WELL SENSE HEALTH PLAN DRUG LIST (Effective 12/12/2013 ) Below is a list of prescription drugs covered by Well Sense Health Plan (Plan). Covered devices are listed on the OTC formulary (drug list) at wellsense.org. The list is subject to change. If a drug is not on the list, it may still be available. All newly approved drugs require prior approval from Well Sense before they can be covered, and members may be required to try the generic version of a drug before the brand drug will be covered. Excluded drugs are outlined in the Member Handbook.

Questions? Please contact Well Sense Health Plan at: 1-877-957-1300 Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants ZENZEDI TAB 2.5MG Brand 2 ZENZEDI TAB 5MG generic 1 PREF QL 90/30 PA DEXTROAMPHET TAB 5MG generic 1 PREF QL 90/30 PA ZENZEDI TAB 7.5MG Brand 2 ZENZEDI TAB 10MG generic 1 PREF QL 180/30 PA DEXTROAMPHET TAB 10MG generic 1 PREF QL 180/30 PA PROCENTRA SOL 5MG/5ML generic 1 DEXTROAMPHET SOL 5MG/5ML generic 1 DEXTROAMPHET CAP 5MG ER generic 1 PREF QL 60/30 PA DEXEDRINE CAP 5MG CR Brand 2 NON-PREF ST QL 60/30 DEXTROAMPHET CAP 10MG ER generic 1 PREF QL 150/30 PA DEXEDRINE CAP 10MG CR Brand 2 NON-PREF ST QL 150/30 DEXTROAMPHET CAP 15MG ER generic 1 PREF QL 120/30 PA DEXEDRINE CAP 15MG CR Brand 2 NON-PREF ST QL 120/30 VYVANSE CAP 20MG Brand 2 PREF QL 30/30 PA VYVANSE CAP 30MG Brand 2 PREF QL 30/30 PA VYVANSE CAP 40MG Brand 2 PREF QL 30/30 PA VYVANSE CAP 50MG Brand 2 PREF QL 30/30 PA VYVANSE CAP 60MG Brand 2 PREF QL 30/30 PA VYVANSE CAP 70MG Brand 2 PREF QL 30/30 PA METHAMPHETAM TAB 5MG generic 1 PREF PA DESOXYN TAB 5MG Brand 2 NON-PREF ST AMPHETAMINE TAB 5MG generic 1 PREF QL 90/30 PA

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 1 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ADDERALL TAB 5MG Brand 2 NON-PREF ST QL 90/30 ADDERALL TAB 7.5MG Brand 2 NON-PREF ST QL 90/30 AMPHETAMINE TAB 7.5MG generic 1 PREF QL 90/30 PA AMPHETAMINE TAB 10MG generic 1 PREF QL 90/30 PA ADDERALL TAB 10MG Brand 2 NON-PREF ST QL 90/30 AMPHETAMINE TAB 12.5MG generic 1 PREF QL 90/30 PA ADDERALL TAB 12.5MG Brand 2 NON-PREF ST QL 90/30 AMPHETAMINE TAB 15MG generic 1 PREF QL 90/30 PA ADDERALL TAB 15MG Brand 2 NON-PREF ST QL 90/30 AMPHETAMINE TAB 20MG generic 1 PREF QL 90/30 PA ADDERALL TAB 20MG Brand 2 NON-PREF ST QL 90/30 AMPHETAMINE TAB 30MG generic 1 PREF QL 90/30 PA ADDERALL TAB 30MG Brand 2 NON-PREF ST QL 90/30 AMPHETAMINE CAP 5MG ER generic 1 NON-PREF ST QL 60/30 ADDERALL XR CAP 5MG Brand 2 PREF QL 60/30 PA AMPHETAMINE CAP 10MG ER generic 1 NON-PREF ST QL 60/30 ADDERALL XR CAP 10MG Brand 2 PREF QL 60/30 PA AMPHETAMINE CAP 15MG ER generic 1 NON-PREF ST QL 60/30 ADDERALL XR CAP 15MG Brand 2 PREF QL 60/30 PA ADDERALL XR CAP 20MG Brand 2 PREF QL 60/30 PA AMPHETAMINE CAP 20MG ER generic 1 NON-PREF ST QL 60/30 AMPHETAMINE CAP 25MG ER generic 1 NON-PREF ST QL 60/30 ADDERALL XR CAP 25MG Brand 2 PREF QL 60/30 PA AMPHETAMINE CAP 30MG ER generic 1 NON-PREF ST QL 60/30 ADDERALL XR CAP 30MG Brand 2 PREF QL 60/30 PA BENZPHETAMIN TAB 50MG generic 1 PA DIDREX TAB 50MG Brand 2 GR DIETHYLPROP TAB 25MG generic 1 PA DIETHYLPROP TAB 75MG ER generic 1 PA PHENDIMETRAZ TAB 35MG generic 1 PA BONTRIL PDM TAB 35MG Brand 2 GR PHENDIMETRAZ CAP 105MG ER generic 1 PA KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 2 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PHENTERMINE CAP 15MG generic 1 PA PHENTERMINE CAP 30MG generic 1 PA PHENTERMINE CAP 37.5MG generic 1 PA ADIPEX-P CAP 37.5MG Brand 2 GR PHENTERMINE TAB 37.5MG generic 1 PA ADIPEX-P TAB 37.5MG Brand 2 GR XENICAL CAP 120MG Brand 2 PA CAFFEINE CIT INJ 60MG/3ML generic 1 CAFCIT INJ 60MG/3ML Brand 2 GR CAFFEINE CIT SOL 20MG/ML generic 1 CAFFEINE CIT SOL 60MG/3ML generic 1 CAFCIT SOL 60MG/3ML Brand 2 GR CAFFEINE/SOD INJ BENZOATE Brand 2 DOXAPRAM HCL INJ 20MG/ML generic 1 DOPRAM INJ 20MG/ML Brand 2 GR KAPVAY MIS 0.1&0.2 Brand 2 CLONIDINE TAB 0.1MG ER generic 1 KAPVAY TAB 0.1 MG Brand 2 GR INTUNIV TAB 1MG Brand 2 NON-PREF ST QL 30/30 INTUNIV TAB 2MG Brand 2 NON-PREF ST QL 30/30 INTUNIV TAB 3MG Brand 2 NON-PREF ST QL 30/30 INTUNIV TAB 4MG Brand 2 NON-PREF ST QL 30/30 STRATTERA CAP 10MG Brand 2 NON-PREF ST QL 60/30 STRATTERA CAP 18MG Brand 2 NON-PREF ST QL 60/30 STRATTERA CAP 25MG Brand 2 NON-PREF ST QL 60/30 STRATTERA CAP 40MG Brand 2 NON-PREF ST QL 60/30 STRATTERA CAP 60MG Brand 2 NON-PREF ST QL 60/30 STRATTERA CAP 80MG Brand 2 NON-PREF ST QL 60/30 STRATTERA CAP 100MG Brand 2 NON-PREF ST QL 60/30 NUVIGIL TAB 50MG Brand 2 QL 60/30 PA NUVIGIL TAB 150MG Brand 2 QL 30/30 PA NUVIGIL TAB 250MG Brand 2 QL 30/30 PA KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 3 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO FOCALIN TAB 2.5MG Brand 2 NON-PREF ST QL 60/30 DEXMETHYLPH TAB 2.5MG generic 1 PREF QL 60/30 PA DEXMETHYLPH TAB 5MG generic 1 FOCALIN TAB 5MG Brand 2 NON-PREF ST QL 60/30 DEXMETHYLPH TAB 10MG generic 1 FOCALIN TAB 10MG Brand 2 FOCALIN XR CAP 5MG Brand 2 FOCALIN XR CAP 10MG Brand 2 PREF QL 30/30 PA FOCALIN XR CAP 15MG Brand 2 PREF QL 30/30 PA FOCALIN XR CAP 20MG Brand 2 PREF QL 30/30 PA FOCALIN XR CAP 25MG Brand 2 PREF QL 30/30 PA FOCALIN XR CAP 30MG Brand 2 PREF QL 30/30 PA FOCALIN XR CAP 35MG Brand 2 PREF QL 30/30 PA FOCALIN XR CAP 40MG Brand 2 PREF QL 30/30 PA DAYTRANA DIS 10MG/9HR Brand 2 NON-PREF ST QL 30/30 DAYTRANA DIS 15MG/9HR Brand 2 NON-PREF ST QL 30/30 DAYTRANA DIS 20MG/9HR Brand 2 NON-PREF ST QL 30/30 DAYTRANA DIS 30MG/9HR Brand 2 NON-PREF ST QL 30/30 METADATE CD CAP 10MG Brand 2 NON-PREF ST QL 60/30 METHYLPHENID CAP 10MG generic 1 NON-PREF ST QL 60/30 METHYLPHENID CAP 20MG generic 1 NON-PREF ST QL 60/30 METADATE CD CAP 20MG Brand 2 NON-PREF ST QL 60/30 METHYLPHENID CAP 30MG generic 1 NON-PREF ST QL 60/30 METADATE CD CAP 30MG Brand 2 NON-PREF ST QL 60/30 METHYLPHENID CAP 40MG generic 1 NON-PREF ST QL 60/30 METADATE CD CAP 40MG Brand 2 NON-PREF ST QL 60/30 METHYLPHENID CAP 50MG generic 1 NON-PREF ST QL 60/30 METADATE CD CAP 50MG Brand 2 NON-PREF ST QL 60/30 METHYLPHENID CAP 60MG generic 1 NON-PREF ST QL 60/30 METADATE CD CAP 60MG Brand 2 NON-PREF ST QL 60/30 RITALIN TAB 5MG Brand 2 NON-PREF ST QL 90/30 METHYLPHENID TAB 5MG generic 1 PREF QL 90/30 PA KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 4 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO METHYLPHENID TAB 10MG generic 1 PREF QL 90/30 PA RITALIN TAB 10MG Brand 2 NON-PREF ST QL 90/30 METHYLPHENID TAB 20MG generic 1 PREF QL 90/30 PA RITALIN TAB 20MG Brand 2 NON-PREF ST QL 90/30 METHYLPHENID TAB 10MG ER generic 1 PREF QL 60/30 PA METADATE TAB 20MG ER generic 1 PREF QL 60/30 PA RITALIN TAB 20MG SR Brand 2 NON-PREF ST QL 60/30 METHYLPHENID TAB 18MG ER generic 1 PREF QL 30/30 CONCERTA TAB 18MG Brand 2 GR METHYLPHENID TAB 27MG ER generic 1 PREF QL 30/30 CONCERTA TAB 27MG Brand 2 GR METHYLPHENID TAB 36MG ER generic 1 PREF QL 60/30 CONCERTA TAB 36MG Brand 2 GR CONCERTA TAB 54MG Brand 2 GR METHYLPHENID TAB 54MG ER generic 1 PREF QL 30/30 METHYLIN CHW 2.5MG generic 1 PREF QL 90/30 PA METHYLIN CHW 5MG generic 1 PREF QL 90/30 PA METHYLIN CHW 10MG generic 1 PREF QL 180/30 PA QUILLIVANT SUS XR Brand 2 NON-PREF ST QL 240/30 METHYLIN SOL 5MG/5ML Brand 2 GR METHYLIN SOL 10MG/5ML Brand 2 GR RITALIN LA CAP 10MG Brand 2 METHYLPHENID CAP 20MG ER generic 1 NON-PREF ST QL 60/30 RITALIN LA CAP 20MG Brand 2 NON-PREF ST QL 30/30 METHYLPHENID CAP 30MG ER generic 1 NON-PREF ST QL 60/30 RITALIN LA CAP 30MG Brand 2 NON-PREF ST QL 30/30 METHYLPHENID CAP 40MG ER generic 1 NON-PREF ST QL 60/30 RITALIN LA CAP 40MG Brand 2 NON-PREF ST QL 30/30 MODAFINIL TAB 100MG generic 1 QL 30/30 PA PROVIGIL TAB 100MG Brand 2 GR MODAFINIL TAB 200MG generic 1 QL 30/30 PA PROVIGIL TAB 200MG Brand 2 GR KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 5 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO Alternative Medicines QUINZYME TAB 90MG Brand 2 Amebicides YODOXIN TAB 210MG Brand 2 YODOXIN TAB 650MG Brand 2 Aminoglycosides AMIKACIN INJ 500/2ML generic 1 AMIKACIN INJ 1GM/4ML generic 1 GENTAMICIN INJ 10MG/ML generic 1 GENTAMICIN INJ 10MG/ML generic 1 GENTAMICIN INJ 40MG/ML generic 1 GENTAM/NACL INJ 80MG PB generic 1 GENTAM/NACL INJ 80MG generic 1 GENTAM/NACL INJ 0.9MG/ML generic 1 GENTAM/NACL INJ 100MG generic 1 GENTAM/NACL INJ 60MG generic 1 GENTAM/NACL INJ 120MG generic 1 GENTAM/NACL INJ 60MG PB generic 1 GENTAM/NACL INJ 1.4MG/ML generic 1 GENTAM/NACL INJ 80MG generic 1 GENTAM/NACL INJ 100MG PB Brand 2 NEOMYCIN TAB 500MG generic 1 NEO-FRADIN SOL 125/5ML Brand 2 PAROMOMYCIN CAP 250MG generic 1 STREPTOMYCIN INJ 1GM generic 1 TOBI PODHALR CAP 28MG Brand 2 TOBI NEB 300/5ML Brand 2 BETHKIS NEB 300/4ML Brand 2 PA TOBRAMYCIN INJ 10MG/ML generic 1 TOBRAMYCIN INJ 80MG/2ML generic 1 TOBRAMYCIN INJ 40MG/ML generic 1

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 6 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO TOBRAMYCIN INJ 1.2/30ML generic 1 TOBRAMYCIN INJ 40MG/ML generic 1 TOBRAMYCIN INJ 40MG/ML generic 1 TOBRAMYCIN INJ 1.2GM generic 1 TOBRA/NACL INJ 80/0.9 generic 1 TOBRA/NACL INJ 60/0.9 generic 1 Analgesics – Anti-inflammatory ZORVOLEX CAP 18MG Brand 2 ZORVOLEX CAP 35MG Brand 2 ZIPSOR CAP 25MG Brand 2 QL 120/30 PA CATAFLAM TAB 50MG Brand 2 GR DICLOFEN POT TAB 50MG generic 1 DICLOFENAC TAB 25MG DR generic 1 DICLOFENAC TAB 50MG DR generic 1 DICLOFENAC TAB 75MG DR generic 1 DICLOFENAC TAB 100MG ER generic 1 DICLOFENAC TAB 100MG XR generic 1 VOLTAREN-XR TAB 100MG Brand 2 GR ETODOLAC CAP 200MG generic 1 ETODOLAC CAP 300MG generic 1 ETODOLAC TAB 400MG generic 1 ETODOLAC TAB 500MG generic 1 ETODOLAC ER TAB 400MG generic 1 ETODOLAC ER TAB 500MG generic 1 ETODOLAC ER TAB 600MG generic 1 NALFON CAP 400MG Brand 2 FENOPROFEN TAB 600MG generic 1 FLURBIPROFEN TAB 50MG generic 1 FLURBIPROFEN TAB 100MG generic 1 IBUPROFEN TAB 400MG generic 1 IBUPROFEN TAB 600MG generic 1

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 7 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO IBUPROFEN TAB 800MG generic 1 IBUPROFEN SUS 100/5ML generic 1 CALDOLOR INJ 400/4ML Brand 2 CALDOLOR INJ 800/8ML Brand 2 NEOPROFEN SOL 10MG/ML Brand 2 INDOMETHACIN CAP 25MG generic 1 INDOMETHACIN CAP 50MG generic 1 INDOMETHACIN CAP 75MG ER generic 1 INDOCIN SUS 25MG/5ML Brand 2 INDOCIN SUP 50MG Brand 2 INDOMETHACIN INJ 1MG generic 1 INDOCIN IV INJ 1MG Brand 2 GR KETOPROFEN CAP 50MG generic 1 KETOPROFEN CAP 75MG generic 1 KETOPROFEN CAP 200MG ER generic 1 KETOROLAC TAB 10MG generic 1 KETOROLAC INJ 15MG/ML generic 1 KETOROLAC INJ 30MG/ML generic 1 KETOROLAC INJ 60MG/2ML generic 1 KETOROLAC INJ 30MG/ML Brand 2 KETOROLAC INJ 30MG/ML generic 1 KETOROLAC INJ 60MG/2ML generic 1 SPRIX SPR 15.75MG Brand 2 QL 5/90 PA MECLOFEN SOD CAP 50MG generic 1 MECLOFEN SOD CAP 100MG generic 1 PONSTEL CAP 250MG Brand 2 GR MEFENAM ACID CAP 250MG generic 1 PA MO MOBIC TAB 7.5MG Brand 2 NON-PREF ST MO MELOXICAM TAB 7.5MG generic 1 PREF MO MOBIC TAB 15MG Brand 2 NON-PREF ST MO MELOXICAM TAB 15MG generic 1 PREF MO MELOXICAM SUS 7.5/5ML generic 1 PREF MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 8 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO MOBIC SUS 7.5/5ML Brand 2 NABUMETONE TAB 500MG generic 1 NABUMETONE TAB 750MG generic 1 NAPROXEN TAB 250MG generic 1 NAPROSYN TAB 250MG Brand 2 GR NAPROSYN TAB 375MG Brand 2 GR NAPROXEN TAB 375MG generic 1 NAPROSYN TAB 500MG Brand 2 GR NAPROXEN TAB 500MG generic 1 EC-NAPROSYN TAB 375MG Brand 2 GR NAPROXEN DR TAB 375MG generic 1 NAPROXEN DR TAB 500MG generic 1 EC-NAPROSYN TAB 500MG Brand 2 GR NAPROXEN SUS 125/5ML generic 1 NAPROSYN SUS 125/5ML Brand 2 GR NAPROXEN SOD TAB 275MG generic 1 ANAPROX TAB 275MG Brand 2 GR NAPROXEN SOD TAB 550MG generic 1 ANAPROX DS TAB 550MG Brand 2 GR NAPRELAN TAB 375MG CR Brand 2 NAPRELAN TAB 500MG CR Brand 2 NAPRELAN TAB 750MG CR Brand 2 DAYPRO TAB 600MG Brand 2 GR OXAPROZIN TAB 600MG generic 1 PIROXICAM CAP 10MG generic 1 FELDENE CAP 10MG Brand 2 GR PIROXICAM CAP 20MG generic 1 FELDENE CAP 20MG Brand 2 GR SULINDAC TAB 150MG generic 1 SULINDAC TAB 200MG generic 1 CLINORIL TAB 200MG Brand 2 GR TOLMETIN SOD CAP 400MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 9 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO TOLMETIN SOD TAB 200MG generic 1 TOLMETIN SOD TAB 600MG generic 1 CELEBREX CAP 50MG Brand 2 PREF QL 60/30 PA MO CELEBREX CAP 100MG Brand 2 PREF QL 60/30 PA MO CELEBREX CAP 200MG Brand 2 PREF QL 60/30 PA MO CELEBREX CAP 400MG Brand 2 PREF QL 60/30 PA MO ARTHROTEC 50 TAB Brand 2 GR DICLO/MISOPR TAB 50-0.2MG generic 1 DICLO/MISOPR TAB 75-0.2MG generic 1 ARTHROTEC 75 TAB Brand 2 GR DUEXIS TAB 800-26.6 Brand 2 VIMOVO TAB 375-20MG Brand 2 NON-PREF ST QL 60/30 MO VIMOVO TAB 500-20MG Brand 2 NON-PREF ST QL 60/30 MO RIDAURA CAP 3MG Brand 2 RHEUMATREX TAB 2.5MG Brand 2 KINERET INJ Brand 2 NON-PREF ST QL 20.1/30 PA SP HUMIRA KIT 20MG/0.4 Brand 2 PREF QL 2/28 PA SP HUMIRA PEN KIT 40MG/0.8 Brand 2 PREF QL 2/28 PA SP SIMPONI ARIA SOL 50MG/4ML Brand 2 PA SIMPONI INJ 50MG Brand 2 NON-PREF ST QL 0.5/30 PA SP SIMPONI INJ 100MG/ML Brand 2 ARAVA TAB 10MG Brand 2 GR LEFLUNOMIDE TAB 10MG generic 1 LEFLUNOMIDE TAB 20MG generic 1 ARAVA TAB 20MG Brand 2 GR ENBREL INJ 50MG/ML Brand 2 PREF QL 4/28 PA SP ENBREL SRCLK INJ 50MG/ML Brand 2 PREF QL 4/28 PA SP ENBREL INJ 25/0.5ML Brand 2 PREF QL 4/28 PA SP ENBREL INJ 25MG Brand 2 PREF QL 1/28 PA SP ORENCIA INJ 125MG/ML Brand 2 NON-PREF ST QL 4/28 PA SP ORENCIA INJ 250MG Brand 2 NON-PREF ST PA SP ARCALYST INJ 220MG Brand 2 QL / PA SP KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 10 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ILARIS INJ 180MG Brand 2 QL 1/56 PA SP ACTEMRA INJ 80MG/4ML Brand 2 NON-PREF ST PA SP ACTEMRA INJ 200/10ML Brand 2 NON-PREF ST PA SP ACTEMRA INJ 400/20ML Brand 2 NON-PREF ST PA SP ACTEMRA INJ 162/0.9 Brand 2 XELJANZ TAB 5MG Brand 2 NON-PREF ST QL 60/30 PA SP THERAPROFEN PAK -90 Brand 2 THERAPROFEN PAK -60 Brand 2 TREPOXICAM PAK 7.5MG Brand 2 TREPOXEN PAK 250MG Brand 2 THERAPROXEN PAK -60 Brand 2 THERAPROXEN PAK -90 Brand 2 THERAFELDAMI PAK Brand 2 Analgesics – Nonnarcotic DIFLUNISAL TAB 500MG generic 1 MST 600 TAB Brand 2 SALSALATE TAB 500MG generic 1 SALSALATE TAB 750MG generic 1 CHO MAG TRIS TAB 500MG generic 1 CHO MAG TRIS TAB 1000MG generic 1 CHO MAG TRIS LIQ 500/5ML generic 1 PRIALT INJ 25MCG/ML Brand 2 PRIALT INJ 100MCG Brand 2 PRIALT INJ 500MCG Brand 2 OFIRMEV INJ 10MG/ML Brand 2 CLONIDINE INJ generic 1 DURACLON INJ Brand 2 GR CLONIDINE INJ generic 1 DURACLON INJ Brand 2 GR DURAXIN CAP generic 1 ED-FLEX CAP generic 1

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 11 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO LEVACET TAB Brand 2 PHRENILIN CAP FORTE Brand 2 BUPAP TAB 50-300MG Brand 2 MARTEN-TAB TAB 50-325MG generic 1 BUTAL/APAP TAB 50-325MG generic 1 TENCON TAB 50-650MG Brand 2 EQUAGESIC TAB 200-325 Brand 2 BIOGESIC TAB 30-500MG generic 1 DOLOGESIC TAB 30-500MG generic 1 DOLOREX TAB 50-500MG generic 1 ALI-FLEX TAB 50-500MG generic 1 BIOREGESIC TAB 50-650MG Brand 2 RELAGESIC TAB 50-650MG Brand 2 RHINOFLEX TAB 50-650MG generic 1 ALPAIN TAB Brand 2 ZFLEX TAB generic 1 STAFLEX TAB 55-500MG Brand 2 GR ZGESIC TAB 66-600MG Brand 2 DOLOGESIC LIQ 30-500MG Brand 2 BUT/APAP/CAF CAP generic 1 FIORICET CAP Brand 2 GR CAPACET CAP generic 1 MARGESIC CAP generic 1 BUT/APAP/CAF CAP generic 1 ESGIC CAP Brand 2 GR ZEBUTAL CAP generic 1 ESGIC-PLUS CAP Brand 2 GR REPAN TAB generic 1 BUT/APAP/CAF TAB generic 1 ESGIC TAB Brand 2 GR BUT/APAP/CAF TAB generic 1 ESGIC-PLUS TAB Brand 2 GR KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 12 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DOLGIC PLUS TAB Brand 2 ALAGESIC LQ SOL Brand 2 BUT/ASA/CAFF CAP generic 1 FIORINAL CAP Brand 2 GR BUT/ASA/CAFF TAB generic 1 Analgesics – Opioids ALFENTANIL INJ 500/ML generic 1 ALFENTA INJ 500/ML Brand 2 GR CODEINE PHOS INJ 30MG/2ML Brand 2 CODEINE PHOS INJ 60MG/2ML Brand 2 CODEINE SULF TAB 15MG Brand 2 CODEINE SULF TAB 30MG generic 1 CODEINE SULF TAB 60MG Brand 2 CODEINE SULF SOL 30MG/5ML Brand 2 SUBSYS SPR 100MCG Brand 2 QL 120/30 PA SUBSYS SPR 200MCG Brand 2 QL 120/30 PA SUBSYS SPR 400MCG Brand 2 QL 120/30 PA SUBSYS SPR 600MCG Brand 2 QL 120/30 PA SUBSYS SPR 800MCG Brand 2 QL 120/30 PA SUBSYS SPR 1200MCG Brand 2 QL 120/30 PA SUBSYS SPR 1600MCG Brand 2 QL 120/30 PA FENTANYL DIS 12MCG/HR generic 1 PREF QL 20/30 DURAGESIC DIS 12MCG/HR Brand 2 NON-PREF ST QL 20/30 FENTANYL DIS 25MCG/HR generic 1 PREF QL 20/30 DURAGESIC DIS 25MCG/HR Brand 2 NON-PREF ST QL 20/30 FENTANYL DIS 50MCG/HR generic 1 PREF QL 20/30 DURAGESIC DIS 50MCG/HR Brand 2 NON-PREF ST QL 20/30 FENTANYL DIS 75MCG/HR generic 1 PREF QL 20/30 DURAGESIC DIS 75MCG/HR Brand 2 NON-PREF ST QL 20/30 FENTANYL DIS 100MCG/H generic 1 PREF QL 20/30 DURAGESIC DIS 100MCG/H Brand 2 NON-PREF ST QL 20/30

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 13 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO FENTORA TAB 100MCG Brand 2 QL 28/30 PA FENTORA TAB 200MCG Brand 2 QL 28/30 PA FENTORA TAB 400MCG Brand 2 QL 28/30 PA FENTORA TAB 600MCG Brand 2 QL 28/30 PA FENTORA TAB 800MCG Brand 2 QL 28/30 PA ABSTRAL SUB 100MCG Brand 2 QL 120/30 PA ABSTRAL SUB 200MCG Brand 2 QL 120/30 PA ABSTRAL SUB 300MCG Brand 2 QL 30/30 PA ABSTRAL SUB 400MCG Brand 2 QL 30/30 PA ABSTRAL SUB 600MCG Brand 2 QL 30/30 PA ABSTRAL SUB 800MCG Brand 2 QL 30/30 PA FENTANYL CIT INJ 0.05MG/1 generic 1 SUBLIMAZE INJ 0.05MG/1 Brand 2 GR FENTANYL CIT INJ 2500MCG generic 1 FENTANYL CIT INJ 250MCG generic 1 FENTANYL CIT INJ 100MCG generic 1 FENTANYL CIT INJ 1000MCG generic 1 LAZANDA SPR 100MCG Brand 2 QL 35/28 PA LAZANDA SPR 400MCG Brand 2 QL 35/28 PA ONSOLIS MIS 200MCG Brand 2 QL 120/30 PA SP ONSOLIS MIS 400MCG Brand 2 QL 30/30 PA SP ONSOLIS MIS 600MCG Brand 2 QL 30/30 PA SP ONSOLIS MIS 800MCG Brand 2 QL 30/30 PA SP ONSOLIS MIS 1200MCG Brand 2 QL 30/30 PA SP FENTANYL OT LOZ 200MCG generic 1 QL 15/30 PA FENTANYL OT LOZ 400MCG generic 1 QL 15/30 PA ACTIQ LOZ 400MCG Brand 2 GR FENTANYL OT LOZ 600MCG generic 1 QL 15/30 PA ACTIQ LOZ 600MCG Brand 2 GR FENTANYL OT LOZ 800MCG generic 1 QL 15/30 PA ACTIQ LOZ 800MCG Brand 2 GR FENTANYL OT LOZ 1200MCG generic 1 QL 15/30 PA KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 14 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ACTIQ LOZ 1200MCG Brand 2 GR ACTIQ LOZ 1600MCG Brand 2 GR FENTANYL OT LOZ 1600MCG generic 1 QL 15/30 PA HYDROMORPHON TAB 2MG generic 1 DILAUDID TAB 2MG Brand 2 GR HYDROMORPHON TAB 4MG generic 1 DILAUDID TAB 4MG Brand 2 GR HYDROMORPHON TAB 8MG generic 1 DILAUDID TAB 8MG Brand 2 GR DILAUDID-5 LIQ 1MG/ML Brand 2 GR HYDROMORPHON LIQ 1MG/ML generic 1 HYDROMORPHON INJ 1MG/ML generic 1 DILAUDID INJ 1MG/ML Brand 2 GR HYDROMORPHON INJ 2MG/ML generic 1 HYDROMORPHON INJ 2MG/ML generic 1 DILAUDID INJ 2MG/ML Brand 2 GR HYDROMORPHON INJ 4MG/ML generic 1 DILAUDID INJ 4MG/ML Brand 2 GR HYDROMORPHON INJ 10MG/ML generic 1 DILAUDID-HP INJ 10MG/ML Brand 2 GR HYDROMORPHON INJ 500/50ML generic 1 HYDROMORPHON INJ 50MG/5ML generic 1 DILAUDID-HP INJ 250MG Brand 2 HYDROMORPHON SUP 3MG Brand 2 EXALGO TAB 8MG Brand 2 NON-PREF ST QL 30/30 EXALGO TAB 12MG Brand 2 NON-PREF ST QL 30/30 EXALGO TAB 16MG Brand 2 NON-PREF ST QL 120/30 EXALGO TAB 32MG Brand 2 NON-PREF ST QL 60/30 LEVORPHANOL TAB 2MG Brand 2 MEPERIDINE TAB 50MG generic 1 MEPERITAB TAB 50MG generic 1 DEMEROL TAB 50MG Brand 2 GR KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 15 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO MEPERIDINE TAB 100MG generic 1 MEPERITAB TAB 100MG generic 1 DEMEROL TAB 100MG Brand 2 GR MEPERIDINE INJ 10MG/ML generic 1 DEMEROL INJ 25MG/ML Brand 2 GR MEPERIDINE INJ 25MG/ML generic 1 DEMEROL INJ 25MG/0.5 Brand 2 MEPERIDINE INJ 50MG/ML generic 1 DEMEROL INJ 50MG/ML Brand 2 GR DEMEROL INJ 75MG/1.5 Brand 2 DEMEROL INJ 100/2ML Brand 2 DEMEROL INJ 75MG/ML Brand 2 DEMEROL INJ 100MG/ML Brand 2 GR MEPERIDINE INJ 100MG/ML generic 1 MEPERIDINE SOL 50MG/5ML generic 1 DOLOPHINE TAB 5MG Brand 2 GR METHADONE TAB 5MG generic 1 METHADONE TAB 10MG generic 1 METHADOSE TAB 10MG generic 1 DOLOPHINE TAB 10MG Brand 2 GR METHADOSE CON 10MG/ML generic 1 METHADOSE SF CON 10MG/ML generic 1 METHADONE CON 10MG/ML generic 1 METHADONE INJ 10MG/ML Brand 2 METHADONE SOL 5MG/5ML generic 1 METHADONE SOL 10MG/5ML generic 1 METHADONE TAB 40MG generic 1 METHADOSE TAB 40MG generic 1 MORPHINE SUL TAB 15MG generic 1 MORPHINE SUL TAB 30MG generic 1 MORPHINE SUL TAB 15MG ER generic 1 PREF MS CONTIN TAB 15MG CR Brand 2 NON-PREF ST KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 16 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO MS CONTIN TAB 30MG CR Brand 2 NON-PREF ST MORPHINE SUL TAB 30MG ER generic 1 PREF MS CONTIN TAB 60MG CR Brand 2 NON-PREF ST MORPHINE SUL TAB 60MG ER generic 1 PREF MORPHINE SUL TAB 100MG ER generic 1 PREF MS CONTIN TAB 100MG CR Brand 2 NON-PREF ST MORPHINE SUL TAB 200MG ER generic 1 PREF MS CONTIN TAB 200MG CR Brand 2 NON-PREF ST MORPHINE SUL INJ 1MG/ML generic 1 MORPHINE SUL INJ 2MG/ML generic 1 MORPHINE SUL INJ 4MG/ML generic 1 MORPHINE SUL INJ 5MG/ML Brand 2 MORPHINE SUL INJ 150/30ML Brand 2 MORPHINE SUL INJ 8MG/ML generic 1 MORPHINE SUL INJ 10MG/ML generic 1 MORPHINE SUL INJ 15MG/ML generic 1 MORPHINE SUL INJ 25MG/ML generic 1 MORPHINE SUL INJ 50MG/ML generic 1 ASTRAMORPH INJ 1MG/2ML generic 1 DURAMORPH INJ 0.5MG/ML generic 1 MORPHINE SUL INJ 0.5MG/ML generic 1 MORPHINE SUL INJ 1MG/ML generic 1 ASTRAMORPH INJ 10/10ML generic 1 ASTRAMORPH INJ 2MG/2ML generic 1 DURAMORPH INJ 1MG/ML generic 1 MORPHINE SUL INJ 2MG/ML Brand 2 MORPHINE SUL INJ 4MG/ML Brand 2 MORPHINE SUL INJ 8MG/ML Brand 2 MORPHINE SUL INJ 10MG/ML Brand 2 MORPHINE SUL INJ 15MG/ML Brand 2 MORPHINE SUL SOL 10MG/5ML generic 1 MORPHINE SUL SOL 20MG/5ML generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 17 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO MORPHINE SUL SOL 20MG/ML generic 1 MORPHINE SUL SOL 100/5ML generic 1 MORPHINE SUL SUP 5MG Brand 2 MORPHINE SUL SUP 10MG Brand 2 MORPHINE SUL SUP 20MG Brand 2 MORPHINE SUL SUP 30MG generic 1 MORPHINE SUL INJ 10/0.7ML Brand 2 MORPHINE SUL CAP 10MG ER generic 1 KADIAN CAP 10MG CR Brand 2 GR MORPHINE SUL CAP 20MG ER generic 1 NON-PREF ST QL 120/30 KADIAN CAP 20MG CR Brand 2 PREF QL 120/30 MORPHINE SUL CAP 30MG ER generic 1 NON-PREF ST QL 60/30 KADIAN CAP 30MG CR Brand 2 PREF QL 60/30 KADIAN CAP 40MG CR Brand 2 PREF QL 60/30 MORPHINE SUL CAP 50MG ER generic 1 NON-PREF ST QL 60/30 KADIAN CAP 50MG CR Brand 2 PREF QL 60/30 KADIAN CAP 60MG CR Brand 2 PREF QL 60/30 MORPHINE SUL CAP 60MG ER generic 1 NON-PREF ST QL 60/30 KADIAN CAP 70MG CR Brand 2 PREF QL 60/30 KADIAN CAP 80MG CR Brand 2 PREF QL 60/30 MORPHINE SUL CAP 80MG ER generic 1 NON-PREF ST QL 60/30 MORPHINE SUL CAP 100MG ER generic 1 NON-PREF ST QL 60/30 KADIAN CAP 100MG CR Brand 2 PREF QL 60/30 KADIAN CAP 130MG CR Brand 2 PREF QL 60/30 KADIAN CAP 150MG CR Brand 2 PREF QL 60/30 KADIAN CAP 200MG CR Brand 2 PREF QL 60/30 AVINZA CAP 30MG Brand 2 NON-PREF ST QL 30/30 AVINZA CAP 45MG Brand 2 NON-PREF ST QL 30/30 AVINZA CAP 60MG Brand 2 NON-PREF ST QL 30/30 AVINZA CAP 75MG Brand 2 NON-PREF ST QL 30/30 AVINZA CAP 90MG Brand 2 NON-PREF ST QL 30/30 AVINZA CAP 120MG Brand 2 NON-PREF ST QL 30/30 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 18 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO INFUMORPH INJ 10MG/ML Brand 2 INFUMORPH INJ 25MG/ML Brand 2 DEPODUR INJ 10MG/ML Brand 2 DEPODUR INJ 15/1.5ML Brand 2 OXYCODONE CAP 5MG generic 1 OXYCODONE TAB 5MG generic 1 ROXICODONE TAB 5MG Brand 2 GR OXYCODONE TAB 10MG generic 1 OXYCODONE TAB 15MG generic 1 ROXICODONE TAB 15MG Brand 2 GR OXYCODONE TAB 20MG generic 1 OXYCODONE TAB 30MG generic 1 ROXICODONE TAB 30MG Brand 2 GR OXYCODONE CON 100/5ML generic 1 OXYCODONE CON 20MG/ML generic 1 OXYCODONE SOL 5MG/5ML generic 1 OXECTA TAB 5MG Brand 2 PA OXECTA TAB 7.5MG Brand 2 PA OXYCONTIN TAB 10MG CR Brand 2 NON-PREF ST QL 90/30 PA OXYCONTIN TAB 15MG CR Brand 2 NON-PREF ST QL 90/30 PA OXYCONTIN TAB 20MG CR Brand 2 NON-PREF ST QL 90/30 PA OXYCONTIN TAB 30MG CR Brand 2 NON-PREF ST QL 90/30 PA OXYCONTIN TAB 40MG CR Brand 2 NON-PREF ST QL 90/30 PA OXYCONTIN TAB 60MG CR Brand 2 NON-PREF ST QL 90/30 PA OXYCONTIN TAB 80MG CR Brand 2 NON-PREF ST QL 90/30 PA OXYMORPHONE TAB HCL 5MG generic 1 PA OPANA TAB 5MG Brand 2 GR OXYMORPHONE TAB HCL 10MG generic 1 PA OPANA TAB 10MG Brand 2 GR OPANA INJ 1MG/ML Brand 2 OXYMORPHONE TAB 5MG ER generic 1 NON-PREF ST QL 90/30 OXYMORPHONE TAB 7.5MG ER generic 1 NON-PREF ST QL 90/30 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 19 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO OXYMORPHONE TAB 10MG ER generic 1 NON-PREF ST QL 90/30 OXYMORPHONE TAB 15MG ER generic 1 NON-PREF ST QL 90/30 OXYMORPHONE TAB 20MG ER generic 1 NON-PREF ST QL 90/30 OXYMORPHONE TAB 30MG ER generic 1 NON-PREF ST QL 90/30 OXYMORPHONE TAB 40MG ER generic 1 NON-PREF ST QL 90/30 OPANA ER TAB 5MG Brand 2 NON-PREF ST QL 90/30 OPANA ER TAB 7.5MG Brand 2 NON-PREF ST QL 90/30 OPANA ER TAB 10MG Brand 2 NON-PREF ST QL 90/30 OPANA ER TAB 15MG Brand 2 NON-PREF ST QL 90/30 OPANA ER TAB 20MG Brand 2 NON-PREF ST QL 90/30 OPANA ER TAB 30MG Brand 2 NON-PREF ST QL 90/30 OPANA ER TAB 40MG Brand 2 NON-PREF ST QL 90/30 ULTIVA INJ 1MG Brand 2 ULTIVA INJ 2MG Brand 2 ULTIVA INJ 5MG Brand 2 SUFENTA INJ 50MCG/ML Brand 2 GR SUFENTANIL INJ 50MCG/ML generic 1 SUFENTANIL INJ 100/2ML generic 1 SUFENTA INJ 50MCG/ML Brand 2 GR SUFENTANIL INJ 250/5ML generic 1 SUFENTA INJ 50MCG/ML Brand 2 GR NUCYNTA TAB 50MG Brand 2 NON-PREF ST QL 180/30 NUCYNTA TAB 75MG Brand 2 NON-PREF ST QL 180/30 NUCYNTA TAB 100MG Brand 2 NON-PREF ST QL 180/30 NUCYNTA ER TAB 50MG Brand 2 NON-PREF ST QL 60/30 NUCYNTA ER TAB 100MG Brand 2 NON-PREF ST QL 60/30 NUCYNTA ER TAB 150MG Brand 2 NON-PREF ST QL 60/30 NUCYNTA ER TAB 200MG Brand 2 NON-PREF ST QL 60/30 NUCYNTA ER TAB 250MG Brand 2 NON-PREF ST QL 60/30 ULTRAM TAB 50MG Brand 2 NON-PREF ST TRAMADOL HCL TAB 50MG generic 1 PREF CONZIP CAP 100MG Brand 2 NON-PREF ST QL 30/30 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 20 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO TRAMADOL HCL CAP 150MG ER Brand 2 CONZIP CAP 200MG Brand 2 NON-PREF ST QL 30/30 CONZIP CAP 300MG Brand 2 NON-PREF ST QL 30/30 TRAMADOL HCL TAB 100MG ER generic 1 NON-PREF ST QL 30/30 ULTRAM ER TAB 100MG Brand 2 NON-PREF ST QL 30/30 TRAMADOL HCL TAB 200MG ER generic 1 NON-PREF ST QL 30/30 ULTRAM ER TAB 200MG Brand 2 NON-PREF ST QL 30/30 ULTRAM ER TAB 300MG Brand 2 NON-PREF ST QL 30/30 TRAMADOL HCL TAB 300MG ER generic 1 NON-PREF ST QL 30/30 TRAMADOL HCL TAB 100MG ER generic 1 TRAMADOL HCL TAB 200MG ER generic 1 TRAMADOL HCL TAB 300MG ER generic 1 BUTRANS DIS 5MCG/HR Brand 2 NON-PREF ST QL 4/28 BUTRANS DIS 10MCG/HR Brand 2 NON-PREF ST QL 4/28 BUTRANS DIS 15MCG/HR Brand 2 BUTRANS DIS 20MCG/HR Brand 2 NON-PREF ST QL 4/28 BUPRENORPHIN SUB 2MG generic 1 QL 90/30 PA BUPRENORPHIN SUB 8MG generic 1 QL 90/30 PA BUPRENORPHIN INJ 0.3MG/ML generic 1 BUPRENEX INJ 0.3MG/ML Brand 2 GR ZUBSOLV SUB 1.4-0.36 Brand 2 QL 60/30 PA BUPREN/NALOX SUB 2-0.5MG generic 1 ZUBSOLV SUB 5.7-1.4 Brand 2 QL 60/30 PA BUPREN/NALOX SUB 8-2MG generic 1 SUBOXONE MIS 2-0.5MG Brand 2 QL 90/30 PA SUBOXONE MIS 4-1MG Brand 2 QL 90/30 PA SUBOXONE MIS 8-2MG Brand 2 QL 60/30 PA SUBOXONE MIS 12-3MG Brand 2 QL 30/30 PA BUTORPHANOL INJ 1MG/ML generic 1 BUTORPHANOL INJ 2MG/ML generic 1 BUTORPHANOL SOL 10MG/ML generic 1 QL 5/30 NALBUPHINE INJ 10MG/ML generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 21 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO NALBUPHINE INJ 20MG/ML generic 1 TALWIN INJ 30MG/ML Brand 2 PENTAZ/NALOX TAB 50-0.5MG generic 1 OXYCOD/APAP CAP 5-500MG generic 1 QL 240/30 OXYCOD/APAP TAB 2.5-325 generic 1 QL 360/30 PERCOCET TAB 2.5-325 Brand 2 GR PRIMLEV TAB 5-300MG Brand 2 QL 390/30 ENDOCET TAB 5-325MG generic 1 QL 360/30 ROXICET TAB 5-325MG generic 1 QL 360/30 PERCOCET TAB 5-325MG Brand 2 GR OXYCOD/APAP TAB 5-325MG generic 1 QL 360/30 MAGNACET TAB 5-400MG Brand 2 QL 300/30 PRIMLEV TAB 7.5-300 Brand 2 QL 390/30 OXYCOD/APAP TAB 7.5-325 generic 1 QL 360/30 ENDOCET TAB 7.5-325 generic 1 QL 360/30 PERCOCET TAB 7.5-325 Brand 2 GR MAGNACET TAB 7.5-400 Brand 2 QL 300/30 ENDOCET TAB 7.5-500M generic 1 QL 240/30 OXYCOD/APAP TAB 7.5-500 generic 1 QL 240/30 PERCOCET TAB 7.5-500 Brand 2 GR PRIMLEV TAB 10-300MG Brand 2 QL 390/30 ENDOCET TAB 10-325MG generic 1 QL 360/30 PERCOCET TAB 10-325MG Brand 2 GR OXYCOD/APAP TAB 10-325MG generic 1 QL 360/30 MAGNACET TAB 10-400MG Brand 2 QL 300/30 XOLOX TAB 10-500MG Brand 2 QL 240/30 PERCOCET TAB 10-650MG Brand 2 GR OXYCOD/APAP TAB 10-650MG generic 1 QL 180/30 ENDOCET TAB 10-650MG generic 1 QL 180/30 ROXICET SOL 5-325/5 generic 1 PERCODAN TAB Brand 2 GR ENDODAN TAB generic 1 QL 360/30 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 22 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO OXYCOD/ASA TAB generic 1 QL 360/30 OXYCOD/IBU TAB 5-400MG generic 1 QL 240/30 APAP/CODEINE TAB 300-15MG generic 1 TYLENOL/COD TAB #3 Brand 2 GR APAP/CODEINE TAB 300-30MG generic 1 APAP/CODEINE TAB 300-60MG generic 1 TYLENOL/COD TAB #4 Brand 2 GR CAPITAL/COD SUS 120-12/5 Brand 2 APAP/CODEINE SOL 120-12/5 generic 1 BUT/APAP/CAF CAP CODEINE generic 1 FIORICET CAP CODEINE Brand 2 GR BUT/APAP/CAF CAP CODEINE generic 1 BUT/ASA/CAF/ CAP COD 30MG generic 1 ASCOMP/COD CAP 30MG generic 1 FIORINAL/COD CAP 30MG Brand 2 GR TREZIX CAP Brand 2 APAP/CAFF/DI TAB HYDROCOD generic 1 DIHYDROCOD/ CAP ASA/CAFF generic 1 SYNALGOS-DC CAP Brand 2 GR HYDROGESIC CAP 5-500MG generic 1 STAGESIC CAP 5-500MG generic 1 HYDROCO/APAP TAB 2.5-325 generic 1 NORCO TAB 10-325MG Brand 2 GR HYDROCO/APAP TAB 10-325MG generic 1 HYDROCO/APAP TAB 2.5-500 generic 1 XODOL TAB 5-300MG Brand 2 GR HYDROCO/APAP TAB 5-300MG generic 1 VICODIN TAB 5-300MG generic 1 HYDROCO/APAP TAB 5-500MG generic 1 LORTAB TAB 5-500MG Brand 2 GR XODOL TAB 7.5-300 Brand 2 GR VICODIN ES TAB 7.5-300 generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 23 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO HYDROCO/APAP TAB 7.5-300 generic 1 HYDROCO/APAP TAB 7.5-500 generic 1 LORTAB TAB 7.5-500 Brand 2 GR HYDROCO/APAP TAB 10-500MG generic 1 LORTAB TAB 10-500MG Brand 2 GR HYDROCO/APAP TAB 7.5-650 generic 1 LORCET PLUS TAB 7.5-650 Brand 2 GR HYDROCO/APAP TAB 10-650MG generic 1 LORCET TAB 10-650MG Brand 2 GR HYDROCO/APAP TAB 10-660MG generic 1 HYDROCO/APAP TAB 7.5-750 generic 1 HYDROCO/APAP TAB 10-750MG generic 1 MAXIDONE TAB 10-750MG Brand 2 GR NORCO TAB 5-325MG Brand 2 GR HYDROCO/APAP TAB 5-325MG generic 1 HYDROCO/APAP TAB 7.5-325 generic 1 NORCO TAB 7.5-325 Brand 2 GR ZYDONE TAB 5-400MG Brand 2 ZYDONE TAB 7.5-400 Brand 2 ZYDONE TAB 10-400MG Brand 2 HYDROCO/APAP TAB 10-300MG generic 1 XODOL TAB 10-300MG Brand 2 GR VICODIN HP TAB 10-300MG generic 1 HYDROCO/APAP SOL 5-217/10 generic 1 HYDROCO/APAP SOL generic 1 HYCET SOL 7.5-325 Brand 2 GR HYDROCO/APAP SOL 7.5-325 generic 1 HYDROCO/APAP SOL 7.5-500 generic 1 LORTAB ELX 10-300MG generic 1 ZAMICET SOL 10-325MG Brand 2 LIQUICET SOL 10-500MG Brand 2 HYDROCOD/IBU TAB 2.5-200 generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 24 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO REPREXAIN TAB 2.5-200 Brand 2 GR REPREXAIN TAB 5-200MG Brand 2 GR IBUDONE TAB 5-200MG generic 1 HYDROCOD/IBU TAB 5-200MG generic 1 HYDROCOD/IBU TAB 7.5-200 generic 1 VICOPROFEN TAB 7.5-200 Brand 2 GR HYDROCOD/IBU TAB 10-200MG generic 1 REPREXAIN TAB 10-200MG generic 1 IBUDONE TAB 10-200MG Brand 2 GR PENTA/APAP TAB 25-650MG generic 1 TRAMADL/APAP TAB 37.5-325 generic 1 PREF ULTRACET TAB 37.5-325 Brand 2 NON-PREF ST Androgen-Anabolic DANAZOL CAP 50MG generic 1 DANAZOL CAP 100MG generic 1 DANAZOL CAP 200MG generic 1 ANDROXY TAB 10MG Brand 2 TESTRED CAP 10MG Brand 2 ANDROID CAP 10MG Brand 2 METHITEST TAB 10MG Brand 2 AXIRON SOL 30MG/ACT Brand 2 NON-PREF ST ANDROGEL GEL 1%(25MG) Brand 2 PREF ANDROGEL GEL 1%(50MG) Brand 2 PREF ANDROGEL GEL PUMP 1% Brand 2 PREF ANDROGEL GEL 1.62% Brand 2 ANDROGEL GEL 1.62% Brand 2 ANDROGEL GEL 1.62% Brand 2 PREF FORTESTA GEL 10MG/ACT Brand 2 NON-PREF ST STRIANT MIS 30MG Brand 2 ANDRODERM DIS 2MG/24HR Brand 2 PREF ANDRODERM DIS 4MG/24HR Brand 2 PREF

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 25 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO TESTOPEL MIS PELLETS Brand 2 TESTOST CYP INJ 100MG/ML generic 1 DEPO-TESTOST INJ 100MG/ML Brand 2 GR DEPO-TESTOST INJ 200MG/ML Brand 2 GR TESTOST CYP INJ 200MG/ML generic 1 DELATESTRYL INJ 200MG/ML Brand 2 GR TESTOST ENAN INJ 200MG/ML generic 1 FIRST-TESTOS CRE MC 2% Brand 2 FIRST-TESTOS OIN 2% Brand 2 OXANDRIN TAB 2.5MG Brand 2 GR OXANDROLONE TAB 2.5MG generic 1 PA OXANDROLONE TAB 10MG generic 1 PA OXANDRIN TAB 10MG Brand 2 GR ANADROL-50 TAB 50MG Brand 2 PA Anorectal Agents PROCTOCORT CRE 1% Brand 2 GR PROCTO-PAK CRE 1% generic 1 PROCTOSOL HC CRE 2.5% generic 1 PROCTOZONE CRE -HC 2.5% generic 1 ANUSOL-HC CRE 2.5% Brand 2 GR HYDROCORT ENE 100MG generic 1 COLOCORT ENE 100MG generic 1 CORTENEMA ENE 100MG Brand 2 GR CORTIFOAM AER 90MG Brand 2 RECTIV OIN 0.4% Brand 2 QL 30/30 PA LIDOCAINE/HC CRE 3%-0.5% generic 1 LIDAZONE CRE generic 1 LIDO-HYDRO GEL 2.8-0.55 Brand 2 LIDOCAINE/HC KIT 2-2% Brand 2 LIDOCAINE/HC KIT 3%-0.5% generic 1 LIDOCAINE/HC KIT 3%-1% generic 1

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 26 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO LIDOCAINE/HC KIT 3-2.5% generic 1 PROCTOFOAM AER HC 1% Brand 2 ANALPRAM-HC LOT 2.5% Brand 2 ANALPRAM KIT ADVANCED Brand 2 Anthelmintics ALBENZA TAB 200MG Brand 2 STROMECTOL TAB 3MG Brand 2 BILTRICIDE TAB 600MG Brand 2 Antianginal Agents DILATRATE SR CAP 40MG Brand 2 ISOSORB DIN TAB 5MG generic 1 ISORDIL TAB 5MG Brand 2 GR ISOSORB DIN TAB 10MG generic 1 ISOSORB DIN TAB 20MG generic 1 ISOSORB DIN TAB 30MG generic 1 ISORDIL TAB 40MG Brand 2 ISODITRATE TAB 40MG ER generic 1 ISOSORB DIN TAB 40MG ER generic 1 ISOSORB DIN SUB 2.5MG generic 1 ISOSORB MONO TAB 10MG generic 1 ISOSORB MONO TAB 20MG generic 1 ISOSORB MONO TAB 30MG ER generic 1 IMDUR TAB 30MG ER Brand 2 GR ISOSORB MONO TAB 60MG ER generic 1 IMDUR TAB 60MG ER Brand 2 GR IMDUR TAB 120MG ER Brand 2 GR ISOSORB MONO TAB 120MG ER generic 1 NITROSTAT SUB 0.3MG Brand 2 NITROSTAT SUB 0.4MG Brand 2 NITROSTAT SUB 0.6MG Brand 2 NITROGLYCER INJ 5MG/ML generic 1

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 27 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO NITROGLYCRN SPR 0.4MG generic 1 NITROGLYCRN SPR LINGUAL generic 1 NITROLINGUAL SPR PUMPSPRA Brand 2 GR NITROMIST AER 400MCG Brand 2 NITROGLYCER AER 400MCG Brand 2 NITRO-BID OIN 2% Brand 2 NITRO-DUR DIS 0.1MG/HR Brand 2 GR MINITRAN DIS 0.1MG/HR generic 1 NITROGLYCER DIS 0.1MG/HR generic 1 NITRO-DUR DIS 0.2MG/HR Brand 2 GR MINITRAN DIS 0.2MG/HR generic 1 NITROGLYCER DIS 0.2MG/HR generic 1 NITRO-DUR DIS 0.3MG/HR Brand 2 NITROGLYCER DIS 0.4MG/HR generic 1 MINITRAN DIS 0.4MG/HR generic 1 NITRO-DUR DIS 0.4MG/HR Brand 2 GR NITRO-DUR DIS 0.6MG/HR Brand 2 GR NITROGLYCER DIS 0.6MG/HR generic 1 NITROGLYCERI DIS 0.6MG/HR generic 1 MINITRAN DIS 0.6MG/HR generic 1 NITRO-DUR DIS 0.8MG/HR Brand 2 RANEXA TAB 500MG Brand 2 PA MO RANEXA TAB 1000MG Brand 2 PA MO Antianxiety Agents ALPRAZOLAM TAB 0.25MG generic 1 PREF XANAX TAB 0.25MG Brand 2 NON-PREF ST ALPRAZOLAM TAB 0.5MG generic 1 PREF XANAX TAB 0.5MG Brand 2 NON-PREF ST ALPRAZOLAM TAB 1MG generic 1 PREF XANAX TAB 1MG Brand 2 NON-PREF ST XANAX TAB 2MG Brand 2 NON-PREF ST

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 28 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ALPRAZOLAM TAB 2MG generic 1 PREF ALPRAZOLAM CON 1 MG/ML Brand 2 PREF NIRAVAM TAB 0.25MG Brand 2 NON-PREF ST ALPRAZOLAM TAB 0.25 ODT generic 1 PREF ALPRAZOLAM TAB 0.5MG OD generic 1 PREF NIRAVAM TAB 0.5MG Brand 2 NON-PREF ST ALPRAZOLAM TAB 1MG ODT generic 1 PREF NIRAVAM TAB 1MG Brand 2 NON-PREF ST NIRAVAM TAB 2MG Brand 2 NON-PREF ST ALPRAZOLAM TAB 2MG ODT generic 1 PREF XANAX XR TAB 0.5MG Brand 2 NON-PREF ST ALPRAZOLAM TAB 0.5MG ER generic 1 NON-PREF ST ALPRAZOLAM TAB 0.5MG XR generic 1 NON-PREF ST ALPRAZOLAM TAB 1MG ER generic 1 NON-PREF ST ALPRAZOLAM TAB 1MG XR generic 1 NON-PREF ST XANAX XR TAB 1MG Brand 2 NON-PREF ST XANAX XR TAB 2MG Brand 2 NON-PREF ST ALPRAZOLAM TAB 2MG ER generic 1 NON-PREF ST ALPRAZOLAM TAB 2MG XR generic 1 NON-PREF ST ALPRAZOLAM TAB 3MG ER generic 1 NON-PREF ST ALPRAZOLAM TAB 3MG XR generic 1 NON-PREF ST XANAX XR TAB 3MG Brand 2 NON-PREF ST CHLORDIAZEP CAP 5MG generic 1 PREF CHLORDIAZEP CAP 10MG generic 1 PREF CHLORDIAZEP CAP 25MG generic 1 PREF CLORAZ DIPOT TAB 3.75MG generic 1 PREF TRANXENE T TAB 3.75MG Brand 2 NON-PREF ST CLORAZ DIPOT TAB 7.5MG generic 1 PREF TRANXENE T TAB 7.5MG Brand 2 NON-PREF ST CLORAZ DIPOT TAB 15MG generic 1 PREF TRANXENE T TAB 15MG Brand 2 NON-PREF ST DIAZEPAM TAB 2MG generic 1 PREF KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 29 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO VALIUM TAB 2MG Brand 2 GR DIAZEPAM TAB 5MG generic 1 PREF VALIUM TAB 5MG Brand 2 GR VALIUM TAB 10MG Brand 2 GR DIAZEPAM TAB 10MG generic 1 PREF DIAZEPAM CON 5MG/ML Brand 2 PREF DIAZEPAM SOL 1MG/ML Brand 2 PREF DIAZEPAM INJ 5MG/ML generic 1 DIAZEPAM INJ 10MG/2ML Brand 2 LORAZEPAM TAB 0.5MG generic 1 PREF ATIVAN TAB 0.5MG Brand 2 NON-PREF ST ATIVAN TAB 1MG Brand 2 NON-PREF ST LORAZEPAM TAB 1MG generic 1 PREF LORAZEPAM TAB 2MG generic 1 PREF ATIVAN TAB 2MG Brand 2 NON-PREF ST LORAZEPAM CON 2MG/ML generic 1 PREF LORAZEPAM INJ 2MG/ML generic 1 ATIVAN INJ 2MG/ML Brand 2 GR LORAZEPAM INJ 4MG/ML generic 1 ATIVAN INJ 4MG/ML Brand 2 GR OXAZEPAM CAP 10MG generic 1 PREF OXAZEPAM CAP 15MG generic 1 PREF OXAZEPAM CAP 30MG generic 1 PREF BUSPIRONE TAB 5MG generic 1 PREF BUSPIRONE TAB 7.5MG generic 1 PREF BUSPIRONE TAB 10MG generic 1 PREF BUSPIRONE TAB 15MG generic 1 PREF BUSPIRONE TAB 30MG generic 1 PREF DROPERIDOL INJ 2.5MG/ML generic 1 HYDROXYZ HCL TAB 10MG generic 1 HYDROXYZ HCL TAB 25MG generic 1 HYDROXYZ HCL TAB 50MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 30 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO HYDROXYZ HCL SYP 10MG/5ML generic 1 HYDROXYZ HCL SOL 10MG/5ML generic 1 HYDROXYZ HCL INJ 25MG/ML generic 1 HYDROXYZ HCL INJ 50MG/ML generic 1 VISTARIL CAP 25MG Brand 2 GR HYDROXYZ PAM CAP 25MG generic 1 VISTARIL CAP 50MG Brand 2 GR HYDROXYZ PAM CAP 50MG generic 1 HYDROXYZ PAM CAP 100MG generic 1 MEPROBAMATE TAB 200MG generic 1 MEPROBAMATE TAB 400MG generic 1 Antiarrhythmics DISOPYRAMIDE CAP 100MG generic 1 NORPACE CAP 100MG Brand 2 GR NORPACE CAP 150MG Brand 2 GR DISOPYRAMIDE CAP 150MG generic 1 NORPACE CAP 100MG CR Brand 2 NORPACE CAP 150MG CR Brand 2 PROCAINAMIDE INJ 100MG/ML generic 1 PROCAINAMIDE INJ 500MG/ML generic 1 QUINIDINE GL TAB 324MG CR generic 1 QUINIDINE GL TAB 324MG ER generic 1 QUINIDINE GL INJ 80MG/ML Brand 2 QUINIDINE SU TAB 200MG generic 1 QUINIDINE SU TAB 300MG generic 1 QUINIDINE SU TAB 300MG ER generic 1 LIDOCAINE INJ 10MG/ML generic 1 LIDOCAINE INJ 20MG/ML generic 1 XYLOCAINE INJ 2% Brand 2 GR MEXILETINE CAP 150MG generic 1 MEXILETINE CAP 200MG generic 1

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 31 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO MEXILETINE CAP 250MG generic 1 FLECAINIDE TAB 50MG generic 1 FLECAINIDE TAB 100MG generic 1 FLECAINIDE TAB 150MG generic 1 PROPAFENONE TAB 150MG generic 1 RYTHMOL TAB 150MG Brand 2 GR PROPAFENONE TAB 225MG generic 1 RYTHMOL TAB 225MG Brand 2 GR PROPAFENONE TAB 300MG generic 1 RYTHMOL SR CAP 225MG Brand 2 GR PROPAFENONE CAP 225MG ER generic 1 PROPAFENONE CAP 325MG ER generic 1 RYTHMOL SR CAP 325MG Brand 2 GR PROPAFENONE CAP 425MG SR generic 1 RYTHMOL SR CAP 425MG Brand 2 GR AMIODARONE TAB 100MG generic 1 PACERONE TAB 100MG generic 1 AMIODARONE TAB 200MG generic 1 PACERONE TAB 200MG generic 1 CORDARONE TAB 200MG Brand 2 GR AMIODARONE TAB 400MG generic 1 PACERONE TAB 400MG generic 1 AMIODARONE INJ 150MG/3M generic 1 AMIODARONE INJ 50MG/ML generic 1 AMIODARONE INJ 50MG/ML generic 1 AMIODARONE INJ 50MG/ML generic 1 NEXTERONE INJ Brand 2 NEXTERONE INJ Brand 2 TIKOSYN CAP 125MCG Brand 2 TIKOSYN CAP 250MCG Brand 2 TIKOSYN CAP 500MCG Brand 2 MULTAQ TAB 400MG Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 32 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO IBUTILIDE INJ 1MG/10ML generic 1 CORVERT INJ 1MG/10ML Brand 2 GR ADENOCARD INJ 6MG/2ML Brand 2 GR ADENOSINE INJ 6MG/2ML generic 1 ADENOSINE INJ 3MG/ML generic 1 ADENOCARD INJ 3MG/ML Brand 2 GR ADENOCARD INJ 12MG/4ML Brand 2 GR ADENOSINE INJ 12MG/4ML generic 1 Antiasthmatic and Bronchodilator Agents TUDORZA PRES AER 400/ACT Brand 2 QL 1/30 MO IPRATROPIUM SOL 0.02%INH generic 1 ATROVENT HFA AER 17MCG Brand 2 QL 25.8/30 MO SPIRIVA CAP HANDIHLR Brand 2 QL 30/30 MO CROMOLYN SOD NEB 20MG/2ML generic 1 ALBUTEROL TAB 2MG generic 1 ALBUTEROL TAB 4MG generic 1 ALBUTEROL SYP 2MG/5ML generic 1 ALBUTEROL NEB 0.083% generic 1 PREF QL 360/30 MO ALBUTEROL NEB 0.5% generic 1 PREF QL 120/30 MO ALBUTEROL NEB 0.63MG/3 generic 1 PREF QL 360/30 MO ACCUNEB NEB 0.63MG/3 Brand 2 NON-PREF ST QL 360/30 MO ALBUTEROL NEB 1.25MG/3 generic 1 PREF QL 360/30 MO ACCUNEB NEB 1.25MG/3 Brand 2 NON-PREF ST QL 360/30 MO VOSPIRE ER TAB 4MG Brand 2 GR ALBUTEROL TAB 4MG ER generic 1 ALBUTEROL TAB 8MG ER generic 1 VOSPIRE ER TAB 8MG Brand 2 GR BROVANA NEB 15MCG Brand 2 NON-PREF ST MO FORADIL CAP AEROLIZE Brand 2 PREF QL 60/30 MO PERFOROMIST NEB 20MCG Brand 2 NON-PREF ST MO ISUPREL INJ 0.2MG/ML Brand 2

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 33 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ARCAPTA CAP 75MCG Brand 2 NON-PREF ST QL 30/30 MO LEVALBUTEROL NEB 0.31MG generic 1 XOPENEX NEB 0.31MG Brand 2 NON-PREF ST QL 288/30 MO XOPENEX NEB 0.63MG Brand 2 NON-PREF ST QL 288/30 MO LEVALBUTEROL NEB 0.63MG generic 1 XOPENEX NEB 1.25/3ML Brand 2 NON-PREF ST QL 288/30 MO LEVALBUTEROL NEB 1.25MG generic 1 XOPENEX CONC NEB 1.25/0.5 Brand 2 NON-PREF ST QL 288/30 MO LEVALBUTEROL NEB 1.25/0.5 generic 1 NON-PREF ST QL 288/30 MO XOPENEX HFA AER Brand 2 NON-PREF ST QL 30/30 MO METAPROTEREN TAB 10MG generic 1 METAPROTEREN TAB 20MG generic 1 METAPROTEREN SYP 10MG/5ML generic 1 MAXAIR AUTOH AER 200MCG Brand 2 PREF QL 28/30 MO SEREVENT DIS AER 50MCG Brand 2 PREF QL 60/30 MO TERBUTALINE TAB 2.5MG generic 1 TERBUTALINE TAB 5MG generic 1 TERBUTALINE INJ 1MG/ML generic 1 EPINEPHRINE INJ 0.1MG/ML generic 1 EPINEPHRINE INJ 1MG/ML generic 1 IPRATROPIUM/ SOL ALBUTER generic 1 NON-PREF ST QL 540/30 MO DUONEB SOL Brand 2 NON-PREF ST QL 540/30 MO COMBIVENT AER Brand 2 QL 29.4/30 MO COMBIVENT AER RESPIMAT Brand 2 SYMBICORT AER 80-4.5 Brand 2 PREF QL 10.2/30 MO SYMBICORT AER 160-4.5 Brand 2 PREF QL 10.2/30 MO ADVAIR HFA AER 45/21 Brand 2 PREF QL 12/30 MO ADVAIR HFA AER 115/21 Brand 2 PREF QL 12/30 MO ADVAIR HFA AER 230/21 Brand 2 PREF QL 12/30 MO ADVAIR DISKU AER 100/50 Brand 2 PREF QL 60/30 MO ADVAIR DISKU AER 250/50 Brand 2 PREF QL 60/30 MO ADVAIR DISKU AER 500/50 Brand 2 PREF QL 60/30 MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 34 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO BREO ELLIPTA INH 100-25 Brand 2 DULERA AER 100-5MCG Brand 2 PREF QL 13/30 MO DULERA AER 200-5MCG Brand 2 PREF QL 13/30 MO AMINOPHYLLIN INJ 25MG/ML generic 1 LUFYLLIN TAB 200MG Brand 2 LUFYLLIN TAB 400MG Brand 2 ELIXOPHYLLIN ELX 80/15ML Brand 2 THEOPHYLLINE SOL 80/15ML generic 1 THEO-24 CAP 100MG CR Brand 2 THEO-24 CAP 200MG CR Brand 2 THEO-24 CAP 300MG CR Brand 2 THEO-24 CAP 400MG ER Brand 2 THEOCHRON TAB 100MG CR generic 1 THEOPHYLLINE TAB 100MG ER generic 1 THEOPHYLLINE TAB 100MG CR generic 1 THEOPHYLLINE TAB 200MG CR generic 1 THEOCHRON TAB 200MG CR generic 1 THEOPHYLLINE TAB 200MG ER generic 1 THEOPHYLLINE TAB 300MG ER generic 1 THEOCHRON TAB 300MG CR generic 1 THEOPHYLLINE TAB 450MG ER generic 1 THEOPHYLLINE TAB 400MG generic 1 THEOPHYLLINE TAB 400MG ER generic 1 THEOPHYLLINE TAB 600MG ER generic 1 QVAR AER 40MCG Brand 2 PREF QL 17.4/30 MO QVAR AER 80MCG Brand 2 PREF QL 17.4/30 MO BUDESONIDE SUS 0.25MG/2 generic 1 NON-PREF ST QL 120/30 MO PULMICORT SUS 0.25MG/2 Brand 2 NON-PREF ST QL 120/30 MO BUDESONIDE SUS 0.5MG/2 generic 1 NON-PREF ST QL 120/30 MO PULMICORT SUS 0.5MG/2 Brand 2 NON-PREF ST QL 120/30 MO PULMICORT SUS 1MG/2ML Brand 2 PULMICORT INH 90MCG Brand 2 NON-PREF ST QL 2/30 MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 35 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PULMICORT INH 180MCG Brand 2 NON-PREF ST QL 2/30 MO ALVESCO AER 80MCG Brand 2 NON-PREF ST QL 6.1/30 MO ALVESCO AER 160MCG Brand 2 NON-PREF ST QL 6.1/30 MO FLOVENT DISK AER 50MCG Brand 2 PREF QL 60/30 MO FLOVENT DISK AER 100MCG Brand 2 PREF QL 60/30 MO FLOVENT DISK AER 250MCG Brand 2 PREF QL 60/30 MO FLOVENT HFA AER 44MCG Brand 2 PREF QL 10.6/30 MO FLOVENT HFA AER 110MCG Brand 2 PREF QL 10.6/30 MO FLOVENT HFA AER 220MCG Brand 2 PREF QL 10.6/30 MO ASMANEX 7 AER 110MCG Brand 2 PREF QL 1/30 MO ASMANEX 30 AER 110MCG Brand 2 PREF QL 1/30 MO ASMANEX 60 AER 220MCG Brand 2 PREF QL 1/30 MO ASMANEX 30 AER 220MCG Brand 2 PREF QL 1/30 MO ASMANEX 14 AER 220MCG Brand 2 PREF QL 1/30 MO ASMANEX 120 AER 220MCG Brand 2 PREF QL 1/30 MO DALIRESP TAB 500MCG Brand 2 PA MO ZYFLO TAB 600MG Brand 2 NON-PREF ST MO ZYFLO CR TAB 600MG Brand 2 NON-PREF ST MO SINGULAIR TAB 10MG Brand 2 NON-PREF ST MO MONTELUKAST TAB 10MG generic 1 PREF MO SINGULAIR CHW 4MG Brand 2 NON-PREF ST MO MONTELUKAST CHW 4MG generic 1 PREF MO MONTELUKAST CHW 5MG generic 1 PREF MO SINGULAIR CHW 5MG Brand 2 NON-PREF ST MO MONTELUKAST GRA 4MG generic 1 PREF MO SINGULAIR GRA 4MG Brand 2 NON-PREF ST MO ZAFIRLUKAST TAB 10MG generic 1 PREF MO ACCOLATE TAB 10MG Brand 2 NON-PREF ST MO ZAFIRLUKAST TAB 20MG generic 1 PREF MO ACCOLATE TAB 20MG Brand 2 NON-PREF ST MO XOLAIR SOL 150MG Brand 2 PA SP DIFIL-G FORT LIQ 100-100 generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 36 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO Anticoagulants HEPARIN SOD INJ 1000/ML generic 1 HEPARIN SOD INJ 2000/ML generic 1 HEPARIN SOD INJ 2500/ML generic 1 HEPARIN SOD INJ 5000/ML generic 1 HEPARIN SOD INJ 5000/0.5 generic 1 HEPARIN SOD INJ 10000/ML generic 1 HEPARIN SOD INJ 10000/ML generic 1 HEPARIN SOD INJ 20000/ML generic 1 HEP SOD/NACL INJ 1000UNIT generic 1 HEP SOD/NACL INJ 2UNIT/ML generic 1 HEP SOD/NACL INJ 2000UNIT Brand 2 GR HEP SOD/NACL INJ 12500UNT generic 1 HEP SOD/NACL INJ 25000UNT generic 1 HEP SOD/NACL INJ 25000UNT generic 1 HEPARIN LOCK INJ 1UNIT/ML generic 1 HEPARIN LOCK INJ 2UNIT/ML Brand 2 HEPARIN LOCK INJ 10UNT/ML generic 1 HEP FLUSH-10 INJ 10UNT/ML generic 1 HEPARIN LOCK INJ 100/ML generic 1 HEPARIN LOCK KIT 10UNT/ML generic 1 SASH KIT 10UNT/ML generic 1 HEPARIN LOCK KIT 100/ML generic 1 SASH KIT 100/ML generic 1 FRAGMIN INJ 10000/ML Brand 2 PREF SP FRAGMIN INJ 2500/0.2 Brand 2 PREF SP FRAGMIN INJ 5000/0.2 Brand 2 PREF SP FRAGMIN INJ 7500/0.3 Brand 2 PREF SP FRAGMIN INJ 12500UNT Brand 2 PREF SP FRAGMIN INJ 15000UNT Brand 2 PREF SP FRAGMIN INJ 18000UNT Brand 2 PREF SP

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 37 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO FRAGMIN INJ 25000/ML Brand 2 PREF SP LOVENOX INJ 30/0.3ML Brand 2 PREF SP ENOXAPARIN INJ 30/0.3ML generic 1 NON-PREF ST SP LOVENOX INJ 40/0.4ML Brand 2 PREF SP ENOXAPARIN INJ 40/0.4ML generic 1 NON-PREF ST SP LOVENOX INJ 60/0.6ML Brand 2 PREF SP ENOXAPARIN INJ 60/0.6ML generic 1 NON-PREF ST SP LOVENOX INJ 80/0.8ML Brand 2 PREF SP ENOXAPARIN INJ 80/0.8ML generic 1 NON-PREF ST SP ENOXAPARIN INJ 100MG/ML generic 1 NON-PREF ST SP LOVENOX INJ 100MG/ML Brand 2 PREF SP ENOXAPARIN INJ 120/0.8 generic 1 NON-PREF ST SP LOVENOX INJ 120/0.8 Brand 2 PREF SP LOVENOX INJ 150MG/ML Brand 2 PREF SP ENOXAPARIN INJ 150MG/ML generic 1 NON-PREF ST SP ENOXAPARIN INJ 300/3ML generic 1 NON-PREF ST SP LOVENOX INJ 300/3ML Brand 2 PREF SP FONDAPARINUX SOL 2.5/0.5 generic 1 NON-PREF ST SP ARIXTRA SOL 2.5/0.5 Brand 2 NON-PREF ST SP FONDAPARINUX SOL 5.0/0.4 generic 1 NON-PREF ST SP ARIXTRA SOL 5.0/0.4 Brand 2 NON-PREF ST SP FONDAPARINUX SOL 7.5/0.6 generic 1 NON-PREF ST SP ARIXTRA SOL 7.5/0.6 Brand 2 NON-PREF ST SP ARIXTRA SOL 10/0.8 Brand 2 NON-PREF ST SP FONDAPARINUX SOL 10/0.8 generic 1 NON-PREF ST SP WARFARIN TAB 1MG generic 1 PREF JANTOVEN TAB 1MG generic 1 PREF COUMADIN TAB 1MG Brand 2 NON-PREF ST WARFARIN TAB 2MG generic 1 PREF JANTOVEN TAB 2MG generic 1 PREF COUMADIN TAB 2MG Brand 2 NON-PREF ST COUMADIN TAB 2.5MG Brand 2 NON-PREF ST KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 38 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO WARFARIN TAB 2.5MG generic 1 PREF JANTOVEN TAB 2.5MG generic 1 PREF WARFARIN TAB 3MG generic 1 PREF COUMADIN TAB 3MG Brand 2 NON-PREF ST JANTOVEN TAB 3MG generic 1 PREF JANTOVEN TAB 4MG generic 1 PREF COUMADIN TAB 4MG Brand 2 NON-PREF ST WARFARIN TAB 4MG generic 1 PREF WARFARIN TAB 5MG generic 1 PREF JANTOVEN TAB 5MG generic 1 PREF COUMADIN TAB 5MG Brand 2 NON-PREF ST WARFARIN TAB 6MG generic 1 PREF JANTOVEN TAB 6MG generic 1 PREF COUMADIN TAB 6MG Brand 2 NON-PREF ST WARFARIN TAB 7.5MG generic 1 PREF JANTOVEN TAB 7.5MG generic 1 PREF COUMADIN TAB 7.5MG Brand 2 NON-PREF ST WARFARIN TAB 10MG generic 1 PREF JANTOVEN TAB 10MG generic 1 PREF COUMADIN TAB 10MG Brand 2 NON-PREF ST COUMADIN INJ 5 MG Brand 2 ANGIOMAX INJ 250MG Brand 2 IPRIVASK INJ 15MG Brand 2 PA SP ARGATROBAN INJ 100MG/ML generic 1 ARGATROBAN INJ 50MG/50M Brand 2 ARGATROBAN INJ 125/125 Brand 2 PRADAXA CAP 75MG Brand 2 PREF QL 60/30 PRADAXA CAP 150MG Brand 2 PREF QL 60/30 ELIQUIS TAB 2.5MG Brand 2 NON-PREF ST QL 60/30 ELIQUIS TAB 5MG Brand 2 NON-PREF ST QL 60/30 XARELTO TAB 10MG Brand 2 PREF QL 35/365 XARELTO TAB 15MG Brand 2 PREF QL 60/30 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 39 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO XARELTO TAB 20MG Brand 2 PREF QL 30/30 Anticonvulsants ONFI TAB 5MG Brand 2 PA MO ONFI TAB 10MG Brand 2 PA MO ONFI TAB 20MG Brand 2 PA MO ONFI SUS 2.5MG/ML Brand 2 PA KLONOPIN TAB 0.5MG Brand 2 GR CLONAZEPAM TAB 0.5MG generic 1 PREF CLONAZEPAM TAB 1MG generic 1 PREF KLONOPIN TAB 1MG Brand 2 GR CLONAZEPAM TAB 2MG generic 1 PREF KLONOPIN TAB 2MG Brand 2 GR CLONAZEP ODT TAB 0.125MG generic 1 PREF CLONAZEP ODT TAB 0.25MG generic 1 PREF CLONAZEP ODT TAB 0.5MG generic 1 PREF CLONAZEP ODT TAB 1MG generic 1 PREF CLONAZEP ODT TAB 2MG generic 1 DIASTAT PED GEL 2.5M GEL Brand 2 PREF DIAZEPAM GEL 2.5MG generic 1 NON-PREF ST DIASTAT ACDL GEL 5-10MG Brand 2 PREF DIAZEPAM GEL 10MG generic 1 NON-PREF ST DIASTAT ACDL GEL 12.5-20 Brand 2 PREF DIAZEPAM GEL 20MG generic 1 NON-PREF ST FELBATOL TAB 400MG Brand 2 PREF MO FELBAMATE TAB 400MG generic 1 NON-PREF ST MO FELBATOL TAB 600MG Brand 2 PREF MO FELBAMATE TAB 600MG generic 1 NON-PREF ST MO FELBAMATE SUS 600/5ML generic 1 NON-PREF ST MO FELBATOL SUS 600/5ML Brand 2 PREF MO GABITRIL TAB 2MG Brand 2 PREF MO TIAGABINE TAB 2MG generic 1 NON-PREF ST MO

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 40 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO TIAGABINE TAB 4MG generic 1 NON-PREF ST MO GABITRIL TAB 4MG Brand 2 PREF MO GABITRIL TAB 12MG Brand 2 PREF MO GABITRIL TAB 16MG Brand 2 PREF MO SABRIL TAB 500MG Brand 2 NON-PREF ST QL 180/30 SP SABRIL POW 500MG Brand 2 NON-PREF ST QL 100/30 SP PEGANONE TAB 250MG Brand 2 FOSPHENYTOIN INJ 100/2ML generic 1 CEREBYX INJ 100/2ML Brand 2 GR FOSPHENYTOIN INJ 500/10ML generic 1 CEREBYX INJ 500/10ML Brand 2 GR PHENYTOIN CHW 50MG generic 1 NON-PREF ST MO DILANTIN CHW 50MG Brand 2 PREF MO PHENYTOIN SUS 125/5ML generic 1 PREF MO DILANTIN-125 SUS 125/5ML Brand 2 NON-PREF ST MO PHENYTOIN INJ 50MG/ML generic 1 DILANTIN CAP 30MG Brand 2 PHENYTOIN EX CAP 100MG generic 1 PREF MO DILANTIN CAP 100MG Brand 2 NON-PREF ST MO PHENYTOIN EX CAP 200MG generic 1 NON-PREF ST MO PHENYTEK CAP 200MG Brand 2 NON-PREF ST MO PHENYTOIN EX CAP 300MG generic 1 NON-PREF ST MO PHENYTEK CAP 300MG Brand 2 NON-PREF ST MO ZARONTIN CAP 250MG Brand 2 NON-PREF ST MO ETHOSUXIMIDE CAP 250MG generic 1 PREF MO ETHOSUXIMIDE SOL 250/5ML generic 1 PREF MO ZARONTIN SOL 250/5ML Brand 2 NON-PREF ST MO CELONTIN CAP 300MG Brand 2 PREF MO DIVALPROEX TAB 125MG DR generic 1 PREF MO DEPAKOTE TAB 125MG DR Brand 2 NON-PREF ST MO DIVALPROEX TAB 250MG DR generic 1 PREF MO DEPAKOTE TAB 250MG DR Brand 2 NON-PREF ST MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 41 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DIVALPROEX TAB 500MG DR generic 1 PREF MO DEPAKOTE TAB 500MG DR Brand 2 NON-PREF ST MO DEPAKOTE SPR CAP 125MG Brand 2 PREF MO DIVALPROEX CAP 125MG generic 1 PREF MO DIVALPROEX TAB 250MG ER generic 1 PREF MO DEPAKOTE ER TAB 250MG Brand 2 NON-PREF ST MO DIVALPROEX TAB 500MG ER generic 1 PREF MO DEPAKOTE ER TAB 500MG Brand 2 NON-PREF ST MO DEPAKENE SYP 250/5ML Brand 2 NON-PREF ST MO VALPROIC ACD SOL 250/5ML generic 1 PREF MO VALPROIC ACD SYP 250/5ML generic 1 PREF MO VALPROATE INJ 500/5ML generic 1 DEPACON INJ 100MG/ML Brand 2 GR VALPROATE INJ 100MG/ML generic 1 VALPROIC ACD CAP 250MG generic 1 PREF MO DEPAKENE CAP 250MG Brand 2 NON-PREF ST MO STAVZOR CAP 125MG Brand 2 NON-PREF ST MO STAVZOR CAP 250MG Brand 2 NON-PREF ST MO STAVZOR CAP 500MG Brand 2 NON-PREF ST MO CARBAMAZEPIN TAB 200MG generic 1 PREF MO EPITOL TAB 200MG generic 1 PREF MO TEGRETOL TAB 200MG Brand 2 NON-PREF ST MO CARBAMAZEPIN CHW 100MG generic 1 PREF MO CARBAMAZEPIN SUS 100/5ML generic 1 PREF MO TEGRETOL SUS 100/5ML Brand 2 NON-PREF ST MO CARBAMAZEPIN CAP 100MG ER generic 1 NON-PREF ST MO CARBATROL CAP 100MG Brand 2 PREF MO CARBATROL CAP 200MG Brand 2 PREF MO CARBAMAZEPIN CAP 200MG ER generic 1 NON-PREF ST MO CARBAMAZEPIN CAP 300MG ER generic 1 NON-PREF ST MO CARBATROL CAP 300MG Brand 2 PREF MO TEGRETOL-XR TAB 100MG Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 42 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO TEGRETOL-XR TAB 200MG Brand 2 NON-PREF ST MO CARBAMAZEPIN TAB 200MG ER generic 1 PREF MO CARBAMAZEPIN TAB 400MG ER generic 1 PREF MO TEGRETOL-XR TAB 400MG Brand 2 NON-PREF ST MO POTIGA TAB 50MG Brand 2 NON-PREF ST QL 270/30 MO POTIGA TAB 200MG Brand 2 NON-PREF ST QL 90/30 MO POTIGA TAB 300MG Brand 2 NON-PREF ST QL 90/30 MO POTIGA TAB 400MG Brand 2 NON-PREF ST QL 90/30 MO GABAPENTIN CAP 100MG generic 1 PREF NEURONTIN CAP 100MG Brand 2 NON-PREF ST GABAPENTIN CAP 300MG generic 1 PREF NEURONTIN CAP 300MG Brand 2 NON-PREF ST GABAPENTIN CAP 400MG generic 1 PREF NEURONTIN CAP 400MG Brand 2 NON-PREF ST NEURONTIN TAB 600MG Brand 2 NON-PREF ST GABAPENTIN TAB 600MG generic 1 PREF GABAPENTIN TAB 800MG generic 1 PREF NEURONTIN TAB 800MG Brand 2 NON-PREF ST GABAPENTIN SOL 250/5ML generic 1 PREF NEURONTIN SOL 250/5ML Brand 2 NON-PREF ST VIMPAT TAB 50MG Brand 2 NON-PREF ST QL 90/30 MO VIMPAT TAB 100MG Brand 2 NON-PREF ST QL 90/30 MO VIMPAT TAB 150MG Brand 2 NON-PREF ST QL 60/30 MO VIMPAT TAB 200MG Brand 2 NON-PREF ST QL 60/30 MO VIMPAT INJ 200MG/20 Brand 2 VIMPAT SOL 10MG/ML Brand 2 NON-PREF ST QL 1395/30 MO LAMICTAL TAB 25MG Brand 2 NON-PREF ST QL 180/30 MO LAMOTRIGINE TAB 25MG generic 1 PREF QL 180/30 MO LAMOTRIGINE TAB 100MG generic 1 PREF QL 90/30 MO LAMICTAL TAB 100MG Brand 2 NON-PREF ST QL 90/30 MO LAMOTRIGINE TAB 150MG generic 1 PREF QL 90/30 MO LAMICTAL TAB 150MG Brand 2 NON-PREF ST QL 90/30 MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 43 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO LAMOTRIGINE TAB 200MG generic 1 PREF QL 90/30 MO LAMICTAL TAB 200MG Brand 2 NON-PREF ST QL 90/30 MO LAMOTRIGINE CHW 5MG generic 1 PREF MO LAMICTAL CHW 5MG Brand 2 NON-PREF ST MO LAMICTAL CHW 25MG Brand 2 NON-PREF ST QL 180/30 MO LAMOTRIGINE CHW 25MG generic 1 PREF QL 180/30 MO LAMICTAL KIT START 35 Brand 2 NON-PREF ST MO LAMICTAL KIT START 49 Brand 2 NON-PREF ST MO LAMICTAL KIT START 98 Brand 2 NON-PREF ST MO LAMICTAL ODT KIT Brand 2 NON-PREF ST MO LAMICTAL ODT KIT Brand 2 NON-PREF ST MO LAMICTAL ODT KIT Brand 2 NON-PREF ST MO LAMICTAL XR KIT Brand 2 NON-PREF ST MO LAMICTAL XR KIT Brand 2 NON-PREF ST MO LAMICTAL XR KIT Brand 2 NON-PREF ST MO LAMICTAL ODT TAB 25MG Brand 2 NON-PREF ST QL 180/30 MO LAMICTAL ODT TAB 50MG Brand 2 NON-PREF ST QL 90/30 MO LAMICTAL ODT TAB 100MG Brand 2 NON-PREF ST QL 60/30 MO LAMICTAL ODT TAB 200MG Brand 2 NON-PREF ST QL 60/30 MO LAMOTRIGINE TAB 25MG ER generic 1 NON-PREF ST QL 30/30 MO LAMICTAL XR TAB 25MG Brand 2 NON-PREF ST QL 30/30 MO LAMOTRIGINE TAB 50MG ER generic 1 NON-PREF ST QL 30/30 MO LAMICTAL XR TAB 50MG Brand 2 NON-PREF ST QL 30/30 MO LAMICTAL XR TAB 100MG Brand 2 NON-PREF ST QL 30/30 MO LAMOTRIGINE TAB 100MG ER generic 1 NON-PREF ST QL 30/30 MO LAMICTAL XR TAB 200MG Brand 2 NON-PREF ST QL 90/30 MO LAMOTRIGINE TAB 200MG ER generic 1 NON-PREF ST QL 90/30 MO LAMOTRIGINE TAB 250MG ER generic 1 NON-PREF ST QL 60/30 MO LAMICTAL XR TAB 250MG Brand 2 NON-PREF ST QL 60/30 MO LAMICTAL XR TAB 300MG Brand 2 NON-PREF ST QL 60/30 MO LAMOTRIGINE TAB 300MG ER generic 1 NON-PREF ST QL 60/30 MO LEVETIRACETA TAB 250MG generic 1 PREF MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 44 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO KEPPRA TAB 250MG Brand 2 NON-PREF ST MO KEPPRA TAB 500MG Brand 2 NON-PREF ST MO LEVETIRACETA TAB 500MG generic 1 PREF MO KEPPRA TAB 750MG Brand 2 NON-PREF ST MO LEVETIRACETA TAB 750MG generic 1 PREF MO KEPPRA TAB 1000MG Brand 2 NON-PREF ST MO LEVETIRACETA TAB 1000MG generic 1 PREF MO LEVETIRACETA SOL 100MG/ML generic 1 PREF MO KEPPRA SOL 100MG/ML Brand 2 NON-PREF ST MO LEVETIRACETA SOL 500/5ML generic 1 PREF MO KEPPRA INJ 500/5ML Brand 2 GR LEVETIRACETM INJ 500/5ML generic 1 KEPPRA XR TAB 500MG Brand 2 NON-PREF ST QL 180/30 MO LEVETIRACETA TAB 500MG ER generic 1 KEPPRA XR TAB 750MG Brand 2 NON-PREF ST QL 120/30 MO LEVETIRACETA TAB 750MG ER generic 1 LEVETIRACETA INJ 5MG/ML Brand 2 LEVETIRACETA INJ 10MG/ML Brand 2 LEVETIRACETA INJ 15MG/ML Brand 2 OXCARBAZEPIN TAB 150MG generic 1 PREF MO TRILEPTAL TAB 150MG Brand 2 NON-PREF ST MO OXCARBAZEPIN TAB 300MG generic 1 PREF MO TRILEPTAL TAB 300MG Brand 2 NON-PREF ST MO TRILEPTAL TAB 600MG Brand 2 NON-PREF ST MO OXCARBAZEPIN TAB 600MG generic 1 PREF MO TRILEPTAL SUS 300MG/5M Brand 2 NON-PREF ST MO OXCARBAZEPIN SUS 300MG/5M generic 1 PREF MO OXTELLAR XR TAB 150MG Brand 2 NON-PREF ST QL 60/30 MO OXTELLAR XR TAB 300MG Brand 2 NON-PREF ST QL 60/30 MO OXTELLAR XR TAB 600MG Brand 2 NON-PREF ST QL 120/30 MO LYRICA CAP 25MG Brand 2 NON-PREF ST QL 90/30 PA LYRICA CAP 50MG Brand 2 NON-PREF ST QL 90/30 PA KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 45 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO LYRICA CAP 75MG Brand 2 NON-PREF ST QL 90/30 PA LYRICA CAP 100MG Brand 2 NON-PREF ST QL 90/30 PA LYRICA CAP 150MG Brand 2 NON-PREF ST QL 90/30 PA LYRICA CAP 200MG Brand 2 NON-PREF ST QL 90/30 PA LYRICA CAP 225MG Brand 2 NON-PREF ST QL 90/30 PA LYRICA CAP 300MG Brand 2 NON-PREF ST QL 90/30 PA LYRICA SOL 20MG/ML Brand 2 NON-PREF ST QL 900/30 PA PRIMIDONE TAB 50MG generic 1 PREF MO MYSOLINE TAB 50MG Brand 2 GR PRIMIDONE TAB 250MG generic 1 PREF MO MYSOLINE TAB 250MG Brand 2 GR BANZEL TAB 200MG Brand 2 NON-PREF ST QL 60/30 MO BANZEL TAB 400MG Brand 2 NON-PREF ST QL 240/30 MO BANZEL SUS 40MG/ML Brand 2 NON-PREF ST QL 2760/30 MO TOPIRAGEN TAB 25MG generic 1 PREF MO TOPIRAMATE TAB 25MG generic 1 PREF MO TOPAMAX TAB 25MG Brand 2 NON-PREF ST MO TOPIRAGEN TAB 50MG generic 1 PREF MO TOPIRAMATE TAB 50MG generic 1 PREF MO TOPAMAX TAB 50MG Brand 2 NON-PREF ST MO TOPAMAX TAB 100MG Brand 2 NON-PREF ST MO TOPIRAGEN TAB 100MG generic 1 PREF MO TOPIRAMATE TAB 100MG generic 1 PREF MO TOPAMAX TAB 200MG Brand 2 NON-PREF ST MO TOPIRAGEN TAB 200MG generic 1 PREF MO TOPIRAMATE TAB 200MG generic 1 PREF MO TOPIRAMATE CAP 15MG generic 1 PREF MO TOPAMAX SPR CAP 15MG Brand 2 NON-PREF ST MO TOPIRAMATE CAP 25MG generic 1 PREF MO TOPAMAX SPR CAP 25MG Brand 2 NON-PREF ST MO TROKENDI XR CAP 25MG Brand 2 PA TROKENDI XR CAP 50MG Brand 2 PA KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 46 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO TROKENDI XR CAP 100MG Brand 2 PA TROKENDI XR CAP 200MG Brand 2 PA ZONISAMIDE CAP 25MG generic 1 PREF MO ZONEGRAN CAP 25MG Brand 2 NON-PREF ST MO ZONISAMIDE CAP 50MG generic 1 PREF MO ZONEGRAN CAP 100MG Brand 2 NON-PREF ST MO ZONISAMIDE CAP 100MG generic 1 PREF MO Antidepressants MIRTAZAPINE TAB 7.5MG generic 1 PREF QL 30/30 MO REMERON TAB 15MG Brand 2 NON-PREF ST QL 30/30 MO MIRTAZAPINE TAB 15MG generic 1 PREF QL 30/30 MO MIRTAZAPINE TAB 30MG generic 1 PREF QL 30/30 MO REMERON TAB 30MG Brand 2 NON-PREF ST QL 30/30 MO REMERON TAB 45MG Brand 2 NON-PREF ST QL 30/30 MO MIRTAZAPINE TAB 45MG generic 1 PREF QL 30/30 MO REMERON SLTB TAB 15MG Brand 2 NON-PREF ST QL 30/30 MO MIRTAZAPINE TAB 15MG ODT generic 1 PREF QL 30/30 MO REMERON SLTB TAB 30MG Brand 2 NON-PREF ST QL 30/30 MO MIRTAZAPINE TAB 30MG ODT generic 1 PREF QL 30/30 MO REMERON SLTB TAB 45MG Brand 2 NON-PREF ST QL 30/30 MO MIRTAZAPINE TAB 45MG ODT generic 1 PREF QL 30/30 MO MARPLAN TAB 10MG Brand 2 PHENELZINE TAB 15MG generic 1 NARDIL TAB 15MG Brand 2 GR EMSAM DIS 6MG/24HR Brand 2 NON-PREF ST MO EMSAM DIS 9MG/24HR Brand 2 NON-PREF ST MO EMSAM DIS 12MG/24H Brand 2 NON-PREF ST MO PARNATE TAB 10MG Brand 2 GR TRANYLCYPROM TAB 10MG generic 1 NEFAZODONE TAB 50MG generic 1 PREF MO NEFAZODONE TAB 100MG generic 1 PREF MO

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 47 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO NEFAZODONE TAB 150MG generic 1 PREF MO NEFAZODONE TAB 200MG generic 1 PREF MO NEFAZODONE TAB 250MG generic 1 PREF MO TRAZODONE TAB 50MG generic 1 PREF MO TRAZODONE TAB 100MG generic 1 PREF MO TRAZODONE TAB 150MG generic 1 PREF MO TRAZODONE TAB 300MG generic 1 PREF MO VIIBRYD TAB 10MG Brand 2 NON-PREF ST QL 60/30 MO VIIBRYD TAB 20MG Brand 2 NON-PREF ST QL 30/30 MO VIIBRYD TAB 40MG Brand 2 NON-PREF ST QL 60/30 MO VIIBRYD KIT Brand 2 NON-PREF ST QL 30/life BRINTELLIX TAB 5MG Brand 2 PA BRINTELLIX TAB 10MG Brand 2 PA BRINTELLIX TAB 20MG Brand 2 PA CELEXA TAB 10MG Brand 2 NON-PREF ST QL 45/30 MO CITALOPRAM TAB 10MG generic 1 PREF QL 45/30 MO CITALOPRAM TAB 20MG generic 1 PREF QL 45/30 MO CELEXA TAB 20MG Brand 2 NON-PREF ST QL 45/30 MO CITALOPRAM TAB 40MG generic 1 PREF QL 30/30 MO CELEXA TAB 40MG Brand 2 NON-PREF ST QL 30/30 MO CITALOPRAM SOL 10MG/5ML generic 1 PREF MO LEXAPRO TAB 5MG Brand 2 NON-PREF ST QL 45/30 MO ESCITALOPRAM TAB 5MG generic 1 PREF QL 45/30 MO LEXAPRO TAB 10MG Brand 2 NON-PREF ST QL 45/30 MO ESCITALOPRAM TAB 10MG generic 1 PREF QL 45/30 MO ESCITALOPRAM TAB 20MG generic 1 PREF QL 45/30 MO LEXAPRO TAB 20MG Brand 2 NON-PREF ST QL 45/30 MO ESCITALOPRAM SOL 5MG/5ML generic 1 PREF MO LEXAPRO SOL 5MG/5ML Brand 2 NON-PREF ST MO FLUOXETINE CAP 10MG generic 1 PREF QL 30/30 MO PROZAC CAP 10MG Brand 2 NON-PREF ST QL 30/30 MO FLUOXETINE CAP 20MG generic 1 PREF QL 90/30 MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 48 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PROZAC CAP 20MG Brand 2 NON-PREF ST QL 30/30 MO FLUOXETINE CAP 40MG generic 1 PREF QL 60/30 MO PROZAC CAP 40MG Brand 2 NON-PREF ST QL 30/30 MO FLUOXETINE TAB 10MG generic 1 PREF QL 45/30 MO FLUOXETINE TAB 20MG generic 1 PREF QL 90/30 MO FLUOXETINE TAB 60MG Brand 2 PREF QL 30/30 MO FLUOXETINE SOL 20MG/5ML generic 1 PREF MO PROZAC WEEKL CAP 90MG Brand 2 NON-PREF ST QL 4/28 MO FLUOXETINE CAP 90MG DR generic 1 NON-PREF ST QL 4/28 MO FLUVOXAMINE TAB 25MG generic 1 PREF QL 60/30 MO FLUVOXAMINE TAB 50MG generic 1 PREF QL 60/30 MO FLUVOXAMINE TAB 100MG generic 1 PREF QL 90/30 MO FLUVOXAMINE CAP 100MG ER generic 1 QL 30/30 PA LUVOX CR CAP 100MG Brand 2 NON-PREF ST QL 30/30 MO FLUVOXAMINE CAP 150MG ER generic 1 QL 30/30 PA LUVOX CR CAP 150MG Brand 2 NON-PREF ST QL 30/30 MO PAROXETINE TAB 10MG generic 1 PREF QL 30/30 MO PAXIL TAB 10MG Brand 2 NON-PREF ST QL 30/30 MO PAROXETINE TAB 20MG generic 1 PREF QL 30/30 MO PAXIL TAB 20MG Brand 2 NON-PREF ST QL 30/30 MO PAXIL TAB 30MG Brand 2 NON-PREF ST QL 60/30 MO PAROXETINE TAB 30MG generic 1 PREF QL 60/30 MO PAROXETINE TAB 40MG generic 1 PREF QL 60/30 MO PAXIL TAB 40MG Brand 2 NON-PREF ST QL 60/30 MO PAXIL SUS 10MG/5ML Brand 2 PAROXETIN ER TAB 12.5MG generic 1 NON-PREF ST QL 30/30 MO PAXIL CR TAB 12.5MG Brand 2 NON-PREF ST QL 30/30 MO PAROXETINE TAB 25MG ER generic 1 NON-PREF ST QL 30/30 MO PAXIL CR TAB 25MG Brand 2 NON-PREF ST QL 30/30 MO PAROXETIN ER TAB 37.5MG generic 1 NON-PREF ST QL 30/30 MO PAXIL CR TAB 37.5MG Brand 2 NON-PREF ST QL 30/30 MO PEXEVA TAB 10MG Brand 2 NON-PREF ST QL 30/30 MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 49 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PEXEVA TAB 20MG Brand 2 NON-PREF ST QL 30/30 MO PEXEVA TAB 30MG Brand 2 NON-PREF ST QL 60/30 MO PEXEVA TAB 40MG Brand 2 NON-PREF ST QL 60/30 MO SERTRALINE TAB 25MG generic 1 PREF QL 45/30 MO ZOLOFT TAB 25MG Brand 2 NON-PREF ST QL 45/30 MO SERTRALINE TAB 50MG generic 1 PREF QL 45/30 MO ZOLOFT TAB 50MG Brand 2 NON-PREF ST QL 45/30 MO ZOLOFT TAB 100MG Brand 2 NON-PREF ST QL 60/30 MO SERTRALINE TAB 100MG generic 1 PREF QL 60/30 MO ZOLOFT CON 20MG/ML Brand 2 NON-PREF ST MO SERTRALINE CON 20MG/ML generic 1 PREF MO KHEDEZLA TAB 50MG ER Brand 2 QL 30/30 PA DESVENLAFAX TAB 50MG ER Brand 2 QL 30/30 PA DESVENLAFAX TAB 100MG ER Brand 2 QL 30/30 PA KHEDEZLA TAB 100MG ER Brand 2 QL 30/30 PA PRISTIQ TAB 50MG Brand 2 NON-PREF ST QL 30/30 MO PRISTIQ TAB 100MG Brand 2 NON-PREF ST QL 30/30 MO CYMBALTA CAP 20MG Brand 2 NON-PREF ST QL 60/30 PA MO CYMBALTA CAP 30MG Brand 2 NON-PREF ST QL 60/30 PA MO CYMBALTA CAP 60MG Brand 2 NON-PREF ST QL 60/30 PA MO FETZIMA CAP 20MG Brand 2 FETZIMA CAP 40MG Brand 2 FETZIMA CAP 80MG Brand 2 FETZIMA CAP 120MG Brand 2 FETZIMA CAP TITRATIO Brand 2 VENLAFAXINE TAB 25MG generic 1 PREF QL 90/30 MO VENLAFAXINE TAB 37.5MG generic 1 PREF QL 90/30 MO VENLAFAXINE TAB 50MG generic 1 PREF QL 90/30 MO VENLAFAXINE TAB 75MG generic 1 PREF QL 90/30 MO VENLAFAXINE TAB 100MG generic 1 PREF QL 90/30 MO EFFEXOR XR CAP 37.5MG Brand 2 NON-PREF ST QL 60/30 MO VENLAFAXINE CAP 37.5MG generic 1 NON-PREF ST QL 60/30 MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 50 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO VENLAFAXINE CAP 75MG ER generic 1 NON-PREF ST QL 60/30 MO EFFEXOR XR CAP 75MG Brand 2 NON-PREF ST QL 60/30 MO EFFEXOR XR CAP 150MG Brand 2 NON-PREF ST QL 60/30 MO VENLAFAXINE CAP 150MG ER generic 1 NON-PREF ST QL 60/30 MO VENLAFAXINE TAB 37.5 ER generic 1 NON-PREF ST QL 60/30 MO VENLAFAXINE TAB 75MG ER generic 1 NON-PREF ST QL 60/30 MO VENLAFAXINE TAB 150MG ER generic 1 NON-PREF ST QL 60/30 MO VENLAFAXINE TAB 225MG ER generic 1 NON-PREF ST QL 30/30 MO AMITRIPTYLIN TAB 10MG generic 1 AMITRIPTYLIN TAB 25MG generic 1 AMITRIPTYLIN TAB 50MG generic 1 AMITRIPTYLIN TAB 75MG generic 1 AMITRIPTYLIN TAB 100MG generic 1 AMITRIPTYLIN TAB 150MG generic 1 AMOXAPINE TAB 25MG generic 1 AMOXAPINE TAB 50MG generic 1 AMOXAPINE TAB 100MG generic 1 AMOXAPINE TAB 150MG generic 1 ANAFRANIL CAP 25MG Brand 2 GR CLOMIPRAMINE CAP 25MG generic 1 CLOMIPRAMINE CAP 50MG generic 1 ANAFRANIL CAP 50MG Brand 2 GR CLOMIPRAMINE CAP 75MG generic 1 ANAFRANIL CAP 75MG Brand 2 GR DESIPRAMINE TAB 10MG generic 1 NORPRAMIN TAB 10MG Brand 2 GR DESIPRAMINE TAB 25MG generic 1 NORPRAMIN TAB 25MG Brand 2 GR DESIPRAMINE TAB 50MG generic 1 NORPRAMIN TAB 50MG Brand 2 GR NORPRAMIN TAB 75MG Brand 2 GR DESIPRAMINE TAB 75MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 51 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DESIPRAMINE TAB 100MG generic 1 NORPRAMIN TAB 100MG Brand 2 GR NORPRAMIN TAB 150MG Brand 2 GR DESIPRAMINE TAB 150MG generic 1 DOXEPIN HCL CAP 10MG generic 1 DOXEPIN HCL CAP 25MG generic 1 DOXEPIN HCL CAP 50MG generic 1 DOXEPIN HCL CAP 75MG generic 1 DOXEPIN HCL CAP 100MG generic 1 DOXEPIN HCL CAP 150MG generic 1 DOXEPIN HCL CON 10MG/ML generic 1 TOFRANIL TAB 10MG Brand 2 GR IMIPRAM HCL TAB 10MG generic 1 TOFRANIL TAB 25MG Brand 2 GR IMIPRAM HCL TAB 25MG generic 1 IMIPRAM HCL TAB 50MG generic 1 TOFRANIL TAB 50MG Brand 2 GR TOFRANIL-PM CAP 75MG Brand 2 GR IMIPRAM PAM CAP 75MG generic 1 IMIPRAM PAM CAP 100MG generic 1 TOFRANIL-PM CAP 100MG Brand 2 GR TOFRANIL-PM CAP 125MG Brand 2 GR IMIPRAM PAM CAP 125MG generic 1 IMIPRAM PAM CAP 150MG generic 1 TOFRANIL-PM CAP 150MG Brand 2 GR PAMELOR CAP 10MG Brand 2 GR NORTRIPTYLIN CAP 10MG generic 1 PAMELOR CAP 25MG Brand 2 GR NORTRIPTYLIN CAP 25MG generic 1 PAMELOR CAP 50MG Brand 2 GR NORTRIPTYLIN CAP 50MG generic 1 NORTRIPTYLIN CAP 75MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 52 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PAMELOR CAP 75MG Brand 2 GR NORTRIPTYLIN SOL 10MG/5ML Brand 2 VIVACTIL TAB 5MG Brand 2 GR PROTRIPTYLIN TAB 5MG generic 1 VIVACTIL TAB 10MG Brand 2 GR PROTRIPTYLIN TAB 10MG generic 1 SURMONTIL CAP 25MG Brand 2 SURMONTIL CAP 50MG Brand 2 SURMONTIL CAP 100MG Brand 2 MAPROTILINE TAB 25MG generic 1 MAPROTILINE TAB 50MG generic 1 MAPROTILINE TAB 75MG generic 1 WELLBUTRIN TAB 75MG Brand 2 BUPROPION TAB 75MG generic 1 PREF QL 90/30 MO WELLBUTRIN TAB 100MG Brand 2 BUPROPION TAB 100MG generic 1 PREF QL 90/30 MO BUPROPION TAB 100MG ER generic 1 PREF QL 60/30 MO WELLBUTRIN TAB 100MG SR Brand 2 BUPROPION TAB 100MG SR generic 1 PREF QL 60/30 MO WELLBUTRIN TAB 150MG SR Brand 2 BUDEPRION TAB 150MG SR generic 1 PREF QL 90/30 MO BUPROPION TAB 150MG ER generic 1 PREF QL 90/30 MO BUPROPION TAB 150MG SR generic 1 PREF QL 90/30 MO BUPROPION TAB 200MG ER generic 1 PREF QL 60/30 MO BUPROPION TAB 200MG SR generic 1 PREF QL 60/30 MO WELLBUTRIN TAB 200MG SR Brand 2 WELLBUTRIN TAB XL 150MG Brand 2 NON-PREF ST QL 30/30 MO BUPROPN HCL TAB 150MG XL generic 1 PREF QL 30/30 MO WELLBUTRIN TAB XL 300MG Brand 2 NON-PREF ST QL 30/30 MO BUPROPN HCL TAB 300MG XL generic 1 PREF QL 30/30 MO FORFIVO XL TAB 450MG Brand 2 NON-PREF ST QL 30/30 MO APLENZIN TAB 174MG Brand 2 NON-PREF ST QL 30/30 MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 53 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO APLENZIN TAB 348MG Brand 2 NON-PREF ST QL 30/30 MO APLENZIN TAB 522MG Brand 2 NON-PREF ST QL 30/30 MO Antidiabetics NOVOLOG INJ 100/ML Brand 2 PREF MO NOVOLOG INJ PENFILL Brand 2 PREF MO NOVOLOG INJ FLEXPEN Brand 2 PREF MO LANTUS INJ 100/ML Brand 2 PREF MO APIDRA INJ SOLOSTAR Brand 2 NON-PREF ST MO APIDRA INJ U-100 Brand 2 NON-PREF ST MO HUMALOG INJ 100/ML Brand 2 NON-PREF ST MO HUMALOG KWIK INJ 100/ML Brand 2 NON-PREF ST MO LEVEMIR FLEXPEN 100/ML Brand 2 NON-PREF ST MO LEVEMIR INJ 100/ML Brand 2 PREF MO HUMULIN R INJ U-500 Brand 2 NON-PREF ST MO NOVOLOG MIX INJ FLEXPEN Brand 2 PREF MO NOVOLOG MIX INJ 70/30 Brand 2 PREF MO HUMALOG MIX SUS 75/25 Brand 2 NON-PREF ST MO HUMALOG MIX INJ 75/25KWP Brand 2 NON-PREF ST MO HUMALOG MIX INJ 50/50 Brand 2 NON-PREF ST MO HUMALOG MIX INJ 50/50KWP Brand 2 NON-PREF ST MO SYMLINPEN 60 INJ 1000MCG Brand 2 SYMLNPEN 120 INJ 1000MCG Brand 2 BYDUREON INJ Brand 2 PA MO BYETTA INJ 5MCG Brand 2 PA MO BYETTA INJ 10MCG Brand 2 PA MO VICTOZA INJ 18MG/3ML Brand 2 PA MO CHLORPROPAM TAB 100MG generic 1 CHLORPROPAM TAB 250MG generic 1 AMARYL TAB 1MG Brand 2 NON-PREF ST MO GLIMEPIRIDE TAB 1MG generic 1 NON-PREF ST MO GLIMEPIRIDE TAB 2MG generic 1 NON-PREF ST MO

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 54 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO AMARYL TAB 2MG Brand 2 NON-PREF ST MO GLIMEPIRIDE TAB 4MG generic 1 NON-PREF ST MO AMARYL TAB 4MG Brand 2 NON-PREF ST MO GLIPIZIDE TAB 5MG generic 1 PREF MO GLUCOTROL TAB 5MG Brand 2 NON-PREF ST MO GLIPIZIDE TAB 10MG generic 1 PREF MO GLUCOTROL TAB 10MG Brand 2 NON-PREF ST MO GLUCOTROL XL TAB 2.5MG Brand 2 NON-PREF ST MO GLIPIZIDE XL TAB 2.5MG generic 1 PREF MO GLIPIZIDE ER TAB 2.5MG generic 1 PREF MO GLIPIZIDE XL TAB 5MG generic 1 PREF MO GLIPIZIDE ER TAB 5MG generic 1 PREF MO GLUCOTROL XL TAB 5MG Brand 2 NON-PREF ST MO GLIPIZIDE ER TAB 10MG generic 1 PREF MO GLIPIZIDE XL TAB 10MG generic 1 PREF MO GLUCOTROL XL TAB 10MG Brand 2 NON-PREF ST MO GLYBURIDE TAB 1.25MG generic 1 PREF MO DIABETA TAB 1.25MG Brand 2 NON-PREF ST MO DIABETA TAB 2.5MG Brand 2 NON-PREF ST MO GLYBURIDE TAB 2.5MG generic 1 PREF MO GLYBURIDE TAB 5MG generic 1 PREF MO DIABETA TAB 5MG Brand 2 NON-PREF ST MO GLYBURID MCR TAB 1.5MG generic 1 PREF MO GLYNASE TAB 1.5MG Brand 2 NON-PREF ST MO GLYBURID MCR TAB 3MG generic 1 PREF MO GLYNASE TAB 3MG Brand 2 NON-PREF ST MO GLYBURID MCR TAB 6MG generic 1 PREF MO GLYNASE TAB 6MG Brand 2 NON-PREF ST MO TOLAZAMIDE TAB 250MG generic 1 TOLAZAMIDE TAB 500MG generic 1 TOLBUTAMIDE TAB 500MG generic 1 METFORMIN TAB 500MG generic 1 PREF MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 55 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO GLUCOPHAGE TAB 500MG Brand 2 NON-PREF ST MO METFORMIN TAB 850MG generic 1 PREF MO GLUCOPHAGE TAB 850MG Brand 2 NON-PREF ST MO METFORMIN TAB 1000MG generic 1 PREF MO GLUCOPHAGE TAB 1000MG Brand 2 NON-PREF ST MO RIOMET SOL Brand 2 NON-PREF ST MO METFORMIN TAB 500MG ER generic 1 PREF MO GLUCOPHAGE TAB 500MG XR Brand 2 NON-PREF ST MO GLUCOPHAGE TAB 750MG XR Brand 2 NON-PREF ST MO METFORMIN TAB 750MG ER generic 1 PREF MO METFORMIN TAB 500MG ER generic 1 FORTAMET TAB 500MG Brand 2 NON-PREF ST MO METFORMIN ER TAB 1000MG generic 1 PREF MO FORTAMET TAB 1000MG Brand 2 NON-PREF ST MO GLUMETZA TAB 500MG Brand 2 NON-PREF ST MO GLUMETZA TAB 1000MG Brand 2 NON-PREF ST MO NATEGLINIDE TAB 60MG generic 1 PREF MO STARLIX TAB 60MG Brand 2 NON-PREF ST MO STARLIX TAB 120MG Brand 2 NON-PREF ST MO NATEGLINIDE TAB 120MG generic 1 PREF MO REPAGLINIDE TAB 0.5MG generic 1 PRANDIN TAB 0.5MG Brand 2 GR REPAGLINIDE TAB 1MG generic 1 PRANDIN TAB 1MG Brand 2 GR REPAGLINIDE TAB 2MG generic 1 PRANDIN TAB 2MG Brand 2 GR GLUCAGON KIT 1MG Brand 2 GLUCAGEN INJ HYPOKIT Brand 2 GLUCAGEN INJ 1MG Brand 2 PROGLYCEM SUS 50MG/ML Brand 2 KORLYM TAB 300MG Brand 2 SP ACARBOSE TAB 25MG generic 1 PREF MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 56 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PRECOSE TAB 25MG Brand 2 NON-PREF ST MO ACARBOSE TAB 50MG generic 1 PREF MO PRECOSE TAB 50MG Brand 2 NON-PREF ST MO PRECOSE TAB 100MG Brand 2 NON-PREF ST MO ACARBOSE TAB 100MG generic 1 PREF MO GLYSET TAB 25MG Brand 2 PREF MO GLYSET TAB 50MG Brand 2 PREF MO GLYSET TAB 100MG Brand 2 PREF MO NESINA TAB 6.25MG Brand 2 PA MO NESINA TAB 12.5MG Brand 2 PA MO NESINA TAB 25MG Brand 2 PA MO TRADJENTA TAB 5MG Brand 2 NON-PREF ST PA MO ONGLYZA TAB 2.5MG Brand 2 PREF PA MO ONGLYZA TAB 5MG Brand 2 PREF PA MO JANUVIA TAB 25MG Brand 2 PREF PA MO JANUVIA TAB 50MG Brand 2 PREF PA MO JANUVIA TAB 100MG Brand 2 PREF PA MO CYCLOSET TAB 0.8MG Brand 2 QL 180/30 PA MO ACTOS TAB 15MG Brand 2 NON-PREF ST MO PIOGLITAZONE TAB 15MG generic 1 PREF MO PIOGLITAZONE TAB 30MG generic 1 PREF MO ACTOS TAB 30MG Brand 2 NON-PREF ST MO PIOGLITAZONE TAB 45MG generic 1 PREF MO ACTOS TAB 45MG Brand 2 NON-PREF ST MO AVANDIA TAB 2MG Brand 2 NON-PREF ST MO AVANDIA TAB 4MG Brand 2 NON-PREF ST MO AVANDIA TAB 8MG Brand 2 NON-PREF ST MO INVOKANA TAB 100MG Brand 2 PA INVOKANA TAB 300MG Brand 2 PA KAZANO 12.5- TAB 500MG Brand 2 PA MO KAZANO 12.5- TAB 1000MG Brand 2 PA MO JENTADUETO TAB 2.5-500 Brand 2 NON-PREF ST PA MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 57 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO JENTADUETO TAB 2.5-850 Brand 2 NON-PREF ST PA MO JENTADUETO TAB 2.5-1000 Brand 2 NON-PREF ST PA MO KOMBIGLYZE TAB 2.5-1000 Brand 2 PREF PA MO KOMBIGLYZE TAB 5-500MG Brand 2 PREF PA MO KOMBIGLYZE TAB 5-1000MG Brand 2 PREF PA MO JANUMET TAB 50-500MG Brand 2 PREF PA MO JANUMET TAB 50-1000 Brand 2 PREF PA MO JANUMET XR TAB 50-500MG Brand 2 NON-PREF ST PA MO JANUMET XR TAB 50-1000 Brand 2 NON-PREF ST PA MO JANUMET XR TAB 100-1000 Brand 2 NON-PREF ST PA MO OSENI TAB 12.5-15 Brand 2 PA MO OSENI TAB 12.5-30 Brand 2 PA MO OSENI TAB 12.5-45 Brand 2 PA MO OSENI TAB 25-15MG Brand 2 PA MO OSENI TAB 25-30MG Brand 2 PA MO OSENI TAB 25-45MG Brand 2 PA MO PRANDIMET TAB 1-500MG Brand 2 NON-PREF ST MO PRANDIMET TAB 2-500MG Brand 2 NON-PREF ST MO GLIP/METFORM TAB 2.5-250M generic 1 NON-PREF ST MO METAGLIP TAB 2.5-250M Brand 2 GR GLIP/METFORM TAB 2.5-500M generic 1 NON-PREF ST MO GLIP/METFORM TAB 5-500MG generic 1 NON-PREF ST MO GLYB/METFORM TAB 1.25-250 generic 1 PREF MO GLUCOVANCE TAB 1.25-250 Brand 2 GR GLUCOVANCE TAB 2.5-500 Brand 2 NON-PREF ST MO GLUCOVANCE TAB 5-500MG Brand 2 NON-PREF ST MO PIOGLIT/GLIM TAB 30-2MG generic 1 NON-PREF ST MO DUETACT TAB 30-2MG Brand 2 PREF MO PIOGLIT/GLIM TAB 30-4MG generic 1 NON-PREF ST MO DUETACT TAB 30-4MG Brand 2 PREF MO AVANDARYL TAB 4-1MG Brand 2 NON-PREF ST MO AVANDARYL TAB 4-2MG Brand 2 NON-PREF ST MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 58 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO AVANDARYL TAB 4-4MG Brand 2 NON-PREF ST MO AVANDARYL TAB 8-2MG Brand 2 NON-PREF ST MO AVANDARYL TAB 8-4MG Brand 2 NON-PREF ST MO ACTOPLUS MET TAB 15-500MG Brand 2 NON-PREF ST MO PIOGLITA/MET TAB 15-500MG generic 1 NON-PREF ST MO PIOGLITA/MET TAB 15-850MG generic 1 NON-PREF ST MO ACTOPLUS MET TAB 15-850MG Brand 2 NON-PREF ST MO ACTOPLUS MET TAB XR Brand 2 ACTOPLUS MET TAB XR Brand 2 AVANDAMET TAB 2-500MG Brand 2 NON-PREF ST MO AVANDAMET TAB 2-1000MG Brand 2 NON-PREF ST MO AVANDAMET TAB 4-500MG Brand 2 NON-PREF ST MO AVANDAMET TAB 4-1000MG Brand 2 NON-PREF ST MO Antidiarrheals LOMOTIL TAB 2.5MG Brand 2 GR LONOX TAB 2.5MG generic 1 DIPHEN/ATROP TAB 2.5MG generic 1 LOFENE TAB 2.5MG generic 1 DIPHEN/ATROP LIQ 2.5/5 generic 1 MOTOFEN TAB Brand 2 LOPERAMIDE CAP 2MG generic 1 OPIUM TIN 1% generic 1 PAREGORIC TIN 2MG/5ML Brand 2 FULYZAQ TAB 125MG Brand 2 Antidotes ACETYLCYST INJ 200MG/ML generic 1 ACETADOTE INJ 200MG/ML Brand 2 GR DEFEROXAMINE INJ 500MG generic 1 DESFERAL INJ 500MG Brand 2 GR DEFEROXAMINE INJ 2GM generic 1 DESFERAL INJ 2GM Brand 2 GR

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 59 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DIGIFAB INJ 40MG Brand 2 BAL IN OIL INJ 100MG/ML Brand 2 CALCIUM DISO INJ 1GM/5ML Brand 2 FOMEPIZOLE INJ 1GM/ML generic 1 FOMEPIZOLE INJ 1.5GM generic 1 ANTIZOL INJ 1GM/ML Brand 2 GR CYANOKIT INJ 5GM Brand 2 METHYLENE BL INJ 1% generic 1 PHYSOS SALIC INJ 1MG/ML Brand 2 PROTOPAM CHL INJ 1GM Brand 2 PRALIDOXIME INJ 600/2ML Brand 2 SOD NITRITE INJ 30MG/ML Brand 2 SOD THIOSULF INJ 10% Brand 2 SOD THIOSULF INJ 25% generic 1 EXJADE TAB 125MG Brand 2 PA SP EXJADE TAB 250MG Brand 2 PA SP EXJADE TAB 500MG Brand 2 PA SP FERRIPROX TAB 500MG Brand 2 PA SP CA-DTPA SOL 1000MG Brand 2 ZN-DTPA SOL 1000MG Brand 2 CHEMET CAP 100MG Brand 2 FLUMAZENIL INJ 0.5MG/5 generic 1 FLUMAZENIL INJ 1MG/10ML generic 1 NALOXONE INJ 0.4MG/ML Brand 2 NALOXONE INJ 1MG/ML generic 1 VIVITROL INJ 380MG Brand 2 QL 1/30 PA SP REVIA TAB 50MG Brand 2 GR NALTREXONE TAB 50MG generic 1 DUODOTE INJ Brand 2 NITHIODOTE KIT Brand 2 Antiemetics

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 60 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DIMENHYDRIN INJ 50MG/ML Brand 2 MECLIZINE TAB 12.5MG generic 1 ANTIVERT TAB 12.5MG Brand 2 GR MECLIZINE TAB 25MG generic 1 MOTION SICK TAB 25MG generic 1 ANTIVERT TAB 25MG Brand 2 GR UNIVERT TAB 32MG generic 1 TRANSDERM-SC DIS 1.5MG Brand 2 TRIMETHOBENZ CAP 300MG generic 1 TIGAN CAP 300MG Brand 2 GR TIGAN INJ 100MG/ML Brand 2 GR TRIMETHOBENZ INJ 100MG/ML generic 1 ANZEMET TAB 50MG Brand 2 NON-PREF ST QL 5/30 ANZEMET TAB 100MG Brand 2 NON-PREF ST QL 5/30 ANZEMET INJ 20MG/ML Brand 2 PA SANCUSO DIS 3.1MG Brand 2 NON-PREF ST QL 4/30 GRANISETRON TAB 1MG generic 1 PREF QL 10/30 GRANISETRON INJ 0.1MG/ML generic 1 PA GRANISETRON INJ 1MG/ML generic 1 PA GRANISETRON INJ 1MG/ML generic 1 GRANISETRON INJ 4MG/4ML generic 1 GRANISOL SOL 2MG/10ML Brand 2 ZOFRAN TAB 4MG ODT Brand 2 NON-PREF ST QL 15/30 ONDANSETRON TAB 4MG ODT generic 1 PREF QL 30/30 ZOFRAN TAB 8MG ODT Brand 2 NON-PREF ST QL 15/30 ONDANSETRON TAB 8MG ODT generic 1 PREF QL 30/30 ZUPLENZ MIS 4MG Brand 2 NON-PREF ST QL 15/30 ZUPLENZ MIS 8MG Brand 2 NON-PREF ST QL 15/30 ZOFRAN TAB 4MG Brand 2 NON-PREF ST QL 30/30 ONDANSETRON TAB 4MG generic 1 PREF QL 30/30 ZOFRAN TAB 8MG Brand 2 NON-PREF ST QL 30/30 ONDANSETRON TAB 8MG generic 1 PREF QL 30/30 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 61 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ONDANSETRON TAB 24MG generic 1 PREF QL 30/30 ONDANSETRON INJ 4MG/2ML generic 1 PA ZOFRAN INJ 40/20ML Brand 2 GR ONDANSETRON INJ 40/20ML generic 1 PA ZOFRAN SOL 4MG/5ML Brand 2 NON-PREF ST QL 75/30 ONDANSETRON SOL 4MG/5ML generic 1 PREF QL 75/30 ALOXI INJ 0.25MG/5 Brand 2 PA EMEND CAP 40MG Brand 2 NON-PREF ST QL 1/30 EMEND CAP 80MG Brand 2 NON-PREF ST QL 8/30 EMEND CAP 125MG Brand 2 NON-PREF ST QL 4/30 EMEND PAK 80 & 125 Brand 2 NON-PREF ST QL 12/30 EMEND SOL 150MG Brand 2 PA DRONABINOL CAP 2.5MG generic 1 QL 30/30 PA MARINOL CAP 2.5MG Brand 2 GR DRONABINOL CAP 5MG generic 1 QL 30/30 PA MARINOL CAP 5MG Brand 2 GR DRONABINOL CAP 10MG generic 1 QL 30/30 PA MARINOL CAP 10MG Brand 2 GR CESAMET CAP 1MG Brand 2 PA DICLEGIS TAB 10-10MG Brand 2 Antifungals AMPHOTERICIN INJ 50MG generic 1 AMPHOTEC INJ 50MG Brand 2 AMPHOTEC INJ 100MG Brand 2 ABELCET INJ 5MG/ML Brand 2 AMBISOME INJ 50MG Brand 2 ANCOBON CAP 250MG Brand 2 GR FLUCYTOSINE CAP 250MG generic 1 FLUCYTOSINE CAP 500MG generic 1 ANCOBON CAP 500MG Brand 2 GR GRISEOFULVIN TAB MICR 500 generic 1

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 62 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO GRIFULVIN V TAB 500MG Brand 2 GR GRISEOFULVIN SUS 125/5ML generic 1 GRIS-PEG TAB 125MG Brand 2 GR GRISEOFULVIN TAB ULTR 125 generic 1 GRISEOFULVIN TAB ULTR 250 generic 1 GRIS-PEG TAB 250MG Brand 2 GR BIO-STATIN CAP 500000 Brand 2 BIO-STATIN CAP 1000000 Brand 2 NYSTATIN TAB 500000 generic 1 TERBINAFINE TAB 250MG generic 1 PREF QL 90/365 LAMISIL TAB 250MG Brand 2 NON-PREF ST QL 90/365 LAMISIL GRA 125MG Brand 2 NON-PREF ST QL 84/365 LAMISIL GRA 187.5MG Brand 2 NON-PREF ST QL 42/365 TERBINEX KIT Brand 2 NON-PREF ST KETOCONAZOLE TAB 200MG generic 1 FLUCONAZOLE TAB 50MG generic 1 DIFLUCAN TAB 50MG Brand 2 GR FLUCONAZOLE TAB 100MG generic 1 DIFLUCAN TAB 100MG Brand 2 GR DIFLUCAN TAB 150MG Brand 2 GR FLUCONAZOLE TAB 150MG generic 1 FLUCONAZOLE TAB 200MG generic 1 DIFLUCAN TAB 200MG Brand 2 GR DIFLUCAN SUS 10MG/ML Brand 2 GR FLUCONAZOLE SUS 10MG/ML generic 1 FLUCONAZOLE SUS 40MG/ML generic 1 DIFLUCAN SUS 40MG/ML Brand 2 GR FLUCONAZOLE/ INJ NACL 100 Brand 2 FLUCONAZOLE/ INJ NACL 200 generic 1 FLUCONAZOLE/ INJ NACL 400 generic 1 FLUCONAZOLE/ INJ DEX 200 generic 1 FLUCONAZOLE/ INJ DEX 400 generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 63 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO SPORANOX CAP 100MG Brand 2 NON-PREF ST SPORANOX CAP PULSEPAK Brand 2 NON-PREF ST ITRACONAZOLE CAP 100MG generic 1 NON-PREF ST QL 180/365 ONMEL TAB 200MG Brand 2 NON-PREF ST QL 90/365 SPORANOX SOL 10MG/ML Brand 2 NON-PREF ST NOXAFIL SUS 40MG/ML Brand 2 PA VORICONAZOLE TAB 50MG generic 1 PA VFEND TAB 50MG Brand 2 GR VORICONAZOLE TAB 200MG generic 1 PA VFEND TAB 200MG Brand 2 GR VFEND SUS 40MG/ML Brand 2 GR VORICONAZOLE SUS 40MG/ML generic 1 VFEND IV INJ 200MG Brand 2 GR VORICONAZOLE INJ 200MG generic 1 PA ERAXIS INJ 50MG Brand 2 ERAXIS INJ 100MG Brand 2 CANCIDAS INJ 50MG Brand 2 CANCIDAS INJ 70MG Brand 2 MYCAMINE INJ 50MG Brand 2 MYCAMINE INJ 100MG Brand 2 Antihistamines RESPA-BR TAB 11MG Brand 2 BROMPHENIRAM CHW 12MG generic 1 ED-CHLOR-TAN TAB 8MG Brand 2 AHIST TAB 12MG Brand 2 ED CHLORPED SUS 2MG/ML Brand 2 DEXCHLORPHEN SYP 2MG/5ML generic 1 CARBINOXAMIN TAB 4MG generic 1 ARBINOXA TAB 4MG generic 1 PALGIC TAB 4MG Brand 2 GR CARBINOXAMIN SOL 4MG/5ML generic 1

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 64 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PALGIC SOL 4MG/5ML generic 1 ARBINOXA SOL 4MG/5ML generic 1 CLEMASTINE TAB 2.68MG generic 1 CLEMASTINE SYP 0.5/5ML generic 1 DIPHENHYDRAM CAP 50MG generic 1 DIPHENHYDRAM ELX 12.5/5ML generic 1 DIPHENHYDRAM INJ 50MG/ML generic 1 DOXYTEX LIQ Brand 2 PROMETHAZINE TAB 12.5MG generic 1 PROMETHAZINE TAB 25MG generic 1 PROMETHAZINE TAB 50MG generic 1 PROMETHAZINE SYP 6.25/5ML generic 1 PROMETHAZINE SOL 6.25/5ML generic 1 PHENERGAN INJ 25MG/ML Brand 2 GR PROMETHAZINE INJ 25MG/ML generic 1 PROMETHAZINE INJ 50MG/ML generic 1 PHENERGAN INJ 50MG/ML Brand 2 GR PROMETHAZINE SUP 12.5MG generic 1 PHENADOZ SUP 12.5MG generic 1 PROMETHEGAN SUP 12.5MG generic 1 PROMETHAZINE SUP 25MG generic 1 PHENADOZ SUP 25MG generic 1 PROMETHEGAN SUP 25MG generic 1 PROMETHEGAN SUP 50MG generic 1 CYPROHEPTAD TAB 4MG generic 1 CYPROHEPTAD SYP 2MG/5ML generic 1 CETIRIZINE SYP 1MG/ML generic 1 PREF CETIRIZINE SYP 5MG/5ML generic 1 PREF CLARINEX TAB 5MG Brand 2 NON-PREF ST DESLORATADIN TAB 5MG generic 1 NON-PREF ST CLARINEX SYP 0.5MG/ML Brand 2 NON-PREF ST CLARINEX RDT TAB 2.5MG Brand 2 NON-PREF ST KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 65 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DESLORATADIN TAB 2.5 ODT generic 1 NON-PREF ST DESLORATADIN TAB 5MG ODT generic 1 NON-PREF ST CLARINEX RDT TAB 5MG Brand 2 NON-PREF ST XYZAL TAB 5MG Brand 2 NON-PREF ST LEVOCETIRIZI TAB 5MG generic 1 NON-PREF ST LEVOCETIRIZI SOL 2.5/5ML generic 1 NON-PREF ST XYZAL SOL Brand 2 NON-PREF ST Antihyperlipidemics CHOLESTYRAM POW 4GM generic 1 QUESTRAN POW 4GM Brand 2 GR WELCHOL TAB 625MG Brand 2 WELCHOL PAK 3.75GM Brand 2 COLESTIPOL TAB 1GM generic 1 COLESTID TAB 1GM Brand 2 GR COLESTID FLA GRA 5GM Brand 2 GR COLESTID GRA 5GM Brand 2 GR COLESTIPOL GRA 5GM generic 1 COLESTIPOL GRA 5GM generic 1 COLESTID POW 5GM Brand 2 GR COLESTID FLA GRA 5/7.5GM Brand 2 GR TRILIPIX CAP 45MG Brand 2 GR FENOFIBRIC CAP 45MG DR generic 1 FENOFIBRIC CAP 135MG DR generic 1 TRILIPIX CAP 135MG Brand 2 GR FIBRICOR TAB 35MG Brand 2 NON-PREF ST QL 60/30 MO FENOFIBRIC TAB 35MG Brand 2 NON-PREF ST QL 60/30 MO FENOFIBRIC TAB 105MG Brand 2 NON-PREF ST QL 30/30 MO FIBRICOR TAB 105MG Brand 2 NON-PREF ST QL 30/30 MO LIPOFEN CAP 50MG Brand 2 NON-PREF ST QL 60/30 MO LIPOFEN CAP 150MG Brand 2 NON-PREF ST QL 30/30 MO FENOGLIDE TAB 40MG Brand 2 NON-PREF ST QL 60/30 MO

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 66 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO TRICOR TAB 48MG Brand 2 PREF QL 60/30 MO FENOFIBRATE TAB 48MG generic 1 NON-PREF ST QL 60/30 MO FENOFIBRATE TAB 54MG generic 1 NON-PREF ST QL 60/30 MO LOFIBRA TAB 54MG Brand 2 NON-PREF ST QL 60/30 MO FENOGLIDE TAB 120MG Brand 2 NON-PREF ST QL 30/30 MO TRICOR TAB 145MG Brand 2 PREF QL 30/30 MO FENOFIBRATE TAB 145MG generic 1 NON-PREF ST QL 30/30 MO FENOFIBRATE TAB 160MG generic 1 NON-PREF ST QL 30/30 MO LOFIBRA TAB 160MG Brand 2 NON-PREF ST QL 30/30 MO TRIGLIDE TAB 160MG Brand 2 NON-PREF ST QL 30/30 MO ANTARA CAP 30MG Brand 2 ANTARA CAP 43MG Brand 2 NON-PREF ST QL 60/30 MO FENOFIBRATE CAP 43MG generic 1 FENOFIBRATE CAP 67MG generic 1 NON-PREF ST QL 30/30 MO LOFIBRA CAP 67MG Brand 2 NON-PREF ST QL 30/30 MO ANTARA CAP 90MG Brand 2 ANTARA CAP 130MG Brand 2 NON-PREF ST QL 30/30 MO FENOFIBRATE CAP 130MG generic 1 FENOFIBRATE CAP 134MG generic 1 NON-PREF ST QL 30/30 MO LOFIBRA CAP 134MG Brand 2 NON-PREF ST QL 30/30 MO FENOFIBRATE CAP 200MG generic 1 NON-PREF ST QL 30/30 MO LOFIBRA CAP 200MG Brand 2 NON-PREF ST QL 30/30 MO GEMFIBROZIL TAB 600MG generic 1 PREF MO LOPID TAB 600MG Brand 2 NON-PREF ST MO ZETIA TAB 10MG Brand 2 NON-PREF ST MO LIPITOR TAB 10MG Brand 2 NON-PREF ST MO ATORVASTATIN TAB 10MG generic 1 PREF MO LIPITOR TAB 20MG Brand 2 NON-PREF ST MO ATORVASTATIN TAB 20MG generic 1 PREF MO LIPITOR TAB 40MG Brand 2 NON-PREF ST MO ATORVASTATIN TAB 40MG generic 1 PREF MO ATORVASTATIN TAB 80MG generic 1 PREF MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 67 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO LIPITOR TAB 80MG Brand 2 NON-PREF ST MO LESCOL CAP 20MG Brand 2 PREF MO FLUVASTATIN CAP 20MG generic 1 NON-PREF ST MO FLUVASTATIN CAP 40MG generic 1 NON-PREF ST MO LESCOL CAP 40MG Brand 2 PREF MO LESCOL XL TAB 80MG Brand 2 LOVASTATIN TAB 10MG generic 1 PREF MO LOVASTATIN TAB 20MG generic 1 PREF MO MEVACOR TAB 20MG Brand 2 NON-PREF ST MO MEVACOR TAB 40MG Brand 2 NON-PREF ST MO LOVASTATIN TAB 40MG generic 1 PREF MO ALTOPREV TAB 20MG ER Brand 2 PREF MO ALTOPREV TAB 40MG ER Brand 2 PREF MO ALTOPREV TAB 60MG ER Brand 2 PREF MO LIVALO TAB 1MG Brand 2 NON-PREF ST MO LIVALO TAB 2MG Brand 2 NON-PREF ST MO LIVALO TAB 4MG Brand 2 NON-PREF ST MO CRESTOR TAB 5MG Brand 2 NON-PREF ST MO CRESTOR TAB 10MG Brand 2 NON-PREF ST MO CRESTOR TAB 20MG Brand 2 NON-PREF ST MO CRESTOR TAB 40MG Brand 2 NON-PREF ST MO PRAVASTATIN TAB 10MG generic 1 PREF MO PRAVASTATIN TAB 20MG generic 1 PREF MO PRAVACHOL TAB 20MG Brand 2 NON-PREF ST MO PRAVASTATIN TAB 40MG generic 1 PREF MO PRAVACHOL TAB 40MG Brand 2 NON-PREF ST MO PRAVACHOL TAB 80MG Brand 2 NON-PREF ST MO PRAVASTATIN TAB 80MG generic 1 PREF MO SIMVASTATIN TAB 5MG generic 1 PREF MO ZOCOR TAB 5MG Brand 2 NON-PREF ST MO SIMVASTATIN TAB 10MG generic 1 PREF MO ZOCOR TAB 10MG Brand 2 NON-PREF ST MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 68 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ZOCOR TAB 20MG Brand 2 NON-PREF ST MO SIMVASTATIN TAB 20MG generic 1 PREF MO SIMVASTATIN TAB 40MG generic 1 PREF MO ZOCOR TAB 40MG Brand 2 NON-PREF ST MO SIMVASTATIN TAB 80MG generic 1 PREF MO ZOCOR TAB 80MG Brand 2 NON-PREF ST MO ADVICOR TAB 500-20MG Brand 2 NON-PREF ST MO ADVICOR TAB 750-20MG Brand 2 NON-PREF ST MO ADVICOR TAB 1000-20 Brand 2 NON-PREF ST MO ADVICOR TAB 1000-40 Brand 2 NON-PREF ST MO SIMCOR TAB 500-20MG Brand 2 NON-PREF ST MO SIMCOR TAB 500-40MG Brand 2 NON-PREF ST MO SIMCOR TAB 750-20MG Brand 2 NON-PREF ST MO SIMCOR TAB 1000-20 Brand 2 NON-PREF ST MO SIMCOR TAB 1000-40 Brand 2 NON-PREF ST MO NIACOR TAB 500MG Brand 2 NIACIN ER TAB 500MG generic 1 NIASPAN TAB 500MG ER Brand 2 GR NIASPAN TAB 750MG ER Brand 2 GR NIACIN ER TAB 750MG generic 1 NIASPAN TAB 1000 ER Brand 2 GR NIACIN ER TAB 1000MG generic 1 JUXTAPID CAP 5MG Brand 2 JUXTAPID CAP 10MG Brand 2 JUXTAPID CAP 20MG Brand 2 VASCEPA CAP 1GM Brand 2 NON-PREF ST QL 120/30 MO KYNAMRO INJ 200MG/ML Brand 2 LOVAZA CAP 1GM Brand 2 NON-PREF ST QL 120/30 MO LIPTRUZET TAB 10-10MG Brand 2 PA LIPTRUZET TAB 10-20MG Brand 2 PA LIPTRUZET TAB 10-40MG Brand 2 PA LIPTRUZET TAB 10-80MG Brand 2 PA KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 69 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO VYTORIN TAB 10-10MG Brand 2 NON-PREF ST MO VYTORIN TAB 10-20MG Brand 2 NON-PREF ST MO VYTORIN TAB 10-40MG Brand 2 NON-PREF ST MO VYTORIN TAB 10-80MG Brand 2 NON-PREF ST MO Antihypertensives BENAZEPRIL TAB 5MG generic 1 PREF MO BENAZEPRIL TAB 10MG generic 1 PREF MO LOTENSIN TAB 10MG Brand 2 NON-PREF ST MO LOTENSIN TAB 20MG Brand 2 NON-PREF ST MO BENAZEPRIL TAB 20MG generic 1 PREF MO LOTENSIN TAB 40MG Brand 2 NON-PREF ST MO BENAZEPRIL TAB 40MG generic 1 PREF MO CAPTOPRIL TAB 12.5MG generic 1 PREF MO CAPTOPRIL TAB 25MG generic 1 PREF MO CAPTOPRIL TAB 50MG generic 1 PREF MO CAPTOPRIL TAB 100MG generic 1 PREF MO VASOTEC TAB 2.5MG Brand 2 NON-PREF ST MO ENALAPRIL TAB 2.5MG generic 1 PREF MO VASOTEC TAB 5MG Brand 2 NON-PREF ST MO ENALAPRIL TAB 5MG generic 1 PREF MO VASOTEC TAB 10MG Brand 2 NON-PREF ST MO ENALAPRIL TAB 10MG generic 1 PREF MO ENALAPRIL TAB 20MG generic 1 PREF MO VASOTEC TAB 20MG Brand 2 NON-PREF ST MO EPANED SOL 1MG/ML Brand 2 PA ENALAPRILAT INJ 1.25/ML generic 1 FOSINOPRIL TAB 10MG generic 1 NON-PREF ST MO FOSINOPRIL TAB 20MG generic 1 NON-PREF ST MO FOSINOPRIL TAB 40MG generic 1 NON-PREF ST MO LISINOPRIL TAB 2.5MG generic 1 PREF MO ZESTRIL TAB 2.5MG Brand 2 NON-PREF ST MO

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 70 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO LISINOPRIL TAB 5MG generic 1 PREF MO PRINIVIL TAB 5MG Brand 2 NON-PREF ST MO ZESTRIL TAB 5MG Brand 2 NON-PREF ST MO LISINOPRIL TAB 10MG generic 1 PREF MO ZESTRIL TAB 10MG Brand 2 NON-PREF ST MO PRINIVIL TAB 10MG Brand 2 NON-PREF ST MO LISINOPRIL TAB 20MG generic 1 PREF MO PRINIVIL TAB 20MG Brand 2 NON-PREF ST MO ZESTRIL TAB 20MG Brand 2 NON-PREF ST MO ZESTRIL TAB 30MG Brand 2 NON-PREF ST MO LISINOPRIL TAB 30MG generic 1 PREF MO ZESTRIL TAB 40MG Brand 2 NON-PREF ST MO LISINOPRIL TAB 40MG generic 1 PREF MO MOEXIPRIL TAB 7.5MG generic 1 NON-PREF ST MO UNIVASC TAB 7.5MG Brand 2 NON-PREF ST MO UNIVASC TAB 15MG Brand 2 NON-PREF ST MO MOEXIPRIL TAB 15MG generic 1 NON-PREF ST MO PERINDOPRIL TAB 2MG generic 1 PERINDOPRIL TAB 4MG generic 1 ACEON TAB 4MG Brand 2 NON-PREF ST MO ACEON TAB 8MG Brand 2 NON-PREF ST MO PERINDOPRIL TAB 8MG generic 1 QUINAPRIL TAB 5MG generic 1 NON-PREF ST MO ACCUPRIL TAB 5MG Brand 2 NON-PREF ST MO QUINAPRIL TAB 10MG generic 1 NON-PREF ST MO ACCUPRIL TAB 10MG Brand 2 NON-PREF ST MO QUINAPRIL TAB 20MG generic 1 NON-PREF ST MO ACCUPRIL TAB 20MG Brand 2 NON-PREF ST MO ACCUPRIL TAB 40MG Brand 2 NON-PREF ST MO QUINAPRIL TAB 40MG generic 1 NON-PREF ST MO RAMIPRIL CAP 1.25MG generic 1 NON-PREF ST MO ALTACE CAP 1.25MG Brand 2 NON-PREF ST MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 71 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ALTACE CAP 2.5MG Brand 2 NON-PREF ST MO RAMIPRIL CAP 2.5MG generic 1 NON-PREF ST MO RAMIPRIL CAP 5MG generic 1 NON-PREF ST MO ALTACE CAP 5MG Brand 2 NON-PREF ST MO ALTACE CAP 10MG Brand 2 NON-PREF ST MO RAMIPRIL CAP 10MG generic 1 NON-PREF ST MO MAVIK TAB 1MG Brand 2 NON-PREF ST MO TRANDOLAPRIL TAB 1MG generic 1 NON-PREF ST MO TRANDOLAPRIL TAB 2MG generic 1 NON-PREF ST MO MAVIK TAB 2MG Brand 2 NON-PREF ST MO TRANDOLAPRIL TAB 4MG generic 1 NON-PREF ST MO MAVIK TAB 4MG Brand 2 NON-PREF ST MO EDARBI TAB 40MG Brand 2 NON-PREF ST MO EDARBI TAB 80MG Brand 2 NON-PREF ST MO CANDESARTAN TAB 4MG generic 1 ATACAND TAB 4MG Brand 2 NON-PREF ST MO CANDESARTAN TAB 8MG generic 1 ATACAND TAB 8MG Brand 2 GR CANDESARTAN TAB 16MG generic 1 ATACAND TAB 16MG Brand 2 GR ATACAND TAB 32MG Brand 2 GR CANDESARTAN TAB 32MG generic 1 EPROSART MES TAB 600MG generic 1 NON-PREF ST MO TEVETEN TAB 600MG Brand 2 NON-PREF ST MO IRBESARTAN TAB 75MG generic 1 NON-PREF ST MO AVAPRO TAB 75MG Brand 2 NON-PREF ST MO IRBESARTAN TAB 150MG generic 1 NON-PREF ST MO AVAPRO TAB 150MG Brand 2 NON-PREF ST MO AVAPRO TAB 300MG Brand 2 NON-PREF ST MO IRBESARTAN TAB 300MG generic 1 NON-PREF ST MO LOSARTAN POT TAB 25MG generic 1 PREF MO COZAAR TAB 25MG Brand 2 NON-PREF ST MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 72 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO LOSARTAN POT TAB 50MG generic 1 PREF MO COZAAR TAB 50MG Brand 2 NON-PREF ST MO COZAAR TAB 100MG Brand 2 NON-PREF ST MO LOSARTAN POT TAB 100MG generic 1 PREF MO BENICAR TAB 5MG Brand 2 NON-PREF ST MO BENICAR TAB 20MG Brand 2 NON-PREF ST MO BENICAR TAB 40MG Brand 2 NON-PREF ST MO MICARDIS TAB 20MG Brand 2 NON-PREF ST MO MICARDIS TAB 40MG Brand 2 NON-PREF ST MO MICARDIS TAB 80MG Brand 2 NON-PREF ST MO DIOVAN TAB 40MG Brand 2 DIOVAN TAB 80MG Brand 2 DIOVAN TAB 160MG Brand 2 DIOVAN TAB 320MG Brand 2 TEKTURNA TAB 150MG Brand 2 PA MO TEKTURNA TAB 300MG Brand 2 CLONIDINE TAB 0.1MG generic 1 CATAPRES TAB 0.1MG Brand 2 GR CATAPRES TAB 0.2MG Brand 2 GR CLONIDINE TAB 0.2MG generic 1 CATAPRES TAB 0.3MG Brand 2 GR CLONIDINE TAB 0.3MG generic 1 CATAPRES-TTS DIS 0.1/24HR Brand 2 GR CLONIDINE DIS 0.1/24HR generic 1 CLONIDINE DIS 0.2/24HR generic 1 CATAPRES-TTS DIS 0.2/24HR Brand 2 GR CATAPRES-TTS DIS 0.3/24HR Brand 2 GR CLONIDINE DIS 0.3/24HR generic 1 GUANFACINE TAB 1MG generic 1 TENEX TAB 1MG Brand 2 GR TENEX TAB 2MG Brand 2 GR GUANFACINE TAB 2MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 73 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO METHYLDOPA TAB 250MG generic 1 METHYLDOPA TAB 500MG generic 1 METHYLDOPATE INJ 250/5ML generic 1 DOXAZOSIN TAB 1MG generic 1 CARDURA TAB 1MG Brand 2 GR CARDURA TAB 2MG Brand 2 GR DOXAZOSIN TAB 2MG generic 1 DOXAZOSIN TAB 4MG generic 1 CARDURA TAB 4MG Brand 2 GR CARDURA TAB 8MG Brand 2 GR DOXAZOSIN TAB 8MG generic 1 PRAZOSIN HCL CAP 1MG generic 1 MINIPRESS CAP 1MG Brand 2 GR MINIPRESS CAP 2MG Brand 2 GR PRAZOSIN HCL CAP 2MG generic 1 PRAZOSIN HCL CAP 5MG generic 1 MINIPRESS CAP 5MG Brand 2 GR TERAZOSIN CAP 1MG generic 1 TERAZOSIN CAP 2MG generic 1 TERAZOSIN CAP 5MG generic 1 TERAZOSIN CAP 10MG generic 1 RESERPINE TAB 0.1MG generic 1 RESERPINE TAB 0.25MG generic 1 INSPRA TAB 25MG Brand 2 GR EPLERENONE TAB 25MG generic 1 EPLERENONE TAB 50MG generic 1 INSPRA TAB 50MG Brand 2 GR DIBENZYLINE CAP 10MG Brand 2 DEMSER CAP 250MG Brand 2 HYDRALAZINE TAB 10MG generic 1 HYDRALAZINE TAB 25MG generic 1 HYDRALAZINE TAB 50MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 74 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO HYDRALAZINE TAB 100MG generic 1 HYDRALAZINE INJ 20MG/ML generic 1 MINOXIDIL TAB 2.5MG generic 1 MINOXIDIL TAB 10MG generic 1 NITROPRESS INJ 25MG/ML Brand 2 FENOLDOPAM INJ 10MG/ML generic 1 CORLOPAM INJ 10MG/ML Brand 2 GR FENOLDOPAM INJ 20MG/2ML generic 1 CORLOPAM INJ 10MG/ML Brand 2 GR VECAMYL TAB 2.5MG generic 1 AMLOD/BENAZP CAP 2.5-10MG generic 1 PREF MO LOTREL CAP 2.5-10MG Brand 2 NON-PREF ST MO LOTREL CAP 5-10MG Brand 2 NON-PREF ST MO AMLOD/BENAZP CAP 5-10MG generic 1 PREF MO LOTREL CAP 5-20MG Brand 2 NON-PREF ST MO AMLOD/BENAZP CAP 5-20MG generic 1 PREF MO LOTREL CAP 5-40MG Brand 2 NON-PREF ST MO AMLOD/BENAZP CAP 5-40MG generic 1 PREF MO LOTREL CAP 10-20MG Brand 2 NON-PREF ST MO AMLOD/BENAZP CAP 10-20MG generic 1 PREF MO LOTREL CAP 10-40MG Brand 2 NON-PREF ST MO AMLOD/BENAZP CAP 10-40MG generic 1 PREF MO TARKA TAB 1-240 CR Brand 2 NON-PREF ST MO TARKA TAB 2-180 CR Brand 2 NON-PREF ST MO TARKA TAB 2-240 CR Brand 2 NON-PREF ST MO TARKA TAB 4-240 CR Brand 2 NON-PREF ST MO BENAZEP/HCTZ TAB 5-6.25 generic 1 PREF MO BENAZEP/HCTZ TAB 10-12.5 generic 1 LOTENSIN HCT TAB 10-12.5 Brand 2 NON-PREF ST MO LOTENSIN HCT TAB 20-12.5 Brand 2 NON-PREF ST MO BENAZEP/HCTZ TAB 20-12.5 generic 1 LOTENSIN HCT TAB 20-25MG Brand 2 NON-PREF ST MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 75 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO BENAZEP/HCTZ TAB 20-25MG generic 1 CAPTOPR/HCTZ TAB 25-15MG generic 1 PREF MO CAPTOPR/HCTZ TAB 25-25MG generic 1 CAPTOPR/HCTZ TAB 50-15MG generic 1 CAPTOPR/HCTZ TAB 50-25MG generic 1 ENALAPR/HCTZ TAB 5-12.5MG generic 1 PREF MO ENALAPR/HCTZ TAB 10-25MG generic 1 VASERETIC TAB 10-25MG Brand 2 NON-PREF ST MO FOSINOP/HCTZ TAB 10/12.5 generic 1 NON-PREF ST MO FOSINOP/HCTZ TAB 20/12.5 generic 1 NON-PREF ST MO ZESTORETIC TAB 10-12.5 Brand 2 NON-PREF ST MO LISINOP/HCTZ TAB 10-12.5 generic 1 PREF MO ZESTORETIC TAB 20-12.5 Brand 2 NON-PREF ST MO LISINOP/HCTZ TAB 20-12.5 generic 1 ZESTORETIC TAB 20-25MG Brand 2 NON-PREF ST MO LISINOP/HCTZ TAB 20-25MG generic 1 MOEXIPR/HCTZ TAB 7.5-12.5 generic 1 NON-PREF ST MO UNIRETIC TAB 7.5-12.5 Brand 2 NON-PREF ST MO MOEXIPR/HCTZ TAB 15-12.5 generic 1 UNIRETIC TAB 15-12.5 Brand 2 NON-PREF ST MO UNIRETIC TAB 15-25MG Brand 2 NON-PREF ST MO MOEXIPR/HCTZ TAB 15-25MG generic 1 QNAPRIL/HCTZ TAB 10-12.5 generic 1 NON-PREF ST MO ACCURETIC TAB 10-12.5 Brand 2 NON-PREF ST MO ACCURETIC TAB 20-12.5 Brand 2 NON-PREF ST MO QNAPRIL/HCTZ TAB 20-12.5 generic 1 QNAPRIL/HCTZ TAB 20-25MG generic 1 ACCURETIC TAB 20-25MG Brand 2 NON-PREF ST MO ATENOL/CHLOR TAB 50-25MG generic 1 PREF MO TENORETIC TAB 50 Brand 2 NON-PREF ST MO ATENOL/CHLOR TAB 100-25MG generic 1 TENORETIC TAB 100 Brand 2 NON-PREF ST MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 76 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ZIAC TAB 2.5/6.25 Brand 2 NON-PREF ST MO BISOPRL/HCTZ TAB 2.5/6.25 generic 1 PREF MO ZIAC TAB 5-6.25MG Brand 2 NON-PREF ST MO BISOPRL/HCTZ TAB 5-6.25MG generic 1 BISOPRL/HCTZ TAB 10/6.25 generic 1 ZIAC TAB 10/6.25 Brand 2 NON-PREF ST MO LOPRESS HCT TAB 50-25MG Brand 2 NON-PREF ST MO METOPRL/HCTZ TAB 50-25MG generic 1 LOPRESS HCT TAB 100-25MG Brand 2 NON-PREF ST MO METOPRL/HCTZ TAB 100-25MG generic 1 METOPRL/HCTZ TAB 100-50MG generic 1 DUTOPROL TAB 25-12.5 Brand 2 NON-PREF ST MO DUTOPROL TAB 50-12.5 Brand 2 NON-PREF ST MO DUTOPROL TAB 100-12.5 Brand 2 NON-PREF ST MO NADOLOL/BEND TAB 40-5MG generic 1 PREF MO CORZIDE TAB 40-5MG Brand 2 NON-PREF ST MO CORZIDE TAB 80-5MG Brand 2 NON-PREF ST MO NADOLOL/BEND TAB 80-5MG generic 1 PROPRAN/HCTZ TAB 40/25 generic 1 PREF MO PROPRAN/HCTZ TAB 80/25 generic 1 PREF MO AZOR TAB 5-20MG Brand 2 NON-PREF ST MO AZOR TAB 5-40MG Brand 2 NON-PREF ST MO AZOR TAB 10-20MG Brand 2 NON-PREF ST MO AZOR TAB 10-40MG Brand 2 NON-PREF ST MO EXFORGE TAB 5-160MG Brand 2 NON-PREF ST MO EXFORGE TAB 5-320MG Brand 2 NON-PREF ST MO EXFORGE TAB 10-160MG Brand 2 NON-PREF ST MO EXFORGE TAB 10-320MG Brand 2 NON-PREF ST MO TWYNSTA TAB 40-5MG Brand 2 NON-PREF ST MO TWYNSTA TAB 40-10MG Brand 2 NON-PREF ST MO TWYNSTA TAB 80-5MG Brand 2 NON-PREF ST MO TWYNSTA TAB 80-10MG Brand 2 NON-PREF ST MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 77 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO EDARBYCLOR TAB 40-12.5 Brand 2 NON-PREF ST MO EDARBYCLOR TAB 40-25MG Brand 2 NON-PREF ST MO CANDESA/HCTZ TAB 16-12.5 generic 1 NON-PREF ST MO ATACAND HCT TAB 16-12.5 Brand 2 NON-PREF ST MO CANDESA/HCTZ TAB 32-12.5 generic 1 NON-PREF ST MO ATACAND HCT TAB 32-12.5 Brand 2 NON-PREF ST MO ATACAND HCT TAB 32-25MG Brand 2 NON-PREF ST MO CANDESA/HCTZ TAB 32-25MG generic 1 NON-PREF ST MO TEVETEN HCT TAB 600-12.5 Brand 2 TEVETEN HCT TAB 600-25MG Brand 2 AVALIDE TAB 150-12.5 Brand 2 NON-PREF ST MO IRBESAR/HCTZ TAB 150-12.5 generic 1 NON-PREF ST MO IRBESAR/HCTZ TAB 300-12.5 generic 1 AVALIDE TAB 300-12.5 Brand 2 NON-PREF ST MO LOSARTAN/HCT TAB 50-12.5 generic 1 PREF MO HYZAAR TAB 50-12.5 Brand 2 NON-PREF ST MO LOSARTAN/HCT TAB 100-12.5 generic 1 HYZAAR TAB 100-12.5 Brand 2 NON-PREF ST MO HYZAAR TAB 100-25 Brand 2 NON-PREF ST MO LOSARTAN/HCT TAB 100-25 generic 1 BENICAR HCT TAB 20-12.5 Brand 2 NON-PREF ST MO BENICAR HCT TAB 40-12.5 Brand 2 NON-PREF ST MO BENICAR HCT TAB 40-25MG Brand 2 NON-PREF ST MO MICARDIS HCT TAB 40/12.5 Brand 2 NON-PREF ST MO MICARDIS HCT TAB 80/12.5 Brand 2 NON-PREF ST MO MICARDIS HCT TAB 80-25MG Brand 2 NON-PREF ST MO DIOVAN HCT TAB 80/12.5 Brand 2 PREF MO VALSART/HCTZ TAB 80-12.5 generic 1 NON-PREF ST MO VALSART/HCTZ TAB 160-12.5 generic 1 NON-PREF ST MO DIOVAN HCT TAB 160-12.5 Brand 2 PREF MO VALSART/HCTZ TAB 160-25MG generic 1 NON-PREF ST MO DIOVAN HCT TAB 160-25MG Brand 2 PREF MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 78 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO VALSART/HCTZ TAB 320-12.5 generic 1 NON-PREF ST MO DIOVAN HCT TAB 320-12.5 Brand 2 PREF MO DIOVAN HCT TAB 320-25MG Brand 2 PREF MO VALSART/HCTZ TAB 320-25MG generic 1 NON-PREF ST MO EXFORGEH/5- TAB 160-12.5 Brand 2 NON-PREF ST MO EXFORGEH/5- TAB 160-25 Brand 2 NON-PREF ST MO EXFORGEH/10- TAB 160-12.5 Brand 2 NON-PREF ST MO EXFORGEH/10- TAB 160-25 Brand 2 NON-PREF ST MO EXFORGEH/10- TAB 320-25 Brand 2 NON-PREF ST MO TRIBENZOR20- TAB 5-12.5MG Brand 2 NON-PREF ST MO TRIBENZOR40- TAB 5-12.5MG Brand 2 TRIBENZOR40- TAB 5-25MG Brand 2 TRIBENZOR40- TAB 10-12.5 Brand 2 TRIBENZOR40- TAB 10-25MG Brand 2 CLORPRES TAB 0.1-15MG Brand 2 CLORPRES TAB 0.2-15MG Brand 2 CLORPRES TAB 0.3-15MG Brand 2 METHYLD/HCTZ TAB 250/15 generic 1 METHYLD/HCTZ TAB 250/25 generic 1 TEKTURNA HCT TAB 150-12.5 Brand 2 TEKTURNA HCT TAB 150-25MG Brand 2 TEKTURNA HCT TAB 300-12.5 Brand 2 TEKTURNA HCT TAB 300-25MG Brand 2 PA MO TEKAMLO TAB 150-5MG Brand 2 NON-PREF ST PA MO TEKAMLO TAB 150-10MG Brand 2 NON-PREF ST PA MO TEKAMLO TAB 300-5MG Brand 2 NON-PREF ST PA MO TEKAMLO TAB 300-10MG Brand 2 NON-PREF ST PA MO AMTURNIDE150 TAB -5-12.5 Brand 2 NON-PREF ST PA MO AMTURNIDE300 TAB -5-12.5 Brand 2 AMTURNIDE300 TAB -5-25MG Brand 2 AMTURNIDE300 TAB -10-12.5 Brand 2 AMTURNIDE300 TAB -10-25MG Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 79 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO Anti-infectives Agents Misc AZACTAM INJ 1GM Brand 2 GR AZTREONAM INJ 1GM generic 1 AZTREONAM INJ 2GM generic 1 AZACTAM INJ 2GM Brand 2 GR AZACTAM/DEX INJ 1GM Brand 2 AZACTAM/DEX INJ 2GM Brand 2 CAYSTON INH 75MG Brand 2 BACIIM INJ 50000UNT generic 1 BACITRACIN INJ 50000UNT generic 1 COLY-MYCIN M INJ 150MG Brand 2 GR COLISTIMETH INJ 150MG generic 1 FLAGYL CAP 375MG Brand 2 FLAGYL TAB 250MG Brand 2 GR METRONIDAZOL TAB 250MG generic 1 METRONIDAZOL TAB 500MG generic 1 FLAGYL TAB 500MG Brand 2 GR FLAGYL ER TAB 750MG Brand 2 METRO IV INJ 5MG/ML Brand 2 METRON/NACL INJ 500MG generic 1 PENTAM 300 INJ 300MG Brand 2 NEBUPENT INH 300MG Brand 2 XIFAXAN TAB 200MG Brand 2 QL 9/365 PA XIFAXAN TAB 550MG Brand 2 QL 60/30 PA VIBATIV INJ 750MG Brand 2 TINIDAZOLE TAB 250MG generic 1 TINDAMAX TAB 250MG Brand 2 GR TINIDAZOLE TAB 500MG generic 1 TINDAMAX TAB 500MG Brand 2 GR TRIMETHOPRIM TAB 100MG generic 1 PRIMSOL SOL 50MG/5ML Brand 2

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 80 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO VANCOMYCIN CAP 125MG generic 1 VANCOCIN HCL CAP 125MG Brand 2 GR VANCOMYCIN CAP 250MG generic 1 VANCOCIN HCL CAP 250MG Brand 2 GR VANCOMYCIN INJ 500MG generic 1 VANCOMYCIN INJ 750MG Brand 2 VANCOMYCIN INJ 1 GM generic 1 VANCOMYCIN INJ 1000MG generic 1 VANCOMYCIN INJ 5GM generic 1 VANCOMYCIN INJ 10GM generic 1 VANCOMYC/DEX INJ 500MG Brand 2 VANCOMYC/DEX INJ 750MG Brand 2 VANCOMYC/DEX INJ 1GM Brand 2 POLYMYXIN B INJ 500000 generic 1 DORIBAX INJ 250MG Brand 2 DORIBAX INJ 500MG Brand 2 INVANZ INJ 1GM Brand 2 INVANZ INJ 1GM Brand 2 MEROPENEM INJ 500MG generic 1 MERREM INJ 500MG Brand 2 GR MEROPENEM INJ 1GM generic 1 MERREM INJ 1GM Brand 2 GR IMIPENEM/CIL INJ 250MG generic 1 PRIMAXIN IV INJ 250MG Brand 2 GR IMIPENEM/CIL INJ 500MG generic 1 PRIMAXIN IV INJ 500MG Brand 2 GR CHLORAMPHEN INJ 1GM generic 1 KETEK TAB 300MG Brand 2 KETEK TAB 400MG Brand 2 LINCOCIN INJ 300MG/ML Brand 2 CLINDAMYCIN CAP 75MG generic 1 CLEOCIN CAP 75MG Brand 2 GR KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 81 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO CLEOCIN CAP 150MG Brand 2 GR CLINDAMYCIN CAP 150MG generic 1 CLEOCIN CAP 300MG Brand 2 GR CLINDAMYCIN CAP 300MG generic 1 CLEOCIN PED SOL 75MG/5ML Brand 2 GR CLINDAMYCIN SOL 75MG/5ML generic 1 CLEOCIN PHOS INJ 300MG Brand 2 GR CLINDAMYCIN INJ 300MG generic 1 CLINDAMYCIN INJ 300/2ML generic 1 CLINDAMYCIN INJ 150MG/ML generic 1 CLINDAMYCIN INJ 150MG/ML generic 1 CLEOCIN PHOS INJ 600MG Brand 2 GR CLINDAMYCIN INJ 600/4ML generic 1 CLINDAMYCIN INJ 600MG generic 1 CLEOCIN PHOS INJ 900MG Brand 2 GR CLINDAMYCIN INJ 900MG generic 1 CLINDAMYCIN INJ 900/6ML generic 1 CLINDAMYCIN INJ 150MG/ML generic 1 CLINDAMYCIN INJ 150MG/ML generic 1 CLINDAMYCIN INJ 9000/60 generic 1 CLEOCIN PHOS INJ 9GM/60ML Brand 2 GR CLINDAMYCIN INJ 150MG/ML generic 1 CLINDAMYCIN INJ 150MG/ML generic 1 CLEOCIN PHOS INJ 600MG Brand 2 GR CLINDAMYCIN INJ 150MG/ML generic 1 CLEOCIN PHOS INJ 900MG Brand 2 GR CLEOCIN/D5W INJ 300MG Brand 2 GR CLINDAMYCIN INJ 300MG generic 1 CLEOCIN/D5W INJ 600MG Brand 2 GR CLINDAMYCIN INJ 600MG generic 1 CLEOCIN/D5W INJ 900MG Brand 2 GR CLINDAMYCIN INJ 900MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 82 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ZYVOX TAB 600MG Brand 2 QL 60/30 PA ZYVOX SUS 100MG/5M Brand 2 QL 900/14 PA ZYVOX SOL 2MG/ML Brand 2 SYNERCID INJ 500MG Brand 2 CUBICIN SOL 500MG Brand 2 TYGACIL INJ 50MG Brand 2 DAPSONE TAB 25MG generic 1 DAPSONE TAB 100MG generic 1 MEPRON SUS Brand 2 ALINIA TAB 500MG Brand 2 ALINIA SUS 100/5ML Brand 2 NEUTREXIN INJ 25MG Brand 2 E.S.P. SUS 200-600 generic 1 EES/SULFISOX SUS 200-600 generic 1 BACTRIM TAB 400-80MG Brand 2 GR SMZ-TMP TAB 400-80MG generic 1 BACTRIM DS TAB 800-160 Brand 2 GR SMZ/TMP DS TAB 800-160 generic 1 SMZ-TMP SUS 200-40/5 generic 1 SULFATRIM PD SUS 200-40/5 generic 1 SMZ-TMP INJ 400-80/5 generic 1 Antimalarials CHLOROQUINE TAB 250MG generic 1 QL 12/90 CHLOROQUINE TAB 500MG generic 1 QL 12/90 ARALEN TAB 500MG Brand 2 GR HYDROXYCHLOR TAB 200MG generic 1 PLAQUENIL TAB 200MG Brand 2 GR MEFLOQUINE TAB 250MG generic 1 PRIMAQUINE TAB 26.3MG Brand 2 DARAPRIM TAB 25MG Brand 2 QUALAQUIN CAP 324MG Brand 2 GR

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 83 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO QUININE SULF CAP 324MG generic 1 COARTEM TAB 20-120MG Brand 2 ATOVAQ/PROGU TAB 62.5-25 generic 1 MALARONE TAB 62.5-25 Brand 2 MALARONE TAB 250-100 Brand 2 GR ATOVAQ/PROGU TAB 250-100 generic 1 Antimycobacterial Agents PASER GRA 4GM Brand 2 SIRTURO TAB 100MG Brand 2 CAPASTAT SUL INJ 1GM Brand 2 CYCLOSERINE CAP 250MG generic 1 ETHAMBUTOL TAB 100MG generic 1 MYAMBUTOL TAB 100MG Brand 2 GR MYAMBUTOL TAB 400MG Brand 2 GR ETHAMBUTOL TAB 400MG generic 1 TRECATOR TAB 250MG Brand 2 ISONIAZID TAB 100MG generic 1 ISONIAZID TAB 300MG generic 1 ISONIAZID SYP 50MG/5ML generic 1 ISONIAZID INJ 100MG/ML generic 1 PYRAZINAMIDE TAB 500MG generic 1 MYCOBUTIN CAP 150MG Brand 2 RIFADIN CAP 150MG Brand 2 GR RIFAMPIN CAP 150MG generic 1 RIFADIN CAP 300MG Brand 2 GR RIFAMPIN CAP 300MG generic 1 RIFADIN INJ 600 MG Brand 2 GR RIFAMPIN INJ 600 MG generic 1 PRIFTIN TAB 150MG Brand 2 RIFAMATE CAP Brand 2 RIFATER TAB Brand 2

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 84 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO Antimysasthenic Agents ENLON INJ 150/15ML Brand 2 GUANIDINE TAB 125MG Brand 2 PROSTIGMIN TAB 15MG Brand 2 NEOSTIG METH INJ 0.5MG/ML generic 1 PROSTIGMIN INJ 0.5MG/ML Brand 2 GR BLOXIVERZ INJ 5MG/10ML Brand 2 Exc NEOSTIG METH INJ 1MG/ML generic 1 BLOXIVERZ INJ 1MG/ML Brand 2 Exc MESTINON TAB 60MG Brand 2 GR PYRIDOSTIGM TAB 60MG generic 1 MESTINON TAB TIMESPAN Brand 2 MESTINON SYP 60MG/5ML Brand 2 REGONOL INJ 5MG/ML Brand 2 ENLON-PLUS INJ 10-0.14 Brand 2 Antineoplastic and Adjunctive Therapies HEXALEN CAP 50MG Brand 2 TREANDA INJ 25MG Brand 2 TREANDA INJ 100MG Brand 2 MYLERAN TAB 2MG Brand 2 BUSULFEX INJ 6MG/ML Brand 2 CARBOPLATIN INJ 50MG/5ML generic 1 CARBOPLATIN INJ 150/15ML generic 1 CARBOPLATIN INJ 450/45ML generic 1 CARBOPLATIN INJ 600/60ML generic 1 CARBOPLATIN INJ 150MG Brand 2 CISPLATIN INJ 50/50ML generic 1 CISPLATIN INJ 100MG generic 1 CISPLATIN INJ 200MG Brand 2 OXALIPLATIN INJ 50MG generic 1 ELOXATIN INJ 50MG Brand 2 GR

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 85 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO OXALIPLATIN INJ 100MG generic 1 ELOXATIN INJ 100MG Brand 2 GR ELOXATIN INJ 200MG Brand 2 OXALIPLATIN INJ 50MG generic 1 OXALIPLATIN INJ 100MG generic 1 THIOTEPA INJ 15MG generic 1 LEUKERAN TAB 2MG Brand 2 CYCLOPHOSPH TAB 25MG generic 1 CYCLOPHOSPH TAB 50MG generic 1 CYCLOPHOSPH INJ 500MG Brand 2 CYCLOPHOSPH INJ 1GM generic 1 CYCLOPHOSPH INJ 2GM Brand 2 IFOSFAMIDE INJ 1GM/20ML generic 1 IFOSFAMIDE INJ 3GM/60ML generic 1 IFOSFAMIDE INJ 1GM generic 1 IFEX INJ 1GM Brand 2 GR IFOSFAMIDE INJ 3GM generic 1 IFEX INJ 3GM Brand 2 MUSTARGEN INJ 10MG Brand 2 ALKERAN TAB 2MG Brand 2 MELPHALAN INJ 50MG generic 1 ALKERAN INJ 50MG Brand 2 GR BICNU INJ 100MG Brand 2 GLIADEL WAF 7.7MG Brand 2 LOMUSTINE CAP 10MG generic 1 LOMUSTINE CAP 40MG generic 1 LOMUSTINE CAP 100MG generic 1 ZANOSAR INJ 1GM Brand 2 TEMOZOLOMIDE CAP 5MG generic 1 TEMODAR CAP 5MG Brand 2 GR TEMOZOLOMIDE CAP 20MG generic 1 TEMODAR CAP 20MG Brand 2 GR KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 86 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO TEMOZOLOMIDE CAP 100MG generic 1 TEMODAR CAP 100MG Brand 2 GR TEMOZOLOMIDE CAP 140MG generic 1 TEMODAR CAP 140MG Brand 2 GR TEMOZOLOMIDE CAP 180MG generic 1 TEMODAR CAP 180MG Brand 2 GR TEMOZOLOMIDE CAP 250MG generic 1 TEMODAR CAP 250MG Brand 2 GR TEMODAR INJ 100MG Brand 2 BLEOMYCIN INJ 15UNIT generic 1 BLEOMYCIN INJ 30UNIT generic 1 COSMEGEN INJ 0.5MG Brand 2 GR DACTINOMYCIN INJ 0.5MG generic 1 DAUNOXOME INJ 2MG/ML Brand 2 CERUBIDINE INJ 20MG Brand 2 GR DAUNORUBICIN INJ 20MG generic 1 DAUNORUBICIN INJ 5MG/ML generic 1 DOXORUBICIN INJ 10MG generic 1 DOXORUBICIN INJ 2MG/ML generic 1 DOXORUBICIN INJ 50MG generic 1 DOXORUBICIN INJ 200MG generic 1 DOXORUBICIN INJ 200/100 generic 1 DOXORUBICIN INJ 150/75ML generic 1 DOXORUBICIN INJ 50/25ML generic 1 DOXORUBICIN INJ 20/10ML generic 1 DOXORUBICIN INJ 10/5ML generic 1 ADRIAMYCIN INJ 2MG/ML generic 1 DOXORUBICIN INJ 10MG/5ML generic 1 DOXORUBICIN INJ 10MG generic 1 ADRIAMYCIN INJ 10MG generic 1 ADRIAMYCIN INJ 20MG generic 1 DOXORUBICIN INJ 50MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 87 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ADRIAMYC INJ 50MG generic 1 DOXORUBICIN INJ 2MG/ML generic 1 LIPODOX INJ 2MG/ML generic 1 DOXIL INJ 2MG/ML Brand 2 GR LIPODOX 50 INJ 2MG/ML generic 1 ELLENCE INJ 2MG/ML Brand 2 GR EPIRUBICIN INJ 50/25ML generic 1 EPIRUBICIN INJ 200MG generic 1 ELLENCE INJ 2MG/ML Brand 2 GR EPIRUBICIN INJ 50MG Brand 2 IDARUBICIN INJ 5MG/5ML generic 1 IDAMYCIN PFS INJ 5MG/5ML Brand 2 GR IDAMYCIN PFS INJ 10/10ML Brand 2 GR IDARUBICIN INJ 10/10ML generic 1 IDARUBICIN INJ 20/20ML generic 1 IDAMYCIN PFS INJ 20/20ML Brand 2 GR MITOMYCIN INJ 5MG generic 1 MITOMYCIN INJ 40MG generic 1 MITOMYCIN INJ 20MG generic 1 MITOMYCIN INJ 20MG generic 1 MITOMYCIN INJ 40MG generic 1 MITOXANTRON INJ 2MG/ML generic 1 MITOXANTRON INJ 2MG/ML generic 1 MITOXANTRON INJ 2MG/ML generic 1 VALSTAR SOL 40MG/ML Brand 2 ELSPAR INJ 10000UNT Brand 2 ERWINAZE INJ 10000UNT Brand 2 PA SP ONCASPAR INJ 750/ML Brand 2 AZACITIDINE INJ 100MG generic 1 VIDAZA INJ 100MG Brand 2 GR XELODA TAB 150MG Brand 2 XELODA TAB 500MG Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 88 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO CLADRIBINE INJ 1MG/ML generic 1 CLOLAR INJ 1MG/ML Brand 2 CYTARABINE INJ 20MG/ML generic 1 CYTARABINE INJ 20MG/ML generic 1 CYTARABINE INJ 100MG/ML generic 1 CYTARABINE INJ 100MG generic 1 CYTARABINE INJ 500MG generic 1 CYTARABINE INJ 1GM Brand 2 DEPOCYT INJ 50MG/5ML Brand 2 DACOGEN INJ 50MG Brand 2 GR DECITABINE INJ 50MG generic 1 FLOXURIDINE INJ 0.5GM generic 1 FLUDARABINE INJ 50MG/2ML generic 1 FLUDARABINE INJ 50MG generic 1 FLUDARA INJ 50MG Brand 2 GR ADRUCIL INJ 500/10ML generic 1 FLUOROURACIL INJ 500/10ML generic 1 FLUOROURACIL INJ 1GM/20ML generic 1 FLUOROURACIL INJ 2.5G/50M generic 1 ADRUCIL INJ 2.5G/50M generic 1 FLUOROURACIL INJ 5GM/100M generic 1 ADRUCIL INJ 5GM/100M generic 1 GEMCITABINE INJ 200MG Brand 2 GEMCITABINE INJ 1GM Brand 2 GEMCITABINE INJ 2GM Brand 2 GEMCITABINE INJ 200MG generic 1 GEMZAR INJ 200MG Brand 2 GR GEMCITABINE INJ 1GM generic 1 GEMZAR INJ 1GM Brand 2 GR GEMCITABINE INJ 2GM generic 1 PURINETHOL TAB 50MG Brand 2 GR MERCAPTOPUR TAB 50MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 89 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO METHOTREXATE TAB 2.5MG generic 1 TREXALL TAB 5MG Brand 2 TREXALL TAB 7.5MG Brand 2 TREXALL TAB 10MG Brand 2 TREXALL TAB 15MG Brand 2 METHOTREXATE INJ 25MG/ML generic 1 METHOTREXATE INJ 250/10ML generic 1 METHOTREXATE INJ 25MG/ML generic 1 METHOTREXATE INJ 1GM/40ML generic 1 METHOTREXATE INJ 100/4ML generic 1 METHOTREXATE INJ 50MG/2ML generic 1 METHOTREXATE INJ 200/8ML generic 1 METHOTREXATE INJ 1GM generic 1 ARRANON INJ 5MG/ML Brand 2 ALIMTA INJ 100MG Brand 2 ALIMTA INJ 500MG Brand 2 FOLOTYN INJ 20MG/ML Brand 2 FOLOTYN INJ 40MG/2ML Brand 2 TABLOID TAB 40MG Brand 2 ZALTRAP INJ 100/4ML Brand 2 PA SP ZALTRAP INJ 200/8ML Brand 2 PA SP AVASTIN INJ Brand 2 AVASTIN INJ Brand 2 ERBITUX INJ 100MG Brand 2 ERBITUX INJ 200MG Brand 2 YERVOY INJ 50MG Brand 2 YERVOY INJ 200MG Brand 2 GAZYVA INJ 25MG/ML Brand 2 ARZERRA CON 100/5ML Brand 2 ARZERRA CON 1000/50 Brand 2 VECTIBIX INJ 100MG Brand 2 VECTIBIX INJ 400MG Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 90 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PERJETA INJ 420/14ML Brand 2 RITUXAN INJ 500MG Brand 2 PA SP RITUXAN INJ 100MG Brand 2 PA SP HERCEPTIN INJ 440MG Brand 2 ADCETRIS INJ 50MG Brand 2 PA SP KADCYLA INJ 100MG Brand 2 PA SP KADCYLA INJ 160MG Brand 2 PA SP ZEVALIN KIT Y-90 Brand 2 BEXXAR CON 14MG/ML Brand 2 ERIVEDGE CAP 150MG Brand 2 LYSODREN TAB 500MG Brand 2 BICALUTAMIDE TAB 50MG generic 1 CASODEX TAB 50MG Brand 2 GR XTANDI CAP 40MG Brand 2 FLUTAMIDE CAP 125MG generic 1 NILANDRON TAB 150MG Brand 2 TAMOXIFEN TAB 10MG generic 1 TAMOXIFEN TAB 20MG generic 1 SOLTAMOX SOL 10MG/5ML Brand 2 FARESTON TAB 60MG Brand 2 ARIMIDEX TAB 1MG Brand 2 GR ANASTROZOLE TAB 1MG generic 1 AROMASIN TAB 25MG Brand 2 GR EXEMESTANE TAB 25MG generic 1 FEMARA TAB 2.5MG Brand 2 GR LETROZOLE TAB 2.5MG generic 1 EMCYT CAP 140MG Brand 2 FASLODEX INJ 250MG Brand 2 DEPO-PROVERA INJ 400/ML Brand 2 MEGESTROL AC TAB 20MG generic 1 MEGESTROL AC TAB 40MG generic 1 MEGESTROL AC SUS 400MG/10 generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 91 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO MEGESTROL AC SUS 40MG/ML generic 1 MEGACE ORAL SUS 40MG/ML Brand 2 GR ZOLADEX IMP 3.6MG Brand 2 PA SP ZOLADEX IMP 10.8MG Brand 2 PA SP VANTAS KIT 50MG Brand 2 PA SP LUPRON DEPOT INJ 3.75MG Brand 2 PA SP LEUPROLIDE INJ 1MG/0.2 generic 1 PA SP LUPRON DEPOT INJ 7.5MG Brand 2 ELIGARD INJ 7.5MG Brand 2 PA SP LUPRON DEPOT INJ 11.25MG Brand 2 PA SP LUPRON DEPOT INJ 22.5MG Brand 2 PA SP ELIGARD INJ 22.5MG Brand 2 PA SP LUPRON DEPOT INJ 30MG Brand 2 PA SP ELIGARD INJ 30MG Brand 2 PA SP ELIGARD INJ 45MG Brand 2 PA SP LUPRON DEPOT INJ 45MG Brand 2 TRELSTAR DEP INJ 3.75MG Brand 2 PA SP TRELSTAR LA INJ 11.25MG Brand 2 PA SP TRELSTAR MIX INJ 22.5MG Brand 2 PA SP FIRMAGON INJ 80MG Brand 2 PA SP FIRMAGON INJ 120MG Brand 2 PA SP ZYTIGA TAB 250MG Brand 2 POMALYST CAP 1MG Brand 2 PA SP POMALYST CAP 2MG Brand 2 PA SP POMALYST CAP 3MG Brand 2 PA SP POMALYST CAP 4MG Brand 2 PA SP JEVTANA INJ 60/1.5ML Brand 2 DOCETAXEL INJ 20MG/ML Brand 2 TAXOTERE INJ 20MG/ML Brand 2 DOCETAXEL INJ 80MG/4ML Brand 2 TAXOTERE INJ 80MG/4ML Brand 2 DOCETAXEL INJ 140/7ML Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 92 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DOCETAXEL INJ 160/8ML Brand 2 DOCETAXEL INJ 20/0.5ML Brand 2 DOCETAXEL INJ 80MG/2ML Brand 2 DOCETAXEL INJ 20MG/2ML Brand 2 DOCETAXEL INJ 80MG/8ML Brand 2 DOCETAXEL INJ 160/16ML Brand 2 DOCEFREZ INJ 20MG Brand 2 DOCEFREZ INJ 80MG Brand 2 HALAVEN INJ 1MG/2ML Brand 2 ETOPOSIDE CAP 50MG generic 1 TOPOSAR INJ 100/5ML generic 1 ETOPOSIDE INJ 20MG/ML generic 1 ETOPOSIDE INJ 100/5ML generic 1 ETOPOSIDE INJ 20MG/ML generic 1 ETOPOSIDE INJ 500/25ML generic 1 TOPOSAR INJ 500/25ML generic 1 TOPOSAR INJ 20MG/ML generic 1 TOPOSAR INJ 1GM/50ML generic 1 TOPOSAR INJ 20MG/ML generic 1 ETOPOSIDE INJ 20MG/ML generic 1 ETOPOPHOS INJ 100MG Brand 2 IXEMPRA KIT INJ 15MG Brand 2 IXEMPRA KIT INJ 45MG Brand 2 PACLITAXEL INJ 30MG/5ML generic 1 PACLITAXEL INJ 100MG generic 1 PACLITAXEL INJ 150/25ML generic 1 PACLITAXEL INJ 300/50ML generic 1 ABRAXANE INJ 100MG Brand 2 TENIPOSIDE INJ 50MG/5ML Brand 2 VINCRISTINE INJ 1MG/ML generic 1 VINCASAR PFS INJ 1MG/ML generic 1 MARQIBO INJ 5MG/31ML Brand 2 PA KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 93 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO VINBLASTINE INJ 1MG/ML generic 1 VINBLASTINE INJ 10MG generic 1 VINORELBINE INJ 10MG/ML generic 1 NAVELBINE INJ 10MG/ML Brand 2 GR VINORELBINE INJ 50MG/5ML generic 1 VINORELBINE INJ 10MG/ML generic 1 NAVELBINE INJ 50MG/5ML Brand 2 GR ISTODAX INJ 10MG Brand 2 ZOLINZA CAP 100MG Brand 2 QL 120/30 SP TAFINLAR CAP 50MG Brand 2 TAFINLAR CAP 75MG Brand 2 ZELBORAF TAB 240MG Brand 2 AFINITOR TAB 2.5MG Brand 2 QL 60/30 AFINITOR TAB 5MG Brand 2 AFINITOR TAB 7.5MG Brand 2 AFINITOR TAB 10MG Brand 2 AFINITOR DIS TAB 2MG Brand 2 AFINITOR DIS TAB 3MG Brand 2 AFINITOR DIS TAB 5MG Brand 2 TORISEL SOL 25MG/ML Brand 2 STIVARGA TAB 40MG Brand 2 PA SP NEXAVAR TAB 200MG Brand 2 QL 120/30 SP SUTENT CAP 12.5MG Brand 2 QL 30/30 SP SUTENT CAP 25MG Brand 2 QL 30/30 SP SUTENT CAP 50MG Brand 2 QL 30/30 SP MEKINIST TAB 0.5MG Brand 2 MEKINIST TAB 2MG Brand 2 GILOTRIF TAB 20MG Brand 2 PA GILOTRIF TAB 30MG Brand 2 PA GILOTRIF TAB 40MG Brand 2 PA INLYTA TAB 1MG Brand 2 PA SP INLYTA TAB 5MG Brand 2 PA SP KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 94 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO BOSULIF TAB 100MG Brand 2 PA SP BOSULIF TAB 500MG Brand 2 PA SP COMETRIQ KIT 60MG Brand 2 COMETRIQ KIT 100MG Brand 2 COMETRIQ KIT 140MG Brand 2 XALKORI CAP 200MG Brand 2 XALKORI CAP 250MG Brand 2 SPRYCEL TAB 20MG Brand 2 QL 60/30 SP SPRYCEL TAB 50MG Brand 2 QL 60/30 SP SPRYCEL TAB 70MG Brand 2 QL 60/30 SP SPRYCEL TAB 80MG Brand 2 SPRYCEL TAB 100MG Brand 2 QL 30/30 SP SPRYCEL TAB 140MG Brand 2 TARCEVA TAB 25MG Brand 2 QL 90/30 SP TARCEVA TAB 100MG Brand 2 QL 30/30 SP TARCEVA TAB 150MG Brand 2 QL 30/30 SP IMBRUVICA CAP 140MG Brand 2 GLEEVEC TAB 100MG Brand 2 QL 90/30 SP GLEEVEC TAB 400MG Brand 2 QL 60/30 SP TYKERB TAB 250MG Brand 2 QL 180/30 SP TASIGNA CAP 150MG Brand 2 QL 120/30 SP TASIGNA CAP 200MG Brand 2 QL 120/30 SP VOTRIENT TAB 200MG Brand 2 QL 120/30 SP ICLUSIG TAB 15MG Brand 2 PA SP ICLUSIG TAB 45MG Brand 2 PA SP CAPRELSA TAB 100MG Brand 2 CAPRELSA TAB 300MG Brand 2 VELCADE INJ 3.5MG Brand 2 KYPROLIS SOL 60MG Brand 2 PA SP JAKAFI TAB 5MG Brand 2 JAKAFI TAB 10MG Brand 2 JAKAFI TAB 15MG Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 95 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO JAKAFI TAB 20MG Brand 2 JAKAFI TAB 25MG Brand 2 IRINOTECAN INJ 40MG/2ML generic 1 CAMPTOSAR INJ 40MG/2ML Brand 2 GR IRINOTECAN INJ 100/5ML generic 1 CAMPTOSAR INJ 100/5ML Brand 2 GR CAMPTOSAR INJ 300/15ML Brand 2 IRINOTECAN INJ 500MG/25 generic 1 HYCAMTIN CAP 0.25MG Brand 2 HYCAMTIN CAP 1MG Brand 2 TOPOTECAN INJ 4MG/4ML Brand 2 TOPOTECAN INJ 4MG generic 1 HYCAMTIN INJ 4MG Brand 2 GR BEXXAR 131 I INJ 0.61/ML Brand 2 BEXXAR 131 I INJ 5.6MCI/M Brand 2 XOFIGO INJ 1000KBQ Brand 2 QUADRAMET INJ Brand 2 METASTRON INJ Brand 2 PROVENGE INJ Brand 2 TRISENOX SOL 10MG/10M Brand 2 TICE BCG INJ Brand 2 THERACYS INJ Brand 2 DACARBAZINE INJ 100MG Brand 2 DACARBAZINE INJ 200MG generic 1 HYDROXYUREA CAP 500MG generic 1 HYDREA CAP 500MG Brand 2 GR SYNRIBO INJ 3.5MG Brand 2 PA SP NIPENT INJ 10MG Brand 2 GR PENTOSTATIN INJ 10MG generic 1 MATULANE CAP 50MG Brand 2 INTRON-A INJ 18MU Brand 2 INTRON-A INJ 25MU Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 96 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO INTRON-A INJ 10MU Brand 2 INTRON-A INJ 18MU Brand 2 INTRON-A INJ 50MU Brand 2 ALFERON N INJ 5MU/ML Brand 2 ACTIMMUNE INJ 2MU/0.5 Brand 2 SYLATRON KIT 296MCG Brand 2 SYLATRON KIT 444MCG Brand 2 SYLATRON KIT 888MCG Brand 2 SYLATRON KIT 296MCG Brand 2 SYLATRON KIT 444MCG Brand 2 SYLATRON KIT 888MCG Brand 2 PROLEUKIN INJ 22MU Brand 2 UVADEX INJ 20MCG/ML Brand 2 PHOTOFRIN INJ 75MG Brand 2 TRETINOIN CAP 10MG generic 1 TARGRETIN CAP 75MG Brand 2 ZINECARD INJ 250MG Brand 2 GR DEXRAZOXANE INJ 250MG generic 1 TOTECT INJ 500MG Brand 2 ZINECARD INJ 500MG Brand 2 GR DEXRAZOXANE INJ 500MG generic 1 LEUCOVOR CA TAB 5MG generic 1 LEUCOVOR CA TAB 10MG generic 1 LEUCOVOR CA TAB 15MG generic 1 LEUCOVOR CA TAB 25MG generic 1 LEUCOVOR CA INJ 10MG/ML Brand 2 CALC FOLINAT INJ 300/30ML Brand 2 LEUCOVOR CA INJ 50MG generic 1 LEUCOVOR CA INJ 100MG generic 1 LEUCOVOR CA INJ 200MG generic 1 LEUCOVOR CA INJ 350MG generic 1 LEUCOVORIN INJ CALCIUM generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 97 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO FUSILEV INJ 50MG Brand 2 VORAXAZE INJ 1000UNIT Brand 2 AMIFOSTINE INJ 500MG generic 1 ETHYOL INJ 500MG Brand 2 GR MESNEX TAB 400MG Brand 2 MESNA INJ 1GM generic 1 MESNEX INJ 1GM Brand 2 GR ELITEK INJ 1.5MG Brand 2 ELITEK INJ 7.5MG Brand 2 KEPIVANCE INJ 6.25MG Brand 2 IFOSFAMIDE KIT MESNA Brand 2 Antiparkinson Agents BENZTROPINE TAB 0.5MG generic 1 BENZTROPINE TAB 1MG generic 1 BENZTROPINE TAB 2MG generic 1 BENZTROPINE INJ 1MG/ML generic 1 COGENTIN INJ 1MG/ML Brand 2 GR TRIHEXYPHEN TAB 2MG generic 1 TRIHEXYPHEN TAB 5MG generic 1 TRIHEXYPHEN ELX 0.4MG/ML generic 1 TASMAR TAB 100MG Brand 2 ENTACAPONE TAB 200MG generic 1 COMTAN TAB 200MG Brand 2 GR AMANTADINE CAP 100MG generic 1 PREF MO AMANTADINE TAB 100MG generic 1 PREF MO AMANTADINE SYP 50MG/5ML generic 1 PREF MO PARLODEL CAP 5MG Brand 2 GR BROMOCRIPTIN CAP 5MG generic 1 BROMOCRIPTIN TAB 2.5MG generic 1 PARLODEL TAB 2.5MG Brand 2 GR APOKYN INJ 10MG/ML Brand 2

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 98 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PRAMIPEXOLE TAB 0.125MG generic 1 PREF MO MIRAPEX TAB 0.125MG Brand 2 NON-PREF ST MO PRAMIPEXOLE TAB 0.25MG generic 1 PREF MO MIRAPEX TAB 0.25MG Brand 2 NON-PREF ST MO PRAMIPEXOLE TAB 0.5MG generic 1 PREF MO MIRAPEX TAB 0.5MG Brand 2 NON-PREF ST MO PRAMIPEXOLE TAB 0.75MG generic 1 PREF MO MIRAPEX TAB 0.75MG Brand 2 NON-PREF ST MO PRAMIPEXOLE TAB 1MG generic 1 PREF MO MIRAPEX TAB 1MG Brand 2 NON-PREF ST MO PRAMIPEXOLE TAB 1.5MG generic 1 PREF MO MIRAPEX TAB 1.5MG Brand 2 NON-PREF ST MO MIRAPEX ER TAB 0.375MG Brand 2 MIRAPEX ER TAB 0.75MG Brand 2 MIRAPEX ER TAB 1.5MG Brand 2 MIRAPEX ER TAB 2.25MG Brand 2 MIRAPEX ER TAB 3MG Brand 2 MIRAPEX ER TAB 3.75MG Brand 2 MIRAPEX ER TAB 4.5MG Brand 2 ROPINIROLE TAB 0.25MG generic 1 PREF MO REQUIP TAB 0.25MG Brand 2 NON-PREF ST MO ROPINIROLE TAB 0.5MG generic 1 PREF MO REQUIP TAB 0.5MG Brand 2 NON-PREF ST MO ROPINIROLE TAB 1MG generic 1 PREF MO REQUIP TAB 1MG Brand 2 NON-PREF ST MO ROPINIROLE TAB 2MG generic 1 PREF MO REQUIP TAB 2MG Brand 2 NON-PREF ST MO REQUIP TAB 3MG Brand 2 NON-PREF ST MO ROPINIROLE TAB 3MG generic 1 PREF MO ROPINIROLE TAB 4MG generic 1 PREF MO REQUIP TAB 4MG Brand 2 NON-PREF ST MO ROPINIROLE TAB 5MG generic 1 PREF MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 99 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO REQUIP TAB 5MG Brand 2 NON-PREF ST MO ROPINIROLE TAB 2MG ER generic 1 NON-PREF ST QL 30/30 MO REQUIP XL TAB 2MG Brand 2 NON-PREF ST QL 30/30 MO ROPINIROLE TAB 4MG ER generic 1 NON-PREF ST QL 30/30 MO REQUIP XL TAB 4MG Brand 2 NON-PREF ST QL 30/30 MO REQUIP XL TAB 6MG Brand 2 NON-PREF ST QL 30/30 MO ROPINIROLE TAB 6MG ER generic 1 NON-PREF ST QL 30/30 MO ROPINIROLE TAB 8MG ER generic 1 NON-PREF ST QL 30/30 MO REQUIP XL TAB 8MG Brand 2 NON-PREF ST QL 30/30 MO ROPINIROLE TAB 12MG ER generic 1 NON-PREF ST QL 30/30 MO REQUIP XL TAB 12MG Brand 2 NON-PREF ST QL 30/30 MO NEUPRO DIS 1MG/24HR Brand 2 NON-PREF ST QL 30/30 MO NEUPRO DIS 2MG/24HR Brand 2 NEUPRO DIS 3MG/24HR Brand 2 NON-PREF ST QL 30/30 MO NEUPRO DIS 4MG/24HR Brand 2 NEUPRO DIS 6MG/24HR Brand 2 NEUPRO DIS 8MG/24HR Brand 2 NON-PREF ST QL 30/30 MO SINEMET TAB 10-100MG Brand 2 GR CARB/LEVO TAB 10-100MG generic 1 CARB/LEVO TAB 25-100MG generic 1 SINEMET TAB 25-100MG Brand 2 GR SINEMET TAB 25-250MG Brand 2 GR CARB/LEVO TAB 25-250MG generic 1 SINEMET CR TAB 25-100MG Brand 2 GR CARB/LEVO SR TAB 25-100MG generic 1 CARB/LEVO ER TAB 25-100MG generic 1 CARB/LEVO ER TAB 50-200MG generic 1 CARB/LEVO SR TAB 50-200MG generic 1 SINEMET CR TAB 50-200MG Brand 2 GR CARB/LEVO TAB 10-100MG generic 1 PARCOPA TAB 10-100MG Brand 2 GR PARCOPA TAB 25-100MG Brand 2 GR KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 100 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO CARB/LEVO TAB 25-100MG generic 1 CARB/LEVO TAB 25-250MG generic 1 PARCOPA TAB 25-250MG Brand 2 GR CARB/LEVO 50 TAB /ENTACAP generic 1 STALEVO 50 TAB Brand 2 CARB/LEVO 75 TAB /ENTACAP generic 1 STALEVO 75 TAB Brand 2 CARB/LEVO100 TAB /ENTACAP generic 1 STALEVO 100 TAB Brand 2 CARB/LEVO125 TAB /ENTACAP generic 1 STALEVO 125 TAB Brand 2 CARB/LEVO150 TAB /ENTACAP generic 1 STALEVO 150 TAB Brand 2 CARB/LEVO200 TAB /ENTACAP generic 1 STALEVO 200 TAB Brand 2 AZILECT TAB 0.5MG Brand 2 AZILECT TAB 1MG Brand 2 ELDEPRYL CAP 5MG Brand 2 GR SELEGILINE CAP 5MG generic 1 SELEGILINE TAB 5MG generic 1 ZELAPAR TAB 1.25MG Brand 2 LODOSYN TAB 25MG Brand 2 Antipsychotics/Antimanic Agents FANAPT TAB 1MG Brand 2 PREF QL 60/30 FANAPT TAB 2MG Brand 2 PREF QL 60/30 FANAPT TAB 4MG Brand 2 PREF QL 60/30 FANAPT TAB 6MG Brand 2 PREF QL 60/30 FANAPT TAB 8MG Brand 2 PREF QL 60/30 FANAPT TAB 10MG Brand 2 PREF QL 60/30 FANAPT TAB 12MG Brand 2 PREF QL 60/30 FANAPT PAK Brand 2 PREF QL 8/life

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 101 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO INVEGA TAB 1.5MG Brand 2 NON-PREF ST QL 30/30 MO INVEGA TAB 3MG Brand 2 NON-PREF ST QL 60/30 MO INVEGA TAB 6MG Brand 2 NON-PREF ST QL 60/30 MO INVEGA TAB 9MG Brand 2 NON-PREF ST QL 30/30 MO INVEGA SUST INJ 39/0.25 Brand 2 NON-PREF ST QL 0.25/30 INVEGA SUST INJ 78/0.5ML Brand 2 NON-PREF ST QL 0.5/30 INVEGA SUST INJ 117/0.75 Brand 2 NON-PREF ST QL 0.75/30 INVEGA SUST INJ 156MG/ML Brand 2 NON-PREF ST QL 1/30 INVEGA SUST INJ 234/1.5 Brand 2 NON-PREF ST QL 1.5/30 RISPERIDONE TAB 0.25MG generic 1 PREF QL 60/30 MO RISPERDAL TAB 0.25MG Brand 2 NON-PREF ST QL 60/30 MO RISPERIDONE TAB 0.5MG generic 1 PREF QL 120/30 MO RISPERDAL TAB 0.5MG Brand 2 NON-PREF ST QL 120/30 MO RISPERIDONE TAB 1MG generic 1 PREF QL 60/30 MO RISPERDAL TAB 1MG Brand 2 NON-PREF ST QL 60/30 MO RISPERIDONE TAB 2MG generic 1 PREF QL 60/30 MO RISPERDAL TAB 2MG Brand 2 NON-PREF ST QL 60/30 MO RISPERIDONE TAB 3MG generic 1 PREF QL 60/30 MO RISPERDAL TAB 3MG Brand 2 NON-PREF ST QL 60/30 MO RISPERIDONE TAB 4MG generic 1 PREF QL 60/30 MO RISPERDAL TAB 4MG Brand 2 NON-PREF ST QL 60/30 MO RISPERIDONE SOL 1MG/ML generic 1 PREF QL 120/30 MO RISPERDAL SOL 1MG/ML Brand 2 NON-PREF ST QL 120/30 MO RISPERIDONE TAB 0.25 ODT generic 1 PREF QL 60/30 MO RISPERIDONE TAB 0.5MG OD generic 1 PREF QL 120/30 MO RISPERDAL M TAB 0.5MG Brand 2 NON-PREF ST QL 120/30 MO RISPERDAL M TAB 1MG Brand 2 NON-PREF ST QL 60/30 MO RISPERIDONE TAB 1MG ODT generic 1 PREF QL 60/30 MO RISPERIDONE TAB 2MG ODT generic 1 PREF QL 60/30 MO RISPERDAL M TAB 2MG Brand 2 NON-PREF ST QL 60/30 MO RISPERIDONE TAB 3MG ODT generic 1 PREF QL 60/30 MO RISPERDAL M TAB 3MG Brand 2 NON-PREF ST QL 60/30 MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 102 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO RISPERIDONE TAB 4MG ODT generic 1 PREF QL 60/30 MO RISPERDAL M TAB 4MG Brand 2 NON-PREF ST QL 60/30 MO RISPERDAL INJ 12.5MG Brand 2 NON-PREF ST QL 2/30 RISPERDAL INJ 25MG Brand 2 NON-PREF ST QL 2/30 RISPERDAL INJ 37.5MG Brand 2 NON-PREF ST QL 2/30 RISPERDAL INJ 50MG Brand 2 NON-PREF ST QL 2/30 HALOPERIDOL TAB 0.5MG generic 1 HALOPERIDOL TAB 1MG generic 1 HALOPERIDOL TAB 2MG generic 1 HALOPERIDOL TAB 5MG generic 1 HALOPERIDOL TAB 10MG generic 1 HALOPERIDOL TAB 20MG generic 1 HALOPERIDOL CON 2MG/ML generic 1 HALOPER LAC INJ 5MG/ML generic 1 HALDOL INJ 5MG/ML Brand 2 GR HALOPER DEC INJ 50MG/ML generic 1 HALDOL DECAN INJ 50MG/ML Brand 2 GR HALOPER DEC INJ 100MG/ML generic 1 HALDOL DECAN INJ 100MG/ML Brand 2 GR CLOZARIL TAB 25MG Brand 0 NON-PREF ST CLOZAPINE TAB 25MG generic 0 PREF CLOZAPINE TAB 50MG generic 0 PREF CLOZAPINE TAB 100MG generic 0 PREF CLOZARIL TAB 100MG Brand 0 NON-PREF ST CLOZAPINE TAB 200MG generic 0 PREF FAZACLO TAB 12.5/ODT Brand 0 PREF CLOZAPINE TAB 12.5/ODT Brand 0 PREF CLOZAPINE TAB 25MG ODT Brand 0 PREF FAZACLO TAB 25MG ODT Brand 0 PREF FAZACLO TAB 100/ODT Brand 0 PREF CLOZAPINE TAB 100/ODT Brand 0 PREF FAZACLO TAB 150MG Brand 0 NON-PREF ST KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 103 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO FAZACLO TAB 200MG Brand 0 NON-PREF ST QUETIAPINE TAB 25MG generic 1 PREF QL 120/30 MO SEROQUEL TAB 25MG Brand 2 NON-PREF ST QL 120/30 MO SEROQUEL TAB 50MG Brand 2 NON-PREF ST QL 120/30 MO QUETIAPINE TAB 50MG generic 1 PREF QL 120/30 MO SEROQUEL TAB 100MG Brand 2 NON-PREF ST QL 90/30 MO QUETIAPINE TAB 100MG generic 1 PREF QL 90/30 MO QUETIAPINE TAB 200MG generic 1 PREF QL 120/30 MO SEROQUEL TAB 200MG Brand 2 NON-PREF ST QL 120/30 MO QUETIAPINE TAB 300MG generic 1 PREF QL 90/30 MO SEROQUEL TAB 300MG Brand 2 NON-PREF ST QL 90/30 MO QUETIAPINE TAB 400MG generic 1 PREF QL 90/30 MO SEROQUEL TAB 400MG Brand 2 NON-PREF ST QL 90/30 MO SEROQUEL XR TAB 50MG Brand 2 PREF QL 60/30 MO SEROQUEL XR TAB 150MG Brand 2 PREF QL 30/30 MO SEROQUEL XR TAB 200MG Brand 2 PREF QL 30/30 MO SEROQUEL XR TAB 300MG Brand 2 PREF QL 30/30 MO SEROQUEL XR TAB 400MG Brand 2 PREF QL 30/30 MO LOXAPINE CAP 5MG generic 1 LOXITANE CAP 5MG Brand 2 GR LOXAPINE CAP 10MG generic 1 LOXAPINE CAP 25MG generic 1 LOXAPINE CAP 50MG generic 1 SAPHRIS SUB 5MG Brand 2 NON-PREF ST QL 60/30 MO SAPHRIS SUB 10MG Brand 2 NON-PREF ST QL 60/30 MO OLANZAPINE TAB 2.5MG generic 1 PREF QL 60/30 MO ZYPREXA TAB 2.5MG Brand 2 NON-PREF ST QL 60/30 MO OLANZAPINE TAB 5MG generic 1 PREF QL 60/30 MO ZYPREXA TAB 5MG Brand 2 NON-PREF ST QL 60/30 MO ZYPREXA TAB 7.5MG Brand 2 NON-PREF ST QL 60/30 MO OLANZAPINE TAB 7.5MG generic 1 PREF QL 60/30 MO OLANZAPINE TAB 10MG generic 1 PREF QL 60/30 MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 104 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ZYPREXA TAB 10MG Brand 2 NON-PREF ST QL 60/30 MO OLANZAPINE TAB 15MG generic 1 PREF QL 60/30 MO ZYPREXA TAB 15MG Brand 2 NON-PREF ST QL 60/30 MO OLANZAPINE TAB 20MG generic 1 PREF QL 60/30 MO ZYPREXA TAB 20MG Brand 2 NON-PREF ST QL 60/30 MO OLANZAPINE INJ 10MG generic 1 PREF QL 6/30 ZYPREXA INJ 10MG Brand 2 NON-PREF ST QL 6/30 OLANZAPINE TAB 5MG ODT generic 1 PREF QL 60/30 MO ZYPREXA ZYDI TAB 5MG Brand 2 NON-PREF ST QL 60/30 MO OLANZAPINE TAB 10MG ODT generic 1 PREF QL 60/30 MO ZYPREXA ZYDI TAB 10MG Brand 2 NON-PREF ST QL 60/30 MO OLANZAPINE TAB 15MG ODT generic 1 PREF QL 60/30 MO ZYPREXA ZYDI TAB 15MG Brand 2 NON-PREF ST QL 60/30 MO OLANZAPINE TAB 20MG ODT generic 1 PREF QL 60/30 MO ZYPREXA ZYDI TAB 20MG Brand 2 NON-PREF ST QL 60/30 MO ZYPREXA RELP INJ 210MG Brand 2 NON-PREF ST ZYPREXA RELP INJ 300MG Brand 2 NON-PREF ST ZYPREXA RELP INJ 405MG Brand 2 NON-PREF ST CHLORPROMAZ TAB 10MG generic 1 CHLORPROMAZ TAB 25MG generic 1 CHLORPROMAZ TAB 50MG generic 1 CHLORPROMAZ TAB 100MG generic 1 CHLORPROMAZ TAB 200MG generic 1 CHLORPROMAZ INJ 25MG/ML generic 1 FLUPHENAZINE TAB 1MG generic 1 FLUPHENAZINE TAB 2.5MG generic 1 FLUPHENAZINE TAB 5MG generic 1 FLUPHENAZINE TAB 10MG generic 1 FLUPHENAZINE ELX 2.5/5ML generic 1 FLUPHENAZINE CON 5MG/ML generic 1 FLUPHENAZINE INJ 2.5MG/ML generic 1 FLUPHENAZ DE INJ 25MG/ML generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 105 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PERPHENAZINE TAB 2MG generic 1 PERPHENAZINE TAB 4MG generic 1 PERPHENAZINE TAB 8MG generic 1 PERPHENAZINE TAB 16MG generic 1 COMPRO SUP 25MG generic 1 COMPAZINE SUP 25MG generic 1 PROCHLORPER SUP 25MG generic 1 PROCHLORPER TAB 5MG generic 1 PROCHLORPER TAB 10MG generic 1 PROCHLORPER INJ 5MG/ML Brand 2 THIORIDAZINE TAB 10MG generic 1 THIORIDAZINE TAB 25MG generic 1 THIORIDAZINE TAB 50MG generic 1 THIORIDAZINE TAB 100MG generic 1 TRIFLUOPERAZ TAB 1MG generic 1 TRIFLUOPERAZ TAB 2MG generic 1 TRIFLUOPERAZ TAB 5MG generic 1 TRIFLUOPERAZ TAB 10MG generic 1 ABILIFY TAB 2MG Brand 2 NON-PREF ST QL 30/30 MO ABILIFY TAB 5MG Brand 2 NON-PREF ST QL 30/30 MO ABILIFY TAB 10MG Brand 2 NON-PREF ST QL 30/30 MO ABILIFY TAB 15MG Brand 2 NON-PREF ST QL 30/30 MO ABILIFY TAB 20MG Brand 2 NON-PREF ST QL 30/30 MO ABILIFY TAB 30MG Brand 2 NON-PREF ST QL 30/30 MO ABILIFY MAIN INJ 300MG Brand 2 QL 30/30 MO ABILIFY MAIN INJ 400MG Brand 2 QL 1/30 MO ABILIFY SOL 1MG/ML Brand 2 NON-PREF ST QL 900/30 MO ABILIFY INJ 9.75MG Brand 2 NON-PREF ST ABILIFY DISC TAB 10MG Brand 2 NON-PREF ST QL 30/30 MO ABILIFY DISC TAB 15MG Brand 2 NON-PREF ST QL 30/30 MO THIOTHIXENE CAP 1MG generic 1 THIOTHIXENE CAP 2MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 106 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO THIOTHIXENE CAP 5MG generic 1 THIOTHIXENE CAP 10MG generic 1 EQUETRO CAP 100MG Brand 2 EQUETRO CAP 200MG Brand 2 EQUETRO CAP 300MG Brand 2 LATUDA TAB 20MG Brand 2 PREF QL 30/30 MO LATUDA TAB 40MG Brand 2 PREF QL 30/30 MO LATUDA TAB 60MG Brand 2 LATUDA TAB 80MG Brand 2 PREF QL 30/30 MO LATUDA TAB 120MG Brand 2 PREF QL 30/30 MO ZIPRASIDONE CAP 20MG generic 1 PREF QL 60/30 MO GEODON CAP 20MG Brand 2 NON-PREF ST QL 60/30 MO GEODON CAP 40MG Brand 2 NON-PREF ST QL 60/30 MO ZIPRASIDONE CAP 40MG generic 1 PREF QL 60/30 MO GEODON CAP 60MG Brand 2 NON-PREF ST QL 60/30 MO ZIPRASIDONE CAP 60MG generic 1 PREF QL 60/30 MO GEODON CAP 80MG Brand 2 NON-PREF ST QL 60/30 MO ZIPRASIDONE CAP 80MG generic 1 PREF QL 60/30 MO GEODON INJ 20MG Brand 2 NON-PREF ST LITHIUM CARB CAP 150MG generic 1 LITHIUM CARB CAP 300MG generic 1 LITHIUM CARB CAP 600MG generic 1 LITHIUM CARB TAB 300MG generic 1 LITHIUM CARB TAB 300MG ER generic 1 LITHOBID TAB 300MG CR Brand 2 GR LITHIUM CARB TAB 450MG ER generic 1 LITHIUM CITR SOL 8MEQ/5ML generic 1 Antiseptics & Disinfectants FORMA-RAY SOL 20% Brand 2 FORMALDEHYDE SOL 37% Brand 2 GLUTARALDEHY SOL 25% Brand 2

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 107 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO HYDROGEN PER SOL 30% Brand 2 TRIPLE DYE LIQ Brand 2 KERR TRIPLE MIS DYE SWAB Brand 2 BENZALKONIUM SOL NF Brand 2 BENZALKONIUM SOL 50% generic 1 CHLORHEX GLU SOL 20% Brand 2 IODOFLEX PAD PAD Brand 2 IODINE TIN 2% MILD Brand 2 IODINE TIN 2% Brand 2 IODINE TIN STRONG Brand 2 LUGOLS SOL STRONG Brand 2 BUCALSEP SPR Brand 2 BUCALSEP SOL Brand 2 SKIN SCRUB KIT PREP TRY Brand 2 Antivirals SELZENTRY TAB 150MG Brand 2 PA SP SELZENTRY TAB 300MG Brand 2 PA SP FUZEON INJ 90MG Brand 2 TIVICAY TAB 50MG Brand 2 ISENTRESS TAB 400MG Brand 2 ISENTRESS CHW 25MG Brand 2 ISENTRESS CHW 100MG Brand 2 REYATAZ CAP 150MG Brand 2 REYATAZ CAP 200MG Brand 2 REYATAZ CAP 300MG Brand 2 PREZISTA TAB 75MG Brand 2 PREZISTA TAB 150MG Brand 2 PREZISTA TAB 400MG Brand 2 PREZISTA TAB 600MG Brand 2 PREZISTA TAB 800MG Brand 2 PREZISTA SUS 100MG/ML Brand 2

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 108 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO LEXIVA TAB 700MG Brand 2 LEXIVA SUS 50MG/ML Brand 2 CRIXIVAN CAP 200MG Brand 2 CRIXIVAN CAP 400MG Brand 2 VIRACEPT TAB 250MG Brand 2 VIRACEPT TAB 625MG Brand 2 NORVIR CAP 100MG Brand 2 NORVIR TAB 100MG Brand 2 NORVIR SOL 80MG/ML Brand 2 INVIRASE CAP 200MG Brand 2 INVIRASE TAB 500MG Brand 2 APTIVUS CAP 250MG Brand 2 APTIVUS SOL Brand 2 ZIAGEN TAB 300MG Brand 2 GR ABACAVIR TAB 300MG generic 1 ZIAGEN SOL 20MG/ML Brand 2 VIDEX SOL 2GM Brand 2 VIDEX SOL 4GM Brand 2 DIDANOSINE CAP 125MG generic 1 VIDEX EC CAP 125MG Brand 2 GR DIDANOSINE CAP 200MG generic 1 VIDEX EC CAP 200MG Brand 2 GR VIDEX EC CAP 250MG Brand 2 GR DIDANOSINE CAP 250MG generic 1 VIDEX EC CAP 400MG Brand 2 GR DIDANOSINE CAP 400MG generic 1 EMTRIVA CAP 200MG Brand 2 EMTRIVA SOL 10MG/ML Brand 2 EPIVIR HBV TAB 100MG Brand 2 EPIVIR TAB 150MG Brand 2 GR LAMIVUDINE TAB 150MG generic 1 EPIVIR TAB 300MG Brand 2 GR KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 109 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO LAMIVUDINE TAB 300MG generic 1 EPIVIR HBV SOL 5MG/ML Brand 2 EPIVIR SOL 10MG/ML Brand 2 STAVUDINE CAP 15MG generic 1 ZERIT CAP 15MG Brand 2 GR ZERIT CAP 20MG Brand 2 GR STAVUDINE CAP 20MG generic 1 ZERIT CAP 30MG Brand 2 GR STAVUDINE CAP 30MG generic 1 ZERIT CAP 40MG Brand 2 GR STAVUDINE CAP 40MG generic 1 ZERIT SOL 1MG/ML Brand 2 GR STAVUDINE SOL 1MG/ML generic 1 RETROVIR CAP 100MG Brand 2 GR ZIDOVUDINE CAP 100MG generic 1 ZIDOVUDINE TAB 300MG generic 1 RETROVIR SYP 50MG/5ML Brand 2 GR ZIDOVUDINE SYP 50MG/5ML generic 1 RETROVIR INJ 10MG/ML Brand 2 VIREAD TAB 150MG Brand 2 VIREAD TAB 200MG Brand 2 VIREAD TAB 250MG Brand 2 VIREAD TAB 300MG Brand 2 RESCRIPTOR TAB 100 MG Brand 2 RESCRIPTOR TAB 200MG Brand 2 SUSTIVA CAP 50MG Brand 2 SUSTIVA CAP 200MG Brand 2 SUSTIVA TAB 600MG Brand 2 INTELENCE TAB 25MG Brand 2 INTELENCE TAB 100MG Brand 2 INTELENCE TAB 200MG Brand 2 NEVIRAPINE TAB 200MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 110 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO VIRAMUNE TAB 200MG Brand 2 GR NEVIRAPINE SUS 50MG/5ML Brand 2 VIRAMUNE SUS 50MG/5ML Brand 2 VIRAMUNE XR TAB 100MG Brand 2 VIRAMUNE XR TAB 400MG Brand 2 EDURANT TAB 25MG Brand 2 EPZICOM TAB 600-300 Brand 2 TRUVADA TAB 200-300 Brand 2 LAMIVUD/ZIDO TAB 150-300 generic 1 COMBIVIR TAB 150-300 Brand 2 GR KALETRA TAB 100-25MG Brand 2 KALETRA TAB 200-50MG Brand 2 KALETRA SOL Brand 2 TRIZIVIR TAB Brand 2 ATRIPLA TAB Brand 2 COMPLERA TAB Brand 2 STRIBILD TAB Brand 2 PA SP VISTIDE INJ 75MG/ML Brand 2 GR CIDOFOVIR INJ 75MG/ML generic 1 FOSCAVIR INJ 24MG/ML Brand 2 FOSCARNET INJ 24MG/ML generic 1 CYTOVENE INJ 500MG Brand 2 GR GANCICLOVIR INJ 500MG generic 1 VALCYTE TAB 450MG Brand 2 VALCYTE SOL 50MG/ML Brand 2 ADEFOV DIPIV TAB 10MG generic 1 HEPSERA TAB 10MG Brand 2 GR BARACLUDE TAB 0.5MG Brand 2 BARACLUDE TAB 1MG Brand 2 BARACLUDE SOL .05MG/ML Brand 2 TYZEKA TAB 600MG Brand 2 VICTRELIS CAP 200MG Brand 2 PREF PA SP KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 111 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO INFERGEN INJ 9MCG Brand 2 INFERGEN INJ 15MCG Brand 2 PEGASYS INJ 180MCG/M Brand 2 PREF PA SP PEGASYS INJ PROCLICK Brand 2 PREF PA SP PEGASYS INJ Brand 2 PREF PA SP PEGASYS INJ PROCLICK Brand 2 PREF PA SP PEGASYS KIT Brand 2 PREF PA SP PEG-INTRON KIT 50MCG RP Brand 2 NON-PREF ST PA SP PEG-INTRON KIT 50MCG Brand 2 NON-PREF ST PA SP PEG-INTRON KIT 80MCG Brand 2 NON-PREF ST PA SP PEG-INTRON KIT 80MCG RP Brand 2 NON-PREF ST PA SP PEG-INTRON KIT 120 RP Brand 2 NON-PREF ST PA SP PEG-INTRON KIT 120MCG Brand 2 NON-PREF ST PA SP PEG-INTRON KIT 150 RP Brand 2 NON-PREF ST PA SP PEG-INTRON KIT 150MCG Brand 2 NON-PREF ST PA SP RIBAVIRIN CAP 200MG generic 1 PREF PA SP REBETOL CAP 200MG Brand 2 NON-PREF ST PA SP RIBAVIRIN TAB 200MG generic 1 PREF PA SP COPEGUS TAB 200MG Brand 2 NON-PREF ST PA SP RIBAPAK PAK 800/DAY generic 1 NON-PREF ST PA SP RIBASPHERE TAB 400MG Brand 2 NON-PREF ST PA SP RIBATAB TAB 800/DAY Brand 2 NON-PREF ST PA SP RIBASPHERE TAB 600MG Brand 2 NON-PREF ST PA SP RIBATAB TAB 1200/DAY Brand 2 NON-PREF ST PA SP RIBAPAK PAK 1200/DAY generic 1 NON-PREF ST PA SP REBETOL SOL 40MG/ML Brand 2 NON-PREF ST PA SP RIBAPAK MIS 600/DAY Brand 2 NON-PREF ST PA SP RIBAPAK PAK 1000/DAY generic 1 NON-PREF ST PA SP RIBATAB PAK 1000/DAY Brand 2 INCIVEK TAB 375MG Brand 2 PREF PA SP ACYCLOVIR CAP 200MG generic 1 PREF ZOVIRAX CAP 200MG Brand 2 NON-PREF ST KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 112 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ACYCLOVIR TAB 400MG generic 1 PREF ZOVIRAX TAB 400MG Brand 2 NON-PREF ST ACYCLOVIR TAB 800MG generic 1 PREF ZOVIRAX TAB 800MG Brand 2 NON-PREF ST ACYCLOVIR SUS 200/5ML generic 1 PREF ZOVIRAX SUS 200/5ML Brand 2 NON-PREF ST ACYCLOVIR NA INJ 50MG/ML generic 1 ACYCLOVIR NA INJ 500MG generic 1 ACYCLOVIR NA INJ 1000MG generic 1 VALACYCLOVIR TAB 500MG generic 1 PREF VALTREX TAB 500MG Brand 2 NON-PREF ST VALTREX TAB 1GM Brand 2 NON-PREF ST VALACYCLOVIR TAB 1GM generic 1 PREF FAMCICLOVIR TAB 125MG generic 1 PREF FAMVIR TAB 125MG Brand 2 NON-PREF ST FAMCICLOVIR TAB 250MG generic 1 PREF FAMVIR TAB 250MG Brand 2 NON-PREF ST FAMCICLOVIR TAB 500MG generic 1 PREF FAMVIR TAB 500MG Brand 2 NON-PREF ST FLUMADINE TAB 100MG Brand 2 NON-PREF ST MO RIMANTADINE TAB 100MG generic 1 PREF TAMIFLU CAP 30MG Brand 2 PREF QL 20/30 TAMIFLU CAP 45MG Brand 2 PREF QL 10/30 TAMIFLU CAP 75MG Brand 2 PREF QL 10/30 TAMIFLU SUS 6MG/ML Brand 2 PREF QL 75/30 RELENZA MIS DISKHALE Brand 2 PREF QL 20/30 VIRAZOLE INH 6GM Brand 2 Assorted Classes NEXAVIR INJ Brand 2 AMMONIA AROM INH Brand 2 ENDRATE INJ 150MG/ML Brand 2

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 113 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO SYPRINE CAP 250MG Brand 2 CUPRIMINE CAP 250MG Brand 2 DEPEN TITRA TAB 250MG Brand 2 XIAFLEX INJ 0.9MG Brand 2 PA SP HYLENEX INJ 150 UNIT Brand 2 VITRASE INJ 200/ML Brand 2 AMPHADASE INJ 150/ML Brand 2 THALOMID CAP 50MG Brand 2 QL 30/30 SP THALOMID CAP 100MG Brand 2 QL 30/30 SP THALOMID CAP 150MG Brand 2 QL 30/30 SP THALOMID CAP 200MG Brand 2 QL 60/30 SP REVLIMID CAP 2.5MG Brand 2 QL 21/28 SP REVLIMID CAP 5MG Brand 2 QL 30/30 SP REVLIMID CAP 10MG Brand 2 QL 30/30 SP REVLIMID CAP 15MG Brand 2 QL 21/28 SP REVLIMID CAP 20MG Brand 2 REVLIMID CAP 25MG Brand 2 QL 21/28 SP SANDIMMUNE CAP 25MG Brand 2 CYCLOSPORINE CAP 25MG generic 1 CYCLOSPORINE CAP 100MG generic 1 SANDIMMUNE CAP 100MG Brand 2 SANDIMMUNE INJ 50MG/ML Brand 2 GR CYCLOSPORINE INJ 50MG/ML generic 1 SANDIMMUNE SOL 100MG/ML Brand 2 CYCLOSPORINE CAP 25MG MOD generic 1 NEORAL CAP 25MG Brand 2 GR GENGRAF CAP 25MG generic 1 CYCLOSPORINE CAP 50MG MOD generic 1 CYCLOSPORINE CAP 100MG MD generic 1 GENGRAF CAP 100MG generic 1 NEORAL CAP 100MG Brand 2 GR CYCLOSPORINE SOL MODIFIED generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 114 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO GENGRAF SOL 100MG/ML generic 1 NEORAL SOL 100MG/ML Brand 2 GR ATGAM INJ 250MG Brand 2 THYMOGLOBULN INJ 25MG Brand 2 CELLCEPT CAP 250MG Brand 2 GR MYCOPHENOLAT CAP 250MG generic 1 MYCOPHENOLAT TAB 500MG generic 1 CELLCEPT TAB 500MG Brand 2 GR CELLCEPT SUS 200MG/ML Brand 2 CELLCEPT IV INJ 500MG Brand 2 MYFORTIC TAB 180MG Brand 2 MYFORTIC TAB 360MG Brand 2 ZORTRESS TAB 0.25MG Brand 2 ZORTRESS TAB 0.5MG Brand 2 ZORTRESS TAB 0.75MG Brand 2 RAPAMUNE TAB 0.5MG Brand 2 RAPAMUNE TAB 1MG Brand 2 RAPAMUNE TAB 2MG Brand 2 RAPAMUNE SOL 1MG/ML Brand 2 PROGRAF CAP 0.5MG Brand 2 GR HECORIA CAP 0.5MG generic 1 TACROLIMUS CAP 0.5MG generic 1 PROGRAF CAP 1MG Brand 2 GR TACROLIMUS CAP 1MG generic 1 HECORIA CAP 1MG generic 1 PROGRAF CAP 5MG Brand 2 GR TACROLIMUS CAP 5MG generic 1 HECORIA CAP 5MG generic 1 PROGRAF INJ 5MG/ML Brand 2 ASTAGRAF XL CAP 0.5MG Brand 2 ASTAGRAF XL CAP 1MG Brand 2 ASTAGRAF XL CAP 5MG Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 115 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO SIMULECT INJ 10MG Brand 2 SIMULECT INJ 20MG Brand 2 IMURAN TAB 50MG Brand 2 GR AZATHIOPRINE TAB 50MG generic 1 AZASAN TAB 75 MG Brand 2 AZASAN TAB 100MG Brand 2 AZATHIOPRINE INJ 100MG generic 1 NULOJIX INJ 250MG Brand 2 BENLYSTA INJ 120MG Brand 2 PA SP BENLYSTA INJ 400MG Brand 2 PA SP SPS SUS 15GM/60 generic 1 KIONEX SUS 15GM/60 generic 1 SOD POLY SUL SUS 15GM/60 generic 1 SOD POLY SUL SUS 30/120ML generic 1 SOD POLY SUL SUS 50/200ML generic 1 SOTRADECOL INJ 1% Brand 2 SOTRADECOL INJ 3% Brand 2 ETHAMOLIN INJ 5% Brand 2 ASCLERA INJ 0.5% Brand 2 ASCLERA INJ 1% Brand 2 SCLEROMATE INJ 5% generic 1 MORRHUAT SOD INJ 5% generic 1 VIASPAN SOL Brand 2 Beta Blockers CORGARD TAB 20MG Brand 2 NON-PREF ST MO NADOLOL TAB 20MG generic 1 PREF MO NADOLOL TAB 40MG generic 1 PREF MO CORGARD TAB 40MG Brand 2 NON-PREF ST MO CORGARD TAB 80MG Brand 2 NON-PREF ST MO NADOLOL TAB 80MG generic 1 PREF MO LEVATOL TAB 20MG Brand 2 NON-PREF ST MO

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 116 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PINDOLOL TAB 5MG generic 1 PREF MO PINDOLOL TAB 10MG generic 1 PREF MO PROPRANOLOL TAB 10MG generic 1 PREF MO PROPRANOLOL TAB 20MG generic 1 PREF MO PROPRANOLOL TAB 40MG generic 1 PREF MO PROPRANOLOL TAB 60MG generic 1 PREF MO PROPRANOLOL TAB 80MG generic 1 PREF MO PROPRANOLOL INJ 1MG/ML generic 1 PROPRANOLOL SOL 20MG/5ML generic 1 PREF MO PROPRANOLOL SOL 40MG/5ML generic 1 PREF MO PROPRANOLOL CAP 60MG ER generic 1 PREF MO INDERAL LA CAP 60MG Brand 2 PREF MO PROPRANOLOL CAP 80MG ER generic 1 PREF MO INDERAL LA CAP 80MG Brand 2 PREF MO PROPRANOLOL CAP 120MG ER generic 1 PREF MO INDERAL LA CAP 120MG Brand 2 PREF MO INDERAL LA CAP 160MG Brand 2 PREF MO PROPRANOLOL CAP 160MG ER generic 1 PREF MO INNOPRAN XL CAP 80MG Brand 2 NON-PREF ST MO INNOPRAN XL CAP 120MG Brand 2 NON-PREF ST MO BETAPACE TAB 80MG Brand 2 NON-PREF ST MO BETAPACE TAB 120MG Brand 2 NON-PREF ST MO BETAPACE TAB 160MG Brand 2 NON-PREF ST MO BETAPACE AF TAB 80MG Brand 2 NON-PREF ST MO SOTALOL AF TAB 80MG generic 1 PREF MO SOTALOL AF TAB 120MG generic 1 PREF MO BETAPACE AF TAB 120MG Brand 2 NON-PREF ST MO BETAPACE AF TAB 160MG Brand 2 NON-PREF ST MO SOTALOL AF TAB 160MG generic 1 PREF MO TIMOLOL MAL TAB 5MG generic 1 PREF MO TIMOLOL MAL TAB 10MG generic 1 PREF MO TIMOLOL MAL TAB 20MG generic 1 PREF MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 117 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO SECTRAL CAP 200MG Brand 2 NON-PREF ST MO ACEBUTOLOL CAP 200MG generic 1 PREF MO SECTRAL CAP 400MG Brand 2 NON-PREF ST MO ACEBUTOLOL CAP 400MG generic 1 PREF MO ATENOLOL TAB 25MG generic 1 PREF MO TENORMIN TAB 25MG Brand 2 NON-PREF ST MO ATENOLOL TAB 50MG generic 1 PREF MO TENORMIN TAB 50MG Brand 2 NON-PREF ST MO TENORMIN TAB 100MG Brand 2 NON-PREF ST MO ATENOLOL TAB 100MG generic 1 PREF MO BETAXOLOL TAB 10MG generic 1 PREF MO KERLONE TAB 10MG Brand 2 NON-PREF ST MO KERLONE TAB 20MG Brand 2 NON-PREF ST MO BETAXOLOL TAB 20MG generic 1 PREF MO ZEBETA TAB 5MG Brand 2 NON-PREF ST MO BISOPROL FUM TAB 5MG generic 1 PREF MO ZEBETA TAB 10MG Brand 2 NON-PREF ST MO BISOPROL FUM TAB 10MG generic 1 BREVIBLOC INJ 10MG/ML Brand 2 GR ESMOLOL HCL INJ 10MG/ML generic 1 ESMOLOL HCL INJ 100MG/10 generic 1 BREVIBLOC SOL 10MG/ML Brand 2 BREVIBLOC SOL Brand 2 METOPROLOL TAB 25MG ER generic 1 NON-PREF ST MO TOPROL XL TAB 25MG Brand 2 NON-PREF ST MO METOPROLOL TAB 50MG ER generic 1 NON-PREF ST MO TOPROL XL TAB 50MG Brand 2 NON-PREF ST MO METOPROLOL TAB 100MG ER generic 1 NON-PREF ST MO TOPROL XL TAB 100MG Brand 2 NON-PREF ST MO TOPROL XL TAB 200MG Brand 2 NON-PREF ST MO METOPROLOL TAB 200MG ER generic 1 NON-PREF ST MO METOPROL TAR TAB 25MG generic 1 PREF MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 118 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO METOPROL TAR TAB 50MG generic 1 PREF MO LOPRESSOR TAB 50MG Brand 2 NON-PREF ST MO METOPROL TAR TAB 100MG generic 1 PREF MO LOPRESSOR TAB 100MG Brand 2 NON-PREF ST MO METOPROLOL INJ 5MG/5ML generic 1 METOPROLOL INJ 1MG/ML generic 1 LOPRESSOR INJ 5MG/5ML Brand 2 GR BYSTOLIC TAB 2.5MG Brand 2 NON-PREF ST MO BYSTOLIC TAB 5MG Brand 2 NON-PREF ST MO BYSTOLIC TAB 10MG Brand 2 NON-PREF ST MO BYSTOLIC TAB 20MG Brand 2 NON-PREF ST MO CARVEDILOL TAB 3.125MG generic 1 PREF MO COREG TAB 3.125MG Brand 2 NON-PREF ST MO CARVEDILOL TAB 6.25MG generic 1 PREF MO COREG TAB 6.25MG Brand 2 NON-PREF ST MO CARVEDILOL TAB 12.5MG generic 1 PREF MO COREG TAB 12.5MG Brand 2 NON-PREF ST MO COREG TAB 25MG Brand 2 NON-PREF ST MO CARVEDILOL TAB 25MG generic 1 PREF MO COREG CR CAP 10MG Brand 2 COREG CR CAP 20MG Brand 2 COREG CR CAP 40MG Brand 2 COREG CR CAP 80MG Brand 2 LABETALOL TAB 100MG generic 1 PREF MO TRANDATE TAB 100MG Brand 2 NON-PREF ST MO LABETALOL TAB 200MG generic 1 PREF MO TRANDATE TAB 200MG Brand 2 NON-PREF ST MO LABETALOL TAB 300MG generic 1 PREF MO TRANDATE TAB 300MG Brand 2 NON-PREF ST MO LABETALOL INJ 5MG/ML generic 1 Biologicals Misc

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 119 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ADAGEN INJ 250/ML Brand 2 STAPHAGE LYS INJ Brand 2 CAT HAIR INJ EXTRACT Brand 2 BEE VENOM INJ 550MCG Brand 2 HONEY BEE INJ 1000MCG Brand 2 BEE VENOM INJ 1300MCG Brand 2 VENOMIL KIT HONEYBEE Brand 2 HONEY BEE KIT 100MCG Brand 2 VENOMIL KIT HONEYBEE Brand 2 VENOMIL MIX INJ VESPID Brand 2 MIXED VESPID INJ 1650MCG Brand 2 MIXED VESPID INJ 3900MCG Brand 2 MIXED VESPID KIT 300MCG Brand 2 MIXED VESPID KIT 3000MCG Brand 2 YELLOW HORN INJ 550MCG Brand 2 YELLOW HORNT SOL 1000MCG Brand 2 VENOMIL KIT YEL HORN Brand 2 YELLOW HORNT KIT 100MCG Brand 2 VENOMIL KIT YEL HORN Brand 2 YELLOW JACK INJ 550MCG Brand 2 YELLOW JACKT SOL 1000MCG Brand 2 YELLOW JACK INJ 1300MCG Brand 2 VENOMIL KIT YEL JACK Brand 2 YELLOW JACKT KIT 100MCG Brand 2 VENOMIL KIT YEL JACK Brand 2 WASP VENOM INJ 550MCG Brand 2 WASP VENOM INJ 1000MCG Brand 2 WASP VENOM INJ 1300MCG Brand 2 VENOMIL KIT WASP Brand 2 WASP VENOM KIT 100MCG Brand 2 VENOMIL KIT WASP Brand 2 HORNET VENOM INJ 550MCG Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 120 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO WHITE HORNET SOL 1000MCG Brand 2 HORNET VENOM INJ 1300MCG Brand 2 VENOMIL KIT WHT HORN Brand 2 WHITE HORNET KIT 100MCG Brand 2 VENOMIL KIT WHT HORN Brand 2 Calcium Channel Blockers AMLODIPINE TAB 2.5MG generic 1 PREF MO NORVASC TAB 2.5MG Brand 2 NON-PREF ST MO NORVASC TAB 5MG Brand 2 NON-PREF ST MO AMLODIPINE TAB 5MG generic 1 PREF MO AMLODIPINE TAB 10MG generic 1 PREF MO NORVASC TAB 10MG Brand 2 NON-PREF ST MO CLEVIPREX EMU 0.5MG/ML Brand 2 CARDIZEM TAB 30MG Brand 2 NON-PREF ST MO DILTIAZEM TAB 30MG generic 1 PREF MO DILTIAZEM TAB 60MG generic 1 PREF MO CARDIZEM TAB 60MG Brand 2 NON-PREF ST MO DILTIAZEM TAB 90MG generic 1 PREF MO DILTIAZEM TAB 120MG generic 1 PREF MO CARDIZEM TAB 120MG Brand 2 NON-PREF ST MO DILTIAZEM INJ 25MG/5ML generic 1 DILTIAZEM INJ 50/10ML generic 1 DILTIAZEM INJ 125/25ML generic 1 DILTIAZEM INJ 100MG generic 1 DILTIAZEM CAP 60MG ER generic 1 PREF MO DILTIAZEM CAP 90MG ER generic 1 PREF MO DILTIAZEM CAP 120MG ER generic 1 PREF MO DILTIAZEM CAP 120MG ER generic 1 DILT-XR CAP 120MG generic 1 DILTIAZEM CAP 180MG ER generic 1 PREF MO DILT-XR CAP 180MG generic 1 PREF MO

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 121 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DILTIAZEM CAP 240MG ER generic 1 PREF MO DILACOR XR CAP 240MG/24 Brand 2 NON-PREF ST MO DILT-XR CAP 240MG generic 1 PREF MO DILTZAC CAP 120MG/24 generic 1 PREF MO TAZTIA XT CAP 120MG/24 generic 1 PREF MO TIAZAC CAP 120MG/24 Brand 2 NON-PREF ST MO DILTIAZEM CAP 120MG/24 generic 1 PREF MO TIAZAC CAP 180MG/24 Brand 2 NON-PREF ST MO DILTZAC CAP 180MG/24 generic 1 PREF MO TAZTIA XT CAP 180MG/24 generic 1 PREF MO DILTIAZEM CAP 180MG/24 generic 1 PREF MO DILTIAZEM CAP 240MG/24 generic 1 PREF MO DILTZAC CAP 240MG/24 generic 1 PREF MO TIAZAC CAP 240MG/24 Brand 2 NON-PREF ST MO TAZTIA XT CAP 240MG/24 generic 1 PREF MO TIAZAC CAP 300MG/24 Brand 2 NON-PREF ST MO DILTZAC CAP 300MG/24 generic 1 PREF MO DILTIAZEM CAP 300MG/24 generic 1 PREF MO TAZTIA XT CAP 300MG/24 generic 1 PREF MO TAZTIA XT CAP 360MG/24 generic 1 PREF MO DILTZAC CAP 360MG/24 generic 1 PREF MO TIAZAC CAP 360MG/24 Brand 2 NON-PREF ST MO DILTIAZEM CAP 360MG/24 generic 1 PREF MO TIAZAC CAP 420MG/24 Brand 2 NON-PREF ST MO DILTIAZEM CAP 420MG/24 generic 1 PREF MO DILTIAZEM CAP 120MG ER generic 1 PREF MO DILT-CD CAP 120MG generic 1 PREF MO CARTIA XT CAP 120/24HR generic 1 PREF MO CARDIZEM CD CAP 120MG/24 Brand 2 NON-PREF ST MO DILTIAZEM CAP 120MG CD generic 1 PREF MO CARDIZEM CD CAP 180MG/24 Brand 2 NON-PREF ST MO DILTIAZEM CAP 180MG CD generic 1 PREF MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 122 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DILTIAZEM CAP 180MG ER generic 1 PREF MO CARTIA XT CAP 180/24HR generic 1 PREF MO DILT-CD CAP 180MG generic 1 PREF MO CARTIA XT CAP 240/24HR generic 1 PREF MO DILT-CD CAP 240MG generic 1 PREF MO DILTIAZEM CAP 240MG ER generic 1 PREF MO DILTIAZEM CAP 240MG CD generic 1 PREF MO CARDIZEM CD CAP 240MG/24 Brand 2 NON-PREF ST MO DILTIAZEM CAP 300MG CD generic 1 PREF MO CARTIA XT CAP 300/24HR generic 1 PREF MO CARDIZEM CD CAP 300MG/24 Brand 2 NON-PREF ST MO DILT-CD CAP 300MG generic 1 PREF MO DILTIAZEM CAP 300MG ER generic 1 PREF MO CARDIZEM CD CAP 360MG/24 Brand 2 NON-PREF ST MO DILTIAZEM CAP 360MG CD generic 1 PREF MO DILTIAZEM CAP 360MG ER generic 1 PREF MO CARDIZEM LA TAB 120MG Brand 2 MATZIM LA TAB 180MG/24 generic 1 CARDIZEM LA TAB 180MG Brand 2 NON-PREF ST MO MATZIM LA TAB 240MG/24 generic 1 CARDIZEM LA TAB 240MG Brand 2 NON-PREF ST MO CARDIZEM LA TAB 300MG/24 Brand 2 NON-PREF ST MO MATZIM LA TAB 300MG/24 generic 1 NON-PREF ST MO CARDIZEM LA TAB 360MG Brand 2 NON-PREF ST MO MATZIM LA TAB 360MG/24 generic 1 NON-PREF ST MO CARDIZEM LA TAB 420MG/24 Brand 2 NON-PREF ST MO MATZIM LA TAB 420MG/24 generic 1 NON-PREF ST MO FELODIPINE TAB 2.5MG ER generic 1 PREF MO FELODIPINE TAB 5MG ER generic 1 PREF MO FELODIPINE TAB 10MG ER generic 1 PREF MO ISRADIPINE CAP 2.5MG generic 1 PREF MO ISRADIPINE CAP 5MG generic 1 PREF MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 123 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO NICARDIPINE CAP 20MG generic 1 PREF MO NICARDIPINE CAP 30MG generic 1 PREF MO NICARDIPINE INJ 25/10ML generic 1 CARDENE I.V. INJ 2.5MG/ML Brand 2 GR CARDENE SR CAP 30MG Brand 2 CARDENE SR CAP 60MG Brand 2 CARDENE IV SOL 20/200ML Brand 2 CARDENE IV INJ 40/200ML Brand 2 CARDENE IV SOL 20/200ML Brand 2 CARDENE IV INJ 40/200ML Brand 2 NIFEDIPINE CAP 10MG generic 1 PREF MO PROCARDIA CAP 10MG Brand 2 NON-PREF ST MO NIFEDIPINE CAP 20MG generic 1 PREF MO ADALAT CC TAB 30MG ER Brand 2 NON-PREF ST MO NIFEDIAC CC TAB 30MG ER generic 1 PREF MO NIFEDIPINE TAB 30MG ER generic 1 PREF MO AFEDITAB TAB 30MG CR generic 1 PREF MO ADALAT CC TAB 60MG ER Brand 2 NON-PREF ST MO AFEDITAB TAB 60MG CR generic 1 PREF MO NIFEDIAC CC TAB 60MG ER generic 1 PREF MO NIFEDIPINE TAB 60MG ER generic 1 PREF MO NIFEDIAC CC TAB 90MG ER generic 1 PREF MO NIFEDIPINE TAB 90MG ER generic 1 PREF MO ADALAT CC TAB 90MG ER Brand 2 NON-PREF ST MO NIFEDIPINE TAB 30MG ER generic 1 PREF MO NIFEDICAL XL TAB 30MG generic 1 PREF MO PROCARDIA XL TAB 30MG CR Brand 2 NON-PREF ST MO PROCARDIA XL TAB 60MG CR Brand 2 NON-PREF ST MO NIFEDICAL XL TAB 60MG generic 1 PREF MO NIFEDIPINE TAB 60MG ER generic 1 PREF MO PROCARDIA XL TAB 90MG CR Brand 2 NON-PREF ST MO NIFEDIPINE TAB 90MG ER generic 1 PREF MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 124 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO NIMODIPINE CAP 30MG generic 1 NON-PREF ST MO NYMALIZE SOL 60/20ML Brand 2 NISOLDIPINE TAB 8.5MG ER generic 1 PREF MO SULAR TAB 8.5MG Brand 2 NON-PREF ST MO NISOLDIPINE TAB 17MG ER generic 1 PREF MO SULAR TAB 17MG Brand 2 NON-PREF ST MO NISOLDIPINE TAB 20MG generic 1 PREF MO NISOLDIPINE TAB 25.5MG generic 1 PREF MO NISOLDIPINE TAB 30MG generic 1 PREF MO NISOLDIPINE TAB 34MG ER generic 1 PREF MO SULAR TAB 34MG Brand 2 NON-PREF ST MO NISOLDIPINE TAB 40MG generic 1 PREF MO VERAPAMIL TAB 40MG generic 1 PREF MO CALAN TAB 80MG Brand 2 NON-PREF ST MO VERAPAMIL TAB 80MG generic 1 PREF MO CALAN TAB 120MG Brand 2 NON-PREF ST MO VERAPAMIL TAB 120MG generic 1 PREF MO VERAPAMIL TAB 120MG ER generic 1 PREF MO ISOPTIN SR TAB 120MG Brand 2 NON-PREF ST MO CALAN SR TAB 120MG Brand 2 NON-PREF ST MO CALAN SR TAB 180MG Brand 2 NON-PREF ST MO ISOPTIN SR TAB 180MG Brand 2 NON-PREF ST MO VERAPAMIL TAB 180MG ER generic 1 PREF MO ISOPTIN SR TAB 240MG Brand 2 NON-PREF ST MO CALAN SR TAB 240MG Brand 2 NON-PREF ST MO VERAPAMIL TAB 240MG ER generic 1 PREF MO VERAPAMIL INJ 2.5MG/ML generic 1 VERELAN PM CAP 100MG Brand 2 NON-PREF ST MO VERAPAMIL CAP 100MG ER generic 1 MO VERAPAMIL CAP 120MG ER generic 1 PREF MO VERAPAMIL CAP 120MG SR generic 1 PREF MO VERELAN CAP 120MG SR Brand 2 NON-PREF ST MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 125 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO VERAPAMIL CAP 180MG ER generic 1 PREF MO VERAPAMIL CAP 180MG SR generic 1 PREF MO VERELAN CAP 180MG Brand 2 NON-PREF ST MO VERAPAMIL CAP 200MG ER generic 1 MO VERELAN PM CAP 200MG Brand 2 NON-PREF ST MO VERAPAMIL CAP 240MG ER generic 1 PREF MO VERAPAMIL CAP 240MG SR generic 1 PREF MO VERELAN CAP 240MG SR Brand 2 NON-PREF ST MO VERAPAMIL CAP 300MG ER generic 1 MO VERELAN PM CAP 300MG Brand 2 NON-PREF ST MO VERELAN CAP 360MG SR Brand 2 NON-PREF ST MO VERAPAMIL CAP 360MG SR generic 1 PREF MO Cardiotonics MILRINONE INJ 10/10ML generic 1 MILRINONE INJ 1MG/ML generic 1 MILRINONE INJ 1MG/ML generic 1 MILRINONE INJ 20/20ML generic 1 MILRINONE INJ 50/50ML generic 1 MILRINONE INJ 1MG/ML generic 1 MILRINONE/D5 INJ 20/100ML generic 1 MILRINONE/D5 INJ 40/200ML generic 1 LANOXIN TAB 0.125MG Brand 2 GR DIGOXIN TAB 0.125MG generic 1 LANOXIN TAB 0.25MG Brand 2 GR DIGOXIN TAB 0.25MG generic 1 LANOXIN PED INJ 0.1MG/ML Brand 2 DIGOXIN INJ 0.25MG/1 generic 1 LANOXIN INJ 0.25MG/1 Brand 2 GR DIGOXIN SOL 50MCG/ML generic 1 Cardiovascular Agents ADEMPAS TAB 0.5MG Brand 2 PA

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 126 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ADEMPAS TAB 1MG Brand 2 PA ADEMPAS TAB 1.5MG Brand 2 PA ADEMPAS TAB 2MG Brand 2 PA ADEMPAS TAB 2.5MG Brand 2 PA SILDENAFIL TAB 20MG generic 1 PREF PA SP REVATIO TAB 20MG Brand 2 NON-PREF ST SP REVATIO INJ Brand 2 PA SP ADCIRCA TAB 20MG Brand 2 PREF SP LETAIRIS TAB 5MG Brand 2 PREF SP LETAIRIS TAB 10MG Brand 2 PREF SP TRACLEER TAB 62.5MG Brand 2 PREF SP TRACLEER TAB 125MG Brand 2 PREF SP OPSUMIT TAB 10MG Brand 2 EPOPROSTENOL INJ 0.5MG generic 1 PA SP VELETRI INJ 0.5MG Brand 2 PA SP FLOLAN INJ 0.5MG Brand 2 GR SP EPOPROSTENOL INJ 1.5MG generic 1 PA SP VELETRI INJ 1.5MG Brand 2 PA SP FLOLAN INJ 1.5MG Brand 2 GR SP VENTAVIS SOL 10MCG/ML Brand 2 NON-PREF ST SP VENTAVIS SOL 20MCG/ML Brand 2 NON-PREF ST SP TYVASO START SOL 0.6MG/ML Brand 2 NON-PREF ST SP TYVASO REFIL SOL 0.6MG/ML Brand 2 NON-PREF ST SP TYVASO SOL 0.6MG/ML Brand 2 NON-PREF ST SP REMODULIN INJ 1MG/ML Brand 2 PA SP REMODULIN INJ 2.5MG/ML Brand 2 PA SP REMODULIN INJ 5MG/ML Brand 2 PA SP REMODULIN INJ 10MG/ML Brand 2 PA SP NATRECOR INJ 1.5MG Brand 2 CARDIOPLEGIC SOL generic 1 PLEGISOL SOL Brand 2 GR CIALIS TAB 5MG Brand 2 QL 30/30 PA KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 127 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO CADUET TAB 2.5-10MG Brand 2 GR AMLOD/ATORVA TAB 2.5-10MG generic 1 NON-PREF ST MO AMLOD/ATORVA TAB 2.5-20MG generic 1 NON-PREF ST MO CADUET TAB 2.5-20MG Brand 2 GR AMLOD/ATORVA TAB 2.5-40MG generic 1 NON-PREF ST MO CADUET TAB 2.5-40MG Brand 2 GR AMLOD/ATORVA TAB 5-10MG generic 1 NON-PREF ST MO CADUET TAB 5-10MG Brand 2 GR AMLOD/ATORVA TAB 5-20MG generic 1 NON-PREF ST MO CADUET TAB 5-20MG Brand 2 GR AMLOD/ATORVA TAB 5-40MG generic 1 NON-PREF ST MO CADUET TAB 5-40MG Brand 2 GR AMLOD/ATORVA TAB 5-80MG generic 1 NON-PREF ST MO CADUET TAB 5-80MG Brand 2 GR AMLOD/ATORVA TAB 10-10MG generic 1 NON-PREF ST MO CADUET TAB 10-10MG Brand 2 GR AMLOD/ATORVA TAB 10-20MG generic 1 NON-PREF ST MO CADUET TAB 10-20MG Brand 2 GR AMLOD/ATORVA TAB 10-40MG generic 1 NON-PREF ST MO CADUET TAB 10-40MG Brand 2 GR CADUET TAB 10-80MG Brand 2 GR AMLOD/ATORVA TAB 10-80MG generic 1 NON-PREF ST MO BIDIL TAB Brand 2 Cephalosporins CEFADROXIL CAP 500MG generic 1 CEFADROXIL TAB 1GM generic 1 CEFADROXIL SUS 250/5ML generic 1 CEFADROXIL SUS 500/5ML generic 1 CEFAZOLIN INJ 500MG generic 1 CEFAZOLIN INJ 1GM generic 1 CEFAZOLIN INJ 1GM Brand 2

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 128 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO CEFAZOLIN INJ 10GM generic 1 CEFAZOLIN INJ 20GM generic 1 CEFAZOLIN INJ 100GM Brand 2 CEFAZOLIN INJ 300GM Brand 2 CEFAZOLIN INJ 1GM/50ML generic 1 CEFAZOL/DEX SOL 1GM generic 1 CEFAZOL/DEX SOL 2GM Brand 2 CEPHALEXIN CAP 250MG generic 1 KEFLEX CAP 250MG Brand 2 GR CEPHALEXIN CAP 500MG generic 1 KEFLEX CAP 500MG Brand 2 GR KEFLEX CAP 750MG Brand 2 GR CEPHALEXIN CAP 750MG generic 1 CEPHALEXIN TAB 250MG generic 1 CEPHALEXIN TAB 500MG generic 1 CEPHALEXIN SUS 125/5ML generic 1 CEPHALEXIN SUS 250/5ML generic 1 CEFACLOR CAP 250MG generic 1 NON-PREF ST CEFACLOR CAP 500MG generic 1 NON-PREF ST CEFACLOR SUS 125/5ML Brand 2 PREF CEFACLOR SUS 250/5ML Brand 2 PREF CEFACLOR SUS 375/5ML Brand 2 PREF CEFACLOR ER TAB 500MG generic 1 NON-PREF ST CEFOTETAN INJ 1GM/10ML generic 1 CEFOTETAN INJ 2GM/20ML generic 1 CEFOTETAN INJ 10G Brand 2 CEFOTET/DEX INJ 1-3.58% Brand 2 CEFOTET/DEX INJ 2-2.08% Brand 2 CEFOXITIN INJ 1GM generic 1 CEFOXITIN INJ 2GM generic 1 CEFOXITIN INJ 10GM generic 1 MEFOXIN INJ 1GM/50ML Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 129 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO MEFOXIN INJ 2GM/50ML Brand 2 CEFOXITIN INJ 1GM generic 1 CEFOXITIN INJ 2GM generic 1 CEFPROZIL TAB 250MG generic 1 PREF CEFPROZIL TAB 500MG generic 1 PREF CEFPROZIL SUS 125/5ML generic 1 PREF CEFPROZIL SUS 250/5ML generic 1 PREF CEFTIN TAB 250MG Brand 2 NON-PREF ST CEFUROXIME TAB 250MG generic 1 PREF CEFTIN TAB 500MG Brand 2 NON-PREF ST CEFUROXIME TAB 500MG generic 1 PREF CEFTIN SUS 125/5ML Brand 2 NON-PREF ST CEFUROXIME SUS 125/5ML generic 1 CEFTIN SUS 250/5ML Brand 2 NON-PREF ST CEFUROXIME INJ 750MG generic 1 ZINACEF INJ 750MG Brand 2 GR ZINACEF INJ 750MG Brand 2 ZINACEF INJ 1.5GM Brand 2 GR CEFUROXIME INJ 1.5GM generic 1 CEFUROXIME INJ 1.5GM generic 1 ZINACEF INJ 1.5GM Brand 2 GR ZINACEF INJ 7.5GM Brand 2 GR CEFUROXIME INJ 7.5GM generic 1 CEFUROXIME INJ 7.5GM Brand 2 CEFUROXIME INJ 75GM Brand 2 CEFUROXIME INJ 225GM Brand 2 ZINACEF/H20 INJ 1.5GM PB Brand 2 CEFUROX/DEXT INJ 750MG generic 1 CEFUROX/DEXT INJ 1.5GM generic 1 CEFDINIR CAP 300MG generic 1 PREF CEFDINIR SUS 125/5ML generic 1 PREF CEFDINIR SUS 250/5ML generic 1 PREF KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 130 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO SPECTRACEF TAB 200MG Brand 2 NON-PREF ST CEFDITOREN TAB 200MG Brand 2 NON-PREF ST CEFDITOREN TAB 400MG Brand 2 NON-PREF ST SPECTRACEF TAB 400MG Brand 2 NON-PREF ST SUPRAX CAP 400MG Brand 2 SUPRAX TAB 400MG Brand 2 PREF SUPRAX CHW 100MG Brand 2 SUPRAX CHW 200MG Brand 2 SUPRAX SUS 100/5ML Brand 2 PREF SUPRAX SUS 200/5ML Brand 2 PREF SUPRAX SUS 500/5ML Brand 2 CEFPODOXIME TAB 100MG generic 1 PREF CEFPODOXIME TAB 200MG generic 1 PREF CEFPODO PROX SUS 50MG/5ML generic 1 PREF CEFPODO PROX SUS 100/5ML generic 1 PREF CLAFORAN INJ 500MG Brand 2 GR CEFOTAXIME INJ 500MG generic 1 CLAFORAN INJ 1GM Brand 2 GR CEFOTAXIME INJ 1GM generic 1 CLAFORAN INJ 1GM Brand 2 CEFOTAXIME INJ 2GM generic 1 CLAFORAN INJ 2GM Brand 2 GR CLAFORAN INJ 2GM Brand 2 CLAFORAN INJ 10GM Brand 2 GR CEFOTAXIME INJ 10GM generic 1 FORTAZ INJ 500MG Brand 2 TAZICEF INJ 1GM generic 1 CEFTAZIDIME INJ 1GM generic 1 FORTAZ INJ 1GM Brand 2 GR FORTAZ INJ 1GM Brand 2 GR TAZICEF INJ 1GM generic 1 CEFTAZIDIME INJ 2GM generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 131 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO FORTAZ INJ 2GM Brand 2 GR TAZICEF INJ 2GM generic 1 TAZICEF INJ 2GM generic 1 FORTAZ INJ 2GM Brand 2 GR CEFTAZIDIME INJ 6GM generic 1 FORTAZ INJ 6GM Brand 2 GR TAZICEF INJ 6GM generic 1 CEFTAZIDIME INJ 100GM Brand 2 FORTAZ INJ 1GM Brand 2 FORTAZ INJ 2GM Brand 2 TAZICEF INJ 1GM/50ML Brand 2 CEFTIBUTEN CAP 400MG generic 1 CEDAX CAP 400MG Brand 2 GR CEDAX SUS 90MG/5ML Brand 2 NON-PREF ST CEFTIBUTEN SUS 180/5ML generic 1 CEDAX SUS 180/5ML Brand 2 GR CEFTRIAXONE INJ 250MG generic 1 CEFTRIAXONE INJ 500MG generic 1 ROCEPHIN INJ 500MG Brand 2 GR ROCEPHIN INJ 1GM Brand 2 GR CEFTRIAXONE INJ 1GM generic 1 CEFTRIAXONE INJ 1GM generic 1 CEFTRIAXONE INJ 2GM generic 1 CEFTRIAXONE INJ 2GM generic 1 CEFTRIAXONE INJ 10GM generic 1 CEFTRIAXONE/ INJ DEX 1GM Brand 2 CEFTRIAXONE/ INJ DEX 2GM Brand 2 CEFTRIAX/DEX INJ 1GM generic 1 CEFTRIAX/DEX INJ 2GM generic 1 CEFEPIME INJ 1GM generic 1 CEFEPIME INJ 2GM generic 1 CEFEPIME INJ 1GM generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 132 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO MAXIPIME INJ 1GM Brand 2 GR MAXIPIME INJ 1GM Brand 2 MAXIPIME INJ 2GM Brand 2 GR CEFEPIME INJ 2GM generic 1 MAXIPIME INJ 2GM Brand 2 CEFEPIME INJ 1GM Brand 2 CEFEPIME INJ 2GM Brand 2 TEFLARO INJ 400MG Brand 2 TEFLARO INJ 600MG Brand 2 Chemicals ACETIC ACID SOL 5% Brand 2 ACETIC ACID SOL GLACIAL generic 1 FUMARIC ACID POW Brand 2 GLYCOLIC ACD GRA Brand 2 GLYCOLIC ACD CRY Brand 2 HYDROCHLORIC LIQ ACID Brand 2 HYDROCHL ACD LIQ 10% Brand 2 HYDROCHL ACD LIQ 37% Brand 2 LACTIC ACID SOL Brand 2 NITRIC ACID LIQ Brand 2 OXALIC ACID CRY Brand 2 OXALIC ACID POW DIHYDRAT Brand 2 PHOSPHOR ACD SOL 85% Brand 2 SULFURIC ACD SOL Brand 2 AMMONIUM SOL HYDROXID Brand 2 POT HYDROXID SOL 5% Brand 2 POTASSIUM SOL HYDROXID Brand 2 POTASSIUM MIS HYDROXID Brand 2 NA HYDROXIDE SOL 10% Brand 2 SODIUM MIS HYDROXID Brand 2 TARTARIC ACD POW Brand 2

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 133 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO BORAX GRA Brand 2 SODIUM BORAT POW DECAHYDR Brand 2 SOD CARBONAT POW ANHYDROU Brand 2 AMMONIUM LAC SOL 70% Brand 2 BENZYL BENZO LIQ Brand 2 CAMPHOR SOL SPIRITS Brand 2 CHLORHEXIDIN SOL GLUCONAT Brand 2 DIMETHYL SOL SULFOXID Brand 2 CRYOSERV SOL Brand 2 GLYCEROL LIQ FORMAL Brand 2 GLYCERIN LIQ Brand 2 GLYCERINE LIQ Brand 2 GLYCERIN SOL SYNTHETC Brand 2 GUAIACOL SOL Brand 2 ISOPROPYL LIQ PALMITAT Brand 2 PINE TAR LIQ Brand 2 POLYSORBATE SOL 20 Brand 2 POLYSORBATE SOL 40 Brand 2 POLYSORBATE LIQ 60 Brand 2 POLYSORBATE LIQ 80 Brand 2 SOD SILICATE SOL 40% Brand 2 UNDECYLENIC LIQ ACID Brand 2 ACETONE SOL Brand 2 ETHYL ALCOHO SOL 95% Brand 2 DENATURED SOL ALCOHOL Brand 2 CHLOROFORM SOL NF Brand 2 ETHER SOL Brand 2 ISOPROPYL SOL ALCOHOL Brand 2 ISOP ALCOHOL SOL 70% Brand 2 ISOPROPANOL SOL 70% Brand 2 ISOP ALCOHOL SOL 99% Brand 2 ISOP ALCOHOL SOL 70% RUB generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 134 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO OIL-ALMOND OIL SWEET Brand 2 ALMOND OIL SWEET Brand 2 BASE G ALMON OIL SWEET Brand 2 CASTOR OIL Brand 2 OIL-COCONUT OIL Brand 2 COCONUT OIL Brand 2 COTTONSEED OIL Brand 2 LINSEED OIL RAW Brand 2 OLIVE OIL Brand 2 PEANUT OIL NF Brand 2 SAFFLOWER OIL Brand 2 SESAME OIL Brand 2 SOYBEAN OIL Brand 2 GLYCINE SOYA SOL PROTEIN Brand 2 CEDAR LEAF OIL Brand 2 CINNAMON OIL ARTIFIC Brand 2 CITRONELLA OIL Brand 2 CLOVE OIL NF Brand 2 CLOVE OIL Brand 2 EUCALYPTUS OIL Brand 2 EUGENOL SOL Brand 2 JUNIPER TAR OIL Brand 2 LAVENDER OIL NATURAL Brand 2 LAVENDER OIL FRAGRANC Brand 2 ACTIPHYTE OF LIQ LEMONGRA Brand 2 NIAOULI OIL Brand 2 PEPPERMINT OIL Brand 2 PINE OIL Brand 2 ROSE OIL Brand 2 ROSEMARY OIL Brand 2 SASSAFRAS OIL Brand 2 ALUM AMMONIU POW Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 135 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ALUMINUM POT GRA SULFATE Brand 2 ALUMINUM POT POW SULFATE Brand 2 AMMONIUM GRA CHLORIDE Brand 2 AMMONIUM CAR POW Brand 2 AMMONIUM BRO GRA Brand 2 AMMONIUM BRO POW Brand 2 AMMONIUM GRA SULFATE Brand 2 ALUMINUM GRA SULFATE Brand 2 L-ASPARTIC POW Brand 2 BISMUTH SUBC POW Brand 2 BISMUTH POW SUBNITRA Brand 2 BISMUTH POW SUBSALIC Brand 2 BORIC ACID POW Brand 2 BHT POW Brand 2 CALCIUM POW HYDROXID Brand 2 CALC SULFATE POW ANHYDR Brand 2 CALC SULFATE POW HEMIHYDR Brand 2 CARBOXYM SOD GRA MED VISC Brand 2 CARBOXYMETHY POW SODIUM Brand 2 CITRIC ACID GRA ANHYDROU Brand 2 CITRIC ACID POW ANHYDROU Brand 2 CITRIC ACID POW MONOHYD Brand 2 DINITROCHLOR CRY 99% Brand 2 FULLERS POW EARTH Brand 2 GERMANIUM POW Brand 2 GINGER ROOT POW Brand 2 LEAD ACETATE POW TRIHYDRA Brand 2 LICORICE POW ROOT Brand 2 MANNITOL POW Brand 2 MENTHOL CRY Brand 2 POTASH SULFU MIS LUMP Brand 2 POT BITARTRA POW Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 136 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO POT BROMIDE GRA Brand 2 POTASSIUM POW BROMIDE Brand 2 POT GLUCONAT POW ANHYDROU Brand 2 POT NITRATE GRA Brand 2 POT NITRATE POW Brand 2 POT PERCHLOR CRY Brand 2 PUMICE POW FLOUR Brand 2 ROSIN LUMP MIS Brand 2 SILICON POW DIOXIDE Brand 2 SILICA GEL Brand 2 SOD BROMIDE GRA Brand 2 CACODYLATE POW SODIUM Brand 2 SOD NITRITE GRA USP Brand 2 SOD NITRITE GRA Brand 2 SOD PERBORAT POW PURIFIED Brand 2 SOD PERBORAT CRY Brand 2 SOD SULFATE POW Brand 2 SOD SULFITE POW ANHYDROU Brand 2 SODIUM BUTYR POW Brand 2 SORBITOL POW Brand 2 CORN STARCH POW Brand 2 STRONTIUM CRY NITRATE Brand 2 SUCROSE POW Brand 2 SULFANILAMID POW Brand 2 TALC POW Brand 2 THEOPHYLLINE POW ANHYDROU Brand 2 THYMOL CRY Brand 2 THYMOL POW IODIDE Brand 2 IODOFORM POW Brand 2 METHENAMINE POW Brand 2 METHENAMINE POW MANDELAT Brand 2 PHENYLMERCUR POW ACETATE Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 137 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PHENYLMERCUR POW NITRATE Brand 2 PILOCARPINE POW HCL Brand 2 PILOCARPINE POW NITRATE Brand 2 DHEA POW Brand 2 DEHYDROEPIAN POW MICRO Brand 2 PREGNENOLONE POW Brand 2 PREGNENOLONE POW MICRONIZ Brand 2 PYROGALLOL CRY Brand 2 QUINIDINE CRY SULFATE Brand 2 RESORCINOL POW Brand 2 RESORCINOL CRY Brand 2 STANNOUS POW FLUORIDE Brand 2 ALLANTOIN POW Brand 2 ALUMINUM POW HYDROXID Brand 2 CAPSICUM LIQ OLEORESI Brand 2 CARBIDOPA POW ANHYDROU Brand 2 CARBIDOPA POW Brand 2 COENZYME Q10 POW Brand 2 DIMENHYDRIN POW USP Brand 2 DMPS POW Brand 2 EDETATE ACID POW Brand 2 EDETATE POW DISODIUM Brand 2 EDETATE POW SODIUM Brand 2 EPINEPHRINE POW Brand 2 FLUORESCEIN POW Brand 2 FLUORESCEIN POW SODIUM Brand 2 HOMATROPINE POW METHYLBR Brand 2 HYDROXYTRYPT POW Brand 2 5-HYDROXY-L- POW TRYPTOPH Brand 2 KETOCONAZOLE POW Brand 2 KOJIC ACID POW Brand 2 MELATONIN POW generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 138 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO MENADIONE NA CRY BISULFIT Brand 2 METHYLENE POW BLUE Brand 2 MINOXIDIL POW Brand 2 OXYBENZONE POW Brand 2 PYRUVIC ACID LIQ Brand 2 PYRUVIC ACID POW Brand 2 TINIDAZOLE POW Brand 2 DSS/SOD BENZ POW 85-15% Brand 2 NACL/NA BICA POW Brand 2 COAL TAR SOL 20% Brand 2 COAL TAR SOL Brand 2 COAL TAR SOL USP Brand 2 COAL TAR MIS Brand 2 PERUVIAN MIS BALSAM Brand 2 PERUVIAN LIQ BALSAM Brand 2 PERUVIAN POW BALSAM Brand 2 ACEPROMAZINE POW MALEATE Brand 2 ACESULFAME POW POTASSIU Brand 2 ACETAMIN POW Brand 2 ACETAMIN POW USP/NF Brand 2 APAP CRYSTAL CRY 60 MESH Brand 2 ACETARSONE POW Brand 2 ACETAZOLAMID POW Brand 2 HEXAPEPTIDE SOL ACETYL Brand 2 GLUCOSAMINE POW ACETYL-D Brand 2 ACETYL DIPEP SOL CETYL ES Brand 2 ACETYL-L-CAR POW HCL Brand 2 ACETYLCHOLIN POW CHLORIDE Brand 2 ACYCLOVIR POW Brand 2 ADENOSINE POW Brand 2 BLUE AGAVE LIQ ORGANIC Brand 2 ALASKAN RED POW ALGAE Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 139 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ALBENDAZOLE POW Brand 2 BOVINE SERUM POW ALBUMIN Brand 2 ALDOSTERONE POW Brand 2 ACTIPHYTE OF LIQ ALGAE Brand 2 ALGINIC ACID POW Brand 2 ALKYL BENZOA LIQ C12-15 Brand 2 ALLOPURINOL POW Brand 2 ALOE VERA OIL Brand 2 ALOE VERA POW Brand 2 ALOE VERA POW 200:1 Brand 2 ALOE VERA POW LEAF Brand 2 KETOGLUTARIC POW ACID Brand 2 ALPHA LIPOIC POW ACID Brand 2 LIPOIC ACID POW Brand 2 A-LIPOIC POW ACID Brand 2 ALPRAZOLAM POW Brand 2 ALPRAZOLAM POW USP Brand 2 ALTRENOGEST POW Brand 2 ALUMINUM POW ACETATE Brand 2 ALUMINUM POW CHLOROHY Brand 2 AMANTADINE POW HCL Brand 2 AMIKACIN POW Brand 2 AMINOCAPROIC POW ACID Brand 2 6-AMINOCAPRO POW ACID Brand 2 AMINOSALICYL POW SODIUM Brand 2 AMITRIPTYLIN KIT 2% Brand 2 AMLODIPINE POW BESYLATE Brand 2 MAGNASWEET LIQ 110 Brand 2 MAGNASWEET POW 135 Brand 2 AMMONIUM LIQ LAURYL Brand 2 AMMONIUM POW MOLYBDAT Brand 2 ANASTROZOLE POW Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 140 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ANDROSTENEDI POW Brand 2 ANISINDIONE POW Brand 2 ANTIMONY CRY TRICHLOR Brand 2 ANTIMONY POW TRISULF Brand 2 ANTIPYRINE CRY Brand 2 APOMORPHINE POW HCL Brand 2 ARBUTIN POW ALPHA Brand 2 ARGININE HCL POW Brand 2 L-ARGININE POW HCL Brand 2 ARSENIC POW TRIOXIDE Brand 2 ASCORBIC ACD GRA Brand 2 ASCORBIC ACD POW Brand 2 ASCORBIC ACD POW FINE Brand 2 ASCORBIC ACD POW CASSAVE Brand 2 ASCORBYL POW PALMITAT Brand 2 ASHWAGANDHA POW EXT 2.5% Brand 2 ASPARAGINE POW MONOHYDR Brand 2 ASTRAGALUS POW EXTRACT Brand 2 ATTAPULGITE POW Brand 2 AVOCADO OIL REFINED Brand 2 AZELAIC ACID MIS Brand 2 AZITHROMYCIN POW Brand 2 AZITHROMYCIN POW DIHYDRAT Brand 2 BACITRACIN POW MICRONIZ Brand 2 BASIC FUCHSI POW HCL Brand 2 BECLOMETHASO POW DIPROPIO Brand 2 BELLADONNA TIN Brand 2 BELLADONNA POW EXTRACT Brand 2 BENACTYZINE POW HCL Brand 2 BENAZEPRIL POW HCL Brand 2 BENZETHONIUM POW CHLORIDE Brand 2 BENZOIN GUM POW Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 141 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO BENZOQUINONE CRY PARA Brand 2 BETA CAROTEN BEA 10% Brand 2 CYCLODEXTRIN POW BETA Brand 2 BETA GLUCAN POW Brand 2 BETAHISTINE POW DIHCL Brand 2 BETAINE POW ANHYDROU Brand 2 BETAINE HCL POW Brand 2 BETAMETH ACE POW Brand 2 BETAMETH ACE POW MICRONIZ Brand 2 BETANAPHTHOL POW 99% Brand 2 BETHANECHOL POW CHLORIDE Brand 2 BISABOLOL LIQ ALPHA-L Brand 2 BISMUTH POW CITRATE Brand 2 BITTER MELON POW EXTRACT Brand 2 BORON CITRAT POW 5% Brand 2 BOSWELLIA POW SERRATA Brand 2 BRILLIANT POW GREEN Brand 2 BUDESONIDE POW Brand 2 BUFLOMEDIL POW HCL Brand 2 BUPRENORPHIN POW HCL Brand 2 BUPROPION POW HCL Brand 2 BUSPIRONE POW HCL Brand 2 BUTALBITAL POW Brand 2 BUTORPHANOL POW TARTRATE Brand 2 BUTYL ALCOHO LIQ Brand 2 HYDROXYANISO POW BUTYLATE Brand 2 BUTYLENE LIQ GLYCOL Brand 2 CALCIPOTRIEN POW Brand 2 CALCITRIOL POW Brand 2 CALCITRIOL OIL ALMOND Brand 2 CALCIUM POW ACETATE Brand 2 CALCIUM POW ALGINATE Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 142 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO CA CHLORIDE POW ANHYDR Brand 2 CALCIUM POW CITRATE Brand 2 CALCIUM POW GLUBIONA Brand 2 CALCIUM LEV POW DIHYDRAT Brand 2 CALCIUM POW PYRUVATE Brand 2 THIOGLYCOLAT POW CALCIUM Brand 2 YLANG-YLANG OIL FRAGRANC Brand 2 CAPRYLIC LIQ ACID Brand 2 CAPRYLIC CAP LIQ TRIGLYCE Brand 2 CAPRYLIC/CAP POW TRIGLYCE Brand 2 CAPTOPRIL POW Brand 2 CARBACHOL POW Brand 2 CARBAMIDE POW PEROXIDE Brand 2 CARBAZOCHROM POW Brand 2 ADRENOCHROME POW SEMICARB Brand 2 CARBIMAZOLE POW Brand 2 ETHOXY LIQ DIGLYCOL Brand 2 DIETHYLENE POW MONOETHY Brand 2 CARBOPOL 940 POW Brand 2 CARBOPOL 940 POW NF Brand 2 CARBOMER POW 934P Brand 2 CARBOMER POW 940 Brand 2 CARNAUBA WAX MIS Brand 2 CARNOSINE L POW Brand 2 L-CARNOSINE POW Brand 2 LOCUST BEAN POW GUM Brand 2 CANADIAN LIQ BALSAM Brand 2 CEFTAZIDIME POW SODIUM Brand 2 CEFTRIAXONE POW SODIUM Brand 2 CELECOXIB POW Brand 2 CELLULASE POW Brand 2 AVICEL PH105 POW MICROCRY Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 143 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO CELLULOSE POW MICROCRY Brand 2 CELLULOSE CRY MICROCRY Brand 2 CELLULOSE/ POW CMC NA Brand 2 CERESIN WAX MIS Brand 2 CESIUM CHLOR POW Brand 2 CETEARYL ALC POW /CET-20 Brand 2 FREEDOM LIQ ESTERDER Brand 2 CETYL MYRIST OIL OLEATE Brand 2 CETYL MYRIST OIL 40% Brand 2 CETYL MYRIST POW OLEATE Brand 2 CETYL MYRIST POW OLEATE Brand 2 CETYL MYRIST POW 20% Brand 2 CETYL MYRIST MIS OLEATE Brand 2 CETYLPYRIDIN CRY CHLORIDE Brand 2 CHICKEN POW PROTEIN Brand 2 CHLORAMBUCIL POW USP Brand 2 CHLORAMBUCIL POW Brand 2 CHLORAMPHENI POW PALMITAT Brand 2 CHLORHEXIDIN POW DIACETAT Brand 2 CHLOROPHYLLN POW COPPER Brand 2 CHLOROXINE POW Brand 2 CHLOROXYLEN POW Brand 2 VITAMIN D3 LIQ Brand 2 VITAMIN D3 POW Brand 2 VITAMIN D3 POW Brand 2 CHOLESTEROL POW Brand 2 CHOLESTEROL MIS FLAKES Brand 2 CHOLESTYRAMI POW Brand 2 CHOLESTYRAMI POW RESIN Brand 2 CHOLINE POW CHLORIDE Brand 2 CHOLINE MAGN POW TRISALIC Brand 2 CHONDROITIN POW SULFATE Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 144 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO CHORIONIC POW GONADOTR Brand 2 CHROMIUM POW CHLORIDE Brand 2 CHROMIC CRY CHLORIDE Brand 2 CHROMIUM POW PICOLINA Brand 2 CHROMIUM POW POLYNICO Brand 2 CHROMIUM K CRY SULF DOD Brand 2 CHRYSIN POW Brand 2 CINNAMON BRK POW CASSIA Brand 2 CIPROFLOXACN POW Brand 2 CIPROFLOXACN POW HCL Brand 2 CISAPRIDE POW MONOHYDR Brand 2 CITRULLINE POW (L) Brand 2 L-CITRULLINE POW Brand 2 CITRUS BIOFL POW 13% Brand 2 CLARITHROMYC POW Brand 2 CLEMIZOLE POW HCL Brand 2 CLIDINIUM POW BROMIDE Brand 2 CLINDAMYCIN POW HCL Brand 2 CLINDAMYCIN POW HCL MONO Brand 2 CLINDAMYCIN POW PHOSPHAT Brand 2 CLOFAZIMINE POW Brand 2 CLONAZEPAM POW Brand 2 CLOMIPRAMINE POW HCL Brand 2 CLORSULON POW Brand 2 COBALT POW GLUCONAT Brand 2 COBAMAMIDE POW Brand 2 COCAMIDE DEA POW Brand 2 COLISTIMETHA POW SODIUM Brand 2 COLLAGEN POW HYDROLYS Brand 2 COPPER POW GLUCONAT Brand 2 COPPER POW PEPTIDE Brand 2 CORAL POW CALCIUM Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 145 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO CORN OIL Brand 2 ANDRENOCORTI POW HORMONE Brand 2 CORTICOTROPH POW Brand 2 COUMARIN POW Brand 2 CRANBERRY POW Brand 2 CREATINE POW Brand 2 CREATINE POW MONOHYDR Brand 2 CREATININE POW Brand 2 CRESOL LIQ Brand 2 CROTON OIL Brand 2 ACTIPHYTE OF LIQ CUCUMBER Brand 2 COPPER POW GLYCINAT Brand 2 CUPUACU MIS BUTTER Brand 2 CYCLOMETHICO LIQ Brand 2 CYCLOPENTOLA POW HCL Brand 2 CYCLANDELATE POW Brand 2 CYCLOPHOSPHA POW Brand 2 CYCLOPHOSPHA POW USP Brand 2 CYCLOSERINE POW Brand 2 CYCLOSPORINE POW A Brand 2 CYCLOSPORINE POW Brand 2 CYPROHEPTADI POW Brand 2 CYPROHEPTADI POW USP Brand 2 CYSTEAMINE POW Brand 2 L-CYSTEINE POW Brand 2 L-CYSTEINE POW HCL MONO Brand 2 DANTROLENE POW Brand 2 DAPIPRAZOLE POW HCL Brand 2 DAPSONE POW Brand 2 DEANOL LIQ Brand 2 PCCA DMAE LIQ COMPLEX Brand 2 DMAE POW BITARTRA Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 146 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DOW CORNING LIQ 1501 FL Brand 2 DEMECARIUM POW BROMIDE Brand 2 DEOXYCHOLIC POW ACID Brand 2 2-DEOXY-D POW -GLUCOSE Brand 2 BEEF LIVER POW DESICCAT Brand 2 DESMOPRESSIN POW ACETATE Brand 2 DESOXIMETASN POW Brand 2 DESOXYCORTIC POW ACETATE Brand 2 DEXAMETHASON POW ISONICOT Brand 2 DEXPANTHENOL LIQ Brand 2 DEXPANTHENOL POW Brand 2 DIAMINOPYRID POW Brand 2 GERMALL PLUS LIQ Brand 2 DIAZEPAM POW Brand 2 DIAZOXIDE POW Brand 2 DIBUCAINE POW Brand 2 DICHLOROACET LIQ Brand 2 DICHLORALPHE POW USP Brand 2 DICLAZURIL POW Brand 2 DICLOFENAC POW SODIUM Brand 2 DICUMAROL POW Brand 2 DICYCLOMINE POW Brand 2 DIETHANOLAMI LIQ Brand 2 DIETHYLCARB POW CITRATE Brand 2 DIETHYLPROPI POW HCL Brand 2 DIETHYLSTILB POW Brand 2 DIETHYL TOLU LIQ 98% Brand 2 DIHYROCODEIN POW BITARTRA Brand 2 DIIODO-L- POW THYRONIN Brand 2 DIINDOLYLMET POW Brand 2 DILTIAZEM POW Brand 2 DIMETHYLACET LIQ Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 147 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DIMETHYL POW FUMARATE Brand 2 DIMETHYLGLYC POW HCL Brand 2 PROSTAGLAND POW E2 Brand 2 DIOSGENIN POW Brand 2 DIOSMIN POW Brand 2 DIOXYBENZONE POW Brand 2 SYN-AKE LIQ Brand 2 DIPHENIDOL POW HCL Brand 2 DIPHENYLCYCL POW Brand 2 DIPYRIDAMOLE POW Brand 2 DISOPHENOL POW 97% Brand 2 DISULFIRAM POW Brand 2 D-MANNOSE POW Brand 2 DOCOSANOL POW Brand 2 DOPAMINE HCL POW Brand 2 RIBOSE (D) POW Brand 2 D-RIBOSE POW Brand 2 HYDROXYAPATI POW CALCIUM Brand 2 DYCLONINE POW USP Brand 2 DYCLONINE POW Brand 2 DYPHYLLINE POW Brand 2 ECONAZOLE POW NITRATE Brand 2 EDROPHONIUM POW CHLORIDE Brand 2 EMU OIL Brand 2 ENALAPRIL POW MALEATE Brand 2 ENROFLOXACIN POW Brand 2 EPINEPHRINE POW BITARTRA Brand 2 ERGOLOID POW MESYLATE Brand 2 ERYTHROMYCIN POW ESTOLATE Brand 2 ESTRADIOL POW BENZOATE Brand 2 ESTRADIOL POW CYPIONAT Brand 2 ESTRADIOL POW CYP USP Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 148 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ESTRADIOL POW VALERATE Brand 2 ETHOSUXIMIDE POW Brand 2 ETHYL OLEATE LIQ Brand 2 ETHYLENEDIAM LIQ 99% Brand 2 ETODOLAC POW Brand 2 ETOMIDATE POW Brand 2 ETOPOSIDE POW Brand 2 EUCALYPTOL LIQ Brand 2 FAMOTIDINE POW Brand 2 4 AMINOPYRID POW Brand 2 FENBENDAZOLE POW Brand 2 FERRIC CHLOR MIS HEXAHYDR Brand 2 FERRIC SUBSU SOL Brand 2 FERRIC POW SULFATE Brand 2 FERR BISGLYC POW CHELATE Brand 2 FERROUS POW FUMARATE Brand 2 FERROUS GRA GLUCONAT Brand 2 FERULIC ACID POW Brand 2 FEVERFEW POW Brand 2 FINASTERIDE POW Brand 2 FINASTERIDE CRY Brand 2 FLOXURIDINE POW Brand 2 FLUCONAZOLE POW generic 1 FLUCYTOSINE POW Brand 2 FLUNIXIN POW MEGLUMIN Brand 2 FLUOROURACIL POW Brand 2 FLUOROURACIL POW USP Brand 2 FLUOROURACIL POW USP/NF Brand 2 FLUOXETINE POW HCL Brand 2 FLUOXYMESTER POW Brand 2 FLUPHENAZINE POW DECANOAT Brand 2 FLUTICASONE POW PROPIONA Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 149 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO METHYLPYRAZO LIQ Brand 2 FORMOTEROL POW FUMARATE Brand 2 FORSKOLIN POW Brand 2 FURAZOLIDONE POW Brand 2 GALACTOSE POW Brand 2 4-AMINOBUTYR CRY ACID Brand 2 GABAPENTIN POW Brand 2 GARDENIA OIL FRAGRANC Brand 2 GINKGO BILOB POW Brand 2 GINSENG ROOT POW Brand 2 GLUCONOLACTO POW Brand 2 GLUCOSAMINE POW HCL Brand 2 GLUCOSAMINE POW SULFATE Brand 2 GLUCOSAMINE POW SULFATE Brand 2 GLUCOSAMINE POW SUL NACL Brand 2 GLUTARALDEHY LIQ 50% Brand 2 GLUTARALDEHY SOL 25% Brand 2 GLYCEROL POW MONOOLEA Brand 2 GLYCERYL MIS MONOSTEA Brand 2 ARLACEL 165 POW Brand 2 GUANIDINEACE POW ACID Brand 2 GLYCOFUROL LIQ Brand 2 GLYCOSAMINOG LIQ Brand 2 GLYCYRRHIZIC POW ACID Brand 2 GOLD SODIUM POW THIOMALA Brand 2 GRAMICIDIN D POW Brand 2 GRAPESEED OIL Brand 2 GRAPE SEED OIL Brand 2 GREEN SOAP EMU Brand 2 GREEN TEA POW Brand 2 EGCG POW Brand 2 GREEN TEA OIL FRAGRANC Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 150 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO GRISEOFULVIN POW MICRONIZ Brand 2 GRISEOFULVIN POW Brand 2 GUANABENZ POW ACETATE Brand 2 GUANETHIDINE POW SULFATE Brand 2 GUAR GUM POW Brand 2 GYMNEMA SYLV POW LEAF Brand 2 HALOPERIDOL POW Brand 2 HALOPERIDOL POW DECANOAT Brand 2 WITCH HAZEL EXT Brand 2 HAWTHORN POW BERRY Brand 2 ACTIPHYTE OF LIQ IVY Brand 2 HEMATOXYLIN POW Brand 2 HEPARIN SOD POW PORCINE Brand 2 HEPES POW Brand 2 HEPTAMINOL POW Brand 2 HISTAMINE CRY DIPHOSPH Brand 2 HISTAMINE CRY PHOSPHAT Brand 2 HONEY ALMOND LIQ FRAGRANC Brand 2 HUPRZN SER A POW 1% Brand 2 HYALURONIC POW ACID Brand 2 HYALURONIDAS POW BOVINE Brand 2 HYALURONATE POW SODIUM Brand 2 HYALURONIC POW SODIUM Brand 2 HYDRAZINE CRY SULFATE Brand 2 HYDROXOCOBAL POW Brand 2 HYDROXYAMPHE POW HBR Brand 2 HYDROXYCHLOR POW SULFATE Brand 2 HYDROXYETHYL POW CELLULOS Brand 2 HYDROXY CELL POW 1500 CPS Brand 2 HYDROXY CELL POW Brand 2 HYDROXYPROPY POW BETA-CYC Brand 2 HYDROXOCOBAL POW HCL Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 151 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO HYDROXY METH POW 4000 Brand 2 METHOCEL POW K100M Brand 2 METHOCEL POW K100 Brand 2 METHOCEL E4M POW PREMIUM Brand 2 HYDROXYPROG POW CAPROATE Brand 2 HYDROXYUREA POW Brand 2 HYDROXYZINE POW HCL Brand 2 HYDROFLUORIC LIQ 48% Brand 2 HYDROXYETHYL POW METHACRY Brand 2 IDEBENONE POW Brand 2 IDOXURIDINE POW Brand 2 IMIDUREA POW Brand 2 IMIQUIMOD POW Brand 2 LIPACTIVE IN LIQ INCHI WO Brand 2 INDOCYANINE POW GREEN Brand 2 INDOLE-3- POW CARBINOL Brand 2 INOSITOL POW Brand 2 INOSITOL POW HEXANICO Brand 2 IODINE GRA RESUBLIM Brand 2 LUGOLS SOL Brand 2 IODINE SOL STRONG Brand 2 IOPANOIC POW ACID Brand 2 CERAPHYL SLK LIQ Brand 2 ISOMETHEPTEN POW MUCATE Brand 2 ISOPROPYL SOL MYRISTAT Brand 2 ISOPROTERENO POW HCL Brand 2 ISOSORBIDE POW Brand 2 ISOXSUPRINE POW HCL Brand 2 ITRACONAZOLE POW Brand 2 IVERMECTIN POW Brand 2 JASMINE LIQ FRAGRANC Brand 2 JOJOBA OIL Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 152 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO KANAMYCIN POW SULFATE Brand 2 KETAMINE HCL POW Brand 2 KETOROLAC POW TROMETHA Brand 2 7-KETO DHEA POW Brand 2 KETOTIFEN POW FUMARATE Brand 2 KINETIN POW Brand 2 KIWI LIQ FRAGRANC Brand 2 PINENE POW L-ALPHA Brand 2 LABETALOL POW Brand 2 LACTASE 5000 POW Brand 2 ACIDO LACTOB POW 1BU/GM Brand 2 ACIDOPHILUS POW LACTOBAC Brand 2 ACIDO LACTOB POW 10BU/GM Brand 2 LAMOTRIGINE POW Brand 2 LANSOPRAZOLE POW Brand 2 LAURETH-9 LIQ POLIDOCA Brand 2 LAURIC ACID POW Brand 2 LEAD TETROXI POW 99% Brand 2 LEFLUNOMIDE POW Brand 2 LETROZOLE POW Brand 2 LEUCOVORIN POW CALCIUM Brand 2 CALCIUM POW FOLINATE Brand 2 LEUPROLIDE POW ACETATE Brand 2 LEVETIRACETA POW Brand 2 L-CARNITINE POW Brand 2 CARNITINE POW (L) Brand 2 LEVOCARNITIN POW Brand 2 LEVOCETIRIZI POW DHCL Brand 2 LEVOFLOXACIN POW HEMIHYDR Brand 2 LEVOFLOXACIN POW Brand 2 LEVOFLOXACIN POW HEMIHYDR Brand 2 LEVORPHANOL POW TARTRATE Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 153 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO L-THYROXINE POW Brand 2 LEVOTHYROXIN POW SODIUM Brand 2 T4 SODIUM POW DILUTION Brand 2 LICORICE POW DEGLYCY Brand 2 LINCOMYCIN POW HCL Brand 2 LIDOCAINE POW Brand 2 LIDOCAINE POW USP Brand 2 LIDOCAINE POW BASE Brand 2 LIDOCAINE CRY Brand 2 LIMONENE LIQ Brand 2 LINOLEIC LIQ ACID Brand 2 LISINOPRIL POW Brand 2 LITHIUM CITR POW TETRAHYD Brand 2 LORATADINE POW Brand 2 LORAZEPAM POW Brand 2 L-SELENOMETH POW Brand 2 LUTEIN POW Brand 2 LUTEIN BEA 5% Brand 2 L-LYSINE HCL POW Brand 2 MAFENIDE POW ACETATE Brand 2 MAGNESIUM POW ALUMINUM Brand 2 MAGNESIUM POW ASCORBAT Brand 2 MAGNSIUM BIS POW DIHYDRAT Brand 2 MAG CITRATE POW TRIBASIC Brand 2 MAG CITRATE POW Brand 2 MAGNESIUM POW GLUCONAT Brand 2 MAGNESIUM POW GLYCINAT Brand 2 MAGNESIUM POW HYDROXID Brand 2 MAGNESIUM POW MALATE Brand 2 MAGNESIUM POW PHOSPHAT Brand 2 MALEIC ACID POW Brand 2 MALIC ACID POW Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 154 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO MALTODEXTRIN POW Brand 2 MANDELIC POW ACID Brand 2 MANGANESE POW CHLORIDE Brand 2 MANGANESE POW GLUCONAT Brand 2 MANGANESE POW SULFATE Brand 2 MECAMYLAMINE POW HCL Brand 2 MECHLORETHAM POW HCL Brand 2 MECLOFENOXAT POW HCL Brand 2 MEDROXYPROG POW MICRONIZ Brand 2 MEDROXYPROGE POW ACETATE Brand 2 MEDROXYPROGE POW ACETATE Brand 2 MEGLUMINE POW Brand 2 MELOXICAM POW Brand 2 MENADIONE POW USP Brand 2 MEQUINOL POW Brand 2 MERCAPTOPURI POW USP Brand 2 MERCAPTOPURI POW MONOHYDR Brand 2 MERCAPTOPURI POW Brand 2 METACRESOL LIQ ACETATE Brand 2 METFORMIN POW HCL Brand 2 METHACRYLIC POW COPOLYME Brand 2 METHANESULFO LIQ ACID 99% Brand 2 METHOCARBAM POW Brand 2 2-METHOXYEST POW Brand 2 METHOXYETHAN LIQ Brand 2 METHSCOPOLAM POW BROMIDE Brand 2 METHSCOPOLAM POW NITRATE Brand 2 METHYLCOBALA POW Brand 2 METHYLCOBALA POW PREMIUM Brand 2 5-METHYLTETR POW CALCIUM Brand 2 METHYLPHENID POW HCL Brand 2 METHYSERGIDE POW MALEATE Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 155 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DIMETHYL POW SULFONE Brand 2 METRONIDAZOL POW Brand 2 METRONIDAZOL POW USP Brand 2 MEXILETINE POW HCL Brand 2 MIDAZOLAM POW Brand 2 MILK THISTLE POW Brand 2 MILK THISTLE POW EXTRACT Brand 2 MIRTAZAPINE POW ANHYDROU Brand 2 MISOPROSTOL POW HPMC 1% Brand 2 MITOMYCIN POW Brand 2 MITOMYCIN C POW Brand 2 MITOTANE POW Brand 2 MOLYBDENUM POW Brand 2 MOMETASONE POW Brand 2 MONOETHANOLA LIQ Brand 2 L-GLUTAMIC POW ACID Brand 2 MONTELUKAST POW SODIUM Brand 2 MORANTEL POW TARTRATE Brand 2 MOXISYLYTE POW HCL Brand 2 MUPIROCIN POW Brand 2 NABUMETONE POW Brand 2 NICOTINAMIDE POW ADENINE Brand 2 NALBUPHINE POW HCL Brand 2 NALOXONE HCL POW Brand 2 NALOXONE HCL POW DIHYDRAT Brand 2 NALTREXONE POW HCL Brand 2 NANDROLONE POW DECANOAT Brand 2 NEOSTIGMINE POW METHYLSU Brand 2 NICLOSAMIDE POW Brand 2 NADH DISODIU POW Brand 2 NADH DISODIU POW REDUCED Brand 2 NICOTINE POW POLACRIL Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 156 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO NICOTINE POW TARTRATE Brand 2 NIMODIPINE POW Brand 2 NITROFURANTN POW ANHYDR Brand 2 NITROFURANTN POW Brand 2 NORETHINDRON POW Brand 2 TRITON X-100 LIQ Brand 2 OCTINOXATE LIQ Brand 2 OMEPRAZOLE POW Brand 2 ONDANSETRON POW HCL Brand 2 ORIGANUM OIL Brand 2 L-ORNITHINE POW HCL Brand 2 ORNITHINE POW HCL Brand 2 OXANDROLONE POW Brand 2 OXYBUTININ POW CHLORIDE Brand 2 OXYMETAZOLIN POW HCL Brand 2 HYDROXYQUINO POW SULFATE Brand 2 OXYTETRACYCL POW DIHYDRAT Brand 2 OXYTOCIN POW Brand 2 PALMAROSA OIL Brand 2 PALMITOYL GEL PENT-3 Brand 2 PANCREATIN POW Brand 2 PANCURONIUM POW BROMIDE Brand 2 PANTHENOL POW Brand 2 DL-PANTHENOL POW Brand 2 PAPAIN POW Brand 2 PARACHLOROPH POW Brand 2 PAROMOMYCIN POW SULFATE Brand 2 PEG-40 CASTO OIL Brand 2 PEG 400 POW MONOSTEA Brand 2 PEMOLINE POW Brand 2 PENNYROYAL OIL Brand 2 PENTOSAN POW SODIUM Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 157 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PENTOXIFYL POW Brand 2 PENTYLENE LIQ GLYCOL Brand 2 PENTYLENETET CRY Brand 2 PERGOLIDE POW MESYLATE Brand 2 PERMETHRIN LIQ Brand 2 PERPHENAZINE POW Brand 2 PEUCEDANUM SOL OSTRUTHI Brand 2 PHENELZINE POW SULFATE Brand 2 PHENINDIONE POW Brand 2 PHENOXYETHAN LIQ Brand 2 PHENOLSULFON LIQ ACID Brand 2 PHENOXYBENZA POW Brand 2 PHENTERMINE POW HCL Brand 2 PHENYL SALIC CRY Brand 2 PHENYLETHYLA POW HCL Brand 2 PHENYTOIN POW Brand 2 PHOSPHATIDYL POW CHOLINE Brand 2 PHYTIC ACID LIQ 50% Brand 2 PHYTONADIONE LIQ Brand 2 VITAMIN K1 POW Brand 2 PIMOBENDAN POW Brand 2 PINE NEEDLE OIL Brand 2 PINEAPPLE LIQ EXTRACT Brand 2 PIPERINE POW Brand 2 PIRACETAM POW Brand 2 PODOFILOX POW Brand 2 COSMOCIL CQ LIQ Brand 2 POLYHEXAMETH LIQ 20% BIGU Brand 2 BRIJ 35 MIS Brand 2 BRIJ 93 LIQ Brand 2 BRIJ 700 MIS Brand 2 POLYVINYL POW ALCOHOL Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 158 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO POMEGRANATE OIL 80% Brand 2 PONAZURIL POW Brand 2 POTASSIUM POW ACETATE Brand 2 POT ACETATE CRY Brand 2 POTASSIUM POW METABISU Brand 2 POTASSIUM POW ASPARTAT Brand 2 POT AZELAOYL LIQ DIGLYCIN Brand 2 POTASSIUM GRA IODIDE Brand 2 POTASSIUM POW IODIDE Brand 2 POTASSIUM CRY IODIDE Brand 2 POT PHOSPHAT POW MONOBAS Brand 2 POT PHOSPHAT CRY MONOBASI Brand 2 POT PHOSPHAT GRA DIBASIC Brand 2 POT PHOSPHAT POW DIBASIC Brand 2 POTASSIUM POW SULFATE Brand 2 POVIDONE POW K-30 Brand 2 POVIDONE POW Brand 2 POVIDONE POW IODINE Brand 2 POWDER SCENT LIQ FRAGRANC Brand 2 PRALIDOXIME POW CHLORIDE Brand 2 PRAZIQUANTEL POW Brand 2 PRIMIDONE POW Brand 2 PROCHLORPERA POW EDISYLAT Brand 2 PROFLAVINE POW HEMISULF Brand 2 PROMAZINE POW HCL Brand 2 PROMETHAZINE POW HCL Brand 2 PROMETHAZINE CRY HCL Brand 2 PROPARACAINE POW HCL Brand 2 PROPYL POW GALLATE Brand 2 PROPYLENE LIQ GLYCOL Brand 2 PROPYLENE GL BEA MONOSTEA Brand 2 PROPYLTHIOUR POW Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 159 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PROTAMINE POW SULFATE Brand 2 PROTIRELIN POW Brand 2 PSYLLIUM POW HUSK Brand 2 PYRANTEL POW PAMOATE Brand 2 PYRIDOSTIGMI POW BROMIDE Brand 2 PYRIDOXAL-5- POW PHOSPHAT Brand 2 PYRIMETHAMIN POW Brand 2 ZINC PYRITHI LIQ Brand 2 QUATERNIUM- POW 15 Brand 2 QUERCETIN POW DIHYDRAT Brand 2 QUININE HCL CRY Brand 2 RACEPINEPHRI POW HCL Brand 2 RANITIDINE POW HCL Brand 2 RAPESEED OIL Brand 2 RAUWOLFIA POW SERPENTI Brand 2 RED YEAST POW RICE Brand 2 RESVERATROL POW Brand 2 RIBAVIRIN POW Brand 2 RIBOFLAVIN POW Brand 2 RIBO-5-PHOSP POW SODIUM Brand 2 RONIDAZOLE POW Brand 2 ROSE BENGAL POW B Brand 2 RUBIDIUM POW CHLORIDE Brand 2 RUTIN POW Brand 2 SACCHARIN CRY CALCIUM Brand 2 AC DERMAPEPT LIQ Brand 2 SAGE LEAF POW Brand 2 SALSALATE POW Brand 2 SAW PALMETTO POW Brand 2 SAW PALMETTO POW BERRY Brand 2 SCARLET RED POW Brand 2 SECRETIN- POW MANNITOL Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 160 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO SELENIUM POW SULFIDE Brand 2 SELENIUM POW YEAST Brand 2 SENNA EXT Brand 2 SERMORELIN POW ACETATE Brand 2 SEROTONIN POW HCL Brand 2 SERTRALINE POW Brand 2 SHARK POW CARTLG Brand 2 SHOWER FRESH LIQ FRAGRANC Brand 2 SIB GINSENG POW Brand 2 SILICONE LIQ Brand 2 DOW CORNING LIQ 200 Brand 2 SILICONE GEL BLEND Brand 2 SILICNE BLND PST CUSTOM Brand 2 SILVER SULFA POW Brand 2 SIMVASTATIN POW Brand 2 SINCALIDE IN POW MANNITOL Brand 2 SIROLIMUS POW Brand 2 SOD ACETATE POW TRIHYDRA Brand 2 SOD ALGINATE POW Brand 2 ASCRBYL PHOS POW SOD DIHY Brand 2 SODIUM POW CAPRATE Brand 2 SODIUM POW CAPYRLAT Brand 2 SODIUM POW BICARBON Brand 2 SOD BISULFIT GRA Brand 2 SODIUM MIS CHLORITE Brand 2 SOD CITRATE POW DIHYDRAT Brand 2 NA COCOYL LIQ GLUTAMTE Brand 2 DEHYDROACETA POW SODIUM Brand 2 DEOXYCHOLATE POW SODIUM Brand 2 DEOXYCHOLIC POW ACID Brand 2 SODIUM POW DICHLORO Brand 2 SOD FLUORIDE POW Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 161 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO SODIUM POW GLUCONAT Brand 2 SOD IODIDE GRA Brand 2 SOD LACTATE SOL 60% Brand 2 SODIUM LAURE POW SULFATE Brand 2 SOD METABISU GRA Brand 2 SOD METABISU POW Brand 2 SOD FLUORO POW PHOSPHAT Brand 2 SODIUM POW NITRATE Brand 2 SODIUM POW OLEATE Brand 2 PHENYLBUTYRA POW SODIUM Brand 2 SOD PHOSPHAT GRA DIBASIC Brand 2 SOD PHOS DIB POW ANHYDR Brand 2 SOD PHOS DIB POW DRIED Brand 2 SOD PHOS DIB POW HEPTAHYD Brand 2 SOD PHOSPHAT CRY DIBASIC Brand 2 NA PHOS MONO POW ANHYDROU Brand 2 SOD PHOSPHAT CRY TRIBASIC Brand 2 SODIUM LIQ PIDOLATE Brand 2 SOD PROPION POW Brand 2 SODIUM POW SELENITE Brand 2 SOD STEARATE POW Brand 2 SOD STEARYL POW FUMARATE Brand 2 SODIUM POW SUCCINAT Brand 2 SODIUM TARTR POW DIHYDRAT Brand 2 SOD TETR SUL SOL 27% Brand 2 SODIUM TETRA POW SULFATE Brand 2 THIOSALICYLI POW SODIUM Brand 2 SORBITAN LIQ MONOLAUR Brand 2 SORBITAN LIQ MONOOLEA Brand 2 SORBITAN POW MONOPALM Brand 2 SOYABEAN POW CASEIN Brand 2 LECITHIN SOY GRA Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 162 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO LECITHIN GRA SOYA Brand 2 LECITHIN GRA Brand 2 LECITHIN SOY POW Brand 2 PHOSPHATIDYL POW 40% Brand 2 CETYL ESTERS MIS Brand 2 SQUALANE LIQ Brand 2 SQUALANE OIL Brand 2 SQUARIC ACID POW Brand 2 DIBUTYL LIQ SQUARATE Brand 2 STANNOUS CRY CHLORIDE Brand 2 STANOZOLOL POW Brand 2 STEVIA POW EXTRACT Brand 2 STEVIOL GLYC POW 95% Brand 2 STEVIOSIDE EXT 15% Brand 2 STEVIOSIDE POW 90% Brand 2 ST JOHNS POW WORT Brand 2 STRONTIUM CRY CHLORIDE Brand 2 DIMERCAPTOSU POW ACID Brand 2 SUCCIMER DMS POW Brand 2 SUCCINIC ACD CRY Brand 2 SUCCINYLCHOL POW CHLORIDE Brand 2 SUCROSE OCTA CRY ACETATE Brand 2 SUFENTANIL POW CITRATE Brand 2 SULFACETAMID POW USP Brand 2 SULFADIMETHO POW Brand 2 SULFAMERAZIN POW Brand 2 SULFOSALICYL POW DIHYDRAT Brand 2 SULFUR POW Brand 2 SULFUR POW PRECIPIT Brand 2 SULFUR POW SUBLIMED Brand 2 SULPIRIDE POW Brand 2 SUMATRIPTAN POW Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 163 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO SUMATRIPTAN POW SUCCINAT Brand 2 SUPEROXIDE SOL DISMUTAS Brand 2 SUPEROXIDE POW DISMUTAS Brand 2 TACROLIMUS POW MONOHYD Brand 2 TACROLIMUS POW Brand 2 TAMOXIFEN POW CITRATE Brand 2 TAZAROTENE POW Brand 2 TEA TREE OIL Brand 2 TERBINAFINE POW HCL Brand 2 TESTOSTERONE POW MICRONIZ Brand 2 TESTOSTERONE CRY YAM Brand 2 TESTOSTERONE POW ENANTHAT Brand 2 TETRACAINE POW Brand 2 TETRAHYDROBI POW DIHCL Brand 2 TETRAHYDROZ POW Brand 2 THEANINE POW Brand 2 THEOBROMINE POW Brand 2 THIOGUANINE POW Brand 2 THIORIDAZINE POW HCL Brand 2 THIOTEPA POW Brand 2 THYROID 3X POW PORCINE Brand 2 TITANIUM DIO LIQ 30% Brand 2 TITANIUM POW DIOXIDE Brand 2 TIZANIDINE POW HCL Brand 2 TOBRAMYCIN POW Brand 2 TOLAZOLINE POW HCL Brand 2 TOLUIDINE POW BLUE O Brand 2 TOLTRAZURIL POW Brand 2 TOPIRAMATE POW Brand 2 TRAMADOL HCL POW Brand 2 TRANEXAMIC POW ACID Brand 2 TRANILAST POW Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 164 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO RENOVAGE LIQ Brand 2 TRIACETIN LIQ Brand 2 TRIAMCINOLON POW USP Brand 2 TRIAMCINOLON POW Brand 2 TRIAMCINOLON POW HEXACETO Brand 2 TRICHLORMETH POW USP Brand 2 TRICLOSAN POW Brand 2 TEA LAURYL LIQ SULFATE Brand 2 TRIFLURIDINE POW Brand 2 TRILOSTANE POW Brand 2 TRIMEPRAZINE POW TARTRATE Brand 2 TRIMETHOBENZ POW HCL Brand 2 TRIOXSALEN POW Brand 2 TRIPROLIDINE CRY Brand 2 TROMETHAMINE POW Brand 2 TROPOLONE POW Brand 2 TRYPSIN POW Brand 2 TURMERIC POW Brand 2 CURCUMIN POW Brand 2 TYLOSIN POW TARTRATE Brand 2 TYLOXAPOL LIQ Brand 2 UBIQUINOL POW Brand 2 UBIQUINOL POW 30% Brand 2 UREA POW Brand 2 URIDINE POW Brand 2 URSODIOL POW Brand 2 VALACYCLOVIR POW HCL Brand 2 VALERIAN POW ROOT Brand 2 VALPROIC ACI LIQ Brand 2 SOD VALPROAT POW Brand 2 VALPROATE POW SODIUM Brand 2 VANADIUM POW Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 165 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO VANADYL CRY SULFATE Brand 2 VIDARABINE POW Brand 2 VINPOCETINE POW Brand 2 RETINOL FILM OIL MOLECULR Brand 2 VITAMIN A BEA ACETATE Brand 2 VITAMIN A LIQ PALMITAT Brand 2 TOCOPHEROL LIQ ALPHA Brand 2 VITAMIN E LIQ ACETATE Brand 2 VITAMIN E POW SUCCINAT Brand 2 TOCOPHERYL POW SUCCINAT Brand 2 VORICONAZOLE POW Brand 2 WHEY PROTEIN POW ISOLATE Brand 2 WHITE KIDNEY POW BEAN EXT Brand 2 SEPICALM VG LIQ Brand 2 XYLAZINE HCL POW Brand 2 XYLITOL POW Brand 2 XYLOMETAZOLI POW HCL Brand 2 YEAST EXTRCT LIQ Brand 2 YOHIMBINE POW Brand 2 ZEAXANTHIN POW Brand 2 ZINC ACETATE POW Brand 2 ZINC CHLORID POW Brand 2 ZINC CITRATE POW Brand 2 ZINC GLUCONA POW Brand 2 MONOMETHIONI POW ZINC Brand 2 ZINC OXIDE POW Brand 2 ZINC PICOLIN POW Brand 2 ZN UNDECYLEN POW USP Brand 2 ZN UNDECYLEN POW Brand 2 ZIRCONIUM POW OXIDE Brand 2 NATAPRES LIQ Brand 2 POLYOX POW WSR-301 Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 166 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO Contraceptives PARAGARD IUD T380A Brand 0 JOLIVETTE TAB 0.35MG generic 0 ERRIN TAB 0.35MG generic 0 NORA-BE TAB 0.35MG generic 0 ORTHO MICRON TAB 0.35MG Brand 0 GR JENCYCLA TAB 0.35MG generic 0 NOR-QD TAB 0.35MG Brand 0 GR CAMILA TAB 0.35MG generic 0 NORETHINDRON TAB 0.35MG generic 0 LYZA TAB 0.35MG generic 0 HEATHER TAB 0.35MG generic 0 MEDROXYPR AC INJ 150MG/ML generic 0 QL 1/90 DEPO-PROVERA INJ 150MG/ML Brand 0 GR DEPO-SQ PROV INJ 104 Brand 0 SKYLA IUD 13.5MG Brand 0 QL 1/365 MIRENA IUD SYSTEM Brand 0 NEXPLANON IMP 68MG Brand 0 IMPLANON IMP 68MG Brand 0 LEVONORGESTR TAB 0.75MG generic 0 PLAN B TAB 0.75MG Brand 0 GR NEXT CHOICE TAB 1.5MG generic 0 MY WAY TAB 1.5MG generic 0 PLAN B TAB 1.5MG Brand 0 GR LEVONORGESTR TAB 1.5MG generic 0 ELLA TAB 30MG Brand 0 ORTHO EVRA DIS WEEK Brand 0 NUVARING MIS Brand 0 APRI TAB generic 0 ENSKYCE TAB generic 0 ORTHO-CEPT TAB 28 Brand 0 GR

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 167 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DESOGEN-28 TAB Brand 0 GR SOLIA TAB generic 0 RECLIPSEN TAB generic 0 EMOQUETTE TAB generic 0 VESTURA TAB 3-0.02MG generic 0 YAZ TAB 3-0.02MG Brand 0 GR LORYNA TAB 3-0.02MG generic 0 GIANVI TAB 3-0.02MG generic 0 OCELLA TAB 3-0.03MG generic 0 ZARAH TAB 3-0.03MG generic 0 SYEDA TAB 3-0.03MG generic 0 DROSPIR/ETHI TAB 3-0.03MG generic 0 YASMIN 28 TAB 3-0.03MG Brand 0 GR KELNOR TAB 1/35 generic 0 ZOVIA 1/35E TAB generic 0 ZOVIA 1/50E TAB Brand 0 LUTERA TAB generic 0 AUBRA TAB 0.1-0.02 generic 0 FALMINA TAB generic 0 ORSYTHIA TAB generic 0 LEVONOR/ETHI TAB 0.1-0.02 generic 0 AVIANE TAB generic 0 LESSINA TAB generic 0 SRONYX TAB generic 0 MARLISSA TAB 0.15/30 generic 0 PORTIA-28 TAB generic 0 LEVORA-28 TAB 0.15/30 generic 0 LEVONOR/ETHI TAB ESTRADIO generic 0 KURVELO TAB 0.15/30 generic 0 ALTAVERA TAB generic 0 CHATEAL TAB 0.15/30 generic 0 OVCON-35 TAB Brand 0 GR KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 168 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ZENCHENT TAB generic 0 BRIELLYN TAB generic 0 BALZIVA TAB generic 0 PHILITH TAB 0.4-35 generic 0 GILDAGIA TAB 0.4-35 generic 0 BREVICON TAB 0.5/35 Brand 0 GR MODICON TAB 0.5/35 Brand 0 GR NORTREL TAB 0.5/35 generic 0 NECON TAB 0.5/35 generic 0 WERA TAB 0.5/35 generic 0 NORINYL TAB 1/35 Brand 0 GR CYCLAFEM TAB 1/35 generic 0 ALYACEN TAB 1/35 generic 0 DASETTA TAB 1/35 generic 0 PIRMELLA TAB 1/35 generic 0 NORTREL TAB 1/35 generic 0 ORTHO-NOVUM TAB 1/35 Brand 0 GR NECON TAB 1/35 generic 0 LOESTRIN TAB 1/20-21 Brand 0 GR GILDESS TAB 1/20 generic 0 JUNEL 1/20 TAB generic 0 MICROGESTIN TAB 1/20 generic 0 LOESTRIN 21 TAB 1.5/30 Brand 0 GR JUNEL 1.5/30 TAB generic 0 MICROGESTIN TAB 1.5/30 generic 0 GILDESS TAB 1.5/30 generic 0 NECON TAB 1/50-28 Brand 0 NORINYL TAB 1+50-28 Brand 0 LOW-OGESTREL TAB generic 0 ELINEST TAB generic 0 CRYSELLE-28 TAB 28 TABS generic 0 OGESTREL TAB generic 0 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 169 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO MONONESSA TAB generic 0 MONO-LINYAH TAB 0.25-35 generic 0 ESTARYLLA TAB 0.25-35 generic 0 NORGEST/ETHI TAB 0.25/35 generic 0 ORTHO-CYCLEN TAB 0.25/35 Brand 0 GR PREVIFEM TAB generic 0 SPRINTEC 28 TAB 28 DAY generic 0 BEYAZ TAB Brand 0 SAFYRAL TAB Brand 0 WYMZYA FE CHW 0.4MG-35 generic 0 ZENCHENT FE CHW 0.4MG-35 generic 0 FEMCON FE CHW Brand 0 GR GENERESS FE CHW Brand 0 LOESTRIN FE TAB 1/20 Brand 0 GR GILDESS FE TAB 1/20 generic 0 JUNEL FE TAB 1/20 generic 0 MICROGESTIN TAB FE 1/20 generic 0 MICROGESTIN TAB FE1.5/30 generic 0 LOESTRIN FE TAB 1.5/30 Brand 0 GR JUNEL FE TAB 1.5/30 generic 0 GILDESS FE TAB 1.5/30 generic 0 MINASTRIN 24 CHW FE Brand 0 AZURETTE TAB 28 DAY generic 0 VIORELE TAB generic 0 KARIVA TAB 28 DAY generic 0 MIRCETTE TAB 28 DAY Brand 0 GR NECON TAB 10/11-28 generic 0 LO LOESTRIN TAB Brand 0 LO MINASTRIN PAK FE Brand 0 CYCLESSA PAK Brand 0 GR VELIVET PAK generic 0 CAZIANT PAK generic 0 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 170 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO CESIA PAK generic 0 LEVONEST TAB generic 0 MYZILRA TAB generic 0 TRIVORA-28 TAB generic 0 ENPRESSE-28 TAB generic 0 CYCLAFEM TAB 7/7/7 generic 0 NECON TAB 7/7/7 generic 0 NORTREL TAB 7/7/7 generic 0 DASETTA TAB 7/7/7 generic 0 ALYACEN TAB 7/7/7 generic 0 PIRMELLA TAB 7/7/7 generic 0 ORTHO-NOVUM TAB 7/7/7 Brand 0 GR LEENA TAB generic 0 TRI-NORINYL TAB 28 Brand 0 GR ARANELLE TAB generic 0 ORTHO TRI- TAB CYCLN LO Brand 0 NORGEST/ETHI TAB ESTRADIO generic 0 TRI-ESTARYLL TAB generic 0 ORTHO TRI- TAB CYCLEN Brand 0 GR TRINESSA TAB generic 0 TRI-PREVIFEM TAB generic 0 TRI-SPRINTEC TAB generic 0 TRI-LINYAH TAB generic 0 TILIA FE TAB generic 0 TRI-LEGEST TAB FE generic 0 ESTROSTEP FE TAB Brand 0 GR NATAZIA TAB Brand 0 AMETHIA LO TAB generic 0 LOSEASONIQUE TAB Brand 0 GR CAMRESE LO TAB generic 0 LEVONOR/ETHI TAB ESTRADIO generic 0 LEVONOR/ETHI TAB ESTRADIO generic 0 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 171 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO INTROVALE TAB generic 0 JOLESSA TAB generic 0 QUASENSE TAB generic 0 SEASONIQUE TAB Brand 0 GR DAYSEE TAB generic 0 CAMRESE TAB generic 0 AMETHIA TAB generic 0 QUARTETTE TAB Brand 0 AMETHYST TAB 90-20MCG generic 0 Corticosteroids CELESTONE SOL 0.6MG/5 Brand 2 ENTOCORT EC CAP 3MG/24HR Brand 2 GR BUDESONIDE CAP 3MG/24HR generic 1 UCERIS TAB 9MG Brand 2 QL 90/30 CORTISONE AC TAB 25MG generic 1 DEXAMETHASON TAB 0.5MG generic 1 DEXAMETHASON TAB 0.75MG generic 1 DEXAMETHASON TAB 1MG generic 1 DEXAMETHASON TAB 1.5MG generic 1 DEXAMETHASON TAB 2MG generic 1 DEXAMETHASON TAB 4MG generic 1 DEXAMETHASON TAB 6MG generic 1 DEXAMETHASON ELX 0.5/5ML generic 1 BAYCADRON ELX 0.5/5ML generic 1 DEXAMETHASON CON 1MG/ML generic 1 DEXAMETHASON SOL 0.5/5ML generic 1 DEXPAK PAK 6 DAY Brand 2 DEXPAK PAK 13 DAY Brand 2 DEXPAK PAK 10 DAY Brand 2 DEXAMETH PHO INJ 4MG/ML generic 1 DEXAMETH PHO INJ 10MG/ML generic 1

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 172 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DEXAMETH PHO INJ 10MG/ML generic 1 CORTEF TAB 5MG Brand 2 GR HYDROCORT TAB 5MG generic 1 HYDROCORT TAB 10MG generic 1 CORTEF TAB 10MG Brand 2 GR HYDROCORT TAB 20MG generic 1 CORTEF TAB 20MG Brand 2 GR A-HYDROCORT INJ 100MG generic 1 SOLU-CORTEF INJ 100MG Brand 2 GR SOLU-CORTEF INJ 250MG Brand 2 SOLU-CORTEF INJ 500MG Brand 2 SOLU-CORTEF INJ 1000MG Brand 2 MEDROL TAB 2MG Brand 2 METHYLPRED TAB 4MG generic 1 MEDROL TAB 4MG Brand 2 GR METHYLPRED TAB 8MG generic 1 MEDROL TAB 8MG Brand 2 GR MEDROL TAB 16MG Brand 2 GR METHYLPRED TAB 16MG generic 1 METHYLPRED TAB 32MG generic 1 MEDROL TAB 32MG Brand 2 GR METHYLPRED PAK 4MG generic 1 MEDROL PAK 4MG Brand 2 GR DEPO-MEDROL INJ 20MG/ML Brand 2 METHYLPR ACE INJ 40MG/ML generic 1 DEPO-MEDROL INJ 40MG/ML Brand 2 GR DEPO-MEDROL INJ 80MG/ML Brand 2 GR METHYLPR ACE INJ 80MG/ML generic 1 A-METHAPRED INJ 40MG generic 1 SOLU-MEDROL INJ 40MG Brand 2 GR METHYLPR SS INJ 40MG generic 1 A-METHAPRED INJ 125MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 173 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO SOLU-MEDROL INJ 125MG Brand 2 GR METHYLPR SS INJ 125MG generic 1 SOLU-MEDROL INJ 500MG Brand 2 GR METHYLPR SS INJ 500MG generic 1 SOLU-MEDROL INJ 1GM Brand 2 GR METHYLPR SS INJ 1000MG generic 1 METHYLPR SS INJ 1GM generic 1 SOLU-MEDROL INJ 2GM Brand 2 MILLIPRED TAB 5MG Brand 2 PREDNISOLONE SOL 15MG/5ML generic 1 PREDNISOLONE SYP 15MG/5ML generic 1 PRELONE SYP 15MG/5ML Brand 2 GR MILLIPRED DP PAK 5MG Brand 2 FLO-PRED SUS Brand 2 PA ASMALPRED SOL PLUS generic 1 PREDNISOLONE SOL 15MG/5ML generic 1 ORAPRED SOL 15MG/5ML Brand 2 GR PREDNISOLONE SOL 25MG/5ML generic 1 PEDIAPRED SOL 6.7/5ML Brand 2 GR PRED SOD PHO SOL 5MG/5ML generic 1 MILLIPRED SOL 10MG/5ML Brand 2 VERIPRED 20 SOL 20MG/5ML Brand 2 ORAPRED ODT TAB 10MG Brand 2 ORAPRED ODT TAB 15MG Brand 2 ORAPRED ODT TAB 30MG Brand 2 PREDNISONE TAB 1MG generic 1 PREDNISONE TAB 2.5MG generic 1 PREDNISONE TAB 5MG generic 1 PREDNISONE TAB 10MG generic 1 PREDNISONE TAB 20MG generic 1 PREDNISONE TAB 50MG generic 1 RAYOS TAB 1MG Brand 2 PA KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 174 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO RAYOS TAB 2MG Brand 2 PA RAYOS TAB 5MG Brand 2 PA PREDNISONE CON 5MG/ML generic 1 PREDNISONE SOL 5MG/5ML generic 1 PREDNISONE PAK 5MG generic 1 PREDNISONE PAK 10MG generic 1 KENALOG-10 INJ 10MG/ML Brand 2 KENALOG-40 INJ 40MG/ML Brand 2 ARISTOSPAN INJ 5MG/ML Brand 2 ARISTOSPAN INJ 20MG/ML Brand 2 CELESTONE INJ SOLUSPAN Brand 2 GR BETA-PHOS/AC INJ 3-3MG/ML generic 1 PHYS EZ USE KIT M-PRED Brand 2 JNT/TUNNEL/ KIT TRIGGER Brand 2 FLUDROCORT TAB 0.1MG generic 1 Cough/Cold/Allergy HYDROCODONE/ TAB HOMATROP generic 1 TUSSIGON TAB 5MG generic 1 HYDROCOD/HOM SYP 5-1.5/5 generic 1 HYDROMET SYP 5-1.5/5 generic 1 BENZONATATE CAP 100MG generic 1 BENZONATATE CAP 200MG generic 1 ACETYLCYST SOL 10% generic 1 ACETYLCYST SOL 20% generic 1 SOD CHLORIDE NEB 0.9% generic 1 NEBUSAL NEB 3% generic 1 SODIUM CHLOR NEB 3% generic 1 SODIUM CHLOR NEB 7% generic 1 SODIUM CHLOR NEB 10% generic 1 CLARINEX-D TAB 2.5-120 Brand 2 NON-PREF ST CLARINEX-D TAB 5-240MG Brand 2 NON-PREF ST

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 175 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PROMETH VC SYP PLAIN generic 1 PROMETH/COD SYP 6.25-10 generic 1 HYD POL/CPM LIQ 10-8/5ML generic 1 PROMETHAZINE SYP DM generic 1 TGQ 7.5PEH/4 LIQ BRM/15DM generic 1 DM/CPM/PE DRO generic 1 HDC DM SYP generic 1 BROMFED DM SYP generic 1 TGQ 30/PSE/3 SYP BRM/15DM generic 1 TGQ 50PSE/3 SYP BRM/30DM generic 1 PE/GUAIFENES DRO 1.5-20MG generic 1 GUAIATUSSIN SYP AC generic 1 NORTUSS-EX LIQ 200-20/5 generic 1 BIOTUSS LIQ generic 1 TUSSAFED EX LIQ generic 1 BIOTUSS LIQ PEDIATRC generic 1 NORTUSS-DE DRO generic 1 TGQ 30/ SYP 150/15 generic 1 Dermatologics ADAPALENE CRE 0.1% generic 1 NON-PREF ST DIFFERIN CRE 0.1% Brand 2 PREF ADAPALENE GEL 0.1% generic 1 NON-PREF ST DIFFERIN GEL 0.1% Brand 2 PREF DIFFERIN GEL 0.3% Brand 2 PREF DIFFERIN LOT 0.1% Brand 2 PREF AZELEX CRE 20% Brand 2 BP WASH LIQ 2.5% generic 1 LAVOCLEN-4 LIQ CREM WSH Brand 2 BENZAC AC LIQ 5% WASH Brand 2 GR BENZAC W LIQ 5% WASH Brand 2 GR SE BPO WASH LIQ 7% generic 1

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 176 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO BP WASH LIQ 7% generic 1 PR BENZOYL LIQ 7% WASH generic 1 LAVOCLEN-8 LIQ CREM WSH Brand 2 BENZIQ WASH LIQ 5.25% generic 1 RIAX AER 5.5% Brand 2 PA RIAX AER 9.5% Brand 2 PA BP FOAM AER 9.8% generic 1 BENZEFOAM AER 9.8% Brand 2 GR BENZEPRO SC AER 9.8% generic 1 BENZOYL PERO AER 9.8% generic 1 BENZOYL PER AER 9.8% generic 1 BENZIQ LS GEL 2.75% Brand 2 BENZIQ GEL 5.25% Brand 2 BPO GEL 4% generic 1 BPO GEL 8% Brand 2 CLEARPLEX X GEL 10% generic 1 OSCION CLNSR LOT 6% generic 1 ZACLIR LOT 8% generic 1 BPO CLOTHS MIS 3% Brand 2 BPO CLOTHS MIS 6% Brand 2 BPO CLOTHS MIS 9% Brand 2 BPO CREAMY KIT 8% WASH generic 1 BENZOYL PERO KIT ACNE PCK generic 1 NUOX GEL 6-3% Brand 2 PA ZENATANE CAP 10MG generic 1 AMNESTEEM CAP 10MG generic 1 CLARAVIS CAP 10MG generic 1 ABSORICA CAP 10MG Brand 2 QL 60/30 PA MYORISAN CAP 10MG generic 1 MYORISAN CAP 20MG generic 1 ZENATANE CAP 20MG generic 1 AMNESTEEM CAP 20MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 177 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO CLARAVIS CAP 20MG generic 1 ABSORICA CAP 20MG Brand 2 QL 60/30 PA ABSORICA CAP 30MG Brand 2 QL 60/30 PA CLARAVIS CAP 30MG generic 1 ABSORICA CAP 40MG Brand 2 QL 60/30 PA CLARAVIS CAP 40MG generic 1 MYORISAN CAP 40MG generic 1 ZENATANE CAP 40MG generic 1 AMNESTEEM CAP 40MG generic 1 SULFOAM SHA 2% Brand 2 FABIOR AER 0.1% Brand 2 PA AVITA CRE 0.025% generic 1 NON-PREF ST TRETINOIN CRE 0.025% generic 1 PREF RETIN-A CRE 0.025% Brand 2 NON-PREF ST TRETIN-X CRE 0.0375% Brand 2 TRETINOIN CRE 0.05% generic 1 PREF RETIN-A CRE 0.05% Brand 2 NON-PREF ST TRETIN-X CRE 0.075% Brand 2 TRETINOIN CRE 0.1% generic 1 PREF RETIN-A CRE 0.1% Brand 2 NON-PREF ST RETIN-A GEL 0.01% Brand 2 NON-PREF ST TRETINOIN GEL 0.01% generic 1 PREF AVITA GEL 0.025% generic 1 NON-PREF ST TRETINOIN GEL 0.025% generic 1 PREF RETIN-A GEL 0.025% Brand 2 NON-PREF ST ATRALIN GEL 0.05% Brand 2 NON-PREF ST TRETINOIN GEL 0.04% generic 1 PREF TRETINOIN GEL 0.04%PMP generic 1 PREF RETIN-A MICR GEL 0.04% Brand 2 GR RETIN-A MICR GEL 0.04%PMP Brand 2 GR TRETINOIN GEL 0.1%PUMP generic 1 PREF RETIN-A MICR GEL 0.1% Brand 2 NON-PREF ST KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 178 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO TRETINOIN GEL 0.1% generic 1 PREF RETIN-A MICR GEL 0.1%PUMP Brand 2 NON-PREF ST CLINDAMYCIN SOL 1% generic 1 CLEOCIN-T SOL 1% Brand 2 GR CLINDAMYCIN AER 1% generic 1 EVOCLIN AER 1% Brand 2 GR CLINDAMAX GEL 1% generic 1 CLINDAGEL GEL 1% Brand 2 PA CLINDAMYCIN GEL 1% generic 1 CLEOCIN-T GEL 1% Brand 2 GR CLEOCIN-T LOT 1% Brand 2 GR CLINDAMYCIN LOT 1% generic 1 CLINDAMYCIN LOT 10MG/ML generic 1 CLINDAMAX LOT 10MG/ML generic 1 CLEOCIN-T PAD 1% Brand 2 GR CLINDAMYCIN PAD 1% generic 1 CLINDACIN-P PAD 1% generic 1 CLINDACIN MIS ETZ 1% generic 1 ACZONE GEL 5% Brand 2 PA ERYTHROMYCIN SOL 2% generic 1 ERYTHROMYCIN GEL 2% generic 1 AKNE-MYCIN OIN 2% Brand 2 PA ERYTHROMYCIN PAD 2% generic 1 ERY PAD 2% generic 1 SULFACETAMID LOT 10% generic 1 SULFACETAMID SUS 10% generic 1 KLARON LOT 10% Brand 2 GR EPIDUO GEL 0.1-2.5% Brand 2 NON-PREF ST BENZAMYCIN GEL PAK Brand 2 ERYTHROMYCIN GEL /BENZOYL generic 1 BENZAMYCIN GEL Brand 2 GR BENZAMYCIN GEL 5-3% Brand 2 GR KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 179 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ZACARE KIT KIT 4% Brand 2 ZACARE KIT KIT 8% Brand 2 CLINDAMY/BEN GEL 1-5% generic 1 NON-PREF ST BENZACLIN GEL 1-5% Brand 2 PREF PA BENZACLIN GEL 1-5%PUMP Brand 2 PREF PA ACANYA GEL 1.2-2.5% Brand 2 NON-PREF ST CLINDAMY/BEN GEL 1.2-5% generic 1 NON-PREF ST DUAC GEL 1.2-5% Brand 2 GR VELTIN GEL Brand 2 NON-PREF ST ZIANA GEL Brand 2 NON-PREF ST VANOXIDE-HC LOT 5-0.5% Brand 2 ZENCIA LIQ 9-4% generic 1 SUMAXIN WASH LIQ 9-4% Brand 2 GR SOD SUL/SULF LIQ WASH generic 1 SOD SUL/SULF LIQ 9-4.5% generic 1 SUMADAN WASH LIQ 9-4.5% Brand 2 GR SOD SUL/SULF LIQ 10-2% generic 1 AVAR LS LIQ 10-2% Brand 2 GR BP 10-1 EMU generic 1 CERISA WASH EMU 10-1% generic 1 SOD SUL/SULF EMU 10-5% generic 1 PRASCION EMU generic 1 AVAR CLEANSE EMU 10-5% generic 1 ROSANIL EMU CLEANSER generic 1 SUMAXIN TS SUS 8-4% Brand 2 GR SULFACLEANSE SUS 8-4% generic 1 SOD SUL/SULF SUS 8-4% generic 1 SOD SUL/SULF SUS 10-5% Brand 2 SOD SUL/SULF CRE 10-2% generic 1 PA AVAR-E LS CRE 10-2% Brand 2 GR SE 10-5 SS CRE 10-5% generic 1 SSS CRE 10%-5% generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 180 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO SOD SUL/SULF CRE 10-5% generic 1 VIRTI-SULF CRE 10-5% generic 1 AVAR-E GREEN CRE 10-5% generic 1 AVAR-E EMOLL CRE 10-5% generic 1 SSS 10-4 AER 10-4% Brand 2 PA SOD SUL/SULF AER 10-5% generic 1 CLARIFOAM EF AER 10-5% Brand 2 GR SSS 10-5 AER 10-5% generic 1 SOD SUL/SULF LOT 10-5% generic 1 AVAR PAD 9.5-5% Brand 2 AVAR LS PAD 10-2% Brand 2 SOD SUL/SULF PAD 10-4% generic 1 SUMAXIN PAD 10-4% Brand 2 GR SOD SUL/SULF PAD 10-5% generic 1 PRASCION FC PAD 10-5% generic 1 BP CLEANSING EMU 10-4% generic 1 CLARIS WASH EMU 10-4% generic 1 SOD SUL/SULF EMU 10-5% generic 1 SOD SUL/SULF GEL 10-5% Brand 2 ROSANIL KIT Brand 2 SUMAXIN CP KIT Brand 2 PRASCION RA CRE 10-5% generic 1 FINACEA GEL 15% Brand 2 PA MIRVASO GEL 0.33% Brand 2 PA ORACEA CAP 40MG Brand 2 PA ROSADAN CRE 0.75% generic 1 METRONIDAZOL CRE 0.75% generic 1 METROCREAM CRE 0.75% Brand 2 GR NORITATE CRE 1% Brand 2 PA ROSADAN GEL 0.75% generic 1 METRONIDAZOL GEL 0.75% generic 1 METRONIDAZOL GEL 1% generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 181 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO METROGEL GEL 1% Brand 2 GR METROLOTION LOT 0.75% Brand 2 GR METRONIDAZOL LOT 0.75% generic 1 ROSADAN KIT 0.75% Brand 2 ROSADAN KIT 0.75% Brand 2 GENTAMICIN CRE 0.1% generic 1 GENTAMICIN OIN 0.1% generic 1 MUPIROCIN OIN 2% generic 1 PREF BACTROBAN OIN 2% Brand 2 NON-PREF ST CENTANY OIN 2% Brand 2 NON-PREF ST CENTANY AT KIT 2% Brand 2 NON-PREF ST MUPIROCIN CA CRE 2% generic 1 NON-PREF ST MUPIROCIN CRE 2% generic 1 NON-PREF ST BACTROBAN CRE 2% Brand 2 PREF ALTABAX OIN 1% Brand 2 PREF CORTISPORIN CRE 0.5% Brand 2 CORTISPORIN OIN 1% Brand 2 PA MENTAX CRE 1% Brand 2 PA CICLODAN SOL 8% generic 1 PREF PA CICLOPIROX SOL 8% generic 1 PREF PA PENLAC SOL 8% Brand 2 NON-PREF ST CICLOPIROX GEL 0.77% generic 1 PREF PA LOPROX GEL 0.77% Brand 2 GR CICLOPIROX SHA 1% generic 1 LOPROX SHA 1% Brand 2 GR CICLOPIROX KIT 8% generic 1 PREF PA CICLODAN SOL KIT 8% Brand 2 PREF PA CNL8 NAIL KIT Brand 2 NON-PREF ST CICLOPIROX SUS 0.77% generic 1 PREF PA CICLOPIROX CRE 0.77% generic 1 PREF PA CICLODAN CRE 0.77% generic 1 PREF PA CICLODAN CRE KIT 0.77% Brand 2 PREF PA KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 182 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO CICLOPIROX KIT 8% generic 1 NON-PREF ST PA HALOTIN CRE 1% Brand 2 NAFTIN CRE 1% Brand 2 PA NAFTIN CRE 2% Brand 2 PA NAFTIN GEL 1% Brand 2 PA NAFTIN GEL 2% Brand 2 PA NYSTATIN CRE 100000 generic 1 NYSTATIN OIN 100000 generic 1 LAMISIL SPR 1% Brand 2 CLOTRIMAZOLE SOL 1% generic 1 CLOTRIMAZOLE CRE 1% generic 1 ECONAZOLE CRE 1% generic 1 KETOCONAZOLE CRE 2% generic 1 EXTINA AER 2% Brand 2 GR KETODAN AER 2% generic 1 XOLEGEL GEL 2% Brand 2 PA KETOCONAZOLE SHA 2% generic 1 NIZORAL SHA 2% Brand 2 GR OXISTAT CRE 1% Brand 2 PA OXISTAT LOT 1% Brand 2 PA ERTACZO CRE 2% Brand 2 PA EXELDERM SOL 1% Brand 2 EXELDERM CRE 1% Brand 2 PA CLOTRIM/BETA CRE DIPROP generic 1 CLOTRIM/BETA CRE 1-0.05% generic 1 LOTRISONE CRE Brand 2 GR CLOTRIM/BETA LOT DIPROP generic 1 XOLEGEL DUO/ KIT XOLEX Brand 2 XOLEGEL DUO/ KIT HEAD&SHD Brand 2 NYSTAT/TRIAM CRE generic 1 NYSTAT/TRIAM OIN generic 1 EXODERM LOT 25-1% generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 183 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO VERSICLEAR LOT generic 1 XOLEGEL KIT COREPAK Brand 2 VYTONE CRE 1-1.9% Brand 2 PA VUSION OIN Brand 2 FLECTOR DIS 1.3% Brand 2 QL 60/30 PA PENNSAID SOL 1.5% Brand 2 QL 300/30 PA VOLTAREN GEL 1% Brand 2 QL 200/30 PA NAPRO CRE 15% Brand 2 LIDOPROFEN CRE 5-5-2% Brand 2 PRUDOXIN CRE 5% Brand 2 ZONALON CRE 5% Brand 2 DRITHO-CREME CRE HP 1% Brand 2 ZITHRANOL-RR CRE 1.2% Brand 2 ZITHRANOL SHA 1% Brand 2 PA CALCIPOTRIEN SOL 0.005% generic 1 PREF CALCIPOTRIEN CRE 0.005% generic 1 NON-PREF ST DOVONEX CRE 0.005% Brand 2 PREF SORILUX AER 0.005% Brand 2 NON-PREF ST PA CALCITRENE OIN 0.005% generic 1 NON-PREF ST PA CALCIPOTRIEN OIN 0.005% generic 1 NON-PREF ST PA CALCITRIOL OIN 3MCG/GM Brand 2 NON-PREF ST VECTICAL OIN 3MCG/GM Brand 2 NON-PREF ST TAZORAC CRE 0.05% Brand 2 NON-PREF ST TAZORAC CRE 0.1% Brand 2 NON-PREF ST TAZORAC GEL 0.05% Brand 2 NON-PREF ST TAZORAC GEL 0.1% Brand 2 NON-PREF ST ACITRETIN CAP 10MG generic 1 SORIATANE CAP 10MG Brand 2 GR ACITRETIN CAP 17.5MG generic 1 SORIATANE CAP 17.5MG Brand 2 GR ACITRETIN CAP 25MG generic 1 SORIATANE CAP 25MG Brand 2 GR KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 184 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO 8-MOP CAP 10MG Brand 2 OXSORALEN-UL CAP 10MG Brand 2 STELARA INJ 45MG/0.5 Brand 2 NON-PREF ST QL 0.5/30 PA SP STELARA INJ 90MG/ML Brand 2 NON-PREF ST QL 1/90 PA SP GLYCOLIC ACD SOL 70% Brand 2 TERSI FOAM AER 2.25% Brand 2 SELENIUM SUL SHA 2.5% generic 1 SELENIUM SUL LOT 2.5% generic 1 SODIUM SULFA LIQ 10% WASH generic 1 MEXAR WASH LIQ 10% generic 1 SEB-PREV LIQ WASH generic 1 OVACE WASH LIQ 10% Brand 2 GR OVACE PLUS LIQ 10% WASH Brand 2 GR OVACE PLUS CRE 10% Brand 2 SOD SULFACET GEL 10% generic 1 OVACE PLUS GEL 10% WASH Brand 2 GR SEB-PREV LOT 10% Brand 2 SOD SULFACET SHA 10% generic 1 OVACE PLUS SHA 10% Brand 2 GR PROMISEB KIT COMPLETE Brand 2 SODIUM SULFA LIQ 10% WASH Brand 2 SOD SULFACET PAD 10% Brand 2 SELENIUM SUL SHA 2.25% Brand 2 SELRX SHA 2.3% Brand 2 ZOVIRAX CRE 5% Brand 2 ACYCLOVIR OIN 5% generic 1 ZOVIRAX OIN 5% Brand 2 GR DENAVIR CRE 1% Brand 2 XERESE CRE 5-1% Brand 2 VALCHLOR GEL 0.016% Brand 2 FLUOROURACIL SOL 2% generic 1 FLUOROURACIL DRO 2% generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 185 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO FLUOROURACIL SOL 5% generic 1 FLUOROURACIL DRO 5% generic 1 CARAC CRE 0.5% Brand 2 FLUOROPLEX CRE 1% Brand 2 EFUDEX CRE 5% Brand 2 GR FLUOROURACIL CRE 5% generic 1 SOLARAZE GEL 3% W/W Brand 2 QL 100/30 PA LEVULAN KERA SOL 20% Brand 2 PANRETIN GEL 0.1% Brand 2 TARGRETIN GEL 1% Brand 2 PICATO GEL 0.015% Brand 2 QL 3/60 PA PICATO GEL 0.05% Brand 2 QL 2/60 PA MAFENIDE ACE PAK 5% generic 1 SULFAMYLON PAK 5% Brand 2 GR SULFAMYLON CRE 85MG/GM Brand 2 THERMAZENE CRE 1% generic 1 SILVADENE CRE 1% Brand 2 GR SSD CRE 1% generic 1 SILVER SULFA CRE 1% generic 1 SILVER NITRA SOL 0.5% Brand 2 SILVER NITRA SOL 10% Brand 2 SILVER NITRA SOL 25% Brand 2 SILVER NITRA SOL 50% Brand 2 SILVER NITRA OIN 10% Brand 2 TRI-CHLOR LIQ 80% Brand 2 GRAFCO SILVR MIS NIT APPL generic 1 ARZOL SILVER MIS NITR APP Brand 2 GR COAL TAR SOL 20% Brand 2 ALCLOMETASON CRE 0.05% generic 1 PREF ACLOVATE CRE 0.05% Brand 2 GR ALCLOMETASON OIN 0.05% generic 1 PREF AMCINONIDE CRE 0.1% generic 1 NON-PREF ST KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 186 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO AMCINONIDE LOT 0.1% generic 1 NON-PREF ST AMCINONIDE OIN 0.1% generic 1 NON-PREF ST BETAMETH DIP CRE 0.05% generic 1 PREF BETAMETH DIP LOT 0.05% generic 1 PREF BETAMETH DIP OIN 0.05% generic 1 PREF AUG BETAMET CRE 0.05% generic 1 DIPROLENE AF CRE 0.05% Brand 2 GR ALPHATREX GEL 0.05% generic 1 PREF AUG BETAMET GEL 0.05% generic 1 PREF AUG BETAMET LOT 0.05% generic 1 DIPROLENE LOT 0.05% Brand 2 GR AUG BETAMET OIN 0.05% generic 1 DIPROLENE OIN 0.05% Brand 2 GR BETAMETH VAL CRE 0.1% generic 1 PREF LUXIQ AER 0.12% Brand 2 NON-PREF ST BETAMETH VAL AER 0.12% generic 1 PREF BETAMETH VAL LOT 0.1% generic 1 PREF BETAMETH VAL OIN 0.1% generic 1 PREF CLOBEX SPR 0.05% Brand 2 NON-PREF ST CLOBETASOL SOL 0.05% generic 1 NON-PREF ST CORMAX SCALP SOL 0.05% generic 1 NON-PREF ST TEMOVATE SOL 0.05% Brand 2 NON-PREF ST CLOBETASOL CRE 0.05% generic 1 PREF TEMOVATE CRE 0.05% Brand 2 NON-PREF ST CLOBETASOL AER 0.05% generic 1 PREF OLUX AER 0.05% Brand 2 NON-PREF ST CLOBETASOL GEL 0.05% generic 1 PREF TEMOVATE GEL 0.05% Brand 2 NON-PREF ST CLOBETASOL LOT 0.05% generic 1 NON-PREF ST CLOBEX LOT 0.05% Brand 2 NON-PREF ST CLOBETASOL OIN 0.05% generic 1 PREF TEMOVATE OIN 0.05% Brand 2 NON-PREF ST KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 187 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO CLOBETASOL SHA 0.05% generic 1 NON-PREF ST CLOBEX SHA 0.05% Brand 2 NON-PREF ST CLOBETASOL E CRE 0.05% generic 1 PREF TEMOVATE E CRE 0.05%EML Brand 2 NON-PREF ST CLOBETASOL AER 0.05% generic 1 OLUX-E AER 0.05% Brand 2 NON-PREF ST CLODERM CRE 0.1% PMP Brand 2 CLODERM CRE 0.1% Brand 2 DESONIDE CRE 0.05% generic 1 PREF DESOWEN CRE 0.05% Brand 2 GR VERDESO AER 0.05% Brand 2 NON-PREF ST DESONATE GEL 0.05% Brand 2 NON-PREF ST LOKARA LOT 0.05% generic 1 PREF DESOWEN LOT 0.05% Brand 2 GR DESONIDE LOT 0.05% generic 1 PREF DESOWEN OIN 0.05% Brand 2 GR DESONIDE OIN 0.05% generic 1 PREF DESOWEN CRM KIT 0.05% Brand 2 DESOWEN OINT KIT 0.05% Brand 2 TOPICORT SPR 0.25% Brand 2 DESOXIMETAS CRE 0.05% generic 1 NON-PREF ST TOPICORT CRE 0.05% Brand 2 DESOXIMETAS CRE 0.25% generic 1 NON-PREF ST TOPICORT CRE 0.25% Brand 2 GR DESOXIMETAS GEL 0.05% generic 1 NON-PREF ST TOPICORT GEL 0.05% Brand 2 GR TOPICORT OIN 0.05% Brand 2 NON-PREF ST DESOXIMETAS OIN 0.05% Brand 2 NON-PREF ST DESOXIMETAS OIN 0.25% generic 1 NON-PREF ST TOPICORT OIN 0.25% Brand 2 GR DIFLORASONE CRE 0.05% generic 1 NON-PREF ST DIFLORASONE OIN 0.05% generic 1 NON-PREF ST KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 188 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO APEXICON OIN 0.05% generic 1 NON-PREF ST APEXICON E CRE 0.05% Brand 2 NON-PREF ST FLUOCIN ACET OIL BODY generic 1 NON-PREF ST FLUOCIN ACET OIL 0.01% SC generic 1 NON-PREF ST FLUOCIN ACET OIL SCALP generic 1 NON-PREF ST DERMA-SMOOTH OIL /FS BODY Brand 2 NON-PREF ST DERMA-SMOOTH OIL /FS SCLP Brand 2 NON-PREF ST FLUOCIN ACET SOL 0.01% generic 1 PREF SYNALAR SOL 0.01% Brand 2 GR FLUOCIN ACET CRE 0.01% generic 1 PREF SYNALAR CRE 0.025% Brand 2 GR FLUOCIN ACET CRE 0.025% generic 1 PREF SYNALAR OIN 0.025% Brand 2 GR FLUOCIN ACET OIN 0.025% generic 1 PREF CAPEX SHA 0.01% Brand 2 NON-PREF ST FLUOCINONIDE SOL 0.05% generic 1 PREF FLUOCINONIDE CRE 0.05% generic 1 PREF VANOS CRE 0.1% Brand 2 NON-PREF ST FLUOCINONIDE GEL 0.05% generic 1 PREF FLUOCINONIDE OIN 0.05% generic 1 PREF FLUOCINONIDE CRE -E 0.05% generic 1 PREF CORDRAN SP CRE 0.05% Brand 2 PA CORDRAN LOT 0.05% Brand 2 PA CORDRAN 24X3 TAP 4MCG/CM Brand 2 NON-PREF ST CORDRAN 80X3 TAP 4MCG/CM Brand 2 NON-PREF ST FLUTICASONE CRE 0.05% generic 1 PREF CUTIVATE CRE 0.05% Brand 2 NON-PREF ST FLUTICASONE LOT 0.05% generic 1 PREF CUTIVATE LOT 0.05% Brand 2 NON-PREF ST FLUTICASONE OIN 0.005% generic 1 PREF CUTIVATE OIN 0.005% Brand 2 NON-PREF ST HALOG CRE 0.1% Brand 2 NON-PREF ST KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 189 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO HALOG OIN 0.1% Brand 2 NON-PREF ST HALOBETASOL CRE 0.05% generic 1 PREF ULTRAVATE CRE 0.05% Brand 2 NON-PREF ST HALOBETASOL OIN 0.05% generic 1 PREF ULTRAVATE OIN 0.05% Brand 2 NON-PREF ST TEXACORT SOL 2.5% Brand 2 HYDROCORT CRE 1% generic 1 PREF ALA CORT CRE 1% generic 1 PREF HYDROCORT CRE 2.5% generic 1 PREF FRST-HYDRCRT GEL 10% Brand 2 PA SCALACORT LOT 2% generic 1 ALA SCALP LOT 2% Brand 2 GR HYDROCORT LOT 2.5% generic 1 PREF HYDROCORT OIN 1% generic 1 PREF HYDROCORT/AB OIN 1% generic 1 PREF HYDROCORT OIN 2.5% generic 1 PREF NUCORT LOT 2% Brand 2 PA HC VALERATE CRE 0.2% generic 1 PREF HC VALERATE OIN 0.2% generic 1 PREF WESTCORT OIN 0.2% Brand 2 GR PANDEL CRE 0.1% Brand 2 NON-PREF ST HC BUTYRATE SOL 0.1% generic 1 PREF LOCOID SOL 0.1% Brand 2 GR HC BUTYRATE CRE 0.1% generic 1 PREF LOCOID CRE 0.1% Brand 2 GR LOCOID LOT 0.1% Brand 2 LOCOID OIN 0.1% Brand 2 GR HC BUTYRATE OIN 0.1% generic 1 PREF HC BUTYRATE CRE 0.1% generic 1 LOCOID LIPO CRE 0.1% Brand 2 GR PEDIADERM HC KIT Brand 2 NON-PREF ST MOMETASONE SOL 0.1% generic 1 PREF KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 190 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ELOCON LOT 0.1% Brand 2 GR MOMETASONE CRE 0.1% generic 1 PREF ELOCON CRE 0.1% Brand 2 GR MOMETASONE OIN 0.1% generic 1 PREF ELOCON OIN 0.1% Brand 2 GR PREDNICARBAT CRE 0.1% generic 1 PREF DERMATOP CRE 0.1% Brand 2 GR DERMATOP OIN 0.1% Brand 2 GR PREDNICARBAT OIN 0.1% generic 1 PREF KENALOG AER SPRAY Brand 2 NON-PREF ST TRIAMCINOLON CRE 0.025% generic 1 PREF TRIAMCINOLON CRE 0.1% generic 1 PREF TRIDERM CRE 0.1% generic 1 PREF TRIAMCINOLON CRE 0.5% generic 1 PREF TRIAMCINOLON LOT 0.025% generic 1 PREF TRIAMCINOLON LOT 0.1% generic 1 PREF TRIAMCINOLON OIN 0.025% generic 1 PREF TRIANEX OIN 0.05% Brand 2 TRIAMCINOLON OIN 0.1% generic 1 PREF TRIAMCINOLON OIN 0.5% generic 1 PREF PRAMOSONE CRE 1% Brand 2 EPIFOAM AER 1% Brand 2 PRAMOSONE LOT 1% Brand 2 PRAMOSONE LOT 2.5% Brand 2 TACLONEX SUS Brand 2 TACLONEX OIN Brand 2 NON-PREF ST SYNALAR KIT 0.025% Brand 2 SYNALAR KIT 0.025% Brand 2 ULTRAVATE KIT PAC Brand 2 NON-PREF ST HALONATE PAC KIT generic 1 NON-PREF ST HALAC KIT generic 1 NON-PREF ST ULTRAVATE KIT Brand 2 NON-PREF ST KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 191 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO HALONATE KIT Brand 2 NON-PREF ST ULTRAVATE X KIT 0.05-10% Brand 2 NON-PREF ST ULTRAVATE X KIT 0.05-10% Brand 2 NON-PREF ST HC AC/ALOE GEL 2% generic 1 CORTALO GEL 2% generic 1 NUZON GEL 2% Brand 2 GR CARMOL-HC CRE 1% Brand 2 GR U-CORT CRE 1% generic 1 AMMONIUM LAC CRE 12% generic 1 LAC-HYDRIN CRE 12% Brand 2 GR LACTIC ACID LOT 10% generic 1 AMMONIUM LAC LOT 12% generic 1 LACLOTION LOT 12% generic 1 LAC-HYDRIN LOT 12% Brand 2 GR UMECTA PD SUS 40-0.3% Brand 2 UREA HYDRATI AER 35% generic 1 SANTYL OIN 250/GM Brand 2 PODOFILOX SOL 0.5% generic 1 CONDYLOX SOL 0.5% Brand 2 GR CONDYLOX GEL 0.5% Brand 2 PODOCON SOL 25% Brand 2 VIRASAL LIQ 27.5% Brand 2 GR SALICYLIC AC LIQ 27.5% generic 1 SALICYLIC AC LIQ 26% generic 1 SALICYLIC AC CRE 6% generic 1 SALACYN CRE 6% generic 1 SALICYLIC AER 6% generic 1 SALVAX AER 6% Brand 2 GR SALICYLIC AC GEL 6% generic 1 KERALYT GEL 6% Brand 2 GR SALICYLIC AC LOT 6% generic 1 SALACYN LOT 6% generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 192 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO SALICYLIC AC SHA 6% generic 1 ALICLEN SHA 6% generic 1 SALEX SHA 6% Brand 2 GR KERALYT KIT SCALP 6% Brand 2 PYROGALL ACD OIN Brand 2 SALICYLIC AC AER 6% Brand 2 SALKERA AER 6% Brand 2 BENSAL HP OIN Brand 2 GORDOFILM SOL Brand 2 SALVAX DUO KIT PLUS Brand 2 VEREGEN OIN 15% Brand 2 ZYCLARA PUMP CRE 2.5% Brand 2 PA ZYCLARA PUMP CRE 3.75% Brand 2 PA ZYCLARA CRE 3.75% Brand 2 QL 56/42 PA IMIQUIMOD CRE 5% generic 1 QL 48/112 PA ALDARA CRE 5% Brand 2 GR ELIDEL CRE 1% Brand 2 PREF QL 30/30 PA PROTOPIC OIN 0.03% Brand 2 NON-PREF ST QL 30/30 PROTOPIC OIN 0.1% Brand 2 NON-PREF ST QL 30/30 ANACAINE OIN Brand 2 PA QUTENZA KIT 8% 2-PCH Brand 2 QL 4/90 PA SP QUTENZA KIT 8% 1-PCH Brand 2 QL 4/90 PA SP COCAINE HCL SOL 4% generic 1 COCAINE HCL SOL 10% generic 1 LIDOCAINE OIN 5% generic 1 LIDOCAINE PAD 5% generic 1 LIDODERM DIS 5% Brand 2 GR LIDOCAINE SOL 4% generic 1 XYLOCAINE SOL 4% Brand 2 GR LIDOCAINE CRE 3% generic 1 LIDOCAINE GEL 2% JELLY generic 1 LIDOCAINE GEL 2% generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 193 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO LIDORX GEL 3% Brand 2 LIDOCAINE LOT 3% Brand 2 PRAMOX GEL 1% generic 1 PONTOCAINE SOL 2% Brand 2 ETHYL CHLOR AER MIST Brand 2 ETHYL CHLOR AER MED JET Brand 2 ETHYL CHLOR AER FINE PIN Brand 2 ETHYL CHLOR AER MED STRM Brand 2 ETHYL CHLOR AER FN STRM Brand 2 GEBAUERS SPR AER /STRETCH Brand 2 PAIN EASE AER MIST Brand 2 PAIN EASE AER MD STRM Brand 2 ALEVEER DIS 0.0375-5 Brand 2 SYNERA DIS 70-70MG Brand 2 ELENZAPATCH DIS 4-1% Brand 2 LIDO/PRILOCN CRE 2.5-2.5% generic 1 EMLA CRE 2.5-2.5% Brand 2 GR LIDO/PRILOCN KIT 2.5-2.5% Brand 2 BOTOX COSMET INJ 100UNIT Brand 2 ULESFIA LOT 5% Brand 2 PREF EURAX CRE 10% Brand 2 PREF EURAX LOT 10% Brand 2 PREF SKLICE LOT 0.5% Brand 2 NON-PREF ST PA LINDANE LOT 1% generic 1 NON-PREF ST LINDANE SHA 1% generic 1 NON-PREF ST OVIDE LOT 0.5% Brand 2 NON-PREF ST MALATHION LOT 0.5% generic 1 NON-PREF ST PERMETHRIN CRE 5% generic 1 PREF ACTICIN CRE 5% generic 1 PREF ELIMITE CRE 5% Brand 2 GR SPINOSAD SUS 0.9% Brand 2 NON-PREF ST NATROBA SUS 0.9% Brand 2 NON-PREF ST KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 194 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO SULF LIME SOL USP Brand 2 LYCELLE GEL Brand 2 DRYSOL SOL 20% Brand 2 GR HYPERCARE SOL 20% generic 1 ARNICA TIN FLOWER Brand 2 BORIC ACID GRA Brand 2 ALUMINUM SOL ACETATE Brand 2 XERAC-AC SOL 6.25% Brand 2 BENZOIN TIN NF Brand 2 BENZOIN CMPD TIN Brand 2 GENADUR LIQ Brand 2 TL-CERMIDE EMU Brand 2 EMULSION SB EMU Brand 2 EPICERAM EMU Brand 2 XCLAIR CRE Brand 2 AURSTAT ANTI GEL -ITCH Brand 2 PR CREAM KIT Brand 2 TETRIX KIT Brand 2 AURSTAT KIT HYDROGEL Brand 2 GENADUR KIT Brand 2 Diagnostic Products CYSVIEW INJ 100MG Brand 2 Digestive Aids VIOKACE TAB Brand 2 NON-PREF ST VIOKACE TAB Brand 2 NON-PREF ST CREON CAP 3000UNIT Brand 2 PREF ZENPEP CAP 3000UNIT Brand 2 PREF PANCREAZE CAP 4200UNIT Brand 2 NON-PREF ST ZENPEP CAP 5000UNIT Brand 2 PREF PANCRELIPASE CAP 5000UNIT Brand 2 PREF CREON CAP 6000UNIT Brand 2 PREF

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 195 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PERTZYE CAP Brand 2 NON-PREF ST ZENPEP CAP 10000UNT Brand 2 PREF PANCREAZE CAP 10500UNT Brand 2 NON-PREF ST CREON CAP 12000UNT Brand 2 PREF ULTRESA CAP 13800UNT Brand 2 NON-PREF ST ZENPEP CAP 15000UNT Brand 2 PREF PERTZYE CAP Brand 2 PANCREAZE CAP 16800UNT Brand 2 NON-PREF ST ZENPEP CAP 20000UNT Brand 2 PREF ULTRESA CAP 20700UNT Brand 2 NON-PREF ST PANCREAZE CAP 21000UNT Brand 2 NON-PREF ST ULTRESA CAP 23000UNT Brand 2 NON-PREF ST CREON CAP 24000UNT Brand 2 PREF ZENPEP CAP 25000UNT Brand 2 PREF CREON CAP 36000UNT Brand 2 SUCRAID SOL 8500/ML Brand 2 Diuretics ACETAZOLAMID TAB 125MG generic 1 ACETAZOLAMID TAB 250MG generic 1 DIAMOX SEQUE CAP 500MG CR Brand 2 GR ACETAZOLAMID CAP 500MG ER generic 1 ACETAZOLAMID INJ 500MG generic 1 NEPTAZANE TAB 25MG Brand 2 GR METHAZOLAMID TAB 25MG generic 1 NEPTAZANE TAB 50MG Brand 2 GR METHAZOLAMID TAB 50MG generic 1 BUMETANIDE TAB 0.5MG generic 1 BUMETANIDE TAB 1MG generic 1 BUMETANIDE TAB 2MG generic 1 BUMETANIDE INJ 0.25/ML generic 1 EDECRIN TAB 25MG Brand 2

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 196 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO SOD EDECRIN INJ 50MG Brand 2 FUROSEMIDE TAB 20MG generic 1 LASIX TAB 20MG Brand 2 GR FUROSEMIDE TAB 40MG generic 1 LASIX TAB 40MG Brand 2 GR FUROSEMIDE TAB 80MG generic 1 LASIX TAB 80MG Brand 2 GR FUROSEMIDE INJ 10MG/ML generic 1 FUROSEMIDE SOL 8MG/ML generic 1 FUROSEMIDE SOL 10MG/ML generic 1 TORSEMIDE TAB 5MG generic 1 DEMADEX TAB 5MG Brand 2 GR TORSEMIDE TAB 10MG generic 1 DEMADEX TAB 10MG Brand 2 GR DEMADEX TAB 20MG Brand 2 GR TORSEMIDE TAB 20MG generic 1 DEMADEX TAB 100MG Brand 2 GR TORSEMIDE TAB 100MG generic 1 TORSEMIDE INJ 20MG/2ML Brand 2 TORSEMIDE INJ 50MG/5ML Brand 2 INTROL SOL 75% Brand 2 MANNITOL INJ 5% generic 1 OSMITROL INJ 5% generic 1 OSMITROL INJ 10% generic 1 MANNITOL INJ 10% generic 1 MANNITOL INJ 15% generic 1 OSMITROL INJ 15% generic 1 OSMITROL VFX INJ 20% generic 1 MANNITOL INJ 20% generic 1 MANNITOL INJ 25% generic 1 AMILORIDE TAB 5MG generic 1 SPIRONOLACT TAB 25MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 197 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ALDACTONE TAB 25MG Brand 2 GR SPIRONOLACT TAB 50MG generic 1 ALDACTONE TAB 50MG Brand 2 GR ALDACTONE TAB 100MG Brand 2 GR SPIRONOLACT TAB 100MG generic 1 DYRENIUM CAP 50MG Brand 2 DYRENIUM CAP 100MG Brand 2 CHLOROTHIAZ TAB 250MG generic 1 CHLOROTHIAZ TAB 500MG generic 1 DIURIL SUS 250/5ML Brand 2 SOD DIURIL INJ 500MG Brand 2 GR CHLOROTHIAZ INJ 500MG generic 1 CHLORTHALID TAB 25MG generic 1 CHLORTHALID TAB 50MG generic 1 HYDROCHLOROT CAP 12.5MG generic 1 MICROZIDE CAP 12.5MG Brand 2 GR HYDROCHLOROT TAB 12.5MG generic 1 HYDROCHLOROT TAB 25MG generic 1 HYDROCHLOROT TAB 50MG generic 1 INDAPAMIDE TAB 1.25MG generic 1 INDAPAMIDE TAB 2.5MG generic 1 METHYCLOTHIA TAB 5MG generic 1 METOLAZONE TAB 2.5MG generic 1 ZAROXOLYN TAB 2.5MG Brand 2 GR METOLAZONE TAB 5MG generic 1 ZAROXOLYN TAB 5MG Brand 2 GR METOLAZONE TAB 10MG generic 1 AMILOR/HCTZ TAB 5-50 generic 1 SPIRONO/HCTZ TAB 25/25 generic 1 ALDACTAZIDE TAB 25/25 Brand 2 GR ALDACTAZIDE TAB 50/50 Brand 2 TRIAMT/HCTZ CAP 37.5-25 generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 198 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DYAZIDE CAP 37.5-25 Brand 2 GR TRIAMT/HCTZ CAP 50-25MG Brand 2 TRIAMT/HCTZ TAB 37.5-25 generic 1 MAXZIDE-25 TAB Brand 2 GR TRIAMT/HCTZ TAB 75-50MG generic 1 MAXZIDE TAB 75-50 Brand 2 GR Endocrine and Metabolic Agents Misc. ALENDRONATE TAB 5MG generic 1 PREF MO ALENDRONATE TAB 10MG generic 1 PREF MO ALENDRONATE TAB 35MG generic 1 PREF MO ALENDRONATE TAB 40MG generic 1 PREF MO FOSAMAX TAB 70MG Brand 2 NON-PREF ST MO ALENDRONATE TAB 70MG generic 1 PREF MO BINOSTO TAB 70MG Brand 2 NON-PREF ST MO ALENDRONATE SOL 70/75ML Brand 2 PREF MO FOSAMAX + D TAB 70-2800 Brand 2 PREF MO FOSAMAX + D TAB 70-5600 Brand 2 PREF MO ETIDRON DISD TAB 200MG Brand 2 ETIDRON DISD TAB 400MG Brand 2 BONIVA TAB 150MG Brand 2 NON-PREF ST MO IBANDRONATE TAB 150MG generic 1 NON-PREF ST MO BONIVA INJ 3MG/3ML Brand 2 QL 3/90 PA SP PAMIDRONATE INJ 30/10ML generic 1 PAMIDRONATE INJ 6MG/ML generic 1 PAMIDRONATE INJ 90/10ML generic 1 PAMIDRONATE INJ 30MG generic 1 PAMIDRONATE INJ 90MG generic 1 ACTONEL TAB 5MG Brand 2 NON-PREF ST MO ACTONEL TAB 30MG Brand 2 NON-PREF ST MO ACTONEL TAB 35MG Brand 2 NON-PREF ST MO ACTONEL TAB 150MG Brand 2 NON-PREF ST MO

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 199 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ATELVIA TAB Brand 2 NON-PREF ST MO SKELID TAB 200MG Brand 2 ZOLEDRONIC INJ 4MG/100 generic 1 ZOMETA INJ 4MG/100 Brand 2 ZOLEDRONIC INJ 5/100ML generic 1 RECLAST INJ 5/100ML Brand 2 GR ZOLEDRONIC INJ 4MG Brand 2 MIACALCIN INJ 200/ML Brand 2 CALCITONIN SPR 200/ACT generic 1 PREF MO FORTICAL SPR 200/ACT Brand 2 NON-PREF ST MO MIACALCIN SPR 200/ACT Brand 2 NON-PREF ST MO FORTEO SOL 600/2.4 Brand 2 QL 43.2/life PA SP PROLIA SOL 60MG/ML Brand 2 QL 2/365 PA SP XGEVA INJ Brand 2 QL 1.7/30 PA SP GANITE INJ 25MG/ML Brand 2 OSPHENA TAB 60MG Brand 2 EVISTA TAB 60MG Brand 2 PREGNYL INJ 10000UNT Brand 2 GR CHOR GONADOT INJ 10000UNT generic 1 NOVAREL INJ 10000UNT generic 1 SEROPHENE TAB 50MG generic 1 CLOMID TAB 50MG Brand 2 GR CLOMIPHENE TAB 50MG generic 1 SUPPRELIN LA KIT 50MG Brand 2 QL 1/365 PA SP LUPR DEP-PED INJ 7.5MG Brand 2 PA SP LUPR DEP-PED INJ 11.25MG Brand 2 PA SP LUPR DEP-PED INJ 15MG Brand 2 PA SP LUPR DEP-PED INJ 11.25MG Brand 2 LUPR DEP-PED INJ 30MG Brand 2 PA SP SYNAREL SOL 2MG/ML Brand 2 NUTROPIN AQ INJ NUSPIN 5 Brand 2 NON-PREF ST PA SP NUTROPIN AQ INJ 10MG/2ML Brand 2 NON-PREF ST PA SP KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 200 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO NORDITROPIN INJ 10/1.5ML Brand 2 PREF PA SP NORDITROPIN INJ 15/1.5ML Brand 2 PREF PA SP NUTROPIN AQ INJ 20MG/2ML Brand 2 NON-PREF ST PA SP NORDITROPIN INJ 30/3ML Brand 2 PREF PA SP HUMATROPE INJ 5MG Brand 2 NON-PREF ST PA SP GENOTROPIN INJ 5MG Brand 2 PREF PA SP OMNITROPE INJ 5.8MG Brand 2 NON-PREF ST PA SP HUMATROPE INJ 6MG Brand 2 NON-PREF ST PA SP HUMATROPE INJ 12MG Brand 2 NON-PREF ST PA SP GENOTROPIN INJ 12MG Brand 2 PREF PA SP NUTROPIN INJ 10MG Brand 2 NON-PREF ST PA SP HUMATROPE INJ 24MG Brand 2 NON-PREF ST PA SP GENOTROPIN INJ 0.2MG Brand 2 PREF PA SP GENOTROPIN INJ 0.4MG Brand 2 PREF PA SP GENOTROPIN INJ 0.6MG Brand 2 PREF PA SP GENOTROPIN INJ 0.8MG Brand 2 PREF PA SP GENOTROPIN INJ 1MG Brand 2 PREF PA SP GENOTROPIN INJ 1.2MG Brand 2 PREF PA SP GENOTROPIN INJ 1.4MG Brand 2 PREF PA SP GENOTROPIN INJ 1.6MG Brand 2 PREF PA SP GENOTROPIN INJ 1.8MG Brand 2 PREF PA SP GENOTROPIN INJ 2MG Brand 2 PREF PA SP SEROSTIM INJ 4MG Brand 2 NON-PREF ST PA SP SAIZEN INJ 5MG Brand 2 PREF PA SP SEROSTIM INJ 5MG Brand 2 NON-PREF ST PA SP SEROSTIM INJ 6MG Brand 2 NON-PREF ST PA SP SAIZEN INJ 8.8MG Brand 2 PREF PA SP ZORBTIVE INJ 8.8MG Brand 2 NON-PREF ST PA SP EGRIFTA SOL 2MG Brand 2 QL 60/30 PA SP INCRELEX INJ 40MG/4ML Brand 2 PA SP SOMATULINE INJ 60/0.2ML Brand 2 SOMATULINE INJ 90/0.3ML Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 201 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO SOMATULINE INJ 120/.5ML Brand 2 OCTREOTIDE INJ 50MCG/ML generic 1 SANDOSTATIN INJ 50MCG/ML Brand 2 GR OCTREOTIDE INJ 100MCG generic 1 SANDOSTATIN INJ 100MCG Brand 2 GR OCTREOTIDE INJ 200MCG generic 1 OCTREOTIDE INJ 1000MCG generic 1 SANDOSTATIN INJ 200MCG Brand 2 GR OCTREOTIDE INJ 500MCG generic 1 SANDOSTATIN INJ 500MCG Brand 2 GR OCTREOTIDE INJ 1000MCG generic 1 SANDOSTATIN INJ 1000MCG Brand 2 GR SANDOSTATIN KIT LAR 10MG Brand 2 SANDOSTATIN KIT LAR 20MG Brand 2 SANDOSTATIN KIT LAR 30MG Brand 2 SIGNIFOR INJ 0.3MG/ML Brand 2 SIGNIFOR INJ 0.6MG/ML Brand 2 SIGNIFOR INJ 0.9MG/ML Brand 2 SOMAVERT INJ 10MG Brand 2 SOMAVERT INJ 15MG Brand 2 SOMAVERT INJ 20MG Brand 2 DESMOPRESSIN TAB 0.1MG generic 1 DDAVP TAB 0.1MG Brand 2 GR DESMOPRESSIN TAB 0.2MG generic 1 DDAVP TAB 0.2MG Brand 2 GR STIMATE SOL 1.5MG/ML Brand 2 DESMOPRESSIN INJ 4MCG/ML generic 1 DDAVP INJ 4MCG/ML Brand 2 GR DDAVP SOL 0.01% Brand 2 GR DESMOPRESSIN SOL 0.01% generic 1 DESMOPRESSIN SPR 0.01% generic 1 DESMOPRESSIN SPR 0.01% generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 202 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DDAVP SPR 0.01% Brand 2 GR VASOPRESSIN INJ 20UNT/ML generic 1 VASOPRESSIN INJ 10/0.5ML generic 1 PITRESSIN INJ 20UNT/ML Brand 2 GR ACTHAR HP INJ 80UNIT Brand 2 PA SP CABERGOLINE TAB 0.5MG generic 1 VAPRISOL INJ Brand 2 SAMSCA TAB 15MG Brand 2 QL 30/30 PA SP SAMSCA TAB 30MG Brand 2 QL 60/30 PA SP MIFEPREX TAB 200MG Brand 2 LEVOCARNITIN TAB 330MG generic 1 CARNITOR TAB 330MG Brand 2 GR LEVOCARNITIN SOL 1GM/10ML generic 1 CARNITOR SOL 1GM/10ML Brand 2 GR CARNITOR SF SOL 1GM/10ML Brand 2 GR LEVOCARNITIN INJ 200MG/ML generic 1 CARNITOR INJ 1GM/5ML Brand 2 GR FABRAZYME INJ 5MG Brand 2 FABRAZYME INJ 35MG Brand 2 ORFADIN CAP 2MG Brand 2 ORFADIN CAP 5MG Brand 2 ORFADIN CAP 10MG Brand 2 CYSTADANE POW Brand 2 CALCITRIOL CAP 0.25MCG generic 1 ROCALTROL CAP 0.25MCG Brand 2 GR CALCITRIOL CAP 0.5MCG generic 1 ROCALTROL CAP 0.5MCG Brand 2 GR CALCITRIOL INJ 1MCG/ML generic 1 CALCITRIOL SOL 1MCG/ML generic 1 ROCALTROL SOL 1MCG/ML Brand 2 GR HECTOROL CAP 0.5MCG Brand 2 HECTOROL CAP 1MCG Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 203 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO HECTOROL CAP 2.5MCG Brand 2 HECTOROL INJ 4MCG/2ML Brand 2 HECTOROL INJ 2MCG/ML Brand 2 ZEMPLAR CAP 1MCG Brand 2 GR PARICALCITOL CAP 1 MCG generic 1 PARICALCITOL CAP 2 MCG generic 1 ZEMPLAR CAP 2MCG Brand 2 GR ZEMPLAR CAP 4MCG Brand 2 GR PARICALCITOL CAP 4 MCG generic 1 ZEMPLAR INJ 2MCG/ML Brand 2 ZEMPLAR INJ 5MCG/ML Brand 2 SENSIPAR TAB 30MG Brand 2 SENSIPAR TAB 60MG Brand 2 SENSIPAR TAB 90MG Brand 2 ALDURAZYME INJ 2.9MG/5M Brand 2 ELAPRASE INJ 6MG/3ML Brand 2 NAGLAZYME INJ 1MG/ML Brand 2 LUMIZYME INJ 50MG Brand 2 MYOZYME INJ 50MG Brand 2 RAVICTI LIQ 1.1GM/ML Brand 2 AMMONUL INJ 10% Brand 2 BUPHENYL TAB 500MG Brand 2 PHENYLBUTYRA POW SODIUM generic 1 BUPHENYL POW Brand 2 GR CARBAGLU TAB 200MG Brand 2 PA SP KUVAN TAB 100MG Brand 2 Estrogens PREMARIN TAB 0.3MG Brand 2 PREMARIN TAB 0.45MG Brand 2 PREMARIN TAB 0.625MG Brand 2 PREMARIN TAB 0.9MG Brand 2

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 204 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PREMARIN TAB 1.25MG Brand 2 PREMARIN INJ 25MG Brand 2 CENESTIN TAB 0.3MG Brand 2 CENESTIN TAB 0.45MG Brand 2 CENESTIN TAB 0.625MG Brand 2 CENESTIN TAB 0.9MG Brand 2 ENJUVIA TAB 0.3MG Brand 2 ENJUVIA TAB 0.45MG Brand 2 ENJUVIA TAB 0.625MG Brand 2 ENJUVIA TAB 0.9MG Brand 2 ENJUVIA TAB 1.25MG Brand 2 MENEST TAB 0.3MG Brand 2 MENEST TAB 0.625MG Brand 2 MENEST TAB 1.25MG Brand 2 MENEST TAB 2.5MG Brand 2 ESTRACE TAB 0.5MG Brand 2 GR ESTRADIOL TAB 0.5MG generic 1 ESTRADIOL TAB 1MG generic 1 ESTRACE TAB 1MG Brand 2 GR ESTRACE TAB 2MG Brand 2 GR ESTRADIOL TAB 2MG generic 1 ESTRASORB EMU Brand 2 EVAMIST SPR 1.53MG Brand 2 ELESTRIN GEL 0.06% Brand 2 ESTROGEL GEL Brand 2 DIVIGEL GEL 0.25MG Brand 2 DIVIGEL GEL 0.5MG Brand 2 DIVIGEL GEL 1MG/GM Brand 2 VIVELLE-DOT DIS 0.025MG Brand 2 ALORA DIS 0.025MG Brand 2 MINIVELLE DIS 0.0375MG Brand 2 VIVELLE-DOT DIS 0.0375MG Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 205 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO MINIVELLE DIS 0.05MG Brand 2 ALORA DIS 0.05MG Brand 2 VIVELLE-DOT DIS 0.05MG Brand 2 VIVELLE-DOT DIS 0.075MG Brand 2 ALORA DIS 0.075MG Brand 2 MINIVELLE DIS 0.075MG Brand 2 VIVELLE-DOT DIS 0.1MG Brand 2 MINIVELLE DIS 0.1MG Brand 2 ALORA DIS 0.1MG Brand 2 MENOSTAR DIS 14MCG Brand 2 CLIMARA DIS 0.025MG Brand 2 GR ESTRADIOL DIS 0.025MG generic 1 ESTRADIOL DIS 0.0375MG generic 1 CLIMARA DIS 0.0375MG Brand 2 GR ESTRADIOL DIS 0.05MG generic 1 CLIMARA DIS 0.05MG Brand 2 GR ESTRADIOL DIS 0.06MG generic 1 CLIMARA DIS 0.06MG Brand 2 GR ESTRADIOL DIS 0.075MG generic 1 CLIMARA DIS 0.075MG Brand 2 GR CLIMARA DIS 0.1MG Brand 2 GR ESTRADIOL DIS 0.1MG generic 1 DEPO-ESTRADI INJ 5MG/ML Brand 2 ESTRAD VAL INJ 10MG/ML generic 1 DELESTROGEN INJ 10MG/ML Brand 2 GR DELESTROGEN INJ 20MG/ML Brand 2 GR ESTRAD VAL INJ 20MG/ML generic 1 ESTRAD VAL INJ 40MG/ML generic 1 DELESTROGEN INJ 40MG/ML Brand 2 GR ESTRAD VAL INJ 200MG/5 generic 1 ORTHO-EST TAB 0.625 generic 1 ESTROPIPATE TAB 0.75MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 206 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ORTHO-EST TAB 1.25 generic 1 ESTROPIPATE TAB 1.5MG generic 1 ESTROPIPATE TAB 3MG generic 1 PREMPRO TAB 0.3-1.5 Brand 2 PREMPRO TAB 0.45-1.5 Brand 2 PREMPRO TAB .625-2.5 Brand 2 PREMPRO TAB 0.625-5 Brand 2 PREMPHASE TAB Brand 2 ESTRA/NORETH TAB 0.5-0.1 generic 1 ACTIVELLA TAB 0.5-0.1 Brand 2 GR ESTRA/NORETH TAB 1-0.5MG generic 1 MIMVEY TAB 1-0.5MG generic 1 ACTIVELLA TAB 1-0.5MG Brand 2 GR COMBIPATCH DIS .05/.14 Brand 2 COMBIPATCH DIS .05/.25 Brand 2 FEMHRT TAB 0.5-2.5 Brand 2 JINTELI TAB 1MG-5MCG generic 1 ANGELIQ TAB 0.25-0.5 Brand 2 ANGELIQ TAB 0.5-1MG Brand 2 CLIMARA PRO DIS WEEKLY Brand 2 PREFEST TAB Brand 2 Fluoroquinolones CIPRO (5%) SUS 250MG/5 Brand 2 PREF CIPRO (10%) SUS 500MG/5 Brand 2 PREF CIPROFLOXACN INJ 200MG generic 1 CIPROFLOXACN INJ 400MG generic 1 CIPROFLOXACN TAB 500MG ER generic 1 NON-PREF ST CIPRO XR TAB 500MG Brand 2 NON-PREF ST CIPROFLOXACN TAB 1000MG generic 1 NON-PREF ST CIPRO XR TAB 1000MG Brand 2 NON-PREF ST CIPROFLOXACN TAB 100MG generic 1 PREF

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 207 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO CIPROFLOXACN TAB 250MG generic 1 PREF CIPRO TAB 250MG Brand 2 NON-PREF ST CIPRO TAB 500MG Brand 2 NON-PREF ST CIPROFLOXACN TAB 500MG generic 1 PREF CIPROFLOXACN TAB 750MG generic 1 PREF CIPROFLOXACN INJ 200MG generic 1 CIPRO I.V. INJ 200MG Brand 2 GR LEVOFLOXACIN TAB 250MG generic 1 PREF LEVAQUIN TAB 250MG Brand 2 NON-PREF ST LEVOFLOXACIN TAB 500MG generic 1 PREF LEVAQUIN TAB 500MG Brand 2 NON-PREF ST LEVAQUIN TAB 750MG Brand 2 NON-PREF ST LEVOFLOXACIN TAB 750MG generic 1 PREF LEVOFLOXACIN INJ 25MG/ML generic 1 LEVOFLOXACIN SOL 25MG/ML generic 1 PREF LEVAQUIN SOL 25MG/ML Brand 2 NON-PREF ST AVELOX ABC TAB 400MG Brand 2 PREF AVELOX TAB 400MG Brand 2 PREF AVELOX INJ Brand 2 NOROXIN TAB 400MG Brand 2 NON-PREF ST OFLOXACIN TAB 200MG generic 1 PREF OFLOXACIN TAB 300MG generic 1 PREF OFLOXACIN TAB 400MG generic 1 PREF FACTIVE TAB 320MG Brand 2 NON-PREF ST Gastrointestinal Agents Misc CHENODAL TAB 250MG Brand 2 ACTIGALL CAP 300MG Brand 2 GR URSODIOL CAP 300MG generic 1 URSODIOL TAB 250MG generic 1 URSO 250 TAB 250MG Brand 2 GR URSODIOL TAB 500MG generic 1

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 208 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO URSO FORTE TAB 500MG Brand 2 GR CROMOLYN SOD CON 100/5ML generic 1 GASTROCROM CON 100/5ML Brand 2 GR DEXPANTHENOL INJ 250MG/ML generic 1 METOCLOPRAM TAB 5MG generic 1 METOCLOPRAM TAB 10MG generic 1 METOCLOPRAM INJ 5MG/ML generic 1 METOCLOPRAM INJ 10MG/2ML generic 1 METOCLOPRAM SOL 10/10ML generic 1 METOCLOPRAM SOL 5MG/5ML generic 1 METOZOLV ODT TAB 5MG Brand 2 NON-PREF ST QL 120/30 LACTULOSE SOL 10GM/15 generic 1 GENERLAC SOL 10GM/15 generic 1 ENULOSE SOL 10GM/15 generic 1 AMITIZA CAP 8MCG Brand 2 PA MO AMITIZA CAP 24MCG Brand 2 PA MO COLAZAL CAP 750MG Brand 2 NON-PREF ST BALSALAZIDE CAP 750MG generic 1 PREF GIAZO TAB 1.1GM Brand 2 NON-PREF ST PENTASA CAP 250MG CR Brand 2 PREF MO PENTASA CAP 500MG CR Brand 2 PREF MO ASACOL HD TAB 800MG Brand 2 NON-PREF ST MO LIALDA TAB 1.2GM Brand 2 NON-PREF ST MESALAMINE ENE 4GM generic 1 PREF SFROWASA ENE 4GM Brand 2 NON-PREF ST CANASA SUP 1000MG Brand 2 PREF DELZICOL CAP 400MG Brand 2 NON-PREF ST APRISO CAP 0.375GM Brand 2 PREF MO ROWASA KIT 4GM Brand 2 NON-PREF ST MESALAMINE KIT 4GM generic 1 PREF DIPENTUM CAP 250MG Brand 2 NON-PREF ST MO SULFASALAZIN TAB 500MG generic 1 PREF MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 209 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO AZULFIDINE TAB 500MG Brand 2 NON-PREF ST MO SULFAZINE TAB 500MG generic 1 PREF MO SULFAZINE EC TAB 500MG generic 1 PREF MO SULFASALAZIN TAB 500MG DR generic 1 PREF MO AZULFIDINE TAB 500MG EN Brand 2 NON-PREF ST MO CIMZIA KIT Brand 2 NON-PREF ST QL 2/30 PA SP CIMZIA PREFL KIT 200MG/ML Brand 2 NON-PREF ST QL 2/30 PA SP CIMZIA KIT STARTER Brand 2 NON-PREF ST QL 6/30 PA SP REMICADE INJ 100MG Brand 2 NON-PREF ST PA SP GATTEX KIT 5MG Brand 2 LOTRONEX TAB 0.5MG Brand 2 LOTRONEX TAB 1MG Brand 2 LINZESS CAP 145MCG Brand 2 PA MO LINZESS CAP 290MCG Brand 2 PA MO RELISTOR INJ 8/0.4ML Brand 2 QL 6/30 PA RELISTOR INJ 12/0.6ML Brand 2 QL 9/30 PA RELISTOR KIT 12/0.6ML Brand 2 QL 21/30 PA PHOSLO CAP 667MG Brand 2 NON-PREF ST CALC ACETATE CAP 667MG generic 1 PREF ELIPHOS TAB 667MG generic 1 NON-PREF ST PHOSLYRA SOL Brand 2 NON-PREF ST FOSRENOL CHW 500MG Brand 2 NON-PREF ST FOSRENOL CHW 750MG Brand 2 NON-PREF ST FOSRENOL CHW 1000MG Brand 2 NON-PREF ST RENVELA TAB 800MG Brand 2 PREF RENVELA PAK 0.8GM Brand 2 PREF RENVELA PAK 2.4GM Brand 2 PREF RENAGEL TAB 400MG Brand 2 PREF RENAGEL TAB 800MG Brand 2 PREF General Anesthetics COMPOUND 347 LIQ generic 1

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 210 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ETHRANE INH Brand 2 GR FORANE SOL Brand 2 GR TERRELL SOL generic 1 ISOFLURANE SOL generic 1 ULTANE SOL Brand 2 GR SOJOURN SOL generic 1 SEVOFLURANE SOL generic 1 ETOMIDATE INJ 2MG/ML generic 1 AMIDATE INJ 2MG/ML Brand 2 GR KETALAR INJ 10MG/ML Brand 2 GR KETAMINE INJ 10MG/ML generic 1 KETALAR INJ 50MG/ML Brand 2 GR KETAMINE INJ 50MG/ML generic 1 KETALAR INJ 100MG/ML Brand 2 GR KETAMINE INJ 100MG/ML generic 1 PROPOVEN INJ 10MG/ML generic 1 DIPRIVAN INJ 10MG/ML Brand 2 GR PROPOFOL INJ 10MG/ML generic 1 Genitourinary Agents Misc K-PHOS TAB NO 2 Brand 2 HYDROCHLORIC INJ 1:500 generic 1 SODIUM CITRA GRA Brand 2 UROCIT-K 5 TAB Brand 2 POT CITRATE TAB 540MG generic 1 POT CITRATE TAB 1080MG generic 1 UROCIT-K 10 TAB Brand 2 UROCIT-K 15 TAB Brand 2 CITRIC ACID/ SOL SOD CITR generic 1 CYTRA-2 SOL generic 1 SHOHLS SOL MODIFIED Brand 2 GR ORACIT SOL Brand 2

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 211 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO CYTRA-K SOL Brand 2 TARON GRA CRYSTALS generic 1 CYTRA K GRA CRYSTALS generic 1 CITROLITH TAB Brand 2 CYTRA-3 SYP generic 1 TRICITRATES SOL Brand 2 PHENAZOPYRID TAB 100MG generic 1 PYRIDIUM TAB 100MG Brand 2 GR PYRIDIUM TAB 200MG Brand 2 GR PHENAZO TAB 200MG generic 1 PHENAZOPYRID TAB 200MG generic 1 CYSTAGON CAP 50MG Brand 2 CYSTAGON CAP 150MG Brand 2 PROCYSBI CAP 25MG Brand 2 PROCYSBI CAP 75MG Brand 2 RIMSO-50 SOL 50% Brand 2 ELMIRON CAP 100MG Brand 2 LITHOSTAT TAB 250MG Brand 2 THIOLA TAB 100MG Brand 2 RENACIDIN SOL IRR Brand 2 ACETIC ACID SOL 0.25%IRR generic 1 AMINOAC ACID SOL 1.5% IRR generic 1 GLYCINE SOL 1.5% IRR generic 1 ARGYL SALINE SOL 0.9% generic 1 CURITY SALIN SOL 0.9% IRR generic 1 SODIUM CHLOR SOL 0.9% IRR generic 1 RESECTISOL SOL 5% Brand 2 SORBITOL SOL 3% IRR Brand 2 SORBITOL SOL 3.3% IRR Brand 2 SORBITOL-MAN SOL Brand 2 NEO/POLY GU SOL 40/ML IR generic 1 NEOSPORIN GU SOL 40/ML IR Brand 2 GR KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 212 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO AVODART CAP 0.5MG Brand 2 NON-PREF ST QL 30/30 MO PROSCAR TAB 5MG Brand 2 NON-PREF ST MO FINASTERIDE TAB 5MG generic 1 PREF QL 30/30 MO UROXATRAL TAB 10MG Brand 2 NON-PREF ST QL 30/30 MO ALFUZOSIN TAB 10MG generic 1 PREF QL 30/30 MO CARDURA XL TAB 4MG Brand 2 QL 30/30 PA MO CARDURA XL TAB 8MG Brand 2 QL 30/30 PA MO RAPAFLO CAP 4MG Brand 2 NON-PREF ST QL 30/30 MO RAPAFLO CAP 8MG Brand 2 NON-PREF ST QL 30/30 MO FLOMAX CAP 0.4MG Brand 2 NON-PREF ST MO TAMSULOSIN CAP 0.4MG generic 1 PREF MO JALYN CAP Brand 2 NON-PREF ST QL 30/30 MO Gout Agents ZYLOPRIM TAB 100MG Brand 2 GR ALLOPURINOL TAB 100MG generic 1 ZYLOPRIM TAB 300MG Brand 2 GR ALLOPURINOL TAB 300MG generic 1 ALOPRIM INJ 500MG Brand 2 GR ALLOPURINOL INJ 500MG generic 1 COLCRYS TAB 0.6MG Brand 2 ULORIC TAB 40MG Brand 2 PA ULORIC TAB 80MG Brand 2 PA KRYSTEXXA INJ 8MG/ML Brand 2 PA SP PROBENECID TAB 500MG generic 1 PROBEN/COLCH TAB 500-0.5 generic 1 Hematologic Agents Misc HEMOFIL M INJ 220-400 Brand 2 PA SP HEMOFIL M INJ 250UNIT Brand 2 PA SP KOATE-DVI INJ 250UNIT Brand 2 PA SP HEMOFIL M INJ 401-800 Brand 2 PA SP HEMOFIL M INJ 500UNIT Brand 2 PA SP

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 213 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO KOATE-DVI INJ 500UNIT Brand 2 PA SP HEMOFIL M INJ 1000UNIT Brand 2 PA SP KOATE-DVI INJ 1000UNIT Brand 2 PA SP HEMOFIL M INJ 1700UNIT Brand 2 HEMOFIL M SOL 801-1500 Brand 2 PA SP HEMOFIL M SOL 501-2000 Brand 2 PA SP MONOCLATE-P INJ 250UNIT Brand 2 PA SP MONOCLATE-P INJ 500UNIT Brand 2 PA SP MONOCLATE-P INJ 1000UNIT Brand 2 PA SP MONOCLATE-P INJ 1500UNIT Brand 2 PA SP RECOMBINATE INJ 220-400 Brand 2 PA SP RECOMBINATE INJ 401-800 Brand 2 PA SP RECOMBINATE INJ 801-1240 Brand 2 PA SP RECOMBINATE INJ Brand 2 PA SP RECOMBINATE INJ Brand 2 PA SP HELIXATE FS INJ 250UNIT Brand 2 PA SP KOGENATE FS INJ 250UNIT Brand 2 PA SP KOGENATE FS INJ 250/BS Brand 2 PA SP HELIXATE FS SOL 250UNIT Brand 2 PA SP HELIXATE FS SOL 500UNIT Brand 2 PA SP HELIXATE FS INJ 500UNIT Brand 2 PA SP KOGENATE FS INJ 500UNIT Brand 2 PA SP KOGENATE FS INJ 500/BS Brand 2 PA SP HELIXATE FS SOL 1000UNIT Brand 2 PA SP KOGENATE FS INJ 1000/BS Brand 2 PA SP KOGENATE FS INJ 1000UNIT Brand 2 PA SP HELIXATE FS INJ 1000UNIT Brand 2 PA SP HELIXATE FS INJ 2000UNIT Brand 2 PA SP KOGENATE FS INJ 2000UNIT Brand 2 PA SP KOGENATE FS INJ 2000/BS Brand 2 PA SP HELIXATE FS INJ 3000UNIT Brand 2 PA SP KOGENATE FS INJ 3000UNIT Brand 2 PA SP KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 214 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO KOGENATE FS INJ 3000/BS Brand 2 PA SP ADVATE INJ 250UNIT Brand 2 PA SP ADVATE INJ 500UNIT Brand 2 PA SP ADVATE INJ 1000UNIT Brand 2 PA SP ADVATE INJ 1500UNIT Brand 2 PA SP ADVATE INJ 2000UNIT Brand 2 PA SP ADVATE INJ 3000UNIT Brand 2 PA SP ADVATE INJ 4000UNIT Brand 2 PA SP XYNTHA INJ 250UNIT Brand 2 PA SP XYNTHA SOLOF KIT 250UNIT Brand 2 PA SP XYNTHA INJ 500UNIT Brand 2 PA SP XYNTHA SOLOF INJ 500UNIT Brand 2 PA SP XYNTHA INJ 1000UNIT Brand 2 PA SP XYNTHA SOLOF INJ 1000UNIT Brand 2 PA SP XYNTHA SOLOF INJ 2000UNIT Brand 2 PA SP XYNTHA INJ 2000UNIT Brand 2 PA SP XYNTHA SOLOF INJ 3000UNIT Brand 2 PA SP HUMATE-P INJ 600UNIT Brand 2 PA SP WILATE INJ Brand 2 PA SP HUMATE-P SOL 1200UNIT Brand 2 PA SP WILATE INJ Brand 2 PA SP HUMATE-P SOL 2400UNIT Brand 2 PA SP ALPHANATE INJ VWF/HUM Brand 2 PA SP ALPHANATE INJ VWF/HUM Brand 2 PA SP ALPHANATE INJ VWF/HUM Brand 2 PA SP ALPHANATE INJ VWF/HUM Brand 2 PA SP FEIBA VH INJ IMMUNO Brand 2 PA SP FEIBA NF INJ Brand 2 PA SP NOVOSEVEN RT INJ 1MG Brand 2 PA SP NOVOSEVEN RT INJ 2MG Brand 2 PA SP NOVOSEVEN RT INJ 5MG Brand 2 PA SP NOVOSEVEN RT INJ 8MG Brand 2 PA SP KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 215 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO MONONINE INJ 250UNIT Brand 2 PA SP MONONINE INJ 500UNIT Brand 2 PA SP ALPHANINE SD INJ 500UNIT Brand 2 PA SP MONONINE INJ 1000UNIT Brand 2 PA SP ALPHANINE SD INJ 1000UNIT Brand 2 PA SP ALPHANINE SD INJ 1500UNIT Brand 2 PA SP RIXUBIS INJ 250 UNIT Brand 2 PA SP BENEFIX INJ 250UNIT Brand 2 PA SP RIXUBIS INJ 500UNIT Brand 2 PA SP BENEFIX INJ 500UNIT Brand 2 PA SP BENEFIX INJ 1000UNIT Brand 2 PA SP RIXUBIS INJ 1000UNIT Brand 2 PA SP RIXUBIS INJ 2000UNIT Brand 2 PA SP BENEFIX INJ 2000UNIT Brand 2 PA SP BENEFIX INJ 3000UNIT Brand 2 PA SP RIXUBIS INJ 3000UNIT Brand 2 PA SP PROFILNINE INJ 500UNIT Brand 2 PA SP PROFILNINE INJ 1000UNIT Brand 2 PA SP PROFILNINE INJ 1500UNIT Brand 2 PA SP BEBULIN INJ 200-1200 Brand 2 PA SP BEBULIN VH INJ 200-1200 Brand 2 PA SP CORIFACT KIT Brand 2 PA SP RIASTAP SOL 1GM Brand 2 KCENTRA KIT 500UNIT Brand 2 PERSANTINE TAB 25MG Brand 2 GR DIPYRIDAMOLE TAB 25MG generic 1 DIPYRIDAMOLE TAB 50MG generic 1 PERSANTINE TAB 50MG Brand 2 GR DIPYRIDAMOLE TAB 75MG generic 1 PERSANTINE TAB 75MG Brand 2 GR REOPRO INJ 2MG/ML Brand 2 INTEGRILIN INJ 0.75MG/1 Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 216 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO INTEGRILIN INJ 2MG/ML Brand 2 AGGRASTAT INJ 25MG/500 Brand 2 PLETAL TAB 50MG Brand 2 GR CILOSTAZOL TAB 50MG generic 1 PLETAL TAB 100MG Brand 2 GR CILOSTAZOL TAB 100MG generic 1 ANAGRELIDE CAP 0.5MG generic 1 AGRYLIN CAP 0.5MG Brand 2 GR ANAGRELIDE CAP 1MG generic 1 CLOPIDOGREL TAB 75MG generic 1 PLAVIX TAB 75MG Brand 2 GR CLOPIDOGREL TAB 300MG generic 1 PLAVIX TAB 300MG Brand 2 GR EFFIENT TAB 5MG Brand 2 EFFIENT TAB 10MG Brand 2 TICLOPIDINE TAB 250MG generic 1 BRILINTA TAB 90MG Brand 2 AGGRENOX CAP 25-200MG Brand 2 PENTOXIFYLLI TAB 400MG ER generic 1 PANHEMATIN INJ 313MG Brand 2 HETASTARCH INJ 6%/NACL generic 1 ALBUMIN-ZLB INJ generic 1 ALBUMIN HUM INJ 5% generic 1 ALBUKED 5 INJ 5% generic 1 ALBUTEIN INJ 5% generic 1 ALBUMINAR-5 INJ 5% generic 1 BUMINATE INJ 5% generic 1 ALBURX INJ 5% generic 1 PLASBUMIN-5 INJ 5% generic 1 ALBUMIN-ZLB SOL 25% generic 1 FLEXBUMIN INJ 25% generic 1 PLASBUMIN-25 INJ 25% generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 217 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ALBUMIN HUM INJ 25% generic 1 BUMINATE INJ 25% generic 1 ALBUMINAR-25 INJ 25% generic 1 ALBUKED 25 INJ 25% generic 1 ALBUTEIN INJ 25% generic 1 KEDBUMIN INJ 25% generic 1 THROMBAT III INJ 500UNIT Brand 2 THROMBAT III INJ 1000UNIT Brand 2 PLASMANATE INJ 5% Brand 2 OCTAPLAS INJ GROUP B Brand 2 OCTAPLAS INJ GROUP AB Brand 2 OCTAPLAS INJ GROUP O Brand 2 OCTAPLAS INJ GROUP A Brand 2 PROTAMINE SU SOL 10MG/ML Brand 2 CEPROTIN INJ 500 UNIT Brand 2 CEPROTIN INJ 1000UNIT Brand 2 KINLYTIC INJ 250000 Brand 2 CATHFLO ACTI INJ VASE Brand 2 ACTIVASE INJ 50MG Brand 2 ACTIVASE INJ 100MG Brand 2 RETAVASE INJ HALF-KIT Brand 2 RETAVASE INJ Brand 2 TNKASE KIT 50MG Brand 2 SOLIRIS INJ 10MG/ML Brand 2 CINRYZE SOL 500 UNIT Brand 2 QL 16/30 PA SP BERINERT INJ 500UNIT Brand 2 PA SP FIRAZYR INJ 30MG/3ML Brand 2 PA SP KALBITOR INJ 10MG/ML Brand 2 PA SP Hematopoietics Agents CYANOCOBALAM INJ 1000MCG generic 1 NASCOBAL SPR 500MCG Brand 2

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 218 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO B-12 COMP KIT 1000MCG Brand 2 HYDROXOCOBAL INJ 1000MCG Brand 2 FOLIC ACID TAB 1MG generic 1 FOLIC ACID INJ 5MG/ML Brand 2 INFED INJ 50MG/ML generic 1 DEXFERRUM INJ 50MG/ML generic 1 VENOFER INJ 20MG/ML Brand 2 INJECTAFER INJ 750/15ML Brand 2 PA FERAHEME INJ 510/17ML Brand 2 FERRLECIT INJ 12.5MG/M Brand 2 GR FERRIC GLUCO INJ 12.5MG/M generic 1 ARANESP INJ 25MCG Brand 2 ARANESP INJ 25MCG Brand 2 ARANESP INJ 40MCG Brand 2 ARANESP INJ 40MCG Brand 2 ARANESP INJ 60MCG Brand 2 PREF PA SP ARANESP INJ 60MCG Brand 2 ARANESP INJ 100MCG Brand 2 ARANESP INJ 100MCG Brand 2 ARANESP INJ 150MCG Brand 2 ARANESP INJ 150MCG Brand 2 ARANESP INJ 200MCG Brand 2 ARANESP INJ 200MCG Brand 2 ARANESP INJ 300MCG Brand 2 ARANESP INJ 300MCG Brand 2 ARANESP INJ 500MCG Brand 2 PREF PA SP EPOGEN INJ 2000/ML Brand 2 PREF PA SP PROCRIT INJ 2000/ML Brand 2 PREF PA SP EPOGEN INJ 3000/ML Brand 2 PREF PA SP PROCRIT INJ 3000/ML Brand 2 PREF PA SP EPOGEN INJ 4000/ML Brand 2 PREF PA SP PROCRIT INJ 4000/ML Brand 2 PREF PA SP KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 219 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO EPOGEN INJ 10000/ML Brand 2 PREF PA SP PROCRIT INJ 10000/ML Brand 2 PREF PA SP PROCRIT INJ 20000/ML Brand 2 PREF PA SP EPOGEN INJ 20000/ML Brand 2 PREF PA SP PROCRIT INJ 40000/ML Brand 2 PREF PA SP OMONTYS INJ 10MG/ML Brand 2 PA SP OMONTYS INJ 20MG/2ML Brand 2 PA SP NEUPOGEN INJ 300MCG Brand 2 NEUPOGEN INJ 480MCG Brand 2 NEUPOGEN INJ 300/0.5 Brand 2 NEUPOGEN INJ 480/0.8 Brand 2 GRANIX INJ 300/0.5 Brand 2 GRANIX INJ 480/0.8 Brand 2 NEULASTA INJ 6MG/0.6M Brand 2 LEUKINE INJ 500 MCG Brand 2 LEUKINE INJ 250MCG Brand 2 NEUMEGA INJ 5MG Brand 2 PROMACTA TAB 12.5MG Brand 2 PROMACTA TAB 25MG Brand 2 PA SP PROMACTA TAB 50MG Brand 2 PA SP PROMACTA TAB 75MG Brand 2 PA SP NPLATE INJ 250MCG Brand 2 PA SP NPLATE INJ 500MCG Brand 2 PA SP MOZOBIL INJ Brand 2 PA SP CEREZYME INJ 200UNIT Brand 2 CEREZYME INJ 400UNIT Brand 2 ZAVESCA CAP 100MG Brand 2 ELELYSO INJ 200UNIT Brand 2 VPRIV INJ 400UNIT Brand 2 DROXIA CAP 200MG Brand 2 DROXIA CAP 300MG Brand 2 DROXIA CAP 400MG Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 220 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO B6 FOLIC ACD CAP Brand 2 FOLTRATE TAB Brand 2 NEURIN-SL SUB Brand 2 PRE-FOLIC TAB 1-100MG Brand 2 FOLPLEX 2.2 TAB generic 1 FA-B6-B12 TAB generic 1 FOLGARD RX TAB Brand 2 FABB TAB generic 1 TL GARD RX TAB generic 1 CENFOL TAB Brand 2 AIRAVITE TAB generic 1 FOLBEE TAB generic 1 NUFOL TAB generic 1 VIRT-VITE TAB generic 1 BP VIT 3 CAP Brand 2 ANIMI-3 CAP Brand 2 ANIMI-3 CAP VIT D Brand 2 HEMATOGEN CAP generic 1 CORVITE FE TAB Brand 2 CORVITE 150 TAB Brand 2 HEMOCYTE-F ELX Brand 2 ED CYTE F TAB Brand 2 ALBAFORT INJ Brand 2 MYFERON 150 CAP FORTE generic 1 POLY-IRON CAP 150 FORT generic 1 IFEREX 150 CAP FORTE generic 1 FERREX 150 CAP FORTE generic 1 POLYSACCHARI CAP IRON generic 1 TL-FOL 500 TAB generic 1 NOVAFERRUM SOL Brand 2 FE C PLUS TAB generic 1 ICAR-C PLUS TAB Brand 2 GR KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 221 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO HEMATOGEN FA CAP Brand 2 TRIGELS-F CAP FORTE generic 1 HEMATOGEN CAP FORTE generic 1 FERROGELS FO CAP FORTE generic 1 FERROTRIN CAP Brand 2 NEPHRON FA TAB Brand 2 TRICON CAP generic 1 FEROTRINSIC CAP generic 1 FEROCON CAP generic 1 TL ICON CAP generic 1 FOLTRIN CAP generic 1 TARON FORTE CAP Brand 2 MAXARON TAB FORTE Brand 2 MULTIGEN TAB Brand 2 MULTIGEN TAB FOLIC Brand 2 FOLIVANE-PLS CAP Brand 2 INTEGRA PLUS CAP Brand 2 CORVITA 150 TAB generic 1 CORVITE 150 TAB Brand 2 GR PROTECTIRON TAB Brand 2 FERRO-PLEX TAB Brand 2 MULTIGEN PLS TAB Brand 2 FERREX 150 CAP FORTE PL Brand 2 IROSPAN 24/6 MIS Brand 2 FERIVA CAP 75-1MG Brand 2 FUSION PLUS CAP Brand 2 TL-HEM 150 TAB generic 1 HEMATRON-AF TAB Brand 2 GR SE-TAN PLUS CAP generic 1 PUREVIT DUAL CAP FE PLUS generic 1 TANDEM PLUS CAP Brand 2 GR HEMOCYTE PLS CAP Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 222 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PUREFE CAP PLUS Brand 2 CENTRATEX CAP Brand 2 HEMOCYTE TAB -PLUS generic 1 HEMATINIC PL TAB VIT/MIN generic 1 FERROCITE TAB PLUS generic 1 HEMATINIC/FA TAB generic 1 HEMOCYTE-F TAB generic 1 PROFERRIN- TAB FORTE Brand 2 TANDEM F CAP Brand 2 INTEGRA F CAP Brand 2 FOLIVANE-F CAP Brand 2 BIFERARX TAB Brand 2 HEMETAB TAB Brand 2 FERRAPLUS 90 TAB Brand 2 FERREX 28 TAB Brand 2 FE 90 PLUS TAB Brand 2 NATALVIRT TAB FLT Brand 2 FERRALET 90 TAB Brand 2 Hemostatics AMINOCAPR AC TAB 500MG generic 1 AMICAR TAB 500MG Brand 2 GR AMICAR TAB 1000MG Brand 2 AMINOCAPR AC TAB 1000MG Brand 2 AMICAR SYP 25% Brand 2 GR AMINOCAPR AC SYP 25% generic 1 AMINOCAPR AC INJ 250MG/ML generic 1 TRASYLOL INJ 10000/ML Brand 2 LYSTEDA TAB 650MG Brand 2 GR TRANEX ACID TAB 650MG generic 1 QL 30/28 PA TRANEX ACID INJ 100MG/ML generic 1 CYKLOKAPRON INJ 100MG/ML Brand 2 GR

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 223 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO Hypnotics AMYTAL SOD INJ 500MG Brand 2 BUTISOL SOD TAB 30MG Brand 2 BUTISOL SOD TAB 50MG Brand 2 BUTISOL SOD ELX 30MG/5ML Brand 2 NEMBUTAL SOD INJ 50MG/ML Brand 2 PHENOBARB TAB 15MG generic 1 PHENOBARB TAB 16.2MG generic 1 PHENOBARB TAB 30MG generic 1 PHENOBARB TAB 32.4MG generic 1 PHENOBARB TAB 60MG generic 1 PHENOBARB TAB 64.8MG generic 1 PHENOBARB TAB 97.2MG generic 1 PHENOBARB TAB 100MG generic 1 PHENOBARB ELX 20MG/5ML generic 1 PHENOBARB SOL 20MG/5ML generic 1 PHENOBARB INJ 65MG/ML Brand 2 LUMINAL INJ 130MG/ML Brand 2 GR PHENOBARB INJ 130MG/ML generic 1 SECONAL CAP 100MG Brand 2 ESTAZOLAM TAB 1MG generic 1 PREF ESTAZOLAM TAB 2MG generic 1 PREF FLURAZEPAM CAP 15MG generic 1 PREF FLURAZEPAM CAP 30MG generic 1 PREF MIDAZOLAM SYP 2MG/ML generic 1 MIDAZOLAM INJ 2MG/2ML generic 1 MIDAZOLAM INJ 5MG/5ML generic 1 MIDAZOLAM INJ 10/10ML generic 1 MIDAZOLAM INJ 5MG/ML generic 1 MIDAZOLAM INJ 10MG/2ML generic 1 MIDAZOLAM INJ 5MG/ML generic 1

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 224 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO MIDAZOLAM INJ 25MG/5ML generic 1 MIDAZOLAM INJ 50MG/10 generic 1 MIDAZOLAM INJ 5MG/ML generic 1 QUAZEPAM TAB 15MG generic 1 DORAL TAB 15MG Brand 2 TEMAZEPAM CAP 7.5MG generic 1 PREF RESTORIL CAP 7.5MG Brand 2 NON-PREF ST TEMAZEPAM CAP 15MG generic 1 PREF RESTORIL CAP 15MG Brand 2 NON-PREF ST TEMAZEPAM CAP 22.5MG generic 1 PREF RESTORIL CAP 22.5MG Brand 2 NON-PREF ST TEMAZEPAM CAP 30MG generic 1 PREF RESTORIL CAP 30MG Brand 2 NON-PREF ST TRIAZOLAM TAB 0.125MG generic 1 PREF HALCION TAB 0.25MG Brand 2 NON-PREF ST TRIAZOLAM TAB 0.25MG generic 1 PREF LUNESTA TAB 1MG Brand 2 NON-PREF ST QL 30/30 LUNESTA TAB 2MG Brand 2 NON-PREF ST QL 30/30 LUNESTA TAB 3MG Brand 2 NON-PREF ST QL 30/30 ZALEPLON CAP 5MG generic 1 NON-PREF ST QL 30/30 SONATA CAP 5MG Brand 2 NON-PREF ST ZALEPLON CAP 10MG generic 1 NON-PREF ST QL 30/30 SONATA CAP 10MG Brand 2 NON-PREF ST ZOLPIDEM TAB 5MG generic 1 PREF QL 30/30 AMBIEN TAB 5MG Brand 2 NON-PREF ST QL 30/30 ZOLPIDEM TAB 10MG generic 1 PREF QL 30/30 AMBIEN TAB 10MG Brand 2 NON-PREF ST QL 30/30 ZOLPIDEM ER TAB 6.25MG generic 1 NON-PREF ST QL 30/30 AMBIEN CR TAB 6.25MG Brand 2 NON-PREF ST QL 30/30 ZOLPIDEM ER TAB 12.5MG generic 1 NON-PREF ST QL 30/30 AMBIEN CR TAB 12.5MG Brand 2 NON-PREF ST QL 30/30 INTERMEZZO SUB 1.75MG Brand 2 NON-PREF ST QL 30/30 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 225 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO INTERMEZZO SUB 3.5MG Brand 2 NON-PREF ST QL 30/30 EDLUAR SUB 5MG Brand 2 NON-PREF ST QL 30/30 EDLUAR SUB 10MG Brand 2 NON-PREF ST QL 30/30 ZOLPIMIST SPR 5MG Brand 2 NON-PREF ST QL 7.7/30 PRECEDEX INJ 100MCG Brand 2 PRECEDEX INJ 200/50ML Brand 2 PRECEDEX INJ 400/100 Brand 2 ROZEREM TAB 8MG Brand 2 NON-PREF ST QL 30/30 SILENOR TAB 3MG Brand 2 NON-PREF ST QL 30/30 SILENOR TAB 6MG Brand 2 NON-PREF ST QL 30/30 Laxatives MAGN SULFATE POW HEPTAHYD Brand 2 MAGN SULFATE POW Brand 2 OSMOPREP TAB 1.5GM Brand 2 BISACODYL POW Brand 2 CASCARA EXT SAGRADA Brand 2 SENNA LEAVES MIS Brand 2 MINERAL OIL HEAVY Brand 2 MINERAL OIL Brand 2 MINERAL OIL HEAVY Brand 2 MURI-LUBE OIL Brand 2 MINERAL OIL LIGHT Brand 2 LACTULOSE SOL 20GM/30 generic 1 LACTULOSE SOL 10GM/15 generic 1 CONSTULOSE SOL 10GM/15 generic 1 KRISTALOSE PAK 10GM Brand 2 KRISTALOSE PAK 20GM Brand 2 PEGYLAX POW generic 1 POLYETH GLYC POW 3350 NF generic 1 PREPOPIK PAK Brand 2 SUPREP BOWEL SOL PREP Brand 2

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 226 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO GAVILYTE-N SOL FLAV PK generic 1 PEG-3350/KCL SOL /SODIUM generic 1 NULYTELY SOL FLAV PKS Brand 2 GR TRILYTE SOL generic 1 COLYTE/FLAVR SOL PACKS Brand 2 GAVILYTE-G SOL generic 1 PEG-3350 SOL ELECTROL generic 1 GOLYTELY SOL PINEAPPL Brand 2 GR GOLYTELY SOL Brand 2 GR COLYTE/FLAVR SOL PACKS Brand 2 GR GAVILYTE-C SOL generic 1 PEG 3350 SOL ELECTROL generic 1 GOLYTELY SOL Brand 2 MOVIPREP SOL Brand 2 SUCLEAR KIT Brand 2 Local Anesthetics - Parenteral BUPIVACAINE INJ 0.25% generic 1 SENSORCAINE INJ 0.25% generic 1 MARCAINE INJ 0.25% Brand 2 GR BUPIVACAINE INJ 0.25% generic 1 MARCAINE INJ 0.25% Brand 2 GR SENSORCAINE INJ MPF0.25% generic 1 BUPIVACAINE INJ 0.5% generic 1 SENSORCAINE INJ 0.5% generic 1 MARCAINE INJ 0.5% Brand 2 GR BUPIVACAINE INJ 0.5% generic 1 SENSORCAINE INJ MPF 0.5% generic 1 MARCAINE INJ 0.5% Brand 2 GR BUPIVACAINE INJ 0.75% generic 1 SENSORCAINE INJ MPF0.75% generic 1 MARCAINE INJ 0.75% Brand 2 GR

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 227 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO BUPIVACAINE INJ SPINAL generic 1 SENSORCAINE INJ MPF SPIN generic 1 MARCAINE INJ SPINAL Brand 2 GR LIDOCAINE INJ 0.5% generic 1 XYLOCAINE INJ 0.5% Brand 2 GR XYLOCAINE INJ MPF 0.5% Brand 2 GR LIDOCAINE INJ 0.5% generic 1 LIDOCAINE INJ 1% generic 1 XYLOCAINE INJ 1% Brand 2 GR LIDOCAINE INJ 1% generic 1 XYLOCAINE INJ -MPF 1% Brand 2 GR LIDOCAINE INJ 1.5% generic 1 XYLOCAINE INJ MPF 1.5% Brand 2 GR LIDOCAINE INJ 2% generic 1 XYLOCAINE INJ 2% Brand 2 GR LIDOCAINE INJ 2% generic 1 XYLOCAINE INJ -MPF 2% Brand 2 GR XYLOCAINE INJ -MPF 4% Brand 2 GR LIDOCAINE INJ 4% generic 1 CARBOCAINE INJ 1% Brand 2 GR POLOCAINE INJ 1% generic 1 CARBOCAINE INJ 1% PF Brand 2 GR POLOCAINE INJ -MPF 1% generic 1 CARBOCAINE INJ 1.5% PF Brand 2 GR POLOCAINE INJ MPF 1.5% generic 1 POLOCAINE INJ 2% generic 1 CARBOCAINE INJ 2% Brand 2 GR CARBOCAINE INJ 2% PF Brand 2 GR POLOCAINE INJ -MPF 2% generic 1 NESACAINE INJ 2% Brand 2 GR NESACAINE INJ -MPF 2% Brand 2 GR CHLOROPROC INJ 2% generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 228 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO CHLOROPROC INJ 3% generic 1 NESACAINE INJ -MPF 3% Brand 2 GR TETRACAINE INJ 1% generic 1 PONTOCAINE INJ 1% Brand 2 GR MARCAINE/EPI INJ 0.25% Brand 2 GR SENSORCAINE/ INJ EPI 0.25 generic 1 BUPIVACAINE/ INJ EPI 0.25 generic 1 MARCAINE/EPI INJ 0.25% Brand 2 GR BUPIVACAINE/ INJ EPI 0.25 generic 1 SENSORCAINE INJ -MPF/EPI generic 1 BUPIVACAINE/ INJ EPI 0.5% generic 1 SENSORCAINE/ INJ EPI 0.5% generic 1 MARCAINE/EPI INJ 0.5% Brand 2 GR BUPIVACAINE/ INJ EPI 0.5% generic 1 SENSORCAINE INJ -MPF/EPI generic 1 MARCAINE/EPI INJ 0.5% Brand 2 GR LIDO/EPI INJ 0.5% generic 1 XYLO/EPI INJ 0.5% Brand 2 GR LIDO/EPI 1%- INJ 1:100000 generic 1 XYLO/EPI 1%- INJ 1:100000 Brand 2 GR XYLO-MPF/EPI INJ 1.5% Brand 2 GR LIDO/EPI INJ 1.5% generic 1 LIDO/EPI INJ 2% generic 1 XYLO-MPF/EPI INJ 2% Brand 2 GR LIDO/EPI INJ 2% generic 1 XYLO/EPI INJ 2% Brand 2 GR LIDO/EPI INJ 2% generic 1 Macrolides ERYTHROMYCIN TAB 250MG BS generic 1 PREF ERYTHROMYCIN TAB 500MG BS generic 1 PREF ERY-TAB TAB 250MG EC Brand 2 PREF

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 229 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ERY-TAB TAB 333MG EC Brand 2 PREF ERY-TAB TAB 500MG EC generic 1 PREF ERYTHROMYCIN CAP 250MG EC generic 1 PCE TAB 333MG EC Brand 2 NON-PREF ST PCE TAB 500MG EC Brand 2 NON-PREF ST ERYTHROCIN TAB 250MG generic 1 E.E.S. 400 TAB 400MG generic 1 NON-PREF ST E.E.S. GRAN SUS 200/5ML Brand 2 NON-PREF ST ERYPED SUS 200/5ML Brand 2 NON-PREF ST ERYPED SUS 400/5ML Brand 2 NON-PREF ST ERYTHROCIN INJ 500MG generic 1 ERYTHROCIN INJ 1000MG generic 1 AZITHROMYCIN TAB 250MG generic 1 PREF ZITHROMAX TAB Z-PAK Brand 2 NON-PREF ST ZITHROMAX TAB 250MG Brand 2 NON-PREF ST AZITHROMYCIN TAB 500MG generic 1 PREF ZITHROMAX TAB 500MG Brand 2 NON-PREF ST ZITHROMAX TAB TRI-PAK Brand 2 NON-PREF ST AZITHROMYCIN TAB 600MG generic 1 PREF ZITHROMAX TAB 600MG Brand 2 NON-PREF ST AZITHROMYCIN SUS 100/5ML generic 1 PREF ZITHROMAX SUS 100/5ML Brand 2 NON-PREF ST AZITHROMYCIN SUS 200/5ML generic 1 PREF ZITHROMAX SUS 200/5ML Brand 2 NON-PREF ST ZMAX SUS 2GM Brand 2 NON-PREF ST AZITHROMYCIN INJ 500MG generic 1 ZITHROMAX INJ 500MG Brand 2 GR ZITHROMAX POW 1GM PAK Brand 2 NON-PREF ST AZITHROMYCIN POW 1GM PAK generic 1 PREF AZITHROMYCIN INJ 2.5GM Brand 2 CLARITHROMYC TAB 250MG generic 1 PREF BIAXIN TAB 250MG Brand 2 NON-PREF ST KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 230 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO CLARITHROMYC TAB 500MG generic 1 PREF BIAXIN TAB 500MG Brand 2 NON-PREF ST CLARITHROMYC SUS 125/5ML generic 1 PREF CLARITHROMYC SUS 250/5ML generic 1 PREF BIAXIN SUS 250/5ML Brand 2 NON-PREF ST CLARITHROMYC TAB 500MG ER generic 1 NON-PREF ST BIAXIN XL TAB 500MG Brand 2 NON-PREF ST BIAXIN XL TAB PAC 500 Brand 2 NON-PREF ST DIFICID TAB 200MG Brand 2 QL 60/30 PA Medical Devices INSULIN SYRG MIS 1ML Brand 2 INSULIN SYRG MIS 0.3/29G Brand 2 INSULIN SYRG MIS 0.5/29G Brand 2 INSULIN SYRG MIS 0.5/30G Brand 2 INSULIN SYRG MIS 1ML/27G Brand 2 INSULIN SYRG MIS 1ML/28G Brand 2 AUTOSHIELD MIS 30GX3/16 Brand 2 OPTICHAMBER MIS DIA LG Brand 2 AERCHMBR PLS MIS FLOW-VU Brand 2 POCKET SPACE MIS Brand 2 POCKET CHAMB MIS Brand 2 RITEFLO MIS Brand 2 E-Z SPACER MIS Brand 2 E-Z SPACER MIS BODY GRD Brand 2 VORTEX VALVE MIS CHAMBER Brand 2 INSPIREASE MIS DD SYST Brand 2 MICROCHAMBER MIS Brand 2 WATCHHALER MIS Brand 2 OPTICHAMBER MIS DIA SM Brand 2 AERCHMBR PLS MIS SM MASK Brand 2 EASIVENT MIS MASK LG Brand 2

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 231 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO EASIVENT MIS MASK MED Brand 2 EASIVENT MIS MASK SM Brand 2 EASIVENT MIS Brand 2 MICROSPACER MIS Brand 2 BREATHERITE MIS SM MASK Brand 2 BREATHERITE MIS MED MASK Brand 2 BREATHERITE MIS LG MASK Brand 2 BREATHERITE MIS W/MASK Brand 2 BREATHERITE MIS SPACER Brand 2 OPTICHAMBER MIS DIA MD Brand 2 AERCHMBR PLS MIS LRG MASK Brand 2 OPTICHAMBER MIS ADV LRG Brand 2 OPTICHAMBER MIS ADV MED Brand 2 OPTICHAMBER MIS ADV SM Brand 2 OPTICHAMBER MIS ADVANTAG Brand 2 AEROCHAMBER MIS MV Brand 2 AEROCHAMBER MIS PLUS Brand 2 AEROCHAMBER MIS FLOSIGNA Brand 2 AERCHMBR PLS MIS MED MASK Brand 2 AERCHMBR Z- MIS STAT PLS Brand 2 AEROCHAMBER MIS PLUS Brand 2 BREATHERITE MIS Brand 2 OPTIHALER MIS Brand 2 VALVD HOLDNG MIS CHAMBER Brand 2 OPTICHAMBER MIS DIAMOND Brand 2 LITEAIRE MIS Brand 2 AEROCHAMBER MIS CHAMBER Brand 2 PARI LC PLUS MIS NEBULIZR Brand 2 PARI LC STAR MIS NEBULIZR Brand 2 PARI LC MIS SPRINT Brand 2 PARI SINUS MIS AERO SYS Brand 2 VIOS LC MIS SPRINT Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 232 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO VIOS LC PLUS MIS DELUXE Brand 2 VIOS MIS SYSTEM Brand 2 VIOS LC PLUS MIS Brand 2 VIOS LC PLUS MIS PEDIATRC Brand 2 ALTERA MIS NEBULIZE Brand 2 EFLOW SCF MIS NEBULIZR Brand 2 PARI PRONEB MIS ULTRA II Brand 2 AIRIAL MIS VOYAGER Brand 2 AIRIAL PEDIA MIS PANDA Brand 2 AEROECLIPSE MIS II NEB Brand 2 MINI COMPRES MIS NEBULIZR Brand 2 PRONEB ULTRA MIS LC PLUS Brand 2 PARI TREK S MIS Brand 2 PARI BABY MIS SIZE 0 Brand 2 PARI BABY MIS SIZE 2 Brand 2 HEALTHY LIV MIS COMPRESS Brand 2 PARI BABY MIS SIZE 1 Brand 2 PULMO-AIDE MIS COMP/NEB Brand 2 PRONEB ULTRA MIS II/LCD Brand 2 PRONEB ULTRA MIS LC SPRNT Brand 2 PRONEB ULTRA MIS LC STAR Brand 2 VIXONE DISP MIS NEBULIZR Brand 2 INSPIRATION MIS NEBULIZR Brand 2 SIDESTREAM MIS NEBULIZR Brand 2 INNOSPIRE EL MIS NEBULIZE Brand 2 MICROELITE MIS COMP/NEB Brand 2 OPTIONHOME MIS NEBULIZR Brand 2 SIDESTREAM MIS PLUS Brand 2 MICRO PLUS MIS NEBULIZR Brand 2 MINI PLUS MIS NEBULIZR Brand 2 INNOSPIRE ES MIS NEBULIZE Brand 2 NEBULIZER MIS ULTRASNC Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 233 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO NEBULIZER MIS CMPRESSR Brand 2 NEBULIZER MIS POCKET Brand 2 PARI LC D MIS NEBULIZR Brand 2 DEVILBISS MIS NEBULIZR Brand 2 MINIELITE MIS COMP/NEB Brand 2 AIRIAL PEDIA MIS FIRE ENG Brand 2 NEBULIZER MIS Brand 2 PULMOMATE/ MIS NEBULIZR Brand 2 LUMINEB II MIS NEBULIZR Brand 2 NEBULIZER MIS ULTRASON Brand 2 PARI LC PLUS MIS Brand 2 PARI LC STAR MIS Brand 2 COMP AIR MIS ELITE Brand 2 MICRO AIR MIS NEBULIZR Brand 2 COMP AIR MIS COMP/NEB Brand 2 ELITE SYSTEM MIS NEBULIZR Brand 2 MISTERNEB MIS NEBULIZE Brand 2 ERAPID MIS NEBULIZE Brand 2 NEBULIZER MIS COMPRESS Brand 2 PRONEB ULTRA MIS II/PED Brand 2 AIRIAL PEDIA MIS DUCK Brand 2 AIRIAL COMP MIS COMPRESS Brand 2 AIRIAL PEDIA MIS BUILDING Brand 2 AIRIAL PEDIA MIS PENGUIN Brand 2 AIRIAL MIS COMPACT Brand 2 INSPIRATION MIS ELITE Brand 2 TRUZONE PEAK MIS FLOW MTR Brand 2 ALCOH-WIPE PAD 12"X12" Brand 0 ALCOH-GLOVE PAD CONTOURE Brand 0 Migraine Products ERGOMAR SUB 2MG Brand 2

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 234 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DIHYDROERGOT INJ 1MG/ML generic 1 D.H.E. 45 INJ 1MG/ML Brand 2 GR MIGRANAL SPR 4MG/ML Brand 2 GR DIHYDROERGOT SPR 4MG/ML generic 1 QL 12/30 MIGRAL TAB 130MG Brand 2 AXERT TAB 6.25MG Brand 2 NON-PREF ST QL 12/30 AXERT TAB 12.5MG Brand 2 NON-PREF ST QL 12/30 RELPAX TAB 20MG Brand 2 NON-PREF ST QL 12/30 RELPAX TAB 40MG Brand 2 NON-PREF ST QL 12/30 FROVA TAB 2.5MG Brand 2 NON-PREF ST QL 12/30 AMERGE TAB 1MG Brand 2 NON-PREF ST QL 12/30 NARATRIPTAN TAB 1MG generic 1 NON-PREF ST QL 12/30 AMERGE TAB 2.5MG Brand 2 NON-PREF ST QL 12/30 NARATRIPTAN TAB 2.5MG generic 1 NON-PREF ST QL 12/30 RIZATRIPTAN TAB 5MG generic 1 NON-PREF ST QL 12/30 MAXALT TAB 5MG Brand 2 NON-PREF ST QL 12/30 RIZATRIPTAN TAB 10MG generic 1 NON-PREF ST QL 12/30 MAXALT TAB 10MG Brand 2 NON-PREF ST QL 12/30 RIZATRIPTAN TAB 5MG ODT generic 1 NON-PREF ST QL 12/30 MAXALT-MLT TAB 5MG Brand 2 PREF QL 12/30 RIZATRIPTAN TAB 10MG ODT generic 1 NON-PREF ST QL 12/30 MAXALT-MLT TAB 10MG Brand 2 PREF QL 12/30 IMITREX SPR 5MG/ACT Brand 2 NON-PREF ST QL 12/30 SUMATRIPTAN SPR 5MG/ACT generic 1 PREF QL 12/30 SUMATRIPTAN SPR 20MG/ACT generic 1 PREF QL 12/30 IMITREX SPR 20MG/ACT Brand 2 NON-PREF ST QL 12/30 SUMATRIPTAN TAB 25MG generic 1 PREF QL 12/30 IMITREX TAB 25MG Brand 2 NON-PREF ST QL 12/30 SUMATRIPTAN TAB 50MG generic 1 PREF QL 12/30 IMITREX TAB 50MG Brand 2 NON-PREF ST QL 12/30 IMITREX TAB 100MG Brand 2 NON-PREF ST QL 12/30 SUMATRIPTAN TAB 100MG generic 1 PREF QL 12/30 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 235 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO IMITREX INJ 4MG/0.5 Brand 2 NON-PREF ST QL 6/30 SUMATRIPTAN INJ 4MG/0.5 generic 1 PREF QL 3/30 SUMATRIPTAN INJ 6MG/0.5 generic 1 PREF QL 5/30 IMITREX INJ 6MG/0.5 Brand 2 NON-PREF ST QL 5/30 ALSUMA INJ 6MG/0.5 Brand 2 NON-PREF ST QL 5/30 SUMAVEL DOSE INJ 6MG/0.5 Brand 2 NON-PREF ST QL 6/30 ZOLMITRIPTAN TAB 2.5MG generic 1 ZOMIG TAB 2.5MG Brand 2 GR ZOLMITRIPTAN TAB 5MG generic 1 ZOMIG TAB 5MG Brand 2 GR ZOMIG NASAL SPR 5MG Brand 2 NON-PREF ST QL 12/30 ZOLMITRIPTAN TAB 2.5 MG generic 1 ZOMIG ZMT TAB 2.5 MG Brand 2 GR ZOMIG ZMT TAB 5MG Brand 2 GR ZOLMITRIPTAN TAB 5MG generic 1 CAMBIA POW 50MG Brand 2 QL 9/30 PA CAFERGOT TAB 1-100MG Brand 2 MIGERGOT SUP 2/100 generic 1 TREXIMET TAB 85-500MG Brand 2 NON-PREF ST QL 12/30 Mineral & Electrolytes SOD ACETATE INJ 2MEQ/ML generic 1 SOD ACETATE INJ 4MEQ/ML generic 1 NEUT INJ 4% Brand 2 SOD BICARB INJ 4.2% generic 1 SOD BICARB INJ 7.5% generic 1 SOD BICARB INJ 8.4% generic 1 SOD LACTATE INJ 5MEQ/ML Brand 2 SOD LACTATE INJ 1/6M generic 1 THAM INJ 30MEQ Brand 2 CALCIUM CL INJ 10% generic 1 CALCIUM GLUC INJ 10% generic 1

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 236 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO CALCIUM-FA WAF PLUS D generic 1 CALCIFOL WAF Brand 2 AMMONIUM CHL INJ 5MEQ/ML generic 1 SOD FLUORIDE TAB 0.5MG F Brand 2 SOD FLUORIDE TAB 1MG F Brand 2 SOD FLUORIDE CHW 0.25MG F generic 1 FLUORITAB CHW 0.25MG F generic 1 EPIFLUR CHW 0.25MG F generic 1 LURIDE CHW 0.25MG F Brand 2 GR LUDENT CHW 0.25MG F generic 1 FLUORIDE CHW 0.25MG F generic 1 EPIFLUR CHW 0.5MG F generic 1 FLUORIDE CHW 0.5MG F generic 1 SOD FLUORIDE CHW 0.5MG F generic 1 SOD FLUORIDE CHW 1.1MG generic 1 FLUORITAB CHW 0.5MG F generic 1 LUDENT CHW 0.5MG F generic 1 LURIDE CHW 0.5MG F Brand 2 GR FLUORIDE CHW 1MG F generic 1 LURIDE CHW 1MG F Brand 2 GR LUDENT CHW 1MG F generic 1 SOD FLUORIDE CHW 1MG F generic 1 NAFRINSE CHW 1MG F generic 1 SOD FLUORIDE CHW 2.2MG generic 1 EPIFLUR CHW 1MG F generic 1 FLUORITAB CHW 1MG F generic 1 FLUORITAB CHW 2.2MG generic 1 NAFRINSE DRO 0.125MG generic 1 FLURA-DROPS DRO 0.125MG generic 1 FLUORITAB DRO 0.125MG generic 1 KARIDIUM DRO 0.125MG generic 1 FLUOR-A-DAY DRO 0.125MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 237 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO FLURA-DROPS DRO 0.25MG F Brand 2 FLUORABON DRO Brand 2 SOD FLUORIDE DRO 0.5MG/ML generic 1 LURIDE DRO 0.5MG/ML Brand 2 GR LOZI-FLUR LOZ 1MG F Brand 2 FLUOR-A-DAY CHW 0.25MG F Brand 2 FLUOR-A-DAY CHW 0.5MG F Brand 2 FLUOR-A-DAY CHW 1MG F Brand 2 SSKI SOL 1GM/ML Brand 2 IODOPEN INJ 100MCG Brand 2 IODINE SOL STRONG Brand 2 MAGNESIUM CL INJ 20% generic 1 CHLOROMAG INJ 20% generic 1 MAGNESIUM SU INJ 40MG/ML generic 1 MAGNESIUM SU INJ 80MG/ML generic 1 MAGNESIUM SU INJ 50% generic 1 MAGNEBIND TAB 400 Brand 2 MANGANESE CL INJ 0.1MG/ML Brand 2 MANGANESE SU INJ 0.1MG/ML Brand 2 POT PHOSPHAT INJ 3MM/ML generic 1 K-PHOS TAB Brand 2 GLYCOPHOS SOL 1MM/ML Brand 2 SOD PHOSPHAT INJ 3MM/ML generic 1 PHOSPHA 250 TAB NEUTRAL generic 1 K-PHOS TAB NEUTRAL Brand 2 GR POT ACETATE INJ 2MEQ/ML generic 1 POT ACETATE INJ 4MEQ/ML generic 1 K-EFFERVESCE TAB 25MEQ EF generic 1 KLOR-CON/EF TAB 25MEQ FR generic 1 POTASSIUM TAB 25MEQ EF generic 1 K-VESCENT TAB 25MEQ EF generic 1 EFFER-K TAB 25MEQ EF generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 238 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO POT BICARBON TAB 25MEQ EF generic 1 K-PRIME TAB 25MEQ EF generic 1 POT CHLORIDE CAP 8MEQ ER generic 1 MICRO-K CAP 8MEQ CR Brand 2 GR MICRO-K CAP 10MEQ CR Brand 2 GR POT CHLORIDE CAP 10MEQ ER generic 1 POT CHLORIDE TAB 8MEQ ER generic 1 POT CHLORIDE TAB 8MEQ SR generic 1 KLOR-CON 8 TAB 8MEQ ER generic 1 POT CHLORIDE TAB 10MEQ ER generic 1 POT CHLORIDE TAB 10MEQ CR generic 1 KLOR-CON 10 TAB 10MEQ ER generic 1 K-TABS TAB 10MEQ CR Brand 2 GR POT CHLORIDE LIQ 10% SF generic 1 POT CHLORIDE SOL 10% SF generic 1 POT CHLORIDE LIQ 10% generic 1 POT CHLORIDE LIQ 20% generic 1 POT CHLORIDE INJ 2MEQ/ML generic 1 POT CHLORIDE INJ 10MEQ generic 1 POT CHLORIDE INJ 10MEQ generic 1 POT CHLORIDE INJ 20MEQ generic 1 POT CHLORIDE INJ 30MEQ generic 1 POT CHLORIDE INJ 20MEQ generic 1 POT CHLORIDE INJ 40MEQ generic 1 POT CL MICRO TAB 10MEQ ER generic 1 POT CL MICRO TAB 10MEQ CR generic 1 KLOR-CON M10 TAB 10MEQ ER generic 1 KLOR-CON M15 TAB generic 1 POT CL MICRO TAB 20MEQ ER generic 1 KLOR-CON M20 TAB 20MEQ ER generic 1 POT/CHLORIDE TAB 25MEQ EF generic 1 POT CHLORIDE TAB 25MEQ EF generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 239 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO EFFER-K TAB 10MEQ Brand 2 EFFER-K TAB 20MEQ Brand 2 SOD CHLORIDE INJ 0.45% generic 1 FLUSH SYRING INJ 0.9% generic 1 SOD CHLORIDE INJ 0.9% generic 1 SOD CHLORIDE INJ 0.9% generic 1 SOD CHLORIDE INJ 3% generic 1 SOD CHLORIDE INJ 5% generic 1 SOD CHLORIDE INJ 23.4% generic 1 SOD CHLORIDE INJ 4MEQ/ML generic 1 SOD CHLORIDE INJ 2.5/ML generic 1 NORMAL SALIN INJ 0.9% generic 1 NORML SALINE INJ FLUSH generic 1 SOD CHLORIDE INJ 0.9% generic 1 BD POSIFLUSH INJ 0.9% generic 1 SALINE FLUSH INJ 0.9% generic 1 SALINE FLUSH INJ ZR 0.9% generic 1 SWABFLUSH INJ 0.9% generic 1 NORML SALINE INJ IV FLUSH generic 1 GALZIN CAP 25MG Brand 2 GALZIN CAP 50MG Brand 2 ZINC SULFATE CAP 220MG generic 1 ZINC SULFATE INJ 1MG/ML Brand 2 ZINC SULFATE INJ 5MG/ML Brand 2 ZINC TRACE INJ 1MG/ML Brand 2 MULTITRACE-4 INJ NEONATAL Brand 2 MULTITRACE-4 INJ PED Brand 2 TRACE ELEM 4 INJ PED Brand 2 MULTITRACE-4 INJ Brand 2 MULTITRACE-4 INJ CONC generic 1 MULTITRACE-5 INJ REGULAR Brand 2 MULTITRACE-5 INJ generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 240 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO MULTITRACE-5 INJ CONC generic 1 PEDITRACE INJ Brand 2 ADDAMEL N INJ Brand 2 Mouth/Throat/Dental Agents NYSTATIN SUS 100000 generic 1 CLOTRIMAZOLE LOZ 10MG generic 1 CLOTRIMAZOLE TRO 10MG generic 1 ORAVIG TAB 50MG Brand 2 FIRST DUKES SUS MOUTHWSH Brand 2 BXN MOUTHWSH SUS Brand 2 FIRST-MARYS SUS MOUTHWSH Brand 2 CHLORHEX GLU SOL 0.12% generic 1 PERIOGARD SOL 0.12% generic 1 PERIDEX SOL 0.12% Brand 2 GR DEBACTEROL SOL 30-50% Brand 2 TRIAMCINOLON PST 0.1% generic 1 TRIAMCIN/ORA PST 0.1% generic 1 ORALONE PST 0.1% generic 1 APHTHASOL PST 5% Brand 2 DOBELLS SOL generic 1 TOPEX TOPCAL SPR ANESTHET generic 1 LIDOCAINE SOL 4% generic 1 LTA 360 KIT SOL 4% Brand 2 GR LIDOCAINE SOL 2% VISC generic 1 FIRST-MOUTHW SUS BLM Brand 2 SOD FLUORIDE SOL 0.2% generic 1 SOD FLUORIDE SOL 0.2%MINT generic 1 CAVIRINSE SOL 0.2% generic 1 PREVIDENT SOL RINSE Brand 2 GR NAFRINSE DLY SOL /NEUTRAL Brand 2 NAFRINSE WK SOL 0.2% Brand 2

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 241 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO SF 5000 PLUS CRE 1.1% generic 1 PREVIDENT CRE 5000 PLS Brand 2 GR CONTROLRX CRE 1.1% generic 1 DENTA 5000 CRE PLUS generic 1 DENTA 5000 CRE PLUS 2PK generic 1 FLUORIDEX GEL WHITENIN generic 1 KARIGEL GEL 0.5% generic 1 CAVAREST GEL 1.1% generic 1 PHOS-FLUR GEL 1.1% generic 1 DENTAGEL GEL 1.1% generic 1 KARIGEL-N GEL 1.1% generic 1 NEUTRAGARD GEL 1.1% generic 1 SF GEL 1.1% generic 1 THERA-FLUR-N DRO 1.1% Brand 2 GR PREVIDENT GEL 1.1% MIN Brand 2 GR PREVIDENT GEL 1.1% BER Brand 2 GR PREVIDENT GEL 1.1% CHR Brand 2 GR FLUORIDEX GEL 1.1% generic 1 PREVIDENT PST 1.1% Brand 2 GR PREVDNT 5000 PST 1.1% Brand 2 GR CONTROLRX PST 1.1% generic 1 CLINPRO 5000 PST 1.1% generic 1 PREVIDENT PST 5000 BST Brand 2 GR STAN FLUORID CON 0.63% generic 1 PERIO MED CON 0.63% generic 1 GEL-KAM CON 0.63% Brand 2 GR EASYGEL GEL 0.4%CHRY generic 1 EASYGEL GEL 0.4%CITR generic 1 EASYGEL GEL 0.4% generic 1 EASYGEL GEL 0.4%MINT generic 1 NAFRINSE SOL DAILY Brand 2 FLUORIDEX GEL SENSITIV Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 242 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO FLUORIDEX DD PST SENSITIV generic 1 PRVDNT 5000 PST ENAML PR Brand 2 GR PREVIDENT PST 5000 SEN Brand 2 GR ARESTIN MIS 1MG Brand 2 NUMOISYN LIQ Brand 2 CAPHOSOL SOL Brand 2 AQUORAL AER Brand 2 NUMOISYN LOZ Brand 2 GR CEVIMELINE CAP 30MG generic 1 EVOXAC CAP 30MG Brand 2 GR PILOCARPINE TAB 5MG generic 1 SALAGEN TAB 5MG Brand 2 GR PILOCARPINE TAB 7.5MG generic 1 SALAGEN TAB 7.5MG Brand 2 GR ORAFATE PST 10% Brand 2 PROTHELIAL PST 10% Brand 2 GELCLAIR GEL Brand 2 SALICEPT SUS Brand 2 ORAMAGICRX SUS Brand 2 MUCOTROL WAF Brand 2 GELX GEL Brand 2 Multivitamins COD LIVER OIL Brand 2 PA NICOMIDE TAB Brand 2 PA VIT B-COMPLX INJ 100 generic 1 B-COMPLEX INJ generic 1 B-COMPLEX INJ 100 generic 1 VITAJECT INJ Brand 2 PA NEURODEP SOL Brand 2 PA RENAL CAP SOFTGEL generic 1 RENO CAP generic 1

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 243 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO MYNEPHROCAPS CAP generic 1 RENALPREN CAP generic 1 TRIPHROCAPS CAP generic 1 NEPHROCAPS CAP Brand 2 GR B-PLEX TAB generic 1 SM B-COMPLEX TAB /VIT C Brand 2 PA STROVITE TAB Brand 2 GR NEPHRO-VITE TAB RX Brand 2 GR DIALYVITE TAB generic 1 VOL-CARE RX TAB generic 1 NEPHRONEX TAB 1MG generic 1 RENA-VITE RX TAB generic 1 FOLBEE PLUS TAB generic 1 VIRT-VITE TAB PLUS generic 1 NEPHROCAPS TAB QT Brand 2 PA DIALYVITE/ TAB ZINC Brand 2 PA NEPHPLEX RX TAB Brand 2 PA SUPERVITE LIQ Brand 2 PA NUTRIVIT LIQ 800-15-1 Brand 2 PA RENATABS TAB Brand 2 PA DIALYVITE TAB 3000 Brand 2 PA DIALYVITE TAB 5000 Brand 2 PA RENATABS MIS IRON Brand 2 PA VITAL-D RX TAB Brand 2 PA DIATX ZN TAB Brand 2 GR FOLBEE PLUS TAB CZ generic 1 ALBAFORT INJ Brand 2 PA ADRENAL C TAB FORMULA Brand 2 PA M.V.I PEDIAT INJ Brand 2 PA M.V.I-12 W/O INJ VIT K Brand 2 PA M.V.I. ADULT INJ Brand 2 PA INFUVITE INJ PEDIATRI generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 244 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO INFUVITE INJ generic 1 INFUVITE INJ ADULT generic 1 PROTECT PLUS CAP Brand 2 PA FORTAVIT CAP Brand 2 PA VIC-FORTE CAP generic 1 VITA-MIN CAP generic 1 V-C FORTE CAP generic 1 NICAZEL TAB FORTE Brand 2 PA STROVITE FOR TAB Brand 2 GR VITAROCA PLU TAB Brand 2 GR STROVITE ONE TAB Brand 2 PA STROVITE PLU TAB generic 1 B-PLEX PLUS TAB generic 1 CHOICE-TABS TAB generic 1 BIOCEL TAB generic 1 LYSIPLEX TAB PLUS generic 1 VITACEL TAB generic 1 VITA S FORTE TAB generic 1 REQ 49+ TAB Brand 2 PA CORVITE FREE TAB generic 1 TRI-ZEL TAB Brand 2 PA BACMIN TAB Brand 2 PA SIDEROL TAB Brand 2 PA AP-ZEL TAB Brand 2 PA NUTRICAP TAB Brand 2 PA VP-ZEL TAB Brand 2 PA NICAZEL TAB Brand 2 PA NUTRIFAC ZX TAB generic 1 PROTECT PLUS LIQ Brand 2 PA SUPPORT LIQ Brand 2 PA SYNATEK CAP Brand 2 PA SYNAGEX CAP 1.25MG Brand 2 PA KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 245 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO UDAMIN SP TAB Brand 2 PA CORVITE TAB Brand 2 GR CORVITA TAB generic 1 UDAMIN TAB Brand 2 PA RENAX TAB 2.5MG Brand 2 PA DIALYVITE TAB SUPREM D Brand 2 PA SUPERVITE EC TAB Brand 2 PA STROVITE FOR SYP Brand 2 PA ADVANCED MIS AM/PM Brand 2 PA FOLGARD OS TAB Brand 2 PA TL G-FOL OS TAB Brand 2 PA PROTECTBONE WAF Brand 2 PA VITAMAX PED DRO generic 1 ACD/FLUORIDE DRO 0.25MG generic 1 TRI-VIT/FL DRO 0.25MG generic 1 TRI-VIT/FLUO DRO 0.25MG generic 1 TRI-VITA/FL DRO 0.25MG generic 1 TRI-VIT/FLUO DRO 0.5MG generic 1 TRI-VIT/FL DRO 0.5MG generic 1 TRI-VI-FLORO SUS 0.25/ML Brand 2 PA TRI-VI-FLOR SUS 0.25/ML Brand 2 PA TRI-VI-FLORO SUS 0.5MG/ML Brand 2 PA TRI-VI-FLOR SUS 0.5MG/ML Brand 2 PA MULTIVIT/FL CHW 0.25MG generic 1 MULTI-VIT/FL CHW 0.25MG generic 1 MVC-FLUORIDE CHW 0.25MG generic 1 MULTIVIT/FL CHW 0.5MG generic 1 MULT-VIT/FL CHW 0.5MG generic 1 MULTI-VIT/FL CHW 0.5MG generic 1 MVC-FLUORIDE CHW 0.5MG generic 1 MVC-FLUORIDE CHW 1MG generic 1 MULTIVIT/FL CHW 1MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 246 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO MULTI-VIT/FL CHW 1MG generic 1 POLY-VI-FLOR CHW 0.25MG Brand 2 PA POLY-VI-FLOR CHW 0.5MG Brand 2 PA POLY-VI-FLOR CHW 1MG Brand 2 PA POLY-VI-FLOR SUS 0.25/ML Brand 2 PA MULTI-VIT/FL DRO 0.25MG generic 1 MULTI-VIT/FL DRO 0.5MG/ML generic 1 TL-FLUORIVIT CHW Brand 2 PA ESCAVITE CHW Brand 2 PA POLY-VI-FLOR CHW W/IRON Brand 2 PA POLY-VI-FLOR SUS /IRON Brand 2 PA ESCAVITE LQ DRO Brand 2 PA MULTI-VIT/FE DRO /FL 0.25 Brand 2 PA MULTI-VIT/FL DRO /FE 0.25 Brand 2 PA MYKIDZ IRON SUS FL Brand 2 PA TRI-VIT/FE DRO /FL 0.25 generic 1 PRENA1 CHW QUATREFO Brand 0 REDICHEW CHW RX Brand 0 PRENAISSANCE TAB NEXT Brand 0 ZINGIBER TAB Brand 0 VP-GGR-B6 TAB PRENATAL Brand 0 FOCALGIN-B TAB Brand 0 PRENAISSANCE TAB NEXT-B Brand 0 TRIMESIS RX TAB Brand 0 FOLBECAL TAB Brand 0 BP FOLINATAL TAB PLUS B Brand 0 PRENATE AM TAB 1MG Brand 0 PRENATE CHW 0.6-0.4 Brand 0 MYNATAL CAP Brand 0 PRENATABS RX TAB Brand 0 NATAL-V RX TAB 29-1MG Brand 0 PRENATAL TAB PLUS FE Brand 0 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 247 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO VOL-TAB RX TAB Brand 0 PRENATAL+FE TAB 29-1MG Brand 0 ELITE-OB TAB Brand 0 OB COMPLETE TAB Brand 0 ATABEX TAB PRENATAL Brand 0 OB COMPLETE/ CAP DHA Brand 0 OB COMPLETE TAB PREMIER Brand 0 O-CAL TAB PRENATAL Brand 0 PRENAFIRST TAB Brand 0 NATELLE-EZ TAB Brand 0 M-VIT TAB 27-1MG Brand 0 TRICARE TAB PRENATAL Brand 0 PRENAPLUS TAB Brand 0 PNV FOLIC AC TAB + IRON Brand 0 PNV PRENATAL TAB PLUS Brand 0 PRENATAL TAB PLUS Brand 0 VOL-PLUS TAB Brand 0 PRENATAL TAB LOW IRON Brand 0 O-CAL FA TAB Brand 0 PRENATAL VIT TAB PLUS Brand 0 PRENATAL TAB 27-1MG Brand 0 TRINATE TAB Brand 0 VOL-NATE TAB Brand 0 VENATAL-FA TAB Brand 0 CO-NATAL FA TAB 29-1MG Brand 0 PRENATABS FA TAB Brand 0 VINATE ONE TAB Brand 0 SE-NATAL ONE TAB Brand 0 TRINATAL RX TAB 1 Brand 0 MYNATAL PLUS TAB Brand 0 VITAFOL-PN TAB Brand 0 MYNATAL-Z TAB Brand 0 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 248 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO VITAFOL-OB TAB 65-1MG Brand 0 NATALVIT TAB 75-1MG Brand 0 COMPLETENATE CHW Brand 0 SE-NATAL 19 CHW Brand 0 PRENATAL 19 CHW 29-1MG Brand 0 PRENATAL 19 CHW TAB Brand 0 CAVAN ONE CAP OMEGA Brand 0 FOLCAPS CAP OMEGA 3 Brand 0 ULTIMATECARE CAP ONE Brand 0 OB-NATAL ONE CAP 27-1MG generic 0 RELNATE DHA CAP Brand 0 C-NATE DHA CAP 28-1-200 Brand 0 VIVA DHA CAP Brand 0 VP-PNV-DHA CAP Brand 0 SE-PLETE DHA CAP Brand 0 ELITE OB CAP W/DHA Brand 0 PRENATE TAB ELITE Brand 0 VIRT-PN TAB Brand 0 PNV-SELECT TAB Brand 0 ZATEAN-PN TAB Brand 0 SELECT-OB CHW Brand 0 VINATE CAL TAB Brand 0 VINATE AZ TAB Brand 0 GENTEX ADE TAB 28-1MG Brand 0 VINATE II TAB Brand 0 VINATE AZ EX TAB Brand 0 NATACHEW CHW Brand 0 PRENATAL-U CAP Brand 0 TRIVEEN-U CAP Brand 0 BP MULTINATL TAB PLUS Brand 0 SE-CARE TAB CONCEIVE Brand 0 VINATE C TAB Brand 0 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 249 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO VIVA CT CHW 28-1MG Brand 0 PRENATA CHW 29-1MG Brand 0 SE-CARE CHW Brand 0 BP MULTINATL CHW PLUS Brand 0 VINATE CARE CHW Brand 0 TARON-EC CAL TAB 28-1MG Brand 0 CAVAN TAB PRENATAL Brand 0 TRI RX TAB Brand 0 VINACAL TAB Brand 0 CITRANATAL TAB RX Brand 0 VITASPIRE TAB Brand 0 PRENATABS TAB OBN Brand 0 VINATE PN TAB CARE Brand 0 COMPLETE-RF TAB PRENATAL Brand 0 NATAFORT TAB Brand 0 PROVIDA OB CAP Brand 0 FOLIVANE-OB CAP Brand 0 CONCEPT OB CAP Brand 0 VINATE IC CAP Brand 0 PUREFE OB CAP PLUS Brand 0 TANDEM OB CAP Brand 0 ULTIMATECARE MIS ADVANTAG Brand 0 ULTIMATECARE MIS COMBO Brand 0 VINATE M TAB Brand 0 TRIVEEN-ONE CAP Brand 0 NATELLE ONE CAP Brand 0 VIRT-PN PLUS CAP Brand 0 ZATEAN-PN CAP PLUS Brand 0 PNV-OMEGA CAP Brand 0 PRENATE CAP ESSENTIL Brand 0 TARON-BC MIS Brand 0 VITA-PREN TAB Brand 0 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 250 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO OBSTETRIX EC TAB Brand 0 MYNATAL TAB ADVANCE Brand 0 INATAL GT TAB Brand 0 INATAL ULTRA TAB Brand 0 TRIADVANCE TAB Brand 0 PRENATAL AD TAB Brand 0 VINATE GT TAB Brand 0 VINATE ULTRA TAB Brand 0 TRINATAL TAB ULTRA Brand 0 TRINATAL GT TAB Brand 0 ULTRA TABS TAB Brand 0 INATAL ADV TAB Brand 0 MYNATAL TAB Brand 0 ATABEX EC TAB Brand 0 NESTABS TAB Brand 0 NESTABS DHA PAK Brand 0 MARNATAL-F CAP Brand 0 SE-NATAL 19 TAB Brand 0 PRENATAL 19 TAB Brand 0 PRENATAL 19 TAB 29-1MG Brand 0 MYNATE 90 TAB PLUS Brand 0 SE-NATAL 90 TAB Brand 0 VINACAL B MIS Brand 0 CITRANATAL MIS B-CALM Brand 0 OB COMPLETE CAP 400 Brand 0 OB COMPLETE CAP ONE Brand 0 OB COMPLETE CAP PETITE Brand 0 OB COMPLETE CHW Brand 0 NEEVO DHA CAP 27-1.13 Brand 0 PRENATAL MIS COMPLEAT Brand 0 VINATE DHA CAP Brand 0 PROTECTNATAL TAB Brand 0 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 251 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PREFERA OB MIS + DHA Brand 0 HEMENATAL OB MIS + DHA Brand 0 VP-ERA OB PAK PLUS Brand 0 PREFERA OB TAB Brand 0 HEMENATAL OB TAB 28-6-1MG Brand 0 SE-TAN DHA CAP Brand 0 TANDEM DHA CAP Brand 0 TARON-C DHA CAP Brand 0 CONCEPT DHA CAP Brand 0 OB-NATAL ONE CAP 20-7-1MG Brand 0 ULTIMATECARE CAP ONE NF Brand 0 OBSTETRIX PAK DHA Brand 0 TL-CARE DHA CAP 27-1-500 Brand 0 TRICARE PRE CAP 27-1-500 Brand 0 TRICARE DHA CAP 301 Brand 0 ELITE-OB 400 CAP Brand 0 PNV-TOTAL CAP Brand 0 CAVAN-EC SOD MIS DHA Brand 0 DUET DHA MIS BALANCED Brand 0 DUET DHA MIS BALANCED Brand 0 DUET DHA 400 MIS 25-1-400 Brand 0 DUET DHA 430 MIS 25-1-430 Brand 0 DUET DHA 400 MIS 25-1-400 Brand 0 DUET DHA 430 MIS 25-1-430 Brand 0 MOMS CHOICE MIS RX Brand 0 DUET DHA MIS BALANCED Brand 0 VIRT-BAL DHA MIS Brand 0 BAL-CARE DHA MIS ESSNTIAL Brand 0 PRENAISSANCE MIS HARMONY Brand 0 VIRT-BAL DHA MIS PLUS Brand 0 VENATAL COMP MIS DHA Brand 0 BAL-CARE MIS DHA Brand 0 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 252 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO VENA-BAL MIS DHA Brand 0 COMPLETE NAT PAK DHA Brand 0 TRIVEEN-DUO PAK DHA Brand 0 PR NATAL 400 PAK Brand 0 PR NATAL 400 PAK EC Brand 0 SETONET PAK Brand 0 PR NATAL 430 PAK Brand 0 SETON ET-EC PAK Brand 0 PR NATAL 430 PAK EC Brand 0 MARNATAL-F MIS PLUS DUO Brand 0 NESTABS ABC MIS Brand 0 ACTIVE OB CAP Brand 0 R-NATAL OB CAP 20-1-320 Brand 0 TRIVEEN-TEN TAB Brand 0 PREQUE 10 TAB Brand 0 FOLIVANE-EC PAK CA DHA Brand 0 GESTICARE PAK DHA Brand 0 TARON EC PAK CALCIUM Brand 0 VITAFOL-OB PAK +DHA Brand 0 PNV-OB/DHA PAK Brand 0 LEVOMEFOLATE CAP DHA Brand 0 PRENATE MINI CAP Brand 0 VIRT-PN DHA CAP Brand 0 PNV-DHA CAP Brand 0 ZATEAN-PN CAP DHA Brand 0 PRENATE CAP RESTORE Brand 0 PRENATE DHA CAP Brand 0 PRENATE CAP ENHANCE Brand 0 VITAMEDMD CAP ONE RX Brand 0 PRENA1 CAP QUATREFO Brand 0 VITAFOL-PLUS CAP Brand 0 REAPHIRM CAP Brand 0 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 253 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PNV-FIRST CAP Brand 0 VITAFOL-ONE CAP Brand 0 CHOICE-OB+ PAK DHA Brand 0 SELECT-OB+ PAK DHA Brand 0 ZATEAN-CH CAP Brand 0 MACNATAL CN CAP DHA Brand 0 PRENAISSANCE CAP PLUS Brand 0 CITRANATAL CAP HARMONY Brand 0 INFANATE CAP BALANCE Brand 0 VP-CH PLUS CAP Brand 0 PRENAISSANCE CAP BALANCE Brand 0 VP-CH-PNV CAP Brand 0 TRIVEEN-PRX CAP RNF Brand 0 PREFOL-DHA CAP Brand 0 PNV-DHA CAP DOCUSATE Brand 0 FOLCAL DHA CAP Brand 0 VEMAVITE- CAP PRX 2 Brand 0 TARON-PREX CAP Brand 0 FOLIVANE-PRX CAP DHA NF Brand 0 PRENAISSANCE CAP Brand 0 VIRT-SELECT CAP Brand 0 TL-SELECT CAP Brand 0 NEXA PLUS CAP Brand 0 TL-SELECT CAP DHA Brand 0 EXTRA-VIRT CAP PLUS DHA Brand 0 PRENAISSANCE PAK DHA Brand 0 PNV OB+DHA PAK Brand 0 CITRANATAL PAK DHA Brand 0 PRENAISSANCE PAK PROMISE Brand 0 NATALVIRT CA PAK Brand 0 CITRANATAL PAK ASSURE Brand 0 CITRANATAL MIS 90 DHA Brand 0 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 254 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PRENAISSANCE PAK 90 DHA Brand 0 NATALVIRT MIS 90 DHA Brand 0 CRNATAL PAK Brand 0 PREFERAOB CAP ONE Brand 0 VP-HEME ONE CAP Brand 0 ULTIMATE OB MIS DHA Brand 0 PAIRE OB MIS Brand 0 VITAFOL CAP ULTRA Brand 0 VITAMEDMD MIS PLUS RX Brand 0 PRENA1 PLUS MIS QUATREFO Brand 0 VITAFOL TAB Brand 2 GR VITAFOL SYP Brand 2 PA Musculoskeletal Therapy Agents BACLOFEN TAB 10MG generic 1 PREF BACLOFEN TAB 20MG generic 1 PREF LIORESAL INT INJ 0.05MG/1 Brand 2 GABLOFEN INJ 50MCG/ML Brand 2 GABLOFEN INJ 10000/20 Brand 2 LIORESAL INT INJ 10MG/20 Brand 2 GABLOFEN INJ 20000/20 Brand 2 LIORESAL INT INJ 10MG/5ML Brand 2 GABLOFEN INJ 40000/20 Brand 2 LIORESAL INT INJ 40MG/20 Brand 2 CARISOPRODOL TAB 250MG generic 1 PREF QL 120/180 SOMA TAB 250MG Brand 2 NON-PREF ST QL 120/180 SOMA TAB 350MG Brand 2 NON-PREF ST QL 120/180 CARISOPRODOL TAB 350MG generic 1 PREF QL 120/180 LORZONE TAB 375MG Brand 2 NON-PREF ST PARAFON FORT TAB 500MG Brand 2 NON-PREF ST CHLORZOXAZON TAB 500MG generic 1 PREF LORZONE TAB 750MG Brand 2 NON-PREF ST

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 255 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO CYCLOBENZAPR TAB 5MG generic 1 PREF FEXMID TAB 7.5MG Brand 2 NON-PREF ST CYCLOBENZAPR TAB 7.5MG generic 1 CYCLOBENZAPR TAB 10MG generic 1 PREF CYCLOBENZAPR CRE 20MG/GM Brand 2 AMRIX CAP 15MG Brand 2 NON-PREF ST AMRIX CAP 30MG Brand 2 NON-PREF ST SKELAXIN TAB 800MG Brand 2 GR METAXALONE TAB 800MG generic 1 METHOCARBAM TAB 500MG generic 1 ROBAXIN TAB 500MG Brand 2 GR ROBAXIN-750 TAB 750MG Brand 2 GR METHOCARBAM TAB 750MG generic 1 ROBAXIN INJ 100MG/ML Brand 2 ORPHENADRINE INJ 30MG/ML generic 1 NORFLEX INJ 30MG/ML Brand 2 GR ORPHENADRINE TAB 100MG ER generic 1 TIZANIDINE CAP 2MG generic 1 ZANAFLEX CAP 2MG Brand 2 GR ZANAFLEX CAP 4MG Brand 2 GR TIZANIDINE CAP 4MG generic 1 TIZANIDINE CAP 6MG generic 1 ZANAFLEX CAP 6MG Brand 2 GR TIZANIDINE TAB 2MG generic 1 TIZANIDINE TAB 4MG generic 1 ZANAFLEX TAB 4MG Brand 2 GR DANTRIUM CAP 25MG Brand 2 GR DANTROLENE CAP 25MG generic 1 DANTRIUM CAP 50MG Brand 2 GR DANTROLENE CAP 50MG generic 1 DANTRIUM CAP 100MG Brand 2 GR DANTROLENE CAP 100MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 256 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DANTRIUM IV INJ 20MG Brand 2 GR REVONTO INJ 20MG generic 1 GEL-ONE INJ 30MG/3ML Brand 2 QL 6/180 PA SP SYNVISC INJ 8MG/ML Brand 2 QL 12/180 PA SP ORTHOVISC INJ 15MG/ML Brand 2 QL 16/180 PA SP HYALGAN INJ 20MG/2ML Brand 2 QL 20/180 PA SP SUPARTZ INJ 25/2.5ML Brand 2 QL 25/180 PA SP CARISOPR/ASA TAB 200-325 generic 1 QL 240/180 CARISOPRODOL TAB ASA/COD generic 1 QL 240/180 ORPH/ASA/CAF TAB generic 1 TIZANIDINE KIT COMFORT Brand 2 Nasal Agents - Systemic and Topical ADRENALIN SOL 1:1000 Brand 2 TYZINE PED DRO 0.05% Brand 2 TYZINE SOL 0.1% Brand 2 QNASL AER 80MCG Brand 2 NON-PREF ST BECONASE AQ SUS 0.042% Brand 2 NON-PREF ST RHINOCORT SUS AQUA Brand 2 NON-PREF ST OMNARIS SPR Brand 2 NON-PREF ST ZETONNA AER 37MCG Brand 2 NON-PREF ST FLUNISOLIDE SPR 0.025% generic 1 NON-PREF ST VERAMYST SPR 27.5MCG Brand 2 NON-PREF ST FLUTICASONE SPR 50MCG generic 1 PREF FLONASE SPR 0.05% Brand 2 NON-PREF ST NASONEX SPR 50MCG/AC Brand 2 PREF NASACORT AQ AER 55MCG/AC Brand 2 NON-PREF ST TRIAMCINOLON SPR 55MCG/AC generic 1 NON-PREF ST BACTROBAN OIN NASAL 2% Brand 2 NON-PREF ST ATROVENT NAS SOL 0.03% Brand 2 GR IPRATROPIUM SPR 0.03% generic 1 IPRATROPIUM SPR 0.06% generic 1

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 257 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ATROVENT NAS SOL 0.06% Brand 2 GR ASTELIN NASA SPR 137MCG Brand 2 PREF AZELASTINE SPR 0.1% generic 1 NON-PREF ST ASTEPRO SPR 0.15% Brand 2 PREF PATANASE SPR 0.6% Brand 2 NON-PREF ST DYMISTA SPR 137-50 Brand 2 NON-PREF ST Neuromuscular Agents ANECTINE INJ 20MG/ML Brand 2 GR QUELICIN INJ 20MG/ML Brand 2 GR QUELICIN INJ -1000 Brand 2 ATRACURIUM INJ 50MG/5ML generic 1 ATRACURIUM INJ 10MG/ML generic 1 ATRACURIUM INJ 10MG/ML generic 1 CISATRACURIU INJ 2MG/ML generic 1 NIMBEX INJ 2MG/ML Brand 2 GR NIMBEX INJ 2MG/ML Brand 2 GR CISATRACURIU INJ 2MG/ML generic 1 CISATRACURIU INJ 10MG/ML generic 1 NIMBEX INJ 10MG/ML Brand 2 GR PANCURONIUM INJ 1MG/ML generic 1 PANCURONIUM INJ 2MG/ML generic 1 ROCURONIUM INJ 50MG/5ML generic 1 ROCURONIUM INJ 10MG/ML generic 1 ZEMURON INJ 10MG/ML Brand 2 GR ROCURONIUM INJ 100MG/10 generic 1 ROCURONIUM INJ 10MG/ML generic 1 ZEMURON INJ 10MG/ML Brand 2 GR VECURONIUM INJ 10MG generic 1 VECURONIUM INJ 20MG generic 1 DYSPORT INJ 300UNIT Brand 2 PA SP DYSPORT INJ 500UNIT Brand 2 PA SP

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 258 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO BOTOX INJ 100UNIT Brand 2 PA SP BOTOX INJ 200UNIT Brand 2 PA SP MYOBLOC INJ 2500/0.5 Brand 2 PA SP MYOBLOC INJ 5000/ML Brand 2 PA SP MYOBLOC INJ 10000/2 Brand 2 PA SP XEOMIN INJ 50 UNIT Brand 2 PA SP XEOMIN INJ 100UNIT Brand 2 PA SP RILUTEK TAB 50MG Brand 2 GR RILUZOLE TAB 50MG generic 1 Nutrients ALCOHOL INJ 98% generic 1 DEXTROSE INJ 2.5% generic 1 DEXTROSE INJ 5% generic 1 DEXTROSE INJ 5% PGBK generic 1 DEXTROSE INJ 10% generic 1 DEXTROSE INJ 30% generic 1 DEXTROSE INJ 50% generic 1 DEXTROSE INJ 70% generic 1 INTRALIPID INJ 20% generic 1 LIPOSYN III INJ 30% generic 1 PREMASOL SOL 6% generic 1 AMINOSYN II INJ 15% Brand 2 GR CLINIMIX INJ 4.25/D10 Brand 2 CYSTEINE HCL INJ 50MG/ML Brand 2 GR Ophthalmic Agents AZASITE SOL 1% Brand 2 NON-PREF ST BACITRACIN OIN OP generic 1 BESIVANCE SUS 0.6% Brand 2 NON-PREF ST CILOXAN SOL 0.3% OP Brand 2 NON-PREF ST CIPROFLOXACN SOL 0.3% OP generic 1 PREF CILOXAN OIN 0.3% OP Brand 2 NON-PREF ST

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 259 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ERYTHROMYCIN OIN 5MG/GM generic 1 ILOTYCIN OIN OP generic 1 ERYTHROMYCIN OIN OP generic 1 ROMYCIN OIN OP generic 1 GATIFLOXACIN SOL 0.5% generic 1 ZYMAXID SOL 0.5% Brand 2 NON-PREF ST GARAMYCIN SOL 0.3% OP Brand 2 GR GENTAMICIN SOL 0.3% OP generic 1 GARAMYCIN OIN 0.3% OP generic 1 GENTAK OIN 0.3% OP generic 1 GENTAMICIN OIN 0.3% OP generic 1 LEVOFLOXACIN SOL 0.5% generic 1 PREF VIGAMOX DRO 0.5% Brand 2 PREF MOXEZA SOL 0.5% Brand 2 PREF OCUFLOX DRO 0.3% OP Brand 2 NON-PREF ST OFLOXACIN DRO 0.3% OP generic 1 PREF TOBRAMYCIN SOL 0.3% OP generic 1 TOBREX SOL 0.3% OP Brand 2 GR TOBREX OIN 0.3% OP Brand 2 PA MITOSOL KIT 0.2MG Brand 2 BLEPH-10 SOL 10% OP Brand 2 GR SULFACET SOD SOL 10% OP generic 1 SOD SULFACET SOL 10% OP generic 1 SULFACET SOD OIN 10% OP Brand 2 VITRAVENE INJ 6.6MG/ML Brand 2 ZIRGAN GEL 0.15% Brand 2 TRIFLURIDINE SOL 1% OP generic 1 VIROPTIC SOL 1% OP Brand 2 GR NATACYN SUS 5% OP Brand 2 BETADINE SOL 5% OP Brand 2 BACIT/POLYMY OIN OP generic 1 AK-POLY-BAC OIN OP generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 260 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO POLYCIN B OIN OP generic 1 POLYCIN OIN OP generic 1 POLYTRIM SOL OP Brand 2 GR POLYMYXIN B/ SOL TRIMETHP generic 1 TRIMETHOPRIM SOL POLYMYXN generic 1 NEO-POLYCIN OIN OP generic 1 NEO/BAC/POLY OIN OP generic 1 NEOSPORIN SOL OP Brand 2 GR NEO/POLY/GRA SOL OP generic 1 LACRISERT MIS 5MG OP Brand 2 BETOPTIC-S SUS 0.25% OP Brand 2 BETAXOLOL SOL 0.5% OP generic 1 CARTEOLOL SOL 1% OP generic 1 METIPRANOLOL SOL 0.3% OPH generic 1 OPTIPRANOLOL SOL 0.3% OP Brand 2 GR LEVOBUNOLOL SOL 0.25% OP Brand 2 BETAGAN SOL 0.5% OP Brand 2 GR LEVOBUNOLOL SOL 0.5% OP generic 1 BETIMOL SOL 0.25% Brand 2 BETIMOL SOL 0.5% Brand 2 TIMOPTIC SOL 0.25% OP Brand 2 GR TIMOLOL MAL SOL 0.25% OP generic 1 TIMOPTIC OCU SOL 0.25% OP Brand 2 TIMOPTIC SOL 0.5% OP Brand 2 GR TIMOLOL MAL SOL 0.5% OP generic 1 TIMOPTIC OCU SOL 0.5% OP Brand 2 ISTALOL SOL 0.5% OP Brand 2 TIMOPTIC-XE SOL 0.25% OP Brand 2 GR TIMOLOL GEL SOL 0.25% OP generic 1 TIMOLOL GEL SOL 0.5% OP generic 1 TIMOPTIC-XE SOL 0.5% OP Brand 2 GR COMBIGAN SOL 0.2/0.5% Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 261 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DORZOL/TIMOL SOL 2-0.5%OP generic 1 COSOPT SOL 2-0.5%OP Brand 2 GR COSOPT PF SOL Brand 2 MAXIDEX SUS 0.1% OP Brand 2 DEXAMETH PHO SOL 0.1% OP generic 1 DUREZOL EMU 0.05% Brand 2 PA FLUOROMETHOL SUS 0.1% OP generic 1 FML LIQUIFLM SUS 0.1% OP Brand 2 GR FML FORTE SUS 0.25% OP Brand 2 FML OIN 0.1% OP Brand 2 FLAREX SUS 0.1% OP Brand 2 ALREX SUS 0.2% Brand 2 NON-PREF ST LOTEMAX SUS 0.5% Brand 2 PA LOTEMAX GEL 0.5% Brand 2 PA LOTEMAX OIN 0.5% Brand 2 PA PRED MILD SUS 0.12% OP Brand 2 PREDNISOLONE SUS 1% OP generic 1 PRED FORTE SUS 1% OP Brand 2 GR OMNIPRED SUS 1% OP Brand 2 GR PRED SOD PHO SOL 1% OP generic 1 VEXOL SUS 1% OP Brand 2 TRIESENCE INJ 40MG/ML Brand 2 PRED-G SUS OP Brand 2 PRED-G S.O.P OIN OP Brand 2 ZYLET SUS 0.5-0.3% Brand 2 PA BLEPHAMIDE SUS OP Brand 2 SULF/PRED NA SOL OP generic 1 BLEPHAMIDE OIN S.O.P. Brand 2 PA TOBRADEX ST SUS 0.3-0.05 Brand 2 PA TOBRADEX SUS 0.3-0.1% Brand 2 GR TOBRA/DEXAME SUS 0.3-0.1% generic 1 TOBRADEX OIN 0.3-0.1% Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 262 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO MAXITROL SUS 0.1% OP Brand 2 GR NEO/POLY/DEX SUS 0.1% OP generic 1 POLY-DEX OIN 0.1% OP generic 1 NEO/POLY/DEX OIN 0.1% OP generic 1 MAXITROL OIN 0.1% OP Brand 2 GR NEO/POLY/HC SUS OP generic 1 NEO-POLYCIN OIN HC 1%OP generic 1 NEO/POLY/BAC OIN /HC 1%OP generic 1 LUMIGAN SOL 0.01% Brand 2 LATANOPROST SOL 0.005% generic 1 XALATAN SOL 0.005% Brand 2 GR ZIOPTAN DRO 0.0015% Brand 2 TRAVOPROST DRO 0.004% generic 1 TRAVATAN Z DRO 0.004% Brand 2 RESCULA SOL 0.15% Brand 2 ATROPIN-CARE SOL 1% OP generic 1 ISO ATROPINE SOL 1% OP Brand 2 GR ATROPINE SUL SOL 1% OP generic 1 ATROPINE SUL OIN 1% OP generic 1 CYCLOGYL SOL 0.5% OP Brand 2 CYCLOPENTOL SOL 1% OP generic 1 CYCLOGYL SOL 1% OP Brand 2 GR CYCLOPENTOL SOL 2% OP generic 1 CYCLOGYL SOL 2% OP Brand 2 GR ISO HOMATROP SOL 2% OP Brand 2 HOMATROPINE SOL 5% OP generic 1 HOMATROPAIRE SOL 5% OP generic 1 ISO HOMATROP SOL 5% OP Brand 2 GR ISO HYOSCINE SOL 0.25% OP Brand 2 TROPICAMIDE SOL 0.5% OP generic 1 MYDRAL SOL 0.5% OP generic 1 TROPICAMIDE SOL 1% OP generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 263 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO MYDRAL SOL 1% OP generic 1 MYDRIACYL SOL 1% OP Brand 2 GR CYCLOMYDRIL SOL OP Brand 2 NAPHAZOLINE SOL 0.1% OP generic 1 PHENYLEPHRIN SOL 2.5% OP generic 1 NEOFRIN SOL 2.5% OP generic 1 ALTAFRIN SOL 2.5% OP generic 1 MYDFRIN SOL 2.5% OP Brand 2 GR ALTAFRIN SOL 10% OP generic 1 NEOFRIN SOL 10% OP generic 1 PHENYLEPHRIN SOL 10% OP generic 1 MIOCHOL-E SOL 1:100 Brand 2 MIOSTAT INJ 0.01% OP Brand 2 ISO CARBACHO SOL 1.5% OP Brand 2 ISO CARBACHO SOL 3% OP Brand 2 PILOCARPINE SOL 1% OP generic 1 ISOPTO CARP SOL 1% OP Brand 2 GR ISOPTO CARP SOL 2% OP Brand 2 GR PILOCARPINE SOL 2% OP generic 1 ISOPTO CARP SOL 4% OP Brand 2 GR PILOCARPINE SOL 4% OP generic 1 PILOPINE HS GEL 4% OP Brand 2 PHOSPHOLINE SOL 0.125%OP Brand 2 APRACLONIDIN SOL 0.5% OP generic 1 IOPIDINE SOL 0.5% OP Brand 2 GR IOPIDINE SOL 1% OP Brand 2 ALPHAGAN P SOL 0.1% Brand 2 BRIMONIDINE SOL 0.15% generic 1 ALPHAGAN P SOL 0.15% Brand 2 GR BRIMONIDINE SOL 0.2% OP generic 1 SIMBRINZA SUS 1-0.2% Brand 2 EYLEA INJ 2/0.05ML Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 264 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO MACUGEN INJ Brand 2 LUCENTIS SOL 0.3MG Brand 2 LUCENTIS SOL 0.5MG Brand 2 VISUDYNE INJ 15MG Brand 2 RESTASIS EMU 0.05% Brand 2 QL 60/30 PA PROPARACAINE SOL 0.5% OP generic 1 PARCAINE SOL 0.5% OP generic 1 ALCAINE SOL 0.5% OP Brand 2 GR TETCAINE SOL 0.5% OP generic 1 ALTACAINE SOL 0.5% OP generic 1 TETRAVISC SOL FORTE generic 1 TETRAVISC SOL 0.5% OP generic 1 TETRACAINE SOL 0.5% OP generic 1 JETREA INJ 2.5MG/ML Brand 2 LASTACAFT SOL 0.25% Brand 2 NON-PREF ST AZELASTINE DRO 0.05% generic 1 NON-PREF ST OPTIVAR DRO 0.05% Brand 2 NON-PREF ST BEPREVE DRO 1.5% Brand 2 NON-PREF ST CROMOLYN SOD SOL 4% OP generic 1 NON-PREF ST EMADINE SOL 0.05% OP Brand 2 NON-PREF ST ELESTAT DRO 0.05% Brand 2 NON-PREF ST EPINASTINE DRO 0.05% generic 1 NON-PREF ST ALOMIDE SOL 0.1% OP Brand 2 NON-PREF ST ALOCRIL SOL 2% Brand 2 NON-PREF ST PATANOL SOL 0.1% OP Brand 2 NON-PREF ST PATADAY SOL 0.2% Brand 2 PREF AZOPT SUS 1% OP Brand 2 DORZOLAMIDE SOL 2% OP generic 1 TRUSOPT SOL 2% OP Brand 2 GR BAL SALT SOL OP generic 1 AKORN BALANC SOL SALT OP generic 1 BALANCED SAL SOL OP generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 265 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO BSS PLUS SOL OP Brand 2 GR BSS SOL OP generic 1 PROLENSA SOL 0.07% Brand 2 BROMFENAC SOL 0.09% generic 1 NON-PREF ST DICLOFENAC SOL 0.1% OP generic 1 PREF FLURBIPROFEN SOL 0.03% OP generic 1 PREF OCUFEN SOL 0.03% OP Brand 2 NON-PREF ST ACULAR LS SOL 0.4% Brand 2 NON-PREF ST KETOROLAC SOL 0.4% generic 1 PREF ACUVAIL SOL 0.45% Brand 2 NON-PREF ST ACULAR SOL 0.5% OP Brand 2 NON-PREF ST KETOROLAC SOL 0.5% generic 1 PREF NEVANAC SUS 0.1% Brand 2 NON-PREF ST ILEVRO DRO 0.3% OP Brand 2 NON-PREF ST CYSTARAN SOL 0.44% Brand 2 FUL-GLO TES 0.6MG OP Brand 2 BIO GLO TES 1MG OP generic 1 FUL-GLO TES 1MG OP generic 1 FLUORETS TES 1MG OP generic 1 FLUOR-I-STRI TES 1MG OP generic 1 AK-FLUOR INJ 10% OP generic 1 FLUORESCITE INJ 10% OP Brand 2 GR AK-FLUOR INJ 25% OP Brand 2 ALTAFLUOR SOL 0.25-0.4 generic 1 FLURESS SOL OP Brand 2 GR FLUROX SOL OP generic 1 FLUORE-BENOX SOL 0.25-0.4 generic 1 FLUORESCEIN/ SOL PROPARAC generic 1 FLUORACAINE SOL OP Brand 2 GR FLUCAINE SOL 0.25-0.5 generic 1 PAREMYD SOL 1-0.25% Brand 2 LISSAMINE GR TES 1.5MG Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 266 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ROSE GLO TES 1.5MG Brand 2 Otic Agents CIPROFLOXACN SOL 0.2% Brand 2 CETRAXAL SOL 0.2% Brand 2 OFLOXACIN DRO 0.3%OTIC generic 1 PINNACAINE DRO 20% OTIC Brand 2 FLUOCIN ACET OIL EAR0.01% generic 1 FLUOCIN ACET OIL 0.01% generic 1 DERMOTIC OIL 0.01% Brand 2 GR ACETASOL HC SOL OTIC generic 1 VOSOL HC SOL OTIC Brand 2 GR HC/ACET ACID SOL OTIC generic 1 ACETIC ACID SOL 2% OTIC generic 1 ACE ACD/ALUM SOL 2% OTIC generic 1 CRESYLATE SOL 25% OTIC Brand 2 CIPRODEX SUS 0.3-0.1% Brand 2 CIPRO HC SUS OTIC Brand 2 NEO/POLY/HC SUS 1% OTIC generic 1 NEO/POLY/HC SOL 1% OTIC generic 1 CORTISPORIN SOL 1% OTIC Brand 2 GR CORTISPORIN SUS -TC OTIC Brand 2 COLY-MYCIN S SUS OTIC Brand 2 AURODEX SOL OTIC generic 1 ANTIPY/BENZO SOL OTIC generic 1 ANTIPY/BENZO SOL OTIC generic 1 PA AURALGAN SOL 5.5-1.4% Brand 2 GR OTICIN DRO 1-0.1% generic 1 PRAMOTIC DRO 1-0.1% Brand 2 GR TREAGAN OTIC DRO Brand 2 GR OTIC CARE DRO generic 1 MYOXIN SUS OTIC Brand 2

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 267 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO OTOZIN DRO Brand 2 Oxytocics METHYLERGON TAB 0.2MG generic 1 METHYLERGON INJ 0.2MG/ML generic 1 OXYTOCIN INJ 10UNT/ML generic 1 PITOCIN INJ 10UNT/ML Brand 2 GR Passive Immunizing Agents GAMASTAN S/D INJ Brand 2 FLEBOGAMMA INJ DIF 5% Brand 2 PA SP FLEBOGAMMA INJ 5% Brand 2 PA SP OCTAGAM INJ 1GM Brand 2 PA SP OCTAGAM INJ 2.5GM Brand 2 PA SP FLEBOGAMMA INJ DIF 5% Brand 2 PA SP GAMMAPLEX INJ 2.5GM Brand 2 PA SP GAMMAPLEX INJ 5GM Brand 2 PA SP FLEBOGAMMA INJ DIF 5% Brand 2 PA SP OCTAGAM INJ 5GM Brand 2 PA SP GAMMAPLEX INJ 10GM Brand 2 PA SP FLEBOGAMMA INJ DIF 5% Brand 2 PA SP OCTAGAM INJ 10GM Brand 2 PA SP FLEBOGAMMA INJ DIF 5% Brand 2 PA SP OCTAGAM INJ 25GM Brand 2 PA SP PRIVIGEN INJ 5 GRAMS Brand 2 PA SP BIVIGAM INJ 10% Brand 2 PA SP FLEBOGAMMA INJ 10% Brand 2 PA SP PRIVIGEN INJ 10GRAMS Brand 2 PA SP BIVIGAM INJ 10% Brand 2 PA SP FLEBOGAMMA INJ 10% Brand 2 PA SP PRIVIGEN INJ 20GRAMS Brand 2 PA SP FLEBOGAMMA INJ 10% Brand 2 PA SP PRIVIGEN INJ 40GRAMS Brand 2

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 268 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO GAMMAGARD SD INJ 2.5GM HU Brand 2 CARIMUNE NF INJ 3GM Brand 2 GAMMAGARD SD INJ 5GM HU Brand 2 PA SP CARIMUNE NF INJ 6GM Brand 2 GAMMAGARD SD INJ 10GM HU Brand 2 PA SP CARIMUNE NF INJ 12GM Brand 2 PA SP HIZENTRA INJ 1GM/5ML Brand 2 PA SP HIZENTRA INJ 2GM/10ML Brand 2 PA SP HIZENTRA INJ 4GM/20ML Brand 2 PA SP HIZENTRA INJ 10/50ML Brand 2 GAMMAGARD INJ 1GM/10ML Brand 2 PA SP GAMUNEX-C INJ 1GM/10ML Brand 2 PA SP GAMMAKED INJ 1GM/10ML Brand 2 PA SP GAMMAKED INJ 2.5GM/25 Brand 2 PA SP GAMUNEX-C INJ 2.5GM/25 Brand 2 PA SP GAMMAGARD INJ 2.5GM/25 Brand 2 PA SP GAMMAKED INJ 5GM/50ML Brand 2 PA SP GAMUNEX-C INJ 5GM/50ML Brand 2 PA SP GAMMAGARD INJ 5GM/50ML Brand 2 PA SP GAMMAGARD INJ 10GM/100 Brand 2 PA SP GAMMAKED INJ 10GM/100 Brand 2 PA SP GAMUNEX-C INJ 10GM/100 Brand 2 PA SP GAMMAKED INJ 20GM/200 Brand 2 PA SP GAMUNEX-C INJ 20GM/200 Brand 2 PA SP GAMMAGARD INJ 20GM/200 Brand 2 PA SP GAMMAGARD INJ 30GM/300 Brand 2 PA SP SYNAGIS INJ 50MG Brand 2 PA SP SYNAGIS INJ 100MG/ML Brand 2 PA SP Penicillins PFIZERPEN-G INJ 5MU generic 1 PENICILLN GK INJ 5MU generic 1

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 269 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PENICILLN GK INJ 20MU generic 1 PFIZERPEN-G INJ 20MU Brand 2 GR PENICILL GK/ INJ DEX 1MU generic 1 PENICILL GK/ INJ DEX 2MU generic 1 PENICILL GK/ INJ DEX 3MU generic 1 PEN G SOD INJ 5000000 generic 1 BICILLIN L-A INJ 600000 Brand 2 BICILLIN L-A INJ 1200000 Brand 2 BICILLIN L-A INJ 2400000 Brand 2 PEN G PROC INJ 600000 Brand 2 PENICILLN VK TAB 250MG generic 1 PENICILLN VK TAB 500MG generic 1 PENICILLN VK SOL 125/5ML generic 1 PENICILLN VK SOL 250/5ML generic 1 AMOXICILLIN CAP 250MG generic 1 AMOXICILLIN CAP 500MG generic 1 AMOXICILLIN TAB 500MG generic 1 AMOXICILLIN TAB 875MG generic 1 AMOXICILLIN CHW 125MG generic 1 AMOXICILLIN CHW 250MG generic 1 AMOXICILLIN SUS 125/5ML generic 1 AMOXICILLIN SUS 200/5ML generic 1 AMOXICILLIN SUS 250/5ML generic 1 AMOXICILLIN SUS 400/5ML generic 1 MOXATAG TAB 775MG Brand 2 AMPICILLIN CAP 250MG generic 1 AMPICILLIN CAP 500MG generic 1 AMPICILLIN SUS 125/5ML generic 1 AMPICILLIN SUS 250/5ML generic 1 AMPICILLIN INJ 125MG generic 1 AMPICILLIN INJ 250MG generic 1 AMPICILLIN INJ 500MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 270 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO AMPICILLIN INJ 1GM generic 1 AMPICILLIN INJ 1GM Brand 2 AMPICILLIN INJ 2GM generic 1 AMPICILLIN INJ 2GM Brand 2 AMPICILLIN INJ 10GM generic 1 AMPICILLIN INJ 10GM generic 1 DICLOXACILL CAP 250MG generic 1 DICLOXACILL CAP 500MG generic 1 NAFCILLIN INJ 1GM generic 1 NAFCILLIN INJ 1GM Brand 2 NAFCILLIN INJ 2GM generic 1 NAFCILLIN INJ 2GM generic 1 NAFCILLIN INJ 10GM generic 1 NALLPEN/DEX INJ 1GM/50ML Brand 2 NALLPEN/DEX INJ 2GM/100 Brand 2 OXACILLIN INJ 1GM generic 1 OXACILLIN INJ 2GM generic 1 OXACILLIN INJ 10GM generic 1 BACTOCILL INJ DEX 1GM Brand 2 BACTOCILL INJ DEX 2GM Brand 2 BICILLIN C-R INJ 1200000 Brand 2 BICILLIN C-R INJ 900/300 Brand 2 AMOX/K CLAV TAB 250MG generic 1 AMOX/K CLAV TAB 500MG generic 1 AUGMENTIN TAB 500MG Brand 2 GR AUGMENTIN TAB 875MG Brand 2 GR AMOX/K CLAV TAB 875MG generic 1 AMOX/K CLAV CHW 200MG generic 1 AMOX/K CLAV CHW 400MG generic 1 AUGMENTIN SUS 125/5ML Brand 2 AMOX/K CLAV SUS 200/5ML generic 1 AUGMENTIN SUS 250/5ML Brand 2 GR KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 271 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO AMOX/K CLAV SUS 250/5ML generic 1 AMOX/K CLAV SUS 400/5ML generic 1 AUGMENTIN SUS ES-600 Brand 2 GR AMOX/K CLAV SUS 600/5ML generic 1 AUGMENTIN XR TAB 12HR Brand 2 GR AMOX-POT CLA TAB ER generic 1 AMP-SULBACTA INJ 1-0.5GM generic 1 AMP-SULBACTA INJ 1.5GM generic 1 UNASYN INJ 1.5GM Brand 2 GR AMP-SULBACTA INJ 1.5GM generic 1 UNASYN INJ 3GM Brand 2 GR AMP-SULBACTA INJ 3GM generic 1 AMP-SULBACTA INJ 2-1GM generic 1 AMP-SULBACTA INJ 3GM generic 1 AMP-SULBACTA INJ 10-5GM generic 1 UNASYN INJ 15GM Brand 2 GR AMP-SULBACTA INJ 15GM generic 1 AMP-SULBACTA INJ 10-5GM generic 1 TIMENTIN INJ 3.1GM Brand 2 TIMENTIN INJ 3.1GM Brand 2 TIMENTIN INJ 31GM Brand 2 ZOSYN INJ 2-0.25GM Brand 2 GR PIPER/TAZOBA INJ 2-0.25GM generic 1 ZOSYN INJ 3-0.375G Brand 2 GR PIPER/TAZOBA INJ 3-0.375G generic 1 PIPER/TAZOBA INJ 4-0.5GM generic 1 ZOSYN INJ 4-0.5GM Brand 2 GR PIPER/TAZOBA INJ 36-4.5GM generic 1 ZOSYN INJ 36-4.5GM Brand 2 GR ZOSYN SOL 2-0.25GM Brand 2 ZOSYN SOL 4-0.50GM Brand 2 ZOSYN SOL 3-0.375G Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 272 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO Pharmaceutical Adjuvants LANOLIN MIS ALCOHOL Brand 2 LANOLIN OIL Brand 2 LANOLIN ANHY OIN Brand 2 LANOLIN OIN Brand 2 Progestins MAKENA INJ 250MG/ML Brand 2 QL 5/30 PA SP PROVERA TAB 2.5MG Brand 2 GR MEDROXYPR AC TAB 2.5MG generic 1 MEDROXYPR AC TAB 5MG generic 1 PROVERA TAB 5MG Brand 2 GR MEDROXYPR AC TAB 10MG generic 1 PROVERA TAB 10MG Brand 2 GR MEGACE ES SUS 625/5ML Brand 2 AYGESTIN TAB 5MG Brand 2 GR NORETHIN ACE TAB 5MG generic 1 PROGESTERONE INJ 50MG/ML generic 1 PROGESTERONE CAP 100MG generic 1 PROMETRIUM CAP 100MG Brand 2 GR PROGESTERONE CAP 200MG generic 1 PROMETRIUM CAP 200MG Brand 2 GR Psychotherapeutic and Neurological Agents Misc ERGOLOID MES TAB 1MG ORAL generic 1 ORAP TAB 1MG Brand 2 ORAP TAB 2MG Brand 2 DONEPEZIL TAB 5MG generic 1 PREF MO ARICEPT TAB 5MG Brand 2 NON-PREF ST MO DONEPEZIL TAB 10MG generic 1 PREF MO ARICEPT TAB 10MG Brand 2 NON-PREF ST MO DONEPEZIL TAB HCL 23MG generic 1 ARICEPT TAB 23MG Brand 2 GR

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 273 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DONEPEZIL TAB 5MG ODT generic 1 NON-PREF ST MO ARICEPT ODT TAB 5MG Brand 2 NON-PREF ST MO ARICEPT ODT TAB 10MG Brand 2 NON-PREF ST MO DONEPEZIL TAB 10MG ODT generic 1 NON-PREF ST MO RAZADYNE TAB 4MG Brand 2 NON-PREF ST MO GALANTAMINE TAB 4MG generic 1 NON-PREF ST MO GALANTAMINE TAB 8MG generic 1 NON-PREF ST MO RAZADYNE TAB 8MG Brand 2 NON-PREF ST MO GALANTAMINE TAB 12MG generic 1 NON-PREF ST MO RAZADYNE TAB 12MG Brand 2 NON-PREF ST MO RAZADYNE SOL 4MG/ML Brand 2 NON-PREF ST MO GALANTAMINE SOL 4MG/ML generic 1 NON-PREF ST MO GALANTAMINE CAP 8MG ER generic 1 NON-PREF ST MO RAZADYNE ER CAP 8MG Brand 2 NON-PREF ST MO RAZADYNE ER CAP 16MG Brand 2 NON-PREF ST MO GALANTAMINE CAP 16MG ER generic 1 NON-PREF ST MO RAZADYNE ER CAP 24MG Brand 2 NON-PREF ST MO GALANTAMINE CAP 24MG ER generic 1 NON-PREF ST MO EXELON DIS 4.6MG/24 Brand 2 NON-PREF ST MO EXELON DIS 9.5MG/24 Brand 2 NON-PREF ST MO EXELON DIS 13.3/24 Brand 2 NON-PREF ST MO EXELON CAP 1.5MG Brand 2 NON-PREF ST MO RIVASTIGMINE CAP 1.5MG generic 1 PREF MO RIVASTIGMINE CAP 3MG generic 1 PREF MO EXELON CAP 3MG Brand 2 NON-PREF ST MO EXELON CAP 4.5MG Brand 2 NON-PREF ST MO RIVASTIGMINE CAP 4.5MG generic 1 PREF MO RIVASTIGMINE CAP 6MG generic 1 PREF MO EXELON CAP 6MG Brand 2 NON-PREF ST MO EXELON SOL 2MG/ML Brand 2 NON-PREF ST MO NAMENDA TAB 5MG Brand 2 NON-PREF ST MO NAMENDA TAB 10MG Brand 2 NON-PREF ST MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 274 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO NAMENDA TAB 5-10MG Brand 2 NON-PREF ST MO NAMENDA SOL 10MG/5ML Brand 2 NON-PREF ST MO NAMENDA XR CAP 7MG Brand 2 NAMENDA XR CAP 14MG Brand 2 NAMENDA XR CAP 21MG Brand 2 NAMENDA XR CAP 28MG Brand 2 NAMENDA XR CAP TITRATIO Brand 2 BUPROPION TAB 150MG generic 1 PREF BUPROBAN TAB 150MG generic 1 PREF ZYBAN TAB 150MG SR Brand 2 NON-PREF ST NICOTROL NS SPR 10MG/ML Brand 2 NON-PREF ST NICOTROL INH Brand 2 NON-PREF ST QL 504/30 CHANTIX TAB 0.5MG Brand 2 NON-PREF ST QL 60/30 CHANTIX TAB 1MG Brand 2 NON-PREF ST QL 60/30 CHANTIX PAK 1MG Brand 2 NON-PREF ST QL 60/30 CHANTIX PAK 0.5& 1MG Brand 2 NON-PREF ST QL 60/30 FLUOXETINE CAP 10MG generic 1 FLUOXETINE CAP 20MG generic 1 SARAFEM TAB 10MG Brand 2 NON-PREF ST QL 30/30 MO SARAFEM TAB 20MG Brand 2 NON-PREF ST QL 30/30 MO BRISDELLE CAP 7.5MG Brand 2 QL 30/30 PA XENAZINE TAB 12.5MG Brand 2 XENAZINE TAB 25MG Brand 2 COPAXONE KIT 20MG/ML Brand 2 PREF SP REBIF INJ 22/0.5 Brand 2 NON-PREF ST SP REBIF REBIDO INJ 22/0.5 Brand 2 NON-PREF ST SP REBIF INJ 44/0.5 Brand 2 NON-PREF ST SP REBIF REBIDO INJ 44/0.5 Brand 2 NON-PREF ST SP REBIF TITRTN SOL PACK Brand 2 NON-PREF ST SP REBIF REBIDO SOL TITRATN Brand 2 NON-PREF ST SP AVONEX KIT 30MCG Brand 2 PREF SP AVONEX PEN KIT 30MCG Brand 2 PREF SP KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 275 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO AVONEX PREFL KIT 30MCG Brand 2 PREF SP BETASERON INJ 0.3MG Brand 2 PREF SP BETASERON INJ 0.3MG Brand 2 AUBAGIO TAB 7MG Brand 2 QL 30/30 SP AUBAGIO TAB 14MG Brand 2 QL 30/30 SP TYSABRI INJ 300/15ML Brand 2 TECFIDERA MIS STARTER Brand 2 TECFIDERA CAP 120MG Brand 2 TECFIDERA CAP 240MG Brand 2 AMPYRA TAB 10MG Brand 2 QL 60/30 PA SP GILENYA CAP 0.5MG Brand 2 QL 30/30 PA SP XYREM SOL 500MG/ML Brand 2 SAVELLA TAB 12.5MG Brand 2 QL 60/30 PA MO SAVELLA TAB 25MG Brand 2 QL 60/30 PA MO SAVELLA TAB 50MG Brand 2 QL 60/30 PA MO SAVELLA TAB 100MG Brand 2 QL 60/30 PA MO SAVELLA MIS TITR PAK Brand 2 QL 55/365 PA GRALISE TAB 300MG Brand 2 QL 60/30 PA GRALISE TAB 600MG Brand 2 QL 90/30 PA GRALISE STAR MIS 300/600 Brand 2 HORIZANT TAB 600MG Brand 2 QL 30/30 PA NUEDEXTA CAP 20-10MG Brand 2 QL 60/30 PA MO ACAMPRO CAL TAB 333MG generic 1 CAMPRAL TAB 333MG Brand 2 GR DISULFIRAM TAB 250MG generic 1 ANTABUSE TAB 250MG Brand 2 GR ANTABUSE TAB 500MG Brand 2 GR DISULFIRAM TAB 500MG generic 1 CDP/AMITRIP TAB 5-12.5MG generic 1 CDP/AMITRIP TAB 10-25MG generic 1 PERPHEN/AMIT TAB 2-10MG generic 1 PERPHEN/AMIT TAB 2-25MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 276 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PERPHEN/AMIT TAB 4-10MG generic 1 PERPHEN/AMIT TAB 4-25MG generic 1 PERPHEN/AMIT TAB 4-50MG generic 1 OLANZA/FLUOX CAP 3-25MG generic 1 NON-PREF ST QL 30/30 MO SYMBYAX CAP 3-25MG Brand 2 NON-PREF ST QL 30/30 MO SYMBYAX CAP 6-25MG Brand 2 NON-PREF ST QL 30/30 MO OLANZA/FLUOX CAP 6-25MG generic 1 NON-PREF ST QL 30/30 MO OLANZA/FLUOX CAP 6-50MG generic 1 NON-PREF ST QL 30/30 MO SYMBYAX CAP 6-50MG Brand 2 NON-PREF ST QL 30/30 MO OLANZA/FLUOX CAP 12-25MG generic 1 NON-PREF ST QL 30/30 MO SYMBYAX CAP 12-25MG Brand 2 GR OLANZA/FLUOX CAP 12-50MG generic 1 NON-PREF ST QL 30/30 MO SYMBYAX CAP 12-50MG Brand 2 GR Respiratory Agents Misc SURVANTA INH Brand 2 INFASURF SUS 35MG/ML Brand 2 CUROSURF SUS 80MG/ML Brand 2 GLASSIA INJ Brand 2 ARALAST NP INJ 400MG Brand 2 ARALAST NP INJ 500MG Brand 2 ARALAST NP INJ 800MG Brand 2 ARALAST NP INJ 1000MG Brand 2 ZEMAIRA INJ 1000MG Brand 2 PROLASTIN-C INJ 1000MG Brand 2 KALYDECO TAB 150MG Brand 2 SP PULMOZYME SOL 1MG/ML Brand 2 STERIL TALC SUS 5GM Brand 2 SCLEROSOL AER INTRAPLE Brand 2 Sulfonamides SULFADIAZINE TAB 500MG generic 1 Tetracyclines

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 277 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DEMECLOCYCL TAB 150MG generic 1 DEMECLOCYCL TAB 300MG generic 1 DOXYCYC MONO CAP 50MG generic 1 DOXYCYCLINE CAP 75MG generic 1 MONODOX CAP 75MG Brand 2 GR DOXYCYC MONO CAP 100MG generic 1 MONODOX CAP 100MG Brand 2 GR DOXYCYCLINE CAP 150MG generic 1 ADOXA CAP 150MG Brand 2 GR DOXYCYC MONO TAB 50MG generic 1 ADOXA TAB 50MG Brand 2 GR DOXYCYC MONO TAB 75MG generic 1 ADOXA TAB 75MG Brand 2 GR ADOXA PAK 1/ TAB 100MG Brand 2 GR DOXYCYC MONO TAB 100MG generic 1 AVIDOXY TAB 100MG generic 1 ADOXA TAB 100MG Brand 2 GR ADOXA PAK 2/ TAB 100MG Brand 2 GR DOXYCYC MONO TAB 150MG generic 1 ADOXA PAK 1/ TAB 150MG Brand 2 GR VIBRAMYCIN SUS 25MG/5ML Brand 2 GR DOXYCYCLINE SUS 25MG/5ML generic 1 DOXYCYCL HYC CAP 50MG generic 1 VIBRAMYCIN CAP 100MG Brand 2 GR DOXYCYCL HYC CAP 100MG generic 1 MORGIDOX CAP 2X100MG generic 1 MORGIDOX CAP 1X100MG generic 1 DOXYCYCLINE TAB 20MG generic 1 DOXYCYCL HYC TAB 100MG generic 1 DOXYCYCL HYC TAB 75MG DR generic 1 DOXYCYCL HYC TAB 100MG DR generic 1 DORYX TAB 150MG Brand 2 GR KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 278 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO DOXYCYCL HYC TAB 150MG DR generic 1 DORYX TAB 200MG Brand 2 DOXY 100 INJ 100MG generic 1 DOXYCYCL HYC INJ 100MG generic 1 DOXYCYCL HYC CAP 100MG generic 1 VIBRAMYCIN SYP 50MG/5ML Brand 2 MORGIDOX KIT 1X100MG Brand 2 MORGIDOX KIT 2X100MG Brand 2 NUTRIDOX KIT Brand 2 MINOCIN CAP 50MG Brand 2 GR MINOCYCLINE CAP 50MG generic 1 MINOCYCLINE CAP 75MG generic 1 MINOCYCLINE CAP 100MG generic 1 MINOCIN CAP 100MG Brand 2 GR MINOCYCLINE TAB 50MG generic 1 MINOCYCLINE TAB 75MG generic 1 MINOCYCLINE TAB 100MG generic 1 MINOCIN INJ 100MG Brand 2 MINOCYCLINE TAB 45MG ER generic 1 PA SOLODYN TAB 55MG Brand 2 PA SOLODYN TAB 65MG Brand 2 PA SOLODYN TAB 80MG Brand 2 PA MINOCYCLINE TAB 90MG ER generic 1 PA SOLODYN TAB 105MG Brand 2 PA SOLODYN TAB 115MG Brand 2 PA MINOCYCLINE TAB 135MG ER generic 1 PA MINOCIN KIT 50MG Brand 2 MINOCIN KIT 100MG Brand 2 TETRACYCLINE CAP 250MG Brand 2 TETRACYCLINE CAP 500MG Brand 2 NICAZELDOXY KIT 60 Brand 2 NICAZELDOXY KIT 30 Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 279 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO Thyroid Agents TIROSINT CAP 13MCG Brand 2 TIROSINT CAP 25MCG Brand 2 TIROSINT CAP 50MCG Brand 2 TIROSINT CAP 75MCG Brand 2 TIROSINT CAP 88MCG Brand 2 TIROSINT CAP 100MCG Brand 2 TIROSINT CAP 112MCG Brand 2 TIROSINT CAP 125MCG Brand 2 TIROSINT CAP 137MCG Brand 2 TIROSINT CAP 150MCG Brand 2 SYNTHROID TAB 25MCG Brand 2 UNITH DIRECT TAB 25MCG generic 1 UNITHROID TAB 25MCG generic 1 LEVOTHYROXIN TAB 25MCG generic 1 LEVOTHYROXIN TAB 50MCG generic 1 UNITHROID TAB 50MCG generic 1 SYNTHROID TAB 50MCG Brand 2 UNITH DIRECT TAB 50MCG generic 1 LEVOTHYROXIN TAB 75MCG generic 1 UNITH DIRECT TAB 75MCG generic 1 SYNTHROID TAB 75MCG Brand 2 UNITHROID TAB 75MCG generic 1 UNITH DIRECT TAB 88MCG generic 1 UNITHROID TAB 88MCG generic 1 LEVOTHYROXIN TAB 88MCG generic 1 SYNTHROID TAB 88MCG Brand 2 SYNTHROID TAB 100MCG Brand 2 UNITH DIRECT TAB 100MCG generic 1 LEVOTHYROXIN TAB 100MCG generic 1 UNITHROID TAB 100MCG generic 1

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 280 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO SYNTHROID TAB 112MCG Brand 2 UNITH DIRECT TAB 112MCG generic 1 LEVOTHYROXIN TAB 112MCG generic 1 UNITHROID TAB 112MCG generic 1 UNITHROID TAB 125MCG generic 1 LEVOTHYROXIN TAB 125MCG generic 1 SYNTHROID TAB 125MCG Brand 2 UNITH DIRECT TAB 125MCG generic 1 LEVOTHYROXIN TAB 137MCG generic 1 UNITHROID TAB 137MCG generic 1 SYNTHROID TAB 137MCG Brand 2 LEVOTHYROXIN TAB 150MCG generic 1 UNITHROID TAB 150MCG generic 1 SYNTHROID TAB 150MCG Brand 2 UNITH DIRECT TAB 150MCG generic 1 LEVOTHYROXIN TAB 175MCG generic 1 UNITHROID TAB 175MCG generic 1 UNITH DIRECT TAB 175MCG generic 1 SYNTHROID TAB 175MCG Brand 2 UNITHROID TAB 200MCG generic 1 SYNTHROID TAB 200MCG Brand 2 UNITH DIRECT TAB 200MCG generic 1 LEVOTHYROXIN TAB 200MCG generic 1 UNITH DIRECT TAB 300MCG generic 1 LEVOTHYROXIN TAB 300MCG generic 1 UNITHROID TAB 300MCG generic 1 SYNTHROID TAB 300MCG Brand 2 LEVOTHYROXIN INJ 100MCG Brand 2 LEVOTHYROXIN INJ 200MCG Brand 2 LEVOTHYROXIN INJ 500MCG Brand 2 LIOTHYRONINE TAB 5MCG generic 1 CYTOMEL TAB 5MCG Brand 2 GR KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 281 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO CYTOMEL TAB 25MCG Brand 2 GR LIOTHYRONINE TAB 25MCG generic 1 LIOTHYRONINE TAB 50MCG generic 1 CYTOMEL TAB 50MCG Brand 2 GR LIOTHYRONINE INJ 10MCG/ML generic 1 TRIOSTAT INJ 10MCG/ML Brand 2 GR THYROLAR-1/4 TAB 15MG Brand 2 THYROLAR-1/2 TAB 30MG Brand 2 THYROLAR-1 TAB 60MG Brand 2 THYROLAR-2 TAB 120MG Brand 2 THYROLAR-3 TAB 180MG Brand 2 ARMOUR THYRO TAB 15MG Brand 2 NATURE-THROI TAB 16.25MG generic 1 WESTHROID TAB 16.25MG Brand 2 WP THYROID TAB 16.25MG Brand 2 ARMOUR THYRO TAB 30MG Brand 2 GR NP THYROID TAB 30MG generic 1 NATURE-THROI TAB 32.5MG Brand 2 WESTHROID TAB 32.5MG Brand 2 WP THYROID TAB 32.5MG Brand 2 NATURE-THROI TAB 48.75MG Brand 2 WP THYROID TAB 48.75MG Brand 2 WESTHROID TAB 48.75MG Brand 2 ARMOUR THYRO TAB 60MG Brand 2 GR NP THYROID TAB 60MG generic 1 NATURE-THROI TAB 65MG Brand 2 WESTHROID TAB 65MG Brand 2 WP THYROID TAB 65MG Brand 2 NATURE-THROI TAB 81.25MG Brand 2 WESTHROID TAB 81.25MG Brand 2 ARMOUR THYRO TAB 90MG Brand 2 GR NP THYROID TAB 90MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 282 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO WESTHROID TAB 97.5MG Brand 2 NATURE-THROI TAB 97.5MG Brand 2 WP THYROID TAB 97.5MG Brand 2 NATURE-THROI TAB 113.75MG Brand 2 WESTHROID TAB 113.75MG Brand 2 ARMOUR THYRO TAB 120MG Brand 2 WP THYROID TAB 130MG Brand 2 NATURE-THROI TAB 130MG Brand 2 WESTHROID TAB 130MG Brand 2 NATURE THROI TAB 162.5MG Brand 2 WESTHROID TAB 162.50MG Brand 2 ARMOUR THYRO TAB 180MG Brand 2 WESTHROID TAB 195MG Brand 2 NATURE-THROI TAB 195MG Brand 2 ARMOUR THYRO TAB 240MG Brand 2 WESTHROID TAB 260MG Brand 2 NATURE-THROI TAB 260MG Brand 2 ARMOUR THYRO TAB 300MG Brand 2 WESTHROID TAB 325MG Brand 2 NATURE-THROI TAB 325MG Brand 2 NATURE-THROI TAB 146.25MG Brand 2 WESTHROID TAB 146.25MG Brand 2 METHIMAZOLE TAB 5MG generic 1 TAPAZOLE TAB 5MG Brand 2 GR METHIMAZOLE TAB 10MG generic 1 TAPAZOLE TAB 10MG Brand 2 GR PROPYLTHIOUR TAB 50MG generic 1 Ulcer Drugs ATROPINE SUL INJ 0.05MG/1 generic 1 ATROPINE SUL INJ 0.1MG/ML generic 1 ATROPINE SUL INJ 0.4MG/ML generic 1

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 283 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ATROPINE SUL INJ 0.4/0.5 generic 1 ATROPINE SUL INJ 1MG/ML generic 1 ATROPEN INJ 0.25MG Brand 2 ATROPEN INJ 0.5MG Brand 2 ATROPEN INJ 1MG Brand 2 ATROPEN INJ 2MG Brand 2 HYOSCYAMINE TAB 0.125MG generic 1 LEVSIN TAB 0.125MG Brand 2 GR OSCIMIN TAB 0.125MG generic 1 SYMAX DUOTAB TAB Brand 2 HYOMAX-SL SUB 0.125MG generic 1 SYMAX-SL SUB 0.125MG generic 1 OSCIMIN SUB 0.125MG generic 1 HYOSCYAMINE SUB 0.125MG generic 1 LEVSIN/SL SUB 0.125MG Brand 2 GR HYOSCYAMINE ELX 0.125/5 generic 1 HYOSYNE ELX 0.125/5 generic 1 LEVSIN INJ 0.5MG/ML Brand 2 HYOSCYAMINE DRO 0.125/ML generic 1 HYOSYNE DRO 0.125/ML generic 1 SYMAX FASTAB TAB 0.125MG generic 1 ED-SPAZ TAB 0.125MG generic 1 NULEV TAB 0.125MG generic 1 ANASPAZ TAB 0.125MG Brand 2 GR HYOSCYAMINE TAB 0.125MG generic 1 OSCIMIN TAB 0.125MG generic 1 HYOSCYAMINE TAB 0.375 ER generic 1 SYMAX-SR TAB 0.375MG generic 1 OSCIMIN SR TAB 0.375MG generic 1 LEVBID TAB 0.375 ER Brand 2 GR SCOPOLAMINE INJ 0.4MG/ML Brand 2 GLYCOPYRROL TAB 1MG generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 284 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ROBINUL TAB 1MG Brand 2 GR GLYCATE TAB 1.5MG Brand 2 GLYCOPYRROL TAB 2MG generic 1 ROBINUL FORT TAB 2MG Brand 2 GR GLYCOPYRROL INJ 0.2MG/ML generic 1 ROBINUL INJ 0.2MG/ML Brand 2 GR GLYCOPYRROL INJ 0.4/2ML generic 1 GLYCOPYRROL INJ 0.2MG/ML generic 1 ROBINUL INJ 0.2MG/ML Brand 2 GR ROBINUL INJ 0.4/2ML Brand 2 GR ROBINUL INJ 0.2MG/ML Brand 2 GR GLYCOPYRROL INJ 0.2MG/ML generic 1 GLYCOPYRROL INJ 1MG/5ML generic 1 GLYCOPYRROL INJ 4MG/20ML generic 1 GLYCOPYRROL INJ 0.2MG/ML generic 1 ROBINUL INJ 0.2MG/ML Brand 2 GR CUVPOSA SOL 1MG/5ML Brand 2 PA MO CANTIL TAB 25MG Brand 2 PAMINE TAB 2.5MG Brand 2 GR METHSCOPOLAM TAB 2.5MG generic 1 PAMINE FORTE TAB 5MG Brand 2 GR METHSCOPOLAM TAB 5MG generic 1 PROPANTHELIN TAB 15MG generic 1 BENTYL CAP 10MG Brand 2 GR DICYCLOMINE CAP 10MG generic 1 BENTYL TAB 20MG Brand 2 GR DICYCLOMINE TAB 20MG generic 1 BENTYL INJ 10MG/ML Brand 2 DICYCLOMINE SOL 10MG/5ML generic 1 BELLA/OPIUM SUP 16.2-30 Brand 2 BELLA/OPIUM SUP 16.2-60 generic 1 PAMINE FQ KIT Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 285 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO GASTRINEX NF CAP generic 1 CIMETIDINE TAB 200MG generic 1 CIMETIDINE TAB 300MG generic 1 CIMETIDINE TAB 400MG generic 1 CIMETIDINE TAB 800MG generic 1 CIMETIDINE SOL 300/5ML generic 1 RANITIDINE CAP 150MG generic 1 RANITIDINE CAP 300MG generic 1 ZANTAC TAB 150MG Brand 2 GR RANITIDINE TAB 150MG generic 1 ZANTAC TAB 300MG Brand 2 GR RANITIDINE TAB 300MG generic 1 RANITIDINE SYP 150/10ML generic 1 ZANTAC SYP 15MG/ML Brand 2 GR RANITIDINE SYP 75MG/5ML generic 1 RANITIDINE SYP 15MG/ML generic 1 RANITIDINE INJ 50MG/2ML generic 1 ZANTAC INJ 25MG/ML Brand 2 GR RANITIDINE INJ 150/6ML generic 1 ZANTAC INJ 25MG/ML Brand 2 GR RANITIDINE INJ 25MG/ML generic 1 ZANTAC INJ 25MG/ML Brand 2 GR FAMOTIDINE TAB 20MG generic 1 PEPCID TAB 20MG Brand 2 GR PEPCID TAB 40MG Brand 2 GR FAMOTIDINE TAB 40MG generic 1 FAMOTIDINE SUS 40MG/5ML generic 1 PEPCID SUS 40MG/5ML Brand 2 GR FAMOTIDINE INJ 20MG/2ML generic 1 FAMOTIDINE INJ 40MG/4ML generic 1 FAMOTIDINE INJ 200/20ML generic 1 FAMOTIDINE INJ 10MG/ML generic 1 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 286 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO FAMOTIDINE INJ 20MG/50M Brand 2 NIZATIDINE CAP 150MG generic 1 NIZATIDINE CAP 300MG generic 1 AXID CAP 300MG Brand 2 GR NIZATIDINE SOL 15MG/ML generic 1 AXID SOL 15MG/ML Brand 2 GR MISOPROSTOL TAB 100MCG generic 1 CYTOTEC TAB 100MCG Brand 2 GR CYTOTEC TAB 200MCG Brand 2 GR MISOPROSTOL TAB 200MCG generic 1 DEXILANT CAP 30MG DR Brand 2 NON-PREF ST QL 30/30 PA DEXILANT CAP 60MG DR Brand 2 NON-PREF ST QL 30/30 PA NEXIUM GRA 2.5MG DR Brand 2 NEXIUM GRA 5MG DR Brand 2 NEXIUM GRA 10MG DR Brand 2 NON-PREF ST QL 30/30 PA NEXIUM GRA 20MG DR Brand 2 NON-PREF ST QL 30/30 PA NEXIUM GRA 40MG DR Brand 2 NON-PREF ST QL 30/30 PA NEXIUM CAP 20MG Brand 2 NON-PREF ST QL 30/30 PA NEXIUM CAP 40MG Brand 2 NON-PREF ST QL 30/30 PA NEXIUM I.V. INJ 20MG Brand 2 NEXIUM I.V. INJ 40MG Brand 2 ESOMEPRAZOLE CAP 24.65MG Brand 2 PA ESOMEPRAZOLE CAP 49.3MG Brand 2 PA LANSOPRAZOLE SUS 3MG/ML Brand 2 QL 300/30 MO LANSOPRAZOLE CAP 15MG DR generic 1 NON-PREF ST QL 30/30 PA PREVACID CAP 15MG DR Brand 2 NON-PREF ST QL 30/30 PA PREVACID CAP 30MG DR Brand 2 NON-PREF ST QL 30/30 PA LANSOPRAZOLE CAP 30MG DR generic 1 NON-PREF ST QL 30/30 PA PREVACID TAB 15MG STB Brand 2 NON-PREF ST QL 30/30 PA PREVACID TAB 30MG STB Brand 2 NON-PREF ST QL 30/30 PA FIRST-OMEPRA SUS 2MG/ML Brand 2 QL 300/30 MO OMEPRAZOLE + SUS SYRSPEND Brand 2 QL 300/30 MO KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 287 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PRILOSEC CAP 10MG Brand 2 NON-PREF ST QL 30/30 PA OMEPRAZOLE CAP 10MG generic 1 PREF QL 30/30 PA OMEPRAZOLE CAP 20MG generic 1 PREF QL 30/30 PA PRILOSEC CAP 20MG Brand 2 NON-PREF ST QL 30/30 PA PRILOSEC CAP 40MG Brand 2 NON-PREF ST QL 30/30 PA OMEPRAZOLE CAP 40MG generic 1 PREF QL 30/30 PA PRILOSEC POW 2.5MG Brand 2 PRILOSEC POW 10MG Brand 2 PANTOPRAZOLE TAB 20MG generic 1 PREF QL 30/30 PA PROTONIX TAB 20MG Brand 2 NON-PREF ST QL 30/30 PA PANTOPRAZOLE TAB 40MG generic 1 PREF QL 30/30 PA PROTONIX TAB 40MG Brand 2 NON-PREF ST QL 30/30 PA PROTONIX INJ 40MG Brand 2 GR PANTOPRAZOLE INJ 40MG generic 1 PROTONIX PAK Brand 2 ACIPHEX TAB 20MG Brand 2 GR RABEPRAZOLE TAB 20MG generic 1 ACIPHEX SPR CAP 5MG Brand 2 ACIPHEX SPR CAP 10MG Brand 2 SUCRALFATE TAB 1GM generic 1 CARAFATE TAB 1GM Brand 2 GR CARAFATE SUS 1GM/10ML Brand 2 PYLERA CAP Brand 2 PA HELIDAC MIS Brand 2 LANSOPR/AMOX MIS /CLARITH generic 1 PREVPAC MIS Brand 2 GR OMECLAMOX- MIS PAK Brand 2 PA OMEPRA/BICAR CAP 20-1100 generic 1 NON-PREF ST QL 30/30 PA ZEGERID CAP 20-1100 Brand 2 NON-PREF ST PA ZEGERID CAP 40-1100 Brand 2 GR OMEPRA/BICAR CAP 40-1100 generic 1 ZEGERID POW 20-1680 Brand 2 KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 288 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ZEGERID POW 40-1680 Brand 2 Urinary Anti-infectives MONUROL PAK GRANULES Brand 2 METHENAM MAN TAB 500MG Brand 2 METHENAM MAN TAB 1GM generic 1 METHENAM MAN TAB 1000MG generic 1 UREX TAB 1GM Brand 2 GR METHENAM HIP TAB 1GM generic 1 HIPREX TAB 1GM Brand 2 GR NITROFURANTN SUS 25MG/5ML generic 1 FURADANTIN SUS 25MG/5ML Brand 2 GR MACRODANTIN CAP 25MG Brand 2 NITROFUR MAC CAP 50MG generic 1 MACRODANTIN CAP 50MG Brand 2 GR NITROFUR MAC CAP 100MG generic 1 MACRODANTIN CAP 100MG Brand 2 GR NITROFURANTN CAP 100MG generic 1 MACROBID CAP 100MG Brand 2 GR UROQID #2 TAB Brand 2 URYL TAB generic 1 UROGESIC- TAB BLUE Brand 2 GR HYOPHEN TAB generic 1 PROSED/DS TAB Brand 2 GR UTICAP CAP generic 1 USTELL CAP generic 1 UTA CAP 120MG generic 1 URELLE TAB Brand 2 PHOSPHASAL TAB generic 1 UTIRA-C TAB generic 1 UR N-C TAB generic 1 UTRONA-C TAB generic 1

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 289 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO URIN D/S TAB generic 1 URETRON D/S TAB generic 1 URIMAR-T TAB Brand 2 URETRON D/S TAB Brand 2 Urinary Antispasmodics ENABLEX TAB 7.5MG Brand 2 NON-PREF ST QL 30/30 MO ENABLEX TAB 15MG Brand 2 NON-PREF ST QL 30/30 MO TOVIAZ TAB 4MG Brand 2 PREF QL 30/30 MO TOVIAZ TAB 8MG Brand 2 PREF QL 30/30 MO GELNIQUE GEL 3% Brand 2 OXYTROL DIS 3.9MG/24 Brand 2 NON-PREF ST QL 8/30 MO OXYBUTYNIN TAB 5MG generic 1 PREF MO OXYBUTYNIN SYP 5MG/5ML generic 1 PREF MO GELNIQUE GEL 10% Brand 2 NON-PREF ST QL 30/30 MO OXYBUTYNIN TAB 5MG ER generic 1 NON-PREF ST QL 30/30 MO DITROPAN XL TAB 5MG Brand 2 NON-PREF ST MO DITROPAN XL TAB 10MG Brand 2 NON-PREF ST MO OXYBUTYNIN TAB 10MG ER generic 1 NON-PREF ST QL 60/30 MO OXYBUTYNIN TAB 15MG ER generic 1 NON-PREF ST QL 60/30 MO DITROPAN XL TAB 15MG Brand 2 NON-PREF ST MO VESICARE TAB 5MG Brand 2 PREF QL 30/30 MO VESICARE TAB 10MG Brand 2 PREF QL 30/30 MO TOLTERODINE TAB 1MG generic 1 NON-PREF ST MO DETROL TAB 1MG Brand 2 NON-PREF ST MO TOLTERODINE TAB 2MG generic 1 NON-PREF ST MO DETROL TAB 2MG Brand 2 NON-PREF ST MO DETROL LA CAP 2MG Brand 2 NON-PREF ST QL 30/30 MO DETROL LA CAP 4MG Brand 2 NON-PREF ST QL 30/30 MO TROSPIUM CL TAB 20MG generic 1 SANCTURA TAB 20MG Brand 2 NON-PREF ST MO TROSPIUM CHL CAP 60MG ER generic 1 NON-PREF ST QL 30/30 MO

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 290 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO SANCTURA XR CAP 60MG Brand 2 NON-PREF ST QL 30/30 MO MYRBETRIQ TAB 25MG Brand 2 NON-PREF ST QL 30/30 MO MYRBETRIQ TAB 50MG Brand 2 NON-PREF ST QL 30/30 MO BETHANECHOL TAB 5MG generic 1 URECHOLINE TAB 5MG Brand 2 GR URECHOLINE TAB 10MG Brand 2 GR BETHANECHOL TAB 10MG generic 1 URECHOLINE TAB 25MG Brand 2 GR BETHANECHOL TAB 25MG generic 1 URECHOLINE TAB 50MG Brand 2 GR BETHANECHOL TAB 50MG generic 1 FLAVOXATE TAB 100MG generic 1 Vaccines FLUZONE SPLT INJ 2013-14 Brand 2 AFLURIA INJ 2012-13 Brand 2 AFLURIA INJ 2013-14 Brand 2 FLULAVAL INJ 2013-14 Brand 2 FLUZONE INJ INTRADRM Brand 2 FLUZONE PED/ INJ PF 13-14 Brand 2 AFLURIA INJ PF 13-14 Brand 2 AFLURIA INJ PF 12-13 Brand 2 FLUARIX PF INJ 2013-14 Brand 2 FLUZONE INJ PF 13-14 Brand 2 FLUZONE HD INJ PF 13-14 Brand 2 FLULAVAL QUA INJ 2013-14 Brand 2 FLUZONE QUAD INJ 13-14 Brand 2 FLUARIX QUAD INJ 2013-14 Brand 2 FLUZONE QUAD INJ 13-14 Brand 2 EZ FLU SHOT KIT 13-14 Brand 2 FLUVIRIN INJ 2013-14 Brand 2 EZ USE FLU KIT 2012-13 Brand 2

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 291 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO FLUVIRIN INJ PF 13-14 Brand 2 EZ FLU SHOT KIT PF 13-14 Brand 2 FLUMIST NASA LIQ 2012-13 Brand 2 FLUMIST QUAD SUS 2013-14 Brand 2 INFLUENZA A SPR 09 H1N1 Brand 2 FLUCELVAX INJ 2013-14 Brand 2 FLUBLOK SOL 2013-14 Brand 2 GARDASIL INJ Brand 2 PA CERVARIX INJ Brand 2 PA ZOSTAVAX INJ Brand 2 QL 1/Life PA Vaginal Products CLEOCIN CRE 2% VAG Brand 2 GR CLINDAMYCIN CRE 2% VAG generic 1 CLEOCIN SUP 100MG Brand 2 CLINDESSE CRE 2% Brand 2 METRONIDAZOL GEL 0.75%VAG generic 1 VANDAZOLE GEL 0.75% generic 1 METROGEL-VAG GEL 0.75% Brand 2 GR AVC CRE 15% Brand 2 GYNAZOLE-1 CRE 2% Brand 2 MICONAZOLE 3 SUP 200MG generic 1 MICONAZOLE 3 KIT COMBO PK generic 1 ZAZOLE CRE 0.4% generic 1 TERAZOL 7 CRE 0.4% Brand 2 GR TERCONAZOLE CRE 0.4% generic 1 ZAZOLE CRE 0.8% generic 1 TERAZOL 3 CRE 0.8% Brand 2 GR TERCONAZOLE CRE 0.8% generic 1 TERCONAZOLE SUP 80MG generic 1 ZAZOLE SUP 80MG generic 1 TERAZOL 3 SUP 80MG Brand 2 GR

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 292 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO VAGIFEM TAB 10MCG Brand 2 ESTRACE VAG CRE 0.1MG/GM Brand 2 ESTRING MIS 2MG Brand 2 FEMRING MIS 0.05/24H Brand 2 FEMRING MIS 0.1MG/24 Brand 2 PREMARIN VAG CRE 0.625MG Brand 2 CRINONE GEL 4% VAG Brand 2 CRINONE GEL 8% VAG Brand 2 PROGESTERONE SUP VGS 25 Brand 2 PROGESTERONE SUP VGS 50 Brand 2 PROGESTERONE SUP VGS 100 Brand 2 PROGESTERONE SUP VGS 200 Brand 2 PROGESTERONE SUP VGS 400 Brand 2 ENDOMETRIN SUP 100MG Brand 2 FEM PH GEL Brand 2 RELAGARD GEL Brand 2 Vasopressors DOBUTAMINE INJ 250MG generic 1 DOBUTAMINE INJ 500MG generic 1 DOPAMINE INJ 40MG/ML generic 1 DOPAMINE INJ 80MG/ML generic 1 DOPAMINE INJ 160MG/ML Brand 2 EPHEDRINE SU INJ 50MG/ML generic 1 MIDODRINE TAB 2.5MG generic 1 MIDODRINE TAB 5MG generic 1 MIDODRINE TAB 10MG generic 1 LEVOPHED INJ 1MG/ML Brand 2 GR NOREPINEPHR INJ 1MG/ML generic 1 PHENYLEPHRIN INJ 10MG/ML generic 1 ADRENALIN INJ 1MG/ML Brand 2 EPIPEN-JR INJ 2-PAK Brand 2 QL 4/30

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 293 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO EPINEPHRINE INJ 0.15MG generic 1 AUVI-Q INJ 0.15MG Brand 2 ADRENACLICK INJ 0.15MG Brand 2 GR EPINEPHRINE INJ 0.3MG generic 1 AUVI-Q INJ 0.3MG Brand 2 QL 4/30 EPIPEN 2-PAK INJ 0.3MG Brand 2 QL 4/30 ADRENACLICK INJ 0.3MG Brand 2 GR Vitamins THIAMINE HCL INJ 100MG/ML generic 1 PYRIDOXINE INJ 100MG/ML generic 1 ASCOR L 500 INJ 500MG/ML generic 1 MEGA-C/A PLU INJ 500MG/ML generic 1 ASCORBIC ACD INJ 500MG/ML generic 1 ASCOR L NC INJ 500MG/ML generic 1 ORTHO-CS 250 INJ 250MG/ML generic 1 VITAMIN C INJ 222MG/ML generic 1 AQUASOL A INJ 50000/ML Brand 2 PA DRISDOL CAP 50000UNT Brand 2 GR ERGOCALCIFER CAP 50000UNT generic 1 VITAMIN D CAP 50000UNT generic 1 DECARA CAP 25000UNT Brand 2 PA WHEAT GERM OIL Brand 2 PA MEPHYTON TAB 5MG Brand 2 PA VITAMIN K1 INJ 1MG/0.5 generic 1 PHYTONADIONE INJ 1MG/0.5 generic 1 VITAMIN K1 INJ 10MG/ML Brand 2 PA

KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 294 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170.