLAMINES*** - DRUGS FOR ALLERGIES carbinoxamine maleate oral solution 1 or 1b* carbinoxamine maleate oral tablet 4 mg 1 or 1b* CLEMASTINE FUMARATE ORAL SYRUP 3 clemastine fumarate oral tablet 2.68 mg 1 or 1b* diphen oral elixir 1 or 1a* QL (4 mL per 1 day) di-phen oral elixir 1 or 1a* QL (4 mL per 1 day) hcl injection solution 1 or 1b* diphenhydramine hcl oral elixir 1 or 1a* QL (4 mL per 1 day) KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE 3 QL (40 mL per 1 day) (carbinoxamine maleate) RYVENT ORAL TABLET (carbinoxamine maleate) 1 or 1b* QL (4 tablets per 1 day) *ANTIHISTAMINES - NON-SEDATING*** - DRUGS FOR ALLERGIES cetirizine hcl oral solution 1 or 1b* CLARINEX ORAL TABLET (desloratadine) 3 ST; QL (1 tablet per 1 day) desloratadine oral tablet 1 or 1b* QL (1 tablet per 1 day) desloratadine oral tablet dispersible 1 or 1b* QL (1 tablet per 1 day) levocetirizine dihydrochloride oral solution 1 or 1b* QL (10 mL per 1 day) levocetirizine dihydrochloride oral tablet 1 or 1b* QL (1 tablet per 1 day) QUZYTTIR INTRAVENOUS SOLUTION (cetirizine hcl) 3 *ANTIHISTAMINES - *** - DRUGS FOR ALLERGIES PHENERGAN INJECTION SOLUTION ( hcl) 3 promethazine hcl injection solution 1 or 1a*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 54 Coverage Requirements and Prescription Drug Name Drug Tier Limits promethazine hcl oral solution 1 or 1a* promethazine hcl oral syrup 1 or 1a* promethazine hcl oral tablet 12.5 mg, 50 mg 1 or 1a* promethazine hcl oral tablet 25 mg 1 or 1a* QL (4 tablets per 1 day) promethazine hcl rectal suppository 1 or 1b* promethegan rectal suppository 1 or 1b* *ANTIHISTAMINES - PIPERIDINES*** - DRUGS FOR ALLERGIES hcl oral syrup 1 or 1b* cyproheptadine hcl oral tablet 1 or 1b* *ANTIHYPERLIPIDEMICS* - DRUGS FOR THE HEART *ACL INHIB-INTESTINAL ABSORPTION INHIB COMB*** - DRUGS FOR CHOLESTEROL NEXLIZET ORAL TABLET (bempedoic acid-ezetimibe) 3 PA; QL (1 tablet per 1 day) *ADENOSINE TRIPHOSPHATE-CITRATE LYASE (ACL) INHIBITORS*** - DRUGS FOR CHOLESTEROL NEXLETOL ORAL TABLET (bempedoic acid) 3 PA; QL (1 tablet per 1 day) *ANTIHYPERLIPIDEMICS - MISC.*** - DRUGS FOR CHOLESTEROL icosapent ethyl oral capsule 1 or 1b* PA; QL (4 capsule per 1 day) omega-3-acid ethyl esters oral capsule 1 or 1b* PA; QL (4 capsule per 1 day) VASCEPA ORAL CAPSULE 0.5 GM (icosapent ethyl) 2 PA; QL (8 capsules per 1 day) VASCEPA ORAL CAPSULE 1 GM (icosapent ethyl) 2 PA; QL (4 capsule per 1 day) * SEQUESTRANTS*** - DRUGS FOR CHOLESTEROL cholestyramine light oral packet 1 or 1b* QL (24 grams per 1 day) cholestyramine light oral powder 1 or 1b* QL (24 grams per 1 day) cholestyramine oral packet 1 or 1b* QL (6 packets per 1 day) cholestyramine oral powder 1 or 1b* QL (54 gm per 1 day) colesevelam hcl oral packet 1 or 1b* QL (1 packet per 1 day) colesevelam hcl oral tablet 1 or 1b* QL (6 tablets per 1 day) COLESTID FLAVORED ORAL GRANULES (colestipol hcl) 3 QL (30 grams per 1 day) COLESTID FLAVORED ORAL PACKET (colestipol hcl) 3 QL (30 grams per 1 day) COLESTID ORAL GRANULES (colestipol hcl) 3 QL (30 grams per 1 day) COLESTID ORAL PACKET (colestipol hcl) 3 QL (30 grams per 1 day) COLESTID ORAL TABLET (colestipol hcl) 3 QL (16 tablets per 1 day) colestipol hcl oral granules 1 or 1b* QL (30 grams per 1 day) colestipol hcl oral packet 1 or 1b* QL (30 grams per 1 day) colestipol hcl oral tablet 1 or 1b* QL (16 tablets per 1 day) prevalite oral packet 1 or 1b* QL (24 grams per 1 day) prevalite oral powder 1 or 1b* QL (24 grams per 1 day) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 55 Coverage Requirements and Prescription Drug Name Drug Tier Limits QUESTRAN LIGHT ORAL POWDER (cholestyramine light) 3 QL (24 grams per 1 day) QUESTRAN ORAL PACKET (cholestyramine) 3 QL (6 packets per 1 day) QUESTRAN ORAL POWDER (cholestyramine) 3 QL (54 gm per 1 day) *FIBRIC ACID DERIVATIVES*** - DRUGS FOR CHOLESTEROL fenofibrate micronized oral capsule 1 or 1b* QL (1 capsule per 1 day) fenofibrate oral capsule 1 or 1b* QL (1 capsule per 1 day) fenofibrate oral tablet 1 or 1b* QL (1 tablet per 1 day) fenofibric acid oral capsule delayed release 1 or 1b* QL (1 capsule per 1 day) fenofibric acid oral tablet 1 or 1b* QL (1 tablet per 1 day) FENOGLIDE ORAL TABLET (fenofibrate) 3 ST; QL (1 tablet per 1 day) FIBRICOR ORAL TABLET (fenofibric acid) 3 ST; QL (1 tablet per 1 day) gemfibrozil oral tablet 1 or 1b* QL (2 tablets per 1 day) LIPOFEN ORAL CAPSULE (fenofibrate) 3 ST; QL (1 capsule per 1 day) LOPID ORAL TABLET (gemfibrozil) 3 ST; QL (2 tablets per 1 day) TRICOR ORAL TABLET (fenofibrate) 3 ST; QL (1 tablet per 1 day) TRILIPIX ORAL CAPSULE DELAYED RELEASE (choline fenofibrate) 3 ST; QL (1 capsule per 1 day) *HMG COA REDUCTASE INHIBITORS*** - DRUGS FOR CHOLESTEROL atorvastatin calcium oral tablet 10 mg, 20 mg 1 or 1b*; $0 DO atorvastatin calcium oral tablet 40 mg 1 or 1b* DO atorvastatin calcium oral tablet 80 mg 1 or 1b* QL (1 tablet per 1 day) fluvastatin sodium er oral tablet extended release 24 hour 1 or 1b*; $0 QL (1 tablet per 1 day) fluvastatin sodium oral capsule 1 or 1b*; $0 DO oral tablet 10 mg, 20 mg 1 or 1b*; $0 DO lovastatin oral tablet 40 mg 1 or 1b*; $0 QL (2 tablets per 1 day) pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg 1 or 1b*; $0 DO pravastatin sodium oral tablet 80 mg 1 or 1b*; $0 QL (1 tablet per 1 day) rosuvastatin calcium oral tablet 10 mg, 5 mg 1 or 1b*; $0 DO rosuvastatin calcium oral tablet 20 mg 1 or 1b* DO rosuvastatin calcium oral tablet 40 mg 1 or 1b* QL (1 tablet per 1 day) oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 or 1b*; $0 DO simvastatin oral tablet 80 mg 1 or 1b* PA; QL (1 tablet per 1 day) *INTEST CHOLEST ABSORP INHIB-HMG COA REDUCTASE INHIB COMB*** - DRUGS FOR CHOLESTEROL ezetimibe-simvastatin oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) *INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS*** - DRUGS FOR CHOLESTEROL ezetimibe oral tablet 1 or 1b* ST; QL (1 tablet per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 56 Coverage Requirements and Prescription Drug Name Drug Tier Limits *MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN INHIBITORS*** - DRUGS FOR CHOLESTEROL JUXTAPID ORAL CAPSULE (lomitapide mesylate) 3 PA; DO; LD *NICOTINIC ACID DERIVATIVES*** - DRUGS FOR CHOLESTEROL niacin (antihyperlipidemic) oral tablet 1 or 1b* ST; QL (12 tablets per 1 day) niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 750 mg 1 or 1b* ST; QL (2 tablets per 1 day) niacin er (antihyperlipidemic) oral tablet extended release 500 mg 1 or 1b* ST; QL (1 tablet per 1 day) niacor oral tablet 1 or 1b* ST; QL (12 tablets per 1 day) NIASPAN ORAL TABLET EXTENDED RELEASE 1000 MG, 750 MG 3 ST; QL (2 tablets per 1 day) (niacin (antihyperlipidemic)) NIASPAN ORAL TABLET EXTENDED RELEASE 500 MG (niacin 3 ST; QL (1 tablet per 1 day) (antihyperlipidemic)) *PCSK9 INHIBITORS*** - DRUGS FOR CHOLESTEROL PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 PA; QL (2 injection per 28 days) (alirocumab) REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION 3 PA; QL (1 injector per 30 days) CARTRIDGE (evolocumab) REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 PA; QL (2 syringe per 28 days) (evolocumab) REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 PA; QL (2 syringe per 28 days) (evolocumab) *ANTIHYPERTENSIVES* - DRUGS FOR THE HEART *ACE INHIBITOR & CALCIUM COMBINATIONS*** - DRUGS FOR HIGH besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 5-40 mg 1 or 1b* QL (1 capsule per 1 day) amlodipine besy-benazepril hcl oral capsule 2.5-10 mg, 5-10 mg, 5-20 mg 1 or 1b* DO PRESTALIA ORAL TABLET 14-10 MG (perindopril arg-amlodipine) 3 QL (1 tablet per 1 day) PRESTALIA ORAL TABLET 3.5-2.5 MG, 7-5 MG (perindopril arg- 3 DO amlodipine) TARKA ORAL TABLET EXTENDED RELEASE (trandolapril- 3 QL (1 tablet per 1 day) hcl) trandolapril-verapamil hcl er oral tablet extended release 1-240 mg 1 or 1b* DO trandolapril-verapamil hcl er oral tablet extended release 2-180 mg, 2-240 1 or 1b* QL (1 tablet per 1 day) mg, 4-240 mg *ACE INHIBITORS & /THIAZIDE-LIKE*** - DRUGS FOR HIGH BLOOD PRESSURE ACCURETIC ORAL TABLET (quinapril-hydrochlorothiazide) 3 QL (2 tablets per 1 day) benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 5-6.25 mg 1 or 1b* DO benazepril-hydrochlorothiazide oral tablet 20-12.5 mg, 20-25 mg 1 or 1b* QL (1 tablet per 1 day) enalapril-hydrochlorothiazide oral tablet 1 or 1b* QL (2 tablets per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 57 Coverage Requirements and Prescription Drug Name Drug Tier Limits fosinopril sodium-hctz oral tablet 10-12.5 mg 1 or 1b* QL (2 tablets per 1 day) fosinopril sodium-hctz oral tablet 20-12.5 mg 1 or 1b* QL (4 tablets per 1 day) lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg 1 or 1b* DO lisinopril-hydrochlorothiazide oral tablet 20-12.5 mg 1 or 1b* QL (4 tablets per 1 day) lisinopril-hydrochlorothiazide oral tablet 20-25 mg 1 or 1b* QL (2 tablets per 1 day) LOTENSIN HCT ORAL TABLET 10-12.5 MG (benazepril- 3 DO hydrochlorothiazide) LOTENSIN HCT ORAL TABLET 20-12.5 MG, 20-25 MG (benazepril- 3 QL (1 tablet per 1 day) hydrochlorothiazide) quinapril-hydrochlorothiazide oral tablet 1 or 1b* QL (2 tablets per 1 day) VASERETIC ORAL TABLET (enalapril-hydrochlorothiazide) 3 QL (2 tablets per 1 day) ZESTORETIC ORAL TABLET 10-12.5 MG (lisinopril-hydrochlorothiazide) 3 DO ZESTORETIC ORAL TABLET 20-12.5 MG (lisinopril-hydrochlorothiazide) 3 QL (4 tablets per 1 day) ZESTORETIC ORAL TABLET 20-25 MG (lisinopril-hydrochlorothiazide) 3 QL (2 tablets per 1 day) *ACE INHIBITORS*** - DRUGS FOR HIGH BLOOD PRESSURE benazepril hcl oral tablet 1 or 1a* QL (2 tablets per 1 day) captopril oral tablet 1 or 1b* QL (3 tablets per 1 day) enalapril maleate oral tablet 1 or 1b* QL (2 tablets per 1 day) enalaprilat intravenous injectable 1 or 1b* EPANED ORAL SOLUTION (enalapril maleate) 3 QL (40 mg per 1 day) fosinopril sodium oral tablet 1 or 1b* QL (2 tablets per 1 day) lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 or 1a* DO lisinopril oral tablet 30 mg, 40 mg 1 or 1a* QL (2 tablets per 1 day) LOTENSIN ORAL TABLET (benazepril hcl) 3 QL (2 tablets per 1 day) moexipril hcl oral tablet 15 mg 1 or 1b* QL (4 tablets per 1 day) moexipril hcl oral tablet 7.5 mg 1 or 1b* QL (2 tablets per 1 day) perindopril erbumine oral tablet 1 or 1b* QL (2 tablets per 1 day) QBRELIS ORAL SOLUTION (lisinopril) 3 QL (40 mg per 1 day) quinapril hcl oral tablet 1 or 1b* QL (2 tablets per 1 day) ramipril oral capsule 1 or 1b* QL (2 capsules per 1 day) trandolapril oral tablet 1 or 1b* QL (2 tablets per 1 day) *AGENTS FOR PHEOCHROMOCYTOMA*** - DRUGS FOR HIGH BLOOD PRESSURE DEMSER ORAL CAPSULE (metyrosine) 3 PA; QL (16 capsules per 1 day) DIBENZYLINE ORAL CAPSULE (phenoxybenzamine hcl) 3 PA; QL (12 capsules per 1 day) metyrosine oral capsule 1 or 1b* PA; QL (16 capsules per 1 day) phenoxybenzamine hcl oral capsule 1 or 1b* PA; QL (12 capsules per 1 day) mesylate injection solution reconstituted 1 or 1b*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 58 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANGIOTENSIN II RECEPTOR ANTAG & CA CHANNEL BLOCKER COMB*** - DRUGS FOR HIGH BLOOD PRESSURE amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, 5-320 mg 1 or 1b* QL (1 tablet per 1 day) amlodipine besylate-valsartan oral tablet 5-160 mg 1 or 1b* DO amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-40 mg 1 or 1b* QL (1 tablet per 1 day) amlodipine-olmesartan oral tablet 5-20 mg 1 or 1b* DO -amlodipine oral tablet 40-10 mg, 80-10 mg, 80-5 mg 1 or 1b* QL (1 tablet per 1 day) telmisartan-amlodipine oral tablet 40-5 mg 1 or 1b* DO TWYNSTA ORAL TABLET 40-10 MG, 80-10 MG, 80-5 MG (telmisartan- 3 QL (1 tablet per 1 day) amlodipine) TWYNSTA ORAL TABLET 40-5 MG (telmisartan-amlodipine) 3 DO *ANGIOTENSIN II RECEPTOR ANTAG & THIAZIDE/THIAZIDE- LIKE*** - DRUGS FOR HIGH BLOOD PRESSURE candesartan cilexetil-hctz oral tablet 16-12.5 mg 1 or 1b* QL (2 tablets per 1 day) candesartan cilexetil-hctz oral tablet 32-12.5 mg, 32-25 mg 1 or 1b* QL (1 tablet per 1 day) EDARBYCLOR ORAL TABLET (azilsartan-chlorthalidone) 3 QL (1 tablet per 1 day) irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg 1 or 1b* QL (2 tablets per 1 day) irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg 1 or 1b* QL (1 tablet per 1 day) losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg 1 or 1b* QL (1 tablet per 1 day) losartan potassium-hctz oral tablet 50-12.5 mg 1 or 1b* DO olmesartan medoxomil-hctz oral tablet 20-12.5 mg 1 or 1b* DO olmesartan medoxomil-hctz oral tablet 40-12.5 mg, 40-25 mg 1 or 1b* QL (1 tablet per 1 day) telmisartan-hctz oral tablet 40-12.5 mg 1 or 1b* DO telmisartan-hctz oral tablet 80-12.5 mg 1 or 1b* QL (2 tablets per 1 day) telmisartan-hctz oral tablet 80-25 mg 1 or 1b* QL (1 tablet per 1 day) valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 80-12.5 mg 1 or 1b* DO valsartan-hydrochlorothiazide oral tablet 160-25 mg, 320-12.5 mg, 320-25 mg 1 or 1b* QL (1 tablet per 1 day) *ANGIOTENSIN II RECEPTOR ANTAGONISTS*** - DRUGS FOR HIGH BLOOD PRESSURE candesartan cilexetil oral tablet 16 mg, 4 mg, 8 mg 1 or 1b* QL (2 tablets per 1 day) candesartan cilexetil oral tablet 32 mg 1 or 1b* QL (1 tablet per 1 day) EDARBI ORAL TABLET 40 MG (azilsartan medoxomil) 3 DO EDARBI ORAL TABLET 80 MG (azilsartan medoxomil) 3 QL (1 tablet per 1 day) irbesartan oral tablet 150 mg, 75 mg 1 or 1b* DO irbesartan oral tablet 300 mg 1 or 1b* QL (1 tablet per 1 day) losartan potassium oral tablet 100 mg 1 or 1b* QL (1 tablet per 1 day) losartan potassium oral tablet 25 mg, 50 mg 1 or 1b* QL (2 tablets per 1 day) olmesartan medoxomil oral tablet 20 mg 1 or 1b* DO olmesartan medoxomil oral tablet 40 mg 1 or 1b* QL (1 tablet per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 59 Coverage Requirements and Prescription Drug Name Drug Tier Limits olmesartan medoxomil oral tablet 5 mg 1 or 1b* QL (2 tablets per 1 day) telmisartan oral tablet 20 mg, 40 mg 1 or 1b* DO telmisartan oral tablet 80 mg 1 or 1b* QL (2 tablets per 1 day) valsartan oral tablet 160 mg 1 or 1b* QL (2 tablets per 1 day) valsartan oral tablet 320 mg 1 or 1b* QL (1 tablet per 1 day) valsartan oral tablet 40 mg, 80 mg 1 or 1b* QL (3 tablet per 1 day) *ANGIOTENSIN II RECEPTOR ANT-CA CHANNEL BLOCKER- *** - DRUGS FOR HIGH BLOOD PRESSURE amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320- 1 or 1b* QL (1 tablet per 1 day) 25 mg, 5-160-25 mg amlodipine-valsartan-hctz oral tablet 5-160-12.5 mg 1 or 1b* DO olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg 1 or 1b* DO olmesartan-amlodipine-hctz oral tablet 40-10-12.5 mg, 40-10-25 mg, 40-5- 1 or 1b* QL (1 tablet per 1 day) 12.5 mg, 40-5-25 mg *ANTIADRENERGICS - CENTRALLY ACTING*** - DRUGS FOR HIGH BLOOD PRESSURE CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY (clonidine) 3 CATAPRES-TTS-2 TRANSDERMAL PATCH WEEKLY (clonidine) 3 CATAPRES-TTS-3 TRANSDERMAL PATCH WEEKLY (clonidine) 3 clonidine hcl oral tablet 1 or 1a* QL (4 tablets per 1 day) clonidine transdermal patch weekly 1 or 1b* guanfacine hcl oral tablet 1 or 1b* oral tablet 250 mg 1 or 1b* DO methyldopa oral tablet 500 mg 1 or 1b* QL (6 tablets per 1 day) *ANTIADRENERGICS - PERIPHERALLY ACTING*** - DRUGS FOR HIGH BLOOD PRESSURE CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG ( mesylate) 3 QL (1 tablet per 1 day) CARDURA ORAL TABLET 8 MG (doxazosin mesylate) 3 QL (2 tablets per 1 day) doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg 1 or 1b* QL (1 tablet per 1 day) doxazosin mesylate oral tablet 8 mg 1 or 1b* QL (2 tablets per 1 day) MINIPRESS ORAL CAPSULE ( hcl) 3 prazosin hcl oral capsule 1 or 1b* terazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1 or 1b* QL (1 capsule per 1 day) terazosin hcl oral capsule 10 mg 1 or 1b* QL (2 capsules per 1 day) *ANTIHYPERTENSIVES - MISC.*** - DRUGS FOR HIGH BLOOD PRESSURE VECAMYL ORAL TABLET ( hcl) 3 * & DIURETIC COMBINATIONS*** - DRUGS FOR HIGH BLOOD PRESSURE atenolol-chlorthalidone oral tablet 1 or 1b* QL (1 tablet per 1 day) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 60 Coverage Requirements and Prescription Drug Name Drug Tier Limits bisoprolol-hydrochlorothiazide oral tablet 1 or 1b* QL (2 tablets per 1 day) DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 QL (2 tablets per 1 day) (metoprolol-hydrochlorothiazide) metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 50-25 mg 1 or 1b* QL (2 tablets per 1 day) metoprolol-hydrochlorothiazide oral tablet 100-50 mg 1 or 1b* QL (1 tablet per 1 day) TENORETIC 100 ORAL TABLET (atenolol-chlorthalidone) 3 QL (1 tablet per 1 day) TENORETIC 50 ORAL TABLET (atenolol-chlorthalidone) 3 QL (1 tablet per 1 day) ZIAC ORAL TABLET (bisoprolol-hydrochlorothiazide) 3 QL (2 tablets per 1 day) *DIRECT RENIN INHIBITORS & THIAZIDE/THIAZIDE-LIKE COMB*** - DRUGS FOR HIGH BLOOD PRESSURE TEKTURNA HCT ORAL TABLET 150-12.5 MG (aliskiren- 3 DO hydrochlorothiazide) TEKTURNA HCT ORAL TABLET 150-25 MG, 300-12.5 MG, 300-25 MG 3 QL (1 tablet per 1 day) (aliskiren-hydrochlorothiazide) *DIRECT RENIN INHIBITORS*** - DRUGS FOR HIGH BLOOD PRESSURE aliskiren fumarate oral tablet 150 mg 1 or 1b* DO aliskiren fumarate oral tablet 300 mg 1 or 1b* QL (1 tablet per 1 day) *DOPAMINE D1 RECEPTOR AGONISTS*** - DRUGS FOR HIGH BLOOD PRESSURE CORLOPAM INTRAVENOUS SOLUTION (fenoldopam mesylate) 3 *SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)*** - DRUGS FOR HIGH BLOOD PRESSURE eplerenone oral tablet 1 or 1b* INSPRA ORAL TABLET (eplerenone) 3 *VASODILATORS*** - DRUGS FOR HIGH BLOOD PRESSURE hydralazine hcl injection solution 1 or 1b* hydralazine hcl oral tablet 1 or 1b* oral tablet 1 or 1b* NIPRIDE RTU INTRAVENOUS SOLUTION (nitroprusside sodium-nacl) 3 nitroprusside sodium intravenous solution 1 or 1b* sodium nitroprusside intravenous solution 1 or 1b* *ANTI-INFECTIVE AGENTS - MISC.* - DRUGS FOR INFECTIONS *ANTI-INFECTIVE AGENTS - MISC.*** - DRUGS FOR INFECTIONS AEMCOLO ORAL TABLET DELAYED RELEASE (rifamycin sodium) 3 PA; QL (12 tablets per 30 days) bacitracin intramuscular solution reconstituted 1 or 1b* FLAGYL ORAL CAPSULE (metronidazole) 3 FLAGYL ORAL TABLET (metronidazole) 3 IMPAVIDO ORAL CAPSULE (miltefosine) 3 PA; QL (84 capsules per 1 fill)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 61 Coverage Requirements and Prescription Drug Name Drug Tier Limits metronidazole in nacl intravenous solution 5-0.79 mg/ml-%, 500-0.79 1 or 1b* mg/100ml-% METRONIDAZOLE IN NACL INTRAVENOUS SOLUTION 500-0.74 3 MG/100ML-% metronidazole oral capsule 1 or 1a* metronidazole oral tablet 1 or 1a* NEBUPENT INHALATION SOLUTION RECONSTITUTED (pentamidine 3 isethionate) pentamidine isethionate inhalation solution reconstituted 1 or 1b* pentamidine isethionate injection solution reconstituted 4 PRIMSOL ORAL SOLUTION (trimethoprim hcl) 3 tinidazole oral tablet 250 mg 1 or 1b* QL (5 tablets per 28 days) tinidazole oral tablet 500 mg 1 or 1b* QL (20 tablets per 1 fill) trimethoprim oral tablet 1 or 1a* XIFAXAN ORAL TABLET 200 MG () 3 PA; QL (9 tablets per 30 days) XIFAXAN ORAL TABLET 550 MG (rifaximin) 3 PA; QL (126 tablet per 252 days) *ANTI-INFECTIVE MISC. - COMBINATIONS*** - ANTIBIOTICS BACTRIM DS ORAL TABLET (sulfamethoxazole-trimethoprim) 3 BACTRIM ORAL TABLET (sulfamethoxazole-trimethoprim) 3 sulfamethoxazole-trimethoprim intravenous solution 1 or 1b* sulfamethoxazole-trimethoprim oral suspension 1 or 1a* sulfamethoxazole-trimethoprim oral tablet 1 or 1a* sulfatrim pediatric oral suspension 1 or 1a* *ANTIPROTOZOAL AGENTS*** - DRUGS FOR PARASITES ALINIA ORAL SUSPENSION RECONSTITUTED (nitazoxanide) 3 ALINIA ORAL TABLET (nitazoxanide) 3 atovaquone oral suspension 1 or 1b* LAMPIT ORAL TABLET (nifurtimox) 3 MEPRON ORAL SUSPENSION (atovaquone) 3 nitazoxanide oral tablet 1 or 1b* *CARBAPENEM COMBINATIONS*** - ANTIBIOTICS imipenem-cilastatin intravenous solution reconstituted 1 or 1b* PRIMAXIN IV INTRAVENOUS SOLUTION RECONSTITUTED 3 (imipenem-cilastatin) RECARBRIO INTRAVENOUS SOLUTION RECONSTITUTED (imipenem- 3 cilastatin-relebactam) VABOMERE INTRAVENOUS SOLUTION RECONSTITUTED 3 (meropenem-vaborbactam)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 62 Coverage Requirements and Prescription Drug Name Drug Tier Limits *CARBAPENEMS*** - ANTIBIOTICS ertapenem sodium injection solution reconstituted 1 or 1b* INVANZ INJECTION SOLUTION RECONSTITUTED (ertapenem sodium) 3 meropenem intravenous solution reconstituted 1 or 1b* MEROPENEM-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 RECONSTITUTED *CHLORAMPHENICALS*** - ANTIBIOTICS chloramphenicol sod succinate intravenous solution reconstituted 1 or 1b* *CYCLIC LIPOPEPTIDES*** - ANTIBIOTICS CUBICIN INTRAVENOUS SOLUTION RECONSTITUTED (daptomycin) 3 CUBICIN RF INTRAVENOUS SOLUTION RECONSTITUTED 3 (daptomycin) DAPTOMYCIN INTRAVENOUS SOLUTION RECONSTITUTED 350 MG 3 daptomycin intravenous solution reconstituted 500 mg 1 or 1b* *GLYCOPEPTIDES*** - ANTIBIOTICS DALVANCE INTRAVENOUS SOLUTION RECONSTITUTED 3 (dalbavancin hcl) FIRVANQ ORAL SOLUTION RECONSTITUTED (vancomycin hcl) 3 PA; QL (1200 mL per 30 days) KIMYRSA INTRAVENOUS SOLUTION RECONSTITUTED (oritavancin 3 diphosphate) ORBACTIV INTRAVENOUS SOLUTION RECONSTITUTED (oritavancin 3 diphosphate) VANCOCIN HCL ORAL CAPSULE (vancomycin hcl) 3 PA; QL (240 capsules per 30 days) VANCOCIN ORAL CAPSULE (vancomycin hcl) 3 PA; QL (240 capsules per 30 days) VANCOMYCIN HCL IN DEXTROSE INTRAVENOUS SOLUTION 1-5 3 GM/200ML-%, 500-5 MG/100ML-%, 750-5 MG/150ML-% VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 1.5-0.9 3 GM/250ML-%, 1.5-0.9 GM/500ML-%, 1.75-0.9 GM/250ML-% VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 1-0.9 3 GM/200ML-%, 500-0.9 MG/100ML-%, 750-0.9 MG/150ML-% VANCOMYCIN HCL INTRAVENOUS SOLUTION 3 vancomycin hcl intravenous solution reconstituted 1 gm, 1000 mg, 500 mg 1 or 1b* QL (2 vials per 1 day) VANCOMYCIN HCL INTRAVENOUS SOLUTION RECONSTITUTED 3 1.25 GM, 1.5 GM, 250 MG vancomycin hcl intravenous solution reconstituted 10 gm, 100 gm, 5 gm, 750 1 or 1b* mg vancomycin hcl oral capsule 1 or 1b* PA; QL (240 capsules per 30 days) VANCOMYCIN HCL ORAL SOLUTION RECONSTITUTED 3 PA; QL (1200 mL per 30 days) VIBATIV INTRAVENOUS SOLUTION RECONSTITUTED (telavancin hcl) 3 *LEPROSTATICS*** - ANTIBIOTICS dapsone oral tablet 1 or 1b* BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 63 Coverage Requirements and Prescription Drug Name Drug Tier Limits *LINCOSAMIDES*** - ANTIBIOTICS CLEOCIN ORAL CAPSULE ( hcl) 3 CLEOCIN ORAL SOLUTION RECONSTITUTED (clindamycin palmitate 3 hcl) CLEOCIN PHOSPHATE INJECTION SOLUTION (clindamycin phosphate) 3 QL (20 mL per 1 day) clindamycin hcl oral capsule 1 or 1b* clindamycin palmitate hcl oral solution reconstituted 1 or 1b* clindamycin phosphate in d5w intravenous solution 1 or 1b* CLINDAMYCIN PHOSPHATE IN NACL INTRAVENOUS SOLUTION 3 clindamycin phosphate injection solution 1 or 1b* QL (20 mL per 1 day) LINCOCIN INJECTION SOLUTION (lincomycin hcl) 3 lincomycin hcl injection solution 1 or 1b* *MONOBACTAMS*** - ANTIBIOTICS AZACTAM INJECTION SOLUTION RECONSTITUTED (aztreonam) 3 aztreonam injection solution reconstituted 1 or 1b* *OXAZOLIDINONES*** - ANTIBIOTICS in sodium chloride intravenous solution 1 or 1b* linezolid intravenous solution 1 or 1b* linezolid oral suspension reconstituted 1 or 1b* PA; QL (900 mL per 30 days) linezolid oral tablet 1 or 1b* PA; QL (28 tablet per 30 days) SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED (tedizolid 3 phosphate) SIVEXTRO ORAL TABLET (tedizolid phosphate) 3 PA; QL (6 tablet per 30 days) ZYVOX INTRAVENOUS SOLUTION (linezolid) 3 ZYVOX ORAL SUSPENSION RECONSTITUTED (linezolid) 3 PA; QL (900 mL per 30 days) ZYVOX ORAL TABLET (linezolid) 3 PA; QL (28 tablet per 30 days) *PLEUROMUTILINS*** - ANTIBIOTICS XENLETA INTRAVENOUS SOLUTION (lefamulin acetate) 3 LD XENLETA ORAL TABLET (lefamulin acetate) 3 PA; LD; QL (10 tablets per 30 days) *POLYMYXINS*** - ANTIBIOTICS colistimethate sodium (cba) injection solution reconstituted 1 or 1b* COLY-MYCIN M INJECTION SOLUTION RECONSTITUTED 3 (colistimethate sodium) polymyxin b sulfate injection solution reconstituted 1 or 1b* *STREPTOGRAMIN COMBINATIONS*** - ANTIBIOTICS SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED 3 (quinupristin-dalfopristin) *URINARY ANTI-INFECTIVES*** - ANTIBIOTICS fosfomycin tromethamine oral packet 1 or 1b* QL (1 pack per 1 fill)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 64 Coverage Requirements and Prescription Drug Name Drug Tier Limits HIPREX ORAL TABLET (methenamine hippurate) 3 MACROBID ORAL CAPSULE (nitrofurantoin monohyd macro) 3 QL (14 capsules per 1 fill) MACRODANTIN ORAL CAPSULE (nitrofurantoin macrocrystal) 3 QL (4 capsules per 1 day) methenamine hippurate oral tablet 1 or 1b* MONUROL ORAL PACKET (fosfomycin tromethamine) 3 QL (1 pack per 1 fill) nitrofurantoin macrocrystal oral capsule 1 or 1b* QL (4 capsules per 1 day) nitrofurantoin monohyd macro oral capsule 1 or 1b* QL (14 capsules per 1 fill) nitrofurantoin oral suspension 1 or 1b* QL (80 mL per 1 day) *ANTIMALARIALS* - DRUGS FOR INFECTIONS *ANTIMALARIAL COMBINATIONS*** - DRUGS FOR PARASITES atovaquone-proguanil hcl oral tablet 1 or 1b* COARTEM ORAL TABLET (artemether-lumefantrine) 3 MALARONE ORAL TABLET (atovaquone-proguanil hcl) 3 *ANTIMALARIALS*** - DRUGS FOR PARASITES ARAKODA ORAL TABLET (tafenoquine succinate) 3 QL (56 tablets per 1 year) ARTESUNATE INTRAVENOUS SOLUTION RECONSTITUTED 3 chloroquine phosphate oral tablet 1 or 1a* DARAPRIM ORAL TABLET (pyrimethamine) 3 PA; LD; QL (3 tablets per 1 day) hydroxychloroquine sulfate oral tablet 1 or 1b* QL (90 tablets per 30 days) KRINTAFEL ORAL TABLET (tafenoquine succinate) 3 QL (2 tablets per 1 fill) mefloquine hcl oral tablet 1 or 1b* QL (5 tablets per 28 days) PRIMAQUINE PHOSPHATE ORAL TABLET 3 pyrimethamine oral tablet 1 or 1b* PA; QL (3 tablets per 1 day) QUALAQUIN ORAL CAPSULE (quinine sulfate) 3 PA; QL (60 capsule per 365 days) quinine sulfate oral capsule 1 or 1b* PA; QL (60 capsule per 365 days) *ANTIMYASTHENIC/CHOLINERGIC AGENTS* - DRUGS FOR NERVES AND MUSCLES *ANTIMYASTHENIC/CHOLINERGIC AGENTS*** - DRUGS FOR NERVES AND MUSCLES BLOXIVERZ INTRAVENOUS SOLUTION (neostigmine methylsulfate) 3 MESTINON ORAL SOLUTION (pyridostigmine bromide) 3 MESTINON ORAL TABLET (pyridostigmine bromide) 3 MESTINON ORAL TABLET EXTENDED RELEASE (pyridostigmine 3 bromide) NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION 10 3 MG/10ML, 5 MG/10ML pyridostigmine bromide er oral tablet extended release 1 or 1b* pyridostigmine bromide oral solution 1 or 1b* pyridostigmine bromide oral tablet 1 or 1b*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 65 Coverage Requirements and Prescription Drug Name Drug Tier Limits REGONOL INTRAVENOUS SOLUTION (pyridostigmine bromide) 3 *ANTIMYCOBACTERIAL AGENTS* - DRUGS FOR INFECTIONS *ANTIMYCOBACTERIAL AGENTS*** - ANTIBIOTICS CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 3 (capreomycin sulfate) cycloserine oral capsule 1 or 1b* ethambutol hcl oral tablet 1 or 1b* isoniazid injection solution 1 or 1a* isoniazid oral syrup 1 or 1a* isoniazid oral tablet 1 or 1a* MYAMBUTOL ORAL TABLET (ethambutol hcl) 3 MYCOBUTIN ORAL CAPSULE (rifabutin) 3 PASER ORAL PACKET (aminosalicylic acid) 3 PRETOMANID ORAL TABLET 3 PRIFTIN ORAL TABLET (rifapentine) 2 pyrazinamide oral tablet 1 or 1b* rifabutin oral capsule 1 or 1b* RIFADIN INTRAVENOUS SOLUTION RECONSTITUTED (rifampin) 3 rifampin intravenous solution reconstituted 1 or 1b* rifampin oral capsule 1 or 1b* SIRTURO ORAL TABLET (bedaquiline fumarate) 3 TRECATOR ORAL TABLET (ethionamide) 3 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* - DRUGS FOR CANCER *ALKYLATING AGENTS*** - DRUGS FOR CANCER BELRAPZO INTRAVENOUS SOLUTION ( hcl) 3 PA; LD; SP BENDEKA INTRAVENOUS SOLUTION (bendamustine hcl) 3 PA; LD; SP intravenous solution 1 or 1b* SP BUSULFEX INTRAVENOUS SOLUTION (busulfan) 3 SP intravenous solution 1 or 1b* SP intravenous solution 1 or 1b* SP CISPLATIN INTRAVENOUS SOLUTION RECONSTITUTED 3 SP MYLERAN ORAL TABLET (busulfan) 2; OC intravenous solution 1 or 1b* SP oxaliplatin intravenous solution reconstituted 1 or 1b* SP paraplatin intravenous solution 1 or 1b* SP TEPADINA INJECTION SOLUTION RECONSTITUTED () 3 SP thiotepa injection solution reconstituted 1 or 1b* SP

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 66 Coverage Requirements and Prescription Drug Name Drug Tier Limits TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (bendamustine hcl) ZEPZELCA INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (lurbinectedin) * BIOSYNTHESIS INHIBITORS*** - DRUGS FOR CANCER oral tablet 250 mg 1 or 1b*; OC PA; SP; QL (4 tablet per 1 day) abiraterone acetate oral tablet 500 mg 1 or 1b*; OC PA; SP; QL (2 tablets per 1 day) PA; LD; SP; QL (4 tablets per 1 YONSA ORAL TABLET (abiraterone acetate) 3; OC day) ZYTIGA ORAL TABLET 250 MG (abiraterone acetate) 3; OC PA; LD; SP; QL (4 tablet per 1 day) PA; LD; SP; QL (2 tablets per 1 ZYTIGA ORAL TABLET 500 MG (abiraterone acetate) 3; OC day) *ANTIADRENALS*** - DRUGS FOR CANCER LYSODREN ORAL TABLET () 2; OC LD; QL (38 tablet per 1 day) **** - DRUGS FOR CANCER oral tablet 1 or 1b*; OC CASODEX ORAL TABLET (bicalutamide) 3; OC PA; LD; SP; QL (4 tablets per 1 ERLEADA ORAL TABLET () 2; OC day) oral capsule 1 or 1b*; OC NILANDRON ORAL TABLET () 3; OC QL (1 tablet per 1 day) nilutamide oral tablet 1 or 1b*; OC QL (1 tablet per 1 day) PA; LD; SP; QL (4 tablets per 1 NUBEQA ORAL TABLET () 3; OC day) PA; LD; SP; QL (4 capsules per 1 XTANDI ORAL CAPSULE () 2; OC day) PA; LD; SP; QL (4 tablets per 1 XTANDI ORAL TABLET 40 MG (enzalutamide) 2; OC day) PA; LD; SP; QL (2 tablets per 1 XTANDI ORAL TABLET 80 MG (enzalutamide) 2; OC day) **** - DRUGS FOR CANCER FARESTON ORAL TABLET (toremifene citrate) 3; OC QL (1 tablet per 1 day) SOLTAMOX ORAL SOLUTION ( citrate) 2; OC; $0 tamoxifen citrate oral tablet 1 or 1b*; OC; $0 toremifene citrate oral tablet 1 or 1b*; OC QL (1 tablet per 1 day) *ANTIMETABOLITES*** - DRUGS FOR CANCER ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED ( 3 PA; SP disodium) ARRANON INTRAVENOUS SOLUTION () 3 SP injection suspension reconstituted 1 or 1b* PA; SP

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 67 Coverage Requirements and Prescription Drug Name Drug Tier Limits oral tablet 1 or 1b*; OC PA; SP intravenous solution 1 or 1b* SP intravenous solution 1 or 1b* SP CLOLAR INTRAVENOUS SOLUTION (clofarabine) 3 SP (pf) injection solution 1 or 1b* SP cytarabine injection solution 1 or 1b* SP DACOGEN INTRAVENOUS SOLUTION RECONSTITUTED () 3 SP decitabine intravenous solution reconstituted 1 or 1b* SP injection solution reconstituted 1 or 1b* SP phosphate intravenous solution 1 or 1b* SP fludarabine phosphate intravenous solution reconstituted 1 or 1b* SP intravenous solution 1 or 1b* SP FOLOTYN INTRAVENOUS SOLUTION () 3 SP HCL INTRAVENOUS SOLUTION 3 SP gemcitabine hcl intravenous solution reconstituted 1 or 1b* SP INFUGEM INTRAVENOUS SOLUTION (gemcitabine hcl-nacl) 3 SP oral tablet 1 or 1b*; OC methotrexate oral tablet 1 or 1b*; OC methotrexate sodium (pf) injection solution 1 or 1b* methotrexate sodium injection solution 1 or 1b* methotrexate sodium injection solution reconstituted 1 or 1b* methotrexate sodium oral tablet 1 or 1b*; OC PA; LD; SP; QL (14 tablets per 28 ONUREG ORAL TABLET (azacitidine) 3; OC days) PURIXAN ORAL SUSPENSION (mercaptopurine) 3; OC PA; LD TABLOID ORAL TABLET (thioguanine) 2; OC TREXALL ORAL TABLET (methotrexate sodium) 2; OC VIDAZA INJECTION SUSPENSION RECONSTITUTED (azacitidine) 3 PA; LD; SP XATMEP ORAL SOLUTION (methotrexate) 3; OC PA; SP XELODA ORAL TABLET (capecitabine) 3; OC PA; LD; SP *ANTINEOPLASTIC - ALK INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (8 capsule per 1 ALECENSA ORAL CAPSULE (alectinib hcl) 3; OC day) ALUNBRIG ORAL TABLET 180 MG (brigatinib) 3; OC PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (6 tablets per 1 ALUNBRIG ORAL TABLET 30 MG (brigatinib) 3; OC day) PA; LD; SP; QL (2 tablets per 1 ALUNBRIG ORAL TABLET 90 MG (brigatinib) 3; OC day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 68 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; LD; SP; QL (1 pack per 30 ALUNBRIG ORAL TABLET THERAPY PACK (brigatinib) 3; OC days) LORBRENA ORAL TABLET 100 MG (lorlatinib) 3; OC PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (3 tablets per 1 LORBRENA ORAL TABLET 25 MG (lorlatinib) 3; OC day) PA; LD; SP; QL (4 capsules per 1 XALKORI ORAL CAPSULE (crizotinib) 2; OC day) PA; LD; SP; QL (3 capsules per 1 ZYKADIA ORAL TABLET (ceritinib) 3; OC day) *ANTINEOPLASTIC - ANTI-BCMA ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER BLENREP INTRAVENOUS SOLUTION RECONSTITUTED (belantamab 3 PA; LD; SP mafodotin-blmf) *ANTINEOPLASTIC - ANTI-CCR4 ANTIBODIES*** - DRUGS FOR CANCER POTELIGEO INTRAVENOUS SOLUTION (mogamulizumab-kpkc) 3 LD; SP *ANTINEOPLASTIC - ANTI-CD19 ANTIBODIES*** - DRUGS FOR CANCER MONJUVI INTRAVENOUS SOLUTION RECONSTITUTED (tafasitamab- 3 PA; LD cxix) *ANTINEOPLASTIC - ANTI-CD19 ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER ZYNLONTA INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD (loncastuximab tesirine-lpyl) *ANTINEOPLASTIC - ANTI-CD20 ANTIBODIES*** - DRUGS FOR CANCER ARZERRA INTRAVENOUS CONCENTRATE (ofatumumab) 3 PA; LD; SP GAZYVA INTRAVENOUS SOLUTION (obinutuzumab) 3 PA; LD; SP RIABNI INTRAVENOUS SOLUTION (rituximab-arrx) 3 PA; LD; SP RITUXAN INTRAVENOUS SOLUTION (rituximab) 3 PA; LD; SP RUXIENCE INTRAVENOUS SOLUTION (rituximab-pvvr) 3 PA; SP TRUXIMA INTRAVENOUS SOLUTION (rituximab-abbs) 3 PA; SP *ANTINEOPLASTIC - ANTI-CD22 ANTIBODIES*** - DRUGS FOR CANCER LUMOXITI INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (moxetumomab pasudotox-tdfk) *ANTINEOPLASTIC - ANTI-CD22 ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER BESPONSA INTRAVENOUS SOLUTION RECONSTITUTED (inotuzumab 3 PA; LD; SP ozogamicin)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 69 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTINEOPLASTIC - ANTI-CD30 ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER ADCETRIS INTRAVENOUS SOLUTION RECONSTITUTED (brentuximab 3 PA; LD; SP vedotin) *ANTINEOPLASTIC - ANTI-CD33 ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (gemtuzumab ozogamicin) *ANTINEOPLASTIC - ANTI-CD38 ANTIBODIES*** - DRUGS FOR CANCER DARZALEX INTRAVENOUS SOLUTION (daratumumab) 3 PA; LD; SP SARCLISA INTRAVENOUS SOLUTION (isatuximab-irfc) 3 PA; LD; SP *ANTINEOPLASTIC - ANTI-CD79B ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER POLIVY INTRAVENOUS SOLUTION RECONSTITUTED (polatuzumab 3 PA; LD; SP vedotin-piiq) *ANTINEOPLASTIC - ANTI-CTLA-4 ANTIBODIES*** - DRUGS FOR CANCER YERVOY INTRAVENOUS SOLUTION (ipilimumab) 3 PA; LD; SP *ANTINEOPLASTIC - ANTI-GD2 ANTIBODIES*** - DRUGS FOR CANCER DANYELZA INTRAVENOUS SOLUTION (naxitamab-gqgk) 3 PA; LD UNITUXIN INTRAVENOUS SOLUTION (dinutuximab) 3 LD *ANTINEOPLASTIC - ANTI-HER2 AGENTS*** - DRUGS FOR CANCER HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 3 LD; SP (trastuzumab) HERZUMA INTRAVENOUS SOLUTION RECONSTITUTED (trastuzumab- 3 LD; SP pkrb) KANJINTI INTRAVENOUS SOLUTION RECONSTITUTED (trastuzumab- 3 LD; SP anns) MARGENZA INTRAVENOUS SOLUTION (margetuximab-cmkb) 3 PA; LD OGIVRI INTRAVENOUS SOLUTION RECONSTITUTED (trastuzumab- 3 LD; SP dkst) ONTRUZANT INTRAVENOUS SOLUTION RECONSTITUTED 3 LD; SP (trastuzumab-dttb) PERJETA INTRAVENOUS SOLUTION (pertuzumab) 3 PA; LD; SP TRAZIMERA INTRAVENOUS SOLUTION RECONSTITUTED 3 SP (trastuzumab-qyyp) TUKYSA ORAL TABLET (tucatinib) 3; OC PA; LD; QL (4 tablets per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 70 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTINEOPLASTIC - ANTI-NECTIN-4 ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER PADCEV INTRAVENOUS SOLUTION RECONSTITUTED (enfortumab 3 PA; LD; SP vedotin-ejfv) *ANTINEOPLASTIC - ANTI-PD-1 ANTIBODIES*** - DRUGS FOR CANCER JEMPERLI INTRAVENOUS SOLUTION (dostarlimab-gxly) 3 PA; LD; SP KEYTRUDA INTRAVENOUS SOLUTION (pembrolizumab) 3 PA; LD; SP LIBTAYO INTRAVENOUS SOLUTION (cemiplimab-rwlc) 3 PA; LD OPDIVO INTRAVENOUS SOLUTION (nivolumab) 3 PA; LD; SP *ANTINEOPLASTIC - ANTI-PD-L1 ANTIBODIES*** - DRUGS FOR CANCER BAVENCIO INTRAVENOUS SOLUTION (avelumab) 3 PA; LD IMFINZI INTRAVENOUS SOLUTION (durvalumab) 3 PA; LD; SP TECENTRIQ INTRAVENOUS SOLUTION () 3 PA; LD; SP *ANTINEOPLASTIC - ANTI-SLAMF7 ANTIBODIES*** - DRUGS FOR CANCER EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED (elotuzumab) 3 PA; LD; SP *ANTINEOPLASTIC - BCL-2 INHIBITORS*** - DRUGS FOR CANCER VENCLEXTA ORAL TABLET 10 MG () 3; OC PA; LD; QL (2 tablets per 1 day) VENCLEXTA ORAL TABLET 100 MG (venetoclax) 3; OC PA; LD; QL (6 tablet per 1 day) VENCLEXTA ORAL TABLET 50 MG (venetoclax) 3; OC PA; LD; QL (1 tablet per 1 day) VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 pack per 365 days) (venetoclax) *ANTINEOPLASTIC - BCR-ABL KINASE INHIBITORS*** - DRUGS FOR CANCER BOSULIF ORAL TABLET 100 MG (bosutinib) 2; OC PA; SP; QL (4 tablet per 1 day) BOSULIF ORAL TABLET 400 MG, 500 MG (bosutinib) 2; OC PA; SP; QL (1 tablet per 1 day) ICLUSIG ORAL TABLET 10 MG, 30 MG, 45 MG (ponatinib hcl) 2; OC PA; LD; QL (1 tablet per 1 day) ICLUSIG ORAL TABLET 15 MG (ponatinib hcl) 2; OC PA; LD; QL (2 tablets per 1 day) imatinib mesylate oral tablet 1 or 1b*; OC PA; SP; QL (2 tablets per 1 day) SPRYCEL ORAL TABLET (dasatinib) 2; OC PA; SP; QL (1 tablet per 1 day) TASIGNA ORAL CAPSULE (nilotinib hcl) 2; OC PA; SP; QL (4 capsules per 1 day) *ANTINEOPLASTIC - BISPECIFIC T-CELL ENGAGERS*** - DRUGS FOR CANCER BLINCYTO INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (blinatumomab)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 71 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTINEOPLASTIC - BRAF KINASE INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (6 capsules per 1 BRAFTOVI ORAL CAPSULE (encorafenib) 3; OC day) PA; LD; SP; QL (4 capsule per 1 TAFINLAR ORAL CAPSULE (dabrafenib mesylate) 3; OC day) ZELBORAF ORAL TABLET (vemurafenib) 2; OC PA; LD; SP; QL (8 tablet per 1 day) *ANTINEOPLASTIC - BTK INHIBITORS*** - DRUGS FOR CANCER BRUKINSA ORAL CAPSULE (zanubrutinib) 3; OC PA; LD; QL (4 capsules per 1 day) CALQUENCE ORAL CAPSULE (acalabrutinib) 3; OC PA; LD; QL (1 capsule per 1 day) IMBRUVICA ORAL CAPSULE 140 MG (ibrutinib) 3; OC PA; LD; QL (3 capsule per 1 day) IMBRUVICA ORAL CAPSULE 70 MG (ibrutinib) 3; OC PA; LD; QL (1 tablet per 1 day) IMBRUVICA ORAL TABLET (ibrutinib) 3; OC PA; LD; QL (1 tablet per 1 day) *ANTINEOPLASTIC - EGFR INHIBITORS*** - DRUGS FOR CANCER ERBITUX INTRAVENOUS SOLUTION (cetuximab) 3 PA; SP erlotinib hcl oral tablet 100 mg, 150 mg 1 or 1b*; OC PA; SP; QL (1 tablet per 1 day) erlotinib hcl oral tablet 25 mg 1 or 1b*; OC PA; SP; QL (3 tablets per 1 day) GILOTRIF ORAL TABLET (afatinib dimaleate) 3; OC PA; LD; QL (1 tablet per 1 day) IRESSA ORAL TABLET (gefitinib) 2; OC PA; LD; SP; QL (1 tablet per 1 day) PORTRAZZA INTRAVENOUS SOLUTION (necitumumab) 3 LD; SP TAGRISSO ORAL TABLET (osimertinib mesylate) 3; OC PA; LD; SP; QL (1 tablet per 1 day) TARCEVA ORAL TABLET 100 MG, 150 MG (erlotinib hcl) 3; OC PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (3 tablets per 1 TARCEVA ORAL TABLET 25 MG (erlotinib hcl) 3; OC day) VECTIBIX INTRAVENOUS SOLUTION (panitumumab) 3 PA; SP VIZIMPRO ORAL TABLET (dacomitinib) 3; OC PA; LD; SP; QL (1 tablet per 1 day) *ANTINEOPLASTIC - FGFR KINASE INHIBITORS*** - DRUGS FOR CANCER BALVERSA ORAL TABLET 3 MG (erdafitinib) 3; OC PA; LD; QL (3 tablets per 1 day) BALVERSA ORAL TABLET 4 MG (erdafitinib) 3; OC PA; LD; QL (2 tablets per 1 day) BALVERSA ORAL TABLET 5 MG (erdafitinib) 3; OC PA; LD; QL (1 tablet per 1 day) PEMAZYRE ORAL TABLET (pemigatinib) 3; OC PA; LD; QL (14 tablets per 21 days) TRUSELTIQ (100MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 3; OC PA; LD; QL (1 carton per 28 days) (infigratinib phosphate) TRUSELTIQ (125MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 3; OC PA; LD; QL (1 carton per 28 days) (infigratinib phosphate) TRUSELTIQ (50MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 3; OC PA; LD; QL (1 carton per 28 days) (infigratinib phosphate) TRUSELTIQ (75MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 3; OC PA; LD; QL (1 carton per 28 days) (infigratinib phosphate) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 72 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS*** - DRUGS FOR CANCER DAURISMO ORAL TABLET 100 MG (glasdegib maleate) 3; OC PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (2 tablets per 1 DAURISMO ORAL TABLET 25 MG (glasdegib maleate) 3; OC day) PA; LD; SP; QL (1 capsule per 1 ERIVEDGE ORAL CAPSULE (vismodegib) 2; OC day) PA; LD; SP; QL (1 capsule per 1 ODOMZO ORAL CAPSULE (sonidegib phosphate) 3; OC day) *ANTINEOPLASTIC - HISTONE DEACETYLASE INHIBITORS*** - DRUGS FOR CANCER BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED () 3 PA; LD; SP PA; LD; SP; QL (1 capsule per 1 FARYDAK ORAL CAPSULE ( lactate) 3; OC day) ISTODAX (OVERFILL) INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP () ROMIDEPSIN INTRAVENOUS SOLUTION 3 PA; SP ZOLINZA ORAL CAPSULE () 2; OC PA; SP; QL (4 capsule per 1 day) *ANTINEOPLASTIC - HORMONAL AND RELATED AGENT COMBINATIONS*** - DRUGS FOR CANCER LEUPROLIDE ACETATE-BUPIVACAINE INTRAMUSCULAR 3 SOLUTION *ANTINEOPLASTIC - IMMUNOMODULATORS*** - DRUGS FOR CANCER PA; LD; SP; QL (21 capsules per 28 POMALYST ORAL CAPSULE (pomalidomide) 3; OC days) *ANTINEOPLASTIC - KRAS INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (8 tablets per 1 LUMAKRAS ORAL TABLET (sotorasib) 3; OC day) *ANTINEOPLASTIC - MEK INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (3 tablets per 1 COTELLIC ORAL TABLET (cobimetinib fumarate) 3; OC day) KOSELUGO ORAL CAPSULE 10 MG (selumetinib sulfate) 3; OC PA; LD; QL (8 capsules per 1 day) KOSELUGO ORAL CAPSULE 25 MG (selumetinib sulfate) 3; OC PA; LD; QL (4 capsules per 1 day) PA; LD; SP; QL (3 tablets per 1 MEKINIST ORAL TABLET 0.5 MG (trametinib dimethyl sulfoxide) 3; OC day) MEKINIST ORAL TABLET 2 MG (trametinib dimethyl sulfoxide) 3; OC PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (6 tablets per 1 MEKTOVI ORAL TABLET (binimetinib) 3; OC day) *ANTINEOPLASTIC - MET INHIBITORS*** - DRUGS FOR CANCER TABRECTA ORAL TABLET (capmatinib hcl) 3; OC PA; SP; QL (4 tablets per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 73 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTINEOPLASTIC - METHYLTRANSFERASE INHIBITORS*** - DRUGS FOR CANCER TAZVERIK ORAL TABLET (tazemetostat hbr) 3; OC PA; LD; QL (8 tablets per 1 day) *ANTINEOPLASTIC - MTOR KINASE INHIBITORS*** - DRUGS FOR CANCER AFINITOR DISPERZ ORAL TABLET SOLUBLE () 3; OC PA; SP AFINITOR ORAL TABLET 10 MG (everolimus) 2; OC PA; SP AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG (everolimus) 3; OC PA; SP everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg 1 or 1b*; OC PA; SP intravenous solution 1 or 1b* PA; SP TORISEL INTRAVENOUS SOLUTION (temsirolimus) 3 PA; SP *ANTINEOPLASTIC - MULTIKINASE INHIBITORS*** - DRUGS FOR CANCER CABOMETYX ORAL TABLET (cabozantinib s-malate) 3; OC PA; LD; SP; QL (1 tablet per 1 day) CAPRELSA ORAL TABLET 100 MG (vandetanib) 2; OC PA; LD; QL (3 tablet per 1 day) CAPRELSA ORAL TABLET 300 MG (vandetanib) 2; OC PA; LD; QL (1 tablet per 1 day) PA; LD; SP; QL (1 dose-pack per COMETRIQ (100 MG DAILY DOSE) ORAL KIT (cabozantinib s-malate) 3; OC 56 days) PA; LD; SP; QL (1 dose pack per COMETRIQ (140 MG DAILY DOSE) ORAL KIT (cabozantinib s-malate) 3; OC 28 days) PA; LD; SP; QL (1 dose pack per COMETRIQ (60 MG DAILY DOSE) ORAL KIT (cabozantinib s-malate) 3; OC 28 days) PA; LD; QL (21 capsules per 28 FOTIVDA ORAL CAPSULE (tivozanib hcl) 3; OC days) lapatinib ditosylate oral tablet 1 or 1b*; OC PA; SP; QL (6 tablet per 1 day) PA; LD; SP; QL (6 tablets per 1 NERLYNX ORAL TABLET (neratinib maleate) 3; OC day) NEXAVAR ORAL TABLET ( tosylate) 2; OC PA; LD; SP; QL (4 tablet per 1 day) QINLOCK ORAL TABLET (ripretinib) 3; OC PA; LD; QL (3 tablets per 1 day) RYDAPT ORAL CAPSULE (midostaurin) 3; OC PA; SP; QL (8 capsules per 1 day) PA; LD; SP; QL (84 tablets per 28 STIVARGA ORAL TABLET (regorafenib) 2; OC days) PA; LD; SP; QL (1 capsule per 1 SUTENT ORAL CAPSULE (sunitinib malate) 2; OC day) TEPMETKO ORAL TABLET (tepotinib hcl) 3; OC PA; LD; QL (2 tablets per 1 day) TURALIO ORAL CAPSULE (pexidartinib hcl) 3; OC PA; LD; QL (4 tablets per 1 day) TYKERB ORAL TABLET (lapatinib ditosylate) 3; OC PA; LD; SP; QL (6 tablet per 1 day) UKONIQ ORAL TABLET ( tosylate) 3; OC PA; LD; QL (4 tablets per 1 day) VOTRIENT ORAL TABLET (pazopanib hcl) 2; OC PA; LD; SP; QL (4 tablet per 1 day) XOSPATA ORAL TABLET (gilteritinib fumarate) 3; OC PA; LD; QL (3 tablets per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 74 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTINEOPLASTIC - MULTIPLE RECEPTOR ANTIBODIES*** - DRUGS FOR CANCER RYBREVANT INTRAVENOUS SOLUTION (amivantamab-vmjw) 3 LD; SP *ANTINEOPLASTIC - PDGFR-ALPHA INHIBITORS*** - DRUGS FOR CANCER AYVAKIT ORAL TABLET (avapritinib) 3; OC PA; LD; QL (1 tablet per 1 day) *ANTINEOPLASTIC - PROTEASOME INHIBITORS*** - DRUGS FOR CANCER INTRAVENOUS SOLUTION RECONSTITUTED 3 PA KYPROLIS INTRAVENOUS SOLUTION RECONSTITUTED () 3 PA; LD; SP PA; LD; SP; QL (3 capsule per 28 NINLARO ORAL CAPSULE ( citrate) 3; OC days) VELCADE INJECTION SOLUTION RECONSTITUTED (bortezomib) 3 PA; SP *ANTINEOPLASTIC - RET INHIBITORS*** - DRUGS FOR CANCER GAVRETO ORAL CAPSULE (pralsetinib) 3; OC PA; LD; QL (4 capsules per 1 day) PA; LD; SP; QL (6 capsules per 1 RETEVMO ORAL CAPSULE 40 MG (selpercatinib) 3; OC day) PA; LD; SP; QL (4 capsules per 1 RETEVMO ORAL CAPSULE 80 MG (selpercatinib) 3; OC day) *ANTINEOPLASTIC - TROPOMYOSIN RECEPTOR KINASE INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (1 capsule per 1 ROZLYTREK ORAL CAPSULE 100 MG (entrectinib) 3; OC day) PA; LD; SP; QL (3 capsules per 1 ROZLYTREK ORAL CAPSULE 200 MG (entrectinib) 3; OC day) PA; LD; SP; QL (2 tablets per 1 VITRAKVI ORAL CAPSULE 100 MG (larotrectinib sulfate) 3; OC day) PA; LD; SP; QL (6 tablets per 1 VITRAKVI ORAL CAPSULE 25 MG (larotrectinib sulfate) 3; OC day) VITRAKVI ORAL SOLUTION (larotrectinib sulfate) 3; OC PA; LD; SP; QL (10 mL per 1 day) *ANTINEOPLASTIC - XPO1 INHIBITORS*** - DRUGS FOR CANCER XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 carton per 28 days) (selinexor) XPOVIO (40 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 carton per 28 days) (selinexor) XPOVIO (40 MG TWICE WEEKLY) ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 carton per 28 days) (selinexor) XPOVIO (60 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 carton per 28 days) (selinexor) XPOVIO (60 MG TWICE WEEKLY) ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 pack per 1 week) (selinexor)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 75 Coverage Requirements and Prescription Drug Name Drug Tier Limits XPOVIO (80 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 carton per 28 days) (selinexor) XPOVIO (80 MG TWICE WEEKLY) ORAL TABLET THERAPY PACK 3; OC PA; LD; QL (1 pack per 1 week) (selinexor) *ANTINEOPLASTIC ANTIBIOTICS*** - DRUGS FOR CANCER adriamycin intravenous solution 1 or 1b* SP adriamycin intravenous solution reconstituted 1 or 1b* SP sulfate injection solution reconstituted 1 or 1b* SP COSMEGEN INTRAVENOUS SOLUTION RECONSTITUTED 3 SP () dactinomycin intravenous solution reconstituted 1 or 1b* SP HCL INTRAVENOUS SOLUTION 3 SP DOXIL INTRAVENOUS INJECTABLE ( hcl liposomal) 3 PA; SP doxorubicin hcl intravenous solution 1 or 1b* SP doxorubicin hcl intravenous solution reconstituted 1 or 1b* SP doxorubicin hcl liposomal intravenous injectable 1 or 1b* PA; SP ELLENCE INTRAVENOUS SOLUTION ( hcl) 3 PA; SP epirubicin hcl intravenous solution 1 or 1b* PA; SP IDAMYCIN PFS INTRAVENOUS SOLUTION ( hcl) 3 SP idarubicin hcl intravenous solution 1 or 1b* SP JELMYTO SOLUTION RECONSTITUTED (mitomycin) 3 PA; LD mitomycin intravenous solution reconstituted 1 or 1b* SP MITOMYCIN INTRAVESICAL SOLUTION PREFILLED SYRINGE 3 hcl intravenous concentrate 1 or 1b* SP mutamycin intravenous solution reconstituted 1 or 1b* SP intravesical solution 1 or 1b* SP VALSTAR INTRAVESICAL SOLUTION (valrubicin) 3 LD; SP *ANTINEOPLASTIC -ANTIBODY FOR RADIOPHARMACEUTICAL THERAPY*** - DRUGS FOR CANCER ZEVALIN Y-90 INTRAVENOUS KIT (ibritumomab tiuxetan for y-90) 3 PA; LD *ANTINEOPLASTIC ANTIBODY-DRUG COMPLEXES*** - DRUGS FOR CANCER ENHERTU INTRAVENOUS SOLUTION RECONSTITUTED (fam- 3 PA; LD; SP trastuzumab deruxtec-nxki) KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED (ado- 3 PA; LD; SP ) *ANTINEOPLASTIC COMBINATIONS*** - DRUGS FOR CANCER DARZALEX FASPRO SUBCUTANEOUS SOLUTION (daratumumab- 3 PA; LD; SP hyaluronidase-fihj)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 76 Coverage Requirements and Prescription Drug Name Drug Tier Limits HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION (trastuzumab- 3 LD; SP hyaluronidase-oysk) PA; LD; SP; QL (5 tablets per 28 INQOVI ORAL TABLET (decitabine-cedazuridine) 3; OC days) KISQALI FEMARA (400 MG DOSE) ORAL TABLET THERAPY PACK 2; OC PA; SP; QL (0.04 unit per 1 day) (-letrozole) KISQALI FEMARA (600 MG DOSE) ORAL TABLET THERAPY PACK 2; OC PA; SP; QL (0.04 unit per 1 day) (ribociclib-letrozole) KISQALI FEMARA(200 MG DOSE) ORAL TABLET THERAPY PACK 2; OC PA; SP; QL (0.04 unit per 1 day) (ribociclib-letrozole) LONSURF ORAL TABLET (trifluridine-tipiracil) 3; OC PA; LD; SP PHESGO SUBCUTANEOUS SOLUTION (pertuz-trastuz-hyaluron-zzxf) 3 PA; LD; SP RITUXAN HYCELA SUBCUTANEOUS SOLUTION (rituximab- 3 LD; SP hyaluronidase human) VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED 3 LD; SP (daunorubicin-cytarabine lipo) *ANTINEOPLASTIC ENZYMES*** - DRUGS FOR CANCER ASPARLAS INTRAVENOUS SOLUTION (calaspargase pegol-mknl) 3 PA; LD; SP ERWINASE INJECTION SOLUTION RECONSTITUTED ( 3 PA; LD; SP erwinia chrysanth) ERWINAZE INJECTION SOLUTION RECONSTITUTED (asparaginase 3 PA; LD; SP erwinia chrysanth) ONCASPAR INJECTION SOLUTION () 3 PA; SP *ANTINEOPLASTIC RADIOPHARMACEUTICALS*** - DRUGS FOR CANCER LUTATHERA INTRAVENOUS SOLUTION (lutetium lu 177 dotatate) 3 PA; LD QUADRAMET INTRAVENOUS SOLUTION (samarium sm 153 3 lexidronam) STRONTIUM CHLORIDE SR-89 INTRAVENOUS SOLUTION 3 XOFIGO INTRAVENOUS SOLUTION (radium ra 223 dichloride) 3 PA; LD *ANTINEOPLASTICS - INTERLEUKINS*** - DRUGS FOR CANCER ELZONRIS INTRAVENOUS SOLUTION (tagraxofusp-erzs) 3 PA; LD PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; SP (aldesleukin) *ANTINEOPLASTICS - PHOTOACTIVATED AGENTS*** - DRUGS FOR CANCER PHOTOFRIN INTRAVENOUS SOLUTION RECONSTITUTED (porfimer 3 sodium) UVADEX INJECTION SOLUTION (methoxsalen (photopheresis)) 3 *ANTINEOPLASTICS MISC.*** - DRUGS FOR CANCER intravenous solution 1 or 1b* SP intravenous solution reconstituted 1 or 1b* SP BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 77 Coverage Requirements and Prescription Drug Name Drug Tier Limits HYDREA ORAL CAPSULE (hydroxyurea) 3; OC hydroxyurea oral capsule 1 or 1b*; OC MATULANE ORAL CAPSULE ( hcl) 2; OC LD NIPENT INTRAVENOUS SOLUTION RECONSTITUTED () 3 SP SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3 PA; LD (omacetaxine mepesuccinate) TRISENOX INTRAVENOUS SOLUTION (arsenic trioxide) 3 LD; SP *AROMATASE INHIBITORS*** - DRUGS FOR CANCER oral tablet 1 or 1b*; OC; $0 QL (1 tablet per 1 day) AROMASIN ORAL TABLET () 3; OC QL (2 tablets per 1 day) exemestane oral tablet 1 or 1b*; OC; $0 QL (2 tablets per 1 day) FEMARA ORAL TABLET (letrozole) 3; OC QL (1 tablet per 1 day) letrozole oral tablet 1 or 1b*; OC; $0 QL (1 tablet per 1 day) *CARBOXYPEPTIDASE ENZYME AGENTS*** - DRUGS FOR CANCER VORAXAZE INTRAVENOUS SOLUTION RECONSTITUTED 3 LD (glucarpidase) *CARDIAC PROTECTIVE AGENTS*** - DRUGS FOR CANCER dexrazoxane hcl intravenous solution reconstituted 1 or 1b* SP TOTECT INTRAVENOUS SOLUTION RECONSTITUTED (dexrazoxane 3 SP hcl) *CHEMOTHERAPY ADJUNCTS - HYPERURICEMIA AGENTS*** - DRUGS FOR CANCER ELITEK INTRAVENOUS SOLUTION RECONSTITUTED (rasburicase) 3 PA; SP *CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (21 capsules per 28 IBRANCE ORAL CAPSULE () 2; OC days) PA; LD; SP; QL (21 tablets per 28 IBRANCE ORAL TABLET 100 MG, 75 MG (palbociclib) 2; OC days) IBRANCE ORAL TABLET 125 MG (palbociclib) 2; OC PA; LD; SP; QL (1 tablet per 1 day) KISQALI (200 MG DOSE) ORAL TABLET THERAPY PACK (ribociclib 2; OC PA; SP; QL (3 tablets per 1 day) succinate) KISQALI (400 MG DOSE) ORAL TABLET THERAPY PACK (ribociclib 2; OC PA; SP; QL (3 tablets per 1 day) succinate) KISQALI (600 MG DOSE) ORAL TABLET THERAPY PACK (ribociclib 2; OC PA; SP; QL (3 tablets per 1 day) succinate) PA; LD; SP; QL (2 tablets per 1 VERZENIO ORAL TABLET () 3; OC day) * *** - DRUGS FOR CANCER FASLODEX INTRAMUSCULAR SOLUTION (fulvestrant) 3 PA; SP

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 78 Coverage Requirements and Prescription Drug Name Drug Tier Limits fulvestrant intramuscular solution 1 or 1b* PA; SP *ESTROGENS-ANTINEOPLASTIC*** - DRUGS FOR CANCER EMCYT ORAL CAPSULE ( sodium) 2; OC PA *FOLIC ACID ANTAGONISTS RESCUE AGENTS*** - DRUGS FOR CANCER KHAPZORY INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (levoleucovorin) leucovorin calcium injection solution 1 or 1b* leucovorin calcium injection solution reconstituted 1 or 1b* leucovorin calcium oral tablet 1 or 1b* levoleucovorin calcium intravenous solution reconstituted 1 or 1b* PA levoleucovorin calcium pf intravenous solution 1 or 1b* * RELEASING HORMONE (GNRH) ANTAGONISTS*** - DRUGS FOR CANCER FIRMAGON (240 MG DOSE) SUBCUTANEOUS SOLUTION 3 PA; SP; QL (2 units per 310 days) RECONSTITUTED ( acetate) FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED (degarelix 3 PA; SP; QL (1 kit per 28 days) acetate) ORGOVYX ORAL TABLET () 3; OC PA; LD; QL (1 tablet per 1 day) *IMIDAZOTETRAZINES*** - DRUGS FOR CANCER TEMODAR INTRAVENOUS SOLUTION RECONSTITUTED 2 PA; SP () TEMODAR ORAL CAPSULE (temozolomide) 3; OC PA; SP; QL (2 capsules per 1 day) temozolomide oral capsule 100 mg, 140 mg, 180 mg, 250 mg 1 or 1b*; OC PA; SP; QL (2 capsules per 1 day) temozolomide oral capsule 20 mg 1 or 1b*; OC PA; SP; QL (4 capsule per 1 day) temozolomide oral capsule 5 mg 1 or 1b*; OC PA; SP; QL (3 capsule per 1 day) *ISOCITRATE DEHYDROGENASE-1 (IDH1) INHIBITORS*** - DRUGS FOR CANCER TIBSOVO ORAL TABLET (ivosidenib) 3; OC PA; LD; QL (2 tablets per 1 day) *ISOCITRATE DEHYDROGENASE-2 (IDH2) INHIBITORS*** - DRUGS FOR CANCER IDHIFA ORAL TABLET 100 MG (enasidenib mesylate) 3; OC PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (2 tablets per 1 IDHIFA ORAL TABLET 50 MG (enasidenib mesylate) 3; OC day) *JANUS ASSOCIATED KINASE (JAK) INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (4 capsules per 1 INREBIC ORAL CAPSULE (fedratinib hcl) 3; OC day) PA; LD; SP; QL (2 tablets per 1 JAKAFI ORAL TABLET (ruxolitinib phosphate) 2; OC day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 79 Coverage Requirements and Prescription Drug Name Drug Tier Limits *LHRH ANALOGS*** - DRUGS FOR CANCER ELIGARD SUBCUTANEOUS KIT 22.5 MG (leuprolide acetate (3 month)) 3 PA; SP; QL (1 syringe per 84 days) PA; SP; QL (1 syringe per 112 ELIGARD SUBCUTANEOUS KIT 30 MG (leuprolide acetate (4 month)) 3 days) PA; SP; QL (1 syringe per 168 ELIGARD SUBCUTANEOUS KIT 45 MG (leuprolide acetate (6 month)) 3 days) ELIGARD SUBCUTANEOUS KIT 7.5 MG (leuprolide acetate) 3 PA; SP; QL (1 syringe per 28 days) leuprolide acetate injection kit 1 or 1b* PA; SP LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 7.5 MG (leuprolide 3 PA; SP; QL (1 kit per 28 days) acetate) LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 22.5 MG 3 PA; SP; QL (1 kit per 84 days) (leuprolide acetate (3 month)) LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT (leuprolide acetate 3 PA; SP; QL (1 kit per 112 days) (4 month)) LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT (leuprolide acetate PA; SP; QL (1 syringe kit per 168 3 (6 month)) days) TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION 3 PA; SP; QL (1 vial per 84 days) RECONSTITUTED 11.25 MG ( pamoate) TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION PA; SP; QL (1 syringe per 168 3 RECONSTITUTED 22.5 MG (triptorelin pamoate) days) TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION 3 PA; SP; QL (1 kit per 28 days) RECONSTITUTED 3.75 MG (triptorelin pamoate) PA; LD; SP; QL (1 implant per 365 VANTAS SUBCUTANEOUS KIT ( acetate) 3 days) ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG ( acetate) 3 PA; SP; QL (1 EA per 84 days) ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG (goserelin acetate) 3 PA; SP; QL (1 unit per 28 days) *MITOTIC INHIBITORS*** - DRUGS FOR CANCER ABRAXANE INTRAVENOUS SUSPENSION RECONSTITUTED 3 PA; LD; SP (paclitaxel protein-bound part) INTRAVENOUS CONCENTRATE 3 PA; SP DOCETAXEL INTRAVENOUS SOLUTION 3 PA; SP ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED ( 3 SP phosphate) etoposide intravenous solution 1 or 1b* SP etoposide oral capsule 1 or 1b*; OC SP HALAVEN INTRAVENOUS SOLUTION ( mesylate) 3 PA; SP IXEMPRA KIT INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; SP () JEVTANA INTRAVENOUS SOLUTION () 3 PA; LD; SP MARQIBO INTRAVENOUS SUSPENSION ( sulfate liposome) 3 LD NAVELBINE INTRAVENOUS SOLUTION ( tartrate) 3 SP

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 80 Coverage Requirements and Prescription Drug Name Drug Tier Limits paclitaxel intravenous concentrate 1 or 1b* SP INTRAVENOUS SOLUTION 3 SP toposar intravenous solution 1 or 1b* SP sulfate intravenous solution 1 or 1b* SP vincristine sulfate intravenous solution 1 or 1b* SP vinorelbine tartrate intravenous solution 1 or 1b* SP *MYELOPROTECTIVE AGENTS*** - DRUGS FOR CANCER COSELA INTRAVENOUS SOLUTION RECONSTITUTED (trilaciclib 3 PA; LD dihydrochloride) *NITROGEN MUSTARDS*** - DRUGS FOR CANCER ALKERAN INTRAVENOUS SOLUTION RECONSTITUTED ( 3 SP hcl) ALKERAN ORAL TABLET (melphalan) 3; OC SP injection solution reconstituted 1 or 1b* SP CYCLOPHOSPHAMIDE INTRAVENOUS SOLUTION 3 SP cyclophosphamide oral capsule 1 or 1b*; OC SP CYCLOPHOSPHAMIDE ORAL TABLET 3; OC EVOMELA INTRAVENOUS SOLUTION RECONSTITUTED (melphalan 3 LD; SP hcl) IFEX INTRAVENOUS SOLUTION RECONSTITUTED () 3 SP ifosfamide intravenous solution 1 or 1b* SP ifosfamide intravenous solution reconstituted 1 gm 1 or 1b* SP IFOSFAMIDE INTRAVENOUS SOLUTION RECONSTITUTED 3 GM 3 SP LEUKERAN ORAL TABLET () 2; OC melphalan hcl intravenous solution reconstituted 1 or 1b* SP melphalan oral tablet 1 or 1b*; OC SP PEPAXTO INTRAVENOUS SOLUTION RECONSTITUTED (melphalan 3 PA; LD flufenamide hcl) **** - DRUGS FOR CANCER BICNU INTRAVENOUS SOLUTION RECONSTITUTED () 3 SP carmustine intravenous solution reconstituted 1 or 1b* SP GLEOSTINE ORAL CAPSULE () 3; OC PA GLIADEL WAFER IMPLANT WAFER (carmustine in polifeprosan) 3 ZANOSAR INTRAVENOUS SOLUTION RECONSTITUTED (streptozocin) 3 LD; SP *ONCOLYTIC VIRAL AGENTS - HSV1*** - DRUGS FOR CANCER IMLYGIC INTRALESIONAL SUSPENSION (talimogene laherparepvec) 3 LD

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 81 Coverage Requirements and Prescription Drug Name Drug Tier Limits *PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS*** - DRUGS FOR CANCER ALIQOPA INTRAVENOUS SOLUTION RECONSTITUTED ( 3 PA; LD hcl) COPIKTRA ORAL CAPSULE () 3; OC PA; LD; QL (2 tablets per 1 day) PIQRAY (200 MG DAILY DOSE) ORAL TABLET THERAPY PACK 3; OC PA; SP; QL (1 pack per 28 days) () PIQRAY (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 3; OC PA; SP; QL (1 pack per 28 days) (alpelisib) PIQRAY (300 MG DAILY DOSE) ORAL TABLET THERAPY PACK 3; OC PA; SP; QL (1 pack per 28 days) (alpelisib) PA; LD; SP; QL (2 tablets per 1 ZYDELIG ORAL TABLET () 3; OC day) *POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (4 tablets per 1 LYNPARZA ORAL TABLET () 3; OC day) RUBRACA ORAL TABLET 200 MG, 300 MG ( camsylate) 3; OC PA; LD; SP; QL (4 tablet per 1 day) PA; LD; SP; QL (4 tablets per 1 RUBRACA ORAL TABLET 250 MG (rucaparib camsylate) 3; OC day) PA; LD; SP; QL (3 capsules per 1 TALZENNA ORAL CAPSULE 0.25 MG ( tosylate) 3; OC day) PA; LD; SP; QL (1 capsule per 1 TALZENNA ORAL CAPSULE 1 MG (talazoparib tosylate) 3; OC day) ZEJULA ORAL CAPSULE ( tosylate) 3; OC PA; LD; QL (3 capsules per 1 day) *PROGESTINS-ANTINEOPLASTIC*** - DRUGS FOR CANCER hydroxyprogesterone caproate intramuscular solution 1 or 1b* PA; LD oral suspension 40 mg/ml, 400 mg/10ml 1 or 1b*; OC megestrol acetate oral tablet 1 or 1b*; OC **** - DRUGS FOR CANCER oral capsule 1 or 1b*; OC *SELECTIVE X RECEPTOR AGONISTS*** - DRUGS FOR CANCER oral capsule 1 or 1b*; OC PA; SP; QL (10 capsules per 1 day) *TETRAHYDROISOQUINOLINES*** - DRUGS FOR CANCER YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED () 3 LD; SP *TOPOISOMERASE I INHIBITORS - ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER TRODELVY INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD (sacituzumab govitecan-hziy) *TOPOISOMERASE I INHIBITORS*** - DRUGS FOR CANCER CAMPTOSAR INTRAVENOUS SOLUTION ( hcl) 3 SP BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 82 Coverage Requirements and Prescription Drug Name Drug Tier Limits HYCAMTIN INTRAVENOUS SOLUTION RECONSTITUTED ( 3 SP hcl) HYCAMTIN ORAL CAPSULE (topotecan hcl) 2; OC PA; SP irinotecan hcl intravenous solution 1 or 1b* SP ONIVYDE INTRAVENOUS INJECTABLE (irinotecan hcl liposome) 3 LD TOPOTECAN HCL INTRAVENOUS SOLUTION 3 SP topotecan hcl intravenous solution reconstituted 1 or 1b* SP *URINARY TRACT PROTECTIVE AGENTS*** - DRUGS FOR CANCER ETHYOL INTRAVENOUS SOLUTION RECONSTITUTED (amifostine) 3 PA; SP mesna intravenous solution 1 or 1b* PA MESNEX INTRAVENOUS SOLUTION (mesna) 3 PA MESNEX ORAL TABLET (mesna) 2 PA *VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) INHIBITORS*** - DRUGS FOR CANCER AVASTIN INTRAVENOUS SOLUTION () 3 PA; LD; SP CYRAMZA INTRAVENOUS SOLUTION () 3 PA; LD; SP PA; LD; SP; QL (6 tablets per 1 INLYTA ORAL TABLET 1 MG (axitinib) 2; OC day) INLYTA ORAL TABLET 5 MG (axitinib) 2; OC PA; LD; SP; QL (4 tablet per 1 day) LENVIMA (10 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (30 capsules per 30 3; OC (lenvatinib mesylate) days) LENVIMA (12 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (1 pack per 30 3; OC (lenvatinib mesylate) days) LENVIMA (14 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (60 capsules per 30 3; OC (lenvatinib mesylate) days) LENVIMA (18 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (1 pack per 30 3; OC (lenvatinib mesylate) days) LENVIMA (20 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (60 capsules per 30 3; OC (lenvatinib mesylate) days) LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (90 capsules per 30 3; OC (lenvatinib mesylate) days) LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (30 capsules per 30 3; OC (lenvatinib mesylate) days) LENVIMA (8 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK PA; LD; SP; QL (1 pack per 30 3; OC (lenvatinib mesylate) days) MVASI INTRAVENOUS SOLUTION (bevacizumab-awwb) 3 PA; LD; SP ZALTRAP INTRAVENOUS SOLUTION (ziv-aflibercept) 3 PA; LD; SP ZIRABEV INTRAVENOUS SOLUTION (bevacizumab-bvzr) 3 PA; LD; SP

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 83 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTIPARKINSON AND RELATED THERAPY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM *ANTIPARKINSON ANTICHOLINERGICS*** - DRUGS FOR PARKINSON benztropine mesylate injection solution 1 or 1a* benztropine mesylate oral tablet 1 or 1a* COGENTIN INJECTION SOLUTION (benztropine mesylate) 3 trihexyphenidyl hcl oral solution 1 or 1a* trihexyphenidyl hcl oral tablet 1 or 1a* *ANTIPARKINSON *** - DRUGS FOR PARKINSON hcl oral capsule 1 or 1b* QL (4 capsule per 1 day) amantadine hcl oral syrup 1 or 1b* QL (40 mL per 1 day) amantadine hcl oral tablet 1 or 1b* QL (4 tablet per 1 day) bromocriptine mesylate oral capsule 1 or 1b* bromocriptine mesylate oral tablet 1 or 1b* GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR 137 MG 3 PA; LD; QL (2 capsules per 1 day) (amantadine hcl) GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR 68.5 MG 3 PA; DO; LD (amantadine hcl) OSMOLEX ER ORAL TABLET ER 24 HOUR THERAPY PACK 3 PA; LD; QL (2 tablets per 1 day) (amantadine hcl) OSMOLEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 129 MG 3 PA; DO; LD (amantadine hcl) OSMOLEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 193 MG, 3 PA; LD; QL (1 tablet per 1 day) 258 MG (amantadine hcl) PARLODEL ORAL CAPSULE (bromocriptine mesylate) 3 PARLODEL ORAL TABLET (bromocriptine mesylate) 3 *ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS*** - DRUGS FOR PARKINSON AZILECT ORAL TABLET (rasagiline mesylate) 3 rasagiline mesylate oral tablet 1 or 1b* selegiline hcl oral capsule 1 or 1b* selegiline hcl oral tablet 1 or 1b* XADAGO ORAL TABLET 100 MG ( mesylate) 3 PA; QL (1 tablet per 1 day) XADAGO ORAL TABLET 50 MG (safinamide mesylate) 3 PA; QL (2 tablets per 1 day) ZELAPAR ORAL TABLET DISPERSIBLE (selegiline hcl) 3 PA; QL (2 tablets per 1 day) *CENTRAL/PERIPHERAL COMT INHIBITORS*** - DRUGS FOR PARKINSON TASMAR ORAL TABLET (tolcapone) 3 PA; QL (6 tablet per 1 day) tolcapone oral tablet 1 or 1b* PA; QL (6 tablet per 1 day) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 84 Coverage Requirements and Prescription Drug Name Drug Tier Limits *DECARBOXYLASE INHIBITORS*** - DRUGS FOR PARKINSON carbidopa oral tablet 1 or 1b* LODOSYN ORAL TABLET (carbidopa) 3 *LEVODOPA COMBINATIONS*** - DRUGS FOR PARKINSON carbidopa-levodopa er oral tablet extended release 1 or 1b* carbidopa-levodopa oral tablet 1 or 1b* carbidopa-levodopa oral tablet dispersible 1 or 1b* carbidopa-levodopa-entacapone oral tablet 1 or 1b* DUOPA ENTERAL SUSPENSION (carbidopa-levodopa) 3 PA; LD; SP RYTARY ORAL CAPSULE EXTENDED RELEASE (carbidopa-levodopa) 3 SINEMET ORAL TABLET (carbidopa-levodopa) 3 STALEVO 100 ORAL TABLET (carbidopa-levodopa-entacapone) 3 STALEVO 125 ORAL TABLET (carbidopa-levodopa-entacapone) 3 STALEVO 150 ORAL TABLET (carbidopa-levodopa-entacapone) 3 STALEVO 200 ORAL TABLET (carbidopa-levodopa-entacapone) 3 STALEVO 50 ORAL TABLET (carbidopa-levodopa-entacapone) 3 STALEVO 75 ORAL TABLET (carbidopa-levodopa-entacapone) 3 *NONERGOLINE DOPAMINE RECEPTOR AGONISTS*** - DRUGS FOR PARKINSON KYNMOBI SUBLINGUAL FILM ( hcl) 3 PA; LD; QL (5 films per 1 day) MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 3 QL (1 tablet per 1 day) ( dihydrochloride) MIRAPEX ORAL TABLET (pramipexole dihydrochloride) 3 QL (3 tablet per 1 day) NEUPRO TRANSDERMAL PATCH 24 HOUR () 3 QL (1 patch per 1 day) pramipexole dihydrochloride er oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) pramipexole dihydrochloride oral tablet 1 or 1b* QL (3 tablet per 1 day) hcl er oral tablet extended release 24 hour 1 or 1b* ropinirole hcl oral tablet 1 or 1b* *PERIPHERAL COMT INHIBITORS*** - DRUGS FOR PARKINSON COMTAN ORAL TABLET (entacapone) 3 QL (8 tablet per 1 day) entacapone oral tablet 1 or 1b* QL (8 tablet per 1 day) ONGENTYS ORAL CAPSULE 25 MG (opicapone) 3 PA; QL (1 tablet per 1 day) ONGENTYS ORAL CAPSULE 50 MG (opicapone) 3 PA; QL (6 tablets per 1 day) *ANTIPSYCHOTICS/ANTIMANIC AGENTS* - DRUGS FOR THE NERVOUS SYSTEM *ANTIMANIC AGENTS*** - DRUGS FOR SEVERE MENTAL DISORDERS lithium carbonate er oral tablet extended release 1 or 1a* lithium carbonate oral capsule 1 or 1a*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 85 Coverage Requirements and Prescription Drug Name Drug Tier Limits lithium carbonate oral tablet 1 or 1a* *ANTIPSYCHOTICS - MISC.*** - DRUGS FOR SEVERE MENTAL DISORDERS CAPLYTA ORAL CAPSULE ( tosylate) 3 ST; QL (1 capsule per 1 day) EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 3 QL (8 capsules per 1 day) 200 MG (carbamazepine ()) EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 300 MG 3 QL (5 capsules per 1 day) (carbamazepine (antipsychotic)) GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 3 ( mesylate) LATUDA ORAL TABLET 120 MG ( hcl) 3 QL (1 tablet per 1 day) LATUDA ORAL TABLET 20 MG, 40 MG, 60 MG (lurasidone hcl) 3 DO LATUDA ORAL TABLET 80 MG (lurasidone hcl) 3 QL (2 tablets per 1 day) VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG ( hcl) 3 ST; DO VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG (cariprazine hcl) 3 ST; QL (1 capsule per 1 day) VRAYLAR ORAL CAPSULE THERAPY PACK (cariprazine hcl) 3 ST; QL (1 pack per 1 year) ziprasidone hcl oral capsule 20 mg, 40 mg 1 or 1b* DO ziprasidone hcl oral capsule 60 mg, 80 mg 1 or 1b* QL (2 capsules per 1 day) ziprasidone mesylate intramuscular solution reconstituted 1 or 1b* *BENZISOXAZOLES*** - DRUGS FOR SEVERE MENTAL DISORDERS FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG, 6 MG () 3 ST; DO FANAPT ORAL TABLET 10 MG, 12 MG, 8 MG (iloperidone) 3 ST; QL (2 tablets per 1 day) FANAPT TITRATION PACK ORAL TABLET (iloperidone) 3 ST; QL (1 pack per 1 year) INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED 3 QL (1 syringe per 28 days) SYRINGE ( palmitate) INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED 3 QL (1 syringe per 90 days) SYRINGE (paliperidone palmitate) paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg 1 or 1b* DO paliperidone er oral tablet extended release 24 hour 6 mg 1 or 1b* QL (2 tablets per 1 day) paliperidone er oral tablet extended release 24 hour 9 mg 1 or 1b* QL (1 tablet per 1 day) PERSERIS SUBCUTANEOUS PREFILLED SYRINGE () 3 QL (1 syringe per 30 days) RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION 2 QL (2 injections per 1 day) RECONSTITUTED ER 12.5 MG (risperidone microspheres) RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION 2 QL (2 injections per 28 days) RECONSTITUTED ER 25 MG, 37.5 MG, 50 MG (risperidone microspheres) risperidone oral solution 1 or 1b* ST; QL (8 mL per 1 day) risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 or 1b* QL (2 tablets per 1 day) risperidone oral tablet 3 mg, 4 mg 1 or 1b* QL (4 tablets per 1 day) risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 or 1b* QL (2 tablets per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 86 Coverage Requirements and Prescription Drug Name Drug Tier Limits risperidone oral tablet dispersible 3 mg, 4 mg 1 or 1b* QL (4 tablets per 1 day) *BUTYROPHENONES*** - DRUGS FOR SEVERE MENTAL DISORDERS HALDOL DECANOATE INTRAMUSCULAR SOLUTION 100 MG/ML 3 QL (5 injections per 30 days) ( decanoate) HALDOL DECANOATE INTRAMUSCULAR SOLUTION 50 MG/ML 3 QL (5 ampules per 30 days) () HALDOL INJECTION SOLUTION (haloperidol lactate) 3 haloperidol decanoate intramuscular solution 100 mg/ml 1 or 1b* QL (5 injections per 30 days) haloperidol decanoate intramuscular solution 50 mg/ml 1 or 1b* QL (5 ampules per 30 days) haloperidol lactate injection solution 1 or 1b* haloperidol lactate oral concentrate 1 or 1b* haloperidol oral tablet 1 or 1b* *DIBENZODIAZEPINES*** - DRUGS FOR SEVERE MENTAL DISORDERS oral tablet 100 mg 1 or 1b* QL (9 tablets per 1 day) clozapine oral tablet 200 mg 1 or 1b* QL (4 tablets per 1 day) clozapine oral tablet 25 mg, 50 mg 1 or 1b* DO clozapine oral tablet dispersible 100 mg 1 or 1b* QL (9 tablets per 1 day) clozapine oral tablet dispersible 12.5 mg, 25 mg 1 or 1b* DO clozapine oral tablet dispersible 150 mg 1 or 1b* QL (6 tablets per 1 day) clozapine oral tablet dispersible 200 mg 1 or 1b* QL (4 tablets per 1 day) VERSACLOZ ORAL SUSPENSION (clozapine) 3 QL (18 mL per 1 day) *DIBENZO-OXEPINO PYRROLES*** - DRUGS FOR SEVERE MENTAL DISORDERS maleate sublingual tablet sublingual 10 mg 1 or 1b* QL (2 tablets per 1 day) asenapine maleate sublingual tablet sublingual 2.5 mg, 5 mg 1 or 1b* DO SECUADO TRANSDERMAL PATCH 24 HOUR (asenapine) 3 ST; QL (1 patch per 1 day) *DIBENZOTHIAZEPINES*** - DRUGS FOR SEVERE MENTAL DISORDERS fumarate er oral tablet extended release 24 hour 150 mg, 200 mg 1 or 1b* DO quetiapine fumarate er oral tablet extended release 24 hour 300 mg, 400 mg, 1 or 1b* QL (2 tablets per 1 day) 50 mg quetiapine fumarate oral tablet 100 mg, 25 mg, 50 mg 1 or 1b* DO quetiapine fumarate oral tablet 200 mg 1 or 1b* QL (3 tablets per 1 day) quetiapine fumarate oral tablet 300 mg, 400 mg 1 or 1b* QL (2 tablets per 1 day) *DIBENZOXAZEPINES*** - DRUGS FOR SEVERE MENTAL DISORDERS ADASUVE INHALATION AEROSOL POWDER BREATH ACTIVATED 3 ()

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 87 Coverage Requirements and Prescription Drug Name Drug Tier Limits loxapine succinate oral capsule 1 or 1b* *DIHYDROINDOLONES*** - DRUGS FOR SEVERE MENTAL DISORDERS hcl oral tablet 1 or 1b* *PHENOTHIAZINES*** - DRUGS FOR SEVERE MENTAL DISORDERS hcl injection solution 1 or 1b* chlorpromazine hcl oral tablet 1 or 1b* compro rectal suppository 1 or 1b* decanoate injection solution 1 or 1b* fluphenazine hcl injection solution 1 or 1b* fluphenazine hcl oral concentrate 1 or 1b* fluphenazine hcl oral elixir 1 or 1b* fluphenazine hcl oral tablet 1 or 1b* oral tablet 1 or 1b* edisylate injection solution 1 or 1b* prochlorperazine maleate oral tablet 1 or 1a* prochlorperazine rectal suppository 1 or 1b* hcl oral tablet 1 or 1b* hcl oral tablet 1 or 1b* *QUINOLINONE DERIVATIVES*** - DRUGS FOR SEVERE MENTAL DISORDERS ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 3 () ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION 3 QL (1 injection per 30 days) RECONSTITUTED ER (aripiprazole) ABILIFY MYCITE MAINTENANCE KIT ORAL TABLET 10 MG, 15 MG, 3 ST; DO 2 MG, 5 MG (aripiprazole) ABILIFY MYCITE MAINTENANCE KIT ORAL TABLET 20 MG, 30 MG 3 ST; QL (1 tablet per 1 day) (aripiprazole) ABILIFY MYCITE ORAL TABLET 10 MG, 15 MG, 2 MG, 5 MG 3 ST; DO (aripiprazole) ABILIFY MYCITE ORAL TABLET 20 MG, 30 MG (aripiprazole) 3 ST; QL (1 tablet per 1 day) ABILIFY MYCITE STARTER KIT ORAL TABLET 10 MG, 15 MG, 2 MG, 3 ST; DO 5 MG (aripiprazole) ABILIFY MYCITE STARTER KIT ORAL TABLET 20 MG, 30 MG 3 ST; QL (1 tablet per 1 day) (aripiprazole) aripiprazole oral solution 1 or 1b* QL (30 mL per 1 day) aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 5 mg 1 or 1b* DO aripiprazole oral tablet 20 mg, 30 mg 1 or 1b* QL (1 tablet per 1 day) aripiprazole oral tablet dispersible 10 mg 1 or 1b* QL (3 tablets per 1 day) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 88 Coverage Requirements and Prescription Drug Name Drug Tier Limits aripiprazole oral tablet dispersible 15 mg 1 or 1b* QL (2 tablets per 1 day) ARISTADA INITIO INTRAMUSCULAR PREFILLED SYRINGE 3 QL (1 syringe per 1 fill) () ARISTADA INTRAMUSCULAR PREFILLED SYRINGE (aripiprazole 3 lauroxil) REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG () 3 ST; DO REXULTI ORAL TABLET 3 MG, 4 MG (brexpiprazole) 3 ST; QL (1 tablet per 1 day) *THIENBENZODIAZEPINES*** - DRUGS FOR SEVERE MENTAL DISORDERS intramuscular solution reconstituted 1 or 1b* olanzapine oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg 1 or 1b* DO olanzapine oral tablet 15 mg, 20 mg 1 or 1b* QL (1 tablets per 1 day) olanzapine oral tablet dispersible 10 mg, 5 mg 1 or 1b* DO olanzapine oral tablet dispersible 15 mg 1 or 1b* QL (1 tablets per 1 day) olanzapine oral tablet dispersible 20 mg 1 or 1b* QL (1 tablet per 1 day) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION 3 RECONSTITUTED (olanzapine pamoate) **** - DRUGS FOR SEVERE MENTAL DISORDERS thiothixene oral capsule 1 or 1b* *ANTISEPTICS & DISINFECTANTS* - ANTISEPTICS AND DISINFECTANTS *ANTISEPTICS & DISINFECTANTS*** - ANTISEPTICS AND DISINFECTANTS EXTERNAL SOLUTION 37 % 3 GLUTARALDEHYDE EXTERNAL SOLUTION 2 *CHLORINE ANTISEPTICS*** - ANTISEPTICS AND DISINFECTANTS BENZALKONIUM CHLORIDE EXTERNAL SOLUTION 3 *IODINE ANTISEPTICS*** - ANTISEPTICS AND DISINFECTANTS IODINE TINCTURE EXTERNAL TINCTURE 2 % 3 IODOFLEX EXTERNAL PAD (cadexomer iodine) 3 IODOSORB EXTERNAL GEL (cadexomer iodine) 3 *ANTIVIRALS* - DRUGS FOR INFECTIONS *ANTIRETROVIRAL COMBINATIONS*** - DRUGS FOR VIRAL INFECTIONS abacavir sulfate-lamivudine oral tablet 1 or 1b* QL (1 tablet per 1 day) abacavir-lamivudine-zidovudine oral tablet 1 or 1b* QL (2 tablets per 1 day) BIKTARVY ORAL TABLET (bictegravir-emtricitab-tenofov) 2 QL (1 tablet per 1 day) CABENUVA INTRAMUSCULAR SUSPENSION EXTENDED RELEASE 3 PA; LD; QL (1 kit per 28 days) 400 & 600 MG/2ML BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 89 Coverage Requirements and Prescription Drug Name Drug Tier Limits CABENUVA INTRAMUSCULAR SUSPENSION EXTENDED RELEASE PA; LD; QL (1 kit per 1 one-time 3 600 & 900 MG/3ML fill) CIMDUO ORAL TABLET (lamivudine-tenofovir) 3 QL (1 tablet per 1 day) COMBIVIR ORAL TABLET (lamivudine-zidovudine) 3 QL (2 tablets per 1 day) COMPLERA ORAL TABLET (emtricitab-rilpivir-tenofovir) 3 PA; QL (1 tablet per 1 day) DELSTRIGO ORAL TABLET (doravirin-lamivudin-tenofov df) 3 QL (1 tablet per 1 day) DESCOVY ORAL TABLET (emtricitabine-tenofovir af) 3; $0 QL (1 tablet per 1 day) DOVATO ORAL TABLET (dolutegravir-lamivudine) 2 QL (1 tablet per 1 day) -emtricitab-tenofovir oral tablet 1 or 1b* QL (1 tablet per 1 day) efavirenz-lamivudine-tenofovir oral tablet 1 or 1b* QL (1 tablet per 1 day) emtricitabine-tenofovir df oral tablet 100-150 mg, 133-200 mg, 167-250 mg 1 or 1b* QL (1 tablet per 1 day) emtricitabine-tenofovir df oral tablet 200-300 mg 1 or 1b*; $0 QL (1 tablet per 1 day) EPZICOM ORAL TABLET (abacavir sulfate-lamivudine) 3 QL (1 tablet per 1 day) EVOTAZ ORAL TABLET (atazanavir-cobicistat) 3 QL (1 tablet per 1 day) GENVOYA ORAL TABLET (elviteg-cobic-emtricit-tenofaf) 2 QL (1 tablet per 1 day) JULUCA ORAL TABLET (dolutegravir-rilpivirine) 3 PA; QL (1 tablet per 1 day) KALETRA ORAL SOLUTION (lopinavir-) 3 QL (16 mL per 1 day) KALETRA ORAL TABLET 100-25 MG (lopinavir-ritonavir) 2 QL (10 tablets per 1 day) KALETRA ORAL TABLET 200-50 MG (lopinavir-ritonavir) 2 QL (4 tablets per 1 day) lamivudine-zidovudine oral tablet 1 or 1b* QL (2 tablets per 1 day) lopinavir-ritonavir oral solution 1 or 1b* QL (16 mL per 1 day) lopinavir-ritonavir oral tablet 100-25 mg 1 or 1b* QL (10 tablets per 1 day) lopinavir-ritonavir oral tablet 200-50 mg 1 or 1b* QL (4 tablets per 1 day) ODEFSEY ORAL TABLET (emtricitab-rilpivir-tenofov af) 3 PA; QL (1 tablet per 1 day) PREZCOBIX ORAL TABLET (darunavir-cobicistat) 3 QL (1 tablet per 1 day) STRIBILD ORAL TABLET (elviteg-cobic-emtricit-tenofdf) 2 QL (1 tablet per 1 day) SYMTUZA ORAL TABLET (darun-cobic-emtricit-tenofaf) 3 QL (1 tablet per 1 day) TEMIXYS ORAL TABLET (lamivudine-tenofovir) 3 QL (1 tablet per 1 day) TRIUMEQ ORAL TABLET (abacavir-dolutegravir-lamivud) 2 QL (1 tablet per 1 day) TRIZIVIR ORAL TABLET (abacavir-lamivudine-zidovudine) 3 QL (2 tablets per 1 day) TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG 2 ST; QL (1 tablet per 1 day) (emtricitabine-tenofovir df) *ANTIRETROVIRALS - CCR5 ANTAGONISTS (ENTRY INHIBITOR)*** - DRUGS FOR VIRAL INFECTIONS SELZENTRY ORAL SOLUTION (maraviroc) 3 QL (62 mL per 1 day) SELZENTRY ORAL TABLET 150 MG, 300 MG (maraviroc) 2 QL (4 tablets per 1 day) SELZENTRY ORAL TABLET 25 MG (maraviroc) 2 QL (8 tablets per 1 day) SELZENTRY ORAL TABLET 75 MG (maraviroc) 2 QL (2 tablets per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 90 Coverage Requirements and Prescription Drug Name Drug Tier Limits *ANTIRETROVIRALS - CD4-DIRECTED POST-ATTACHMENT INHIBITOR*** - DRUGS FOR VIRAL INFECTIONS TROGARZO INTRAVENOUS SOLUTION (ibalizumab-uiyk) 3 PA; LD; QL (8 vials per 28 days) *ANTIRETROVIRALS - FUSION INHIBITORS*** - DRUGS FOR VIRAL INFECTIONS FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED (enfuvirtide) 2 PA; LD; QL (60 vials per 30 days) *ANTIRETROVIRALS - GP120-DIRECTED ATTACHMENT INHIBITOR*** - DRUGS FOR VIRAL INFECTIONS RUKOBIA ORAL TABLET EXTENDED RELEASE 12 HOUR (fostemsavir 3 PA; QL (2 tablets per 1 day) tromethamine) *ANTIRETROVIRALS - INTEGRASE INHIBITORS*** - DRUGS FOR VIRAL INFECTIONS ISENTRESS HD ORAL TABLET (raltegravir potassium) 3 QL (2 tablets per 1 day) ISENTRESS ORAL PACKET (raltegravir potassium) 3 QL (2 packets per 1 day) ISENTRESS ORAL TABLET (raltegravir potassium) 2 QL (4 tablets per 1 day) ISENTRESS ORAL TABLET CHEWABLE 100 MG (raltegravir potassium) 2 QL (6 tablets per 1 day) ISENTRESS ORAL TABLET CHEWABLE 25 MG (raltegravir potassium) 2 QL (24 tablets per 1 day) TIVICAY ORAL TABLET 10 MG (dolutegravir sodium) 3 QL (4 tablets per 1 day) TIVICAY ORAL TABLET 25 MG, 50 MG (dolutegravir sodium) 3 QL (2 tablets per 1 day) TIVICAY PD ORAL TABLET SOLUBLE (dolutegravir sodium) 3 QL (12 tablets per 1 day) *ANTIRETROVIRALS - PROTEASE INHIBITORS*** - DRUGS FOR VIRAL INFECTIONS APTIVUS ORAL CAPSULE (tipranavir) 2 PA; QL (4 capsules per 1 day) atazanavir sulfate oral capsule 150 mg, 200 mg 1 or 1b* QL (2 capsules per 1 day) atazanavir sulfate oral capsule 300 mg 1 or 1b* QL (1 capsule per 1 day) CRIXIVAN ORAL CAPSULE ( sulfate) 2 QL (6 capsules per 1 day) fosamprenavir calcium oral tablet 1 or 1b* QL (4 tablets per 1 day) INVIRASE ORAL TABLET (saquinavir mesylate) 2 QL (4 tablets per 1 day) LEXIVA ORAL SUSPENSION (fosamprenavir calcium) 2 QL (60 mL per 1 day) LEXIVA ORAL TABLET (fosamprenavir calcium) 3 QL (4 tablets per 1 day) NORVIR ORAL PACKET (ritonavir) 3 QL (12 packets per 1 day) NORVIR ORAL SOLUTION (ritonavir) 2 QL (16 mL per 1 day) NORVIR ORAL TABLET (ritonavir) 3 QL (12 tablets per 1 day) PREZISTA ORAL SUSPENSION (darunavir ethanolate) 2 QL (14 mL per 1 day) PREZISTA ORAL TABLET 150 MG (darunavir ethanolate) 2 QL (6 tablets per 1 day) PREZISTA ORAL TABLET 600 MG (darunavir ethanolate) 2 QL (2 tablets per 1 day) PREZISTA ORAL TABLET 75 MG (darunavir ethanolate) 2 QL (10 tablets per 1 day) PREZISTA ORAL TABLET 800 MG (darunavir ethanolate) 2 QL (1 tablet per 1 day) REYATAZ ORAL CAPSULE 150 MG, 200 MG (atazanavir sulfate) 3 QL (2 capsules per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 91 Coverage Requirements and Prescription Drug Name Drug Tier Limits REYATAZ ORAL CAPSULE 300 MG (atazanavir sulfate) 3 QL (1 capsule per 1 day) REYATAZ ORAL PACKET (atazanavir sulfate) 2 QL (5 packets per 1 day) ritonavir oral tablet 1 or 1b* QL (12 tablets per 1 day) VIRACEPT ORAL TABLET 250 MG (nelfinavir mesylate) 2 QL (10 tablets per 1 day) VIRACEPT ORAL TABLET 625 MG (nelfinavir mesylate) 2 QL (4 tablets per 1 day) *ANTIRETROVIRALS - RTI-NON-NUCLEOSIDE ANALOGUES*** - DRUGS FOR VIRAL INFECTIONS EDURANT ORAL TABLET (rilpivirine hcl) 2 PA; QL (1 tablet per 1 day) efavirenz oral capsule 200 mg 1 or 1b* QL (4 capsules per 1 day) efavirenz oral capsule 50 mg 1 or 1b* QL (12 capsules per 1 day) efavirenz oral tablet 1 or 1b* QL (1 tablet per 1 day) etravirine oral tablet 100 mg 1 or 1b* PA; QL (4 tablets per 1 day) etravirine oral tablet 200 mg 1 or 1b* PA; QL (2 tablets per 1 day) INTELENCE ORAL TABLET 100 MG (etravirine) 2 PA; QL (4 tablets per 1 day) INTELENCE ORAL TABLET 200 MG (etravirine) 2 PA; QL (2 tablets per 1 day) INTELENCE ORAL TABLET 25 MG (etravirine) 2 PA; QL (16 tablets per 1 day) er oral tablet extended release 24 hour 100 mg 1 or 1b* QL (3 tablets per 1 day) nevirapine er oral tablet extended release 24 hour 400 mg 1 or 1b* QL (1 tablet per 1 day) nevirapine oral suspension 1 or 1b* QL (40 mL per 1 day) nevirapine oral tablet 1 or 1b* QL (2 tablets per 1 day) PIFELTRO ORAL TABLET (doravirine) 3 QL (1 tablet per 1 day) SUSTIVA ORAL CAPSULE 200 MG (efavirenz) 3 QL (4 capsules per 1 day) SUSTIVA ORAL CAPSULE 50 MG (efavirenz) 3 QL (12 capsules per 1 day) SUSTIVA ORAL TABLET (efavirenz) 3 QL (1 tablet per 1 day) VIRAMUNE ORAL SUSPENSION (nevirapine) 3 QL (40 mL per 1 day) VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 QL (1 tablet per 1 day) (nevirapine) *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- PURINES*** - DRUGS FOR VIRAL INFECTIONS abacavir sulfate oral solution 1 or 1b* QL (32 mL per 1 day) abacavir sulfate oral tablet 1 or 1b* QL (2 tablets per 1 day) ZIAGEN ORAL SOLUTION (abacavir sulfate) 3 QL (32 mL per 1 day) ZIAGEN ORAL TABLET (abacavir sulfate) 3 QL (2 tablets per 1 day) *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- PYRIMIDINES*** - DRUGS FOR VIRAL INFECTIONS emtricitabine oral capsule 1 or 1b*; $0 QL (1 capsule per 1 day) EMTRIVA ORAL CAPSULE (emtricitabine) 3 QL (1 capsule per 1 day) EMTRIVA ORAL SOLUTION (emtricitabine) 2 QL (29 mL per 1 day) EPIVIR ORAL SOLUTION (lamivudine) 3 QL (32 mL per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 92 Coverage Requirements and Prescription Drug Name Drug Tier Limits EPIVIR ORAL TABLET 150 MG (lamivudine) 3 QL (2 tablets per 1 day) EPIVIR ORAL TABLET 300 MG (lamivudine) 3 QL (1 tablet per 1 day) lamivudine oral solution 1 or 1b* QL (32 mL per 1 day) lamivudine oral tablet 150 mg 1 or 1b* QL (2 tablets per 1 day) lamivudine oral tablet 300 mg 1 or 1b* QL (1 tablet per 1 day) *ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- THYMIDINES*** - DRUGS FOR VIRAL INFECTIONS RETROVIR INTRAVENOUS SOLUTION (zidovudine) 2 RETROVIR ORAL CAPSULE (zidovudine) 3 QL (6 capsules per 1 day) RETROVIR ORAL SYRUP (zidovudine) 3 QL (64 mL per 1 day) stavudine oral capsule 15 mg, 20 mg 1 or 1b* QL (4 capsules per 1 day) stavudine oral capsule 30 mg, 40 mg 1 or 1b* QL (2 capsules per 1 day) zidovudine oral capsule 1 or 1b* QL (6 capsules per 1 day) zidovudine oral syrup 1 or 1b* QL (64 mL per 1 day) zidovudine oral tablet 1 or 1b* QL (2 tablets per 1 day) *ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES*** - DRUGS FOR VIRAL INFECTIONS tenofovir disoproxil fumarate oral tablet 1 or 1b*; $0 QL (1 tablet per 1 day) VIREAD ORAL POWDER (tenofovir disoproxil fumarate) 2 QL (8 grams per 1 day) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG (tenofovir disoproxil 2 QL (1 tablet per 1 day) fumarate) *ANTIRETROVIRALS ADJUVANTS*** - DRUGS FOR VIRAL INFECTIONS TYBOST ORAL TABLET (cobicistat) 3 QL (1 tablet per 1 day) *CMV AGENTS*** - DRUGS FOR VIRAL INFECTIONS cidofovir intravenous solution 1 or 1b* foscarnet sodium intravenous solution 1 or 1b* FOSCAVIR INTRAVENOUS SOLUTION (foscarnet sodium) 3 ganciclovir sodium intravenous solution reconstituted 4 SP VALCYTE ORAL SOLUTION RECONSTITUTED (valganciclovir hcl) 3 VALCYTE ORAL TABLET (valganciclovir hcl) 3 valganciclovir hcl oral solution reconstituted 1 or 1b* valganciclovir hcl oral tablet 1 or 1b* *HEPATITIS B AGENTS*** - DRUGS FOR VIRAL INFECTIONS adefovir dipivoxil oral tablet 4 SP; QL (1 tablet per 1 day) entecavir oral tablet 4 QL (1 tablet per 1 day) lamivudine oral tablet 100 mg 1 or 1b* QL (1 tablet per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 93 Coverage Requirements and Prescription Drug Name Drug Tier Limits *HEPATITIS C AGENT - COMBINATIONS*** - DRUGS FOR VIRAL INFECTIONS EPCLUSA ORAL TABLET (sofosbuvir-velpatasvir) 4 PA; SP; QL (1 tablet per 1 day) HARVONI ORAL PACKET 33.75-150 MG (ledipasvir-sofosbuvir) 4 PA; QL (1 packet per 1 day) HARVONI ORAL PACKET 45-200 MG (ledipasvir-sofosbuvir) 4 PA; QL (2 packets per 1 day) HARVONI ORAL TABLET 45-200 MG (ledipasvir-sofosbuvir) 4 PA; QL (1 tablet per 1 day) HARVONI ORAL TABLET 90-400 MG (ledipasvir-sofosbuvir) 4 PA; SP; QL (1 tablet per 1 day) VOSEVI ORAL TABLET (sofosbuv-velpatasv-voxilaprev) 4 PA; SP; QL (1 tablet per 1 day) *HEPATITIS C AGENTS*** - DRUGS FOR VIRAL INFECTIONS PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML (peginterferon 4 LD; SP; QL (2 syringe per 28 days) alfa-2a) PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML (peginterferon 4 LD; SP; QL (4 vials per 28 days) alfa-2a) ribavirin oral capsule 4 SP ribavirin oral tablet 4 SP *HERPES AGENTS - PURINE ANALOGUES*** - DRUGS FOR VIRAL INFECTIONS acyclovir oral capsule 1 or 1b* acyclovir oral suspension 1 or 1b* acyclovir oral tablet 1 or 1b* acyclovir sodium intravenous solution 1 or 1b* valacyclovir hcl oral tablet 1 gm 1 or 1b* QL (30 tablets per 1 fill) valacyclovir hcl oral tablet 500 mg 1 or 1b* QL (60 tablets per 1 fill) ZOVIRAX ORAL SUSPENSION (acyclovir) 3 *HERPES AGENTS - THYMIDINE ANALOGUES*** - DRUGS FOR VIRAL INFECTIONS famciclovir oral tablet 125 mg, 250 mg 1 or 1b* QL (60 tablets per 1 fill) famciclovir oral tablet 500 mg 1 or 1b* QL (21 tablets per 1 fill) *INFLUENZA AGENTS*** - DRUGS FOR VIRAL INFECTIONS hcl oral tablet 1 or 1b* *NEURAMINIDASE INHIBITORS*** - DRUGS FOR VIRAL INFECTIONS oseltamivir phosphate oral capsule 30 mg 1 or 1b* QL (20 capsule per 90 days) oseltamivir phosphate oral capsule 45 mg, 75 mg 1 or 1b* QL (10 capsule per 90 days) oseltamivir phosphate oral suspension reconstituted 1 or 1b* QL (180 mL per 90 days) RAPIVAB INTRAVENOUS SOLUTION (peramivir) 3 RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH 2 QL (1 package per 90 days) ACTIVATED (zanamivir) TAMIFLU ORAL CAPSULE 30 MG (oseltamivir phosphate) 3 QL (20 capsule per 90 days) TAMIFLU ORAL CAPSULE 45 MG, 75 MG (oseltamivir phosphate) 3 QL (10 capsule per 90 days) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 94 Coverage Requirements and Prescription Drug Name Drug Tier Limits TAMIFLU ORAL SUSPENSION RECONSTITUTED (oseltamivir 3 QL (180 mL per 90 days) phosphate) *PA ENDONUCLEASE INHIBITORS*** - DRUGS FOR VIRAL INFECTIONS XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY PACK (baloxavir 3 QL (1 dose pack per 90 days) marboxil) XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY PACK (baloxavir 3 QL (1 dose pack per 90 days) marboxil) *RSV AGENTS - NUCLEOSIDE ANALOGUES*** - DRUGS FOR VIRAL INFECTIONS ribavirin inhalation solution reconstituted 1 or 1b* VIRAZOLE INHALATION SOLUTION RECONSTITUTED (ribavirin) 3 *BETA BLOCKERS* - DRUGS FOR THE HEART *ALPHA-BETA BLOCKERS*** - DRUGS FOR HIGH BLOOD PRESSURE oral tablet 12.5 mg, 3.125 mg, 6.25 mg 1 or 1b* QL (2 tablets per 1 day) carvedilol oral tablet 25 mg 1 or 1b* QL (4 tablets per 1 day) carvedilol phosphate er oral capsule extended release 24 hour 1 or 1b* QL (1 capsule per 1 day) labetalol hcl oral tablet 1 or 1b* QL (8 tablets per 1 day) LABETALOL HCL-DEXTROSE INTRAVENOUS SOLUTION 3 LABETALOL HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 *BETA BLOCKERS CARDIO-SELECTIVE*** - DRUGS FOR HIGH BLOOD PRESSURE acebutolol hcl oral capsule 200 mg 1 or 1b* QL (6 capsules per 1 day) acebutolol hcl oral capsule 400 mg 1 or 1b* QL (3 capsules per 1 day) atenolol oral tablet 1 or 1a* QL (2 tablets per 1 day) betaxolol hcl oral tablet 10 mg 1 or 1b* QL (1 tablet per 1 day) betaxolol hcl oral tablet 20 mg 1 or 1b* QL (2 tablets per 1 day) bisoprolol fumarate oral tablet 10 mg 1 or 1b* QL (2 tablets per 1 day) bisoprolol fumarate oral tablet 5 mg 1 or 1b* QL (1 tablet per 1 day) BREVIBLOC IN NACL INTRAVENOUS SOLUTION (esmolol hcl-sodium 3 chloride) BREVIBLOC INTRAVENOUS SOLUTION (esmolol hcl) 3 BREVIBLOC PREMIXED DS INTRAVENOUS SOLUTION (esmolol hcl- 3 sodium chloride) BREVIBLOC PREMIXED INTRAVENOUS SOLUTION (esmolol hcl- 3 sodium chloride) BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 5 MG (nebivolol hcl) 2 QL (1 tablet per 1 day) BYSTOLIC ORAL TABLET 20 MG (nebivolol hcl) 2 QL (2 tablets per 1 day) esmolol hcl intravenous solution 100 mg/10ml 1 or 1b*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 95 Coverage Requirements and Prescription Drug Name Drug Tier Limits ESMOLOL HCL INTRAVENOUS SOLUTION 2000 MG/100ML, 2500 3 MG/250ML ESMOLOL HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE 3 esmolol hcl-sodium chloride intravenous solution 1 or 1b* KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 3 QL (1 capsule per 1 day) MG, 25 MG, 50 MG (metoprolol succinate) KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 200 3 QL (2 capsules per 1 day) MG (metoprolol succinate) metoprolol succinate er oral tablet extended release 24 hour 1 or 1b* metoprolol tartrate intravenous solution 1 or 1a* metoprolol tartrate oral tablet 100 mg 1 or 1a* QL (4 tablets per 1 day) metoprolol tartrate oral tablet 25 mg, 37.5 mg, 50 mg, 75 mg 1 or 1a* QL (2 tablets per 1 day) *BETA BLOCKERS NON-SELECTIVE*** - DRUGS FOR HIGH BLOOD PRESSURE HEMANGEOL ORAL SOLUTION ( hcl) 3 INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 QL (1 capsule per 1 day) (propranolol hcl sr beads) INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 QL (1 capsule per 1 day) (propranolol hcl sr beads) nadolol oral tablet 20 mg 1 or 1b* QL (1 tablet per 1 day) nadolol oral tablet 40 mg 1 or 1b* QL (3 tablets per 1 day) nadolol oral tablet 80 mg 1 or 1b* QL (4 tablets per 1 day) pindolol oral tablet 1 or 1b* QL (6 tablets per 1 day) propranolol hcl er oral capsule extended release 24 hour 120 mg 1 or 1b* QL (2 capsules per 1 day) propranolol hcl er oral capsule extended release 24 hour 160 mg 1 or 1b* QL (4 capsules per 1 day) propranolol hcl er oral capsule extended release 24 hour 60 mg, 80 mg 1 or 1b* QL (1 capsule per 1 day) propranolol hcl intravenous solution 1 or 1b* propranolol hcl oral solution 20 mg/5ml 1 or 1b* QL (20 mL per 1 day) propranolol hcl oral solution 40 mg/5ml 1 or 1b* QL (80 mL per 1 day) propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg 1 or 1b* QL (4 tablets per 1 day) propranolol hcl oral tablet 80 mg 1 or 1b* QL (8 tablets per 1 day) sorine oral tablet 120 mg, 80 mg 1 or 1b* QL (3 tablets per 1 day) sorine oral tablet 160 mg 1 or 1b* QL (4 tablets per 1 day) sorine oral tablet 240 mg 1 or 1b* QL (2 tablets per 1 day) hcl (af) oral tablet 1 or 1b* SOTALOL HCL INTRAVENOUS SOLUTION 3 sotalol hcl oral tablet 120 mg, 80 mg 1 or 1b* QL (3 tablets per 1 day) sotalol hcl oral tablet 160 mg 1 or 1b* QL (4 tablets per 1 day) sotalol hcl oral tablet 240 mg 1 or 1b* QL (2 tablets per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 96 Coverage Requirements and Prescription Drug Name Drug Tier Limits SOTYLIZE ORAL SOLUTION (sotalol hcl) 3 timolol maleate oral tablet 10 mg, 5 mg 1 or 1b* QL (6 tablets per 1 day) timolol maleate oral tablet 20 mg 1 or 1b* QL (3 tablets per 1 day) *CALCIUM CHANNEL BLOCKERS* - DRUGS FOR THE HEART *CALCIUM CHANNEL BLOCKERS*** - DRUGS FOR HIGH BLOOD PRESSURE amlodipine besylate oral tablet 10 mg 1 or 1b* QL (1 tablet per 1 day) amlodipine besylate oral tablet 2.5 mg, 5 mg 1 or 1b* DO CALAN SR ORAL TABLET EXTENDED RELEASE (verapamil hcl) 3 QL (2 tablets per 1 day) CARDENE IV INTRAVENOUS SOLUTION ( hcl in nacl) 3 CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 3 DO MG ( hcl coated beads) CARDIZEM ORAL TABLET 120 MG (diltiazem hcl) 3 QL (3 tablet per 1 day) CARDIZEM ORAL TABLET 30 MG, 60 MG (diltiazem hcl) 3 DO cartia xt oral capsule extended release 24 hour 120 mg, 180 mg 1 or 1b* DO cartia xt oral capsule extended release 24 hour 240 mg, 300 mg 1 or 1b* QL (1 capsule per 1 day) CLEVIPREX INTRAVENOUS EMULSION () 3 CONJUPRI ORAL TABLET 2.5 MG (levamlodipine maleate) 3 ST; DO CONJUPRI ORAL TABLET 5 MG (levamlodipine maleate) 3 ST; QL (1 tablet per 1 day) diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 1 or 1b* DO 360 mg diltiazem hcl er beads oral capsule extended release 24 hour 240 mg, 300 mg, 1 or 1b* QL (1 capsule per 1 day) 420 mg diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 1 or 1b* DO 180 mg diltiazem hcl er coated beads oral capsule extended release 24 hour 240 mg, 1 or 1b* QL (1 capsule per 1 day) 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 hour 180 mg 1 or 1b* DO diltiazem hcl er coated beads oral tablet extended release 24 hour 240 mg, 1 or 1b* QL (1 tablet per 1 day) 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 1 or 1b* QL (2 capsules per 1 day) diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg 1 or 1b* DO diltiazem hcl er oral capsule extended release 24 hour 240 mg 1 or 1b* QL (1 capsule per 1 day) diltiazem hcl intravenous solution 1 or 1b* DILTIAZEM HCL INTRAVENOUS SOLUTION RECONSTITUTED 3 diltiazem hcl oral tablet 120 mg 1 or 1b* QL (3 tablet per 1 day) diltiazem hcl oral tablet 30 mg, 60 mg 1 or 1b* DO diltiazem hcl oral tablet 90 mg 1 or 1b* QL (4 tablet per 1 day) DILTIAZEM HCL-DEXTROSE INTRAVENOUS SOLUTION 3

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 97 Coverage Requirements and Prescription Drug Name Drug Tier Limits DILTIAZEM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 125- 3 0.7 MG/125ML-% dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg 1 or 1b* DO dilt-xr oral capsule extended release 24 hour 240 mg 1 or 1b* QL (1 capsule per 1 day) er oral tablet extended release 24 hour 10 mg 1 or 1b* QL (1 tablet per 1 day) felodipine er oral tablet extended release 24 hour 2.5 mg, 5 mg 1 or 1b* DO oral capsule 2.5 mg 1 or 1b* QL (2 capsules per 1 day) isradipine oral capsule 5 mg 1 or 1b* QL (4 capsule per 1 day) KATERZIA ORAL SUSPENSION (amlodipine benzoate) 3 QL (300 mL per 30 days) matzim la oral tablet extended release 24 hour 180 mg 1 or 1b* DO matzim la oral tablet extended release 24 hour 240 mg, 300 mg, 360 mg, 420 1 or 1b* QL (1 tablet per 1 day) mg NICARDIPINE HCL IN NACL INTRAVENOUS SOLUTION 3 NICARDIPINE HCL IN NACL INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE nicardipine hcl intravenous solution 1 or 1b* nicardipine hcl oral capsule 20 mg 1 or 1b* QL (6 capsule per 1 day) nicardipine hcl oral capsule 30 mg 1 or 1b* QL (4 capsule per 1 day) er oral tablet extended release 24 hour 30 mg 1 or 1b* DO nifedipine er oral tablet extended release 24 hour 60 mg, 90 mg 1 or 1b* QL (1 tablet per 1 day) nifedipine er osmotic release oral tablet extended release 24 hour 30 mg 1 or 1b* DO nifedipine er osmotic release oral tablet extended release 24 hour 60 mg, 90 1 or 1b* QL (1 tablet per 1 day) mg nifedipine oral capsule 1 or 1b* QL (4 capsule per 1 day) oral capsule 1 or 1b* QL (12 capsule per 1 day) er oral tablet extended release 24 hour 17 mg, 20 mg, 8.5 mg 1 or 1b* DO nisoldipine er oral tablet extended release 24 hour 25.5 mg, 30 mg, 34 mg, 40 1 or 1b* QL (1 tablet per 1 day) mg NYMALIZE ORAL SOLUTION (nimodipine) 3 QL (60 mL per 1 day) PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 30 3 DO MG (nifedipine) PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 60 3 QL (1 tablet per 1 day) MG, 90 MG (nifedipine) SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 MG, 8.5 MG 3 DO (nisoldipine) SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 34 MG 3 QL (1 tablet per 1 day) (nisoldipine) taztia xt oral capsule extended release 24 hour 120 mg, 180 mg, 360 mg 1 or 1b* DO taztia xt oral capsule extended release 24 hour 240 mg, 300 mg 1 or 1b* QL (1 capsule per 1 day) tiadylt er oral capsule extended release 24 hour 120 mg, 180 mg, 360 mg 1 or 1b* DO

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 98 Coverage Requirements and Prescription Drug Name Drug Tier Limits tiadylt er oral capsule extended release 24 hour 240 mg, 300 mg, 420 mg 1 or 1b* QL (1 capsule per 1 day) TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 3 DO MG, 360 MG (diltiazem hcl er beads) TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 240 MG, 300 3 QL (1 capsule per 1 day) MG, 420 MG (diltiazem hcl er beads) verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 1 or 1b* DO mg verapamil hcl er oral capsule extended release 24 hour 200 mg, 300 mg, 360 1 or 1b* QL (1 capsule per 1 day) mg verapamil hcl er oral capsule extended release 24 hour 240 mg 1 or 1b* QL (2 capsules per 1 day) verapamil hcl er oral tablet extended release 1 or 1b* QL (2 tablets per 1 day) verapamil hcl intravenous solution 1 or 1b* verapamil hcl oral tablet 120 mg, 80 mg 1 or 1b* QL (4 tablet per 1 day) verapamil hcl oral tablet 40 mg 1 or 1b* QL (3 tablet per 1 day) VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 3 DO 180 MG (verapamil hcl) VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 240 MG 3 QL (2 capsules per 1 day) (verapamil hcl) VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 360 MG 3 QL (1 capsule per 1 day) (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 3 DO MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 3 QL (1 capsule per 1 day) MG, 300 MG (verapamil hcl) *CARDIOTONICS* - DRUGS FOR THE HEART *CARDIAC GLYCOSIDES*** - DRUGS FOR THE HEART digitek oral tablet 1 or 1b* digox oral tablet 1 or 1b* digoxin injection solution 1 or 1b* digoxin oral solution 1 or 1b* digoxin oral tablet 1 or 1b* LANOXIN INJECTION SOLUTION (digoxin) 3 LANOXIN ORAL TABLET 62.5 MCG (digoxin) 2 LANOXIN PEDIATRIC INJECTION SOLUTION (digoxin) 2 *INOTROPES*** - DRUGS FOR SERIOUS ALLERGIC REACTION hcl intravenous solution 1 or 1b* DOBUTAMINE IN D5W INTRAVENOUS SOLUTION 3 dopamine hcl intravenous solution 1 or 1b* DOPAMINE IN D5W INTRAVENOUS SOLUTION 3 lactate in dextrose intravenous solution 1 or 1b*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 99 Coverage Requirements and Prescription Drug Name Drug Tier Limits milrinone lactate intravenous solution 1 or 1b* *CARDIOVASCULAR AGENTS - MISC.* - DRUGS FOR THE HEART * & HMG COA REDUCTASE INHIBIT COMB*** - DRUGS FOR CHOLESTEROL amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 1 or 1b* QL (1 tablet per 1 day) 5-80 mg amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 1 or 1b* DO 5-20 mg, 5-40 mg CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5-80 3 QL (1 tablet per 1 day) MG (amlodipine-atorvastatin) CADUET ORAL TABLET 5-10 MG, 5-20 MG, 5-40 MG (amlodipine- 3 DO atorvastatin) *CARDIOPLEGIC SOLUTIONS*** - DRUGS FOR THE HEART ADENOCAINE INTRAVENOUS SOLUTION PREFILLED SYRINGE 3 (cardioplegic soln) PLEGISOL PERFUSION SOLUTION (cardioplegic soln) 3 *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** - DRUGS FOR HIGH BLOOD PRESSURE ENTRESTO ORAL TABLET (sacubitril-valsartan) 3 QL (6 tablets per 1 day) *NITRATE & VASODILATOR COMBINATIONS*** - DRUGS FOR HIGH BLOOD PRESSURE BIDIL ORAL TABLET (isosorb dinitrate-hydralazine) 2 *PROSTAGLANDIN - IMPOTENCE AGENTS*** - DRUGS FOR THE HEART CAVERJECT IMPULSE INTRACAVERNOSAL KIT (alprostadil 3 PA (vasodilator)) CAVERJECT INTRACAVERNOSAL SOLUTION RECONSTITUTED 3 PA (alprostadil (vasodilator)) EDEX INTRACAVERNOSAL KIT (alprostadil (vasodilator)) 3 PA MUSE URETHRAL PELLET (alprostadil (vasodilator)) 3 PA *PROSTAGLANDIN VASODILATORS*** - DRUGS FOR HIGH BLOOD PRESSURE epoprostenol sodium intravenous solution reconstituted 4 PA; LD; SP treprostinil injection solution 4 PA; LD; SP VELETRI INTRAVENOUS SOLUTION RECONSTITUTED (epoprostenol 4 PA; LD; SP sodium) *PULM HYPERTEN-SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC)*** - DRUGS FOR HIGH BLOOD PRESSURE PA; LD; SP; QL (3 tablets per 1 ADEMPAS ORAL TABLET (riociguat) 4 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 100 Coverage Requirements and Prescription Drug Name Drug Tier Limits * - ANTAGONISTS*** - DRUGS FOR HIGH BLOOD PRESSURE oral tablet 4 PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (2 tablets per 1 oral tablet 4 day) OPSUMIT ORAL TABLET () 4 PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (2 tablets per 1 TRACLEER ORAL TABLET (bosentan) 4 day) PA; LD; SP; QL (2 tablets per 1 TRACLEER ORAL TABLET SOLUBLE (bosentan) 4 day) *PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS*** - DRUGS FOR HIGH BLOOD PRESSURE alyq oral tablet 4 PA; SP; QL (2 tablets per 1 day) sildenafil citrate intravenous solution 4 PA; SP; QL (3 vial per 1 day) sildenafil citrate oral suspension reconstituted 4 PA; SP; QL (6 mL per 1 day) sildenafil citrate oral tablet 20 mg 4 PA; SP; QL (3 tablets per 1 day) tadalafil (pah) oral tablet 4 PA; SP; QL (2 tablets per 1 day) *SELECTIVE CGMP PHOSPHODIESTERASE TYPE 5 INHIBITORS*** - DRUGS FOR THE HEART sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg 1 or 1b* PA tadalafil oral tablet 10 mg, 20 mg 1 or 1b* PA tadalafil oral tablet 2.5 mg, 5 mg 1 or 1b* PA; QL (30 tablets per 30 days) vardenafil hcl oral tablet 1 or 1b* PA vardenafil hcl oral tablet dispersible 1 or 1b* PA *SEPTAL AGENTS - ABLATION** - DRUGS FOR THE HEART ABLYSINOL INTRA-ARTERIAL SOLUTION (dehydrated ) 3 *SINUS NODE INHIBITORS** - DRUGS FOR HIGH BLOOD PRESSURE CORLANOR ORAL SOLUTION (ivabradine hcl) 3 PA; QL (4 ampules per 1 day) CORLANOR ORAL TABLET (ivabradine hcl) 2 PA; QL (2 tablets per 1 day) *VASOACTIVE SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC)*** - DRUGS FOR ANGINA VERQUVO ORAL TABLET 10 MG, 5 MG (vericiguat) 3 PA; QL (1 tablet per 1 day) VERQUVO ORAL TABLET 2.5 MG (vericiguat) 3 PA; QL (1 tablets per 1 day) *CEPHALOSPORINS* - DRUGS FOR INFECTIONS *CEPHALOSPORIN COMBINATIONS*** - ANTIBIOTICS AVYCAZ INTRAVENOUS SOLUTION RECONSTITUTED (ceftazidime- 3 avibactam) ZERBAXA INTRAVENOUS SOLUTION RECONSTITUTED (ceftolozane- 3 tazobactam)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 101 Coverage Requirements and Prescription Drug Name Drug Tier Limits *CEPHALOSPORINS - 1ST GENERATION*** - ANTIBIOTICS cefadroxil oral capsule 1 or 1b* cefadroxil oral suspension reconstituted 1 or 1b* cefadroxil oral tablet 1 or 1b* CEFAZOLIN IN SODIUM CHLORIDE INTRAVENOUS SOLUTION 2-0.9 3 GM/100ML-% cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 500 mg 1 or 1b* CEFAZOLIN SODIUM INJECTION SOLUTION RECONSTITUTED 100 3 GM, 300 GM CEFAZOLIN SODIUM INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 1 GM/10ML cefazolin sodium intravenous solution reconstituted 1 or 1b* CEFAZOLIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION 3 CEFAZOLIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION 3 RECONSTITUTED cephalexin oral capsule 1 or 1a* cephalexin oral suspension reconstituted 1 or 1a* cephalexin oral tablet 1 or 1a* KEFLEX ORAL CAPSULE (cephalexin) 3 *CEPHALOSPORINS - 2ND GENERATION*** - ANTIBIOTICS CEFACLOR ER ORAL TABLET EXTENDED RELEASE 12 HOUR 3 cefaclor oral capsule 1 or 1b* cefaclor oral suspension reconstituted 1 or 1b* CEFOTAN INJECTION SOLUTION RECONSTITUTED (cefotetan 3 disodium) cefotetan disodium injection solution reconstituted 1 or 1b* CEFOTETAN DISODIUM-DEXTROSE INTRAVENOUS SOLUTION 3 RECONSTITUTED cefoxitin sodium injection solution reconstituted 1 or 1b* cefoxitin sodium intravenous solution reconstituted 1 or 1b* CEFOXITIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION 3 RECONSTITUTED cefprozil oral suspension reconstituted 1 or 1b* cefprozil oral tablet 1 or 1b* cefuroxime axetil oral tablet 1 or 1b* cefuroxime sodium injection solution reconstituted 1 or 1b* cefuroxime sodium intravenous solution reconstituted 1 or 1b* *CEPHALOSPORINS - 3RD GENERATION*** - ANTIBIOTICS cefdinir oral capsule 1 or 1b* QL (20 capsules per 1 fill) cefdinir oral suspension reconstituted 125 mg/5ml 1 or 1b* QL (240 mL per 1 fill) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 102 Coverage Requirements and Prescription Drug Name Drug Tier Limits cefdinir oral suspension reconstituted 250 mg/5ml 1 or 1b* QL (120 mL per 1 fill) cefixime oral capsule 1 or 1b* QL (10 capsules per 1 fill) cefixime oral suspension reconstituted 100 mg/5ml 1 or 1b* QL (200 mL per 1 fill) cefixime oral suspension reconstituted 200 mg/5ml 1 or 1b* QL (100 mL per 1 fill) cefotaxime sodium injection solution reconstituted 1 or 1b* cefpodoxime proxetil oral suspension reconstituted 1 or 1b* cefpodoxime proxetil oral tablet 1 or 1b* CEFTAZIDIME AND DEXTROSE INTRAVENOUS SOLUTION 3 RECONSTITUTED ceftazidime injection solution reconstituted 1 or 1b* ceftriaxone sodium in dextrose intravenous solution 1 or 1b* QL (3000 mL per 30 days) ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 500 mg 1 or 1b* QL (60 vials per 30 fills) CEFTRIAXONE SODIUM INJECTION SOLUTION RECONSTITUTED 100 3 GM ceftriaxone sodium injection solution reconstituted 250 mg 1 or 1b* QL (1 vial per 30 fills) ceftriaxone sodium intravenous solution reconstituted 1 gm, 2 gm 1 or 1b* QL (60 vials per 30 days) ceftriaxone sodium intravenous solution reconstituted 10 gm 1 or 1b* CEFTRIAXONE SODIUM-DEXTROSE INTRAVENOUS SOLUTION 3 QL (60 IV Bags per 30 days) RECONSTITUTED FORTAZ INJECTION SOLUTION RECONSTITUTED (ceftazidime) 3 FORTAZ INTRAVENOUS SOLUTION RECONSTITUTED (ceftazidime) 3 SUPRAX ORAL CAPSULE (cefixime) 3 QL (10 capsules per 1 fill) SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML (cefixime) 3 QL (200 mL per 1 fill) SUPRAX ORAL SUSPENSION RECONSTITUTED 200 MG/5ML (cefixime) 3 QL (100 mL per 1 fill) SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML (cefixime) 3 QL (40 mL per 1 fill) SUPRAX ORAL TABLET CHEWABLE 100 MG (cefixime) 3 QL (40 tablets per 1 fill) SUPRAX ORAL TABLET CHEWABLE 200 MG (cefixime) 3 QL (20 tablets per 1 fill) tazicef injection solution reconstituted 1 or 1b* TAZICEF INTRAVENOUS SOLUTION (ceftazidime sodium in dextrose) 3 tazicef intravenous solution reconstituted 1 or 1b* *CEPHALOSPORINS - 4TH GENERATION*** - ANTIBIOTICS cefepime hcl injection solution reconstituted 1 or 1b* CEFEPIME HCL INTRAVENOUS SOLUTION 3 CEFEPIME HCL INTRAVENOUS SOLUTION RECONSTITUTED 3 CEFEPIME-DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 3 *CEPHALOSPORINS - 5TH GENERATION*** - ANTIBIOTICS TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED (ceftaroline 3 fosamil)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 103 Coverage Requirements and Prescription Drug Name Drug Tier Limits *CEPHALOSPORINS - SIDEROPHORES*** - ANTIBIOTICS FETROJA INTRAVENOUS SOLUTION RECONSTITUTED (cefiderocol 3 sulfate tosylate) *CONTRACEPTIVES* - DRUGS FOR WOMEN *BIPHASIC CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS azurette oral tablet 1 or 1b*; $0 bekyree oral tablet 1 or 1b*; $0 -ethinyl oral tablet 0.15-0.02/0.01 mg (21/5) 1 or 1b*; $0 kariva oral tablet 1 or 1b*; $0 LO LOESTRIN FE ORAL TABLET (norethin-eth estrad-fe biphas) 2 MIRCETTE ORAL TABLET (desogestrel-ethinyl estradiol) 3 pimtrea oral tablet 1 or 1b*; $0 simliya oral tablet 1 or 1b*; $0 viorele oral tablet 1 or 1b*; $0 volnea oral tablet 1 or 1b*; $0 *COMBINATION CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS afirmelle oral tablet 1 or 1a*; $0 altavera oral tablet 1 or 1a*; $0 alyacen 1/35 oral tablet 1 or 1a*; $0 apri oral tablet 1 or 1a*; $0 aubra eq oral tablet 1 or 1a*; $0 aubra oral tablet 1 or 1a*; $0 aurovela 1.5/30 oral tablet 1 or 1a*; $0 aurovela 1/20 oral tablet 1 or 1a*; $0 aurovela 24 fe oral tablet 1 or 1a*; $0 aurovela fe 1.5/30 oral tablet 1 or 1a*; $0 aurovela fe 1/20 oral tablet 1 or 1a*; $0 aviane oral tablet 1 or 1a*; $0 ayuna oral tablet 1 or 1a*; $0 BALCOLTRA ORAL TABLET (levonorgest-eth estrad-fe bisg) 3 balziva oral tablet 1 or 1a*; $0 BEYAZ ORAL TABLET (drospiren-eth estrad-levomefol) 3 blisovi 24 fe oral tablet 1 or 1a*; $0 blisovi fe 1.5/30 oral tablet 1 or 1a*; $0 blisovi fe 1/20 oral tablet 1 or 1a*; $0 briellyn oral tablet 1 or 1a*; $0 charlotte 24 fe oral tablet chewable 1 or 1a*; $0 BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 104 Coverage Requirements and Prescription Drug Name Drug Tier Limits chateal eq oral tablet 1 or 1a*; $0 chateal oral tablet 1 or 1a*; $0 cryselle-28 oral tablet 1 or 1a*; $0 cyclafem 1/35 oral tablet 1 or 1a*; $0 cyred eq oral tablet 1 or 1a*; $0 cyred oral tablet 1 or 1a*; $0 dasetta 1/35 oral tablet 1 or 1a*; $0 delyla oral tablet 1 or 1a*; $0 desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg 1 or 1a*; $0 drospiren-eth estrad-levomefol oral tablet 1 or 1b*; $0 -ethinyl estradiol oral tablet 1 or 1b*; $0 elinest oral tablet 1 or 1a*; $0 emoquette oral tablet 1 or 1a*; $0 enskyce oral tablet 1 or 1a*; $0 estarylla oral tablet 1 or 1a*; $0 ethynodiol diac-eth estradiol oral tablet 1 or 1a*; $0 FALESSA ORAL KIT (-eth estrad & fa) 3 falmina oral tablet 1 or 1a*; $0 femynor oral tablet 1 or 1a*; $0 gemmily oral capsule 1 or 1b*; $0 GENERESS FE ORAL TABLET CHEWABLE (norethin-eth estradiol-fe) 3 hailey 1.5/30 oral tablet 1 or 1a*; $0 hailey 24 fe oral tablet 1 or 1a*; $0 hailey fe 1.5/30 oral tablet 1 or 1a*; $0 hailey fe 1/20 oral tablet 1 or 1a*; $0 isibloom oral tablet 1 or 1a*; $0 jasmiel oral tablet 1 or 1b*; $0 juleber oral tablet 1 or 1a*; $0 junel 1.5/30 oral tablet 1 or 1a*; $0 junel 1/20 oral tablet 1 or 1a*; $0 junel fe 1.5/30 oral tablet 1 or 1a*; $0 junel fe 1/20 oral tablet 1 or 1a*; $0 junel fe 24 oral tablet 1 or 1a*; $0 kaitlib fe oral tablet chewable 1 or 1b*; $0 kalliga oral tablet 1 or 1a*; $0 kelnor 1/35 oral tablet 1 or 1a*; $0 kelnor 1/50 oral tablet 1 or 1a*; $0 kurvelo oral tablet 1 or 1a*; $0 BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 105 Coverage Requirements and Prescription Drug Name Drug Tier Limits larin 1.5/30 oral tablet 1 or 1a*; $0 larin 1/20 oral tablet 1 or 1a*; $0 larin 24 fe oral tablet 1 or 1a*; $0 larin fe 1.5/30 oral tablet 1 or 1a*; $0 larin fe 1/20 oral tablet 1 or 1a*; $0 larissia oral tablet 1 or 1a*; $0 layolis fe oral tablet chewable 1 or 1b*; $0 lessina oral tablet 1 or 1a*; $0 levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg 1 or 1a*; $0 levora 0.15/30 (28) oral tablet 1 or 1a*; $0 lillow oral tablet 1 or 1a*; $0 loestrin 1.5/30 (21) oral tablet 1 or 1a*; $0 loestrin 1/20 (21) oral tablet 1 or 1a*; $0 loestrin fe 1.5/30 oral tablet 1 or 1a*; $0 loestrin fe 1/20 oral tablet 1 or 1a*; $0 loryna oral tablet 1 or 1b*; $0 low-ogestrel oral tablet 1 or 1a*; $0 lo-zumandimine oral tablet 1 or 1b*; $0 lutera oral tablet 1 or 1a*; $0 marlissa oral tablet 1 or 1a*; $0 merzee oral capsule 1 or 1b*; $0 mibelas 24 fe oral tablet chewable 1 or 1a*; $0 microgestin 1.5/30 oral tablet 1 or 1a*; $0 microgestin 1/20 oral tablet 1 or 1a*; $0 microgestin 24 fe oral tablet 1 or 1a*; $0 microgestin fe 1.5/30 oral tablet 1 or 1a*; $0 microgestin fe 1/20 oral tablet 1 or 1a*; $0 mili oral tablet 1 or 1a*; $0 MINASTRIN 24 FE ORAL TABLET CHEWABLE (norethin ace-eth estrad- 3 fe) mono-linyah oral tablet 1 or 1a*; $0 necon 0.5/35 (28) oral tablet 1 or 1a*; $0 NEXTSTELLIS ORAL TABLET (drospirenone-estetrol) 3 nikki oral tablet 1 or 1b*; $0 norethin ace-eth estrad-fe oral capsule 1 or 1b*; $0 norethin ace-eth estrad-fe oral tablet 1 or 1a*; $0 norethin ace-eth estrad-fe oral tablet chewable 1 or 1a*; $0 norethindrone acet-ethinyl est oral tablet 1 or 1a*; $0

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 106 Coverage Requirements and Prescription Drug Name Drug Tier Limits norethin-eth estradiol-fe oral tablet chewable 1 or 1b*; $0 norgestimate-eth estradiol oral tablet 1 or 1a*; $0 nortrel 0.5/35 (28) oral tablet 1 or 1a*; $0 nortrel 1/35 (21) oral tablet 1 or 1a*; $0 nortrel 1/35 (28) oral tablet 1 or 1a*; $0 nymyo oral tablet 1 or 1a*; $0 ocella oral tablet 1 or 1b*; $0 orsythia oral tablet 1 or 1a*; $0 philith oral tablet 1 or 1a*; $0 pirmella 1/35 oral tablet 1 or 1a*; $0 portia-28 oral tablet 1 or 1a*; $0 previfem oral tablet 1 or 1a*; $0 reclipsen oral tablet 1 or 1a*; $0 SAFYRAL ORAL TABLET (drospiren-eth estrad-levomefol) 3 sprintec 28 oral tablet 1 or 1a*; $0 sronyx oral tablet 1 or 1a*; $0 syeda oral tablet 1 or 1b*; $0 tarina 24 fe oral tablet 1 or 1a*; $0 tarina fe 1/20 eq oral tablet 1 or 1a*; $0 tarina fe 1/20 oral tablet 1 or 1a*; $0 TAYTULLA ORAL CAPSULE (norethin ace-eth estrad-fe) 3 TYBLUME ORAL TABLET CHEWABLE (levonorgestrel-ethinyl estrad) 3 tydemy oral tablet 1 or 1b*; $0 vestura oral tablet 1 or 1b*; $0 vienva oral tablet 1 or 1a*; $0 vyfemla oral tablet 1 or 1a*; $0 vylibra oral tablet 1 or 1a*; $0 wera oral tablet 1 or 1a*; $0 wymzya fe oral tablet chewable 1 or 1b*; $0 YASMIN 28 ORAL TABLET (drospirenone-ethinyl estradiol) 3 YAZ ORAL TABLET (drospirenone-ethinyl estradiol) 3 zarah oral tablet 1 or 1b*; $0 zovia 1/35 (28) oral tablet 1 or 1a*; $0 zovia 1/35e (28) oral tablet 1 or 1a*; $0 zumandimine oral tablet 1 or 1b*; $0 *COMBINATION CONTRACEPTIVES - TRANSDERMAL*** - BIRTH CONTROL PILLS TWIRLA TRANSDERMAL PATCH WEEKLY (levonorgestrel-eth estradiol) 3

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 107 Coverage Requirements and Prescription Drug Name Drug Tier Limits xulane transdermal patch weekly 1 or 1b*; $0 zafemy transdermal patch weekly 1 or 1b*; $0 *COMBINATION CONTRACEPTIVES - VAGINAL*** - BIRTH CONTROL PILLS ANNOVERA VAGINAL RING (segesterone-ethinyl estradiol) 3 eluryng vaginal ring 1 or 1b*; $0 -ethinyl estradiol vaginal ring 1 or 1b*; $0 NUVARING VAGINAL RING (etonogestrel-ethinyl estradiol) 3 *CONTINUOUS CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS amethyst oral tablet 1 or 1b*; $0 dolishale oral tablet 1 or 1b*; $0 levonorgestrel-ethinyl estrad oral tablet 90-20 mcg 1 or 1b*; $0 *COPPER CONTRACEPTIVES - IUD*** - BIRTH CONTROL PILLS PARAGARD INTRAUTERINE COPPER INTRAUTERINE 3 INTRAUTERINE DEVICE (copper) *EMERGENCY CONTRACEPTIVES*** - BIRTH CONTROL PILLS aftera oral tablet 1 or 1b*; $0 econtra ez oral tablet 1 or 1b*; $0 econtra one-step oral tablet 1 or 1b*; $0 ELLA ORAL TABLET (ulipristal acetate) 3; $0 levonorgestrel oral tablet 1 or 1b*; $0 my choice oral tablet 1 or 1b*; $0 my way oral tablet 1 or 1b*; $0 new day oral tablet 1 or 1b*; $0 opcicon one-step oral tablet 1 or 1b*; $0 option 2 oral tablet 1 or 1b*; $0 preventeza oral tablet 1 or 1b*; $0 react oral tablet 1 or 1b*; $0 take action oral tablet 1 or 1b*; $0 *EXTENDED-CYCLE CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS amethia oral tablet 1 or 1b*; $0 ashlyna oral tablet 1 or 1b*; $0 camrese lo oral tablet 1 or 1b*; $0 camrese oral tablet 1 or 1b*; $0 daysee oral tablet 1 or 1b*; $0 fayosim oral tablet 1 or 1b*; $0 iclevia oral tablet 1 or 1b*; $0

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 108 Coverage Requirements and Prescription Drug Name Drug Tier Limits introvale oral tablet 1 or 1b*; $0 jaimiess oral tablet 1 or 1b*; $0 jolessa oral tablet 1 or 1b*; $0 levonorgest-eth est & eth est oral tablet 1 or 1b*; $0 levonorgest-eth estrad 91-day oral tablet 1 or 1b*; $0 lojaimiess oral tablet 1 or 1b*; $0 LOSEASONIQUE ORAL TABLET (levonorgest-eth estrad 91-day) 3 QUARTETTE ORAL TABLET (levonorgest-eth estrad 91-day) 3 rivelsa oral tablet 1 or 1b*; $0 SEASONIQUE ORAL TABLET (levonorgest-eth estrad 91-day) 3 setlakin oral tablet 1 or 1b*; $0 simpesse oral tablet 1 or 1b*; $0 *FOUR PHASE CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS NATAZIA ORAL TABLET (estradiol valerate-) 3 *PROGESTIN CONTRACEPTIVES - INJECTABLE*** - BIRTH CONTROL PILLS DEPO-PROVERA INTRAMUSCULAR SUSPENSION 3 (medroxyprogesterone acetate) DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED 3 SYRINGE (medroxyprogesterone acetate) DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION 3; $0 PREFILLED SYRINGE (medroxyprogesterone acetate) medroxyprogesterone acetate intramuscular suspension 1 or 1b*; $0 medroxyprogesterone acetate intramuscular suspension prefilled syringe 1 or 1b*; $0 *PROGESTIN CONTRACEPTIVES - IUD*** - BIRTH CONTROL PILLS LILETTA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 3 LD; SP (levonorgestrel) MIRENA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 3 LD; SP (levonorgestrel) SKYLA INTRAUTERINE INTRAUTERINE DEVICE (levonorgestrel) 3 LD; SP *PROGESTIN CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS camila oral tablet 1 or 1b*; $0 deblitane oral tablet 1 or 1b*; $0 errin oral tablet 1 or 1b*; $0 heather oral tablet 1 or 1b*; $0 incassia oral tablet 1 or 1b*; $0 jencycla oral tablet 1 or 1b*; $0

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 109 Coverage Requirements and Prescription Drug Name Drug Tier Limits lyleq oral tablet 1 or 1b*; $0 lyza oral tablet 1 or 1b*; $0 nora-be oral tablet 1 or 1b*; $0 norethindrone oral tablet 1 or 1b*; $0 norlyda oral tablet 1 or 1b*; $0 norlyroc oral tablet 1 or 1b*; $0 sharobel oral tablet 1 or 1b*; $0 SLYND ORAL TABLET (drospirenone) 3 tulana oral tablet 1 or 1b*; $0 *TRIPHASIC CONTRACEPTIVES - ORAL*** - BIRTH CONTROL PILLS alyacen 7/7/7 oral tablet 1 or 1a*; $0 aranelle oral tablet 1 or 1a*; $0 caziant oral tablet 1 or 1a*; $0 cyclafem 7/7/7 oral tablet 1 or 1a*; $0 dasetta 7/7/7 oral tablet 1 or 1a*; $0 enpresse-28 oral tablet 1 or 1a*; $0 ESTROSTEP FE ORAL TABLET (norethindron-ethinyl estrad-fe) 3 leena oral tablet 1 or 1a*; $0 levonest oral tablet 1 or 1a*; $0 levonorg-eth estrad triphasic oral tablet 1 or 1a*; $0 norgestim-eth estrad triphasic oral tablet 1 or 1b*; $0 nortrel 7/7/7 oral tablet 1 or 1a*; $0 nylia 7/7/7 oral tablet 1 or 1a*; $0 pirmella 7/7/7 oral tablet 1 or 1a*; $0 tilia fe oral tablet 1 or 1b*; $0 tri femynor oral tablet 1 or 1b*; $0 tri-estarylla oral tablet 1 or 1b*; $0 tri-legest fe oral tablet 1 or 1b*; $0 tri-linyah oral tablet 1 or 1b*; $0 tri-lo-estarylla oral tablet 1 or 1b*; $0 tri-lo-marzia oral tablet 1 or 1b*; $0 tri-lo-mili oral tablet 1 or 1b*; $0 tri-lo-sprintec oral tablet 1 or 1b*; $0 tri-mili oral tablet 1 or 1b*; $0 tri-nymyo oral tablet 1 or 1b*; $0 tri-previfem oral tablet 1 or 1b*; $0 tri-sprintec oral tablet 1 or 1b*; $0

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 110 Coverage Requirements and Prescription Drug Name Drug Tier Limits trivora (28) oral tablet 1 or 1a*; $0 tri-vylibra lo oral tablet 1 or 1b*; $0 tri-vylibra oral tablet 1 or 1b*; $0 velivet oral tablet 1 or 1a*; $0 *CORTICOSTEROIDS* - HORMONES *GLUCOCORTICOSTEROIDS*** - DRUGS FOR INFLAMMATION ALKINDI SPRINKLE ORAL CAPSULE SPRINKLE (hydrocortisone) 3 PA; LD budesonide er oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) budesonide oral capsule delayed release particles 1 or 1b* QL (3 capsule per 1 day) CORTEF ORAL TABLET (hydrocortisone) 3 decadron oral tablet 1 or 1a* DEPO-MEDROL INJECTION SUSPENSION ( acetate) 3 DEXABLISS ORAL TABLET THERAPY PACK 3 INTENSOL ORAL CONCENTRATE (dexamethasone) 2 dexamethasone oral elixir 1 or 1a* dexamethasone oral solution 1 or 1a* dexamethasone oral tablet 1 or 1a* dexamethasone oral tablet therapy pack 1 or 1b* DEXAMETHASONE SOD PHOS-NACL INTRAVENOUS SOLUTION 3 dexamethasone sod phosphate pf injection solution 1 or 1b* DEXAMETHASONE SOD PHOSPHATE PF INJECTION SOLUTION 3 PREFILLED SYRINGE DEXAMETHASONE SODIUM PHOSPHATE INJECTION SOLUTION 10 3 MG/ML, 4 MG/ML dexamethasone sodium phosphate injection solution 100 mg/10ml, 120 1 or 1b* mg/30ml, 20 mg/5ml DXEVO 11-DAY ORAL TABLET THERAPY PACK (dexamethasone) 3 ENTOCORT EC ORAL CAPSULE DELAYED RELEASE PARTICLES 3 QL (3 capsule per 1 day) (budesonide) HEMADY ORAL TABLET (dexamethasone) 3 PA; QL (2 tablets per 1 day) hydrocortisone oral tablet 1 or 1b* KENALOG INJECTION SUSPENSION (triamcinolone acetonide) 3 KENALOG-80 INJECTION SUSPENSION (triamcinolone acetonide) 3 MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG 3 (methylprednisolone) MEDROL ORAL TABLET 2 MG (methylprednisolone) 2 MEDROL ORAL TABLET THERAPY PACK (methylprednisolone) 3 methylprednisolone oral tablet 1 or 1a* methylprednisolone oral tablet therapy pack 1 or 1a*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 111 Coverage Requirements and Prescription Drug Name Drug Tier Limits methylprednisolone sodium succ injection solution reconstituted 1 or 1b* MILLIPRED ORAL TABLET () 3 ORAPRED ODT ORAL TABLET DISPERSIBLE 10 MG, 30 MG 3 QL (2 tablets per 1 day) (prednisolone sodium phosphate) ORAPRED ODT ORAL TABLET DISPERSIBLE 15 MG (prednisolone 3 DO sodium phosphate) ORTIKOS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 QL (1 capsule per 1 day) (budesonide) PEDIAPRED ORAL SOLUTION (prednisolone sodium phosphate) 3 prednisolone oral solution 1 or 1a* prednisolone sodium phosphate oral solution 1 or 1a* prednisolone sodium phosphate oral tablet dispersible 10 mg, 30 mg 1 or 1a* QL (2 tablets per 1 day) prednisolone sodium phosphate oral tablet dispersible 15 mg 1 or 1a* DO PREDNISONE INTENSOL ORAL CONCENTRATE (prednisone) 3 prednisone oral solution 1 or 1a* prednisone oral tablet 1 or 1a* prednisone oral tablet therapy pack 1 or 1a* SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 3 (hydrocortisone sod succinate) SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 3 (methylprednisolone sodium succ) taperdex 12-day oral tablet therapy pack 1 or 1b* taperdex 6-day oral tablet therapy pack 1 or 1b* taperdex 7-day oral tablet therapy pack 1 or 1b* UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR (budesonide) 3 QL (1 tablet per 1 day) ZCORT 7-DAY ORAL TABLET THERAPY PACK 3 *MINERALOCORTICOIDS*** - DRUGS FOR INFLAMMATION fludrocortisone acetate oral tablet 1 or 1b* *STEROID COMBINATIONS*** - DRUGS FOR INFLAMMATION BSP 0820 INJECTION KIT 3 CELESTONE SOLUSPAN INJECTION SUSPENSION (betamethasone sod 3 phos & acet) *COUGH/COLD/ALLERGY* - DRUGS FOR THE LUNGS *ANTITUSSIVE - NONNARCOTIC*** - DRUGS FOR ALLERGIES benzonatate oral capsule 1 or 1b* TESSALON PERLES ORAL CAPSULE (benzonatate) 3 *ANTITUSSIVE - OPIOID*** - DRUGS FOR COUGH AND COLD HYCODAN ORAL SYRUP (hydrocodone-homatropine) 3 hydrocodone-homatropine oral syrup 1 or 1a*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 112 Coverage Requirements and Prescription Drug Name Drug Tier Limits hydrocodone-homatropine oral tablet 1 or 1a* hydromet oral syrup 1 or 1a* *ANTITUSSIVE-EXPECTORANT*** - DRUGS FOR COUGH AND COLD CODITUSSIN AC ORAL LIQUID 3 g tussin ac oral solution 1 or 1a* guaiatussin ac oral syrup 1 or 1a* guaifenesin ac oral syrup 1 or 1a* guaifenesin-codeine oral solution 1 or 1a* MAR-COF CG EXPECTORANT ORAL LIQUID (guaifenesin-codeine) 2 maxi-tuss ac oral solution 1 or 1a* M-CLEAR WC ORAL SOLUTION 2 NINJACOF-XG ORAL LIQUID (guaifenesin-codeine) 3 trymine cg oral liquid 1 or 1a* virtussin a/c oral solution 1 or 1a* virtussin ac w/alc oral liquid 1 or 1a* *ANTITUSSIVE-EXPECTORANTS-DECONGESTANT*** - DRUGS FOR COUGH AND COLD CODITUSSIN DAC ORAL LIQUID 3 TUSNEL C ORAL SYRUP (pseudoephedrine-codeine-gg) 2 VIRTUSSIN DAC ORAL SOLUTION 2 *DECONGESTANT & ANTIHISTAMINE*** - DRUGS FOR COUGH AND COLD CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 3 ST; QL (2 tablets per 1 day) HOUR (desloratadine-pseudoephedrine) promethazine vc oral syrup 1 or 1b* QL (120 mL per 1 fill) promethazine- oral syrup 1 or 1b* QL (120 mL per 1 fill) *DECONGESTANT W/ EXPECTORANT*** - DRUGS FOR COUGH AND COLD GILPHEX TR ORAL TABLET (phenylephrine-guaifenesin) 3 *IODINE EXPECTORANTS*** - DRUGS FOR COUGH AND COLD SSKI ORAL SOLUTION (potassium iodide (expectorant)) 3 *MISC. RESPIRATORY INHALANTS*** - DRUGS FOR ALLERGIES HYPERSAL INHALATION NEBULIZATION SOLUTION (sodium 3 chloride) sodium chloride inhalation nebulization solution 1 or 1b* *MUCOLYTICS*** - DRUGS FOR THE LUNGS acetylcysteine inhalation solution 1 or 1b*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 113 Coverage Requirements and Prescription Drug Name Drug Tier Limits *NON-NARC ANTITUSSIVE-ANTIHISTAMINE*** - DRUGS FOR COUGH AND COLD promethazine-dm oral syrup 1 or 1a* QL (120 mL per 1 fill) *NON-NARC ANTITUSSIVE-DECONGESTANT- ANTIHISTAMINE*** - DRUGS FOR COUGH AND COLD pseudoeph-bromphen-dm oral syrup 1 or 1b* *OPIOID ANTITUSSIVE-ANTIHISTAMINE*** - DRUGS FOR COUGH AND COLD hydrocod polst-cpm polst er oral suspension extended release 1 or 1b* QL (120 mL per 1 fill) promethazine-codeine oral solution 1 or 1a* QL (120 mL per 1 fill) promethazine-codeine oral syrup 1 or 1a* QL (120 mL per 1 fill) TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 HOUR (hydrocod 2 polst-chlorphen polst) TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 HOUR 3 (chlorpheniramine-codeine) TUZISTRA XR ORAL SUSPENSION EXTENDED RELEASE (codeine 3 polst-chlorphen polst) *OPIOID ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE*** - DRUGS FOR COUGH AND COLD CAPCOF ORAL SYRUP 3 HISTEX-AC ORAL SYRUP (phenyleph-triprolidine-codeine) 3 MAR-COF BP ORAL LIQUID (pseudoeph-bromphen-cod) 3 MAXI-TUSS CD ORAL LIQUID 2 M-END PE ORAL LIQUID (phenylephrine-bromphen-codeine) 3 POLY-TUSSIN AC ORAL LIQUID 2 promethazine vc/codeine oral syrup 1 or 1b* QL (120 mL per 1 fill) promethazine-phenyleph-codeine oral syrup 1 or 1b* QL (120 mL per 1 fill) PRO-RED AC ORAL SYRUP (phenyleph-dexchlorphen-codeine) 3 RYDEX ORAL LIQUID (pseudoeph-bromphen-cod) 2 *DERMATOLOGICALS* - DRUGS FOR THE SKIN *ACNE ANTIBIOTICS*** - DRUGS FOR THE SKIN CLEOCIN-T EXTERNAL LOTION (clindamycin phosphate) 3 ST; QL (4 mL per 1 day) clindacin etz external swab 1 or 1b* QL (2 pads per 1 day) clindacin-p external swab 1 or 1b* QL (2 pads per 1 day) clindamycin phosphate external foam 1 or 1b* QL (100 grams per 30 days) clindamycin phosphate external gel 1 or 1b* QL (60 grams per 30 days) clindamycin phosphate external lotion 1 or 1b* QL (4 mL per 1 day) clindamycin phosphate external solution 1 or 1b* QL (4 mL per 1 day) clindamycin phosphate external swab 1 or 1b* QL (2 pads per 1 day) dapsone external gel 1 or 1b* ST; QL (60 grams per 30 days) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 114 Coverage Requirements and Prescription Drug Name Drug Tier Limits ery external pad 1 or 1b* QL (2 pads per 1 day) ERYGEL EXTERNAL GEL () 3 QL (60 grams per 30 days) erythromycin external gel 1 or 1b* QL (60 grams per 30 days) erythromycin external solution 1 or 1b* EVOCLIN EXTERNAL FOAM (clindamycin phosphate) 3 ST; QL (100 grams per 30 days) KLARON EXTERNAL LOTION (sulfacetamide sodium (acne)) 3 sulfacetamide sodium (acne) external lotion 1 or 1b* *ACNE COMBINATIONS*** - DRUGS FOR THE SKIN adapalene-benzoyl peroxide external gel 1 or 1b* PA; QL (45 grams per 30 days) BENZAMYCIN EXTERNAL GEL (benzoyl peroxide-erythromycin) 3 ST; QL (46.6 grams per 30 days) benzoyl peroxide-erythromycin external gel 1 or 1b* QL (2 packets per 1 day) clindamycin phos-benzoyl perox external gel 1.2-5 % 1 or 1b* QL (45 grams per 30 days) clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 % 1 or 1b* QL (50 grams per 30 days) clindamycin-tretinoin external gel 1 or 1b* neuac external gel 1 or 1b* QL (45 grams per 30 days) ONEXTON EXTERNAL GEL (clindamycin phos-benzoyl perox) 2 QL (50 grams per 30 days) sulfacetamide sod-sulfur wash external liquid 1 or 1b* PA TAROXIA EXTERNAL GEL 3 *ACNE PRODUCTS*** - DRUGS FOR THE SKIN ABSORICA LD ORAL CAPSULE (isotretinoin micronized) 3 PA ABSORICA ORAL CAPSULE (isotretinoin) 3 PA accutane oral capsule 2 PA adapalene external cream 1 or 1b* PA; QL (1.5 grams per 1 day) adapalene external gel 1 or 1b* PA; QL (45 grams per 30 days) adapalene external pad 1 or 1b* PA AKLIEF EXTERNAL CREAM (trifarotene) 3 ST; QL (1 pump per 30 days) amnesteem oral capsule 2 PA ARAZLO EXTERNAL LOTION (tazarotene) 3 ST; QL (45 grams per 30 days) avita external cream 1 or 1b* PA; QL (45 grams per 30 days) avita external gel 1 or 1b* PA; QL (45 grams per 30 days) bp wash external liquid 2.5 %, 7 % 1 or 1b* claravis oral capsule 2 PA isotretinoin oral capsule 2 PA myorisan oral capsule 2 PA tretinoin external cream 1 or 1b* PA; QL (45 grams per 30 days) tretinoin external gel 1 or 1b* PA; QL (45 grams per 30 days) tretinoin microsphere external gel 1 or 1b* PA; QL (45 grams per 30 days) tretinoin microsphere pump external gel 1 or 1b* PA; QL (45 grams per 30 days) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 115 Coverage Requirements and Prescription Drug Name Drug Tier Limits zenatane oral capsule 2 PA *AGENTS FOR EXTERNAL GENITAL AND PERIANAL WARTS*** - DRUGS FOR THE SKIN VEREGEN EXTERNAL OINTMENT (sinecatechins) 3 *AGENTS FOR FACIAL WRINKLES - RETINOIDS*** - DRUGS FOR THE SKIN refissa external cream 1 or 1b* PA; QL (40 grams per 30 days) RENOVA EXTERNAL CREAM (tretinoin (facial wrinkles)) 3 PA; QL (40 grams per 30 days) RENOVA PUMP EXTERNAL CREAM (tretinoin (facial wrinkles)) 3 PA; QL (44 grams per 30 days) tretinoin (emollient) external cream 1 or 1b* PA; QL (40 grams per 30 days) *ANTIBIOTIC STEROID COMBINATIONS - TOPICAL*** - DRUGS FOR THE SKIN NEO-SYNALAR EXTERNAL CREAM (neomycin-fluocinolone) 3 *ANTIBIOTICS - TOPICAL*** - DRUGS FOR THE SKIN ALTABAX EXTERNAL OINTMENT (retapamulin) 2 QL (30 grams per 1 fill) CENTANY EXTERNAL OINTMENT (mupirocin) 3 QL (30 grams per 1 fill) gentamicin sulfate external cream 1 or 1b* QL (30 grams per 1 fill) gentamicin sulfate external ointment 1 or 1b* QL (30 grams per 1 fill) mupirocin calcium external cream 1 or 1b* QL (30 grams per 1 fill) mupirocin external ointment 1 or 1b* QL (30 grams per 1 fill) XEPI EXTERNAL CREAM (ozenoxacin) 3 QL (45 grams per 1 fill) *ANTIFUNGALS - TOPICAL COMBINATIONS*** - DRUGS FOR THE SKIN -betamethasone external cream 1 or 1b* QL (120 grams per 30 days) clotrimazole-betamethasone external lotion 1 or 1b* QL (120 mL per 30 days) miconazole-zinc oxide-petrolat external ointment 1 or 1b* QL (50 grams per 30 days) nystatin-triamcinolone external cream 1 or 1b* QL (120 grams per 30 days) nystatin-triamcinolone external ointment 1 or 1b* QL (120 grams per 30 days) VUSION EXTERNAL OINTMENT (miconazole-zinc oxide-petrolat) 3 QL (50 grams per 30 days) *ANTIFUNGALS - TOPICAL*** - DRUGS FOR THE SKIN ciclopirox external gel 1 or 1b* QL (100 grams per 30 days) ciclopirox external shampoo 1 or 1b* QL (120 mL per 30 days) ciclopirox external solution 1 or 1b* QL (7 mL per 30 days) ciclopirox olamine external cream 1 or 1b* QL (90 grams per 30 days) ciclopirox olamine external suspension 1 or 1b* QL (60 mL per 30 days) LOPROX EXTERNAL CREAM (ciclopirox olamine) 3 ST; QL (90 grams per 30 days) LOPROX EXTERNAL SHAMPOO (ciclopirox) 3 QL (120 mL per 30 days) LOPROX EXTERNAL SUSPENSION (ciclopirox olamine) 3 ST; QL (60 mL per 30 days) MENTAX EXTERNAL CREAM (butenafine hcl) 3 ST; QL (30 grams per 30 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 116 Coverage Requirements and Prescription Drug Name Drug Tier Limits naftifine hcl external cream 1 % 1 or 1b* ST; QL (90 grams per 30 days) naftifine hcl external cream 2 % 1 or 1b* QL (60 grams per 30 days) naftifine hcl external gel 1 or 1b* ST; QL (90 grams per 30 days) NAFTIN EXTERNAL GEL 1 % (naftifine hcl) 3 ST; QL (90 grams per 30 days) NAFTIN EXTERNAL GEL 2 % (naftifine hcl) 3 ST; QL (60 grams per 30 days) nyamyc external powder 1 or 1b* QL (30 grams per 30 days) nystatin external cream 1 or 1b* QL (120 grams per 30 days) nystatin external ointment 1 or 1b* QL (120 grams per 30 days) nystatin external powder 1 or 1b* QL (30 grams per 30 days) nystop external powder 1 or 1b* QL (30 grams per 30 days) *ANTI-INFLAMMATORY AGENTS - TOPICAL*** - DRUGS FOR THE SKIN diclofenac sodium external gel 1 % 1 or 1b* QL (1000 gm per 30 days) *ANTI-INFLAMMATORY COMBINATIONS - TOPICAL*** - DRUGS FOR THE SKIN ziclopro combination therapy pack 1 or 1b* *ANTINEOPLASTIC ALKYLATING AGENTS - TOPICAL*** - DRUGS FOR THE SKIN VALCHLOR EXTERNAL GEL (mechlorethamine hcl (topical)) 3 PA; LD; QL (1 tube per 30 days) *ANTINEOPLASTIC ANTIMETABOLITES - TOPICAL*** - DRUGS FOR THE SKIN CARAC EXTERNAL CREAM (fluorouracil) 3 ST; QL (30 gm per 365 days) EFUDEX EXTERNAL CREAM (fluorouracil) 3 ST; QL (40 gm per 365 days) FLUOROPLEX EXTERNAL CREAM (fluorouracil) 3 ST; QL (60 gm per 365 days) fluorouracil external cream 0.5 % 1 or 1b* ST; QL (30 gm per 365 days) fluorouracil external cream 5 % 1 or 1b* QL (40 gm per 365 days) fluorouracil external solution 1 or 1b* QL (10 mL per 365 days) *ANTINEOPLASTIC RETINOIDS - TOPICAL*** - DRUGS FOR THE SKIN PANRETIN EXTERNAL GEL () 3 SP *ANTIPRURITICS - TOPICAL*** - DRUGS FOR THE SKIN doxepin hcl external cream 1 or 1b* PA; QL (1 tube per 1 fill) *ANTIPSORIATICS - SYSTEMIC*** - DRUGS FOR THE SKIN acitretin oral capsule 1 or 1b* COSENTYX (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED PA; LD; SP; QL (2 syringes per 28 4 SYRINGE (secukinumab) days) COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS SOLUTION PA; LD; SP; QL (2 pens per 28 4 AUTO-INJECTOR (secukinumab) days) COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO- 4 PA; LD; SP; QL (1 pen per 28 days) INJECTOR (secukinumab)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 117 Coverage Requirements and Prescription Drug Name Drug Tier Limits COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; SP; QL (1 syringe per 28 4 (secukinumab) days) methoxsalen rapid oral capsule 1 or 1b*; OC SP SKYRIZI (150 MG DOSE) SUBCUTANEOUS PREFILLED SYRINGE KIT 4 PA; SP; QL (2 syringes per 84 days) (risankizumab-rzaa) SKYRIZI PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 4 PA; SP; QL (1 carton per 84 days) (risankizumab-rzaa) SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (1 carton per 84 days) (risankizumab-rzaa) SORIATANE ORAL CAPSULE (acitretin) 3 STELARA SUBCUTANEOUS SOLUTION (ustekinumab) 4 PA; SP; QL (1 vial per 84 days) STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (1 syringe per 84 days) (ustekinumab) PA; SP; QL (1 autoinjector per 56 TREMFYA SUBCUTANEOUS SOLUTION PEN-INJECTOR (guselkumab) 4 days) TREMFYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (1 syringe per 47 days) (guselkumab) *ANTIPSORIATICS*** - DRUGS FOR THE SKIN calcipotriene external cream 1 or 1b* QL (120 grams per 30 days) calcipotriene external foam 1 or 1b* QL (120 grams per 30 days) calcipotriene external ointment 1 or 1b* QL (120 grams per 30 days) calcipotriene external solution 1 or 1b* QL (60 mL per 30 days) calcitrene external ointment 1 or 1b* QL (120 grams per 30 days) calcitriol external ointment 1 or 1b* QL (800 grams per 28 days) DOVONEX EXTERNAL CREAM (calcipotriene) 3 QL (120 grams per 30 days) SORILUX EXTERNAL FOAM (calcipotriene) 3 QL (120 grams per 30 days) tazarotene external cream 1 or 1b* QL (30 grams per 30 days) TAZORAC EXTERNAL CREAM 0.05 % (tazarotene) 2 QL (30 grams per 30 days) TAZORAC EXTERNAL GEL 0.05 % (tazarotene) 2 QL (30 grams per 30 days) TAZORAC EXTERNAL GEL 0.1 % (tazarotene) 2 QL (1 gram per 1 day) *ANTISEBORRHEIC COMBINATIONS*** - DRUGS FOR THE SKIN PROMISEB EXTERNAL CREAM (antiseborrheic products, misc.) 3 SODIUM SULFACETAMIDE- EXTERNAL LIQUID 3 *ANTISEBORRHEIC PRODUCTS*** - DRUGS FOR THE SKIN selenium sulfide external lotion 1 or 1a* QL (120 mL per 30 days) *ANTIVIRAL TOPICAL COMBINATIONS*** - DRUGS FOR THE SKIN XERESE EXTERNAL CREAM (acyclovir-hydrocortisone) 3 PA; QL (5 gm per 30 days) *ANTIVIRALS - TOPICAL*** - DRUGS FOR THE SKIN acyclovir external cream 1 or 1b* PA; QL (5 gm per 30 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 118 Coverage Requirements and Prescription Drug Name Drug Tier Limits acyclovir external ointment 1 or 1b* QL (30 gm per 30 days) DENAVIR EXTERNAL CREAM (penciclovir) 3 PA; QL (5 gm per 30 days) ZOVIRAX EXTERNAL OINTMENT (acyclovir) 3 QL (30 gm per 30 days) *BURN PRODUCTS*** - DRUGS FOR THE SKIN mafenide acetate external packet 1 or 1b* SILVADENE EXTERNAL CREAM (silver sulfadiazine) 3 silver sulfadiazine external cream 1 or 1a* ssd external cream 1 or 1a* SULFAMYLON EXTERNAL CREAM (mafenide acetate) 3 SULFAMYLON EXTERNAL PACKET (mafenide acetate) 3 *CORTICOSTEROIDS - TOPICAL*** - DRUGS FOR THE SKIN ala-cort external cream 1 or 1a* QL (454 grams per 30 days) alclometasone dipropionate external cream 1 or 1b* QL (60 grams per 30 days) alclometasone dipropionate external ointment 1 or 1b* QL (2 grams per 1 day) amcinonide external cream 3 ST; QL (60 grams per 30 days) amcinonide external lotion 3 ST; QL (60 mL per 30 days) beser external lotion 1 or 1b* QL (120 mL per 30 days) betamethasone dipropionate aug external cream 1 or 1b* QL (50 grams per 30 days) betamethasone dipropionate aug external gel 1 or 1b* QL (50 grams per 30 days) betamethasone dipropionate aug external lotion 1 or 1b* QL (60 mL per 30 days) betamethasone dipropionate aug external ointment 1 or 1b* QL (50 grams per 30 days) betamethasone dipropionate external cream 1 or 1b* QL (45 grams per 30 days) betamethasone dipropionate external lotion 1 or 1b* QL (60 mL per 30 days) betamethasone dipropionate external ointment 1 or 1b* QL (45 grams per 30 days) betamethasone valerate external cream 1 or 1b* QL (45 grams per 30 days) betamethasone valerate external foam 3 ST; QL (100 grams per 30 days) betamethasone valerate external lotion 1 or 1b* ST; QL (60 mL per 30 days) betamethasone valerate external ointment 1 or 1b* QL (45 grams per 30 days) clobetasol prop emollient base external cream 1 or 1b* QL (60 grams per 30 days) clobetasol propionate e external cream 1 or 1b* QL (60 grams per 30 days) clobetasol propionate emulsion external foam 1 or 1b* QL (100 grams per 30 days) clobetasol propionate external cream 1 or 1b* QL (60 grams per 30 days) clobetasol propionate external foam 1 or 1b* QL (100 mL per 30 days) clobetasol propionate external gel 1 or 1b* QL (60 grams per 30 days) clobetasol propionate external liquid 1 or 1b* QL (125 mL per 30 days) clobetasol propionate external lotion 1 or 1b* QL (118 mL per 30 days) clobetasol propionate external ointment 1 or 1b* QL (60 grams per 30 days) clobetasol propionate external shampoo 1 or 1b* QL (3.94 mL per 1 day) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 119 Coverage Requirements and Prescription Drug Name Drug Tier Limits clobetasol propionate external solution 1 or 1b* QL (50 mL per 30 days) clocortolone pivalate external cream 3 ST; QL (90 grams per 30 days) clodan external shampoo 1 or 1b* QL (3.94 mL per 1 day) desonide external cream 1 or 1b* QL (60 grams per 30 days) desonide external gel 1 or 1b* QL (2 grams per 1 day) desonide external lotion 1 or 1b* QL (118 mL per 30 days) desonide external ointment 1 or 1b* QL (60 grams per 30 days) desoximetasone external cream 3 ST; QL (100 grams per 30 days) desoximetasone external gel 3 ST; QL (60 grams per 30 days) desoximetasone external liquid 3 ST; QL (100 mL per 30 days) desoximetasone external ointment 3 ST; QL (100 grams per 30 days) desrx external gel 1 or 1b* QL (2 grams per 1 day) diflorasone diacetate external cream 3 ST; QL (60 grams per 30 days) diflorasone diacetate external ointment 3 ST; QL (60 grams per 30 days) fluocinolone acetonide body external oil 1 or 1b* ST; QL (120 mL per 30 days) fluocinolone acetonide external cream 0.01 % 1 or 1b* QL (60 grams per 30 days) fluocinolone acetonide external cream 0.025 % 1 or 1b* QL (120 grams per 30 days) fluocinolone acetonide external ointment 1 or 1b* QL (120 grams per 30 days) fluocinolone acetonide external solution 1 or 1b* QL (90 mL per 30 days) fluocinolone acetonide scalp external oil 1 or 1b* QL (120 mL per 30 days) fluocinonide emulsified base external cream 1 or 1b* QL (60 grams per 30 days) fluocinonide external cream 1 or 1b* QL (120 grams per 30 days) fluocinonide external gel 1 or 1b* QL (60 grams per 30 days) fluocinonide external ointment 1 or 1b* QL (60 grams per 30 days) fluocinonide external solution 1 or 1b* QL (60 mL per 30 days) flurandrenolide external cream 3 ST; QL (120 grams per 30 days) flurandrenolide external lotion 3 ST; QL (120 mL per 30 days) flurandrenolide external ointment 3 ST; QL (60 grams per 30 days) fluticasone propionate external cream 1 or 1b* QL (60 grams per 30 days) fluticasone propionate external lotion 1 or 1b* QL (120 mL per 30 days) fluticasone propionate external ointment 1 or 1b* QL (60 grams per 30 days) halcinonide external cream 3 ST; QL (60 grams per 30 days) halobetasol propionate external cream 1 or 1b* QL (50 grams per 30 days) halobetasol propionate external ointment 1 or 1b* QL (50 grams per 30 days) hydrocortisone butyr lipo base external cream 3 ST; QL (60 grams per 30 days) hydrocortisone butyrate external cream 3 ST; QL (60 grams per 30 days) hydrocortisone butyrate external lotion 3 ST; QL (3.94 mL per 1 day) hydrocortisone butyrate external ointment 3 ST; QL (60 grams per 30 days) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 120 Coverage Requirements and Prescription Drug Name Drug Tier Limits hydrocortisone butyrate external solution 3 ST; QL (60 mL per 30 days) hydrocortisone external cream 1 %, 2.5 % 1 or 1a* QL (454 grams per 30 days) hydrocortisone external lotion 2.5 % 1 or 1a* QL (118 mL per 30 days) hydrocortisone external ointment 1 %, 2.5 % 1 or 1a* QL (454 grams per 30 days) hydrocortisone valerate external cream 3 ST; QL (60 grams per 30 days) hydrocortisone valerate external ointment 3 ST; QL (60 grams per 30 days) mometasone furoate external cream 1 or 1b* QL (50 grams per 30 days) mometasone furoate external ointment 1 or 1b* QL (50 grams per 30 days) mometasone furoate external solution 1 or 1b* QL (60 mL per 30 days) nolix external lotion 3 ST; QL (120 mL per 30 days) prednicarbate external ointment 1 or 1b* QL (60 grams per 30 days) tovet external foam 1 or 1b* QL (100 grams per 30 days) triamcinolone acetonide external aerosol solution 3 ST; QL (100 grams per 30 days) triamcinolone acetonide external cream 1 or 1a* QL (454 grams per 30 days) triamcinolone acetonide external lotion 1 or 1a* QL (60 mL per 30 days) triamcinolone acetonide external ointment 0.025 %, 0.1 % 1 or 1a* QL (454 grams per 30 days) triamcinolone acetonide external ointment 0.05 % 3 ST; QL (430 grams per 30 days) triamcinolone acetonide external ointment 0.5 % 1 or 1a* QL (30 grams per 30 days) triderm external cream 1 or 1a* QL (454 grams per 30 days) tritocin external ointment 3 QL (430 grams per 30 days) *DEPIGMENTING AGENTS*** - DRUGS FOR THE SKIN blanche external cream 1 or 1b* *DEPIGMENTING COMBINATIONS*** - DRUGS FOR THE SKIN TRI-LUMA EXTERNAL CREAM (fluocin-hydroquinone-tretinoin) 3 *EMOLLIENT COMBINATIONS*** - DRUGS FOR THE SKIN LACTIC ACID E EXTERNAL CREAM 3 *EMOLLIENT/KERATOLYTIC AGENTS*** - DRUGS FOR THE SKIN CEROVEL EXTERNAL LOTION (urea) 3 *EMOLLIENTS*** - DRUGS FOR THE SKIN ammonium lactate external cream 1 or 1b* QL (450 grams per 30 days) ammonium lactate external lotion 1 or 1b* LACTIC ACID EXTERNAL LOTION 3 *ENZYMES - TOPICAL*** - DRUGS FOR THE SKIN SANTYL EXTERNAL OINTMENT (collagenase) 3 QL (30 grams per 30 days) *IMIDAZOLE-RELATED ANTIFUNGALS - TOPICAL*** - DRUGS FOR THE SKIN clotrimazole external cream 1 or 1b* QL (1 gram per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 121 Coverage Requirements and Prescription Drug Name Drug Tier Limits clotrimazole external solution 1 or 1b* QL (60 mL per 30 days) econazole nitrate external cream 1 or 1b* QL (85 grams per 30 days) ECOZA EXTERNAL FOAM (econazole nitrate) 3 ST; QL (70 grams per 30 days) ERTACZO EXTERNAL CREAM (sertaconazole nitrate) 3 ST; QL (60 grams per 30 days) EXELDERM EXTERNAL CREAM (sulconazole nitrate) 3 ST; QL (60 grams per 30 days) EXELDERM EXTERNAL SOLUTION (sulconazole nitrate) 3 ST; QL (60 mL per 30 days) EXTINA EXTERNAL FOAM (ketoconazole) 3 QL (100 grams per 30 days) JUBLIA EXTERNAL SOLUTION (efinaconazole) 3 QL (4 mL per 1 day) ketoconazole external cream 1 or 1b* QL (120 grams per 30 days) ketoconazole external foam 1 or 1b* QL (100 grams per 30 days) ketoconazole external shampoo 1 or 1b* QL (120 mL per 30 days) luliconazole external cream 1 or 1b* ST; QL (60 grams per 30 days) LUZU EXTERNAL CREAM (luliconazole) 3 ST; QL (60 grams per 30 days) oxiconazole nitrate external cream 1 or 1b* QL (60 grams per 30 days) OXISTAT EXTERNAL CREAM (oxiconazole nitrate) 3 ST; QL (60 grams per 30 days) OXISTAT EXTERNAL LOTION (oxiconazole nitrate) 3 ST; QL (60 mL per 30 days) sulconazole nitrate external cream 1 or 1b* ST; QL (60 grams per 30 days) sulconazole nitrate external solution 1 or 1b* ST; QL (60 mL per 30 days) XOLEGEL EXTERNAL GEL (ketoconazole) 3 QL (45 grams per 30 days) *IMMUNOMODULATORS IMIDAZOQUINOLINAMINES - TOPICAL*** - DRUGS FOR THE SKIN ALDARA EXTERNAL CREAM (imiquimod) 3 ST; QL (48 packet per 365 days) imiquimod external cream 3.75 % 1 or 1b* ST; QL (28 units per 28 days) imiquimod external cream 5 % 1 or 1b* QL (48 packet per 365 days) imiquimod pump external cream 1 or 1b* ST; QL (1 pump bottle per 28 days) ZYCLARA EXTERNAL CREAM (imiquimod) 3 ST; QL (28 units per 28 days) ZYCLARA PUMP EXTERNAL CREAM 2.5 % (imiquimod) 3 ST; QL (1 pump bottle per 28 days) ZYCLARA PUMP EXTERNAL CREAM 3.75 % (imiquimod) 3 ST; QL (1 bottle per 28 days) *KERATOLYTIC/ANTIMITOTIC AGENTS*** - DRUGS FOR THE SKIN ACNESIC EXTERNAL GEL (salicylic acid) 3 CONDYLOX EXTERNAL GEL (podofilox) 3 podofilox external solution 1 or 1b* *LOCAL ANESTHETICS - TOPICAL*** - DRUGS FOR THE SKIN glydo external prefilled syringe 1 or 1b* lidocaine external ointment 5 % 1 or 1b* QL (5 grams per 1 day) lidocaine external patch 5 % 1 or 1b* PA; QL (3 patches per 1 day) lidocaine hcl external solution 1 or 1b* QL (10 mL per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 122 Coverage Requirements and Prescription Drug Name Drug Tier Limits lidocaine hcl urethral/mucosal external gel 1 or 1b* lidocaine hcl urethral/mucosal external prefilled syringe 1 or 1b* QUTENZA (4 PATCH) EXTERNAL KIT (-cleansing gel) 3 LD *MACROLIDE IMMUNOSUPPRESSANTS - TOPICAL*** - DRUGS FOR THE SKIN pimecrolimus external cream 1 or 1b* ST; QL (100 grams per 90 days) external ointment 1 or 1b* ST; QL (100 grams per 90 days) * AGONISTS (UV PROTECTIVE)*** - DRUGS FOR THE SKIN PA; LD; QL (1 implant per 2 SCENESSE SUBCUTANEOUS IMPLANT (afamelanotide acetate) 3 monthss) * INHIBITORS - TOPICAL*** - DRUGS FOR THE SKIN KLISYRI EXTERNAL OINTMENT (tirbanibulin) 3 ST; QL (5 packets per 1 fill) *MISC. DERMATOLOGICAL PRODUCTS*** - DRUGS FOR THE SKIN ILIDERM EXTERNAL EMULSION 3 *MISC. TOPICAL*** - DRUGS FOR THE SKIN BORIC ACID EXTERNAL GRANULES 3 QBREXZA EXTERNAL PAD (glycopyrronium tosylate) 3 PA; QL (1 cloth per 1 day) *ORNITHINE DECARBOXYLASE (ODC) INHIBITORS - TOPICAL*** - DRUGS FOR THE SKIN VANIQA EXTERNAL CREAM (eflornithine hcl) 3 *OXABOROLE-RELATED ANTIFUNGALS - TOPICAL*** - DRUGS FOR THE SKIN tavaborole external solution 1 or 1b* ST; QL (1 bottle per 30 days) *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL*** - DRUGS FOR THE SKIN EUCRISA EXTERNAL OINTMENT (crisaborole) 3 ST; QL (100 grams per 30 days) * AGENTS - TOPICAL*** - DRUGS FOR THE SKIN AMELUZ EXTERNAL GEL ( hcl) 3 LEVULAN KERASTICK EXTERNAL SOLUTION RECONSTITUTED 3 (aminolevulinic acid hcl) *PROSTAGLANDINS - TOPICAL*** - DRUGS FOR THE SKIN bimatoprost external solution 1 or 1b* LATISSE EXTERNAL SOLUTION (bimatoprost) 3 *ROSACEA AGENTS*** - DRUGS FOR THE SKIN azelaic acid external gel 1 or 1b* QL (50 grams per 30 days) FINACEA EXTERNAL FOAM (azelaic acid) 2 QL (1.67 grams per 1 day) ivermectin external cream 1 or 1b* QL (45 grams per 30 days) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 123 Coverage Requirements and Prescription Drug Name Drug Tier Limits METROCREAM EXTERNAL CREAM (metronidazole) 3 ST; QL (45 grams per 30 days) metronidazole external cream 1 or 1b* QL (45 grams per 30 days) metronidazole external gel 0.75 % 1 or 1b* QL (45 grams per 30 days) metronidazole external gel 1 % 1 or 1b* QL (55 grams per 30 days) metronidazole external lotion 1 or 1b* QL (59 mL per 30 days) MIRVASO EXTERNAL GEL (brimonidine tartrate) 3 QL (30 grams per 30 days) NORITATE EXTERNAL CREAM (metronidazole) 3 ST; QL (60 grams per 30 days) RHOFADE EXTERNAL CREAM (oxymetazoline hcl) 3 QL (60 grams per 30 days) rosadan external cream 1 or 1b* QL (45 grams per 30 days) rosadan external gel 1 or 1b* QL (45 grams per 30 days) SOOLANTRA EXTERNAL CREAM (ivermectin) 3 QL (45 grams per 30 days) ZILXI EXTERNAL FOAM (minocycline hcl micronized) 3 ST; QL (1 gram per 1 day) *SCABICIDES & PEDICULICIDES*** - DRUGS FOR THE SKIN crotan external lotion 1 or 1b* QL (60 mL per 30 days) ivermectin external lotion 1 or 1b* QL (120 grams per 30 days) lindane external shampoo 1 or 1b* QL (60 mL per 30 days) malathion external lotion 1 or 1b* QL (4 mL per 1 day) NATROBA EXTERNAL SUSPENSION (spinosad) 3 QL (120 mL per 7 days) OVIDE EXTERNAL LOTION (malathion) 3 QL (4 mL per 1 day) external cream 1 or 1b* QL (120 grams per 30 days) spinosad external suspension 1 or 1b* QL (120 mL per 7 days) SULFURATED LIME EXTERNAL SOLUTION 3 *SEBORRHEIC KERATOSIS PRODUCTS** - DRUGS FOR THE SKIN ESKATA EXTERNAL SOLUTION () 3 *STEROID- COMBINATIONS*** - DRUGS FOR THE SKIN EPIFOAM EXTERNAL FOAM (pramoxine-hc) 3 PRAMOSONE EXTERNAL CREAM 1-1 % (pramoxine-hc) 2 PRAMOSONE EXTERNAL LOTION (pramoxine-hc) 2 *TAR PRODUCTS*** - DRUGS FOR THE SKIN coal tar external solution 1 or 1b* *TISSUE REPLACEMENTS*** - DRUGS FOR THE SKIN AFFINITY EXTERNAL SHEET (amniotic membrane allograft) 3 AMNIOFIX INJECTION SUSPENSION RECONSTITUTED (amniotic 3 membrane allograft) AMNIOTEXT EXTERNAL SHEET (amniotic membrane allograft) 3 AMPHENOL-40 INJECTION SUSPENSION RECONSTITUTED 3 APLIGRAF EXTERNAL DISK (cultured skin substitute) 3

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 124 Coverage Requirements and Prescription Drug Name Drug Tier Limits BIOVANCE EXTERNAL SHEET (amniotic membrane allograft) 3 EPICORD EXTERNAL SHEET (umbilical cord allograft) 3 EPIFIX EXTERNAL DISK (amniotic membrane allograft) 3 EPIFIX EXTERNAL SHEET (amniotic membrane allograft) 3 EPIFIX MICRONIZED INJECTION SUSPENSION RECONSTITUTED 3 (amniotic membrane allograft) KARDIAMEMBRANE EXTERNAL SHEET (amniotic membrane allograft) 3 NEOX 100 EXTERNAL SHEET (amniotic membrane allograft) 3 NEOX CORD 1K EXTERNAL SHEET (amniotic membrane allograft) 3 NOVACHOR EXTERNAL SHEET (chorion membrane allograft) 3 NUSHIELD EXTERNAL DISK (amniotic membrane allograft) 3 NUSHIELD EXTERNAL SHEET 2 CM X 4 CM , 4 CM X 3 CM , 4 CM X 4 3 CM , 4 CM X 6 CM , 6 CM X 6 CM (amniotic membrane allograft) PALINGEN FLOW INJECTION INJECTABLE (amniotic memb-fluid 3 allograft) PALINGEN HYDROMEMBRANE EXTERNAL SHEET (amniotic 3 membrane allograft) PALINGEN INOVOFLO INJECTION INJECTABLE (amniotic fluid 3 allograft) PALINGEN MEMBRANE EXTERNAL SHEET (amniotic membrane 3 allograft) PALINGEN XPLUS HYDROMEMBRANE EXTERNAL SHEET (amniotic 3 membrane allograft) PALINGEN XPLUS MEMBRANE EXTERNAL SHEET (amniotic 3 membrane allograft) STRAVIX EXTERNAL SHEET (amniotic membrane allograft) 3 TRUSKIN EXTERNAL SHEET (skin allograft (human)) 3 * COMBINATIONS*** - DRUGS FOR THE SKIN CETACAINE EXTERNAL GEL (butamben--) 3 FLEXIN EXTERNAL PATCH 3 lidocaine- external kit 1 or 1b* QL (1 kit per 30 days) PRILO PATCH II EXTERNAL KIT (lidocaine-prilocaine) 3 REAL HEAL-I EXTERNAL KIT (lidocaine-prilocaine-dressing) 3 VENIPUNCTURE PX1 PHLEBOTOMY EXTERNAL KIT (lidocaine hcl- 3 blood collection) *TOPICAL ANESTHETIC GASES*** - DRUGS FOR THE SKIN CRYODOSE TA EXTERNAL AEROSOL (pentafluoroprop-tetrafluoroeth) 3 *TOPICAL SELECTIVE AGONISTS*** - DRUGS FOR THE SKIN TARGRETIN EXTERNAL GEL (bexarotene) 2 PA; SP

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 125 Coverage Requirements and Prescription Drug Name Drug Tier Limits *TOPICAL STEROID COMBINATIONS*** - DRUGS FOR THE SKIN calcipotriene-betameth diprop external ointment 1 or 1b* ST; QL (400 grams per 28 days) calcipotriene-betameth diprop external suspension 1 or 1b* ST; QL (420 grams per 28 days) DUOBRII EXTERNAL LOTION (halobetasol prop-tazarotene) 3 PA; QL (200 grams per 30 days) ENSTILAR EXTERNAL FOAM (calcipotriene-betameth diprop) 3 QL (420 grams per 28 days) TACLONEX EXTERNAL OINTMENT (calcipotriene-betameth diprop) 3 ST; QL (400 grams per 28 days) TACLONEX EXTERNAL SUSPENSION (calcipotriene-betameth diprop) 3 ST; QL (420 grams per 28 days) WYNZORA EXTERNAL CREAM (calcipotriene-betameth diprop) 3 ST; QL (420 grams per 28 days) *TYPE II 5-ALPHA REDUCTASE INHIBITORS*** - DRUGS FOR THE SKIN oral tablet 1 mg 1 or 1b* PROPECIA ORAL TABLET (finasteride) 3 *WOUND CARE - GROWTH FACTOR AGENTS*** - DRUGS FOR THE SKIN REGRANEX EXTERNAL GEL (becaplermin) 3 *WOUND DRESSINGS*** - DRUGS FOR THE SKIN KENDALL HYDROGEL WOUND DRESS EXTERNAL (hydroactive 3 dressings) TEGADERM AG MESH EXTERNAL PAD 2"X2" (silver) 2 WOUNDGELHA MATRIX EXTERNAL GEL (hyaluronate sodium) 3 *DIAGNOSTIC PRODUCTS* *DIAGNOSTIC TESTS*** ACCU-CHEK AVIVA PLUS STRIP (glucose blood) 2 QL (204 strips per 30 days) ACCU-CHEK COMPACT PLUS IN VITRO STRIP (glucose blood) 2 QL (204 strips per 30 days) ACCU-CHEK GUIDE IN VITRO STRIP (glucose blood) 2 QL (204 strips per 30 days) ACCU-CHEK SMARTVIEW IN VITRO STRIP (glucose blood) 2 QL (204 strips per 30 days) ACCUTREND GLUCOSE IN VITRO STRIP (glucose blood) 2 QL (204 strips per 30 days) ONETOUCH ULTRA IN VITRO STRIP (glucose blood) 2 ST; QL (204 strips per 30 days) ONETOUCH VERIO IN VITRO STRIP (glucose blood) 2 QL (204 strips per 30 days) *DIGESTIVE AIDS* - DRUGS FOR THE STOMACH *DIGESTIVE ENZYMES*** - DRUGS FOR THE STOMACH CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 2 QL (25 capsules per 1 day) (pancrelipase (lip-prot-amyl)) PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500- 35500 UNIT, 16800-56800 UNIT, 21000-54700 UNIT, 2600-8800 UNIT, 3 ST; QL (25 capsules per 1 day) 4200-14200 UNIT (pancrelipase (lip-prot-amyl)) PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 3 ST; QL (25 capsules per 1 day) (pancrelipase (lip-prot-amyl)) VIOKACE ORAL TABLET (pancrelipase (lip-prot-amyl)) 3 QL (25 tablets per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 126 Coverage Requirements and Prescription Drug Name Drug Tier Limits ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 2 QL (25 capsules per 1 day) (pancrelipase (lip-prot-amyl)) *DIURETICS* - DRUGS FOR THE HEART *CARBONIC ANHYDRASE INHIBITORS*** - DRUGS FOR HIGH BLOOD PRESSURE acetazolamide er oral capsule extended release 12 hour 1 or 1b* acetazolamide oral tablet 1 or 1b* acetazolamide sodium injection solution reconstituted 1 or 1b* methazolamide oral tablet 1 or 1b* *DIURETIC COMBINATIONS*** - DRUGS FOR HIGH BLOOD PRESSURE ALDACTAZIDE ORAL TABLET 25-25 MG (-hctz) 3 DO ALDACTAZIDE ORAL TABLET 50-50 MG (spironolactone-hctz) 3 QL (4 tablets per 1 day) -hydrochlorothiazide oral tablet 1 or 1b* MAXZIDE ORAL TABLET (-hctz) 3 MAXZIDE-25 ORAL TABLET (triamterene-hctz) 3 spironolactone-hctz oral tablet 1 or 1b* DO triamterene-hctz oral capsule 1 or 1a* triamterene-hctz oral tablet 1 or 1a* *LOOP DIURETICS*** - DRUGS FOR HIGH BLOOD PRESSURE bumetanide injection solution 1 or 1b* bumetanide oral tablet 1 or 1b* BUMEX ORAL TABLET (bumetanide) 3 EDECRIN ORAL TABLET (ethacrynic acid) 3 ethacrynate sodium intravenous solution reconstituted 1 or 1b* ethacrynic acid oral tablet 1 or 1b* FUROSEMIDE IN SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 furosemide injection solution 1 or 1a* furosemide oral solution 1 or 1a* furosemide oral tablet 1 or 1a* LASIX ORAL TABLET (furosemide) 3 SODIUM EDECRIN INTRAVENOUS SOLUTION RECONSTITUTED 3 (ethacrynate sodium) torsemide oral tablet 1 or 1b* *OSMOTIC DIURETICS*** - DRUGS FOR HIGH BLOOD PRESSURE mannitol intravenous solution 1 or 1b* osmitrol intravenous solution 1 or 1b*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 127 Coverage Requirements and Prescription Drug Name Drug Tier Limits *POTASSIUM SPARING DIURETICS*** - DRUGS FOR HIGH BLOOD PRESSURE ALDACTONE ORAL TABLET 100 MG (spironolactone) 3 QL (4 tablets per 1 day) ALDACTONE ORAL TABLET 25 MG, 50 MG (spironolactone) 3 DO amiloride hcl oral tablet 1 or 1b* CAROSPIR ORAL SUSPENSION (spironolactone) 3 QL (20 mL per 1 day) spironolactone oral tablet 100 mg 1 or 1a* QL (4 tablets per 1 day) spironolactone oral tablet 25 mg, 50 mg 1 or 1a* DO triamterene oral capsule 1 or 1b* *THIAZIDES AND THIAZIDE-LIKE DIURETICS*** - DRUGS FOR HIGH BLOOD PRESSURE chlorothiazide sodium intravenous solution reconstituted 1 or 1b* chlorthalidone oral tablet 1 or 1a* DIURIL ORAL SUSPENSION (chlorothiazide) 3 hydrochlorothiazide oral capsule 1 or 1a* DO hydrochlorothiazide oral tablet 12.5 mg, 25 mg 1 or 1a* DO hydrochlorothiazide oral tablet 50 mg 1 or 1a* QL (2 tablets per 1 day) indapamide oral tablet 1 or 1b* metolazone oral tablet 1 or 1b* SODIUM DIURIL INTRAVENOUS SOLUTION RECONSTITUTED 3 (chlorothiazide sodium) *ENDOCRINE AND METABOLIC AGENTS - MISC.* - HORMONES *ABORTIFACIENT - RECEPTOR ANTAGONISTS*** - DRUGS FOR WOMEN MIFEPREX ORAL TABLET () 3 mifepristone oral tablet 1 or 1b* *BISPHOSPHONATES*** - DRUGS FOR MENOPAUSE AND BONE LOSS ACTONEL ORAL TABLET 150 MG (risedronate sodium) 3 QL (1 tablet per 30 days) ACTONEL ORAL TABLET 35 MG (risedronate sodium) 3 QL (4 tablets per 28 days) alendronate sodium oral solution 1 or 1b* QL (10.72 mg per 1 day) alendronate sodium oral tablet 10 mg, 5 mg 1 or 1b* QL (1 tablet per 1 day) alendronate sodium oral tablet 35 mg, 70 mg 1 or 1b* QL (4 tablets per 28 days) ATELVIA ORAL TABLET DELAYED RELEASE (risedronate sodium) 3 QL (4 tablets per 28 days) BINOSTO ORAL TABLET EFFERVESCENT (alendronate sodium) 3 QL (4 tablets per 28 days) BONIVA ORAL TABLET (ibandronate sodium) 3 ST; QL (1 tablet per 28 days) FOSAMAX ORAL TABLET (alendronate sodium) 3 QL (4 tablets per 28 days) FOSAMAX PLUS D ORAL TABLET (alendronate-) 2 QL (4 tablets per 28 days) ibandronate sodium intravenous solution 4

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 128 Coverage Requirements and Prescription Drug Name Drug Tier Limits ibandronate sodium oral tablet 1 or 1b* QL (1 tablet per 28 days) pamidronate disodium intravenous solution 30 mg/10ml, 90 mg/10ml 4 SP PAMIDRONATE DISODIUM INTRAVENOUS SOLUTION 6 MG/ML 4 SP risedronate sodium oral tablet 150 mg 1 or 1b* QL (1 tablet per 30 days) risedronate sodium oral tablet 30 mg, 5 mg 1 or 1b* QL (1 tablet per 1 day) risedronate sodium oral tablet 35 mg 1 or 1b* QL (4 tablets per 28 days) risedronate sodium oral tablet delayed release 1 or 1b* QL (4 tablets per 28 days) zoledronic acid intravenous concentrate 1 or 1b* PA; SP ZOLEDRONIC ACID INTRAVENOUS SOLUTION 4 MG/100ML 4 PA; SP zoledronic acid intravenous solution 5 mg/100ml 4 PA; SP; QL (100 mL per 375 days) *CALCIMIMETIC AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS cinacalcet hcl oral tablet 30 mg, 60 mg 4 PA; QL (2 tablets per 1 day) cinacalcet hcl oral tablet 90 mg 4 PA; QL (4 tablets per 1 day) *CALCITONINS*** - DRUGS FOR MENOPAUSE AND BONE LOSS (salmon) injection solution 4 calcitonin (salmon) nasal solution 1 or 1b* QL (1 bottle per 30 days) *CARNITINE REPLENISHER - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS CARNITOR INTRAVENOUS SOLUTION (levocarnitine) 3 CARNITOR ORAL SOLUTION (levocarnitine) 3 CARNITOR ORAL TABLET (levocarnitine) 3 CARNITOR SF ORAL SOLUTION (levocarnitine) 3 levocarnitine oral solution 1 or 1b* levocarnitine oral tablet 1 or 1b* levocarnitine sf oral solution 1 or 1b* *CORTICOTROPIN*** - HORMONES ACTHAR INJECTION GEL (corticotropin) 4 PA; LD; SP *DOPAMINE RECEPTOR AGONISTS*** - DRUGS FOR WOMEN oral tablet 1 or 1b* QL (16 tablets per 28 days) *GNRH/LHRH ANTAGONISTS*** - DRUGS FOR WOMEN ORILISSA ORAL TABLET 150 MG ( sodium) 3 PA; QL (1 tablet per 1 day) ORILISSA ORAL TABLET 200 MG (elagolix sodium) 3 PA; QL (2 tablets per 1 day) *GROWTH HORMONES*** - DRUGS FOR GROWTH HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 5 MG, 4 PA; SP; QL (1 vial per 1 day) 6 MG (somatropin) HUMATROPE INJECTION SOLUTION RECONSTITUTED 24 MG 4 PA; SP; QL (1 injection per 1 day) (somatropin)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 129 Coverage Requirements and Prescription Drug Name Drug Tier Limits NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION PEN- 4 PA; LD; SP; QL (1 vial per 1 day) INJECTOR (somatropin) NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS SOLUTION PEN- 4 PA; LD; SP; QL (1 vial per 1 day) INJECTOR (somatropin) NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS SOLUTION PEN- 4 PA; LD; SP; QL (1 vial per 1 day) INJECTOR (somatropin) *HEREDITARY OROTIC ACIDURIA TREATMENT - AGENTS** - DRUGS FOR MENOPAUSE AND BONE LOSS XURIDEN ORAL PACKET (uridine triacetate) 3 PA; LD; QL (4 packets per 1 day) *HEREDITARY TYROSINEMIA TYPE 1 (HT-1) TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS nitisinone oral capsule 4 PA; SP *HOMOCYSTINURIA TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS CYSTADANE ORAL POWDER (betaine) 3 LD *HYPERPARATHYROID TREATMENT - VITAMIN D ANALOGS*** - DRUGS FOR MENOPAUSE AND BONE LOSS calcitriol intravenous solution 1 or 1b* PA calcitriol oral capsule 1 or 1b* PA calcitriol oral solution 1 or 1b* PA doxercalciferol intravenous solution 1 or 1b* PA doxercalciferol oral capsule 1 or 1b* PA HECTOROL INTRAVENOUS SOLUTION (doxercalciferol) 3 PA paricalcitol intravenous solution 1 or 1b* PA paricalcitol oral capsule 1 or 1b* PA RAYALDEE ORAL CAPSULE EXTENDED RELEASE (calcifediol) 3 PA; QL (2 tablets per 1 day) ROCALTROL ORAL CAPSULE (calcitriol) 3 PA ROCALTROL ORAL SOLUTION (calcitriol) 3 PA ZEMPLAR INTRAVENOUS SOLUTION (paricalcitol) 3 PA ZEMPLAR ORAL CAPSULE (paricalcitol) 3 PA *LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS*** - DRUGS FOR WOMEN FENSOLVI (6 MONTH) SUBCUTANEOUS KIT (leuprolide acetate (6 PA; LD; SP; QL (1 kit per 24 3 month)) weekss) *LYSOSOMAL ACID LIPASE (LAL) DEFICIENCY - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS KANUMA INTRAVENOUS SOLUTION (sebelipase alfa) 3 PA; LD; SP *OVULATION STIMULANTS-*** - DRUGS FOR WOMEN GONAL-F INJECTION SOLUTION RECONSTITUTED (follitropin alfa) 4 PA; SP GONAL-F RFF REDIJECT SUBCUTANEOUS SOLUTION (follitropin alfa) 4 PA; SP

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 130 Coverage Requirements and Prescription Drug Name Drug Tier Limits GONAL-F RFF SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; SP (follitropin alfa) *OVULATION STIMULANTS-SYNTHETIC*** - DRUGS FOR WOMEN clomiphene citrate oral tablet 1 or 1b* PA * AND DERIVATIVES*** - DRUGS FOR MENOPAUSE AND BONE LOSS FORTEO SUBCUTANEOUS SOLUTION PEN-INJECTOR ( 4 PA; SP; QL (1 pen per 28 days) (recombinant)) NATPARA SUBCUTANEOUS CARTRIDGE (parathyroid hormone PA; LD; SP; QL (2 cartridge per 30 3 (recomb)) days) *PHENYLKETONURIA TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS sapropterin dihydrochloride oral packet 4 PA; SP sapropterin dihydrochloride oral tablet 4 PA; SP *RANK LIGAND (RANKL) INHIBITORS*** - DRUGS FOR MENOPAUSE AND BONE LOSS PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; SP; QL (2 injections per 365 3 (denosumab) days) XGEVA SUBCUTANEOUS SOLUTION (denosumab) 3 PA; SP; QL (1 vial per 28 days) *SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)*** - DRUGS FOR MENOPAUSE AND BONE LOSS EVISTA ORAL TABLET (raloxifene hcl) 3; $0 OSPHENA ORAL TABLET (ospemifene) 3 PA; QL (1 tablet per 1 day) raloxifene hcl oral tablet 1 or 1b*; $0 *SELECTIVE VASOPRESSIN V2-RECEPTOR ANTAGONISTS*** - HORMONES SAMSCA ORAL TABLET 15 MG (tolvaptan) 3 PA; LD; SP; QL (1 tablet per 1 day) PA; LD; SP; QL (2 tablets per 1 SAMSCA ORAL TABLET 30 MG (tolvaptan) 3 day) tolvaptan oral tablet 15 mg 1 or 1b* PA; QL (1 tablet per 1 day) tolvaptan oral tablet 30 mg 1 or 1b* PA; QL (2 tablets per 1 day) *SOMATOSTATIC AGENTS*** - DRUGS FOR GROWTH acetate injection solution 4 PA; SP *UREA CYCLE DISORDER - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS AMMONUL INTRAVENOUS SOLUTION (sod benz-sod phenylacet) 3 BUPHENYL ORAL POWDER (sodium phenylbutyrate) 3 PA; LD; QL (25 GM per 1 day) BUPHENYL ORAL TABLET (sodium phenylbutyrate) 3 PA; LD; QL (40 tablets per 1 day) CITRULLINE EASY ORAL TABLET EXTENDED RELEASE 3

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 131 Coverage Requirements and Prescription Drug Name Drug Tier Limits PA; LD; SP; QL (17.5 mL per 1 RAVICTI ORAL LIQUID (glycerol phenylbutyrate) 3 day) sod benz-sod phenylacet intravenous solution 1 or 1b* sodium phenylbutyrate oral powder 1 or 1b* PA; QL (25 GM per 1 day) sodium phenylbutyrate oral tablet 1 or 1b* PA; QL (40 tablets per 1 day) *V1A/V2-ARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTS*** - HORMONES VAPRISOL INTRAVENOUS SOLUTION (conivaptan hcl in dextrose) 3 *VASOPRESSIN*** - HORMONES DDAVP INJECTION SOLUTION (desmopressin acetate) 3 DDAVP ORAL TABLET 0.1 MG (desmopressin acetate) 3 DO DDAVP ORAL TABLET 0.2 MG (desmopressin acetate) 3 QL (6 tablets per 1 day) DDAVP PF INJECTION SOLUTION (desmopressin acetate) 3 desmopressin ace spray refrig nasal solution 1 or 1b* desmopressin acetate injection solution 1 or 1b* desmopressin acetate oral tablet 0.1 mg 1 or 1b* DO desmopressin acetate oral tablet 0.2 mg 1 or 1b* QL (6 tablets per 1 day) desmopressin acetate pf injection solution 1 or 1b* desmopressin acetate spray nasal solution 1 or 1b* STIMATE NASAL SOLUTION (desmopressin acetate) 3 PA; QL (5 mL per 30 days) VASOSTRICT INTRAVENOUS SOLUTION (vasopressin) 3 *ESTROGENS* - HORMONES *ESTROGEN & ANDROGEN*** - DRUGS FOR WOMEN est estrogens-methyltest oral tablet 0.625-1.25 mg 1 or 1b* *ESTROGEN & PROGESTIN*** - DRUGS FOR WOMEN ACTIVELLA ORAL TABLET (estradiol-norethindrone acet) 3 amabelz oral tablet 1 or 1b* ANGELIQ ORAL TABLET (drospirenone-estradiol) 3 BIJUVA ORAL CAPSULE (estradiol-progesterone) 2 QL (1 capsule per 1 day) CLIMARA PRO TRANSDERMAL PATCH WEEKLY (estradiol- 2 QL (4 patch per 28 days) levonorgestrel) COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY (estradiol- 2 QL (8 patch per 28 days) norethindrone acet) estradiol-norethindrone acet oral tablet 1 or 1b* FEMHRT ORAL TABLET (norethindrone-eth estradiol) 3 fyavolv oral tablet 1 or 1b* jinteli oral tablet 1 or 1b* mimvey oral tablet 1 or 1b* norethindrone-eth estradiol oral tablet 1 or 1b*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 132 Coverage Requirements and Prescription Drug Name Drug Tier Limits PREFEST ORAL TABLET (estradiol-norgestimate) 3 PREMPHASE ORAL TABLET (conj estrog-medroxyprogest ace) 2 PREMPRO ORAL TABLET (conj estrog-medroxyprogest ace) 2 *ESTROGEN-PROGESTIN-GNRH ANTAGONIST*** - DRUGS FOR WOMAN MYFEMBREE ORAL TABLET (relugolix-estradiol-norethind) 3 PA; QL (1 tablet per 1 day) ORIAHNN ORAL CAPSULE THERAPY PACK (elagolix-estradiol- 3 PA; QL (1 carton per 28 days) norethind) *ESTROGENS*** - DRUGS FOR WOMEN ALORA TRANSDERMAL PATCH TWICE WEEKLY (estradiol) 3 QL (8 patch per 28 days) CLIMARA TRANSDERMAL PATCH WEEKLY (estradiol) 3 QL (4 patches per 28 days) DELESTROGEN INTRAMUSCULAR OIL (estradiol valerate) 3 DEPO-ESTRADIOL INTRAMUSCULAR OIL (estradiol cypionate) 3 DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 2 QL (1 packet per 1 day) MG/0.75GM, 1 MG/GM (estradiol) DIVIGEL TRANSDERMAL GEL 1.25 MG/1.25GM (estradiol) 2 QL (30 packets per 30 days) dotti transdermal patch twice weekly 1 or 1b* QL (8 patch per 28 days) ELESTRIN TRANSDERMAL GEL (estradiol) 3 QL (1 pump per 30 days) ESTRADIOL IMPLANT PELLET 3 estradiol oral tablet 1 or 1b* estradiol transdermal patch twice weekly 1 or 1b* QL (8 patch per 28 days) estradiol transdermal patch weekly 1 or 1b* QL (4 patches per 28 days) estradiol valerate intramuscular oil 1 or 1b* ESTROGEL TRANSDERMAL GEL (estradiol) 3 QL (1 pump per 30 days) EVAMIST TRANSDERMAL SOLUTION (estradiol) 2 QL (2 bottles per 30 days) lyllana transdermal patch twice weekly 1 or 1b* QL (8 patch per 28 days) MENEST ORAL TABLET (esterified estrogens) 2 MENOSTAR TRANSDERMAL PATCH WEEKLY (estradiol) 3 QL (4 patch per 28 days) PREMARIN INJECTION SOLUTION RECONSTITUTED (estrogens 2 conjugated) PREMARIN ORAL TABLET (estrogens conjugated) 2 QL (1 tablet per 1 day) *ESTROGEN-SELECTIVE ESTROGEN COMB*** - DRUGS FOR WOMEN DUAVEE ORAL TABLET (conj estrogens-bazedoxifene) 3 PA; QL (1 tablet per 1 day) *FLUOROQUINOLONES* - DRUGS FOR INFECTIONS *FLUOROQUINOLONES*** - ANTIBIOTICS BAXDELA INTRAVENOUS SOLUTION RECONSTITUTED (delafloxacin 3 meglumine) BAXDELA ORAL TABLET (delafloxacin meglumine) 3 PA; QL (28 tablets per 30 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 133 Coverage Requirements and Prescription Drug Name Drug Tier Limits CIPRO ORAL SUSPENSION RECONSTITUTED (ciprofloxacin) 3 QL (3 bottle per 30 days) CIPRO ORAL TABLET (ciprofloxacin hcl) 3 QL (28 tablets per 30 days) ciprofloxacin hcl oral tablet 1 or 1b* QL (28 tablets per 30 days) ciprofloxacin in d5w intravenous solution 1 or 1b* levofloxacin in d5w intravenous solution 1 or 1b* levofloxacin intravenous solution 1 or 1b* levofloxacin oral solution 1 or 1b* QL (480 mL per 30 days) levofloxacin oral tablet 1 or 1b* QL (14 tablets per 30 days) moxifloxacin hcl in nacl intravenous solution 1 or 1b* MOXIFLOXACIN HCL INTRAVENOUS SOLUTION 3 moxifloxacin hcl oral tablet 1 or 1b* QL (21 tablet per 30 days) ofloxacin oral tablet 1 or 1b* QL (28 tablet per 30 days) *GASTROINTESTINAL AGENTS - MISC.* - DRUGS FOR THE STOMACH *BILE ACID SYNTHESIS DISORDER AGENTS*** - DRUGS FOR THE STOMACH CHOLBAM ORAL CAPSULE (cholic acid) 3 PA; LD; QL (4 capsule per 1 day) *GALLSTONE SOLUBILIZING AGENTS*** - DRUGS FOR THE STOMACH CHENODAL ORAL TABLET (chenodiol) 3 PA; LD; QL (7 tablets per 1 day) RELTONE ORAL CAPSULE (ursodiol) 3 URSO 250 ORAL TABLET (ursodiol) 3 URSO FORTE ORAL TABLET (ursodiol) 3 ursodiol oral capsule 1 or 1b* ursodiol oral tablet 1 or 1b* *GASTROINTESTINAL ANTIALLERGY AGENTS*** - DRUGS FOR THE STOMACH cromolyn sodium oral concentrate 1 or 1b* GASTROCROM ORAL CONCENTRATE (cromolyn sodium) 3 *GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS*** - DRUGS FOR IRRITABLE BOWEL SYNDROME lubiprostone oral capsule 1 or 1b* QL (2 capsules per 1 day) *GASTROINTESTINAL STIMULANTS*** - DRUGS FOR THE STOMACH DEXPANTHENOL INJECTION SOLUTION 3 GIMOTI NASAL SOLUTION ( hcl) 3 PA; QL (1 bottle per 4 weekss) metoclopramide hcl injection solution 1 or 1a* metoclopramide hcl oral solution 1 or 1a* QL (60 mL per 1 day) metoclopramide hcl oral tablet 10 mg 1 or 1a* QL (6 tablets per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 134 Coverage Requirements and Prescription Drug Name Drug Tier Limits metoclopramide hcl oral tablet 5 mg 1 or 1a* QL (12 tablets per 1 day) METOCLOPRAMIDE HCL ORAL TABLET DISPERSIBLE 10 MG 3 ST; QL (6 tablets per 1 day) metoclopramide hcl oral tablet dispersible 5 mg 1 or 1a* ST; QL (12 tablets per 1 day) REGLAN ORAL TABLET 10 MG (metoclopramide hcl) 3 QL (6 tablets per 1 day) REGLAN ORAL TABLET 5 MG (metoclopramide hcl) 3 QL (12 tablets per 1 day) *GLUCAGON-LIKE PEPTIDE-2 (GLP-2) ANALOGS*** - DRUGS FOR THE STOMACH GATTEX SUBCUTANEOUS KIT ( (rdna)) 3 PA; LD; SP *IBS AGENT - GUANYLATE CYCLASE-C (GC-C) AGONISTS*** - DRUGS FOR CONSTIPATION LINZESS ORAL CAPSULE (linaclotide) 2 QL (1 capsule per 1 day) *IBS AGENT - MU- AGONISTS*** - DRUGS FOR IRRITABLE BOWEL SYNDROME VIBERZI ORAL TABLET (eluxadoline) 3 PA; QL (2 tablets per 1 day) *IBS AGENT - SELECTIVE 5-HT3 RECEPTOR ANTAGONISTS*** - DRUGS FOR IRRITABLE BOWEL SYNDROME alosetron hcl oral tablet 1 or 1b* PA; QL (2 tablets per 1 day) LOTRONEX ORAL TABLET (alosetron hcl) 3 PA; QL (2 tablets per 1 day) *INFLAMMATORY BOWEL AGENTS*** - DRUGS FOR INFLAMMATORY BOWEL DISEASE APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR (mesalamine) 3 ST; QL (4 capsule per 1 day) AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 3 QL (8 tablet per 1 day) (sulfasalazine) AZULFIDINE ORAL TABLET (sulfasalazine) 3 QL (8 tablet per 1 day) balsalazide disodium oral capsule 1 or 1b* QL (9 capsule per 1 day) CANASA RECTAL SUPPOSITORY (mesalamine) 3 QL (1 suppository per 1 day) DELZICOL ORAL CAPSULE DELAYED RELEASE (mesalamine) 3 ST; QL (6 tablets per 1 day) DIPENTUM ORAL CAPSULE (olsalazine sodium) 3 ST; QL (4 capsule per 1 day) mesalamine er oral capsule extended release 24 hour 1 or 1b* QL (4 capsules per 1 day) mesalamine oral capsule delayed release 1 or 1b* QL (6 tablets per 1 day) mesalamine oral tablet delayed release 1.2 gm 1 or 1b* QL (4 tablets per 1 day) mesalamine oral tablet delayed release 800 mg 1 or 1b* QL (6 tablet per 1 day) mesalamine rectal enema 1 or 1b* QL (60 mL per 1 day) mesalamine rectal suppository 1 or 1b* QL (1 suppository per 1 day) mesalamine-cleanser rectal kit 1 or 1b* QL (1 kit per 28 days) PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG (mesalamine) 2 QL (16 capsule per 1 day) PENTASA ORAL CAPSULE EXTENDED RELEASE 500 MG (mesalamine) 2 QL (8 capsule per 1 day) ROWASA RECTAL KIT (mesalamine-cleanser) 3 QL (1 kit per 28 days) SFROWASA RECTAL ENEMA (mesalamine) 3 QL (60 mL per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 135 Coverage Requirements and Prescription Drug Name Drug Tier Limits sulfasalazine oral tablet 1 or 1b* QL (8 tablet per 1 day) sulfasalazine oral tablet delayed release 1 or 1b* QL (8 tablet per 1 day) * RECEPTOR ANTAGONISTS*** - DRUGS FOR INFLAMMATORY BOWEL DISEASE ENTYVIO INTRAVENOUS SOLUTION RECONSTITUTED (vedolizumab) 4 PA; LD; SP; QL (1 vial per 56 days) *INTERLEUKIN ANTAGONISTS*** - DRUGS FOR INFLAMMATORY BOWEL DISEASE PA; LD; SP; QL (4 vial per 365 STELARA INTRAVENOUS SOLUTION (ustekinumab) 4 days) *INTESTINAL ACIDIFIERS*** - DRUGS FOR THE STOMACH enulose oral solution 1 or 1b* generlac oral solution 1 or 1b* lactulose encephalopathy oral solution 1 or 1b* *PERIPHERAL OPIOID RECEPTOR ANTAGONISTS*** - DRUGS FOR THE STOMACH alvimopan oral capsule 1 or 1b* ENTEREG ORAL CAPSULE (alvimopan) 3 MOVANTIK ORAL TABLET (naloxegol oxalate) 2 QL (1 tablet per 1 day) RELISTOR ORAL TABLET (methylnaltrexone bromide) 3 ST; QL (3 tablets per 1 day) RELISTOR SUBCUTANEOUS SOLUTION (methylnaltrexone bromide) 3 ST; QL (1 syringe per 1 day) SYMPROIC ORAL TABLET (naldemedine tosylate) 3 ST; QL (1 tablet per 1 day) *PHOSPHATE BINDER AGENTS*** - DRUGS FOR THE STOMACH AURYXIA ORAL TABLET (ferric citrate) 3 ST; QL (9 tablets per 1 day) calcium acetate (phos binder) oral capsule 1 or 1b* QL (12 capsules per 1 day) calcium acetate (phos binder) oral tablet 1 or 1b* QL (12 tablets per 1 day) calcium acetate oral tablet 667 mg 1 or 1b* QL (12 tablets per 1 day) FOSRENOL ORAL PACKET (lanthanum carbonate) 3 ST; QL (3 stick packs per 1 day) FOSRENOL ORAL TABLET CHEWABLE (lanthanum carbonate) 3 ST; QL (3 tablets per 1 day) lanthanum carbonate oral tablet chewable 1 or 1b* QL (3 tablets per 1 day) PHOSLYRA ORAL SOLUTION (calcium acetate (phos binder)) 3 ST; QL (60 mL per 1 day) RENVELA ORAL PACKET 0.8 GM (sevelamer carbonate) 3 ST; QL (6 packets per 1 day) RENVELA ORAL PACKET 2.4 GM (sevelamer carbonate) 3 ST; QL (3 packets per 1 day) RENVELA ORAL TABLET (sevelamer carbonate) 3 ST; QL (9 tablets per 1 day) sevelamer carbonate oral packet 0.8 gm 1 or 1b* QL (6 packets per 1 day) sevelamer carbonate oral packet 2.4 gm 1 or 1b* QL (3 packets per 1 day) sevelamer carbonate oral tablet 1 or 1b* QL (9 tablets per 1 day) sevelamer hcl oral tablet 400 mg 1 or 1b* QL (15 tablets per 1 day) sevelamer hcl oral tablet 800 mg 1 or 1b* QL (9 tablets per 1 day) VELPHORO ORAL TABLET CHEWABLE (sucroferric oxyhydroxide) 3 ST; QL (3 tablets per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 136 Coverage Requirements and Prescription Drug Name Drug Tier Limits *TUMOR NECROSIS FACTOR ALPHA BLOCKERS*** - DRUGS FOR INFLAMMATORY BOWEL DISEASE INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED (infliximab- 4 PA; LD; SP dyyb) REMICADE INTRAVENOUS SOLUTION RECONSTITUTED (infliximab) 4 PA; LD; SP *GENERAL ANESTHETICS* - DRUGS FOR PAIN AND FEVER *ANESTHETICS - MISC.*** - DRUGS FOR SEDATION AMIDATE INTRAVENOUS SOLUTION (etomidate) 3 ANESTHESIA S/I-40A INTRAVENOUS KIT 3 ANESTHESIA S/I-40H INTRAVENOUS KIT 3 ANESTHESIA S/I-40S INTRAVENOUS KIT 3 DIPRIVAN INTRAVENOUS EMULSION (propofol) 3 etomidate intravenous solution 1 or 1b* propoven intravenous emulsion 1000 mg/100ml, 200 mg/20ml, 500 1 or 1b* mg/50ml KETALAR INJECTION SOLUTION ( hcl) 3 ketamine hcl injection solution 10 mg/ml, 100 mg/ml, 50 mg/ml 1 or 1b* KETAMINE HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE 3 KETAMINE HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE propofol intravenous emulsion 1 or 1b* propofol-lipuro intravenous emulsion 1 or 1b* * ANESTHETICS*** - DRUGS FOR SEDATION BREVITAL SODIUM INJECTION SOLUTION RECONSTITUTED 3 (methohexital sodium) METHOHEXITAL SODIUM INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE *VOLATILE ANESTHETICS*** - DRUGS FOR SEDATION desflurane inhalation solution 1 or 1b* FORANE INHALATION SOLUTION (isoflurane) 3 isoflurane inhalation solution 1 or 1b* sevoflurane inhalation solution 1 or 1b* SUPRANE INHALATION SOLUTION (desflurane) 3 terrell inhalation solution 1 or 1b* ULTANE INHALATION SOLUTION (sevoflurane) 3 *GENITOURINARY AGENTS - MISCELLANEOUS* - DRUGS FOR THE URINARY SYSTEM *5-ALPHA REDUCTASE INHIBITORS*** - DRUGS FOR THE PROSTATE oral capsule 1 or 1b* QL (1 capsule per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 137 Coverage Requirements and Prescription Drug Name Drug Tier Limits finasteride oral tablet 5 mg 1 or 1b* QL (1 tablet per 1 day) PROSCAR ORAL TABLET (finasteride) 3 QL (1 tablet per 1 day) *ALPHA 1-ADRENOCEPTOR ANTAGONISTS*** - DRUGS FOR THE PROSTATE alfuzosin hcl er oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) CARDURA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 QL (1 tablet per 1 day) (doxazosin mesylate) silodosin oral capsule 1 or 1b* QL (1 capsule per 1 day) tamsulosin hcl oral capsule 1 or 1b* QL (2 capsules per 1 day) *ANTI-INFECTIVE GENITOURINARY IRRIGANTS*** - DRUGS FOR THE URINARY SYSTEM neomycin-polymyxin b gu irrigation solution 1 or 1b* *CITRATES*** - DRUGS FOR INFECTIONS pot & sod cit-cit ac oral solution 1 or 1b* potassium citrate er oral tablet extended release 1 or 1b* UROCIT-K 10 ORAL TABLET EXTENDED RELEASE (potassium citrate) 3 UROCIT-K 15 ORAL TABLET EXTENDED RELEASE (potassium citrate) 3 UROCIT-K 5 ORAL TABLET EXTENDED RELEASE (potassium citrate) 3 *GENITOURINARY IRRIGANTS*** - DRUGS FOR THE URINARY SYSTEM acetic acid irrigation solution 1 or 1b* aminoacetic acid irrigation solution 1 or 1b* argyle sterile saline irrigation solution 1 or 1b* curity sterile saline irrigation solution 1 or 1b* glycine irrigation solution 1 or 1b* glycine urologic irrigation solution 1 or 1b* RENACIDIN IRRIGATION SOLUTION (citric ac-gluconolact-mg carb) 3 RESECTISOL IRRIGATION SOLUTION (mannitol (gu irrigant)) 3 sodium chloride irrigation solution 1 or 1b* SORBITOL IRRIGATION SOLUTION 3 SORBITOL-MANNITOL IRRIGATION SOLUTION 3 *INTERSTITIAL CYSTITIS AGENTS*** - DRUGS FOR THE URINARY SYSTEM ELMIRON ORAL CAPSULE (pentosan polysulfate sodium) 3 QL (3 capsules per 1 day) RIMSO-50 INTRAVESICAL SOLUTION (dimethyl sulfoxide) 3 *PHOSPHATES*** - DRUGS FOR INFECTIONS K-PHOS NO 2 ORAL TABLET (pot & sod ac phosphates) 3

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 138 Coverage Requirements and Prescription Drug Name Drug Tier Limits *PROSTATIC HYPERTROPHY AGENT COMBINATIONS*** - DRUGS FOR THE PROSTATE dutasteride-tamsulosin hcl oral capsule 1 or 1b* QL (1 capsule per 1 day) JALYN ORAL CAPSULE (dutasteride-tamsulosin hcl) 3 QL (1 capsule per 1 day) *URINARY STONE AGENTS*** - DRUGS FOR THE URINARY SYSTEM LITHOSTAT ORAL TABLET (acetohydroxamic acid) 3 THIOLA EC ORAL TABLET DELAYED RELEASE 100 MG (tiopronin) 3 PA; LD; QL (10 tablet per 1 day) THIOLA EC ORAL TABLET DELAYED RELEASE 300 MG (tiopronin) 3 PA; LD; QL (3 tablet per 1 day) THIOLA ORAL TABLET (tiopronin) 3 PA; LD; QL (10 tablet per 1 day) tiopronin oral tablet 1 or 1b* PA; QL (10 tablet per 1 day) *VESICOURETERAL REFLUX (VUR) AGENT COMBINATIONS*** - DRUGS FOR THE URINARY SYSTEM DEFLUX INJECTION PREFILLED SYRINGE (dextranomer-hyaluronic 3 acid) *GOUT AGENTS* - DRUGS FOR PAIN AND FEVER *GOUT AGENT COMBINATIONS*** - GOUT DRUGS - oral tablet 1 or 1b* *GOUT AGENTS*** - GOUT DRUGS allopurinol oral tablet 1 or 1a* allopurinol sodium intravenous solution reconstituted 1 or 1b* ALOPRIM INTRAVENOUS SOLUTION RECONSTITUTED (allopurinol 3 sodium) colchicine oral tablet 2 QL (2.3 tablet per 1 day) febuxostat oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) GLOPERBA ORAL SOLUTION (colchicine) 3 ST; QL (2 bottles per 30 days) ZYLOPRIM ORAL TABLET (allopurinol) 3 *URICOSURICS*** - GOUT DRUGS probenecid oral tablet 1 or 1b* *HEMATOLOGICAL AGENTS - MISC.* - DRUGS FOR THE BLOOD *ANTIHEMOPHILIC PRODUCTS*** - DRUGS TO PREVENT BLEEDING KCENTRA INTRAVENOUS KIT (prothrombin complex conc human) 3 RIASTAP INTRAVENOUS SOLUTION RECONSTITUTED (fibrinogen 3 PA; LD concentrate (human)) * B2 RECEPTOR ANTAGONISTS*** - DRUGS FOR THE BLOOD PA; SP; QL (24 syringes per 30 acetate subcutaneous solution 4 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 139 Coverage Requirements and Prescription Drug Name Drug Tier Limits *DIRECT-ACTING P2Y12 INHIBITORS*** - DRUGS FOR THE BLOOD BRILINTA ORAL TABLET (ticagrelor) 2 QL (2 tablets per 1 day) KENGREAL INTRAVENOUS SOLUTION RECONSTITUTED (cangrelor 3 tetrasodium) *GLYCOPROTEIN IIB/IIIA RECEPTOR INHIBITORS*** - DRUGS FOR THE BLOOD AGGRASTAT INTRAVENOUS CONCENTRATE (tirofiban hcl) 3 AGGRASTAT INTRAVENOUS SOLUTION (tirofiban hcl in nacl) 3 eptifibatide intravenous solution 1 or 1b* *HEMATORHEOLOGIC AGENTS*** - DRUGS FOR THE BLOOD pentoxifylline er oral tablet extended release 1 or 1b* *HEMIN*** - DRUGS FOR THE BLOOD PANHEMATIN INTRAVENOUS SOLUTION RECONSTITUTED (hemin) 3 *PHOSPHODIESTERASE III INHIBITORS*** - DRUGS FOR THE BLOOD cilostazol oral tablet 1 or 1b* *PLASMA EXPANDERS*** - DRUGS FOR THE BLOOD HESPAN INTRAVENOUS SOLUTION (hetastarch-nacl) 3 hetastarch-nacl intravenous solution 1 or 1b* HEXTEND INTRAVENOUS SOLUTION (hetastarch in lact electrolyte) 3 lmd in d5w intravenous solution 1 or 1b* lmd in nacl intravenous solution 1 or 1b* *PLASMA PROTEINS*** - DRUGS FOR THE BLOOD ALBUKED 25 INTRAVENOUS SOLUTION (albumin human) 3 ALBUKED 5 INTRAVENOUS SOLUTION (albumin human) 3 ALBUMIN HUMAN INTRAVENOUS SOLUTION 3 ALBUMINEX INTRAVENOUS SOLUTION (albumin human-kjda) 3 ALBUMIN-ZLB INTRAVENOUS SOLUTION 3 ALBURX INTRAVENOUS SOLUTION 3 ALBUTEIN INTRAVENOUS SOLUTION (albumin human) 3 FLEXBUMIN INTRAVENOUS SOLUTION (albumin human) 3 HUMAN ALBUMIN GRIFOLS INTRAVENOUS SOLUTION (albumin 3 human) KEDBUMIN INTRAVENOUS SOLUTION 3 OCTAPLAS BLOOD GROUP A INTRAVENOUS SOLUTION (plasma 3 human) OCTAPLAS BLOOD GROUP AB INTRAVENOUS SOLUTION (plasma 3 human)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 140 Coverage Requirements and Prescription Drug Name Drug Tier Limits OCTAPLAS BLOOD GROUP B INTRAVENOUS SOLUTION (plasma 3 human) OCTAPLAS BLOOD GROUP O INTRAVENOUS SOLUTION (plasma 3 human) PLASBUMIN-25 INTRAVENOUS SOLUTION (albumin human) 3 PLASBUMIN-5 INTRAVENOUS SOLUTION (albumin human) 3 PLASMANATE INTRAVENOUS SOLUTION (plasma protein fraction) 3 THROMBATE III INTRAVENOUS SOLUTION RECONSTITUTED 3 (antithrombin iii (human)) *PLATELET AGGREGATION INHIBITOR COMBINATIONS*** - DRUGS FOR THE BLOOD aspirin-dipyridamole er oral capsule extended release 12 hour 1 or 1b* QL (2 capsules per 1 day) ASPIRIN- ORAL TABLET DELAYED RELEASE 3 PA; QL (1 tablet per 1 day) YOSPRALA ORAL TABLET DELAYED RELEASE (aspirin-omeprazole) 3 PA; QL (1 tablet per 1 day) *PLATELET AGGREGATION INHIBITORS*** - DRUGS FOR THE BLOOD dipyridamole oral tablet 1 or 1b* DURLAZA ORAL CAPSULE EXTENDED RELEASE 24 HOUR (aspirin) 3 PA; QL (1 capsule per 1 day) *PROTAMINE*** - DRUGS FOR THE BLOOD protamine sulfate intravenous solution 1 or 1b* *PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS*** - DRUGS FOR THE BLOOD ZONTIVITY ORAL TABLET (vorapaxar sulfate) 3 PA; QL (1 tablet per 1 day) *QUINAZOLINE AGENTS*** - DRUGS FOR THE BLOOD AGRYLIN ORAL CAPSULE ( hcl) 3 anagrelide hcl oral capsule 1 or 1b* *THIENOPYRIDINE DERIVATIVES*** - DRUGS FOR THE BLOOD clopidogrel bisulfate oral tablet 300 mg 1 or 1b* clopidogrel bisulfate oral tablet 75 mg 1 or 1b* QL (1 tablet per 1 day) prasugrel hcl oral tablet 10 mg 1 or 1b* QL (1 tablet per 1 day) prasugrel hcl oral tablet 5 mg 1 or 1b* DO *TISSUE PLASMINOGEN ACTIVATORS*** - DRUGS FOR THE BLOOD ACTIVASE INTRAVENOUS SOLUTION RECONSTITUTED (alteplase) 3 CATHFLO ACTIVASE INJECTION SOLUTION RECONSTITUTED 3 (alteplase) RETAVASE HALF-KIT INTRAVENOUS KIT (reteplase) 3 RETAVASE INTRAVENOUS KIT (reteplase) 3 TNKASE INTRAVENOUS KIT (tenecteplase) 3

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 141 Coverage Requirements and Prescription Drug Name Drug Tier Limits *HEMATOPOIETIC AGENTS* - DRUGS FOR NUTRITION *AGENTS FOR GAUCHER DISEASE*** - DRUGS FOR NUTRITION miglustat oral capsule 4 PA; SP *COBALAMIN COMBINATIONS*** - DRUGS FOR NUTRITION LIPO-B INTRAMUSCULAR SOLUTION 3 NEURIN-SL SUBLINGUAL TABLET SUBLINGUAL 3 *COBALAMINS*** - DRUGS FOR NUTRITION cyanocobalamin injection solution 1000 mcg/ml 1 or 1a* CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML 3 hydroxocobalamin acetate intramuscular solution 1 or 1b* METHYLCOBALAMIN INJECTION SOLUTION RECONSTITUTED 3 *CYTOTOXIC AGENTS*** - DRUGS FOR NUTRITION DROXIA ORAL CAPSULE (hydroxyurea) 2 SIKLOS ORAL TABLET (hydroxyurea) 3 PA; SP *ERYTHROPOIESIS-STIMULATING AGENTS (ESAS)*** - DRUGS FOR NUTRITION ARANESP (ALBUMIN FREE) INJECTION SOLUTION (darbepoetin alfa) 4 PA; SP; QL (4 vials per 28 days) ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 100 MCG/0.5ML, 150 MCG/0.3ML, 200 4 PA; SP; QL (4 syringes per 28 days) MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 60 MCG/0.3ML (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED 4 PA; SP; QL (4 syringes per 30 days) SYRINGE 500 MCG/ML (darbepoetin alfa) PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 4 PA; SP; QL (12 mL per 28 days) UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML (epoetin alfa) PROCRIT INJECTION SOLUTION 20000 UNIT/ML (epoetin alfa) 4 PA; SP; QL (24 vials per 28 days) RETACRIT INJECTION SOLUTION (epoetin alfa-epbx) 4 PA; SP; QL (12 mL per 28 days) *FOLIC ACID/FOLATE COMBINATIONS*** - DRUGS FOR NUTRITION fa-vitamin b-6-vitamin b-12 oral tablet 1 or 1b* FOLGARD RX ORAL TABLET (folic acid-vit b6-vit b12) 3 foltabs 800 oral tablet 1 or 1b*; $0 millguard oral tablet 1 or 1b*; $0 *FOLIC ACID/FOLATES*** - DRUGS FOR NUTRITION cvs folic acid oral tablet 1 or 1a*; $0 fa-8 oral capsule 1 or 1b*; $0 folate oral tablet 1 or 1a*; $0 folic acid injection solution 1 or 1a* folic acid oral capsule 0.8 mg 1 or 1b*; $0 folic acid oral tablet 1 mg 1 or 1a* BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 142 Coverage Requirements and Prescription Drug Name Drug Tier Limits folic acid oral tablet 400 mcg, 800 mcg 1 or 1a*; $0 gnp folic acid oral tablet 1 or 1a*; $0 hm folic acid oral tablet 1 or 1a*; $0 kp folic acid oral tablet 800 mcg 1 or 1a*; $0 px folic acid oral tablet 1 or 1a*; $0 qc folic acid oral tablet 1 or 1a*; $0 ra folic acid oral tablet 1 or 1a*; $0 sm folic acid oral tablet 1 or 1a*; $0 yl folic acid oral tablet 1 or 1a*; $0 *GRANULOCYTE COLONY-STIMULATING FACTORS (G-CSF)*** - DRUGS FOR NUTRITION NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT PA; SP; QL (2 injectors/kits per 28 4 (pegfilgrastim) days) NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (2 syringes per 28 days) (pegfilgrastim) NEUPOGEN INJECTION SOLUTION (filgrastim) 4 PA; SP NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE (filgrastim) 4 PA; SP UDENYCA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (2 syringes per 28 days) (pegfilgrastim-cbqv) ZARXIO INJECTION SOLUTION PREFILLED SYRINGE (filgrastim-sndz) 4 PA; SP *IRON COMBINATIONS*** - DRUGS FOR NUTRITION foltrin oral capsule 1 or 1b* *IRON*** - DRUGS FOR NUTRITION ACCRUFER ORAL CAPSULE (ferric maltol) 3 MONOFERRIC INTRAVENOUS SOLUTION (ferric derisomaltose) 3 PA; SP; QL (1 vial per 1 day) na ferric gluc cplx in intravenous solution 4 SP *HEMOSTATICS* - DRUGS FOR THE BLOOD *HEMOSTATIC COMBINATIONS - TOPICAL*** - DRUGS TO PREVENT BLEEDING ARTISS EXTERNAL SOLUTION (fibrin sealant component) 3 THROMBI-GEL 10 EXTERNAL PAD (thrombin-cmc-cacl-gelatin) 3 THROMBI-GEL 100 EXTERNAL PAD (thrombin-cmc-cacl-gelatin) 3 THROMBI-GEL 40 EXTERNAL PAD (thrombin-cmc-cacl-gelatin) 3 THROMBI-PAD EXTERNAL PAD (thrombin-cmc-cacl) 3 TISSEEL EXTERNAL KIT (fibrin sealant component) 3 TISSEEL EXTERNAL SOLUTION (fibrin sealant component) 3 *HEMOSTATICS - SYSTEMIC*** - DRUGS TO PREVENT BLEEDING AMICAR ORAL SOLUTION (aminocaproic acid) 3 QL (120 mL per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 143 Coverage Requirements and Prescription Drug Name Drug Tier Limits AMICAR ORAL TABLET 1000 MG (aminocaproic acid) 3 AMICAR ORAL TABLET 500 MG (aminocaproic acid) 3 QL (60 tablets per 1 day) aminocaproic acid intravenous solution 1 or 1b* aminocaproic acid oral solution 1 or 1b* QL (120 mL per 1 day) aminocaproic acid oral tablet 1000 mg 1 or 1b* aminocaproic acid oral tablet 500 mg 1 or 1b* QL (60 tablets per 1 day) CYKLOKAPRON INTRAVENOUS SOLUTION (tranexamic acid) 3 LYSTEDA ORAL TABLET (tranexamic acid) 3 QL (6 tablets per 1 day) tranexamic acid intravenous solution 1 or 1b* tranexamic acid oral tablet 1 or 1b* QL (6 tablets per 1 day) TRANEXAMIC ACID-NACL INTRAVENOUS SOLUTION 3 *HEMOSTATICS - TOPICAL*** - DRUGS TO PREVENT BLEEDING ACTIFOAM SPONGE EXTERNAL (absorbable collagen 3 hemostat) AVITENE EXTERNAL PAD (microfibrillar coll hemostat) 3 AVITENE FLOUR EXTERNAL POWDER (microfibrillar coll hemostat) 3 ENDO AVITENE EXTERNAL (absorbable collagen hemostat) 3 GEL-FLOW NT EXTERNAL PREFILLED SYRINGE (gelatin absorbable) 3 GELFOAM COMPRESSED SIZE 100 EXTERNAL (gelatin absorbable) 3 GELFOAM DENTAL PACK SIZE 4 EXTERNAL (gelatin absorbable) 3 GELFOAM MOUTH/THROAT POWDER (gelatin absorbable) 3 GELFOAM SPONGE EXTERNAL (gelatin absorbable) 3 GELFOAM SPONGE SIZE 100 EXTERNAL (gelatin absorbable) 3 GELFOAM SPONGE SIZE 200 EXTERNAL (gelatin absorbable) 3 GELFOAM SPONGE SIZE 50 EXTERNAL (gelatin absorbable) 3 INSTAT EXTERNAL PAD (absorbable collagen hemostat) 3 INTERCEED (TC7) EXTERNAL PAD (oxidized cellulose) 3 INTERCEED EXTERNAL PAD (oxidized cellulose) 3 RECOTHROM EXTERNAL SOLUTION RECONSTITUTED (thrombin 3 (recombinant)) RECOTHROM SPRAY KIT EXTERNAL SOLUTION RECONSTITUTED 3 (thrombin (recombinant)) SURGICEL FIBRILLAR EXTERNAL PAD (oxidized cellulose) 3 SURGICEL NU-KNIT EXTERNAL PAD (oxidized cellulose) 3 SYRINGE AVITENE EXTERNAL (absorbable collagen hemostat) 3 TACHOSIL EXTERNAL PATCH (absorbable fibrin sealant) 3 THROMBIN-JMI EPISTAXIS EXTERNAL KIT (thrombin) 3 THROMBIN-JMI EXTERNAL KIT (thrombin) 3 THROMBIN-JMI EXTERNAL SOLUTION RECONSTITUTED (thrombin) 3 BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 144 Coverage Requirements and Prescription Drug Name Drug Tier Limits THROMBOGEN EXTERNAL KIT (thrombin) 3 THROMBOGEN EXTERNAL SOLUTION RECONSTITUTED (thrombin) 3 ULTRAFOAM SPONGE 2X6.25X7CM EXTERNAL (microfibrillar coll 3 hemostat) ULTRAFOAM SPONGE 8X12.5X1CM EXTERNAL (microfibrillar coll 3 hemostat) ULTRAFOAM SPONGE 8X12.5X3CM EXTERNAL (microfibrillar coll 3 hemostat) ULTRAFOAM SPONGE 8X25X1CM EXTERNAL (microfibrillar coll 3 hemostat) ULTRAFOAM SPONGE 8X6.25X1CM EXTERNAL (microfibrillar coll 3 hemostat) *HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS* - DRUGS FOR THE NERVOUS SYSTEM *BARBITURATE HYPNOTICS*** - DRUGS FOR INSOMNIA NEMBUTAL INJECTION SOLUTION (pentobarbital sodium) 3 pentobarbital sodium injection solution 1 or 1b* oral elixir 1 or 1b* QL (100 mL per 1 day) phenobarbital oral tablet 100 mg 1 or 1b* QL (4 tablets per 1 day) phenobarbital oral tablet 15 mg 1 or 1b* QL (800 tablets per 30 days) phenobarbital oral tablet 16.2 mg 1 or 1b* QL (741 tablets per 30 days) phenobarbital oral tablet 30 mg 1 or 1b* QL (400 tablets per 30 days) phenobarbital oral tablet 32.4 mg 1 or 1b* QL (370 tablets per 30 days) phenobarbital oral tablet 60 mg 1 or 1b* QL (200 tablets per 30 days) phenobarbital oral tablet 64.8 mg 1 or 1b* QL (185 tablets per 30 days) phenobarbital oral tablet 97.2 mg 1 or 1b* QL (123 tablets per 30 days) phenobarbital sodium injection solution 1 or 1b* *BENZODIAZEPINE HYPNOTICS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN DORAL ORAL TABLET (quazepam) 3 ST; QL (1 tablet per 1 day) estazolam oral tablet 1 or 1b* QL (1 tablet per 1 day) flurazepam hcl oral capsule 1 or 1b* QL (1 capsule per 1 day) HALCION ORAL TABLET (triazolam) 3 QL (1 tablet per 1 day) midazolam hcl (pf) injection solution 1 or 1b* midazolam hcl injection solution 1 or 1b* midazolam hcl oral syrup 1 or 1b* QL (10 mL per 1 fill) MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 100-0.8 MG/100ML-%, 50-0.8 MG/50ML-% MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 145 Coverage Requirements and Prescription Drug Name Drug Tier Limits MIDAZOLAM INTRAVENOUS SOLUTION PREFILLED SYRINGE 2 3 MG/2ML, 25 MG/25ML MIDAZOLAM-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 MIDAZOLAM-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 30-0.9 MG/30ML-%, 50-0.9 MG/50ML-%, 60-0.9 3 MG/30ML-% quazepam oral tablet 1 or 1b* QL (1 tablet per 1 day) RESTORIL ORAL CAPSULE (temazepam) 3 QL (1 capsule per 1 day) temazepam oral capsule 1 or 1b* QL (1 capsule per 1 day) triazolam oral tablet 1 or 1b* QL (1 tablet per 1 day) *HYPNOTICS - TRICYCLIC AGENTS*** - DRUGS FOR INSOMNIA doxepin hcl oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) SILENOR ORAL TABLET (doxepin hcl) 3 ST; QL (1 tablet per 1 day) *NON-BENZODIAZEPINE - GABA-RECEPTOR MODULATORS*** - DRUGS FOR INSOMNIA EDLUAR SUBLINGUAL TABLET SUBLINGUAL (zolpidem tartrate) 3 ST; QL (1 tablet per 1 day) eszopiclone oral tablet 1 or 1b* QL (1 tablet per 1 day) zaleplon oral capsule 1 or 1b* QL (1 capsule per 1 day) zolpidem tartrate er oral tablet extended release 1 or 1b* ST; QL (1 tablet per 1 day) zolpidem tartrate oral tablet 1 or 1b* QL (1 tablet per 1 day) zolpidem tartrate sublingual tablet sublingual 1 or 1b* ST; QL (1 tablet per 1 day) ZOLPIMIST ORAL SOLUTION (zolpidem tartrate) 3 ST; QL (1 bottle per 30 days) * RECEPTOR ANTAGONISTS*** - DRUGS FOR INSOMNIA BELSOMRA ORAL TABLET () 3 ST; QL (1 tablet per 1 day) DAYVIGO ORAL TABLET () 3 ST; QL (1 tablet per 1 day) *SELECTIVE ALPHA2-ADRENORECEPTOR AGONIST SEDATIVES*** - DRUGS FOR INSOMNIA dexmedetomidine hcl in nacl intravenous solution 1 or 1b* DEXMEDETOMIDINE HCL IN NACL INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE DEXMEDETOMIDINE HCL INTRAVENOUS SOLUTION 1000 3 MCG/10ML, 400 MCG/4ML dexmedetomidine hcl intravenous solution 200 mcg/2ml 1 or 1b* DEXMEDETOMIDINE HCL-DEXTROSE INTRAVENOUS SOLUTION 3 PRECEDEX INTRAVENOUS SOLUTION (dexmedetomidine hcl in nacl) 3 *SELECTIVE MELATONIN RECEPTOR AGONISTS*** - DRUGS FOR INSOMNIA ramelteon oral tablet 1 or 1b* ST; QL (1 tablet per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 146 Coverage Requirements and Prescription Drug Name Drug Tier Limits *LAXATIVES* - DRUGS FOR THE STOMACH *BOWEL EVACUANT COMBINATIONS*** - DRUGS TO PREVENT CONSTIPATION CLENPIQ ORAL SOLUTION (sod picosulfate-mag ox-cit acd) 3 QL (320 mL per 30 days) gavilyte-c oral solution reconstituted 1 or 1a*; $0 QL (4000 grams per 30 days) gavilyte-g oral solution reconstituted 1 or 1a*; $0 QL (4000 grams per 30 days) gavilyte-n with flavor pack oral solution reconstituted 1 or 1a*; $0 QL (4000 grams per 30 days) GOLYTELY ORAL SOLUTION RECONSTITUTED (peg 3350-kcl-nabcb- 3 QL (4000 grams per 30 days) nacl-nasulf) MOVIPREP ORAL SOLUTION RECONSTITUTED (peg-kcl-nacl-nasulf-na 3 QL (1 gram per 30 days) asc-c) NULYTELY LEMON-LIME ORAL SOLUTION RECONSTITUTED (peg 3 QL (4000 grams per 30 days) 3350-kcl-na bicarb-nacl) peg 3350-kcl-na bicarb-nacl oral solution reconstituted 1 or 1a*; $0 QL (4000 grams per 30 days) peg-3350/electrolytes oral solution reconstituted 1 or 1a*; $0 QL (4000 grams per 30 days) peg-3350/electrolytes/ascorbat oral solution reconstituted 1 or 1b*; $0 QL (1 gram per 30 days) peg-kcl-nacl-nasulf-na asc-c oral solution reconstituted 1 or 1b*; $0 QL (1 gram per 30 days) peg-prep oral kit 1 or 1b*; $0 QL (1 kit per 30 days) PLENVU ORAL SOLUTION RECONSTITUTED (peg-kcl-nacl-nasulf-na 3 QL (1 gram per 30 days) asc-c) SUPREP BOWEL PREP KIT ORAL SOLUTION (na sulfate-k sulfate-mg 2 QL (1 kit per 30 days) sulf) SUTAB ORAL TABLET (sodium sulfate-mag sulfate-kcl) 3 QL (24 tablets per 30 days) *LAXATIVES - MISCELLANEOUS*** - DRUGS TO PREVENT CONSTIPATION clearlax oral powder 1 or 1b*; $0 constulose oral solution 1 or 1b* cvs purelax oral packet 1 or 1b*; $0 cvs purelax oral powder 1 or 1b*; $0 eq clearlax oral powder 1 or 1b*; $0 eql clearlax oral powder 1 or 1b*; $0 gavilax oral powder 1 or 1b*; $0 gentlelax oral powder 1 or 1b*; $0 glycolax oral powder 1 or 1b*; $0 gnp clearlax oral packet 1 or 1b*; $0 gnp clearlax oral powder 1 or 1b*; $0 goodsense clearlax oral powder 1 or 1b*; $0 healthylax oral packet 1 or 1b*; $0 hm clearlax oral packet 1 or 1b*; $0 hm clearlax oral powder 1 or 1b*; $0 BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 147 Coverage Requirements and Prescription Drug Name Drug Tier Limits kls laxaclear oral powder 1 or 1b*; $0 KRISTALOSE ORAL PACKET (lactulose) 3 LACTULOSE ORAL PACKET 1 or 1b* lactulose oral solution 1 or 1b* mm clearlax oral powder 1 or 1b*; $0 peg 3350 oral packet 1 or 1b*; $0 peg 3350 oral powder 1 or 1b*; $0 polyethylene glycol 3350 oral packet 17 gm 1 or 1b*; $0 polyethylene glycol 3350 oral powder 1 or 1b*; $0 qc natura-lax oral powder 1 or 1b*; $0 ra laxative oral powder 1 or 1b*; $0 sb polyethylene glycol 3350 oral powder 1 or 1b*; $0 sm clearlax oral powder 1 or 1b*; $0 smooth lax oral packet 1 or 1b*; $0 smooth lax oral powder 1 or 1b*; $0 *LUBRICANT LAXATIVES*** - DRUGS TO PREVENT CONSTIPATION mineral oil heavy oral oil 1 or 1b* *SALINE LAXATIVE MIXTURES*** - DRUGS TO PREVENT CONSTIPATION OSMOPREP ORAL TABLET (sod phos mono-sod phos dibasic) 3 QL (32 tablet per 30 days) *SALINE LAXATIVES*** - DRUGS TO PREVENT CONSTIPATION citrate of magnesia oral solution 1 or 1a*; $0 citroma oral solution 1 or 1a*; $0 cvs citrate of magnesia oral solution 1 or 1a*; $0 cvs citrate oral solution 1 or 1a*; $0 cvs milk of magnesia oral suspension 1 or 1b*; $0 dulcolax milk of magnesia oral suspension 1 or 1b*; $0 dulcolax oral suspension 1 or 1b*; $0 eq magnesium citrate oral solution 1 or 1a*; $0 eql magnesium citrate oral solution 1 or 1a*; $0 eql milk of magnesia oral suspension 1 or 1b*; $0 gnp milk of magnesia oral suspension 1 or 1b*; $0 goodsense magnesium citrate oral solution 1 or 1a*; $0 hm magnesium citrate oral solution 1 or 1a*; $0 hm milk of magnesia oral suspension 1 or 1b*; $0 magnesium citrate oral solution 1 or 1a*; $0 milk of magnesia concentrate oral suspension 1 or 1b*; $0

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 148 Coverage Requirements and Prescription Drug Name Drug Tier Limits milk of magnesia oral suspension 1 or 1b*; $0 phillips milk of magnesia oral suspension 400 mg/5ml 1 or 1b*; $0 px milk of magnesia oral suspension 1 or 1b*; $0 qc magnesium citrate oral solution 1 or 1a*; $0 qc milk of magnesia oral suspension 1 or 1b*; $0 ra milk of magnesia oral suspension 1 or 1b*; $0 sb magnesium citrate oral solution 1 or 1a*; $0 sb milk of magnesia oral suspension 1 or 1b*; $0 sm magnesium citrate oral solution 1 or 1a*; $0 sm milk of magnesia oral suspension 1 or 1b*; $0 *STIMULANT LAXATIVES*** - DRUGS TO PREVENT CONSTIPATION alophen oral tablet delayed release 1 or 1a*; $0 bisacodyl ec oral tablet delayed release 1 or 1a*; $0 CASCARA SAGRADA ORAL FLUID EXTRACT 3 correctol oral tablet delayed release 1 or 1a*; $0 cvs bisacodyl oral tablet delayed release 1 or 1a*; $0 cvs c-lax laxative oral tablet delayed release 1 or 1a*; $0 cvs gentle laxative oral tablet delayed release 1 or 1a*; $0 cvs gentle laxative womens oral tablet delayed release 1 or 1a*; $0 eq gentle laxative oral tablet delayed release 1 or 1a*; $0 eql gentle laxative oral tablet delayed release 1 or 1a*; $0 eql laxative oral tablet delayed release 1 or 1a*; $0 ex-lax ultra oral tablet delayed release 1 or 1a*; $0 feenamint oral tablet delayed release 1 or 1a*; $0 gentle laxative oral tablet delayed release 1 or 1a*; $0 gnp gentle laxative oral tablet delayed release 1 or 1a*; $0 gnp womens gentle laxative oral tablet delayed release 1 or 1a*; $0 goodsense bisacodyl ec oral tablet delayed release 1 or 1a*; $0 goodsense womens laxative oral tablet delayed release 1 or 1a*; $0 hm laxative oral tablet delayed release 1 or 1a*; $0 kp bisacodyl oral tablet delayed release 1 or 1a*; $0 laxative oral tablet delayed release 1 or 1a*; $0 px laxative oral tablet delayed release 1 or 1a*; $0 qc gentle laxative oral tablet delayed release 1 or 1a*; $0 ra laxative oral tablet delayed release 1 or 1a*; $0 ra womens laxative oral tablet delayed release 1 or 1a*; $0 sb bisacodyl laxative ec oral tablet delayed release 1 or 1a*; $0

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 149 Coverage Requirements and Prescription Drug Name Drug Tier Limits sb gentle lax-women oral tablet delayed release 1 or 1a*; $0 sm gentle laxative oral tablet delayed release 1 or 1a*; $0 womans laxative oral tablet delayed release 1 or 1a*; $0 womens laxative oral tablet delayed release 1 or 1a*; $0 *LOCAL ANESTHETICS-PARENTERAL* - DRUGS FOR PAIN AND FEVER *LOCAL ANESTHETIC & SYMPATHOMIMETIC*** - DRUGS FOR SEDATION articadent dental injection solution cartridge 3 bupivacaine-epinephrine (pf) injection solution 1 or 1b* bupivacaine-epinephrine injection solution 1 or 1b* lidocaine-epinephrine injection solution 1 or 1b* MARCAINE/EPINEPHRINE INJECTION SOLUTION (bupivacaine- 3 epinephrine) MARCAINE/EPINEPHRINE PF INJECTION SOLUTION (bupivacaine- 3 epinephrine) ORABLOC INJECTION SOLUTION CARTRIDGE (-epinephrine) 3 sensorcaine/epinephrine injection solution 1 or 1b* sensorcaine-mpf/epinephrine injection solution 0.25% -1:200000, 0.5% - 1 or 1b* 1:200000 SENSORCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 0.75- 3 1:200000 % (bupivacaine-epinephrine) XYLOCAINE/EPINEPHRINE INJECTION SOLUTION (lidocaine- 3 epinephrine) XYLOCAINE-MPF/EPINEPHRINE INJECTION SOLUTION (lidocaine- 3 epinephrine) *LOCAL ANESTHETIC COMBINATIONS*** - DRUGS FOR SEDATION LIDOCAINE-SODIUM BICARBONATE INJECTION SOLUTION 3 PREFILLED SYRINGE POINT OF CARE LM-2.5 INJECTION KIT (lidocaine hcl-bupivacaine hcl) 3 *LOCAL ANESTHETICS - AMIDES*** - DRUGS FOR SEDATION BUPIVACAINE FISIOPHARMA INJECTION SOLUTION 3 bupivacaine hcl (pf) injection solution 1 or 1b* bupivacaine hcl injection solution 0.25 %, 0.5 % 1 or 1b* BUPIVACAINE HCL-NACL EPIDURAL SOLUTION 3 BUPIVACAINE HCL-NACL EPIDURAL SOLUTION PREFILLED 3 SYRINGE bupivacaine in dextrose intrathecal solution 1 or 1b* bupivacaine spinal intrathecal solution 1 or 1b* CARBOCAINE INJECTION SOLUTION ( hcl) 3

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 150 Coverage Requirements and Prescription Drug Name Drug Tier Limits CARBOCAINE PRESERVATIVE-FREE INJECTION SOLUTION 3 (mepivacaine hcl) lidocaine hcl (pf) injection solution 1 or 1b* lidocaine hcl injection solution 0.5 % 1 or 1b* LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 200 3 MG/10ML lidocaine hcl intradermal jet-injector 1 or 1b* LIDOCAINE IN DEXTROSE SOLUTION 3 MARCAINE INJECTION SOLUTION (bupivacaine hcl) 3 MARCAINE PRESERVATIVE FREE INJECTION SOLUTION (bupivacaine 3 hcl) MARCAINE SPINAL INTRATHECAL SOLUTION (bupivacaine in 3 dextrose) MONOJECT BONE MARROW BIOPSY INJECTION KIT (lidocaine hcl) 3 NAROPIN INJECTION SOLUTION (ropivacaine hcl) 3 polocaine injection solution 1 or 1b* polocaine-mpf injection solution 1 or 1b* ropivacaine hcl injection solution 10 mg/ml, 5 mg/ml, 7.5 mg/ml 1 or 1b* ROPIVACAINE HCL-NACL EPIDURAL SOLUTION 3 sensorcaine injection solution 1 or 1b* sensorcaine-mpf injection solution 1 or 1b* XARACOLL IMPLANT IMPLANT (bupivacaine hcl) 3 XYLOCAINE INJECTION SOLUTION (lidocaine hcl) 3 XYLOCAINE-MPF INJECTION SOLUTION (lidocaine hcl) 3 ZINGO INTRADERMAL JET-INJECTOR (lidocaine hcl) 3 *LOCAL ANESTHETICS - ESTERS*** - DRUGS FOR SEDATION hcl (pf) injection solution 1 or 1b* CLOROTEKAL INTRATHECAL SOLUTION (chloroprocaine hcl) 3 NESACAINE INJECTION SOLUTION (chloroprocaine hcl) 3 NESACAINE-MPF INJECTION SOLUTION (chloroprocaine hcl) 3 *MACROLIDES* - DRUGS FOR INFECTIONS *AZITHROMYCIN*** - ANTIBIOTICS azithromycin intravenous solution reconstituted 1 or 1b* azithromycin oral packet 1 or 1b* QL (2 packets per 30 days) azithromycin oral suspension reconstituted 100 mg/5ml 1 or 1b* QL (15 ML per 30 days) azithromycin oral suspension reconstituted 200 mg/5ml 1 or 1b* QL (15 mL per 30 days) azithromycin oral tablet 250 mg 1 or 1b* QL (6 tablets per 30 days) azithromycin oral tablet 500 mg 1 or 1b* QL (3 tablets per 30 days) azithromycin oral tablet 600 mg 1 or 1b* QL (8 tablet per 28 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 151 Coverage Requirements and Prescription Drug Name Drug Tier Limits ZITHROMAX INTRAVENOUS SOLUTION RECONSTITUTED 3 (azithromycin) ZITHROMAX ORAL PACKET (azithromycin) 3 QL (2 packets per 30 days) ZITHROMAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML 3 QL (15 ML per 30 days) (azithromycin) ZITHROMAX ORAL SUSPENSION RECONSTITUTED 200 MG/5ML 3 QL (15 mL per 30 days) (azithromycin) ZITHROMAX ORAL TABLET 250 MG (azithromycin) 3 QL (6 tablets per 30 days) ZITHROMAX ORAL TABLET 500 MG (azithromycin) 3 QL (3 tablets per 30 days) ZITHROMAX TRI-PAK ORAL TABLET (azithromycin) 3 QL (3 tablets per 30 days) ZITHROMAX Z-PAK ORAL TABLET (azithromycin) 3 QL (6 tablets per 30 days) *CLARITHROMYCIN*** - ANTIBIOTICS clarithromycin er oral tablet extended release 24 hour 1 or 1b* clarithromycin oral suspension reconstituted 1 or 1b* QL (300 mL per 1 fill) clarithromycin oral tablet 1 or 1b* QL (28 tablets per 1 fill) **** - ANTIBIOTICS ery-tab oral tablet delayed release 1 or 1b* ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION 3 RECONSTITUTED (erythromycin lactobionate) erythrocin stearate oral tablet 1 or 1b* erythromycin base oral capsule delayed release particles 1 or 1b* erythromycin base oral tablet 1 or 1b* erythromycin base oral tablet delayed release 1 or 1b* erythromycin ethylsuccinate oral suspension reconstituted 1 or 1b* erythromycin ethylsuccinate oral tablet 1 or 1b* erythromycin oral tablet delayed release 1 or 1b* *FIDAXOMICIN*** - ANTIBIOTICS DIFICID ORAL SUSPENSION RECONSTITUTED (fidaxomicin) 3 DIFICID ORAL TABLET (fidaxomicin) 3 *MEDICAL DEVICES AND SUPPLIES* - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT *CERVICAL CAPS*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT FEMCAP VAGINAL DEVICE (cervical caps) 2; $0 *CONDOMS - FEMALE*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT FC FEMALE CONDOM (condoms - female) 2; $0 QL (12 units per 1 fill) FC2 FEMALE CONDOM (condoms - female) 2; $0 QL (12 units per 1 fill)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 152 Coverage Requirements and Prescription Drug Name Drug Tier Limits *DENTAL DESENSITIZING PRODUCTS*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT REMESENSE DENTAL (dental desensitizing product) 3 *DENTIFRICES*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT MI PASTE DENTAL PASTE (dentifrices) 3 MI PASTE PLUS DENTAL PASTE (dentifrices) 3 *DIAPHRAGMS*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT CAYA VAGINAL DIAPHRAGM (diaphragm arc-spring) 2; $0 OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM (diaphragms) 3 WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM (diaphragm wide 2; $0 seal) WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM (diaphragm wide 2; $0 seal) WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM (diaphragm wide 2; $0 seal) WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM (diaphragm wide 2; $0 seal) WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM (diaphragm wide 2; $0 seal) WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM (diaphragm wide 2; $0 seal) WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM (diaphragm wide 2; $0 seal) WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM (diaphragm wide 2; $0 seal) *GLUCOSE MONITORING TEST SUPPLIES*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT 1ST TIER UNILET COMFORTOUCH 2 QL (204 lancets per 30 days) ACCU-CHEK FASTCLIX LANCET KIT (lancets misc.) 2 QL (200 units per 30 days) ACCU-CHEK FASTCLIX LANCETS (lancets) 2 QL (204 lancets per 30 days) ACCU-CHEK MULTICLIX LANCETS (lancets) 2 QL (204 lancets per 30 days) ACCU-CHEK SAFE-T PRO LANCETS (lancets) 2 QL (204 lancets per 30 days) ACCU-CHEK SOFTCLIX LANCET DEV KIT (lancets misc.) 2 QL (200 units per 30 days) ACCU-CHEK SOFTCLIX LANCETS (lancets) 2 QL (204 lancets per 30 days) ACTI-LANCE 28G 2 QL (204 lancets per 30 days) ACTI-LANCE LITE LANCETS 28G 2 QL (204 lancets per 30 days) ACTI-LANCE SPECIAL LANCETS 17G 2 QL (204 lancets per 30 days) ACTI-LANCE UNIVERSAL 23G 2 QL (204 lancets per 30 days) ADVANCED MOBILE LANCET 2 QL (204 lancets per 30 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 153 Coverage Requirements and Prescription Drug Name Drug Tier Limits ADVOCATE LANCETS (lancets) 2 QL (204 lancets per 30 days) ADVOCATE LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) ADVOCATE SAFETY LANCETS (lancets) 2 QL (204 lancets per 30 days) ADVOCATE SAFETY LANCETS 26G (lancets) 2 QL (204 lancets per 30 days) AGAMATRIX ULTRA-THIN LANCETS (lancets) 2 QL (204 lancets per 30 days) AIMSCO TWIST LANCETS 32G 2 QL (204 lancets per 30 days) AIMSCO TWIST LANCETS 33G (lancets) 2 QL (204 lancets per 30 days) AQUALANCE LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) ASSURE COMFORT LANCETS 28G 2 QL (204 lancets per 30 days) ASSURE HAEMOLANCE PLUS HIGH (lancets) 2 QL (204 lancets per 30 days) ASSURE HAEMOLANCE PLUS LOW (lancets) 2 QL (204 lancets per 30 days) ASSURE HAEMOLANCE PLUS MICRO (lancets) 2 QL (204 lancets per 30 days) ASSURE HAEMOLANCE PLUS NORMAL (lancets) 2 QL (204 lancets per 30 days) ASSURE HAEMOLANCE PLUS PED (lancets) 2 QL (204 lancets per 30 days) ASSURE LANCE LANCETS (lancets) 2 QL (204 lancets per 30 days) ASSURE LANCE LANCETS 21G (lancets) 2 QL (204 lancets per 30 days) ASSURE LANCE PLUS SAFETY 25G (lancets) 2 QL (204 lancets per 30 days) ASSURE LANCE PLUS SAFETY 30G (lancets) 2 QL (204 lancets per 30 days) ASSURE LANCE SAFETY LANCET 28G (lancets) 2 QL (204 lancets per 30 days) AURORA LANCET SUPER THIN 30G 2 QL (204 lancets per 30 days) AURORA LANCET THIN 23G 2 QL (204 lancets per 30 days) AUTOLET II CLINISAFE KIT (lancets misc.) 2 QL (200 units per 30 days) AUTOLET LITE CLINISAFE KIT (lancets misc.) 2 QL (200 units per 30 days) AUTOLET LITE STARTER PACK KIT (lancets misc.) 2 QL (200 units per 30 days) AUTOLET PLATFORMS (lancets misc.) 2 QL (200 units per 30 days) BD LANCET ULTRAFINE 30G (lancets) 2 QL (204 lancets per 30 days) BD LANCET ULTRAFINE 33G (lancets) 2 QL (204 lancets per 30 days) BD MICROTAINER LANCETS (lancets) 2 QL (204 lancets per 30 days) CAREONE LANCET SUPER THIN 30G (lancets) 2 QL (204 lancets per 30 days) CAREONE LANCET THIN 23G 2 QL (204 lancets per 30 days) CARESENS LANCETS (lancets) 2 QL (204 lancets per 30 days) CARETOUCH SAFETY LANCETS (lancets) 2 QL (204 lancets per 30 days) CARETOUCH SAFETY LANCETS 26G (lancets) 2 QL (204 lancets per 30 days) CARETOUCH TWIST LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) CARETOUCH TWIST LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) CARETOUCH TWIST LANCETS 33G (lancets) 2 QL (204 lancets per 30 days) CLEANLET LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) CLEVER CHEK LANCETS (lancets) 2 QL (204 lancets per 30 days) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 154 Coverage Requirements and Prescription Drug Name Drug Tier Limits CLEVER CHOICE LANCETS 21G (lancets) 2 QL (204 lancets per 30 days) CLEVER CHOICE LANCETS 23G (lancets) 2 QL (204 lancets per 30 days) CLEVER CHOICE LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) COAGUCHEK LANCETS (lancets) 2 QL (204 lancets per 30 days) COMFORT ASSURED LANCETS 28G 2 QL (204 lancets per 30 days) COMFORT ASSURED LANCETS 33G 2 QL (204 lancets per 30 days) COMFORT LANCETS 2 QL (204 lancets per 30 days) COMFORT TOUCH LANCETS 31G (lancets) 2 QL (204 lancets per 30 days) COMFORT TOUCH PLUS LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) CVS LANCETS 21G 2 QL (204 lancets per 30 days) CVS LANCETS MICRO THIN 33G 2 QL (204 lancets per 30 days) CVS LANCETS ORIGINAL 2 QL (204 lancets per 30 days) CVS LANCETS THIN 26G 2 QL (204 lancets per 30 days) CVS LANCETS ULTRA THIN 30G 2 QL (204 lancets per 30 days) CVS LANCETS ULTRA-THIN 30G 2 QL (204 lancets per 30 days) CVS ULTRA THIN LANCETS 2 QL (204 lancets per 30 days) DEXCOM G4 PLAT PED RCV/SHARE DEVICE (continuous blood gluc 2 PA; QL (1 unit per 365 days) receiver) DEXCOM G4 PLAT PED RECEIVER DEVICE (continuous blood gluc 2 PA; QL (1 unit per 365 days) receiver) DEXCOM G4 PLATINUM RCV/SHARE DEVICE (continuous blood gluc 2 PA; QL (1 unit per 365 days) receiver) DEXCOM G4 PLATINUM RECEIVER DEVICE (continuous blood gluc 2 PA; QL (1 unit per 365 days) receiver) DEXCOM G4 PLATINUM TRANSMITTER (continuous blood gluc 2 PA transmit) DEXCOM G4 SENSOR (continuous blood gluc sensor) 2 PA DEXCOM G5 MOB/G4 PLAT SENSOR (continuous blood gluc sensor) 2 PA; QL (5 units per 30 days) DEXCOM G5 MOBILE RECEIVER DEVICE (continuous blood gluc 2 PA; QL (1 unit per 365 days) receiver) DEXCOM G5 MOBILE TRANSMITTER (continuous blood gluc transmit) 2 PA; QL (1 unit per 90 days) DEXCOM G5 RECEIVER KIT DEVICE (continuous blood gluc receiver) 2 PA; QL (1 unit per 365 days) DEXCOM G6 RECEIVER DEVICE (continuous blood gluc receiver) 2 PA; QL (1 unit per 365 days) DEXCOM G6 SENSOR (continuous blood gluc sensor) 2 PA; QL (3 units per 30 days) DEXCOM G6 TRANSMITTER (continuous blood gluc transmit) 2 PA; QL (1 unit per 90 days) DIATHRIVE LANCET ULTRA THIN 30 (lancets) 2 QL (204 lancets per 30 days) DIATHRIVE LANCETS (lancets) 2 QL (204 lancets per 30 days) DROPLET LANCETS ULTRA THIN 30G (lancets) 2 QL (204 lancets per 30 days) DROPLET PERSONAL LANCETS 30G (lancets) 2 QL (204 lancets per 30 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 155 Coverage Requirements and Prescription Drug Name Drug Tier Limits DRUG MART LANCETS THIN 26G 2 QL (204 lancets per 30 days) DRUG MART ON-THE-GO LANCET 30G (lancets) 2 QL (204 lancets per 30 days) DRUG MART UNILET LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) DRUG MART UNILET LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) DRUG MART UNILET LANCETS 33G (lancets) 2 QL (204 lancets per 30 days) EASY COMFORT LANCETS 2 QL (204 lancets per 30 days) EASY COMFORT LANCETS TWIST TOP 2 QL (204 lancets per 30 days) EASY TOUCH LANCETS 21G (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH LANCETS 23G (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH LANCETS 26G (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH LANCETS 28G/TWIST (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH LANCETS 30G/TWIST (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH LANCETS 32G (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH LANCETS 32G/TWIST (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH LANCETS 33G/TWIST (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH SAFETY LANCETS 21G (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH SAFETY LANCETS 23G (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH SAFETY LANCETS 26G (lancets) 2 QL (204 lancets per 30 days) EASY TOUCH SAFETY LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) EMBRACE LANCETS ULTRA THIN 30G (lancets) 2 QL (204 lancets per 30 days) ENLITE GLUCOSE SENSOR (continuous blood gluc sensor) 3 PA EQL COLOR LANCETS 21G 2 QL (204 lancets per 30 days) EQL COLOR LANCETS MICRO 33G 2 QL (204 lancets per 30 days) EQL SUPER THIN LANCETS 30G 2 QL (204 lancets per 30 days) EQL THIN LANCETS 26G 2 QL (204 lancets per 30 days) EVERSENSE SENSOR/HOLDER (continuous blood gluc sensor) 3 PA EVERSENSE SMART TRANSMITTER (continuous blood gluc transmit) 3 PA; QL (1 unit per 365 days) E-Z JECT LANCET MICRO-THIN 33G (lancets) 2 QL (204 lancets per 30 days) E-Z JECT LANCET SUPER THIN 30G (lancets) 2 QL (204 lancets per 30 days) E-Z JECT LANCETS (lancets) 2 QL (204 lancets per 30 days) E-Z JECT LANCETS 21G (lancets) 2 QL (204 lancets per 30 days) E-Z JECT LANCETS THIN 26G (lancets) 2 QL (204 lancets per 30 days) EZ-LETS LANCETS 21G (lancets) 2 QL (204 lancets per 30 days) EZ-LETS LANCETS 26G (lancets) 2 QL (204 lancets per 30 days) EZ-LETS LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) EZ-LETS LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 156 Coverage Requirements and Prescription Drug Name Drug Tier Limits FIFTY50 SAFETY SEAL LANCETS (lancets) 2 QL (204 lancets per 30 days) FIFTY50 UNILET LANCETS 33G (lancets) 2 QL (204 lancets per 30 days) FINE 30 (lancets) 2 QL (204 lancets per 30 days) FINGERSTIX LANCETS (lancets) 2 QL (204 lancets per 30 days) FORA LANCETS (lancets) 2 QL (204 lancets per 30 days) FREDS PHARMACY UNILET LANC 28G 2 QL (204 lancets per 30 days) FREDS PHARMACY UNILET LANC 30G 2 QL (204 lancets per 30 days) FREESTYLE LANCETS (lancets) 2 QL (204 lancets per 30 days) FREESTYLE LIBRE 14 DAY READER DEVICE (continuous blood gluc 2 PA; QL (1 unit per 365 days) receiver) FREESTYLE LIBRE 14 DAY SENSOR (continuous blood gluc sensor) 2 PA; QL (2 units per 28 days) FREESTYLE LIBRE 2 READER DEVICE (continuous blood gluc receiver) 2 PA; QL (1 reader per 1 year) FREESTYLE LIBRE 2 SENSOR (continuous blood gluc sensor) 2 PA; QL (2 units per 28 days) FREESTYLE LIBRE READER DEVICE (continuous blood gluc receiver) 2 PA; QL (1 unit per 365 days) FREESTYLE LIBRE SENSOR SYSTEM (continuous blood gluc sensor) 2 PA; QL (2 units per 28 days) FREESTYLE UNISTICK II LANCETS (lancets) 2 QL (204 lancets per 30 days) GENTEEL BUTTERFLY TOUCH LANCET (lancets) 2 QL (204 lancets per 30 days) GENTEEL CONTACT TIPS (BLUE) (lancets misc.) 2 QL (200 units per 30 days) GENTEEL CONTACT TIPS (CLEAR) (lancets misc.) 2 QL (200 units per 30 days) GENTEEL CONTACT TIPS (GREEN) (lancets misc.) 2 QL (200 units per 30 days) GENTEEL CONTACT TIPS (ORANGE) (lancets misc.) 2 QL (200 units per 30 days) GENTEEL CONTACT TIPS (RAINBOW) (lancets misc.) 2 QL (200 units per 30 days) GENTEEL CONTACT TIPS (VIOLET) (lancets misc.) 2 QL (200 units per 30 days) GENTEEL CONTACT TIPS (YELLOW) (lancets misc.) 2 QL (200 units per 30 days) GENTEEL LANCING KIT (BLUE) KIT (lancets misc.) 2 QL (200 units per 30 days) GENTEEL NOZZLES (lancets misc.) 2 QL (200 units per 30 days) GENTLE-LET GP LANCETS (lancets) 2 QL (204 lancets per 30 days) GENTLE-LET LANCETS (lancets) 2 QL (204 lancets per 30 days) GENTLE-LET PLATFORMS (lancets misc.) 2 QL (200 units per 30 days) GLOBAL INJECT EASE LANCETS 28G 2 QL (204 lancets per 30 days) GLOBAL INJECT EASE LANCETS 30G 2 QL (204 lancets per 30 days) GLUCOCOM LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) GLUCOCOM LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) GLUCOCOM LANCETS 33G (lancets) 2 QL (204 lancets per 30 days) GNP LANCETS 21G 2 QL (204 lancets per 30 days) GNP LANCETS MICRO THIN 33G 2 QL (204 lancets per 30 days) GNP LANCETS SUPER THIN 30G 2 QL (204 lancets per 30 days) GNP LANCETS THIN 2 QL (204 lancets per 30 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 157 Coverage Requirements and Prescription Drug Name Drug Tier Limits GNP LANCETS THIN 26G 2 QL (204 lancets per 30 days) GOJJI STERILE LANCETS (lancets) 2 QL (204 lancets per 30 days) GOODSENSE COLOR LANCETS 33G 2 QL (204 lancets per 30 days) GOODSENSE LANCETS 26G UNIV 2 QL (204 lancets per 30 days) GOODSENSE LANCETS 30G 2 QL (204 lancets per 30 days) GOODSENSE LANCETS 30G UNIV 2 QL (204 lancets per 30 days) GOODSENSE LANCETS 33G 2 QL (204 lancets per 30 days) GOODSENSE LANCETS 33G UNIV 2 QL (204 lancets per 30 days) GUARDIAN CONNECT TRANSMITTER (continuous blood gluc transmit) 3 PA; QL (2 units per 365 days) GUARDIAN LINK 3 TRANSMITTER (continuous blood gluc transmit) 3 PA GUARDIAN REAL-TIME REPLACE PED DEVICE (continuous blood gluc 3 PA; QL (1 unit per 365 days) receiver) GUARDIAN SENSOR (3) (continuous blood gluc sensor) 3 PA; QL (5 units per 30 days) GUARDIAN SENSOR 3 3 PA; QL (5 units per 30 days) HAEMOLANCE (lancets) 2 QL (204 lancets per 30 days) HAEMOLANCE LOW FLOW LANCETS (lancets) 2 QL (204 lancets per 30 days) HAEMOLANCE PLUS (lancets) 2 QL (204 lancets per 30 days) HAEMOLANCE PLUS HIGH FLOW (lancets) 2 QL (204 lancets per 30 days) HAEMOLANCE PLUS LOW FLOW (lancets) 2 QL (204 lancets per 30 days) HAEMOLANCE PLUS MAX FLOW (lancets) 2 QL (204 lancets per 30 days) HAEMOLANCE PLUS PEDIATRIC FLOW (lancets) 2 QL (204 lancets per 30 days) HEALTHY ACCENTS UNILET LANCETS 2 QL (204 lancets per 30 days) H-E-B INCONTROL LANCETS 28G 2 QL (204 lancets per 30 days) H-E-B INCONTROL LANCETS 30G 2 QL (204 lancets per 30 days) H-E-B INCONTROL LANCETS 33G 2 QL (204 lancets per 30 days) HYPOLANCE AST LANCING KIT (lancets misc.) 2 QL (200 units per 30 days) HY-VEE LANCETS (lancets) 2 QL (204 lancets per 30 days) HY-VEE THIN LANCETS 2 QL (204 lancets per 30 days) IN TOUCH STERILE LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) KINNEY LANCETS 2 QL (204 lancets per 30 days) KINNEY THIN LANCETS 2 QL (204 lancets per 30 days) KROGER HEALTHPRO LANCET 26G (lancets) 2 QL (204 lancets per 30 days) KROGER LANCETS 2 QL (204 lancets per 30 days) KROGER LANCETS 21G 2 QL (204 lancets per 30 days) KROGER LANCETS MICRO THIN 33G 2 QL (204 lancets per 30 days) KROGER LANCETS SUPER THIN 2 QL (204 lancets per 30 days) KROGER LANCETS THIN 2 QL (204 lancets per 30 days) KROGER LANCETS THIN 26G 2 QL (204 lancets per 30 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 158 Coverage Requirements and Prescription Drug Name Drug Tier Limits KROGER LANCETS ULTRATHIN 30G 2 QL (204 lancets per 30 days) LANCET TRANSPORTER CASE 2 QL (200 units per 30 days) LANCETS 2 QL (204 lancets per 30 days) LANCETS 30G 2 QL (204 lancets per 30 days) LANCETS 33G 2 QL (204 lancets per 30 days) LANCETS MICRO THIN 33G 2 QL (204 lancets per 30 days) LANCETS SUPER THIN 28G 2 QL (204 lancets per 30 days) LANCETS THIN 2 QL (204 lancets per 30 days) LANCETS ULTRA THIN (lancets) 2 QL (204 lancets per 30 days) LANCETS ULTRA THIN 30G 2 QL (204 lancets per 30 days) LIBERTY MEDICAL LANCETS (lancets) 2 QL (204 lancets per 30 days) LIFESCAN UNISTIK 2 (lancets) 2 QL (204 lancets per 30 days) LIFESCAN UNISTIK II LANCETS (lancets) 2 QL (204 lancets per 30 days) LITE TOUCH LANCETS 2 QL (204 lancets per 30 days) LITETOUCH LANCETS (lancets) 2 QL (204 lancets per 30 days) LIVE BETTER LANCET SUPER THIN 2 QL (204 lancets per 30 days) LIVE BETTER LANCET ULTRA THIN 2 QL (204 lancets per 30 days) LONGS LANCETS STANDARD 2 QL (204 lancets per 30 days) LONGS LANCETS THIN 2 QL (204 lancets per 30 days) LONGS LANCETS ULTRA THIN 2 QL (204 lancets per 30 days) MEDICHOICE SAFETY LANCET 2 QL (204 lancets per 30 days) MEDICHOICE SAFETY LANCET EXTRA 2 QL (204 lancets per 30 days) MEDICHOICE SAFETY LANCET NORM 2 QL (204 lancets per 30 days) MEDISENSE THIN LANCETS (lancets) 2 QL (204 lancets per 30 days) MEDLANCE EXTRA 21G (lancets) 2 QL (204 lancets per 30 days) MEDLANCE LITE 25G (lancets) 2 QL (204 lancets per 30 days) MEDLANCE PLUS EXTRA 21G (lancets) 2 QL (204 lancets per 30 days) MEDLANCE PLUS LANCETS (lancets) 2 QL (204 lancets per 30 days) MEDLANCE PLUS LITE 25G (lancets) 2 QL (204 lancets per 30 days) MEDLANCE PLUS SPECIAL 0.8MM (lancets) 2 QL (204 lancets per 30 days) MEDLANCE PLUS SUPERLITE 30G (lancets) 2 QL (204 lancets per 30 days) MEDLANCE PLUS UNIVERSAL 21G (lancets) 2 QL (204 lancets per 30 days) MEDLANCE UNIVERSAL 21G (lancets) 2 QL (204 lancets per 30 days) MEIJER LANCETS (lancets) 2 QL (204 lancets per 30 days) MEIJER LANCETS THIN (lancets) 2 QL (204 lancets per 30 days) MEIJER LANCETS UNIVERSAL 21G (lancets) 2 QL (204 lancets per 30 days) MEIJER LANCETS UNIVERSAL 30G (lancets) 2 QL (204 lancets per 30 days) MEIJER LANCETS UNIVERSAL 33G (lancets) 2 QL (204 lancets per 30 days) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 159 Coverage Requirements and Prescription Drug Name Drug Tier Limits MEIJER SUPER THIN LANCETS (lancets) 2 QL (204 lancets per 30 days) MICROLET LANCETS (lancets) 2 QL (204 lancets per 30 days) MINILINK REAL-TIME TRANSMITTER (continuous blood gluc transmit) 3 PA MINIMED 630G GUARDIAN PRESS (continuous blood gluc transmit) 3 PA MINIMED GUARDIAN LINK 3 (continuous blood gluc transmit) 3 PA MM TWIST LANCETS (lancets) 2 QL (204 lancets per 30 days) MONOLET LANCETS (lancets) 2 QL (204 lancets per 30 days) MONOLET OPD LANCETS (lancets) 2 QL (204 lancets per 30 days) MONOLETTOR SAFETY LANCETS (lancets) 2 QL (204 lancets per 30 days) MPD SAFETY LANCET 21G 2 QL (204 lancets per 30 days) MPD SAFETY LANCET 23G 2 QL (204 lancets per 30 days) MPD SAFETY LANCET 28G 2 QL (204 lancets per 30 days) MPD SAFETY LANCET 30G 2 QL (204 lancets per 30 days) MULTI-LANCET DEVICE 2 KIT (lancets misc.) 2 QL (200 units per 30 days) MYGLUCOHEALTH LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) NOVA SAFETY LANCETS 23G (lancets) 2 QL (204 lancets per 30 days) NOVA SAFETY LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) NOVA SUREFLEX LANCETS (lancets) 2 QL (204 lancets per 30 days) ONETOUCH CLUB LANCETS FINE PT (lancets) 2 QL (204 lancets per 30 days) ONETOUCH DELICA LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) ONETOUCH DELICA LANCETS 33G (lancets) 2 QL (204 lancets per 30 days) ONETOUCH DELICA PLUS LANCET30G (lancets) 2 QL (204 lancets per 30 days) ONETOUCH DELICA PLUS LANCET33G (lancets) 2 QL (204 lancets per 30 days) ONETOUCH FINEPOINT LANCETS (lancets) 2 QL (204 lancets per 30 days) ONETOUCH SURESOFT LANCING DEV (lancets misc.) 2 QL (200 units per 30 days) ONETOUCH ULTRASOFT LANCETS (lancets) 2 QL (204 lancets per 30 days) PARADIGM REAL-TIME TRANSMITTER (continuous blood gluc 3 PA transmit) PC LANCETS SUPER THIN 30G 2 QL (204 lancets per 30 days) PENLET II BLOOD SAMPLER KIT (lancets misc.) 2 QL (200 units per 30 days) PENLET II REPLACEMENT CAP (lancets misc.) 2 QL (200 units per 30 days) PERFECT LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) PERFECT LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) PHARMACIST CHOICE LANCETS (lancets) 2 QL (204 lancets per 30 days) PHARMACY COUNTER LANCETS (lancets) 2 QL (204 lancets per 30 days) PIP LANCETS 28G 2 QL (204 lancets per 30 days) PIP LANCETS 30G 2 QL (204 lancets per 30 days) PRECISION THINS GP LANCETS (lancets) 2 QL (204 lancets per 30 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 160 Coverage Requirements and Prescription Drug Name Drug Tier Limits PREFERRED PLUS LANCETS COLORED 2 QL (204 lancets per 30 days) PREFERRED PLUS LANCETS THIN 2 QL (204 lancets per 30 days) PRO COMFORT LANCETS 30G 2 QL (204 lancets per 30 days) PRO COMFORT LANCETS 31G 2 QL (204 lancets per 30 days) PRODIGY LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) PRODIGY SAFETY LANCETS 26G (lancets) 2 QL (204 lancets per 30 days) PRODIGY TWIST TOP LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) PSS SELECT GP LANCETS (lancets) 2 QL (204 lancets per 30 days) PSS SELECT PLATFORMS (lancets misc.) 2 QL (200 units per 30 days) PSS SELECT SAFETY LANCETS (lancets) 2 QL (204 lancets per 30 days) PURE COMFORT LANCETS 30G 2 QL (204 lancets per 30 days) PX LANCETS MICROTHIN 33G 2 QL (204 lancets per 30 days) PX LANCETS ULTRA THIN 2 QL (204 lancets per 30 days) PX LANCETS ULTRA THIN 28G 2 QL (204 lancets per 30 days) QC LANCETS SUPER THIN 30G 2 QL (204 lancets per 30 days) QC LANCETS ULTRA THIN 2 QL (204 lancets per 30 days) QC UNILET LANCETS 28G 2 QL (204 lancets per 30 days) QC UNILET LANCETS MICRO THIN 2 QL (204 lancets per 30 days) RA E-ZJECT LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) RA E-ZJECT LANCETS THIN 26G (lancets) 2 QL (204 lancets per 30 days) RA E-ZJECT LANCETS THIN 28G (lancets) 2 QL (204 lancets per 30 days) RA E-ZJECT LANCETS ULTRA THIN (lancets) 2 QL (204 lancets per 30 days) READYLANCE SAFETY LANCETS (lancets) 2 QL (204 lancets per 30 days) REALITY LANCETS 2 QL (204 lancets per 30 days) REALITY TRIGGER LANCETS 2 QL (204 lancets per 30 days) RELION LANCETS MICRO-THIN 33G (lancets) 2 QL (204 lancets per 30 days) RELION LANCETS THIN 26G (lancets) 2 QL (204 lancets per 30 days) RELION LANCETS ULTRA-THIN 30G (lancets) 2 QL (204 lancets per 30 days) RELION LANCING DEVICE KIT (lancets misc.) 2 QL (200 units per 30 days) RELION ULTRA THIN LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) RELION ULTRA THIN PLUS LANCETS (lancets) 2 QL (204 lancets per 30 days) REXALL LANCETS ULTRA THIN 30G (lancets) 2 QL (204 lancets per 30 days) RIGHTEST ALTERNATE SITE ADAPT (lancets misc.) 2 QL (200 units per 30 days) RIGHTEST GL300 LANCETS (lancets) 2 QL (204 lancets per 30 days) SAFE-T-LANCE (lancets) 2 QL (204 lancets per 30 days) SAFE-T-LANCE PLUS (lancets) 2 QL (204 lancets per 30 days) SAFETY LANCET 30G/PRESSURE ACT 2 QL (204 lancets per 30 days) SAFETY LANCETS (lancets) 2 QL (204 lancets per 30 days) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 161 Coverage Requirements and Prescription Drug Name Drug Tier Limits SAFETY LANCETS 21G (lancets) 2 QL (204 lancets per 30 days) SAFETY LANCETS 28G 2 QL (204 lancets per 30 days) SAPS HEALTH TWIST TOP LANCETS 2 QL (204 lancets per 30 days) SAPS TWIST TOP LANCETS 2 QL (204 lancets per 30 days) SAPSCARE TWIST TOP LANCETS 2 QL (204 lancets per 30 days) SB LANCETS THIN 2 QL (204 lancets per 30 days) SB LANCETS ULTRA THIN 2 QL (204 lancets per 30 days) SELECT-LITE DEVICE/LANCETS KIT 2 QL (200 units per 30 days) SHOPKO ON-THE-GO LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) SHOPKO UNILET LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) SHOPKO UNILET LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) SINGLE-LET (lancets) 2 QL (204 lancets per 30 days) SM LANCETS 33G 2 QL (204 lancets per 30 days) SMART SENSE COLOR LANCETS 33G (lancets) 2 QL (204 lancets per 30 days) SMART SENSE STANDARD LANCETS (lancets) 2 QL (204 lancets per 30 days) SMART SENSE SUPER THIN LANCETS (lancets) 2 QL (204 lancets per 30 days) SMART SENSE THIN LANCETS 26G (lancets) 2 QL (204 lancets per 30 days) SMARTEST LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) SOLUS V2 LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) SOLUS V2 TWIST LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) STERILANCE PA (lancets misc.) 2 QL (200 units per 30 days) STERILANCE TL (lancets) 2 QL (204 lancets per 30 days) SUPER THIN LANCETS 2 QL (204 lancets per 30 days) SURE COMFORT LANCETS 18G 2 QL (204 lancets per 30 days) SURE COMFORT LANCETS 21G 2 QL (204 lancets per 30 days) SURE COMFORT LANCETS 23G 2 QL (204 lancets per 30 days) SURE COMFORT LANCETS 28G 2 QL (204 lancets per 30 days) SURE COMFORT LANCETS 30G 2 QL (204 lancets per 30 days) SURE-LANCE FLAT LANCETS (lancets) 2 QL (204 lancets per 30 days) SURE-LANCE LANCETS 26G (lancets) 2 QL (204 lancets per 30 days) SURE-LANCE THIN LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) SURE-LANCE ULTRA THIN LANCETS (lancets) 2 QL (204 lancets per 30 days) SURELITE LANCETS (lancets) 2 QL (204 lancets per 30 days) SURE-TOUCH LANCETS UNIVERSAL (lancets) 2 QL (204 lancets per 30 days) TECHLITE AST LANCETS (lancets) 2 QL (204 lancets per 30 days) TECHLITE LANCETS (lancets) 2 QL (204 lancets per 30 days) TECHLITE LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) TGT LANCET MICRO THIN 33G 2 QL (204 lancets per 30 days) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 162 Coverage Requirements and Prescription Drug Name Drug Tier Limits TGT LANCET THIN 26G 2 QL (204 lancets per 30 days) TGT LANCET ULTRA THIN 30G 2 QL (204 lancets per 30 days) THINLETS GP LANCETS (lancets) 2 QL (204 lancets per 30 days) TODAYS HEALTH THIN LANCETS 28G 2 QL (204 lancets per 30 days) TODAYS HEALTH THIN LANCETS 30G 2 QL (204 lancets per 30 days) TOPCARE LANCETS MICRO-THIN 33G 2 QL (204 lancets per 30 days) TRAVEL LANCETS 2 QL (204 lancets per 30 days) TRAVEL LANCETS ADVANCED 28G (lancets) 2 QL (204 lancets per 30 days) TRUE COMFORT TWIST TOP LANCETS 2 QL (204 lancets per 30 days) TRUEPLUS LANCETS 26G (lancets) 2 QL (204 lancets per 30 days) TRUEPLUS LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) TRUEPLUS LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) TRUEPLUS LANCETS 33G (lancets) 2 QL (204 lancets per 30 days) TRUEPLUS SAFETY LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) ULTILET CLASSIC LANCETS (lancets) 2 QL (204 lancets per 30 days) ULTILET LANCETS (lancets) 2 QL (204 lancets per 30 days) ULTILET SAFETY LANCETS (lancets) 2 QL (204 lancets per 30 days) ULTILET SAFETY LANCETS 23G (lancets) 2 QL (204 lancets per 30 days) ULTRA THIN LANCETS 31G 2 QL (204 lancets per 30 days) ULTRA-CARE LANCETS 30G 2 QL (204 lancets per 30 days) ULTRA-THIN II AUTO LANCET (lancets) 2 QL (204 lancets per 30 days) ULTRA-THIN II LANCETS (lancets) 2 QL (204 lancets per 30 days) UNILET COMFORTOUCH LANCET (lancets) 2 QL (204 lancets per 30 days) UNILET EXCELITE (lancets) 2 QL (204 lancets per 30 days) UNILET EXCELITE II (lancets) 2 QL (204 lancets per 30 days) UNILET G.P. LANCET (lancets) 2 QL (204 lancets per 30 days) UNILET G.P. SUPERLITE LANCET (lancets) 2 QL (204 lancets per 30 days) UNILET GP 28 ULTRA THIN (lancets) 2 QL (204 lancets per 30 days) UNILET LANCET (lancets) 2 QL (204 lancets per 30 days) UNILET MICRO-THIN 33G (lancets) 2 QL (204 lancets per 30 days) UNILET SUPERLITE LANCET (lancets) 2 QL (204 lancets per 30 days) UNILET SUPER-THIN 30G (lancets) 2 QL (204 lancets per 30 days) UNILET ULTRA-THIN 28G (lancets) 2 QL (204 lancets per 30 days) UNISTIK 1 (lancets misc.) 2 QL (200 units per 30 days) UNISTIK 2 (lancets misc.) 2 QL (200 units per 30 days) UNISTIK 2 COMFORT (lancets misc.) 2 QL (200 units per 30 days) UNISTIK 2 EXTRA (lancets misc.) 2 QL (200 units per 30 days) UNISTIK 2 NEONATAL (lancets misc.) 2 QL (200 units per 30 days) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 163 Coverage Requirements and Prescription Drug Name Drug Tier Limits UNISTIK 2 NORMAL (lancets misc.) 2 QL (200 units per 30 days) UNISTIK 2 SUPER (lancets misc.) 2 QL (200 units per 30 days) UNISTIK 3 (lancets misc.) 2 QL (200 units per 30 days) UNISTIK 3 COMFORT (lancets misc.) 2 QL (200 units per 30 days) UNISTIK 3 EXTRA (lancets misc.) 2 QL (200 units per 30 days) UNISTIK 3 GENTLE (lancets) 2 QL (204 lancets per 30 days) UNISTIK 3 NEONATAL (lancets misc.) 2 QL (200 units per 30 days) UNISTIK 3 NORMAL (lancets misc.) 2 QL (200 units per 30 days) UNISTIK CZT COMFORT (lancets misc.) 2 QL (200 units per 30 days) UNISTIK CZT NORMAL (lancets misc.) 2 QL (200 units per 30 days) UNISTIK NORMAL (lancets misc.) 2 QL (200 units per 30 days) UNISTIK PRO SAFETY LANCET (lancets) 2 QL (204 lancets per 30 days) UNISTIK SAFETY LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) UNISTIK SAFETY LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) UNISTIK TOUCH SAFETY LANC 21G (lancets) 2 QL (204 lancets per 30 days) UNISTIK TOUCH SAFETY LANC 23G (lancets) 2 QL (204 lancets per 30 days) UNISTIK TOUCH SAFETY LANC 28G (lancets) 2 QL (204 lancets per 30 days) UNISTIK TOUCH SAFETY LANC 30G (lancets) 2 QL (204 lancets per 30 days) UNIVERSAL 1 LANCETS THIN 26G (lancets) 2 QL (204 lancets per 30 days) UNIVERSAL 1 LANCETS THIN 33G (lancets) 2 QL (204 lancets per 30 days) UNIVERSAL 1 LANCETS ULTRA THIN (lancets) 2 QL (204 lancets per 30 days) VALUE PLUS LANCET STANDARD 21G 2 QL (204 lancets per 30 days) VALUE PLUS LANCETS SUPER THIN 2 QL (204 lancets per 30 days) VALUE PLUS LANCETS THIN 26G 2 QL (204 lancets per 30 days) VALUMARK LANCET SUPER THIN 30G 2 QL (204 lancets per 30 days) VALUMARK LANCET ULTRA THIN 28G 2 QL (204 lancets per 30 days) VIDA MIA UNILET LANCETS 28G (lancets) 2 QL (204 lancets per 30 days) VIDA MIA UNILET LANCETS 30G (lancets) 2 QL (204 lancets per 30 days) VIVAGUARD LANCETS (lancets) 2 QL (204 lancets per 30 days) WALGREENS ADV TRAVEL LANCETS 2 QL (204 lancets per 30 days) WALGREENS LANCETS (lancets) 2 QL (204 lancets per 30 days) WALGREENS LANCETS MICRO THIN 2 QL (204 lancets per 30 days) WALGREENS LANCETS SUPER THIN 2 QL (204 lancets per 30 days) WALGREENS THIN LANCETS (lancets) 2 QL (204 lancets per 30 days) WALGREENS ULTRA THIN LANCETS (lancets) 2 QL (204 lancets per 30 days) *INSULIN ADMINISTRATION SUPPLIES*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT OMNIPOD 5 PACK (insulin disposable pump) 2 PA; QL (15 pods per 30 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 164 Coverage Requirements and Prescription Drug Name Drug Tier Limits OMNIPOD DASH 5 PACK PODS (insulin disposable pump) 2 PA; QL (15 pods per 30 days) OMNIPOD STARTER KIT (insulin disposable pump) 2 PA; QL (1 unit per 4 yearss) *NEEDLES & SYRINGES*** - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT 1ST TIER UNIFINE PENTIPS 3 ST; QL (200 needles per 30 days) 1ST TIER UNIFINE PENTIPS PLUS 3 ST; QL (200 needles per 30 days) ABOUTTIME PEN NEEDLE (insulin pen needle) 3 ST; QL (200 needles per 30 days) ADVOCATE INSULIN PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) ADVOCATE INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ASSURE ID INSULIN SAFETY SYR (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ASSURE ID SAFETY PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) AURORA PEN NEEDLES 3 ST; QL (200 needles per 30 days) AURORA UNIFINE PENTIPS 3 ST; QL (200 needles per 30 days) BD AUTOSHIELD (insulin pen needle) 2 ST; QL (200 needles per 30 days) BD AUTOSHIELD DUO (insulin pen needle) 2 ST; QL (200 needles per 30 days) BD INSULIN SYR ULTRAFINE II (insulin syringe-needle u-100) 2 ST; QL (200 syringes per 30 days) BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 2 QL (200 syringes per 30 days) ML, 27.5G X 5/8" 2 ML (insulin syringe-needle u-100) BD INSULIN SYRINGE 27G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 2 ST; QL (200 syringes per 30 days) 0.5 ML, 29G X 1/2" 1 ML (insulin syringe-needle u-100) BD INSULIN SYRINGE HALF-UNIT (insulin syringe-needle u-100) 2 QL (200 syringes per 30 days) BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML (insulin syringe- 2 QL (200 syringes per 30 days) needle u-100) BD INSULIN SYRINGE MICROFINE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML 2 ST; QL (200 syringes per 30 days) (insulin syringe-needle u-100) BD INSULIN SYRINGE U/F (insulin syringe-needle u-100) 2 ST; QL (200 syringes per 30 days) BD INSULIN SYRINGE U/F 1/2UNIT (insulin syringe-needle u-100) 2 ST; QL (200 syringes per 30 days) BD INSULIN SYRINGE U-100 1 ML (insulin syringes (disposable)) 2 ST; QL (200 syringes per 30 days) BD INSULIN SYRINGE U-500 (insulin syringe/needle u-500) 2 QL (200 syringes per 30 days) BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.5 ML, 31G X 5/16" 0.5 ML (insulin 2 ST; QL (200 syringes per 30 days) syringe-needle u-100) BD INSULIN SYRINGE ULTRAFINE 30G X 1/2" 0.3 ML (insulin syringe- 2 QL (200 syringes per 30 days) needle u-100) BD PEN NEEDLE MICRO U/F (insulin pen needle) 2 ST; QL (200 needles per 30 days) BD PEN NEEDLE MINI U/F (insulin pen needle) 2 ST; QL (200 needles per 30 days) BD PEN NEEDLE NANO 2ND GEN (insulin pen needle) 2 ST; QL (200 needles per 30 days) BD PEN NEEDLE NANO U/F (insulin pen needle) 2 ST; QL (200 needles per 30 days) BD PEN NEEDLE ORIGINAL U/F (insulin pen needle) 2 ST; QL (200 needles per 30 days) BD PEN NEEDLE SHORT U/F (insulin pen needle) 2 ST; QL (200 needles per 30 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 165 Coverage Requirements and Prescription Drug Name Drug Tier Limits BD SAFETYGLIDE INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 2 ST; QL (200 syringes per 30 days) 31G X 5/16" 0.3 ML (insulin syringe-needle u-100) BD SAFETYGLIDE INSULIN SYRINGE 31G X 15/64" 1 ML (insulin 2 QL (200 syringes per 30 days) syringe-needle u-100) BD SAFETY-LOK INSULIN SYRINGE (insulin syringe-needle u-100) 2 ST; QL (200 syringes per 30 days) BD VEO INSULIN SYR U/F 1/2UNIT (insulin syringe-needle u-100) 2 ST; QL (200 syringes per 30 days) BD VEO INSULIN SYRINGE U/F 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 2 ST; QL (200 syringes per 30 days) ML (insulin syringe-needle u-100) BD VEO INSULIN SYRINGE U/F 31G X 15/64" 1 ML (insulin syringe- 2 QL (200 syringes per 30 days) needle u-100) CAREFINE PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) CAREONE INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) CAREONE UNIFINE PENTIPS 3 ST; QL (200 needles per 30 days) CAREONE UNIFINE PENTIPS PLUS 3 ST; QL (200 needles per 30 days) CARETOUCH INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) CARETOUCH PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) CLEVER CHOICE COMFORT EZ (insulin pen needle) 3 ST; QL (200 needles per 30 days) CLICKFINE PEN NEEDLES 3 ST; QL (200 needles per 30 days) COMFORT ASSIST INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) COMFORT EZ INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) COMFORT EZ MICRO PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) COMFORT EZ PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) COMFORT EZ SHORT PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) COMFORT TOUCH INSULIN PEN NEED (insulin pen needle) 3 ST; QL (200 needles per 30 days) DIATHRIVE PEN NEEDLE (insulin pen needle) 3 ST; QL (200 needles per 30 days) DROPLET INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 15/64" 0.3 ML, 30G X 15/64" 1 ML, 30G X 5/16" 0.3 ML, 30G X 3 ST; QL (200 syringes per 30 days) 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) DROPLET INSULIN SYRINGE 30G X 15/64" 0.5 ML (insulin syringe- 3 QL (200 syringes per 30 days) needle u-100) DROPLET MICRON (insulin pen needle) 3 QL (200 needles per 30 days) DROPLET PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) DROPSAFE SAFETY PEN NEEDLES 3 ST; QL (200 needles per 30 days) DRUG MART UNIFINE PENTIPS 3 ST; QL (200 needles per 30 days) DRUG MART UNIFINE PENTIPS PLUS 3 ST; QL (200 needles per 30 days) EASY COMFORT INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) EASY COMFORT PEN NEEDLES 3 ST; QL (200 needles per 30 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 166 Coverage Requirements and Prescription Drug Name Drug Tier Limits EASY GLIDE PEN NEEDLES 3 ST; QL (200 needles per 30 days) EASY TOUCH FLIPLOCK INSULIN SY (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) EASY TOUCH INSULIN SAFETY SYR (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) EASY TOUCH INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) EASY TOUCH PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) EASY TOUCH SAFETY PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) EASY TOUCH SHEATHLOCK SYRINGE 29G X 1/2" 1 ML, 30G X 1/2" 1 3 ST; QL (200 syringes per 30 days) ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) EQL INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) EXEL COMFORT POINT INSULIN SYR (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) EXEL COMFORT POINT PEN NEEDLE (insulin pen needle) 3 ST; QL (200 needles per 30 days) FIFTY50 PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) FIFTY50 SUPERIOR COMFORT SYR (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) FREDS PHARMACY UNIFINE PENTIP+ 3 ST; QL (200 needles per 30 days) FREDS PHARMACY UNIFINE PENTIPS 3 ST; QL (200 needles per 30 days) FREESTYLE PRECISION INS SYR (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) GLOBAL EASE INJECT PEN NEEDLES 3 ST; QL (200 needles per 30 days) GLOBAL EASY GLIDE INSULIN SYR 31G X 15/64" 0.3 ML, 31G X 15/64" 3 ST; QL (200 syringes per 30 days) 0.5 ML, 31G X 5/16" 0.3 ML GLOBAL EASY GLIDE INSULIN SYR 31G X 15/64" 1 ML 3 QL (200 syringes per 30 days) GLOBAL EASY GLIDE PEN NEEDLES 3 ST; QL (200 needles per 30 days) GLOBAL INJECT EASE INSULIN SYR 3 ST; QL (200 syringes per 30 days) GLOBAL INSULIN SYRINGES 3 ST; QL (200 syringes per 30 days) GLUCOPRO INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) GNP CLICKFINE PEN NEEDLES 3 ST; QL (200 needles per 30 days) GNP INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) GNP ULTICARE PEN NEEDLES 3 ST; QL (200 needles per 30 days) GNP ULTRA COM INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) GOODSENSE CLICKFINE PEN NEEDLE 3 ST; QL (200 needles per 30 days) GOODSENSE PEN NEEDLE PENFINE (insulin pen needle) 3 ST; QL (200 needles per 30 days) HEALTHWISE INSULIN SYR/NEEDLE 3 ST; QL (200 syringes per 30 days) HEALTHWISE MICRON PEN NEEDLES 3 ST; QL (200 needles per 30 days) HEALTHWISE MINI PEN NEEDLES 3 ST; QL (200 needles per 30 days) HEALTHWISE PEN NEEDLES 3 ST; QL (200 needles per 30 days) HEALTHWISE SHORT PEN NEEDLES 3 ST; QL (200 needles per 30 days) HEALTHWISE UNIFINE PENTIPS 3 ST; QL (200 needles per 30 days) HEALTHY ACCENTS UNIFINE PENTIP 3 ST; QL (200 needles per 30 days) H-E-B INCONTROL PEN NEEDLES 3 ST; QL (200 needles per 30 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 167 Coverage Requirements and Prescription Drug Name Drug Tier Limits H-E-B INCONTROL UNIFINE PENTIP (insulin pen needle) 3 ST; QL (200 needles per 30 days) HM ULTICARE INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) HM ULTICARE MINI PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) HM ULTICARE SHORT PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) INSULIN SYRINGE/NEEDLE 3 ST; QL (200 syringes per 30 days) INSULIN SYRINGE-NEEDLE U-100 3 ST; QL (200 syringes per 30 days) INSUPEN PEN NEEDLES 3 ST; QL (200 needles per 30 days) INSUPEN SENSITIVE (insulin pen needle) 3 ST; QL (200 needles per 30 days) INSUPEN ULTRAFIN (insulin pen needle) 3 ST; QL (200 needles per 30 days) KINRAY INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) KMART VALU INSULIN SYRINGE 29G 3 ST; QL (200 syringes per 30 days) KMART VALU INSULIN SYRINGE 30G 3 ST; QL (200 syringes per 30 days) KROGER INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) KROGER PEN NEEDLES 3 ST; QL (200 needles per 30 days) LEADER INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) LEADER UNIFINE PENTIPS (insulin pen needle) 3 ST; QL (200 needles per 30 days) LEADER UNIFINE PENTIPS PLUS (insulin pen needle) 3 ST; QL (200 needles per 30 days) LITETOUCH INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) LITETOUCH PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) LONGS INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) MAGELLAN INSULIN SAFETY SYR (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) MARATHON MEDICAL PENTIPS (insulin pen needle) 3 ST; QL (200 needles per 30 days) MAXICOMFORT II PEN NEEDLE (insulin pen needle) 3 ST; QL (200 needles per 30 days) MAXI-COMFORT INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) MAXI-COMFORT SAFETY PEN NEEDLE (insulin pen needle) 3 ST; QL (200 needles per 30 days) MAXICOMFORT SYR 27G X 1/2" (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) MEDIC INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) MEDICINE SHOPPE PEN NEEDLES 3 ST; QL (200 needles per 30 days) MEIJER PEN NEEDLES 3 ST; QL (200 needles per 30 days) MICRODOT PEN NEEDLE (insulin pen needle) 3 ST; QL (200 needles per 30 days) MM INSULIN SYRINGE/NEEDLE 3 ST; QL (200 syringes per 30 days) MM PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) MONOJECT INSULIN SYRINGE (insulin syringes (disposable)) 3 ST; QL (200 syringes per 30 days) MONOJECT ULTRA COMFORT SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) MS INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) NOVOFINE (insulin pen needle) 3 ST; QL (200 needles per 30 days) NOVOFINE AUTOCOVER (insulin pen needle) 3 ST; QL (200 needles per 30 days) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 168 Coverage Requirements and Prescription Drug Name Drug Tier Limits NOVOFINE PLUS (insulin pen needle) 3 ST; QL (200 needles per 30 days) NOVOTWIST (insulin pen needle) 3 ST; QL (200 needles per 30 days) PC UNIFINE PENTIPS 3 ST; QL (200 needles per 30 days) PEN NEEDLES 3 ST; QL (200 needles per 30 days) PEN NEEDLES 1/2" 3 ST; QL (200 needles per 30 days) PEN NEEDLES 5/16" 3 ST; QL (200 needles per 30 days) PENTIPS (insulin pen needle) 3 ST; QL (200 needles per 30 days) PRECISION SUREDOSE PLUS SYR (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) PRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 3 ST; QL (200 syringes per 30 days) 29G X 1/2" 0.5 ML, 30G X 5/16" 0.3 ML (insulin syringe-needle u-100) PRECISION SURE-DOSE SYRINGE 30G X 3/8" 0.5 ML (insulin syringe- 3 QL (200 syringes per 30 days) needle u-100) PREFERRED PLUS INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) PREFERRED PLUS UNIFINE PENTIPS 3 ST; QL (200 needles per 30 days) PREVENT SAFETY PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) PRO COMFORT INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) PRO COMFORT PEN NEEDLES 3 ST; QL (200 needles per 30 days) PRODIGY INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) PURE COMFORT PEN NEEDLE 3 ST; QL (200 needles per 30 days) PX EXTRA SHORT PEN NEEDLES 3 ST; QL (200 needles per 30 days) PX INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) PX MINI PEN NEEDLES 3 ST; QL (200 needles per 30 days) PX PEN NEEDLE 3 ST; QL (200 needles per 30 days) PX SHORTLENGTH PEN NEEDLES 3 ST; QL (200 needles per 30 days) QC PEN NEEDLES 3 ST; QL (200 needles per 30 days) QC UNIFINE PENTIPS 3 ST; QL (200 needles per 30 days) RA INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) RA PEN NEEDLES 3 ST; QL (200 needles per 30 days) REALITY INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) RELION INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) RELION MINI PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) RELION PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) RELION SHORT PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) SAFETY INSULIN SYRINGES 3 ST; QL (200 syringes per 30 days) SB INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) SECURESAFE INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) SECURESAFE SAFETY PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) SHOPKO UNIFINE PENTIPS (insulin pen needle) 3 ST; QL (200 needles per 30 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 169 Coverage Requirements and Prescription Drug Name Drug Tier Limits SHOPKO UNIFINE PENTIPS PLUS (insulin pen needle) 3 ST; QL (200 needles per 30 days) SURE COMFORT INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) SURE COMFORT PEN NEEDLES 3 ST; QL (200 needles per 30 days) SURE-FINE PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) SURE-JECT INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) TECHLITE INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) TECHLITE PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) TODAYS HEALTH MINI PEN NEEDLES 3 ST; QL (200 needles per 30 days) TODAYS HEALTH PEN NEEDLES 3 ST; QL (200 needles per 30 days) TODAYS HEALTH SHORT PEN NEEDLE 3 ST; QL (200 needles per 30 days) TOPCARE CLICKFINE PEN NEEDLES 3 ST; QL (200 needles per 30 days) TOPCARE ULTRA COMFORT INS SYR 3 ST; QL (200 syringes per 30 days) TRUE COMFORT INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) TRUE COMFORT PEN NEEDLES 3 ST; QL (200 needles per 30 days) TRUE COMFORT PRO INSULIN SYR 3 ST; QL (200 syringes per 30 days) TRUE COMFORT PRO PEN NEEDLES 3 ST; QL (200 needles per 30 days) TRUEPLUS 5-BEVEL PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) TRUEPLUS INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) TRUEPLUS PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) ULTICARE INSULIN SAFETY SYR (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ULTICARE INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ULTICARE MICRO PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) ULTICARE MINI PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) ULTICARE PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) ULTICARE SHORT PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) ULTIGUARD SAFEPACK PEN NEEDLE 3 ST; QL (200 needles per 30 days) ULTIGUARD SAFEPACK SYR/NEEDLE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ULTILET INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ULTILET INSULIN SYRINGE SHORT (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ULTILET PEN NEEDLE (insulin pen needle) 3 ST; QL (200 needles per 30 days) ULTRA COMFORT INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) ULTRA FLO INSULIN PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) ULTRA FLO INSULIN SYR 1/2 UNIT (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ULTRA FLO INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ULTRA THIN PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) ULTRACARE INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) ULTRACARE PEN NEEDLES 3 ST; QL (200 needles per 30 days) ULTRA-COMFORT INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 170 Coverage Requirements and Prescription Drug Name Drug Tier Limits ULTRA-THIN II INS SYR SHORT (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ULTRA-THIN II INSULIN SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) ULTRA-THIN II MINI PEN NEEDLE (insulin pen needle) 3 ST; QL (200 needles per 30 days) ULTRA-THIN II PEN NEEDLE SHORT (insulin pen needle) 3 ST; QL (200 needles per 30 days) ULTRA-THIN II PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) UNIFINE PEN NEEDLES (insulin pen needle) 3 ST; QL (200 needles per 30 days) UNIFINE PENTIPS (insulin pen needle) 3 ST; QL (200 needles per 30 days) UNIFINE PENTIPS PLUS (insulin pen needle) 3 ST; QL (200 needles per 30 days) UNIFINE SAFECONTROL PEN NEEDLE (insulin pen needle) 3 ST; QL (200 needles per 30 days) VALUE HEALTH INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) VALUMARK PEN NEEDLES 3 ST; QL (200 needles per 30 days) VANISHPOINT INSULIN SYRINGE 29G X 1/2" 1 ML, 29G X 5/16" 1 ML, 30G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML (insulin syringe- 3 ST; QL (200 syringes per 30 days) needle u-100) VANISHPOINT INSULIN SYRINGE 30G X 3/16" 0.5 ML, 30G X 3/16" 1 3 QL (200 syringes per 30 days) ML (insulin syringe-needle u-100) VIDA MIA UNIFINE PENTIPS (insulin pen needle) 3 ST; QL (200 needles per 30 days) VP INSULIN SYRINGE 3 ST; QL (200 syringes per 30 days) WEGMANS UNIFINE PENTIPS PLUS 3 ST; QL (200 needles per 30 days) *MIGRAINE PRODUCTS* - DRUGS FOR THE NERVOUS SYSTEM *CALCITONIN GENE-RELATED PEPTIDE RECEPTOR ANTAG (CGRP)*** - DRUGS FOR MIGRAINE HEADACHES NURTEC ORAL TABLET DISPERSIBLE ( sulfate) 2 PA; QL (8 tablets per 30 days) *CGRP RECEPTOR ANTAGONISTS - MONOCOLONAL ANTIBODIES*** - DRUGS FOR MIGRAINE HEADACHES AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR (- 3 PA; QL (1 autoinjector per 30 days) aooe) EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED 3 PA; QL (1 syringe per 30 days) SYRINGE (-gnlm) EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 PA; QL (1 pen per 30 days) (galcanezumab-gnlm) EMGALITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 PA; QL (1 syringe per 30 days) (galcanezumab-gnlm) *ERGOT COMBINATIONS*** - DRUGS FOR MIGRAINE HEADACHES -caffeine oral tablet 1 or 1b* migergot rectal suppository 1 or 1b* *MIGRAINE PRODUCTS*** - DRUGS FOR MIGRAINE HEADACHES mesylate injection solution 1 or 1b* PA

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 171 Coverage Requirements and Prescription Drug Name Drug Tier Limits *SELECTIVE SEROTONIN AGONIST-NSAID COMBINATIONS*** - DRUGS FOR MIGRAINE HEADACHES sumatriptan-naproxen sodium oral tablet 1 or 1b* ST; QL (9 tablets per 30 days) *SELECTIVE SEROTONIN AGONISTS 5-HT(1)*** - DRUGS FOR MIGRAINE HEADACHES almotriptan malate oral tablet 1 or 1b* QL (9 tablets per 30 days) eletriptan hydrobromide oral tablet 1 or 1b* QL (9 tablets per 30 days) frovatriptan succinate oral tablet 1 or 1b* ST; QL (9 tablets per 30 days) naratriptan hcl oral tablet 1 or 1b* QL (9 tablets per 30 days) rizatriptan benzoate oral tablet 1 or 1b* QL (9 tablets per 30 days) rizatriptan benzoate oral tablet dispersible 1 or 1b* QL (9 tablets per 30 days) sumatriptan nasal solution 1 or 1b* QL (6 nasal inhalers per 30 days) sumatriptan succinate oral tablet 1 or 1b* QL (9 tablets per 30 days) sumatriptan succinate refill subcutaneous solution cartridge 1 or 1b* QL (6 cartridges per 30 days) sumatriptan succinate subcutaneous solution 1 or 1b* QL (5 vials per 30 days) sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml 1 or 1b* QL (6 syringes (2 ML) per 30 days) sumatriptan succinate subcutaneous solution auto-injector 6 mg/0.5ml 1 or 1b* QL (6 cartridges (2ml) per 30 days) ST; QL (6 nasal inhalers per 30 zolmitriptan nasal solution 1 or 1b* days) zolmitriptan oral tablet 1 or 1b* QL (9 tablets per 30 days) zolmitriptan oral tablet dispersible 1 or 1b* QL (9 tablets per 30 days) *MINERALS & ELECTROLYTES* - DRUGS FOR NUTRITION *BICARBONATES*** - DRUGS FOR NUTRITION SODIUM ACETATE INTRAVENOUS SOLUTION 2 MEQ/ML 3 sodium bicarbonate intravenous solution 7.5 % 1 or 1b* THAM INTRAVENOUS SOLUTION (tromethamine) 3 *CALCIUM COMBINATIONS*** - DRUGS FOR NUTRITION CALCIUM GLUCONATE-NACL INTRAVENOUS SOLUTION 3 *CALCIUM*** - DRUGS FOR NUTRITION CALCIUM GLUCONATE INTRAVENOUS SOLUTION 3 *ELECTROLYTES & DEXTROSE*** - DRUGS FOR NUTRITION DEXTROSE 5%/ELECTROLYTE #48 INTRAVENOUS SOLUTION 3 dextrose in lactated ringers intravenous solution 1 or 1b* DEXTROSE-NACL INTRAVENOUS SOLUTION 10-0.2 %, 2.5-0.45 % 3 dextrose-nacl intravenous solution 10-0.45 %, 5-0.2 %, 5-0.33 %, 5-0.45 %, 1 or 1b* 5-0.9 % dextrose-sodium chloride intravenous solution 2.5-0.45 %, 5-0.45 %, 5-0.9 % 1 or 1b* DEXTROSE-SODIUM CHLORIDE INTRAVENOUS SOLUTION 5-0.225 3 %, 5-0.3 %

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 172 Coverage Requirements and Prescription Drug Name Drug Tier Limits ELLIOTTS B INTRATHECAL SOLUTION (intrathecal elec-dextrose) 3 IONOSOL-MB IN D5W INTRAVENOUS SOLUTION (electrolyte-mb in 3 dextrose) ISOLYTE-P IN D5W INTRAVENOUS SOLUTION (electrolyte-p in 3 dextrose) kcl in dextrose-nacl intravenous solution 10-5-0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.45 meq/l-%-%, 20-5-0.9 meq/l-%-%, 30-5-0.45 meq/l-%- 1 or 1b* %, 40-5-0.45 meq/l-%-% KCL IN DEXTROSE-NACL INTRAVENOUS SOLUTION 20-5-0.225 3 MEQ/L-%-%, 40-5-0.9 MEQ/L-%-% KCL-LACTATED RINGERS-D5W INTRAVENOUS SOLUTION 3 NORMOSOL-M IN D5W INTRAVENOUS SOLUTION (electrolyte-m in 3 dextrose) NORMOSOL-R IN D5W INTRAVENOUS SOLUTION (electrolyte-r in 3 dextrose) potassium chloride in dextrose intravenous solution 1 or 1b* *ELECTROLYTES PARENTERAL*** - DRUGS FOR NUTRITION ISOLYTE-S INTRAVENOUS SOLUTION (electrolyte-s) 3 ISOLYTE-S PH 7.4 INTRAVENOUS SOLUTION (electrolyte-s (ph 7.4)) 3 KCL (IN NACL 0.9%) INTRAVENOUS SOLUTION 3 lactated ringers intravenous solution 1 or 1b* NORMOSOL-R INTRAVENOUS SOLUTION (electrolyte-r) 3 NORMOSOL-R PH 7.4 INTRAVENOUS SOLUTION (electrolyte-r (ph 7.4)) 3 PLASMA-LYTE 148 INTRAVENOUS SOLUTION (electrolyte-148) 3 PLASMA-LYTE A INTRAVENOUS SOLUTION (electrolyte-a) 3 POTASSIUM CHLORIDE IN NACL INTRAVENOUS SOLUTION 20-0.45 3 MEQ/L-%, 40-0.9 MEQ/L-% potassium chloride in nacl intravenous solution 20-0.9 meq/l-% 1 or 1b* ringers intravenous solution 1 or 1b* TPN ELECTROLYTES INTRAVENOUS CONCENTRATE (parenteral 3 electrolytes) *FLUORIDE COMBINATIONS*** - DRUGS FOR NUTRITION FLORIVA ORAL LIQUID (sodium fluoride-vitamin d) 3 *FLUORIDE*** - DRUGS FOR NUTRITION fluoritab oral solution 1 or 1a*; $0 nafrinse drops oral solution 1 or 1a*; $0 nafrinse oral tablet chewable 1 or 1a*; $0 sodium fluoride oral solution 0.5 mg/ml 1 or 1b*; $0 QL (2 mL per 1 day) sodium fluoride oral solution 1.1 (0.5 f) mg/ml 1 or 1a*; $0 QL (2 mL per 1 day) sodium fluoride oral tablet 1 or 1a*; $0

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 173 Coverage Requirements and Prescription Drug Name Drug Tier Limits sodium fluoride oral tablet chewable 1 or 1a*; $0 *MAGNESIUM*** - DRUGS FOR NUTRITION MAGNESIUM SULFATE IN D5W INTRAVENOUS SOLUTION 3 MAGNESIUM SULFATE INTRAVENOUS SOLUTION 3 *MANGANESE*** - DRUGS FOR NUTRITION manganese chloride intravenous solution 1 or 1b* *PHOSPHATE*** - DRUGS FOR NUTRITION K-PHOS ORAL TABLET (potassium phosphate monobasic) 2 K-PHOS-NEUTRAL ORAL TABLET (k phos mono-sod phos di & mono) 3 phosphorous oral tablet 1 or 1b* phospho-trin 250 neutral oral tablet 1 or 1b* POTASSIUM PHOSPHATES INTRAVENOUS SOLUTION 15 3 MMOLE/5ML, 150 MMOLE/50ML potassium phosphates intravenous solution 45 mmole/15ml 1 or 1b* potassium phosphates(66 meq k) intravenous solution 1 or 1b* POTASSIUM PHOSPHATES(71 MEQ K) INTRAVENOUS SOLUTION 3 sodium phosphates intravenous solution 15 mmole/5ml 1 or 1b* virt-phos 250 neutral oral tablet 1 or 1b* *POTASSIUM*** - DRUGS FOR NUTRITION klor-con 10 oral tablet extended release 1 or 1b* klor-con m10 oral tablet extended release 1 or 1a* klor-con m15 oral tablet extended release 1 or 1a* klor-con m20 oral tablet extended release 1 or 1a* klor-con oral packet 1 or 1b* klor-con oral tablet extended release 1 or 1b* K-TAB ORAL TABLET EXTENDED RELEASE (potassium chloride) 3 potassium acetate intravenous solution 1 or 1b* potassium chloride crys er oral tablet extended release 10 meq, 20 meq 1 or 1a* potassium chloride er oral capsule extended release 1 or 1b* potassium chloride er oral tablet extended release 1 or 1b* POTASSIUM CHLORIDE INTRAVENOUS SOLUTION 10 MEQ/100ML, 3 10 MEQ/50ML, 20 MEQ/100ML, 20 MEQ/50ML, 40 MEQ/100ML potassium chloride intravenous solution 2 meq/ml 1 or 1b* potassium chloride oral packet 1 or 1b* potassium chloride oral solution 1 or 1b* *SODIUM*** - DRUGS FOR NUTRITION monoject flush syringe intravenous solution 1 or 1b* QL (200 syringes per 30 days) monoject sodium chloride flush intravenous solution 1 or 1b*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 174 Coverage Requirements and Prescription Drug Name Drug Tier Limits normal saline flush intravenous solution 1 or 1b* sodium chloride flush intravenous solution 1 or 1b* sodium chloride injection solution 1 or 1b* sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 5 % 1 or 1b* *TRACE MINERAL COMBINATIONS*** - DRUGS FOR NUTRITION THE LIQUILIFT TRACE INTRAVENOUS KIT (trace minerals cr-cu-mn-se- 3 zn) TRALEMENT INTRAVENOUS SOLUTION (trace minerals cu-mn-se-zn) 3 *TRACE MINERALS*** - DRUGS FOR NUTRITION chromic chloride intravenous solution 1 or 1b* cupric chloride intravenous solution 1 or 1b* SELENIOUS ACID INTRAVENOUS SOLUTION 3 *ZINC*** - DRUGS FOR NUTRITION GALZIN ORAL CAPSULE (zinc acetate (oral)) 3 WILZIN ORAL CAPSULE (zinc acetate (oral)) 3 zinc chloride intravenous solution 1 or 1b* zinc sulfate intravenous solution 3 mg/ml, 5 mg/ml 1 or 1b* *MISCELLANEOUS THERAPEUTIC CLASSES* - VITAMINS AND MINERALS *ANTILEPROTICS*** - VITAMINS AND MINERALS PA; LD; SP; QL (1 capsule per 1 THALOMID ORAL CAPSULE 100 MG, 50 MG () 2; OC day) PA; LD; SP; QL (2 capsules per 1 THALOMID ORAL CAPSULE 150 MG, 200 MG (thalidomide) 2; OC day) *CHELATING AGENTS*** - VITAMINS AND MINERALS clovique oral capsule 1 or 1b* PA; SP; QL (8 capsules per 1 day) DEPEN TITRATABS ORAL TABLET (penicillamine) 3 PA; QL (8 tablets per 1 day) EDETATE DISODIUM INTRAVENOUS SOLUTION 3 penicillamine oral capsule 1 or 1b* PA; QL (8 capsules per 1 day) penicillamine oral tablet 1 or 1b* PA; QL (8 tablets per 1 day) trientine hcl oral capsule 1 or 1b* PA; SP; QL (8 capsules per 1 day) *CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT) SOLUTIONS*** - VITAMINS AND MINERALS PHOXILLUM B22K4/0 INTRAVENOUS SOLUTION 3 PHOXILLUM BK4/2.5 INTRAVENOUS SOLUTION 3 PRISMASOL B22GK 4/0 INTRAVENOUS SOLUTION (bicarb-dextrose-k 3 (crrt)) PRISMASOL BGK 0/2.5 INTRAVENOUS SOLUTION (bicarb-dextrose-ca 3 (crrt))

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 175 Coverage Requirements and Prescription Drug Name Drug Tier Limits PRISMASOL BGK 2/0 INTRAVENOUS SOLUTION (bicarb-dextrose-k 3 (crrt)) PRISMASOL BGK 2/3.5 INTRAVENOUS SOLUTION (bicarb-dextrose-k-ca 3 (crrt)) PRISMASOL BGK 4/0/1.2 INTRAVENOUS SOLUTION (bicarb-dextose-k- 3 mg (crrt)) PRISMASOL BGK 4/2.5 INTRAVENOUS SOLUTION (bicarb-dextrose-k-ca 3 (crrt)) PRISMASOL BK 0/0/1.2 INTRAVENOUS SOLUTION (bicarb-mg (crrt)) 3 *CYCLOSPORINE ANALOGS*** - VITAMINS AND MINERALS cyclosporine intravenous solution 1 or 1b* SP cyclosporine modified oral capsule 1 or 1b* cyclosporine modified oral solution 1 or 1b* cyclosporine oral capsule 1 or 1b* gengraf oral capsule 1 or 1b* gengraf oral solution 1 or 1b* NEORAL ORAL CAPSULE (cyclosporine modified) 3 NEORAL ORAL SOLUTION (cyclosporine modified) 3 SANDIMMUNE INTRAVENOUS SOLUTION (cyclosporine) 3 SP SANDIMMUNE ORAL CAPSULE (cyclosporine) 3 SANDIMMUNE ORAL SOLUTION (cyclosporine) 3 *ENZYMES*** - VITAMINS AND MINERALS AMPHADASE INJECTION SOLUTION (hyaluronidase bovine) 3 HYLENEX INJECTION SOLUTION (hyaluronidase human) 3 VITRASE INJECTION SOLUTION (hyaluronidase ovine) 3 *IMMUNE GLOBULIN IMMUNOSUPPRESSANTS*** - VITAMINS AND MINERALS ATGAM INTRAVENOUS INJECTABLE (lymphocyte,anti-thymo imm glob) 3 SP THYMOGLOBULIN INTRAVENOUS SOLUTION RECONSTITUTED 3 SP (anti-thymocyte glob (rabbit)) *IMMUNOMODULATORS FOR MYELODYSPLASTIC SYNDROMES*** - VITAMINS AND MINERALS PA; LD; SP; QL (1 capsule per 1 REVLIMID ORAL CAPSULE (lenalidomide) 2; OC day) *INOSINE MONOPHOSPHATE DEHYDROGENASE INHIBITORS*** - VITAMINS AND MINERALS CELLCEPT INTRAVENOUS INTRAVENOUS SOLUTION 3 SP RECONSTITUTED (mycophenolate mofetil hcl) CELLCEPT ORAL CAPSULE (mycophenolate mofetil) 3 CELLCEPT ORAL SUSPENSION RECONSTITUTED (mycophenolate 3 mofetil)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 176 Coverage Requirements and Prescription Drug Name Drug Tier Limits CELLCEPT ORAL TABLET (mycophenolate mofetil) 3 mycophenolate mofetil hcl intravenous solution reconstituted 1 or 1b* SP mycophenolate mofetil intravenous solution reconstituted 1 or 1b* SP mycophenolate mofetil oral capsule 1 or 1b* mycophenolate mofetil oral suspension reconstituted 1 or 1b* mycophenolate mofetil oral tablet 1 or 1b* mycophenolate sodium oral tablet delayed release 1 or 1b* MYFORTIC ORAL TABLET DELAYED RELEASE (mycophenolate 3 sodium) *IRRIGATION SOLUTIONS*** - VITAMINS AND MINERALS argyle sterile water irrigation solution 1 or 1b* lactated ringers irrigation solution 1 or 1b* physiolyte irrigation solution 1 or 1b* physiosol irrigation irrigation solution 1 or 1b* ringers irrigation irrigation solution 1 or 1b* sterile water for irrigation irrigation solution 1 or 1b* tis-u-sol irrigation solution 1 or 1b* water for irrigation, sterile irrigation solution 1 or 1b* *MACROLIDE IMMUNOSUPPRESSANTS*** - VITAMINS AND MINERALS ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 (tacrolimus) ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 (tacrolimus) everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg 1 or 1b* PROGRAF INTRAVENOUS SOLUTION (tacrolimus) 2 SP PROGRAF ORAL CAPSULE (tacrolimus) 3 PROGRAF ORAL PACKET (tacrolimus) 3 RAPAMUNE ORAL SOLUTION () 3 RAPAMUNE ORAL TABLET (sirolimus) 3 sirolimus oral solution 1 or 1b* sirolimus oral tablet 1 or 1b* tacrolimus oral capsule 1 or 1b* ZORTRESS ORAL TABLET (everolimus) 3 *MISCELLANEOUS THERAPEUTIC CLASSES*** - VITAMINS AND MINERALS NEXAVIR INJECTION SOLUTION ( derivative complex) 3 *MONOCLONAL ANTIBODIES*** - VITAMINS AND MINERALS GAMIFANT INTRAVENOUS SOLUTION (emapalumab-lzsg) 3 PA; LD; SP

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 177 Coverage Requirements and Prescription Drug Name Drug Tier Limits SIMULECT INTRAVENOUS SOLUTION RECONSTITUTED (basiliximab) 3 *PERITONEAL DIALYSIS SOLUTIONS*** - VITAMINS AND MINERALS DELFLEX-LC/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DELFLEX-LC/2.5% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DELFLEX-LC/4.25% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DELFLEX-SM/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 2 (peritoneal dialysis solutions) DELFLEX-SM/2.5% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DIANEAL LOW CALCIUM/1.5% DEX INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DIANEAL LOW CALCIUM/2.5% DEX INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DIANEAL LOW CALCIUM/4.25% DEX INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DIANEAL PD-2/1.5% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DIANEAL PD-2/2.5% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) DIANEAL PD-2/4.25% DEXTROSE INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) EXTRANEAL INTRAPERITONEAL SOLUTION (icodextrin-electrolytes) 3 ULTRABAG/DIANEAL PD-2/1.5% DEX INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) ULTRABAG/DIANEAL PD-2/2.5% DEX INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) ULTRABAG/DIANEAL PD-2/4.25%DEX INTRAPERITONEAL 3 SOLUTION (peritoneal dialysis solutions) ULTRABAG/DIANEAL/1.5% DEXTROSE INTRAPERITONEAL 3 SOLUTION (peritoneal dialysis solutions) ULTRABAG/DIANEAL/2.5% DEXTROSE INTRAPERITONEAL 3 SOLUTION (peritoneal dialysis solutions) ULTRABAG/DIANEAL/4.25% DEX INTRAPERITONEAL SOLUTION 3 (peritoneal dialysis solutions) *POTASSIUM REMOVING AGENTS*** - VITAMINS AND MINERALS LOKELMA ORAL PACKET (sodium zirconium cyclosilicate) 3 sodium polystyrene sulfonate oral powder 1 or 1b* sps oral suspension 1 or 1b*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 178 Coverage Requirements and Prescription Drug Name Drug Tier Limits VELTASSA ORAL PACKET (patiromer sorbitex calcium) 3 LD *PROSTAGLANDINS*** - VITAMINS AND MINERALS alprostadil injection solution 1 or 1b* PROSTIN VR INJECTION SOLUTION (alprostadil) 3 *PURINE ANALOGS*** - VITAMINS AND MINERALS AZASAN ORAL TABLET (azathioprine) 3 azathioprine oral tablet 1 or 1b* AZATHIOPRINE SODIUM INJECTION SOLUTION RECONSTITUTED 3 IMURAN ORAL TABLET (azathioprine) 3 *SCLEROSING AGENTS*** - VITAMINS AND MINERALS ASCLERA INTRAVENOUS SOLUTION (polidocanol) 3 ETHAMOLIN INTRAVENOUS SOLUTION (ethanolamine oleate) 3 sodium tetradecyl sulfate intravenous solution 1 or 1b* SOTRADECOL INTRAVENOUS SOLUTION 1 % (sodium tetradecyl 3 sulfate) sotradecol intravenous solution 3 % 1 or 1b* VARITHENA INTRAVENOUS FOAM (polidocanol) 3 LD *SELECTIVE T-CELL COSTIMULATION BLOCKERS*** - VITAMINS AND MINERALS NULOJIX INTRAVENOUS SOLUTION RECONSTITUTED (belatacept) 3 PA; SP *MOUTH/THROAT/DENTAL AGENTS* - DRUGS FOR THE MOUTH AND THROAT *ANESTHETICS TOPICAL ORAL*** - DRUGS FOR THE MOUTH AND THROAT lidocaine hcl mouth/throat solution 1 or 1a* QL (10 mL per 1 day) lidocaine viscous hcl mouth/throat solution 1 or 1a* QL (10 mL per 1 day) *ANTI-INFECTIVES - THROAT*** - DRUGS FOR THE MOUTH AND THROAT clotrimazole mouth/throat troche 1 or 1b* QL (5 tablet per 1 day) nystatin mouth/throat suspension 1 or 1b* QL (750 mL per 30 days) ORAVIG BUCCAL TABLET (miconazole) 3 *ANTISEPTICS - MOUTH/THROAT*** - DRUGS FOR THE MOUTH AND THROAT chlorhexidine gluconate mouth/throat solution 1 or 1a* QL (480 mL per 30 days) PERIDEX MOUTH/THROAT SOLUTION (chlorhexidine gluconate) 3 QL (480 mL per 30 days) periogard mouth/throat solution 1 or 1a* QL (480 mL per 30 days) *DENTAL PRODUCTS - COMBINATIONS*** - DRUGS FOR THE MOUTH AND THROAT fluoridex sensitivity relief dental paste 1 or 1b*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 179 Coverage Requirements and Prescription Drug Name Drug Tier Limits NAFRINSE DAILY ACIDULATED MOUTH/THROAT SOLUTION 3 RECONSTITUTED (sodium fluoride-phosphoric acd) PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE (sod fluoride- 3 potassium nitrate) PREVIDENT 5000 SENSITIVE DENTAL PASTE (sod fluoride-potassium 3 nitrate) sodium fluoride 5000 enamel dental paste 1 or 1b* sodium fluoride 5000 sensitive dental paste 1 or 1b* *FLUORIDE DENTAL PRODUCTS*** - DRUGS FOR THE MOUTH AND THROAT cavarest dental gel 1 or 1b* clinpro 5000 dental paste 1 or 1b* denta 5000 plus dental cream 1 or 1b* dentagel dental gel 1 or 1a* easygel dental gel 1 or 1b* fluoridex daily renewal mouth/throat concentrate 1 or 1b* fluoridex dental paste 1 or 1b* fluoridex enhanced whitening dental paste 1 or 1b* NAFRINSE DAILY/NEUTRAL MOUTH/THROAT SOLUTION 3 RECONSTITUTED (sodium fluoride) NAFRINSE WEEKLY MOUTH/THROAT SOLUTION RECONSTITUTED 3 (sodium fluoride) PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE (sodium fluoride) 3 PREVIDENT 5000 DRY MOUTH DENTAL GEL (sodium fluoride) 3 PREVIDENT 5000 ORTHO DEFENSE DENTAL PASTE (sodium fluoride) 3 PREVIDENT 5000 PLUS DENTAL CREAM (sodium fluoride) 3 PREVIDENT DENTAL GEL (sodium fluoride) 3 PREVIDENT MOUTH/THROAT SOLUTION (sodium fluoride) 3 sf 5000 plus dental cream 1 or 1b* sf dental gel 1 or 1a* sodium fluoride 5000 plus dental cream 1 or 1b* sodium fluoride 5000 ppm dental cream 1 or 1b* sodium fluoride 5000 ppm dental paste 1 or 1b* sodium fluoride dental cream 1 or 1b* sodium fluoride dental gel 1 or 1b* sodium fluoride mouth/throat solution 1 or 1a* *SALIVA STIMULANTS*** - DRUGS FOR THE MOUTH AND THROAT cevimeline hcl oral capsule 1 or 1b* EVOXAC ORAL CAPSULE (cevimeline hcl) 3 BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 180 Coverage Requirements and Prescription Drug Name Drug Tier Limits pilocarpine hcl oral tablet 1 or 1b* QL (4 tablets per 1 day) SALAGEN ORAL TABLET (pilocarpine hcl) 3 QL (4 tablets per 1 day) *STEROIDS - MOUTH/THROAT/DENTAL*** - DRUGS FOR THE MOUTH AND THROAT oralone mouth/throat paste 1 or 1b* triamcinolone acetonide mouth/throat paste 1 or 1b* *MULTIVITAMINS* - DRUGS FOR NUTRITION *B-COMPLEX VITAMINS*** - DRUGS FOR NUTRITION b complex oral tablet 1 or 1b*; $0 b complex-b12 oral tablet 1 or 1b*; $0 B-COMPLEX INJECTION INJECTABLE 3 b-complex/b-12 oral tablet 1 or 1b*; $0 ra b-complex oral tablet 1 or 1b*; $0 ra b-complex with b-12 oral tablet 1 or 1b*; $0 vitamin b complex oral tablet 1 or 1b*; $0 vitamin b-complex oral tablet 1 or 1b*; $0 vitamin-b complex oral tablet 1 or 1b*; $0 *B-COMPLEX W/ C & CALCIUM*** - DRUGS FOR NUTRITION gnp b-complex plus vitamin c oral tablet 1 or 1b*; $0 qc b-complex/vitamin c oral tablet 1 or 1b*; $0 *B-COMPLEX W/ C & FOLIC ACID*** - DRUGS FOR NUTRITION b complex-c-folic acid oral tablet 1 or 1b*; $0 b-complex balanced oral tablet 1 or 1b*; $0 b-complex/vitamin c oral tablet 1 or 1b*; $0 dialyvite 800 oral tablet 1 or 1b*; $0 eql super b complex/vitamin c oral tablet 1 or 1b*; $0 FULL SPECTRUM B/VITAMIN C ORAL TABLET 2; $0 hm vitamin b complex/vitamin c oral tablet 1 or 1b*; $0 kp b complex-c oral tablet 1 or 1b*; $0 nephro vitamins oral tablet 1 or 1b*; $0 NEPHRO-VITE ORAL TABLET (b complex-c-folic acid) 2; $0 px b complex/vitamin c oral tablet 1 or 1b*; $0 renal multivitamin formula oral tablet 1 or 1b*; $0 renal vitamin oral tablet 1 or 1b*; $0 renal-vite oral tablet 1 or 1b*; $0 rena-vite oral tablet 1 or 1b*; $0 sm b super vitamin complex oral tablet 1 or 1b*; $0 SM B-COMPLEX/VITAMIN C ORAL TABLET 2; $0

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 181 Coverage Requirements and Prescription Drug Name Drug Tier Limits stress formula oral tablet 1 or 1b*; $0 super b complex/fa/vit c oral tablet 1 or 1b*; $0 super b-complex/vit c/fa oral tablet 1 or 1b*; $0 VITALINE BIOTIN FORTE ORAL TABLET (b complex-c-folic acid) 2; $0 WEST-VITE W/FOLIC ACID ORAL TABLET 2; $0 *B-COMPLEX W/ C*** - DRUGS FOR NUTRITION allbee/c oral tablet 1 or 1b*; $0 b complex-c oral tablet 1 or 1b*; $0 b-complex-c oral tablet 1 or 1b*; $0 better b complex oral tablet 1 or 1b*; $0 cvs b complex plus c oral tablet 1 or 1b*; $0 cvs super b complex/c oral tablet 1 or 1b*; $0 hm b complex/c oral tablet 1 or 1b*; $0 sm super b complex/c oral tablet 1 or 1b*; $0 sm vitamin b complex/vitamin c oral tablet 1 or 1b*; $0 super b complex/vitamin c oral tablet 1 or 1b*; $0 super b-complex + vitamin c oral tablet 1 or 1b*; $0 vitamin b + c complex oral tablet 1 or 1b*; $0 *B-COMPLEX W/ C-BIOTIN-E & FOLIC ACID*** - DRUGS FOR NUTRITION B COMPLEX-C-BIOTIN-E-FA ORAL TABLET 2; $0 *B-COMPLEX W/ FOLIC ACID*** - DRUGS FOR NUTRITION b complex formula 1 oral tablet 1 or 1b*; $0 b complex plus oral tablet 1 or 1b*; $0 kobee oral tablet 1 or 1b*; $0 sm balanced b-100 oral tablet 1 or 1b*; $0 sm balanced b-50 oral tablet 1 or 1b*; $0 super b complex maxi oral tablet 1 or 1b*; $0 *B-COMPLEX W/BIOTIN & FOLIC ACID*** - DRUGS FOR NUTRITION b complex 100 tr oral tablet extended release 1 or 1b*; $0 b complex-biotin-fa oral tablet 1 or 1b*; $0 b-100 b-complex oral tablet 1 or 1b*; $0 b-100 complex cr oral tablet extended release 1 or 1b*; $0 b-100 tr oral tablet extended release 1 or 1b*; $0 b-50 complex oral tablet extended release 1 or 1b*; $0 balance b-50 oral tablet 1 or 1b*; $0 balanced b complex oral tablet 1 or 1b*; $0

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 182 Coverage Requirements and Prescription Drug Name Drug Tier Limits balanced b-100 oral tablet extended release 1 or 1b*; $0 balanced b-50/fa oral tablet 1 or 1b*; $0 b-compleet-100 oral tablet 1 or 1b*; $0 b-compleet-50 oral tablet 1 or 1b*; $0 b-complex oral tablet 1 or 1b*; $0 big 100 (biotin) oral tablet 1 or 1b*; $0 big 100 oral tablet 1 or 1b*; $0 complex b-50 prolonged release oral tablet extended release 1 or 1b*; $0 endur-b oral tablet extended release 1 or 1b*; $0 eql b complex 50 oral tablet 1 or 1b*; $0 eql b-100 complex oral tablet extended release 1 or 1b*; $0 gnp b-100 complex oral tablet extended release 1 or 1b*; $0 gnp b-50 complex oral tablet extended release 1 or 1b*; $0 hm vitamin b100 complex oral tablet 1 or 1b*; $0 hm vitamin b50 complex oral tablet 1 or 1b*; $0 qc b50 prolonged release oral tablet extended release 1 or 1b*; $0 quin b strong b-25 oral tablet 1 or 1b*; $0 ra balanced b-100 cr oral tablet extended release 1 or 1b*; $0 ra balanced b-100 oral tablet 1 or 1b*; $0 ra balanced b-50 oral tablet 1 or 1b*; $0 ra balanced b-50 tr oral tablet extended release 1 or 1b*; $0 sm b100 complex oral tablet 1 or 1b*; $0 sm b-complex oral tablet 1 or 1b*; $0 super b-100 oral tablet 1 or 1b*; $0 super b-50 oral tablet 1 or 1b*; $0 super b-complex oral tablet 1 or 1b*; $0 super dec b-100 oral tablet 1 or 1b*; $0 super quints b-50 oral tablet 1 or 1b*; $0 yl balanced b-100 oral tablet 1 or 1b*; $0 *BIOFLAVONOID PRODUCTS*** - DRUGS FOR NUTRITION ADRENAL C FORMULA ORAL TABLET (bioflavonoid products) 3 *MULTIPLE VITAMINS & FLUORIDE-FOLIC ACID*** - DRUGS FOR NUTRITION MULTIVITAMIN/FLUORIDE ORAL TABLET CHEWABLE 0.25-0.3 MG, 3 0.5-0.3 MG, 1-0.3 MG *MULTIPLE VITAMINS W/ IRON*** - DRUGS FOR NUTRITION daily multiple vitamins/iron oral tablet 1 or 1b*; $0 daily vitamin formula+iron oral tablet 1 or 1b*; $0

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 183 Coverage Requirements and Prescription Drug Name Drug Tier Limits daily vite multivitamin/iron oral tablet 1 or 1b*; $0 daily-vitamin/iron oral tablet 1 or 1b*; $0 hm one daily/iron oral tablet 1 or 1b*; $0 multi-day plus iron oral tablet 1 or 1b*; $0 multiple vitamins/iron oral tablet 1 or 1b*; $0 multivitamin plus iron adult oral tablet 1 or 1b*; $0 multi-vitamin/iron oral tablet 1 or 1b*; $0 nat-rul daily-vite+iron oral tablet 1 or 1b*; $0 one daily multivitamin/iron oral tablet 1 or 1b*; $0 one-daily multi-vitamin/iron oral tablet 1 or 1b*; $0 one-daily/iron oral tablet 1 or 1b*; $0 qc daily multivitamins/iron oral tablet 1 or 1b*; $0 sm multiple vitamins/iron oral tablet 1 or 1b*; $0 stress b complex/iron oral tablet 1 or 1b*; $0 stress formula/iron oral tablet 1 or 1b*; $0 tab-a-vite/iron oral tablet 1 or 1b*; $0 TAB-A-VITE/IRON/BETA CAROTENE ORAL TABLET (multiple vitamins- 2; $0 iron) *MULTIPLE VITAMINS W/ MINERALS & CALCIUM-FOLIC ACID*** - DRUGS FOR NUTRITION FOLGARD OS ORAL TABLET (multiple vit-min-calcium-fa) 3 *MULTIPLE VITAMINS W/ MINERALS & FLUORIDE-IRON-FOLIC ACID*** - DRUGS FOR NUTRITION QUFLORA FE ORAL TABLET CHEWABLE (multi vit-min-fluoride-fe-fa) 3 *MULTIPLE VITAMINS W/ MINERALS*** - DRUGS FOR NUTRITION one daily multivitamin adult oral tablet 1 or 1b*; $0 tab-a-vite oral tablet 1 or 1b*; $0 VENEXA ORAL TABLET (multiple vitamins-minerals) 3 VITRANOL FE ORAL TABLET (multiple vitamins-minerals) 3 ZYVANA ORAL CAPSULE 3 *MULTIVITAMINS*** - DRUGS FOR NUTRITION anti-oxidant oral tablet 1 or 1b*; $0 daily multiple vitamins oral tablet 1 or 1b*; $0 daily value multivitamin oral tablet 1 or 1b*; $0 daily vitamin oral tablet 1 or 1b*; $0 daily vitamins oral tablet 1 or 1b*; $0 daily vite oral tablet 1 or 1b*; $0 daily vites oral tablet 1 or 1b*; $0

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 184 Coverage Requirements and Prescription Drug Name Drug Tier Limits daily-vitamin oral tablet 1 or 1b*; $0 daily-vite multivitamin oral tablet 1 or 1b*; $0 daily-vite oral tablet 1 or 1b*; $0 ESTROFACTORS ORAL TABLET (multiple vitamin) 2; $0 gnp essential one daily oral tablet 1 or 1b*; $0 healthy hair/skin/nails oral tablet 1 or 1b*; $0 HIGH POTENCY MULTIVITAMIN ORAL TABLET 2; $0 INFUVITE ADULT INTRAVENOUS INJECTABLE (multiple vitamin) 3 M.V.I. ADULT INTRAVENOUS INJECTABLE (multiple vitamin) 3 multi vitamin daily oral tablet 1 or 1b*; $0 MULTI VITAMIN ORAL TABLET 2; $0 MULTI VITAMIN W/D-3 ORAL TABLET 2; $0 multi-day oral tablet 1 or 1b*; $0 multiple vitamin-folic acid oral tablet 1 or 1b*; $0 multiple vitamins essential oral tablet 1 or 1b*; $0 multiple vitamins oral tablet 1 or 1b*; $0 MULTIVITAMIN ADULT ORAL TABLET 2; $0 multi-vitamin daily oral tablet 1 or 1b*; $0 multivitamin iron-free oral tablet 1 or 1b*; $0 MULTIVITAMIN ORAL TABLET 2; $0 multi-vitamin oral tablet 1 or 1b*; $0 NEOMULTIVITE ORAL TABLET (multiple vitamin) 2; $0 OMNICAP ORAL TABLET 2; $0 once daily oral tablet 1 or 1b*; $0 ONE DAILY ESSENTIAL ORAL TABLET (multiple vitamin) 2; $0 one daily oral tablet 1 or 1b*; $0 ONE-A-DAY ESSENTIAL ORAL TABLET (multiple vitamin) 2; $0 ONE-A-DAY MENS ORAL TABLET (multiple vitamin) 2; $0 one-daily multi vitamins oral tablet 1 or 1b*; $0 one-daily multi-vitamin oral tablet 1 or 1b*; $0 qc essentials oral tablet 1 or 1b*; $0 QUINTABS ORAL TABLET 2; $0 sm multiple vitamins essential oral tablet 1 or 1b*; $0 stresstabs energy oral tablet 1 or 1b*; $0 tab-a-vite/beta carotene oral tablet 1 or 1b*; $0 THERA ORAL TABLET (multiple vitamin) 2; $0 thera-mill oral tablet 1 or 1b*; $0 thera-tabs oral tablet 1 or 1b*; $0 BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 185 Coverage Requirements and Prescription Drug Name Drug Tier Limits THEREMS ORAL TABLET (multiple vitamin) 2; $0 vit e-vit c-beta carotene oral tablet 1 or 1b*; $0 vitalee oral tablet 1 or 1b*; $0 *PED MULTI VITAMINS W/FL & FE*** - DRUGS FOR NUTRITION multi-vit/iron/fluoride oral solution 1 or 1b* multi-vitamin/fluoride/iron oral solution 1 or 1b* POLY-VI-FLOR/IRON ORAL SUSPENSION (ped multivitamins-fl-iron) 3 POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE (ped multivitamins-fl- 3 iron) QUFLORA FE PEDIATRIC ORAL LIQUID (ped multivitamins-fl-iron) 3 *PED MV W/ FLUORIDE*** - DRUGS FOR NUTRITION FLORIVA PLUS ORAL SOLUTION (pediatric multivitamins-fl) 3 multivitamin/fluoride oral solution 1 or 1b*; $0 multi-vitamin/fluoride oral solution 1 or 1b*; $0 multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg 1 or 1b*; $0 POLY-VI-FLOR ORAL SUSPENSION (pediatric multivitamins-fl) 3 POLY-VI-FLOR ORAL TABLET CHEWABLE (pediatric multivitamins-fl) 3 QUFLORA GUMMIES ORAL TABLET CHEWABLE (pediatric 2 multivitamins-fl) QUFLORA PEDIATRIC ORAL SOLUTION (pediatric multivitamins-fl) 3 QUFLORA PEDIATRIC ORAL TABLET CHEWABLE (pediatric 3 multivitamins-fl) *PED VITAMINS ACD & FA W/ FLUORIDE*** - DRUGS FOR NUTRITION TRI-VI-FLOR ORAL SUSPENSION (ped vit a-c-d-methylfolate-fl) 3 TRI-VI-FLORO ORAL SUSPENSION 3 *PED VITAMINS ACD W/ FLUORIDE*** - DRUGS FOR NUTRITION adc/f (0.5mg/ml) oral solution 1 or 1b*; $0 multivitamin select/fluoride oral solution 1 or 1b*; $0 tri-vite/fluoride oral solution 1 or 1b*; $0 vitamins acd-fluoride oral solution 1 or 1b*; $0 *PEDIATRIC MULTIPLE VITAMINS & MINERALS W/ FLUORIDE*** - DRUGS FOR NUTRITION FLORIVA ORAL TABLET CHEWABLE (ped multiple vit-minerals-fl) 3 *PEDIATRIC MULTIPLE VITAMINS*** - DRUGS FOR NUTRITION INFUVITE PEDIATRIC INTRAVENOUS SOLUTION (pediatric multiple 3 vitamins) M.V.I. PEDIATRIC INTRAVENOUS SOLUTION RECONSTITUTED 3 (pediatric multiple vitamins)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 186 Coverage Requirements and Prescription Drug Name Drug Tier Limits *PRENATAL MV & MIN W/FE-FA*** - DRUGS FOR NUTRITION ATABEX EC ORAL TABLET DELAYED RELEASE (prenatal vit-dss-fe 3 QL (1 tablet per 1 day) cbn-fa) ATABEX OB ORAL TABLET (prenatal vit w/ fe bisg-fa) 3 QL (1 tablet per 1 day) AZESCHEW PRENATAL/POSTNATAL ORAL TABLET CHEWABLE 3 ST; QL (1 tablet per 1 day) AZESCO ORAL TABLET 3 ST; QL (1 tablet per 1 day) CITRANATAL B-CALM ORAL (prenat w/o a fecbnfeglu-fa &b6) 3 QL (3 EA per 1 day) CITRANATAL BLOOM ORAL TABLET (prenatal-dss-fecb-fegl-fa) 3 ST; QL (2 tablets per 1 day) CITRANATAL RX ORAL TABLET (prenat w/o a-fecb-fegl-dss-fa) 3 ST; QL (1 tablet per 1 day) CLASSIC PRENATAL ORAL TABLET 2; $0 QL (1 tablet per 1 day) C-NATE DHA ORAL CAPSULE 3 QL (1 capsule per 1 day) COMPLETENATE ORAL TABLET CHEWABLE 2 QL (1 tablet per 1 day) CO-NATAL FA ORAL TABLET (prenatal vit-fe fumarate-fa) 3 QL (1 tablet per 1 day) CONCEPT DHA ORAL CAPSULE (prenat-fefum-fepo-fa-omega 3) 3 QL (1 capsule per 1 day) CONCEPT OB ORAL CAPSULE (prenat w/o a vit-fefum-fepo-fa) 3 QL (1 capsule per 1 day) CVS PRENATAL ORAL TABLET 2; $0 QL (1 tablet per 1 day) DUET DHA 400 ORAL (prenat-fepoly-fered-fa-omega 3) 3 ST; QL (2 units per 1 day) DUET DHA BALANCED ORAL (prenat-fepoly-fered-fa-omega 3) 3 ST; QL (2 units per 1 day) elite-ob oral tablet 1 or 1b* QL (1 tablet per 1 day) ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa-omega) 3 ST; QL (1 capsule per 1 day) EQL PRENATAL FORMULA ORAL TABLET 2; $0 QL (1 tablet per 1 day) FOLIVANE-OB ORAL CAPSULE (prenat w/o a vit-fefum-fepo-fa) 2 QL (1 capsule per 1 day) GNP PRENATAL ORAL TABLET 2; $0 QL (1 tablet per 1 day) HM ONE DAILY PRENATAL ORAL 2; $0 QL (1 EA per 1 day) HM PRENATAL ORAL TABLET 2; $0 QL (1 tablet per 1 day) inatal gt oral tablet 1 or 1b* QL (1 tablet per 1 day) JENLIVA PRENATAL/POSTNATAL ORAL CAPSULE 2 QL (1 capsule per 1 day) KOSHER PRENATAL PLUS IRON ORAL TABLET 3 ST; QL (1 tablet per 1 day) KP PRENATAL MULTIVITAMINS ORAL TABLET 2; $0 QL (1 tablet per 1 day) KPN PRENATAL ORAL TABLET 2; $0 QL (1 tablet per 1 day) M-NATAL PLUS ORAL TABLET 3 QL (1 tablet per 1 day) MULTI PRENATAL ORAL TABLET 2; $0 QL (1 tablet per 1 day) MYNATAL ORAL CAPSULE (prenatal multivit-min-fe-fa) 3 QL (1 capsule per 1 day) MYNATAL PLUS ORAL TABLET 2 QL (1 tablet per 1 day) MYNATAL-Z ORAL TABLET 2 QL (1 tablet per 1 day) NATACHEW ORAL TABLET CHEWABLE (prenatal vit-fe fum-fe bisg-fa) 3 ST; QL (1 tablet per 1 day) NATALVIT ORAL TABLET (prenatal vit-fe fumarate-fa) 3 QL (1 tablet per 1 day) NEEVO DHA ORAL CAPSULE (prenat w/oa-fefum-methf-omegas) 3 ST; QL (1 capsule per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 187 Coverage Requirements and Prescription Drug Name Drug Tier Limits NEONATAL COMPLETE ORAL TABLET 3 ST; QL (1 tablet per 1 day) NEONATAL FE ORAL TABLET 3 ST; QL (1 tablet per 1 day) NEONATAL PLUS ORAL TABLET (prenatal vit-fe fumarate-fa) 3 ST; QL (1 tablet per 1 day) NEONATAL VITAMIN ORAL TABLET (prenatal vit-fe fumarate-fa) 2; $0 QL (1 tablet per 1 day) NESTABS DHA ORAL (prenat-w/oa-fe bisgly-fa-omega) 3 ST; QL (2 tablets per 1 day) NESTABS ORAL TABLET (prenat-fe bisgly-fa-w/o vit a) 3 ST; QL (2 tablets per 1 day) NIVA-PLUS ORAL TABLET (prenatal vit-fe fumarate-fa) 3 QL (1 tablet per 1 day) OB COMPLETE ONE ORAL CAPSULE (prenat-fecbn-feaspgl-fa-fish) 3 ST; QL (1 capsule per 1 day) OB COMPLETE ORAL TABLET (prenatal vit-iron carbonyl-fa) 3 ST; QL (1 tablet per 1 day) OB COMPLETE PETITE ORAL CAPSULE (prenat-fecbn-feaspgl-fa-omega) 3 ST; QL (1 capsule per 1 day) OB COMPLETE PREMIER ORAL TABLET (prenatal-fe cbn-fe asp gly-fa) 3 ST; QL (1 tablet per 1 day) OB COMPLETE/DHA ORAL CAPSULE (prenat-fecbn-feaspgl-fa-omega) 3 ST; QL (1 capsule per 1 day) OBSTETRIX DHA ORAL (prenatal-fecbn-fa-dss-omega 3) 3 QL (1 EA per 1 day) OBSTETRIX EC ORAL TABLET (prenatal vit-dss-fe cbn-fa) 3 QL (1 tablet per 1 day) O-CAL PRENATAL ORAL TABLET (prenatal vit-fe fumarate-fa) 3 QL (1 tablet per 1 day) ONE VITE WOMENS ORAL TABLET 2; $0 QL (1 tablet per 1 day) ONE VITE WOMENS PLUS ORAL TABLET 3 QL (1 tablet per 1 day) ONE-A-DAY WOMENS PRENATAL ORAL (prenatal vit-fe fum-fa-omega) 2; $0 QL (1 EA per 1 day) PERRY PRENATAL ORAL CAPSULE (prenatal vit-fe fumarate-fa) 2; $0 QL (1 capsule per 1 day) PNV TABS 20-1 ORAL TABLET 3 ST; QL (1 tablet per 1 day) PNV TABS 29-1 ORAL TABLET 2 QL (1 tablet per 1 day) PNV-OMEGA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) pnv-select oral tablet 1 or 1b* QL (1 tablet per 1 day) PREGENNA ORAL TABLET 3 ST; QL (1 tablet per 1 day) PRENA1 PEARL ORAL CAPSULE EXTENDED RELEASE 3 ST; QL (1 capsule per 1 day) PRENARA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) prenatabs rx oral tablet 1 or 1a* QL (1 tablet per 1 day) PRENATAL 19 ORAL TABLET 29-1 MG 3 QL (1 tablet per 1 day) prenatal 19 oral tablet chewable 1 or 1a* QL (1 tablet per 1 day) PRENATAL 19 ORAL TABLET CHEWABLE 29-1 MG 3 QL (1 tablet per 1 day) PRENATAL COMPLETE ORAL TABLET 2; $0 QL (1 tablet per 1 day) PRE-NATAL FORMULA ORAL TABLET 2; $0 QL (1 tablet per 1 day) PRENATAL FORTE ORAL TABLET 2; $0 QL (1 tablet per 1 day) PRENATAL ONE DAILY ORAL TABLET 2; $0 QL (1 tablet per 1 day) PRENATAL ORAL TABLET 27-0.8 MG, 28-0.8 MG 2; $0 QL (1 tablet per 1 day) PRENATAL ORAL TABLET 27-1 MG 2 QL (1 tablet per 1 day) PRENATAL PLUS IRON ORAL TABLET 2 QL (1 tablet per 1 day) PRENATAL VITAMIN AND MINERAL ORAL TABLET 2; $0 QL (1 tablet per 1 day) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 188 Coverage Requirements and Prescription Drug Name Drug Tier Limits PRENATAL VITAMIN ORAL TABLET 2; $0 QL (1 tablet per 1 day) PRENATAL VITAMIN PLUS LOW IRON ORAL TABLET 2 QL (1 tablet per 1 day) PRENATAL VITAMINS ORAL TABLET 2; $0 QL (1 tablet per 1 day) PRENATAL/IRON ORAL TABLET 2; $0 QL (1 tablet per 1 day) PRENATAL-U ORAL CAPSULE (prenatal w/o a vit-fe fum-fa) 2 QL (1 capsule per 1 day) PRENATE ELITE ORAL TABLET (prenatal-feaspgly-methylfol-fa) 3 ST; QL (1 tablet per 1 day) PRENATRIX ORAL TABLET (prenatal vit-fe fumarate-fa) 3 ST; QL (1 tablet per 1 day) PRENATRYL ORAL TABLET (prenatal vit-fe fumarate-fa) 3 ST; QL (1 tablet per 1 day) PRENATVITE COMPLETE ORAL TABLET 3 ST; QL (1 tablet per 1 day) PRENATVITE PLUS ORAL TABLET 3 ST; QL (1 tablet per 1 day) PRENATVITE RX ORAL TABLET 3 ST; QL (1 tablet per 1 day) PREPLUS ORAL TABLET 2 QL (1 tablet per 1 day) PRETAB ORAL TABLET 2 QL (1 tablet per 1 day) PRIMACARE ORAL CAPSULE (pren-fe-meth-fa-omeg w/o a) 3 ST; QL (1 capsule per 1 day) PROVIDA OB ORAL CAPSULE (prenat w/o a vit-fefum-fepo-fa) 3 QL (1 capsule per 1 day) PX PRENATAL MULTIVITAMINS ORAL TABLET 2; $0 QL (1 tablet per 1 day) QC PRENATAL ORAL TABLET 2; $0 QL (1 tablet per 1 day) RA PRENATAL FORMULA ORAL TABLET 2; $0 QL (1 tablet per 1 day) RA PRENATAL ORAL TABLET 2; $0 QL (1 tablet per 1 day) RELNATE DHA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) SELECT-OB ORAL TABLET CHEWABLE (prenatal vit-fe psac cmplx-fa) 3 ST; QL (1 tablet per 1 day) SE-NATAL 19 ORAL TABLET 2 QL (1 tablet per 1 day) SE-NATAL 19 ORAL TABLET CHEWABLE 2 QL (1 tablet per 1 day) SM ONE DAILY PRENATAL ORAL 2; $0 QL (1 EA per 1 day) SM PRENATAL VITAMINS ORAL TABLET 2; $0 QL (1 tablet per 1 day) TARON-C DHA ORAL CAPSULE (prenat-fefum-fepo-fa-omega 3) 3 QL (1 capsule per 1 day) THRIVITE RX ORAL TABLET 2 QL (1 tablet per 1 day) TRICARE ORAL TABLET (prenatal vit-fe fumarate-fa) 3 QL (1 tablet per 1 day) TRICARE PRENATAL DHA ONE ORAL CAPSULE (prenatal-fefum-fa- 3 ST; QL (1 capsule per 1 day) dss-fish oil) TRINATAL RX 1 ORAL TABLET 2 QL (1 tablet per 1 day) trinate oral tablet 1 or 1a* QL (1 tablet per 1 day) TRINAZ ORAL TABLET 3 ST; QL (1 tablet per 1 day) VINATE DHA RF ORAL CAPSULE (prenat w/oa-fefum-methf-omegas) 3 ST; QL (1 capsule per 1 day) VINATE II ORAL TABLET (prenatal vit w/ fe bisg-fa) 2 QL (1 tablet per 1 day) VINATE ONE ORAL TABLET (prenatal vit-fe fumarate-fa) 2 QL (1 tablet per 1 day) VIRT-C DHA ORAL CAPSULE 3 QL (1 capsule per 1 day) VIRT-NATE DHA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 189 Coverage Requirements and Prescription Drug Name Drug Tier Limits VIRT-PN PLUS ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) VITAFOL GUMMIES ORAL TABLET CHEWABLE (prenatal vit-fe phos- 3 QL (1 tablet per 1 day) fa-omega) VITAFOL-NANO ORAL TABLET (prenatal-fe fum-methf-fa w/o a) 3 ST; QL (1 tablet per 1 day) VITAFOL-OB ORAL TABLET (prenatal vit-fe fumarate-fa) 3 ST; QL (1 tablet per 1 day) VITAPEARL ORAL CAPSULE EXTENDED RELEASE (prenat-fefum- 3 ST; QL (1 capsule per 1 day) fered-fa-dha w/oa) VITATHELY WITH ORAL TABLET (prenatal vit-fe fumarate-fa) 3 ST; QL (1 tablet per 1 day) VIVA DHA ORAL CAPSULE (prenatal vit-fe fum-fa-omega) 3 ST; QL (1 capsule per 1 day) VP-PNV-DHA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) WESTAB PLUS ORAL TABLET 3 ST; QL (1 tablet per 1 day) ZALVIT ORAL TABLET 3 ST; QL (1 tablet per 1 day) ZATEAN-PN PLUS ORAL CAPSULE (prenat w/o a-fe-methf-fa-omega) 3 ST; QL (1 capsule per 1 day) *PRENATAL MV & MIN W/FE-FA-CA-OMEGA 3 FISH OIL*** - DRUGS FOR NUTRITION COMPLETE NATAL DHA ORAL 3 TRIVEEN-DUO DHA ORAL (prenat-febis-fepro-fa-ca-omega) 2 *PRENATAL MV & MIN W/FE-FA-DHA*** - DRUGS FOR NUTRITION CITRANATAL 90 DHA ORAL (prenat w/o a-fecbgl-dss-fa-dha) 3 ST; QL (1 EA per 1 day) CITRANATAL ASSURE ORAL (prenat w/o a-fecbgl-dss-fa-dha) 3 ST; QL (2 units per 1 day) CITRANATAL BLOOM DHA ORAL (prenat w/o a-fecbgl-dss-fa-dha) 3 ST; QL (1 EA per 1 day) CITRANATAL DHA ORAL (prenat w/o a-fecbgl-dss-fa-dha) 3 ST; QL (2 units per 1 day) CITRANATAL ESSENCE ORAL THERAPY PACK (prenat w/o a-fecbgl-fa- 3 dha) CITRANATAL HARMONY ORAL CAPSULE (prenat-fefmcb-dss-fa-dha 3 ST; QL (1 capsule per 1 day) w/o a) CITRANATAL MEDLEY ORAL CAPSULE (prenat-fecb-fefum-fa-dha w/o 3 ST; QL (1 capsule per 1 day) a) ENFAMIL EXPECTA ORAL (prenatal mv-min-fe fum-fa-dha) 2; $0 QL (1 EA per 1 day) NEONATAL + DHA ORAL 3 ST; QL (1 tablet per 1 day) NESTABS ONE ORAL CAPSULE (prenat-fe-methylfol-dha w/o a) 3 ST; QL (1 capsule per 1 day) OBSTETRIX ONE ORAL CAPSULE (prenat-fe-methyl-dss-dha w/o a) 3 QL (1 capsule per 1 day) pnv-dha oral capsule 1 or 1b* ST; QL (1 capsule per 1 day) PNV-DHA+ ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) PREGEN DHA ORAL CAPSULE 3 ST; QL (1 tablet per 1 day) PRENA 1 TRUE ORAL 3 QL (2 tablets per 1 day) PRENAISSANCE ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) PRENAISSANCE PLUS ORAL CAPSULE 3 ST; QL (1 capsule per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 190 Coverage Requirements and Prescription Drug Name Drug Tier Limits PRENATAL MULTIVITAMIN + DHA ORAL (prenatal mv-min-fe fum-fa- 2; $0 QL (1 EA per 1 day) dha) PRENATE DHA ORAL CAPSULE (prenat-feasp-meth-fa-dha w/o a) 3 ST; QL (1 capsule per 1 day) PRENATE ENHANCE ORAL CAPSULE (prenat w/o a-fe-methfol-fa-dha) 3 ST; QL (1 capsule per 1 day) PRENATE ESSENTIAL ORAL CAPSULE (prenat-feasp-meth-fa-dha w/o a) 3 ST; QL (1 capsule per 1 day) PRENATE MINI ORAL CAPSULE (prenat-fecbn-feasp-meth-fa-dha) 3 ST; QL (1 capsule per 1 day) PRENATE PIXIE ORAL CAPSULE (prenat-feasp-meth-fa-dha w/o a) 3 ST; QL (1 capsule per 1 day) PRENATE RESTORE ORAL CAPSULE (prenat w/o a-fe-methfol-fa-dha) 3 ST; QL (1 capsule per 1 day) SELECT-OB+DHA ORAL (prenatal vit-fepoly-fa-dha) 3 ST; QL (2 units per 1 day) TARON-PREX ORAL CAPSULE (prenat-fefum-dss-fa-dha w/o a) 3 QL (1 capsule per 1 day) TRISTART DHA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) TRISTART FREE ORAL CAPSULE (prenat w/o a-fecbn-meth-fa-dha) 3 ST; QL (1 tablet per 1 day) TRISTART ONE ORAL CAPSULE (prenat w/o a-fecbn-meth-fa-dha) 3 ST; QL (1 capsule per 1 day) VIRT-PN DHA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) VITAFOL FE+ ORAL CAPSULE (prenat-fe poly-methfol-fa-dha) 3 ST; QL (2 capsules per 1 day) VITAFOL ULTRA ORAL CAPSULE (prenat-fe poly-methfol-fa-dha) 3 ST; QL (1 capsule per 1 day) VITAFOL-OB+DHA ORAL (prenatal mv-min-fe fum-fa-dha) 3 ST; QL (2 units per 1 day) VITAFOL-ONE ORAL CAPSULE (prenatal vit-fepoly-fa-dha) 3 ST; QL (1 capsule per 1 day) VITAMEDMD ONE RX/QUATREFOLIC ORAL CAPSULE (prenat w/o a- 3 ST; QL (1 capsule per 1 day) fe-methfol-fa-dha) VITATRUE ORAL (prenat-fechel-fa-dha w/o vit a) 3 ST; QL (2 tablets per 1 day) WESTGEL DHA ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) ZATEAN-PN DHA ORAL CAPSULE (prenat w/o a-fe-methfol-fa-dha) 3 ST; QL (1 capsule per 1 day) *PRENATAL MV & MINERALS W/FA WITHOUT IRON*** - DRUGS FOR NUTRITION PRENATE ORAL TABLET CHEWABLE (prenat mv-min-methylfolate-fa) 3 ST; QL (1 tablet per 1 day) *PRENATAL VITAMINS*** - DRUGS FOR NUTRITION NEONATAL 19 ORAL TABLET 3 ST; QL (1 tablet per 1 day) PREMESISRX ORAL TABLET (prenatal ca-b6-b12-fa-ginger) 2 ST; QL (1 tablet per 1 day) PRENA1 ORAL TABLET CHEWABLE 2 ST; QL (1 tablet per 1 day) PRENATE AM ORAL TABLET (prenatal ca-b6-b12-fa-ginger) 3 ST; QL (1 tablet per 1 day) VITAFOL STRIPS ORAL FILM (prenatal-b6-b12-d3-folic acid) 3 QL (1 EA per 1 day) VITAMEDMD REDICHEW RX ORAL TABLET CHEWABLE (prenat-b2- 3 ST; QL (1 tablet per 1 day) b6-b12-d3-fa) *VITAMINS A & D*** - DRUGS FOR NUTRITION COD LIVER OIL ORAL OIL 3 *VITAMINS W/ LIPOTROPICS*** - DRUGS FOR NUTRITION ACTIFLOVIT EAR HEALTH ORAL TABLET (vitamins-lipotropics) 2; $0 b-100 complex oral tablet 1 or 1b*; $0

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 191 Coverage Requirements and Prescription Drug Name Drug Tier Limits b-100 cr oral tablet extended release 1 or 1b*; $0 b-100 oral tablet 1 or 1b*; $0 b-50 oral tablet 1 or 1b*; $0 balance b-100 oral tablet 1 or 1b*; $0 balanced b-100 complex cr oral tablet extended release 1 or 1b*; $0 balanced b-100 oral tablet 1 or 1b*; $0 balanced b-50 complex oral tablet 1 or 1b*; $0 complex b-100 oral tablet extended release 1 or 1b*; $0 complex b-100-inositol oral tablet extended release 1 or 1b*; $0 cvs balanced b50 oral tablet 1 or 1b*; $0 cvs inner ear plus oral tablet 1 or 1b*; $0 ear health formula oral tablet 1 or 1b*; $0 ear health plus oral tablet 1 or 1b*; $0 inner ear plus oral tablet 1 or 1b*; $0 lipo flavonoid plus oral tablet 1 or 1b*; $0 lipoflavovit oral tablet 1 or 1b*; $0 LIPOTRIAD ORAL TABLET (vitamins-lipotropics) 2; $0 mega multiple/chelated mineral oral tablet 1 or 1b*; $0 nat-rul b-50 oral tablet 1 or 1b*; $0 px b-50 oral tablet 1 or 1b*; $0 risanoid plus oral tablet 1 or 1b*; $0 super stress b-complex cr oral tablet extended release 1 or 1b*; $0 ultra b-100 complex oral tablet 1 or 1b*; $0 *MUSCULOSKELETAL THERAPY AGENTS* - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES *CENTRAL MUSCLE RELAXANTS*** - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES intrathecal solution 4 baclofen oral tablet 10 mg, 5 mg 1 or 1b* QL (3 tablets per 1 day) baclofen oral tablet 20 mg 1 or 1b* QL (4 tablets per 1 day) carisoprodol oral tablet 1 or 1b* QL (4 tablets per 1 day) oral tablet 375 mg, 750 mg 1 or 1b* ST; QL (4 tablets per 1 day) chlorzoxazone oral tablet 500 mg 1 or 1b* QL (4 tablets per 1 day) cyclobenzaprine hcl oral tablet 1 or 1b* QL (3 tablets per 1 day) fexmid oral tablet 1 or 1b* ST; QL (3 tablets per 1 day) LIORESAL INTRATHECAL SOLUTION (baclofen) 3 lorzone oral tablet 1 or 1b* ST; QL (4 tablets per 1 day) metaxalone oral tablet 1 or 1b* ST; QL (4 tablets per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 192 Coverage Requirements and Prescription Drug Name Drug Tier Limits methocarbamol injection solution 1 or 1b* methocarbamol oral tablet 500 mg 1 or 1b* QL (8 tablets per 1 day) methocarbamol oral tablet 750 mg 1 or 1b* QL (6 tablets per 1 day) citrate er oral tablet extended release 12 hour 1 or 1b* QL (2 tablets per 1 day) orphenadrine citrate injection solution 1 or 1b* ROBAXIN INJECTION SOLUTION (methocarbamol) 3 ST SKELAXIN ORAL TABLET (metaxalone) 3 ST; QL (4 tablets per 1 day) SOMA ORAL TABLET (carisoprodol) 3 ST; QL (4 tablets per 1 day) tizanidine hcl oral capsule 2 mg 1 or 1b* QL (4 capsules per 1 day) tizanidine hcl oral capsule 4 mg 1 or 1b* QL (9 capsules per 1 day) tizanidine hcl oral capsule 6 mg 1 or 1b* QL (6 capsules per 1 day) tizanidine hcl oral tablet 2 mg 1 or 1b* QL (4 tablets per 1 day) tizanidine hcl oral tablet 4 mg 1 or 1b* QL (9 tablets per 1 day) ZANAFLEX ORAL CAPSULE 2 MG (tizanidine hcl) 3 ST; QL (4 capsules per 1 day) ZANAFLEX ORAL CAPSULE 4 MG (tizanidine hcl) 3 ST; QL (9 capsules per 1 day) ZANAFLEX ORAL CAPSULE 6 MG (tizanidine hcl) 3 ST; QL (6 capsules per 1 day) ZANAFLEX ORAL TABLET (tizanidine hcl) 3 ST; QL (9 tablets per 1 day) *DIRECT MUSCLE RELAXANTS*** - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES DANTRIUM INTRAVENOUS SOLUTION RECONSTITUTED (dantrolene 3 sodium) DANTRIUM ORAL CAPSULE (dantrolene sodium) 3 dantrolene sodium intravenous solution reconstituted 1 or 1b* dantrolene sodium oral capsule 1 or 1b* revonto intravenous solution reconstituted 1 or 1b* RYANODEX INTRAVENOUS SUSPENSION RECONSTITUTED 3 (dantrolene sodium) *MUSCLE RELAXANT COMBINATIONS*** - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES carisoprodol-aspirin-codeine oral tablet 1 or 1b* QL (40 tablets per 30 days) CYCLOPAK COMBINATION THERAPY PACK (cyclobenz-lido-prilo-swall 3 spr) orphenadrine-asa-caffeine oral tablet 1 or 1b* ST orphengesic forte oral tablet 1 or 1b* ST *VISCOSUPPLEMENTS*** - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES MONOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA (hyaluronan) ORTHOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA (hyaluronan)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 193 Coverage Requirements and Prescription Drug Name Drug Tier Limits SYNVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA (hylan) SYNVISC ONE INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA (hylan) *NASAL AGENTS - SYSTEMIC AND TOPICAL* - DRUGS FOR THE NOSE *ANTIHISTAMINE-STEROID*** - ALLERGY azelastine-fluticasone nasal suspension 1 or 1b* QL (1 bottle per 30 days) DYMISTA NASAL SUSPENSION (azelastine-fluticasone) 3 QL (1 bottle per 30 days) *NASAL ANESTHETICS*** - ALLERGY GOPRELTO NASAL SOLUTION 3 NUMBRINO NASAL SOLUTION ( hcl (nasal anesthetic)) 3 *NASAL ANTICHOLINERGICS*** - ALLERGY ipratropium bromide nasal solution 0.03 % 1 or 1b* QL (2 bottles per 30 days) ipratropium bromide nasal solution 0.06 % 1 or 1b* QL (1 mL per 1 day) *NASAL ANTIHISTAMINES*** - ALLERGY azelastine hcl nasal solution 0.1 %, 137 mcg/spray 1 or 1b* QL (1 package per 25 days) azelastine hcl nasal solution 0.15 % 1 or 1b* QL (1 bottle per 25 days) olopatadine hcl nasal solution 1 or 1b* QL (1 bottle per 30 days) PATANASE NASAL SOLUTION (olopatadine hcl) 3 QL (1 bottle per 30 days) *NASAL STEROIDS*** - ALLERGY flunisolide nasal solution 3 ST; QL (1 bottle per 30 days) fluticasone propionate nasal suspension 1 or 1a* QL (1 bottle per 30 days) mometasone furoate nasal suspension 3 ST; QL (1 bottle per 30 days) PROPEL MINI NASAL IMPLANT (mometasone furoate) 3 PROPEL NASAL IMPLANT (mometasone furoate) 3 *NEUROMUSCULAR AGENTS* - DRUGS FOR NERVES AND MUSCLES *BENZATHIAZOLES*** - DRUGS FOR NERVES AND MUSCLES oral tablet 4 SP; QL (4 tablets per 1 day) *DEPOLARIZING MUSCLE RELAXANTS*** - DRUGS FOR NERVES AND MUSCLES ANECTINE INJECTION SOLUTION (succinylcholine chloride) 3 QUELICIN INJECTION SOLUTION (succinylcholine chloride) 3 SUCCINYLCHOLINE CHLORIDE INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE 140 MG/7ML *NONDEPOLARIZING MUSCLE RELAXANTS*** - DRUGS FOR NERVES AND MUSCLES atracurium besylate intravenous solution 1 or 1b* cisatracurium besylate (pf) intravenous solution 1 or 1b* BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 194 Coverage Requirements and Prescription Drug Name Drug Tier Limits cisatracurium besylate intravenous solution 1 or 1b* NIMBEX INTRAVENOUS SOLUTION (cisatracurium besylate) 3 pancuronium bromide intravenous solution 1 or 1b* rocuronium bromide intravenous solution 1 or 1b* ROCURONIUM BROMIDE INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 100 MG/10ML VECURONIUM BROMIDE INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE vecuronium bromide intravenous solution reconstituted 1 or 1b* *NUTRIENTS* - DRUGS FOR NUTRITION *AMINO ACID MIXTURES*** - DRUGS FOR NUTRITION AMINOPROTECT INTRAVENOUS SOLUTION (amino acid infusion) 3 AMINOSYN II INTRAVENOUS SOLUTION (amino acid infusion) 3 AMINOSYN-PF INTRAVENOUS SOLUTION (amino acid infusion) 3 CLINIMIX E/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION (amino ac 3 elect-calc in d5w) CLINIMIX E/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION (amino ac 3 elect-calc in d10w) CLINIMIX E/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION (amino ac 3 elect-calc in d5w) CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS SOLUTION (amino ac 3 elect-calc in d15w) CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS SOLUTION (amino ac 3 elect-calc in d20w) CLINIMIX E/DEXTROSE (8/10) INTRAVENOUS SOLUTION 3 CLINIMIX E/DEXTROSE (8/14) INTRAVENOUS SOLUTION 3 CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION (amino acid 3 infusion in d10w) CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION (amino acid 3 infusion in d5w) CLINIMIX/DEXTROSE (5/15) INTRAVENOUS SOLUTION (amino acid 3 infusion in d15w) CLINIMIX/DEXTROSE (5/20) INTRAVENOUS SOLUTION (amino acid 3 infusion in d20w) CLINIMIX/DEXTROSE (6/5) INTRAVENOUS SOLUTION 3 CLINIMIX/DEXTROSE (8/10) INTRAVENOUS SOLUTION 3 CLINIMIX/DEXTROSE (8/14) INTRAVENOUS SOLUTION 3 clinisol sf intravenous solution 1 or 1b* FREAMINE HBC INTRAVENOUS SOLUTION (amino acid infusion) 3 FREAMINE III INTRAVENOUS SOLUTION (amino acid infusion) 3 plenamine intravenous solution 1 or 1b*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 195 Coverage Requirements and Prescription Drug Name Drug Tier Limits PREMASOL INTRAVENOUS SOLUTION (amino acid infusion) 3 PROCALAMINE INTRAVENOUS SOLUTION (amino acd electrolyte 3 infusion) PROSOL INTRAVENOUS SOLUTION (amino acid infusion) 3 TRAVASOL INTRAVENOUS SOLUTION (amino acid infusion) 3 TROPHAMINE INTRAVENOUS SOLUTION (amino acid infusion) 3 *AMINO ACIDS-SINGLE*** - DRUGS FOR NUTRITION ARGININE HCL INJECTION SOLUTION 3 ELCYS INTRAVENOUS SOLUTION (cysteine hcl) 3 GLUTATHIONE INJECTION SOLUTION 3 GLUTATHIONE INTRAVENOUS SOLUTION 3 GLYCINE INJECTION SOLUTION 3 LYSINE HCL INJECTION SOLUTION 3 n-acetyl-l-cysteine oral capsule 1 or 1b* TAURINE INJECTION SOLUTION 3 *CARBOHYDRATES*** - DRUGS FOR NUTRITION dextrose intravenous solution 10 %, 250 mg/ml, 5 %, 70 % 1 or 1b* DEXTROSE INTRAVENOUS SOLUTION 20 %, 40 % 3 *LIPIDS*** - DRUGS FOR NUTRITION CLINOLIPID INTRAVENOUS EMULSION (fat emulsion based) 3 INTRALIPID INTRAVENOUS EMULSION (fat emulsion plant based) 3 NUTRILIPID INTRAVENOUS EMULSION (fat emulsion plant based) 3 OMEGAVEN INTRAVENOUS EMULSION (fish oil triglyceride based) 3 SMOFLIPID INTRAVENOUS EMULSION (fat emul fish oil/plant based) 3 *LIPOTROPIC COMBINATIONS*** - DRUGS FOR NUTRITION LIPO INTRAMUSCULAR SOLUTION 3 LIPO-C INTRAMUSCULAR SOLUTION 3 *PROTEIN COMBINATIONS*** - DRUGS FOR NUTRITION TRI-AMINO INJECTION SOLUTION 3 *PROTEIN-CARBOHYDRATE-LIPID WITH ELECTROLYTE COMBINATIONS*** - DRUGS FOR NUTRITION KABIVEN INTRAVENOUS EMULSION (amino ac-dext-lipid-electrolyt) 3 PERIKABIVEN INTRAVENOUS EMULSION (amino ac-dext-lipid- 3 electrolyt) *OPHTHALMIC AGENTS* - DRUGS FOR THE EYE *ALPHA & CARBONIC ANHYDRASE INHIB COMB*** - DRUGS FOR GLAUCOMA SIMBRINZA OPHTHALMIC SUSPENSION (brinzolamide-brimonidine) 2 QL (8 mL per 30 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 196 Coverage Requirements and Prescription Drug Name Drug Tier Limits *BETA-BLOCKERS - OPHTHALMIC COMBINATIONS*** - DRUGS FOR GLAUCOMA COMBIGAN OPHTHALMIC SOLUTION (brimonidine tartrate-timolol) 2 QL (15 mL per 30 days) dorzolamide hcl-timolol mal ophthalmic solution 1 or 1b* QL (10 mL per 30 days) dorzolamide hcl-timolol mal pf ophthalmic solution 1 or 1b* QL (12 mL per 30 days) *BETA-BLOCKERS - OPHTHALMIC*** - DRUGS FOR GLAUCOMA betaxolol hcl ophthalmic solution 1 or 1b* QL (0.5 mL per 1 day) BETIMOL OPHTHALMIC SOLUTION (timolol hemihydrate) 3 QL (15 mL per 30 days) BETOPTIC-S OPHTHALMIC SUSPENSION (betaxolol hcl) 2 QL (15 mL per 30 days) carteolol hcl ophthalmic solution 1 or 1a* levobunolol hcl ophthalmic solution 1 or 1b* timolol maleate ocudose ophthalmic solution 1 or 1b* timolol maleate ophthalmic gel forming solution 1 or 1b* QL (5 mL per 30 days) timolol maleate ophthalmic solution 0.25 %, 0.5 % 1 or 1b* QL (20 mL per 30 days) timolol maleate ophthalmic solution 0.5 % (daily) 1 or 1b* QL (5 mL per 30 days) timolol maleate pf ophthalmic solution 1 or 1b* QL (20 mL per 30 days) TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 % (timolol 3 QL (18 mL per 30 days) maleate) TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.5 % (timolol maleate) 3 QL (20 mL per 30 days) TIMOPTIC OPHTHALMIC SOLUTION (timolol maleate) 3 QL (20 mL per 30 days) TIMOPTIC-XE OPHTHALMIC GEL FORMING SOLUTION (timolol 3 QL (5 mL per 30 days) maleate) *CYCLOPLEGIC MYDRIATIC COMBINATIONS*** - DRUGS FOR THE EYE CYCLOMYDRIL OPHTHALMIC SOLUTION (cyclopentolate- 3 phenylephrine) *CYCLOPLEGIC MYDRIATICS*** - DRUGS FOR THE EYE altafrin ophthalmic solution 1 or 1b* atropine sulfate ophthalmic ointment 1 or 1b* QL (3.5 grams per 30 days) ATROPINE SULFATE OPHTHALMIC SOLUTION 0.01 % 3 ATROPINE SULFATE OPHTHALMIC SOLUTION 1 % 3 QL (30 mL per 30 days) CYCLOGYL OPHTHALMIC SOLUTION 0.5 %, 2 % (cyclopentolate hcl) 3 CYCLOGYL OPHTHALMIC SOLUTION 1 % (cyclopentolate hcl) 3 QL (15 mL per 30 days) cyclopentolate hcl ophthalmic solution 0.5 %, 2 % 1 or 1b* cyclopentolate hcl ophthalmic solution 1 % 1 or 1b* QL (15 mL per 30 days) ISOPTO ATROPINE OPHTHALMIC SOLUTION (atropine sulfate) 3 QL (30 mL per 30 days) MYDRIACYL OPHTHALMIC SOLUTION (tropicamide) 3 PHENYLEPHRINE HCL INTRAOCULAR SOLUTION PREFILLED 3 SYRINGE

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 197 Coverage Requirements and Prescription Drug Name Drug Tier Limits phenylephrine hcl ophthalmic solution 1 or 1b* tropicamide ophthalmic solution 1 or 1b* *LYMPHOCYTE FUNCTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAG*** - ANTI-INFECTIVE/ANTI-INFLAMMATORIES XIIDRA OPHTHALMIC SOLUTION () 3 PA; QL (2 vial per 1 day) *MIOTICS - DIRECT ACTING*** - DRUGS FOR GLAUCOMA ISOPTO CARPINE OPHTHALMIC SOLUTION (pilocarpine hcl) 3 MIOCHOL-E INTRAOCULAR SOLUTION RECONSTITUTED 3 (acetylcholine chloride) MIOSTAT INTRAOCULAR SOLUTION (carbachol) 3 pilocarpine hcl ophthalmic solution 1 or 1b* *OPHTHALMIC ADRENERGIC AGENTS*** - DRUGS FOR THE EYE EPINEPHRINE HCL INTRAOCULAR SOLUTION PREFILLED SYRINGE 3 *OPHTHALMIC ANTIALLERGIC*** - DRUGS FOR ITCHY EYE azelastine hcl ophthalmic solution 1 or 1b* QL (1 bottle per 24 days) cromolyn sodium ophthalmic solution 1 or 1a* QL (1 bottle per 30 days) epinastine hcl ophthalmic solution 1 or 1b* QL (1 bottle per 30 days) *OPHTHALMIC ANTIBIOTICS*** - ANTI-INFECTIVE/ANTI- INFLAMMATORIES AZASITE OPHTHALMIC SOLUTION (azithromycin) 3 bacitracin ophthalmic ointment 1 or 1b* QL (7 grams per 30 days) BESIVANCE OPHTHALMIC SUSPENSION (besifloxacin hcl) 3 CILOXAN OPHTHALMIC OINTMENT (ciprofloxacin hcl) 3 QL (3.5 grams per 30 days) CILOXAN OPHTHALMIC SOLUTION (ciprofloxacin hcl) 3 ciprofloxacin hcl ophthalmic solution 1 or 1a* erythromycin ophthalmic ointment 1 or 1a* QL (3.5 grams per 30 days) gatifloxacin ophthalmic solution 1 or 1b* gentak ophthalmic ointment 1 or 1a* QL (7 grams per 30 days) gentamicin sulfate ophthalmic solution 1 or 1a* QL (10 mL per 30 days) levofloxacin ophthalmic solution 1 or 1b* MITOMYCIN INTRAOCULAR SOLUTION PREFILLED SYRINGE 3 MITOSOL OPHTHALMIC KIT (mitomycin) 3 MOXEZA OPHTHALMIC SOLUTION (moxifloxacin hcl) 3 QL (3 mL per 30 days) moxifloxacin hcl (2x day) ophthalmic solution 1 or 1b* QL (3 mL per 30 days) MOXIFLOXACIN HCL INTRAOCULAR SOLUTION 3 MOXIFLOXACIN HCL INTRAOCULAR SOLUTION PREFILLED 3 SYRINGE moxifloxacin hcl ophthalmic solution 1 or 1b* QL (1 vial per 30 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 198 Coverage Requirements and Prescription Drug Name Drug Tier Limits OCUFLOX OPHTHALMIC SOLUTION (ofloxacin) 3 QL (10 mL per 30 days) ofloxacin ophthalmic solution 1 or 1a* QL (10 mL per 30 days) tobramycin ophthalmic solution 1 or 1a* QL (20 mL per 30 days) TOBREX OPHTHALMIC OINTMENT (tobramycin) 3 QL (3.5 grams per 30 days) TOBREX OPHTHALMIC SOLUTION (tobramycin) 3 QL (20 mL per 30 days) VIGAMOX OPHTHALMIC SOLUTION (moxifloxacin hcl) 3 QL (1 vial per 30 days) ZYMAXID OPHTHALMIC SOLUTION (gatifloxacin) 3 *OPHTHALMIC ANTIFUNGAL*** - DRUGS FOR THE EYE NATACYN OPHTHALMIC SUSPENSION (natamycin) 3 *OPHTHALMIC ANTI-INFECTIVE COMBINATIONS*** - ANTI- INFECTIVE/ANTI-INFLAMMATORIES ak-poly-bac ophthalmic ointment 1 or 1a* bacitracin-polymyxin b ophthalmic ointment 1 or 1a* neomycin-bacitracin zn-polymyx ophthalmic ointment 1 or 1b* neomycin-polymyxin-gramicidin ophthalmic solution 1 or 1b* QL (10 mL per 30 days) neo-polycin ophthalmic ointment 1 or 1b* polycin ophthalmic ointment 1 or 1a* polymyxin b-trimethoprim ophthalmic solution 1 or 1a* QL (10 mL per 30 days) POLYTRIM OPHTHALMIC SOLUTION (polymyxin b-trimethoprim) 3 QL (10 mL per 30 days) *OPHTHALMIC ANTISEPTICS*** - ANTI-INFECTIVE/ANTI- INFLAMMATORIES BETADINE OPHTHALMIC PREP OPHTHALMIC SOLUTION (povidone- 3 iodine) *OPHTHALMIC ANTIVIRALS*** - ANTI-INFECTIVE/ANTI- INFLAMMATORIES trifluridine ophthalmic solution 1 or 1b* QL (7.5 mL per 30 days) ZIRGAN OPHTHALMIC GEL (ganciclovir) 3 QL (5 gram per 7 days) *OPHTHALMIC CARBONIC ANHYDRASE INHIBITORS*** - DRUGS FOR GLAUCOMA AZOPT OPHTHALMIC SUSPENSION (brinzolamide) 3 QL (15 ML per 30 days) brinzolamide ophthalmic suspension 1 or 1b* QL (15 mL per 30 days) dorzolamide hcl ophthalmic solution 1 or 1b* QL (10 mL per 30 days) TRUSOPT OPHTHALMIC SOLUTION (dorzolamide hcl) 3 QL (10 mL per 30 days) *OPHTHALMIC DIAGNOSTIC PRODUCTS*** - DRUGS FOR THE EYE ak-fluor intravenous solution 10 % 1 or 1b* AK-FLUOR INTRAVENOUS SOLUTION 25 % 3 altafluor benox ophthalmic solution 1 or 1b* FLUORESCEIN SODIUM/BENOXINATE OPHTHALMIC SOLUTION 3

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 199 Coverage Requirements and Prescription Drug Name Drug Tier Limits fluorescein-benoxinate ophthalmic solution 1 or 1b* FLUORESCITE INTRAVENOUS SOLUTION (fluorescein sodium) 3 fluor-i-strips a.t. ophthalmic strip 1 or 1b* FLURA-SAFE OPHTHALMIC SOLUTION (fluorexon-benoxinate) 3 PAREMYD OPHTHALMIC SOLUTION (hydroxyamphetamine- 3 tropicamide) proparacaine-fluorescein ophthalmic solution 1 or 1b* *OPHTHALMIC IMMUNOMODULATORS*** - ANTI- INFECTIVE/ANTI-INFLAMMATORIES RESTASIS MULTIDOSE OPHTHALMIC EMULSION (cyclosporine) 3 PA; QL (1 bottle per 28 days) RESTASIS OPHTHALMIC EMULSION (cyclosporine) 3 PA; QL (2 vials per 1 day) *OPHTHALMIC IRRIGATION SOLUTIONS*** - DRUGS FOR THE EYE balanced salt intraocular solution 1 or 1b* BSS INTRAOCULAR SOLUTION (ophth irr soln-intraocular) 3 BSS PLUS INTRAOCULAR SOLUTION (ophth irr soln-intraocular) 3 *OPHTHALMIC KINASE INHIBITORS - COMBINATIONS*** - DRUGS FOR GLAUCOMA ROCKLATAN OPHTHALMIC SOLUTION (netarsudil-latanoprost) 3 QL (2.5 mL per 30 days) *OPHTHALMIC LOCAL ANESTHETIC - COMBINATIONS*** - DRUGS FOR THE EYE LIDOCAINE-EPINEPHRINE INTRAOCULAR SOLUTION 3 LIDOCAINE-PHENYLEPHRINE INTRAOCULAR SOLUTION 3 LIDOCAINE-PHENYLEPHRINE-BSS INTRAOCULAR SOLUTION 3 PREFILLED SYRINGE *OPHTHALMIC LOCAL ANESTHETICS*** - DRUGS FOR THE EYE AKTEN OPHTHALMIC GEL (lidocaine hcl) 3 ALCAINE OPHTHALMIC SOLUTION (proparacaine hcl) 3 proparacaine hcl ophthalmic solution 1 or 1b* tetracaine hcl ophthalmic solution 1 or 1b* *OPHTHALMIC NONSTEROIDAL ANTI-INFLAMMATORY AGENTS*** - ANTI-INFECTIVE/ANTI-INFLAMMATORIES ACULAR LS OPHTHALMIC SOLUTION (ketorolac tromethamine) 3 QL (5 mL per 30 days) ACULAR OPHTHALMIC SOLUTION (ketorolac tromethamine) 3 QL (5 mL per 30 days) ACUVAIL OPHTHALMIC SOLUTION (ketorolac tromethamine) 3 QL (1 box per 30 days) bromfenac sodium (once-daily) ophthalmic solution 1 or 1b* QL (1.7 mL per 30 days) BROMSITE OPHTHALMIC SOLUTION (bromfenac sodium) 3 QL (5 mL per 30 days) diclofenac sodium ophthalmic solution 1 or 1b* QL (5 mL per 30 days) flurbiprofen sodium ophthalmic solution 1 or 1b* QL (2.5 mL per 30 days) ILEVRO OPHTHALMIC SUSPENSION (nepafenac) 2 QL (3 mL per 30 days) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 200 Coverage Requirements and Prescription Drug Name Drug Tier Limits ketorolac tromethamine ophthalmic solution 1 or 1b* QL (5 mL per 30 days) NEVANAC OPHTHALMIC SUSPENSION (nepafenac) 3 QL (3 mL per 30 days) PROLENSA OPHTHALMIC SOLUTION (bromfenac sodium) 3 QL (3 mL per 30 days) *OPHTHALMIC PHOTOENHANCER COMBINATIONS*** - DRUGS FOR THE EYE PHOTREXA VISCOUS OPHTHALMIC SOLUTION PREFILLED 3 SYRINGE (riboflavin 5-phosphate-dextran) PHOTREXA-PHOTREXA VISCOUS KIT OPHTHALMIC SOLUTION 3 PREFILLED SYRINGE (riboflav5 & riboflav5-dextran) *OPHTHALMIC RHO KINASE INHIBITORS*** - DRUGS FOR GLAUCOMA RHOPRESSA OPHTHALMIC SOLUTION (netarsudil dimesylate) 3 QL (2.5 mL per 30 days) *OPHTHALMIC SELECTIVE ALPHA ADRENERGIC AGONISTS*** - DRUGS FOR GLAUCOMA ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % (brimonidine tartrate) 2 QL (15 mL per 30 days) ALPHAGAN P OPHTHALMIC SOLUTION 0.15 % (brimonidine tartrate) 3 QL (15 mL per 30 days) apraclonidine hcl ophthalmic solution 1 or 1b* brimonidine tartrate ophthalmic solution 1 or 1b* QL (15 mL per 30 days) IOPIDINE OPHTHALMIC SOLUTION (apraclonidine hcl) 3 *OPHTHALMIC STEROID COMBINATIONS*** - ANTI- INFECTIVE/ANTI-INFLAMMATORIES bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 or 1b* BLEPHAMIDE OPHTHALMIC SUSPENSION (sulfacetamide-prednisolone) 3 QL (15 mL per 30 days) BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT (sulfacetamide- 3 prednisolone) DEXAMETHASONE-MOXIFLOXACIN INTRAOCULAR SOLUTION 3 DEXAMETH-MOXIFLOX-KETOROLAC INTRAOCULAR SOLUTION 3 MAXITROL OPHTHALMIC OINTMENT (neomycin-polymyxin-dexameth) 3 MAXITROL OPHTHALMIC SUSPENSION (neomycin-polymyxin- 3 dexameth) neomycin-polymyxin-dexameth ophthalmic ointment 1 or 1a* neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 1 or 1a* neomycin-polymyxin-hc ophthalmic suspension 1 or 1b* neo-polycin hc ophthalmic ointment 1 or 1b* PRED-G OPHTHALMIC SUSPENSION (gentamicin-prednisolone acet) 3 PRED-G S.O.P. OPHTHALMIC OINTMENT (gentamicin-prednisolone acet) 3 sulfacetamide-prednisolone ophthalmic solution 1 or 1a* QL (15 mL per 30 days) TOBRADEX OPHTHALMIC OINTMENT (tobramycin-dexamethasone) 2 TOBRADEX OPHTHALMIC SUSPENSION (tobramycin-dexamethasone) 3 QL (10 mL per 30 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 201 Coverage Requirements and Prescription Drug Name Drug Tier Limits TOBRADEX ST OPHTHALMIC SUSPENSION (tobramycin- 3 QL (10 mL per 30 days) dexamethasone) tobramycin-dexamethasone ophthalmic suspension 1 or 1b* QL (10 mL per 30 days) TRIAMCINOLONE-MOXIFLOXACIN INTRAOCULAR SUSPENSION 3 ZYLET OPHTHALMIC SUSPENSION (loteprednol-tobramycin) 2 *OPHTHALMIC STEROIDS*** - ANTI-INFECTIVE/ANTI- INFLAMMATORIES ALREX OPHTHALMIC SUSPENSION (loteprednol etabonate) 3 dexamethasone sodium phosphate ophthalmic solution 1 or 1b* DEXTENZA OPHTHALMIC INSERT (dexamethasone) 3 DEXYCU INTRAOCULAR SUSPENSION (dexamethasone) 3 DUREZOL OPHTHALMIC EMULSION (difluprednate) 2 QL (10 mL per 30 days) EYSUVIS OPHTHALMIC SUSPENSION (loteprednol etabonate) 3 PA; QL (2 bottles per 1 fill) FLAREX OPHTHALMIC SUSPENSION ( acetate) 3 fluorometholone ophthalmic suspension 1 or 1b* FML FORTE OPHTHALMIC SUSPENSION (fluorometholone) 3 FML LIQUIFILM OPHTHALMIC SUSPENSION (fluorometholone) 3 FML OPHTHALMIC OINTMENT (fluorometholone) 3 INVELTYS OPHTHALMIC SUSPENSION (loteprednol etabonate) 3 QL (5.6 mL per 30 days) LOTEMAX OPHTHALMIC GEL (loteprednol etabonate) 3 QL (10 grams per 30 days) LOTEMAX OPHTHALMIC OINTMENT (loteprednol etabonate) 3 QL (7 grams per 30 days) LOTEMAX OPHTHALMIC SUSPENSION (loteprednol etabonate) 3 QL (30 mL per 30 days) LOTEMAX SM OPHTHALMIC GEL (loteprednol etabonate) 3 QL (10 grams per 30 days) loteprednol etabonate ophthalmic gel 1 or 1b* QL (10 grams per 30 days) loteprednol etabonate ophthalmic suspension 1 or 1b* QL (30 mL per 30 days) MAXIDEX OPHTHALMIC SUSPENSION (dexamethasone) 3 OZURDEX INTRAVITREAL IMPLANT (dexamethasone) 3 PA; LD; SP PRED MILD OPHTHALMIC SUSPENSION (prednisolone acetate) 3 prednisolone acetate ophthalmic suspension 1 or 1b* QL (20 mL per 30 days) PREDNISOLONE SODIUM PHOSPHATE OPHTHALMIC SOLUTION 3 QL (20 mL per 30 days) RETISERT INTRAVITREAL IMPLANT (fluocinolone acetonide) 3 PA; LD; SP TRIESENCE INTRAOCULAR SUSPENSION (triamcinolone acetonide) 3 YUTIQ INTRAVITREAL IMPLANT (fluocinolone acetonide) 3 PA; LD *OPHTHALMIC SULFONAMIDES*** - ANTI-INFECTIVE/ANTI- INFLAMMATORIES BLEPH-10 OPHTHALMIC SOLUTION (sulfacetamide sodium) 3 QL (15 mL per 30 days) sulfacetamide sodium ophthalmic ointment 1 or 1b* QL (3.5 grams per 30 days) sulfacetamide sodium ophthalmic solution 1 or 1b* QL (15 mL per 30 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 202 Coverage Requirements and Prescription Drug Name Drug Tier Limits *OPHTHALMIC SURGICAL AIDS - COMBINATIONS*** - DRUGS FOR THE EYE DISCOVISC INTRAOCULAR SOLUTION (na chondroit sulf-na hyaluron) 3 DUOVISC INTRAOCULAR KIT 0.4-0.35 ML, 0.55-0.5 ML (na hyalur & na 3 chond-na hyalur) OMIDRIA INTRAOCULAR SOLUTION (phenylephrine-ketorolac) 3 VISCOAT INTRAOCULAR SOLUTION (na chondroit sulf-na hyaluron) 3 *OPHTHALMIC SURGICAL AIDS*** - DRUGS FOR THE EYE CELLUGEL INTRAOCULAR SOLUTION (hypromellose) 3 HYALURONIDASE (INTRAOCULAR) INTRAOCULAR SOLUTION 3 MEMBRANEBLUE OPHTHALMIC SOLUTION (trypan blue) 3 ocucoat viscoadherent intraocular solution 1 or 1b* TISSUEBLUE INTRAOCULAR SOLUTION PREFILLED SYRINGE 3 (brilliant blue g) VISIONBLUE OPHTHALMIC SOLUTION (trypan blue) 3 *OPHTHALMICS - BLEPHAROPTOSIS AGENTS** - DRUGS FOR THE EYE UPNEEQ OPHTHALMIC SOLUTION (oxymetazoline hcl) 3 PA; QL (30 containers per 30 days) *OPHTHALMICS - CYSTINOSIS AGENTS** - DRUGS FOR THE EYE CYSTARAN OPHTHALMIC SOLUTION (cysteamine hcl) 3 PA; LD; QL (60 mL per 28 days) *PROSTAGLANDINS - OPHTHALMIC*** - DRUGS FOR GLAUCOMA bimatoprost ophthalmic solution 1 or 1b* latanoprost ophthalmic solution 1 or 1b* QL (5 mL per 30 days) LUMIGAN OPHTHALMIC SOLUTION (bimatoprost) 2 QL (7.5 mL per 30 days) travoprost (bak free) ophthalmic solution 1 or 1b* QL (5 mL per 30 days) VYZULTA OPHTHALMIC SOLUTION (latanoprostene bunod) 3 QL (5 mL per 30 days) XELPROS OPHTHALMIC EMULSION (latanoprost) 3 QL (5 mL per 30 days) ZIOPTAN OPHTHALMIC SOLUTION (tafluprost) 3 QL (9 mL per 30 days) *VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) ANTAGONISTS*** - DRUGS FOR THE EYE BEVACIZUMAB INTRAOCULAR SOLUTION PREFILLED SYRINGE 3 PA *OTIC AGENTS* - DRUGS FOR THE EAR *OTIC AGENTS - MISCELLANEOUS*** - WAX REMOVAL acetic acid otic solution 1 or 1b* *OTIC COMBINATIONS*** - ANTI-INFECTIVE/ANTI- INFLAMMATORIES PRAMOTIC OTIC LIQUID (pramoxine-chloroxylenol) 3 *OTIC ANTI-INFECTIVES*** - ANTIBIOTICS CETRAXAL OTIC SOLUTION (ciprofloxacin hcl) 3 QL (28 containers per 1 fill) BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 203 Coverage Requirements and Prescription Drug Name Drug Tier Limits ciprofloxacin hcl otic solution 1 or 1b* QL (28 containers per 1 fill) ofloxacin otic solution 1 or 1b* QL (10 mL per 1 fill) OTIPRIO INTRATYMPANIC SUSPENSION (ciprofloxacin) 3 *OTIC STEROID-ANTI-INFECTIVE COMBINATIONS*** - ANTI- INFECTIVE/ANTI-INFLAMMATORIES CIPRO HC OTIC SUSPENSION (ciprofloxacin-hydrocortisone) 3 QL (10 mL per 1 fill) CIPRODEX OTIC SUSPENSION (ciprofloxacin-dexamethasone) 3 QL (7.5 mL per 1 fill) ciprofloxacin-dexamethasone otic suspension 1 or 1b* QL (7.5 mL per 1 fill) ciprofloxacin-fluocinolone pf otic solution 1 or 1b* QL (28 vials per 1 fill) CORTISPORIN-TC OTIC SUSPENSION (neomycin-colist-hc-thonzonium) 3 neomycin-polymyxin-hc otic solution 1 or 1b* neomycin-polymyxin-hc otic suspension 1 or 1b* OTOVEL OTIC SOLUTION (ciprofloxacin-fluocinolone) 3 QL (28 vials per 1 fill) *OTIC STEROIDS*** - ANTI-INFECTIVE/ANTI-INFLAMMATORIES DERMOTIC OTIC OIL (fluocinolone acetonide) 3 flac otic oil 1 or 1b* fluocinolone acetonide otic oil 1 or 1b* hydrocortisone-acetic acid otic solution 1 or 1b* QL (10 mL per 1 fill) *OXYTOCICS* - HORMONES *ABORTIFACIENTS/CERVICAL RIPENING - PROSTAGLANDINS*** - DRUGS FOR WOMEN carboprost tromethamine intramuscular solution 1 or 1b* CERVIDIL VAGINAL INSERT (dinoprostone) 3 HEMABATE INTRAMUSCULAR SOLUTION (carboprost tromethamine) 3 PREPIDIL VAGINAL GEL (dinoprostone) 3 PROSTIN E2 VAGINAL SUPPOSITORY (dinoprostone) 3 *OXYTOCICS*** - DRUGS FOR WOMEN methergine oral tablet 1 or 1b* methylergonovine maleate injection solution 1 or 1b* methylergonovine maleate oral tablet 1 or 1b* oxytocin injection solution 1 or 1b* OXYTOCIN-LACTATED RINGERS INTRAVENOUS SOLUTION 3 OXYTOCIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION 15-0.9 3 UT/250ML-%, 20-0.9 UNIT/L-%, 20-0.9 UNT/L-% PITOCIN INJECTION SOLUTION (oxytocin) 3

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 204 Coverage Requirements and Prescription Drug Name Drug Tier Limits *PASSIVE IMMUNIZING AND TREATMENT AGENTS* - BIOLOGICAL AGENTS *ANTITOXINS-ANTIVENINS*** - BIOLOGICAL AGENTS ANASCORP INTRAVENOUS SOLUTION RECONSTITUTED 3 (centruroides (scorpion) im fab) ANAVIP INTRAVENOUS SOLUTION RECONSTITUTED (crotalidae 3 immune fab (equine)) ANTIVENIN LATRODECTUS MACTANS INJECTION KIT 3 ANTIVENIN MICRURUS FULVIUS INTRAVENOUS SOLUTION 3 RECONSTITUTED CROFAB INTRAVENOUS SOLUTION RECONSTITUTED (crotalidae 3 polyval immune fab) *BACTERIAL MONOCLONAL ANTIBODIES*** - BIOLOGICAL AGENTS ZINPLAVA INTRAVENOUS SOLUTION (bezlotoxumab) 3 PA *IMMUNE SERUMS*** - BIOLOGICAL AGENTS GAMUNEX-C INJECTION SOLUTION (immune globulin (human)) 4 PA; LD; SP HYPERTET S/D INTRAMUSCULAR INJECTABLE (tetanus immune 3 globulin) OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 20 GM/200ML, 25 GM/500ML, 5 4 PA; LD; SP GM/100ML, 5 GM/50ML (immune globulin (human)) OCTAGAM INTRAVENOUS SOLUTION 30 GM/300ML (immune globulin 4 PA; LD (human)) VARIZIG INTRAMUSCULAR SOLUTION (varicella-zoster immune glob) 3 *PENICILLINS* - DRUGS FOR INFECTIONS *AMINOPENICILLINS*** - ANTIBIOTICS amoxicillin oral capsule 1 or 1a* amoxicillin oral suspension reconstituted 1 or 1a* QL (500 mL per 1 fill) amoxicillin oral tablet 1 or 1a* amoxicillin oral tablet chewable 1 or 1a* ampicillin oral capsule 1 or 1a* ampicillin sodium injection solution reconstituted 1 or 1b* ampicillin sodium intravenous solution reconstituted 1 or 1b* *NATURAL PENICILLINS*** - ANTIBIOTICS BICILLIN L-A INTRAMUSCULAR SUSPENSION (penicillin g benzathine) 3 PENICILLIN G POT IN DEXTROSE INTRAVENOUS SOLUTION 3 penicillin g potassium injection solution reconstituted 1 or 1b* PENICILLIN G INTRAMUSCULAR SUSPENSION 3 penicillin g sodium injection solution reconstituted 1 or 1b* penicillin v potassium oral solution reconstituted 1 or 1b* BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 205 Coverage Requirements and Prescription Drug Name Drug Tier Limits penicillin v potassium oral tablet 1 or 1b* pfizerpen injection solution reconstituted 1 or 1b* *PENICILLIN COMBINATIONS*** - ANTIBIOTICS amoxicillin-pot clavulanate er oral tablet extended release 12 hour 1 or 1b* QL (40 tablets per 1 fill) amoxicillin-pot clavulanate oral suspension reconstituted 1 or 1b* amoxicillin-pot clavulanate oral tablet 1 or 1b* amoxicillin-pot clavulanate oral tablet chewable 1 or 1b* ampicillin-sulbactam sodium injection solution reconstituted 1 or 1b* ampicillin-sulbactam sodium intravenous solution reconstituted 1 or 1b* AUGMENTIN ES-600 ORAL SUSPENSION RECONSTITUTED 3 (amoxicillin-pot clavulanate) AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 2 MG/5ML (amoxicillin-pot clavulanate) AUGMENTIN ORAL SUSPENSION RECONSTITUTED 250-62.5 MG/5ML 3 (amoxicillin-pot clavulanate) AUGMENTIN ORAL TABLET (amoxicillin-pot clavulanate) 3 BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION (penicillin g 3 benzathine & proc) BICILLIN C-R INTRAMUSCULAR SUSPENSION (penicillin g benzathine 3 & proc) piperacillin sod-tazobactam so intravenous solution reconstituted 1 or 1b* UNASYN INJECTION SOLUTION RECONSTITUTED (ampicillin- 3 sulbactam sodium) UNASYN INTRAVENOUS SOLUTION RECONSTITUTED (ampicillin- 3 sulbactam sodium) ZOSYN INTRAVENOUS SOLUTION (piperacillin-tazobactam in dex) 3 *PENICILLINASE-RESISTANT PENICILLINS*** - ANTIBIOTICS sodium oral capsule 1 or 1b* SODIUM IN DEXTROSE INTRAVENOUS SOLUTION 3 nafcillin sodium injection solution reconstituted 1 or 1b* nafcillin sodium intravenous solution reconstituted 1 or 1b* OXACILLIN SODIUM IN DEXTROSE INTRAVENOUS SOLUTION 3 oxacillin sodium injection solution reconstituted 1 or 1b* oxacillin sodium intravenous solution reconstituted 1 or 1b* *PROGESTINS* - HORMONES *PROGESTINS*** - DRUGS FOR WOMEN AYGESTIN ORAL TABLET (norethindrone acetate) 3 hydroxyprogesterone caproate intramuscular oil 4 PA; SP; QL (25 mL per 21 weekss) PA; LD; SP; QL (25 mL per 21 MAKENA INTRAMUSCULAR OIL (hydroxyprogesterone caproate) 4 weekss)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 206 Coverage Requirements and Prescription Drug Name Drug Tier Limits MAKENA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; LD; SP; QL (25 mL per 21 4 (hydroxyprogesterone caproate) weekss) medroxyprogesterone acetate oral tablet 1 or 1a* QL (1 tablet per 1 day) megestrol acetate oral suspension 625 mg/5ml 1 or 1b*; OC norethindrone acetate oral tablet 1 or 1b* progesterone intramuscular oil 1 or 1b* progesterone oral capsule 100 mg 1 or 1b* QL (2 capsules per 1 day) progesterone oral capsule 200 mg 1 or 1b* QL (1 capsule per 1 day) PROVERA ORAL TABLET (medroxyprogesterone acetate) 3 QL (1 tablet per 1 day) *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* - DRUGS FOR THE NERVOUS SYSTEM *AGENTS FOR OPIOID WITHDRAWAL*** - DRUGS FOR THE NERVOUS SYSTEM LUCEMYRA ORAL TABLET (lofexidine hcl) 3 QL (16 tablets per 1 day) *ALCOHOL DETERRENTS*** - DRUGS FOR THE NERVOUS SYSTEM acamprosate calcium oral tablet delayed release 1 or 1b* QL (6 tablet per 1 day) disulfiram oral tablet 1 or 1b* *ANTI-CATAPLECTIC AGENTS*** - DRUGS FOR SLEEP DISORDER XYREM ORAL SOLUTION (sodium oxybate) 3 PA; LD; QL (18 mL per 1 day) *ANTIDEMENTIA AGENT COMBINATIONS*** - DRUGS FOR ALZHEIMER'S DISEASE NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK ( 2 hcl-donepezil hcl) NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 QL (1 capsule per 1 day) (memantine hcl-donepezil hcl) *BENZODIAZEPINES & TRICYCLIC AGENTS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN chlordiazepoxide-amitriptyline oral tablet 1 or 1b* *CHOLINOMIMETICS - ACHE INHIBITORS*** - DRUGS FOR ALZHEIMER'S DISEASE ARICEPT ORAL TABLET 10 MG, 23 MG (donepezil hcl) 3 QL (1 tablet per 1 day) ARICEPT ORAL TABLET 5 MG (donepezil hcl) 3 DO donepezil hcl oral tablet 10 mg, 23 mg 1 or 1b* QL (1 tablet per 1 day) donepezil hcl oral tablet 5 mg 1 or 1b* DO donepezil hcl oral tablet dispersible 1 or 1b* QL (1 tablet per 1 day) EXELON TRANSDERMAL PATCH 24 HOUR 13.3 MG/24HR, 9.5 3 ST; QL (1 patch per 1 day) MG/24HR (rivastigmine) EXELON TRANSDERMAL PATCH 24 HOUR 4.6 MG/24HR (rivastigmine) 3 ST; QL (1 gram per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 207 Coverage Requirements and Prescription Drug Name Drug Tier Limits galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 1 or 1b* QL (1 capsule per 1 day) 24 mg galantamine hydrobromide er oral capsule extended release 24 hour 8 mg 1 or 1b* DO galantamine hydrobromide oral solution 1 or 1b* galantamine hydrobromide oral tablet 12 mg, 8 mg 1 or 1b* QL (2 tablets per 1 day) galantamine hydrobromide oral tablet 4 mg 1 or 1b* DO RAZADYNE ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 16 3 QL (1 capsule per 1 day) MG, 24 MG (galantamine hydrobromide) RAZADYNE ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 8 MG 3 DO (galantamine hydrobromide) rivastigmine tartrate oral capsule 1.5 mg, 3 mg 1 or 1b* DO rivastigmine tartrate oral capsule 4.5 mg, 6 mg 1 or 1b* QL (2 capsules per 1 day) rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 9.5 mg/24hr 1 or 1b* QL (1 patch per 1 day) rivastigmine transdermal patch 24 hour 4.6 mg/24hr 1 or 1b* QL (1 gram per 1 day) *FIBROMYALGIA AGENT - SNRIS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN SAVELLA ORAL TABLET (milnacipran hcl) 2 QL (2 tablets per 1 day) SAVELLA TITRATION PACK ORAL (milnacipran hcl) 2 QL (1 pack per 365 days) *MELANOCORTIN RECEPTOR AGONISTS*** - DRUGS FOR THE NERVOUS SYSTEM VYLEESI SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; LD; QL (4 autoinjectors per 30 3 (bremelanotide acetate) days) *MOVEMENT DISORDER DRUG THERAPY*** - DRUGS FOR THE NERVOUS SYSTEM PA; LD; SP; QL (4 tablets per 1 AUSTEDO ORAL TABLET (deutetrabenazine) 4 day) INGREZZA ORAL CAPSULE 40 MG (valbenazine tosylate) 4 PA; DO; LD INGREZZA ORAL CAPSULE 60 MG, 80 MG (valbenazine tosylate) 4 PA; LD; QL (1 capsule per 1 day) INGREZZA ORAL CAPSULE THERAPY PACK (valbenazine tosylate) 4 PA; LD; QL (1 pack per 1 year) tetrabenazine oral tablet 12.5 mg 1 or 1b* PA; SP; QL (8 tablets per 1 day) tetrabenazine oral tablet 25 mg 1 or 1b* PA; SP; QL (4 tablets per 1 day) PA; LD; SP; QL (8 tablets per 1 XENAZINE ORAL TABLET 12.5 MG (tetrabenazine) 3 day) PA; LD; SP; QL (4 tablets per 1 XENAZINE ORAL TABLET 25 MG (tetrabenazine) 3 day) *MS AGENTS - PYRIMIDINE SYNTHESIS INHIBITORS*** - DRUGS FOR MULTIPLE SCLEROSIS AUBAGIO ORAL TABLET (teriflunomide) 4 PA; LD; SP; QL (1 tablet per 1 day)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 208 Coverage Requirements and Prescription Drug Name Drug Tier Limits *MULTIPLE SCLEROSIS AGENTS - ANTIMETABOLITES*** - DRUGS FOR MULTIPLE SCLEROSIS PA; LD; SP; QL (2 packs per 46 MAVENCLAD (10 TABS) ORAL TABLET THERAPY PACK (cladribine) 4 weekss) PA; LD; SP; QL (2 packs per 46 MAVENCLAD (4 TABS) ORAL TABLET THERAPY PACK (cladribine) 4 weekss) PA; LD; SP; QL (2 packs per 46 MAVENCLAD (5 TABS) ORAL TABLET THERAPY PACK (cladribine) 4 weekss) PA; LD; SP; QL (2 packs per 46 MAVENCLAD (6 TABS) ORAL TABLET THERAPY PACK (cladribine) 4 weekss) PA; LD; SP; QL (2 packs per 46 MAVENCLAD (7 TABS) ORAL TABLET THERAPY PACK (cladribine) 4 weekss) PA; LD; SP; QL (2 packs per 46 MAVENCLAD (8 TABS) ORAL TABLET THERAPY PACK (cladribine) 4 weekss) PA; LD; SP; QL (2 packs per 46 MAVENCLAD (9 TABS) ORAL TABLET THERAPY PACK (cladribine) 4 weekss) *MULTIPLE SCLEROSIS AGENTS - INTERFERONS*** - DRUGS FOR MULTIPLE SCLEROSIS AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT (interferon 4 PA; SP; QL (4 kits per 28 days) beta-1a) AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 4 PA; SP; QL (4 kits per 28 days) (interferon beta-1a) BETASERON SUBCUTANEOUS KIT (interferon beta-1b) 4 PA; SP; QL (15 kits per 30 days) PA; LD; SP; QL (15 kits per 30 EXTAVIA SUBCUTANEOUS KIT (interferon beta-1b) 4 days) PLEGRIDY INTRAMUSCULAR SOLUTION PREFILLED SYRINGE PA; LD; SP; QL (2 syringes per 28 4 (peginterferon beta-1a) days) PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN- 4 PA; LD; SP; QL (1 ML per 28 days) INJECTOR (peginterferon beta-1a) PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED 4 PA; LD; SP; QL (1 ML per 28 days) SYRINGE (peginterferon beta-1a) PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR (peginterferon 4 PA; LD; SP; QL (1 ML per 28 days) beta-1a) PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; SP; QL (1 ML per 28 days) (peginterferon beta-1a) REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 4 PA; SP; QL (12 ML per 28 days) (interferon beta-1a) REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION 4 PA; SP; QL (4.2 ML per 28 days) AUTO-INJECTOR (interferon beta-1a) REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE (interferon 4 PA; SP beta-1a) REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED 4 PA; SP SYRINGE (interferon beta-1a)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 209 Coverage Requirements and Prescription Drug Name Drug Tier Limits *MULTIPLE SCLEROSIS AGENTS - NRF2 PATHWAY ACTIVATORS*** - DRUGS FOR MULTIPLE SCLEROSIS PA; LD; SP; QL (14 capsules per dimethyl fumarate oral capsule delayed release 120 mg 4 365 days) PA; LD; SP; QL (2 capsules per 1 dimethyl fumarate oral capsule delayed release 240 mg 4 day) dimethyl fumarate starter pack oral 4 PA; SP; QL (1 kit per 365 days) *MULTIPLE SCLEROSIS AGENTS - BLOCKERS*** - DRUGS FOR MULTIPLE SCLEROSIS dalfampridine er oral tablet extended release 12 hour 4 PA; SP; QL (2 tablets per 1 day) *MULTIPLE SCLEROSIS AGENTS*** - DRUGS FOR MULTIPLE SCLEROSIS COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 PA; LD; SP; QL (1 syringe per 1 4 MG/ML (glatiramer acetate) day) COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 PA; LD; SP; QL (12 ML per 28 4 MG/ML (glatiramer acetate) days) glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml 4 PA; SP; QL (1 syringe per 1 day) glatiramer acetate subcutaneous solution prefilled syringe 40 mg/ml 4 PA; SP; QL (12 ML per 28 days) glatopa subcutaneous solution prefilled syringe 20 mg/ml 4 PA; SP; QL (1 syringe per 1 day) glatopa subcutaneous solution prefilled syringe 40 mg/ml 4 PA; SP; QL (12 ML per 28 days) *N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTS*** - DRUGS FOR ALZHEIMER'S DISEASE memantine hcl er oral capsule extended release 24 hour 14 mg, 7 mg 1 or 1b* DO memantine hcl er oral capsule extended release 24 hour 21 mg, 28 mg 1 or 1b* QL (1 capsule per 1 day) memantine hcl oral solution 1 or 1b* QL (10 mL per 1 day) memantine hcl oral tablet 10 mg 1 or 1b* QL (2 tablets per 1 day) memantine hcl oral tablet 28 x 5 mg & 21 x 10 mg 1 or 1b* QL (1 tablet per 1 day) memantine hcl oral tablet 5 mg 1 or 1b* DO NAMENDA TITRATION PAK ORAL TABLET (memantine hcl) 3 QL (1 tablet per 1 day) *PHENOTHIAZINES & TRICYCLIC AGENTS*** - DRUGS FOR DEPRESSION perphenazine-amitriptyline oral tablet 1 or 1b* *POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN GRALISE ORAL TABLET 300 MG (gabapentin (once-daily)) 2 PA; DO GRALISE ORAL TABLET 600 MG (gabapentin (once-daily)) 2 PA; QL (3 tablets per 1 day) LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR 165 MG, 3 PA; DO 82.5 MG (pregabalin) LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR 330 MG 3 PA; QL (2 tablets per 1 day) (pregabalin)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 210 Coverage Requirements and Prescription Drug Name Drug Tier Limits pregabalin er oral tablet extended release 24 hour 165 mg, 82.5 mg 1 or 1b* PA; DO pregabalin er oral tablet extended release 24 hour 330 mg 1 or 1b* PA; QL (2 tablets per 1 day) *PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS - SSRIS*** - DRUGS FOR DEPRESSION fluoxetine hcl (pmdd) oral tablet 10 mg 1 or 1b* DO fluoxetine hcl (pmdd) oral tablet 20 mg 1 or 1b* QL (4 tablets per 1 day) *PSEUDOBULBAR AFFECT AGENT COMBINATIONS*** - DRUGS FOR SEVERE MENTAL DISORDERS NUEDEXTA ORAL CAPSULE (dextromethorphan-quinidine) 3 PA; QL (2 capsules per 1 day) *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*** - DRUGS FOR SEVERE MENTAL DISORDERS mesylates oral tablet 1 or 1b* QL (3 tablets per 1 day) oral tablet 1 or 1b* *RESTLESS LEG SYNDROME (RLS) AGENTS*** - DRUGS FOR THE NERVOUS SYSTEM HORIZANT ORAL TABLET EXTENDED RELEASE (gabapentin 3 PA; QL (2 tablets per 1 day) enacarbil) *SEROTONIN 1A RECEPT AGONIST/SEROTONIN 2A RECEPT ANTAG*** - DRUGS FOR THE NERVOUS SYSTEM ADDYI ORAL TABLET () 3 PA; QL (1 tablet per 1 day) *SMOKING DETERRENTS*** - DRUGS FOR DEPRESSION bupropion hcl er (smoking det) oral tablet extended release 12 hour 1 or 1b*; $0 PA; QL (2 tablets per 1 day) CHANTIX CONTINUING MONTH PAK ORAL TABLET (varenicline 3; $0 PA; QL (2 tablet per 1 day) tartrate) CHANTIX ORAL TABLET 0.5 MG (varenicline tartrate) 3; $0 PA; QL (2 tablets per 1 day) CHANTIX ORAL TABLET 1 MG (varenicline tartrate) 3; $0 PA; QL (2 tablet per 1 day) PA; QL (1 starting month pack per CHANTIX STARTING MONTH PAK ORAL TABLET (varenicline tartrate) 3; $0 365 days) cvs mouth/throat gum 1 or 1b*; $0 cvs nicotine mouth/throat lozenge 1 or 1b*; $0 cvs nicotine polacrilex mouth/throat gum 1 or 1b*; $0 cvs nicotine polacrilex mouth/throat lozenge 1 or 1b*; $0 cvs nicotine transdermal patch 24 hour 1 or 1b*; $0 eq nicotine mouth/throat lozenge 1 or 1b*; $0 eq nicotine polacrilex mouth/throat gum 1 or 1b*; $0 eq nicotine polacrilex mouth/throat lozenge 1 or 1b*; $0 eq nicotine step 3 transdermal patch 24 hour 1 or 1b*; $0 eq nicotine transdermal patch 24 hour 1 or 1b*; $0 eql nicotine polacrilex mouth/throat lozenge 1 or 1b*; $0 gnp nicotine mini mouth/throat lozenge 1 or 1b*; $0

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 211 Coverage Requirements and Prescription Drug Name Drug Tier Limits gnp nicotine mouth/throat gum 1 or 1b*; $0 gnp nicotine polacrilex mouth/throat gum 1 or 1b*; $0 gnp nicotine polacrilex mouth/throat lozenge 1 or 1b*; $0 gnp nicotine transdermal patch 24 hour 1 or 1b*; $0 goodsense nicotine mouth/throat gum 1 or 1b*; $0 goodsense nicotine mouth/throat lozenge 1 or 1b*; $0 habitrol transdermal patch 24 hour 1 or 1b*; $0 hm nicotine polacrilex mouth/throat gum 1 or 1b*; $0 hm nicotine polacrilex mouth/throat lozenge 1 or 1b*; $0 hm nicotine transdermal patch 24 hour 1 or 1b*; $0 kls quit2 mouth/throat gum 1 or 1b*; $0 kls quit2 mouth/throat lozenge 1 or 1b*; $0 kls quit4 mouth/throat gum 1 or 1b*; $0 kls quit4 mouth/throat lozenge 1 or 1b*; $0 NICODERM CQ TRANSDERMAL PATCH 24 HOUR (nicotine) 2; $0 NICORETTE MINI MOUTH/THROAT LOZENGE (nicotine polacrilex) 2; $0 NICORETTE MOUTH/THROAT GUM (nicotine polacrilex) 2; $0 NICORETTE MOUTH/THROAT LOZENGE (nicotine polacrilex) 2; $0 NICORETTE STARTER KIT MOUTH/THROAT GUM (nicotine polacrilex) 2; $0 nicotine mini mouth/throat lozenge 1 or 1b*; $0 nicotine polacrilex mini mouth/throat lozenge 1 or 1b*; $0 nicotine polacrilex mouth/throat gum 1 or 1b*; $0 nicotine polacrilex mouth/throat lozenge 1 or 1b*; $0 nicotine step 1 transdermal patch 24 hour 1 or 1b*; $0 nicotine step 2 transdermal patch 24 hour 1 or 1b*; $0 nicotine step 3 transdermal patch 24 hour 1 or 1b*; $0 NICOTINE TRANSDERMAL KIT 2; $0 nicotine transdermal patch 24 hour 1 or 1b*; $0 NICOTROL INHALATION INHALER (nicotine) 3; $0 PA NICOTROL NS NASAL SOLUTION (nicotine) 3; $0 PA px stop smoking aid mouth/throat gum 1 or 1b*; $0 px stop smoking aid mouth/throat lozenge 1 or 1b*; $0 qc nicotine transdermal system transdermal patch 24 hour 1 or 1b*; $0 ra mini nicotine mouth/throat lozenge 1 or 1b*; $0 ra nicotine gum mouth/throat gum 1 or 1b*; $0 ra nicotine mouth/throat gum 1 or 1b*; $0 ra nicotine polacrilex mouth/throat lozenge 1 or 1b*; $0 ra nicotine transdermal patch 24 hour 1 or 1b*; $0 BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 212 Coverage Requirements and Prescription Drug Name Drug Tier Limits sm nicotine mouth/throat gum 1 or 1b*; $0 sm nicotine mouth/throat lozenge 1 or 1b*; $0 sm nicotine polacrilex mouth/throat gum 1 or 1b*; $0 sm nicotine polacrilex mouth/throat lozenge 1 or 1b*; $0 sm nicotine transdermal patch 24 hour 1 or 1b*; $0 thrive mouth/throat gum 1 or 1b*; $0 *SPHINGOSINE 1-PHOSPHATE (S1P) RECEPTOR MODULATORS*** - DRUGS FOR MULTIPLE SCLEROSIS GILENYA ORAL CAPSULE 0.5 MG (fingolimod hcl) 4 PA; SP; QL (1 capsule per 1 day) PA; LD; SP; QL (4 tablets per 1 MAYZENT ORAL TABLET 0.25 MG (siponimod fumarate) 4 day) MAYZENT ORAL TABLET 2 MG (siponimod fumarate) 4 PA; LD; SP; QL (1 tablet per 1 day) MAYZENT STARTER PACK ORAL TABLET THERAPY PACK PA; LD; SP; QL (1 pack per 1 one 4 (siponimod fumarate) time fill) *THIENBENZODIAZEPINES & SSRIS*** - DRUGS FOR SEVERE MENTAL DISORDERS olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 6-50 mg 1 or 1b* QL (1 capsule per 1 day) olanzapine-fluoxetine hcl oral capsule 3-25 mg, 6-25 mg 1 or 1b* DO SYMBYAX ORAL CAPSULE (olanzapine-fluoxetine hcl) 3 DO *VASOMOTOR SYMPTOM AGENTS - SSRIS*** - DRUGS FOR THE NERVOUS SYSTEM paroxetine mesylate oral capsule 1 or 1b* *RESPIRATORY AGENTS - MISC.* - DRUGS FOR THE LUNGS *PLEURAL SCLEROSING AGENTS*** - DRUGS FOR THE LUNGS SCLEROSOL INTRAPLEURAL INTRAPLEURAL AEROSOL POWDER 3 (talc) STERILE TALC POWDER INTRAPLEURAL SUSPENSION 3 RECONSTITUTED (talc) STERITALC INTRAPLEURAL POWDER (talc) 3 *RESPIRATORY AGENTS - MISC.*** - DRUGS FOR THE LUNGS CUROSURF INTRATRACHEAL SUSPENSION (poractant alfa) 3 INFASURF INTRATRACHEAL SUSPENSION (calfactant in nacl) 3 SURVANTA INTRATRACHEAL SUSPENSION (beractant in nacl) 3 *SULFONAMIDES* - DRUGS FOR INFECTIONS *SULFONAMIDES*** - ANTIBIOTICS SULFADIAZINE ORAL TABLET 3 *TETRACYCLINES* - DRUGS FOR INFECTIONS *AMINOMETHYLCYCLINES*** - ANTIBIOTICS NUZYRA INTRAVENOUS SOLUTION RECONSTITUTED (omadacycline 3 LD tosylate)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 213 Coverage Requirements and Prescription Drug Name Drug Tier Limits NUZYRA ORAL TABLET (omadacycline tosylate) 3 PA; LD; QL (30 tablets per 30 days) *FLUOROCYCLINES*** - ANTIBIOTICS XERAVA INTRAVENOUS SOLUTION RECONSTITUTED (eravacycline 3 dihydrochloride) *GLYCYLCYCLINES*** - ANTIBIOTICS TIGECYCLINE INTRAVENOUS SOLUTION RECONSTITUTED 3 TYGACIL INTRAVENOUS SOLUTION RECONSTITUTED (tigecycline) 3 *TETRACYCLINES*** - ANTIBIOTICS coremino oral tablet extended release 24 hour 1 or 1b* ST demeclocycline hcl oral tablet 1 or 1b* doxy 100 intravenous solution reconstituted 1 or 1b* QL (2 vials per 1 day) doxycycline hyclate intravenous solution reconstituted 1 or 1b* QL (2 vials per 1 day) doxycycline hyclate oral capsule 100 mg 1 or 1b* QL (2 capsules per 1 day) doxycycline hyclate oral capsule 50 mg 1 or 1b* doxycycline hyclate oral tablet 100 mg, 20 mg, 50 mg 1 or 1b* QL (2 tablets per 1 day) doxycycline hyclate oral tablet 150 mg 1 or 1b* ST; QL (1 tablet per 1 day) doxycycline hyclate oral tablet 75 mg 1 or 1b* ST; QL (2 tablets per 1 day) doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 200 mg, 50 1 or 1b* ST; QL (2 tablets per 1 day) mg, 75 mg doxycycline monohydrate oral capsule 100 mg, 50 mg, 75 mg 1 or 1b* QL (2 capsules per 1 day) doxycycline monohydrate oral capsule 150 mg 1 or 1b* doxycycline monohydrate oral suspension reconstituted 1 or 1b* QL (600 mL per 30 days) doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg 1 or 1b* QL (2 tablets per 1 day) doxycycline monohydrate oral tablet 150 mg 1 or 1b* MINOCIN INTRAVENOUS SOLUTION RECONSTITUTED (minocycline 3 hcl) minocycline hcl er oral tablet extended release 24 hour 1 or 1b* ST minocycline hcl oral capsule 1 or 1b* minocycline hcl oral tablet 1 or 1b* mondoxyne nl oral capsule 1 or 1b* QL (2 capsules per 1 day) morgidox oral capsule 1 or 1b* QL (2 capsules per 1 day) hcl oral capsule 1 or 1b* *THYROID AGENTS* - HORMONES *ANTITHYROID AGENTS - RADIOPHARMACEUTICALS*** - DRUGS FOR THYROID SODIUM IODIDE I-131 ORAL SOLUTION 3 *ANTITHYROID AGENTS*** - DRUGS FOR THYROID methimazole oral tablet 1 or 1a* propylthiouracil oral tablet 1 or 1b*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 214 Coverage Requirements and Prescription Drug Name Drug Tier Limits TAPAZOLE ORAL TABLET (methimazole) 3 *THYROID HORMONES*** - DRUGS FOR THYROID ARMOUR THYROID ORAL TABLET (thyroid) 3 CYTOMEL ORAL TABLET (liothyronine sodium) 3 euthyrox oral tablet 1 or 1b* levo-t oral tablet 1 or 1b* SODIUM INTRAVENOUS SOLUTION 3 LEVOTHYROXINE SODIUM INTRAVENOUS SOLUTION 3 RECONSTITUTED levothyroxine sodium oral capsule 1 or 1b* levothyroxine sodium oral tablet 1 or 1a* levoxyl oral tablet 1 or 1a* liothyronine sodium intravenous solution 1 or 1b* liothyronine sodium oral tablet 1 or 1b* -THROID ORAL TABLET (thyroid) 3 np thyroid oral tablet 1 or 1a* SYNTHROID ORAL TABLET (levothyroxine sodium) 3 THYQUIDITY ORAL SOLUTION (levothyroxine sodium) 3 TIROSINT ORAL CAPSULE (levothyroxine sodium) 3 TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 MCG/ML, 200 3 MCG/ML, 25 MCG/ML, 50 MCG/ML, 75 MCG/ML, 88 MCG/ML (levothyroxine sodium) TRIOSTAT INTRAVENOUS SOLUTION (liothyronine sodium) 3 unithroid oral tablet 1 or 1a* WESTHROID ORAL TABLET (thyroid) 3 WP THYROID ORAL TABLET (thyroid) 3 *TOXOIDS* - BIOLOGICAL AGENTS *TOXOID COMBINATIONS*** - VACCINES ADACEL INTRAMUSCULAR SUSPENSION (tetanus-diphth-acell 3; $0 pertussis) BOOSTRIX INTRAMUSCULAR SUSPENSION (tetanus-diphth-acell 3; $0 pertussis) DAPTACEL INTRAMUSCULAR SUSPENSION (diphth-acell pertussis- 3; $0 tetanus) DIPHTHERIA-TETANUS TOXOIDS DT INTRAMUSCULAR 3; $0 SUSPENSION INFANRIX INTRAMUSCULAR SUSPENSION (diphth-acell pertussis- 3; $0 tetanus) KINRIX INTRAMUSCULAR SUSPENSION (dtap-ipv vaccine) 3; $0

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 215 Coverage Requirements and Prescription Drug Name Drug Tier Limits PEDIARIX INTRAMUSCULAR SUSPENSION (dtap-hepatitis b recomb-ipv) 3; $0 PENTACEL INTRAMUSCULAR SUSPENSION RECONSTITUTED (dtap- 3; $0 ipv-hib vaccine) QUADRACEL INTRAMUSCULAR SUSPENSION (dtap-ipv vaccine) 3; $0 TDVAX INTRAMUSCULAR SUSPENSION (tetanus-diphtheria toxoids td) 3; $0 TENIVAC INTRAMUSCULAR INJECTABLE (tetanus-diphtheria toxoids 3; $0 td) TETANUS-DIPHTHERIA TOXOIDS TD INTRAMUSCULAR 3; $0 SUSPENSION VAXELIS INTRAMUSCULAR SUSPENSION (dtap-ipv-hib-hepatitis b 3 recmb) VAXELIS INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 3 (dtap-ipv-hib-hepatitis b recmb) *ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS* - DRUGS FOR THE STOMACH *ANTICHOLINERGIC COMBINATIONS*** - DRUGS FOR STOMACH CRAMPS chlordiazepoxide-clidinium oral capsule 1 or 1b* LIBRAX ORAL CAPSULE (chlordiazepoxide-clidinium) 3 phenohytro oral elixir 1 or 1b* phenohytro oral tablet 1 or 1b* *ANTISPASMODICS*** - DRUGS FOR STOMACH CRAMPS BENTYL INTRAMUSCULAR SOLUTION (dicyclomine hcl) 3 dicyclomine hcl intramuscular solution 1 or 1b* dicyclomine hcl oral capsule 1 or 1a* dicyclomine hcl oral solution 1 or 1a* dicyclomine hcl oral tablet 1 or 1a* *BELLADONNA *** - DRUGS FOR STOMACH CRAMPS ATROPEN INTRAMUSCULAR SOLUTION AUTO-INJECTOR (atropine 3 sulfate) atropine sulfate injection solution prefilled syringe 0.25 mg/5ml 1 or 1b* ATROPINE SULFATE INTRAVENOUS SOLUTION 3 ATROPINE SULFATE INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 0.8 MG/2ML, 1 MG/2.5ML hyoscyamine sulfate er oral tablet extended release 12 hour 1 or 1b* hyoscyamine sulfate sl sublingual tablet sublingual 1 or 1b* hyoscyamine sulfate sublingual tablet sublingual 1 or 1b* *H-2 ANTAGONISTS*** - DRUGS FOR ULCERS AND STOMACH ACID hcl oral solution 1 or 1b*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 216 Coverage Requirements and Prescription Drug Name Drug Tier Limits cimetidine oral tablet 200 mg 1 or 1b* QL (2 tablets per 1 day) cimetidine oral tablet 300 mg, 400 mg 1 or 1b* QL (4 tablets per 1 day) cimetidine oral tablet 800 mg 1 or 1b* QL (3 tablets per 1 day) famotidine intravenous solution 1 or 1b* famotidine oral suspension reconstituted 1 or 1b* QL (5 mL per 1 day) famotidine oral tablet 20 mg 1 or 1b* QL (4 tablets per 1 day) famotidine oral tablet 40 mg 1 or 1b* QL (2 tablets per 1 day) famotidine premixed intravenous solution 1 or 1b* nizatidine oral capsule 150 mg 1 or 1b* QL (2 capsules per 1 day) nizatidine oral capsule 300 mg 1 or 1b* QL (1 capsule per 1 day) nizatidine oral solution 1 or 1b* QL (20 mL per 1 day) PEPCID ORAL TABLET 20 MG (famotidine) 3 QL (4 tablets per 1 day) PEPCID ORAL TABLET 40 MG (famotidine) 3 QL (2 tablets per 1 day) *MISC. ANTI-ULCER*** - DRUGS FOR ULCERS AND STOMACH ACID CARAFATE ORAL SUSPENSION (sucralfate) 3 CARAFATE ORAL TABLET (sucralfate) 3 sucralfate oral suspension 1 or 1b* sucralfate oral tablet 1 or 1b* * PUMP INHIBITORS*** - DRUGS FOR ULCERS AND STOMACH ACID DEXILANT ORAL CAPSULE DELAYED RELEASE (dexlansoprazole) 2 ST; QL (1 capsule per 1 day) esomeprazole sodium intravenous solution reconstituted 1 or 1b* NEXIUM I.V. INTRAVENOUS SOLUTION RECONSTITUTED 3 (esomeprazole sodium) omeprazole oral capsule delayed release 1 or 1b* pantoprazole sodium intravenous solution reconstituted 1 or 1b* pantoprazole sodium oral tablet delayed release 1 or 1b* PROTONIX INTRAVENOUS SOLUTION RECONSTITUTED (pantoprazole 3 sodium) *QUATERNARY ANTICHOLINERGICS*** - DRUGS FOR STOMACH CRAMPS CUVPOSA ORAL SOLUTION (glycopyrrolate) 3 GLYCATE ORAL TABLET (glycopyrrolate) 3 PA glycopyrrolate injection solution 1 or 1b* glycopyrrolate oral tablet 1 mg, 2 mg 1 or 1b* GLYCOPYRROLATE ORAL TABLET 1.5 MG 3 PA GLYCOPYRROLATE PF INJECTION SOLUTION PREFILLED SYRINGE 3 GLYRX-PF INJECTION SOLUTION (glycopyrrolate) 3

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 217 Coverage Requirements and Prescription Drug Name Drug Tier Limits GLYRX-PF INJECTION SOLUTION PREFILLED SYRINGE 3 (glycopyrrolate) methscopolamine bromide oral tablet 1 or 1b* *ULCER ANTI-INFECTIVE W/ BISMUTH COMBINATIONS*** - DRUGS FOR ULCERS AND STOMACH ACID HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) 3 ST; QL (1 pack per 1 fill) PYLERA ORAL CAPSULE (bis subcit-metronid-tetracyc) 3 ST; QL (1 pack per 1 fill) *ULCER ANTI-INFECTIVE W/ PROTON PUMP INHIBITORS*** - DRUGS FOR ULCERS AND STOMACH ACID amoxicill-clarithro-lansopraz oral 1 or 1b* ST; QL (1 pack per 1 fill) OMECLAMOX-PAK ORAL (amoxicill-clarithro-omeprazole) 3 ST; QL (1 pack per 1 fill) TALICIA ORAL CAPSULE DELAYED RELEASE (amoxicill-rifabutin- 3 ST; QL (1 pack per 1 fill) omeprazole) *ULCER DRUGS - PROSTAGLANDINS*** - DRUGS FOR ULCERS AND STOMACH ACID CYTOTEC ORAL TABLET (misoprostol) 3 misoprostol oral tablet 1 or 1a* *URINARY ANTISPASMODICS* - DRUGS FOR THE URINARY SYSTEM *URINARY ANTISPASMODIC - ANTIMUSCARINIC (ANTICHOLINERGIC)*** - DRUGS FOR THE BLADDER darifenacin hydrobromide er oral tablet extended release 24 hour 1 or 1b* QL (1 tablet per 1 day) oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg 1 or 1b* QL (2 tablets per 1 day) oxybutynin chloride er oral tablet extended release 24 hour 5 mg 1 or 1b* QL (1 tablet per 1 day) oxybutynin chloride oral syrup 1 or 1b* QL (20 mL per 1 day) oxybutynin chloride oral tablet 1 or 1b* QL (4 tablets per 1 day) solifenacin succinate oral tablet 1 or 1b* QL (1 tablet per 1 day) tolterodine tartrate er oral capsule extended release 24 hour 1 or 1b* QL (1 capsule per 1 day) tolterodine tartrate oral tablet 1 or 1b* QL (2 tablets per 1 day) TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR (fesoterodine 3 QL (1 tablet per 1 day) fumarate) trospium chloride er oral capsule extended release 24 hour 1 or 1b* QL (1 capsule per 1 day) trospium chloride oral tablet 1 or 1b* QL (2 tablets per 1 day) *URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS*** - DRUGS FOR THE BLADDER MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 3 QL (1 tablet per 1 day) (mirabegron) *URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS*** - DRUGS FOR THE BLADDER bethanechol chloride oral tablet 1 or 1b*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 218 Coverage Requirements and Prescription Drug Name Drug Tier Limits *URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS*** - DRUGS FOR THE BLADDER flavoxate hcl oral tablet 1 or 1b* *VACCINES* - BIOLOGICAL AGENTS *BACTERIAL VACCINES*** - VACCINES ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED 3; $0 (haemophilus b polysac conj vac) BCG VACCINE INJECTION INJECTABLE 3; $0 BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 3; $0 (meningococcal b recomb omv adj) BIOTHRAX INTRAMUSCULAR SUSPENSION (anthrax vaccine adsorbed) 3 HIBERIX INJECTION SOLUTION RECONSTITUTED (haemophilus b 3; $0 polysac conj vac) MENACTRA INTRAMUSCULAR INJECTABLE (meningococcal a c y&w- 3; $0 135 conj) MENQUADFI INTRAMUSCULAR INJECTABLE (meningococcal a c y&w- 3; $0 135 conj) MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED 3; $0 (meningococcal a c y&w-135 olig) PEDVAX HIB INTRAMUSCULAR SUSPENSION (haemophilus b polysac 3; $0 conj vac) PNEUMOVAX 23 INJECTION INJECTABLE (pneumococcal vac 2; $0 polyvalent) PREVNAR 13 INTRAMUSCULAR SUSPENSION (pneumococcal 13-val 2; $0 conj vacc) TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 3; $0 (meningococcal b vac (recomb)) TYPHIM VI INTRAMUSCULAR SOLUTION (typhoid vi polysaccharide 3 vacc) VAXCHORA ORAL SUSPENSION RECONSTITUTED (cholera vac live 3 attenuated) *VIRAL VACCINE COMBINATIONS*** - VACCINES M-M-R II INJECTION SOLUTION RECONSTITUTED (measles, mumps & 3; $0 rubella vac) PROQUAD SUBCUTANEOUS SUSPENSION RECONSTITUTED (measles- 3; $0 mumps-rubella-varicell) TWINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 3; $0 (hepatitis a-hep b recomb vac) *VIRAL VACCINES*** - VACCINES AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) (influenza vac split quad) AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) PREFILLED SYRINGE (influenza vac split quad)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 219 Coverage Requirements and Prescription Drug Name Drug Tier Limits ENGERIX-B INJECTION SUSPENSION (hepatitis b vac recombinant) 3; $0 FLUAD INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2; $0 QL (1 fill per 180 days) (influenza vac a&b surf ant adj) FLUAD QUADRIVALENT INTRAMUSCULAR PREFILLED SYRINGE 2; $0 QL (1 fill per 180 days) (influenza vac a&b sa adj quad) FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) PREFILLED SYRINGE (influenza vac split quad) FLUBLOK QUADRIVALENT INTRAMUSCULAR SOLUTION 2; $0 QL (1 fill per 180 days) PREFILLED SYRINGE (influenza vac recomb ha quad) FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) (influenza vac subunit quad) FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) PREFILLED SYRINGE (influenza vac subunit quad) FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) PREFILLED SYRINGE (influenza vac split quad) FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) (influenza vac split quad) FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION 2; $0 QL (1 fill per 180 days) PREFILLED SYRINGE (influenza vac split quad) GARDASIL 9 INTRAMUSCULAR SUSPENSION (hpv 9-valent recomb 2; $0 vaccine) GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 2; $0 (hpv 9-valent recomb vaccine) HAVRIX INTRAMUSCULAR SUSPENSION (hepatitis a vaccine) 3; $0 HEPLISAV-B INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 3; $0 (hepatitis b vac recomb adj) IMOVAX RABIES INTRAMUSCULAR INJECTABLE (rabies virus vaccine, 3 hdc) IPOL INJECTION INJECTABLE (poliovirus vaccine inactivated) 3; $0 IXIARO INTRAMUSCULAR SUSPENSION (japanese encephalitis vac 3 inac) RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED 3 (rabies vaccine, pcec) RECOMBIVAX HB INJECTION SUSPENSION (hepatitis b vac 3; $0 recombinant) ROTARIX ORAL SUSPENSION RECONSTITUTED (rotavirus vaccine live 3; $0 oral) ROTATEQ ORAL SOLUTION (rotavirus vac live pentavalent) 3; $0 SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED (zoster 3; $0 vac recomb adjuvanted) STAMARIL INJECTION SUSPENSION RECONSTITUTED 3 VAQTA INTRAMUSCULAR SUSPENSION (hepatitis a vaccine) 3; $0 VARIVAX SUBCUTANEOUS INJECTABLE (varicella virus vaccine live) 3; $0

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 220 Coverage Requirements and Prescription Drug Name Drug Tier Limits YF-VAX SUBCUTANEOUS INJECTABLE (yellow fever vaccine) 3 *VAGINAL AND RELATED PRODUCTS* - DRUGS FOR WOMEN *IMIDAZOLE-RELATED ANTIFUNGALS*** - DRUGS FOR INFECTIONS GYNAZOLE-1 VAGINAL CREAM (butoconazole nitrate (1 dose)) 3 miconazole 3 vaginal suppository 1 or 1b* vaginal cream 0.4 % 1 or 1b* QL (90 grams per 30 days) terconazole vaginal cream 0.8 % 1 or 1b* QL (40 grams per 30 days) terconazole vaginal suppository 1 or 1b* QL (6 suppositories per 30 days) *MISCELLANEOUS VAGINAL PRODUCTS*** - DRUGS FOR WOMEN INTRAROSA VAGINAL INSERT () 3 ST; QL (1 insert per 1 day) *SPERMICIDES*** - BIRTH CONTROL PILLS ENCARE VAGINAL SUPPOSITORY (nonoxynol-9) 2; $0 OPTIONS GYNOL II CONTRACEPTIVE VAGINAL GEL (nonoxynol-9) 2; $0 SHUR-SEAL CONTRACEPTIVE VAGINAL GEL (nonoxynol-9) 2; $0 TODAY SPONGE VAGINAL (nonoxynol-9) 2; $0 VCF VAGINAL CONTRACEPTIVE VAGINAL FILM (nonoxynol-9) 2; $0 VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM (nonoxynol-9) 2; $0 VCF VAGINAL CONTRACEPTIVE VAGINAL GEL (nonoxynol-9) 2; $0 *VAGINAL ANTI-INFECTIVES*** - DRUGS FOR INFECTIONS CLEOCIN VAGINAL CREAM (clindamycin phosphate) 3 CLEOCIN VAGINAL SUPPOSITORY (clindamycin phosphate) 2 clindamycin phosphate vaginal cream 1 or 1b* CLINDESSE VAGINAL CREAM (clindamycin phosphate (1 dose)) 3 metronidazole vaginal gel 1 or 1b* NUVESSA VAGINAL GEL (metronidazole) 3 vandazole vaginal gel 1 or 1b* *VAGINAL CONTRACEPTIVE PH MODULATOR - COMBINATIONS*** - DRUGS FOR WOMEN PHEXXI VAGINAL GEL (lactic ac-citric ac-pot bitart) 3 *VAGINAL ESTROGENS*** - DRUGS FOR WOMEN estradiol vaginal cream 1 or 1b* estradiol vaginal tablet 1 or 1b* QL (18 tablet per 28 days) ESTRING VAGINAL RING (estradiol) 3 QL (1 ring per 90 days) FEMRING VAGINAL RING (estradiol acetate) 3 QL (1 ring per 90 days) IMVEXXY MAINTENANCE PACK VAGINAL INSERT 10 MCG 3 QL (18 inserts per 28 days) (estradiol) IMVEXXY MAINTENANCE PACK VAGINAL INSERT 4 MCG (estradiol) 3 QL (18 packs per 28 days)

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 221 Coverage Requirements and Prescription Drug Name Drug Tier Limits IMVEXXY STARTER PACK VAGINAL INSERT 10 MCG (estradiol) 3 QL (18 inserts per 28 days) IMVEXXY STARTER PACK VAGINAL INSERT 4 MCG (estradiol) 3 QL (18 packs per 28 days) PREMARIN VAGINAL CREAM (estrogens, conjugated) 2 QL (1 gm per 1 day) yuvafem vaginal tablet 1 or 1b* QL (18 tablet per 28 days) *VAGINAL PROGESTINS*** - DRUGS FOR WOMEN ENDOMETRIN VAGINAL INSERT (progesterone) 3 PA *VASOPRESSORS* - DRUGS FOR THE HEART *ANAPHYLAXIS THERAPY AGENTS*** - DRUGS FOR SERIOUS ALLERGIC REACTION ADRENALIN INJECTION SOLUTION (epinephrine) 3 epinephrine (anaphylaxis) injection solution 1 or 1b* epinephrine injection solution auto-injector 1 or 1b* QL (2 pens per 1 fill) SYMJEPI INJECTION SOLUTION PREFILLED SYRINGE (epinephrine) 2 QL (2 syringes per 1 fill) *NEUROGENIC ORTHOSTATIC (NOH) - AGENTS*** - DRUGS FOR SERIOUS ALLERGIC REACTION oral capsule 100 mg 1 or 1b* PA; SP; QL (3 capsules per 1 day) droxidopa oral capsule 200 mg, 300 mg 1 or 1b* PA; SP; QL (6 capsules per 1 day) PA; LD; SP; QL (3 capsules per 1 NORTHERA ORAL CAPSULE 100 MG (droxidopa) 3 day) PA; LD; SP; QL (6 capsules per 1 NORTHERA ORAL CAPSULE 200 MG, 300 MG (droxidopa) 3 day) *VASOPRESSORS*** - DRUGS FOR SERIOUS ALLERGIC REACTION AKOVAZ INTRAVENOUS SOLUTION (ephedrine sulfate (pressors)) 3 BIORPHEN INTRAVENOUS SOLUTION (phenylephrine hcl (pressors)) 3 EMERPHED INTRAVENOUS SOLUTION (ephedrine sulfate (pressors)) 3 EPHEDRINE SULFATE (PRESSORS) INJECTION SOLUTION 3 PREFILLED SYRINGE 50 MG/10ML EPHEDRINE SULFATE INTRAVENOUS SOLUTION 3 EPHEDRINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 10-0.9 MG/ML-%, 100-0.9 MG/10ML-%, 50-0.9 MG/10ML-% EPINEPHRINE HCL-NACL INTRAVENOUS SOLUTION 3 EPINEPHRINE INTRAVENOUS SOLUTION 3 EPINEPHRINE INTRAVENOUS SOLUTION PREFILLED SYRINGE 1 3 MG/10ML EPINEPHRINE PF INJECTION SOLUTION 3 EPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION 3 EPINEPHRINE-NACL INTRAVENOUS SOLUTION 3 GIAPREZA INTRAVENOUS SOLUTION (angiotensin ii acetate) 3 LEVOPHED INTRAVENOUS SOLUTION (norepinephrine bitartrate) 3

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 222 Coverage Requirements and Prescription Drug Name Drug Tier Limits hcl oral tablet 1 or 1b* NOREPINEPHRINE (BASE)-DEXTROSE INTRAVENOUS SOLUTION 4-5 3 MG/250ML-% norepinephrine bitartrate intravenous solution 1 or 1b* NOREPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION 4-5 3 MG/250ML-%, 8-5 MG/250ML-% NOREPINEPHRINE-SODIUM CHLORIDE INTRAVENOUS SOLUTION 8- 3 0.9 MG/500ML-% PHENYLEPHRINE HCL INTRAVENOUS SOLUTION 10 MG/ML 3 PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION 3 PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.4-0.9 MG/10ML-%, 0.8-0.9 MG/10ML-%, 100-0.9 MCG/10ML- 3 %, 20-0.9 MG/50ML-%, 5-0.9 MG/50ML-% VAZCULEP INTRAVENOUS SOLUTION (phenylephrine hcl (pressors)) 3 *VITAMINS* - DRUGS FOR NUTRITION *VITAMIN A*** - DRUGS FOR NUTRITION AQUASOL A INTRAMUSCULAR SOLUTION (vitamin a) 3 *VITAMIN B-1*** - DRUGS FOR NUTRITION thiamine hcl injection solution 1 or 1b* *VITAMIN B-6*** - DRUGS FOR NUTRITION pyridoxine hcl injection solution 1 or 1b* *VITAMIN C*** - DRUGS FOR NUTRITION ASCOR INTRAVENOUS SOLUTION (ascorbic acid) 3 *VITAMIN D*** - DRUGS FOR NUTRITION DRISDOL ORAL CAPSULE (ergocalciferol) 3 ergocalciferol oral capsule 1 or 1a* vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) 1 or 1a* *VITAMIN K*** - DRUGS FOR NUTRITION MEPHYTON ORAL TABLET (phytonadione) 3 phytonadione injection solution 1 or 1b* phytonadione oral tablet 1 or 1b* vitamin k1 injection solution 1 or 1b*

BRAND=Brand drug generic=generic drug *Your plan may include Tiers 1a/1b. Refer to your pharmacy benefit summary for more information Tier 1 or 1a*=Drugs with the lowest cost share Tier 1 or 1b*=drugs with a low cost share Tier 2=Drugs with a higher cost share than Tier 1 Tier 3=Drugs with a higher cost share than Tier 2 Tier 4=Drugs with a higher cost share than Tier 3 and usually include preferred specialty brand and generic drugs Tier 5=Drugs with the highest cost share and are non-preferred specialty brand and generic drugs $0=Preventive Drug DO=Dose Optimization LD=Limited Distribution OC=Oral Chemotherapy PA=Prior Authorization QL=Quantity Limit SP=Specialty Pharmacy ST=Step Therapy Effective 09/01/2021 223 Index 1ST TIER UNIFINE PENTIPS...... 165 ACTI-LANCE SPECIAL LANCETS ala-cort...... 119 1ST TIER UNIFINE PENTIPS PLUS.165 17G...... 153 albendazole...... 31 1ST TIER UNILET COMFORTOUCH ACTI-LANCE UNIVERSAL 23G...... 153 ALBENZA...... 31 ...... 153 ACTIVASE...... 141 ALBUKED 25...... 140 abacavir sulfate...... 92 ACTIVELLA...... 132 ALBUKED 5...... 140 abacavir sulfate-lamivudine...... 89 ACTONEL...... 128 ALBUMIN HUMAN...... 140 abacavir-lamivudine-zidovudine...... 89 ACTOPLUS MET...... 49 ALBUMINEX...... 140 ABELCET...... 53 ACULAR...... 200 ALBUMIN-ZLB...... 140 ABILIFY MAINTENA...... 88 ACULAR LS...... 200 ALBURX...... 140 ABILIFY MYCITE...... 88 ACUVAIL...... 200 ALBUTEIN...... 140 ABILIFY MYCITE MAINTENANCE acyclovir...... 94, 118, 119 albuterol sulfate...... 35 KIT...... 88 acyclovir sodium...... 94 albuterol sulfate hfa...... 34 ABILIFY MYCITE STARTER KIT..... 88 ADACEL...... 215 ALCAINE...... 200 abiraterone acetate...... 67 adapalene...... 115 alclometasone dipropionate...... 119 ABLYSINOL...... 101 adapalene-benzoyl peroxide...... 115 ALDACTAZIDE...... 127 ABOUTTIME PEN NEEDLE...... 165 ADASUVE...... 87 ALDACTONE...... 128 ABRAXANE...... 80 adc/f (0.5mg/ml)...... 186 ALDARA...... 122 ABSORICA...... 115 ADCETRIS...... 70 ALDER...... 15 ABSORICA LD...... 115 ADDYI...... 211 ALECENSA...... 68 ACACIA...... 15 adefovir dipivoxil...... 93 alendronate sodium...... 128 acamprosate calcium...... 207 ADEMPAS...... 100 ALFENTANIL HCL...... 26 acarbose...... 45 ADENOCAINE...... 100 alfuzosin hcl er...... 138 ACCOLATE...... 36 adenosine...... 33 ALIMTA...... 67 ACCRUFER...... 143 ADHANSIA XR...... 13 ALINIA...... 62 ACCU-CHEK AVIVA PLUS...... 126 ADIPEX-P...... 12 ALIQOPA...... 82 ACCU-CHEK COMPACT PLUS...... 126 ADRENAL C FORMULA...... 183 aliskiren fumarate...... 61 ACCU-CHEK FASTCLIX LANCET..153 ADRENALIN...... 222 ALKERAN...... 81 ACCU-CHEK FASTCLIX LANCETS153 adriamycin...... 76 ALKINDI SPRINKLE...... 111 ACCU-CHEK GUIDE...... 126 adult aspirin regimen...... 23 allbee/c...... 182 ACCU-CHEK MULTICLIX ADVAIR HFA...... 34 allopurinol...... 139 LANCETS...... 153 ADVANCED MOBILE LANCET...... 153 allopurinol sodium...... 139 ACCU-CHEK SAFE-T PRO ADVOCATE INSULIN PEN almotriptan malate...... 172 LANCETS...... 153 NEEDLES...... 165 alogliptin benzoate...... 46 ACCU-CHEK SMARTVIEW...... 126 ADVOCATE INSULIN SYRINGE.....165 alogliptin-metformin hcl...... 46 ACCU-CHEK SOFTCLIX LANCET ADVOCATE LANCETS...... 154 alogliptin-pioglitazone...... 46 DEV...... 153 ADVOCATE LANCETS 30G...... 154 alophen...... 149 ACCU-CHEK SOFTCLIX LANCETS153 ADVOCATE SAFETY LANCETS.....154 ALOPRIM...... 139 ACCURETIC...... 57 ADVOCATE SAFETY LANCETS ALORA...... 133 accutane...... 115 26G...... 154 alosetron hcl...... 135 ACCUTREND GLUCOSE...... 126 ADZENYS ER...... 11 ALOXI...... 51 acebutolol hcl...... 95 ADZENYS XR-ODT...... 11 ALPHAGAN P...... 201 ACETADOTE...... 50 AEMCOLO...... 61 alprazolam...... 32 acetaminophen...... 22 AFFINITY...... 124 alprazolam er...... 32 acetaminophen-codeine...... 25 AFINITOR...... 74 ALPRAZOLAM INTENSOL...... 32 acetaminophen-codeine #2...... 25 AFINITOR DISPERZ...... 74 alprazolam xr...... 32 acetaminophen-codeine #3...... 25 afirmelle...... 104 alprostadil...... 179 acetaminophen-codeine #4...... 25 AFLURIA QUADRIVALENT...... 219 ALREX...... 202 acetazolamide...... 127 aftera...... 108 ALTABAX...... 116 acetazolamide er...... 127 AGAMATRIX ULTRA-THIN altafluor benox...... 199 acetazolamide sodium...... 127 LANCETS...... 154 altafrin...... 197 acetic acid...... 138, 203 AGGRASTAT...... 140 altavera...... 104 acetylcysteine...... 50, 113 AGRYLIN...... 141 ALTERNARIA...... 15 acitretin...... 117 AIMOVIG...... 171 ALUNBRIG...... 68, 69 ACNESIC...... 122 AIMSCO TWIST LANCETS 32G...... 154 alvimopan...... 136 ACREMONIUM...... 15 AIMSCO TWIST LANCETS 33G...... 154 alyacen 1/35...... 104 ACTHAR...... 129 ak-fluor...... 199 alyacen 7/7/7...... 110 ACTHIB...... 219 AK-FLUOR...... 199 alyq...... 101 ACTIFLOVIT EAR HEALTH...... 191 AKLIEF...... 115 amabelz...... 132 ACTIFOAM COLLAGEN SPONGE..144 AKOVAZ...... 222 amantadine hcl...... 84 ACTI-LANCE 28G...... 153 ak-poly-bac...... 199 AMARYL...... 49 ACTI-LANCE LITE LANCETS 28G. 153 AKTEN...... 200 AMBISOME...... 53 AKYNZEO...... 51 ambrisentan...... 101 224 amcinonide...... 119 ANORO ELLIPTA...... 34 aspirin low strength...... 23 AMELUZ...... 123 anti-oxidant...... 184 aspirin-dipyridamole er...... 141 AMERICAN BEECH...... 15 ANTIVENIN LATRODECTUS ASPIRIN-OMEPRAZOLE...... 141 AMERICAN COCKROACH...... 15 MACTANS...... 205 ASSURE COMFORT LANCETS 28G154 AMERICAN ELM...... 15 ANTIVENIN MICRURUS FULVIUS 205 ASSURE HAEMOLANCE PLUS amethia...... 108 ANUSOL-HC...... 31 HIGH...... 154 amethyst...... 108 APADAZ...... 29 ASSURE HAEMOLANCE PLUS AMICAR...... 143, 144 apap-caff-dihydrocodeine...... 25 LOW...... 154 AMIDATE...... 137 APLENZIN...... 42, 43 ASSURE HAEMOLANCE PLUS amikacin sulfate...... 19 APLIGRAF...... 124 MICRO...... 154 amiloride hcl...... 128 apraclonidine hcl...... 201 ASSURE HAEMOLANCE PLUS amiloride-hydrochlorothiazide...... 127 aprepitant...... 52 NORMAL...... 154 aminoacetic acid...... 138 apri...... 104 ASSURE HAEMOLANCE PLUS PED aminocaproic acid...... 144 APRISO...... 135 ...... 154 aminophylline...... 36 APTENSIO XR...... 13 ASSURE ID INSULIN SAFETY SYR165 AMINOPROTECT...... 195 APTIOM...... 39 ASSURE ID SAFETY PEN AMINOSYN II...... 195 APTIVUS...... 91 NEEDLES...... 165 AMINOSYN-PF...... 195 AQUALANCE LANCETS 30G...... 154 ASSURE LANCE LANCETS...... 154 amiodarone hcl...... 34 AQUASOL A...... 223 ASSURE LANCE LANCETS 21G..... 154 AMIODARONE HCL IN DEXTROSE.33 ARAKODA...... 65 ASSURE LANCE PLUS SAFETY amitriptyline hcl...... 44 aranelle...... 110 25G...... 154 amlodipine besy-benazepril hcl...... 57 ARANESP (ALBUMIN FREE)...... 142 ASSURE LANCE PLUS SAFETY amlodipine besylate...... 97 ARAVA...... 22 30G...... 154 amlodipine besylate-valsartan...... 59 ARAZLO...... 115 ASSURE LANCE SAFETY LANCET amlodipine-atorvastatin...... 100 arformoterol tartrate...... 35 28G...... 154 amlodipine-olmesartan...... 59 ARGATROBAN...... 38 ASTAGRAF XL...... 177 amlodipine-valsartan-hctz...... 60 ARGATROBAN IN SODIUM ATABEX EC...... 187 ammonium lactate...... 121 CHLORIDE...... 38 ATABEX OB...... 187 AMMONUL...... 131 ARGININE HCL...... 196 atazanavir sulfate...... 91 amnesteem...... 115 argyle sterile saline...... 138 ATELVIA...... 128 AMNIOFIX...... 124 argyle sterile water...... 177 atenolol...... 95 AMNIOTEXT...... 124 ARICEPT...... 207 atenolol-chlorthalidone...... 60 amoxapine...... 44 aripiprazole...... 88, 89 ATGAM...... 176 amoxicill-clarithro-lansopraz...... 218 ARISTADA...... 89 atomoxetine hcl...... 11 amoxicillin...... 205 ARISTADA INITIO...... 89 atorvastatin calcium...... 56 amoxicillin-pot clavulanate...... 206 ARIZONA CYPRESS...... 15 atovaquone...... 62 amoxicillin-pot clavulanate er...... 206 armodafinil...... 13 atovaquone-proguanil hcl...... 65 AMPHADASE...... 176 ARMOUR THYROID...... 215 atracurium besylate...... 194 AMPHENOL-40...... 124 ARNUITY ELLIPTA...... 36 ATROPEN...... 216 amphetamine er...... 11 AROMASIN...... 78 atropine sulfate...... 197, 216 amphetamine sulfate...... 11 ARRANON...... 67 ATROPINE SULFATE...... 197, 216 amphetamine-dextroamphet er...... 11 arsenic trioxide...... 77 ATROVENT HFA...... 35 amphetamine-dextroamphetamine...... 11 ARTESUNATE...... 65 AUBAGIO...... 208 amphotericin b...... 53 articadent dental...... 150 aubra...... 104 ampicillin...... 205 ARTISS...... 143 aubra eq...... 104 ampicillin sodium...... 205 ARZERRA...... 69 AUGMENTIN...... 206 ampicillin-sulbactam sodium...... 206 ASCLERA...... 179 AUGMENTIN ES-600...... 206 anagrelide hcl...... 141 ascomp-codeine...... 25 AUREOBASIDIUM...... 15 ANALPRAM-HC...... 30 ASCOR...... 223 AUREOBASIDIUM PULLULANS...... 15 ANASCORP...... 205 asenapine maleate...... 87 AURORA LANCET SUPER THIN anastrozole...... 78 ashlyna...... 108 30G...... 154 ANAVIP...... 205 ASPARLAS...... 77 AURORA LANCET THIN 23G...... 154 ANCOBON...... 53 ASPERGILLUS FUMIGATUS...... 15 AURORA PEN NEEDLES...... 165 ANDEXXA...... 50 aspirin...... 23 AURORA UNIFINE PENTIPS...... 165 ANDRODERM...... 30 aspirin 81...... 23 aurovela 1.5/30...... 104 ANECTINE...... 194 aspirin adult low dose...... 23 aurovela 1/20...... 104 ANESTHESIA S/I-40A...... 137 aspirin adult low strength...... 23 aurovela 24 fe...... 104 ANESTHESIA S/I-40H...... 137 aspirin childrens...... 23 aurovela fe 1.5/30...... 104 ANESTHESIA S/I-40S...... 137 aspirin ec...... 23 aurovela fe 1/20...... 104 ANGELIQ...... 132 aspirin ec adult low strength...... 23 AURYXIA...... 136 ANGIOMAX...... 38 aspirin ec low dose...... 23 AUSTEDO...... 208 ANJESO...... 20 aspirin ec low strength...... 23 AUSTRALIAN PINE...... 15 ANNOVERA...... 108 aspirin low dose...... 23 AUTOLET II CLINISAFE...... 154 225 AUTOLET LITE CLINISAFE...... 154 balanced b-100 complex cr...... 192 BELSOMRA...... 146 AUTOLET LITE STARTER PACK... 154 balanced b-50 complex...... 192 benazepril hcl...... 58 AUTOLET PLATFORMS...... 154 balanced b-50/fa...... 183 benazepril-hydrochlorothiazide...... 57 AVASTIN...... 83 balanced salt...... 200 BENDEKA...... 66 aviane...... 104 BALCOLTRA...... 104 BENTYL...... 216 avita...... 115 BALD CYPRESS...... 15 BENZALKONIUM CHLORIDE...... 89 AVITENE...... 144 balsalazide disodium...... 135 BENZAMYCIN...... 115 AVITENE FLOUR...... 144 BALVERSA...... 72 BENZHYDROCODONE- AVONEX PEN...... 209 balziva...... 104 ACETAMINOPHEN...... 29 AVONEX PREFILLED...... 209 BANZEL...... 39 BENZNIDAZOLE...... 31 AVYCAZ...... 101 BAQSIMI ONE PACK...... 45 benzonatate...... 112 AYGESTIN...... 206 BAQSIMI TWO PACK...... 45 benzoyl peroxide-erythromycin...... 115 ayuna...... 104 BARHEMSYS...... 52 benzphetamine hcl...... 12 AYVAKIT...... 75 BAVENCIO...... 71 benztropine mesylate...... 84 azacitidine...... 67 BAXDELA...... 133 BERMUDA GRASS...... 15 AZACTAM...... 64 BAYBERRY (WAX MYRTLE)...... 15 beser...... 119 AZASAN...... 179 bayer advanced aspirin reg st...... 23 BESIVANCE...... 198 AZASITE...... 198 bayer aspirin...... 23 BESPONSA...... 69 azathioprine...... 179 bayer aspirin ec low dose...... 23 BETADINE OPHTHALMIC PREP.... 199 AZATHIOPRINE SODIUM...... 179 bayer low dose...... 23 betamethasone dipropionate...... 119 azelaic acid...... 123 BCG VACCINE...... 219 betamethasone dipropionate aug...... 119 azelastine hcl...... 194, 198 b-compleet-100...... 183 betamethasone valerate...... 119 azelastine-fluticasone...... 194 b-compleet-50...... 183 BETASERON...... 209 AZESCHEW B-COMPLEX...... 181 betaxolol hcl...... 95, 197 PRENATAL/POSTNATAL...... 187 b-complex...... 183 bethanechol chloride...... 218 AZESCO...... 187 b-complex balanced...... 181 BETIMOL...... 197 AZILECT...... 84 b-complex/b-12...... 181 BETOPTIC-S...... 197 azithromycin...... 151 b-complex/vitamin c...... 181 better b complex...... 182 AZOPT...... 199 b-complex-c...... 182 BEVACIZUMAB...... 203 aztreonam...... 64 BD AUTOSHIELD...... 165 bexarotene...... 82 AZULFIDINE...... 135 BD AUTOSHIELD DUO...... 165 BEXSERO...... 219 AZULFIDINE EN-TABS...... 135 BD INSULIN SYR ULTRAFINE II....165 BEYAZ...... 104 azurette...... 104 BD INSULIN SYRINGE...... 165 bicalutamide...... 67 b complex...... 181 BD INSULIN SYRINGE HALF-UNIT BICILLIN C-R...... 206 b complex 100 tr...... 182 ...... 165 BICILLIN C-R 900/300...... 206 b complex formula 1...... 182 BD INSULIN SYRINGE BICILLIN L-A...... 205 b complex plus...... 182 MICROFINE...... 165 BICNU...... 81 b complex-b12...... 181 BD INSULIN SYRINGE U/F...... 165 BIDIL...... 100 b complex-biotin-fa...... 182 BD INSULIN SYRINGE U/F 1/2UNIT big 100...... 183 b complex-c...... 182 ...... 165 big 100 (biotin)...... 183 B COMPLEX-C-BIOTIN-E-FA...... 182 BD INSULIN SYRINGE U-500...... 165 BIJUVA...... 132 b complex-c-folic acid...... 181 BD INSULIN SYRINGE BIKTARVY...... 89 b-100...... 192 ULTRAFINE...... 165 BILTRICIDE...... 31 b-100 b-complex...... 182 BD LANCET ULTRAFINE 30G...... 154 bimatoprost...... 123, 203 b-100 complex...... 191 BD LANCET ULTRAFINE 33G...... 154 BINOSTO...... 128 b-100 complex cr...... 182 BD MICROTAINER LANCETS...... 154 BIORPHEN...... 222 b-100 cr...... 192 BD PEN NEEDLE MICRO U/F...... 165 BIOTHRAX...... 219 b-100 tr...... 182 BD PEN NEEDLE MINI U/F...... 165 BIOVANCE...... 125 b-50...... 192 BD PEN NEEDLE NANO 2ND GEN.165 bisacodyl ec...... 149 b-50 complex...... 182 BD PEN NEEDLE NANO U/F...... 165 bisoprolol fumarate...... 95 bac...... 22 BD PEN NEEDLE ORIGINAL U/F....165 bisoprolol-hydrochlorothiazide...... 61 bacitracin...... 61, 198 BD PEN NEEDLE SHORT U/F...... 165 BIVALIRUDIN RTU...... 38 bacitracin-polymyxin b...... 199 BD SAFETYGLIDE INSULIN BIVALIRUDIN-SODIUM bacitra-neomycin-polymyxin-hc...... 201 SYRINGE...... 166 CHLORIDE...... 38 baclofen...... 192 BD SAFETY-LOK INSULIN BLACK WILLOW...... 15 BACTRIM...... 62 SYRINGE...... 166 blanche...... 121 BACTRIM DS...... 62 BD VEO INSULIN SYR U/F 1/2UNIT BLENREP...... 69 BAHIA...... 15 ...... 166 bleomycin sulfate...... 76 BAL IN OIL...... 50 BD VEO INSULIN SYRINGE U/F.....166 BLEPH-10...... 202 balance b-100...... 192 bekyree...... 104 BLEPHAMIDE...... 201 balance b-50...... 182 BELBUCA...... 29 BLEPHAMIDE S.O.P...... 201 balanced b complex...... 182 BELEODAQ...... 73 BLINCYTO...... 71 balanced b-100...... 183, 192 BELRAPZO...... 66 blisovi 24 fe...... 104 226 blisovi fe 1.5/30...... 104 butalbital-acetaminophen...... 22 CAREFINE PEN NEEDLES...... 166 blisovi fe 1/20...... 104 butalbital-apap-caff-cod...... 25 CAREONE INSULIN SYRINGE...... 166 BLOXIVERZ...... 65 butalbital-apap-caffeine...... 22 CAREONE LANCET SUPER THIN BONIVA...... 128 butalbital-asa-caff-codeine...... 25 30G...... 154 BONJESTA...... 51 butalbital-aspirin-caffeine...... 23 CAREONE LANCET THIN 23G...... 154 BOOSTRIX...... 215 butorphanol tartrate...... 29 CAREONE UNIFINE PENTIPS...... 166 BORIC ACID...... 123 BUTRANS...... 29 CAREONE UNIFINE PENTIPS PLUS BORTEZOMIB...... 75 BYSTOLIC...... 95 ...... 166 bosentan...... 101 CABENUVA...... 89, 90 CARESENS LANCETS...... 154 BOSULIF...... 71 cabergoline...... 129 CARETOUCH INSULIN SYRINGE.. 166 BOTRYTIS...... 15 CABOMETYX...... 74 CARETOUCH PEN NEEDLES...... 166 bp wash...... 115 CADUET...... 100 CARETOUCH SAFETY LANCETS.. 154 BRAFTOVI...... 72 CAFCIT...... 12 CARETOUCH SAFETY LANCETS BREO ELLIPTA...... 34 caffeine citrate...... 12 26G...... 154 BRETYLIUM TOSYLATE...... 34 CALAN SR...... 97 CARETOUCH TWIST LANCETS BREVIBLOC...... 95 calcipotriene...... 118 28G...... 154 BREVIBLOC IN NACL...... 95 calcipotriene-betameth diprop...... 126 CARETOUCH TWIST LANCETS BREVIBLOC PREMIXED...... 95 calcitonin (salmon)...... 129 30G...... 154 BREVIBLOC PREMIXED DS...... 95 calcitrene...... 118 CARETOUCH TWIST LANCETS BREVITAL SODIUM...... 137 calcitriol...... 118, 130 33G...... 154 BREZTRI AEROSPHERE...... 34 calcium acetate...... 136 carisoprodol...... 192 BRIDION...... 50 calcium acetate (phos binder)...... 136 carisoprodol-aspirin-codeine...... 193 briellyn...... 104 CALCIUM DISODIUM VERSENATE 50 carmustine...... 81 BRILINTA...... 140 CALCIUM GLUCONATE...... 172 CARNITOR...... 129 brimonidine tartrate...... 201 CALCIUM GLUCONATE-NACL...... 172 CARNITOR SF...... 129 brinzolamide...... 199 CALDOLOR...... 20 CAROSPIR...... 128 BRIVIACT...... 39 CALIFORNIA PEPPER TREE...... 15 carteolol hcl...... 197 BROME...... 15 CALQUENCE...... 72 cartia xt...... 97 bromfenac sodium (once-daily)...... 200 camila...... 109 carvedilol...... 95 bromocriptine mesylate...... 84 CAMPTOSAR...... 82 carvedilol phosphate er...... 95 BROMSITE...... 200 camrese...... 108 CASCARA SAGRADA...... 149 BROVANA...... 35 camrese lo...... 108 CASODEX...... 67 BRUKINSA...... 72 CANASA...... 135 CASPOFUNGIN ACETATE...... 52 BSP 0820...... 112 CANCIDAS...... 52 CAT HAIR EXTRACT...... 16 BSS...... 200 candesartan cilexetil...... 59 cataflam...... 20 BSS PLUS...... 200 candesartan cilexetil-hctz...... 59 CATAPRES-TTS-1...... 60 budesonide...... 36, 111 CANDIDA ALBICANS EXTRACT CATAPRES-TTS-2...... 60 budesonide er...... 111 ...... 15, 16 CATAPRES-TTS-3...... 60 budesonide-formoterol fumarate...... 34 CAPASTAT SULFATE...... 66 CATHFLO ACTIVASE...... 141 bumetanide...... 127 CAPCOF...... 114 CATTLE EPITHELIUM...... 16 BUMEX...... 127 capecitabine...... 68 cavarest...... 180 BUNAVAIL...... 29 CAPLYTA...... 86 CAVERJECT...... 100 bupap...... 22 CAPRELSA...... 74 CAVERJECT IMPULSE...... 100 BUPHENYL...... 131 captopril...... 58 CAYA...... 153 BUPIVACAINE FISIOPHARMA...... 150 CARAC...... 117 caziant...... 110 bupivacaine hcl...... 150 CARAFATE...... 217 CEDAR ELM...... 16 bupivacaine hcl (pf)...... 150 carbamazepine...... 39 cefaclor...... 102 BUPIVACAINE HCL-NACL...... 150 carbamazepine er...... 39 CEFACLOR ER...... 102 bupivacaine in dextrose...... 150 carbidopa...... 85 cefadroxil...... 102 bupivacaine spinal...... 150 carbidopa-levodopa...... 85 CEFAZOLIN IN SODIUM bupivacaine-epinephrine...... 150 carbidopa-levodopa er...... 85 CHLORIDE...... 102 bupivacaine-epinephrine (pf)...... 150 carbidopa-levodopa-entacapone...... 85 cefazolin sodium...... 102 BUPRENEX...... 29 carbinoxamine maleate...... 54 CEFAZOLIN SODIUM...... 102 buprenorphine...... 29 CARBOCAINE...... 150 CEFAZOLIN SODIUM-DEXTROSE.102 buprenorphine hcl...... 29 CARBOCAINE PRESERVATIVE- cefdinir...... 102, 103 buprenorphine hcl-naloxone hcl...... 29 FREE...... 151 cefepime hcl...... 103 bupropion hcl...... 43 carboplatin...... 66 CEFEPIME HCL...... 103 bupropion hcl er (smoking det)...... 211 carboprost tromethamine...... 204 CEFEPIME-DEXTROSE...... 103 bupropion hcl er (sr)...... 43 CARDENE IV...... 97 cefixime...... 103 bupropion hcl er (xl)...... 43 CARDIZEM...... 97 CEFOTAN...... 102 buspirone hcl...... 32 CARDIZEM LA...... 97 cefotaxime sodium...... 103 busulfan...... 66 CARDURA...... 60 cefotetan disodium...... 102 BUSULFEX...... 66 CARDURA XL...... 138 227 CEFOTETAN DISODIUM- cimetidine hcl...... 216 CLINDAMYCIN PHOSPHATE IN DEXTROSE...... 102 cinacalcet hcl...... 129 NACL...... 64 cefoxitin sodium...... 102 CINVANTI...... 52 clindamycin-tretinoin...... 115 CEFOXITIN SODIUM-DEXTROSE..102 CIPRO...... 134 CLINDESSE...... 221 cefpodoxime proxetil...... 103 CIPRO HC...... 204 CLINIMIX E/DEXTROSE (2.75/5).... 195 cefprozil...... 102 CIPRODEX...... 204 CLINIMIX E/DEXTROSE (4.25/10).. 195 ceftazidime...... 103 ciprofloxacin hcl...... 134, 198, 204 CLINIMIX E/DEXTROSE (4.25/5).... 195 CEFTAZIDIME AND DEXTROSE....103 ciprofloxacin in d5w...... 134 CLINIMIX E/DEXTROSE (5/15)...... 195 ceftriaxone sodium...... 103 ciprofloxacin-dexamethasone...... 204 CLINIMIX E/DEXTROSE (5/20)...... 195 CEFTRIAXONE SODIUM...... 103 ciprofloxacin-fluocinolone pf...... 204 CLINIMIX E/DEXTROSE (8/10)...... 195 ceftriaxone sodium in dextrose...... 103 cisatracurium besylate...... 195 CLINIMIX E/DEXTROSE (8/14)...... 195 CEFTRIAXONE SODIUM- cisatracurium besylate (pf)...... 194 CLINIMIX/DEXTROSE (4.25/10)...... 195 DEXTROSE...... 103 cisplatin...... 66 CLINIMIX/DEXTROSE (4.25/5)...... 195 cefuroxime axetil...... 102 CISPLATIN...... 66 CLINIMIX/DEXTROSE (5/15)...... 195 cefuroxime sodium...... 102 citalopram hydrobromide...... 43 CLINIMIX/DEXTROSE (5/20)...... 195 celecoxib...... 20 CITRANATAL 90 DHA...... 190 CLINIMIX/DEXTROSE (6/5)...... 195 CELESTONE SOLUSPAN...... 112 CITRANATAL ASSURE...... 190 CLINIMIX/DEXTROSE (8/10)...... 195 CELLCEPT...... 176, 177 CITRANATAL B-CALM...... 187 CLINIMIX/DEXTROSE (8/14)...... 195 CELLCEPT INTRAVENOUS...... 176 CITRANATAL BLOOM...... 187 clinisol sf...... 195 CELLUGEL...... 203 CITRANATAL BLOOM DHA...... 190 CLINOLIPID...... 196 CELONTIN...... 42 CITRANATAL DHA...... 190 clinpro 5000...... 180 CENTANY...... 116 CITRANATAL ESSENCE...... 190 clobazam...... 38 cephalexin...... 102 CITRANATAL HARMONY...... 190 clobetasol prop emollient base...... 119 CEREBYX...... 42 CITRANATAL MEDLEY...... 190 clobetasol propionate...... 119, 120 CEROVEL...... 121 CITRANATAL RX...... 187 clobetasol propionate e...... 119 CERVIDIL...... 204 citrate of magnesia...... 148 clobetasol propionate emulsion...... 119 CETACAINE...... 125 citroma...... 148 clocortolone pivalate...... 120 cetirizine hcl...... 54 CITRULLINE EASY...... 131 clodan...... 120 CETRAXAL...... 203 CLADOSPORIUM clofarabine...... 68 cevimeline hcl...... 180 CLADOSPORIOIDES...... 16 CLOLAR...... 68 CHANTIX...... 211 CLADOSPORIUM clomiphene citrate...... 131 CHANTIX CONTINUING MONTH SPHAEROSPERMUM...... 16 clomipramine hcl...... 45 PAK...... 211 cladribine...... 68 clonazepam...... 38 CHANTIX STARTING MONTH PAK claravis...... 115 clonidine...... 60 ...... 211 CLARINEX...... 54 clonidine hcl...... 60 charlotte 24 fe...... 104 CLARINEX-D 12 HOUR...... 113 clonidine hcl (analgesia)...... 22 chateal...... 105 clarithromycin...... 152 clonidine hcl er...... 11 chateal eq...... 105 clarithromycin er...... 152 clopidogrel bisulfate...... 141 CHEMET...... 50 CLASSIC PRENATAL...... 187 clorazepate dipotassium...... 32 CHENODAL...... 134 CLEANLET LANCETS 28G...... 154 CLOROTEKAL...... 151 childrens aspirin...... 23 clearlax...... 147 clotrimazole...... 121, 122, 179 chloramphenicol sod succinate...... 63 CLEMASTINE FUMARATE...... 54 clotrimazole-betamethasone...... 116 chlordiazepoxide hcl...... 32 clemastine fumarate...... 54 clovique...... 175 chlordiazepoxide-amitriptyline...... 207 CLENPIQ...... 147 clozapine...... 87 chlordiazepoxide-clidinium...... 216 CLEOCIN...... 64, 221 C-NATE DHA...... 187 chlorhexidine gluconate...... 179 CLEOCIN PHOSPHATE...... 64 COAGUCHEK LANCETS...... 155 chloroprocaine hcl (pf)...... 151 CLEOCIN-T...... 114 coal tar...... 124 chloroquine phosphate...... 65 CLEVER CHEK LANCETS...... 154 COARTEM...... 65 chlorothiazide sodium...... 128 CLEVER CHOICE COMFORT EZ.... 166 COCKLEBUR...... 16 chlorpromazine hcl...... 88 CLEVER CHOICE LANCETS 21G....155 COD LIVER OIL...... 191 chlorthalidone...... 128 CLEVER CHOICE LANCETS 23G....155 CODEINE SULFATE...... 26 chlorzoxazone...... 192 CLEVER CHOICE LANCETS 28G....155 codeine sulfate...... 26 CHOLBAM...... 134 CLEVIPREX...... 97 CODITUSSIN AC...... 113 cholestyramine...... 55 CLICKFINE PEN NEEDLES...... 166 CODITUSSIN DAC...... 113 cholestyramine light...... 55 CLIMARA...... 133 COGENTIN...... 84 chromic chloride...... 175 CLIMARA PRO...... 132 colchicine...... 139 ciclopirox...... 116 clindacin etz...... 114 colchicine-probenecid...... 139 ciclopirox olamine...... 116 clindacin-p...... 114 colesevelam hcl...... 55 cidofovir...... 93 clindamycin hcl...... 64 COLESTID...... 55 cilostazol...... 140 clindamycin palmitate hcl...... 64 COLESTID FLAVORED...... 55 CILOXAN...... 198 clindamycin phos-benzoyl perox...... 115 colestipol hcl...... 55 CIMDUO...... 90 clindamycin phosphate...... 64, 114, 221 colistimethate sodium (cba)...... 64 cimetidine...... 217 clindamycin phosphate in d5w...... 64 COLY-MYCIN M...... 64 228 COMBIGAN...... 197 CRESEMBA...... 53 cyred eq...... 105 COMBIPATCH...... 132 CRIXIVAN...... 91 CYSTADANE...... 130 COMBIVENT RESPIMAT...... 34 CROFAB...... 205 CYSTARAN...... 203 COMBIVIR...... 90 cromolyn sodium...... 34, 134, 198 cytarabine...... 68 COMETRIQ (100 MG DAILY DOSE). 74 crotan...... 124 cytarabine (pf)...... 68 COMETRIQ (140 MG DAILY DOSE). 74 CRYODOSE TA...... 125 CYTOMEL...... 215 COMETRIQ (60 MG DAILY DOSE)... 74 cryselle-28...... 105 CYTOTEC...... 218 COMFORT ASSIST INSULIN CUBICIN...... 63 dacarbazine...... 77 SYRINGE...... 166 CUBICIN RF...... 63 DACOGEN...... 68 COMFORT ASSURED LANCETS cupric chloride...... 175 dactinomycin...... 76 28G...... 155 curity sterile saline...... 138 daily multiple vitamins...... 184 COMFORT ASSURED LANCETS CUROSURF...... 213 daily multiple vitamins/iron...... 183 33G...... 155 CURVULARIA...... 16 daily value multivitamin...... 184 COMFORT EZ INSULIN SYRINGE. 166 CUVPOSA...... 217 daily vitamin...... 184 COMFORT EZ MICRO PEN cvs aspirin...... 23 daily vitamin formula+iron...... 183 NEEDLES...... 166 cvs aspirin adult low dose...... 23 daily vitamins...... 184 COMFORT EZ PEN NEEDLES...... 166 cvs aspirin adult low strength...... 23 daily vite...... 184 COMFORT EZ SHORT PEN cvs aspirin ec...... 23 daily vite multivitamin/iron...... 184 NEEDLES...... 166 cvs aspirin low dose...... 23 daily vites...... 184 COMFORT LANCETS...... 155 cvs aspirin low strength...... 23 daily-vitamin...... 185 COMFORT TOUCH INSULIN PEN cvs b complex plus c...... 182 daily-vitamin/iron...... 184 NEED...... 166 cvs balanced b50...... 192 daily-vite...... 185 COMFORT TOUCH LANCETS 31G.155 cvs bisacodyl...... 149 daily-vite multivitamin...... 185 COMFORT TOUCH PLUS cvs citrate of magnesia...... 148 dalfampridine er...... 210 LANCETS 30G...... 155 cvs c-lax laxative...... 149 DALIRESP...... 36 COMPLERA...... 90 cvs folic acid...... 142 DALVANCE...... 63 COMPLETE NATAL DHA...... 190 cvs gentle laxative...... 149 danazol...... 30 COMPLETENATE...... 187 cvs gentle laxative womens...... 149 DANDELION...... 16 complex b-100...... 192 cvs inner ear plus...... 192 DANTRIUM...... 193 complex b-100-inositol...... 192 CVS LANCETS 21G...... 155 dantrolene sodium...... 193 complex b-50 prolonged release...... 183 CVS LANCETS MICRO THIN 33G...155 DANYELZA...... 70 compro...... 88 CVS LANCETS ORIGINAL...... 155 dapsone...... 63, 114 COMTAN...... 85 CVS LANCETS THIN 26G...... 155 DAPTACEL...... 215 CO-NATAL FA...... 187 CVS LANCETS ULTRA THIN 30G.. 155 DAPTOMYCIN...... 63 CONCEPT DHA...... 187 CVS LANCETS ULTRA-THIN 30G.. 155 daptomycin...... 63 CONCEPT OB...... 187 cvs magnesium citrate...... 148 DARAPRIM...... 65 CONDYLOX...... 122 cvs milk of magnesia...... 148 darifenacin hydrobromide er...... 218 CONJUPRI...... 97 cvs nicotine...... 211 DARZALEX...... 70 constulose...... 147 cvs nicotine polacrilex...... 211 DARZALEX FASPRO...... 76 CONTRAVE...... 13 CVS PRENATAL...... 187 dasetta 1/35...... 105 CONZIP...... 26 cvs purelax...... 147 dasetta 7/7/7...... 110 COPAXONE...... 210 cvs super b complex/c...... 182 DAUNORUBICIN HCL...... 76 COPIKTRA...... 82 CVS ULTRA THIN LANCETS...... 155 DAURISMO...... 73 coremino...... 214 cyanocobalamin...... 142 DAYPRO...... 20 CORLANOR...... 101 CYANOCOBALAMIN...... 142 daysee...... 108 CORLOPAM...... 61 CYANOKIT...... 50 DAYTRANA...... 13 CORN POLLEN...... 16 cyclafem 1/35...... 105 DAYVIGO...... 146 correctol...... 149 cyclafem 7/7/7...... 110 DDAVP...... 132 CORTEF...... 111 cyclobenzaprine hcl...... 192 DDAVP PF...... 132 CORTENEMA...... 30 CYCLOGYL...... 197 deblitane...... 109 CORTIFOAM...... 30 CYCLOMYDRIL...... 197 decadron...... 111 CORTISPORIN-TC...... 204 CYCLOPAK...... 193 decitabine...... 68 CORVERT...... 34 cyclopentolate hcl...... 197 deferasirox...... 50 COSELA...... 81 cyclophosphamide...... 81 deferasirox granules...... 50 COSENTYX...... 118 CYCLOPHOSPHAMIDE...... 81 deferiprone...... 50 COSENTYX (300 MG DOSE)...... 117 cycloserine...... 66 deferoxamine mesylate...... 50 COSENTYX SENSOREADY (300 CYCLOSET...... 46 DEFLUX...... 139 MG)...... 117 cyclosporine...... 176 DELESTROGEN...... 133 COSENTYX SENSOREADY PEN.....117 cyclosporine modified...... 176 DELFLEX-LC/1.5% DEXTROSE...... 178 COSMEGEN...... 76 CYKLOKAPRON...... 144 DELFLEX-LC/2.5% DEXTROSE...... 178 COTELLIC...... 73 cyproheptadine hcl...... 55 DELFLEX-LC/4.25% DEXTROSE.... 178 COTEMPLA XR-ODT...... 13 CYRAMZA...... 83 DELFLEX-SM/1.5% DEXTROSE...... 178 CREON...... 126 cyred...... 105 DELFLEX-SM/2.5% DEXTROSE...... 178 229 DELSTRIGO...... 90 DEXCOM G6 RECEIVER...... 155 digox...... 99 delyla...... 105 DEXCOM G6 SENSOR...... 155 digoxin...... 99 DELZICOL...... 135 DEXCOM G6 TRANSMITTER...... 155 dihydroergotamine mesylate...... 171 demeclocycline hcl...... 214 DEXILANT...... 217 DILANTIN...... 42 DEMEROL...... 26 DEXMEDETOMIDINE HCL...... 146 DILANTIN INFATABS...... 42 DEMSER...... 58 dexmedetomidine hcl...... 146 DILATRATE-SR...... 31 DENAVIR...... 119 dexmedetomidine hcl in nacl...... 146 DILAUDID...... 26 denta 5000 plus...... 180 DEXMEDETOMIDINE HCL IN diltiazem hcl...... 97 dentagel...... 180 NACL...... 146 DILTIAZEM HCL...... 97 DEPEN TITRATABS...... 175 DEXMEDETOMIDINE HCL- diltiazem hcl er...... 97 DEPO-ESTRADIOL...... 133 DEXTROSE...... 146 diltiazem hcl er beads...... 97 DEPO-MEDROL...... 111 dexmethylphenidate hcl...... 13 diltiazem hcl er coated beads...... 97 DEPO-PROVERA...... 109 dexmethylphenidate hcl er...... 13 DILTIAZEM HCL-DEXTROSE...... 97 DEPO-SUBQ PROVERA 104...... 109 DEXPANTHENOL...... 134 DILTIAZEM HCL-SODIUM DEPO-TESTOSTERONE...... 30 dexrazoxane hcl...... 78 CHLORIDE...... 98 DERMOTIC...... 204 DEXTENZA...... 202 dilt-xr...... 98 DESCOVY...... 90 dextroamphetamine sulfate...... 11, 12 DIMENHYDRINATE...... 52 desflurane...... 137 dextroamphetamine sulfate er...... 11 dimethyl fumarate...... 210 desipramine hcl...... 45 dextrose...... 196 dimethyl fumarate starter pack...... 210 desloratadine...... 54 DEXTROSE...... 196 DIPENTUM...... 135 desmopressin ace spray refrig...... 132 DEXTROSE 5%/ELECTROLYTE #48 diphen...... 54 desmopressin acetate...... 132 ...... 172 di-phen...... 54 desmopressin acetate pf...... 132 dextrose in lactated ringers...... 172 diphenhydramine hcl...... 54 desmopressin acetate spray...... 132 DEXTROSE-NACL...... 172 diphenoxylate-atropine...... 49 desogestrel-ethinyl estradiol...... 104, 105 dextrose-nacl...... 172 DIPHTHERIA-TETANUS TOXOIDS desonide...... 120 dextrose-sodium chloride...... 172 DT...... 215 desoximetasone...... 120 DEXTROSE-SODIUM CHLORIDE...172 DIPRIVAN...... 137 desrx...... 120 DEXYCU...... 202 dipyridamole...... 141 DESVENLAFAXINE ER...... 44 dialyvite 800...... 181 DISCOVISC...... 203 desvenlafaxine succinate er...... 44 DIANEAL LOW CALCIUM/1.5% disopyramide phosphate...... 33 DEXABLISS...... 111 DEX...... 178 disulfiram...... 207 dexamethasone...... 111 DIANEAL LOW CALCIUM/2.5% DIURIL...... 128 DEXAMETHASONE INTENSOL...... 111 DEX...... 178 divalproex sodium...... 42 DEXAMETHASONE SOD PHOS- DIANEAL LOW CALCIUM/4.25% divalproex sodium er...... 42 NACL...... 111 DEX...... 178 DIVIGEL...... 133 dexamethasone sod phosphate pf...... 111 DIANEAL PD-2/1.5% DEXTROSE... 178 dobutamine hcl...... 99 DEXAMETHASONE SOD DIANEAL PD-2/2.5% DEXTROSE... 178 DOBUTAMINE IN D5W...... 99 PHOSPHATE PF...... 111 DIANEAL PD-2/4.25% DEXTROSE. 178 DOCETAXEL...... 80 DEXAMETHASONE SODIUM DIASTAT ACUDIAL...... 38 dofetilide...... 34 PHOSPHATE...... 111 DIASTAT PEDIATRIC...... 38 DOG EPITHELIUM...... 16 dexamethasone sodium phosphate DIATHRIVE LANCET ULTRA THIN DOG FENNEL...... 16 ...... 111, 202 30...... 155 dolishale...... 108 DEXAMETHASONE- DIATHRIVE LANCETS...... 155 donepezil hcl...... 207 MOXIFLOXACIN...... 201 DIATHRIVE PEN NEEDLE...... 166 dopamine hcl...... 99 DEXAMETH-MOXIFLOX- diazepam...... 32, 39 DOPAMINE IN D5W...... 99 KETOROLAC...... 201 DIAZEPAM...... 32 DOPRAM...... 12 DEXCOM G4 PLAT PED diazepam intensol...... 32 DORAL...... 145 RCV/SHARE...... 155 diazoxide...... 45 dorzolamide hcl...... 199 DEXCOM G4 PLAT PED RECEIVER DIBENZYLINE...... 58 dorzolamide hcl-timolol mal...... 197 ...... 155 diclofenac potassium...... 20 dorzolamide hcl-timolol mal pf...... 197 DEXCOM G4 PLATINUM diclofenac sodium...... 20, 21, 117, 200 dotti...... 133 RCV/SHARE...... 155 diclofenac sodium er...... 20 DOVATO...... 90 DEXCOM G4 PLATINUM diclofenac-misoprostol...... 20 DOVONEX...... 118 RECEIVER...... 155 dicloxacillin sodium...... 206 doxazosin mesylate...... 60 DEXCOM G4 PLATINUM dicyclomine hcl...... 216 doxepin hcl...... 45, 117, 146 TRANSMITTER...... 155 diethylpropion hcl...... 12 doxercalciferol...... 130 DEXCOM G4 SENSOR...... 155 diethylpropion hcl er...... 12 DOXIL...... 76 DEXCOM G5 MOB/G4 PLAT DIFICID...... 152 doxorubicin hcl...... 76 SENSOR...... 155 diflorasone diacetate...... 120 doxorubicin hcl liposomal...... 76 DEXCOM G5 MOBILE RECEIVER..155 DIFLUCAN...... 53 doxy 100...... 214 DEXCOM G5 MOBILE diflunisal...... 23 doxycycline hyclate...... 214 TRANSMITTER...... 155 DIGIFAB...... 50 doxycycline monohydrate...... 214 DEXCOM G5 RECEIVER KIT...... 155 digitek...... 99 doxylamine-pyridoxine...... 52 230 DRECHSLERA...... 16 EASY COMFORT LANCETS...... 156 ELITEK...... 78 DRISDOL...... 223 EASY COMFORT LANCETS TWIST elite-ob...... 187 dronabinol...... 52 TOP...... 156 ELIXOPHYLLIN...... 36 droperidol...... 32 EASY COMFORT PEN NEEDLES....166 ELLA...... 108 DROPLET INSULIN SYRINGE...... 166 EASY GLIDE PEN NEEDLES...... 167 ELLENCE...... 76 DROPLET LANCETS ULTRA THIN EASY TOUCH FLIPLOCK INSULIN ELLIOTTS B...... 173 30G...... 155 SY...... 167 ELMIRON...... 138 DROPLET MICRON...... 166 EASY TOUCH INSULIN SAFETY eluryng...... 108 DROPLET PEN NEEDLES...... 166 SYR...... 167 ELZONRIS...... 77 DROPLET PERSONAL LANCETS EASY TOUCH INSULIN SYRINGE. 167 EMBRACE LANCETS ULTRA THIN 30G...... 155 EASY TOUCH LANCETS 21G...... 156 30G...... 156 DROPSAFE SAFETY PEN EASY TOUCH LANCETS 23G...... 156 EMCYT...... 79 NEEDLES...... 166 EASY TOUCH LANCETS 26G...... 156 EMEND...... 52 drospiren-eth estrad-levomefol...... 105 EASY TOUCH LANCETS 28G...... 156 EMERPHED...... 222 drospirenone-ethinyl estradiol...... 105 EASY TOUCH LANCETS EMGALITY...... 171 DROXIA...... 142 28G/TWIST...... 156 EMGALITY (300 MG DOSE)...... 171 droxidopa...... 222 EASY TOUCH LANCETS 30G...... 156 emoquette...... 105 DRUG MART LANCETS THIN 26G.156 EASY TOUCH LANCETS EMPLICITI...... 71 DRUG MART ON-THE-GO LANCET 30G/TWIST...... 156 EMSAM...... 43 30G...... 156 EASY TOUCH LANCETS 32G...... 156 emtricitabine...... 92 DRUG MART UNIFINE PENTIPS.... 166 EASY TOUCH LANCETS emtricitabine-tenofovir df...... 90 DRUG MART UNIFINE PENTIPS 32G/TWIST...... 156 EMTRIVA...... 92 PLUS...... 166 EASY TOUCH LANCETS EMVERM...... 31 DRUG MART UNILET LANCETS 33G/TWIST...... 156 enalapril maleate...... 58 28G...... 156 EASY TOUCH PEN NEEDLES...... 167 enalaprilat...... 58 DRUG MART UNILET LANCETS EASY TOUCH SAFETY LANCETS enalapril-hydrochlorothiazide...... 57 30G...... 156 21G...... 156 ENBRACE HR...... 187 DRUG MART UNILET LANCETS EASY TOUCH SAFETY LANCETS ENBREL...... 22 33G...... 156 23G...... 156 ENBREL MINI...... 22 DSUVIA...... 26 EASY TOUCH SAFETY LANCETS ENBREL SURECLICK...... 22 DUAVEE...... 133 26G...... 156 ENCARE...... 221 DUET DHA 400...... 187 EASY TOUCH SAFETY LANCETS ENDO AVITENE...... 144 DUET DHA BALANCED...... 187 28G...... 156 endocet...... 29 DUETACT...... 49 EASY TOUCH SAFETY PEN ENDOMETRIN...... 222 dulcolax...... 148 NEEDLES...... 167 endur-b...... 183 dulcolax milk of magnesia...... 148 EASY TOUCH SHEATHLOCK ENFAMIL EXPECTA...... 190 duloxetine hcl...... 44 SYRINGE...... 167 ENGERIX-B...... 220 DUOBRII...... 126 easygel...... 180 ENHERTU...... 76 DUODOTE...... 50 ec-naproxen...... 21 ENLITE GLUCOSE SENSOR...... 156 DUOPA...... 85 econazole nitrate...... 122 enoxaparin sodium...... 38 DUOVISC...... 203 econtra ez...... 108 enpresse-28...... 110 DURACLON...... 22 econtra one-step...... 108 enskyce...... 105 DURAGESIC-100...... 26 ecotrin low strength...... 24 ENSTILAR...... 126 DURAGESIC-12...... 26 ECOZA...... 122 entacapone...... 85 DURAGESIC-25...... 26 EDARBI...... 59 entecavir...... 93 DURAGESIC-50...... 26 EDARBYCLOR...... 59 ENTEREG...... 136 DURAGESIC-75...... 26 EDECRIN...... 127 ENTOCORT EC...... 111 duramorph...... 26 EDETATE DISODIUM...... 175 ENTRESTO...... 100 DUREZOL...... 202 EDEX...... 100 ENTYVIO...... 136 DURLAZA...... 141 EDLUAR...... 146 enulose...... 136 DUST MITE MIXED ALLERGEN EDURANT...... 92 ENVARSUS XR...... 177 EXT...... 18, 19 efavirenz...... 92 EPANED...... 58 dutasteride...... 137 efavirenz-emtricitab-tenofovir...... 90 EPCLUSA...... 94 dutasteride-tamsulosin hcl...... 139 efavirenz-lamivudine-tenofovir...... 90 EPHEDRINE SULFATE...... 222 DUTOPROL...... 61 EFUDEX...... 117 EPHEDRINE SULFATE DXEVO 11-DAY...... 111 ELCYS...... 196 (PRESSORS)...... 222 DYANAVEL XR...... 12 ELEPSIA XR...... 39 EPHEDRINE SULFATE-NACL...... 222 DYMISTA...... 194 ELESTRIN...... 133 EPICOCCUM...... 16 ear health formula...... 192 eletriptan hydrobromide...... 172 EPICOCCUM NIGRUM...... 16 ear health plus...... 192 ELIGARD...... 80 EPICORD...... 125 EASTERN COTTONWOOD...... 16 elinest...... 105 EPIFIX...... 125 EASY COMFORT INSULIN ELIQUIS...... 37 EPIFIX MICRONIZED...... 125 SYRINGE...... 166 ELIQUIS DVT/PE STARTER PACK...37 EPIFOAM...... 124 231 epinastine hcl...... 198 erythromycin base...... 152 E-Z JECT LANCET SUPER THIN epinephrine...... 222 erythromycin ethylsuccinate...... 152 30G...... 156 EPINEPHRINE...... 222 escitalopram oxalate...... 43 E-Z JECT LANCETS...... 156 epinephrine (anaphylaxis)...... 222 esgic...... 23 E-Z JECT LANCETS 21G...... 156 EPINEPHRINE HCL...... 198 ESKATA...... 124 E-Z JECT LANCETS THIN 26G...... 156 EPINEPHRINE HCL-NACL...... 222 esmolol hcl...... 95 ezetimibe...... 56 EPINEPHRINE PF...... 222 ESMOLOL HCL...... 96 ezetimibe-simvastatin...... 56 EPINEPHRINE-DEXTROSE...... 222 esmolol hcl-sodium chloride...... 96 EZ-LETS LANCETS 21G...... 156 EPINEPHRINE-NACL...... 222 esomeprazole sodium...... 217 EZ-LETS LANCETS 26G...... 156 epirubicin hcl...... 76 est estrogens-methyltest...... 132 EZ-LETS LANCETS 28G...... 156 epitol...... 39 estarylla...... 105 EZ-LETS LANCETS 30G...... 156 EPIVIR...... 92, 93 estazolam...... 145 fa-8...... 142 eplerenone...... 61 ESTRADIOL...... 133 FALESSA...... 105 epoprostenol sodium...... 100 estradiol...... 133, 221 falmina...... 105 eptifibatide...... 140 estradiol valerate...... 133 famciclovir...... 94 EPZICOM...... 90 estradiol-norethindrone acet...... 132 famotidine...... 217 eq aspirin...... 24 ESTRING...... 221 famotidine premixed...... 217 eq aspirin adult low dose...... 24 ESTROFACTORS...... 185 FANAPT...... 86 eq aspirin low dose...... 24 ESTROGEL...... 133 FANAPT TITRATION PACK...... 86 eq clearlax...... 147 ESTROSTEP FE...... 110 FARESTON...... 67 eq gentle laxative...... 149 eszopiclone...... 146 FARXIGA...... 48 eq magnesium citrate...... 148 ethacrynate sodium...... 127 FARYDAK...... 73 eq nicotine...... 211 ethacrynic acid...... 127 FASLODEX...... 78 eq nicotine polacrilex...... 211 ethambutol hcl...... 66 fa-vitamin b-6-vitamin b-12...... 142 eq nicotine step 3...... 211 ETHAMOLIN...... 179 fayosim...... 108 eql aspirin ec...... 24 ethosuximide...... 42 FC FEMALE CONDOM...... 152 eql aspirin low dose...... 24 ethynodiol diac-eth estradiol...... 105 FC2 FEMALE CONDOM...... 152 eql b complex 50...... 183 ETHYOL...... 83 febuxostat...... 139 eql b-100 complex...... 183 etodolac...... 21 feenamint...... 149 eql clearlax...... 147 etodolac er...... 21 felbamate...... 41 EQL COLOR LANCETS 21G...... 156 etomidate...... 137 FELDENE...... 21 EQL COLOR LANCETS MICRO 33G etonogestrel-ethinyl estradiol...... 108 felodipine er...... 98 ...... 156 ETOPOPHOS...... 80 FEMARA...... 78 eql gentle laxative...... 149 etoposide...... 80 FEMCAP...... 152 EQL INSULIN SYRINGE...... 167 etravirine...... 92 FEMHRT...... 132 eql laxative...... 149 EUCRISA...... 123 FEMRING...... 221 eql magnesium citrate...... 148 euthyrox...... 215 femynor...... 105 eql milk of magnesia...... 148 EVAMIST...... 133 fenofibrate...... 56 eql nicotine polacrilex...... 211 EVEKEO ODT...... 12 fenofibrate micronized...... 56 EQL PRENATAL FORMULA...... 187 everolimus...... 74, 177 fenofibric acid...... 56 eql super b complex/vitamin c...... 181 EVERSENSE SENSOR/HOLDER...... 156 FENOGLIDE...... 56 EQL SUPER THIN LANCETS 30G... 156 EVERSENSE SMART fenoprofen calcium...... 21 EQL THIN LANCETS 26G...... 156 TRANSMITTER...... 156 FENSOLVI (6 MONTH)...... 130 EQUETRO...... 86 EVISTA...... 131 fentanyl...... 27 ERAXIS...... 52 EVOCLIN...... 115 fentanyl citrate...... 26 ERBITUX...... 72 EVOMELA...... 81 FENTANYL CITRATE...... 26 ergocalciferol...... 223 EVOTAZ...... 90 FENTANYL CITRATE (PF)...... 26 ergoloid mesylates...... 211 EVOXAC...... 180 fentanyl citrate (pf)...... 26 ergotamine-caffeine...... 171 EXEL COMFORT POINT INSULIN FENTANYL CITRATE PF...... 26 ERIVEDGE...... 73 SYR...... 167 FENTANYL CITRATE-NACL...... 27 ERLEADA...... 67 EXEL COMFORT POINT PEN FENTANYL CIT-ROPIVACAINE- erlotinib hcl...... 72 NEEDLE...... 167 NACL...... 26 errin...... 109 EXELDERM...... 122 FENTANYL-BUPIVACAINE-NACL.. 26 ERTACZO...... 122 EXELON...... 207 FENTORA...... 27 ertapenem sodium...... 63 exemestane...... 78 FETROJA...... 104 ERWINASE...... 77 ex-lax ultra...... 149 FETZIMA...... 44 ERWINAZE...... 77 EXTAVIA...... 209 FETZIMA TITRATION...... 44 ery...... 115 EXTINA...... 122 fexmid...... 192 ERYGEL...... 115 EXTRANEAL...... 178 FIBRICOR...... 56 ery-tab...... 152 EYSUVIS...... 202 FIFTY50 PEN NEEDLES...... 167 ERYTHROCIN LACTOBIONATE.... 152 E-Z JECT LANCET MICRO-THIN FIFTY50 SAFETY SEAL LANCETS.157 erythrocin stearate...... 152 33G...... 156 FIFTY50 SUPERIOR COMFORT erythromycin...... 115, 152, 198 SYR...... 167 232 FIFTY50 UNILET LANCETS 33G.....157 fluticasone propionate...... 120, 194 fresenius propoven...... 137 FINACEA...... 123 fluticasone-salmeterol...... 34 frovatriptan succinate...... 172 finasteride...... 126, 138 fluvastatin sodium...... 56 FULL SPECTRUM B/VITAMIN C.... 181 FINE 30...... 157 fluvastatin sodium er...... 56 fulvestrant...... 79 FINGERSTIX LANCETS...... 157 fluvoxamine maleate...... 43 furosemide...... 127 FIRE ANT...... 16 fluvoxamine maleate er...... 43 FUROSEMIDE IN SODIUM FIRMAGON...... 79 FLUZONE QUADRIVALENT...... 220 CHLORIDE...... 127 FIRMAGON (240 MG DOSE)...... 79 FML...... 202 FUSARIUM...... 16 FIRVANQ...... 63 FML FORTE...... 202 FUZEON...... 91 flac...... 204 FML LIQUIFILM...... 202 fyavolv...... 132 FLAGYL...... 61 FOCALIN...... 13, 14 FYCOMPA...... 38 FLAREX...... 202 folate...... 142 g tussin ac...... 113 flavoxate hcl...... 219 FOLGARD OS...... 184 gabapentin...... 39 flecainide acetate...... 33 FOLGARD RX...... 142 galantamine hydrobromide...... 208 FLEXBUMIN...... 140 folic acid...... 142, 143 galantamine hydrobromide er...... 208 FLEXIN...... 125 FOLIVANE-OB...... 187 GALZIN...... 175 FLORIVA...... 173, 186 FOLOTYN...... 68 GAMIFANT...... 177 FLORIVA PLUS...... 186 foltabs 800...... 142 GAMUNEX-C...... 205 FLOVENT DISKUS...... 36 foltrin...... 143 ganciclovir sodium...... 93 FLOVENT HFA...... 36 fomepizole...... 50 GARDASIL 9...... 220 floxuridine...... 68 fondaparinux sodium...... 38 GASTROCROM...... 134 FLUAD...... 220 FORA LANCETS...... 157 gatifloxacin...... 198 FLUAD QUADRIVALENT...... 220 FORANE...... 137 GATTEX...... 135 FLUARIX QUADRIVALENT...... 220 FORMALDEHYDE...... 89 gavilax...... 147 FLUBLOK QUADRIVALENT...... 220 formoterol fumarate...... 35 gavilyte-c...... 147 FLUCELVAX QUADRIVALENT...... 220 FORTAZ...... 103 gavilyte-g...... 147 fluconazole...... 53 FORTEO...... 131 gavilyte-n with flavor pack...... 147 fluconazole in sodium chloride...... 53 FOSAMAX...... 128 GAVRETO...... 75 flucytosine...... 53 FOSAMAX PLUS D...... 128 GAZYVA...... 69 fludarabine phosphate...... 68 fosamprenavir calcium...... 91 GEL-FLOW NT...... 144 fludrocortisone acetate...... 112 fosaprepitant dimeglumine...... 52 GELFOAM...... 144 FLULAVAL QUADRIVALENT...... 220 foscarnet sodium...... 93 GELFOAM COMPRESSED SIZE 100 flumazenil...... 51 FOSCAVIR...... 93 ...... 144 flunisolide...... 194 fosfomycin tromethamine...... 64 GELFOAM DENTAL PACK SIZE 4..144 fluocinolone acetonide...... 120, 204 fosinopril sodium...... 58 GELFOAM SPONGE...... 144 fluocinolone acetonide body...... 120 fosinopril sodium-hctz...... 58 GELFOAM SPONGE SIZE 100...... 144 fluocinolone acetonide scalp...... 120 fosphenytoin sodium...... 42 GELFOAM SPONGE SIZE 200...... 144 fluocinonide...... 120 FOSRENOL...... 136 GELFOAM SPONGE SIZE 50...... 144 fluocinonide emulsified base...... 120 FOTIVDA...... 74 GEMCITABINE HCL...... 68 FLUORESCEIN FRAGMIN...... 38 gemcitabine hcl...... 68 SODIUM/BENOXINATE...... 199 FREAMINE HBC...... 195 gemfibrozil...... 56 fluorescein-benoxinate...... 200 FREAMINE III...... 195 gemmily...... 105 FLUORESCITE...... 200 FREDS PHARMACY UNIFINE GENERESS FE...... 105 fluoridex...... 180 PENTIP+...... 167 generlac...... 136 fluoridex daily renewal...... 180 FREDS PHARMACY UNIFINE gengraf...... 176 fluoridex enhanced whitening...... 180 PENTIPS...... 167 gentak...... 198 fluoridex sensitivity relief...... 179 FREDS PHARMACY UNILET LANC gentamicin in saline...... 19 fluor-i-strips a.t...... 200 28G...... 157 gentamicin sulfate...... 19, 116, 198 fluoritab...... 173 FREDS PHARMACY UNILET LANC GENTEEL BUTTERFLY TOUCH fluorometholone...... 202 30G...... 157 LANCET...... 157 FLUOROPLEX...... 117 FREESTYLE LANCETS...... 157 GENTEEL CONTACT TIPS (BLUE).157 fluorouracil...... 68, 117 FREESTYLE LIBRE 14 DAY GENTEEL CONTACT TIPS fluoxetine hcl...... 43 READER...... 157 (CLEAR)...... 157 FLUOXETINE HCL...... 43 FREESTYLE LIBRE 14 DAY GENTEEL CONTACT TIPS fluoxetine hcl (pmdd)...... 211 SENSOR...... 157 (GREEN)...... 157 fluphenazine decanoate...... 88 FREESTYLE LIBRE 2 READER...... 157 GENTEEL CONTACT TIPS fluphenazine hcl...... 88 FREESTYLE LIBRE 2 SENSOR...... 157 (ORANGE)...... 157 flurandrenolide...... 120 FREESTYLE LIBRE READER...... 157 GENTEEL CONTACT TIPS FLURA-SAFE...... 200 FREESTYLE LIBRE SENSOR (RAINBOW)...... 157 flurazepam hcl...... 145 SYSTEM...... 157 GENTEEL CONTACT TIPS flurbiprofen...... 21 FREESTYLE PRECISION INS SYR..167 (VIOLET)...... 157 flurbiprofen sodium...... 200 FREESTYLE UNISTICK II GENTEEL CONTACT TIPS flutamide...... 67 LANCETS...... 157 (YELLOW)...... 157 233 GENTEEL LANCING KIT (BLUE)... 157 gnp aspirin low dose...... 24 guanfacine hcl...... 60 GENTEEL NOZZLES...... 157 gnp b-100 complex...... 183 guanfacine hcl er...... 11 gentle laxative...... 149 gnp b-50 complex...... 183 GUARDIAN CONNECT gentlelax...... 147 gnp b-complex plus vitamin c...... 181 TRANSMITTER...... 158 GENTLE-LET GP LANCETS...... 157 gnp clearlax...... 147 GUARDIAN LINK 3 GENTLE-LET LANCETS...... 157 GNP CLICKFINE PEN NEEDLES.....167 TRANSMITTER...... 158 GENTLE-LET PLATFORMS...... 157 gnp essential one daily...... 185 GUARDIAN REAL-TIME REPLACE GENVOYA...... 90 gnp folic acid...... 143 PED...... 158 GEODON...... 86 gnp gentle laxative...... 149 GUARDIAN SENSOR (3)...... 158 GERMAN COCKROACH...... 16 GNP INSULIN SYRINGE...... 167 GUARDIAN SENSOR 3...... 158 GIAPREZA...... 222 GNP LANCETS 21G...... 157 GVOKE HYPOPEN 1-PACK...... 45 GILENYA...... 213 GNP LANCETS MICRO THIN 33G.. 157 GVOKE HYPOPEN 2-PACK...... 45 GILOTRIF...... 72 GNP LANCETS SUPER THIN 30G... 157 GVOKE PFS...... 46 GILPHEX TR...... 113 GNP LANCETS THIN...... 157 GYNAZOLE-1...... 221 GIMOTI...... 134 GNP LANCETS THIN 26G...... 158 habitrol...... 212 glatiramer acetate...... 210 gnp milk of magnesia...... 148 HACKBERRY...... 16 glatopa...... 210 gnp nicotine...... 212 HAEMOLANCE...... 158 GLEOSTINE...... 81 gnp nicotine mini...... 211 HAEMOLANCE LOW FLOW GLIADEL WAFER...... 81 gnp nicotine polacrilex...... 212 LANCETS...... 158 glimepiride...... 49 GNP PRENATAL...... 187 HAEMOLANCE PLUS...... 158 glipizide...... 49 GNP ULTICARE PEN NEEDLES...... 167 HAEMOLANCE PLUS HIGH FLOW 158 glipizide er...... 49 GNP ULTRA COM INSULIN HAEMOLANCE PLUS LOW FLOW.158 glipizide xl...... 49 SYRINGE...... 167 HAEMOLANCE PLUS MAX FLOW.158 glipizide-metformin hcl...... 48 gnp womens gentle laxative...... 149 HAEMOLANCE PLUS PEDIATRIC GLOBAL EASE INJECT PEN GOCOVRI...... 84 FLOW...... 158 NEEDLES...... 167 GOJJI STERILE LANCETS...... 158 hailey 1.5/30...... 105 GLOBAL EASY GLIDE INSULIN GOLDENROD...... 16 hailey 24 fe...... 105 SYR...... 167 GOLYTELY...... 147 hailey fe 1.5/30...... 105 GLOBAL EASY GLIDE PEN GONAL-F...... 130 hailey fe 1/20...... 105 NEEDLES...... 167 GONAL-F RFF...... 131 HALAVEN...... 80 GLOBAL INJECT EASE INSULIN GONAL-F RFF REDIJECT...... 130 halcinonide...... 120 SYR...... 167 GONITRO...... 31 HALCION...... 145 GLOBAL INJECT EASE LANCETS goodsense aspirin...... 24 HALDOL...... 87 28G...... 157 goodsense aspirin adult low st...... 24 HALDOL DECANOATE...... 87 GLOBAL INJECT EASE LANCETS goodsense aspirin adults...... 24 halobetasol propionate...... 120 30G...... 157 goodsense aspirin low dose...... 24 haloperidol...... 87 GLOBAL INSULIN SYRINGES...... 167 goodsense bisacodyl ec...... 149 haloperidol decanoate...... 87 GLOPERBA...... 139 goodsense clearlax...... 147 haloperidol lactate...... 87 GLUCAGEN HYPOKIT...... 45 GOODSENSE CLICKFINE PEN HARVONI...... 94 GLUCAGON EMERGENCY...... 45 NEEDLE...... 167 HAVRIX...... 220 GLUCOCOM LANCETS 28G...... 157 GOODSENSE COLOR LANCETS HEALTHWISE INSULIN GLUCOCOM LANCETS 30G...... 157 33G...... 158 SYR/NEEDLE...... 167 GLUCOCOM LANCETS 33G...... 157 GOODSENSE LANCETS 26G UNIV 158 HEALTHWISE MICRON PEN GLUCOPRO INSULIN SYRINGE..... 167 GOODSENSE LANCETS 30G...... 158 NEEDLES...... 167 GLUCOTROL XL...... 49 GOODSENSE LANCETS 30G UNIV 158 HEALTHWISE MINI PEN NEEDLES GLUTARALDEHYDE...... 89 GOODSENSE LANCETS 33G...... 158 ...... 167 GLUTATHIONE...... 196 GOODSENSE LANCETS 33G UNIV 158 HEALTHWISE PEN NEEDLES...... 167 glyburide...... 49 goodsense magnesium citrate...... 148 HEALTHWISE SHORT PEN glyburide micronized...... 49 goodsense nicotine...... 212 NEEDLES...... 167 glyburide-metformin...... 48 GOODSENSE PEN NEEDLE HEALTHWISE UNIFINE PENTIPS.. 167 GLYCATE...... 217 PENFINE...... 167 HEALTHY ACCENTS UNIFINE glycine...... 138 goodsense womens laxative...... 149 PENTIP...... 167 GLYCINE...... 196 GOPRELTO...... 194 HEALTHY ACCENTS UNILET glycine urologic...... 138 GRALISE...... 210 LANCETS...... 158 glycolax...... 147 granisetron hcl...... 51 healthy hair/skin/nails...... 185 glycopyrrolate...... 217 GRASS POLLEN(K-O-R-T-SWT healthylax...... 147 GLYCOPYRROLATE...... 217 VERN)...... 16 heather...... 109 GLYCOPYRROLATE PF...... 217 GRASTEK...... 16 h-e-b aspirin...... 24 glydo...... 122 griseofulvin microsize...... 53 H-E-B INCONTROL LANCETS 28G 158 GLYNASE...... 49 griseofulvin ultramicrosize...... 53 H-E-B INCONTROL LANCETS 30G 158 GLYRX-PF...... 217, 218 guaiatussin ac...... 113 H-E-B INCONTROL LANCETS 33G 158 gnp adult aspirin low strength...... 24 guaifenesin ac...... 113 H-E-B INCONTROL PEN NEEDLES 167 gnp aspirin...... 24 guaifenesin-codeine...... 113 234 H-E-B INCONTROL UNIFINE HUMATIN...... 19 ibu...... 21 PENTIP...... 168 HUMATROPE...... 129 ibuprofen...... 21 HECTOROL...... 130 HUMIRA...... 20 ibuprofen lysine...... 21 HELIDAC THERAPY...... 218 HUMIRA PEDIATRIC CROHNS ibutilide fumarate...... 34 HEMABATE...... 204 START...... 19 icatibant acetate...... 139 HEMADY...... 111 HUMIRA PEN...... 19, 20 iclevia...... 108 HEMANGEOL...... 96 HUMIRA PEN-CD/UC/HS STARTER.20 ICLUSIG...... 71 heparin (porcine) in nacl...... 37 HUMIRA PEN-PEDIATRIC UC icosapent ethyl...... 55 HEPARIN (PORCINE) IN NACL...... 37 START...... 20 IDAMYCIN PFS...... 76 heparin lock flush...... 37 HUMIRA PEN-PS/UV/ADOL HS idarubicin hcl...... 76 HEPARIN SOD (PORCINE) IN D5W..37 START...... 20 IDHIFA...... 79 heparin sod (porcine) in d5w...... 37 HUMIRA PEN-PSOR/UVEIT IFEX...... 81 heparin sodium (porcine)...... 37 STARTER...... 20 ifosfamide...... 81 HEPARIN SODIUM (PORCINE)...... 38 HUMULIN 70/30...... 47 IFOSFAMIDE...... 81 heparin sodium (porcine) pf...... 38 HUMULIN 70/30 KWIKPEN...... 46 ILEVRO...... 200 HEPARIN SODIUM (PORCINE) PF....38 HUMULIN N...... 47 ILIDERM...... 123 heparin sodium lock flush...... 38 HUMULIN N KWIKPEN...... 47 imatinib mesylate...... 71 HEPLISAV-B...... 220 HUMULIN R...... 47 IMBRUVICA...... 72 HERCEPTIN...... 70 HUMULIN R U-500 IMFINZI...... 71 HERCEPTIN HYLECTA...... 77 (CONCENTRATED)...... 47 imipenem-cilastatin...... 62 HERZUMA...... 70 HUMULIN R U-500 KWIKPEN...... 47 imipramine hcl...... 45 HESPAN...... 140 HYALURONIDASE imipramine pamoate...... 45 hetastarch-nacl...... 140 (INTRAOCULAR)...... 203 imiquimod...... 122 HEXTEND...... 140 HYCAMTIN...... 83 imiquimod pump...... 122 HIBERIX...... 219 HYCODAN...... 112 IMLYGIC...... 81 HIGH POTENCY MULTIVITAMIN..185 hydralazine hcl...... 61 IMOVAX RABIES...... 220 HIPREX...... 65 HYDREA...... 78 IMPAVIDO...... 61 HISTEX-AC...... 114 hydrochlorothiazide...... 128 IMURAN...... 179 hm adult aspirin...... 24 hydrocod polst-cpm polst er...... 114 IMVEXXY MAINTENANCE PACK. 221 hm aspirin...... 24 hydrocodone bitartrate er...... 27 IMVEXXY STARTER PACK...... 222 hm aspirin ec...... 24 hydrocodone-acetaminophen...... 26 IN TOUCH STERILE LANCETS 30G hm aspirin ec low dose...... 24 hydrocodone-homatropine...... 112, 113 ...... 158 hm b complex/c...... 182 hydrocodone-ibuprofen...... 26 inatal gt...... 187 hm clearlax...... 147 hydrocortisone...... 30, 111, 121 incassia...... 109 hm folic acid...... 143 hydrocortisone (perianal)...... 31 indapamide...... 128 hm laxative...... 149 hydrocortisone ace-pramoxine...... 31 INDERAL XL...... 96 hm magnesium citrate...... 148 hydrocortisone butyr lipo base...... 120 indomethacin...... 21 hm milk of magnesia...... 148 hydrocortisone butyrate...... 120, 121 indomethacin er...... 21 hm nicotine...... 212 hydrocortisone valerate...... 121 indomethacin sodium...... 21 hm nicotine polacrilex...... 212 hydrocortisone-acetic acid...... 204 INFANRIX...... 215 HM ONE DAILY PRENATAL...... 187 hydromet...... 113 INFASURF...... 213 hm one daily/iron...... 184 hydromorphone hcl...... 27 INFLECTRA...... 137 HM PRENATAL...... 187 hydromorphone hcl er...... 27 INFUGEM...... 68 HM ULTICARE INSULIN SYRINGE168 HYDROMORPHONE HCL PF...... 27 INFUMORPH 200...... 27 HM ULTICARE MINI PEN hydromorphone hcl pf...... 27 INFUMORPH 500...... 27 NEEDLES...... 168 HYDROMORPHONE HCL-NACL...... 27 INFUVITE ADULT...... 185 HM ULTICARE SHORT PEN hydroxocobalamin acetate...... 142 INFUVITE PEDIATRIC...... 186 NEEDLES...... 168 hydroxychloroquine sulfate...... 65 INGREZZA...... 208 hm vitamin b complex/vitamin c...... 181 hydroxyprogesterone caproate...... 82, 206 INLYTA...... 83 hm vitamin b100 complex...... 183 hydroxyurea...... 78 inner ear plus...... 192 hm vitamin b50 complex...... 183 hydroxyzine hcl...... 32 INNOPRAN XL...... 96 HONEY BEE VENOM...... 16 hydroxyzine pamoate...... 32 INQOVI...... 77 HONEY BEE VENOM PROTEIN...... 16 HYLENEX...... 176 INREBIC...... 79 HORIZANT...... 211 hyoscyamine sulfate...... 216 INSPRA...... 61 HORSE EPITHELIUM...... 16 hyoscyamine sulfate er...... 216 INSTAT...... 144 HUMALOG...... 46 hyoscyamine sulfate sl...... 216 INSULIN LISPRO...... 47 HUMALOG JUNIOR KWIKPEN...... 46 HYPERSAL...... 113 INSULIN LISPRO (1 UNIT DIAL)...... 47 HUMALOG KWIKPEN...... 46 HYPERTET S/D...... 205 INSULIN LISPRO JUNIOR HUMALOG MIX 50/50...... 46 HYPOLANCE AST LANCING...... 158 KWIKPEN...... 47 HUMALOG MIX 50/50 KWIKPEN..... 46 HY-VEE LANCETS...... 158 INSULIN LISPRO PROT & LISPRO... 47 HUMALOG MIX 75/25...... 46 HY-VEE THIN LANCETS...... 158 INSULIN SYRINGE...... 168 HUMALOG MIX 75/25 KWIKPEN..... 46 ibandronate sodium...... 128, 129 INSULIN SYRINGE/NEEDLE...... 168 HUMAN ALBUMIN GRIFOLS...... 140 IBRANCE...... 78 INSULIN SYRINGE-NEEDLE U-100168 235 INSUPEN PEN NEEDLES...... 168 jencycla...... 109 KISQALI (400 MG DOSE)...... 78 INSUPEN SENSITIVE...... 168 JENLIVA PRENATAL/POSTNATAL187 KISQALI (600 MG DOSE)...... 78 INSUPEN ULTRAFIN...... 168 JEVTANA...... 80 KISQALI FEMARA (400 MG DOSE)..77 INTELENCE...... 92 jinteli...... 132 KISQALI FEMARA (600 MG DOSE)..77 INTERCEED...... 144 JOHNSON GRASS...... 16 KISQALI FEMARA(200 MG DOSE)...77 INTERCEED (TC7)...... 144 jolessa...... 109 KLARON...... 115 INTRALIPID...... 196 JORNAY PM...... 14 KLISYRI...... 123 INTRAROSA...... 221 JUBLIA...... 122 klor-con...... 174 introvale...... 109 juleber...... 105 klor-con 10...... 174 INVANZ...... 63 JULUCA...... 90 klor-con m10...... 174 INVEGA SUSTENNA...... 86 JUNE GRASS POLLEN klor-con m15...... 174 INVEGA TRINZA...... 86 STANDARDIZED...... 16 klor-con m20...... 174 INVELTYS...... 202 junel 1.5/30...... 105 kls aspirin low dose...... 24 INVIRASE...... 91 junel 1/20...... 105 kls laxaclear...... 148 IODINE TINCTURE...... 89 junel fe 1.5/30...... 105 kls quit2...... 212 IODOFLEX...... 89 junel fe 1/20...... 105 kls quit4...... 212 IODOSORB...... 89 junel fe 24...... 105 KMART VALU INSULIN SYRINGE IONOSOL-MB IN D5W...... 173 JUXTAPID...... 57 29G...... 168 IOPIDINE...... 201 KABIVEN...... 196 KMART VALU INSULIN SYRINGE IPOL...... 220 KADCYLA...... 76 30G...... 168 ipratropium bromide...... 35, 194 kaitlib fe...... 105 kobee...... 182 ipratropium-albuterol...... 34 KALETRA...... 90 KOCHIA...... 16 irbesartan...... 59 kalliga...... 105 KOSELUGO...... 73 irbesartan-hydrochlorothiazide...... 59 KANJINTI...... 70 KOSHER PRENATAL PLUS IRON...187 IRESSA...... 72 KANUMA...... 130 kp aspirin...... 24 irinotecan hcl...... 83 KAPOK...... 16 kp b complex-c...... 181 ISENTRESS...... 91 KAPSPARGO SPRINKLE...... 96 kp bisacodyl...... 149 ISENTRESS HD...... 91 KAPVAY...... 11 kp folic acid...... 143 isibloom...... 105 KARBINAL ER...... 54 KP PRENATAL MULTIVITAMINS..187 isoflurane...... 137 KARDIAMEMBRANE...... 125 K-PHOS...... 174 ISOLYTE-P IN D5W...... 173 kariva...... 104 K-PHOS NO 2...... 138 ISOLYTE-S...... 173 KATERZIA...... 98 K-PHOS-NEUTRAL...... 174 ISOLYTE-S PH 7.4...... 173 KCENTRA...... 139 KPN PRENATAL...... 187 isoniazid...... 66 KCL (IN NACL 0.9%)...... 173 KRINTAFEL...... 65 isoproterenol hcl...... 35 kcl in dextrose-nacl...... 173 KRISTALOSE...... 148 ISOPROTERENOL-SODIUM KCL IN DEXTROSE-NACL...... 173 KROGER HEALTHPRO LANCET CHLORIDE...... 35 KCL-LACTATED RINGERS-D5W... 173 26G...... 158 ISOPTO ATROPINE...... 197 KEDBUMIN...... 140 KROGER INSULIN SYRINGE...... 168 ISOPTO CARPINE...... 198 KEFLEX...... 102 KROGER LANCETS...... 158 ISORDIL TITRADOSE...... 31 kelnor 1/35...... 105 KROGER LANCETS 21G...... 158 isosorbide dinitrate...... 31 kelnor 1/50...... 105 KROGER LANCETS MICRO THIN isosorbide mononitrate...... 31 KENALOG...... 111 33G...... 158 isosorbide mononitrate er...... 31 KENALOG-80...... 111 KROGER LANCETS SUPER THIN...158 isotretinoin...... 115 KENDALL HYDROGEL WOUND KROGER LANCETS THIN...... 158 isradipine...... 98 DRESS...... 126 KROGER LANCETS THIN 26G...... 158 ISTODAX (OVERFILL)...... 73 KENGREAL...... 140 KROGER LANCETS ULTRATHIN ISUPREL...... 35 KETALAR...... 137 30G...... 159 itraconazole...... 53 ketamine hcl...... 137 KROGER PEN NEEDLES...... 168 ivermectin...... 31, 123, 124 KETAMINE HCL...... 137 K-TAB...... 174 IXEMPRA KIT...... 80 KETAMINE HCL-SODIUM kurvelo...... 105 IXIARO...... 220 CHLORIDE...... 137 KYNMOBI...... 85 jaimiess...... 109 ketoconazole...... 53, 122 KYPROLIS...... 75 JAKAFI...... 79 ketoprofen...... 21 labetalol hcl...... 95 JALYN...... 139 ketoprofen er...... 21 LABETALOL HCL-DEXTROSE...... 95 jantoven...... 37 ketorolac tromethamine...... 21, 201 LABETALOL HCL-SODIUM JANUMET...... 46 KEYTRUDA...... 71 CHLORIDE...... 95 JANUMET XR...... 46 KHAPZORY...... 79 lactated ringers...... 173, 177 JANUVIA...... 46 KIMYRSA...... 63 LACTIC ACID...... 121 JARDIANCE...... 48 KINNEY LANCETS...... 158 LACTIC ACID E...... 121 jasmiel...... 105 KINNEY THIN LANCETS...... 158 LACTULOSE...... 148 JATENZO...... 30 KINRAY INSULIN SYRINGE...... 168 lactulose...... 148 JELMYTO...... 76 KINRIX...... 215 lactulose encephalopathy...... 136 JEMPERLI...... 71 KISQALI (200 MG DOSE)...... 78 lamivudine...... 93 236 lamivudine-zidovudine...... 90 levocarnitine...... 129 lipoflavovit...... 192 lamotrigine...... 40 levocarnitine sf...... 129 LIPOTRIAD...... 192 lamotrigine er...... 39, 40 levocetirizine dihydrochloride...... 54 lisinopril...... 58 lamotrigine starter kit-blue...... 40 levofloxacin...... 134, 198 lisinopril-hydrochlorothiazide...... 58 lamotrigine starter kit-green...... 40 levofloxacin in d5w...... 134 LITE TOUCH LANCETS...... 159 lamotrigine starter kit-orange...... 40 levoleucovorin calcium...... 79 LITETOUCH INSULIN SYRINGE.... 168 LAMPIT...... 62 levoleucovorin calcium pf...... 79 LITETOUCH LANCETS...... 159 LANCET TRANSPORTER CASE...... 159 levonest...... 110 LITETOUCH PEN NEEDLES...... 168 LANCETS...... 159 levonorgest-eth est & eth est...... 109 lithium carbonate...... 85, 86 LANCETS 30G...... 159 levonorgest-eth estrad 91-day...... 109 lithium carbonate er...... 85 LANCETS 33G...... 159 levonorgestrel...... 108 LITHOSTAT...... 139 LANCETS MICRO THIN 33G...... 159 levonorgestrel-ethinyl estrad...... 106, 108 LIVE BETTER LANCET SUPER LANCETS SUPER THIN 28G...... 159 levonorg-eth estrad triphasic...... 110 THIN...... 159 LANCETS THIN...... 159 LEVOPHED...... 222 LIVE BETTER LANCET ULTRA LANCETS ULTRA THIN...... 159 levora 0.15/30 (28)...... 106 THIN...... 159 LANCETS ULTRA THIN 30G...... 159 levorphanol tartrate...... 27 lmd in d5w...... 140 LANOXIN...... 99 levo-t...... 215 lmd in nacl...... 140 LANOXIN PEDIATRIC...... 99 LEVOTHYROXINE SODIUM...... 215 LO LOESTRIN FE...... 104 lanthanum carbonate...... 136 levothyroxine sodium...... 215 LODINE...... 21 LANTUS...... 47 levoxyl...... 215 LODOSYN...... 85 LANTUS SOLOSTAR...... 47 LEVULAN KERASTICK...... 123 loestrin 1.5/30 (21)...... 106 lapatinib ditosylate...... 74 LEXIVA...... 91 loestrin 1/20 (21)...... 106 larin 1.5/30...... 106 LIBERTY MEDICAL LANCETS...... 159 loestrin fe 1.5/30...... 106 larin 1/20...... 106 LIBRAX...... 216 loestrin fe 1/20...... 106 larin 24 fe...... 106 LIBTAYO...... 71 lojaimiess...... 109 larin fe 1.5/30...... 106 lidocaine...... 122 LOKELMA...... 178 larin fe 1/20...... 106 LIDOCAINE (ANORECTAL)...... 31 LOMAIRA...... 12 larissia...... 106 lidocaine hcl...... 122, 151, 179 LOMOTIL...... 49 LASIX...... 127 LIDOCAINE HCL...... 151 LONGS INSULIN SYRINGE...... 168 latanoprost...... 203 LIDOCAINE HCL (CARDIAC)...... 33 LONGS LANCETS STANDARD...... 159 LATISSE...... 123 lidocaine hcl (cardiac)...... 33 LONGS LANCETS THIN...... 159 LATUDA...... 86 LIDOCAINE HCL (CARDIAC) PF...... 33 LONGS LANCETS ULTRA THIN.....159 laxative...... 149 lidocaine hcl (cardiac) pf...... 33 LONHALA MAGNAIR REFILL KIT.. 35 layolis fe...... 106 lidocaine hcl (pf)...... 151 LONHALA MAGNAIR STARTER LEADER INSULIN SYRINGE...... 168 lidocaine hcl urethral/mucosal...... 123 KIT...... 35 LEADER UNIFINE PENTIPS...... 168 lidocaine in d5w...... 33 LONSURF...... 77 LEADER UNIFINE PENTIPS PLUS..168 LIDOCAINE IN DEXTROSE...... 151 loperamide hcl...... 49 leena...... 110 lidocaine viscous hcl...... 179 LOPID...... 56 leflunomide...... 22 lidocaine-epinephrine...... 150 lopinavir-ritonavir...... 90 LENSCALE...... 16 LIDOCAINE-EPINEPHRINE...... 200 LOPROX...... 116 LENVIMA (10 MG DAILY DOSE)...... 83 LIDOCAINE-PHENYLEPHRINE...... 200 lorazepam...... 32, 33 LENVIMA (12 MG DAILY DOSE)...... 83 LIDOCAINE-PHENYLEPHRINE- lorazepam intensol...... 33 LENVIMA (14 MG DAILY DOSE)...... 83 BSS...... 200 LORBRENA...... 69 LENVIMA (18 MG DAILY DOSE)...... 83 lidocaine-prilocaine...... 125 loryna...... 106 LENVIMA (20 MG DAILY DOSE)...... 83 LIDOCAINE-SODIUM lorzone...... 192 LENVIMA (24 MG DAILY DOSE)...... 83 BICARBONATE...... 150 losartan potassium...... 59 LENVIMA (4 MG DAILY DOSE)...... 83 LIFESCAN UNISTIK 2...... 159 losartan potassium-hctz...... 59 LENVIMA (8 MG DAILY DOSE)...... 83 LIFESCAN UNISTIK II LANCETS... 159 LOSEASONIQUE...... 109 lessina...... 106 LILETTA (52 MG)...... 109 LOTEMAX...... 202 letrozole...... 78 lillow...... 106 LOTEMAX SM...... 202 leucovorin calcium...... 79 LINCOCIN...... 64 LOTENSIN...... 58 LEUKERAN...... 81 lincomycin hcl...... 64 LOTENSIN HCT...... 58 leuprolide acetate...... 80 lindane...... 124 loteprednol etabonate...... 202 LEUPROLIDE ACETATE- linezolid...... 64 LOTRONEX...... 135 BUPIVACAINE...... 73 linezolid in sodium chloride...... 64 lovastatin...... 56 levalbuterol hcl...... 35 LINZESS...... 135 low-ogestrel...... 106 levalbuterol tartrate...... 35 LIORESAL...... 192 loxapine succinate...... 88 LEVEMIR...... 47 liothyronine sodium...... 215 lo-zumandimine...... 106 LEVEMIR FLEXTOUCH...... 47 LIPO...... 196 lubiprostone...... 134 levetiracetam...... 40 lipo flavonoid plus...... 192 LUCEMYRA...... 207 levetiracetam er...... 40 LIPO-B...... 142 luliconazole...... 122 LEVETIRACETAM IN NACL...... 40 LIPO-C...... 196 LUMAKRAS...... 73 levobunolol hcl...... 197 LIPOFEN...... 56 LUMIGAN...... 203 237 LUMOXITI...... 69 MAXZIDE...... 127 MEPHYTON...... 223 LUPRON DEPOT (1-MONTH)...... 80 MAXZIDE-25...... 127 meprobamate...... 32 LUPRON DEPOT (3-MONTH)...... 80 MAYZENT...... 213 MEPRON...... 62 LUPRON DEPOT (4-MONTH)...... 80 MAYZENT STARTER PACK...... 213 mercaptopurine...... 68 LUPRON DEPOT (6-MONTH)...... 80 M-CLEAR WC...... 113 meropenem...... 63 LUTATHERA...... 77 MEADOW FESCUE GRASS MEROPENEM-SODIUM CHLORIDE.63 lutera...... 106 POLLEN...... 16 merzee...... 106 LUZU...... 122 meclizine hcl...... 52 mesalamine...... 135 lyleq...... 110 meclofenamate sodium...... 21 mesalamine er...... 135 lyllana...... 133 MEDIC INSULIN SYRINGE...... 168 mesalamine-cleanser...... 135 LYNPARZA...... 82 MEDICHOICE SAFETY LANCET....159 mesna...... 83 LYRICA CR...... 210 MEDICHOICE SAFETY LANCET MESNEX...... 83 LYSINE HCL...... 196 EXTRA...... 159 MESQUITE...... 17 LYSODREN...... 67 MEDICHOICE SAFETY LANCET MESTINON...... 65 LYSTEDA...... 144 NORM...... 159 metaxalone...... 192 lyza...... 110 MEDICINE SHOPPE PEN NEEDLES168 metformin hcl...... 45 M.V.I. ADULT...... 185 MEDISENSE THIN LANCETS...... 159 metformin hcl er...... 45 M.V.I. PEDIATRIC...... 186 MEDLANCE EXTRA 21G...... 159 METHADONE HCL...... 27 MACROBID...... 65 MEDLANCE LITE 25G...... 159 methadone hcl...... 27 MACRODANTIN...... 65 MEDLANCE PLUS EXTRA 21G...... 159 methadone hcl intensol...... 27 mafenide acetate...... 119 MEDLANCE PLUS LANCETS...... 159 METHADOSE...... 27 MAGELLAN INSULIN SAFETY MEDLANCE PLUS LITE 25G...... 159 methadose...... 27 SYR...... 168 MEDLANCE PLUS SPECIAL 0.8MM METHADOSE SUGAR-FREE...... 27 magnesium citrate...... 148 ...... 159 methazolamide...... 127 MAGNESIUM SULFATE...... 174 MEDLANCE PLUS SUPERLITE 30G methenamine hippurate...... 65 MAGNESIUM SULFATE IN D5W....174 ...... 159 methergine...... 204 MAKENA...... 206, 207 MEDLANCE PLUS UNIVERSAL methimazole...... 214 MALARONE...... 65 21G...... 159 methocarbamol...... 193 malathion...... 124 MEDLANCE UNIVERSAL 21G...... 159 METHOHEXITAL SODIUM...... 137 manganese chloride...... 174 MEDROL...... 111 methotrexate...... 68 mannitol...... 127 medroxyprogesterone acetate...... 109, 207 methotrexate sodium...... 68 MARATHON MEDICAL PENTIPS...168 mefenamic acid...... 21 methotrexate sodium (pf)...... 68 MARCAINE...... 151 mefloquine hcl...... 65 methoxsalen rapid...... 118 MARCAINE PRESERVATIVE FREE151 mega multiple/chelated mineral...... 192 methscopolamine bromide...... 218 MARCAINE SPINAL...... 151 megestrol acetate...... 82, 207 METHYLCOBALAMIN...... 142 MARCAINE/EPINEPHRINE...... 150 meijer aspirin ec...... 24 methyldopa...... 60 MARCAINE/EPINEPHRINE PF...... 150 MEIJER LANCETS...... 159 methylergonovine maleate...... 204 MAR-COF BP...... 114 MEIJER LANCETS THIN...... 159 METHYLIN...... 14 MAR-COF CG EXPECTORANT...... 113 MEIJER LANCETS UNIVERSAL methylphenidate hcl...... 14 MARGENZA...... 70 21G...... 159 methylphenidate hcl er...... 14 MARINOL...... 52 MEIJER LANCETS UNIVERSAL METHYLPHENIDATE HCL ER...... 14 marlissa...... 106 30G...... 159 methylphenidate hcl er (cd)...... 14 MARPLAN...... 43 MEIJER LANCETS UNIVERSAL methylphenidate hcl er (la)...... 14 MARQIBO...... 80 33G...... 159 methylphenidate hcl er (xr)...... 14 MATULANE...... 78 MEIJER PEN NEEDLES...... 168 methylprednisolone...... 111 matzim la...... 98 MEIJER SUPER THIN LANCETS.....160 methylprednisolone sodium succ...... 112 MAVENCLAD (10 TABS)...... 209 MEKINIST...... 73 metoclopramide hcl...... 134, 135 MAVENCLAD (4 TABS)...... 209 MEKTOVI...... 73 METOCLOPRAMIDE HCL...... 135 MAVENCLAD (5 TABS)...... 209 MELALEUCA...... 16 metolazone...... 128 MAVENCLAD (6 TABS)...... 209 meloxicam...... 21 metoprolol succinate er...... 96 MAVENCLAD (7 TABS)...... 209 melphalan...... 81 metoprolol tartrate...... 96 MAVENCLAD (8 TABS)...... 209 melphalan hcl...... 81 metoprolol-hydrochlorothiazide...... 61 MAVENCLAD (9 TABS)...... 209 memantine hcl...... 210 METROCREAM...... 124 MAXICOMFORT II PEN NEEDLE... 168 memantine hcl er...... 210 metronidazole...... 62, 124, 221 MAXI-COMFORT INSULIN MEMBRANEBLUE...... 203 metronidazole in nacl...... 62 SYRINGE...... 168 MENACTRA...... 219 METRONIDAZOLE IN NACL...... 62 MAXI-COMFORT SAFETY PEN M-END PE...... 114 metyrosine...... 58 NEEDLE...... 168 MENEST...... 133 mexiletine hcl...... 33 MAXICOMFORT SYR 27G X 1/2"....168 MENOSTAR...... 133 MI PASTE...... 153 MAXIDEX...... 202 MENQUADFI...... 219 MI PASTE PLUS...... 153 MAXITROL...... 201 MENTAX...... 116 mibelas 24 fe...... 106 maxi-tuss ac...... 113 MENVEO...... 219 micafungin sodium...... 52 MAXI-TUSS CD...... 114 meperidine hcl...... 27 miconazole 3...... 221 238 miconazole-zinc oxide-petrolat...... 116 MM INSULIN SYRINGE/NEEDLE...168 multiple vitamins/iron...... 184 MICRODOT PEN NEEDLE...... 168 MM PEN NEEDLES...... 168 multi-vit/iron/fluoride...... 186 microgestin 1.5/30...... 106 MM TWIST LANCETS...... 160 MULTIVITAMIN...... 185 microgestin 1/20...... 106 M-M-R II...... 219 multi-vitamin...... 185 microgestin 24 fe...... 106 M-NATAL PLUS...... 187 MULTIVITAMIN ADULT...... 185 microgestin fe 1.5/30...... 106 modafinil...... 14 multi-vitamin daily...... 185 microgestin fe 1/20...... 106 moexipril hcl...... 58 multivitamin iron-free...... 185 MICROLET LANCETS...... 160 molindone hcl...... 88 multivitamin plus iron adult...... 184 MIDAZOLAM...... 146 mometasone furoate...... 121, 194 multivitamin select/fluoride...... 186 midazolam hcl...... 145 mondoxyne nl...... 214 MULTIVITAMIN/FLUORIDE...... 183 midazolam hcl (pf)...... 145 MONJUVI...... 69 multivitamin/fluoride...... 186 MIDAZOLAM HCL-SODIUM MONOFERRIC...... 143 multi-vitamin/fluoride...... 186 CHLORIDE...... 145 MONOJECT BONE MARROW multi-vitamin/fluoride/iron...... 186 MIDAZOLAM-SODIUM CHLORIDE BIOPSY...... 151 multi-vitamin/iron...... 184 ...... 146 monoject flush syringe...... 174 mupirocin...... 116 midodrine hcl...... 223 MONOJECT INSULIN SYRINGE..... 168 mupirocin calcium...... 116 MIFEPREX...... 128 monoject sodium chloride flush...... 174 MUSE...... 100 mifepristone...... 128 MONOJECT ULTRA COMFORT mutamycin...... 76 migergot...... 171 SYRINGE...... 168 MVASI...... 83 miglitol...... 45 MONOLET LANCETS...... 160 my choice...... 108 miglustat...... 142 MONOLET OPD LANCETS...... 160 my way...... 108 mili...... 106 MONOLETTOR SAFETY LANCETS160 MYAMBUTOL...... 66 milk of magnesia...... 149 mono-linyah...... 106 MYCAMINE...... 52 milk of magnesia concentrate...... 148 MONOVISC...... 193 MYCOBUTIN...... 66 millguard...... 142 montelukast sodium...... 36 mycophenolate mofetil...... 177 MILLIPRED...... 112 MONUROL...... 65 mycophenolate mofetil hcl...... 177 milrinone lactate...... 100 morgidox...... 214 mycophenolate sodium...... 177 milrinone lactate in dextrose...... 99 MORPHINE SULFATE...... 28 MYDAYIS...... 11 mimvey...... 132 morphine sulfate...... 28 MYDRIACYL...... 197 MINASTRIN 24 FE...... 106 morphine sulfate (concentrate)...... 27 MYFEMBREE...... 133 mineral oil heavy...... 148 morphine sulfate (pf)...... 27 MYFORTIC...... 177 MINILINK REAL-TIME MORPHINE SULFATE (PF)...... 28 MYGLUCOHEALTH LANCETS 30G TRANSMITTER...... 160 morphine sulfate er...... 28 ...... 160 MINIMED 630G GUARDIAN PRESS morphine sulfate er beads...... 28 MYLERAN...... 66 ...... 160 MORPHINE SULFATE-NACL...... 28 MYLOTARG...... 70 MINIMED GUARDIAN LINK 3...... 160 MOTOFEN...... 49 MYNATAL...... 187 MINIPRESS...... 60 MOUNTAIN CEDAR...... 17 MYNATAL PLUS...... 187 minitran...... 31 MOUSE EPITHELIUM...... 17 MYNATAL-Z...... 187 MINOCIN...... 214 MOVANTIK...... 136 myorisan...... 115 minocycline hcl...... 214 MOVIPREP...... 147 MYRBETRIQ...... 218 minocycline hcl er...... 214 MOXEZA...... 198 MYTESI...... 49 minoxidil...... 61 MOXIFLOXACIN HCL...... 134, 198 MYXREDLIN...... 47 MIOCHOL-E...... 198 moxifloxacin hcl...... 134, 198 na ferric gluc cplx in sucrose...... 143 MIOSTAT...... 198 moxifloxacin hcl (2x day)...... 198 nabumetone...... 21 MIRAPEX...... 85 moxifloxacin hcl in nacl...... 134 n-acetyl-l-cysteine...... 196 MIRAPEX ER...... 85 MPD SAFETY LANCET 21G...... 160 nadolol...... 96 MIRCETTE...... 104 MPD SAFETY LANCET 23G...... 160 nafcillin sodium...... 206 MIRENA (52 MG)...... 109 MPD SAFETY LANCET 28G...... 160 NAFCILLIN SODIUM IN mirtazapine...... 42 MPD SAFETY LANCET 30G...... 160 DEXTROSE...... 206 MIRVASO...... 124 MS INSULIN SYRINGE...... 168 nafrinse...... 173 misoprostol...... 218 MUCOR...... 17 NAFRINSE DAILY ACIDULATED.. 180 MITE (D. FARINAE)...... 17 MUGWORT...... 17 NAFRINSE DAILY/NEUTRAL...... 180 MITE (D. PTERONYSSINUS)...... 17 MULTAQ...... 34 nafrinse drops...... 173 mitigo...... 27 MULTI PRENATAL...... 187 NAFRINSE WEEKLY...... 180 mitomycin...... 76 MULTI VITAMIN...... 185 naftifine hcl...... 117 MITOMYCIN...... 76, 198 multi vitamin daily...... 185 NAFTIN...... 117 MITOSOL...... 198 MULTI VITAMIN W/D-3...... 185 nalbuphine hcl...... 29 mitoxantrone hcl...... 76 multi-day...... 185 naloxone hcl...... 51 MIXED ASPERGILLUS...... 19 multi-day plus iron...... 184 naltrexone hcl...... 51 MIXED FEATHERS...... 19 MULTI-LANCET DEVICE 2...... 160 NAMENDA TITRATION PAK...... 210 MIXED RAGWEED...... 17 multiple vitamin-folic acid...... 185 NAMZARIC...... 207 MIXED VESPID VENOM PROTEIN.. 17 multiple vitamins...... 185 naproxen...... 21 mm clearlax...... 148 multiple vitamins essential...... 185 naproxen sodium...... 21 239 naratriptan hcl...... 172 NEXLETOL...... 55 norethindrone...... 110 NARCAN...... 51 NEXLIZET...... 55 norethindrone acetate...... 207 NARDIL...... 43 NEXTERONE...... 34 norethindrone acet-ethinyl est...... 106 NAROPIN...... 151 NEXTSTELLIS...... 106 norethindrone-eth estradiol...... 132 NATACHEW...... 187 niacin (antihyperlipidemic)...... 57 norethin-eth estradiol-fe...... 107 NATACYN...... 199 niacin er (antihyperlipidemic)...... 57 norgestimate-eth estradiol...... 107 NATALVIT...... 187 niacor...... 57 norgestim-eth estrad triphasic...... 110 NATAZIA...... 109 NIASPAN...... 57 NORITATE...... 124 nateglinide...... 48 nicardipine hcl...... 98 norlyda...... 110 NATPARA...... 131 NICARDIPINE HCL IN NACL...... 98 norlyroc...... 110 NATROBA...... 124 NICODERM CQ...... 212 normal saline flush...... 175 nat-rul b-50...... 192 NICORETTE...... 212 NORMOSOL-M IN D5W...... 173 nat-rul daily-vite+iron...... 184 NICORETTE MINI...... 212 NORMOSOL-R...... 173 NATURE-THROID...... 215 NICORETTE STARTER KIT...... 212 NORMOSOL-R IN D5W...... 173 NAVELBINE...... 80 NICOTINE...... 212 NORMOSOL-R PH 7.4...... 173 NAYZILAM...... 39 nicotine...... 212 NORPACE...... 33 NEBUPENT...... 62 nicotine mini...... 212 NORPACE CR...... 33 necon 0.5/35 (28)...... 106 nicotine polacrilex...... 212 NORPRAMIN...... 45 NEEVO DHA...... 187 nicotine polacrilex mini...... 212 NORTHERA...... 222 nefazodone hcl...... 44 nicotine step 1...... 212 nortrel 0.5/35 (28)...... 107 NEMBUTAL...... 145 nicotine step 2...... 212 nortrel 1/35 (21)...... 107 NEOMULTIVITE...... 185 nicotine step 3...... 212 nortrel 1/35 (28)...... 107 neomycin sulfate...... 19 NICOTROL...... 212 nortrel 7/7/7...... 110 neomycin-bacitracin zn-polymyx...... 199 NICOTROL NS...... 212 nortriptyline hcl...... 45 neomycin-polymyxin b gu...... 138 nifedipine...... 98 NORVIR...... 91 neomycin-polymyxin-dexameth...... 201 nifedipine er...... 98 NOVA SAFETY LANCETS 23G...... 160 neomycin-polymyxin-gramicidin...... 199 nifedipine er osmotic release...... 98 NOVA SAFETY LANCETS 28G...... 160 neomycin-polymyxin-hc...... 201, 204 nikki...... 106 NOVA SUREFLEX LANCETS...... 160 NEONATAL + DHA...... 190 NILANDRON...... 67 NOVACHOR...... 125 NEONATAL 19...... 191 nilutamide...... 67 NOVOFINE...... 168 NEONATAL COMPLETE...... 188 NIMBEX...... 195 NOVOFINE AUTOCOVER...... 168 NEONATAL FE...... 188 nimodipine...... 98 NOVOFINE PLUS...... 169 NEONATAL PLUS...... 188 NINJACOF-XG...... 113 NOVOTWIST...... 169 NEONATAL VITAMIN...... 188 NINLARO...... 75 NOXAFIL...... 53 neo-polycin...... 199 NIPENT...... 78 np thyroid...... 215 neo-polycin hc...... 201 NIPRIDE RTU...... 61 NUBEQA...... 67 NEOPROFEN...... 21 nisoldipine er...... 98 NUCYNTA...... 28 NEORAL...... 176 nitazoxanide...... 62 NUEDEXTA...... 211 NEOSTIGMINE METHYLSULFATE. 65 NITHIODOTE...... 50 NULOJIX...... 179 NEO-SYNALAR...... 116 nitisinone...... 130 NULYTELY LEMON-LIME...... 147 NEOX 100...... 125 NITRO-BID...... 32 NUMBRINO...... 194 NEOX CORD 1K...... 125 NITRO-DUR...... 32 NURTEC...... 171 nephro vitamins...... 181 nitrofurantoin...... 65 NUSHIELD...... 125 NEPHRO-VITE...... 181 nitrofurantoin macrocrystal...... 65 NUTRILIPID...... 196 NERLYNX...... 74 nitrofurantoin monohyd macro...... 65 NUTROPIN AQ NUSPIN 10...... 130 NESACAINE...... 151 NITROGLYCERIN...... 32 NUTROPIN AQ NUSPIN 20...... 130 NESACAINE-MPF...... 151 nitroglycerin...... 32 NUTROPIN AQ NUSPIN 5...... 130 NESTABS...... 188 nitroglycerin in d5w...... 32 NUVARING...... 108 NESTABS DHA...... 188 NITROLINGUAL...... 32 NUVESSA...... 221 NESTABS ONE...... 190 NITROMIST...... 32 NUZYRA...... 213, 214 neuac...... 115 nitroprusside sodium...... 61 nyamyc...... 117 NEULASTA...... 143 NITROSTAT...... 32 nylia 7/7/7...... 110 NEULASTA ONPRO...... 143 NIVA-PLUS...... 188 NYMALIZE...... 98 NEUPOGEN...... 143 nizatidine...... 217 nymyo...... 107 NEUPRO...... 85 nolix...... 121 nystatin...... 53, 117, 179 NEURIN-SL...... 142 nora-be...... 110 nystatin-triamcinolone...... 116 NEVANAC...... 201 NOREPINEPHRINE (BASE)- nystop...... 117 nevirapine...... 92 DEXTROSE...... 223 OB COMPLETE...... 188 nevirapine er...... 92 norepinephrine bitartrate...... 223 OB COMPLETE ONE...... 188 new day...... 108 NOREPINEPHRINE-DEXTROSE...... 223 OB COMPLETE PETITE...... 188 NEXAVAR...... 74 NOREPINEPHRINE-SODIUM OB COMPLETE PREMIER...... 188 NEXAVIR...... 177 CHLORIDE...... 223 OB COMPLETE/DHA...... 188 NEXIUM I.V...... 217 norethin ace-eth estrad-fe...... 106 OBSTETRIX DHA...... 188 240 OBSTETRIX EC...... 188 ONETOUCH DELICA PLUS OXYCONTIN...... 28 OBSTETRIX ONE...... 190 LANCET33G...... 160 oxymorphone hcl...... 28 O-CAL PRENATAL...... 188 ONETOUCH FINEPOINT LANCETS160 oxymorphone hcl er...... 28 ocella...... 107 ONETOUCH SURESOFT LANCING oxytocin...... 204 OCTAGAM...... 205 DEV...... 160 OXYTOCIN-LACTATED RINGERS.204 OCTAPLAS BLOOD GROUP A...... 140 ONETOUCH ULTRA...... 126 OXYTOCIN-SODIUM CHLORIDE...204 OCTAPLAS BLOOD GROUP AB..... 140 ONETOUCH ULTRASOFT OZEMPIC (0.25 OR 0.5 MG/DOSE).... 47 OCTAPLAS BLOOD GROUP B...... 141 LANCETS...... 160 OZEMPIC (1 MG/DOSE)...... 48 OCTAPLAS BLOOD GROUP O...... 141 ONETOUCH VERIO...... 126 OZURDEX...... 202 octreotide acetate...... 131 ONEXTON...... 115 pacerone...... 34 ocucoat viscoadherent...... 203 ONGENTYS...... 85 paclitaxel...... 81 OCUFLOX...... 199 ONIVYDE...... 83 PADCEV...... 71 ODACTRA...... 19 ONTRUZANT...... 70 PALINGEN FLOW...... 125 ODEFSEY...... 90 ONUREG...... 68 PALINGEN HYDROMEMBRANE....125 ODOMZO...... 73 opcicon one-step...... 108 PALINGEN INOVOFLO...... 125 OFIRMEV...... 22 OPDIVO...... 71 PALINGEN MEMBRANE...... 125 ofloxacin...... 134, 199, 204 OPSUMIT...... 101 PALINGEN XPLUS OGIVRI...... 70 option 2...... 108 HYDROMEMBRANE...... 125 olanzapine...... 89 OPTIONS GYNOL II PALINGEN XPLUS MEMBRANE.... 125 olanzapine-fluoxetine hcl...... 213 CONTRACEPTIVE...... 221 paliperidone er...... 86 OLINVYK...... 28 ORABLOC...... 150 PALONOSETRON HCL...... 51 OLIVE TREE...... 17 ORALAIR...... 19 palonosetron hcl...... 51 olmesartan medoxomil...... 59, 60 oralone...... 181 PAMELOR...... 45 olmesartan medoxomil-hctz...... 59 ORAPRED ODT...... 112 pamidronate disodium...... 129 olmesartan-amlodipine-hctz...... 60 ORAVIG...... 179 PAMIDRONATE DISODIUM...... 129 olopatadine hcl...... 194 ORBACTIV...... 63 PANCREAZE...... 126 OMECLAMOX-PAK...... 218 ORCHARD GRASS POLLEN...... 17 pancuronium bromide...... 195 omega-3-acid ethyl esters...... 55 ORGOVYX...... 79 PANHEMATIN...... 140 OMEGAVEN...... 196 ORIAHNN...... 133 PANRETIN...... 117 omeprazole...... 217 ORILISSA...... 129 pantoprazole sodium...... 217 OMIDRIA...... 203 orphenadrine citrate...... 193 PARADIGM REAL-TIME OMNICAP...... 185 orphenadrine citrate er...... 193 TRANSMITTER...... 160 OMNIFLEX DIAPHRAGM...... 153 orphenadrine-asa-caffeine...... 193 PARAGARD INTRAUTERINE OMNIPOD 5 PACK...... 164 orphengesic forte...... 193 COPPER...... 108 OMNIPOD DASH 5 PACK PODS...... 165 orsythia...... 107 paraplatin...... 66 OMNIPOD STARTER...... 165 ORTHOVISC...... 193 PAREMYD...... 200 ONCASPAR...... 77 ORTIKOS...... 112 paricalcitol...... 130 once daily...... 185 oseltamivir phosphate...... 94 PARLODEL...... 84 ondansetron...... 51 osmitrol...... 127 PARNATE...... 43 ondansetron hcl...... 51 OSMOLEX ER...... 84 paromomycin sulfate...... 19 one daily...... 185 OSMOPREP...... 148 paroxetine hcl...... 43, 44 ONE DAILY ESSENTIAL...... 185 OSPHENA...... 131 paroxetine hcl er...... 43 one daily multivitamin adult...... 184 OTEZLA...... 22 paroxetine mesylate...... 213 one daily multivitamin/iron...... 184 OTIPRIO...... 204 PASER...... 66 ONE VITE WOMENS...... 188 OTOVEL...... 204 PATANASE...... 194 ONE VITE WOMENS PLUS...... 188 OVIDE...... 124 PAXIL...... 44 ONE-A-DAY ESSENTIAL...... 185 oxacillin sodium...... 206 PC LANCETS SUPER THIN 30G...... 160 ONE-A-DAY MENS...... 185 OXACILLIN SODIUM IN PC UNIFINE PENTIPS...... 169 ONE-A-DAY WOMENS PRENATAL DEXTROSE...... 206 PEDIAPRED...... 112 ...... 188 oxaliplatin...... 66 PEDIARIX...... 216 one-daily multi vitamins...... 185 oxandrolone...... 30 PEDVAX HIB...... 219 one-daily multi-vitamin...... 185 oxaprozin...... 22 peg 3350...... 148 one-daily multi-vitamin/iron...... 184 OXAYDO...... 28 peg 3350-kcl-na bicarb-nacl...... 147 one-daily/iron...... 184 oxazepam...... 33 peg-3350/electrolytes...... 147 ONETOUCH CLUB LANCETS FINE oxcarbazepine...... 40 peg-3350/electrolytes/ascorbat...... 147 PT...... 160 oxiconazole nitrate...... 122 PEGASYS...... 94 ONETOUCH DELICA LANCETS OXISTAT...... 122 peg-kcl-nacl-nasulf-na asc-c...... 147 30G...... 160 OXTELLAR XR...... 40 peg-prep...... 147 ONETOUCH DELICA LANCETS oxybutynin chloride...... 218 PEMAZYRE...... 72 33G...... 160 oxybutynin chloride er...... 218 PEN NEEDLES...... 169 ONETOUCH DELICA PLUS oxycodone hcl...... 28 PEN NEEDLES 1/2"...... 169 LANCET30G...... 160 oxycodone hcl er...... 28 PEN NEEDLES 5/16"...... 169 oxycodone-acetaminophen...... 29 penicillamine...... 175 241 PENICILLIN G POT IN DEXTROSE 205 phosphorous...... 174 portia-28...... 107 penicillin g potassium...... 205 phospho-trin 250 neutral...... 174 PORTRAZZA...... 72 PENICILLIN G PROCAINE...... 205 PHOTOFRIN...... 77 posaconazole...... 53 penicillin g sodium...... 205 PHOTREXA VISCOUS...... 201 pot & sod cit-cit ac...... 138 penicillin v potassium...... 205, 206 PHOTREXA-PHOTREXA VISCOUS potassium acetate...... 174 PENICILLIUM NOTATUM...... 17 KIT...... 201 POTASSIUM CHLORIDE...... 174 PENLET II BLOOD SAMPLER...... 160 PHOXILLUM B22K4/0...... 175 potassium chloride...... 174 PENLET II REPLACEMENT CAP.....160 PHOXILLUM BK4/2.5...... 175 potassium chloride crys er...... 174 PENTACEL...... 216 physiolyte...... 177 potassium chloride er...... 174 pentamidine isethionate...... 62 physiosol irrigation...... 177 potassium chloride in dextrose...... 173 PENTASA...... 135 phytonadione...... 223 POTASSIUM CHLORIDE IN NACL.173 pentazocine-naloxone hcl...... 29 PIFELTRO...... 92 potassium chloride in nacl...... 173 PENTETATE CALCIUM pilocarpine hcl...... 181, 198 potassium citrate er...... 138 TRISODIUM...... 50 pimecrolimus...... 123 POTASSIUM PHOSPHATES...... 174 PENTETATE ZINC TRISODIUM...... 50 pimozide...... 211 potassium phosphates...... 174 PENTIPS...... 169 pimtrea...... 104 potassium phosphates(66 meq k)...... 174 pentobarbital sodium...... 145 pindolol...... 96 POTASSIUM PHOSPHATES(71 pentoxifylline er...... 140 pioglitazone hcl...... 49 MEQ K)...... 174 PEPAXTO...... 81 pioglitazone hcl-glimepiride...... 49 POTELIGEO...... 69 PEPCID...... 217 pioglitazone hcl-metformin hcl...... 49 PRALUENT...... 57 PERENNIAL RYE GRASS POLLEN...17 PIP LANCETS 28G...... 160 pramipexole dihydrochloride...... 85 PERFECT LANCETS 28G...... 160 PIP LANCETS 30G...... 160 pramipexole dihydrochloride er...... 85 PERFECT LANCETS 30G...... 160 piperacillin sod-tazobactam so...... 206 PRAMOSONE...... 124 PERFOROMIST...... 35 PIQRAY (200 MG DAILY DOSE)...... 82 PRAMOTIC...... 203 PERIDEX...... 179 PIQRAY (250 MG DAILY DOSE)...... 82 prasugrel hcl...... 141 PERIKABIVEN...... 196 PIQRAY (300 MG DAILY DOSE)...... 82 pravastatin sodium...... 56 perindopril erbumine...... 58 pirmella 1/35...... 107 PRAXBIND...... 50 periogard...... 179 pirmella 7/7/7...... 110 praziquantel...... 31 PERJETA...... 70 piroxicam...... 22 prazosin hcl...... 60 permethrin...... 124 PITOCIN...... 204 PRECEDEX...... 146 perphenazine...... 88 PLASBUMIN-25...... 141 PRECISION SUREDOSE PLUS SYR 169 perphenazine-amitriptyline...... 210 PLASBUMIN-5...... 141 PRECISION SURE-DOSE SYRINGE 169 PERRY PRENATAL...... 188 PLASMA-LYTE 148...... 173 PRECISION THINS GP LANCETS... 160 PERSERIS...... 86 PLASMA-LYTE A...... 173 PRECOSE...... 45 PERTZYE...... 126 PLASMANATE...... 141 PRED MILD...... 202 PEXEVA...... 44 PLEGISOL...... 100 PRED-G...... 201 pfizerpen...... 206 PLEGRIDY...... 209 PRED-G S.O.P...... 201 PHARMACIST CHOICE LANCETS. 160 PLEGRIDY STARTER PACK...... 209 prednicarbate...... 121 PHARMACY COUNTER LANCETS 160 plenamine...... 195 prednisolone...... 112 phendimetrazine tartrate...... 13 PLENITY...... 12 prednisolone acetate...... 202 phendimetrazine tartrate er...... 12 PLENITY WELCOME KIT...... 12 prednisolone sodium phosphate...... 112 phenelzine sulfate...... 43 PLENVU...... 147 PREDNISOLONE SODIUM PHENERGAN...... 54 PNEUMOVAX 23...... 219 PHOSPHATE...... 202 phenobarbital...... 145 PNV TABS 20-1...... 188 prednisone...... 112 phenobarbital sodium...... 145 PNV TABS 29-1...... 188 PREDNISONE INTENSOL...... 112 phenohytro...... 216 pnv-dha...... 190 PREFERRED PLUS INSULIN phenoxybenzamine hcl...... 58 PNV-DHA+DOCUSATE...... 190 SYRINGE...... 169 phentermine hcl...... 13 PNV-OMEGA...... 188 PREFERRED PLUS LANCETS phentolamine mesylate...... 58 pnv-select...... 188 COLORED...... 161 PHENYLEPHRINE HCL...... 197, 223 podofilox...... 122 PREFERRED PLUS LANCETS THIN phenylephrine hcl...... 198 POINT OF CARE LM-2.5...... 150 ...... 161 PHENYLEPHRINE HCL-NACL...... 223 POLIVY...... 70 PREFERRED PLUS UNIFINE PHENYTEK...... 42 polocaine...... 151 PENTIPS...... 169 phenytoin...... 42 polocaine-mpf...... 151 PREFEST...... 133 phenytoin infatabs...... 42 polycin...... 199 pregabalin...... 40 phenytoin sodium...... 42 polyethylene glycol 3350...... 148 pregabalin er...... 211 phenytoin sodium extended...... 42 polymyxin b sulfate...... 64 PREGEN DHA...... 190 PHESGO...... 77 polymyxin b-trimethoprim...... 199 PREGENNA...... 188 PHEXXI...... 221 POLYTRIM...... 199 PREMARIN...... 133, 222 philith...... 107 POLY-TUSSIN AC...... 114 PREMASOL...... 196 phillips milk of magnesia...... 149 POLY-VI-FLOR...... 186 PREMESISRX...... 191 PHOMA EXIGUA...... 17 POLY-VI-FLOR/IRON...... 186 PREMPHASE...... 133 PHOSLYRA...... 136 POMALYST...... 73 PREMPRO...... 133 242 PRENA 1 TRUE...... 190 PRIMAQUINE PHOSPHATE...... 65 propofol-lipuro...... 137 PRENA1...... 191 PRIMAXIN IV...... 62 propranolol hcl...... 96 PRENA1 PEARL...... 188 primidone...... 40 propranolol hcl er...... 96 PRENAISSANCE...... 190 PRIMSOL...... 62 propylthiouracil...... 214 PRENAISSANCE PLUS...... 190 PRISMASOL B22GK 4/0...... 175 PROQUAD...... 219 PRENARA...... 188 PRISMASOL BGK 0/2.5...... 175 PRO-RED AC...... 114 prenatabs rx...... 188 PRISMASOL BGK 2/0...... 176 PROSCAR...... 138 PRENATAL...... 188 PRISMASOL BGK 2/3.5...... 176 PROSOL...... 196 PRENATAL 19...... 188 PRISMASOL BGK 4/0/1.2...... 176 PROSTIN E2...... 204 prenatal 19...... 188 PRISMASOL BGK 4/2.5...... 176 PROSTIN VR...... 179 PRENATAL COMPLETE...... 188 PRISMASOL BK 0/0/1.2...... 176 protamine sulfate...... 141 PRE-NATAL FORMULA...... 188 PRIVET...... 17 PROTONIX...... 217 PRENATAL FORTE...... 188 PRO COMFORT INSULIN SYRINGE PROTOPAM CHLORIDE...... 50 PRENATAL MULTIVITAMIN + ...... 169 protriptyline hcl...... 45 DHA...... 191 PRO COMFORT LANCETS 30G...... 161 PROVAYBLUE...... 50 PRENATAL ONE DAILY...... 188 PRO COMFORT LANCETS 31G...... 161 PROVENTIL HFA...... 35 PRENATAL PLUS IRON...... 188 PRO COMFORT PEN NEEDLES...... 169 PROVERA...... 207 PRENATAL VITAMIN...... 189 PROAIR DIGIHALER...... 35 PROVIDA OB...... 189 PRENATAL VITAMIN AND PROAIR HFA...... 35 pseudoeph-bromphen-dm...... 114 MINERAL...... 188 PROAIR RESPICLICK...... 35 PSS SELECT GP LANCETS...... 161 PRENATAL VITAMIN PLUS LOW probenecid...... 139 PSS SELECT PLATFORMS...... 161 IRON...... 189 PROBUPHINE IMPLANT KIT...... 29 PSS SELECT SAFETY LANCETS.....161 PRENATAL VITAMINS...... 189 procainamide hcl...... 33 PURE COMFORT LANCETS 30G.....161 PRENATAL/IRON...... 189 PROCALAMINE...... 196 PURE COMFORT PEN NEEDLE...... 169 PRENATAL-U...... 189 PROCARDIA XL...... 98 PURIXAN...... 68 PRENATE...... 191 procentra...... 12 px aspirin...... 24 PRENATE AM...... 191 prochlorperazine...... 88 px b complex/vitamin c...... 181 PRENATE DHA...... 191 prochlorperazine edisylate...... 88 px b-50...... 192 PRENATE ELITE...... 189 prochlorperazine maleate...... 88 px enteric aspirin...... 24 PRENATE ENHANCE...... 191 PROCRIT...... 142 PX EXTRA SHORT PEN NEEDLES. 169 PRENATE ESSENTIAL...... 191 PROCTOCORT...... 31 px folic acid...... 143 PRENATE MINI...... 191 PROCTOFOAM HC...... 31 PX INSULIN SYRINGE...... 169 PRENATE PIXIE...... 191 procto-med hc...... 31 PX LANCETS MICROTHIN 33G...... 161 PRENATE RESTORE...... 191 procto-pak...... 31 PX LANCETS ULTRA THIN...... 161 PRENATRIX...... 189 proctozone-hc...... 31 PX LANCETS ULTRA THIN 28G..... 161 PRENATRYL...... 189 PRODIGY INSULIN SYRINGE...... 169 px laxative...... 149 PRENATVITE COMPLETE...... 189 PRODIGY LANCETS 28G...... 161 px milk of magnesia...... 149 PRENATVITE PLUS...... 189 PRODIGY SAFETY LANCETS 26G. 161 PX MINI PEN NEEDLES...... 169 PRENATVITE RX...... 189 PRODIGY TWIST TOP LANCETS PX PEN NEEDLE...... 169 PREPIDIL...... 204 28G...... 161 PX PRENATAL MULTIVITAMINS..189 PREPLUS...... 189 progesterone...... 207 PX SHORTLENGTH PEN NEEDLES169 PRESTALIA...... 57 PROGLYCEM...... 46 px stop smoking aid...... 212 PRETAB...... 189 PROGRAF...... 177 PYLERA...... 218 PRETOMANID...... 66 PROLENSA...... 201 pyrazinamide...... 66 prevalite...... 55 PROLEUKIN...... 77 pyridostigmine bromide...... 65 PREVENT SAFETY PEN NEEDLES.169 PROLIA...... 131 pyridostigmine bromide er...... 65 preventeza...... 108 promethazine hcl...... 54, 55 pyridoxine hcl...... 223 PREVIDENT...... 180 promethazine vc...... 113 pyrimethamine...... 65 PREVIDENT 5000 BOOSTER PLUS.180 promethazine vc/codeine...... 114 QBRELIS...... 58 PREVIDENT 5000 DRY MOUTH...... 180 promethazine-codeine...... 114 QBREXZA...... 123 PREVIDENT 5000 ENAMEL promethazine-dm...... 114 qc aspirin...... 24 PROTECT...... 180 promethazine-phenyleph-codeine...... 114 qc aspirin low dose...... 24 PREVIDENT 5000 ORTHO promethazine-phenylephrine...... 113 qc b50 prolonged release...... 183 DEFENSE...... 180 promethegan...... 55 qc b-complex/vitamin c...... 181 PREVIDENT 5000 PLUS...... 180 PROMISEB...... 118 qc childrens aspirin...... 24 PREVIDENT 5000 SENSITIVE...... 180 propafenone hcl...... 33 qc daily multivitamins/iron...... 184 previfem...... 107 propafenone hcl er...... 33 qc enteric aspirin...... 24 PREVNAR 13...... 219 proparacaine hcl...... 200 qc essentials...... 185 PREZCOBIX...... 90 proparacaine-fluorescein...... 200 qc folic acid...... 143 PREZISTA...... 91 PROPECIA...... 126 qc gentle laxative...... 149 PRIFTIN...... 66 PROPEL...... 194 QC LANCETS SUPER THIN 30G...... 161 PRILO PATCH II...... 125 PROPEL MINI...... 194 QC LANCETS ULTRA THIN...... 161 PRIMACARE...... 189 propofol...... 137 qc magnesium citrate...... 149 243 qc milk of magnesia...... 149 ra nicotine gum...... 212 RELION ULTRA THIN PLUS qc natura-lax...... 148 ra nicotine polacrilex...... 212 LANCETS...... 161 qc nicotine transdermal system...... 212 ra pain relief aspirin...... 25 RELISTOR...... 136 QC PEN NEEDLES...... 169 RA PEN NEEDLES...... 169 RELNATE DHA...... 189 QC PRENATAL...... 189 RA PRENATAL...... 189 RELTONE...... 134 QC UNIFINE PENTIPS...... 169 RA PRENATAL FORMULA...... 189 REMERON...... 42 QC UNILET LANCETS 28G...... 161 ra womens laxative...... 149 REMERON SOLTAB...... 42 QC UNILET LANCETS MICRO RABAVERT...... 220 REMESENSE...... 153 THIN...... 161 RABBIT EPITHELIUM...... 17 REMICADE...... 137 QDOLO...... 28 RADIOGARDASE...... 50 remifentanil hcl...... 28 QINLOCK...... 74 RAGWITEK...... 17 RENACIDIN...... 138 QSYMIA...... 12 raloxifene hcl...... 131 renal multivitamin formula...... 181 QUADRACEL...... 216 ramelteon...... 146 renal vitamin...... 181 QUADRAMET...... 77 ramipril...... 58 renal-vite...... 181 QUALAQUIN...... 65 RANEXA...... 31 rena-vite...... 181 QUARTETTE...... 109 ranolazine er...... 31 RENOVA...... 116 quazepam...... 146 RAPAMUNE...... 177 RENOVA PUMP...... 116 QUDEXY XR...... 40 RAPIVAB...... 94 RENVELA...... 136 QUEEN PALM...... 17 rasagiline mesylate...... 84 repaglinide...... 48 QUELICIN...... 194 RASUVO...... 19 REPATHA...... 57 QUESTRAN...... 56 RAVICTI...... 132 REPATHA PUSHTRONEX SYSTEM. 57 QUESTRAN LIGHT...... 56 RAYALDEE...... 130 REPATHA SURECLICK...... 57 quetiapine fumarate...... 87 RAZADYNE ER...... 208 RESECTISOL...... 138 quetiapine fumarate er...... 87 react...... 108 RESTASIS...... 200 QUFLORA FE...... 184 READYLANCE SAFETY LANCETS 161 RESTASIS MULTIDOSE...... 200 QUFLORA FE PEDIATRIC...... 186 REAL HEAL-I...... 125 RESTORA RX...... 49 QUFLORA GUMMIES...... 186 REALITY INSULIN SYRINGE...... 169 RESTORIL...... 146 QUFLORA PEDIATRIC...... 186 REALITY LANCETS...... 161 RETACRIT...... 142 QUILLICHEW ER...... 14, 15 REALITY TRIGGER LANCETS...... 161 RETAVASE...... 141 QUILLIVANT XR...... 15 REBIF...... 209 RETAVASE HALF-KIT...... 141 quin b strong b-25...... 183 REBIF REBIDOSE...... 209 RETEVMO...... 75 quinapril hcl...... 58 REBIF REBIDOSE TITRATION RETISERT...... 202 quinapril-hydrochlorothiazide...... 58 PACK...... 209 RETROVIR...... 93 quinidine gluconate er...... 33 REBIF TITRATION PACK...... 209 REVLIMID...... 176 quinidine sulfate...... 33 RECARBRIO...... 62 revonto...... 193 quinine sulfate...... 65 reclipsen...... 107 REXALL LANCETS ULTRA THIN QUINTABS...... 185 RECOMBIVAX HB...... 220 30G...... 161 QUTENZA (4 PATCH)...... 123 RECOTHROM...... 144 REXULTI...... 89 QUZYTTIR...... 54 RECOTHROM SPRAY KIT...... 144 REYATAZ...... 91, 92 QVAR REDIHALER...... 36 RECTIV...... 30 RHIZOPUS...... 17 ra aspirin...... 25 RED MAPLE...... 17 RHOFADE...... 124 ra aspirin adult low dose...... 24 RED MULBERRY...... 17 RHOPRESSA...... 201 ra aspirin adult low strength...... 24 RED TOP GRASS POLLEN...... 17 RIABNI...... 69 ra aspirin childrens...... 25 refissa...... 116 RIASTAP...... 139 ra aspirin ec...... 25 REGLAN...... 135 ribavirin...... 94, 95 ra aspirin ec adult low st...... 25 REGONOL...... 66 RIDAURA...... 20 ra balanced b-100...... 183 REGRANEX...... 126 rifabutin...... 66 ra balanced b-100 cr...... 183 relafen...... 22 RIFADIN...... 66 ra balanced b-50...... 183 RELENZA DISKHALER...... 94 rifampin...... 66 ra balanced b-50 tr...... 183 RELEXXII...... 15 RIGHTEST ALTERNATE SITE ra b-complex...... 181 RELION INSULIN SYRINGE...... 169 ADAPT...... 161 ra b-complex with b-12...... 181 RELION LANCETS MICRO-THIN RIGHTEST GL300 LANCETS...... 161 RA E-ZJECT LANCETS 28G...... 161 33G...... 161 riluzole...... 194 RA E-ZJECT LANCETS THIN 26G...161 RELION LANCETS THIN 26G...... 161 rimantadine hcl...... 94 RA E-ZJECT LANCETS THIN 28G...161 RELION LANCETS ULTRA-THIN RIMSO-50...... 138 RA E-ZJECT LANCETS ULTRA 30G...... 161 ringers...... 173 THIN...... 161 RELION LANCING DEVICE...... 161 ringers irrigation...... 177 ra folic acid...... 143 RELION MINI PEN NEEDLES...... 169 RINVOQ...... 19 RA INSULIN SYRINGE...... 169 RELION PEN NEEDLES...... 169 RIOMET...... 45 ra laxative...... 148, 149 RELION SHORT PEN NEEDLES...... 169 risanoid plus...... 192 ra milk of magnesia...... 149 RELION ULTRA THIN LANCETS risedronate sodium...... 129 ra mini nicotine...... 212 30G...... 161 RISPERDAL CONSTA...... 86 ra nicotine...... 212 risperidone...... 86, 87 244 RITALIN...... 15 SAVELLA...... 208 silodosin...... 138 RITALIN LA...... 15 SAVELLA TITRATION PACK...... 208 SILVADENE...... 119 ritonavir...... 92 SAXENDA...... 13 silver sulfadiazine...... 119 RITUXAN...... 69 sb aspirin...... 25 SIMBRINZA...... 196 RITUXAN HYCELA...... 77 sb aspirin adult low strength...... 25 simliya...... 104 rivastigmine...... 208 sb aspirin ec...... 25 simpesse...... 109 rivastigmine tartrate...... 208 sb bisacodyl laxative ec...... 149 SIMPONI...... 20 rivelsa...... 109 sb childrens aspirin...... 25 SIMPONI ARIA...... 20 rizatriptan benzoate...... 172 sb gentle lax-women...... 150 SIMULECT...... 178 ROBAXIN...... 193 SB INSULIN SYRINGE...... 169 simvastatin...... 56 ROCALTROL...... 130 SB LANCETS THIN...... 162 SINEMET...... 85 ROCKLATAN...... 200 SB LANCETS ULTRA THIN...... 162 SINGLE-LET...... 162 rocuronium bromide...... 195 sb low dose asa ec...... 25 sirolimus...... 177 ROCURONIUM BROMIDE...... 195 sb magnesium citrate...... 149 SIRTURO...... 66 ROMIDEPSIN...... 73 sb milk of magnesia...... 149 SIVEXTRO...... 64 ropinirole hcl...... 85 sb polyethylene glycol 3350...... 148 SKELAXIN...... 193 ropinirole hcl er...... 85 SCENESSE...... 123 SKYLA...... 109 ropivacaine hcl...... 151 SCLEROSOL INTRAPLEURAL...... 213 SKYRIZI...... 118 ROPIVACAINE HCL-NACL...... 151 scopolamine...... 52 SKYRIZI (150 MG DOSE)...... 118 rosadan...... 124 SEASONIQUE...... 109 SKYRIZI PEN...... 118 rosuvastatin calcium...... 56 SECUADO...... 87 SLYND...... 110 ROTARIX...... 220 SECURESAFE INSULIN SYRINGE..169 sm aspirin...... 25 ROTATEQ...... 220 SECURESAFE SAFETY PEN sm aspirin adult low strength...... 25 ROUGH MARSH ELDER...... 17 NEEDLES...... 169 sm aspirin ec...... 25 ROWASA...... 135 SELECT-LITE DEVICE/LANCETS...162 sm aspirin ec low strength...... 25 roweepra...... 40 SELECT-OB...... 189 sm aspirin low dose...... 25 ROXICODONE...... 28 SELECT-OB+DHA...... 191 sm aspirin tri-buffered...... 23 ROZLYTREK...... 75 selegiline hcl...... 84 sm b super vitamin complex...... 181 RUBRACA...... 82 SELENIOUS ACID...... 175 sm b100 complex...... 183 rufinamide...... 40, 41 selenium sulfide...... 118 sm balanced b-100...... 182 RUKOBIA...... 91 SELZENTRY...... 90 sm balanced b-50...... 182 RUSSIAN THISTLE...... 17 SEMGLEE...... 47 sm b-complex...... 183 RUXIENCE...... 69 SE-NATAL 19...... 189 SM B-COMPLEX/VITAMIN C...... 181 RYANODEX...... 193 sensorcaine...... 151 sm childrens aspirin...... 25 RYBELSUS...... 48 sensorcaine/epinephrine...... 150 sm clearlax...... 148 RYBREVANT...... 75 sensorcaine-mpf...... 151 sm folic acid...... 143 ryclora...... 54 sensorcaine-mpf/epinephrine...... 150 sm gentle laxative...... 150 RYDAPT...... 74 SENSORCAINE-MPF/EPINEPHRINE SM LANCETS 33G...... 162 RYDEX...... 114 ...... 150 sm magnesium citrate...... 149 RYTARY...... 85 SEREVENT DISKUS...... 35 sm milk of magnesia...... 149 RYTHMOL SR...... 33 sertraline hcl...... 44 sm multiple vitamins essential...... 185 RYVENT...... 54 setlakin...... 109 sm multiple vitamins/iron...... 184 SACCHAROMYCES CEREVISIAE.... 17 sevelamer carbonate...... 136 sm nicotine...... 213 SAFE-T-LANCE...... 161 sevelamer hcl...... 136 sm nicotine polacrilex...... 213 SAFE-T-LANCE PLUS...... 161 sevoflurane...... 137 SM ONE DAILY PRENATAL...... 189 SAFETY INSULIN SYRINGES...... 169 sf...... 180 SM PRENATAL VITAMINS...... 189 SAFETY LANCET 30G/PRESSURE sf 5000 plus...... 180 sm super b complex/c...... 182 ACT...... 161 SFROWASA...... 135 sm vitamin b complex/vitamin c...... 182 SAFETY LANCETS...... 161 SHAGBARK HICKORY...... 17 SMART SENSE COLOR LANCETS SAFETY LANCETS 21G...... 162 sharobel...... 110 33G...... 162 SAFETY LANCETS 28G...... 162 SHEEP SORREL...... 17 SMART SENSE STANDARD SAFYRAL...... 107 SHINGRIX...... 220 LANCETS...... 162 SALAGEN...... 181 SHOPKO ON-THE-GO LANCETS SMART SENSE SUPER THIN SAMSCA...... 131 30G...... 162 LANCETS...... 162 SANCUSO...... 51 SHOPKO UNIFINE PENTIPS...... 169 SMART SENSE THIN LANCETS SANDIMMUNE...... 176 SHOPKO UNIFINE PENTIPS PLUS. 170 26G...... 162 SANTYL...... 121 SHOPKO UNILET LANCETS 28G....162 SMARTEST LANCETS 28G...... 162 sapropterin dihydrochloride...... 131 SHOPKO UNILET LANCETS 30G....162 SMOFLIPID...... 196 SAPS HEALTH TWIST TOP SHORT RAGWEED POLLEN EXT.....17 smooth lax...... 148 LANCETS...... 162 SHUR-SEAL CONTRACEPTIVE...... 221 sod benz-sod phenylacet...... 132 SAPS TWIST TOP LANCETS...... 162 SIKLOS...... 142 SODIUM ACETATE...... 172 SAPSCARE TWIST TOP LANCETS.162 sildenafil citrate...... 101 SODIUM BICARBONATE...... 31 SARCLISA...... 70 SILENOR...... 146 sodium bicarbonate...... 172 245 sodium chloride...... 113, 138, 175 STALEVO 75...... 85 SURE COMFORT INSULIN sodium chloride flush...... 175 STAMARIL...... 220 SYRINGE...... 170 SODIUM CITRATE LOCK FLUSH.....37 stavudine...... 93 SURE COMFORT LANCETS 18G.....162 SODIUM DIURIL...... 128 STELARA...... 118, 136 SURE COMFORT LANCETS 21G.....162 SODIUM EDECRIN...... 127 STEMPHYLIUM...... 18 SURE COMFORT LANCETS 23G.....162 sodium fluoride...... 173, 174, 180 STERILANCE PA...... 162 SURE COMFORT LANCETS 28G.....162 sodium fluoride 5000 enamel...... 180 STERILANCE TL...... 162 SURE COMFORT LANCETS 30G.....162 sodium fluoride 5000 plus...... 180 STERILE TALC POWDER...... 213 SURE COMFORT PEN NEEDLES.... 170 sodium fluoride 5000 ppm...... 180 sterile water for irrigation...... 177 SURE-FINE PEN NEEDLES...... 170 sodium fluoride 5000 sensitive...... 180 STERITALC...... 213 SURE-JECT INSULIN SYRINGE...... 170 SODIUM IODIDE I-131...... 214 STIMATE...... 132 SURE-LANCE FLAT LANCETS...... 162 SODIUM NITRITE...... 50 STIOLTO RESPIMAT...... 34 SURE-LANCE LANCETS 26G...... 162 sodium nitroprusside...... 61 STIVARGA...... 74 SURE-LANCE THIN LANCETS 28G 162 sodium phenylbutyrate...... 132 STRAVIX...... 125 SURE-LANCE ULTRA THIN sodium phosphates...... 174 streptomycin sulfate...... 19 LANCETS...... 162 sodium polystyrene sulfonate...... 178 stress b complex/iron...... 184 SURELITE LANCETS...... 162 SODIUM SULFACETAMIDE- stress formula...... 182 SURE-TOUCH LANCETS BAKUCHIOL...... 118 stress formula/iron...... 184 UNIVERSAL...... 162 sodium tetradecyl sulfate...... 179 stresstabs energy...... 185 SURGICEL FIBRILLAR...... 144 solifenacin succinate...... 218 STRIBILD...... 90 SURGICEL NU-KNIT...... 144 SOLIQUA...... 48 STRIVERDI RESPIMAT...... 35 SURVANTA...... 213 SOLOSEC...... 19 STROMECTOL...... 31 SUSTIVA...... 92 SOLTAMOX...... 67 STRONTIUM CHLORIDE SR-89...... 77 SUSTOL...... 51 SOLU-CORTEF...... 112 subvenite...... 41 SUTAB...... 147 SOLU-MEDROL...... 112 subvenite starter kit-blue...... 41 SUTENT...... 74 SOLUS V2 LANCETS 28G...... 162 subvenite starter kit-green...... 41 SWEET GUM...... 18 SOLUS V2 TWIST LANCETS 30G... 162 subvenite starter kit-orange...... 41 SWEET VERNAL GRASS POLLEN... 18 SOMA...... 193 SUCCINYLCHOLINE CHLORIDE... 194 syeda...... 107 SOOLANTRA...... 124 sucralfate...... 217 SYMBICORT...... 34 SORBITOL...... 138 SUFENTANIL CITRATE...... 28 SYMBYAX...... 213 SORBITOL-MANNITOL...... 138 SULAR...... 98 SYMJEPI...... 222 SORIATANE...... 118 sulconazole nitrate...... 122 SYMLINPEN 120...... 45 SORILUX...... 118 sulfacetamide sodium...... 202 SYMLINPEN 60...... 45 sorine...... 96 sulfacetamide sodium (acne)...... 115 SYMPAZAN...... 39 SORREL/DOCK MIX...... 19 sulfacetamide sod-sulfur wash...... 115 SYMPROIC...... 136 SOTALOL HCL...... 96 sulfacetamide-prednisolone...... 201 SYMTUZA...... 90 sotalol hcl...... 96 SULFADIAZINE...... 213 SYNDROS...... 52 sotalol hcl (af)...... 96 sulfamethoxazole-trimethoprim...... 62 SYNERCID...... 64 SOTRADECOL...... 179 SULFAMYLON...... 119 SYNJARDY...... 48 sotradecol...... 179 sulfasalazine...... 136 SYNJARDY XR...... 48 SOTYLIZE...... 97 sulfatrim pediatric...... 62 SYNRIBO...... 78 spinosad...... 124 SULFURATED LIME...... 124 SYNTHROID...... 215 SPINY PIGWEED...... 17 sulindac...... 22 SYNVISC...... 194 SPIRIVA HANDIHALER...... 36 sumatriptan...... 172 SYNVISC ONE...... 194 SPIRIVA RESPIMAT...... 36 sumatriptan succinate...... 172 SYRINGE AVITENE...... 144 spironolactone...... 128 sumatriptan succinate refill...... 172 tab-a-vite...... 184 spironolactone-hctz...... 127 sumatriptan-naproxen sodium...... 172 tab-a-vite/beta carotene...... 185 SPORANOX...... 53 SUNOSI...... 13 tab-a-vite/iron...... 184 SPORANOX PULSEPAK...... 54 super b complex maxi...... 182 TAB-A-VITE/IRON/BETA sprintec 28...... 107 super b complex/fa/vit c...... 182 CAROTENE...... 184 SPRITAM...... 41 super b complex/vitamin c...... 182 TABLOID...... 68 SPRYCEL...... 71 super b-100...... 183 TABRECTA...... 73 sps...... 178 super b-50...... 183 TACHOSIL...... 144 sronyx...... 107 super b-complex...... 183 TACLONEX...... 126 ssd...... 119 super b-complex + vitamin c...... 182 tacrolimus...... 123, 177 SSKI...... 113 super b-complex/vit c/fa...... 182 tadalafil...... 101 st joseph aspirin...... 25 super dec b-100...... 183 tadalafil (pah)...... 101 st joseph low dose...... 25 super quints b-50...... 183 TAFINLAR...... 72 STALEVO 100...... 85 super stress b-complex cr...... 192 TAGRISSO...... 72 STALEVO 125...... 85 SUPER THIN LANCETS...... 162 take action...... 108 STALEVO 150...... 85 SUPRANE...... 137 TALICIA...... 218 STALEVO 200...... 85 SUPRAX...... 103 TALL RAGWEED...... 18 STALEVO 50...... 85 SUPREP BOWEL PREP KIT...... 147 TALZENNA...... 82 246 TAMIFLU...... 94, 95 TETANUS-DIPHTHERIA TOXOIDS TNKASE...... 141 tamoxifen citrate...... 67 TD...... 216 TOBRADEX...... 201 tamsulosin hcl...... 138 tetrabenazine...... 208 TOBRADEX ST...... 202 TAPAZOLE...... 215 tetracaine hcl...... 200 tobramycin...... 19, 199 taperdex 12-day...... 112 tetracycline hcl...... 214 tobramycin sulfate...... 19 taperdex 6-day...... 112 TGT LANCET MICRO THIN 33G.....162 tobramycin-dexamethasone...... 202 taperdex 7-day...... 112 TGT LANCET THIN 26G...... 163 TOBREX...... 199 TARCEVA...... 72 TGT LANCET ULTRA THIN 30G.....163 TODAY SPONGE...... 221 TARGRETIN...... 125 THALOMID...... 175 TODAYS HEALTH MINI PEN tarina 24 fe...... 107 THAM...... 172 NEEDLES...... 170 tarina fe 1/20...... 107 THE LIQUILIFT TRACE...... 175 TODAYS HEALTH PEN NEEDLES. 170 tarina fe 1/20 eq...... 107 THEO-24...... 36 TODAYS HEALTH SHORT PEN TARKA...... 57 theophylline...... 37 NEEDLE...... 170 TARON-C DHA...... 189 theophylline er...... 37 TODAYS HEALTH THIN LANCETS TARON-PREX...... 191 THEOPHYLLINE IN D5W...... 37 28G...... 163 TAROXIA...... 115 THERA...... 185 TODAYS HEALTH THIN LANCETS TASIGNA...... 71 thera-mill...... 185 30G...... 163 TASMAR...... 84 thera-tabs...... 185 tolbutamide...... 49 TAURINE...... 196 THEREMS...... 186 tolcapone...... 84 tavaborole...... 123 thiamine hcl...... 223 TOLSURA...... 54 TAYTULLA...... 107 THINLETS GP LANCETS...... 163 tolterodine tartrate...... 218 tazarotene...... 118 THIOLA...... 139 tolterodine tartrate er...... 218 tazicef...... 103 THIOLA EC...... 139 tolvaptan...... 131 TAZICEF...... 103 thioridazine hcl...... 88 TOPCARE CLICKFINE PEN TAZORAC...... 118 thiotepa...... 66 NEEDLES...... 170 taztia xt...... 98 thiothixene...... 89 TOPCARE LANCETS MICRO-THIN TAZVERIK...... 74 thrive...... 213 33G...... 163 TDVAX...... 216 THRIVITE RX...... 189 TOPCARE ULTRA COMFORT INS TECENTRIQ...... 71 THROMBATE III...... 141 SYR...... 170 TECHLITE AST LANCETS...... 162 THROMBI-GEL 10...... 143 topiramate...... 41 TECHLITE INSULIN SYRINGE...... 170 THROMBI-GEL 100...... 143 topiramate er...... 41 TECHLITE LANCETS...... 162 THROMBI-GEL 40...... 143 toposar...... 81 TECHLITE LANCETS 30G...... 162 THROMBIN-JMI...... 144 TOPOTECAN HCL...... 83 TECHLITE PEN NEEDLES...... 170 THROMBIN-JMI EPISTAXIS...... 144 topotecan hcl...... 83 TEFLARO...... 103 THROMBI-PAD...... 143 toremifene citrate...... 67 TEGADERM AG MESH...... 126 THROMBOGEN...... 145 TORISEL...... 74 TEKTURNA HCT...... 61 THYMOGLOBULIN...... 176 torsemide...... 127 telmisartan...... 60 THYQUIDITY...... 215 TOTECT...... 78 telmisartan-amlodipine...... 59 tiadylt er...... 98, 99 TOUJEO MAX SOLOSTAR...... 47 telmisartan-hctz...... 59 tiagabine hcl...... 41 TOUJEO SOLOSTAR...... 47 temazepam...... 146 TIAZAC...... 99 tovet...... 121 TEMIXYS...... 90 TIBSOVO...... 79 TOVIAZ...... 218 TEMODAR...... 79 TIGAN...... 52 TPN ELECTROLYTES...... 173 temozolomide...... 79 TIGECYCLINE...... 214 TRACLEER...... 101 temsirolimus...... 74 tilia fe...... 110 TRALEMENT...... 175 tencon...... 23 timolol maleate...... 97, 197 tramadol hcl...... 28, 29 TENIPOSIDE...... 81 timolol maleate ocudose...... 197 tramadol hcl er...... 28 TENIVAC...... 216 timolol maleate pf...... 197 tramadol hcl er (biphasic)...... 28 tenofovir disoproxil fumarate...... 93 TIMOPTIC...... 197 tramadol-acetaminophen...... 30 TENORETIC 100...... 61 TIMOPTIC OCUDOSE...... 197 trandolapril...... 58 TENORETIC 50...... 61 TIMOPTIC-XE...... 197 trandolapril-verapamil hcl er...... 57 TEPADINA...... 66 TIMOTHY GRASS POLLEN tranexamic acid...... 144 TEPMETKO...... 74 ALLERGEN...... 18 TRANEXAMIC ACID-NACL...... 144 terazosin hcl...... 60 tinidazole...... 62 tranylcypromine sulfate...... 43 terbinafine hcl...... 53 tiopronin...... 139 TRAVASOL...... 196 terbutaline sulfate...... 35 TIROSINT...... 215 TRAVEL LANCETS...... 163 terconazole...... 221 TIROSINT-SOL...... 215 TRAVEL LANCETS ADVANCED terrell...... 137 TISSEEL...... 143 28G...... 163 TESSALON PERLES...... 112 TISSUEBLUE...... 203 travoprost (bak free)...... 203 TESTOPEL...... 30 tis-u-sol...... 177 TRAZIMERA...... 70 testosterone...... 30 TIVICAY...... 91 trazodone hcl...... 44 testosterone cypionate...... 30 TIVICAY PD...... 91 TREANDA...... 67 testosterone enanthate...... 30 tizanidine hcl...... 193 TRECATOR...... 66 247 TRELEGY ELLIPTA...... 34 tri-vite/fluoride...... 186 ULTICARE INSULIN SYRINGE...... 170 TRELSTAR MIXJECT...... 80 trivora (28)...... 111 ULTICARE MICRO PEN NEEDLES.170 TREMFYA...... 118 tri-vylibra...... 111 ULTICARE MINI PEN NEEDLES.....170 treprostinil...... 100 tri-vylibra lo...... 111 ULTICARE PEN NEEDLES...... 170 TRESIBA...... 47 TRIZIVIR...... 90 ULTICARE SHORT PEN NEEDLES.170 TRESIBA FLEXTOUCH...... 47 TRODELVY...... 82 ULTIGUARD SAFEPACK PEN tretinoin...... 82, 115 TROGARZO...... 91 NEEDLE...... 170 tretinoin (emollient)...... 116 TROKENDI XR...... 41 ULTIGUARD SAFEPACK tretinoin microsphere...... 115 TROPHAMINE...... 196 SYR/NEEDLE...... 170 tretinoin microsphere pump...... 115 tropicamide...... 198 ULTILET CLASSIC LANCETS...... 163 TREXALL...... 68 trospium chloride...... 218 ULTILET INSULIN SYRINGE...... 170 trezix...... 25 trospium chloride er...... 218 ULTILET INSULIN SYRINGE tri femynor...... 110 TRUE COMFORT INSULIN SHORT...... 170 triamcinolone acetonide...... 121, 181 SYRINGE...... 170 ULTILET LANCETS...... 163 TRIAMCINOLONE- TRUE COMFORT PEN NEEDLES....170 ULTILET PEN NEEDLE...... 170 MOXIFLOXACIN...... 202 TRUE COMFORT PRO INSULIN ULTILET SAFETY LANCETS...... 163 TRI-AMINO...... 196 SYR...... 170 ULTILET SAFETY LANCETS 23G...163 triamterene...... 128 TRUE COMFORT PRO PEN ULTIVA...... 29 triamterene-hctz...... 127 NEEDLES...... 170 ultra b-100 complex...... 192 triazolam...... 146 TRUE COMFORT TWIST TOP ULTRA COMFORT INSULIN tri-buffered aspirin...... 23 LANCETS...... 163 SYRINGE...... 170 TRICARE...... 189 TRUEPLUS 5-BEVEL PEN ULTRA FLO INSULIN PEN TRICARE PRENATAL DHA ONE.... 189 NEEDLES...... 170 NEEDLES...... 170 TRICHOPHYTON...... 18 TRUEPLUS INSULIN SYRINGE...... 170 ULTRA FLO INSULIN SYR 1/2 TRICHOPHYTON TRUEPLUS LANCETS 26G...... 163 UNIT...... 170 MENTAGROPHYTES...... 18 TRUEPLUS LANCETS 28G...... 163 ULTRA FLO INSULIN SYRINGE.....170 TRICOR...... 56 TRUEPLUS LANCETS 30G...... 163 ULTRA THIN LANCETS 31G...... 163 triderm...... 121 TRUEPLUS LANCETS 33G...... 163 ULTRA THIN PEN NEEDLES...... 170 trientine hcl...... 175 TRUEPLUS PEN NEEDLES...... 170 ULTRABAG/DIANEAL PD-2/1.5% TRIESENCE...... 202 TRUEPLUS SAFETY LANCETS 28G DEX...... 178 tri-estarylla...... 110 ...... 163 ULTRABAG/DIANEAL PD-2/2.5% trifluoperazine hcl...... 88 TRULICITY...... 48 DEX...... 178 trifluridine...... 199 TRUMENBA...... 219 ULTRABAG/DIANEAL PD- trihexyphenidyl hcl...... 84 TRUSELTIQ (100MG DAILY DOSE). 72 2/4.25%DEX...... 178 tri-legest fe...... 110 TRUSELTIQ (125MG DAILY DOSE). 72 ULTRABAG/DIANEAL/1.5% tri-linyah...... 110 TRUSELTIQ (50MG DAILY DOSE)... 72 DEXTROSE...... 178 TRILIPIX...... 56 TRUSELTIQ (75MG DAILY DOSE)... 72 ULTRABAG/DIANEAL/2.5% tri-lo-estarylla...... 110 TRUSKIN...... 125 DEXTROSE...... 178 tri-lo-marzia...... 110 TRUSOPT...... 199 ULTRABAG/DIANEAL/4.25% DEX.178 tri-lo-mili...... 110 TRUVADA...... 90 ULTRACARE INSULIN SYRINGE...170 tri-lo-sprintec...... 110 TRUXIMA...... 69 ULTRA-CARE LANCETS 30G...... 163 TRI-LUMA...... 121 trymine cg...... 113 ULTRACARE PEN NEEDLES...... 170 trimethobenzamide hcl...... 52 TUKYSA...... 70 ULTRA-COMFORT INSULIN trimethoprim...... 62 tulana...... 110 SYRINGE...... 170 tri-mili...... 110 TURALIO...... 74 ULTRAFOAM SPONGE trimipramine maleate...... 45 TUSNEL C...... 113 2X6.25X7CM...... 145 TRINATAL RX 1...... 189 TUSSICAPS...... 114 ULTRAFOAM SPONGE trinate...... 189 TUXARIN ER...... 114 8X12.5X1CM...... 145 TRINAZ...... 189 TUZISTRA XR...... 114 ULTRAFOAM SPONGE TRINTELLIX...... 44 TWINRIX...... 219 8X12.5X3CM...... 145 tri-nymyo...... 110 TWIRLA...... 107 ULTRAFOAM SPONGE 8X25X1CM145 TRIOSTAT...... 215 TWYNSTA...... 59 ULTRAFOAM SPONGE tri-previfem...... 110 TYBLUME...... 107 8X6.25X1CM...... 145 TRISENOX...... 78 TYBOST...... 93 ULTRA-THIN II AUTO LANCET..... 163 tri-sprintec...... 110 tydemy...... 107 ULTRA-THIN II INS SYR SHORT....171 TRISTART DHA...... 191 TYGACIL...... 214 ULTRA-THIN II INSULIN SYRINGE TRISTART FREE...... 191 TYKERB...... 74 ...... 171 TRISTART ONE...... 191 TYPHIM VI...... 219 ULTRA-THIN II LANCETS...... 163 tritocin...... 121 UCERIS...... 30, 112 ULTRA-THIN II MINI PEN NEEDLE TRIUMEQ...... 90 UDENYCA...... 143 ...... 171 TRIVEEN-DUO DHA...... 190 UKONIQ...... 74 ULTRA-THIN II PEN NEEDLE TRI-VI-FLOR...... 186 ULTANE...... 137 SHORT...... 171 TRI-VI-FLORO...... 186 ULTICARE INSULIN SAFETY SYR 170 ULTRA-THIN II PEN NEEDLES...... 171 248 UNASYN...... 206 VALCHLOR...... 117 venlafaxine hcl...... 44 UNIFINE PEN NEEDLES...... 171 VALCYTE...... 93 venlafaxine hcl er...... 44 UNIFINE PENTIPS...... 171 valganciclovir hcl...... 93 VENOMIL HONEY BEE VENOM...... 18 UNIFINE PENTIPS PLUS...... 171 valproate sodium...... 42 VENOMIL MIXED VESPID VENOM.18 UNIFINE SAFECONTROL PEN valproic acid...... 42 VENOMIL WASP VENOM...... 18 NEEDLE...... 171 valrubicin...... 76 VENOMIL WHITE FACED HORNET 18 UNILET COMFORTOUCH LANCET valsartan...... 60 VENOMIL YELLOW HORNET ...... 163 valsartan-hydrochlorothiazide...... 59 VENOM...... 18 UNILET EXCELITE...... 163 VALSTAR...... 76 VENOMIL YELLOW JACKET UNILET EXCELITE II...... 163 VALTOCO 10 MG DOSE...... 39 VENOM...... 18 UNILET G.P. LANCET...... 163 VALTOCO 15 MG DOSE...... 39 VENTOLIN HFA...... 35 UNILET G.P. SUPERLITE LANCET.163 VALTOCO 20 MG DOSE...... 39 verapamil hcl...... 99 UNILET GP 28 ULTRA THIN...... 163 VALTOCO 5 MG DOSE...... 39 verapamil hcl er...... 99 UNILET LANCET...... 163 VALUE HEALTH INSULIN VEREGEN...... 116 UNILET MICRO-THIN 33G...... 163 SYRINGE...... 171 VERELAN...... 99 UNILET SUPERLITE LANCET...... 163 VALUE PLUS LANCET VERELAN PM...... 99 UNILET SUPER-THIN 30G...... 163 STANDARD 21G...... 164 VERQUVO...... 101 UNILET ULTRA-THIN 28G...... 163 VALUE PLUS LANCETS SUPER VERSACLOZ...... 87 UNISTIK 1...... 163 THIN...... 164 VERZENIO...... 78 UNISTIK 2...... 163 VALUE PLUS LANCETS THIN 26G 164 vestura...... 107 UNISTIK 2 COMFORT...... 163 VALUMARK LANCET SUPER VFEND...... 54 UNISTIK 2 EXTRA...... 163 THIN 30G...... 164 VIBATIV...... 63 UNISTIK 2 NEONATAL...... 163 VALUMARK LANCET ULTRA VIBERZI...... 135 UNISTIK 2 NORMAL...... 164 THIN 28G...... 164 VICTOZA...... 48 UNISTIK 2 SUPER...... 164 VALUMARK PEN NEEDLES...... 171 VIDA MIA UNIFINE PENTIPS...... 171 UNISTIK 3...... 164 VANCOCIN...... 63 VIDA MIA UNILET LANCETS 28G.164 UNISTIK 3 COMFORT...... 164 VANCOCIN HCL...... 63 VIDA MIA UNILET LANCETS 30G.164 UNISTIK 3 EXTRA...... 164 VANCOMYCIN HCL...... 63 VIDAZA...... 68 UNISTIK 3 GENTLE...... 164 vancomycin hcl...... 63 vienva...... 107 UNISTIK 3 NEONATAL...... 164 VANCOMYCIN HCL IN DEXTROSE 63 vigabatrin...... 41 UNISTIK 3 NORMAL...... 164 VANCOMYCIN HCL IN NACL...... 63 vigadrone...... 41 UNISTIK CZT COMFORT...... 164 vandazole...... 221 VIGAMOX...... 199 UNISTIK CZT NORMAL...... 164 VANIQA...... 123 VIMPAT...... 41 UNISTIK NORMAL...... 164 VANISHPOINT INSULIN SYRINGE 171 VINATE DHA RF...... 189 UNISTIK PRO SAFETY LANCET.... 164 VANTAS...... 80 VINATE II...... 189 UNISTIK SAFETY LANCETS 28G...164 VAPRISOL...... 132 VINATE ONE...... 189 UNISTIK SAFETY LANCETS 30G...164 VAQTA...... 220 vinblastine sulfate...... 81 UNISTIK TOUCH SAFETY LANC vardenafil hcl...... 101 vincristine sulfate...... 81 21G...... 164 VARITHENA...... 179 vinorelbine tartrate...... 81 UNISTIK TOUCH SAFETY LANC VARIVAX...... 220 VIOKACE...... 126 23G...... 164 VARIZIG...... 205 viorele...... 104 UNISTIK TOUCH SAFETY LANC VARUBI (180 MG DOSE)...... 52 VIRACEPT...... 92 28G...... 164 VASCEPA...... 55 VIRAMUNE...... 92 UNISTIK TOUCH SAFETY LANC VASERETIC...... 58 VIRAMUNE XR...... 92 30G...... 164 VASOSTRICT...... 132 VIRAZOLE...... 95 unithroid...... 215 VAXCHORA...... 219 VIREAD...... 93 UNITUXIN...... 70 VAXELIS...... 216 VIRT-C DHA...... 189 UNIVERSAL 1 LANCETS THIN 26G VAZCULEP...... 223 VIRT-NATE DHA...... 189 ...... 164 VCF VAGINAL CONTRACEPTIVE. 221 virt-phos 250 neutral...... 174 UNIVERSAL 1 LANCETS THIN 33G VECAMYL...... 60 VIRT-PN DHA...... 191 ...... 164 VECTIBIX...... 72 VIRT-PN PLUS...... 190 UNIVERSAL 1 LANCETS ULTRA VECURONIUM BROMIDE...... 195 virtussin a/c...... 113 THIN...... 164 vecuronium bromide...... 195 virtussin ac w/alc...... 113 UPNEEQ...... 203 VELCADE...... 75 VIRTUSSIN DAC...... 113 UROCIT-K 10...... 138 VELETRI...... 100 VISCOAT...... 203 UROCIT-K 15...... 138 velivet...... 111 VISIONBLUE...... 203 UROCIT-K 5...... 138 VELPHORO...... 136 VISTARIL...... 32 URSO 250...... 134 VELTASSA...... 179 VISTOGARD...... 50 URSO FORTE...... 134 VENCLEXTA...... 71 vit e-vit c-beta carotene...... 186 ursodiol...... 134 VENCLEXTA STARTING PACK...... 71 VITAFOL FE+...... 191 UVADEX...... 77 VENEXA...... 184 VITAFOL GUMMIES...... 190 VABOMERE...... 62 VENIPUNCTURE PX1 VITAFOL STRIPS...... 191 valacyclovir hcl...... 94 PHLEBOTOMY...... 125 VITAFOL ULTRA...... 191 249 VITAFOL-NANO...... 190 WHITE FACED HORNET VENOM.... 18 XYREM...... 207 VITAFOL-OB...... 190 WHITE MULBERRY...... 18 YASMIN 28...... 107 VITAFOL-OB+DHA...... 191 WHITE OAK...... 18 YAZ...... 107 VITAFOL-ONE...... 191 WHITE PINE...... 18 YELLOW DOCK...... 18 vitalee...... 186 WHITE-FACED HORNET VENOM....18 YELLOW HORNET VENOM VITALINE BIOTIN FORTE...... 182 WIDE-SEAL DIAPHRAGM 60...... 153 PROTEIN...... 18 VITAMEDMD ONE WIDE-SEAL DIAPHRAGM 65...... 153 YELLOW JACKET VENOM RX/QUATREFOLIC...... 191 WIDE-SEAL DIAPHRAGM 70...... 153 PROTEIN...... 18 VITAMEDMD REDICHEW RX...... 191 WIDE-SEAL DIAPHRAGM 75...... 153 YERVOY...... 70 vitamin b + c complex...... 182 WIDE-SEAL DIAPHRAGM 80...... 153 YF-VAX...... 221 vitamin b complex...... 181 WIDE-SEAL DIAPHRAGM 85...... 153 yl balanced b-100...... 183 vitamin b-complex...... 181 WIDE-SEAL DIAPHRAGM 90...... 153 yl folic acid...... 143 vitamin d (ergocalciferol)...... 223 WIDE-SEAL DIAPHRAGM 95...... 153 YONDELIS...... 82 vitamin k1...... 223 WILZIN...... 175 YONSA...... 67 vitamin-b complex...... 181 wixela inhub...... 34 YOSPRALA...... 141 vitamins acd-fluoride...... 186 womans laxative...... 150 YUPELRI...... 36 VITAPEARL...... 190 womens laxative...... 150 YUTIQ...... 202 VITATHELY WITH GINGER...... 190 WOUNDGELHA MATRIX...... 126 yuvafem...... 222 VITATRUE...... 191 WP THYROID...... 215 zafemy...... 108 VITRAKVI...... 75 wymzya fe...... 107 zafirlukast...... 36 VITRANOL FE...... 184 WYNZORA...... 126 zaleplon...... 146 VITRASE...... 176 XADAGO...... 84 ZALTRAP...... 83 VIVA DHA...... 190 XALKORI...... 69 ZALVIT...... 190 VIVAGUARD LANCETS...... 164 XARACOLL...... 151 ZANAFLEX...... 193 VIZIMPRO...... 72 XARELTO...... 37 ZANOSAR...... 81 volnea...... 104 XARELTO STARTER PACK...... 37 zarah...... 107 VORAXAZE...... 78 XATMEP...... 68 ZARXIO...... 143 voriconazole...... 54 XCOPRI...... 41 ZATEAN-PN DHA...... 191 VOSEVI...... 94 XCOPRI (250 MG DAILY DOSE)...... 41 ZATEAN-PN PLUS...... 190 VOTRIENT...... 74 XCOPRI (350 MG DAILY DOSE)...... 41 ZCORT 7-DAY...... 112 VP INSULIN SYRINGE...... 171 XELODA...... 68 zebutal...... 23 VP-PNV-DHA...... 190 XELPROS...... 203 ZEGALOGUE...... 46 VRAYLAR...... 86 XENAZINE...... 208 ZEJULA...... 82 VUSION...... 116 XENICAL...... 13 ZELAPAR...... 84 vyfemla...... 107 XENLETA...... 64 ZELBORAF...... 72 VYLEESI...... 208 XEPI...... 116 ZEMDRI...... 19 vylibra...... 107 XERAVA...... 214 ZEMPLAR...... 130 VYVANSE...... 12 XERESE...... 118 zenatane...... 116 VYXEOS...... 77 XGEVA...... 131 ZENPEP...... 127 VYZULTA...... 203 XIFAXAN...... 62 zenzedi...... 12 WALGREENS ADV TRAVEL XIGDUO XR...... 48 ZEPZELCA...... 67 LANCETS...... 164 XIIDRA...... 198 ZERBAXA...... 101 WALGREENS LANCETS...... 164 XOFIGO...... 77 ZESTORETIC...... 58 WALGREENS LANCETS MICRO XOFLUZA (40 MG DOSE)...... 95 ZEVALIN Y-90...... 76 THIN...... 164 XOFLUZA (80 MG DOSE)...... 95 ZIAC...... 61 WALGREENS LANCETS SUPER XOLEGEL...... 122 ZIAGEN...... 92 THIN...... 164 XOPENEX HFA...... 35 ziclopro...... 117 WALGREENS THIN LANCETS...... 164 XOSPATA...... 74 zidovudine...... 93 WALGREENS ULTRA THIN XPOVIO (100 MG ONCE WEEKLY)..75 ZILXI...... 124 LANCETS...... 164 XPOVIO (40 MG ONCE WEEKLY)....75 zinc chloride...... 175 warfarin sodium...... 37 XPOVIO (40 MG TWICE WEEKLY).. 75 zinc sulfate...... 175 WASP VENOM PROTEIN...... 18 XPOVIO (60 MG ONCE WEEKLY)....75 ZINGO...... 151 water for irrigation, sterile...... 177 XPOVIO (60 MG TWICE WEEKLY).. 75 ZINPLAVA...... 205 WEGMANS UNIFINE PENTIPS XPOVIO (80 MG ONCE WEEKLY)....76 ZIOPTAN...... 203 PLUS...... 171 XPOVIO (80 MG TWICE WEEKLY).. 76 ziprasidone hcl...... 86 WEGOVY...... 13 XTANDI...... 67 ziprasidone mesylate...... 86 wera...... 107 xulane...... 108 ZIRABEV...... 83 WESTAB PLUS...... 190 XULTOPHY...... 48 ZIRGAN...... 199 WESTERN JUNIPER...... 18 XURIDEN...... 130 ZITHROMAX...... 152 WESTGEL DHA...... 191 XYLOCAINE...... 151 ZITHROMAX TRI-PAK...... 152 WESTHROID...... 215 XYLOCAINE/EPINEPHRINE...... 150 ZITHROMAX Z-PAK...... 152 WEST-VITE W/FOLIC ACID...... 182 XYLOCAINE-MPF...... 151 ZOFRAN...... 51 WHITE BIRCH...... 18 XYLOCAINE-MPF/EPINEPHRINE.. 150 ZOLADEX...... 80 250 zoledronic acid...... 129 ZOLEDRONIC ACID...... 129 ZOLINZA...... 73 zolmitriptan...... 172 zolpidem tartrate...... 146 zolpidem tartrate er...... 146 ZOLPIMIST...... 146 zonisamide...... 41 ZONTIVITY...... 141 ZORTRESS...... 177 ZOSYN...... 206 zovia 1/35 (28)...... 107 zovia 1/35e (28)...... 107 ZOVIRAX...... 94, 119 ZUBSOLV...... 29, 30 zumandimine...... 107 ZUPLENZ...... 51 ZYCLARA...... 122 ZYCLARA PUMP...... 122 ZYDELIG...... 82 ZYKADIA...... 69 ZYLET...... 202 ZYLOPRIM...... 139 ZYMAXID...... 199 ZYNLONTA...... 69 ZYPREXA RELPREVV...... 89 ZYTIGA...... 67 ZYVANA...... 184 ZYVOX...... 64

251 Most plans include our home delivery program at no extra cost to you. Find out more by going online to anthem.com/ca or call 866-297-1013.

For information about your pharmacy benefit, log in at

anthem.com/ca.

You’ll find the most up-to-date drug list and details about your benefits. If you still have questions, we’re here. Just call the Member Services number on your ID card.

Speech and hearing impaired (TDD/TTY) users Call 1-800-221-6915, Monday through Friday, 8:30 a.m. to 5 p.m.ET.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Express Scripts, Inc. is a separate company that manages the pharmacy benefit services for members of our health plans. Rev. 11/18