<<

Zero Dollar Copay List

The following drugs, when covered, are available at zero dollar copay under the pharmacy benefit. This list does not imply formulary coverage. Prior authorization and step therapy may apply. Coverage should be verified by reviewing the Preferred Drug List (PDL) on the Healthy Blue website. The list may change throughout the year.

Effective for all members on September 15, 2020 BRAND NAME NAME CATEGORY ACCUPRIL QUINAPRIL HCL Blood Pressure/Heart Health ACCURETIC QUINAPRIL/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health ACEBUTOLOL HCL ACEBUTOLOL HCL Blood Pressure/Heart Health ACEON PERINDOPRIL ERBUMINE Blood Pressure/Heart Health ACETAZOLAMIDE ACETAZOLAMIDE Blood Pressure/Heart Health ACETAZOLAMIDE SODIUM ACETAZOLAMIDE SODIUM Blood Pressure/Heart Health ADALAT CC Blood Pressure/Heart Health ADENOCARD ADENOSINE Blood Pressure/Heart Health ADENOSINE ADENOSINE Blood Pressure/Heart Health AFEDITAB CR NIFEDIPINE Blood Pressure/Heart Health ALDACTAZIDE SPIRONOLACT/HYDROCHLOROTHIAZID Blood Pressure/Heart Health ALDACTONE Blood Pressure/Heart Health ALPROSTADIL ALPROSTADIL Blood Pressure/Heart Health ALTACE RAMIPRIL Blood Pressure/Heart Health AMILORIDE HCL AMILORIDE HCL Blood Pressure/Heart Health AMILORIDE- AMILORIDE/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health HYDROCHLOROTHIAZIDE HCL AMIODARONE HCL Blood Pressure/Heart Health BESYLATE AMLODIPINE BESYLATE Blood Pressure/Heart Health AMLODIPINE ESYLATE- AMLODIPINE BESYLATE/BENAZEPRIL Blood Pressure/Heart Health BENAZEPRIL AMLODIPINE- AMLODIPINE BES/OLMESARTAN MED Blood Pressure/Heart Health OLMESARTAN AMLODIPINE-VALSARTAN AMLODIPINE BESYLATE/VALSARTAN Blood Pressure/Heart Health AMLODIPINE-VALSARTAN- AMLODIPINE/VALSARTAN/HCTHIAZID Blood Pressure/Heart Health HCTZ AMTURNIDE ALISKIREN/AMLODIPIN/HCTHIAZIDE Blood Pressure/Heart Health ATACAND CANDESARTAN CILEXETIL Blood Pressure/Heart Health ATACAND HCT CANDESARTAN/HYDROCHLOROTHIAZID Blood Pressure/Heart Health ATENOLOL ATENOLOL Blood Pressure/Heart Health ATENOLOL- ATENOLOL/CHLORTHALIDONE Blood Pressure/Heart Health CHLORTHALIDONE AVALIDE IRBESARTAN/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health AVAPRO IRBESARTAN Blood Pressure/Heart Health AZOR AMLODIPINE BES/OLMESARTAN MED Blood Pressure/Heart Health BENAZEPRIL HCL BENAZEPRIL HCL Blood Pressure/Heart Health BENAZEPRIL- BENAZEPRIL/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health HYDROCHLOROTHIAZIDE BENICAR OLMESARTAN MEDOXOMIL Blood Pressure/Heart Health

WEBMBSC-0334-20 Healthy Blue Zero Dollar Copay List Page 2 of 20

BRAND NAME GENERIC DRUG NAME CATEGORY BENICAR HCT OLMESARTAN/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health BETAPACE SOTALOL HCL Blood Pressure/Heart Health BETAPACE AF SOTALOL HCL Blood Pressure/Heart Health BETAXOLOL HCL BETAXOLOL HCL Blood Pressure/Heart Health BIDIL ISOSORBIDE DINIT/HYDRALAZINE Blood Pressure/Heart Health BISOPROLOL FUMARATE BISOPROLOL FUMARATE Blood Pressure/Heart Health BISOPROLOL- BISOPROLOL/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health HYDROCHLOROTHIAZIDE BREVIBLOC ESMOLOL HCL Blood Pressure/Heart Health BREVIBLOC ESMOLOL IN SODIUM CHLORIDE, ISO Blood Pressure/Heart Health BUMETANIDE BUMETANIDE Blood Pressure/Heart Health BYSTOLIC NEBIVOLOL HCL Blood Pressure/Heart Health BYVALSON NEBIVOLOL HCL/VALSARTAN Blood Pressure/Heart Health CALAN VERAPAMIL HCL Blood Pressure/Heart Health CALAN SR VERAPAMIL HCL Blood Pressure/Heart Health CANDESARTAN CILEXETIL CANDESARTAN CILEXETIL Blood Pressure/Heart Health CANDESARTAN- CANDESARTAN/HYDROCHLOROTHIAZID Blood Pressure/Heart Health HYDROCHLOROTHIAZID CAPTOPRIL CAPTOPRIL Blood Pressure/Heart Health CAPTOPRIL- CAPTOPRIL/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health HYDROCHLOROTHIAZIDE CARDENE I.V. HCL Blood Pressure/Heart Health CARDIZEM DILTIAZEM HCL Blood Pressure/Heart Health CARDIZEM CD DILTIAZEM HCL Blood Pressure/Heart Health CARDIZEM LA DILTIAZEM HCL Blood Pressure/Heart Health CARDURA DOXAZOSIN MESYLATE Blood Pressure/Heart Health CARDURA XL DOXAZOSIN MESYLATE Blood Pressure/Heart Health CAROSPIR SPIRONOLACTONE Blood Pressure/Heart Health CARTIA XT DILTIAZEM HCL Blood Pressure/Heart Health CARVEDILOL Blood Pressure/Heart Health CARVEDILOL ER CARVEDILOL PHOSPHATE Blood Pressure/Heart Health CATAPRES CLONIDINE HCL Blood Pressure/Heart Health CATAPRES-TTS 1 CLONIDINE Blood Pressure/Heart Health CATAPRES-TTS 2 CLONIDINE Blood Pressure/Heart Health CATAPRES-TTS 3 CLONIDINE Blood Pressure/Heart Health CHLOROTHIAZIDE CHLOROTHIAZIDE Blood Pressure/Heart Health CHLOROTHIAZIDE SODIUM CHLOROTHIAZIDE SODIUM Blood Pressure/Heart Health CHLORTHALIDONE CHLORTHALIDONE Blood Pressure/Heart Health CLEVIPREX CLEVIDIPINE BUTYRATE Blood Pressure/Heart Health CLONIDINE CLONIDINE Blood Pressure/Heart Health CLONIDINE HCL CLONIDINE HCL Blood Pressure/Heart Health CLORPRES CLONIDINE HCL/CHLORTHALIDONE Blood Pressure/Heart Health CORDARONE AMIODARONE HCL Blood Pressure/Heart Health COREG CARVEDILOL Blood Pressure/Heart Health COREG CR CARVEDILOL PHOSPHATE Blood Pressure/Heart Health CORGARD NADOLOL Blood Pressure/Heart Health CORLOPAM FENOLDOPAM MESYLATE Blood Pressure/Heart Health CORVERT IBUTILIDE FUMARATE Blood Pressure/Heart Health CORZIDE NADOLOL/BENDROFLUMETHIAZIDE Blood Pressure/Heart Health COZAAR LOSARTAN POTASSIUM Blood Pressure/Heart Health

WEBMBSC-0334-20 Healthy Blue Zero Dollar Copay List Page 3 of 20

BRAND NAME GENERIC DRUG NAME CATEGORY DEMADEX TORSEMIDE Blood Pressure/Heart Health DEMSER METYROSINE Blood Pressure/Heart Health DIAMOX SEQUELS ACETAZOLAMIDE Blood Pressure/Heart Health DIBENZYLINE PHENOXYBENZAMINE HCL Blood Pressure/Heart Health DIGITEK DIGOXIN Blood Pressure/Heart Health DIGOX DIGOXIN Blood Pressure/Heart Health DIGOXIN DIGOXIN Blood Pressure/Heart Health DILATRATE-SR ISOSORBIDE DINITRATE Blood Pressure/Heart Health DILTIAZEM 12HR ER DILTIAZEM HCL Blood Pressure/Heart Health DILTIAZEM 24HR CD DILTIAZEM HCL Blood Pressure/Heart Health DILTIAZEM 24HR ER DILTIAZEM HCL Blood Pressure/Heart Health DILTIAZEM ER DILTIAZEM HCL Blood Pressure/Heart Health DILTIAZEM HCL DILTIAZEM HCL Blood Pressure/Heart Health DILT-XR DILTIAZEM HCL Blood Pressure/Heart Health DIOVAN VALSARTAN Blood Pressure/Heart Health DIOVAN HCT VALSARTAN/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health DISOPYRAMIDE DISOPYRAMIDE PHOSPHATE Blood Pressure/Heart Health PHOSPHATE DIURETIC SOFTGEL PAMABROM Blood Pressure/Heart Health DIURIL CHLOROTHIAZIDE Blood Pressure/Heart Health DOFETILIDE DOFETILIDE Blood Pressure/Heart Health DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE Blood Pressure/Heart Health DUTOPROL METOPROLOL SU/HYDROCHLOROTHIAZ Blood Pressure/Heart Health DYAZIDE TRIAMTERENE/HYDROCHLOROTHIAZID Blood Pressure/Heart Health DYRENIUM TRIAMTERENE Blood Pressure/Heart Health EDARBI AZILSARTAN MEDOXOMIL Blood Pressure/Heart Health EDARBYCLOR AZILSARTAN MED/CHLORTHALIDONE Blood Pressure/Heart Health EDECRIN ETHACRYNIC ACID Blood Pressure/Heart Health ENALAPRIL MALEATE ENALAPRIL MALEATE Blood Pressure/Heart Health ENALAPRILAT ENALAPRILAT DIHYDRATE Blood Pressure/Heart Health ENALAPRIL- ENALAPRIL/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health HYDROCHLOROTHIAZIDE EPANED ENALAPRIL MALEATE Blood Pressure/Heart Health EPLERENONE EPLERENONE Blood Pressure/Heart Health EPROSARTAN MESYLATE EPROSARTAN MESYLATE Blood Pressure/Heart Health ESMOLOL HCL ESMOLOL HCL Blood Pressure/Heart Health ESMOLOL HCL-WATER ESMOLOL HCL IN STERILE WATER Blood Pressure/Heart Health ETHACRYNATE SODIUM ETHACRYNATE SODIUM Blood Pressure/Heart Health ETHACRYNIC ACID ETHACRYNIC ACID Blood Pressure/Heart Health EXFORGE AMLODIPINE BESYLATE/VALSARTAN Blood Pressure/Heart Health EXFORGE HCT AMLODIPINE/VALSARTAN/HCTHIAZID Blood Pressure/Heart Health ER FELODIPINE Blood Pressure/Heart Health FLECAINIDE ACETATE FLECAINIDE ACETATE Blood Pressure/Heart Health FOSINOPRIL SODIUM FOSINOPRIL SODIUM Blood Pressure/Heart Health FOSINOPRIL- FOSINOPRIL/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health HYDROCHLOROTHIAZIDE FUROSEMIDE FUROSEMIDE Blood Pressure/Heart Health GONITRO NITROGLYCERIN Blood Pressure/Heart Health GUANFACINE HCL GUANFACINE HCL Blood Pressure/Heart Health HEMANGEOL PROPRANOLOL HCL Blood Pressure/Heart Health

WEBMBSC-0334-20 Healthy Blue Zero Dollar Copay List Page 4 of 20

BRAND NAME GENERIC DRUG NAME CATEGORY HYDRALAZINE HCL HYDRALAZINE HCL Blood Pressure/Heart Health HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health HYZAAR LOSARTAN/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health IBUTILIDE FUMARATE IBUTILIDE FUMARATE Blood Pressure/Heart Health INDAPAMIDE INDAPAMIDE Blood Pressure/Heart Health INDERAL LA PROPRANOLOL HCL Blood Pressure/Heart Health INDERAL XL PROPRANOLOL HCL Blood Pressure/Heart Health INNOPRAN XL PROPRANOLOL HCL Blood Pressure/Heart Health INSPRA EPLERENONE Blood Pressure/Heart Health IRBESARTAN IRBESARTAN Blood Pressure/Heart Health IRBESARTAN- IRBESARTAN/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health HYDROCHLOROTHIAZIDE ISOCHRON ISOSORBIDE DINITRATE Blood Pressure/Heart Health ISORDIL ISOSORBIDE DINITRATE Blood Pressure/Heart Health ISORDIL TITRADOSE ISOSORBIDE DINITRATE Blood Pressure/Heart Health ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE Blood Pressure/Heart Health ISOSORBIDE DINITRATE ER ISOSORBIDE DINITRATE Blood Pressure/Heart Health ISOSORBIDE ISOSORBIDE MONONITRATE Blood Pressure/Heart Health MONONITRATE ISOSORBIDE ISOSORBIDE MONONITRATE Blood Pressure/Heart Health MONONITRATE ER ISOXSUPRINE HCL ISOXSUPRINE HCL Blood Pressure/Heart Health ISRADIPINE ISRADIPINE Blood Pressure/Heart Health LABETALOL HCL LABETALOL HCL Blood Pressure/Heart Health LANOXIN DIGOXIN Blood Pressure/Heart Health LANOXIN PEDIATRIC DIGOXIN Blood Pressure/Heart Health LASIX FUROSEMIDE Blood Pressure/Heart Health LEVATOL PENBUTOLOL SULFATE Blood Pressure/Heart Health LIDOCAINE HCL LIDOCAINE HCL/PF Blood Pressure/Heart Health LISINOPRIL LISINOPRIL Blood Pressure/Heart Health LISINOPRIL- LISINOPRIL/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health HYDROCHLOROTHIAZIDE LOPRESSOR METOPROLOL TARTRATE Blood Pressure/Heart Health LOPRESSOR HCT METOPROLOL/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health LOSARTAN POTASSIUM LOSARTAN POTASSIUM Blood Pressure/Heart Health LOSARTAN- LOSARTAN/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health HYDROCHLOROTHIAZIDE LOTENSIN BENAZEPRIL HCL Blood Pressure/Heart Health LOTENSIN HCT BENAZEPRIL/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health LOTREL AMLODIPINE BESYLATE/BENAZEPRIL Blood Pressure/Heart Health MANNITOL MANNITOL Blood Pressure/Heart Health MATZIM LA DILTIAZEM HCL Blood Pressure/Heart Health MAVIK TRANDOLAPRIL Blood Pressure/Heart Health MAXZIDE TRIAMTERENE/HYDROCHLOROTHIAZID Blood Pressure/Heart Health MAXZIDE-25 MG TRIAMTERENE/HYDROCHLOROTHIAZID Blood Pressure/Heart Health METHAZOLAMIDE METHAZOLAMIDE Blood Pressure/Heart Health METHYCLOTHIAZIDE METHYCLOTHIAZIDE Blood Pressure/Heart Health METHYLDOPA METHYLDOPA Blood Pressure/Heart Health METHYLDOPA- METHYLDOPA/HYDROCHLOROTHIAZID Blood Pressure/Heart Health HYDROCHLOROTHIAZIDE E

WEBMBSC-0334-20 Healthy Blue Zero Dollar Copay List Page 5 of 20

BRAND NAME GENERIC DRUG NAME CATEGORY METHYLDOPATE HCL METHYLDOPATE HCL Blood Pressure/Heart Health METOLAZONE METOLAZONE Blood Pressure/Heart Health METOPROLOL SUCCINATE METOPROLOL SUCCINATE Blood Pressure/Heart Health METOPROLOL SUCCINATE METOPROLOL SU/HYDROCHLOROTHIAZ Blood Pressure/Heart Health ER-HCTZ METOPROLOL TARTRATE METOPROLOL TARTRATE Blood Pressure/Heart Health METOPROLOL- METOPROLOL/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health HYDROCHLOROTHIAZIDE MEXILETINE HCL MEXILETINE HCL Blood Pressure/Heart Health MICARDIS Blood Pressure/Heart Health MICARDIS HCT TELMISARTAN/HYDROCHLOROTHIAZID Blood Pressure/Heart Health MICROZIDE HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health MINIPRESS PRAZOSIN HCL Blood Pressure/Heart Health MINITRAN NITROGLYCERIN Blood Pressure/Heart Health MINOXIDIL MINOXIDIL Blood Pressure/Heart Health MOEXIPRIL HCL MOEXIPRIL HCL Blood Pressure/Heart Health MOEXIPRIL- MOEXIPRIL/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health HYDROCHLOROTHIAZIDE MULTAQ DRONEDARONE HCL Blood Pressure/Heart Health NADOLOL NADOLOL Blood Pressure/Heart Health NADOLOL- NADOLOL/BENDROFLUMETHIAZIDE Blood Pressure/Heart Health BENDROFLUMETHIAZIDE NEPTAZANE METHAZOLAMIDE Blood Pressure/Heart Health NICARDIPINE HCL NICARDIPINE HCL Blood Pressure/Heart Health NIFEDICAL XL NIFEDIPINE Blood Pressure/Heart Health NIFEDIPINE NIFEDIPINE Blood Pressure/Heart Health NIFEDIPINE ER NIFEDIPINE Blood Pressure/Heart Health NIMODIPINE NIMODIPINE Blood Pressure/Heart Health NISOLDIPINE Blood Pressure/Heart Health NITRO-BID NITROGLYCERIN Blood Pressure/Heart Health NITRO-DUR NITROGLYCERIN Blood Pressure/Heart Health NITROGLYCERIN NITROGLYCERIN Blood Pressure/Heart Health NITROGLYCERIN PATCH NITROGLYCERIN Blood Pressure/Heart Health NITROLINGUAL NITROGLYCERIN Blood Pressure/Heart Health NITROMIST NITROGLYCERIN Blood Pressure/Heart Health NITRONAL NITROGLYCERIN Blood Pressure/Heart Health NITROPRESS NITROPRUSSIDE SODIUM Blood Pressure/Heart Health NITROSTAT NITROGLYCERIN Blood Pressure/Heart Health NITRO-TIME NITROGLYCERIN Blood Pressure/Heart Health NORPACE DISOPYRAMIDE PHOSPHATE Blood Pressure/Heart Health NORPACE CR DISOPYRAMIDE PHOSPHATE Blood Pressure/Heart Health NORVASC AMLODIPINE BESYLATE Blood Pressure/Heart Health NYMALIZE NIMODIPINE Blood Pressure/Heart Health OLMESARTAN OLMESARTAN MEDOXOMIL Blood Pressure/Heart Health MEDOXOMIL OLMESARTAN- OLMESARTAN/AMLODIPIN/HCTHIAZID Blood Pressure/Heart Health AMLODIPINE-HCTZ OLMESARTAN- OLMESARTAN/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health HYDROCHLOROTHIAZIDE OSMITROL MANNITOL Blood Pressure/Heart Health

WEBMBSC-0334-20 Healthy Blue Zero Dollar Copay List Page 6 of 20

BRAND NAME GENERIC DRUG NAME CATEGORY PACERONE AMIODARONE HCL Blood Pressure/Heart Health PAPAVERINE HCL PAPAVERINE HCL Blood Pressure/Heart Health PERINDOPRIL ERBUMINE PERINDOPRIL ERBUMINE Blood Pressure/Heart Health PHENOXYBENZAMINE HCL PHENOXYBENZAMINE HCL Blood Pressure/Heart Health PHENTOLAMINE MESYLATE PHENTOLAMINE MESYLATE Blood Pressure/Heart Health PINDOLOL PINDOLOL Blood Pressure/Heart Health PRAZOSIN HCL PRAZOSIN HCL Blood Pressure/Heart Health PRESTALIA PERINDOPRIL ARG/AMLODIPINE BES Blood Pressure/Heart Health PRINIVIL LISINOPRIL Blood Pressure/Heart Health PROCAINAMIDE HCL PROCAINAMIDE HCL Blood Pressure/Heart Health PROCARDIA NIFEDIPINE Blood Pressure/Heart Health PROCARDIA XL NIFEDIPINE Blood Pressure/Heart Health PROPAFENONE HCL PROPAFENONE HCL Blood Pressure/Heart Health PROPAFENONE HCL ER PROPAFENONE HCL Blood Pressure/Heart Health PROPRANOLOL HCL PROPRANOLOL HCL Blood Pressure/Heart Health PROPRANOLOL HCL ER PROPRANOLOL HCL Blood Pressure/Heart Health PROPRANOLOL- PROPRANOLOL/HYDROCHLOROTHIAZID Blood Pressure/Heart Health HYDROCHLOROTHIAZID PROSTIN VR PEDIATRIC ALPROSTADIL Blood Pressure/Heart Health QBRELIS LISINOPRIL Blood Pressure/Heart Health QUINAPRIL HCL QUINAPRIL HCL Blood Pressure/Heart Health QUINAPRIL- QUINAPRIL/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health HYDROCHLOROTHIAZIDE QUINIDINE GLUCONATE QUINIDINE GLUCONATE Blood Pressure/Heart Health QUINIDINE SULFATE QUINIDINE SULFATE Blood Pressure/Heart Health RAMIPRIL RAMIPRIL Blood Pressure/Heart Health RANEXA RANOLAZINE Blood Pressure/Heart Health RESECTISOL MANNITOL Blood Pressure/Heart Health RESERPINE Blood Pressure/Heart Health RYTHMOL PROPAFENONE HCL Blood Pressure/Heart Health RYTHMOL SR PROPAFENONE HCL Blood Pressure/Heart Health SECTRAL ACEBUTOLOL HCL Blood Pressure/Heart Health SODIUM DIURIL CHLOROTHIAZIDE SODIUM Blood Pressure/Heart Health SODIUM EDECRIN ETHACRYNATE SODIUM Blood Pressure/Heart Health SODIUM NITROPRUSSIDE NITROPRUSSIDE SODIUM Blood Pressure/Heart Health SORINE SOTALOL HCL Blood Pressure/Heart Health SOTALOL SOTALOL HCL Blood Pressure/Heart Health SOTALOL AF SOTALOL HCL Blood Pressure/Heart Health SOTALOL HCL SOTALOL HCL Blood Pressure/Heart Health SOTYLIZE SOTALOL HCL Blood Pressure/Heart Health SPIRONOLACTONE SPIRONOLACTONE Blood Pressure/Heart Health SPIRONOLACTONE-HCTZ SPIRONOLACT/HYDROCHLOROTHIAZID Blood Pressure/Heart Health SULAR NISOLDIPINE Blood Pressure/Heart Health TARKA TRANDOLAPRIL/VERAPAMIL HCL Blood Pressure/Heart Health TAZTIA XT DILTIAZEM HCL Blood Pressure/Heart Health TEKAMLO ALISKIREN/AMLODIPINE BESYLATE Blood Pressure/Heart Health TEKTURNA ALISKIREN HEMIFUMARATE Blood Pressure/Heart Health TEKTURNA HCT ALISKIREN/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health TELMISARTAN TELMISARTAN Blood Pressure/Heart Health

WEBMBSC-0334-20 Healthy Blue Zero Dollar Copay List Page 7 of 20

BRAND NAME GENERIC DRUG NAME CATEGORY TELMISARTAN- TELMISARTAN/AMLODIPINE Blood Pressure/Heart Health AMLODIPINE TELMISARTAN- TELMISARTAN/HYDROCHLOROTHIAZID Blood Pressure/Heart Health HYDROCHLOROTHIAZID TENEX GUANFACINE HCL Blood Pressure/Heart Health TENORETIC 100 ATENOLOL/CHLORTHALIDONE Blood Pressure/Heart Health TENORETIC 50 ATENOLOL/CHLORTHALIDONE Blood Pressure/Heart Health TENORMIN ATENOLOL Blood Pressure/Heart Health TERAZOSIN HCL TERAZOSIN HCL Blood Pressure/Heart Health TEVETEN EPROSARTAN MESYLATE Blood Pressure/Heart Health TEVETEN HCT EPROSARTAN/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health TIAZAC DILTIAZEM HCL Blood Pressure/Heart Health TIKOSYN DOFETILIDE Blood Pressure/Heart Health TIMOLOL MALEATE TIMOLOL MALEATE Blood Pressure/Heart Health TOPROL XL METOPROLOL SUCCINATE Blood Pressure/Heart Health TORSEMIDE TORSEMIDE Blood Pressure/Heart Health TRANDOLAPRIL TRANDOLAPRIL Blood Pressure/Heart Health TRANDOLAPRIL- TRANDOLAPRIL/VERAPAMIL HCL Blood Pressure/Heart Health VERAPAMIL ER TRIAMTERENE-HCTZ TRIAMTERENE/HYDROCHLOROTHIAZID Blood Pressure/Heart Health TRIAMTERENE- TRIAMTERENE/HYDROCHLOROTHIAZID Blood Pressure/Heart Health HYDROCHLOROTHIAZID TRIBENZOR OLMESARTAN/AMLODIPIN/HCTHIAZID Blood Pressure/Heart Health TWYNSTA TELMISARTAN/AMLODIPINE Blood Pressure/Heart Health URE-NA UREA (OSMOTIC DIURETIC) Blood Pressure/Heart Health VALSARTAN VALSARTAN Blood Pressure/Heart Health VALSARTAN- VALSARTAN/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health HYDROCHLOROTHIAZIDE VASERETIC ENALAPRIL/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health VASOTEC ENALAPRIL MALEATE Blood Pressure/Heart Health VECAMYL MECAMYLAMINE HCL Blood Pressure/Heart Health VERAPAMIL ER VERAPAMIL HCL Blood Pressure/Heart Health VERAPAMIL ER PM VERAPAMIL HCL Blood Pressure/Heart Health VERAPAMIL HCL VERAPAMIL HCL Blood Pressure/Heart Health VERAPAMIL SR VERAPAMIL HCL Blood Pressure/Heart Health VERELAN VERAPAMIL HCL Blood Pressure/Heart Health VERELAN PM VERAPAMIL HCL Blood Pressure/Heart Health ZEBETA BISOPROLOL FUMARATE Blood Pressure/Heart Health ZESTORETIC LISINOPRIL/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health ZESTRIL LISINOPRIL Blood Pressure/Heart Health ZIAC BISOPROLOL/HYDROCHLOROTHIAZIDE Blood Pressure/Heart Health ARGATROBAN ARGATROBAN Blood Thinners/Platelet Agents ARIXTRA FONDAPARINUX SODIUM Blood Thinners/Platelet Agents BEVYXXA BETRIXABAN MALEATE Blood Thinners/Platelet Agents CLOPIDOGREL CLOPIDOGREL BISULFATE Blood Thinners/Platelet Agents COUMADIN WARFARIN SODIUM Blood Thinners/Platelet Agents ELIQUIS APIXABAN Blood Thinners/Platelet Agents ENOXAPARIN SODIUM ENOXAPARIN SODIUM Blood Thinners/Platelet Agents FONDAPARINUX SODIUM FONDAPARINUX SODIUM Blood Thinners/Platelet Agents FRAGMIN DALTEPARIN SODIUM, PORCINE Blood Thinners/Platelet Agents

WEBMBSC-0334-20 Healthy Blue Zero Dollar Copay List Page 8 of 20

BRAND NAME GENERIC DRUG NAME CATEGORY HEPARIN FLUSH HEPARIN SODIUM, PORCINE/PF Blood Thinners/Platelet Agents HEPARIN LOCK HEPARIN SODIUM, PORCINE/PF Blood Thinners/Platelet Agents HEPARIN SODIUM HEPARIN SODIUM, PORCINE/PF Blood Thinners/Platelet Agents HEPARIN SODIUM-0.9% HEPARIN SODIUM,PORCINE/NS/PF Blood Thinners/Platelet Agents NACL JANTOVEN WARFARIN SODIUM Blood Thinners/Platelet Agents LOVENOX ENOXAPARIN SODIUM Blood Thinners/Platelet Agents MONOJECT PREFILL HEPARIN SODIUM, PORCINE/PF Blood Thinners/Platelet Agents MONOJECT PREFILL HEPARIN SODIUM, PORCINE/PF Blood Thinners/Platelet Agents ADVANCED PLAVIX CLOPIDOGREL BISULFATE Blood Thinners/Platelet Agents PRADAXA DABIGATRAN ETEXILATE MESYLATE Blood Thinners/Platelet Agents SAVAYSA EDOXABAN TOSYLATE Blood Thinners/Platelet Agents SODIUM CITRATE SODIUM CITRATE Blood Thinners/Platelet Agents TRICITRASOL SODIUM CITRATE DIHYDRATE Blood Thinners/Platelet Agents WARFARIN SODIUM WARFARIN SODIUM Blood Thinners/Platelet Agents XARELTO RIVAROXABAN Blood Thinners/Platelet Agents ADVICOR NIACIN/ Cholesterol/Heart Health ALGAL-900 DHA DOCOSAHEXANOIC ACID Cholesterol/Heart Health ALTOPREV LOVASTATIN Cholesterol/Heart Health AMLODIPINE- AMLODIPINE/ATORVASTATIN Cholesterol/Heart Health ATORVASTATIN ANTARA FENOFIBRATE, MICRONIZED Cholesterol/Heart Health ATABEX DHA DOCOSAHEXANOIC ACID/EPA Cholesterol/Heart Health ATORVASTATIN ATORVASTATIN CALCIUM Cholesterol/Heart Health CADUET AMLODIPINE/ATORVASTATIN Cholesterol/Heart Health CARDIOSTEROL PHYTOSTEROL/OM-3/DHA/EPA/FISH Cholesterol/Heart Health CHOLEST CARE PHYTOSTEROL COMBINATION NO.1 Cholesterol/Heart Health CHOLESTYRAMINE CHOLESTYRAMINE (WITH SUGAR) Cholesterol/Heart Health CHOLESTYRAMINE LIGHT CHOLESTYRAMINE/ASPARTAME Cholesterol/Heart Health CHOLINE SR CHOLINE BITARTRATE Cholesterol/Heart Health CHONDROITIN SULFATE CHONDROITIN SULFATE A Cholesterol/Heart Health COD OIL OM-3/DHA/EPA/COD LIVER OIL/A/D3 Cholesterol/Heart Health COLESEVELAM HCL COLESEVELAM HCL Cholesterol/Heart Health COLESTID COLESTIPOL HCL Cholesterol/Heart Health COLESTIPOL HCL COLESTIPOL HCL Cholesterol/Heart Health COROMEGA OMEGA-3/DHA/EPA/FISH OIL Cholesterol/Heart Health CRESTOR ROSUVASTATIN CALCIUM Cholesterol/Heart Health DHA DOCOSAHEXANOIC ACID Cholesterol/Heart Health DHA ALGAL-900 DOCOSAHEXANOIC ACID Cholesterol/Heart Health EZETIMIBE EZETIMIBE Cholesterol/Heart Health EZETIMIBE- EZETIMIBE/SIMVASTATIN Cholesterol/Heart Health FENOFIBRATE FENOFIBRATE Cholesterol/Heart Health FENOFIBRATE FENOFIBRATE NANOCRYSTALLIZED Cholesterol/Heart Health FENOFIBRATE FENOFIBRATE,MICRONIZED Cholesterol/Heart Health FENOFIBRIC ACID FENOFIBRIC ACID Cholesterol/Heart Health FENOFIBRIC ACID FENOFIBRIC ACID (CHOLINE) Cholesterol/Heart Health FENOGLIDE FENOFIBRATE Cholesterol/Heart Health FIBRICOR FENOFIBRIC ACID Cholesterol/Heart Health FISH OIL OMEGA-3 FATTY ACIDS/FISH OIL Cholesterol/Heart Health

WEBMBSC-0334-20 Healthy Blue Zero Dollar Copay List Page 9 of 20

BRAND NAME GENERIC DRUG NAME CATEGORY FISH OIL CONCENTRATE OMEGA-3 FATTY ACIDS/FISH OIL Cholesterol/Heart Health FISH OIL OMEGA-3 OMEGA-3 FATTY ACIDS/FISH OIL Cholesterol/Heart Health FISH OIL PEARLS OMEGA-3 FATTY ACIDS/FISH OIL Cholesterol/Heart Health FISH OIL WITH KRILL KRILL OIL/OMEGA-3/DHA/EPA Cholesterol/Heart Health FISH OIL-PHYTOSTEROLS PHYTOSTEROL/OM-3/DHA/EPA/FISH Cholesterol/Heart Health FISH OIL-VIT D3 OMEGA3/DHA/EPA/FISH OIL/VIT D3 Cholesterol/Heart Health FISH OIL-VIT D3 OMEGA-3S/DHA/EPA/FISH OIL/D3 Cholesterol/Heart Health FISH-FLAX-BORAGE OIL FISH,SAF,FLX,BRG OILS/O3, 6, 9N2 Cholesterol/Heart Health FISH-FLAX-BORAGE OILS FISH OIL/FLAX OIL/E.PRIM/BCURR Cholesterol/Heart Health FLAXSEED-FISH-BORAGE OIL FISH OIL/BORAGE/FLAX/OM3, 6, 9 1 Cholesterol/Heart Health FLOLIPID SIMVASTATIN Cholesterol/Heart Health FLUVASTATIN ER FLUVASTATIN SODIUM Cholesterol/Heart Health FLUVASTATIN SODIUM FLUVASTATIN SODIUM Cholesterol/Heart Health GEMFIBROZIL GEMFIBROZIL Cholesterol/Heart Health GRAM-O-LECI LECITHIN Cholesterol/Heart Health INOSITOL INOSITOL Cholesterol/Heart Health JUXTAPID LOMITAPIDE MESYLATE Cholesterol/Heart Health KRILL OIL KRILL OIL Cholesterol/Heart Health KYNAMRO MIPOMERSEN SODIUM Cholesterol/Heart Health LECITHIN LECITHIN Cholesterol/Heart Health LECITHIN LECITHIN, SOY Cholesterol/Heart Health LESCOL FLUVASTATIN SODIUM Cholesterol/Heart Health LESCOL XL FLUVASTATIN SODIUM Cholesterol/Heart Health LIPITOR ATORVASTATIN CALCIUM Cholesterol/Heart Health LIPOCHOL METHIONINE/INOSI/CHOL/LYS/B12 Cholesterol/Heart Health LIPOCHOL PLUS METHIONINE/INOSI/CHOL/FOLIC AC Cholesterol/Heart Health LIPOFEN FENOFIBRATE Cholesterol/Heart Health LIPOGEN INOSITOL/CHOLINE/VIT B COMP Cholesterol/Heart Health LIPTRUZET EZETIMIBE/ATORVASTATIN CALCIUM Cholesterol/Heart Health LIVALO PITAVASTATIN CALCIUM Cholesterol/Heart Health LOFIBRA FENOFIBRATE Cholesterol/Heart Health LOFIBRA FENOFIBRATE, MICRONIZED Cholesterol/Heart Health LOPID GEMFIBROZIL Cholesterol/Heart Health LOVASTATIN LOVASTATIN Cholesterol/Heart Health LOVAZA OMEGA-3 ACID ETHYL ESTERS Cholesterol/Heart Health MAXEPA OMEGA-3 FATTY ACIDS Cholesterol/Heart Health MEGAKRILL KRILL/OMEGA-3/DHAEPA/LIPIDS Cholesterol/Heart Health NIACIN ER NIACIN Cholesterol/Heart Health NIACOR NIACIN Cholesterol/Heart Health NIASPAN NIACIN Cholesterol/Heart Health OMEGA-3 OMEGA-3 FATTY ACIDS/FISH OIL Cholesterol/Heart Health OMEGA-3 2100 OMEGA-3/DHA/EPA/DPA/FISH OIL Cholesterol/Heart Health OMERA OMEGA-3/DHA/EPA/FISH OIL Cholesterol/Heart Health OVEGA-3 OMEGA-3 FATTY ACIDS/DHA/EPA Cholesterol/Heart Health POLICOSANOL-GARLIC- POLICOS/INOSITOL NIAC/GARLIC Cholesterol/Heart Health NIACIN PRAVACHOL PRAVASTATIN SODIUM Cholesterol/Heart Health PRAVASTATIN SODIUM PRAVASTATIN SODIUM Cholesterol/Heart Health PRENATAL DHA DOCOSAHEXANOIC ACID Cholesterol/Heart Health PREVALITE CHOLESTYRAMINE/ASPARTAME Cholesterol/Heart Health

WEBMBSC-0334-20 Healthy Blue Zero Dollar Copay List Page 10 of 20

BRAND NAME GENERIC DRUG NAME CATEGORY QUESTRAN CHOLESTYRAMINE (WITH SUGAR) Cholesterol/Heart Health QUESTRAN LIGHT CHOLESTYRAMINE/ASPARTAME Cholesterol/Heart Health RESTORA OMEG3/DHA/EPA/FISH OIL/L.CASEI Cholesterol/Heart Health ROSUVASTATIN CALCIUM ROSUVASTATIN CALCIUM Cholesterol/Heart Health SALMON OIL SALMON OIL/OMEGA-3 FATTY ACIDS Cholesterol/Heart Health SALMON OIL-1000 SALMON OIL/OMEGA-3 FATTY ACIDS Cholesterol/Heart Health SIMCOR NIACIN/SIMVASTATIN Cholesterol/Heart Health SIMVASTATIN SIMVASTATIN Cholesterol/Heart Health SUPER DHA GEMS OMEGA-3/DHA/EPA/FISH OIL Cholesterol/Heart Health SUPER OMEGA-3 OMEGA-3 FATTY ACIDS Cholesterol/Heart Health SUPER TWIN EPA-DHA OMEGA-3 FATTY ACIDS Cholesterol/Heart Health TRICOR FENOFIBRATE NANOCRYSTALLIZED Cholesterol/Heart Health TRIGLIDE FENOFIBRATE NANOCRYSTALLIZED Cholesterol/Heart Health TRIKLO OMEGA-3 ACID ETHYL ESTERS Cholesterol/Heart Health TRILIPIX FENOFIBRIC ACID (CHOLINE) Cholesterol/Heart Health VASCAZEN OMEGA-3S/DHA/EPA/FISH OIL Cholesterol/Heart Health VASCEPA ICOSAPENT ETHYL Cholesterol/Heart Health VAYAROL PHYTOSTEROL/OM-3/DHA/EPA/FISH Cholesterol/Heart Health VYTORIN EZETIMIBE/SIMVASTATIN Cholesterol/Heart Health WELCHOL COLESEVELAM HCL Cholesterol/Heart Health ZETIA EZETIMIBE Cholesterol/Heart Health ZOCOR SIMVASTATIN Cholesterol/Heart Health ZYNCOL POLICOSANOL COMBINATION NO.3 Cholesterol/Heart Health ZYPITAMAG PITAVASTATIN Cholesterol/Heart Health AFTERA Contraceptives ALTAVERA LEVONORGESTREL-ETHIN Contraceptives ALYACEN NORETHINDRONE-ETHINYL ESTRAD Contraceptives AMETHIA L-NORGEST/E.ESTRADIOL-E.ESTRAD Contraceptives AMETHIA LO L-NORGEST/E.ESTRADIOL-E.ESTRAD Contraceptives AMETHYST LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives APRI -ETHINYL ESTRADIOL Contraceptives ARANELLE NORETHINDRONE-ETHINYL ESTRAD Contraceptives ASHLYNA L-NORGEST/E.ESTRADIOL-E.ESTRAD Contraceptives AUBRA LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives AVIANE LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives AZURETTE DESOG-E.ESTRADIOL/E.ESTRADIOL Contraceptives BALCOLTRA LEVONORGEST/ETH.ESTRADIOL/IRON Contraceptives BALZIVA NORETHINDRONE-ETHINYL ESTRAD Contraceptives BEKYREE DESOG-E.ESTRADIOL/E.ESTRADIOL Contraceptives BEYAZ DROSPIR/ETH ESTRA/LEVOMEFOL CA Contraceptives BLISOVI 24 FE NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives BLISOVI FE NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives BREVICON NORETHINDRONE-ETHINYL ESTRAD Contraceptives BRIELLYN NORETHINDRONE-ETHINYL ESTRAD Contraceptives CAMILA NORETHINDRONE Contraceptives CAMRESE L-NORGEST/E.ESTRADIOL-E.ESTRAD Contraceptives CAMRESE LO L-NORGEST/E.ESTRADIOL-E.ESTRAD Contraceptives CAZIANT DESOGESTREL-ETHINYL ESTRADIOL Contraceptives CHATEAL LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives CRYSELLE -ETHINYL ESTRADIOL Contraceptives

WEBMBSC-0334-20 Healthy Blue Zero Dollar Copay List Page 11 of 20

BRAND NAME GENERIC DRUG NAME CATEGORY CYCLAFEM NORETHINDRONE-ETHINYL ESTRAD Contraceptives CYCLESSA DESOGESTREL-ETHINYL ESTRADIOL Contraceptives CYRED DESOGESTREL-ETHINYL ESTRADIOL Contraceptives DASETTA NORETHINDRONE-ETHINYL ESTRAD Contraceptives DAYSEE L-NORGEST/E.ESTRADIOL-E.ESTRAD Contraceptives DEBLITANE NORETHINDRONE Contraceptives DELYLA LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives DESOGEN DESOGESTREL-ETHINYL ESTRADIOL Contraceptives DESOGESTREL-ETHINYL DESOGESTREL-ETHINYL ESTRADIOL Contraceptives ESTRADIOL DESOGESTR-ETH ESTRAD DESOG-E.ESTRADIOL/E.ESTRADIOL Contraceptives ETH ESTRA -ETH DROSPIR/ETH ESTRA/LEVOMEFOL CA Contraceptives ESTRA-LEVOMEF DROSPIRENONE-ETHINYL ETHINYL ESTRADIOL/DROSPIRENONE Contraceptives ESTRADIOL ECONTRA EZ LEVONORGESTREL Contraceptives ECONTRA ONE-STEP LEVONORGESTREL Contraceptives ELINEST NORGESTREL-ETHINYL ESTRADIOL Contraceptives ELLA Contraceptives EMOQUETTE DESOGESTREL-ETHINYL ESTRADIOL Contraceptives ENPRESSE LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives ENSKYCE DESOGESTREL-ETHINYL ESTRADIOL Contraceptives ERRIN NORETHINDRONE Contraceptives ESTARYLLA -ETHINYL ESTRADIOL Contraceptives ESTROSTEP FE NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives ETHYNODIOL-ETHINYL ETHYNODIOL D-ETHINYL ESTRADIOL Contraceptives ESTRADIOL FALLBACK SOLO LEVONORGESTREL Contraceptives FALMINA LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives FAYOSIM L-NORGEST/E.ESTRADIOL-E.ESTRAD Contraceptives FEMCON FE NORETH-ETHINYL ESTRADIOL/IRON Contraceptives FEMYNOR NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives GENERESS FE NORETH-ETHINYL ESTRADIOL/IRON Contraceptives GIANVI ETHINYL ESTRADIOL/DROSPIRENONE Contraceptives GILDAGIA NORETHINDRONE-ETHINYL ESTRAD Contraceptives GILDESS NORETHINDRONE AC-ETH ESTRADIOL Contraceptives GILDESS 24 FE NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives GILDESS FE NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives HEATHER NORETHINDRONE Contraceptives INTROVALE LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives ISIBLOOM DESOGESTREL-ETHINYL ESTRADIOL Contraceptives JENCYCLA NORETHINDRONE Contraceptives JOLESSA LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives JOLIVETTE NORETHINDRONE Contraceptives JULEBER DESOGESTREL-ETHINYL ESTRADIOL Contraceptives JUNEL NORETHINDRONE AC-ETH ESTRADIOL Contraceptives JUNEL FE NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives JUNEL FE 24 NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives KAITLIB FE NORETH-ETHINYL ESTRADIOL/IRON Contraceptives

WEBMBSC-0334-20 Healthy Blue Zero Dollar Copay List Page 12 of 20

BRAND NAME GENERIC DRUG NAME CATEGORY KARIVA DESOG-E.ESTRADIOL/E.ESTRADIOL Contraceptives KELNOR 1-35 ETHYNODIOL D-ETHINYL ESTRADIOL Contraceptives KELNOR 1-50 ETHYNODIOL D-ETHINYL ESTRADIOL Contraceptives KIMIDESS DESOG-E.ESTRADIOL/E.ESTRADIOL Contraceptives KURVELO LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives LARIN NORETHINDRONE AC-ETH ESTRADIOL Contraceptives LARIN 24 FE NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives LARIN FE NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives LARISSIA LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives LAYOLIS FE NORETH-ETHINYL ESTRADIOL/IRON Contraceptives LEENA NORETHINDRONE-ETHINYL ESTRAD Contraceptives LESSINA LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives LEVONEST LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives LEVONORGESTREL LEVONORGESTREL Contraceptives LEVONORGESTREL-ETH LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives ESTRADIOL LEVONORG-ETH ESTRAD L-NORGEST/E.ESTRADIOL-E.ESTRAD Contraceptives ETH ESTRAD LEVORA-28 LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives LILLOW LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives LO LOESTRIN FE NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives LOESTRIN NORETHINDRONE AC-ETH ESTRADIOL Contraceptives LOESTRIN FE NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives LOMEDIA 24 FE NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives LORYNA ETHINYL ESTRADIOL/DROSPIRENONE Contraceptives LOSEASONIQUE L-NORGEST/E.ESTRADIOL-E.ESTRAD Contraceptives LOW-OGESTREL NORGESTREL-ETHINYL ESTRADIOL Contraceptives LUTERA LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives LYZA NORETHINDRONE Contraceptives MARLISSA LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives MELODETTA 24 FE NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives MIBELAS 24 FE NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives MICROGESTIN NORETHINDRONE AC-ETH ESTRADIOL Contraceptives MICROGESTIN 24 FE NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives MICROGESTIN FE NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives MILI NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives MINASTRIN 24 FE NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives MIRCETTE DESOG-E.ESTRADIOL/E.ESTRADIOL Contraceptives MODICON NORETHINDRONE-ETHINYL ESTRAD Contraceptives MONO-LINYAH NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives MONONESSA NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives MY CHOICE LEVONORGESTREL Contraceptives MY WAY LEVONORGESTREL Contraceptives MYZILRA LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives NATAZIA ESTRADIOL VALERATE/ Contraceptives NECON NORETHINDRONE-ETHINYL ESTRAD Contraceptives NECON NORETHINDRONE-MESTRANOL Contraceptives NEXT CHOICE ONE DOSE LEVONORGESTREL Contraceptives NIKKI ETHINYL ESTRADIOL/DROSPIRENONE Contraceptives NORA-BE NORETHINDRONE Contraceptives

WEBMBSC-0334-20 Healthy Blue Zero Dollar Copay List Page 13 of 20

BRAND NAME GENERIC DRUG NAME CATEGORY NORETHINDRONE NORETHINDRONE Contraceptives NORETHINDRON-ETHINYL NORETHINDRONE AC-ETH ESTRADIOL Contraceptives ESTRADIOL NORETHIN-ETH ESTRA- NORETH-ETHINYL ESTRADIOL/IRON Contraceptives FERROUS FUM NORETHIN-ETH ESTRA- NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives FERROUS FUM NORGESTIMATE-ETHINYL NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives ESTRADIOL NORINYL 1+50 NORETHINDRONE-MESTRANOL Contraceptives NORINYL 1-35 NORETHINDRONE-ETHINYL ESTRAD Contraceptives NORLYDA NORETHINDRONE Contraceptives NORLYROC NORETHINDRONE Contraceptives NOR-Q-D NORETHINDRONE Contraceptives NORTREL NORETHINDRONE-ETHINYL ESTRAD Contraceptives NUVARING /ETHINYL ESTRADIOL Contraceptives OCELLA ETHINYL ESTRADIOL/DROSPIRENONE Contraceptives OGESTREL NORGESTREL-ETHINYL ESTRADIOL Contraceptives OPCICON ONE-STEP LEVONORGESTREL Contraceptives OPTION 2 LEVONORGESTREL Contraceptives ORSYTHIA LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives ORTHO EVRA NORELGESTROMIN/ETHIN.ESTRADIOL Contraceptives ORTHO MICRONOR NORETHINDRONE Contraceptives ORTHO TRI-CYCLEN NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives ORTHO TRI-CYCLEN LO NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives ORTHO-CEPT DESOGESTREL-ETHINYL ESTRADIOL Contraceptives ORTHO-CYCLEN NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives ORTHO-NOVUM NORETHINDRONE-ETHINYL ESTRAD Contraceptives OVCON-35 NORETHINDRONE-ETHINYL ESTRAD Contraceptives PHILITH NORETHINDRONE-ETHINYL ESTRAD Contraceptives PIMTREA DESOG-E.ESTRADIOL/E.ESTRADIOL Contraceptives PIRMELLA NORETHINDRONE-ETHINYL ESTRAD Contraceptives PLAN B ONE-STEP LEVONORGESTREL Contraceptives PORTIA LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives PREVIFEM NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives QUARTETTE L-NORGEST/E.ESTRADIOL-E.ESTRAD Contraceptives QUASENSE LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives RAJANI DROSPIR/ETH ESTRA/LEVOMEFOL CA Contraceptives REACT LEVONORGESTREL Contraceptives RECLIPSEN DESOGESTREL-ETHINYL ESTRADIOL Contraceptives RIVELSA L-NORGEST/E.ESTRADIOL-E.ESTRAD Contraceptives SAFYRAL DROSPIR/ETH ESTRA/LEVOMEFOL CA Contraceptives SEASONIQUE L-NORGEST/E.ESTRADIOL-E.ESTRAD Contraceptives SETLAKIN LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives SHAROBEL NORETHINDRONE Contraceptives SPRINTEC NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives SRONYX LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives SYEDA ETHINYL ESTRADIOL/DROSPIRENONE Contraceptives TAKE ACTION LEVONORGESTREL Contraceptives TARINA FE NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives

WEBMBSC-0334-20 Healthy Blue Zero Dollar Copay List Page 14 of 20

BRAND NAME GENERIC DRUG NAME CATEGORY TAYTULLA NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives TILIA FE NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives TRI FEMYNOR NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives TRI-ESTARYLLA NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives TRI-LEGEST FE NORETHINDRONE-E.ESTRADIOL-IRON Contraceptives TRI-LINYAH NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives TRI-LO-ESTARYLLA NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives TRI-LO-MARZIA NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives TRI-LO-SPRINTEC NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives TRI-MILI NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives TRINESSA NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives TRINESSA LO NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives TRI-NORINYL NORETHINDRONE-ETHINYL ESTRAD Contraceptives TRI-PREVIFEM NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives TRI-SPRINTEC NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives TRIVORA-28 LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives TRI-VYLIBRA NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives TULANA NORETHINDRONE Contraceptives TYDEMY DROSPIR/ETH ESTRA/LEVOMEFOL CA Contraceptives VELIVET DESOGESTREL-ETHINYL ESTRADIOL Contraceptives VESTURA ETHINYL ESTRADIOL/DROSPIRENONE Contraceptives VIENVA LEVONORGESTREL-ETHIN ESTRADIOL Contraceptives VIORELE DESOG-E.ESTRADIOL/E.ESTRADIOL Contraceptives VYFEMLA NORETHINDRONE-ETHINYL ESTRAD Contraceptives VYLIBRA NORGESTIMATE-ETHINYL ESTRADIOL Contraceptives WERA NORETHINDRONE-ETHINYL ESTRAD Contraceptives WYMZYA FE NORETH-ETHINYL ESTRADIOL/IRON Contraceptives XULANE NORELGESTROMIN/ETHIN.ESTRADIOL Contraceptives YASMIN 28 ETHINYL ESTRADIOL/DROSPIRENONE Contraceptives YAZ ETHINYL ESTRADIOL/DROSPIRENONE Contraceptives ZARAH ETHINYL ESTRADIOL/DROSPIRENONE Contraceptives ZENCHENT NORETHINDRONE-ETHINYL ESTRAD Contraceptives ZENCHENT FE NORETH-ETHINYL ESTRADIOL/IRON Contraceptives ZEOSA NORETH-ETHINYL ESTRADIOL/IRON Contraceptives ZOVIA 1-35E ETHYNODIOL D-ETHINYL ESTRADIOL Contraceptives ZOVIA 1-50E ETHYNODIOL D-ETHINYL ESTRADIOL Contraceptives ACARBOSE ACARBOSE Diabetes Care ACTOPLUS MET PIOGLITAZONE HCL/METFORMIN HCL Diabetes Care ACTOPLUS MET XR PIOGLITAZONE HCL/METFORMIN HCL Diabetes Care ACTOS PIOGLITAZONE HCL Diabetes Care ADLYXIN LIXISENATIDE Diabetes Care ADMELOG INSULIN LISPRO Diabetes Care ADMELOG SOLOSTAR INSULIN LISPRO Diabetes Care AFREZZA INSULIN REGULAR, HUMAN Diabetes Care ALOGLIPTIN ALOGLIPTIN BENZOATE Diabetes Care ALOGLIPTIN-METFORMIN ALOGLIPTIN BENZ/METFORMIN HCL Diabetes Care ALOGLIPTIN- ALOGLIPTIN BENZ/PIOGLITAZONE Diabetes Care PIOGLITAZONE AMARYL GLIMEPIRIDE Diabetes Care APIDRA INSULIN GLULISINE Diabetes Care

WEBMBSC-0334-20 Healthy Blue Zero Dollar Copay List Page 15 of 20

BRAND NAME GENERIC DRUG NAME CATEGORY APIDRA SOLOSTAR INSULIN GLULISINE Diabetes Care AVANDAMET ROSIGLITAZONE/METFORMIN HCL Diabetes Care AVANDARYL ROSIGLITAZONE/GLIMEPIRIDE Diabetes Care AVANDIA ROSIGLITAZONE MALEATE Diabetes Care BASAGLAR KWIKPEN U-100 INSULIN GLARGINE,HUM.REC.ANLOG Diabetes Care BYDUREON EXENATIDE MICROSPHERES Diabetes Care BYDUREON BCISE EXENATIDE MICROSPHERES Diabetes Care BYDUREON PEN EXENATIDE MICROSPHERES Diabetes Care BYETTA EXENATIDE Diabetes Care CHLORPROPAMIDE CHLORPROPAMIDE Diabetes Care CYCLOSET BROMOCRIPTINE MESYLATE Diabetes Care DIABETA GLYBURIDE Diabetes Care DM2 METFORMIN/BLOOD SUGAR DIAGNOST Diabetes Care DUETACT PIOGLITAZONE HCL/GLIMEPIRIDE Diabetes Care FARXIGA DAPAGLIFLOZIN PROPANEDIOL Diabetes Care FIASP INSULIN ASPART (NIACINAMIDE) Diabetes Care FIASP FLEXTOUCH INSULIN ASPART (NIACINAMIDE) Diabetes Care FORTAMET METFORMIN HCL Diabetes Care GLIMEPIRIDE GLIMEPIRIDE Diabetes Care GLIPIZIDE GLIPIZIDE Diabetes Care GLIPIZIDE ER GLIPIZIDE Diabetes Care GLIPIZIDE XL GLIPIZIDE Diabetes Care GLIPIZIDE-METFORMIN GLIPIZIDE/METFORMIN HCL Diabetes Care GLUCOPHAGE METFORMIN HCL Diabetes Care GLUCOPHAGE XR METFORMIN HCL Diabetes Care GLUCOTROL GLIPIZIDE Diabetes Care GLUCOTROL XL GLIPIZIDE Diabetes Care GLUCOVANCE GLYBURIDE/METFORMIN HCL Diabetes Care GLUMETZA METFORMIN HCL Diabetes Care GLYBURIDE GLYBURIDE Diabetes Care GLYBURIDE MICRONIZED GLYBURIDE,MICRONIZED Diabetes Care GLYBURIDE-METFORMIN GLYBURIDE/METFORMIN HCL Diabetes Care HCL GLYNASE GLYBURIDE, MICRONIZED Diabetes Care GLYSET MIGLITOL Diabetes Care HUMALOG INSULIN LISPRO Diabetes Care HUMALOG JUNIOR INSULIN LISPRO Diabetes Care KWIKPEN HUMALOG KWIKPEN U-100 INSULIN LISPRO Diabetes Care HUMALOG KWIKPEN U-200 INSULIN LISPRO Diabetes Care HUMALOG MIX 50-50 INSULIN LISPRO PROTAMIN/LISPRO Diabetes Care HUMALOG MIX 50-50 INSULIN LISPRO PROTAMIN/LISPRO Diabetes Care KWIKPEN HUMALOG MIX 75-25 INSULIN LISPRO PROTAMIN/LISPRO Diabetes Care HUMALOG MIX 75-25 INSULIN LISPRO PROTAMIN/LISPRO Diabetes Care KWIKPEN HUMULIN 70/30 KWIKPEN INSULIN NPH HUM/REG INSULIN HM Diabetes Care HUMULIN 70-30 INSULIN NPH HUM/REG INSULIN HM Diabetes Care HUMULIN N INSULIN NPH HUMAN ISOPHANE Diabetes Care HUMULIN N KWIKPEN INSULIN NPH HUMAN ISOPHANE Diabetes Care

WEBMBSC-0334-20 Healthy Blue Zero Dollar Copay List Page 16 of 20

BRAND NAME GENERIC DRUG NAME CATEGORY HUMULIN R INSULIN REGULAR, HUMAN Diabetes Care HUMULIN R U-500 INSULIN REGULAR, HUMAN Diabetes Care HUMULIN R U-500 INSULIN REGULAR, HUMAN Diabetes Care KWIKPEN INVOKANA CANAGLIFLOZIN Diabetes Care JANUMET SITAGLIPTIN PHOS/METFORMIN HCL Diabetes Care JANUMET XR SITAGLIPTIN PHOS/METFORMIN HCL Diabetes Care JANUVIA SITAGLIPTIN PHOSPHATE Diabetes Care JARDIANCE EMPAGLIFLOZIN Diabetes Care JENTADUETO LINAGLIPTIN/METFORMIN HCL Diabetes Care JENTADUETO XR LINAGLIPTIN/METFORMIN HCL Diabetes Care KAZANO ALOGLIPTIN BENZ/METFORMIN HCL Diabetes Care KOMBIGLYZE XR SAXAGLIPTIN HCL/METFORMIN HCL Diabetes Care KORLYM Diabetes Care LANTUS INSULIN GLARGINE, HUM.REC.ANLOG Diabetes Care LANTUS SOLOSTAR INSULIN GLARGINE, HUM.REC.ANLOG Diabetes Care LEVEMIR INSULIN DETEMIR Diabetes Care LEVEMIR FLEXTOUCH INSULIN DETEMIR Diabetes Care METFORMIN HCL METFORMIN HCL Diabetes Care METFORMIN HCL ER METFORMIN HCL Diabetes Care MIGLITOL MIGLITOL Diabetes Care NATEGLINIDE NATEGLINIDE Diabetes Care NESINA ALOGLIPTIN BENZOATE Diabetes Care NOVOLIN 70-30 INSULIN NPH HUM/REG INSULIN HM Diabetes Care NOVOLIN N INSULIN NPH HUMAN ISOPHANE Diabetes Care NOVOLIN R INSULIN REGULAR, HUMAN Diabetes Care NOVOLOG INSULIN ASPART Diabetes Care NOVOLOG FLEXPEN INSULIN ASPART Diabetes Care NOVOLOG MIX 70-30 INSULIN ASPART PROT/INSULN ASP Diabetes Care NOVOLOG MIX 70-30 INSULIN ASPART PROT/INSULN ASP Diabetes Care FLEXPEN ONGLYZA SAXAGLIPTIN HCL Diabetes Care OSENI ALOGLIPTIN BENZ/PIOGLITAZONE Diabetes Care OZEMPIC SEMAGLUTIDE Diabetes Care PIOGLITAZONE HCL PIOGLITAZONE HCL Diabetes Care PIOGLITAZONE- PIOGLITAZONE HCL/GLIMEPIRIDE Diabetes Care GLIMEPIRIDE PIOGLITAZONE- PIOGLITAZONE HCL/METFORMIN HCL Diabetes Care METFORMIN PRANDIMET REPAGLINIDE/METFORMIN HCL Diabetes Care PRANDIN REPAGLINIDE Diabetes Care PRECOSE ACARBOSE Diabetes Care REPAGLINIDE REPAGLINIDE Diabetes Care REPAGLINIDE- REPAGLINIDE/METFORMIN HCL Diabetes Care METFORMIN HCL RIOMET METFORMIN HCL Diabetes Care STARLIX NATEGLINIDE Diabetes Care STEGLATRO ERTUGLIFLOZIN PIDOLATE Diabetes Care SYMLINPEN 120 PRAMLINTIDE ACETATE Diabetes Care SYMLINPEN 60 PRAMLINTIDE ACETATE Diabetes Care

WEBMBSC-0334-20 Healthy Blue Zero Dollar Copay List Page 17 of 20

BRAND NAME GENERIC DRUG NAME CATEGORY TANZEUM ALBIGLUTIDE Diabetes Care TOLAZAMIDE TOLAZAMIDE Diabetes Care TOLBUTAMIDE TOLBUTAMIDE Diabetes Care TOUJEO MAX SOLOSTAR INSULIN GLARGINE, HUM.REC.ANLOG Diabetes Care TOUJEO SOLOSTAR INSULIN GLARGINE, HUM.REC.ANLOG Diabetes Care TRADJENTA LINAGLIPTIN Diabetes Care TRESIBA FLEXTOUCH U-100 INSULIN DEGLUDEC Diabetes Care TRESIBA FLEXTOUCH U-200 INSULIN DEGLUDEC Diabetes Care TRULICITY DULAGLUTIDE Diabetes Care VICTOZA 2-PAK LIRAGLUTIDE Diabetes Care VICTOZA 3-PAK LIRAGLUTIDE Diabetes Care ABACAVIR ABACAVIR SULFATE HIV/Antivirals ABACAVIR-LAMIVUDINE ABACAVIR SULFATE/LAMIVUDINE HIV/Antivirals ABACAVIR-LAMIVUDINE- ABACAVIR/LAMIVUDINE/ZIDOVUDINE HIV/Antivirals ZIDOVUDINE ACYCLOVIR ACYCLOVIR HIV/Antivirals APTIVUS TIPRANAVIR HIV/Antivirals APTIVUS TIPRANAVIR/VITAMIN E TPGS HIV/Antivirals ATAZANAVIR SULFATE ATAZANAVIR SULFATE HIV/Antivirals ATRIPLA /EMTRICIT/TENOFOVR DF HIV/Antivirals BIKTARVY BICTEGRAV/EMTRICIT/TENOFOV ALA HIV/Antivirals CIMDUO LAMIVUDINE/TENOFOVIR DISOP FUM HIV/Antivirals COMBIVIR LAMIVUDINE/ZIDOVUDINE HIV/Antivirals COMPLERA EMTRICITA/RILPIVIRINE/TENOF DF HIV/Antivirals CRIXIVAN SULFATE HIV/Antivirals DESCOVY EMTRICITABINE/TENOFOV ALAFENAM HIV/Antivirals DIDANOSINE DIDANOSINE HIV/Antivirals EDURANT RILPIVIRINE HCL HIV/Antivirals EFAVIRENZ EFAVIRENZ HIV/Antivirals EMTRIVA EMTRICITABINE HIV/Antivirals EPIVIR LAMIVUDINE HIV/Antivirals EPZICOM ABACAVIR SULFATE/LAMIVUDINE HIV/Antivirals EVOTAZ ATAZANAVIR SULFATE/COBICISTAT HIV/Antivirals FOSAMPRENAVIR FOSAMPRENAVIR CALCIUM HIV/Antivirals CALCIUM FUZEON ENFUVIRTIDE HIV/Antivirals GENVOYA ELVITEG/COB/EMTRI/TENOF ALAFEN HIV/Antivirals INTELENCE ETRAVIRINE HIV/Antivirals INVIRASE SAQUINAVIR MESYLATE HIV/Antivirals ISENTRESS RALTEGRAVIR POTASSIUM HIV/Antivirals ISENTRESS HD RALTEGRAVIR POTASSIUM HIV/Antivirals KALETRA LOPINAVIR/ HIV/Antivirals LAMIVUDINE LAMIVUDINE HIV/Antivirals LAMIVUDINE-ZIDOVUDINE LAMIVUDINE/ZIDOVUDINE HIV/Antivirals LEXIVA FOSAMPRENAVIR CALCIUM HIV/Antivirals LOPINAVIR-RITONAVIR LOPINAVIR/RITONAVIR HIV/Antivirals NEVIRAPINE HIV/Antivirals NEVIRAPINE ER NEVIRAPINE HIV/Antivirals NORVIR RITONAVIR HIV/Antivirals ODEFSEY EMTRICITAB/RILPIVIRI/TENOF ALA HIV/Antivirals

WEBMBSC-0334-20 Healthy Blue Zero Dollar Copay List Page 18 of 20

BRAND NAME GENERIC DRUG NAME CATEGORY PREZCOBIX DARUNAVIR/COBICISTAT HIV/Antivirals RESCRIPTOR DELAVIRDINE MESYLATE HIV/Antivirals RETROVIR ZIDOVUDINE HIV/Antivirals REYATAZ ATAZANAVIR SULFATE HIV/Antivirals RITONAVIR RITONAVIR HIV/Antivirals SELZENTRY MARAVIROC HIV/Antivirals SITAVIG ACYCLOVIR HIV/Antivirals STAVUDINE STAVUDINE HIV/Antivirals STRIBILD ELVITEG/COB/EMTRI/TENOFO DISOP HIV/Antivirals SUSTIVA EFAVIRENZ HIV/Antivirals SYMFI EFAVIRENZ/LAMIVU/TENOFOV DISOP HIV/Antivirals SYMFI LO EFAVIRENZ/LAMIVU/TENOFOV DISOP HIV/Antivirals TENOFOVIR DISOPROXIL TENOFOVIR DISOPROXIL FUMARATE HIV/Antivirals FUMARATE TIVICAY DOLUTEGRAVIR SODIUM HIV/Antivirals TRIZIVIR ABACAVIR/LAMIVUDINE/ZIDOVUDINE HIV/Antivirals TRUVADA EMTRICITABINE/TENOFOVIR (TDF) HIV/Antivirals VALACYCLOVIR VALACYCLOVIR HCL HIV/Antivirals VALTREX VALACYCLOVIR HCL HIV/Antivirals VIDEX DIDANOSINE HIV/Antivirals VIDEX EC DIDANOSINE HIV/Antivirals VIRACEPT NELFINAVIR MESYLATE HIV/Antivirals VIRAMUNE NEVIRAPINE HIV/Antivirals VIRAMUNE XR NEVIRAPINE HIV/Antivirals VIREAD TENOFOVIR DISOPROXIL FUMARATE HIV/Antivirals VITEKTA ELVITEGRAVIR HIV/Antivirals ZERIT STAVUDINE HIV/Antivirals ZIAGEN ABACAVIR SULFATE HIV/Antivirals ZIDOVUDINE ZIDOVUDINE HIV/Antivirals ZOVIRAX ACYCLOVIR HIV/Antivirals NALOXONE HCL NALOXONE HCL Naloxone NARCAN NALOXONE HCL Naloxone CUT N CRUSH MEDICAL SUPPLY, MISCELLANEOUS Pill Cutters DELUXE TABLET CUTTER MEDICAL SUPPLY, MISCELLANEOUS Pill Cutters TABLET CUTTER MEDICAL SUPPLY, MISCELLANEOUS Pill Cutters ADCIRCA TADALAFIL Pulmonary Hypertension EPOPROSTENOL SODIUM EPOPROSTENOL SODIUM (GLYCINE) Pulmonary Hypertension FLOLAN EPOPROSTENOL SODIUM (GLYCINE) Pulmonary Hypertension ORENITRAM ER TREPROSTINIL DIOLAMINE Pulmonary Hypertension REMODULIN TREPROSTINIL SODIUM Pulmonary Hypertension REVATIO SILDENAFIL CITRATE Pulmonary Hypertension SILDENAFIL SILDENAFIL CITRATE Pulmonary Hypertension SILDENAFIL CITRATE SILDENAFIL CITRATE Pulmonary Hypertension TYVASO TREPROSTINIL Pulmonary Hypertension TYVASO INSTITUTIONAL TREPROSTINIL/NEBULIZER/ACCESOR Pulmonary Hypertension START KIT TYVASO REFILL KIT TREPROSTINIL/NEB ACCESSORIES Pulmonary Hypertension TYVASO STARTER KIT TREPROSTINIL/NEBULIZER/ACCESOR Pulmonary Hypertension UPTRAVI SELEXIPAG Pulmonary Hypertension VELETRI EPOPROSTENOL SODIUM (ARGININE) Pulmonary Hypertension

WEBMBSC-0334-20 Healthy Blue Zero Dollar Copay List Page 19 of 20

BRAND NAME GENERIC DRUG NAME CATEGORY VENTAVIS ILOPROST TROMETHAMINE Pulmonary Hypertension CHANTIX VARENICLINE TARTRATE Smoking Cessation NICODERM CQ Smoking Cessation NICORELIEF NICOTINE POLACRILEX Smoking Cessation NICORETTE NICOTINE POLACRILEX Smoking Cessation NICOTINE GUM NICOTINE POLACRILEX Smoking Cessation NICOTINE LOZENGE NICOTINE POLACRILEX Smoking Cessation NICOTINE PATCH NICOTINE Smoking Cessation NICOTROL NICOTINE Smoking Cessation NICOTROL NS NICOTINE Smoking Cessation NTS NICOTINE Smoking Cessation QUIT 2 NICOTINE POLACRILEX Smoking Cessation QUIT 4 NICOTINE POLACRILEX Smoking Cessation STOP SMOKING AID NICOTINE POLACRILEX Smoking Cessation ZYBAN BUPROPION HCL Smoking Cessation ADACEL TDAP DIPH, PERTUSS(ACELL),TET VAC/PF Vaccines BEXSERO MENINGOCOCCAL B VACCINE, 4-COMP Vaccines BOOSTRIX DIPH, PERTUSS(ACELL), TET VAC/PF Vaccines BOOSTRIX TDAP DIPHTH, PERTUSS(ACELL), TET VAC Vaccines DAPTACEL DTAP DIPH, PERTUSS(ACELL), TET PED/PF Vaccines DIPHTHERIA-TETANUS TETANUS, DIPHTHERIA TOXD PED/PF Vaccines TOXOIDS-PED FLU VACCINES COVERED FLU VACCINES Vaccines INFANRIX DTAP DIPH, PERTUSS(ACELL), TET PED/PF Vaccines KINRIX DIPH, PERTUS(ACEL), TET, POLIO/PF Vaccines MENHIBRIX MENINGOCOCCAL VAC C, Y/HIB/PF Vaccines MENOMUNE-A-C-Y-W-135 MENINGOCOC VAC A, C, Y, W-135/PF Vaccines MENOMUNE-A-C-Y-W-135 MENINGOCOCCAL VAC A, C, Y, W-135 Vaccines MENVEO A-C-Y-W-135-DIP MENING VAC A, C, Y, W-135 DIP/PF Vaccines M-M-R II VACCINE MEASLES, MUMPS, RUBELLA VACC/PF Vaccines PENTACEL DIPHT, PERT(A), TET-POLIO/HIB/PF Vaccines PNEUMOVAX 23 PNEUMOCOCCAL 23-VAL P-SAC VAC Vaccines PREVNAR 13 PNEUMOC 13-VAL CONJ-DIP CRM/PF Vaccines PROQUAD MEASLES, MUMPS, RUB, VARICELLA/PF Vaccines QUADRACEL DTAP-IPV DIPH, PERTUS (ACEL), TET, POLIO/PF Vaccines SHINGRIX VARICELLA-ZOSTER GE/AS01B/PF Vaccines TENIVAC TETANUS-DIPHTHERIA TOXOIDS/PF Vaccines TETANUS DIPHTHERIA TETANUS, DIPHTHERIA TOX, ADULT Vaccines TOXOIDS TETANUS TOXOID TETANUS TOXOID, ADSORBED/PF Vaccines ADSORBED TRUMENBA N.MENINGITIDIS B, LIPID FHBP RC Vaccines VARIVAX VACCINE VARICELLA VACCINE LIVE/PF Vaccines ZOSTAVAX ZOSTER VACCINE LIVE/PF Vaccines Updated 8/1/2020

BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. BlueChoice HealthPlan has contracted with Amerigroup Partnership Plan, LLC, an independent company, for services to support administration of Healthy Connections.

WEBMBSC-0334-20 Healthy Blue Zero Dollar Copay List Page 20 of 20

Notice of Non-Discrimination BlueChoice HealthPlan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BlueChoice HealthPlan does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

Language services Do you need help with your health care, talking with us, or reading what we send you? We provide our materials in other languages and formats at no cost to you. Call us toll free at 866-781-5094 (TTY 866-773-9634).

¿Necesita ayuda con su cuidado de la salud, para hablar con nosotros o leer lo que le enviamos? Proporcionamos nuestros materiales en otros idiomas y formatos sin costo alguno para usted. Llámenos a la línea gratuita al 866-781-5094 (TTY 866-773-9634).

ﺑﻧﺎ ﻣﻌﻧﺎ أو ﻗراءة ﻣﺎ ﻧﻘوم ﺑﺈرﺳﺎﻟﮫ إﻟﯾك؟ ﻧﺣن ﻧﻘدم اﻟﻣواد اﻟﺧﺎﺻﺔ ھل ﺗﺣﺗﺎج إﻟﻰ ﻣﺳﺎﻋدة ﻓﻲ رﻋﺎﯾﺗك اﻟﺻﺣﯾﺔ أو ﻓﻲ اﻟﺗﺣدث TTY 866-773-9634) 866-781-5094).ﺑﻠﻐﺎت وﺗﻧﺳﯾﻘﺎت أﺧرى ﺑدون ﺗﻛﻠﻔﺔ ﻋﻠﯾك. اﺗﺻل ﺑﻧﺎ ﻋﻠﻰ اﻟرﻗم اﻟﻣﺟﺎﻧﻲ

WEBMBSC-0334-20