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National Drug List

Drug list — Four 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 drugs 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 Please note: The formulary is subject to change and all previous versions of the formulary are no longer in effect.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 LG National Drug List Four-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 *ANALGESICS - ANTI-INFLAMMATORY* - DRUGS FOR PAIN AND FEVER...... 20 *ANALGESICS - NONNARCOTIC* - DRUGS FOR PAIN AND FEVER...... 23 *ANALGESICS - OPIOID* - DRUGS FOR PAIN AND FEVER...... 26 *ANDROGENS-ANABOLIC* - HORMONES...... 31 *ANORECTAL AND RELATED PRODUCTS* - RECTAL PREPARATIONS...... 31 *ANTACIDS* - DRUGS FOR THE STOMACH...... 32 *ANTHELMINTICS* - DRUGS FOR INFECTIONS...... 32 *ANTIANGINAL AGENTS* - DRUGS FOR THE HEART...... 32 *ANTIANXIETY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 33 *ANTIARRHYTHMICS* - DRUGS FOR THE HEART...... 34 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* - DRUGS FOR THE LUNGS...... 35 *ANTICOAGULANTS* - DRUGS FOR THE BLOOD...... 38 *ANTICONVULSANTS* - DRUGS FOR THE NERVOUS SYSTEM...... 40 *ANTIDEPRESSANTS* - DRUGS FOR THE NERVOUS SYSTEM...... 44 *ANTIDIABETICS* - HORMONES...... 46 *ANTIDIARRHEAL/PROBIOTIC AGENTS* - DRUGS FOR THE STOMACH...... 51 *ANTIDOTES AND SPECIFIC ANTAGONISTS* - DRUGS FOR OVERDOSE OR POISONING...... 51 *ANTIEMETICS* - DRUGS FOR THE STOMACH...... 53 *ANTIFUNGALS* - DRUGS FOR INFECTIONS...... 54 *ANTIHISTAMINES* - DRUGS FOR THE LUNGS...... 56 *ANTIHYPERLIPIDEMICS* - DRUGS FOR THE HEART...... 57 *ANTIHYPERTENSIVES* - DRUGS FOR THE HEART...... 59 *ANTI-INFECTIVE AGENTS - MISC.* - DRUGS FOR INFECTIONS...... 63 *ANTIMALARIALS* - DRUGS FOR INFECTIONS...... 66 *ANTIMYASTHENIC/CHOLINERGIC AGENTS* - DRUGS FOR NERVES AND MUSCLES...... 67 *ANTIMYCOBACTERIAL AGENTS* - DRUGS FOR INFECTIONS...... 67 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* - DRUGS FOR CANCER...... 68 *ANTIPARKINSON AND RELATED THERAPY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 85 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 87 *ANTISEPTICS & DISINFECTANTS* - ANTISEPTICS AND DISINFECTANTS...... 91 *ANTIVIRALS* - DRUGS FOR INFECTIONS...... 91 *BETA BLOCKERS* - DRUGS FOR THE HEART...... 97 *CALCIUM CHANNEL BLOCKERS* - DRUGS FOR THE HEART...... 99 *CARDIOTONICS* - DRUGS FOR THE HEART...... 101 *CARDIOVASCULAR AGENTS - MISC.* - DRUGS FOR THE HEART...... 102 *CEPHALOSPORINS* - DRUGS FOR INFECTIONS...... 104 *CONTRACEPTIVES* - DRUGS FOR WOMEN...... 106 *CORTICOSTEROIDS* - HORMONES...... 113 *COUGH/COLD/ALLERGY* - DRUGS FOR THE LUNGS...... 115 *DERMATOLOGICALS* - DRUGS FOR THE SKIN...... 117 *DIAGNOSTIC PRODUCTS*...... 129 *DIGESTIVE AIDS* - DRUGS FOR THE STOMACH...... 129 *DIURETICS* - DRUGS FOR THE HEART...... 129 *ENDOCRINE AND METABOLIC AGENTS - MISC.* - HORMONES...... 131 ** - HORMONES...... 138 *FLUOROQUINOLONES* - DRUGS FOR INFECTIONS...... 139 *GASTROINTESTINAL AGENTS - MISC.* - DRUGS FOR THE STOMACH...... 139 *GENERAL ANESTHETICS* - DRUGS FOR PAIN AND FEVER...... 142 *GENITOURINARY AGENTS - MISCELLANEOUS* - DRUGS FOR THE URINARY SYSTEM...... 143 *GOUT AGENTS* - DRUGS FOR PAIN AND FEVER...... 145 *HEMATOLOGICAL AGENTS - MISC.* - DRUGS FOR THE BLOOD...... 145 *HEMATOPOIETIC AGENTS* - DRUGS FOR NUTRITION...... 150 *HEMOSTATICS* - DRUGS FOR THE BLOOD...... 153 TOC-2 *HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 155 *LAXATIVES* - DRUGS FOR THE STOMACH...... 157 *LOCAL ANESTHETICS-PARENTERAL* - DRUGS FOR PAIN AND FEVER...... 160 *MACROLIDES* - DRUGS FOR INFECTIONS...... 161 *MEDICAL DEVICES AND SUPPLIES* - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT...... 162 *MIGRAINE PRODUCTS* - DRUGS FOR THE NERVOUS SYSTEM...... 181 *MINERALS & ELECTROLYTES* - DRUGS FOR NUTRITION...... 182 *MISCELLANEOUS THERAPEUTIC CLASSES* - VITAMINS AND MINERALS...... 185 *MOUTH/THROAT/DENTAL AGENTS* - DRUGS FOR THE MOUTH AND THROAT...... 189 *MULTIVITAMINS* - DRUGS FOR NUTRITION...... 191 *MUSCULOSKELETAL THERAPY AGENTS* - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES...... 202 *NASAL AGENTS - SYSTEMIC AND TOPICAL* - DRUGS FOR THE NOSE...... 204 *NEUROMUSCULAR AGENTS* - DRUGS FOR NERVES AND MUSCLES...... 205 *NUTRIENTS* - DRUGS FOR NUTRITION...... 206 *OPHTHALMIC AGENTS* - DRUGS FOR THE EYE...... 208 *OTIC AGENTS* - DRUGS FOR THE EAR...... 215 *OXYTOCICS* - HORMONES...... 216 *PASSIVE IMMUNIZING AND TREATMENT AGENTS* - BIOLOGICAL AGENTS...... 216 *PENICILLINS* - DRUGS FOR INFECTIONS...... 218 *PROGESTINS* - HORMONES...... 219 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* - DRUGS FOR THE NERVOUS SYSTEM...... 220 *RESPIRATORY AGENTS - MISC.* - DRUGS FOR THE LUNGS...... 226 *SULFONAMIDES* - DRUGS FOR INFECTIONS...... 228 *TETRACYCLINES* - DRUGS FOR INFECTIONS...... 228 *THYROID AGENTS* - HORMONES...... 229 *TOXOIDS* - BIOLOGICAL AGENTS...... 229 *ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS* - DRUGS FOR THE STOMACH...... 230 *URINARY ANTISPASMODICS* - DRUGS FOR THE URINARY SYSTEM...... 232 *VACCINES* - BIOLOGICAL AGENTS...... 233 *VAGINAL AND RELATED PRODUCTS* - DRUGS FOR WOMEN...... 235 *VASOPRESSORS* - DRUGS FOR THE HEART...... 236 *VITAMINS* - DRUGS FOR NUTRITION...... 237

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 you pay after you have paid the deductible, if a deductible applies to the health care benefit.

“Copayment” means a fixed dollar amount that you pay for a covered health care benefit after you have paid the deductible, if a deductible applies to the health care benefit.

“Deductible” means the amount you pay for covered health care benefits that are subject to the deductible before your health insurer begins to pay. If your health insurance policy has a deductible, it may have either one deductible or separate deductibles for medical benefits and benefits. After you pay your deductible, you usually pay only a copayment or coinsurance for covered health care benefits. Your insurance company pays the rest.

“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” means a group of prescription drugs that correspond to a specified cost sharing tier in your health insurance policy. The drug tier in which a prescription drug is placed determines your portion of the cost for the drug.

“Exception request” means a request for coverage of a non-formulary drug. If you, your designee, or your prescribing health care provider submits a request for coverage of a non-formulary drug, your insurer must cover the non-formulary drug when it is medically necessary for you to take the drug.

“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” means the list of drugs that is covered by your health insurance policy under the prescription drug benefit of the policy.

“Generic drug” means a drug that is the same as its BRAND name drug equivalent in dosage, strength, effect, how it is taken, quality, safety, and intended use. A generic drug is listed in this formulary in 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.

“Non-formulary drug” means a prescription drug that is not listed on this formulary.

“Oral Chemotherapy (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” means your expenses for health care benefits that aren't reimbursed by your health insurance. Out-of- pocket costs include deductibles, copayments, and coinsurance for covered health care benefits, plus all costs for health care benefits that are not covered.

“Prescribing provider” means a health care provider who can write a prescription for a drug to diagnose, treat, or prevent a medical condition.

“Prescription” means an oral, written, or electronic order from a prescribing provider authorizing a prescription drug to be provided to a specific individual.

“Prescription drug” means a drug that by law requires a prescription.

“Prior Authorization (PA)” means a decision by your health insurer that a health care benefit is medically necessary for you. If a prescription drug is subject to prior authorization in this formulary, your prescribing provider must request approval from your health insurer to cover the drug before you fill your prescription. Your health insurer must grant a prior authorization request when it is medically necessary for you to take 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)” means a specific sequence in which prescription drugs for a particular medical condition must be tried. If a drug is subject to step therapy in this formulary, you may have to try one or more other drugs before your health insurance policy will cover that drug for your medical condition. If your prescribing provider submits a request for an exception to the step therapy requirement, your health insurer must grant the request when it is medically necessary for you to take the drug.

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 Drug class, 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 lowercase italicized 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 lowercase italicized 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 833-236-6196. 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 Pharmacy 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 Pharmacy 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 glucose 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 recently approved by the FDA.

o Tier 4 drugs have the highest cost share and usually include 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.

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, bold type.

Generic drugs are in lower case, plain 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 = drugs have the highest cost share and usually include specialty brand and generic drugs. ST = step therapy. You may need to use another They may cost more than drugs on lower tiers that recommended drug first before a prescribed drug is are used to treat the same condition. covered.

Four-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 clonidine hcl er oral tablet extended release 12 hour 1 or 1b* PA; QL (4 tablets per 1 day) guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg 1 or 1b* PA 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 atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg, 40 mg 1 or 1b* PA 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 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, 7.5 1 or 1b* PA 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* dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 1 or 1b* PA; QL (4 capsules per 1 day) mg dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg 1 or 1b* PA dextroamphetamine sulfate oral solution 1 or 1b* PA; QL (60 mL per 1 day) dextroamphetamine sulfate oral tablet 10 mg 1 or 1b* PA; 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 the highest cost share and usually include 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 5 mg 1 or 1b* PA 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 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 (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 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 (caffeine 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-topiramate) *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 phendimetrazine tartrate oral tablet 1 or 1b* PA phentermine hcl oral capsule 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 the highest cost share and usually include 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 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) *DOPAMINE 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 *HISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTS*** - DRUGS FOR SLEEP DISORDER PA; LD; SP; QL (2 tablets per 1 WAKIX ORAL TABLET 17.8 MG (pitolisant hcl) 4 day) WAKIX ORAL TABLET 4.45 MG (pitolisant hcl) 4 PA; LD; SP *LIPASE INHIBITORS*** - DRUGS FOR THE NERVOUS SYSTEM XENICAL ORAL CAPSULE (orlistat) 3 PA *MELANOCORTIN 4 (MC4) RECEPTOR AGONISTS*** - DRUGS FOR THE NERVOUS SYSTEM IMCIVREE SUBCUTANEOUS SOLUTION (setmelanotide acetate) 4 PA; LD; QL (9 vials per 30 days) *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 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) armodafinil 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 (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 mg, 20 mg, 5 mg

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 the highest cost share and usually include 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 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 FOCALIN ORAL TABLET 10 MG (dexmethylphenidate hcl) 3 PA; QL (2 tablets per 1 day) FOCALIN ORAL TABLET 2.5 MG, 5 MG (dexmethylphenidate hcl) 3 PA JORNAY PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 3 ST; QL (1 capsule per 1 day) MG, 60 MG, 80 MG (methylphenidate hcl) JORNAY PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 3 ST MG, 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 mg 1 or 1b* PA methylphenidate hcl er (cd) oral capsule extended release 40 mg, 50 mg, 60 mg 1 or 1b* PA; QL (1 capsule per 1 day) methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 1 or 1b* PA 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 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 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 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 3 ST; QL (1 tablet per 1 day) RELEASE 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 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 methylphenidate hcl oral tablet chewable 5 mg 1 or 1b* PA modafinil oral tablet 100 mg 1 or 1b* PA modafinil oral tablet 200 mg 1 or 1b* PA; QL (1 tablet per 1 day) QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED 3 ST RELEASE 20 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 the highest cost share and usually include 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 3 ST; QL (2 tablets per 1 day) RELEASE 30 MG (methylphenidate hcl) QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED 3 ST; QL (1 tablet per 1 day) RELEASE 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 3 ST; QL (1 tablet per 1 day) hcl) RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 3 PA MG, 20 MG (methylphenidate hcl) RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 30 3 PA; QL (2 capsules per 1 day) MG (methylphenidate hcl) RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 40 3 PA; QL (1 capsule per 1 day) MG (methylphenidate hcl) RITALIN ORAL TABLET 10 MG, 5 MG (methylphenidate hcl) 3 PA 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 TREE 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 the highest cost share and usually include 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 INJECTION SOLUTION 3 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 3 SOLUTION CLADOSPORIUM SPHAEROSPERMUM SUBCUTANEOUS 3 SOLUTION 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 3 RECONSTITUTED HORSE EPITHELIUM SUBCUTANEOUS SOLUTION 3 JOHNSON GRASS SUBCUTANEOUS SOLUTION 3 JUNE GRASS POLLEN STANDARDIZED SUBCUTANEOUS 3 SOLUTION KAPOK SUBCUTANEOUS SOLUTION 3 KOCHIA 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 the highest cost share and usually include 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 LENSCALE SUBCUTANEOUS SOLUTION 3 MEADOW FESCUE GRASS POLLEN SUBCUTANEOUS SOLUTION 3 MELALEUCA SUBCUTANEOUS SOLUTION 3 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 PALFORZIA (12 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (120 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (160 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (20 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (200 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (240 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (3 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (300 MG MAINTENANCE) ORAL PACKET (peanut PA; LD; SP; QL (1 packet per 1 4 powder-dnfp) day) PALFORZIA (300 MG TITRATION) ORAL PACKET (peanut powder- 4 PA; LD; SP; QL (1 kit per 1 fill) dnfp) PALFORZIA (40 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (6 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA (80 MG DAILY DOSE) ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PALFORZIA INITIAL ESCALATION ORAL (peanut powder-dnfp) 4 PA; LD; SP; QL (1 kit per 1 fill) PENICILLIUM NOTATUM INJECTION SOLUTION 3 PENICILLIUM NOTATUM SUBCUTANEOUS SOLUTION 3 PERENNIAL RYE GRASS POLLEN INJECTION SOLUTION 3 PHOMA EXIGUA 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 the highest cost share and usually include 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 PRIVET SUBCUTANEOUS SOLUTION 3 QUEEN PALM SUBCUTANEOUS SOLUTION 3 RABBIT EPITHELIUM SUBCUTANEOUS SOLUTION 3 RAGWITEK SUBLINGUAL TABLET SUBLINGUAL (short ragweed 3 PA; QL (1 tablet per 1 day) pollen 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 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 3 SOLUTION TRICHOPHYTON MENTAGROPHYTES SUBCUTANEOUS 3 SOLUTION 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 3 hornet venom) VENOMIL YELLOW HORNET VENOM INJECTION KIT (yellow 3 hornet venom) VENOMIL YELLOW JACKET VENOM INJECTION KIT (yellow jacket 3 venom) WASP VENOM PROTEIN INJECTION SOLUTION 3 RECONSTITUTED WASP VENOM PROTEIN SUBCUTANEOUS SOLUTION 3 RECONSTITUTED

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 the highest cost share and usually include 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 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 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* ARIKAYCE INHALATION SUSPENSION (amikacin sulfate liposome) 4 PA; LD; QL (1 kit per 28 days) BETHKIS INHALATION NEBULIZATION SOLUTION (tobramycin) 4 LD; SP; QL (224 mL per 28 days) 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* 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 the highest cost share and usually include 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 streptomycin sulfate intramuscular solution reconstituted 1 or 1b* LD; SP; QL (224 capsules per 28 TOBI PODHALER INHALATION CAPSULE (tobramycin) 4 days) 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 4 PA; SP; QL (1 tablet per 1 day) (upadacitinib) XELJANZ ORAL SOLUTION (tofacitinib citrate) 4 PA; SP; QL (10 mL per 1 day) XELJANZ ORAL TABLET (tofacitinib citrate) 4 PA; SP; QL (2 tablets per 1 day) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 4 PA; SP; QL (1 tablet per 1 day) MG (tofacitinib citrate) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 22 4 PA; QL (1 tablet per 1 day) MG (tofacitinib citrate) *ANTIRHEUMATIC ANTIMETABOLITES*** - ARTHRITIS AND PAIN DRUGS OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; SP; QL (4 auto-injector per 28 4 (methotrexate (anti-rheumatic)) days) RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; SP; QL (4 auto-injector per 28 4 (methotrexate (anti-rheumatic)) days) REDITREX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; QL (4 auto-injector per 28 4 (methotrexate (anti-rheumatic)) days) *ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES*** - ARTHRITIS AND PAIN DRUGS HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS 4 PA; SP; QL (1 kit per 365 days) PREFILLED SYRINGE KIT (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML 4 PA; SP; QL (2 EA per 28 days) (adalimumab) 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- 4 PA; SP; QL (1 kit per 365 days) INJECTOR KIT (adalimumab) HUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS PEN- 4 PA; SP; QL (1 kit per 365 days) INJECTOR KIT (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 the highest cost share and usually include 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 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 4 PA; SP; QL (2 EA per 28 days) MG/0.1ML, 20 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 4 PA; SP; QL (1 pen per 28 days) (golimumab) SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (1 syringe per 28 days) (golimumab) *CYCLOOXYGENASE 2 (COX-2) INHIBITORS*** - ARTHRITIS AND PAIN DRUGS celecoxib 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 *INTERLEUKIN-1 BLOCKERS*** - ARTHRITIS AND PAIN DRUGS ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED PA; LD; SP; QL (4 vials per 28 4 (rilonacept) days) *INTERLEUKIN-1BETA BLOCKERS*** - ARTHRITIS AND PAIN DRUGS PA; LD; SP; QL (2 vials per 28 ILARIS SUBCUTANEOUS SOLUTION (canakinumab) 4 days) *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) 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*

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 the highest cost share and usually include 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 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 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) mefenamic acid 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 oxaprozin oral tablet 1 or 1b* QL (2 tablets per 1 day) piroxicam 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 the highest cost share and usually include 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 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 ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE PA; SP; QL (4 cartridge per 28 4 (etanercept) 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 4 PA; SP; QL (8 vials per 28 days) (etanercept) ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- 4 PA; SP; QL (4 pens per 28 days) INJECTOR (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) 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)

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 the highest cost share and usually include 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 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* 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 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 the highest cost share and usually include 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 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 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

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 the highest cost share and usually include 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 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 *SELECTIVE N-TYPE NEURONAL CALCIUM CHANNEL BLOCKERS*** - ARTHRITIS AND PAIN DRUGS PRIALT INTRATHECAL SOLUTION (ziconotide acetate) 4 PA; LD *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 the highest cost share and usually include 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 COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS FENTANYL CIT-ROPIVACAINE-NACL EPIDURAL SOLUTION 3 FENTANYL-BUPIVACAINE-NACL EPIDURAL SOLUTION 3 *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 (tramadol 3 PA; QL (1 capsule per 1 day) hcl) 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, 3 250 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 3 FENTANYL CITRATE INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE FENTANYL CITRATE PF INJECTION SOLUTION PREFILLED 3 SYRINGE FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE fentanyl transdermal patch 72 hour 1 or 1b* PA; QL (15 patches 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 the highest cost share and usually include 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 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 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 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 (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 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) 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)

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 the highest cost share and usually include 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 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 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 3 PREFILLED SYRINGE 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 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 3 PA; QL (2 tablets per 1 day) MG, 15 MG, 20 MG, 30 MG, 40 MG (oxycodone hcl) OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 60 3 PA; QL (2 tablet per 1 day) MG, 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) 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)

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 the highest cost share and usually include 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 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 (buprenorphine 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) SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 LD; QL (1 syringe per 28 days) (buprenorphine) 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) 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) 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 the highest cost share and usually include 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 *TRAMADOL COMBINATIONS*** - ARTHRITIS AND PAIN DRUGS tramadol-acetaminophen oral tablet 1 or 1b* QL (8 tablet per 1 day) *ANDROGENS-ANABOLIC* - HORMONES *ANABOLIC STEROIDS*** - DRUGS FOR MEN oxandrolone oral tablet 1 or 1b* PA *ANDROGENS*** - DRUGS FOR MEN ANDRODERM TRANSDERMAL PATCH 24 HOUR (testosterone) 3 PA; QL (1 patch per 1 day) danazol oral capsule 1 or 1b* DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION (testosterone 3 PA cypionate) JATENZO ORAL CAPSULE 158 MG, 198 MG (testosterone undecanoate) 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 testosterone cypionate intramuscular solution 1 or 1b* PA testosterone enanthate 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) * VASODILATING AGENTS*** - RECTAL PREPARATIONS RECTIV RECTAL OINTMENT (nitroglycerin) 3 QL (1 unit per 1 day) *RECTAL ANESTHETIC/STEROIDS*** - RECTAL PREPARATIONS ANALPRAM-HC EXTERNAL CREAM (hydrocortisone ace-pramoxine) 3 ANALPRAM-HC EXTERNAL LOTION (hydrocortisone ace-pramoxine) 3 hydrocortisone ace-pramoxine external cream 1 or 1b* PROCTOFOAM HC EXTERNAL FOAM (hydrocortisone ace-pramoxine) 3 *RECTAL LOCAL ANESTHETICS*** - RECTAL PREPARATIONS LIDOCAINE (ANORECTAL) RECTAL SUPPOSITORY 3 *RECTAL STEROIDS*** - RECTAL PREPARATIONS ANUSOL-HC EXTERNAL CREAM (hydrocortisone) 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 the highest cost share and usually include 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 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) ranolazine er oral tablet extended release 12 hour 1 or 1b* **** - DRUGS FOR ANGINA DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE (isosorbide 2 dinitrate) GONITRO SUBLINGUAL PACKET (nitroglycerin) 3 ISORDIL TITRADOSE ORAL TABLET () 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* NITRO-BID TRANSDERMAL OINTMENT (nitroglycerin) 3 NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 3 MG/HR, 0.4 MG/HR, 0.6 MG/HR (nitroglycerin) NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 2 MG/HR (nitroglycerin) nitroglycerin in d5w intravenous solution 1 or 1b* NITROGLYCERIN 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 the highest cost share and usually include 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 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 buspirone hcl oral tablet 1 or 1b* droperidol injection solution 1 or 1b* hydroxyzine 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) lorazepam injection solution 1 or 1b* lorazepam intensol oral concentrate 1 or 1b* QL (3 mL per 1 day) lorazepam oral concentrate 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)

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 the highest cost share and usually include 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 *ANTIARRHYTHMICS* - DRUGS FOR THE HEART *ANTIARRHYTHMICS - MISC.*** - DRUGS FOR ABNORMAL HEART RHYTHMS adenosine intravenous solution 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* quinidine 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 3 PREFILLED SYRINGE 100 MG/10ML LIDOCAINE HCL (CARDIAC) INTRAVENOUS SOLUTION 3 PREFILLED 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 1 or 1b* mexiletine hcl oral capsule 1 or 1b* *ANTIARRHYTHMICS TYPE I-C*** - DRUGS FOR ABNORMAL HEART RHYTHMS flecainide 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 AMIODARONE HCL IN DEXTROSE INTRAVENOUS SOLUTION 3 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) BRETYLIUM TOSYLATE INJECTION SOLUTION 3 CORVERT INTRAVENOUS SOLUTION (ibutilide fumarate) 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 the highest cost share and usually include 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 dofetilide 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- 3 QL (1 inhaler per 30 days) glycopyrrol-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 2 QL (1 inhaler per 30 days) (tiotropium bromide-olodaterol) SYMBICORT INHALATION AEROSOL (budesonide-formoterol 2 QL (3 inhalers per 30 days) fumarate) 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-IGE MONOCLONAL ANTIBODIES*** - DRUGS FOR ASTHMA/COPD XOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; SP (omalizumab) XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (omalizumab) *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 the highest cost share and usually include 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 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 mg/0.5ml 1 or 1b* QL (60 mL per 30 days) 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 3 SOLUTION 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 3 QL (120 ML per 30 days) (formoterol 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 3 QL (1 inhaler per 30 days) (olodaterol hcl) terbutaline sulfate injection solution 1 or 1b* terbutaline sulfate oral tablet 1 or 1b* VENTOLIN HFA INHALATION AEROSOL SOLUTION (albuterol 2 ST; QL (2 inhalers per 30 days) sulfate) 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 the highest cost share and usually include 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 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) *INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)*** - DRUGS FOR ASTHMA/COPD FASENRA PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; LD; QL (1 autoinjector per 8 4 (benralizumab) weekss) FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; SP; QL (1 syringes per 8 4 (benralizumab) weekss) NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; LD; SP; QL (1 autoinjector per 4 (mepolizumab) 4 weekss) NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; SP; QL (1 syringe per 4 4 (mepolizumab) weekss) NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED PA; LD; SP; QL (1 injections per 28 4 (mepolizumab) days) *INTERLEUKIN-5 ANTAGONISTS (IGG4 KAPPA)*** - DRUGS FOR ASTHMA/COPD CINQAIR INTRAVENOUS SOLUTION (reslizumab) 4 PA; LD; SP *LEUKOTRIENE RECEPTOR ANTAGONISTS*** - DRUGS FOR ASTHMA/COPD ACCOLATE ORAL TABLET (zafirlukast) 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) *STEROID 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 2 QL (1 inhaler per 30 days) MCG/ACT (fluticasone propionate hfa)

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 the highest cost share and usually include 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 FLOVENT HFA INHALATION AEROSOL 220 MCG/ACT (fluticasone 2 QL (2 inhalers per 30 days) propionate hfa) QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 2 QL (1 inhaler per 30 days) 40 MCG/ACT (beclomethasone diprop hfa) QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 2 QL (2 inhalers per 30 days) 80 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, 2 QL (2 capsules per 1 day) 400 MG (theophylline) 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)

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 the highest cost share and usually include 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 *HEPARINS AND HEPARINOID-LIKE AGENTS*** - DRUGS TO PREVENT BLOOD CLOTS heparin (porcine) in nacl intravenous solution 1000-0.9 ut/500ml-%, 2000-0.9 1 or 1b* unit/l-% HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 12500- 3 0.45 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* 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 4 QL (30 syringes per 30 days) UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML (dalteparin sodium) FRAGMIN SUBCUTANEOUS SOLUTION 95000 UNIT/3.8ML 4 QL (6 vials per 30 days) (dalteparin sodium) *SYNTHETIC HEPARINOID-LIKE AGENTS*** - DRUGS TO PREVENT BLOOD CLOTS ARIXTRA SUBCUTANEOUS SOLUTION (fondaparinux sodium) 4 QL (30 syringes per 30 days) fondaparinux sodium subcutaneous solution 4 QL (30 syringes per 30 days) *THROMBIN INHIBITORS - HIRUDIN TYPE*** - DRUGS TO PREVENT BLOOD CLOTS ANGIOMAX INTRAVENOUS SOLUTION RECONSTITUTED 3 (bivalirudin 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

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 the highest cost share and usually include 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 *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) 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 (eslicarbazepine acetate) 3 APTIOM ORAL TABLET 600 MG, 800 MG (eslicarbazepine acetate) 3 QL (2 tablets per 1 day) BANZEL ORAL SUSPENSION (rufinamide) 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 3 QL (2 tablets per 1 day) (brivaracetam) carbamazepine 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) 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 the highest cost share and usually include 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 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) DIACOMIT ORAL CAPSULE 250 MG (stiripentol) 4 PA; LD; QL (12 capsules per 1 day) DIACOMIT ORAL CAPSULE 500 MG (stiripentol) 4 PA; LD; QL (6 capsules per 1 day) DIACOMIT ORAL PACKET 250 MG (stiripentol) 4 PA; LD; QL (8 packets per 1 day) DIACOMIT ORAL PACKET 500 MG (stiripentol) 4 PA; LD; QL (6 packets per 1 day) ELEPSIA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 QL (2 tablets per 1 day) (levetiracetam) EPIDIOLEX ORAL SOLUTION (cannabidiol) 4 PA; LD; SP epitol oral tablet 1 or 1b* QL (8 tablets per 1 day) FINTEPLA ORAL SOLUTION (fenfluramine hcl) 4 PA; LD; QL (26 mg per 1 day) gabapentin 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) lamotrigine er oral tablet extended release 24 hour 100 mg 1 or 1b* QL (4 tablets per 1 day) 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) 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 the highest cost share and usually include 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 oxcarbazepine 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) pregabalin 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) primidone oral tablet 1 or 1b* QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 25 3 ST; QL (1 capsule per 1 day) MG, 50 MG (topiramate) QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 150 MG, 200 3 ST; QL (2 capsules per 1 day) MG (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) rufinamide oral tablet 400 mg 1 or 1b* QL (8 tablets per 1 day) SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 3 QL (2 tablets per 1 day) 250 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 2 QL (1 capsule per 1 day) 100 MG, 25 MG, 50 MG (topiramate) TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 QL (2 capsules per 1 day) 200 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) zonisamide oral capsule 1 or 1b* QL (6 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 the highest cost share and usually include 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 *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 3 QL (1 blister pack per 28 days) 100 & 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) *HYDANTOINS*** - DRUGS FOR SEIZURES /PERSONALITY DISORDER/NERVE PAIN CEREBYX INJECTION SOLUTION (fosphenytoin sodium) 3 DILANTIN INFATABS ORAL TABLET CHEWABLE (phenytoin) 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) 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 the highest cost share and usually include 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 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) valproate 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 (bupropion hbr) 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* 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* 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* *GABA RECEPTOR MODULATOR - NEUROACTIVE STEROID*** - DRUGS FOR DEPRESSION ZULRESSO INTRAVENOUS SOLUTION (brexanolone) 4 PA; LD; SP *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* *N-METHYL-D-ASPARTIC ACID (NMDA) RECEPTOR ANTAGONISTS*** - DRUGS FOR DEPRESSION SPRAVATO (56 MG DOSE) NASAL SOLUTION THERAPY PACK 4 PA; LD; QL (4 kits per 28 days) (esketamine 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 the highest cost share and usually include 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 SPRAVATO (84 MG DOSE) NASAL SOLUTION THERAPY PACK 4 PA; LD; QL (4 kits per 28 days) (esketamine hcl) *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* 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* escitalopram oxalate oral tablet 20 mg 1 or 1b* QL (1 tablet per 1 day) fluoxetine hcl oral capsule 10 mg 1 or 1b* 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* 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* paroxetine hcl er oral tablet extended release 24 hour 12.5 mg 1 or 1b* 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* paroxetine hcl oral tablet 30 mg 1 or 1b* QL (2 tablets per 1 day) 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 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* *SEROTONIN MODULATORS*** - DRUGS FOR DEPRESSION nefazodone hcl oral tablet 1 or 1b* trazodone hcl oral tablet 1 or 1a* TRINTELLIX ORAL TABLET 10 MG, 5 MG (vortioxetine hbr) 3 TRINTELLIX ORAL TABLET 20 MG (vortioxetine hbr) 3 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 the highest cost share and usually include 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 *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 mg 1 or 1b* 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* 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 3 ST; QL (28 pack per 365 days) PACK (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* 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* venlafaxine hcl oral tablet 1 or 1b* QL (3 tablet per 1 day) *TRICYCLIC AGENTS*** - DRUGS FOR DEPRESSION amitriptyline hcl oral tablet 1 or 1a* amoxapine 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* clomipramine hcl oral capsule 1 or 1b* desipramine hcl oral tablet 1 or 1b* doxepin hcl oral capsule 1 or 1b* doxepin hcl oral concentrate 1 or 1b* imipramine hcl oral tablet 1 or 1b* imipramine pamoate oral capsule 1 or 1b* NORPRAMIN ORAL TABLET (desipramine hcl) 3 nortriptyline 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* trimipramine maleate oral capsule 1 or 1b* *ANTIDIABETICS* - HORMONES *ALPHA-GLUCOSIDASE INHIBITORS*** - DRUGS FOR DIABETES acarbose oral tablet 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 the highest cost share and usually include 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 miglitol 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) *BIGUANIDES*** - DRUGS FOR DIABETES metformin 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) diazoxide 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 3 RECONSTITUTED 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) 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 alogliptin benzoate oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) JANUVIA ORAL TABLET (sitagliptin phosphate) 2 ST; QL (1 tablet per 1 day) *DIPEPTIDYL PEPTIDASE-4 INHIBITOR-BIGUANIDE 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- 2 ST; QL (1 tablet per 1 day) 1000 MG (sitagliptin-metformin 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 the highest cost share and usually include 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 JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 50- 2 ST; QL (2 tablets per 1 day) 1000 MG, 50-500 MG (sitagliptin-metformin hcl) *DOPAMINE RECEPTOR AGONISTS - ERGOT DERIVATIVES*** - DRUGS FOR DIABETES CYCLOSET ORAL TABLET ( mesylate) 3 *DPP-4 INHIBITOR-THIAZOLIDINEDIONE COMBINATIONS*** - DRUGS FOR DIABETES alogliptin-pioglitazone 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- 2 QL (30 mL per 30 days) INJECTOR (insulin lispro) HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION 2 QL (30 mL per 30 days) PEN-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 2 QL (30 mL per 30 days) PEN-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) 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 2 PA; QL (20 mL per 30 days) SOLUTION (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)

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 the highest cost share and usually include 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 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- 2 QL (30 mL per 30 days) INJECTOR () 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- 2 QL (30 mL per 30 days) INJECTOR 100 UNIT/ML () TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- 2 QL (18 mL per 30 days) INJECTOR 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 2 ST; QL (1 pen per 28 days) PEN-INJECTOR (semaglutide) OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN- 2 ST; QL (2 pens per 28 days) INJECTOR 2 MG/1.5ML (semaglutide) OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN- 2 ST; QL (1 unit per 28 days) INJECTOR 4 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 2 ST; QL (4 syringes per 28 days) MG/0.5ML, 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 nateglinide oral tablet 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 the highest cost share and usually include 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 repaglinide 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) * RECEPTOR ANTAGONISTS*** - DRUGS FOR DIABETES KORLYM ORAL TABLET (mifepristone) 4 PA; LD *SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS*** - DRUGS FOR DIABETES FARXIGA ORAL TABLET (dapagliflozin propanediol) 2 ST; QL (1 tablet per 1 day) JARDIANCE ORAL TABLET (empagliflozin) 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- 2 ST; QL (1 tablet per 1 day) 1000 MG, 10-500 MG, 5-500 MG (dapagliflozin-metformin hcl) XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5- 2 ST; QL (2 tablet per 1 day) 1000 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) *SULFONYLUREA-BIGUANIDE COMBINATIONS*** - DRUGS FOR DIABETES glipizide-metformin hcl oral tablet 1 or 1b* ST glyburide-metformin oral tablet 1 or 1b* ST *SULFONYLUREAS*** - DRUGS FOR DIABETES AMARYL ORAL TABLET (glimepiride) 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 tolbutamide 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) 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 the highest cost share and usually include 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 *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) *THIAZOLIDINEDIONES*** - 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 DIARRHEA 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 *ANTIDOTES AND SPECIFIC ANTAGONISTS* - DRUGS FOR OVERDOSE OR POISONING *ANTIDOTE COMBINATIONS*** - DRUGS FOR OVERDOSE OR POISONING DUODOTE INTRAMUSCULAR SOLUTION AUTO-INJECTOR 3 (atropine-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 EXJADE ORAL TABLET SOLUBLE (deferasirox) 4 PA; LD; SP FERRIPROX ORAL SOLUTION (deferiprone) 4 PA; LD FERRIPROX ORAL TABLET (deferiprone) 4 PA; LD FERRIPROX TWICE-A-DAY ORAL TABLET (deferiprone) 4 PA; LD JADENU ORAL TABLET (deferasirox) 4 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 the highest cost share and usually include 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 JADENU SPRINKLE ORAL PACKET (deferasirox) 4 PA; LD; SP PENTETATE CALCIUM TRISODIUM COMBINATION SOLUTION 3 PENTETATE ZINC 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 3 xa 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 DESFERAL INJECTION SOLUTION RECONSTITUTED (deferoxamine 4 SP mesylate) DIGIFAB INTRAVENOUS SOLUTION RECONSTITUTED (digoxin 3 immune fab) fomepizole intravenous solution 1 or 1b* PRAXBIND INTRAVENOUS SOLUTION (idarucizumab) 3 PROTOPAM CHLORIDE INTRAVENOUS SOLUTION 3 RECONSTITUTED (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) *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) VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 4 SP; QL (1 vial per 28 days) (naltrexone)

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 the highest cost share and usually include 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 *ANTIEMETICS* - DRUGS FOR THE STOMACH *5-HT3 RECEPTOR ANTAGONISTS*** - DRUGS FOR VOMITING AND NAUSEA 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) 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 meclizine 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 (trimethobenzamide hcl) 3 trimethobenzamide hcl oral capsule 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 the highest cost share and usually include 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 *ANTIEMETICS - ANTIDOPAMINERGIC*** - DRUGS FOR VOMITING AND NAUSEA BARHEMSYS INTRAVENOUS SOLUTION (amisulpride (antiemetic)) 3 *ANTIEMETICS - MISCELLANEOUS*** - DRUGS FOR VOMITING AND NAUSEA dronabinol oral capsule 1 or 1b* MARINOL ORAL CAPSULE (dronabinol) 3 SYNDROS ORAL SOLUTION (dronabinol) 3 *SUBSTANCE P/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 *ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS)*** - ANTIBIOTICS CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 3 (caspofungin acetate) CASPOFUNGIN ACETATE INTRAVENOUS SOLUTION 3 RECONSTITUTED ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 3 (anidulafungin) micafungin sodium intravenous solution reconstituted 1 or 1b* MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 3 (micafungin sodium) *ANTIFUNGALS*** - DRUGS FOR FUNGUS 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 griseofulvin microsize oral suspension 1 or 1b* griseofulvin microsize 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 the highest cost share and usually include 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 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 ketoconazole 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) 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)

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 the highest cost share and usually include 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 *ANTIHISTAMINES* - DRUGS FOR THE LUNGS *ANTIHISTAMINES - ALKYLAMINES*** - DRUGS FOR ALLERGIES ryclora oral solution 1 or 1b* *ANTIHISTAMINES - ETHANOLAMINES*** - DRUGS FOR ALLERGIES carbinoxamine maleate oral solution 1 or 1b* carbinoxamine maleate oral tablet 1 or 1b* CLEMASTINE FUMARATE ORAL SYRUP 3 clemastine fumarate oral tablet 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) diphenhydramine 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 - PHENOTHIAZINES*** - DRUGS FOR ALLERGIES PHENERGAN INJECTION SOLUTION (promethazine hcl) 3 promethazine hcl injection solution 1 or 1a* 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 cyproheptadine hcl oral syrup 1 or 1b* cyproheptadine hcl 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 the highest cost share and usually include 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 *ANTIHYPERLIPIDEMICS* - DRUGS FOR THE HEART *ACL INHIB-INTESTINAL CHOLESTEROL 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) *ANGIOPOIETIN-LIKE PROTEIN 3 (ANGPTL3) INHIBITORS*** - DRUGS FOR CHOLESTEROL EVKEEZA INTRAVENOUS SOLUTION (evinacumab-dgnb) 4 PA; LD *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) *BILE ACID 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) 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) 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 the highest cost share and usually include 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 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 atorvastatin calcium oral tablet 40 mg 1 or 1b* 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 lovastatin oral tablet 10 mg, 20 mg 1 or 1b*; $0 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 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 rosuvastatin calcium oral tablet 20 mg 1 or 1b* rosuvastatin calcium oral tablet 40 mg 1 or 1b* QL (1 tablet per 1 day) simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 or 1b*; $0 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) *MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN INHIBITORS*** - DRUGS FOR CHOLESTEROL JUXTAPID ORAL CAPSULE (lomitapide mesylate) 3 PA; 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)

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 the highest cost share and usually include 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 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- 3 PA; QL (2 syringe per 28 days) INJECTOR (evolocumab) *ANTIHYPERTENSIVES* - DRUGS FOR THE HEART *ACE INHIBITOR & CALCIUM CHANNEL BLOCKER COMBINATIONS*** - DRUGS FOR HIGH BLOOD PRESSURE amlodipine 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* 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 amlodipine) TARKA ORAL TABLET EXTENDED RELEASE (trandolapril-verapamil 3 QL (1 tablet per 1 day) hcl) trandolapril-verapamil hcl er oral tablet extended release 1-240 mg 1 or 1b* trandolapril-verapamil hcl er oral tablet extended release 2-180 mg, 2-240 mg, 1 or 1b* QL (1 tablet per 1 day) 4-240 mg *ACE INHIBITORS & THIAZIDE/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* 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) 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* 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 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)

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 the highest cost share and usually include 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 VASERETIC ORAL TABLET (enalapril-hydrochlorothiazide) 3 QL (2 tablets per 1 day) ZESTORETIC ORAL TABLET 10-12.5 MG (lisinopril- 3 hydrochlorothiazide) ZESTORETIC ORAL TABLET 20-12.5 MG (lisinopril- 3 QL (4 tablets per 1 day) hydrochlorothiazide) 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* 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) phentolamine mesylate injection solution reconstituted 1 or 1b* *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* 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* telmisartan-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* TWYNSTA ORAL TABLET 40-10 MG, 80-10 MG, 80-5 MG (telmisartan- 3 QL (1 tablet per 1 day) amlodipine)

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 the highest cost share and usually include 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 TWYNSTA ORAL TABLET 40-5 MG (telmisartan-amlodipine) 3 *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* olmesartan medoxomil-hctz oral tablet 20-12.5 mg 1 or 1b* 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* 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* 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 EDARBI ORAL TABLET 80 MG (azilsartan medoxomil) 3 QL (1 tablet per 1 day) irbesartan oral tablet 150 mg, 75 mg 1 or 1b* 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* olmesartan medoxomil oral tablet 40 mg 1 or 1b* QL (1 tablet per 1 day) 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* 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- THIAZIDES*** - 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* 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 the highest cost share and usually include 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 olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg 1 or 1b* olmesartan-amlodipine-hctz oral tablet 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 1 or 1b* QL (1 tablet per 1 day) 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* methyldopa oral tablet 250 mg 1 or 1b* 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 (doxazosin 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 (prazosin 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 (mecamylamine hcl) 3 *BETA BLOCKER & DIURETIC COMBINATIONS*** - DRUGS FOR HIGH BLOOD PRESSURE atenolol-chlorthalidone oral tablet 1 or 1b* QL (1 tablet per 1 day) 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 hydrochlorothiazide) 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 the highest cost share and usually include 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 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* 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* minoxidil 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) 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 3 (pentamidine isethionate) PENTAM INJECTION SOLUTION RECONSTITUTED (pentamidine 4 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) 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 the highest cost share and usually include 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 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 (rifaximin) 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 3 (imipenem-cilastatin-relebactam) VABOMERE INTRAVENOUS SOLUTION RECONSTITUTED 3 (meropenem-vaborbactam) *CARBAPENEMS*** - ANTIBIOTICS ertapenem sodium injection solution reconstituted 1 or 1b* INVANZ INJECTION SOLUTION RECONSTITUTED (ertapenem 3 sodium) 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 *** - ANTIBIOTICS CUBICIN INTRAVENOUS SOLUTION RECONSTITUTED 3 (daptomycin) CUBICIN RF INTRAVENOUS SOLUTION RECONSTITUTED 3 (daptomycin)

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 the highest cost share and usually include 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 DAPTOMYCIN INTRAVENOUS SOLUTION RECONSTITUTED 350 3 MG 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 3 (oritavancin diphosphate) ORBACTIV INTRAVENOUS SOLUTION RECONSTITUTED 3 (oritavancin 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 3 VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 3 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 3 hcl) *LEPROSTATICS*** - ANTIBIOTICS dapsone oral tablet 1 or 1b* *LINCOSAMIDES*** - ANTIBIOTICS CLEOCIN ORAL CAPSULE (clindamycin hcl) 3 CLEOCIN ORAL SOLUTION RECONSTITUTED (clindamycin palmitate 3 hcl) CLEOCIN PHOSPHATE INJECTION SOLUTION (clindamycin 3 QL (20 mL per 1 day) phosphate) 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*

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 the highest cost share and usually include 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 *MONOBACTAMS*** - ANTIBIOTICS AZACTAM INJECTION SOLUTION RECONSTITUTED (aztreonam) 3 aztreonam injection solution reconstituted 1 or 1b* CAYSTON INHALATION SOLUTION RECONSTITUTED (aztreonam 4 LD; SP; QL (84 vials per 28 days) lysine) *OXAZOLIDINONES*** - ANTIBIOTICS linezolid 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) 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* 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 the highest cost share and usually include 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 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 FIRDAPSE ORAL TABLET (amifampridine phosphate) 4 PA; LD; QL (8 tablets per 1 day) MESTINON ORAL SOLUTION (pyridostigmine bromide) 3 MESTINON ORAL TABLET (pyridostigmine bromide) 3 MESTINON ORAL TABLET EXTENDED RELEASE (pyridostigmine 3 bromide) NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION 3 pyridostigmine bromide er oral tablet extended release 1 or 1b* pyridostigmine bromide oral solution 1 or 1b* pyridostigmine bromide oral tablet 1 or 1b* REGONOL INTRAVENOUS SOLUTION (pyridostigmine bromide) 3 RUZURGI ORAL TABLET (amifampridine) 4 PA; LD; QL (10 tablets per 1 day) *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 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 the highest cost share and usually include 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 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 (bendamustine hcl) 3 PA; LD; SP BENDEKA INTRAVENOUS SOLUTION (bendamustine hcl) 3 PA; LD; SP busulfan intravenous solution 1 or 1b* SP BUSULFEX INTRAVENOUS SOLUTION (busulfan) 3 SP carboplatin intravenous solution 1 or 1b* SP cisplatin intravenous solution 1 or 1b* SP CISPLATIN INTRAVENOUS SOLUTION RECONSTITUTED 3 SP MYLERAN ORAL TABLET (busulfan) 2; OC oxaliplatin 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 (thiotepa) 3 SP thiotepa injection solution reconstituted 1 or 1b* SP TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (bendamustine hcl) ZEPZELCA INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (lurbinectedin) *ANDROGEN BIOSYNTHESIS INHIBITORS*** - DRUGS FOR CANCER abiraterone acetate 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)

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 the highest cost share and usually include 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 *ANTIADRENALS*** - DRUGS FOR CANCER LYSODREN ORAL TABLET (mitotane) 2; OC LD; QL (38 tablet per 1 day) *ANTIANDROGENS*** - DRUGS FOR CANCER bicalutamide oral tablet 1 or 1b*; OC CASODEX ORAL TABLET (bicalutamide) 3; OC PA; LD; SP; QL (4 tablets per 1 ERLEADA ORAL TABLET (apalutamide) 2; OC day) flutamide oral capsule 1 or 1b*; OC NILANDRON ORAL TABLET (nilutamide) 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 (darolutamide) 3; OC day) PA; LD; SP; QL (4 capsules per 1 XTANDI ORAL CAPSULE (enzalutamide) 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) *ANTIESTROGENS*** - DRUGS FOR CANCER FARESTON ORAL TABLET (toremifene citrate) 3; OC QL (1 tablet per 1 day) SOLTAMOX ORAL SOLUTION (tamoxifen 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 (pemetrexed 3 PA; SP disodium) ARRANON INTRAVENOUS SOLUTION (nelarabine) 3 SP azacitidine injection suspension reconstituted 1 or 1b* PA; SP capecitabine oral tablet 1 or 1b*; OC PA; SP cladribine intravenous solution 1 or 1b* SP clofarabine intravenous solution 1 or 1b* SP CLOLAR INTRAVENOUS SOLUTION (clofarabine) 3 SP cytarabine (pf) injection solution 1 or 1b* SP cytarabine injection solution 1 or 1b* SP DACOGEN INTRAVENOUS SOLUTION RECONSTITUTED 3 SP (decitabine) decitabine intravenous solution reconstituted 1 or 1b* SP floxuridine injection solution reconstituted 1 or 1b* SP fludarabine phosphate intravenous solution 1 or 1b* SP fludarabine phosphate 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 the highest cost share and usually include 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 fluorouracil intravenous solution 1 or 1b* SP FOLOTYN INTRAVENOUS SOLUTION (pralatrexate) 3 SP GEMCITABINE HCL INTRAVENOUS SOLUTION 3 SP gemcitabine hcl intravenous solution reconstituted 1 or 1b* SP INFUGEM INTRAVENOUS SOLUTION (gemcitabine hcl-nacl) 3 SP mercaptopurine 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) 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 3 PA; LD; SP (belantamab mafodotin-blmf)

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 the highest cost share and usually include 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-CCR4 ANTIBODIES*** - DRUGS FOR CANCER POTELIGEO INTRAVENOUS SOLUTION (mogamulizumab-kpkc) 3 LD; SP *ANTINEOPLASTIC - ANTI-CD19 ANTIBODIES*** - DRUGS FOR CANCER MONJUVI INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD (tafasitamab-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 3 PA; LD; SP (inotuzumab ozogamicin) *ANTINEOPLASTIC - ANTI-CD30 ANTIBODY-DRUG COMPLEX*** - DRUGS FOR CANCER ADCETRIS INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (brentuximab 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)

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 the highest cost share and usually include 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 - 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 3 LD; SP (trastuzumab-pkrb) KANJINTI INTRAVENOUS SOLUTION RECONSTITUTED 3 LD; SP (trastuzumab-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) *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 (atezolizumab) 3 PA; LD; SP *ANTINEOPLASTIC - ANTI-SLAMF7 ANTIBODIES*** - DRUGS FOR CANCER EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (elotuzumab) 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 the highest cost share and usually include 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 - AUTOLOGOUS CELLULAR IMMUNOTHERAPY*** - DRUGS FOR CANCER PROVENGE INTRAVENOUS SUSPENSION (sipuleucel-t) 4 PA; LD *ANTINEOPLASTIC - BCL-2 INHIBITORS*** - DRUGS FOR CANCER VENCLEXTA ORAL TABLET 10 MG (venetoclax) 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) *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)

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 the highest cost share and usually include 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 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 3; OC PA; LD; QL (1 carton per 28 days) PACK (infigratinib phosphate) TRUSELTIQ (125MG DAILY DOSE) ORAL CAPSULE THERAPY 3; OC PA; LD; QL (1 carton per 28 days) PACK (infigratinib phosphate) TRUSELTIQ (50MG DAILY DOSE) ORAL CAPSULE THERAPY 3; OC PA; LD; QL (1 carton per 28 days) PACK (infigratinib phosphate) TRUSELTIQ (75MG DAILY DOSE) ORAL CAPSULE THERAPY 3; OC PA; LD; QL (1 carton per 28 days) PACK (infigratinib phosphate) *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 (belinostat) PA; LD; SP; QL (1 capsule per 1 FARYDAK ORAL CAPSULE (panobinostat lactate) 3; OC day) ISTODAX (OVERFILL) INTRAVENOUS SOLUTION 3 PA; LD; SP RECONSTITUTED (romidepsin) ROMIDEPSIN INTRAVENOUS SOLUTION 3 PA; SP ZOLINZA ORAL CAPSULE (vorinostat) 2; OC PA; SP; QL (4 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 the highest cost share and usually include 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 - 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) *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 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)

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 the highest cost share and usually include 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 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 (sorafenib 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 (umbralisib 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) *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 BORTEZOMIB INTRAVENOUS SOLUTION RECONSTITUTED 3 PA KYPROLIS INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; LD; SP (carfilzomib) PA; LD; SP; QL (3 capsule per 28 NINLARO ORAL CAPSULE (ixazomib 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)

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 the highest cost share and usually include 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 *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 3; OC PA; LD; QL (1 carton per 28 days) PACK (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 3; OC PA; LD; QL (1 pack per 1 week) PACK (selinexor) 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 3; OC PA; LD; QL (1 pack per 1 week) PACK (selinexor) *ANTINEOPLASTIC ANTIBIOTICS*** - DRUGS FOR CANCER adriamycin intravenous solution 1 or 1b* SP adriamycin intravenous solution reconstituted 1 or 1b* SP bleomycin sulfate injection solution reconstituted 1 or 1b* SP COSMEGEN INTRAVENOUS SOLUTION RECONSTITUTED 3 SP (dactinomycin) dactinomycin intravenous solution reconstituted 1 or 1b* SP DAUNORUBICIN HCL INTRAVENOUS SOLUTION 3 SP DOXIL INTRAVENOUS INJECTABLE (doxorubicin 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 (epirubicin hcl) 3 PA; SP epirubicin hcl intravenous solution 1 or 1b* PA; SP IDAMYCIN PFS INTRAVENOUS SOLUTION (idarubicin 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 the highest cost share and usually include 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 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 mitoxantrone hcl intravenous concentrate 1 or 1b* SP mutamycin intravenous solution reconstituted 1 or 1b* SP valrubicin 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 trastuzumab emtansine) *ANTINEOPLASTIC COMBINATIONS*** - DRUGS FOR CANCER DARZALEX FASPRO SUBCUTANEOUS SOLUTION (daratumumab- 3 PA; LD; SP hyaluronidase-fihj) 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) (ribociclib-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 (asparaginase 3 PA; LD; SP erwinia chrysanth) ERWINAZE INJECTION SOLUTION RECONSTITUTED (asparaginase 3 PA; LD; SP erwinia chrysanth)

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 the highest cost share and usually include 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 ONCASPAR INJECTION SOLUTION (pegaspargase) 3 PA; SP *ANTINEOPLASTIC RADIOPHARMACEUTICALS*** - DRUGS FOR CANCER AZEDRA DOSIMETRIC INTRAVENOUS SOLUTION (iobenguane i 4 PA; LD 131) AZEDRA THERAPEUTIC INTRAVENOUS SOLUTION (iobenguane i 4 PA; LD 131) 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 3 (porfimer sodium) UVADEX INJECTION SOLUTION (methoxsalen (photopheresis)) 3 *ANTINEOPLASTICS MISC.*** - DRUGS FOR CANCER ACTIMMUNE SUBCUTANEOUS SOLUTION (interferon gamma-1b) 4 PA; LD; SP ALFERON N INJECTION SOLUTION (interferon alfa-n3) 4 SP arsenic trioxide intravenous solution 1 or 1b* SP dacarbazine intravenous solution reconstituted 1 or 1b* SP HYDREA ORAL CAPSULE (hydroxyurea) 3; OC hydroxyurea oral capsule 1 or 1b*; OC INTRON A INJECTION SOLUTION (interferon alfa-2b) 4 LD; SP INTRON A INJECTION SOLUTION RECONSTITUTED (interferon alfa- 4 LD; SP 2b) MATULANE ORAL CAPSULE (procarbazine hcl) 2; OC LD NIPENT INTRAVENOUS SOLUTION RECONSTITUTED (pentostatin) 3 SP SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3 PA; LD (omacetaxine mepesuccinate) TICE BCG INTRAVESICAL SUSPENSION RECONSTITUTED (bcg 4 SP live) TRISENOX INTRAVENOUS SOLUTION (arsenic trioxide) 3 LD; SP *AROMATASE INHIBITORS*** - DRUGS FOR CANCER anastrozole oral tablet 1 or 1b*; OC; $0 QL (1 tablet per 1 day) AROMASIN ORAL TABLET (exemestane) 3; OC 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 the highest cost share and usually include 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 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 *CHEMOTHERAPY ADJUNCTS - KERATINOCYTE GROWTH FACTORS*** - DRUGS FOR CANCER KEPIVANCE INTRAVENOUS SOLUTION RECONSTITUTED 4 (palifermin) *CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (21 capsules per 28 IBRANCE ORAL CAPSULE (palbociclib) 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 (abemaciclib) 3; OC day) * RECEPTOR ANTAGONIST*** - DRUGS FOR CANCER FASLODEX INTRAMUSCULAR SOLUTION (fulvestrant) 3 PA; SP fulvestrant intramuscular solution 1 or 1b* PA; SP *ESTROGENS-ANTINEOPLASTIC*** - DRUGS FOR CANCER EMCYT ORAL CAPSULE (estramustine phosphate 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* 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 the highest cost share and usually include 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 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* *GONADOTROPIN RELEASING HORMONE (GNRH) ANTAGONISTS*** - DRUGS FOR CANCER FIRMAGON (240 MG DOSE) SUBCUTANEOUS SOLUTION 3 PA; SP; QL (2 units per 310 days) RECONSTITUTED (degarelix acetate) FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 3 PA; SP; QL (1 kit per 28 days) (degarelix acetate) ORGOVYX ORAL TABLET (relugolix) 3; OC PA; LD; QL (1 tablet per 1 day) *IMIDAZOTETRAZINES*** - DRUGS FOR CANCER TEMODAR INTRAVENOUS SOLUTION RECONSTITUTED 2 PA; SP (temozolomide) 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) *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 3.75 MG PA; SP; QL (1 syringe kit per 28 4 (leuprolide acetate) 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 the highest cost share and usually include 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 LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 7.5 MG 3 PA; SP; QL (1 kit per 28 days) (leuprolide acetate) LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG 4 PA; SP; QL (1 kit per 84 days) (leuprolide acetate (3 month)) 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 3 PA; SP; QL (1 kit per 112 days) acetate (4 month)) LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT (leuprolide PA; SP; QL (1 syringe kit per 168 3 acetate (6 month)) days) TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION 3 PA; SP; QL (1 vial per 84 days) RECONSTITUTED 11.25 MG (triptorelin 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 (histrelin acetate) 3 days) ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG (goserelin 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) DOCETAXEL INTRAVENOUS CONCENTRATE 3 PA; SP DOCETAXEL INTRAVENOUS SOLUTION 3 PA; SP ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED 3 SP (etoposide phosphate) etoposide intravenous solution 1 or 1b* SP etoposide oral capsule 1 or 1b*; OC SP HALAVEN INTRAVENOUS SOLUTION (eribulin mesylate) 3 PA; SP IXEMPRA KIT INTRAVENOUS SOLUTION RECONSTITUTED 3 PA; SP (ixabepilone) JEVTANA INTRAVENOUS SOLUTION (cabazitaxel) 3 PA; LD; SP MARQIBO INTRAVENOUS SUSPENSION (vincristine sulfate liposome) 3 LD NAVELBINE INTRAVENOUS SOLUTION (vinorelbine tartrate) 3 SP paclitaxel intravenous concentrate 1 or 1b* SP TENIPOSIDE INTRAVENOUS SOLUTION 3 SP toposar intravenous solution 1 or 1b* SP vinblastine sulfate intravenous solution 1 or 1b* SP vincristine sulfate intravenous solution 1 or 1b* SP vinorelbine tartrate intravenous solution 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 the highest cost share and usually include 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 *MYELOPROTECTIVE AGENTS*** - DRUGS FOR CANCER COSELA INTRAVENOUS SOLUTION RECONSTITUTED (trilaciclib 3 PA; LD dihydrochloride) *NITROGEN MUSTARDS*** - DRUGS FOR CANCER ALKERAN INTRAVENOUS SOLUTION RECONSTITUTED (melphalan 3 SP hcl) ALKERAN ORAL TABLET (melphalan) 3; OC SP cyclophosphamide 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 3 LD; SP (melphalan hcl) IFEX INTRAVENOUS SOLUTION RECONSTITUTED (ifosfamide) 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 (chlorambucil) 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) *NITROSOUREAS*** - DRUGS FOR CANCER BICNU INTRAVENOUS SOLUTION RECONSTITUTED (carmustine) 3 SP carmustine intravenous solution reconstituted 1 or 1b* SP GLEOSTINE ORAL CAPSULE (lomustine) 3; OC PA GLIADEL WAFER IMPLANT WAFER (carmustine in polifeprosan) 3 ZANOSAR INTRAVENOUS SOLUTION RECONSTITUTED 3 LD; SP (streptozocin) *ONCOLYTIC VIRAL AGENTS - HSV1*** - DRUGS FOR CANCER IMLYGIC INTRALESIONAL SUSPENSION (talimogene laherparepvec) 3 LD *PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS*** - DRUGS FOR CANCER ALIQOPA INTRAVENOUS SOLUTION RECONSTITUTED (copanlisib 3 PA; LD hcl) COPIKTRA ORAL CAPSULE (duvelisib) 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) (alpelisib) PIQRAY (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 3; OC PA; SP; QL (1 pack per 28 days) (alpelisib)

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 the highest cost share and usually include 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 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 (idelalisib) 3; OC day) *POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS*** - DRUGS FOR CANCER PA; LD; SP; QL (4 tablets per 1 LYNPARZA ORAL TABLET (olaparib) 3; OC day) RUBRACA ORAL TABLET 200 MG, 300 MG (rucaparib 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 (talazoparib 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 (niraparib 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 megestrol acetate oral suspension 1 or 1b*; OC megestrol acetate oral tablet 1 or 1b*; OC *RETINOIDS*** - DRUGS FOR CANCER tretinoin oral capsule 1 or 1b*; OC *SELECTIVE RETINOID X RECEPTOR AGONISTS*** - DRUGS FOR CANCER bexarotene 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 (trabectedin) *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 (irinotecan hcl) 3 SP HYCAMTIN INTRAVENOUS SOLUTION RECONSTITUTED 3 SP (topotecan 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

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 the highest cost share and usually include 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 *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 (bevacizumab) 3 PA; LD; SP CYRAMZA INTRAVENOUS SOLUTION (ramucirumab) 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 *ANTIPARKINSON AND RELATED THERAPY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM *ADENOSINE RECEPTOR ANTAGONIST*** - DRUGS FOR PARKINSON NOURIANZ ORAL TABLET (istradefylline) 4 PA; LD; SP; QL (1 tablet per 1 day) *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

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 the highest cost share and usually include 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 trihexyphenidyl hcl oral solution 1 or 1a* trihexyphenidyl hcl oral tablet 1 or 1a* *ANTIPARKINSON DOPAMINERGICS*** - DRUGS FOR PARKINSON amantadine 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 3 PA; LD MG (amantadine hcl) INBRIJA INHALATION CAPSULE (levodopa) 4 PA; LD; QL (5 kits per 30 days) 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 3 PA; LD MG (amantadine hcl) OSMOLEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 193 3 PA; LD; QL (1 tablet per 1 day) MG, 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 (safinamide 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) *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* 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 the highest cost share and usually include 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 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- 3 levodopa) 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 APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE (apomorphine 4 PA; LD; SP; QL (2 mL per 1 day) hcl) KYNMOBI SUBLINGUAL FILM (apomorphine 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) (pramipexole dihydrochloride) MIRAPEX ORAL TABLET (pramipexole dihydrochloride) 3 QL (3 tablet per 1 day) NEUPRO TRANSDERMAL PATCH 24 HOUR (rotigotine) 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) ropinirole 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* lithium carbonate oral tablet 1 or 1a* *ANTIPSYCHOTICS - MISC.*** - DRUGS FOR SEVERE MENTAL DISORDERS CAPLYTA ORAL CAPSULE (lumateperone tosylate) 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 the highest cost share and usually include 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 EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 3 QL (8 capsules per 1 day) MG, 200 MG (carbamazepine (antipsychotic)) EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 300 3 QL (5 capsules per 1 day) MG (carbamazepine (antipsychotic)) GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 3 (ziprasidone mesylate) LATUDA ORAL TABLET 120 MG (lurasidone hcl) 3 QL (1 tablet per 1 day) LATUDA ORAL TABLET 20 MG, 40 MG, 60 MG (lurasidone hcl) 3 LATUDA ORAL TABLET 80 MG (lurasidone hcl) 3 QL (2 tablets per 1 day) PA; LD; SP; QL (1 capsule per 1 NUPLAZID ORAL CAPSULE (pimavanserin tartrate) 4 day) NUPLAZID ORAL TABLET (pimavanserin tartrate) 4 PA; LD; SP; QL (1 tablet per 1 day) VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG (cariprazine hcl) 3 ST 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* 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 (iloperidone) 3 ST 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 (paliperidone 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* 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 RECONSTITUTED ER 25 MG, 37.5 MG, 50 MG (risperidone 2 QL (2 injections per 28 days) 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) risperidone oral tablet dispersible 3 mg, 4 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 the highest cost share and usually include 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 *BUTYROPHENONES*** - DRUGS FOR SEVERE MENTAL DISORDERS HALDOL DECANOATE INTRAMUSCULAR SOLUTION 100 MG/ML 3 QL (5 injections per 30 days) (haloperidol decanoate) HALDOL DECANOATE INTRAMUSCULAR SOLUTION 50 MG/ML 3 QL (5 ampules per 30 days) (haloperidol decanoate) 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 clozapine 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* 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* 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 asenapine 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* SECUADO TRANSDERMAL PATCH 24 HOUR (asenapine) 3 ST; QL (1 patch per 1 day) *DIBENZOTHIAZEPINES*** - DRUGS FOR SEVERE MENTAL DISORDERS quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 200 mg 1 or 1b* 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* 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 3 ACTIVATED (loxapine) loxapine succinate oral capsule 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 the highest cost share and usually include 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 *DIHYDROINDOLONES*** - DRUGS FOR SEVERE MENTAL DISORDERS molindone hcl oral tablet 1 or 1b* *PHENOTHIAZINES*** - DRUGS FOR SEVERE MENTAL DISORDERS chlorpromazine hcl injection solution 1 or 1b* chlorpromazine hcl oral tablet 1 or 1b* compro rectal suppository 1 or 1b* fluphenazine 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* perphenazine oral tablet 1 or 1b* prochlorperazine edisylate injection solution 1 or 1b* prochlorperazine maleate oral tablet 1 or 1a* prochlorperazine rectal suppository 1 or 1b* thioridazine hcl oral tablet 1 or 1b* trifluoperazine hcl oral tablet 1 or 1b* *QUINOLINONE DERIVATIVES*** - DRUGS FOR SEVERE MENTAL DISORDERS ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 3 (aripiprazole) ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION 3 QL (1 injection per 30 days) RECONSTITUTED ER (aripiprazole) ABILIFY MYCITE MAINTENANCE KIT ORAL TABLET 10 MG, 15 3 ST MG, 2 MG, 5 MG (aripiprazole) ABILIFY MYCITE MAINTENANCE KIT ORAL TABLET 20 MG, 30 3 ST; QL (1 tablet per 1 day) MG (aripiprazole) ABILIFY MYCITE ORAL TABLET 10 MG, 15 MG, 2 MG, 5 MG 3 ST (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 3 ST MG, 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* 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) aripiprazole oral tablet dispersible 15 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 the highest cost share and usually include 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 ARISTADA INITIO INTRAMUSCULAR PREFILLED SYRINGE 3 QL (1 syringe per 1 fill) (aripiprazole lauroxil) ARISTADA INTRAMUSCULAR PREFILLED SYRINGE (aripiprazole 3 lauroxil) REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG 3 ST (brexpiprazole) REXULTI ORAL TABLET 3 MG, 4 MG (brexpiprazole) 3 ST; QL (1 tablet per 1 day) *THIENBENZODIAZEPINES*** - DRUGS FOR SEVERE MENTAL DISORDERS olanzapine intramuscular solution reconstituted 1 or 1b* olanzapine oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg 1 or 1b* 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* 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) *THIOXANTHENES*** - DRUGS FOR SEVERE MENTAL DISORDERS thiothixene oral capsule 1 or 1b* *ANTISEPTICS & DISINFECTANTS* - ANTISEPTICS AND DISINFECTANTS *ANTISEPTICS & DISINFECTANTS*** - ANTISEPTICS AND DISINFECTANTS FORMALDEHYDE EXTERNAL SOLUTION 3 GLUTARALDEHYDE EXTERNAL SOLUTION 2 *CHLORINE ANTISEPTICS*** - ANTISEPTICS AND DISINFECTANTS BENZALKONIUM CHLORIDE EXTERNAL SOLUTION 3 *IODINE ANTISEPTICS*** - ANTISEPTICS AND DISINFECTANTS IODINE TINCTURE EXTERNAL TINCTURE 3 IODOFLEX EXTERNAL PAD () 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 3 PA; LD; QL (1 kit per 28 days) RELEASE 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 the highest cost share and usually include 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 CABENUVA INTRAMUSCULAR SUSPENSION EXTENDED PA; LD; QL (1 kit per 1 one-time 3 RELEASE 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) efavirenz-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-ritonavir) 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 (emtricitabine-tenofovir df) 2 ST; QL (1 tablet per 1 day) *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 the highest cost share and usually include 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 *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 2 PA; LD; QL (60 vials per 30 days) (enfuvirtide) *ANTIRETROVIRALS - GP120-DIRECTED ATTACHMENT INHIBITOR*** - DRUGS FOR VIRAL INFECTIONS RUKOBIA ORAL TABLET EXTENDED RELEASE 12 HOUR 3 PA; QL (2 tablets per 1 day) (fostemsavir 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 2 QL (6 tablets per 1 day) potassium) 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 (indinavir 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 the highest cost share and usually include 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 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) nevirapine 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) EPIVIR ORAL TABLET 150 MG (lamivudine) 3 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 the highest cost share and usually include 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 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 (tenofovir disoproxil fumarate) 2 QL (1 tablet per 1 day) *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 INTRAVENOUS SOLUTION 4 SP GANCICLOVIR SODIUM INTRAVENOUS SOLUTION 4 SP ganciclovir sodium intravenous solution reconstituted 4 SP PREVYMIS INTRAVENOUS SOLUTION (letermovir) 4 PA; SP; QL (1 vial per 1 day) PREVYMIS ORAL TABLET (letermovir) 4 PA; SP; QL (1 tablet per 1 day) 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) BARACLUDE ORAL SOLUTION (entecavir) 4 QL (20 mL per 1 day) entecavir oral tablet 4 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 the highest cost share and usually include 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 EPIVIR HBV ORAL SOLUTION (lamivudine) 4 QL (20 mL per 1 day) EPIVIR HBV ORAL TABLET (lamivudine) 4 QL (1 tablet per 1 day) HEPSERA ORAL TABLET (adefovir dipivoxil) 4 SP; QL (1 tablet per 1 day) lamivudine oral tablet 1 or 1b* QL (1 tablet per 1 day) VEMLIDY ORAL TABLET (tenofovir alafenamide fumarate) 4 SP; QL (1 tablet per 1 day) *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 4 LD; SP; QL (2 syringe per 28 days) (peginterferon 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 rimantadine 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)

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 the highest cost share and usually include 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 RAPIVAB INTRAVENOUS SOLUTION (peramivir) 3 RELENZA DISKHALER INHALATION AEROSOL POWDER 2 QL (1 package per 90 days) BREATH 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) 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 carvedilol 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- 3 sodium 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) 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 the highest cost share and usually include 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 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* 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 3 QL (1 capsule per 1 day) 100 MG, 25 MG, 50 MG (metoprolol succinate) KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 3 QL (2 capsules per 1 day) 200 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 (propranolol 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) sotalol 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)

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 the highest cost share and usually include 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 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) 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* CALAN SR ORAL TABLET EXTENDED RELEASE (verapamil hcl) 3 QL (2 tablets per 1 day) CARDENE IV INTRAVENOUS SOLUTION (nicardipine hcl in nacl) 3 CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 3 (diltiazem 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 cartia xt oral capsule extended release 24 hour 120 mg, 180 mg 1 or 1b* cartia xt oral capsule extended release 24 hour 240 mg, 300 mg 1 or 1b* QL (1 capsule per 1 day) CLEVIPREX INTRAVENOUS EMULSION (clevidipine) 3 CONJUPRI ORAL TABLET 2.5 MG (levamlodipine maleate) 3 ST 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* 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* 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* diltiazem hcl er coated beads oral tablet extended release 24 hour 240 mg, 300 1 or 1b* QL (1 tablet per 1 day) 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* 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* diltiazem hcl oral tablet 90 mg 1 or 1b* QL (4 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 the highest cost share and usually include 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 DILTIAZEM HCL-DEXTROSE INTRAVENOUS SOLUTION 3 DILTIAZEM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg 1 or 1b* dilt-xr oral capsule extended release 24 hour 240 mg 1 or 1b* QL (1 capsule per 1 day) felodipine 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* isradipine 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* 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 3 PREFILLED 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) nifedipine er oral tablet extended release 24 hour 30 mg 1 or 1b* 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* 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) nimodipine oral capsule 1 or 1b* QL (12 capsule per 1 day) nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, 8.5 mg 1 or 1b* 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 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 3 MG (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* 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* tiadylt er oral capsule extended release 24 hour 240 mg, 300 mg, 420 mg 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 the highest cost share and usually include 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 TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 3 180 MG, 360 MG (diltiazem hcl er beads) TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 240 MG, 3 QL (1 capsule per 1 day) 300 MG, 420 MG (diltiazem hcl er beads) verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 1 or 1b* 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 3 MG, 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 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 (digoxin) 2 LANOXIN PEDIATRIC INJECTION SOLUTION (digoxin) 2 *INOTROPES*** - DRUGS FOR SERIOUS ALLERGIC REACTION dobutamine 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 milrinone lactate in dextrose intravenous solution 1 or 1b* milrinone lactate 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 the highest cost share and usually include 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 *CARDIOVASCULAR AGENTS - MISC.* - DRUGS FOR THE HEART *CALCIUM CHANNEL BLOCKER & 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* 5-20 mg, 5-40 mg CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5- 3 QL (1 tablet per 1 day) 80 MG (amlodipine-atorvastatin) CADUET ORAL TABLET 5-10 MG, 5-20 MG, 5-40 MG (amlodipine- 3 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 (-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 FLOLAN INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (epoprostenol sodium) ORENITRAM ORAL TABLET EXTENDED RELEASE (treprostinil 4 PA; LD; SP diolamine) REMODULIN INJECTION SOLUTION (treprostinil) 4 PA; LD; SP treprostinil injection solution 4 PA; LD; SP TYVASO INHALATION SOLUTION (treprostinil) 4 PA; LD; SP; QL (1 kit per 28 days) TYVASO REFILL INHALATION SOLUTION (treprostinil) 4 PA; LD; SP; QL (1 kit per 28 days) TYVASO STARTER INHALATION SOLUTION (treprostinil) 4 PA; LD; SP; QL (1 kit per 28 days) VELETRI INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (epoprostenol 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 the highest cost share and usually include 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 VENTAVIS INHALATION SOLUTION (iloprost) 4 PA; LD; SP; QL (9 mL per 1 day) *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) *PULMONARY HYPERTENSION - RECEPTOR 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 4 PA; SP; QL (3 tablets per 1 day) tadalafil (pah) oral tablet 4 PA; SP; QL (2 tablets per 1 day) *PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST*** - DRUGS FOR HIGH BLOOD PRESSURE PA; LD; SP; QL (2 tablets per 1 UPTRAVI ORAL TABLET (selexipag) 4 day) PA; LD; SP; QL (1 pack per 365 UPTRAVI ORAL TABLET THERAPY PACK (selexipag) 4 days) *SELECTIVE CGMP PHOSPHODIESTERASE TYPE 5 INHIBITORS*** - DRUGS FOR THE HEART sildenafil citrate oral tablet 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 alcohol) 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)

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 the highest cost share and usually include 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 *TRANSTHYRETIN STABILIZERS*** - DRUGS FOR THE HEART PA; LD; SP; QL (1 capsule per 1 VYNDAMAX ORAL CAPSULE (tafamidis) 4 day) PA; LD; SP; QL (4 capsules per 1 VYNDAQEL ORAL CAPSULE (tafamidis meglumine (cardiac)) 4 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 3 (ceftolozane-tazobactam) *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 3 cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 500 mg 1 or 1b* CEFAZOLIN SODIUM INJECTION SOLUTION RECONSTITUTED 3 100 GM, 300 GM CEFAZOLIN SODIUM INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 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*

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 the highest cost share and usually include 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 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) 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 3 RECONSTITUTED 100 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 3 QL (200 mL per 1 fill) (cefixime) SUPRAX ORAL SUSPENSION RECONSTITUTED 200 MG/5ML 3 QL (100 mL per 1 fill) (cefixime)

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 the highest cost share and usually include 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 SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML 3 QL (40 mL per 1 fill) (cefixime) 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 3 RECONSTITUTED *CEPHALOSPORINS - 5TH GENERATION*** - ANTIBIOTICS TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED (ceftaroline 3 fosamil) *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 desogestrel-ethinyl oral tablet 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

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 the highest cost share and usually include 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 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 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 1 or 1a*; $0 drospiren-eth estrad-levomefol oral tablet 1 or 1b*; $0 drospirenone-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 (levonorgestrel-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

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 the highest cost share and usually include 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 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 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 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

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 the highest cost share and usually include 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 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 3 estrad-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 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 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 the highest cost share and usually include 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 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 3 estradiol) 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 etonogestrel-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 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

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 the highest cost share and usually include 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 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 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-dienogest) 3 *PROGESTIN CONTRACEPTIVES - IMPLANTS*** - BIRTH CONTROL PILLS NEXPLANON SUBCUTANEOUS IMPLANT (etonogestrel) 4 LD; SP *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)

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 the highest cost share and usually include 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 medroxyprogesterone acetate intramuscular suspension 1 or 1b*; $0 medroxyprogesterone acetate intramuscular suspension prefilled syringe 1 or 1b*; $0 *PROGESTIN CONTRACEPTIVES - IUD*** - BIRTH CONTROL PILLS KYLEENA INTRAUTERINE INTRAUTERINE DEVICE (levonorgestrel) 4 LD; SP 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 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

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 the highest cost share and usually include 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 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 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 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 (methylprednisolone acetate) 3 DEXABLISS ORAL TABLET THERAPY PACK 3 DEXAMETHASONE INTENSOL ORAL CONCENTRATE 2 (dexamethasone) 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

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 the highest cost share and usually include 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 DEXAMETHASONE SODIUM PHOSPHATE INJECTION SOLUTION 3 10 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* methylprednisolone sodium succ injection solution reconstituted 1 or 1b* MILLIPRED ORAL TABLET (prednisolone) 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 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* 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*

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 the highest cost share and usually include 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 UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR (budesonide) 3 QL (1 tablet per 1 day) ZCORT 7-DAY ORAL TABLET THERAPY PACK 3 ZILRETTA INTRA-ARTICULAR SUSPENSION RECONSTITUTED 4 PA; LD; QL (1 injection per 1 knee) ER (triamcinolone acetonide) *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 3 sod 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* 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

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 the highest cost share and usually include 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 *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-phenylephrine 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* *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 2 (hydrocod 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 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 the highest cost share and usually include 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 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) ery external pad 1 or 1b* QL (2 pads per 1 day) ERYGEL EXTERNAL GEL (erythromycin) 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)

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 the highest cost share and usually include 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 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 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) 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 clotrimazole-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) 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 the highest cost share and usually include 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 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) 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 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) 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 the highest cost share and usually include 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 fluorouracil external solution 1 or 1b* QL (10 mL per 365 days) *ANTINEOPLASTIC RETINOIDS - TOPICAL*** - DRUGS FOR THE SKIN PANRETIN EXTERNAL GEL (alitretinoin) 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 PA; LD; SP; QL (2 syringes per 28 4 PREFILLED 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 4 PA; LD; SP; QL (1 pen per 28 days) AUTO-INJECTOR (secukinumab) 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 4 PA; SP; QL (2 syringes per 84 days) KIT (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) TREMFYA SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; SP; QL (1 autoinjector per 56 4 (guselkumab) 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 (tazarotene) 2 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 the highest cost share and usually include 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 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-BAKUCHIOL 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) 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) *ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES*** - DRUGS FOR THE SKIN DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 4 PA; SP; QL (2 syringes per 28 days) (dupilumab) DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (2 syringes per 28 days) (dupilumab) *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) 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 the highest cost share and usually include 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 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) 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)

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 the highest cost share and usually include 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 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) hydrocortisone butyrate external solution 3 ST; QL (60 mL per 30 days) hydrocortisone external cream 1 or 1a* QL (454 grams per 30 days) hydrocortisone external lotion 1 or 1a* QL (118 mL per 30 days) hydrocortisone external ointment 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*

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 the highest cost share and usually include 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 *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) *GLABELLAR LINES (FROWN LINES) AGENTS*** - DRUGS FOR THE SKIN BOTOX COSMETIC INTRAMUSCULAR SOLUTION 4 PA RECONSTITUTED (onabotulinumtoxina (cosmetic)) *IMIDAZOLE-RELATED ANTIFUNGALS - TOPICAL*** - DRUGS FOR THE SKIN clotrimazole external cream 1 or 1b* QL (1 gram per 1 day) 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)

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 the highest cost share and usually include 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 *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 1 or 1b* QL (5 grams per 1 day) lidocaine external patch 1 or 1b* PA; QL (3 patches per 1 day) lidocaine hcl external solution 1 or 1b* QL (10 mL per 1 day) lidocaine hcl urethral/mucosal external gel 1 or 1b* lidocaine hcl urethral/mucosal external prefilled syringe 1 or 1b* QUTENZA (4 PATCH) EXTERNAL KIT (capsaicin-cleansing gel) 3 LD *MACROLIDE IMMUNOSUPPRESSANTS - TOPICAL*** - DRUGS FOR THE SKIN pimecrolimus external cream 1 or 1b* ST; QL (100 grams per 90 days) tacrolimus 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) *MICROTUBULE 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)

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 the highest cost share and usually include 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 *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) *PHOTODYNAMIC THERAPY AGENTS - TOPICAL*** - DRUGS FOR THE SKIN AMELUZ EXTERNAL GEL (aminolevulinic acid 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) 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)

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 the highest cost share and usually include 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 permethrin 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 (hydrogen peroxide) 3 *STEROID-LOCAL ANESTHETIC COMBINATIONS*** - DRUGS FOR THE SKIN EPIFOAM EXTERNAL FOAM (pramoxine-hc) 3 PRAMOSONE EXTERNAL CREAM (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 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 3 allograft) 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 (amniotic membrane allograft) 3 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)

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 the highest cost share and usually include 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 PALINGEN XPLUS HYDROMEMBRANE EXTERNAL SHEET 3 (amniotic 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 *TOPICAL ANESTHETIC COMBINATIONS*** - DRUGS FOR THE SKIN CETACAINE EXTERNAL GEL (butamben-tetracaine-benzocaine) 3 FLEXIN EXTERNAL PATCH 3 lidocaine-prilocaine 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 RETINOID X RECEPTOR AGONISTS*** - DRUGS FOR THE SKIN TARGRETIN EXTERNAL GEL (bexarotene) 2 PA; SP *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 finasteride oral tablet 1 or 1b* PROPECIA ORAL TABLET (finasteride) 3 *WOUND CARE - GROWTH FACTOR AGENTS*** - DRUGS FOR THE SKIN REGRANEX EXTERNAL GEL () 3 *WOUND DRESSINGS*** - DRUGS FOR THE SKIN KENDALL HYDROGEL WOUND DRESS EXTERNAL (hydroactive 3 dressings) TEGADERM AG MESH EXTERNAL PAD (silver) 2 WOUNDGELHA MATRIX EXTERNAL GEL (hyaluronate sodium) 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 the highest cost share and usually include 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 *DIAGNOSTIC PRODUCTS* *DIAGNOSTIC TESTS*** ACCU-CHEK AVIVA PLUS IN VITRO 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 3 ST; QL (25 capsules per 1 day) (pancrelipase (lip-prot-amyl)) PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 3 ST; QL (25 capsules per 1 day) (pancrelipase (lip-prot-amyl)) SUCRAID ORAL SOLUTION (sacrosidase) 4 PA; LD; QL (4 bottles per 30 days) VIOKACE ORAL TABLET (pancrelipase (lip-prot-amyl)) 3 QL (25 tablets per 1 day) 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* KEVEYIS ORAL TABLET (dichlorphenamide) 4 PA; LD; QL (4 tablet per 1 day) methazolamide oral tablet 1 or 1b* *DIURETIC COMBINATIONS*** - DRUGS FOR HIGH BLOOD PRESSURE ALDACTAZIDE ORAL TABLET 25-25 MG (spironolactone-hctz) 3 ALDACTAZIDE ORAL TABLET 50-50 MG (spironolactone-hctz) 3 QL (4 tablets per 1 day) amiloride-hydrochlorothiazide oral tablet 1 or 1b* MAXZIDE ORAL TABLET (triamterene-hctz) 3 MAXZIDE-25 ORAL TABLET (triamterene-hctz) 3 spironolactone-hctz oral tablet 1 or 1b* triamterene-hctz oral capsule 1 or 1a* triamterene-hctz oral tablet 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 the highest cost share and usually include 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 *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* *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 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* 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* hydrochlorothiazide oral tablet 12.5 mg, 25 mg 1 or 1a* 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)

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 the highest cost share and usually include 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 *ENDOCRINE AND METABOLIC AGENTS - MISC.* - HORMONES *ABORTIFACIENT - PROGESTERONE RECEPTOR ANTAGONISTS*** - DRUGS FOR WOMEN MIFEPREX ORAL TABLET (mifepristone) 3 mifepristone oral tablet 1 or 1b* *ADENOSINE DEAMINASE SCID TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS REVCOVI INTRAMUSCULAR SOLUTION (elapegademase-lvlr) 4 PA; LD *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-cholecalciferol) 2 QL (4 tablets per 28 days) ibandronate sodium intravenous solution 4 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 RECLAST INTRAVENOUS SOLUTION (zoledronic acid) 4 PA; SP; QL (100 mL per 375 days) 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) PARSABIV INTRAVENOUS SOLUTION (etelcalcetide hcl) 4 PA SENSIPAR ORAL TABLET 30 MG, 60 MG (cinacalcet hcl) 4 PA; QL (2 tablets per 1 day) SENSIPAR ORAL TABLET 90 MG (cinacalcet hcl) 4 PA; 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 the highest cost share and usually include 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 *CALCITONINS*** - DRUGS FOR MENOPAUSE AND BONE LOSS (salmon) injection solution 4 calcitonin (salmon) nasal solution 1 or 1b* QL (1 bottle per 30 days) MIACALCIN INJECTION SOLUTION (calcitonin (salmon)) 4 *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 *CORTISOL SYNTHESIS INHIBITORS*** - HORMONES ISTURISA ORAL TABLET 1 MG, 5 MG (osilodrostat phosphate) 4 PA; LD; QL (4 tablets per 1 day) ISTURISA ORAL TABLET 10 MG (osilodrostat phosphate) 4 PA; LD; QL (6 tablets per 1 day) *DOPAMINE RECEPTOR AGONISTS*** - DRUGS FOR WOMEN oral tablet 1 or 1b* QL (16 tablets per 28 days) *FABRY DISEASE - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (agalsidase beta) PA; LD; QL (14 capsules per 30 GALAFOLD ORAL CAPSULE (migalastat hcl) 4 days) *GAA DEFICIENCY TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS LUMIZYME INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (alglucosidase alfa) *GNRH/LHRH ANTAGONISTS*** - DRUGS FOR WOMEN CETROTIDE SUBCUTANEOUS KIT (cetrorelix acetate) 4 PA; SP GANIRELIX ACETATE SUBCUTANEOUS SOLUTION PREFILLED 4 PA; SP SYRINGE ORILISSA ORAL TABLET 150 MG (elagolix sodium) 3 PA; QL (1 tablet per 1 day) ORILISSA ORAL TABLET 200 MG (elagolix sodium) 3 PA; QL (2 tablets per 1 day) * RECEPTOR ANTAGONISTS*** - DRUGS FOR GROWTH SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; SP; QL (1 vial per 1 day) (pegvisomant)

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 the highest cost share and usually include 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 *GROWTH HORMONE RELEASING HORMONES (GHRH)*** - DRUGS FOR GROWTH EGRIFTA SV SUBCUTANEOUS SOLUTION RECONSTITUTED PA; LD; QL (1 package per 30 4 (tesamorelin acetate) days) *GROWTH HORMONES*** - DRUGS FOR GROWTH HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 5 4 PA; SP; QL (1 vial per 1 day) MG, 6 MG (somatropin) HUMATROPE INJECTION SOLUTION RECONSTITUTED 24 MG 4 PA; SP; QL (1 injection per 1 day) (somatropin) 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) SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG 4 PA; LD; QL (1 vial per 1 day) (somatropin (non-refrigerated)) SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 5 MG, 6 4 PA; LD; QL (1 solution per 1 day) MG (somatropin (non-refrigerated)) ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; SP; QL (1 injection per 1 day) (somatropin (non-refrigerated)) *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 NITYR ORAL TABLET (nitisinone) 4 PA; LD ORFADIN ORAL CAPSULE (nitisinone) 4 PA; LD ORFADIN ORAL SUSPENSION (nitisinone) 4 PA; LD *HOMOCYSTINURIA TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS CYSTADANE ORAL POWDER (betaine) 3 LD *HYPERAMMONEMIA TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS CARBAGLU ORAL TABLET (carglumic acid) 4 PA; 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 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 the highest cost share and usually include 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 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 *HYPOPHOSPHATASIA (HPP) AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS STRENSIQ SUBCUTANEOUS SOLUTION (asfotase alfa) 4 PA; LD *INSULIN-LIKE GROWTH FACTOR-1 RECEPTOR INHIBITORS(IGF-1R)*** - DRUGS FOR THYROID TEPEZZA INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; QL (8 fills per 168 days) (teprotumumab-trbw) *INSULIN-LIKE GROWTH FACTORS ()*** - HORMONES INCRELEX SUBCUTANEOUS SOLUTION () 4 PA; LD; SP * ANALOGUES*** - HORMONES MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD () *LHRH/GNRH AGONIST ANALOG COMBINATIONS*** - DRUGS FOR WOMEN LUPANETA PACK COMBINATION KIT 11.25 & 5 MG (leuprolide & 4 PA; SP; QL (1 kit per 84 days) norethindrone) LUPANETA PACK COMBINATION KIT 3.75 & 5 MG (leuprolide & 4 PA; SP; QL (1 kit per 28 days) norethindrone) *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) LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 11.25 MG, 4 PA; SP; QL (1 kit per 28 days) 15 MG (leuprolide acetate) LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 7.5 MG PA; SP; QL (1 syringe kit per 28 4 (leuprolide acetate) days) LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 11.25 MG 4 PA; SP; QL (1 kit per 12 weekss) (PED) (leuprolide acetate (3 month)) LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 30 MG 4 PA; SP; QL (1 kit per 84 days) (PED) (leuprolide acetate (3 month)) PA; LD; SP; QL (1 kit per 365 SUPPRELIN LA SUBCUTANEOUS KIT (histrelin acetate (cpp)) 4 days) SYNAREL NASAL SOLUTION (nafarelin acetate) 4 PA; SP; QL (5 bottle 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 the highest cost share and usually include 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 TRIPTODUR INTRAMUSCULAR SUSPENSION RECONSTITUTED 4 PA; LD; QL (1 vial per 168 days) ER (triptorelin pamoate) *LYSOSOMAL ACID LIPASE (LAL) DEFICIENCY - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS KANUMA INTRAVENOUS SOLUTION (sebelipase alfa) 3 PA; LD; SP *MOLYBDENUM COFACTOR DEFICIENCY (MOCD) - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS NULIBRY INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD (fosdenopterin hydrobromide) *MUCOPOLYSACCHARIDOSIS I (MPS I) - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS ALDURAZYME INTRAVENOUS SOLUTION (laronidase) 4 PA; LD; SP *MUCOPOLYSACCHARIDOSIS II (MPS II) - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS ELAPRASE INTRAVENOUS SOLUTION (idursulfase) 4 PA; LD; SP *MUCOPOLYSACCHARIDOSIS IV (MPS IV) - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS VIMIZIM INTRAVENOUS SOLUTION (elosulfase alfa) 4 PA; LD; SP *MUCOPOLYSACCHARIDOSIS VI (MPS VI) - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS NAGLAZYME INTRAVENOUS SOLUTION (galsulfase) 4 PA; LD; SP *MUCOPOLYSACCHARIDOSIS VII (MPS VII) - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS MEPSEVII INTRAVENOUS SOLUTION (vestronidase alfa-vjbk) 4 PA; LD *OVULATION STIMULANTS-GONADOTROPINS*** - DRUGS FOR WOMEN CHORIONIC GONADOTROPIN INTRAMUSCULAR SOLUTION 4 PA; SP RECONSTITUTED GONAL-F INJECTION SOLUTION RECONSTITUTED (follitropin alfa) 4 PA; SP GONAL-F RFF REDIJECT SUBCUTANEOUS SOLUTION (follitropin 4 PA; SP alfa) GONAL-F RFF SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; SP (follitropin alfa) MENOPUR SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; SP (menotropins) NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 4 PA; SP (chorionic gonadotropin) OVIDREL SUBCUTANEOUS INJECTABLE (choriogonadotropin alfa) 4 PA; SP PREGNYL INTRAMUSCULAR SOLUTION RECONSTITUTED 4 PA; SP (chorionic gonadotropin) *OVULATION STIMULANTS-SYNTHETIC*** - DRUGS FOR WOMEN clomiphene citrate oral tablet 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 the highest cost share and usually include 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 * 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) TERIPARATIDE (RECOMBINANT) SUBCUTANEOUS SOLUTION 4 PA; SP; QL (1 pen per 28 days) PEN-INJECTOR TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 4 PA; SP; QL (1 mL per 30 days) () *PHENYLKETONURIA TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS KUVAN ORAL PACKET (sapropterin dihydrochloride) 4 PA; LD; SP KUVAN ORAL TABLET (sapropterin dihydrochloride) 4 PA; LD; SP PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10 4 PA; LD; SP MG/0.5ML, 2.5 MG/0.5ML (pegvaliase-pqpz) PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 PA; LD; SP; QL (1 syringe per 1 4 MG/ML (pegvaliase-pqpz) day) 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) *SCLEROSTIN INHIBITORS*** - DRUGS FOR MENOPAUSE AND BONE LOSS EVENITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (2 syringes per 30 days) (romosozumab-aqqg) *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 JYNARQUE ORAL TABLET (tolvaptan) 4 PA; LD; QL (4 tablets per 1 day) JYNARQUE ORAL TABLET THERAPY PACK (tolvaptan) 4 PA; LD; QL (1 carton per 28 days) 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) 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 the highest cost share and usually include 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 *SOMATOSTATIC AGENTS*** - DRUGS FOR GROWTH MYCAPSSA ORAL CAPSULE DELAYED RELEASE (octreotide acetate) 4 PA; LD; QL (4 capsules per 1 day) octreotide acetate injection solution 4 PA; SP SANDOSTATIN INJECTION SOLUTION (octreotide acetate) 4 PA; SP SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 30 MG 4 PA; SP; QL (1 kit per 28 days) (octreotide acetate) SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 20 MG 4 PA; SP; QL (2 kits per 28 days) (octreotide acetate) SIGNIFOR LAR INTRAMUSCULAR SUSPENSION 4 PA; LD; QL (1 kit per 28 days) RECONSTITUTED ER (pasireotide pamoate) SIGNIFOR SUBCUTANEOUS SOLUTION (pasireotide diaspartate) 4 PA; LD; QL (2 mL per 1 day) SOMATULINE DEPOT SUBCUTANEOUS SOLUTION (lanreotide PA; LD; SP; QL (1 syringe/vial per 4 acetate) 28 days) *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 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 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* 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* NOCDURNA SUBLINGUAL TABLET SUBLINGUAL (desmopressin 4 PA; QL (1 tablet per 1 day) acetate) STIMATE NASAL SOLUTION (desmopressin acetate) 3 PA; QL (5 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 the highest cost share and usually include 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 VASOSTRICT INTRAVENOUS SOLUTION (vasopressin) 3 *X-LINKED HYPOPHOSPHATEMIA (XLH) TREATMENT - AGENTS*** - DRUGS FOR MENOPAUSE AND BONE LOSS CRYSVITA SUBCUTANEOUS SOLUTION (burosumab-twza) 4 PA; LD; SP *ESTROGENS* - HORMONES *ESTROGEN & ANDROGEN*** - DRUGS FOR WOMEN est estrogens-methyltest oral tablet 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* 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)

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 the highest cost share and usually include 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 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 RECEPTOR MODULATOR 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 3 (delafloxacin meglumine) BAXDELA ORAL TABLET (delafloxacin meglumine) 3 PA; QL (28 tablets per 30 days) 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)

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 the highest cost share and usually include 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 *FARNESOID X RECEPTOR (FXR) AGONISTS*** - DRUGS FOR THE STOMACH OCALIVA ORAL TABLET (obeticholic acid) 4 PA; LD; SP; QL (1 tablet 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) 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 -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)

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 the highest cost share and usually include 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 *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 3 ST; QL (4 capsule per 1 day) (mesalamine) 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 2 QL (16 capsule per 1 day) (mesalamine) PENTASA ORAL CAPSULE EXTENDED RELEASE 500 MG 2 QL (8 capsule per 1 day) (mesalamine) ROWASA RECTAL KIT (mesalamine-cleanser) 3 QL (1 kit per 28 days) SFROWASA RECTAL ENEMA (mesalamine) 3 QL (60 mL per 1 day) 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 4 PA; LD; SP; QL (1 vial per 56 days) (vedolizumab) *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*

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 the highest cost share and usually include 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 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 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) *TRYPTOPHAN HYDROXYLASE INHIBITORS*** - DRUGS FOR DIARRHEA XERMELO ORAL TABLET (telotristat etiprate) 4 PA; LD; QL (3 tablets per 1 day) *TUMOR NECROSIS FACTOR ALPHA BLOCKERS*** - DRUGS FOR INFLAMMATORY BOWEL DISEASE INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (infliximab-dyyb) REMICADE INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (infliximab) *GENERAL ANESTHETICS* - DRUGS FOR PAIN AND FEVER *ANESTHETICS - MISC.*** - DRUGS FOR SEDATION AMIDATE INTRAVENOUS SOLUTION (etomidate) 3 ANESTHESIA S/I-40A INTRAVENOUS KIT 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 the highest cost share and usually include 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 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* fresenius propoven intravenous emulsion 1 or 1b* KETALAR INJECTION SOLUTION (ketamine hcl) 3 ketamine hcl injection solution 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* *BARBITURATE 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 dutasteride oral capsule 1 or 1b* QL (1 capsule per 1 day) finasteride oral tablet 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)

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 the highest cost share and usually include 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 *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 3 citrate) UROCIT-K 15 ORAL TABLET EXTENDED RELEASE (potassium 3 citrate) UROCIT-K 5 ORAL TABLET EXTENDED RELEASE (potassium citrate) 3 *CYSTINOSIS AGENTS*** - DRUGS FOR THE URINARY SYSTEM CYSTAGON ORAL CAPSULE (cysteamine bitartrate) 4 LD; SP PROCYSBI ORAL CAPSULE DELAYED RELEASE (cysteamine 4 ST; LD bitartrate) PROCYSBI ORAL PACKET (cysteamine bitartrate) 4 ST; LD *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 *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)

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 the highest cost share and usually include 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 *SMALL INTERFERING RIBONUCLEIC ACID AGENTS (SIRNA)*** - DRUGS FOR THE URINARY SYSTEM OXLUMO SUBCUTANEOUS SOLUTION (lumasiran sodium) 4 PA; LD *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 colchicine-probenecid 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 3 (allopurinol 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) PA; LD; SP; QL (0.08 mL per 1 KRYSTEXXA INTRAVENOUS SOLUTION (pegloticase) 4 day) ZYLOPRIM ORAL TABLET (allopurinol) 3 *URICOSURICS*** - GOUT DRUGS probenecid oral tablet 1 or 1b* *HEMATOLOGICAL AGENTS - MISC.* - DRUGS FOR THE BLOOD *AMINOLEVULINATE SYNTHASE 1-DIRECTED SIRNA*** - DRUGS FOR THE BLOOD GIVLAARI SUBCUTANEOUS SOLUTION (givosiran sodium) 4 PA; LD *ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES*** - DRUGS FOR THE BLOOD HEMLIBRA SUBCUTANEOUS SOLUTION (emicizumab-kxwh) 4 PA; LD; SP *ANTIHEMOPHILIC PRODUCTS*** - DRUGS TO PREVENT BLEEDING ADVATE INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemophil factor (rahf-pfm))

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 the highest cost share and usually include 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 ADYNOVATE INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP AFSTYLA INTRAVENOUS KIT (antihemophil fact single chain) 4 PA; LD; SP ALPHANATE INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemophilic factor-vwf) ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor ix) ALPROLIX INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor ix (rfixfc)) BENEFIX INTRAVENOUS KIT (coagulation factor ix (recomb)) 4 PA; LD; SP COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor x (human)) CORIFACT INTRAVENOUS KIT (factor xiii concentrate human) 4 PA; LD; SP ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED (antihem 4 PA; LD; SP fact (bdd-rfviiifc)) ESPEROCT INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemoph fact rcmb gpeg-exei) FEIBA INTRAVENOUS SOLUTION RECONSTITUTED (antiinhibitor 4 PA; LD; SP coagulant cmplx) FIBRYGA INTRAVENOUS SOLUTION RECONSTITUTED (fibrinogen 4 PA; LD concentrate (human)) HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemophilic factor) HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemophilic factor-vwf) IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor ix (rix-fp)) IXINITY INTRAVENOUS SOLUTION RECONSTITUTED (coagulation 4 PA; LD; SP factor ix (recomb)) JIVI INTRAVENOUS SOLUTION RECONSTITUTED (ahf (bdd-rfviii 4 PA; LD; SP peg-aucl)) KCENTRA INTRAVENOUS KIT (prothrombin complex conc human) 3 KOATE INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemophilic factor) KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemophilic factor) KOGENATE FS INTRAVENOUS KIT (antihem factor recomb (rfviii)) 4 PA; LD; SP KOVALTRY INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemophil factor (rahf-pfm)) MONONINE INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor ix) NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihemophil fact bd truncated) NOVOSEVEN RT INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor viia recomb)

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 the highest cost share and usually include 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 NUWIQ INTRAVENOUS KIT (antihem fact (bdd-rfviii,sim)) 4 PA; LD; SP NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED (antihem fact 4 PA; LD; SP (bdd-rfviii,sim)) OBIZUR INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED (factor 4 PA; LD; SP ix complex) REBINYN INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor ix glycopeg) RECOMBINATE INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (antihem factor recomb (rfviii)) RIASTAP INTRAVENOUS SOLUTION RECONSTITUTED (fibrinogen 3 PA; LD concentrate (human)) RIXUBIS INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP SEVENFACT INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor viia-jncw) TRETTEN INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (coagulation factor xiii a-sub) VONVENDI INTRAVENOUS SOLUTION RECONSTITUTED (von 4 PA; LD; SP willebrand factor (recomb)) WILATE INTRAVENOUS KIT (antihemophilic factor-vwf) 4 PA; LD; SP XYNTHA INTRAVENOUS KIT (antihem fact (bdd-rfviii,mor)) 4 PA; LD; SP XYNTHA SOLOFUSE INTRAVENOUS KIT (antihem fact (bdd- 4 PA; LD; SP rfviii,mor)) *ANTI-VON WILLEBRAND FACTOR AGENTS*** - DRUGS FOR THE BLOOD CABLIVI INJECTION KIT (caplacizumab-yhdp) 4 PA; LD * B2 RECEPTOR ANTAGONISTS*** - DRUGS FOR THE BLOOD PA; LD; SP; QL (24 syringes per 30 FIRAZYR SUBCUTANEOUS SOLUTION ( acetate) 4 days) PA; SP; QL (24 syringes per 30 icatibant acetate subcutaneous solution 4 days) *C1 INHIBITORS*** - DRUGS FOR THE BLOOD PA; LD; SP; QL (24 vials per 30 BERINERT INTRAVENOUS KIT (c1 esterase inhibitor (human)) 4 days) CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED (c1 esterase PA; LD; SP; QL (20 vials per 30 4 inhibitor (human)) days) HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED 2000 PA; LD; SP; QL (24 vials per 28 4 UNIT (c1 esterase inhibitor (human)) days) HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED 3000 PA; LD; SP; QL (16 vials per 28 4 UNIT (c1 esterase inhibitor (human)) days) RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED (c1 PA; LD; SP; QL (16 vials per 30 4 esterase inhibitor (recomb)) 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 the highest cost share and usually include 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 *COMPLEMENT INHIBITORS*** - DRUGS FOR THE BLOOD EMPAVELI SUBCUTANEOUS SOLUTION (pegcetacoplan) 4 PA; LD; QL (9 vials per 28 days) SOLIRIS INTRAVENOUS SOLUTION (eculizumab) 4 PA; LD; SP ULTOMIRIS INTRAVENOUS SOLUTION 1100 MG/11ML PA; LD; SP; QL (3 vials per 56 4 (ravulizumab-cwvz) days) ULTOMIRIS INTRAVENOUS SOLUTION 300 MG/3ML (ravulizumab- PA; LD; SP; QL (12 vials per 56 4 cwvz) days) *DIRECT-ACTING P2Y12 INHIBITORS*** - DRUGS FOR THE BLOOD BRILINTA ORAL TABLET (ticagrelor) 2 QL (2 tablets per 1 day) KENGREAL INTRAVENOUS SOLUTION RECONSTITUTED 3 (cangrelor 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 3 (hemin) *HUMAN PROTEIN C*** - DRUGS FOR THE BLOOD CEPROTIN INTRAVENOUS SOLUTION RECONSTITUTED (protein c 4 LD; SP concentrate (human)) *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 KALLIKREIN INHIBITORS - MONOCLONAL ANTIBODIES*** - DRUGS FOR THE BLOOD PA; LD; SP; QL (1 syringe per 28 TAKHZYRO SUBCUTANEOUS SOLUTION (lanadelumab-flyo) 4 days) *PLASMA KALLIKREIN INHIBITORS*** - DRUGS FOR THE BLOOD PA; LD; SP; QL (48 vials per 30 KALBITOR SUBCUTANEOUS SOLUTION (ecallantide) 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 the highest cost share and usually include 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 ORLADEYO ORAL CAPSULE (berotralstat hcl) 4 PA; LD; QL (1 capsule per 1 day) *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) 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-OMEPRAZOLE 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)

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 the highest cost share and usually include 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 *QUINAZOLINE AGENTS*** - DRUGS FOR THE BLOOD AGRYLIN ORAL CAPSULE (anagrelide hcl) 3 anagrelide hcl oral capsule 1 or 1b* *SPLEEN TYROSINE KINASE (SYK) INHIBITORS*** - DRUGS FOR THE BLOOD TAVALISSE ORAL TABLET (fostamatinib disodium) 4 PA; LD; QL (2 tablets per 1 day) *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* *THROMBOLYTIC AGENT - MISC*** - DRUGS FOR THE BLOOD DEFITELIO INTRAVENOUS SOLUTION (defibrotide sodium) 4 *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 *HEMATOPOIETIC AGENTS* - DRUGS FOR NUTRITION *AGENTS FOR GAUCHER DISEASE*** - DRUGS FOR NUTRITION CERDELGA ORAL CAPSULE (eliglustat tartrate) 4 PA; LD; SP CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (imiglucerase) ELELYSO INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (taliglucerase alfa) miglustat oral capsule 4 PA; SP VPRIV INTRAVENOUS SOLUTION RECONSTITUTED (velaglucerase 4 PA; LD; SP alfa) *AMINO ACIDS*** - DRUGS FOR NUTRITION ENDARI ORAL PACKET (glutamine (sickle cell)) 4 PA; LD *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*

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 the highest cost share and usually include 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 METHYLCOBALAMIN INJECTION SOLUTION RECONSTITUTED 3 *CXCR4 RECEPTOR ANTAGONIST*** - DRUGS FOR NUTRITION MOZOBIL SUBCUTANEOUS SOLUTION (plerixafor) 4 PA; LD; SP *CYTOTOXIC AGENTS*** - DRUGS FOR NUTRITION DROXIA ORAL CAPSULE (hydroxyurea) 2 SIKLOS ORAL TABLET (hydroxyurea) 3 PA; SP *ERYTHROID MATURATION AGENTS*** - DRUGS FOR NUTRITION REBLOZYL SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (luspatercept-aamt) *ERYTHROPOIESIS-STIMULATING AGENTS (ESAS)*** - DRUGS FOR NUTRITION ARANESP (ALBUMIN FREE) INJECTION SOLUTION (darbepoetin 4 PA; SP; QL (4 vials per 28 days) alfa) 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) EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 4 PA; SP; QL (12 mL per 28 days) 3000 UNIT/ML, 4000 UNIT/ML (epoetin alfa) EPOGEN INJECTION SOLUTION 20000 UNIT/ML (epoetin alfa) 4 PA; SP; QL (24 vials per 28 days) MIRCERA INJECTION SOLUTION PREFILLED SYRINGE (methoxy PA; LD; QL (2 syringes per 28 4 peg-epoetin beta) days) PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 4 PA; SP; QL (12 mL per 28 days) 3000 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 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 the highest cost share and usually include 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 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 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 FULPHILA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (2 syringes per 28 days) (pegfilgrastim-jmdb) GRANIX SUBCUTANEOUS SOLUTION (tbo-filgrastim) 4 PA; SP GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE (tbo- 4 PA; SP filgrastim) 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 4 PA; SP (filgrastim) NIVESTYM INJECTION SOLUTION (filgrastim-aafi) 4 PA; SP NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE 4 PA; SP (filgrastim-aafi) NYVEPRIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (2 syringes per 28 days) (pegfilgrastim-apgf) UDENYCA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP; QL (2 syringes per 28 days) (pegfilgrastim-cbqv) ZARXIO INJECTION SOLUTION PREFILLED SYRINGE (filgrastim- 4 PA; SP sndz) ZIEXTENZO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; SP; QL (2 injections per 28 4 (pegfilgrastim-bmez) days) *GRANULOCYTE/MACROPHAGE COLONY-STIMULATING FACTOR(GM-CSF)*** - DRUGS FOR NUTRITION LEUKINE INJECTION SOLUTION RECONSTITUTED (sargramostim) 4 PA; SP *HEMOGLOBIN S (HBS) POLYMERIZATION INHIBITORS*** - DRUGS FOR NUTRITION PA; LD; SP; QL (3 tablets per 1 OXBRYTA ORAL TABLET (voxelotor) 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 the highest cost share and usually include 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 *IRON COMBINATIONS*** - DRUGS FOR NUTRITION foltrin oral capsule 1 or 1b* *IRON*** - DRUGS FOR NUTRITION ACCRUFER ORAL CAPSULE (ferric maltol) 3 FERAHEME INTRAVENOUS SOLUTION (ferumoxytol) 4 PA; SP; QL (2 vials per 6 days) FERRLECIT INTRAVENOUS SOLUTION (na ferric gluc cplx in sucrose) 4 PA; SP; QL (16 vials per 8 weekss) INFED INJECTION SOLUTION (iron dextran) 4 PA; SP INJECTAFER INTRAVENOUS SOLUTION (ferric carboxymaltose) 4 PA; SP; QL (2 vials per 14 days) MONOFERRIC INTRAVENOUS SOLUTION (ferric derisomaltose) 3 PA; SP; QL (1 vial per 1 day) na ferric gluc cplx in sucrose intravenous solution 4 SP TRIFERIC HEMODIALYSIS PACKET (ferric pyrophosphate citrate) 4 PA TRIFERIC HEMODIALYSIS SOLUTION (ferric pyrophosphate citrate) 4 PA VENOFER INTRAVENOUS SOLUTION (iron sucrose) 4 PA; SP; QL (15 mL per 71 days) *SELECTIN BLOCKERS*** - DRUGS FOR NUTRITION ADAKVEO INTRAVENOUS SOLUTION (crizanlizumab-tmca) 4 PA; SP *THROMBOPOIETIN (TPO) RECEPTOR AGONISTS*** - DRUGS FOR NUTRITION PA; LD; SP; QL (60 tablets per 30 DOPTELET ORAL TABLET (avatrombopag maleate) 4 days) MULPLETA ORAL TABLET (lusutrombopag) 4 PA; SP; QL (1 tablet per 1 day) NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED 125 MCG 4 PA (romiplostim) NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED 250 MCG, 4 PA; SP 500 MCG (romiplostim) PROMACTA ORAL PACKET 12.5 MG (eltrombopag olamine) 4 PA; LD; SP PA; LD; SP; QL (3 dose-packs per 1 PROMACTA ORAL PACKET 25 MG (eltrombopag olamine) 4 day) PROMACTA ORAL TABLET 12.5 MG, 25 MG (eltrombopag olamine) 4 PA; LD; SP PA; LD; SP; QL (3 tablets per 1 PROMACTA ORAL TABLET 50 MG (eltrombopag olamine) 4 day) PROMACTA ORAL TABLET 75 MG (eltrombopag olamine) 4 PA; LD; SP; QL (1 tablet per 1 day) *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

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 the highest cost share and usually include 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 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) 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 3 absorbable) 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 3 RECONSTITUTED (thrombin (recombinant)) SURGICEL FIBRILLAR EXTERNAL PAD (oxidized cellulose) 3 SURGICEL NU-KNIT EXTERNAL PAD (oxidized cellulose) 3 SYRINGE AVITENE EXTERNAL (absorbable collagen hemostat) 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 the highest cost share and usually include 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 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 3 (thrombin) THROMBOGEN EXTERNAL KIT (thrombin) 3 THROMBOGEN EXTERNAL SOLUTION RECONSTITUTED 3 (thrombin) 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* phenobarbital 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 BYFAVO INTRAVENOUS SOLUTION RECONSTITUTED 4 (remimazolam besylate) 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)

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 the highest cost share and usually include 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 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 3 SOLUTION MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS 3 SOLUTION PREFILLED SYRINGE MIDAZOLAM INTRAVENOUS SOLUTION PREFILLED SYRINGE 3 MIDAZOLAM-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 MIDAZOLAM-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE 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

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 the highest cost share and usually include 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 *SELECTIVE MELATONIN RECEPTOR AGONISTS*** - DRUGS FOR INSOMNIA HETLIOZ LQ ORAL SUSPENSION (tasimelteon) 4 PA; LD; QL (5 mL per 1 day) HETLIOZ ORAL CAPSULE (tasimelteon) 4 PA; LD; QL (1 capsule per 1 day) ramelteon oral tablet 1 or 1b* ST; QL (1 tablet per 1 day) *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- 3 QL (4000 grams per 30 days) nabcb-nacl-nasulf) MOVIPREP ORAL SOLUTION RECONSTITUTED (peg-kcl-nacl-nasulf- 3 QL (1 gram per 30 days) na asc-c) NULYTELY LEMON-LIME ORAL SOLUTION RECONSTITUTED 3 QL (4000 grams per 30 days) (peg 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 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 the highest cost share and usually include 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 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 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 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 magnesium 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

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 the highest cost share and usually include 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 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 milk of magnesia oral suspension 1 or 1b*; $0 phillips milk of magnesia oral suspension 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 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 the highest cost share and usually include 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 ra womens laxative oral tablet delayed release 1 or 1a*; $0 sb bisacodyl laxative ec oral tablet delayed release 1 or 1a*; $0 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 (articaine- 3 epinephrine) 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 3 hcl) *LOCAL ANESTHETICS - AMIDES*** - DRUGS FOR SEDATION BUPIVACAINE FISIOPHARMA INJECTION SOLUTION 3 bupivacaine hcl (pf) injection solution 1 or 1b* bupivacaine hcl injection solution 1 or 1b* BUPIVACAINE HCL-NACL EPIDURAL SOLUTION 3 BUPIVACAINE HCL-NACL EPIDURAL 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 the highest cost share and usually include 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 bupivacaine in dextrose intrathecal solution 1 or 1b* bupivacaine spinal intrathecal solution 1 or 1b* CARBOCAINE INJECTION SOLUTION (mepivacaine hcl) 3 CARBOCAINE PRESERVATIVE-FREE INJECTION SOLUTION 3 (mepivacaine hcl) lidocaine hcl (pf) injection solution 1 or 1b* lidocaine hcl injection solution 1 or 1b* LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 3 lidocaine hcl intradermal jet-injector 1 or 1b* LIDOCAINE IN DEXTROSE SOLUTION 3 MARCAINE INJECTION SOLUTION (bupivacaine hcl) 3 MARCAINE PRESERVATIVE FREE INJECTION SOLUTION 3 (bupivacaine 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 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 chloroprocaine 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)

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 the highest cost share and usually include 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 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) 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) *ERYTHROMYCINS*** - 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 the highest cost share and usually include 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 *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 2; $0 wide seal) WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM (diaphragm 2; $0 wide seal) WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM (diaphragm 2; $0 wide seal) WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM (diaphragm 2; $0 wide seal) WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM (diaphragm 2; $0 wide seal) WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM (diaphragm 2; $0 wide seal) WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM (diaphragm 2; $0 wide seal) WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM (diaphragm 2; $0 wide 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) ADVOCATE 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 the highest cost share and usually include 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 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) CLEVER CHOICE LANCETS 21G (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 the highest cost share and usually include 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 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) 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)

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 the highest cost share and usually include 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 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) FIFTY50 SAFETY SEAL LANCETS (lancets) 2 QL (204 lancets per 30 days) FIFTY50 UNILET LANCETS 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 the highest cost share and usually include 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 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 2 PA; QL (1 reader per 1 year) receiver) 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) GNP LANCETS THIN 26G 2 QL (204 lancets per 30 days) GOJJI STERILE 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 the highest cost share and usually include 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 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 3 PA; QL (1 unit per 365 days) gluc 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) 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) 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 the highest cost share and usually include 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 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) 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 3 PA transmit) 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 the highest cost share and usually include 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 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) 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) 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 the highest cost share and usually include 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 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) 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)

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 the highest cost share and usually include 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 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) 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)

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 the highest cost share and usually include 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 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) 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)

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 the highest cost share and usually include 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 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) 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)

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 the highest cost share and usually include 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 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 2 ST; QL (200 syringes per 30 days) 1/2" 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 2 ST; QL (200 syringes per 30 days) ML (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 2 ST; QL (200 syringes per 30 days) (insulin syringe-needle u-100) BD INSULIN SYRINGE ULTRAFINE 30G X 1/2" 0.3 ML (insulin 2 QL (200 syringes per 30 days) syringe-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) 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)

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 the highest cost share and usually include 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 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" 2 ST; QL (200 syringes per 30 days) 0.5 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 3 ST; QL (200 syringes per 30 days) X 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) 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) 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 the highest cost share and usually include 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 EASY TOUCH SHEATHLOCK SYRINGE (insulin syringe-needle u-100) 3 ST; QL (200 syringes per 30 days) 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 3 ST; QL (200 syringes per 30 days) 15/64" 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) 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) 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 the highest cost share and usually include 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 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- 3 ST; QL (200 syringes per 30 days) 100) 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) 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) 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 the highest cost share and usually include 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 PRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 3 ST; QL (200 syringes per 30 days) ML, 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) 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)

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 the highest cost share and usually include 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 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) 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)

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 the highest cost share and usually include 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 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 3 ST; QL (200 syringes per 30 days) syringe-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 3 PA; QL (1 syringe per 30 days) PREFILLED 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 ergotamine-caffeine oral tablet 1 or 1b* migergot rectal suppository 1 or 1b* *MIGRAINE PRODUCTS*** - DRUGS FOR MIGRAINE HEADACHES dihydroergotamine mesylate injection solution 1 or 1b* PA *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)

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 the highest cost share and usually include 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 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 3 sodium bicarbonate intravenous solution 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 %, 5- 1 or 1b* 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- 3 0.225 %, 5-0.3 % 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)

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 the highest cost share and usually include 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 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 3 7.4)) PLASMA-LYTE 148 INTRAVENOUS SOLUTION (electrolyte-148) 3 PLASMA-LYTE A INTRAVENOUS SOLUTION (electrolyte-a) 3 POTASSIUM CHLORIDE IN NACL INTRAVENOUS SOLUTION 20- 3 0.45 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 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*

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 the highest cost share and usually include 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 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 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 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, 10 MEQ/50ML, 20 MEQ/100ML, 20 MEQ/50ML, 40 3 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* 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 1 or 1b* *TRACE MINERAL COMBINATIONS*** - DRUGS FOR NUTRITION THE LIQUILIFT TRACE INTRAVENOUS KIT (trace minerals cr-cu-mn- 3 se-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 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 the highest cost share and usually include 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 *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 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 (thalidomide) 2; OC day) PA; LD; SP; QL (2 capsules per 1 THALOMID ORAL CAPSULE 150 MG, 200 MG (thalidomide) 2; OC day) *B-LYMPHOCYTE STIMULATOR (BLYS)-SPECIFIC INHIBITORS*** - VITAMINS AND MINERALS BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (belimumab) BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; LD; SP; QL (4 autoinjectors per 4 (belimumab) 28 days) BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; SP; QL (4 pens per 28 4 (belimumab) days) *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- 3 ca (crrt)) PRISMASOL BGK 2/0 INTRAVENOUS SOLUTION (bicarb-dextrose-k 3 (crrt)) PRISMASOL BGK 2/3.5 INTRAVENOUS SOLUTION (bicarb-dextrose-k- 3 ca (crrt)) PRISMASOL BGK 4/0/1.2 INTRAVENOUS SOLUTION (bicarb-dextose- 3 k-mg (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 the highest cost share and usually include 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 PRISMASOL BGK 4/2.5 INTRAVENOUS SOLUTION (bicarb-dextrose-k- 3 ca (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* LUPKYNIS ORAL CAPSULE (voclosporin) 4 PA; LD; QL (6 capsules per 1 day) 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 XIAFLEX INJECTION SOLUTION RECONSTITUTED (collagenase 4 PA; LD clostrid histolyt) *FARNESYLTRANSFERASE INHIBITORS*** - VITAMINS AND MINERALS ZOKINVY ORAL CAPSULE (lonafarnib) 4 PA; LD; QL (4 capsules per 1 day) * BULKING AGENT - COMBINATIONS*** - VITAMINS AND MINERALS SOLESTA INJECTION GEL (dextranomer-) 4 LD; SP *IMMUNE GLOBULIN IMMUNOSUPPRESSANTS*** - VITAMINS AND MINERALS ATGAM INTRAVENOUS INJECTABLE (lymphocyte,anti-thymo imm 3 SP glob) 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) 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 the highest cost share and usually include 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 CELLCEPT ORAL CAPSULE (mycophenolate mofetil) 3 CELLCEPT ORAL SUSPENSION RECONSTITUTED (mycophenolate 3 mofetil) 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) *INTERLEUKIN-6 (IL-6) ANTAGONISTS*** - VITAMINS AND MINERALS SYLVANT INTRAVENOUS SOLUTION RECONSTITUTED (siltuximab) 4 PA; LD; SP *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 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

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 the highest cost share and usually include 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 *MISCELLANEOUS THERAPEUTIC CLASSES*** - VITAMINS AND MINERALS NEXAVIR INJECTION SOLUTION (liver derivative complex) 3 *MONOCLONAL ANTIBODIES*** - VITAMINS AND MINERALS ENSPRYNG SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; SP; QL (1 syringe per 28 4 (satralizumab-mwge) days) GAMIFANT INTRAVENOUS SOLUTION (emapalumab-lzsg) 3 PA; LD; SP SIMULECT INTRAVENOUS SOLUTION RECONSTITUTED 3 (basiliximab) UPLIZNA INTRAVENOUS SOLUTION (inebilizumab-cdon) 4 PA; LD; QL (30 mL per 180 days) *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 3 SOLUTION (peritoneal dialysis solutions) DIANEAL LOW CALCIUM/2.5% DEX INTRAPERITONEAL 3 SOLUTION (peritoneal dialysis solutions) DIANEAL LOW CALCIUM/4.25% DEX INTRAPERITONEAL 3 SOLUTION (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 3 SOLUTION (peritoneal dialysis solutions) ULTRABAG/DIANEAL PD-2/2.5% DEX INTRAPERITONEAL 3 SOLUTION (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)

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 the highest cost share and usually include 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 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* 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 3 RECONSTITUTED 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

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 the highest cost share and usually include 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 *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* 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 3 RECONSTITUTED (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 3 fluoride) 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*

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 the highest cost share and usually include 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 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 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

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 the highest cost share and usually include 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 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 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

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 the highest cost share and usually include 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 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 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

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 the highest cost share and usually include 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 *MULTIPLE VITAMINS & FLUORIDE-FOLIC ACID*** - DRUGS FOR NUTRITION MULTIVITAMIN/FLUORIDE ORAL TABLET CHEWABLE 3 *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 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 2; $0 vitamins-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

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 the highest cost share and usually include 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 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 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

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 the highest cost share and usually include 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 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 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- 3 fl-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 1 or 1b*; $0 POLY-VI-FLOR ORAL SUSPENSION (pediatric multivitamins-fl) 3 POLY-VI-FLOR ORAL TABLET CHEWABLE (pediatric multivitamins- 3 fl) 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

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 the highest cost share and usually include 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 *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) *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)

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 the highest cost share and usually include 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 MYNATAL-Z ORAL TABLET 2 QL (1 tablet per 1 day) NATACHEW ORAL TABLET CHEWABLE (prenatal vit-fe fum-fe bisg- 3 ST; QL (1 tablet per 1 day) fa) 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) 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- 3 ST; QL (1 capsule per 1 day) omega) OB COMPLETE PREMIER ORAL TABLET (prenatal-fe cbn-fe asp gly- 3 ST; QL (1 tablet per 1 day) fa) 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 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)

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 the highest cost share and usually include 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 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) 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) 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 the highest cost share and usually include 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 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) VIRT-PN PLUS ORAL CAPSULE 3 ST; QL (1 capsule per 1 day) VITAFOL GUMMIES ORAL TABLET CHEWABLE (prenatal vit-fe 3 QL (1 tablet per 1 day) phos-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 GINGER ORAL TABLET (prenatal vit-fe fumarate- 3 ST; QL (1 tablet per 1 day) fa) 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- 3 fa-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+DOCUSATE 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 the highest cost share and usually include 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 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) 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 3 ST; QL (1 capsule per 1 day) a) 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 3 ST; QL (1 capsule per 1 day) a-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- 3 ST; QL (1 tablet per 1 day) b2-b6-b12-d3-fa)

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 the highest cost share and usually include 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 *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 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 baclofen 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) chlorzoxazone 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)

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 the highest cost share and usually include 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 fexmid oral tablet 1 or 1b* ST; QL (3 tablets per 1 day) GABLOFEN INTRATHECAL SOLUTION (baclofen) 4 GABLOFEN INTRATHECAL SOLUTION PREFILLED SYRINGE 4 (baclofen) 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) 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) orphenadrine 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 3 (dantrolene 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- 3 swall spr) orphenadrine-asa-caffeine 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 the highest cost share and usually include 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 orphengesic forte oral tablet 1 or 1b* ST *VISCOSUPPLEMENTS*** - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES DUROLANE INTRA-ARTICULAR PREFILLED SYRINGE (sodium 4 PA hyaluronate (viscosup)) EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA (sodium hyaluronate (viscosup)) GEL-ONE INTRA-ARTICULAR PREFILLED SYRINGE (cross-linked 4 PA; SP hyaluronate) GELSYN-3 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA; SP (sodium hyaluronate (viscosup)) HYALGAN INTRA-ARTICULAR SOLUTION (sodium hyaluronate 4 PA (viscosup)) HYALGAN INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA (sodium hyaluronate (viscosup)) HYMOVIS INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA; LD; SP (hyaluronan) MONOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA (hyaluronan) ORTHOVISC INTRA-ARTICULAR SOLUTION PREFILLED 4 PA SYRINGE (hyaluronan) SUPARTZ FX INTRA-ARTICULAR SOLUTION PREFILLED 4 PA SYRINGE (sodium hyaluronate (viscosup)) SYNVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA (hylan) SYNVISC ONE INTRA-ARTICULAR SOLUTION PREFILLED 4 PA SYRINGE (hylan) TRILURON INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA; SP (sodium hyaluronate (viscosup)) VISCO-3 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 4 PA; SP (sodium hyaluronate (viscosup)) *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 (cocaine 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)

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 the highest cost share and usually include 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 *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 EXSERVAN ORAL FILM (riluzole) 4 LD; QL (4 films per 1 day) RILUTEK ORAL TABLET (riluzole) 4 SP; QL (4 tablets per 1 day) riluzole oral tablet 4 SP; QL (4 tablets per 1 day) TIGLUTIK ORAL SUSPENSION (riluzole) 4 LD *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 *MUSCULAR DYSTROPHY AGENTS*** - DRUGS FOR NERVES AND MUSCLES AMONDYS 45 INTRAVENOUS SOLUTION 4 PA; LD EXONDYS 51 INTRAVENOUS SOLUTION (eteplirsen) 4 PA; LD VILTEPSO INTRAVENOUS SOLUTION (viltolarsen) 4 PA; LD VYONDYS 53 INTRAVENOUS SOLUTION (golodirsen) 4 PA; LD *NEUROMUSCULAR BLOCKING AGENT - NEUROTOXINS*** - DRUGS FOR NERVES AND MUSCLES BOTOX INJECTION SOLUTION RECONSTITUTED 4 PA; SP (onabotulinumtoxina) DYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED 4 PA; SP (abobotulinumtoxina) MYOBLOC INTRAMUSCULAR SOLUTION (rimabotulinumtoxinb) 4 PA; SP XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED 4 PA; LD; SP (incobotulinumtoxina)

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 the highest cost share and usually include 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 *NONDEPOLARIZING MUSCLE RELAXANTS*** - DRUGS FOR NERVES AND MUSCLES atracurium besylate intravenous solution 1 or 1b* cisatracurium besylate (pf) intravenous solution 1 or 1b* 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 VECURONIUM BROMIDE INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE vecuronium bromide intravenous solution reconstituted 1 or 1b* *SPINAL MUSCULAR ATROPHY-SMN2 SPLICING MODIFIERS*** - DRUGS FOR NERVES AND MUSCLES EVRYSDI ORAL SOLUTION RECONSTITUTED (risdiplam) 4 PA; LD; QL (5 mg per 1 day) *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 3 ac elect-calc in d5w) CLINIMIX E/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION (amino 3 ac elect-calc in d10w) CLINIMIX E/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION (amino 3 ac 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 3 acid infusion in d10w) CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION (amino 3 acid 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

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 the highest cost share and usually include 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 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* 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 plant based) 3 PA; LD; SP; QL (2 bottles per 30 DOJOLVI ORAL LIQUID (triheptanoin) 4 days) 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

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 the highest cost share and usually include 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 *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 ADRENERGIC AGONIST & CARBONIC ANHYDRASE INHIB COMB*** - DRUGS FOR GLAUCOMA SIMBRINZA OPHTHALMIC SUSPENSION (brinzolamide-brimonidine) 2 QL (8 mL per 30 days) *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 3 QL (20 mL per 30 days) maleate) 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)

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 the highest cost share and usually include 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 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 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 (lifitegrast) 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 3 SYRINGE *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*

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 the highest cost share and usually include 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 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) 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 3 (povidone-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)

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 the highest cost share and usually include 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 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 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 NERVE GROWTH FACTORS*** - DRUGS FOR THE EYE OXERVATE OPHTHALMIC SOLUTION (cenegermin-bkbj) 4 PA; LD; QL (2 vials 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 the highest cost share and usually include 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 *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) 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 PHOTODYNAMIC THERAPY AGENTS*** - DRUGS FOR THE EYE VISUDYNE INTRAVENOUS SOLUTION RECONSTITUTED 4 LD; SP (verteporfin) *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- 3 QL (15 mL per 30 days) prednisolone) BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT (sulfacetamide- 3 prednisolone) DEXAMETHASONE-MOXIFLOXACIN INTRAOCULAR 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 the highest cost share and usually include 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 DEXAMETH-MOXIFLOX-KETOROLAC INTRAOCULAR 3 SOLUTION MAXITROL OPHTHALMIC OINTMENT (neomycin-polymyxin- 3 dexameth) MAXITROL OPHTHALMIC SUSPENSION (neomycin-polymyxin- 3 dexameth) neomycin-polymyxin-dexameth ophthalmic ointment 1 or 1a* neomycin-polymyxin-dexameth ophthalmic suspension 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 3 acet) 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) 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 (fluorometholone 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 ILUVIEN INTRAVITREAL IMPLANT (fluocinolone acetonide) 4 PA; LD; SP 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)

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 the highest cost share and usually include 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 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) *OPHTHALMIC SURGICAL AIDS - COMBINATIONS*** - DRUGS FOR THE EYE DISCOVISC INTRAOCULAR SOLUTION (na chondroit sulf-na hyaluron) 3 DUOVISC INTRAOCULAR KIT (na hyalur & na chond-na hyalur) 3 OMIDRIA INTRAOCULAR SOLUTION (phenylephrine-ketorolac) 3 VISCOAT INTRAOCULAR SOLUTION (na chondroit sulf-na hyaluron) 3 *OPHTHALMIC SURGICAL AIDS*** - DRUGS FOR THE EYE AMVISC INTRAOCULAR SOLUTION (sodium hyaluronate) 4 AMVISC PLUS INTRAOCULAR SOLUTION (sodium hyaluronate) 4 CELLUGEL INTRAOCULAR SOLUTION (hypromellose) 3 HEALON DUET PRO INTRAOCULAR SOLUTION PREFILLED 4 SYRINGE (sodium hyaluronate) HEALON GV INTRAOCULAR SOLUTION (sodium hyaluronate) 4 HEALON GV PRO INTRAOCULAR SOLUTION (sodium hyaluronate) 4 HEALON INTRAOCULAR SOLUTION (sodium hyaluronate) 4 HEALON PRO INTRAOCULAR SOLUTION (sodium hyaluronate) 4 HEALON5 INTRAOCULAR SOLUTION (sodium hyaluronate) 4 HEALON5 PRO INTRAOCULAR SOLUTION (sodium hyaluronate) 4 HYALURONIDASE (INTRAOCULAR) INTRAOCULAR SOLUTION 3 MEMBRANEBLUE OPHTHALMIC SOLUTION (trypan blue) 3 ocucoat viscoadherent intraocular solution 1 or 1b* PROVISC INTRAOCULAR SOLUTION (sodium hyaluronate) 4 TISSUEBLUE INTRAOCULAR SOLUTION PREFILLED SYRINGE 3 (brilliant blue g) VISIONBLUE OPHTHALMIC SOLUTION (trypan blue) 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 the highest cost share and usually include 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 *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 CYSTADROPS OPHTHALMIC SOLUTION (cysteamine hcl) 4 PA; LD; QL (4 bottles per 28 days) 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* PA; LD; SP; QL (2 applicators per 1 DURYSTA INTRAOCULAR IMPLANT (bimatoprost) 4 lifetime) 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 BEOVU INTRAVITREAL SOLUTION (brolucizumab-dbll) 4 PA; LD; SP BEVACIZUMAB INTRAOCULAR SOLUTION PREFILLED SYRINGE 3 PA EYLEA INTRAVITREAL SOLUTION (aflibercept) 4 PA; LD; SP EYLEA INTRAVITREAL SOLUTION PREFILLED SYRINGE 4 PA; LD (aflibercept) LUCENTIS INTRAVITREAL SOLUTION (ranibizumab) 4 PA; LD; SP LUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINGE 4 PA; LD; SP (ranibizumab) *OTIC AGENTS* - DRUGS FOR THE EAR *OTIC AGENTS - MISCELLANEOUS*** - WAX REMOVAL acetic acid otic solution 1 or 1b* *OTIC ANALGESIC 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) 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) 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 the highest cost share and usually include 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 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 3 PITOCIN INJECTION SOLUTION (oxytocin) 3 *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)

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 the highest cost share and usually include 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 *ANTIVIRAL MONOCLONAL ANTIBODIES*** - BIOLOGICAL AGENTS SOTROVIMAB INTRAVENOUS SOLUTION 4 SYNAGIS INTRAMUSCULAR SOLUTION (palivizumab) 4 PA; LD; SP *BACTERIAL MONOCLONAL ANTIBODIES*** - BIOLOGICAL AGENTS ZINPLAVA INTRAVENOUS SOLUTION (bezlotoxumab) 3 PA *IMMUNE SERUMS*** - BIOLOGICAL AGENTS ASCENIV INTRAVENOUS SOLUTION (immune globulin (human)-slra) 4 PA; LD; SP BIVIGAM INTRAVENOUS SOLUTION (immune globulin (human)) 4 PA; LD; SP CUTAQUIG SUBCUTANEOUS SOLUTION (immune globulin (human)- 4 PA; LD; SP hipp) CUVITRU SUBCUTANEOUS SOLUTION (immune globulin (human)) 4 PA; LD; SP CYTOGAM INTRAVENOUS INJECTABLE (cytomegalovirus immune 4 SP glob) FLEBOGAMMA DIF INTRAVENOUS SOLUTION (immune globulin 4 PA; LD; SP (human)) GAMASTAN INTRAMUSCULAR INJECTABLE (immune globulin 4 PA; LD; SP (human)) GAMMAGARD INJECTION SOLUTION (immune globulin (human)) 4 PA; LD; SP GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION 4 PA; LD; SP RECONSTITUTED (immune globulin (human)) GAMMAKED INJECTION SOLUTION (immune globulin (human)) 4 PA; LD; SP GAMMAPLEX INTRAVENOUS SOLUTION (immune globulin (human)) 4 PA; LD; SP GAMUNEX-C INJECTION SOLUTION (immune globulin (human)) 4 PA; LD; SP HEPAGAM B INJECTION SOLUTION (hepatitis b immune globulin) 4 SP HIZENTRA SUBCUTANEOUS SOLUTION (immune globulin (human)) 4 PA; LD; SP HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; LD; SP (immune globulin (human)) HYPERHEP B INTRAMUSCULAR SOLUTION (hepatitis b immune 4 LD; SP globulin) HYPERRAB INJECTION SOLUTION (rabies immune globulin) 4 SP HYPERRHO S/D INTRAMUSCULAR SOLUTION PREFILLED LD; SP; QL (2 syringes per 365 4 SYRINGE (rho d immune globulin) days) HYPERTET S/D INTRAMUSCULAR INJECTABLE (tetanus immune 3 globulin) IMOGAM RABIES-HT INJECTION SOLUTION (rabies immune 4 SP globulin) KEDRAB INJECTION SOLUTION 4 SP MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR 4 SP; QL (2 syringes per 365 days) SOLUTION PREFILLED SYRINGE (rho d immune globulin) NABI-HB INTRAMUSCULAR SOLUTION (hepatitis b immune globulin) 4 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 the highest cost share and usually include 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 OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 20 GM/200ML, 25 4 PA; LD; SP GM/500ML, 5 GM/100ML, 5 GM/50ML (immune globulin (human)) OCTAGAM INTRAVENOUS SOLUTION 30 GM/300ML (immune 4 PA; LD globulin (human)) PANZYGA INTRAVENOUS SOLUTION (immune globulin (human)-ifas) 4 PA; LD; SP PRIVIGEN INTRAVENOUS SOLUTION (immune globulin (human)) 4 PA; LD; SP RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION 4 SP; QL (2 syringes per 365 days) PREFILLED SYRINGE (rho d immune globulin) RHOPHYLAC INJECTION SOLUTION PREFILLED SYRINGE (rho d 4 LD; SP; QL (2 fills per 365 days) immune globulin) VARIZIG INTRAMUSCULAR SOLUTION (varicella-zoster immune glob) 3 WINRHO SDF INJECTION SOLUTION (rho d immune globulin) 4 SP; QL (2 fills per 365 days) XEMBIFY SUBCUTANEOUS SOLUTION (immune globulin (human)- 4 PA; LD; SP klhw) *MONOCLONAL ANTIBODY - COMBINATIONS*** - BIOLOGICAL AGENTS REGEN-COV INTRAVENOUS SOLUTION (casirivimab-imdevimab) 4 *PASSIVE IMMUNIZING AGENTS - COMBINATIONS*** - BIOLOGICAL AGENTS HYQVIA SUBCUTANEOUS KIT (immune globulin-hyaluronidase) 4 PA; LD; SP *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 3 benzathine) PENICILLIN G POT IN DEXTROSE INTRAVENOUS SOLUTION 3 penicillin g potassium injection solution reconstituted 1 or 1b* PENICILLIN G PROCAINE INTRAMUSCULAR SUSPENSION 3 penicillin g sodium injection solution reconstituted 1 or 1b* penicillin v potassium oral solution reconstituted 1 or 1b* penicillin v potassium oral tablet 1 or 1b* pfizerpen 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 the highest cost share and usually include 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 *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 3 MG/5ML (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 3 benzathine & 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 dicloxacillin sodium oral capsule 1 or 1b* NAFCILLIN 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) 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)

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 the highest cost share and usually include 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 megestrol acetate oral suspension 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 (memantine hcl-donepezil hcl) NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 QL (1 capsule per 1 day) (memantine hcl-donepezil hcl) *ANTISENSE OLIGONUCLEOTIDE (ASO) INHIBITOR AGENTS*** - DRUGS FOR THE NERVOUS SYSTEM TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PA; LD; QL (4 syringes per 28 4 (inotersen sodium) days) *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 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* 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 3 ST; QL (1 gram per 1 day) (rivastigmine)

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 the highest cost share and usually include 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 galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 1 or 1b* QL (1 capsule per 1 day) mg galantamine hydrobromide er oral capsule extended release 24 hour 8 mg 1 or 1b* 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* 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 3 MG (galantamine hydrobromide) rivastigmine tartrate oral capsule 1.5 mg, 3 mg 1 or 1b* 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; 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) *MULTIPLE SCLEROSIS AGENTS - ANTIMETABOLITES*** - DRUGS FOR MULTIPLE SCLEROSIS MAVENCLAD (10 TABS) ORAL TABLET THERAPY PACK PA; LD; SP; QL (2 packs per 46 4 (cladribine) 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 the highest cost share and usually include 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 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 4 PA; SP; QL (4 kits per 28 days) KIT (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 4 PA; LD; SP; QL (1 ML per 28 days) PREFILLED SYRINGE (peginterferon beta-1a) PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR 4 PA; LD; SP; QL (1 ML per 28 days) (peginterferon 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 4 PA; SP (interferon beta-1a) REBIF TITRATION PACK SUBCUTANEOUS SOLUTION 4 PA; SP PREFILLED SYRINGE (interferon beta-1a) *MULTIPLE SCLEROSIS AGENTS - MONOCLONAL ANTIBODIES*** - DRUGS FOR MULTIPLE SCLEROSIS KESIMPTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PA; LD; SP; QL (1 syringe per 28 4 (ofatumumab) days) PA; LD; SP; QL (3 vials per 365 LEMTRADA INTRAVENOUS SOLUTION (alemtuzumab) 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 the highest cost share and usually include 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 TYSABRI INTRAVENOUS CONCENTRATE (natalizumab) 4 PA; LD; SP; QL (1 vial per 28 days) *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 - POTASSIUM CHANNEL BLOCKERS*** - DRUGS FOR MULTIPLE SCLEROSIS AMPYRA ORAL TABLET EXTENDED RELEASE 12 HOUR PA; LD; SP; QL (2 tablets per 1 4 (dalfampridine) day) 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* 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* 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 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 3 PA MG, 82.5 MG (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 the highest cost share and usually include 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 Coverage Requirements and Prescription Drug Name Drug Tier Limits LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR 330 3 PA; QL (2 tablets per 1 day) MG (pregabalin) pregabalin er oral tablet extended release 24 hour 165 mg, 82.5 mg 1 or 1b* PA 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* 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 ergoloid mesylates oral tablet 1 or 1b* QL (3 tablets per 1 day) pimozide 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 (flibanserin) 3 PA; QL (1 tablet per 1 day) *SMALL INTERFERING RIBONUCLEIC ACID (SIRNA) AGENTS*** - DRUGS FOR THE NERVOUS SYSTEM ONPATTRO INTRAVENOUS SOLUTION (patisiran sodium) 4 PA; LD; QL (0.72 mL 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) CHANTIX STARTING MONTH PAK ORAL TABLET (varenicline PA; QL (1 starting month pack per 3; $0 tartrate) 365 days) cvs nicotine 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

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 the highest cost share and usually include 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 224 Coverage Requirements and Prescription Drug Name Drug Tier Limits 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 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 2; $0 polacrilex) 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 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 the highest cost share and usually include 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 225 Coverage Requirements and Prescription Drug Name Drug Tier Limits 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 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 (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) PONVORY ORAL TABLET (ponesimod) 4 PA; LD; SP; QL (1 tablet per 1 day) PONVORY STARTER PACK ORAL TABLET THERAPY PACK PA; LD; SP; QL (1 pack per 1 one 4 (ponesimod) time fill) ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE THERAPY PACK 4 PA; LD; SP; QL (1 pack per 1 fill) (ozanimod hcl) PA; LD; SP; QL (1 capsule per 1 ZEPOSIA ORAL CAPSULE (ozanimod hcl) 4 day) ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY PACK 4 PA; LD; SP; QL (1 pack per 1 fill) (ozanimod hcl) *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* SYMBYAX ORAL CAPSULE (olanzapine-fluoxetine hcl) 3 *VASOMOTOR SYMPTOM AGENTS - SSRIS*** - DRUGS FOR THE NERVOUS SYSTEM paroxetine mesylate oral capsule 1 or 1b* *RESPIRATORY AGENTS - MISC.* - DRUGS FOR THE LUNGS *ALPHA-PROTEINASE INHIBITOR (HUMAN)*** - DRUGS FOR ASTHMA/COPD ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD; SP (alpha1-proteinase inhibitor) GLASSIA INTRAVENOUS SOLUTION (alpha1-proteinase inhibitor) 4 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 the highest cost share and usually include 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 226 Coverage Requirements and Prescription Drug Name Drug Tier Limits PROLASTIN-C INTRAVENOUS SOLUTION (alpha1-proteinase 4 PA; LD inhibitor) PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 4 PA; LD (alpha1-proteinase inhibitor) ZEMAIRA INTRAVENOUS SOLUTION RECONSTITUTED (alpha1- 4 PA; LD; SP proteinase inhibitor) *CFTR POTENTIATORS*** - DRUGS FOR CYSTIC FIBROSIS KALYDECO ORAL PACKET 25 MG (ivacaftor) 4 PA; LD; QL (2 packets per 1 day) KALYDECO ORAL PACKET 50 MG, 75 MG (ivacaftor) 4 PA; LD; QL (2 packet per 1 day) KALYDECO ORAL TABLET (ivacaftor) 4 PA; LD; QL (2 tablets per 1 day) *CYSTIC FIBROSIS AGENT - COMBINATIONS*** - DRUGS FOR CYSTIC FIBROSIS ORKAMBI ORAL PACKET (lumacaftor-ivacaftor) 4 PA; LD; QL (2 packets per 1 day) ORKAMBI ORAL TABLET (lumacaftor-ivacaftor) 4 PA; LD; QL (4 tablet per 1 day) SYMDEKO ORAL TABLET THERAPY PACK (tezacaftor-ivacaftor) 4 PA; LD; QL (1 carton per 28 days) TRIKAFTA ORAL TABLET THERAPY PACK (elexacaftor-tezacaftor- 4 PA; LD; QL (1 carton per 28 days) ivacaft) *CYSTIC FIBROSIS AGENTS - MISCELLANEOUS*** - DRUGS FOR CYSTIC FIBROSIS PA; LD; SP; QL (560 tablets per 28 BRONCHITOL INHALATION CAPSULE (mannitol (cystic fibrosis)) 4 days) BRONCHITOL TOLERANCE TEST INHALATION CAPSULE 4 PA; LD; SP; QL (1 test per 1 fill) (mannitol (cystic fibrosis)) *HYDROLYTIC ENZYMES*** - DRUGS FOR THE LUNGS PULMOZYME INHALATION SOLUTION (dornase alfa) 4 LD; SP; QL (150 mL per 30 days) *PLEURAL SCLEROSING AGENTS*** - DRUGS FOR THE LUNGS SCLEROSOL INTRAPLEURAL INTRAPLEURAL AEROSOL 3 POWDER (talc) STERILE TALC POWDER INTRAPLEURAL SUSPENSION 3 RECONSTITUTED (talc) STERITALC INTRAPLEURAL POWDER (talc) 3 *PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS*** - DRUGS FOR THE LUNGS PA; LD; SP; QL (2 capsules per 1 OFEV ORAL CAPSULE (nintedanib esylate) 4 day) *PULMONARY FIBROSIS AGENTS*** - DRUGS FOR THE LUNGS PA; LD; SP; QL (9 capsule per 1 ESBRIET ORAL CAPSULE (pirfenidone) 4 day) PA; LD; SP; QL (9 tablets per 1 ESBRIET ORAL TABLET 267 MG (pirfenidone) 4 day) PA; LD; SP; QL (3 tablets per 1 ESBRIET ORAL TABLET 801 MG (pirfenidone) 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 the highest cost share and usually include 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 227 Coverage Requirements and Prescription Drug Name Drug Tier Limits *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 3 LD (omadacycline tosylate) NUZYRA ORAL TABLET (omadacycline tosylate) 3 PA; LD; QL (30 tablets per 30 days) *FLUOROCYCLINES*** - ANTIBIOTICS XERAVA INTRAVENOUS SOLUTION RECONSTITUTED 3 (eravacycline dihydrochloride) *GLYCYLCYCLINES*** - ANTIBIOTICS TIGECYCLINE INTRAVENOUS SOLUTION RECONSTITUTED 3 TYGACIL INTRAVENOUS SOLUTION RECONSTITUTED 3 (tigecycline) *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 1 or 1b* ST; QL (2 tablets per 1 day) 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 3 (minocycline 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* 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 the highest cost share and usually include 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 228 Coverage Requirements and Prescription Drug Name Drug Tier Limits 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) tetracycline 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* 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* LEVOTHYROXINE 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* NATURE-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 (levothyroxine sodium) 3 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) 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 the highest cost share and usually include 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 229 Coverage Requirements and Prescription Drug Name Drug Tier Limits 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 PEDIARIX INTRAMUSCULAR SUSPENSION (dtap-hepatitis b recomb- 3; $0 ipv) PENTACEL INTRAMUSCULAR SUSPENSION RECONSTITUTED 3; $0 (dtap-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 ALKALOIDS*** - DRUGS FOR STOMACH CRAMPS ATROPEN INTRAMUSCULAR SOLUTION AUTO-INJECTOR 3 (atropine sulfate) atropine sulfate injection solution prefilled syringe 1 or 1b* ATROPINE SULFATE 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 the highest cost share and usually include 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 230 Coverage Requirements and Prescription Drug Name Drug Tier Limits ATROPINE SULFATE INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 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 cimetidine hcl oral solution 1 or 1b* 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* *PROTON 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 3 (pantoprazole 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 the highest cost share and usually include 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 231 Coverage Requirements and Prescription Drug Name Drug Tier Limits *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 3 SYRINGE GLYRX-PF INJECTION SOLUTION (glycopyrrolate) 3 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 3 QL (1 tablet per 1 day) (fesoterodine fumarate)

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 the highest cost share and usually include 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 232 Coverage Requirements and Prescription Drug Name Drug Tier Limits 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* *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 3 adsorbed) HIBERIX INJECTION SOLUTION RECONSTITUTED (haemophilus b 3; $0 polysac conj vac) MENACTRA INTRAMUSCULAR INJECTABLE (meningococcal a c 3; $0 y&w-135 conj) MENQUADFI INTRAMUSCULAR INJECTABLE (meningococcal a c 3; $0 y&w-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 3; $0 SYRINGE (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) 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 the highest cost share and usually include 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 233 Coverage Requirements and Prescription Drug Name Drug Tier Limits PROQUAD SUBCUTANEOUS SUSPENSION RECONSTITUTED 3; $0 (measles-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) 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 2; $0 SYRINGE (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 3 vaccine, 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)

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 the highest cost share and usually include 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 234 Coverage Requirements and Prescription Drug Name Drug Tier Limits ROTARIX ORAL SUSPENSION RECONSTITUTED (rotavirus vaccine 3; $0 live oral) ROTATEQ ORAL SOLUTION (rotavirus vac live pentavalent) 3; $0 SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 3; $0 (zoster 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 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* terconazole 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 (prasterone) 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

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 the highest cost share and usually include 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 235 Coverage Requirements and Prescription Drug Name Drug Tier Limits *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 3 QL (18 packs per 28 days) (estradiol) 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 CRINONE VAGINAL GEL 4 % (progesterone) 4 SP CRINONE VAGINAL GEL 8 % (progesterone) 4 PA; SP; QL (1 applicator per 1 day) 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 2 QL (2 syringes per 1 fill) (epinephrine) *NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS*** - DRUGS FOR SERIOUS ALLERGIC REACTION droxidopa 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 EPHEDRINE SULFATE 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 the highest cost share and usually include 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 236 Coverage Requirements and Prescription Drug Name Drug Tier Limits EPHEDRINE SULFATE-NACL INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE EPINEPHRINE HCL-NACL INTRAVENOUS SOLUTION 3 EPINEPHRINE INTRAVENOUS SOLUTION 3 EPINEPHRINE INTRAVENOUS SOLUTION PREFILLED SYRINGE 3 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 midodrine hcl oral tablet 1 or 1b* NOREPINEPHRINE (BASE)-DEXTROSE INTRAVENOUS SOLUTION 3 norepinephrine bitartrate intravenous solution 1 or 1b* NOREPINEPHRINE-DEXTROSE INTRAVENOUS SOLUTION 3 NOREPINEPHRINE-SODIUM CHLORIDE INTRAVENOUS 3 SOLUTION PHENYLEPHRINE HCL INTRAVENOUS SOLUTION 3 PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION 3 PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE 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 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 the highest cost share and usually include 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 237 Index 1ST TIER UNIFINE PENTIPS...... 174 ACTIFOAM COLLAGEN SPONGE AIMOVIG...... 181 1ST TIER UNIFINE PENTIPS ...... 154 AIMSCO TWIST LANCETS 32G... 164 PLUS...... 175 ACTI-LANCE 28G...... 163 AIMSCO TWIST LANCETS 33G... 164 1ST TIER UNILET ACTI-LANCE LITE LANCETS ak-fluor...... 211 COMFORTOUCH...... 163 28G...... 163 AK-FLUOR...... 211 abacavir sulfate...... 94 ACTI-LANCE SPECIAL LANCETS AKLIEF...... 118 abacavir sulfate-lamivudine...... 91 17G...... 163 AKOVAZ...... 236 abacavir-lamivudine-zidovudine...... 91 ACTI-LANCE UNIVERSAL 23G....163 ak-poly-bac...... 210 ABELCET...... 54 ACTIMMUNE...... 79 AKTEN...... 211 ABILIFY MAINTENA...... 90 ACTIVASE...... 150 AKYNZEO...... 53 ABILIFY MYCITE...... 90 ACTIVELLA...... 138 ala-cort...... 121 ABILIFY MYCITE ACTONEL...... 131 albendazole...... 32 MAINTENANCE KIT...... 90 ACTOPLUS MET...... 51 ALBENZA...... 32 ABILIFY MYCITE STARTER KIT..90 ACULAR...... 212 ALBUKED 25...... 149 abiraterone acetate...... 68 ACULAR LS...... 212 ALBUKED 5...... 149 ABLYSINOL...... 103 ACUVAIL...... 212 ALBUMIN HUMAN...... 149 ABOUTTIME PEN NEEDLE...... 175 acyclovir...... 96, 121 ALBUMINEX...... 149 ABRAXANE...... 82 acyclovir sodium...... 96 ALBUMIN-ZLB...... 149 ABSORICA...... 117 ADACEL...... 229 ALBURX...... 149 ABSORICA LD...... 117 ADAKVEO...... 153 ALBUTEIN...... 149 ACACIA...... 15 adapalene...... 117, 118 albuterol sulfate...... 36 acamprosate calcium...... 220 adapalene-benzoyl peroxide...... 117 albuterol sulfate hfa...... 35 acarbose...... 46 ADASUVE...... 89 ALCAINE...... 211 ACCOLATE...... 37 adc/f (0.5mg/ml)...... 196 alclometasone dipropionate...... 121 ACCRUFER...... 153 ADCETRIS...... 71 ALDACTAZIDE...... 129 ACCU-CHEK AVIVA PLUS...... 129 ADDYI...... 224 ALDACTONE...... 130 ACCU-CHEK COMPACT PLUS.... 129 adefovir dipivoxil...... 95 ALDARA...... 125 ACCU-CHEK FASTCLIX LANCET ADEMPAS...... 103 ALDER...... 15 ...... 163 ADENOCAINE...... 102 ALDURAZYME...... 135 ACCU-CHEK FASTCLIX adenosine...... 34 ALECENSA...... 70 LANCETS...... 163 ADHANSIA XR...... 13 alendronate sodium...... 131 ACCU-CHEK GUIDE...... 129 ADIPEX-P...... 12 ALFENTANIL HCL...... 27 ACCU-CHEK MULTICLIX ADRENAL C FORMULA...... 193 ALFERON N...... 79 LANCETS...... 163 ADRENALIN...... 236 alfuzosin hcl er...... 143 ACCU-CHEK SAFE-T PRO adriamycin...... 77 ALIMTA...... 69 LANCETS...... 163 adult aspirin regimen...... 24 ALINIA...... 64 ACCU-CHEK SMARTVIEW...... 129 ADVAIR HFA...... 35 ALIQOPA...... 83 ACCU-CHEK SOFTCLIX LANCET ADVANCED MOBILE LANCET....163 aliskiren fumarate...... 63 DEV...... 163 ADVATE...... 145 ALKERAN...... 83 ACCU-CHEK SOFTCLIX ADVOCATE INSULIN PEN ALKINDI SPRINKLE...... 113 LANCETS...... 163 NEEDLES...... 175 allbee/c...... 192 ACCURETIC...... 59 ADVOCATE INSULIN SYRINGE.. 175 allopurinol...... 145 accutane...... 117 ADVOCATE LANCETS...... 163 allopurinol sodium...... 145 ACCUTREND GLUCOSE...... 129 ADVOCATE LANCETS 30G...... 164 almotriptan malate...... 181 acebutolol hcl...... 97 ADVOCATE SAFETY LANCETS.. 164 alogliptin benzoate...... 47 ACETADOTE...... 52 ADVOCATE SAFETY LANCETS alogliptin-metformin hcl...... 47 acetaminophen...... 23 26G...... 164 alogliptin-pioglitazone...... 48 acetaminophen-codeine...... 26 ADYNOVATE...... 146 alophen...... 159 acetaminophen-codeine #2...... 26 ADZENYS ER...... 11 ALOPRIM...... 145 acetaminophen-codeine #3...... 26 ADZENYS XR-ODT...... 11 ALORA...... 138 acetaminophen-codeine #4...... 26 AEMCOLO...... 63 alosetron hcl...... 141 acetazolamide...... 129 AFFINITY...... 127 ALOXI...... 53 acetazolamide er...... 129 AFINITOR...... 75 ALPHAGAN P...... 212 acetazolamide sodium...... 129 AFINITOR DISPERZ...... 75 ALPHANATE...... 146 acetic acid...... 144, 215 afirmelle...... 106 ALPHANINE SD...... 146 acetylcysteine...... 52, 116 AFLURIA QUADRIVALENT...... 234 alprazolam...... 33 acitretin...... 120 AFSTYLA...... 146 alprazolam er...... 33 ACNESIC...... 125 aftera...... 110 ALPRAZOLAM INTENSOL...... 33 ACREMONIUM...... 15 AGAMATRIX ULTRA-THIN alprazolam xr...... 33 ACTHAR...... 132 LANCETS...... 164 ALPROLIX...... 146 ACTHIB...... 233 AGGRASTAT...... 148 alprostadil...... 189 ACTIFLOVIT EAR HEALTH...... 202 AGRYLIN...... 150 ALREX...... 213 238 ALTABAX...... 118 ampicillin-sulbactam sodium...... 219 ARMOUR THYROID...... 229 altafluor benox...... 211 AMPYRA...... 223 ARNUITY ELLIPTA...... 37 altafrin...... 208 AMVISC...... 214 AROMASIN...... 79 altavera...... 106 AMVISC PLUS...... 214 ARRANON...... 69 ALTERNARIA...... 15 anagrelide hcl...... 150 arsenic trioxide...... 79 ALUNBRIG...... 70 ANALPRAM-HC...... 31 ARTESUNATE...... 67 alvimopan...... 142 ANASCORP...... 216 articadent dental...... 160 alyacen 1/35...... 106 anastrozole...... 79 ARTISS...... 153 alyacen 7/7/7...... 112 ANAVIP...... 216 ARZERRA...... 71 alyq...... 103 ANCOBON...... 54 ASCENIV...... 217 amabelz...... 138 ANDEXXA...... 52 ASCLERA...... 189 amantadine hcl...... 86 ANDRODERM...... 31 ascomp-codeine...... 26 AMARYL...... 50 ANECTINE...... 205 ASCOR...... 237 AMBISOME...... 54 ANESTHESIA S/I-40A...... 142 asenapine maleate...... 89 ambrisentan...... 103 ANESTHESIA S/I-40H...... 143 ashlyna...... 111 amcinonide...... 121 ANESTHESIA S/I-40S...... 143 ASPARLAS...... 78 AMELUZ...... 126 ANGELIQ...... 138 ASPERGILLUS FUMIGATUS...... 15 AMERICAN BEECH...... 15 ANGIOMAX...... 39 aspirin...... 24 AMERICAN COCKROACH...... 15 ANJESO...... 21 aspirin 81...... 24 AMERICAN ELM...... 15 ANNOVERA...... 110 aspirin adult low dose...... 24 amethia...... 111 ANORO ELLIPTA...... 35 aspirin adult low strength...... 24 amethyst...... 110 anti-oxidant...... 194 aspirin childrens...... 24 AMICAR...... 154 ANTIVENIN LATRODECTUS aspirin ec...... 24 AMIDATE...... 142 MACTANS...... 216 aspirin ec adult low strength...... 24 amikacin sulfate...... 19 ANTIVENIN MICRURUS aspirin ec low dose...... 24 amiloride hcl...... 130 FULVIUS...... 216 aspirin ec low strength...... 24 amiloride-hydrochlorothiazide...... 129 ANUSOL-HC...... 31 aspirin low dose...... 24 aminoacetic acid...... 144 APADAZ...... 29 aspirin low strength...... 24 aminocaproic acid...... 154 apap-caff-dihydrocodeine...... 26 aspirin-dipyridamole er...... 149 aminophylline...... 38 APLENZIN...... 44 ASPIRIN-OMEPRAZOLE...... 149 AMINOPROTECT...... 206 APLIGRAF...... 127 ASSURE COMFORT LANCETS AMINOSYN II...... 206 APOKYN...... 87 28G...... 164 AMINOSYN-PF...... 206 apraclonidine hcl...... 212 ASSURE HAEMOLANCE PLUS amiodarone hcl...... 34 aprepitant...... 54 HIGH...... 164 AMIODARONE HCL IN apri...... 106 ASSURE HAEMOLANCE PLUS DEXTROSE...... 34 APRISO...... 141 LOW...... 164 amitriptyline hcl...... 46 APTENSIO XR...... 13 ASSURE HAEMOLANCE PLUS amlodipine besy-benazepril hcl...... 59 APTIOM...... 40 MICRO...... 164 amlodipine besylate...... 99 APTIVUS...... 93 ASSURE HAEMOLANCE PLUS amlodipine besylate-valsartan...... 60 AQUALANCE LANCETS 30G...... 164 NORMAL...... 164 amlodipine-atorvastatin...... 102 AQUASOL A...... 237 ASSURE HAEMOLANCE PLUS amlodipine-olmesartan...... 60 ARAKODA...... 67 PED...... 164 amlodipine-valsartan-hctz...... 61 ARALAST NP...... 226 ASSURE ID INSULIN SAFETY ammonium lactate...... 124 aranelle...... 112 SYR...... 175 AMMONUL...... 137 ARANESP (ALBUMIN FREE)...... 151 ASSURE ID SAFETY PEN amnesteem...... 118 ARAVA...... 23 NEEDLES...... 175 AMNIOFIX...... 127 ARAZLO...... 118 ASSURE LANCE LANCETS...... 164 AMNIOTEXT...... 127 ARCALYST...... 21 ASSURE LANCE LANCETS 21G... 164 AMONDYS 45...... 205 arformoterol tartrate...... 36 ASSURE LANCE PLUS SAFETY amoxapine...... 46 ARGATROBAN...... 39 25G...... 164 amoxicill-clarithro-lansopraz...... 232 ARGATROBAN IN SODIUM ASSURE LANCE PLUS SAFETY amoxicillin...... 218 CHLORIDE...... 39 30G...... 164 amoxicillin-pot clavulanate...... 219 ARGININE HCL...... 207 ASSURE LANCE SAFETY amoxicillin-pot clavulanate er...... 219 argyle sterile saline...... 144 LANCET 28G...... 164 AMPHADASE...... 186 argyle sterile water...... 187 ASTAGRAF XL...... 187 AMPHENOL-40...... 127 ARICEPT...... 220 ATABEX EC...... 197 amphetamine er...... 11 ARIKAYCE...... 19 ATABEX OB...... 197 amphetamine sulfate...... 11 aripiprazole...... 90 atazanavir sulfate...... 93 amphetamine-dextroamphet er...... 11 ARISTADA...... 91 ATELVIA...... 131 amphetamine-dextroamphetamine...... 11 ARISTADA INITIO...... 91 atenolol...... 97 amphotericin b...... 54 ARIXTRA...... 39 atenolol-chlorthalidone...... 62 ampicillin...... 218 ARIZONA CYPRESS...... 15 ATGAM...... 186 ampicillin sodium...... 218 armodafinil...... 13 atomoxetine hcl...... 11 239 atorvastatin calcium...... 58 azurette...... 106 BD INSULIN SYR ULTRAFINE II. 175 atovaquone...... 64 b complex...... 191 BD INSULIN SYRINGE...... 175 atovaquone-proguanil hcl...... 66 b complex 100 tr...... 192 BD INSULIN SYRINGE HALF- atracurium besylate...... 206 b complex formula 1...... 192 UNIT...... 175 ATROPEN...... 230 b complex plus...... 192 BD INSULIN SYRINGE atropine sulfate...... 208, 230 b complex-b12...... 191 MICROFINE...... 175 ATROPINE SULFATE..... 208, 230, 231 b complex-biotin-fa...... 192 BD INSULIN SYRINGE U/F...... 175 ATROVENT HFA...... 36 b complex-c...... 192 BD INSULIN SYRINGE U/F AUBAGIO...... 221 B COMPLEX-C-BIOTIN-E-FA...... 192 1/2UNIT...... 175 aubra...... 106 b complex-c-folic acid...... 191 BD INSULIN SYRINGE U-500...... 175 aubra eq...... 106 b-100...... 202 BD INSULIN SYRINGE AUGMENTIN...... 219 b-100 b-complex...... 193 ULTRAFINE...... 175 AUGMENTIN ES-600...... 219 b-100 complex...... 202 BD LANCET ULTRAFINE 30G...... 164 AUREOBASIDIUM...... 15 b-100 complex cr...... 193 BD LANCET ULTRAFINE 33G...... 164 AUREOBASIDIUM PULLULANS....15 b-100 cr...... 202 BD MICROTAINER LANCETS...... 164 AURORA LANCET SUPER THIN b-100 tr...... 193 BD PEN NEEDLE MICRO U/F...... 175 30G...... 164 b-50...... 202 BD PEN NEEDLE MINI U/F...... 175 AURORA LANCET THIN 23G...... 164 b-50 complex...... 193 BD PEN NEEDLE NANO 2ND GEN AURORA PEN NEEDLES...... 175 bac...... 23 ...... 175 AURORA UNIFINE PENTIPS...... 175 bacitracin...... 63, 209 BD PEN NEEDLE NANO U/F...... 175 aurovela 1.5/30...... 107 bacitracin-polymyxin b...... 210 BD PEN NEEDLE ORIGINAL U/F.175 aurovela 1/20...... 107 bacitra-neomycin-polymyxin-hc...... 212 BD PEN NEEDLE SHORT U/F...... 175 aurovela 24 fe...... 107 baclofen...... 202 BD SAFETYGLIDE INSULIN aurovela fe 1.5/30...... 107 BACTRIM...... 64 SYRINGE...... 175 aurovela fe 1/20...... 107 BACTRIM DS...... 64 BD SAFETY-LOK INSULIN AURYXIA...... 142 BAHIA...... 15 SYRINGE...... 175 AUSTEDO...... 221 BAL IN OIL...... 52 BD VEO INSULIN SYR U/F AUSTRALIAN PINE...... 15 balance b-100...... 202 1/2UNIT...... 176 AUTOLET II CLINISAFE...... 164 balance b-50...... 193 BD VEO INSULIN SYRINGE U/F.. 176 AUTOLET LITE CLINISAFE...... 164 balanced b complex...... 193 bekyree...... 106 AUTOLET LITE STARTER PACK164 balanced b-100...... 193, 202 BELBUCA...... 30 AUTOLET PLATFORMS...... 164 balanced b-100 complex cr...... 202 BELEODAQ...... 74 AVASTIN...... 85 balanced b-50 complex...... 202 BELRAPZO...... 68 aviane...... 107 balanced b-50/fa...... 193 BELSOMRA...... 156 avita...... 118 balanced salt...... 211 benazepril hcl...... 60 AVITENE...... 154 BALCOLTRA...... 107 benazepril-hydrochlorothiazide...... 59 AVITENE FLOUR...... 154 BALD CYPRESS...... 15 BENDEKA...... 68 AVONEX PEN...... 222 balsalazide disodium...... 141 BENEFIX...... 146 AVONEX PREFILLED...... 222 BALVERSA...... 74 BENLYSTA...... 185 AVYCAZ...... 104 balziva...... 107 BENTYL...... 230 AYGESTIN...... 219 BANZEL...... 40 BENZALKONIUM CHLORIDE...... 91 ayuna...... 107 BAQSIMI ONE PACK...... 47 BENZAMYCIN...... 117 AYVAKIT...... 76 BAQSIMI TWO PACK...... 47 BENZHYDROCODONE- azacitidine...... 69 BARACLUDE...... 95 ACETAMINOPHEN...... 29 AZACTAM...... 66 BARHEMSYS...... 54 BENZNIDAZOLE...... 32 AZASAN...... 189 BAVENCIO...... 72 benzonatate...... 115 AZASITE...... 209 BAXDELA...... 139 benzoyl peroxide-erythromycin...... 117 azathioprine...... 189 BAYBERRY (WAX MYRTLE)...... 15 benzphetamine hcl...... 12 AZATHIOPRINE SODIUM...... 189 bayer advanced aspirin reg st...... 24 benztropine mesylate...... 85 AZEDRA DOSIMETRIC...... 79 bayer aspirin...... 24 BEOVU...... 215 AZEDRA THERAPEUTIC...... 79 bayer aspirin ec low dose...... 24 BERINERT...... 147 azelaic acid...... 126 bayer low dose...... 24 BERMUDA GRASS...... 15 azelastine hcl...... 205, 209 BCG VACCINE...... 233 beser...... 121 azelastine-fluticasone...... 204 b-compleet-100...... 193 BESIVANCE...... 209 AZESCHEW b-compleet-50...... 193 BESPONSA...... 71 PRENATAL/POSTNATAL...... 197 B-COMPLEX...... 191 BETADINE OPHTHALMIC PREP 210 AZESCO...... 197 b-complex...... 193 betamethasone dipropionate...... 121, 122 AZILECT...... 86 b-complex balanced...... 191 betamethasone dipropionate aug...... 121 azithromycin...... 161, 162 b-complex/b-12...... 191 betamethasone valerate...... 122 AZOPT...... 210 b-complex/vitamin c...... 191 BETASERON...... 222 aztreonam...... 66 b-complex-c...... 192 betaxolol hcl...... 97, 208 AZULFIDINE...... 141 BD AUTOSHIELD...... 175 bethanechol chloride...... 233 AZULFIDINE EN-TABS...... 141 BD AUTOSHIELD DUO...... 175 BETHKIS...... 19 240 BETIMOL...... 208 briellyn...... 107 calcitonin (salmon)...... 132 BETOPTIC-S...... 208 BRILINTA...... 148 calcitrene...... 120 better b complex...... 192 brimonidine tartrate...... 212 calcitriol...... 120, 133 BEVACIZUMAB...... 215 brinzolamide...... 210 calcium acetate...... 142 bexarotene...... 84 BRIVIACT...... 40 calcium acetate (phos binder)...... 142 BEXSERO...... 233 BROME...... 15 CALCIUM DISODIUM BEYAZ...... 107 bromfenac sodium (once-daily)...... 212 VERSENATE...... 52 bicalutamide...... 69 bromocriptine mesylate...... 86 CALCIUM GLUCONATE...... 182 BICILLIN C-R...... 219 BROMSITE...... 212 CALCIUM GLUCONATE-NACL...182 BICILLIN C-R 900/300...... 219 BRONCHITOL...... 227 CALDOLOR...... 21 BICILLIN L-A...... 218 BRONCHITOL TOLERANCE CALIFORNIA PEPPER TREE...... 15 BICNU...... 83 TEST...... 227 CALQUENCE...... 73 BIDIL...... 102 BROVANA...... 36 camila...... 112 big 100...... 193 BRUKINSA...... 73 CAMPTOSAR...... 84 big 100 (biotin)...... 193 BSP 0820...... 115 camrese...... 111 BIJUVA...... 138 BSS...... 211 camrese lo...... 111 BIKTARVY...... 91 BSS PLUS...... 211 CANASA...... 141 BILTRICIDE...... 32 budesonide...... 37, 113 CANCIDAS...... 54 bimatoprost...... 126, 215 budesonide er...... 113 candesartan cilexetil...... 61 BINOSTO...... 131 budesonide-formoterol fumarate...... 35 candesartan cilexetil-hctz...... 61 BIORPHEN...... 236 bumetanide...... 130 CANDIDA ALBICANS EXTRACT...16 BIOTHRAX...... 233 BUMEX...... 130 CAPASTAT SULFATE...... 67 BIOVANCE...... 127 BUNAVAIL...... 30 CAPCOF...... 116 bisacodyl ec...... 159 bupap...... 23 capecitabine...... 69 bisoprolol fumarate...... 97 BUPHENYL...... 137 CAPLYTA...... 87 bisoprolol-hydrochlorothiazide...... 62 BUPIVACAINE FISIOPHARMA....160 CAPRELSA...... 75 BIVALIRUDIN RTU...... 39 bupivacaine hcl...... 160 captopril...... 60 BIVALIRUDIN-SODIUM bupivacaine hcl (pf)...... 160 CARAC...... 119 CHLORIDE...... 39 BUPIVACAINE HCL-NACL...... 160 CARAFATE...... 231 BIVIGAM...... 217 bupivacaine in dextrose...... 161 CARBAGLU...... 133 BLACK WILLOW...... 15 bupivacaine spinal...... 161 carbamazepine...... 41 blanche...... 123 bupivacaine-epinephrine...... 160 carbamazepine er...... 40 BLENREP...... 70 bupivacaine-epinephrine (pf)...... 160 carbidopa...... 86 bleomycin sulfate...... 77 BUPRENEX...... 30 carbidopa-levodopa...... 86, 87 BLEPH-10...... 214 buprenorphine...... 30 carbidopa-levodopa er...... 86 BLEPHAMIDE...... 212 buprenorphine hcl...... 30 carbidopa-levodopa-entacapone...... 87 BLEPHAMIDE S.O.P...... 212 buprenorphine hcl-naloxone hcl...... 30 carbinoxamine maleate...... 56 BLINCYTO...... 73 bupropion hcl...... 44 CARBOCAINE...... 161 blisovi 24 fe...... 107 bupropion hcl er (smoking det)...... 224 CARBOCAINE PRESERVATIVE- blisovi fe 1.5/30...... 107 bupropion hcl er (sr)...... 44 FREE...... 161 blisovi fe 1/20...... 107 bupropion hcl er (xl)...... 44 carboplatin...... 68 BLOXIVERZ...... 67 buspirone hcl...... 33 carboprost tromethamine...... 216 BONIVA...... 131 busulfan...... 68 CARDENE IV...... 99 BONJESTA...... 53 BUSULFEX...... 68 CARDIZEM...... 99 BOOSTRIX...... 229 butalbital-acetaminophen...... 23 CARDIZEM LA...... 99 BORIC ACID...... 125 butalbital-apap-caff-cod...... 26 CARDURA...... 62 BORTEZOMIB...... 76 butalbital-apap-caffeine...... 23 CARDURA XL...... 143 bosentan...... 103 butalbital-asa-caff-codeine...... 26 CAREFINE PEN NEEDLES...... 176 BOSULIF...... 73 butalbital-aspirin-caffeine...... 23 CAREONE INSULIN SYRINGE..... 176 BOTOX...... 205 butorphanol tartrate...... 30 CAREONE LANCET SUPER THIN BOTOX COSMETIC...... 124 BUTRANS...... 30 30G...... 164 BOTRYTIS...... 15 BYFAVO...... 155 CAREONE LANCET THIN 23G.....164 bp wash...... 118 BYSTOLIC...... 98 CAREONE UNIFINE PENTIPS...... 176 BRAFTOVI...... 73 CABENUVA...... 91, 92 CAREONE UNIFINE PENTIPS BREO ELLIPTA...... 35 cabergoline...... 132 PLUS...... 176 BRETYLIUM TOSYLATE...... 34 CABLIVI...... 147 CARESENS LANCETS...... 164 BREVIBLOC...... 97 CABOMETYX...... 75 CARETOUCH INSULIN SYRINGE BREVIBLOC IN NACL...... 97 CADUET...... 102 ...... 176 BREVIBLOC PREMIXED...... 97 CAFCIT...... 12 CARETOUCH PEN NEEDLES...... 176 BREVIBLOC PREMIXED DS...... 97 caffeine citrate...... 12 CARETOUCH SAFETY LANCETS164 BREVITAL SODIUM...... 143 CALAN SR...... 99 CARETOUCH SAFETY LANCETS BREZTRI AEROSPHERE...... 35 calcipotriene...... 120 26G...... 164 BRIDION...... 52 calcipotriene-betameth diprop...... 128 241 CARETOUCH TWIST LANCETS CEFTRIAXONE SODIUM- CIPRO HC...... 215 28G...... 164 DEXTROSE...... 105 CIPRODEX...... 216 CARETOUCH TWIST LANCETS cefuroxime axetil...... 105 ciprofloxacin hcl...... 139, 209, 215 30G...... 164 cefuroxime sodium...... 105 ciprofloxacin in d5w...... 139 CARETOUCH TWIST LANCETS celecoxib...... 21 ciprofloxacin-dexamethasone...... 216 33G...... 164 CELESTONE SOLUSPAN...... 115 ciprofloxacin-fluocinolone pf...... 216 carisoprodol...... 202 CELLCEPT...... 187 cisatracurium besylate...... 206 carisoprodol-aspirin-codeine...... 203 CELLCEPT INTRAVENOUS...... 186 cisatracurium besylate (pf)...... 206 carmustine...... 83 CELLUGEL...... 214 cisplatin...... 68 CARNITOR...... 132 CELONTIN...... 43 CISPLATIN...... 68 CARNITOR SF...... 132 CENTANY...... 118 citalopram hydrobromide...... 45 CAROSPIR...... 130 cephalexin...... 104 CITRANATAL 90 DHA...... 200 carteolol hcl...... 208 CEPROTIN...... 148 CITRANATAL ASSURE...... 200 cartia xt...... 99 CERDELGA...... 150 CITRANATAL B-CALM...... 197 carvedilol...... 97 CEREBYX...... 43 CITRANATAL BLOOM...... 197 carvedilol phosphate er...... 97 CEREZYME...... 150 CITRANATAL BLOOM DHA...... 200 CASCARA SAGRADA...... 159 CEROVEL...... 124 CITRANATAL DHA...... 200 CASODEX...... 69 CERVIDIL...... 216 CITRANATAL ESSENCE...... 200 CASPOFUNGIN ACETATE...... 54 CETACAINE...... 128 CITRANATAL HARMONY...... 200 CAT HAIR EXTRACT...... 16 cetirizine hcl...... 56 CITRANATAL MEDLEY...... 200 cataflam...... 21 CETRAXAL...... 215 CITRANATAL RX...... 197 CATAPRES-TTS-1...... 62 CETROTIDE...... 132 citrate of magnesia...... 158 CATAPRES-TTS-2...... 62 cevimeline hcl...... 191 citroma...... 158 CATAPRES-TTS-3...... 62 CHANTIX...... 224 CITRULLINE EASY...... 137 CATHFLO ACTIVASE...... 150 CHANTIX CONTINUING MONTH CLADOSPORIUM CATTLE EPITHELIUM...... 16 PAK...... 224 CLADOSPORIOIDES...... 16 cavarest...... 190 CHANTIX STARTING MONTH CLADOSPORIUM CAVERJECT...... 102 PAK...... 224 SPHAEROSPERMUM...... 16 CAVERJECT IMPULSE...... 102 charlotte 24 fe...... 107 cladribine...... 69 CAYA...... 163 chateal...... 107 claravis...... 118 CAYSTON...... 66 chateal eq...... 107 CLARINEX...... 56 caziant...... 112 CHEMET...... 51 CLARINEX-D 12 HOUR...... 116 CEDAR ELM...... 16 CHENODAL...... 140 clarithromycin...... 162 cefaclor...... 104 childrens aspirin...... 24 clarithromycin er...... 162 CEFACLOR ER...... 104 chloramphenicol sod succinate...... 64 CLASSIC PRENATAL...... 197 cefadroxil...... 104 chlordiazepoxide hcl...... 33 CLEANLET LANCETS 28G...... 164 CEFAZOLIN IN SODIUM chlordiazepoxide-amitriptyline...... 220 clearlax...... 157 CHLORIDE...... 104 chlordiazepoxide-clidinium...... 230 CLEMASTINE FUMARATE...... 56 cefazolin sodium...... 104 chlorhexidine gluconate...... 190 clemastine fumarate...... 56 CEFAZOLIN SODIUM...... 104 chloroprocaine hcl (pf)...... 161 CLENPIQ...... 157 CEFAZOLIN SODIUM- chloroquine phosphate...... 67 CLEOCIN...... 65, 235 DEXTROSE...... 104 chlorothiazide sodium...... 130 CLEOCIN PHOSPHATE...... 65 cefdinir...... 105 chlorpromazine hcl...... 90 CLEOCIN-T...... 117 cefepime hcl...... 106 chlorthalidone...... 130 CLEVER CHEK LANCETS...... 164 CEFEPIME HCL...... 106 chlorzoxazone...... 202 CLEVER CHOICE COMFORT EZ 176 CEFEPIME-DEXTROSE...... 106 CHOLBAM...... 139 CLEVER CHOICE LANCETS 21G 164 cefixime...... 105 cholestyramine...... 57 CLEVER CHOICE LANCETS 23G 165 CEFOTAN...... 104 cholestyramine light...... 57 CLEVER CHOICE LANCETS 28G 165 cefotaxime sodium...... 105 CHORIONIC GONADOTROPIN... 135 CLEVIPREX...... 99 cefotetan disodium...... 104 chromic chloride...... 184 CLICKFINE PEN NEEDLES...... 176 CEFOTETAN DISODIUM- ciclopirox...... 119 CLIMARA...... 138 DEXTROSE...... 105 ciclopirox olamine...... 119 CLIMARA PRO...... 138 cefoxitin sodium...... 105 cidofovir...... 95 clindacin etz...... 117 CEFOXITIN SODIUM-DEXTROSE cilostazol...... 148 clindacin-p...... 117 ...... 105 CILOXAN...... 209 clindamycin hcl...... 65 cefpodoxime proxetil...... 105 CIMDUO...... 92 clindamycin palmitate hcl...... 65 cefprozil...... 105 cimetidine...... 231 clindamycin phos-benzoyl perox...... 117 ceftazidime...... 105 cimetidine hcl...... 231 clindamycin phosphate...... 65, 117, 235 CEFTAZIDIME AND DEXTROSE.105 cinacalcet hcl...... 131 clindamycin phosphate in d5w...... 65 ceftriaxone sodium...... 105 CINQAIR...... 37 CLINDAMYCIN PHOSPHATE IN CEFTRIAXONE SODIUM...... 105 CINRYZE...... 147 NACL...... 65 ceftriaxone sodium in dextrose...... 105 CINVANTI...... 54 clindamycin-tretinoin...... 117 CIPRO...... 139 CLINDESSE...... 235 242 CLINIMIX E/DEXTROSE (2.75/5)..206 COMBIVIR...... 92 COTELLIC...... 75 CLINIMIX E/DEXTROSE (4.25/10) 206 COMETRIQ (100 MG DAILY COTEMPLA XR-ODT...... 13 CLINIMIX E/DEXTROSE (4.25/5)..206 DOSE)...... 75 CREON...... 129 CLINIMIX E/DEXTROSE (5/15).....206 COMETRIQ (140 MG DAILY CRESEMBA...... 55 CLINIMIX E/DEXTROSE (5/20).....206 DOSE)...... 76 CRINONE...... 236 CLINIMIX E/DEXTROSE (8/10).....206 COMETRIQ (60 MG DAILY CRIXIVAN...... 93 CLINIMIX E/DEXTROSE (8/14).....206 DOSE)...... 76 CROFAB...... 216 CLINIMIX/DEXTROSE (4.25/10)... 206 COMFORT ASSIST INSULIN cromolyn sodium...... 35, 140, 209 CLINIMIX/DEXTROSE (4.25/5)..... 206 SYRINGE...... 176 crotan...... 126 CLINIMIX/DEXTROSE (5/15)...... 206 COMFORT ASSURED LANCETS CRYODOSE TA...... 128 CLINIMIX/DEXTROSE (5/20)...... 206 28G...... 165 cryselle-28...... 107 CLINIMIX/DEXTROSE (6/5)...... 206 COMFORT ASSURED LANCETS CRYSVITA...... 138 CLINIMIX/DEXTROSE (8/10)...... 207 33G...... 165 CUBICIN...... 64 CLINIMIX/DEXTROSE (8/14)...... 207 COMFORT EZ INSULIN CUBICIN RF...... 64 clinisol sf...... 207 SYRINGE...... 176 cupric chloride...... 184 CLINOLIPID...... 207 COMFORT EZ MICRO PEN curity sterile saline...... 144 clinpro 5000...... 190 NEEDLES...... 176 CUROSURF...... 228 clobazam...... 40 COMFORT EZ PEN NEEDLES...... 176 CURVULARIA...... 16 clobetasol prop emollient base...... 122 COMFORT EZ SHORT PEN CUTAQUIG...... 217 clobetasol propionate...... 122 NEEDLES...... 176 CUVITRU...... 217 clobetasol propionate e...... 122 COMFORT LANCETS...... 165 CUVPOSA...... 232 clobetasol propionate emulsion...... 122 COMFORT TOUCH INSULIN PEN cvs aspirin...... 24 clocortolone pivalate...... 122 NEED...... 176 cvs aspirin adult low dose...... 24 clodan...... 122 COMFORT TOUCH LANCETS cvs aspirin adult low strength...... 24 clofarabine...... 69 31G...... 165 cvs aspirin ec...... 24 CLOLAR...... 69 COMFORT TOUCH PLUS cvs aspirin low dose...... 24 clomiphene citrate...... 135 LANCETS 30G...... 165 cvs aspirin low strength...... 24 clomipramine hcl...... 46 COMPLERA...... 92 cvs b complex plus c...... 192 clonazepam...... 40 COMPLETE NATAL DHA...... 200 cvs balanced b50...... 202 clonidine...... 62 COMPLETENATE...... 197 cvs bisacodyl...... 159 clonidine hcl...... 62 complex b-100...... 202 cvs citrate of magnesia...... 158 clonidine hcl (analgesia)...... 23 complex b-100-inositol...... 202 cvs c-lax laxative...... 159 clonidine hcl er...... 11 complex b-50 prolonged release...... 193 cvs folic acid...... 151 clopidogrel bisulfate...... 150 compro...... 90 cvs gentle laxative...... 159 clorazepate dipotassium...... 33 COMTAN...... 87 cvs gentle laxative womens...... 159 CLOROTEKAL...... 161 CO-NATAL FA...... 197 cvs inner ear plus...... 202 clotrimazole...... 124, 189 CONCEPT DHA...... 197 CVS LANCETS 21G...... 165 clotrimazole-betamethasone...... 118 CONCEPT OB...... 197 CVS LANCETS MICRO THIN 33G165 clovique...... 185 CONDYLOX...... 125 CVS LANCETS ORIGINAL...... 165 clozapine...... 89 CONJUPRI...... 99 CVS LANCETS THIN 26G...... 165 C-NATE DHA...... 197 constulose...... 157 CVS LANCETS ULTRA THIN 30G 165 COAGADEX...... 146 CONTRAVE...... 13 CVS LANCETS ULTRA-THIN 30G165 COAGUCHEK LANCETS...... 165 CONZIP...... 27 cvs magnesium citrate...... 158 coal tar...... 127 COPAXONE...... 223 cvs milk of magnesia...... 158 COARTEM...... 67 COPIKTRA...... 83 cvs nicotine...... 224 COCKLEBUR...... 16 coremino...... 228 cvs nicotine polacrilex...... 224 COD LIVER OIL...... 202 CORIFACT...... 146 CVS PRENATAL...... 197 CODEINE SULFATE...... 27 CORLANOR...... 103 cvs purelax...... 157 codeine sulfate...... 27 CORLOPAM...... 63 cvs super b complex/c...... 192 CODITUSSIN AC...... 115 CORN POLLEN...... 16 CVS ULTRA THIN LANCETS...... 165 CODITUSSIN DAC...... 115 correctol...... 159 cyanocobalamin...... 150 COGENTIN...... 85 CORTEF...... 113 CYANOCOBALAMIN...... 150 colchicine...... 145 CORTENEMA...... 31 CYANOKIT...... 52 colchicine-probenecid...... 145 CORTIFOAM...... 31 cyclafem 1/35...... 107 colesevelam hcl...... 57 CORTISPORIN-TC...... 216 cyclafem 7/7/7...... 112 COLESTID...... 57 CORVERT...... 34 cyclobenzaprine hcl...... 202 COLESTID FLAVORED...... 57 COSELA...... 83 CYCLOGYL...... 209 colestipol hcl...... 57 COSENTYX...... 120 CYCLOMYDRIL...... 208 colistimethate sodium (cba)...... 66 COSENTYX (300 MG DOSE)...... 120 CYCLOPAK...... 203 COLY-MYCIN M...... 66 COSENTYX SENSOREADY (300 cyclopentolate hcl...... 209 COMBIGAN...... 208 MG)...... 120 cyclophosphamide...... 83 COMBIPATCH...... 138 COSENTYX SENSOREADY PEN.. 120 CYCLOPHOSPHAMIDE...... 83 COMBIVENT RESPIMAT...... 35 COSMEGEN...... 77 cycloserine...... 67 243 CYCLOSET...... 48 deferasirox granules...... 51 DEXCOM G4 PLATINUM cyclosporine...... 186 deferiprone...... 51 RECEIVER...... 165 cyclosporine modified...... 186 deferoxamine mesylate...... 52 DEXCOM G4 PLATINUM CYKLOKAPRON...... 154 DEFITELIO...... 150 TRANSMITTER...... 165 cyproheptadine hcl...... 56 DEFLUX...... 145 DEXCOM G4 SENSOR...... 165 CYRAMZA...... 85 DELESTROGEN...... 138 DEXCOM G5 MOB/G4 PLAT cyred...... 107 DELFLEX-LC/1.5% DEXTROSE... 188 SENSOR...... 165 cyred eq...... 107 DELFLEX-LC/2.5% DEXTROSE... 188 DEXCOM G5 MOBILE CYSTADANE...... 133 DELFLEX-LC/4.25% DEXTROSE. 188 RECEIVER...... 165 CYSTADROPS...... 215 DELFLEX-SM/1.5% DEXTROSE...188 DEXCOM G5 MOBILE CYSTAGON...... 144 DELFLEX-SM/2.5% DEXTROSE...188 TRANSMITTER...... 165 CYSTARAN...... 215 DELSTRIGO...... 92 DEXCOM G5 RECEIVER KIT...... 165 cytarabine...... 69 delyla...... 107 DEXCOM G6 RECEIVER...... 165 cytarabine (pf)...... 69 DELZICOL...... 141 DEXCOM G6 SENSOR...... 165 CYTOGAM...... 217 demeclocycline hcl...... 228 DEXCOM G6 TRANSMITTER...... 165 CYTOMEL...... 229 DEMEROL...... 27 DEXILANT...... 231 CYTOTEC...... 232 DEMSER...... 60 DEXMEDETOMIDINE HCL...... 156 dacarbazine...... 79 DENAVIR...... 121 dexmedetomidine hcl...... 156 DACOGEN...... 69 denta 5000 plus...... 190 dexmedetomidine hcl in nacl...... 156 dactinomycin...... 77 dentagel...... 190 DEXMEDETOMIDINE HCL IN daily multiple vitamins...... 194 DEPEN TITRATABS...... 185 NACL...... 156 daily multiple vitamins/iron...... 194 DEPO-ESTRADIOL...... 138 DEXMEDETOMIDINE HCL- daily value multivitamin...... 195 DEPO-MEDROL...... 113 DEXTROSE...... 156 daily vitamin...... 195 DEPO-PROVERA...... 111 dexmethylphenidate hcl...... 14 daily vitamin formula+iron...... 194 DEPO-SUBQ PROVERA 104...... 111 dexmethylphenidate hcl er...... 13, 14 daily vitamins...... 195 DEPO-TESTOSTERONE...... 31 DEXPANTHENOL...... 140 daily vite...... 195 DERMOTIC...... 216 dexrazoxane hcl...... 80 daily vite multivitamin/iron...... 194 DESCOVY...... 92 DEXTENZA...... 213 daily vites...... 195 DESFERAL...... 52 dextroamphetamine sulfate...... 11, 12 daily-vitamin...... 195 desflurane...... 143 dextroamphetamine sulfate er...... 11 daily-vitamin/iron...... 194 desipramine hcl...... 46 dextrose...... 207 daily-vite...... 195 desloratadine...... 56 DEXTROSE...... 207 daily-vite multivitamin...... 195 desmopressin ace spray refrig...... 137 DEXTROSE 5%/ELECTROLYTE dalfampridine er...... 223 desmopressin acetate...... 137 #48...... 182 DALIRESP...... 37 desmopressin acetate pf...... 137 dextrose in lactated ringers...... 182 DALVANCE...... 65 desmopressin acetate spray...... 137 DEXTROSE-NACL...... 182 danazol...... 31 desogestrel-ethinyl estradiol...... 106, 107 dextrose-nacl...... 182 DANDELION...... 16 desonide...... 122 dextrose-sodium chloride...... 182 DANTRIUM...... 203 desoximetasone...... 122 DEXTROSE-SODIUM CHLORIDE182 dantrolene sodium...... 203 desrx...... 122 DEXYCU...... 213 DANYELZA...... 72 DESVENLAFAXINE ER...... 46 DIACOMIT...... 41 dapsone...... 65, 117 desvenlafaxine succinate er...... 46 dialyvite 800...... 191 DAPTACEL...... 230 DEXABLISS...... 113 DIANEAL LOW CALCIUM/1.5% DAPTOMYCIN...... 65 dexamethasone...... 113 DEX...... 188 daptomycin...... 65 DEXAMETHASONE INTENSOL...113 DIANEAL LOW CALCIUM/2.5% DARAPRIM...... 67 DEXAMETHASONE SOD PHOS- DEX...... 188 darifenacin hydrobromide er...... 232 NACL...... 113 DIANEAL LOW CALCIUM/4.25% DARZALEX...... 71 dexamethasone sod phosphate pf...... 113 DEX...... 188 DARZALEX FASPRO...... 78 DEXAMETHASONE SOD DIANEAL PD-2/1.5% DEXTROSE.188 dasetta 1/35...... 107 PHOSPHATE PF...... 113 DIANEAL PD-2/2.5% DEXTROSE.188 dasetta 7/7/7...... 112 DEXAMETHASONE SODIUM DIANEAL PD-2/4.25% DEXTROSE DAUNORUBICIN HCL...... 77 PHOSPHATE...... 114 ...... 188 DAURISMO...... 74 dexamethasone sodium phosphate114, 213 DIASTAT ACUDIAL...... 40 DAYPRO...... 21 DEXAMETHASONE- DIASTAT PEDIATRIC...... 40 daysee...... 111 MOXIFLOXACIN...... 212 DIATHRIVE LANCET ULTRA DAYTRANA...... 13 DEXAMETH-MOXIFLOX- THIN 30...... 165 DAYVIGO...... 156 KETOROLAC...... 213 DIATHRIVE LANCETS...... 165 DDAVP...... 137 DEXCOM G4 PLAT PED DIATHRIVE PEN NEEDLE...... 176 DDAVP PF...... 137 RCV/SHARE...... 165 diazepam...... 33, 40 deblitane...... 112 DEXCOM G4 PLAT PED DIAZEPAM...... 33 decadron...... 113 RECEIVER...... 165 diazepam intensol...... 33 decitabine...... 69 DEXCOM G4 PLATINUM diazoxide...... 47 deferasirox...... 51 RCV/SHARE...... 165 DIBENZYLINE...... 60 244 diclofenac potassium...... 21 dorzolamide hcl...... 210 DURAGESIC-50...... 27 diclofenac sodium...... 21, 119, 212 dorzolamide hcl-timolol mal...... 208 DURAGESIC-75...... 27 diclofenac sodium er...... 21 dorzolamide hcl-timolol mal pf...... 208 duramorph...... 27 diclofenac-misoprostol...... 21 dotti...... 138 DUREZOL...... 213 dicloxacillin sodium...... 219 DOVATO...... 92 DURLAZA...... 149 dicyclomine hcl...... 230 DOVONEX...... 120 DUROLANE...... 204 diethylpropion hcl...... 12 doxazosin mesylate...... 62 DURYSTA...... 215 diethylpropion hcl er...... 12 doxepin hcl...... 46, 120, 156 DUST MITE MIXED ALLERGEN DIFICID...... 162 doxercalciferol...... 133 EXT...... 19 diflorasone diacetate...... 122 DOXIL...... 77 dutasteride...... 143 DIFLUCAN...... 55 doxorubicin hcl...... 77 dutasteride-tamsulosin hcl...... 144 diflunisal...... 24 doxorubicin hcl liposomal...... 77 DUTOPROL...... 62 DIGIFAB...... 52 doxy 100...... 228 DXEVO 11-DAY...... 114 digitek...... 101 doxycycline hyclate...... 228 DYANAVEL XR...... 12 digox...... 101 doxycycline monohydrate...... 228 DYMISTA...... 204 digoxin...... 101 doxylamine-pyridoxine...... 53 DYSPORT...... 205 dihydroergotamine mesylate...... 181 DRECHSLERA...... 16 ear health formula...... 202 DILANTIN...... 43 DRISDOL...... 237 ear health plus...... 202 DILANTIN INFATABS...... 43 dronabinol...... 54 EASTERN COTTONWOOD...... 16 DILATRATE-SR...... 32 droperidol...... 33 EASY COMFORT INSULIN DILAUDID...... 27 DROPLET INSULIN SYRINGE...... 176 SYRINGE...... 176 diltiazem hcl...... 99 DROPLET LANCETS ULTRA EASY COMFORT LANCETS...... 166 DILTIAZEM HCL...... 99 THIN 30G...... 165 EASY COMFORT LANCETS diltiazem hcl er...... 99 DROPLET MICRON...... 176 TWIST TOP...... 166 diltiazem hcl er beads...... 99 DROPLET PEN NEEDLES...... 176 EASY COMFORT PEN NEEDLES.176 diltiazem hcl er coated beads...... 99 DROPLET PERSONAL LANCETS EASY GLIDE PEN NEEDLES...... 176 DILTIAZEM HCL-DEXTROSE...... 100 30G...... 165 EASY TOUCH FLIPLOCK DILTIAZEM HCL-SODIUM DROPSAFE SAFETY PEN INSULIN SY...... 176 CHLORIDE...... 100 NEEDLES...... 176 EASY TOUCH INSULIN SAFETY dilt-xr...... 100 drospiren-eth estrad-levomefol...... 107 SYR...... 176 DIMENHYDRINATE...... 53 drospirenone-ethinyl estradiol...... 107 EASY TOUCH INSULIN SYRINGE dimethyl fumarate...... 223 DROXIA...... 151 ...... 176 dimethyl fumarate starter pack...... 223 droxidopa...... 236 EASY TOUCH LANCETS 21G...... 166 DIPENTUM...... 141 DRUG MART LANCETS THIN EASY TOUCH LANCETS 23G...... 166 diphen...... 56 26G...... 165 EASY TOUCH LANCETS 26G...... 166 di-phen...... 56 DRUG MART ON-THE-GO EASY TOUCH LANCETS 28G...... 166 diphenhydramine hcl...... 56 LANCET 30G...... 165 EASY TOUCH LANCETS diphenoxylate-atropine...... 51 DRUG MART UNIFINE PENTIPS. 176 28G/TWIST...... 166 DIPHTHERIA-TETANUS DRUG MART UNIFINE PENTIPS EASY TOUCH LANCETS 30G...... 166 TOXOIDS DT...... 230 PLUS...... 176 EASY TOUCH LANCETS DIPRIVAN...... 143 DRUG MART UNILET LANCETS 30G/TWIST...... 166 dipyridamole...... 149 28G...... 166 EASY TOUCH LANCETS 32G...... 166 DISCOVISC...... 214 DRUG MART UNILET LANCETS EASY TOUCH LANCETS disopyramide phosphate...... 34 30G...... 166 32G/TWIST...... 166 disulfiram...... 220 DRUG MART UNILET LANCETS EASY TOUCH LANCETS DIURIL...... 130 33G...... 166 33G/TWIST...... 166 divalproex sodium...... 44 DSUVIA...... 27 EASY TOUCH PEN NEEDLES...... 176 divalproex sodium er...... 43, 44 DUAVEE...... 139 EASY TOUCH SAFETY LANCETS DIVIGEL...... 138 DUET DHA 400...... 197 21G...... 166 dobutamine hcl...... 101 DUET DHA BALANCED...... 197 EASY TOUCH SAFETY LANCETS DOBUTAMINE IN D5W...... 101 DUETACT...... 50 23G...... 166 DOCETAXEL...... 82 dulcolax...... 158 EASY TOUCH SAFETY LANCETS dofetilide...... 35 dulcolax milk of magnesia...... 158 26G...... 166 DOG EPITHELIUM...... 16 duloxetine hcl...... 46 EASY TOUCH SAFETY LANCETS DOG FENNEL...... 16 DUOBRII...... 128 28G...... 166 DOJOLVI...... 207 DUODOTE...... 51 EASY TOUCH SAFETY PEN dolishale...... 110 DUOPA...... 87 NEEDLES...... 176 donepezil hcl...... 220 DUOVISC...... 214 EASY TOUCH SHEATHLOCK dopamine hcl...... 101 DUPIXENT...... 121 SYRINGE...... 177 DOPAMINE IN D5W...... 101 DURACLON...... 23 easygel...... 190 DOPRAM...... 12 DURAGESIC-100...... 27 ec-naproxen...... 21 DOPTELET...... 153 DURAGESIC-12...... 27 econazole nitrate...... 124 DORAL...... 155 DURAGESIC-25...... 27 econtra ez...... 110 245 econtra one-step...... 110 endur-b...... 193 EQL COLOR LANCETS 21G...... 166 ecotrin low strength...... 24 ENFAMIL EXPECTA...... 200 EQL COLOR LANCETS MICRO ECOZA...... 124 ENGERIX-B...... 234 33G...... 166 EDARBI...... 61 ENHERTU...... 78 eql gentle laxative...... 159 EDARBYCLOR...... 61 ENLITE GLUCOSE SENSOR...... 166 EQL INSULIN SYRINGE...... 177 EDECRIN...... 130 enoxaparin sodium...... 39 eql laxative...... 159 EDETATE DISODIUM...... 185 enpresse-28...... 112 eql magnesium citrate...... 158 EDEX...... 102 enskyce...... 107 eql milk of magnesia...... 158 EDLUAR...... 156 ENSPRYNG...... 188 eql nicotine polacrilex...... 225 EDURANT...... 94 ENSTILAR...... 128 EQL PRENATAL FORMULA...... 197 efavirenz...... 94 entacapone...... 87 eql super b complex/vitamin c...... 191 efavirenz-emtricitab-tenofovir...... 92 entecavir...... 95 EQL SUPER THIN LANCETS 30G 166 efavirenz-lamivudine-tenofovir...... 92 ENTEREG...... 142 EQL THIN LANCETS 26G...... 166 EFUDEX...... 119 ENTOCORT EC...... 114 EQUETRO...... 88 EGRIFTA SV...... 133 ENTRESTO...... 102 ERAXIS...... 54 ELAPRASE...... 135 ENTYVIO...... 141 ERBITUX...... 73 ELCYS...... 207 enulose...... 141 ergocalciferol...... 237 ELELYSO...... 150 ENVARSUS XR...... 187 ergoloid mesylates...... 224 ELEPSIA XR...... 41 EPANED...... 60 ergotamine-caffeine...... 181 ELESTRIN...... 138 EPCLUSA...... 96 ERIVEDGE...... 74 eletriptan hydrobromide...... 181 EPHEDRINE SULFATE...... 236 ERLEADA...... 69 ELIGARD...... 81 EPHEDRINE SULFATE erlotinib hcl...... 73 elinest...... 107 (PRESSORS)...... 236 errin...... 112 ELIQUIS...... 38 EPHEDRINE SULFATE-NACL...... 237 ERTACZO...... 124 ELIQUIS DVT/PE STARTER EPICOCCUM...... 16 ertapenem sodium...... 64 PACK...... 38 EPICOCCUM NIGRUM...... 16 ERWINASE...... 78 ELITEK...... 80 EPICORD...... 127 ERWINAZE...... 78 elite-ob...... 197 EPIDIOLEX...... 41 ery...... 117 ELIXOPHYLLIN...... 38 EPIFIX...... 127 ERYGEL...... 117 ELLA...... 110 EPIFIX MICRONIZED...... 127 ery-tab...... 162 ELLENCE...... 77 EPIFOAM...... 127 ERYTHROCIN LACTOBIONATE.162 ELLIOTTS B...... 182 epinastine hcl...... 209 erythrocin stearate...... 162 ELMIRON...... 144 epinephrine...... 236 erythromycin...... 117, 162, 209 ELOCTATE...... 146 EPINEPHRINE...... 237 erythromycin base...... 162 eluryng...... 110 epinephrine (anaphylaxis)...... 236 erythromycin ethylsuccinate...... 162 ELZONRIS...... 79 EPINEPHRINE HCL...... 209 ESBRIET...... 227 EMBRACE LANCETS ULTRA EPINEPHRINE HCL-NACL...... 237 escitalopram oxalate...... 45 THIN 30G...... 166 EPINEPHRINE PF...... 237 esgic...... 23 EMCYT...... 80 EPINEPHRINE-DEXTROSE...... 237 ESKATA...... 127 EMEND...... 54 EPINEPHRINE-NACL...... 237 esmolol hcl...... 98 EMERPHED...... 236 epirubicin hcl...... 77 ESMOLOL HCL...... 98 EMGALITY...... 181 epitol...... 41 esmolol hcl-sodium chloride...... 98 EMGALITY (300 MG DOSE)...... 181 EPIVIR...... 94, 95 esomeprazole sodium...... 231 emoquette...... 107 EPIVIR HBV...... 96 ESPEROCT...... 146 EMPAVELI...... 148 eplerenone...... 63 est estrogens-methyltest...... 138 EMPLICITI...... 72 EPOGEN...... 151 estarylla...... 107 EMSAM...... 44 epoprostenol sodium...... 102 estazolam...... 155 emtricitabine...... 94 eptifibatide...... 148 ESTRADIOL...... 139 emtricitabine-tenofovir df...... 92 EPZICOM...... 92 estradiol...... 139, 236 EMTRIVA...... 94 eq aspirin...... 25 estradiol valerate...... 139 EMVERM...... 32 eq aspirin adult low dose...... 24 estradiol-norethindrone acet...... 138 enalapril maleate...... 60 eq aspirin low dose...... 24 ESTRING...... 236 enalaprilat...... 60 eq clearlax...... 157 ESTROFACTORS...... 195 enalapril-hydrochlorothiazide...... 59 eq gentle laxative...... 159 ESTROGEL...... 139 ENBRACE HR...... 197 eq magnesium citrate...... 158 ESTROSTEP FE...... 112 ENBREL...... 23 eq nicotine...... 224, 225 eszopiclone...... 156 ENBREL MINI...... 23 eq nicotine polacrilex...... 224 ethacrynate sodium...... 130 ENBREL SURECLICK...... 23 eq nicotine step 3...... 225 ethacrynic acid...... 130 ENCARE...... 235 eql aspirin ec...... 25 ethambutol hcl...... 67 ENDARI...... 150 eql aspirin low dose...... 25 ETHAMOLIN...... 189 ENDO AVITENE...... 154 eql b complex 50...... 193 ethosuximide...... 43 endocet...... 30 eql b-100 complex...... 193 ethynodiol diac-eth estradiol...... 107 ENDOMETRIN...... 236 eql clearlax...... 157 ETHYOL...... 85 246 etodolac...... 22 FARXIGA...... 50 FIRMAGON (240 MG DOSE)...... 81 etodolac er...... 22 FARYDAK...... 74 FIRVANQ...... 65 etomidate...... 143 FASENRA...... 37 flac...... 216 etonogestrel-ethinyl estradiol...... 110 FASENRA PEN...... 37 FLAGYL...... 63 ETOPOPHOS...... 82 FASLODEX...... 80 FLAREX...... 213 etoposide...... 82 fa-vitamin b-6-vitamin b-12...... 151 flavoxate hcl...... 233 etravirine...... 94 fayosim...... 111 FLEBOGAMMA DIF...... 217 EUCRISA...... 126 FC FEMALE CONDOM...... 162 flecainide acetate...... 34 EUFLEXXA...... 204 FC2 FEMALE CONDOM...... 162 FLEXBUMIN...... 149 euthyrox...... 229 febuxostat...... 145 FLEXIN...... 128 EVAMIST...... 139 feenamint...... 159 FLOLAN...... 102 EVEKEO ODT...... 12 FEIBA...... 146 FLORIVA...... 183, 196 EVENITY...... 136 felbamate...... 43 FLORIVA PLUS...... 196 everolimus...... 75, 187 FELDENE...... 22 FLOVENT DISKUS...... 37 EVERSENSE SENSOR/HOLDER...166 felodipine er...... 100 FLOVENT HFA...... 37, 38 EVERSENSE SMART FEMARA...... 80 floxuridine...... 69 TRANSMITTER...... 166 FEMCAP...... 162 FLUAD...... 234 EVISTA...... 136 FEMHRT...... 138 FLUAD QUADRIVALENT...... 234 EVKEEZA...... 57 FEMRING...... 236 FLUARIX QUADRIVALENT...... 234 EVOCLIN...... 117 femynor...... 107 FLUBLOK QUADRIVALENT...... 234 EVOMELA...... 83 fenofibrate...... 57 FLUCELVAX QUADRIVALENT... 234 EVOTAZ...... 92 fenofibrate micronized...... 57 fluconazole...... 55 EVOXAC...... 191 fenofibric acid...... 58 fluconazole in sodium chloride...... 55 EVRYSDI...... 206 FENOGLIDE...... 58 flucytosine...... 54 EXEL COMFORT POINT fenoprofen calcium...... 22 fludarabine phosphate...... 69 INSULIN SYR...... 177 FENSOLVI (6 MONTH)...... 134 fludrocortisone acetate...... 115 EXEL COMFORT POINT PEN fentanyl...... 27 FLULAVAL QUADRIVALENT...... 234 NEEDLE...... 177 fentanyl citrate...... 27 flumazenil...... 52 EXELDERM...... 124 FENTANYL CITRATE...... 27 flunisolide...... 205 EXELON...... 220 FENTANYL CITRATE (PF)...... 27 fluocinolone acetonide...... 122, 216 exemestane...... 80 fentanyl citrate (pf)...... 27 fluocinolone acetonide body...... 122 EXJADE...... 51 FENTANYL CITRATE PF...... 27 fluocinolone acetonide scalp...... 122 ex-lax ultra...... 159 FENTANYL CITRATE-NACL...... 27 fluocinonide...... 122, 123 EXONDYS 51...... 205 FENTANYL CIT-ROPIVACAINE- fluocinonide emulsified base...... 122 EXSERVAN...... 205 NACL...... 27 FLUORESCEIN EXTAVIA...... 222 FENTANYL-BUPIVACAINE- SODIUM/BENOXINATE...... 211 EXTINA...... 124 NACL...... 27 fluorescein-benoxinate...... 211 EXTRANEAL...... 188 FENTORA...... 28 FLUORESCITE...... 211 EYLEA...... 215 FERAHEME...... 153 fluoridex...... 190 EYSUVIS...... 213 FERRIPROX...... 51 fluoridex daily renewal...... 190 E-Z JECT LANCET MICRO-THIN FERRIPROX TWICE-A-DAY...... 51 fluoridex enhanced whitening...... 190 33G...... 166 FERRLECIT...... 153 fluoridex sensitivity relief...... 190 E-Z JECT LANCET SUPER THIN FETROJA...... 106 fluor-i-strips a.t...... 211 30G...... 166 FETZIMA...... 46 fluoritab...... 183 E-Z JECT LANCETS...... 166 FETZIMA TITRATION...... 46 fluorometholone...... 213 E-Z JECT LANCETS 21G...... 166 fexmid...... 203 FLUOROPLEX...... 119 E-Z JECT LANCETS THIN 26G.....166 FIBRICOR...... 58 fluorouracil...... 70, 119, 120 ezetimibe...... 58 FIBRYGA...... 146 fluoxetine hcl...... 45 ezetimibe-simvastatin...... 58 FIFTY50 PEN NEEDLES...... 177 FLUOXETINE HCL...... 45 EZ-LETS LANCETS 21G...... 166 FIFTY50 SAFETY SEAL fluoxetine hcl (pmdd)...... 224 EZ-LETS LANCETS 26G...... 166 LANCETS...... 166 fluphenazine decanoate...... 90 EZ-LETS LANCETS 28G...... 166 FIFTY50 SUPERIOR COMFORT fluphenazine hcl...... 90 EZ-LETS LANCETS 30G...... 166 SYR...... 177 flurandrenolide...... 123 fa-8...... 151 FIFTY50 UNILET LANCETS 33G..166 FLURA-SAFE...... 211 FABRAZYME...... 132 FINACEA...... 126 flurazepam hcl...... 155 FALESSA...... 107 finasteride...... 128, 143 flurbiprofen...... 22 falmina...... 107 FINE 30...... 167 flurbiprofen sodium...... 212 famciclovir...... 96 FINGERSTIX LANCETS...... 167 flutamide...... 69 famotidine...... 231 FINTEPLA...... 41 fluticasone propionate...... 123, 205 famotidine premixed...... 231 FIRAZYR...... 147 fluticasone-salmeterol...... 35 FANAPT...... 88 FIRDAPSE...... 67 fluvastatin sodium...... 58 FANAPT TITRATION PACK...... 88 FIRE ANT...... 16 fluvastatin sodium er...... 58 FARESTON...... 69 FIRMAGON...... 81 fluvoxamine maleate...... 45 247 fluvoxamine maleate er...... 45 fulvestrant...... 80 GENTEEL CONTACT TIPS FLUZONE QUADRIVALENT...... 234 furosemide...... 130 (CLEAR)...... 167 FML...... 213 FUROSEMIDE IN SODIUM GENTEEL CONTACT TIPS FML FORTE...... 213 CHLORIDE...... 130 (GREEN)...... 167 FML LIQUIFILM...... 213 FUSARIUM...... 16 GENTEEL CONTACT TIPS FOCALIN...... 14 FUZEON...... 93 (ORANGE)...... 167 folate...... 151 fyavolv...... 138 GENTEEL CONTACT TIPS FOLGARD OS...... 194 FYCOMPA...... 40 (RAINBOW)...... 167 FOLGARD RX...... 151 g tussin ac...... 115 GENTEEL CONTACT TIPS folic acid...... 151, 152 gabapentin...... 41 (VIOLET)...... 167 FOLIVANE-OB...... 197 GABLOFEN...... 203 GENTEEL CONTACT TIPS FOLOTYN...... 70 GALAFOLD...... 132 (YELLOW)...... 167 foltabs 800...... 151 galantamine hydrobromide...... 221 GENTEEL LANCING KIT (BLUE) 167 foltrin...... 153 galantamine hydrobromide er...... 221 GENTEEL NOZZLES...... 167 fomepizole...... 52 GALZIN...... 185 gentle laxative...... 159 fondaparinux sodium...... 39 GAMASTAN...... 217 gentlelax...... 157 FORA LANCETS...... 167 GAMIFANT...... 188 GENTLE-LET GP LANCETS...... 167 FORANE...... 143 GAMMAGARD...... 217 GENTLE-LET LANCETS...... 167 FORMALDEHYDE...... 91 GAMMAGARD S/D LESS IGA...... 217 GENTLE-LET PLATFORMS...... 167 formoterol fumarate...... 36 GAMMAKED...... 217 GENVOYA...... 92 FORTAZ...... 105 GAMMAPLEX...... 217 GEODON...... 88 FORTEO...... 136 GAMUNEX-C...... 217 GERMAN COCKROACH...... 16 FOSAMAX...... 131 GANCICLOVIR...... 95 GIAPREZA...... 237 FOSAMAX PLUS D...... 131 GANCICLOVIR SODIUM...... 95 GILENYA...... 226 fosamprenavir calcium...... 93 ganciclovir sodium...... 95 GILOTRIF...... 74 fosaprepitant dimeglumine...... 54 GANIRELIX ACETATE...... 132 GILPHEX TR...... 116 foscarnet sodium...... 95 GARDASIL 9...... 234 GIMOTI...... 140 FOSCAVIR...... 95 GASTROCROM...... 140 GIVLAARI...... 145 fosfomycin tromethamine...... 66 gatifloxacin...... 209 GLASSIA...... 226 fosinopril sodium...... 60 GATTEX...... 140 glatiramer acetate...... 223 fosinopril sodium-hctz...... 59 gavilax...... 157 glatopa...... 223 fosphenytoin sodium...... 43 gavilyte-c...... 157 GLEOSTINE...... 83 FOSRENOL...... 142 gavilyte-g...... 157 GLIADEL WAFER...... 83 FOTIVDA...... 76 gavilyte-n with flavor pack...... 157 glimepiride...... 50 FRAGMIN...... 39 GAVRETO...... 76 glipizide...... 50 FREAMINE HBC...... 207 GAZYVA...... 71 glipizide er...... 50 FREAMINE III...... 207 GEL-FLOW NT...... 154 glipizide xl...... 50 FREDS PHARMACY UNIFINE GELFOAM...... 154 glipizide-metformin hcl...... 50 PENTIP+...... 177 GELFOAM COMPRESSED SIZE GLOBAL EASE INJECT PEN FREDS PHARMACY UNIFINE 100...... 154 NEEDLES...... 177 PENTIPS...... 177 GELFOAM DENTAL PACK SIZE 4 GLOBAL EASY GLIDE INSULIN FREDS PHARMACY UNILET ...... 154 SYR...... 177 LANC 28G...... 167 GELFOAM SPONGE...... 154 GLOBAL EASY GLIDE PEN FREDS PHARMACY UNILET GELFOAM SPONGE SIZE 100...... 154 NEEDLES...... 177 LANC 30G...... 167 GELFOAM SPONGE SIZE 200...... 154 GLOBAL INJECT EASE INSULIN FREESTYLE LANCETS...... 167 GELFOAM SPONGE SIZE 50...... 154 SYR...... 177 FREESTYLE LIBRE 14 DAY GEL-ONE...... 204 GLOBAL INJECT EASE READER...... 167 GELSYN-3...... 204 LANCETS 28G...... 167 FREESTYLE LIBRE 14 DAY GEMCITABINE HCL...... 70 GLOBAL INJECT EASE SENSOR...... 167 gemcitabine hcl...... 70 LANCETS 30G...... 167 FREESTYLE LIBRE 2 READER....167 gemfibrozil...... 58 GLOBAL INSULIN SYRINGES...... 177 FREESTYLE LIBRE 2 SENSOR.....167 gemmily...... 107 GLOPERBA...... 145 FREESTYLE LIBRE READER...... 167 GENERESS FE...... 107 GLUCAGEN HYPOKIT...... 47 FREESTYLE LIBRE SENSOR generlac...... 141 GLUCAGON EMERGENCY...... 47 SYSTEM...... 167 gengraf...... 186 GLUCOCOM LANCETS 28G...... 167 FREESTYLE PRECISION INS SYR gentak...... 209 GLUCOCOM LANCETS 30G...... 167 ...... 177 gentamicin in saline...... 19 GLUCOCOM LANCETS 33G...... 167 FREESTYLE UNISTICK II gentamicin sulfate...... 19, 118, 209 GLUCOPRO INSULIN SYRINGE..177 LANCETS...... 167 GENTEEL BUTTERFLY TOUCH GLUCOTROL XL...... 50 fresenius propoven...... 143 LANCET...... 167 GLUTARALDEHYDE...... 91 frovatriptan succinate...... 181 GENTEEL CONTACT TIPS GLUTATHIONE...... 207 FULL SPECTRUM B/VITAMIN C.191 (BLUE)...... 167 glyburide...... 50 FULPHILA...... 152 glyburide micronized...... 50 248 glyburide-metformin...... 50 GOODSENSE LANCETS 33G HEALON...... 214 GLYCATE...... 232 UNIV...... 168 HEALON DUET PRO...... 214 glycine...... 144 goodsense magnesium citrate...... 158 HEALON GV...... 214 GLYCINE...... 207 goodsense nicotine...... 225 HEALON GV PRO...... 214 glycine urologic...... 144 GOODSENSE PEN NEEDLE HEALON PRO...... 214 glycolax...... 157 PENFINE...... 177 HEALON5...... 214 glycopyrrolate...... 232 goodsense womens laxative...... 159 HEALON5 PRO...... 214 GLYCOPYRROLATE...... 232 GOPRELTO...... 204 HEALTHWISE INSULIN GLYCOPYRROLATE PF...... 232 GRALISE...... 223 SYR/NEEDLE...... 177 glydo...... 125 granisetron hcl...... 53 HEALTHWISE MICRON PEN GLYNASE...... 50 GRANIX...... 152 NEEDLES...... 177 GLYRX-PF...... 232 GRASS POLLEN(K-O-R-T-SWT HEALTHWISE MINI PEN gnp adult aspirin low strength...... 25 VERN)...... 16 NEEDLES...... 177 gnp aspirin...... 25 GRASTEK...... 16 HEALTHWISE PEN NEEDLES...... 177 gnp aspirin low dose...... 25 griseofulvin microsize...... 54 HEALTHWISE SHORT PEN gnp b-100 complex...... 193 griseofulvin ultramicrosize...... 55 NEEDLES...... 177 gnp b-50 complex...... 193 guaiatussin ac...... 115 HEALTHWISE UNIFINE PENTIPS gnp b-complex plus vitamin c...... 191 guaifenesin ac...... 115 ...... 177 gnp clearlax...... 157 guaifenesin-codeine...... 115 HEALTHY ACCENTS UNIFINE GNP CLICKFINE PEN NEEDLES. 177 guanfacine hcl...... 62 PENTIP...... 177 gnp essential one daily...... 195 guanfacine hcl er...... 11 HEALTHY ACCENTS UNILET gnp folic acid...... 152 GUARDIAN CONNECT LANCETS...... 168 gnp gentle laxative...... 159 TRANSMITTER...... 168 healthy hair/skin/nails...... 195 GNP INSULIN SYRINGE...... 177 GUARDIAN LINK 3 healthylax...... 158 GNP LANCETS 21G...... 167 TRANSMITTER...... 168 heather...... 112 GNP LANCETS MICRO THIN 33G GUARDIAN REAL-TIME h-e-b aspirin...... 25 ...... 167 REPLACE PED...... 168 H-E-B INCONTROL LANCETS GNP LANCETS SUPER THIN 30G 167 GUARDIAN SENSOR (3)...... 168 28G...... 168 GNP LANCETS THIN...... 167 GUARDIAN SENSOR 3...... 168 H-E-B INCONTROL LANCETS GNP LANCETS THIN 26G...... 167 GVOKE HYPOPEN 1-PACK...... 47 30G...... 168 gnp milk of magnesia...... 158 GVOKE HYPOPEN 2-PACK...... 47 H-E-B INCONTROL LANCETS gnp nicotine...... 225 GVOKE PFS...... 47 33G...... 168 gnp nicotine mini...... 225 GYNAZOLE-1...... 235 H-E-B INCONTROL PEN gnp nicotine polacrilex...... 225 habitrol...... 225 NEEDLES...... 177 GNP PRENATAL...... 197 HACKBERRY...... 16 H-E-B INCONTROL UNIFINE GNP ULTICARE PEN NEEDLES...177 HAEGARDA...... 147 PENTIP...... 177 GNP ULTRA COM INSULIN HAEMOLANCE...... 168 HECTOROL...... 134 SYRINGE...... 177 HAEMOLANCE LOW FLOW HELIDAC THERAPY...... 232 gnp womens gentle laxative...... 159 LANCETS...... 168 HEMABATE...... 216 GOCOVRI...... 86 HAEMOLANCE PLUS...... 168 HEMADY...... 114 GOJJI STERILE LANCETS...... 167 HAEMOLANCE PLUS HIGH HEMANGEOL...... 98 GOLDENROD...... 16 FLOW...... 168 HEMLIBRA...... 145 GOLYTELY...... 157 HAEMOLANCE PLUS LOW HEMOFIL M...... 146 GONAL-F...... 135 FLOW...... 168 HEPAGAM B...... 217 GONAL-F RFF...... 135 HAEMOLANCE PLUS MAX heparin (porcine) in nacl...... 39 GONAL-F RFF REDIJECT...... 135 FLOW...... 168 HEPARIN (PORCINE) IN NACL...... 39 GONITRO...... 32 HAEMOLANCE PLUS heparin lock flush...... 39 goodsense aspirin...... 25 PEDIATRIC FLOW...... 168 HEPARIN SOD (PORCINE) IN goodsense aspirin adult low st...... 25 hailey 1.5/30...... 107 D5W...... 39 goodsense aspirin adults...... 25 hailey 24 fe...... 107 heparin sod (porcine) in d5w...... 39 goodsense aspirin low dose...... 25 hailey fe 1.5/30...... 108 heparin sodium (porcine)...... 39 goodsense bisacodyl ec...... 159 hailey fe 1/20...... 108 HEPARIN SODIUM (PORCINE)...... 39 goodsense clearlax...... 158 HALAVEN...... 82 heparin sodium (porcine) pf...... 39 GOODSENSE CLICKFINE PEN halcinonide...... 123 HEPARIN SODIUM (PORCINE) NEEDLE...... 177 HALCION...... 155 PF...... 39 GOODSENSE COLOR LANCETS HALDOL...... 89 heparin sodium lock flush...... 39 33G...... 168 HALDOL DECANOATE...... 89 HEPLISAV-B...... 234 GOODSENSE LANCETS 26G halobetasol propionate...... 123 HEPSERA...... 96 UNIV...... 168 haloperidol...... 89 HERCEPTIN...... 72 GOODSENSE LANCETS 30G...... 168 haloperidol decanoate...... 89 HERCEPTIN HYLECTA...... 78 GOODSENSE LANCETS 30G haloperidol lactate...... 89 HERZUMA...... 72 UNIV...... 168 HARVONI...... 96 HESPAN...... 148 GOODSENSE LANCETS 33G...... 168 HAVRIX...... 234 hetastarch-nacl...... 148 249 HETLIOZ...... 157 HUMULIN N KWIKPEN...... 48 IDELVION...... 146 HETLIOZ LQ...... 157 HUMULIN R...... 48 IDHIFA...... 81 HEXTEND...... 148 HUMULIN R U-500 IFEX...... 83 HIBERIX...... 233 (CONCENTRATED)...... 48 ifosfamide...... 83 HIGH POTENCY HUMULIN R U-500 KWIKPEN...... 48 IFOSFAMIDE...... 83 MULTIVITAMIN...... 195 HYALGAN...... 204 ILARIS...... 21 HIPREX...... 66 HYALURONIDASE ILEVRO...... 212 HISTEX-AC...... 116 (INTRAOCULAR)...... 214 ILIDERM...... 125 HIZENTRA...... 217 HYCAMTIN...... 84 ILUVIEN...... 213 hm adult aspirin...... 25 HYCODAN...... 115 imatinib mesylate...... 73 hm aspirin...... 25 hydralazine hcl...... 63 IMBRUVICA...... 73 hm aspirin ec...... 25 HYDREA...... 79 IMCIVREE...... 13 hm aspirin ec low dose...... 25 hydrochlorothiazide...... 130 IMFINZI...... 72 hm b complex/c...... 192 hydrocod polst-cpm polst er...... 116 imipenem-cilastatin...... 64 hm clearlax...... 158 hydrocodone bitartrate er...... 28 imipramine hcl...... 46 hm folic acid...... 152 hydrocodone-acetaminophen...... 27 imipramine pamoate...... 46 hm laxative...... 159 hydrocodone-homatropine...... 115 imiquimod...... 125 hm magnesium citrate...... 158 hydrocodone-ibuprofen...... 27 imiquimod pump...... 125 hm milk of magnesia...... 159 hydrocortisone...... 31, 114, 123 IMLYGIC...... 83 hm nicotine...... 225 hydrocortisone (perianal)...... 32 IMOGAM RABIES-HT...... 217 hm nicotine polacrilex...... 225 hydrocortisone ace-pramoxine...... 31 IMOVAX RABIES...... 234 HM ONE DAILY PRENATAL...... 197 hydrocortisone butyr lipo base...... 123 IMPAVIDO...... 63 hm one daily/iron...... 194 hydrocortisone butyrate...... 123 IMURAN...... 189 HM PRENATAL...... 197 hydrocortisone valerate...... 123 IMVEXXY MAINTENANCE PACK HM ULTICARE INSULIN hydrocortisone-acetic acid...... 216 ...... 236 SYRINGE...... 177 hydromet...... 115 IMVEXXY STARTER PACK...... 236 HM ULTICARE MINI PEN hydromorphone hcl...... 28 IN TOUCH STERILE LANCETS NEEDLES...... 177 hydromorphone hcl er...... 28 30G...... 168 HM ULTICARE SHORT PEN HYDROMORPHONE HCL PF...... 28 inatal gt...... 197 NEEDLES...... 177 hydromorphone hcl pf...... 28 INBRIJA...... 86 hm vitamin b complex/vitamin c...... 191 HYDROMORPHONE HCL-NACL...28 incassia...... 112 hm vitamin b100 complex...... 193 hydroxocobalamin acetate...... 150 INCRELEX...... 134 hm vitamin b50 complex...... 193 hydroxychloroquine sulfate...... 67 indapamide...... 130 HONEY BEE VENOM...... 16 hydroxyprogesterone caproate...... 84, 219 INDERAL XL...... 98 HONEY BEE VENOM PROTEIN.....16 hydroxyurea...... 79 indomethacin...... 22 HORIZANT...... 224 hydroxyzine hcl...... 33 indomethacin er...... 22 HORSE EPITHELIUM...... 16 hydroxyzine pamoate...... 33 indomethacin sodium...... 22 HUMALOG...... 48 HYLENEX...... 186 INFANRIX...... 230 HUMALOG JUNIOR KWIKPEN..... 48 HYMOVIS...... 204 INFASURF...... 228 HUMALOG KWIKPEN...... 48 hyoscyamine sulfate...... 231 INFED...... 153 HUMALOG MIX 50/50...... 48 hyoscyamine sulfate er...... 231 INFLECTRA...... 142 HUMALOG MIX 50/50 KWIKPEN.. 48 hyoscyamine sulfate sl...... 231 INFUGEM...... 70 HUMALOG MIX 75/25...... 48 HYPERHEP B...... 217 INFUMORPH 200...... 28 HUMALOG MIX 75/25 KWIKPEN.. 48 HYPERRAB...... 217 INFUMORPH 500...... 28 HUMAN ALBUMIN GRIFOLS...... 149 HYPERRHO S/D...... 217 INFUVITE ADULT...... 195 HUMATE-P...... 146 HYPERSAL...... 116 INFUVITE PEDIATRIC...... 197 HUMATIN...... 19 HYPERTET S/D...... 217 INGREZZA...... 221 HUMATROPE...... 133 HYPOLANCE AST LANCING...... 168 INJECTAFER...... 153 HUMIRA...... 21 HYQVIA...... 218 INLYTA...... 85 HUMIRA PEDIATRIC CROHNS HY-VEE LANCETS...... 168 inner ear plus...... 202 START...... 20 HY-VEE THIN LANCETS...... 168 INNOPRAN XL...... 98 HUMIRA PEN...... 20 ibandronate sodium...... 131 INQOVI...... 78 HUMIRA PEN-CD/UC/HS IBRANCE...... 80 INREBIC...... 81 STARTER...... 20 ibu...... 22 INSPRA...... 63 HUMIRA PEN-PEDIATRIC UC ibuprofen...... 22 INSTAT...... 154 START...... 20 ibuprofen lysine...... 22 INSULIN LISPRO...... 48 HUMIRA PEN-PS/UV/ADOL HS ibutilide fumarate...... 35 INSULIN LISPRO (1 UNIT DIAL)....48 START...... 21 icatibant acetate...... 147 INSULIN LISPRO JUNIOR HUMIRA PEN-PSOR/UVEIT iclevia...... 111 KWIKPEN...... 48 STARTER...... 21 ICLUSIG...... 73 INSULIN LISPRO PROT & HUMULIN 70/30...... 48 icosapent ethyl...... 57 LISPRO...... 48 HUMULIN 70/30 KWIKPEN...... 48 IDAMYCIN PFS...... 77 INSULIN SYRINGE...... 177 HUMULIN N...... 48 idarubicin hcl...... 78 INSULIN SYRINGE/NEEDLE...... 177 250 INSULIN SYRINGE-NEEDLE U- JANUMET XR...... 47, 48 KETAMINE HCL...... 143 100...... 177 JANUVIA...... 47 KETAMINE HCL-SODIUM INSUPEN PEN NEEDLES...... 177 JARDIANCE...... 50 CHLORIDE...... 143 INSUPEN SENSITIVE...... 178 jasmiel...... 108 ketoconazole...... 55, 124 INSUPEN ULTRAFIN...... 178 JATENZO...... 31 ketoprofen...... 22 INTELENCE...... 94 JELMYTO...... 78 ketoprofen er...... 22 INTERCEED...... 154 JEMPERLI...... 72 ketorolac tromethamine...... 22, 212 INTERCEED (TC7)...... 154 jencycla...... 112 KEVEYIS...... 129 INTRALIPID...... 207 JENLIVA KEYTRUDA...... 72 INTRAROSA...... 235 PRENATAL/POSTNATAL...... 197 KHAPZORY...... 80 INTRON A...... 79 JEVTANA...... 82 KIMYRSA...... 65 introvale...... 111 jinteli...... 138 KINNEY LANCETS...... 168 INVANZ...... 64 JIVI...... 146 KINNEY THIN LANCETS...... 168 INVEGA SUSTENNA...... 88 JOHNSON GRASS...... 16 KINRAY INSULIN SYRINGE...... 178 INVEGA TRINZA...... 88 jolessa...... 111 KINRIX...... 230 INVELTYS...... 213 JORNAY PM...... 14 KISQALI (200 MG DOSE)...... 80 INVIRASE...... 93 JUBLIA...... 124 KISQALI (400 MG DOSE)...... 80 IODINE TINCTURE...... 91 juleber...... 108 KISQALI (600 MG DOSE)...... 80 IODOFLEX...... 91 JULUCA...... 92 KISQALI FEMARA (400 MG IODOSORB...... 91 JUNE GRASS POLLEN DOSE)...... 78 IONOSOL-MB IN D5W...... 182 STANDARDIZED...... 16 KISQALI FEMARA (600 MG IOPIDINE...... 212 junel 1.5/30...... 108 DOSE)...... 78 IPOL...... 234 junel 1/20...... 108 KISQALI FEMARA(200 MG ipratropium bromide...... 36, 204 junel fe 1.5/30...... 108 DOSE)...... 78 ipratropium-albuterol...... 35 junel fe 1/20...... 108 KLARON...... 117 irbesartan...... 61 junel fe 24...... 108 KLISYRI...... 125 irbesartan-hydrochlorothiazide...... 61 JUXTAPID...... 58 klor-con...... 184 IRESSA...... 74 JYNARQUE...... 136 klor-con 10...... 184 irinotecan hcl...... 84 KABIVEN...... 208 klor-con m10...... 184 ISENTRESS...... 93 KADCYLA...... 78 klor-con m15...... 184 ISENTRESS HD...... 93 kaitlib fe...... 108 klor-con m20...... 184 isibloom...... 108 KALBITOR...... 148 kls aspirin low dose...... 25 isoflurane...... 143 KALETRA...... 92 kls laxaclear...... 158 ISOLYTE-P IN D5W...... 182 kalliga...... 108 kls quit2...... 225 ISOLYTE-S...... 183 KALYDECO...... 227 kls quit4...... 225 ISOLYTE-S PH 7.4...... 183 KANJINTI...... 72 KMART VALU INSULIN isoniazid...... 67 KANUMA...... 135 SYRINGE 29G...... 178 isoproterenol hcl...... 36 KAPOK...... 16 KMART VALU INSULIN ISOPROTERENOL-SODIUM KAPSPARGO SPRINKLE...... 98 SYRINGE 30G...... 178 CHLORIDE...... 36 KAPVAY...... 11 KOATE...... 146 ISOPTO ATROPINE...... 209 KARBINAL ER...... 56 KOATE-DVI...... 146 ISOPTO CARPINE...... 209 KARDIAMEMBRANE...... 127 kobee...... 192 ISORDIL TITRADOSE...... 32 kariva...... 106 KOCHIA...... 16 isosorbide dinitrate...... 32 KATERZIA...... 100 KOGENATE FS...... 146 isosorbide mononitrate...... 32 KCENTRA...... 146 KORLYM...... 50 isosorbide mononitrate er...... 32 KCL (IN NACL 0.9%)...... 183 KOSELUGO...... 75 isotretinoin...... 118 kcl in dextrose-nacl...... 182 KOSHER PRENATAL PLUS IRON197 isradipine...... 100 KCL IN DEXTROSE-NACL...... 182 KOVALTRY...... 146 ISTODAX (OVERFILL)...... 74 KCL-LACTATED RINGERS-D5W 182 kp aspirin...... 25 ISTURISA...... 132 KEDBUMIN...... 149 kp b complex-c...... 191 ISUPREL...... 36 KEDRAB...... 217 kp bisacodyl...... 159 itraconazole...... 55 KEFLEX...... 104 kp folic acid...... 152 ivermectin...... 32, 126 kelnor 1/35...... 108 KP PRENATAL MULTIVITAMINS IXEMPRA KIT...... 82 kelnor 1/50...... 108 ...... 197 IXIARO...... 234 KENALOG...... 114 K-PHOS...... 183 IXINITY...... 146 KENALOG-80...... 114 K-PHOS NO 2...... 144 JADENU...... 51 KENDALL HYDROGEL WOUND K-PHOS-NEUTRAL...... 183 JADENU SPRINKLE...... 52 DRESS...... 128 KPN PRENATAL...... 197 jaimiess...... 111 KENGREAL...... 148 KRINTAFEL...... 67 JAKAFI...... 81 KEPIVANCE...... 80 KRISTALOSE...... 158 JALYN...... 144 KESIMPTA...... 222 KROGER HEALTHPRO LANCET jantoven...... 38 KETALAR...... 143 26G...... 168 JANUMET...... 47 ketamine hcl...... 143 KROGER INSULIN SYRINGE...... 178 251 KROGER LANCETS...... 168 LEADER INSULIN SYRINGE...... 178 LIDOCAINE HCL (CARDIAC) PF...34 KROGER LANCETS 21G...... 168 LEADER UNIFINE PENTIPS...... 178 lidocaine hcl (cardiac) pf...... 34 KROGER LANCETS MICRO LEADER UNIFINE PENTIPS PLUS lidocaine hcl (pf)...... 161 THIN 33G...... 168 ...... 178 lidocaine hcl urethral/mucosal...... 125 KROGER LANCETS SUPER THIN leena...... 112 lidocaine in d5w...... 34 ...... 168 leflunomide...... 23 LIDOCAINE IN DEXTROSE...... 161 KROGER LANCETS THIN...... 168 LEMTRADA...... 222 lidocaine viscous hcl...... 189 KROGER LANCETS THIN 26G.....168 LENSCALE...... 17 lidocaine-epinephrine...... 160 KROGER LANCETS ULTRATHIN LENVIMA (10 MG DAILY DOSE)... 85 LIDOCAINE-EPINEPHRINE...... 211 30G...... 168 LENVIMA (12 MG DAILY DOSE)... 85 LIDOCAINE-PHENYLEPHRINE...211 KROGER PEN NEEDLES...... 178 LENVIMA (14 MG DAILY DOSE)... 85 LIDOCAINE-PHENYLEPHRINE- KRYSTEXXA...... 145 LENVIMA (18 MG DAILY DOSE)... 85 BSS...... 211 K-TAB...... 184 LENVIMA (20 MG DAILY DOSE)... 85 lidocaine-prilocaine...... 128 kurvelo...... 108 LENVIMA (24 MG DAILY DOSE)... 85 LIDOCAINE-SODIUM KUVAN...... 136 LENVIMA (4 MG DAILY DOSE)..... 85 BICARBONATE...... 160 KYLEENA...... 112 LENVIMA (8 MG DAILY DOSE)..... 85 LIFESCAN UNISTIK 2...... 169 KYNMOBI...... 87 lessina...... 108 LIFESCAN UNISTIK II LANCETS 169 KYPROLIS...... 76 letrozole...... 80 LILETTA (52 MG)...... 112 labetalol hcl...... 97 leucovorin calcium...... 80, 81 lillow...... 108 LABETALOL HCL-DEXTROSE...... 97 LEUKERAN...... 83 LINCOCIN...... 65 LABETALOL HCL-SODIUM LEUKINE...... 152 lincomycin hcl...... 65 CHLORIDE...... 97 leuprolide acetate...... 81 lindane...... 126 lactated ringers...... 183, 187 LEUPROLIDE ACETATE- linezolid...... 66 LACTIC ACID...... 124 BUPIVACAINE...... 75 linezolid in sodium chloride...... 66 LACTIC ACID E...... 124 levalbuterol hcl...... 36 LINZESS...... 140 LACTULOSE...... 158 levalbuterol tartrate...... 36 LIORESAL...... 203 lactulose...... 158 LEVEMIR...... 49 liothyronine sodium...... 229 lactulose encephalopathy...... 142 LEVEMIR FLEXTOUCH...... 49 LIPO...... 207 lamivudine...... 95, 96 levetiracetam...... 41 lipo flavonoid plus...... 202 lamivudine-zidovudine...... 92 levetiracetam er...... 41 LIPO-B...... 150 lamotrigine...... 41 LEVETIRACETAM IN NACL...... 41 LIPO-C...... 207 lamotrigine er...... 41 levobunolol hcl...... 208 LIPOFEN...... 58 lamotrigine starter kit-blue...... 41 levocarnitine...... 132 lipoflavovit...... 202 lamotrigine starter kit-green...... 41 levocarnitine sf...... 132 LIPOTRIAD...... 202 lamotrigine starter kit-orange...... 41 levocetirizine dihydrochloride...... 56 lisinopril...... 60 LAMPIT...... 64 levofloxacin...... 139, 209 lisinopril-hydrochlorothiazide...... 59 LANCET TRANSPORTER CASE.. 168 levofloxacin in d5w...... 139 LITE TOUCH LANCETS...... 169 LANCETS...... 168 levoleucovorin calcium...... 81 LITETOUCH INSULIN SYRINGE.178 LANCETS 30G...... 169 levoleucovorin calcium pf...... 81 LITETOUCH LANCETS...... 169 LANCETS 33G...... 169 levonest...... 112 LITETOUCH PEN NEEDLES...... 178 LANCETS MICRO THIN 33G...... 169 levonorgest-eth est & eth est...... 111 lithium carbonate...... 87 LANCETS SUPER THIN 28G...... 169 levonorgest-eth estrad 91-day...... 111 lithium carbonate er...... 87 LANCETS THIN...... 169 levonorgestrel...... 110 LITHOSTAT...... 145 LANCETS ULTRA THIN...... 169 levonorgestrel-ethinyl estrad...... 108, 110 LIVE BETTER LANCET SUPER LANCETS ULTRA THIN 30G...... 169 levonorg-eth estrad triphasic...... 112 THIN...... 169 LANOXIN...... 101 LEVOPHED...... 237 LIVE BETTER LANCET ULTRA LANOXIN PEDIATRIC...... 101 levora 0.15/30 (28)...... 108 THIN...... 169 lanthanum carbonate...... 142 levorphanol tartrate...... 28 lmd in d5w...... 148 LANTUS...... 49 levo-t...... 229 lmd in nacl...... 148 LANTUS SOLOSTAR...... 49 LEVOTHYROXINE SODIUM...... 229 LO LOESTRIN FE...... 106 lapatinib ditosylate...... 76 levothyroxine sodium...... 229 LODINE...... 22 larin 1.5/30...... 108 levoxyl...... 229 LODOSYN...... 86 larin 1/20...... 108 LEVULAN KERASTICK...... 126 loestrin 1.5/30 (21)...... 108 larin 24 fe...... 108 LEXIVA...... 93 loestrin 1/20 (21)...... 108 larin fe 1.5/30...... 108 LIBERTY MEDICAL LANCETS....169 loestrin fe 1.5/30...... 108 larin fe 1/20...... 108 LIBRAX...... 230 loestrin fe 1/20...... 108 larissia...... 108 LIBTAYO...... 72 lojaimiess...... 111 LASIX...... 130 lidocaine...... 125 LOKELMA...... 189 latanoprost...... 215 LIDOCAINE (ANORECTAL)...... 31 LOMAIRA...... 12 LATISSE...... 126 lidocaine hcl...... 125, 161, 189 LOMOTIL...... 51 LATUDA...... 88 LIDOCAINE HCL...... 161 LONGS INSULIN SYRINGE...... 178 laxative...... 159 LIDOCAINE HCL (CARDIAC)...... 34 LONGS LANCETS STANDARD.....169 layolis fe...... 108 lidocaine hcl (cardiac)...... 34 LONGS LANCETS THIN...... 169 252 LONGS LANCETS ULTRA THIN..169 MAGELLAN INSULIN SAFETY MEDLANCE PLUS EXTRA 21G.... 169 LONHALA MAGNAIR REFILL SYR...... 178 MEDLANCE PLUS LANCETS...... 169 KIT...... 36 magnesium citrate...... 159 MEDLANCE PLUS LITE 25G...... 169 LONHALA MAGNAIR STARTER MAGNESIUM SULFATE...... 183 MEDLANCE PLUS SPECIAL KIT...... 36 MAGNESIUM SULFATE IN D5W. 183 0.8MM...... 169 LONSURF...... 78 MAKENA...... 219 MEDLANCE PLUS SUPERLITE loperamide hcl...... 51 MALARONE...... 67 30G...... 169 LOPID...... 58 malathion...... 126 MEDLANCE PLUS UNIVERSAL lopinavir-ritonavir...... 92 manganese chloride...... 183 21G...... 169 LOPROX...... 119 mannitol...... 130 MEDLANCE UNIVERSAL 21G...... 169 lorazepam...... 33 MARATHON MEDICAL PENTIPS178 MEDROL...... 114 lorazepam intensol...... 33 MARCAINE...... 161 medroxyprogesterone acetate...... 112, 219 LORBRENA...... 70 MARCAINE PRESERVATIVE mefenamic acid...... 22 loryna...... 108 FREE...... 161 mefloquine hcl...... 67 lorzone...... 203 MARCAINE SPINAL...... 161 mega multiple/chelated mineral...... 202 losartan potassium...... 61 MARCAINE/EPINEPHRINE...... 160 megestrol acetate...... 84, 220 losartan potassium-hctz...... 61 MARCAINE/EPINEPHRINE PF.....160 meijer aspirin ec...... 25 LOSEASONIQUE...... 111 MAR-COF BP...... 116 MEIJER LANCETS...... 169 LOTEMAX...... 213 MAR-COF CG EXPECTORANT....115 MEIJER LANCETS THIN...... 169 LOTEMAX SM...... 213 MARGENZA...... 72 MEIJER LANCETS UNIVERSAL LOTENSIN...... 60 MARINOL...... 54 21G...... 169 LOTENSIN HCT...... 59 marlissa...... 108 MEIJER LANCETS UNIVERSAL loteprednol etabonate...... 214 MARPLAN...... 44 30G...... 169 LOTRONEX...... 141 MARQIBO...... 82 MEIJER LANCETS UNIVERSAL lovastatin...... 58 MATULANE...... 79 33G...... 169 low-ogestrel...... 108 matzim la...... 100 MEIJER PEN NEEDLES...... 178 loxapine succinate...... 89 MAVENCLAD (10 TABS)...... 221 MEIJER SUPER THIN LANCETS. 169 lo-zumandimine...... 108 MAVENCLAD (4 TABS)...... 222 MEKINIST...... 75 lubiprostone...... 140 MAVENCLAD (5 TABS)...... 222 MEKTOVI...... 75 LUCEMYRA...... 220 MAVENCLAD (6 TABS)...... 222 MELALEUCA...... 17 LUCENTIS...... 215 MAVENCLAD (7 TABS)...... 222 meloxicam...... 22 luliconazole...... 124 MAVENCLAD (8 TABS)...... 222 melphalan...... 83 LUMAKRAS...... 75 MAVENCLAD (9 TABS)...... 222 melphalan hcl...... 83 LUMIGAN...... 215 MAXICOMFORT II PEN NEEDLE178 memantine hcl...... 223 LUMIZYME...... 132 MAXI-COMFORT INSULIN memantine hcl er...... 223 LUMOXITI...... 71 SYRINGE...... 178 MEMBRANEBLUE...... 214 LUPANETA PACK...... 134 MAXI-COMFORT SAFETY PEN MENACTRA...... 233 LUPKYNIS...... 186 NEEDLE...... 178 M-END PE...... 116 LUPRON DEPOT (1-MONTH)....81, 82 MAXICOMFORT SYR 27G X 1/2".178 MENEST...... 139 LUPRON DEPOT (3-MONTH)...... 82 MAXIDEX...... 214 MENOPUR...... 135 LUPRON DEPOT (4-MONTH)...... 82 MAXITROL...... 213 MENOSTAR...... 139 LUPRON DEPOT (6-MONTH)...... 82 maxi-tuss ac...... 115 MENQUADFI...... 233 LUPRON DEPOT-PED (1-MONTH) MAXI-TUSS CD...... 116 MENTAX...... 119 ...... 134 MAXZIDE...... 129 MENVEO...... 233 LUPRON DEPOT-PED (3-MONTH) MAXZIDE-25...... 129 meperidine hcl...... 28 ...... 134 MAYZENT...... 226 MEPHYTON...... 237 LUTATHERA...... 79 MAYZENT STARTER PACK...... 226 meprobamate...... 33 lutera...... 108 M-CLEAR WC...... 115 MEPRON...... 64 LUZU...... 124 MEADOW FESCUE GRASS MEPSEVII...... 135 lyleq...... 112 POLLEN...... 17 mercaptopurine...... 70 lyllana...... 139 meclizine hcl...... 53 meropenem...... 64 LYNPARZA...... 84 meclofenamate sodium...... 22 MEROPENEM-SODIUM LYRICA CR...... 223, 224 MEDIC INSULIN SYRINGE...... 178 CHLORIDE...... 64 LYSINE HCL...... 207 MEDICHOICE SAFETY LANCET 169 merzee...... 108 LYSODREN...... 69 MEDICHOICE SAFETY LANCET mesalamine...... 141 LYSTEDA...... 154 EXTRA...... 169 mesalamine er...... 141 lyza...... 112 MEDICHOICE SAFETY LANCET mesalamine-cleanser...... 141 M.V.I. ADULT...... 195 NORM...... 169 mesna...... 85 M.V.I. PEDIATRIC...... 197 MEDICINE SHOPPE PEN MESNEX...... 85 MACROBID...... 66 NEEDLES...... 178 MESQUITE...... 17 MACRODANTIN...... 66 MEDISENSE THIN LANCETS...... 169 MESTINON...... 67 mafenide acetate...... 121 MEDLANCE EXTRA 21G...... 169 metaxalone...... 203 MEDLANCE LITE 25G...... 169 metformin hcl...... 47 253 metformin hcl er...... 47 MIDAZOLAM-SODIUM MONOFERRIC...... 153 METHADONE HCL...... 28 CHLORIDE...... 156 MONOJECT BONE MARROW methadone hcl...... 28 midodrine hcl...... 237 BIOPSY...... 161 methadone hcl intensol...... 28 MIFEPREX...... 131 monoject flush syringe...... 184 METHADOSE...... 28 mifepristone...... 131 MONOJECT INSULIN SYRINGE..178 methadose...... 28 migergot...... 181 monoject sodium chloride flush...... 184 METHADOSE SUGAR-FREE...... 28 miglitol...... 47 MONOJECT ULTRA COMFORT methazolamide...... 129 miglustat...... 150 SYRINGE...... 178 methenamine hippurate...... 66 mili...... 109 MONOLET LANCETS...... 170 methergine...... 216 milk of magnesia...... 159 MONOLET OPD LANCETS...... 170 methimazole...... 229 milk of magnesia concentrate...... 159 MONOLETTOR SAFETY methocarbamol...... 203 millguard...... 151 LANCETS...... 170 METHOHEXITAL SODIUM...... 143 MILLIPRED...... 114 mono-linyah...... 109 methotrexate...... 70 milrinone lactate...... 101 MONONINE...... 146 methotrexate sodium...... 70 milrinone lactate in dextrose...... 101 MONOVISC...... 204 methotrexate sodium (pf)...... 70 mimvey...... 138 montelukast sodium...... 37 methoxsalen rapid...... 120 MINASTRIN 24 FE...... 109 MONUROL...... 66 methscopolamine bromide...... 232 mineral oil heavy...... 158 morgidox...... 229 METHYLCOBALAMIN...... 151 MINILINK REAL-TIME MORPHINE SULFATE...... 29 methyldopa...... 62 TRANSMITTER...... 169 morphine sulfate...... 29 methylergonovine maleate...... 216 MINIMED 630G GUARDIAN morphine sulfate (concentrate)...... 28 METHYLIN...... 14 PRESS...... 170 morphine sulfate (pf)...... 28 methylphenidate hcl...... 14 MINIMED GUARDIAN LINK 3...... 170 MORPHINE SULFATE (PF)...... 28 methylphenidate hcl er...... 14 MINIPRESS...... 62 morphine sulfate er...... 28, 29 METHYLPHENIDATE HCL ER...... 14 minitran...... 32 morphine sulfate er beads...... 28 methylphenidate hcl er (cd)...... 14 MINOCIN...... 228 MORPHINE SULFATE-NACL...... 29 methylphenidate hcl er (la)...... 14 minocycline hcl...... 228 MOTOFEN...... 51 methylphenidate hcl er (xr)...... 14 minocycline hcl er...... 228 MOUNTAIN CEDAR...... 17 methylprednisolone...... 114 minoxidil...... 63 MOUSE EPITHELIUM...... 17 methylprednisolone sodium succ...... 114 MIOCHOL-E...... 209 MOVANTIK...... 142 metoclopramide hcl...... 140 MIOSTAT...... 209 MOVIPREP...... 157 METOCLOPRAMIDE HCL...... 140 MIRAPEX...... 87 MOXEZA...... 210 metolazone...... 130 MIRAPEX ER...... 87 MOXIFLOXACIN HCL...... 139, 210 metoprolol succinate er...... 98 MIRCERA...... 151 moxifloxacin hcl...... 139, 210 metoprolol tartrate...... 98 MIRCETTE...... 106 moxifloxacin hcl (2x day)...... 210 metoprolol-hydrochlorothiazide...... 62 MIRENA (52 MG)...... 112 moxifloxacin hcl in nacl...... 139 METROCREAM...... 126 mirtazapine...... 44 MOZOBIL...... 151 metronidazole...... 63, 126, 235 MIRVASO...... 126 MPD SAFETY LANCET 21G...... 170 metronidazole in nacl...... 63 misoprostol...... 232 MPD SAFETY LANCET 23G...... 170 METRONIDAZOLE IN NACL...... 63 MITE (D. FARINAE)...... 17 MPD SAFETY LANCET 28G...... 170 metyrosine...... 60 MITE (D. PTERONYSSINUS)...... 17 MPD SAFETY LANCET 30G...... 170 mexiletine hcl...... 34 mitigo...... 28 MS INSULIN SYRINGE...... 178 MI PASTE...... 163 mitomycin...... 78 MUCOR...... 17 MI PASTE PLUS...... 163 MITOMYCIN...... 78, 210 MUGWORT...... 17 MIACALCIN...... 132 MITOSOL...... 210 MULPLETA...... 153 mibelas 24 fe...... 108 mitoxantrone hcl...... 78 MULTAQ...... 35 micafungin sodium...... 54 MIXED ASPERGILLUS...... 19 MULTI PRENATAL...... 197 miconazole 3...... 235 MIXED FEATHERS...... 19 MULTI VITAMIN...... 195 miconazole-zinc oxide-petrolat...... 119 MIXED RAGWEED...... 17 multi vitamin daily...... 195 MICRHOGAM ULTRA- MIXED VESPID VENOM MULTI VITAMIN W/D-3...... 195 FILTERED PLUS...... 217 PROTEIN...... 17 multi-day...... 195 MICRODOT PEN NEEDLE...... 178 mm clearlax...... 158 multi-day plus iron...... 194 microgestin 1.5/30...... 108 MM INSULIN SYRINGE/NEEDLE 178 MULTI-LANCET DEVICE 2...... 170 microgestin 1/20...... 109 MM PEN NEEDLES...... 178 multiple vitamin-folic acid...... 195 microgestin 24 fe...... 109 MM TWIST LANCETS...... 170 multiple vitamins...... 195 microgestin fe 1.5/30...... 109 M-M-R II...... 233 multiple vitamins essential...... 195 microgestin fe 1/20...... 109 M-NATAL PLUS...... 197 multiple vitamins/iron...... 194 MICROLET LANCETS...... 169 modafinil...... 14 multi-vit/iron/fluoride...... 196 MIDAZOLAM...... 156 moexipril hcl...... 60 MULTIVITAMIN...... 195 midazolam hcl...... 156 molindone hcl...... 90 multi-vitamin...... 195 midazolam hcl (pf)...... 156 mometasone furoate...... 123, 205 MULTIVITAMIN ADULT...... 195 MIDAZOLAM HCL-SODIUM mondoxyne nl...... 229 multi-vitamin daily...... 195 CHLORIDE...... 156 MONJUVI...... 71 multivitamin iron-free...... 195 254 multivitamin plus iron adult...... 194 NARDIL...... 44 NEXLIZET...... 57 multivitamin select/fluoride...... 196 NAROPIN...... 161 NEXPLANON...... 111 MULTIVITAMIN/FLUORIDE...... 194 NATACHEW...... 198 NEXTERONE...... 35 multivitamin/fluoride...... 196 NATACYN...... 210 NEXTSTELLIS...... 109 multi-vitamin/fluoride...... 196 NATALVIT...... 198 niacin (antihyperlipidemic)...... 58 multi-vitamin/fluoride/iron...... 196 NATAZIA...... 111 niacin er (antihyperlipidemic)...... 58 multi-vitamin/iron...... 194 nateglinide...... 49 niacor...... 58 mupirocin...... 118 NATPARA...... 136 NIASPAN...... 59 mupirocin calcium...... 118 NATROBA...... 126 nicardipine hcl...... 100 MUSE...... 102 nat-rul b-50...... 202 NICARDIPINE HCL IN NACL...... 100 mutamycin...... 78 nat-rul daily-vite+iron...... 194 NICODERM CQ...... 225 MVASI...... 85 NATURE-THROID...... 229 NICORETTE...... 225 my choice...... 110 NAVELBINE...... 82 NICORETTE MINI...... 225 my way...... 110 NAYZILAM...... 40 NICORETTE STARTER KIT...... 225 MYALEPT...... 134 NEBUPENT...... 63 NICOTINE...... 225 MYAMBUTOL...... 67 necon 0.5/35 (28)...... 109 nicotine...... 225 MYCAMINE...... 54 NEEVO DHA...... 198 nicotine mini...... 225 MYCAPSSA...... 137 nefazodone hcl...... 45 nicotine polacrilex...... 225 MYCOBUTIN...... 68 NEMBUTAL...... 155 nicotine polacrilex mini...... 225 mycophenolate mofetil...... 187 NEOMULTIVITE...... 195 nicotine step 1...... 225 mycophenolate mofetil hcl...... 187 neomycin sulfate...... 19 nicotine step 2...... 225 mycophenolate sodium...... 187 neomycin-bacitracin zn-polymyx...... 210 nicotine step 3...... 225 MYDAYIS...... 11 neomycin-polymyxin b gu...... 144 NICOTROL...... 225 MYDRIACYL...... 209 neomycin-polymyxin-dexameth...... 213 NICOTROL NS...... 225 MYFEMBREE...... 138 neomycin-polymyxin-gramicidin...... 210 nifedipine...... 100 MYFORTIC...... 187 neomycin-polymyxin-hc...... 213, 216 nifedipine er...... 100 MYGLUCOHEALTH LANCETS NEONATAL + DHA...... 200 nifedipine er osmotic release...... 100 30G...... 170 NEONATAL 19...... 201 nikki...... 109 MYLERAN...... 68 NEONATAL COMPLETE...... 198 NILANDRON...... 69 MYLOTARG...... 71 NEONATAL FE...... 198 nilutamide...... 69 MYNATAL...... 197 NEONATAL PLUS...... 198 NIMBEX...... 206 MYNATAL PLUS...... 197 NEONATAL VITAMIN...... 198 nimodipine...... 100 MYNATAL-Z...... 198 neo-polycin...... 210 NINJACOF-XG...... 115 MYOBLOC...... 205 neo-polycin hc...... 213 NINLARO...... 76 myorisan...... 118 NEOPROFEN...... 22 NIPENT...... 79 MYRBETRIQ...... 233 NEORAL...... 186 NIPRIDE RTU...... 63 MYTESI...... 51 NEOSTIGMINE nisoldipine er...... 100 MYXREDLIN...... 49 METHYLSULFATE...... 67 nitazoxanide...... 64 na ferric gluc cplx in sucrose...... 153 NEO-SYNALAR...... 118 NITHIODOTE...... 51 NABI-HB...... 217 NEOX 100...... 127 nitisinone...... 133 nabumetone...... 22 NEOX CORD 1K...... 127 NITRO-BID...... 32 n-acetyl-l-cysteine...... 207 nephro vitamins...... 191 NITRO-DUR...... 32 nadolol...... 98 NEPHRO-VITE...... 191 nitrofurantoin...... 66 nafcillin sodium...... 219 NERLYNX...... 76 nitrofurantoin macrocrystal...... 66 NAFCILLIN SODIUM IN NESACAINE...... 161 nitrofurantoin monohyd macro...... 66 DEXTROSE...... 219 NESACAINE-MPF...... 161 NITROGLYCERIN...... 32 nafrinse...... 183 NESTABS...... 198 nitroglycerin...... 33 NAFRINSE DAILY ACIDULATED 190 NESTABS DHA...... 198 nitroglycerin in d5w...... 32 NAFRINSE DAILY/NEUTRAL...... 190 NESTABS ONE...... 200 NITROLINGUAL...... 33 nafrinse drops...... 183 neuac...... 117 NITROMIST...... 33 NAFRINSE WEEKLY...... 190 NEULASTA...... 152 nitroprusside sodium...... 63 naftifine hcl...... 119 NEULASTA ONPRO...... 152 NITROSTAT...... 33 NAFTIN...... 119 NEUPOGEN...... 152 NITYR...... 133 NAGLAZYME...... 135 NEUPRO...... 87 NIVA-PLUS...... 198 nalbuphine hcl...... 30 NEURIN-SL...... 150 NIVESTYM...... 152 naloxone hcl...... 52 NEVANAC...... 212 nizatidine...... 231 naltrexone hcl...... 52 nevirapine...... 94 NOCDURNA...... 137 NAMENDA TITRATION PAK...... 223 nevirapine er...... 94 nolix...... 123 NAMZARIC...... 220 new day...... 110 nora-be...... 112 naproxen...... 22 NEXAVAR...... 76 NOREPINEPHRINE (BASE)- naproxen sodium...... 22 NEXAVIR...... 188 DEXTROSE...... 237 naratriptan hcl...... 181 NEXIUM I.V...... 231 norepinephrine bitartrate...... 237 NARCAN...... 52 NEXLETOL...... 57 NOREPINEPHRINE-DEXTROSE..237 255 NOREPINEPHRINE-SODIUM nylia 7/7/7...... 113 ONE-A-DAY MENS...... 195 CHLORIDE...... 237 NYMALIZE...... 100 ONE-A-DAY WOMENS norethin ace-eth estrad-fe...... 109 nymyo...... 109 PRENATAL...... 198 norethindrone...... 112 nystatin...... 55, 119, 189 one-daily multi vitamins...... 195 norethindrone acetate...... 220 nystatin-triamcinolone...... 119 one-daily multi-vitamin...... 195 norethindrone acet-ethinyl est...... 109 nystop...... 119 one-daily multi-vitamin/iron...... 194 norethindrone-eth estradiol...... 138 NYVEPRIA...... 152 one-daily/iron...... 194 norethin-eth estradiol-fe...... 109 OB COMPLETE...... 198 ONETOUCH CLUB LANCETS norgestimate-eth estradiol...... 109 OB COMPLETE ONE...... 198 FINE PT...... 170 norgestim-eth estrad triphasic...... 112 OB COMPLETE PETITE...... 198 ONETOUCH DELICA LANCETS NORITATE...... 126 OB COMPLETE PREMIER...... 198 30G...... 170 norlyda...... 112 OB COMPLETE/DHA...... 198 ONETOUCH DELICA LANCETS norlyroc...... 112 OBIZUR...... 147 33G...... 170 normal saline flush...... 184 OBSTETRIX DHA...... 198 ONETOUCH DELICA PLUS NORMOSOL-M IN D5W...... 182 OBSTETRIX EC...... 198 LANCET30G...... 170 NORMOSOL-R...... 183 OBSTETRIX ONE...... 200 ONETOUCH DELICA PLUS NORMOSOL-R IN D5W...... 183 O-CAL PRENATAL...... 198 LANCET33G...... 170 NORMOSOL-R PH 7.4...... 183 OCALIVA...... 140 ONETOUCH FINEPOINT NORPACE...... 34 ocella...... 109 LANCETS...... 170 NORPACE CR...... 34 OCTAGAM...... 218 ONETOUCH SURESOFT NORPRAMIN...... 46 OCTAPLAS BLOOD GROUP A..... 149 LANCING DEV...... 170 NORTHERA...... 236 OCTAPLAS BLOOD GROUP AB...149 ONETOUCH ULTRA...... 129 nortrel 0.5/35 (28)...... 109 OCTAPLAS BLOOD GROUP B...... 149 ONETOUCH ULTRASOFT nortrel 1/35 (21)...... 109 OCTAPLAS BLOOD GROUP O..... 149 LANCETS...... 170 nortrel 1/35 (28)...... 109 octreotide acetate...... 137 ONETOUCH VERIO...... 129 nortrel 7/7/7...... 113 ocucoat viscoadherent...... 214 ONEXTON...... 117 nortriptyline hcl...... 46 OCUFLOX...... 210 ONGENTYS...... 87 NORVIR...... 93 ODACTRA...... 19 ONIVYDE...... 84 NOURIANZ...... 85 ODEFSEY...... 92 ONPATTRO...... 224 NOVA SAFETY LANCETS 23G..... 170 ODOMZO...... 74 ONTRUZANT...... 72 NOVA SAFETY LANCETS 28G..... 170 OFEV...... 227 ONUREG...... 70 NOVA SUREFLEX LANCETS...... 170 OFIRMEV...... 23 opcicon one-step...... 111 NOVACHOR...... 127 ofloxacin...... 139, 210, 215 OPDIVO...... 72 NOVAREL...... 135 OGIVRI...... 72 OPSUMIT...... 103 NOVOEIGHT...... 146 olanzapine...... 91 option 2...... 111 NOVOFINE...... 178 olanzapine-fluoxetine hcl...... 226 OPTIONS GYNOL II NOVOFINE AUTOCOVER...... 178 OLINVYK...... 29 CONTRACEPTIVE...... 235 NOVOFINE PLUS...... 178 OLIVE TREE...... 17 ORABLOC...... 160 NOVOSEVEN RT...... 146 olmesartan medoxomil...... 61 ORALAIR...... 19 NOVOTWIST...... 178 olmesartan medoxomil-hctz...... 61 oralone...... 191 NOXAFIL...... 55 olmesartan-amlodipine-hctz...... 62 ORAPRED ODT...... 114 np thyroid...... 229 olopatadine hcl...... 205 ORAVIG...... 189 NPLATE...... 153 OMECLAMOX-PAK...... 232 ORBACTIV...... 65 NUBEQA...... 69 omega-3-acid ethyl esters...... 57 ORCHARD GRASS POLLEN...... 17 NUCALA...... 37 OMEGAVEN...... 207 ORENITRAM...... 102 NUCYNTA...... 29 omeprazole...... 231 ORFADIN...... 133 NUEDEXTA...... 224 OMIDRIA...... 214 ORGOVYX...... 81 NULIBRY...... 135 OMNICAP...... 195 ORIAHNN...... 138 NULOJIX...... 189 OMNIFLEX DIAPHRAGM...... 163 ORILISSA...... 132 NULYTELY LEMON-LIME...... 157 OMNIPOD 5 PACK...... 174 ORKAMBI...... 227 NUMBRINO...... 204 OMNIPOD DASH 5 PACK PODS... 174 ORLADEYO...... 149 NUPLAZID...... 88 OMNIPOD STARTER...... 174 orphenadrine citrate...... 203 NURTEC...... 181 ONCASPAR...... 79 orphenadrine citrate er...... 203 NUSHIELD...... 127 once daily...... 195 orphenadrine-asa-caffeine...... 203 NUTRILIPID...... 207 ondansetron...... 53 orphengesic forte...... 204 NUTROPIN AQ NUSPIN 10...... 133 ondansetron hcl...... 53 orsythia...... 109 NUTROPIN AQ NUSPIN 20...... 133 one daily...... 195 ORTHOVISC...... 204 NUTROPIN AQ NUSPIN 5...... 133 ONE DAILY ESSENTIAL...... 195 ORTIKOS...... 114 NUVARING...... 110 one daily multivitamin adult...... 194 oseltamivir phosphate...... 96 NUVESSA...... 235 one daily multivitamin/iron...... 194 osmitrol...... 130 NUWIQ...... 147 ONE VITE WOMENS...... 198 OSMOLEX ER...... 86 NUZYRA...... 228 ONE VITE WOMENS PLUS...... 198 OSMOPREP...... 158 nyamyc...... 119 ONE-A-DAY ESSENTIAL...... 195 OSPHENA...... 136 256 OTEZLA...... 23 PALINGEN FLOW...... 127 PENTACEL...... 230 OTIPRIO...... 215 PALINGEN HYDROMEMBRANE.127 PENTAM...... 63 OTOVEL...... 216 PALINGEN INOVOFLO...... 127 pentamidine isethionate...... 63 OTREXUP...... 20 PALINGEN MEMBRANE...... 127 PENTASA...... 141 OVIDE...... 126 PALINGEN XPLUS pentazocine-naloxone hcl...... 30 OVIDREL...... 135 HYDROMEMBRANE...... 128 PENTETATE CALCIUM oxacillin sodium...... 219 PALINGEN XPLUS MEMBRANE..128 TRISODIUM...... 52 OXACILLIN SODIUM IN paliperidone er...... 88 PENTETATE ZINC TRISODIUM.... 52 DEXTROSE...... 219 PALONOSETRON HCL...... 53 PENTIPS...... 178 oxaliplatin...... 68 palonosetron hcl...... 53 pentobarbital sodium...... 155 oxandrolone...... 31 PALYNZIQ...... 136 pentoxifylline er...... 148 oxaprozin...... 22 PAMELOR...... 46 PEPAXTO...... 83 OXAYDO...... 29 pamidronate disodium...... 131 PEPCID...... 231 oxazepam...... 33 PAMIDRONATE DISODIUM...... 131 PERENNIAL RYE GRASS OXBRYTA...... 152 PANCREAZE...... 129 POLLEN...... 17 oxcarbazepine...... 42 pancuronium bromide...... 206 PERFECT LANCETS 28G...... 170 OXERVATE...... 211 PANHEMATIN...... 148 PERFECT LANCETS 30G...... 170 oxiconazole nitrate...... 124 PANRETIN...... 120 PERFOROMIST...... 36 OXISTAT...... 124 pantoprazole sodium...... 231 PERIDEX...... 190 OXLUMO...... 145 PANZYGA...... 218 PERIKABIVEN...... 208 OXTELLAR XR...... 42 PARADIGM REAL-TIME perindopril erbumine...... 60 oxybutynin chloride...... 232 TRANSMITTER...... 170 periogard...... 190 oxybutynin chloride er...... 232 PARAGARD INTRAUTERINE PERJETA...... 72 oxycodone hcl...... 29 COPPER...... 110 permethrin...... 127 oxycodone hcl er...... 29 paraplatin...... 68 perphenazine...... 90 oxycodone-acetaminophen...... 30 PAREMYD...... 211 perphenazine-amitriptyline...... 223 OXYCONTIN...... 29 paricalcitol...... 134 PERRY PRENATAL...... 198 oxymorphone hcl...... 29 PARLODEL...... 86 PERSERIS...... 88 oxymorphone hcl er...... 29 PARNATE...... 44 PERTZYE...... 129 oxytocin...... 216 paromomycin sulfate...... 19 PEXEVA...... 45 OXYTOCIN-LACTATED paroxetine hcl...... 45 pfizerpen...... 218 RINGERS...... 216 paroxetine hcl er...... 45 PHARMACIST CHOICE OXYTOCIN-SODIUM CHLORIDE216 paroxetine mesylate...... 226 LANCETS...... 170 OZEMPIC (0.25 OR 0.5 MG/DOSE). 49 PARSABIV...... 131 PHARMACY COUNTER OZEMPIC (1 MG/DOSE)...... 49 PASER...... 68 LANCETS...... 170 OZURDEX...... 214 PATANASE...... 205 phendimetrazine tartrate...... 12 pacerone...... 35 PAXIL...... 45 phendimetrazine tartrate er...... 12 paclitaxel...... 82 PC LANCETS SUPER THIN 30G... 170 phenelzine sulfate...... 44 PADCEV...... 72 PC UNIFINE PENTIPS...... 178 PHENERGAN...... 56 PALFORZIA (12 MG DAILY PEDIAPRED...... 114 phenobarbital...... 155 DOSE)...... 17 PEDIARIX...... 230 phenobarbital sodium...... 155 PALFORZIA (120 MG DAILY PEDVAX HIB...... 233 phenohytro...... 230 DOSE)...... 17 peg 3350...... 158 phenoxybenzamine hcl...... 60 PALFORZIA (160 MG DAILY peg 3350-kcl-na bicarb-nacl...... 157 phentermine hcl...... 12, 13 DOSE)...... 17 peg-3350/electrolytes...... 157 phentolamine mesylate...... 60 PALFORZIA (20 MG DAILY peg-3350/electrolytes/ascorbat...... 157 PHENYLEPHRINE HCL...... 209, 237 DOSE)...... 17 PEGASYS...... 96 phenylephrine hcl...... 209 PALFORZIA (200 MG DAILY peg-kcl-nacl-nasulf-na asc-c...... 157 PHENYLEPHRINE HCL-NACL.....237 DOSE)...... 17 peg-prep...... 157 PHENYTEK...... 43 PALFORZIA (240 MG DAILY PEMAZYRE...... 74 phenytoin...... 43 DOSE)...... 17 PEN NEEDLES...... 178 phenytoin infatabs...... 43 PALFORZIA (3 MG DAILY DOSE). 17 PEN NEEDLES 1/2"...... 178 phenytoin sodium...... 43 PALFORZIA (300 MG PEN NEEDLES 5/16"...... 178 phenytoin sodium extended...... 43 MAINTENANCE)...... 17 penicillamine...... 185 PHESGO...... 78 PALFORZIA (300 MG PENICILLIN G POT IN PHEXXI...... 235 TITRATION)...... 17 DEXTROSE...... 218 philith...... 109 PALFORZIA (40 MG DAILY penicillin g potassium...... 218 phillips milk of magnesia...... 159 DOSE)...... 17 PENICILLIN G PROCAINE...... 218 PHOMA EXIGUA...... 17 PALFORZIA (6 MG DAILY DOSE). 17 penicillin g sodium...... 218 PHOSLYRA...... 142 PALFORZIA (80 MG DAILY penicillin v potassium...... 218 phosphorous...... 183 DOSE)...... 17 PENICILLIUM NOTATUM...... 17 phospho-trin 250 neutral...... 183 PALFORZIA INITIAL PENLET II BLOOD SAMPLER...... 170 PHOTOFRIN...... 79 ESCALATION...... 17 PENLET II REPLACEMENT CAP.170 PHOTREXA VISCOUS...... 212 257 PHOTREXA-PHOTREXA posaconazole...... 55 PREMPHASE...... 138 VISCOUS KIT...... 212 pot & sod cit-cit ac...... 144 PREMPRO...... 138 PHOXILLUM B22K4/0...... 185 potassium acetate...... 184 PRENA 1 TRUE...... 201 PHOXILLUM BK4/2.5...... 185 POTASSIUM CHLORIDE...... 184 PRENA1...... 201 physiolyte...... 187 potassium chloride...... 184 PRENA1 PEARL...... 198 physiosol irrigation...... 187 potassium chloride crys er...... 184 PRENAISSANCE...... 201 phytonadione...... 237 potassium chloride er...... 184 PRENAISSANCE PLUS...... 201 PIFELTRO...... 94 potassium chloride in dextrose...... 183 PRENARA...... 198 pilocarpine hcl...... 191, 209 POTASSIUM CHLORIDE IN prenatabs rx...... 198 pimecrolimus...... 125 NACL...... 183 PRENATAL...... 199 pimozide...... 224 potassium chloride in nacl...... 183 PRENATAL 19...... 198 pimtrea...... 106 potassium citrate er...... 144 prenatal 19...... 198 pindolol...... 98 POTASSIUM PHOSPHATES...... 184 PRENATAL COMPLETE...... 198 pioglitazone hcl...... 51 potassium phosphates...... 184 PRE-NATAL FORMULA...... 198 pioglitazone hcl-glimepiride...... 50 potassium phosphates(66 meq k)...... 184 PRENATAL FORTE...... 199 pioglitazone hcl-metformin hcl...... 51 POTASSIUM PHOSPHATES(71 PRENATAL MULTIVITAMIN + PIP LANCETS 28G...... 170 MEQ K)...... 184 DHA...... 201 PIP LANCETS 30G...... 170 POTELIGEO...... 71 PRENATAL ONE DAILY...... 199 piperacillin sod-tazobactam so...... 219 PRALUENT...... 59 PRENATAL PLUS IRON...... 199 PIQRAY (200 MG DAILY DOSE).....83 pramipexole dihydrochloride...... 87 PRENATAL VITAMIN...... 199 PIQRAY (250 MG DAILY DOSE).....83 pramipexole dihydrochloride er...... 87 PRENATAL VITAMIN AND PIQRAY (300 MG DAILY DOSE).....84 PRAMOSONE...... 127 MINERAL...... 199 pirmella 1/35...... 109 PRAMOTIC...... 215 PRENATAL VITAMIN PLUS LOW pirmella 7/7/7...... 113 prasugrel hcl...... 150 IRON...... 199 piroxicam...... 22 pravastatin sodium...... 58 PRENATAL VITAMINS...... 199 PITOCIN...... 216 PRAXBIND...... 52 PRENATAL/IRON...... 199 PLASBUMIN-25...... 149 praziquantel...... 32 PRENATAL-U...... 199 PLASBUMIN-5...... 149 prazosin hcl...... 62 PRENATE...... 201 PLASMA-LYTE 148...... 183 PRECEDEX...... 156 PRENATE AM...... 201 PLASMA-LYTE A...... 183 PRECISION SUREDOSE PLUS PRENATE DHA...... 201 PLASMANATE...... 149 SYR...... 178 PRENATE ELITE...... 199 PLEGISOL...... 102 PRECISION SURE-DOSE PRENATE ENHANCE...... 201 PLEGRIDY...... 222 SYRINGE...... 179 PRENATE ESSENTIAL...... 201 PLEGRIDY STARTER PACK...... 222 PRECISION THINS GP LANCETS 170 PRENATE MINI...... 201 plenamine...... 207 PRECOSE...... 47 PRENATE PIXIE...... 201 PLENITY...... 12 PRED MILD...... 214 PRENATE RESTORE...... 201 PLENITY WELCOME KIT...... 12 PRED-G...... 213 PRENATRIX...... 199 PLENVU...... 157 PRED-G S.O.P...... 213 PRENATRYL...... 199 PNEUMOVAX 23...... 233 prednicarbate...... 123 PRENATVITE COMPLETE...... 199 PNV TABS 20-1...... 198 prednisolone...... 114 PRENATVITE PLUS...... 199 PNV TABS 29-1...... 198 prednisolone acetate...... 214 PRENATVITE RX...... 199 pnv-dha...... 200 prednisolone sodium phosphate...... 114 PREPIDIL...... 216 PNV-DHA+DOCUSATE...... 200 PREDNISOLONE SODIUM PREPLUS...... 199 PNV-OMEGA...... 198 PHOSPHATE...... 214 PRESTALIA...... 59 pnv-select...... 198 prednisone...... 114 PRETAB...... 199 podofilox...... 125 PREDNISONE INTENSOL...... 114 PRETOMANID...... 68 POINT OF CARE LM-2.5...... 160 PREFERRED PLUS INSULIN prevalite...... 57 POLIVY...... 71 SYRINGE...... 179 PREVENT SAFETY PEN polocaine...... 161 PREFERRED PLUS LANCETS NEEDLES...... 179 polocaine-mpf...... 161 COLORED...... 170 preventeza...... 111 polycin...... 210 PREFERRED PLUS LANCETS PREVIDENT...... 190 polyethylene glycol 3350...... 158 THIN...... 170 PREVIDENT 5000 BOOSTER polymyxin b sulfate...... 66 PREFERRED PLUS UNIFINE PLUS...... 190 polymyxin b-trimethoprim...... 210 PENTIPS...... 179 PREVIDENT 5000 DRY MOUTH... 190 POLYTRIM...... 210 PREFEST...... 138 PREVIDENT 5000 ENAMEL POLY-TUSSIN AC...... 116 pregabalin...... 42 PROTECT...... 190 POLY-VI-FLOR...... 196 pregabalin er...... 224 PREVIDENT 5000 ORTHO POLY-VI-FLOR/IRON...... 196 PREGEN DHA...... 201 DEFENSE...... 190 POMALYST...... 75 PREGENNA...... 198 PREVIDENT 5000 PLUS...... 190 PONVORY...... 226 PREGNYL...... 135 PREVIDENT 5000 SENSITIVE...... 190 PONVORY STARTER PACK...... 226 PREMARIN...... 139, 236 previfem...... 109 portia-28...... 109 PREMASOL...... 207 PREVNAR 13...... 233 PORTRAZZA...... 74 PREMESISRX...... 201 PREVYMIS...... 95 258 PREZCOBIX...... 92 promethazine-phenyleph-codeine...... 117 pyridostigmine bromide er...... 67 PREZISTA...... 93 promethazine-phenylephrine...... 116 pyridoxine hcl...... 237 PRIALT...... 26 promethegan...... 56 pyrimethamine...... 67 PRIFTIN...... 68 PROMISEB...... 121 QBRELIS...... 60 PRILO PATCH II...... 128 propafenone hcl...... 34 QBREXZA...... 125 PRIMACARE...... 199 propafenone hcl er...... 34 qc aspirin...... 25 PRIMAQUINE PHOSPHATE...... 67 proparacaine hcl...... 211 qc aspirin low dose...... 25 PRIMAXIN IV...... 64 proparacaine-fluorescein...... 211 qc b50 prolonged release...... 193 primidone...... 42 PROPECIA...... 128 qc b-complex/vitamin c...... 191 PRIMSOL...... 63 PROPEL...... 205 qc childrens aspirin...... 25 PRISMASOL B22GK 4/0...... 185 PROPEL MINI...... 205 qc daily multivitamins/iron...... 194 PRISMASOL BGK 0/2.5...... 185 propofol...... 143 qc enteric aspirin...... 25 PRISMASOL BGK 2/0...... 185 propofol-lipuro...... 143 qc essentials...... 195 PRISMASOL BGK 2/3.5...... 185 propranolol hcl...... 98 qc folic acid...... 152 PRISMASOL BGK 4/0/1.2...... 185 propranolol hcl er...... 98 qc gentle laxative...... 159 PRISMASOL BGK 4/2.5...... 186 propylthiouracil...... 229 QC LANCETS SUPER THIN 30G...171 PRISMASOL BK 0/0/1.2...... 186 PROQUAD...... 234 QC LANCETS ULTRA THIN...... 171 PRIVET...... 18 PRO-RED AC...... 117 qc magnesium citrate...... 159 PRIVIGEN...... 218 PROSCAR...... 143 qc milk of magnesia...... 159 PRO COMFORT INSULIN PROSOL...... 207 qc natura-lax...... 158 SYRINGE...... 179 PROSTIN E2...... 216 qc nicotine transdermal system...... 225 PRO COMFORT LANCETS 30G....170 PROSTIN VR...... 189 QC PEN NEEDLES...... 179 PRO COMFORT LANCETS 31G....170 protamine sulfate...... 149 QC PRENATAL...... 199 PRO COMFORT PEN NEEDLES...179 PROTONIX...... 231 QC UNIFINE PENTIPS...... 179 PROAIR DIGIHALER...... 36 PROTOPAM CHLORIDE...... 52 QC UNILET LANCETS 28G...... 171 PROAIR HFA...... 36 protriptyline hcl...... 46 QC UNILET LANCETS MICRO PROAIR RESPICLICK...... 36 PROVAYBLUE...... 52 THIN...... 171 probenecid...... 145 PROVENGE...... 73 QDOLO...... 29 PROBUPHINE IMPLANT KIT...... 30 PROVENTIL HFA...... 36 QINLOCK...... 76 procainamide hcl...... 34 PROVERA...... 220 QSYMIA...... 12 PROCALAMINE...... 207 PROVIDA OB...... 199 QUADRACEL...... 230 PROCARDIA XL...... 100 PROVISC...... 214 QUADRAMET...... 79 procentra...... 12 pseudoeph-bromphen-dm...... 116 QUALAQUIN...... 67 prochlorperazine...... 90 PSS SELECT GP LANCETS...... 171 QUARTETTE...... 111 prochlorperazine edisylate...... 90 PSS SELECT PLATFORMS...... 171 quazepam...... 156 prochlorperazine maleate...... 90 PSS SELECT SAFETY LANCETS..171 QUDEXY XR...... 42 PROCRIT...... 151 PULMOZYME...... 227 QUEEN PALM...... 18 PROCTOCORT...... 32 PURE COMFORT LANCETS 30G. 171 QUELICIN...... 205 PROCTOFOAM HC...... 31 PURE COMFORT PEN NEEDLE...179 QUESTRAN...... 57 procto-med hc...... 32 PURIXAN...... 70 QUESTRAN LIGHT...... 57 procto-pak...... 32 px aspirin...... 25 quetiapine fumarate...... 89 proctozone-hc...... 32 px b complex/vitamin c...... 192 quetiapine fumarate er...... 89 PROCYSBI...... 144 px b-50...... 202 QUFLORA FE...... 194 PRODIGY INSULIN SYRINGE...... 179 px enteric aspirin...... 25 QUFLORA FE PEDIATRIC...... 196 PRODIGY LANCETS 28G...... 171 PX EXTRA SHORT PEN QUFLORA GUMMIES...... 196 PRODIGY SAFETY LANCETS 26G NEEDLES...... 179 QUFLORA PEDIATRIC...... 196 ...... 171 px folic acid...... 152 QUILLICHEW ER...... 14, 15 PRODIGY TWIST TOP LANCETS PX INSULIN SYRINGE...... 179 QUILLIVANT XR...... 15 28G...... 171 PX LANCETS MICROTHIN 33G... 171 quin b strong b-25...... 193 PROFILNINE...... 147 PX LANCETS ULTRA THIN...... 171 quinapril hcl...... 60 progesterone...... 220 PX LANCETS ULTRA THIN 28G.. 171 quinapril-hydrochlorothiazide...... 59 PROGLYCEM...... 47 px laxative...... 159 quinidine gluconate er...... 34 PROGRAF...... 187 px milk of magnesia...... 159 quinidine sulfate...... 34 PROLASTIN-C...... 227 PX MINI PEN NEEDLES...... 179 quinine sulfate...... 67 PROLENSA...... 212 PX PEN NEEDLE...... 179 QUINTABS...... 195 PROLEUKIN...... 79 PX PRENATAL MULTIVITAMINS QUTENZA (4 PATCH)...... 125 PROLIA...... 136 ...... 199 QUZYTTIR...... 56 PROMACTA...... 153 PX SHORTLENGTH PEN QVAR REDIHALER...... 38 promethazine hcl...... 56 NEEDLES...... 179 ra aspirin...... 26 promethazine vc...... 116 px stop smoking aid...... 225 ra aspirin adult low dose...... 25 promethazine vc/codeine...... 117 PYLERA...... 232 ra aspirin adult low strength...... 25 promethazine-codeine...... 116 pyrazinamide...... 68 ra aspirin childrens...... 25 promethazine-dm...... 116 pyridostigmine bromide...... 67 ra aspirin ec...... 25 259 ra aspirin ec adult low st...... 25 RECOTHROM SPRAY KIT...... 154 revonto...... 203 ra balanced b-100...... 193 RECTIV...... 31 REXALL LANCETS ULTRA THIN ra balanced b-100 cr...... 193 RED MAPLE...... 18 30G...... 171 ra balanced b-50...... 193 RED MULBERRY...... 18 REXULTI...... 91 ra balanced b-50 tr...... 193 RED TOP GRASS POLLEN...... 18 REYATAZ...... 93, 94 ra b-complex...... 191 REDITREX...... 20 RHIZOPUS...... 18 ra b-complex with b-12...... 191 refissa...... 118 RHOFADE...... 126 RA E-ZJECT LANCETS 28G...... 171 REGEN-COV...... 218 RHOGAM ULTRA-FILTERED RA E-ZJECT LANCETS THIN 26G REGLAN...... 140 PLUS...... 218 ...... 171 REGONOL...... 67 RHOPHYLAC...... 218 RA E-ZJECT LANCETS THIN 28G REGRANEX...... 128 RHOPRESSA...... 212 ...... 171 relafen...... 23 RIABNI...... 71 RA E-ZJECT LANCETS ULTRA RELENZA DISKHALER...... 97 RIASTAP...... 147 THIN...... 171 RELEXXII...... 15 ribavirin...... 96, 97 ra folic acid...... 152 RELION INSULIN SYRINGE...... 179 RIDAURA...... 21 RA INSULIN SYRINGE...... 179 RELION LANCETS MICRO-THIN rifabutin...... 68 ra laxative...... 158, 159 33G...... 171 RIFADIN...... 68 ra milk of magnesia...... 159 RELION LANCETS THIN 26G...... 171 rifampin...... 68 ra mini nicotine...... 225 RELION LANCETS ULTRA-THIN RIGHTEST ALTERNATE SITE ra nicotine...... 226 30G...... 171 ADAPT...... 171 ra nicotine gum...... 226 RELION LANCING DEVICE...... 171 RIGHTEST GL300 LANCETS...... 171 ra nicotine polacrilex...... 226 RELION MINI PEN NEEDLES...... 179 RILUTEK...... 205 ra pain relief aspirin...... 26 RELION PEN NEEDLES...... 179 riluzole...... 205 RA PEN NEEDLES...... 179 RELION SHORT PEN NEEDLES...179 rimantadine hcl...... 96 RA PRENATAL...... 199 RELION ULTRA THIN LANCETS RIMSO-50...... 144 RA PRENATAL FORMULA...... 199 30G...... 171 ringers...... 183 ra womens laxative...... 160 RELION ULTRA THIN PLUS ringers irrigation...... 187 RABAVERT...... 234 LANCETS...... 171 RINVOQ...... 20 RABBIT EPITHELIUM...... 18 RELISTOR...... 142 RIOMET...... 47 RADIOGARDASE...... 52 RELNATE DHA...... 199 risanoid plus...... 202 RAGWITEK...... 18 RELTONE...... 140 risedronate sodium...... 131 raloxifene hcl...... 136 REMERON...... 44 RISPERDAL CONSTA...... 88 ramelteon...... 157 REMERON SOLTAB...... 44 risperidone...... 88 ramipril...... 60 REMESENSE...... 163 RITALIN...... 15 RANEXA...... 32 REMICADE...... 142 RITALIN LA...... 15 ranolazine er...... 32 remifentanil hcl...... 29 ritonavir...... 94 RAPAMUNE...... 187 REMODULIN...... 102 RITUXAN...... 71 RAPIVAB...... 97 RENACIDIN...... 144 RITUXAN HYCELA...... 78 rasagiline mesylate...... 86 renal multivitamin formula...... 192 rivastigmine...... 221 RASUVO...... 20 renal vitamin...... 192 rivastigmine tartrate...... 221 RAVICTI...... 137 renal-vite...... 192 rivelsa...... 111 RAYALDEE...... 134 rena-vite...... 192 RIXUBIS...... 147 RAZADYNE ER...... 221 RENOVA...... 118 rizatriptan benzoate...... 181 react...... 111 RENOVA PUMP...... 118 ROBAXIN...... 203 READYLANCE SAFETY RENVELA...... 142 ROCALTROL...... 134 LANCETS...... 171 repaglinide...... 50 ROCKLATAN...... 211 REAL HEAL-I...... 128 REPATHA...... 59 rocuronium bromide...... 206 REALITY INSULIN SYRINGE...... 179 REPATHA PUSHTRONEX ROCURONIUM BROMIDE...... 206 REALITY LANCETS...... 171 SYSTEM...... 59 ROMIDEPSIN...... 74 REALITY TRIGGER LANCETS....171 REPATHA SURECLICK...... 59 ropinirole hcl...... 87 REBIF...... 222 RESECTISOL...... 144 ropinirole hcl er...... 87 REBIF REBIDOSE...... 222 RESTASIS...... 211 ropivacaine hcl...... 161 REBIF REBIDOSE TITRATION RESTASIS MULTIDOSE...... 211 ROPIVACAINE HCL-NACL...... 161 PACK...... 222 RESTORA RX...... 51 rosadan...... 126 REBIF TITRATION PACK...... 222 RESTORIL...... 156 rosuvastatin calcium...... 58 REBINYN...... 147 RETACRIT...... 151 ROTARIX...... 235 REBLOZYL...... 151 RETAVASE...... 150 ROTATEQ...... 235 RECARBRIO...... 64 RETAVASE HALF-KIT...... 150 ROUGH MARSH ELDER...... 18 RECLAST...... 131 RETEVMO...... 76 ROWASA...... 141 reclipsen...... 109 RETISERT...... 214 roweepra...... 42 RECOMBINATE...... 147 RETROVIR...... 95 ROXICODONE...... 29 RECOMBIVAX HB...... 234 REVCOVI...... 131 ROZLYTREK...... 77 RECOTHROM...... 154 REVLIMID...... 186 RUBRACA...... 84 260 RUCONEST...... 147 SECURESAFE SAFETY PEN SKELAXIN...... 203 rufinamide...... 42 NEEDLES...... 179 SKYLA...... 112 RUKOBIA...... 93 SELECT-LITE DEVICE/LANCETS SKYRIZI...... 120 RUSSIAN THISTLE...... 18 ...... 172 SKYRIZI (150 MG DOSE)...... 120 RUXIENCE...... 71 SELECT-OB...... 199 SKYRIZI PEN...... 120 RUZURGI...... 67 SELECT-OB+DHA...... 201 SLYND...... 112 RYANODEX...... 203 selegiline hcl...... 86 sm aspirin...... 26 RYBELSUS...... 49 SELENIOUS ACID...... 184 sm aspirin adult low strength...... 26 RYBREVANT...... 76 selenium sulfide...... 121 sm aspirin ec...... 26 ryclora...... 56 SELZENTRY...... 92 sm aspirin ec low strength...... 26 RYDAPT...... 76 SEMGLEE...... 49 sm aspirin low dose...... 26 RYDEX...... 117 SE-NATAL 19...... 199 sm aspirin tri-buffered...... 24 RYTARY...... 87 SENSIPAR...... 131 sm b super vitamin complex...... 192 RYTHMOL SR...... 34 sensorcaine...... 161 sm b100 complex...... 193 RYVENT...... 56 sensorcaine/epinephrine...... 160 sm balanced b-100...... 192 SACCHAROMYCES CEREVISIAE.18 sensorcaine-mpf...... 161 sm balanced b-50...... 192 SAFE-T-LANCE...... 171 sensorcaine-mpf/epinephrine...... 160 sm b-complex...... 193 SAFE-T-LANCE PLUS...... 171 SENSORCAINE- SM B-COMPLEX/VITAMIN C...... 192 SAFETY INSULIN SYRINGES...... 179 MPF/EPINEPHRINE...... 160 sm childrens aspirin...... 26 SAFETY LANCET 30G/PRESSURE SEREVENT DISKUS...... 36 sm clearlax...... 158 ACT...... 171 SEROSTIM...... 133 sm folic acid...... 152 SAFETY LANCETS...... 171 sertraline hcl...... 45 sm gentle laxative...... 160 SAFETY LANCETS 21G...... 171 setlakin...... 111 SM LANCETS 33G...... 172 SAFETY LANCETS 28G...... 171 sevelamer carbonate...... 142 sm magnesium citrate...... 159 SAFYRAL...... 109 sevelamer hcl...... 142 sm milk of magnesia...... 159 SALAGEN...... 191 SEVENFACT...... 147 sm multiple vitamins essential...... 195 SAMSCA...... 136 sevoflurane...... 143 sm multiple vitamins/iron...... 194 SANCUSO...... 53 sf...... 190 sm nicotine...... 226 SANDIMMUNE...... 186 sf 5000 plus...... 190 sm nicotine polacrilex...... 226 SANDOSTATIN...... 137 SFROWASA...... 141 SM ONE DAILY PRENATAL...... 199 SANDOSTATIN LAR DEPOT...... 137 SHAGBARK HICKORY...... 18 SM PRENATAL VITAMINS...... 199 SANTYL...... 124 sharobel...... 112 sm super b complex/c...... 192 sapropterin dihydrochloride...... 136 SHEEP SORREL...... 18 sm vitamin b complex/vitamin c...... 192 SAPS HEALTH TWIST TOP SHINGRIX...... 235 SMART SENSE COLOR LANCETS LANCETS...... 171 SHOPKO ON-THE-GO LANCETS 33G...... 172 SAPS TWIST TOP LANCETS...... 171 30G...... 172 SMART SENSE STANDARD SAPSCARE TWIST TOP SHOPKO UNIFINE PENTIPS...... 179 LANCETS...... 172 LANCETS...... 172 SHOPKO UNIFINE PENTIPS SMART SENSE SUPER THIN SARCLISA...... 71 PLUS...... 179 LANCETS...... 172 SAVELLA...... 221 SHOPKO UNILET LANCETS 28G.172 SMART SENSE THIN LANCETS SAVELLA TITRATION PACK...... 221 SHOPKO UNILET LANCETS 30G.172 26G...... 172 SAXENDA...... 13 SHORT RAGWEED POLLEN EXT. 18 SMARTEST LANCETS 28G...... 172 sb aspirin...... 26 SHUR-SEAL CONTRACEPTIVE...235 SMOFLIPID...... 207 sb aspirin adult low strength...... 26 SIGNIFOR...... 137 smooth lax...... 158 sb aspirin ec...... 26 SIGNIFOR LAR...... 137 sod benz-sod phenylacet...... 137 sb bisacodyl laxative ec...... 160 SIKLOS...... 151 SODIUM ACETATE...... 182 sb childrens aspirin...... 26 sildenafil citrate...... 103 SODIUM BICARBONATE...... 32 sb gentle lax-women...... 160 SILENOR...... 156 sodium bicarbonate...... 182 SB INSULIN SYRINGE...... 179 silodosin...... 143 sodium chloride...... 116, 144, 184 SB LANCETS THIN...... 172 SILVADENE...... 121 sodium chloride flush...... 184 SB LANCETS ULTRA THIN...... 172 silver sulfadiazine...... 121 SODIUM CITRATE LOCK FLUSH. 38 sb low dose asa ec...... 26 SIMBRINZA...... 208 SODIUM DIURIL...... 130 sb magnesium citrate...... 159 simliya...... 106 SODIUM EDECRIN...... 130 sb milk of magnesia...... 159 simpesse...... 111 sodium fluoride...... 183, 191 sb polyethylene glycol 3350...... 158 SIMPONI...... 21 sodium fluoride 5000 enamel...... 190 SCENESSE...... 125 SIMPONI ARIA...... 21 sodium fluoride 5000 plus...... 190 SCLEROSOL INTRAPLEURAL.....227 SIMULECT...... 188 sodium fluoride 5000 ppm...... 190, 191 scopolamine...... 53 simvastatin...... 58 sodium fluoride 5000 sensitive...... 190 SEASONIQUE...... 111 SINEMET...... 87 SODIUM IODIDE I-131...... 229 SECUADO...... 89 SINGLE-LET...... 172 SODIUM NITRITE...... 52 SECURESAFE INSULIN SYRINGE sirolimus...... 187 sodium nitroprusside...... 63 ...... 179 SIRTURO...... 68 sodium phenylbutyrate...... 137 SIVEXTRO...... 66 sodium phosphates...... 184 261 sodium polystyrene sulfonate...... 189 sterile water for irrigation...... 187 SURE COMFORT LANCETS 21G. 172 SODIUM SULFACETAMIDE- STERITALC...... 227 SURE COMFORT LANCETS 23G. 172 BAKUCHIOL...... 121 STIMATE...... 137 SURE COMFORT LANCETS 28G. 172 sodium tetradecyl sulfate...... 189 STIOLTO RESPIMAT...... 35 SURE COMFORT LANCETS 30G. 172 SOLESTA...... 186 STIVARGA...... 76 SURE COMFORT PEN NEEDLES.179 solifenacin succinate...... 232 STRAVIX...... 128 SURE-FINE PEN NEEDLES...... 179 SOLIQUA...... 49 STRENSIQ...... 134 SURE-JECT INSULIN SYRINGE...179 SOLIRIS...... 148 streptomycin sulfate...... 20 SURE-LANCE FLAT LANCETS.... 172 SOLOSEC...... 19 stress b complex/iron...... 194 SURE-LANCE LANCETS 26G...... 172 SOLTAMOX...... 69 stress formula...... 192 SURE-LANCE THIN LANCETS SOLU-CORTEF...... 114 stress formula/iron...... 194 28G...... 172 SOLU-MEDROL...... 114 stresstabs energy...... 196 SURE-LANCE ULTRA THIN SOLUS V2 LANCETS 28G...... 172 STRIBILD...... 92 LANCETS...... 172 SOLUS V2 TWIST LANCETS 30G.172 STRIVERDI RESPIMAT...... 36 SURELITE LANCETS...... 172 SOMA...... 203 STROMECTOL...... 32 SURE-TOUCH LANCETS SOMATULINE DEPOT...... 137 STRONTIUM CHLORIDE SR-89..... 79 UNIVERSAL...... 172 SOMAVERT...... 132 SUBLOCADE...... 30 SURGICEL FIBRILLAR...... 154 SOOLANTRA...... 126 subvenite...... 42 SURGICEL NU-KNIT...... 154 SORBITOL...... 144 subvenite starter kit-blue...... 42 SURVANTA...... 228 SORBITOL-MANNITOL...... 144 subvenite starter kit-green...... 42 SUSTIVA...... 94 SORIATANE...... 120 subvenite starter kit-orange...... 42 SUSTOL...... 53 SORILUX...... 120 SUCCINYLCHOLINE CHLORIDE205 SUTAB...... 157 sorine...... 98 SUCRAID...... 129 SUTENT...... 76 SORREL/DOCK MIX...... 19 sucralfate...... 231 SWEET GUM...... 18 SOTALOL HCL...... 98 SUFENTANIL CITRATE...... 29 SWEET VERNAL GRASS sotalol hcl...... 98, 99 SULAR...... 100 POLLEN...... 18 sotalol hcl (af)...... 98 sulconazole nitrate...... 124 syeda...... 109 SOTRADECOL...... 189 sulfacetamide sodium...... 214 SYLVANT...... 187 sotradecol...... 189 sulfacetamide sodium (acne)...... 117 SYMBICORT...... 35 SOTROVIMAB...... 217 sulfacetamide sod-sulfur wash...... 117 SYMBYAX...... 226 SOTYLIZE...... 99 sulfacetamide-prednisolone...... 213 SYMDEKO...... 227 spinosad...... 127 SULFADIAZINE...... 228 SYMJEPI...... 236 SPINY PIGWEED...... 18 sulfamethoxazole-trimethoprim...... 64 SYMLINPEN 120...... 47 SPIRIVA HANDIHALER...... 37 SULFAMYLON...... 121 SYMLINPEN 60...... 47 SPIRIVA RESPIMAT...... 37 sulfasalazine...... 141 SYMPAZAN...... 40 spironolactone...... 130 sulfatrim pediatric...... 64 SYMPROIC...... 142 spironolactone-hctz...... 129 SULFURATED LIME...... 127 SYMTUZA...... 92 SPORANOX...... 55 sulindac...... 23 SYNAGIS...... 217 SPORANOX PULSEPAK...... 55 sumatriptan...... 182 SYNAREL...... 134 SPRAVATO (56 MG DOSE)...... 44 sumatriptan succinate...... 182 SYNDROS...... 54 SPRAVATO (84 MG DOSE)...... 45 sumatriptan succinate refill...... 182 SYNERCID...... 66 sprintec 28...... 109 sumatriptan-naproxen sodium...... 181 SYNJARDY...... 50 SPRITAM...... 42 SUNOSI...... 13 SYNJARDY XR...... 50 SPRYCEL...... 73 SUPARTZ FX...... 204 SYNRIBO...... 79 sps...... 189 super b complex maxi...... 192 SYNTHROID...... 229 sronyx...... 109 super b complex/fa/vit c...... 192 SYNVISC...... 204 ssd...... 121 super b complex/vitamin c...... 192 SYNVISC ONE...... 204 SSKI...... 116 super b-100...... 193 SYRINGE AVITENE...... 154 st joseph aspirin...... 26 super b-50...... 193 tab-a-vite...... 194 st joseph low dose...... 26 super b-complex...... 193 tab-a-vite/beta carotene...... 196 STALEVO 100...... 87 super b-complex + vitamin c...... 192 tab-a-vite/iron...... 194 STALEVO 125...... 87 super b-complex/vit c/fa...... 192 TAB-A-VITE/IRON/BETA STALEVO 150...... 87 super dec b-100...... 193 CAROTENE...... 194 STALEVO 200...... 87 super quints b-50...... 193 TABLOID...... 70 STALEVO 50...... 87 super stress b-complex cr...... 202 TABRECTA...... 75 STALEVO 75...... 87 SUPER THIN LANCETS...... 172 TACHOSIL...... 155 STAMARIL...... 235 SUPPRELIN LA...... 134 TACLONEX...... 128 stavudine...... 95 SUPRANE...... 143 tacrolimus...... 125, 187 STELARA...... 120, 141 SUPRAX...... 105, 106 tadalafil...... 103 STEMPHYLIUM...... 18 SUPREP BOWEL PREP KIT...... 157 tadalafil (pah)...... 103 STERILANCE PA...... 172 SURE COMFORT INSULIN TAFINLAR...... 73 STERILANCE TL...... 172 SYRINGE...... 179 TAGRISSO...... 74 STERILE TALC POWDER...... 227 SURE COMFORT LANCETS 18G. 172 take action...... 111 262 TAKHZYRO...... 148 terconazole...... 235 TIMOTHY GRASS POLLEN TALICIA...... 232 TERIPARATIDE ALLERGEN...... 18 TALL RAGWEED...... 18 (RECOMBINANT)...... 136 tinidazole...... 63, 64 TALZENNA...... 84 terrell...... 143 tiopronin...... 145 TAMIFLU...... 97 TESSALON PERLES...... 115 TIROSINT...... 229 tamoxifen citrate...... 69 TESTOPEL...... 31 TIROSINT-SOL...... 229 tamsulosin hcl...... 143 testosterone...... 31 TISSEEL...... 153, 154 TAPAZOLE...... 229 testosterone cypionate...... 31 TISSUEBLUE...... 214 taperdex 12-day...... 114 testosterone enanthate...... 31 tis-u-sol...... 187 taperdex 6-day...... 114 TETANUS-DIPHTHERIA TIVICAY...... 93 taperdex 7-day...... 114 TOXOIDS TD...... 230 TIVICAY PD...... 93 TARCEVA...... 74 tetrabenazine...... 221 tizanidine hcl...... 203 TARGRETIN...... 128 tetracaine hcl...... 211 TNKASE...... 150 tarina 24 fe...... 109 tetracycline hcl...... 229 TOBI PODHALER...... 20 tarina fe 1/20...... 109 TGT LANCET MICRO THIN 33G. 172 TOBRADEX...... 213 tarina fe 1/20 eq...... 109 TGT LANCET THIN 26G...... 172 TOBRADEX ST...... 213 TARKA...... 59 TGT LANCET ULTRA THIN 30G..172 tobramycin...... 20, 210 TARON-C DHA...... 199 THALOMID...... 185 tobramycin sulfate...... 20 TARON-PREX...... 201 THAM...... 182 tobramycin-dexamethasone...... 213 TAROXIA...... 117 THE LIQUILIFT TRACE...... 184 TOBREX...... 210 TASIGNA...... 73 THEO-24...... 38 TODAY SPONGE...... 235 TASMAR...... 86 theophylline...... 38 TODAYS HEALTH MINI PEN TAURINE...... 207 theophylline er...... 38 NEEDLES...... 179 tavaborole...... 126 THEOPHYLLINE IN D5W...... 38 TODAYS HEALTH PEN NEEDLES TAVALISSE...... 150 THERA...... 196 ...... 179 TAYTULLA...... 109 thera-mill...... 196 TODAYS HEALTH SHORT PEN tazarotene...... 120 thera-tabs...... 196 NEEDLE...... 180 tazicef...... 106 THEREMS...... 196 TODAYS HEALTH THIN TAZICEF...... 106 thiamine hcl...... 237 LANCETS 28G...... 172 TAZORAC...... 120, 121 THINLETS GP LANCETS...... 172 TODAYS HEALTH THIN taztia xt...... 100 THIOLA...... 145 LANCETS 30G...... 173 TAZVERIK...... 75 THIOLA EC...... 145 tolbutamide...... 50 TDVAX...... 230 thioridazine hcl...... 90 tolcapone...... 86 TECENTRIQ...... 72 thiotepa...... 68 TOLSURA...... 55 TECHLITE AST LANCETS...... 172 thiothixene...... 91 tolterodine tartrate...... 232 TECHLITE INSULIN SYRINGE.... 179 thrive...... 226 tolterodine tartrate er...... 232 TECHLITE LANCETS...... 172 THRIVITE RX...... 199 tolvaptan...... 136 TECHLITE LANCETS 30G...... 172 THROMBATE III...... 149 TOPCARE CLICKFINE PEN TECHLITE PEN NEEDLES...... 179 THROMBI-GEL 10...... 153 NEEDLES...... 180 TEFLARO...... 106 THROMBI-GEL 100...... 153 TOPCARE LANCETS MICRO- TEGADERM AG MESH...... 128 THROMBI-GEL 40...... 153 THIN 33G...... 173 TEGSEDI...... 220 THROMBIN-JMI...... 155 TOPCARE ULTRA COMFORT TEKTURNA HCT...... 62, 63 THROMBIN-JMI EPISTAXIS...... 155 INS SYR...... 180 telmisartan...... 61 THROMBI-PAD...... 153 topiramate...... 42 telmisartan-amlodipine...... 60 THROMBOGEN...... 155 topiramate er...... 42 telmisartan-hctz...... 61 THYMOGLOBULIN...... 186 toposar...... 82 temazepam...... 156 THYQUIDITY...... 229 TOPOTECAN HCL...... 84 TEMIXYS...... 92 tiadylt er...... 100 topotecan hcl...... 84 TEMODAR...... 81 tiagabine hcl...... 43 toremifene citrate...... 69 temozolomide...... 81 TIAZAC...... 101 TORISEL...... 75 temsirolimus...... 75 TIBSOVO...... 81 torsemide...... 130 tencon...... 24 TICE BCG...... 79 TOTECT...... 80 TENIPOSIDE...... 82 TIGAN...... 53 TOUJEO MAX SOLOSTAR...... 49 TENIVAC...... 230 TIGECYCLINE...... 228 TOUJEO SOLOSTAR...... 49 tenofovir disoproxil fumarate...... 95 TIGLUTIK...... 205 tovet...... 123 TENORETIC 100...... 62 tilia fe...... 113 TOVIAZ...... 232 TENORETIC 50...... 62 timolol maleate...... 99, 208 TPN ELECTROLYTES...... 183 TEPADINA...... 68 timolol maleate ocudose...... 208 TRACLEER...... 103 TEPEZZA...... 134 timolol maleate pf...... 208 TRALEMENT...... 184 TEPMETKO...... 76 TIMOPTIC...... 208 tramadol hcl...... 29 terazosin hcl...... 62 TIMOPTIC OCUDOSE...... 208 tramadol hcl er...... 29 terbinafine hcl...... 55 TIMOPTIC-XE...... 208 tramadol hcl er (biphasic)...... 29 terbutaline sulfate...... 36 tramadol-acetaminophen...... 31 263 trandolapril...... 60 trimipramine maleate...... 46 TUKYSA...... 72 trandolapril-verapamil hcl er...... 59 TRINATAL RX 1...... 199 tulana...... 112 tranexamic acid...... 154 trinate...... 199 TURALIO...... 76 TRANEXAMIC ACID-NACL...... 154 TRINAZ...... 199 TUSNEL C...... 115 tranylcypromine sulfate...... 44 TRINTELLIX...... 45 TUSSICAPS...... 116 TRAVASOL...... 207 tri-nymyo...... 113 TUXARIN ER...... 116 TRAVEL LANCETS...... 173 TRIOSTAT...... 229 TUZISTRA XR...... 116 TRAVEL LANCETS ADVANCED tri-previfem...... 113 TWINRIX...... 234 28G...... 173 TRIPTODUR...... 135 TWIRLA...... 110 travoprost (bak free)...... 215 TRISENOX...... 79 TWYNSTA...... 60, 61 TRAZIMERA...... 72 tri-sprintec...... 113 TYBLUME...... 109 trazodone hcl...... 45 TRISTART DHA...... 201 TYBOST...... 95 TREANDA...... 68 TRISTART FREE...... 201 tydemy...... 109 TRECATOR...... 68 TRISTART ONE...... 201 TYGACIL...... 228 TRELEGY ELLIPTA...... 35 tritocin...... 123 TYKERB...... 76 TRELSTAR MIXJECT...... 82 TRIUMEQ...... 92 TYMLOS...... 136 TREMFYA...... 120 TRIVEEN-DUO DHA...... 200 TYPHIM VI...... 233 treprostinil...... 102 TRI-VI-FLOR...... 196 TYSABRI...... 223 TRESIBA...... 49 TRI-VI-FLORO...... 196 TYVASO...... 102 TRESIBA FLEXTOUCH...... 49 tri-vite/fluoride...... 196 TYVASO REFILL...... 102 tretinoin...... 84, 118 trivora (28)...... 113 TYVASO STARTER...... 102 tretinoin (emollient)...... 118 tri-vylibra...... 113 UCERIS...... 31, 115 tretinoin microsphere...... 118 tri-vylibra lo...... 113 UDENYCA...... 152 tretinoin microsphere pump...... 118 TRIZIVIR...... 92 UKONIQ...... 76 TRETTEN...... 147 TRODELVY...... 84 ULTANE...... 143 TREXALL...... 70 TROGARZO...... 93 ULTICARE INSULIN SAFETY trezix...... 26 TROKENDI XR...... 42 SYR...... 180 tri femynor...... 113 TROPHAMINE...... 207 ULTICARE INSULIN SYRINGE....180 triamcinolone acetonide...... 123, 191 tropicamide...... 209 ULTICARE MICRO PEN TRIAMCINOLONE- trospium chloride...... 233 NEEDLES...... 180 MOXIFLOXACIN...... 213 trospium chloride er...... 233 ULTICARE MINI PEN NEEDLES. 180 TRI-AMINO...... 207 TRUE COMFORT INSULIN ULTICARE PEN NEEDLES...... 180 triamterene...... 130 SYRINGE...... 180 ULTICARE SHORT PEN triamterene-hctz...... 129 TRUE COMFORT PEN NEEDLES 180 NEEDLES...... 180 triazolam...... 156 TRUE COMFORT PRO INSULIN ULTIGUARD SAFEPACK PEN tri-buffered aspirin...... 24 SYR...... 180 NEEDLE...... 180 TRICARE...... 199 TRUE COMFORT PRO PEN ULTIGUARD SAFEPACK TRICARE PRENATAL DHA ONE.199 NEEDLES...... 180 SYR/NEEDLE...... 180 TRICHOPHYTON...... 18 TRUE COMFORT TWIST TOP ULTILET CLASSIC LANCETS...... 173 TRICHOPHYTON LANCETS...... 173 ULTILET INSULIN SYRINGE...... 180 MENTAGROPHYTES...... 18 TRUEPLUS 5-BEVEL PEN ULTILET INSULIN SYRINGE TRICOR...... 58 NEEDLES...... 180 SHORT...... 180 triderm...... 123 TRUEPLUS INSULIN SYRINGE....180 ULTILET LANCETS...... 173 trientine hcl...... 185 TRUEPLUS LANCETS 26G...... 173 ULTILET PEN NEEDLE...... 180 TRIESENCE...... 214 TRUEPLUS LANCETS 28G...... 173 ULTILET SAFETY LANCETS...... 173 tri-estarylla...... 113 TRUEPLUS LANCETS 30G...... 173 ULTILET SAFETY LANCETS 23G173 TRIFERIC...... 153 TRUEPLUS LANCETS 33G...... 173 ULTIVA...... 29 trifluoperazine hcl...... 90 TRUEPLUS PEN NEEDLES...... 180 ULTOMIRIS...... 148 trifluridine...... 210 TRUEPLUS SAFETY LANCETS ultra b-100 complex...... 202 trihexyphenidyl hcl...... 86 28G...... 173 ULTRA COMFORT INSULIN TRIKAFTA...... 227 TRULICITY...... 49 SYRINGE...... 180 tri-legest fe...... 113 TRUMENBA...... 233 ULTRA FLO INSULIN PEN tri-linyah...... 113 TRUSELTIQ (100MG DAILY NEEDLES...... 180 TRILIPIX...... 58 DOSE)...... 74 ULTRA FLO INSULIN SYR 1/2 tri-lo-estarylla...... 113 TRUSELTIQ (125MG DAILY UNIT...... 180 tri-lo-marzia...... 113 DOSE)...... 74 ULTRA FLO INSULIN SYRINGE..180 tri-lo-mili...... 113 TRUSELTIQ (50MG DAILY DOSE) 74 ULTRA THIN LANCETS 31G...... 173 tri-lo-sprintec...... 113 TRUSELTIQ (75MG DAILY DOSE) 74 ULTRA THIN PEN NEEDLES...... 180 TRI-LUMA...... 124 TRUSKIN...... 128 ULTRABAG/DIANEAL PD-2/1.5% TRILURON...... 204 TRUSOPT...... 211 DEX...... 188 trimethobenzamide hcl...... 53 TRUVADA...... 92 ULTRABAG/DIANEAL PD-2/2.5% trimethoprim...... 64 TRUXIMA...... 71 DEX...... 188 tri-mili...... 113 trymine cg...... 115 264 ULTRABAG/DIANEAL PD- UNISTIK 3 NEONATAL...... 174 VANCOCIN HCL...... 65 2/4.25%DEX...... 188 UNISTIK 3 NORMAL...... 174 VANCOMYCIN HCL...... 65 ULTRABAG/DIANEAL/1.5% UNISTIK CZT COMFORT...... 174 vancomycin hcl...... 65 DEXTROSE...... 188 UNISTIK CZT NORMAL...... 174 VANCOMYCIN HCL IN ULTRABAG/DIANEAL/2.5% UNISTIK NORMAL...... 174 DEXTROSE...... 65 DEXTROSE...... 189 UNISTIK PRO SAFETY LANCET. 174 VANCOMYCIN HCL IN NACL...... 65 ULTRABAG/DIANEAL/4.25% DEX UNISTIK SAFETY LANCETS 28G 174 vandazole...... 235 ...... 189 UNISTIK SAFETY LANCETS 30G 174 VANIQA...... 126 ULTRACARE INSULIN SYRINGE 180 UNISTIK TOUCH SAFETY LANC VANISHPOINT INSULIN ULTRA-CARE LANCETS 30G...... 173 21G...... 174 SYRINGE...... 181 ULTRACARE PEN NEEDLES...... 180 UNISTIK TOUCH SAFETY LANC VANTAS...... 82 ULTRA-COMFORT INSULIN 23G...... 174 VAPRISOL...... 137 SYRINGE...... 180 UNISTIK TOUCH SAFETY LANC VAQTA...... 235 ULTRAFOAM SPONGE 28G...... 174 vardenafil hcl...... 103 2X6.25X7CM...... 155 UNISTIK TOUCH SAFETY LANC VARITHENA...... 189 ULTRAFOAM SPONGE 30G...... 174 VARIVAX...... 235 8X12.5X1CM...... 155 unithroid...... 229 VARIZIG...... 218 ULTRAFOAM SPONGE UNITUXIN...... 72 VARUBI (180 MG DOSE)...... 54 8X12.5X3CM...... 155 UNIVERSAL 1 LANCETS THIN VASCEPA...... 57 ULTRAFOAM SPONGE 26G...... 174 VASERETIC...... 60 8X25X1CM...... 155 UNIVERSAL 1 LANCETS THIN VASOSTRICT...... 138 ULTRAFOAM SPONGE 33G...... 174 VAXCHORA...... 233 8X6.25X1CM...... 155 UNIVERSAL 1 LANCETS ULTRA VAXELIS...... 230 ULTRA-THIN II AUTO LANCET.. 173 THIN...... 174 VAZCULEP...... 237 ULTRA-THIN II INS SYR SHORT.180 UPLIZNA...... 188 VCF VAGINAL ULTRA-THIN II INSULIN UPNEEQ...... 215 CONTRACEPTIVE...... 235 SYRINGE...... 180 UPTRAVI...... 103 VECAMYL...... 62 ULTRA-THIN II LANCETS...... 173 UROCIT-K 10...... 144 VECTIBIX...... 74 ULTRA-THIN II MINI PEN UROCIT-K 15...... 144 VECURONIUM BROMIDE...... 206 NEEDLE...... 180 UROCIT-K 5...... 144 vecuronium bromide...... 206 ULTRA-THIN II PEN NEEDLE URSO 250...... 140 VELCADE...... 76 SHORT...... 180 URSO FORTE...... 140 VELETRI...... 102 ULTRA-THIN II PEN NEEDLES....180 ursodiol...... 140 velivet...... 113 UNASYN...... 219 UVADEX...... 79 VELPHORO...... 142 UNIFINE PEN NEEDLES...... 180 VABOMERE...... 64 VELTASSA...... 189 UNIFINE PENTIPS...... 180 valacyclovir hcl...... 96 VEMLIDY...... 96 UNIFINE PENTIPS PLUS...... 180 VALCHLOR...... 119 VENCLEXTA...... 73 UNIFINE SAFECONTROL PEN VALCYTE...... 95 VENCLEXTA STARTING PACK.....73 NEEDLE...... 180 valganciclovir hcl...... 95 VENEXA...... 194 UNILET COMFORTOUCH valproate sodium...... 44 VENIPUNCTURE PX1 LANCET...... 173 valproic acid...... 44 PHLEBOTOMY...... 128 UNILET EXCELITE...... 173 valrubicin...... 78 venlafaxine hcl...... 46 UNILET EXCELITE II...... 173 valsartan...... 61 venlafaxine hcl er...... 46 UNILET G.P. LANCET...... 173 valsartan-hydrochlorothiazide...... 61 VENOFER...... 153 UNILET G.P. SUPERLITE VALSTAR...... 78 VENOMIL HONEY BEE VENOM... 18 LANCET...... 173 VALTOCO 10 MG DOSE...... 40 VENOMIL MIXED VESPID UNILET GP 28 ULTRA THIN...... 173 VALTOCO 15 MG DOSE...... 40 VENOM...... 18 UNILET LANCET...... 173 VALTOCO 20 MG DOSE...... 40 VENOMIL WASP VENOM...... 18 UNILET MICRO-THIN 33G...... 173 VALTOCO 5 MG DOSE...... 40 VENOMIL WHITE FACED UNILET SUPERLITE LANCET..... 173 VALUE HEALTH INSULIN HORNET...... 18 UNILET SUPER-THIN 30G...... 173 SYRINGE...... 181 VENOMIL YELLOW HORNET UNILET ULTRA-THIN 28G...... 173 VALUE PLUS LANCET VENOM...... 18 UNISTIK 1...... 173 STANDARD 21G...... 174 VENOMIL YELLOW JACKET UNISTIK 2...... 173 VALUE PLUS LANCETS SUPER VENOM...... 18 UNISTIK 2 COMFORT...... 173 THIN...... 174 VENTAVIS...... 103 UNISTIK 2 EXTRA...... 173 VALUE PLUS LANCETS THIN VENTOLIN HFA...... 36 UNISTIK 2 NEONATAL...... 173 26G...... 174 verapamil hcl...... 101 UNISTIK 2 NORMAL...... 173 VALUMARK LANCET SUPER verapamil hcl er...... 101 UNISTIK 2 SUPER...... 173 THIN 30G...... 174 VEREGEN...... 118 UNISTIK 3...... 173 VALUMARK LANCET ULTRA VERELAN...... 101 UNISTIK 3 COMFORT...... 173 THIN 28G...... 174 VERELAN PM...... 101 UNISTIK 3 EXTRA...... 174 VALUMARK PEN NEEDLES...... 181 VERQUVO...... 104 UNISTIK 3 GENTLE...... 174 VANCOCIN...... 65 VERSACLOZ...... 89 265 VERZENIO...... 80 vitamin d (ergocalciferol)...... 237 WIDE-SEAL DIAPHRAGM 60...... 163 vestura...... 109 vitamin k1...... 237 WIDE-SEAL DIAPHRAGM 65...... 163 VFEND...... 55 vitamin-b complex...... 191 WIDE-SEAL DIAPHRAGM 70...... 163 VIBATIV...... 65 vitamins acd-fluoride...... 196 WIDE-SEAL DIAPHRAGM 75...... 163 VIBERZI...... 140 VITAPEARL...... 200 WIDE-SEAL DIAPHRAGM 80...... 163 VICTOZA...... 49 VITATHELY WITH GINGER...... 200 WIDE-SEAL DIAPHRAGM 85...... 163 VIDA MIA UNIFINE PENTIPS...... 181 VITATRUE...... 201 WIDE-SEAL DIAPHRAGM 90...... 163 VIDA MIA UNILET LANCETS 28G VITRAKVI...... 77 WIDE-SEAL DIAPHRAGM 95...... 163 ...... 174 VITRANOL FE...... 194 WILATE...... 147 VIDA MIA UNILET LANCETS 30G VITRASE...... 186 WILZIN...... 185 ...... 174 VIVA DHA...... 200 WINRHO SDF...... 218 VIDAZA...... 70 VIVAGUARD LANCETS...... 174 wixela inhub...... 35 vienva...... 110 VIVITROL...... 52 womans laxative...... 160 vigabatrin...... 43 VIZIMPRO...... 74 womens laxative...... 160 vigadrone...... 43 volnea...... 106 WOUNDGELHA MATRIX...... 128 VIGAMOX...... 210 VONVENDI...... 147 WP THYROID...... 229 VILTEPSO...... 205 VORAXAZE...... 80 wymzya fe...... 110 VIMIZIM...... 135 voriconazole...... 55 WYNZORA...... 128 VIMPAT...... 42 VOSEVI...... 96 XADAGO...... 86 VINATE DHA RF...... 200 VOTRIENT...... 76 XALKORI...... 70 VINATE II...... 200 VP INSULIN SYRINGE...... 181 XARACOLL...... 161 VINATE ONE...... 200 VP-PNV-DHA...... 200 XARELTO...... 38 vinblastine sulfate...... 82 VPRIV...... 150 XARELTO STARTER PACK...... 38 vincristine sulfate...... 82 VRAYLAR...... 88 XATMEP...... 70 vinorelbine tartrate...... 82 VUSION...... 119 XCOPRI...... 43 VIOKACE...... 129 vyfemla...... 110 XCOPRI (250 MG DAILY DOSE).....43 viorele...... 106 VYLEESI...... 221 XCOPRI (350 MG DAILY DOSE).....43 VIRACEPT...... 94 vylibra...... 110 XELJANZ...... 20 VIRAMUNE...... 94 VYNDAMAX...... 104 XELJANZ XR...... 20 VIRAMUNE XR...... 94 VYNDAQEL...... 104 XELODA...... 70 VIRAZOLE...... 97 VYONDYS 53...... 205 XELPROS...... 215 VIREAD...... 95 VYVANSE...... 12 XEMBIFY...... 218 VIRT-C DHA...... 200 VYXEOS...... 78 XENAZINE...... 221 VIRT-NATE DHA...... 200 VYZULTA...... 215 XENICAL...... 13 virt-phos 250 neutral...... 184 WAKIX...... 13 XENLETA...... 66 VIRT-PN DHA...... 201 WALGREENS ADV TRAVEL XEOMIN...... 205 VIRT-PN PLUS...... 200 LANCETS...... 174 XEPI...... 118 virtussin a/c...... 115 WALGREENS LANCETS...... 174 XERAVA...... 228 virtussin ac w/alc...... 115 WALGREENS LANCETS MICRO XERESE...... 121 VIRTUSSIN DAC...... 115 THIN...... 174 XERMELO...... 142 VISCO-3...... 204 WALGREENS LANCETS SUPER XGEVA...... 136 VISCOAT...... 214 THIN...... 174 XIAFLEX...... 186 VISIONBLUE...... 214 WALGREENS THIN LANCETS.....174 XIFAXAN...... 64 VISTARIL...... 33 WALGREENS ULTRA THIN XIGDUO XR...... 50 VISTOGARD...... 52 LANCETS...... 174 XIIDRA...... 209 VISUDYNE...... 212 warfarin sodium...... 38 XOFIGO...... 79 vit e-vit c-beta carotene...... 196 WASP VENOM PROTEIN...... 18 XOFLUZA (40 MG DOSE)...... 97 VITAFOL FE+...... 201 water for irrigation, sterile...... 187 XOFLUZA (80 MG DOSE)...... 97 VITAFOL GUMMIES...... 200 WEGMANS UNIFINE PENTIPS XOLAIR...... 35 VITAFOL STRIPS...... 201 PLUS...... 181 XOLEGEL...... 124 VITAFOL ULTRA...... 201 WEGOVY...... 13 XOPENEX HFA...... 36 VITAFOL-NANO...... 200 wera...... 110 XOSPATA...... 76 VITAFOL-OB...... 200 WESTAB PLUS...... 200 XPOVIO (100 MG ONCE VITAFOL-OB+DHA...... 201 WESTERN JUNIPER...... 19 WEEKLY)...... 77 VITAFOL-ONE...... 201 WESTGEL DHA...... 201 XPOVIO (40 MG ONCE WEEKLY).77 vitalee...... 196 WESTHROID...... 229 XPOVIO (40 MG TWICE VITALINE BIOTIN FORTE...... 192 WEST-VITE W/FOLIC ACID...... 192 WEEKLY)...... 77 VITAMEDMD ONE WHITE BIRCH...... 19 XPOVIO (60 MG ONCE WEEKLY).77 RX/QUATREFOLIC...... 201 WHITE FACED HORNET VENOM.19 XPOVIO (60 MG TWICE VITAMEDMD REDICHEW RX...... 201 WHITE MULBERRY...... 19 WEEKLY)...... 77 vitamin b + c complex...... 192 WHITE OAK...... 19 XPOVIO (80 MG ONCE WEEKLY).77 vitamin b complex...... 191 WHITE PINE...... 19 XPOVIO (80 MG TWICE vitamin b-complex...... 191 WHITE-FACED HORNET VENOM 19 WEEKLY)...... 77 266 XTANDI...... 69 ZIEXTENZO...... 152 xulane...... 110 ZILRETTA...... 115 XULTOPHY...... 49 ZILXI...... 126 XURIDEN...... 133 zinc chloride...... 185 XYLOCAINE...... 161 zinc sulfate...... 185 XYLOCAINE/EPINEPHRINE...... 160 ZINGO...... 161 XYLOCAINE-MPF...... 161 ZINPLAVA...... 217 XYLOCAINE-MPF/EPINEPHRINE ZIOPTAN...... 215 ...... 160 ziprasidone hcl...... 88 XYNTHA...... 147 ziprasidone mesylate...... 88 XYNTHA SOLOFUSE...... 147 ZIRABEV...... 85 XYREM...... 220 ZIRGAN...... 210 YASMIN 28...... 110 ZITHROMAX...... 162 YAZ...... 110 ZITHROMAX TRI-PAK...... 162 YELLOW DOCK...... 19 ZITHROMAX Z-PAK...... 162 YELLOW HORNET VENOM ZOFRAN...... 53 PROTEIN...... 19 ZOKINVY...... 186 YELLOW JACKET VENOM ZOLADEX...... 82 PROTEIN...... 19 zoledronic acid...... 131 YERVOY...... 72 ZOLEDRONIC ACID...... 131 YF-VAX...... 235 ZOLINZA...... 74 yl balanced b-100...... 193 zolmitriptan...... 182 yl folic acid...... 152 zolpidem tartrate...... 156 YONDELIS...... 84 zolpidem tartrate er...... 156 YONSA...... 68 ZOLPIMIST...... 156 YOSPRALA...... 149 zonisamide...... 42 YUPELRI...... 37 ZONTIVITY...... 149 YUTIQ...... 214 ZORBTIVE...... 133 yuvafem...... 236 ZORTRESS...... 187 zafemy...... 110 ZOSYN...... 219 zafirlukast...... 37 zovia 1/35 (28)...... 110 zaleplon...... 156 zovia 1/35e (28)...... 110 ZALTRAP...... 85 ZOVIRAX...... 96, 121 ZALVIT...... 200 ZUBSOLV...... 30 ZANAFLEX...... 203 ZULRESSO...... 44 ZANOSAR...... 83 zumandimine...... 110 zarah...... 110 ZUPLENZ...... 53 ZARXIO...... 152 ZYCLARA...... 125 ZATEAN-PN DHA...... 201 ZYCLARA PUMP...... 125 ZATEAN-PN PLUS...... 200 ZYDELIG...... 84 ZCORT 7-DAY...... 115 ZYKADIA...... 70 zebutal...... 24 ZYLET...... 213 ZEGALOGUE...... 47 ZYLOPRIM...... 145 ZEJULA...... 84 ZYMAXID...... 210 ZELAPAR...... 86 ZYNLONTA...... 71 ZELBORAF...... 73 ZYPREXA RELPREVV...... 91 ZEMAIRA...... 227 ZYTIGA...... 68 ZEMDRI...... 20 ZYVANA...... 194 ZEMPLAR...... 134 ZYVOX...... 66 zenatane...... 118 ZENPEP...... 129 zenzedi...... 12 ZEPOSIA...... 226 ZEPOSIA 7-DAY STARTER PACK226 ZEPOSIA STARTER KIT...... 226 ZEPZELCA...... 68 ZERBAXA...... 104 ZESTORETIC...... 60 ZEVALIN Y-90...... 78 ZIAC...... 62 ZIAGEN...... 94 ziclopro...... 119 zidovudine...... 95 267 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