Four-Tier Drug List Maine Municipal Employees Health Trust

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

Here are a few things to remember about the list:

o You and your doctor can use it as a guide to choose drugs that are best for you. Drugs that aren’t on this list may not be covered by your plan and may cost you more out of pocket.

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

o To help you see how the drug list works with your drug benefit, we've included some frequently asked questions (FAQ) about how the list is set up and what to do if a drug you take isn't on it.

o To view the most up-to-date list of drugs for your plan - including drugs that have been added, generic drugs and more - log in at anthem.com→ My Plan→ Pharmacy.

If you have questions about your pharmacy benefits, we're here to help. Just call us at the Pharmacy Member Services number on your ID card.

29487MEMENABS Anthem Drug List

What is a drug list? The drugs are listed in alphabetical order based on the name of their drug class, also called therapeutic class. You can search the PDF drug list by:

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

The Notes column will tell you if you need preapproval before you can take the drug (called prior authorization or PA), or if you need to try other drugs first for your treatment (called step therapy or ST).

Is this a complete listing of all covered drugs? Yes, this is a complete listing of all the drugs on the drug list. But, it’s possible a drug(s) on this list may not be covered, depending on your plan’s design. Your coverage has limitations and exclusions, which means there are certain conditions that determine what’s covered by your plan and what isn’t. To find out more, read your Certificate/Evidence of Coverage or your Summary Plan Description, which you got when you signed up for your plan.

How can I find a drug on the list? The drugs are listed in alphabetical order based on the name of their drug class, also called therapeutic class. You can search the PDF drug list by:

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

The Notes column will tell you if you need preapproval before you can take the drug (called prior authorization or PA), or if you need to try other drugs first for your treatment (called step therapy or ST).

When I search the list, I see that each drug is on a tier. What are the tiers for? The drug list is set up in tiers or levels. We place drugs on different tiers based on how well they work to improve health, whether there are over-the-counter (OTC) options and their costs compared to other drugs used for the same type of treatment. Your share of the drug cost will depend on what tier a drug is on. The lower the tier, the lower your share of the cost. Here’s a breakdown of the tiers in your plan:

What types of drugs can I expect to find in the different tiers?

 Tier 1 select generic drugs have the lowest copay. These drugs offer the greatest value within a drug class. Select generics are the most commonly prescribed generic drugs. They’re known for their effectiveness and value in treating many conditions. All of these drugs are generic versions of brandname drugs.

 Tier 1 standard drugs have the second lowest copay. These drugs offer a good value. Some of these drugs are generic versions of brand-name drugs.

 Tier 2 drugs have a medium copay. They may be preferred brand-name drugs, based on their effectiveness and value. Some are newer, more expensive generic drugs.

 Tier 3 drugs have a higher copay. They may be higher-cost, brand-name drugs or generic drugs that cost more than others used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA.

 Tier 4 specialty and lifestyle drugs have the highest copay. They may be the highest-cost, brand-name drugs or generic drugs that cost more than others used to treat the same condition. Tier 4 may also include drugs that were recently approved by the FDA. Specialty drugs are used to treat complex, chronic conditions and may need special handling. Lifestyle drugs are most commonly used to treat impotency.

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

If my medicine isn’t on the drug list, what are my options? Here are a few things to think about:

o If you want to take a drug that’s not on the drug list, you may have to pay the full cost for it.

o You can also talk to your doctor or pharmacist to see if there’s another drug covered by your plan that will work just as well, or if generic or OTC drugs are an option. Only you and your doctor can decide what drugs are right for you.

o You can search for generic drugs at anthem.com. OTC drugs aren’t shown on the list.

o If a drug you’re taking isn’t covered, your doctor can ask us to review the coverage. This process is called preapproval or prior authorization. Your doctor can get the process started by calling the Member Services number on the back of your member ID card or by downloading a prior authorization form from our website and submitting it. If your request is approved, the amount you pay for the drug will depend on your plan’s benefit.

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

What’s the difference between brand-name and generic drugs? A brand-name drug is FDA-approved and usually available from only one manufacturer. It may be protected by a patent, which means it can only be made or sold by the company that has the patent.

A generic drug is also FDA-approved and has the same active ingredients as the brand-name drug. But a generic drug is usually available only after the patent on the brand-name drug ends. It may look different, but a generic drug works the same as the brand-name drug.

Online Pharmacy Resources Find your closest network pharmacy, get the most up-to-date coverage information on your drug list including details about pricing your medication, brands and generics, dosage/strength options, and much more — when you log in at anthem.com.

Does the drug list change, and how will I know if it does? Drugs on our list are reviewed on a regular basis. Sometimes, drugs are added, removed or moved to a different tier. We’ll let you know if a drug you take is taken off the list and, in some cases, if a drug you take is moved to a higher tier.

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

Does my plan cover preventive drugs? Preventive drugs are those that can help you avoid many illnesses and conditions. To follow the Affordable Care Act (ACA), the drug list includes preventive-care drugs that may have a zero cost share for you.

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

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

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

Brand name drugs are in UPPER CASE, bold type.

Generic drugs are in lower case, plain type.

$0 = preventive drugs. For some members, this product may be covered at 100% with $0 cost share with a prescription from your provider if specified criteria are met.

DO = dose optimization. Usually, this means you may have to switch from taking a drug twice a day to taking it once a day at a higher strength.

LD = limited distribution. These drugs are available only through certain pharmacies or wholesalers, depending on what the manufacturer decides.

PA = prior authorization. You may need to get benefits approved before certain prescriptions can be filled.

QL = quantity limits. There are limits on the amount of medicine covered within a certain amount of time.

SP = specialty drugs. Specialty drugs are used to treat difficult, long-term conditions. You may need to get this drug through a specialty pharmacy.

ST = step therapy. You may need to use another recommended drug first before a prescribed drug is covered.

T1S = Tier 1 Select

Anthem National Drug List Drug Name Tier Notes ABSORICA LD ORAL Four Tier Tier 3 ST; QL CAPSULE CURRENT AS OF 4/1/2021 ABSORICA ORAL Tier 3 ST; QL CAPSULE Drug Name Tier Notes ACACIA 1ST TIER UNIFINE SUBCUTANEOUS Tier 3 Tier 3 ST; QL PENTIPS SOLUTION 1ST TIER UNIFINE acamprosate calcium oral Tier 3 ST; QL Tier 1 PENTIPS PLUS tablet delayed release 1ST TIER UNILET acarbose oral tablet Tier 1 Tier 2 QL COMFORTOUCH ACCOLATE ORAL Tier 3 abacavir sulfate oral solution Tier 1 QL TABLET abacavir sulfate oral tablet Tier 1 QL ACCU-CHEK AVIVA Tier 2 QL PLUS IN VITRO STRIP abacavir sulfate-lamivudine Tier 1 QL oral tablet ACCU-CHEK COMPACT Tier 2 QL PLUS IN VITRO STRIP abacavir-lamivudine- Tier 1 QL zidovudine oral tablet ACCU-CHEK FASTCLIX Tier 2 LANCET KIT ABELCET Tier 3 ACCU-CHEK FASTCLIX INTRAVENOUS Tier 2 QL SUSPENSION LANCETS ACCU-CHEK GUIDE IN ABILIFY MAINTENA Tier 2 QL INTRAMUSCULAR Tier 3 VITRO STRIP PREFILLED SYRINGE ACCU-CHEK Tier 2 QL ABILIFY MAINTENA MULTICLIX LANCETS INTRAMUSCULAR ACCU-CHEK SAFE-T Tier 3 Tier 2 QL SUSPENSION PRO LANCETS RECONSTITUTED ER ACCU-CHEK ABILIFY MYCITE ORAL SMARTVIEW IN VITRO Tier 2 QL TABLET 10 MG, 15 MG, 2 Tier 3 ST; DO; QL STRIP MG, 5 MG ACCU-CHEK SOFTCLIX ABILIFY MYCITE ORAL Tier 2 Tier 3 ST; QL LANCET DEV KIT TABLET 20 MG, 30 MG ACCU-CHEK SOFTCLIX Tier 2 QL abiraterone acetate oral tablet Tier 1 PA; QL; SP LANCETS ABLYSINOL INTRA- ACCURETIC ORAL Tier 3 Tier 3 ARTERIAL SOLUTION TABLET ABOUTTIME PEN Tier 3 ST; QL accutane oral capsule Tier 2 ST; QL NEEDLE ACCUTREND GLUCOSE Tier 2 QL ABRAXANE IN VITRO STRIP INTRAVENOUS Tier 3 PA; QL; SP SUSPENSION acebutolol hcl oral capsule Tier 1 RECONSTITUTED

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 1 Drug Name Tier Notes Drug Name Tier Notes ACETADOTE ACTHIB INTRAVENOUS Tier 3 INTRAMUSCULAR Tier 3 $0 SOLUTION SOLUTION acetaminophen intravenous RECONSTITUTED Tier 1 solution ACTIFLOVIT EAR Tier 2 $0 ACETAMINOPHEN HEALTH ORAL TABLET INTRAVENOUS ACTIFOAM COLLAGEN Tier 3 Tier 3 SOLUTION PREFILLED SPONGE EXTERNAL SYRINGE ACTI-LANCE 28G Tier 2 QL acetaminophen-codeine #2 ACTI-LANCE LITE Tier 1 QL Tier 2 QL oral tablet LANCETS 28G acetaminophen-codeine #3 ACTI-LANCE SPECIAL Tier 1 QL Tier 2 QL oral tablet LANCETS 17G acetaminophen-codeine #4 ACTI-LANCE Tier 1 QL Tier 2 QL oral tablet UNIVERSAL 23G acetaminophen-codeine oral Tier 1 QL ACTIMMUNE solution SUBCUTANEOUS Tier 4 PA; QL; LD; SP acetaminophen-codeine oral SOLUTION Tier 1 QL tablet ACTIVASE acetazolamide er oral capsule INTRAVENOUS Tier 1 T1S Tier 3 extended release 12 hour SOLUTION acetazolamide oral tablet Tier 1 T1S RECONSTITUTED ACTIVELLA ORAL acetazolamide sodium Tier 3 injection solution Tier 1 TABLET reconstituted ACTONEL ORAL Tier 3 TABLET acetic acid irrigation solution Tier 1 ACTOPLUS MET ORAL Tier 3 ST; QL acetic acid otic solution Tier 1 TABLET acetylcysteine inhalation Tier 1 ACULAR LS solution OPHTHALMIC Tier 3 acetylcysteine intravenous SOLUTION Tier 1 solution ACULAR OPHTHALMIC Tier 3 acitretin oral capsule Tier 1 SOLUTION ACREMONIUM ACUVAIL SUBCUTANEOUS Tier 3 OPHTHALMIC Tier 3 SOLUTION SOLUTION ACTHAR INJECTION acyclovir external cream Tier 1 PA; QL Tier 4 PA; QL; LD; SP GEL acyclovir external ointment Tier 1 acyclovir oral capsule Tier 1 acyclovir oral suspension Tier 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 2 Drug Name Tier Notes Drug Name Tier Notes ADJUSTABLE LANCING acyclovir oral tablet Tier 1 Tier 2 DEVICE acyclovir sodium intravenous Tier 1 ADRENAL C FORMULA solution Tier 3 ORAL TABLET ADACEL ADRENALIN INJECTION INTRAMUSCULAR Tier 3 $0 Tier 3 SUSPENSION SOLUTION adriamycin intravenous ADAKVEO Tier 1 SP INTRAVENOUS Tier 4 PA; QL; SP solution SOLUTION adriamycin intravenous Tier 1 SP adapalene external cream Tier 1 PA; QL solution reconstituted adult aspirin regimen oral adapalene external gel Tier 1 PA; QL Tier 1 $0 tablet delayed release adapalene external pad Tier 1 PA; QL ADVAIR HFA adapalene-benzoyl peroxide Tier 2 Tier 1 PA; QL INHALATION AEROSOL external gel ADVANCED MOBILE Tier 2 QL ADASUVE INHALATION LANCET AEROSOL POWDER Tier 3 BREATH ACTIVATED ADVATE INTRAVENOUS SOLUTION Tier 4 PA; QL; LD; SP adc/f (0.5mg/ml) oral Tier 1 $0 RECONSTITUTED solution ADVOCATE INSULIN Tier 3 ST; QL ADCETRIS PEN NEEDLES INTRAVENOUS Tier 3 PA; QL; LD; SP ADVOCATE INSULIN SOLUTION Tier 3 ST; QL RECONSTITUTED SYRINGE ADDYI ORAL TABLET Tier 3 PA; QL ADVOCATE LANCETS Tier 2 QL ADVOCATE LANCETS adefovir dipivoxil oral tablet Tier 4 SP Tier 2 QL 30G ADEMPAS ORAL Tier 4 PA; QL; LD; SP ADVOCATE LANCING TABLET Tier 2 DEVICE ADENOCARD ADVOCATE RAPID- INTRAVENOUS Tier 3 Tier 2 SOLUTION SAFE LANCING adenosine intravenous ADVOCATE SAFETY Tier 1 Tier 2 QL solution LANCETS ADVOCATE SAFETY ADHANSIA XR ORAL Tier 2 QL CAPSULE EXTENDED Tier 3 PA; QL LANCETS 26G RELEASE 24 HOUR ADYNOVATE ADIPEX-P ORAL INTRAVENOUS Tier 3 PA; QL Tier 4 PA; QL; LD; SP CAPSULE SOLUTION RECONSTITUTED ADIPEX-P ORAL Tier 3 PA; QL TABLET ADZENYS ER ORAL SUSPENSION Tier 3 PA; QL EXTENDED RELEASE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 3 Drug Name Tier Notes Drug Name Tier Notes ADZENYS XR-ODT AIMOVIG ORAL TABLET SUBCUTANEOUS Tier 3 PA; QL Tier 3 PA; QL EXTENDED RELEASE SOLUTION AUTO- DISPERSIBLE INJECTOR AEMCOLO ORAL AIMSCO TWIST Tier 2 QL TABLET DELAYED Tier 3 PA; QL LANCETS 32G RELEASE AIMSCO TWIST Tier 2 QL AFFINITY EXTERNAL LANCETS 33G Tier 3 SHEET ak-fluor intravenous solution Tier 1 AFINITOR DISPERZ 10 % ORAL TABLET Tier 3 PA; QL; SP AK-FLUOR SOLUBLE INTRAVENOUS Tier 3 AFINITOR ORAL SOLUTION 25 % Tier 2 PA; QL; SP TABLET 10 MG AKLIEF EXTERNAL Tier 3 ST; QL AFINITOR ORAL CREAM TABLET 2.5 MG, 5 MG, Tier 3 PA; QL; SP AKOVAZ 7.5 MG INTRAVENOUS Tier 3 afirmelle oral tablet Tier 1 $0 SOLUTION AFLURIA ak-poly-bac ophthalmic Tier 1 QUADRIVALENT ointment Tier 2 QL; $0 INTRAMUSCULAR AKTEN OPHTHALMIC Tier 3 SUSPENSION GEL AFLURIA AKYNZEO QUADRIVALENT INTRAVENOUS Tier 3 PA; QL INTRAMUSCULAR Tier 2 QL; $0 SOLUTION SUSPENSION PREFILLED SYRINGE AKYNZEO INTRAVENOUS AFSTYLA Tier 3 PA; QL Tier 4 PA; QL; LD; SP SOLUTION INTRAVENOUS KIT RECONSTITUTED aftera oral tablet Tier 1 $0 AKYNZEO ORAL Tier 3 AGAMATRIX ULTRA- CAPSULE Tier 2 QL THIN LANCETS ala-cort external cream Tier 1 AGGRASTAT INTRAVENOUS Tier 3 albendazole oral tablet Tier 1 PA; QL CONCENTRATE ALBENZA ORAL Tier 3 PA; QL AGGRASTAT TABLET INTRAVENOUS Tier 3 albuked 25 intravenous Tier 1 SOLUTION solution AGRYLIN ORAL albuked 5 intravenous Tier 3 Tier 1 CAPSULE solution albumin human intravenous Tier 1 solution

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 4 Drug Name Tier Notes Drug Name Tier Notes ALBUMINEX ALFENTANIL HCL INTRAVENOUS Tier 3 INTRAVENOUS Tier 3 SOLUTION SOLUTION albumin-zlb intravenous ALFERON N INJECTION Tier 1 Tier 4 SP solution SOLUTION alfuzosin hcl er oral tablet alburx intravenous solution Tier 1 Tier 1 extended release 24 hour albutein intravenous solution Tier 1 ALIMTA INTRAVENOUS albuterol sulfate er oral tablet Tier 1 SOLUTION Tier 3 PA; QL; SP extended release 12 hour RECONSTITUTED albuterol sulfate hfa Tier 1 ALINIA ORAL inhalation aerosol solution SUSPENSION Tier 3 albuterol sulfate inhalation RECONSTITUTED Tier 1 nebulization solution ALINIA ORAL TABLET Tier 3 albuterol sulfate oral syrup Tier 1 ALIQOPA INTRAVENOUS albuterol sulfate oral tablet Tier 1 Tier 3 PA; QL; LD SOLUTION ALCAINE RECONSTITUTED OPHTHALMIC Tier 3 aliskiren fumarate oral tablet SOLUTION Tier 1 DO 150 mg alclometasone dipropionate Tier 1 aliskiren fumarate oral tablet external cream Tier 1 300 mg alclometasone dipropionate Tier 1 external ointment ALKERAN INTRAVENOUS ALDACTAZIDE ORAL Tier 3 SP Tier 3 SOLUTION TABLET RECONSTITUTED ALDACTONE ORAL ALKERAN ORAL Tier 3 Tier 3 SP TABLET TABLET ALDARA EXTERNAL Tier 3 ST; QL ALKINDI SPRINKLE CREAM ORAL CAPSULE Tier 3 PA; QL; LD ALDER SPRINKLE SUBCUTANEOUS Tier 3 allbee/c oral tablet Tier 1 $0 SOLUTION allopurinol oral tablet Tier 1 T1S ALDURAZYME INTRAVENOUS Tier 4 PA; QL; LD; SP allopurinol sodium SOLUTION intravenous solution Tier 1 reconstituted ALECENSA ORAL Tier 3 PA; QL; LD; SP CAPSULE almotriptan malate oral tablet Tier 1 QL alendronate sodium oral alogliptin benzoate oral Tier 1 Tier 1 ST; QL solution tablet alendronate sodium oral alogliptin-metformin hcl oral Tier 1 Tier 1 ST; QL tablet tablet

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 5 Drug Name Tier Notes Drug Name Tier Notes alogliptin-pioglitazone oral Tier 1 ST; QL alprostadil injection solution Tier 1 tablet ALREX OPHTHALMIC alophen oral tablet delayed Tier 3 Tier 1 $0 SUSPENSION release ALTABAX EXTERNAL Tier 2 ALOPRIM OINTMENT INTRAVENOUS Tier 3 altafluor benox ophthalmic SOLUTION Tier 1 RECONSTITUTED solution ALORA TRANSDERMAL altafrin ophthalmic solution Tier 1 PATCH TWICE Tier 3 altavera oral tablet Tier 1 $0 WEEKLY ALTERNARIA alosetron hcl oral tablet Tier 1 PA; QL SUBCUTANEOUS Tier 3 ALOXI INTRAVENOUS SOLUTION Tier 3 PA; QL SOLUTION ALUNBRIG ORAL Tier 3 PA; QL; LD; SP ALPHAGAN P TABLET OPHTHALMIC Tier 2 ALUNBRIG ORAL SOLUTION 0.1 % TABLET THERAPY Tier 3 PA; QL; LD; SP ALPHAGAN P PACK OPHTHALMIC Tier 3 alvimopan oral capsule Tier 1 SOLUTION 0.15 % alyacen 1/35 oral tablet Tier 1 $0 ALPHANATE INTRAVENOUS alyacen 7/7/7 oral tablet Tier 1 $0 Tier 4 PA; QL; LD; SP SOLUTION alyq oral tablet Tier 4 PA; QL; SP RECONSTITUTED amabelz oral tablet Tier 1 ALPHANINE SD INTRAVENOUS amantadine hcl oral capsule Tier 1 Tier 4 PA; QL; LD; SP SOLUTION amantadine hcl oral syrup Tier 1 RECONSTITUTED alprazolam er oral tablet amantadine hcl oral tablet Tier 1 Tier 1 extended release 24 hour AMARYL ORAL Tier 3 ST; QL ALPRAZOLAM TABLET INTENSOL ORAL Tier 3 AMBISOME CONCENTRATE INTRAVENOUS Tier 3 alprazolam oral tablet Tier 1 SUSPENSION RECONSTITUTED alprazolam oral tablet Tier 1 ambrisentan oral tablet Tier 4 PA; QL; LD; SP dispersible amcinonide external cream Tier 3 ST; QL alprazolam xr oral tablet Tier 1 extended release 24 hour amcinonide external lotion Tier 3 ST; QL AMELUZ EXTERNAL ALPROLIX Tier 3 INTRAVENOUS GEL Tier 4 PA; QL; LD; SP SOLUTION RECONSTITUTED

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 6 Drug Name Tier Notes Drug Name Tier Notes AMERICAN BEECH AMINOSYN-PF SUBCUTANEOUS Tier 3 INTRAVENOUS Tier 3 SOLUTION SOLUTION AMERICAN AMIODARONE HCL IN COCKROACH DEXTROSE Tier 3 Tier 3 SUBCUTANEOUS INTRAVENOUS SOLUTION SOLUTION AMERICAN ELM amiodarone hcl intravenous Tier 1 SUBCUTANEOUS Tier 3 solution SOLUTION amiodarone hcl oral tablet Tier 1 amethia lo oral tablet Tier 1 $0 AMITIZA ORAL Tier 2 amethia oral tablet Tier 1 $0 CAPSULE amethyst oral tablet Tier 1 $0 amitriptyline hcl oral tablet Tier 1 AMICAR ORAL Tier 3 amlodipine besy-benazepril SOLUTION hcl oral capsule 10-20 mg, Tier 1 AMICAR ORAL TABLET Tier 3 10-40 mg, 5-40 mg AMIDATE amlodipine besy-benazepril INTRAVENOUS Tier 3 hcl oral capsule 2.5-10 mg, Tier 1 DO SOLUTION 5-10 mg, 5-20 mg amikacin sulfate injection amlodipine besylate oral Tier 1 Tier 1 T1S solution tablet 10 mg amlodipine besylate oral amiloride hcl oral tablet Tier 1 Tier 1 DO; T1S tablet 2.5 mg, 5 mg amiloride- hydrochlorothiazide oral Tier 1 amlodipine besylate- tablet valsartan oral tablet 10-160 Tier 1 mg, 10-320 mg, 5-320 mg aminoacetic acid irrigation Tier 1 solution amlodipine besylate- valsartan oral tablet 5-160 Tier 1 DO aminocaproic acid Tier 1 mg intravenous solution amlodipine-atorvastatin oral aminocaproic acid oral tablet 10-10 mg, 10-20 mg, Tier 1 Tier 1 solution 10-40 mg, 10-80 mg, 5-80 aminocaproic acid oral tablet Tier 1 mg aminophylline intravenous amlodipine-atorvastatin oral Tier 1 tablet 2.5-10 mg, 2.5-20 mg, solution Tier 1 DO 2.5-40 mg, 5-10 mg, 5-20 AMINOPROTECT mg, 5-40 mg INTRAVENOUS Tier 3 SOLUTION amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, Tier 1 AMINOSYN II 5-40 mg INTRAVENOUS Tier 3 amlodipine-olmesartan oral SOLUTION Tier 1 DO tablet 5-20 mg

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 7 Drug Name Tier Notes Drug Name Tier Notes amlodipine-valsartan-hctz AMPHENOL-40 oral tablet 10-160-12.5 mg, INJECTION Tier 1 Tier 3 10-160-25 mg, 10-320-25 SUSPENSION mg, 5-160-25 mg RECONSTITUTED amlodipine-valsartan-hctz amphetamine er oral Tier 1 DO Tier 1 oral tablet 5-160-12.5 mg suspension extended release ammonium lactate external amphetamine sulfate oral Tier 1 Tier 1 cream tablet 10 mg ammonium lactate external amphetamine sulfate oral Tier 1 Tier 1 DO lotion tablet 5 mg AMMONUL amphetamine-dextroamphet INTRAVENOUS Tier 3 er oral capsule extended Tier 1 PA; DO; QL SOLUTION release 24 hour 10 mg, 15 amnesteem oral capsule Tier 2 PA; QL mg, 5 mg AMNIOFIX INJECTION amphetamine-dextroamphet er oral capsule extended SUSPENSION Tier 3 Tier 1 PA; QL RECONSTITUTED release 24 hour 20 mg, 25 mg, 30 mg amoxapine oral tablet Tier 1 amphetamine- amoxicill-clarithro-lansopraz dextroamphetamine oral Tier 1 ST; QL Tier 1 PA; DO; QL oral tablet 10 mg, 12.5 mg, 15 mg, 5 mg, 7.5 mg amoxicillin oral capsule Tier 1 amphetamine- amoxicillin oral suspension Tier 1 dextroamphetamine oral Tier 1 PA; QL reconstituted tablet 20 mg, 30 mg amoxicillin oral tablet Tier 1 ampicillin oral capsule Tier 1 amoxicillin oral tablet ampicillin sodium injection Tier 1 Tier 1 chewable solution reconstituted amoxicillin-pot clavulanate ampicillin sodium er oral tablet extended Tier 1 intravenous solution Tier 1 release 12 hour reconstituted amoxicillin-pot clavulanate Tier 1 ampicillin-sulbactam sodium oral suspension reconstituted injection solution Tier 1 amoxicillin-pot clavulanate reconstituted Tier 1 oral tablet ampicillin-sulbactam sodium amoxicillin-pot clavulanate intravenous solution Tier 1 Tier 1 oral tablet chewable reconstituted AMPHADASE AMPYRA ORAL TABLET Tier 3 INJECTION SOLUTION EXTENDED RELEASE 12 Tier 4 PA; QL; LD; SP HOUR AMVISC INTRAOCULAR Tier 4 SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 8 Drug Name Tier Notes Drug Name Tier Notes AMVISC PLUS ANNOVERA VAGINAL Tier 3 INTRAOCULAR Tier 4 RING SOLUTION ANORO ELLIPTA INHALATION AEROSOL anagrelide hcl oral capsule Tier 1 Tier 2 POWDER BREATH ANALPRAM-HC Tier 3 ACTIVATED EXTERNAL CREAM anti-oxidant oral tablet Tier 1 $0 ANALPRAM-HC Tier 3 EXTERNAL LOTION ANTIVENIN LATRODECTUS Tier 3 ANASCORP MACTANS INJECTION INTRAVENOUS Tier 3 KIT SOLUTION RECONSTITUTED ANTIVENIN MICRURUS FULVIUS anastrozole oral tablet Tier 1 $0 INTRAVENOUS Tier 3 ANAVIP INTRAVENOUS SOLUTION SOLUTION Tier 3 RECONSTITUTED RECONSTITUTED ANUSOL-HC EXTERNAL Tier 3 ANCOBON ORAL CREAM Tier 3 PA; QL CAPSULE ANZEMET ORAL Tier 3 QL ANDEXXA TABLET INTRAVENOUS Tier 3 APADAZ ORAL TABLET Tier 3 QL SOLUTION apap-caff-dihydrocodeine RECONSTITUTED Tier 1 QL oral capsule ANDRODERM apap-caff-dihydrocodeine TRANSDERMAL PATCH Tier 3 PA; QL Tier 1 QL 24 HOUR oral tablet ANECTINE INJECTION APLENZIN ORAL Tier 3 TABLET EXTENDED SOLUTION Tier 3 ST; DO; QL RELEASE 24 HOUR 174 ANESTHESIA S/I-40A Tier 3 MG INTRAVENOUS KIT APLENZIN ORAL ANESTHESIA S/I-40H TABLET EXTENDED Tier 3 Tier 3 ST; QL INTRAVENOUS KIT RELEASE 24 HOUR 348 ANESTHESIA S/I-40S MG, 522 MG Tier 3 INTRAVENOUS KIT APLIGRAF EXTERNAL Tier 3 ANGELIQ ORAL DISK Tier 3 TABLET APOKYN ANGIOMAX SUBCUTANEOUS Tier 4 PA; QL; LD; SP INTRAVENOUS SOLUTION CARTRIDGE Tier 3 SOLUTION apraclonidine hcl ophthalmic Tier 1 RECONSTITUTED solution ANJESO INTRAVENOUS Tier 3 aprepitant oral Tier 1 INJECTABLE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 9 Drug Name Tier Notes Drug Name Tier Notes aprepitant oral capsule Tier 1 ARAVA ORAL TABLET Tier 3 apri oral tablet Tier 1 $0 ARAZLO EXTERNAL Tier 3 ST; QL APRISO ORAL CAPSULE LOTION EXTENDED RELEASE 24 Tier 3 ARCALYST HOUR SUBCUTANEOUS Tier 4 PA; QL; LD; SP APTENSIO XR ORAL SOLUTION CAPSULE EXTENDED RECONSTITUTED RELEASE 24 HOUR 10 Tier 3 PA; DO; QL ARGATROBAN IN MG, 15 MG, 20 MG, 30 SODIUM CHLORIDE Tier 3 MG INTRAVENOUS APTENSIO XR ORAL SOLUTION CAPSULE EXTENDED ARGATROBAN Tier 3 PA; QL RELEASE 24 HOUR 40 INTRAVENOUS Tier 3 MG, 50 MG, 60 MG SOLUTION APTIOM ORAL TABLET ARGININE HCL Tier 3 DO Tier 3 200 MG, 400 MG INJECTION SOLUTION APTIOM ORAL TABLET argyle sterile saline irrigation Tier 3 Tier 1 600 MG, 800 MG solution APTIVUS ORAL argyle sterile water irrigation Tier 2 PA; QL Tier 1 CAPSULE solution APTIVUS ORAL ARICEPT ORAL Tier 2 PA; QL Tier 3 SOLUTION TABLET 10 MG, 23 MG AQUALANCE LANCETS ARICEPT ORAL Tier 2 QL Tier 3 DO 30G TABLET 5 MG AQUASOL A ARIKAYCE INTRAMUSCULAR Tier 3 INHALATION Tier 4 PA; QL; LD SOLUTION SUSPENSION ARAKODA ORAL Tier 3 aripiprazole oral solution Tier 1 TABLET aripiprazole oral tablet 10 Tier 1 DO ARALAST NP mg, 15 mg, 2 mg, 5 mg INTRAVENOUS Tier 4 PA; QL; LD; SP aripiprazole oral tablet 20 SOLUTION Tier 1 RECONSTITUTED mg, 30 mg aripiprazole oral tablet aranelle oral tablet Tier 1 $0 Tier 1 dispersible ARANESP (ALBUMIN FREE) INJECTION Tier 4 PA; QL; SP ARISTADA INITIO SOLUTION INTRAMUSCULAR Tier 3 PREFILLED SYRINGE ARANESP (ALBUMIN FREE) INJECTION ARISTADA Tier 4 PA; QL; SP SOLUTION PREFILLED INTRAMUSCULAR Tier 3 SYRINGE PREFILLED SYRINGE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 10 Drug Name Tier Notes Drug Name Tier Notes ARIXTRA ashlyna oral tablet Tier 1 $0 SUBCUTANEOUS Tier 4 ASPARLAS SOLUTION INTRAVENOUS Tier 3 PA; QL; LD; SP ARIZONA CYPRESS SOLUTION SUBCUTANEOUS Tier 3 ASPERGILLUS SOLUTION FUMIGATUS Tier 3 armodafinil oral tablet Tier 1 PA; QL INJECTION SOLUTION ARMOUR THYROID aspirin 81 oral tablet Tier 3 Tier 1 $0 ORAL TABLET chewable ARNUITY ELLIPTA aspirin 81 oral tablet delayed Tier 1 $0 INHALATION AEROSOL release Tier 2 POWDER BREATH aspirin adult low dose oral Tier 1 $0 ACTIVATED tablet delayed release AROMASIN ORAL aspirin adult low strength Tier 3 Tier 1 $0 TABLET oral tablet chewable ARRANON aspirin adult low strength Tier 1 $0 INTRAVENOUS Tier 3 SP oral tablet delayed release SOLUTION aspirin childrens oral tablet arsenic trioxide intravenous Tier 1 $0 Tier 1 SP chewable solution aspirin ec adult low strength articadent dental injection Tier 1 $0 Tier 3 oral tablet delayed release solution cartridge aspirin ec low dose oral ARTISS EXTERNAL Tier 1 $0 Tier 3 tablet delayed release SOLUTION aspirin ec low strength oral Tier 1 $0 ARZERRA tablet delayed release INTRAVENOUS Tier 3 PA; QL; LD; SP aspirin ec oral tablet delayed CONCENTRATE Tier 1 $0 release ASCENIV aspirin low dose oral tablet INTRAVENOUS Tier 4 PA; QL; LD; SP Tier 1 $0 SOLUTION chewable aspirin low dose oral tablet ASCLERA Tier 1 $0 INTRAVENOUS Tier 3 delayed release SOLUTION aspirin low strength oral Tier 1 $0 ascomp-codeine oral capsule Tier 1 QL tablet chewable ASCOR INTRAVENOUS aspirin oral tablet Tier 1 $0 Tier 3 SOLUTION aspirin oral tablet chewable Tier 1 $0 asenapine maleate sublingual aspirin oral tablet delayed Tier 1 ST; QL Tier 1 $0 tablet sublingual 10 mg release asenapine maleate sublingual aspirin-dipyridamole er oral tablet sublingual 2.5 mg, 5 Tier 1 ST; DO; QL capsule extended release 12 Tier 1 mg hour

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 11 Drug Name Tier Notes Drug Name Tier Notes ASPIRIN-OMEPRAZOLE ATELVIA ORAL ORAL TABLET Tier 3 PA; QL TABLET DELAYED Tier 3 DELAYED RELEASE RELEASE aspir-low oral tablet delayed atenolol oral tablet Tier 1 T1S Tier 1 $0 release atenolol-chlorthalidone oral Tier 1 ASSURE COMFORT tablet Tier 2 QL LANCETS 28G ATGAM INTRAVENOUS Tier 3 SP ASSURE HAEMOLANCE INJECTABLE Tier 2 QL PLUS HIGH atomoxetine hcl oral capsule Tier 1 PA; DO; QL ASSURE HAEMOLANCE 10 mg, 18 mg, 25 mg, 40 mg Tier 2 QL PLUS LOW atomoxetine hcl oral capsule Tier 1 PA; QL ASSURE HAEMOLANCE 100 mg, 60 mg, 80 mg Tier 2 QL PLUS MICRO atorvastatin calcium oral Tier 1 DO; $0 ASSURE HAEMOLANCE tablet 10 mg, 20 mg Tier 2 QL PLUS NORMAL atorvastatin calcium oral Tier 1 DO ASSURE HAEMOLANCE tablet 40 mg Tier 2 QL PLUS PED atorvastatin calcium oral Tier 1 ASSURE ID INSULIN tablet 80 mg Tier 3 ST; QL SAFETY SYR atovaquone oral suspension Tier 1 ASSURE ID SAFETY PEN Tier 3 ST; QL atovaquone-proguanil hcl NEEDLES Tier 1 oral tablet ASSURE LANCE Tier 2 QL atracurium besylate LANCETS Tier 1 intravenous solution ASSURE LANCE Tier 2 QL LANCETS 21G ATROPEN INTRAMUSCULAR ASSURE LANCE PLUS Tier 3 Tier 2 QL SOLUTION AUTO- SAFETY 25G INJECTOR ASSURE LANCE PLUS atropine sulfate injection Tier 2 QL Tier 1 SAFETY 30G solution prefilled syringe ASSURE LANCE SAFETY Tier 2 QL ATROPINE SULFATE LANCET 28G INTRAVENOUS Tier 3 ASTAGRAF XL ORAL SOLUTION CAPSULE EXTENDED Tier 3 ATROPINE SULFATE RELEASE 24 HOUR INTRAVENOUS Tier 3 ATABEX EC ORAL SOLUTION PREFILLED TABLET DELAYED Tier 3 SYRINGE RELEASE atropine sulfate ophthalmic Tier 1 ATABEX OB ORAL ointment Tier 3 TABLET ATROPINE SULFATE atazanavir sulfate oral OPHTHALMIC Tier 3 Tier 1 QL capsule SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 12 Drug Name Tier Notes Drug Name Tier Notes ATROVENT HFA AUSTEDO ORAL Tier 4 PA; QL; LD; SP INHALATION AEROSOL Tier 2 TABLET SOLUTION AUSTRALIAN PINE AUBAGIO ORAL SUBCUTANEOUS Tier 3 Tier 4 PA; QL; LD; SP TABLET SOLUTION aubra eq oral tablet Tier 1 $0 AUTO-LANCET Tier 2 aubra oral tablet Tier 1 $0 AUTO-LANCET MINI Tier 2 AUGMENTIN ES-600 AUTOLET II CLINISAFE Tier 2 ORAL SUSPENSION Tier 3 KIT RECONSTITUTED AUTOLET LANCING Tier 2 AUGMENTIN ORAL DEVICE SUSPENSION Tier 2 AUTOLET LITE RECONSTITUTED 125- Tier 2 31.25 MG/5ML CLINISAFE KIT AUTOLET LITE AUGMENTIN ORAL Tier 2 SUSPENSION STARTER PACK KIT Tier 3 RECONSTITUTED 250- AUTOLET MINI Tier 2 62.5 MG/5ML AUTOLET PLATFORMS Tier 2 AUGMENTIN ORAL Tier 3 TABLET AUTOLET PLUS Tier 2 AUREOBASIDIUM AVANDIA ORAL Tier 3 ST; QL PULLULANS INJECTION Tier 3 TABLET SOLUTION AVASTIN AUREOBASIDIUM INTRAVENOUS Tier 3 PA; QL; LD; SP SUBCUTANEOUS Tier 3 SOLUTION SOLUTION aviane oral tablet Tier 1 $0 AURORA LANCET Tier 2 QL avita external cream Tier 1 PA; QL SUPER THIN 30G avita external gel Tier 1 PA; QL AURORA LANCET THIN Tier 2 QL 23G AVITENE EXTERNAL Tier 3 AURORA PEN NEEDLES Tier 3 ST; QL PAD AVITENE FLOUR AURORA UNIFINE Tier 3 Tier 3 ST; QL PENTIPS EXTERNAL POWDER aurovela 1.5/30 oral tablet Tier 1 $0 AVONEX PEN INTRAMUSCULAR Tier 4 PA; QL; SP aurovela 1/20 oral tablet Tier 1 $0 AUTO-INJECTOR KIT aurovela 24 fe oral tablet Tier 1 $0 AVONEX PREFILLED INTRAMUSCULAR aurovela fe 1.5/30 oral tablet Tier 1 $0 Tier 4 PA; QL; SP PREFILLED SYRINGE aurovela fe 1/20 oral tablet Tier 1 $0 KIT AURYXIA ORAL Tier 3 ST; QL TABLET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 13 Drug Name Tier Notes Drug Name Tier Notes AVYCAZ AZILECT ORAL Tier 3 INTRAVENOUS TABLET Tier 3 SOLUTION azithromycin intravenous Tier 1 RECONSTITUTED solution reconstituted AYGESTIN ORAL Tier 3 azithromycin oral packet Tier 1 QL TABLET azithromycin oral suspension Tier 1 QL ayuna oral tablet Tier 1 $0 reconstituted AYVAKIT ORAL Tier 3 PA; QL; LD azithromycin oral tablet Tier 1 QL TABLET AZOPT OPHTHALMIC azacitidine injection Tier 2 Tier 1 PA; QL; SP SUSPENSION suspension reconstituted aztreonam injection solution Tier 1 AZACTAM INJECTION reconstituted SOLUTION Tier 3 RECONSTITUTED AZULFIDINE EN-TABS ORAL TABLET Tier 3 AZASAN ORAL TABLET Tier 3 DELAYED RELEASE AZASITE OPHTHALMIC AZULFIDINE ORAL Tier 3 Tier 3 SOLUTION TABLET azathioprine oral tablet Tier 1 azurette oral tablet Tier 1 $0 AZATHIOPRINE b complex 100 tr oral tablet Tier 1 $0 SODIUM INJECTION extended release Tier 3 SOLUTION b complex formula 1 oral Tier 1 $0 RECONSTITUTED tablet AZEDRA DOSIMETRIC b complex oral tablet Tier 1 $0 INTRAVENOUS Tier 4 PA; QL; LD SOLUTION b complex plus oral tablet Tier 1 $0 AZEDRA THERAPEUTIC b complex-b12 oral tablet Tier 1 $0 INTRAVENOUS Tier 4 PA; QL; LD b complex-biotin-fa oral Tier 1 $0 SOLUTION tablet azelaic acid external gel Tier 1 b complex-c oral tablet Tier 1 $0 B COMPLEX-C-BIOTIN- azelastine hcl nasal solution Tier 1 Tier 2 $0 E-FA ORAL TABLET azelastine hcl ophthalmic Tier 1 b complex-c-folic acid oral solution Tier 1 $0 tablet azelastine-fluticasone nasal Tier 1 suspension b-100 b-complex oral tablet Tier 1 $0 b-100 complex cr oral tablet AZESCHEW Tier 1 $0 PRENATAL/POSTNATAL extended release Tier 3 ST; QL ORAL TABLET b-100 complex oral tablet Tier 1 $0 CHEWABLE b-100 cr oral tablet extended Tier 1 $0 AZESCO ORAL TABLET Tier 3 ST; QL release b-100 oral tablet Tier 1 $0

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 14 Drug Name Tier Notes Drug Name Tier Notes b-100 tr oral tablet extended balanced salt intraocular Tier 1 $0 Tier 1 release solution b-50 complex oral tablet BALCOLTRA ORAL Tier 1 $0 Tier 3 extended release TABLET b-50 oral tablet Tier 1 $0 BALD CYPRESS SUBCUTANEOUS Tier 3 bac oral tablet Tier 1 SOLUTION bacitracin intramuscular balsalazide disodium oral Tier 1 Tier 1 solution reconstituted capsule bacitracin ophthalmic BALVERSA ORAL Tier 1 Tier 3 PA; QL; LD ointment TABLET bacitracin-polymyxin b Tier 1 balziva oral tablet Tier 1 $0 ophthalmic ointment BANZEL ORAL Tier 3 bacitra-neomycin- SUSPENSION polymyxin-hc ophthalmic Tier 1 ointment BANZEL ORAL TABLET Tier 3 BAQSIMI ONE PACK baclofen intrathecal solution Tier 4 Tier 3 NASAL POWDER baclofen oral tablet Tier 1 BAQSIMI TWO PACK BACTRIM DS ORAL Tier 3 Tier 3 NASAL POWDER TABLET BARACLUDE ORAL BACTRIM ORAL Tier 4 Tier 3 SOLUTION TABLET BARHEMSYS BAHIA SUBCUTANEOUS Tier 3 INTRAVENOUS Tier 3 SOLUTION SOLUTION BAL IN OIL BAVENCIO INTRAMUSCULAR Tier 3 INTRAVENOUS Tier 3 PA; QL; LD SOLUTION SOLUTION balance b-100 oral tablet Tier 1 $0 BAXDELA INTRAVENOUS balance b-50 oral tablet Tier 1 $0 Tier 3 SOLUTION balanced b complex oral Tier 1 $0 RECONSTITUTED tablet BAXDELA ORAL balanced b-100 complex cr Tier 3 PA; QL Tier 1 $0 TABLET oral tablet extended release BAYBERRY (WAX balanced b-100 oral tablet Tier 1 $0 MYRTLE) Tier 3 balanced b-100 oral tablet SUBCUTANEOUS Tier 1 $0 extended release SOLUTION balanced b-50 complex oral bayer advanced aspirin reg st Tier 1 $0 Tier 1 $0 tablet oral tablet balanced b-50/fa oral tablet Tier 1 $0 bayer aspirin ec low dose Tier 1 $0 oral tablet delayed release

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 15 Drug Name Tier Notes Drug Name Tier Notes bayer aspirin oral tablet Tier 1 $0 BD INSULIN SYRINGE bayer aspirin oral tablet MICROFINE 28G X 1/2" Tier 2 ST; QL Tier 1 $0 delayed release 0.5 ML, 28G X 1/2" 1 ML bayer low dose oral tablet BD INSULIN SYRINGE Tier 1 $0 Tier 2 ST; QL chewable U/F bayer low dose oral tablet BD INSULIN SYRINGE Tier 1 $0 Tier 2 ST; QL delayed release U/F 1/2UNIT BD INSULIN SYRINGE BCG VACCINE Tier 2 INJECTION Tier 3 $0 U-500 INJECTABLE BD INSULIN SYRINGE Tier 2 ST; QL b-compleet-100 oral tablet Tier 1 $0 ULTRAFINE BD LANCET b-compleet-50 oral tablet Tier 1 $0 Tier 2 QL ULTRAFINE 30G b-complex balanced oral Tier 1 $0 BD LANCET tablet Tier 2 QL ULTRAFINE 33G B-COMPLEX BD MICROTAINER INJECTION Tier 3 Tier 2 QL INJECTABLE LANCETS BD PEN NEEDLE MICRO b-complex oral tablet Tier 1 $0 Tier 2 ST; QL U/F b-complex/b-12 oral tablet Tier 1 $0 BD PEN NEEDLE MINI b-complex/vitamin c oral Tier 2 ST; QL Tier 1 $0 U/F tablet BD PEN NEEDLE NANO Tier 2 ST; QL b-complex-c oral tablet Tier 1 $0 2ND GEN BD AUTOSHIELD Tier 2 ST; QL BD PEN NEEDLE NANO Tier 2 ST; QL BD AUTOSHIELD DUO Tier 2 ST; QL U/F BD INSULIN SYR BD PEN NEEDLE Tier 2 ST; QL Tier 2 ST; QL ULTRAFINE II ORIGINAL U/F BD PEN NEEDLE SHORT BD INSULIN SYRINGE Tier 2 ST; QL 25G X 1" 1 ML, 25G X U/F Tier 2 5/8" 1 ML, 26G X 1/2" 1 BD SAFETYGLIDE ML, 27.5G X 5/8" 2 ML INSULIN SYRINGE 29G BD INSULIN SYRINGE X 1/2" 0.3 ML, 29G X 1/2" 27G X 1/2" 1 ML, 29G X 0.5 ML, 30G X 5/16" 0.5 Tier 2 ST; QL 1/2" 0.3 ML, 29G X 1/2" Tier 2 ST; QL ML, 31G X 15/64" 0.3 ML, 0.5 ML, 29G X 1/2" 1 ML, 31G X 15/64" 0.5 ML, 31G U-100 1 ML X 5/16" 0.3 ML BD INSULIN SYRINGE BD SAFETYGLIDE Tier 2 HALF-UNIT INSULIN SYRINGE 31G Tier 2 X 15/64" 1 ML BD INSULIN SYRINGE BD SAFETY-LOK MICROFINE 27G X 5/8" 1 Tier 2 Tier 2 ST; QL ML INSULIN SYRINGE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 16 Drug Name Tier Notes Drug Name Tier Notes BD VEO INSULIN SYR BENLYSTA Tier 2 ST; QL U/F 1/2UNIT SUBCUTANEOUS Tier 4 PA; QL; LD; SP BD VEO INSULIN SOLUTION PREFILLED SYRINGE U/F 31G X SYRINGE Tier 2 ST; QL 15/64" 0.3 ML, 31G X BENTYL 15/64" 0.5 ML INTRAMUSCULAR Tier 3 BD VEO INSULIN SOLUTION SYRINGE U/F 31G X Tier 2 BENZALKONIUM 15/64" 1 ML CHLORIDE EXTERNAL Tier 3 bekyree oral tablet Tier 1 $0 SOLUTION BELBUCA BUCCAL BENZAMYCIN Tier 3 PA; QL Tier 3 ST; QL FILM EXTERNAL GEL BELEODAQ BENZHYDROCODONE- INTRAVENOUS ACETAMINOPHEN Tier 3 QL Tier 3 PA; QL; LD; SP SOLUTION ORAL TABLET RECONSTITUTED BENZNIDAZOLE ORAL Tier 3 BELRAPZO TABLET INTRAVENOUS Tier 3 PA; QL; LD; SP benzonatate oral capsule Tier 1 SOLUTION benzoyl peroxide- BELSOMRA ORAL Tier 1 Tier 3 ST; QL erythromycin external gel TABLET benzphetamine hcl oral tablet Tier 1 benazepril hcl oral tablet Tier 1 T1S 25 mg benazepril- benzphetamine hcl oral tablet Tier 1 PA; QL hydrochlorothiazide oral Tier 1 DO 50 mg tablet 10-12.5 mg, 5-6.25 mg benztropine mesylate Tier 1 benazepril- injection solution hydrochlorothiazide oral Tier 1 benztropine mesylate oral tablet 20-12.5 mg, 20-25 mg Tier 1 tablet BENDEKA BEOVU INTRAVITREAL INTRAVENOUS Tier 3 PA; QL; LD; SP Tier 4 PA; QL; LD; SP SOLUTION SOLUTION BENEFIX BERINERT Tier 4 PA; QL; LD; SP Tier 4 PA; QL; LD; SP INTRAVENOUS KIT INTRAVENOUS KIT BERMUDA GRASS BENLYSTA Tier 3 INTRAVENOUS INJECTION SOLUTION Tier 4 PA; QL; LD; SP SOLUTION BERMUDA GRASS RECONSTITUTED SUBCUTANEOUS Tier 3 BENLYSTA SOLUTION SUBCUTANEOUS Tier 4 PA; QL; LD; SP beser external lotion Tier 1 SOLUTION AUTO- INJECTOR BESIVANCE OPHTHALMIC Tier 3 SUSPENSION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 17 Drug Name Tier Notes Drug Name Tier Notes BESPONSA BETIMOL INTRAVENOUS OPHTHALMIC Tier 3 Tier 3 PA; QL; LD; SP SOLUTION SOLUTION RECONSTITUTED BETOPTIC-S BETADINE OPHTHALMIC Tier 2 OPHTHALMIC PREP SUSPENSION Tier 3 OPHTHALMIC better b complex oral tablet Tier 1 $0 SOLUTION BEVACIZUMAB betamethasone dipropionate INTRAOCULAR Tier 1 Tier 3 PA; QL aug external cream SOLUTION PREFILLED betamethasone dipropionate SYRINGE Tier 1 aug external gel bexarotene oral capsule Tier 1 PA; QL; SP betamethasone dipropionate Tier 1 BEXSERO aug external lotion INTRAMUSCULAR Tier 3 $0 betamethasone dipropionate SUSPENSION Tier 1 aug external ointment PREFILLED SYRINGE betamethasone dipropionate Tier 1 BEYAZ ORAL TABLET Tier 3 external cream bicalutamide oral tablet Tier 1 betamethasone dipropionate Tier 1 external lotion BICILLIN C-R 900/300 INTRAMUSCULAR Tier 3 betamethasone dipropionate Tier 1 SUSPENSION external ointment BICILLIN C-R betamethasone valerate Tier 1 INTRAMUSCULAR Tier 3 external cream SUSPENSION betamethasone valerate Tier 3 ST; QL BICILLIN L-A external foam INTRAMUSCULAR Tier 3 betamethasone valerate SUSPENSION Tier 1 ST; QL external lotion BICNU INTRAVENOUS betamethasone valerate SOLUTION Tier 3 SP Tier 1 external ointment RECONSTITUTED BETASERON Tier 4 PA; QL; SP BIDIL ORAL TABLET Tier 2 SUBCUTANEOUS KIT big 100 (biotin) oral tablet Tier 1 $0 betaxolol hcl ophthalmic Tier 1 solution big 100 oral tablet Tier 1 $0 betaxolol hcl oral tablet Tier 1 BIJUVA ORAL CAPSULE Tier 2 bethanechol chloride oral BIKTARVY ORAL Tier 1 Tier 2 QL tablet TABLET BILTRICIDE ORAL BETHKIS INHALATION Tier 3 NEBULIZATION Tier 4 LD; SP TABLET SOLUTION bimatoprost external solution Tier 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 18 Drug Name Tier Notes Drug Name Tier Notes bimatoprost ophthalmic bleomycin sulfate injection Tier 1 Tier 1 SP solution solution reconstituted BINOSTO ORAL BLEPH-10 TABLET Tier 3 OPHTHALMIC Tier 3 EFFERVESCENT SOLUTION BIOLON INTRAOCULAR BLEPHAMIDE Tier 4 LD SOLUTION OPHTHALMIC Tier 3 BIORPHEN SUSPENSION INTRAVENOUS Tier 3 BLEPHAMIDE S.O.P. SOLUTION OPHTHALMIC Tier 3 BIO-STATIN ORAL OINTMENT Tier 3 CAPSULE BLINCYTO INTRAVENOUS BIOTHRAX Tier 3 PA; QL; LD; SP INTRAMUSCULAR Tier 3 SOLUTION SUSPENSION RECONSTITUTED BIOVANCE EXTERNAL blisovi 24 fe oral tablet Tier 1 $0 Tier 3 SHEET blisovi fe 1.5/30 oral tablet Tier 1 $0 bisacodyl ec oral tablet blisovi fe 1/20 oral tablet Tier 1 $0 Tier 1 $0 delayed release BLOXIVERZ bisoprolol fumarate oral INTRAVENOUS Tier 3 Tier 1 tablet SOLUTION bisoprolol- BONIVA INTRAVENOUS Tier 4 hydrochlorothiazide oral Tier 1 SOLUTION tablet BONIVA ORAL TABLET Tier 3 ST; QL BIVALIRUDIN RTU BONJESTA ORAL INTRAVENOUS Tier 3 TABLET EXTENDED Tier 3 PA; QL SOLUTION RELEASE BIVALIRUDIN-SODIUM BOOSTRIX CHLORIDE Tier 3 INTRAMUSCULAR Tier 3 $0 INTRAVENOUS SUSPENSION SOLUTION BORIC ACID EXTERNAL Tier 3 BIVIGAM GRANULES INTRAVENOUS Tier 4 PA; QL; LD; SP SOLUTION BORTEZOMIB INTRAVENOUS Tier 3 PA; QL BLACK WILLOW SOLUTION SUBCUTANEOUS Tier 3 RECONSTITUTED SOLUTION bosentan oral tablet Tier 4 PA; QL; LD; SP blanche external cream Tier 1 BOSULIF ORAL TABLET Tier 2 PA; QL; SP BLENREP INTRAVENOUS Tier 3 PA; QL; LD; SP SOLUTION RECONSTITUTED

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 19 Drug Name Tier Notes Drug Name Tier Notes BOTOX COSMETIC BRILINTA ORAL Tier 2 INTRAMUSCULAR TABLET Tier 4 PA; QL SOLUTION brimonidine tartrate Tier 1 RECONSTITUTED ophthalmic solution BOTOX INJECTION BRIVIACT SOLUTION Tier 4 PA; QL; SP INTRAVENOUS Tier 3 RECONSTITUTED SOLUTION BOTRYTIS INJECTION BRIVIACT ORAL Tier 3 Tier 3 SOLUTION SOLUTION BOTRYTIS BRIVIACT ORAL Tier 3 SUBCUTANEOUS Tier 3 TABLET SOLUTION BROME bp wash external liquid Tier 1 SUBCUTANEOUS Tier 3 BRAFTOVI ORAL SOLUTION Tier 3 PA; QL; LD CAPSULE bromfenac sodium (once- Tier 1 BREO ELLIPTA daily) ophthalmic solution INHALATION AEROSOL bromocriptine mesylate oral Tier 2 Tier 1 POWDER BREATH capsule ACTIVATED bromocriptine mesylate oral BRETYLIUM TOSYLATE Tier 1 Tier 3 tablet INJECTION SOLUTION BROMSITE BREVIBLOC IN NACL OPHTHALMIC Tier 3 INTRAVENOUS Tier 3 SOLUTION SOLUTION BRONCHITOL Tier 4 LD; SP BREVIBLOC INHALATION CAPSULE INTRAVENOUS Tier 3 SOLUTION BRONCHITOL TOLERANCE TEST Tier 4 LD; SP BREVIBLOC PREMIXED INHALATION CAPSULE DS INTRAVENOUS Tier 3 SOLUTION BROVANA INHALATION NEBULIZATION Tier 3 BREVIBLOC PREMIXED SOLUTION INTRAVENOUS Tier 3 BRUKINSA ORAL SOLUTION Tier 3 PA; QL; LD CAPSULE BREVITAL SODIUM BSP 0820 INJECTION INJECTION SOLUTION Tier 3 Tier 3 RECONSTITUTED KIT BREZTRI AEROSPHERE BSS INTRAOCULAR Tier 3 Tier 3 INHALATION AEROSOL SOLUTION BRIDION BSS PLUS INTRAVENOUS Tier 3 INTRAOCULAR Tier 3 SOLUTION SOLUTION briellyn oral tablet Tier 1 $0

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 20 Drug Name Tier Notes Drug Name Tier Notes budesonide er oral tablet BUPRENEX INJECTION Tier 1 Tier 3 QL extended release 24 hour SOLUTION budesonide inhalation buprenorphine hcl injection Tier 1 Tier 1 QL suspension solution budesonide oral capsule buprenorphine hcl sublingual Tier 1 Tier 1 QL delayed release particles tablet sublingual budesonide-formoterol buprenorphine hcl-naloxone Tier 1 Tier 1 QL fumarate inhalation aerosol hcl sublingual film bumetanide injection solution Tier 1 buprenorphine hcl-naloxone hcl sublingual tablet Tier 1 QL bumetanide oral tablet Tier 1 T1S sublingual BUMEX ORAL TABLET Tier 3 buprenorphine transdermal Tier 1 PA; QL BUNAVAIL BUCCAL patch weekly Tier 3 QL FILM bupropion hcl er (smoking bupap oral tablet Tier 1 det) oral tablet extended Tier 1 PA; QL; $0 release 12 hour BUPHENYL ORAL Tier 3 PA; QL; LD POWDER bupropion hcl er (sr) oral tablet extended release 12 Tier 1 DO BUPHENYL ORAL Tier 3 PA; QL; LD hour 100 mg TABLET bupropion hcl er (sr) oral BUPIVACAINE tablet extended release 12 Tier 1 FISIOPHARMA Tier 3 hour 150 mg, 200 mg INJECTION SOLUTION bupropion hcl er (xl) oral bupivacaine hcl (pf) injection Tier 1 tablet extended release 24 Tier 1 DO solution hour 150 mg bupivacaine hcl injection Tier 1 bupropion hcl er (xl) oral solution tablet extended release 24 Tier 1 BUPIVACAINE HCL- hour 300 mg, 450 mg NACL EPIDURAL Tier 3 bupropion hcl oral tablet 100 Tier 1 SOLUTION mg BUPIVACAINE HCL- bupropion hcl oral tablet 75 NACL EPIDURAL Tier 1 DO Tier 3 mg SOLUTION PREFILLED SYRINGE buspirone hcl oral tablet Tier 1 bupivacaine in dextrose busulfan intravenous solution Tier 1 SP Tier 1 intrathecal solution BUSULFEX bupivacaine spinal INTRAVENOUS Tier 3 SP Tier 1 intrathecal solution SOLUTION bupivacaine-epinephrine (pf) butalbital-acetaminophen Tier 1 Tier 1 injection solution oral tablet bupivacaine-epinephrine butalbital-apap-caff-cod oral Tier 1 Tier 1 QL injection solution capsule

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 21 Drug Name Tier Notes Drug Name Tier Notes butalbital-apap-caffeine oral caffeine citrate intravenous Tier 1 Tier 1 capsule solution butalbital-apap-caffeine oral Tier 1 caffeine citrate oral solution Tier 1 tablet CALAN SR ORAL butalbital-asa-caff-codeine Tier 1 QL TABLET EXTENDED Tier 3 oral capsule RELEASE butalbital-aspirin-caffeine Tier 1 calcipotriene external cream Tier 1 oral capsule CALCIPOTRIENE butorphanol tartrate injection Tier 3 Tier 1 QL EXTERNAL FOAM solution calcipotriene external butorphanol tartrate nasal Tier 1 Tier 1 QL ointment solution calcipotriene external Tier 1 BUTRANS solution TRANSDERMAL PATCH Tier 3 PA; QL calcipotriene-betameth WEEKLY Tier 1 diprop external ointment BYFAVO INTRAVENOUS calcipotriene-betameth SOLUTION Tier 4 Tier 1 RECONSTITUTED diprop external suspension calcitonin (salmon) nasal BYNFEZIA PEN Tier 1 SUBCUTANEOUS solution Tier 4 PA; QL; SP SOLUTION PEN- calcitrene external ointment Tier 1 INJECTOR calcitriol external ointment Tier 1 BYSTOLIC ORAL Tier 2 TABLET calcitriol intravenous Tier 1 PA; QL CABENUVA solution INTRAMUSCULAR calcitriol oral capsule Tier 1 PA; QL Tier 3 LD SUSPENSION calcitriol oral solution Tier 1 PA; QL EXTENDED RELEASE calcium acetate (phos binder) Tier 1 cabergoline oral tablet Tier 1 oral capsule CABLIVI INJECTION calcium acetate (phos binder) Tier 4 PA; QL; LD Tier 1 KIT oral tablet CABOMETYX ORAL Tier 3 PA; QL; LD; SP calcium acetate oral tablet Tier 1 TABLET CALCIUM DISODIUM CADUET ORAL TABLET VERSENATE Tier 3 10-10 MG, 10-20 MG, 10- Tier 3 INJECTION SOLUTION 40 MG, 10-80 MG, 5-80 MG CALCIUM GLUCONATE-NACL Tier 3 CADUET ORAL TABLET INTRAVENOUS 5-10 MG, 5-20 MG, 5-40 Tier 3 DO SOLUTION MG CAFCIT INTRAVENOUS Tier 3 SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 22 Drug Name Tier Notes Drug Name Tier Notes CALDOLOR CAPRELSA ORAL Tier 2 PA; QL; LD INTRAVENOUS Tier 3 TABLET SOLUTION captopril oral tablet Tier 1 CALIFORNIA PEPPER TREE SUBCUTANEOUS Tier 3 captopril- SOLUTION hydrochlorothiazide oral Tier 1 tablet CALQUENCE ORAL Tier 3 PA; QL; LD CARAC EXTERNAL CAPSULE Tier 3 ST; QL CREAM camila oral tablet Tier 1 $0 CARAFATE ORAL Tier 3 CAMPATH SUSPENSION INTRAVENOUS Tier 3 CARAFATE ORAL SOLUTION Tier 3 TABLET CAMPTOSAR CARBAGLU ORAL INTRAVENOUS Tier 3 SP Tier 4 PA; QL; LD SOLUTION TABLET camrese lo oral tablet Tier 1 $0 carbamazepine er oral capsule extended release 12 Tier 1 camrese oral tablet Tier 1 $0 hour CANASA RECTAL carbamazepine er oral tablet Tier 3 Tier 1 SUPPOSITORY extended release 12 hour CANCIDAS carbamazepine oral INTRAVENOUS Tier 1 Tier 3 suspension SOLUTION RECONSTITUTED carbamazepine oral tablet Tier 1 candesartan cilexetil oral carbamazepine oral tablet Tier 1 Tier 1 tablet chewable candesartan cilexetil-hctz carbidopa oral tablet Tier 1 Tier 1 oral tablet carbidopa-levodopa er oral Tier 1 CANDIDA ALBICANS tablet extended release EXTRACT INJECTION Tier 3 carbidopa-levodopa oral Tier 1 SOLUTION tablet CANDIDA ALBICANS carbidopa-levodopa oral EXTRACT Tier 1 Tier 3 tablet dispersible SUBCUTANEOUS carbidopa-levodopa- SOLUTION Tier 1 entacapone oral tablet CAPASTAT SULFATE carbinoxamine maleate oral INJECTION SOLUTION Tier 3 Tier 1 RECONSTITUTED solution carbinoxamine maleate oral CAPCOF ORAL SYRUP Tier 3 Tier 1 tablet capecitabine oral tablet Tier 1 PA; QL; SP CARBOCAINE CAPLYTA ORAL Tier 3 Tier 3 ST; QL INJECTION SOLUTION CAPSULE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 23 Drug Name Tier Notes Drug Name Tier Notes CARBOCAINE CARETOUCH Tier 2 PRESERVATIVE-FREE Tier 3 LANCING/EJECTOR INJECTION SOLUTION CARETOUCH PEN Tier 3 ST; QL carboplatin intravenous NEEDLES Tier 1 SP solution CARETOUCH SAFETY Tier 2 QL carboprost tromethamine LANCETS Tier 1 intramuscular solution CARETOUCH SAFETY Tier 2 QL CARDENE IV LANCETS 26G INTRAVENOUS Tier 3 CARETOUCH TWIST Tier 2 QL SOLUTION LANCETS 28G CARDIOCOM LANCING CARETOUCH TWIST Tier 2 Tier 2 QL DEVICE LANCETS 30G CARDIZEM LA ORAL CARETOUCH TWIST Tier 2 QL TABLET EXTENDED Tier 3 DO LANCETS 33G RELEASE 24 HOUR CARIMUNE NF CARDIZEM ORAL INTRAVENOUS Tier 3 Tier 4 PA; QL; SP TABLET 120 MG SOLUTION CARDIZEM ORAL RECONSTITUTED Tier 3 DO TABLET 30 MG, 60 MG carisoprodol oral tablet Tier 1 CARDURA ORAL Tier 3 carisoprodol-aspirin-codeine TABLET Tier 1 oral tablet CARDURA XL ORAL carmustine intravenous TABLET EXTENDED Tier 3 Tier 1 SP RELEASE 24 HOUR solution reconstituted CAREFINE PEN CARNITOR Tier 3 ST; QL NEEDLES INTRAVENOUS Tier 3 SOLUTION CAREONE ADVANCED Tier 2 CARNITOR ORAL LANCING DEV Tier 3 SOLUTION CAREONE INSULIN Tier 3 ST; QL CARNITOR ORAL SYRINGE Tier 3 TABLET CAREONE LANCET Tier 2 QL CARNITOR SF ORAL SUPER THIN 30G Tier 3 SOLUTION CAREONE LANCET Tier 2 QL CAROSPIR ORAL THIN 23G Tier 3 SUSPENSION CAREONE UNIFINE Tier 3 ST; QL carteolol hcl ophthalmic PENTIPS Tier 1 solution CAREONE UNIFINE Tier 3 ST; QL PENTIPS PLUS cartia xt oral capsule extended release 24 hour 120 Tier 1 DO CARESENS LANCETS Tier 2 QL mg, 180 mg CARETOUCH INSULIN Tier 3 ST; QL SYRINGE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 24 Drug Name Tier Notes Drug Name Tier Notes cartia xt oral capsule CAVERJECT extended release 24 hour 240 Tier 1 INTRACAVERNOSAL Tier 3 PA; QL mg, 300 mg SOLUTION RECONSTITUTED carvedilol oral tablet Tier 1 CAYA VAGINAL Tier 2 $0 carvedilol phosphate er oral DIAPHRAGM capsule extended release 24 Tier 1 hour CAYSTON INHALATION SOLUTION Tier 4 LD; SP CASCARA SAGRADA Tier 3 RECONSTITUTED ORAL FLUID EXTRACT caziant oral tablet Tier 1 $0 CASODEX ORAL Tier 3 TABLET CEDAR ELM SUBCUTANEOUS Tier 3 CASPOFUNGIN SOLUTION ACETATE INTRAVENOUS Tier 3 CEFACLOR ER ORAL SOLUTION TABLET EXTENDED Tier 3 RECONSTITUTED RELEASE 12 HOUR CAT HAIR EXTRACT cefaclor oral capsule Tier 1 Tier 3 INJECTION SOLUTION cefaclor oral suspension Tier 1 CAT HAIR EXTRACT reconstituted SUBCUTANEOUS Tier 3 cefadroxil oral capsule Tier 1 SOLUTION cefadroxil oral suspension cataflam oral tablet Tier 1 Tier 1 reconstituted CATAPRES-TTS-1 cefadroxil oral tablet Tier 1 TRANSDERMAL PATCH Tier 3 WEEKLY CEFAZOLIN IN SODIUM CHLORIDE CATAPRES-TTS-2 Tier 3 TRANSDERMAL PATCH Tier 3 INTRAVENOUS WEEKLY SOLUTION CATAPRES-TTS-3 cefazolin sodium injection TRANSDERMAL PATCH Tier 3 solution reconstituted 1 gm, Tier 1 WEEKLY 10 gm, 500 mg CATHFLO ACTIVASE CEFAZOLIN SODIUM INJECTION SOLUTION INJECTION SOLUTION Tier 3 Tier 3 RECONSTITUTED RECONSTITUTED 100 GM, 300 GM CATTLE EPITHELIUM SUBCUTANEOUS Tier 3 CEFAZOLIN SODIUM INTRAVENOUS SOLUTION Tier 3 SOLUTION PREFILLED cavarest dental gel Tier 1 SYRINGE CAVERJECT IMPULSE cefazolin sodium intravenous Tier 1 INTRACAVERNOSAL Tier 3 PA; QL solution reconstituted KIT

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 25 Drug Name Tier Notes Drug Name Tier Notes CEFAZOLIN SODIUM- cefoxitin sodium intravenous Tier 1 DEXTROSE solution reconstituted Tier 3 INTRAVENOUS CEFOXITIN SODIUM- SOLUTION DEXTROSE CEFAZOLIN SODIUM- INTRAVENOUS Tier 3 DEXTROSE SOLUTION INTRAVENOUS Tier 3 RECONSTITUTED SOLUTION cefpodoxime proxetil oral Tier 1 RECONSTITUTED suspension reconstituted cefdinir oral capsule Tier 1 cefpodoxime proxetil oral Tier 1 cefdinir oral suspension tablet Tier 1 reconstituted cefprozil oral suspension Tier 1 cefepime hcl injection reconstituted Tier 1 solution reconstituted cefprozil oral tablet Tier 1 CEFEPIME HCL CEFTAZIDIME AND INTRAVENOUS Tier 3 DEXTROSE SOLUTION INTRAVENOUS Tier 3 CEFEPIME HCL SOLUTION INTRAVENOUS RECONSTITUTED Tier 3 SOLUTION ceftazidime injection solution Tier 1 RECONSTITUTED reconstituted CEFEPIME-DEXTROSE ceftriaxone sodium in INTRAVENOUS Tier 1 Tier 3 dextrose intravenous solution SOLUTION RECONSTITUTED ceftriaxone sodium injection solution reconstituted 1 gm, Tier 1 cefixime oral capsule Tier 1 2 gm, 250 mg, 500 mg cefixime oral suspension Tier 1 CEFTRIAXONE SODIUM reconstituted INJECTION SOLUTION Tier 3 CEFOTAN INJECTION RECONSTITUTED 100 SOLUTION Tier 3 GM RECONSTITUTED ceftriaxone sodium cefotaxime sodium injection intravenous solution Tier 1 Tier 1 solution reconstituted reconstituted cefotetan disodium injection CEFTRIAXONE Tier 1 solution reconstituted SODIUM-DEXTROSE INTRAVENOUS Tier 3 CEFOTETAN SOLUTION DISODIUM-DEXTROSE RECONSTITUTED INTRAVENOUS Tier 3 SOLUTION cefuroxime axetil oral tablet Tier 1 RECONSTITUTED cefuroxime sodium injection Tier 1 cefoxitin sodium injection solution reconstituted Tier 1 solution reconstituted

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 26 Drug Name Tier Notes Drug Name Tier Notes cefuroxime sodium CEREZYME intravenous solution Tier 1 INTRAVENOUS Tier 4 PA; QL; LD; SP reconstituted SOLUTION celecoxib oral capsule Tier 1 ST; QL RECONSTITUTED CEROVEL EXTERNAL CELESTONE SOLUSPAN Tier 3 INJECTION Tier 3 LOTION SUSPENSION CERVIDIL VAGINAL Tier 3 CELLCEPT INSERT INTRAVENOUS cetirizine hcl oral solution Tier 1 INTRAVENOUS Tier 3 SP CETRAXAL OTIC SOLUTION Tier 3 RECONSTITUTED SOLUTION CELLCEPT ORAL CETROTIDE Tier 3 Tier 4 PA; QL; SP CAPSULE SUBCUTANEOUS KIT CELLCEPT ORAL cevimeline hcl oral capsule Tier 1 SUSPENSION Tier 3 CHANTIX CONTINUING RECONSTITUTED MONTH PAK ORAL Tier 3 PA; QL; $0 CELLCEPT ORAL TABLET Tier 3 TABLET CHANTIX ORAL Tier 3 PA; QL; $0 CELLUGEL TABLET INTRAOCULAR Tier 3 CHANTIX STARTING SOLUTION MONTH PAK ORAL Tier 3 PA; QL; $0 CELONTIN ORAL TABLET Tier 3 CAPSULE charlotte 24 fe oral tablet Tier 1 $0 CENTANY EXTERNAL chewable Tier 3 OINTMENT chateal eq oral tablet Tier 1 $0 cephalexin oral capsule Tier 1 chateal oral tablet Tier 1 $0 cephalexin oral suspension CHEMET ORAL Tier 1 Tier 3 reconstituted CAPSULE CHENODAL ORAL cephalexin oral tablet Tier 1 Tier 3 PA; QL; LD TABLET CEPROTIN INTRAVENOUS childrens aspirin low strength Tier 4 LD; SP Tier 1 $0 SOLUTION oral tablet chewable RECONSTITUTED childrens aspirin oral tablet Tier 1 $0 CERDELGA ORAL chewable Tier 4 PA; QL; LD; SP CAPSULE chloramphenicol sod CEREBYX INJECTION succinate intravenous Tier 1 Tier 3 SOLUTION solution reconstituted chlordiazepoxide hcl oral Tier 1 capsule

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 27 Drug Name Tier Notes Drug Name Tier Notes chlordiazepoxide- Tier 1 ciclopirox external solution Tier 1 amitriptyline oral tablet ciclopirox olamine external chlordiazepoxide-clidinium Tier 1 Tier 1 cream oral capsule ciclopirox olamine external chlorhexidine gluconate Tier 1 Tier 1 suspension mouth/throat solution cidofovir intravenous chloroprocaine hcl (pf) Tier 1 Tier 1 solution injection solution cilostazol oral tablet Tier 1 chloroquine phosphate oral Tier 1 tablet CILOXAN OPHTHALMIC Tier 3 chlorothiazide sodium OINTMENT intravenous solution Tier 1 reconstituted CILOXAN OPHTHALMIC Tier 3 chlorpromazine hcl injection Tier 1 SOLUTION solution CIMDUO ORAL TABLET Tier 3 QL chlorpromazine hcl oral Tier 1 tablet cimetidine hcl oral solution Tier 1 chlorthalidone oral tablet Tier 1 T1S cimetidine oral tablet Tier 1 chlorzoxazone oral tablet 375 Tier 1 ST; QL cinacalcet hcl oral tablet Tier 4 PA; QL mg, 750 mg CINQAIR chlorzoxazone oral tablet 500 Tier 1 INTRAVENOUS Tier 4 PA; QL; LD; SP mg SOLUTION CHOLBAM ORAL Tier 3 PA; QL; LD CINRYZE CAPSULE INTRAVENOUS Tier 4 PA; QL; LD; SP cholestyramine light oral SOLUTION Tier 1 packet RECONSTITUTED cholestyramine light oral CINVANTI Tier 1 powder INTRAVENOUS Tier 3 PA; QL EMULSION cholestyramine oral packet Tier 1 CIPRO HC OTIC Tier 3 cholestyramine oral powder Tier 1 SUSPENSION CHORIONIC CIPRO ORAL GONADOTROPIN SUSPENSION Tier 3 QL INTRAMUSCULAR Tier 4 PA; QL; SP RECONSTITUTED SOLUTION CIPRO ORAL TABLET Tier 3 QL RECONSTITUTED CIPRODEX OTIC chromic chloride intravenous Tier 3 Tier 1 SUSPENSION solution ciprofloxacin hcl ophthalmic Tier 1 ciclopirox external gel Tier 1 solution ciclopirox external shampoo Tier 1 ciprofloxacin hcl oral tablet Tier 1 QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 28 Drug Name Tier Notes Drug Name Tier Notes ciprofloxacin hcl otic CITRANATAL ESSENCE Tier 1 Tier 3 ST; QL solution ORAL THERAPY PACK ciprofloxacin in d5w CITRANATAL Tier 1 intravenous solution HARMONY ORAL Tier 3 ST; QL ciprofloxacin-dexamethasone CAPSULE Tier 1 otic suspension CITRANATAL MEDLEY Tier 3 ST; QL ciprofloxacin-fluocinolone pf ORAL CAPSULE Tier 1 otic solution CITRANATAL RX ORAL Tier 3 ST; QL cisatracurium besylate (pf) TABLET Tier 1 intravenous solution citrate of magnesia oral Tier 1 $0 cisatracurium besylate solution Tier 1 intravenous solution citroma oral solution Tier 1 $0 cisplatin intravenous solution Tier 1 SP CLADOSPORIUM CISPLATIN CLADOSPORIOIDES Tier 3 INTRAVENOUS INJECTION SOLUTION Tier 3 SOLUTION CLADOSPORIUM RECONSTITUTED CLADOSPORIOIDES Tier 3 citalopram hydrobromide INTRADERMAL Tier 1 oral solution SOLUTION citalopram hydrobromide CLADOSPORIUM Tier 1 DO CLADOSPORIOIDES oral tablet 10 mg, 20 mg Tier 3 SUBCUTANEOUS citalopram hydrobromide Tier 1 SOLUTION oral tablet 40 mg CLADOSPORIUM CITANEST FORTE SPHAEROSPERMUM Tier 3 DENTAL INJECTION Tier 3 SUBCUTANEOUS SOLUTION SOLUTION CITANEST PLAIN cladribine intravenous Tier 1 SP DENTAL INJECTION Tier 3 solution SOLUTION claravis oral capsule Tier 2 PA; QL CITRANATAL 90 DHA Tier 3 ST; QL CLARINEX ORAL ORAL Tier 3 ST; QL TABLET CITRANATAL ASSURE Tier 3 ST; QL ORAL CLARINEX-D 12 HOUR ORAL TABLET CITRANATAL B-CALM Tier 3 ST; QL Tier 3 EXTENDED RELEASE 12 ORAL HOUR CITRANATAL BLOOM clarithromycin er oral tablet Tier 3 ST; QL Tier 1 DHA ORAL extended release 24 hour CITRANATAL BLOOM clarithromycin oral Tier 3 ST; QL Tier 1 ORAL TABLET suspension reconstituted CITRANATAL DHA Tier 3 ST; QL clarithromycin oral tablet Tier 1 ORAL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 29 Drug Name Tier Notes Drug Name Tier Notes CLASSIC PRENATAL CLIMARA Tier 2 $0 ORAL TABLET TRANSDERMAL PATCH Tier 3 CLEANLET LANCETS WEEKLY Tier 2 QL 28G clindacin etz external swab Tier 1 clearlax oral powder Tier 1 $0 clindacin-p external swab Tier 1 clemastine fumarate oral Tier 1 clindamycin hcl oral capsule Tier 1 tablet CLENPIQ ORAL clindamycin palmitate hcl Tier 3 Tier 1 SOLUTION oral solution reconstituted CLEOCIN ORAL clindamycin phos-benzoyl Tier 3 Tier 1 CAPSULE perox external gel clindamycin phosphate CLEOCIN ORAL Tier 1 SOLUTION Tier 3 external foam RECONSTITUTED clindamycin phosphate Tier 1 CLEOCIN PHOSPHATE external gel Tier 3 INJECTION SOLUTION clindamycin phosphate Tier 1 CLEOCIN VAGINAL external lotion Tier 3 CREAM clindamycin phosphate Tier 1 CLEOCIN VAGINAL external solution Tier 2 SUPPOSITORY clindamycin phosphate Tier 1 CLEOCIN-T EXTERNAL external swab Tier 3 ST; QL LOTION clindamycin phosphate in Tier 1 CLEVER CHEK d5w intravenous solution Tier 2 QL LANCETS CLINDAMYCIN CLEVER CHOICE PHOSPHATE IN NACL Tier 3 ST; QL Tier 3 COMFORT EZ INTRAVENOUS SOLUTION CLEVER CHOICE Tier 2 QL clindamycin phosphate LANCETS 21G Tier 1 injection solution CLEVER CHOICE Tier 2 QL clindamycin phosphate LANCETS 23G Tier 1 vaginal cream CLEVER CHOICE Tier 2 QL clindamycin-tretinoin LANCETS 28G Tier 1 external gel CLEVIPREX CLINDESSE VAGINAL INTRAVENOUS Tier 3 Tier 3 EMULSION CREAM CLICKFINE PEN CLINIMIX E/DEXTROSE Tier 3 ST; QL NEEDLES (2.75/5) INTRAVENOUS Tier 3 SOLUTION CLIMARA PRO TRANSDERMAL PATCH Tier 2 CLINIMIX E/DEXTROSE WEEKLY (4.25/10) INTRAVENOUS Tier 3 SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 30 Drug Name Tier Notes Drug Name Tier Notes CLINIMIX E/DEXTROSE clobazam oral suspension Tier 1 (4.25/5) INTRAVENOUS Tier 3 SOLUTION clobazam oral tablet Tier 1 clobetasol prop emollient CLINIMIX E/DEXTROSE Tier 1 (5/15) INTRAVENOUS Tier 3 base external cream SOLUTION clobetasol propionate e Tier 1 CLINIMIX E/DEXTROSE external cream (5/20) INTRAVENOUS Tier 3 clobetasol propionate Tier 1 SOLUTION emulsion external foam CLINIMIX E/DEXTROSE clobetasol propionate Tier 1 (8/10) INTRAVENOUS Tier 3 external cream SOLUTION clobetasol propionate Tier 1 CLINIMIX E/DEXTROSE external foam (8/14) INTRAVENOUS Tier 3 clobetasol propionate SOLUTION Tier 1 external gel CLINIMIX/DEXTROSE clobetasol propionate (4.25/10) INTRAVENOUS Tier 3 Tier 1 external liquid SOLUTION clobetasol propionate CLINIMIX/DEXTROSE Tier 1 external lotion (4.25/5) INTRAVENOUS Tier 3 SOLUTION clobetasol propionate Tier 1 CLINIMIX/DEXTROSE external ointment (5/15) INTRAVENOUS Tier 3 clobetasol propionate Tier 1 SOLUTION external shampoo CLINIMIX/DEXTROSE clobetasol propionate Tier 1 (5/20) INTRAVENOUS Tier 3 external solution SOLUTION clocortolone pivalate external Tier 3 ST; QL CLINIMIX/DEXTROSE cream (6/5) INTRAVENOUS Tier 3 clodan external shampoo Tier 1 SOLUTION clofarabine intravenous CLINIMIX/DEXTROSE Tier 1 SP solution (8/10) INTRAVENOUS Tier 3 SOLUTION CLOLAR INTRAVENOUS Tier 3 SP CLINIMIX/DEXTROSE SOLUTION (8/14) INTRAVENOUS Tier 3 SOLUTION clomiphene citrate oral tablet Tier 1 PA; QL clinisol sf intravenous clomipramine hcl oral Tier 1 Tier 1 solution capsule CLINOLIPID clonazepam oral tablet Tier 1 INTRAVENOUS Tier 3 clonazepam oral tablet EMULSION Tier 1 dispersible clinpro 5000 dental paste Tier 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 31 Drug Name Tier Notes Drug Name Tier Notes clonidine hcl (analgesia) Tier 1 coal tar external solution Tier 1 epidural solution COARTEM ORAL clonidine hcl er oral tablet Tier 3 Tier 1 PA; QL TABLET extended release 12 hour COCKLEBUR clonidine hcl oral tablet Tier 1 SUBCUTANEOUS Tier 3 clonidine transdermal patch SOLUTION Tier 1 weekly COD LIVER OIL ORAL Tier 3 clopidogrel bisulfate oral OIL Tier 1 tablet CODEINE SULFATE clorazepate dipotassium oral ORAL TABLET 15 MG, Tier 3 QL Tier 1 tablet 60 MG codeine sulfate oral tablet 30 CLOROTEKAL Tier 1 QL INTRATHECAL Tier 3 mg SOLUTION CODITUSSIN AC ORAL Tier 3 LIQUID clotrimazole external cream Tier 1 CODITUSSIN DAC ORAL clotrimazole external Tier 3 Tier 1 LIQUID solution COGENTIN INJECTION clotrimazole mouth/throat Tier 3 Tier 1 SOLUTION troche colchicine oral tablet Tier 2 clotrimazole-betamethasone Tier 1 external cream colchicine-probenecid oral Tier 1 clotrimazole-betamethasone tablet Tier 1 external lotion colesevelam hcl oral packet Tier 1 clovique oral capsule Tier 1 PA; QL; SP colesevelam hcl oral tablet Tier 1 clozapine oral tablet 100 mg, COLESTID FLAVORED Tier 1 Tier 3 200 mg ORAL GRANULES clozapine oral tablet 25 mg, COLESTID FLAVORED Tier 1 DO Tier 3 50 mg ORAL PACKET clozapine oral tablet COLESTID ORAL Tier 3 dispersible 100 mg, 150 mg, Tier 1 GRANULES 200 mg COLESTID ORAL clozapine oral tablet Tier 3 Tier 1 DO PACKET dispersible 12.5 mg, 25 mg COLESTID ORAL C-NATE DHA ORAL Tier 3 Tier 3 TABLET CAPSULE colestipol hcl oral granules Tier 1 COAGADEX INTRAVENOUS Tier 4 PA; QL; LD; SP colestipol hcl oral packet Tier 1 SOLUTION RECONSTITUTED colestipol hcl oral tablet Tier 1 COAGUCHEK LANCETS Tier 2 QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 32 Drug Name Tier Notes Drug Name Tier Notes colistimethate sodium (cba) COMPLERA ORAL Tier 3 PA; QL injection solution Tier 1 TABLET reconstituted complex b-100 oral tablet Tier 1 $0 COLY-MYCIN M extended release INJECTION SOLUTION Tier 3 complex b-100-inositol oral Tier 1 $0 RECONSTITUTED tablet extended release COMBIGAN complex b-50 prolonged OPHTHALMIC Tier 2 release oral tablet extended Tier 1 $0 SOLUTION release COMBIPATCH compro rectal suppository Tier 1 TRANSDERMAL PATCH Tier 2 TWICE WEEKLY COMTAN ORAL Tier 3 COMBIVENT RESPIMAT TABLET INHALATION AEROSOL Tier 2 CO-NATAL FA ORAL Tier 3 SOLUTION TABLET COMBIVIR ORAL CONCEPT DHA ORAL Tier 3 QL Tier 3 TABLET CAPSULE COMETRIQ (100 MG CONCEPT OB ORAL Tier 3 PA; QL; LD; SP Tier 3 DAILY DOSE) ORAL KIT CAPSULE COMETRIQ (140 MG CONDYLOX EXTERNAL Tier 3 PA; QL; LD; SP Tier 3 DAILY DOSE) ORAL KIT GEL COMETRIQ (60 MG CONJUPRI ORAL Tier 3 PA; QL; LD; SP Tier 3 ST; DO; QL DAILY DOSE) ORAL KIT TABLET 2.5 MG COMFORT ASSIST CONJUPRI ORAL Tier 3 ST; QL Tier 3 ST; QL INSULIN SYRINGE TABLET 5 MG COMFORT ASSURED Tier 2 QL constulose oral solution Tier 1 LANCETS 28G CONTRAVE ORAL COMFORT ASSURED Tier 2 QL TABLET EXTENDED Tier 3 PA; QL LANCETS 33G RELEASE 12 HOUR COMFORT EZ INSULIN Tier 3 ST; QL CONZIP ORAL SYRINGE CAPSULE EXTENDED Tier 3 PA; QL COMFORT EZ MICRO RELEASE 24 HOUR Tier 3 ST; QL PEN NEEDLES COPAXONE COMFORT EZ PEN SUBCUTANEOUS Tier 3 ST; QL Tier 4 PA; QL; LD; SP NEEDLES SOLUTION PREFILLED SYRINGE COMFORT EZ SHORT Tier 3 ST; QL COPIKTRA ORAL PEN NEEDLES Tier 3 PA; QL; LD CAPSULE COMFORT LANCETS Tier 2 QL coremino oral tablet COMFORT TOUCH Tier 1 ST; QL Tier 3 ST; QL extended release 24 hour INSULIN PEN NEED CORIFACT Tier 4 PA; QL; LD; SP INTRAVENOUS KIT

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 33 Drug Name Tier Notes Drug Name Tier Notes CORLANOR ORAL COSENTYX Tier 3 PA; QL SOLUTION SENSOREADY PEN CORLANOR ORAL SUBCUTANEOUS Tier 4 PA; QL; LD; SP Tier 2 PA; QL TABLET SOLUTION AUTO- INJECTOR CORLOPAM INTRAVENOUS Tier 3 COSENTYX SUBCUTANEOUS SOLUTION Tier 4 PA; QL; LD; SP SOLUTION PREFILLED CORN POLLEN SYRINGE SUBCUTANEOUS Tier 3 SOLUTION COSMEGEN INTRAVENOUS correctol oral tablet delayed Tier 3 SP Tier 1 $0 SOLUTION release RECONSTITUTED CORTEF ORAL TABLET Tier 3 COTELLIC ORAL Tier 3 PA; QL; LD; SP CORTENEMA RECTAL TABLET Tier 3 ENEMA COTEMPLA XR-ODT CORTIFOAM ORAL TABLET Tier 3 Tier 3 PA; QL EXTERNAL FOAM EXTENDED RELEASE DISPERSIBLE CORTISPORIN Tier 3 EXTERNAL CREAM CREON ORAL CAPSULE DELAYED RELEASE Tier 2 CORTISPORIN Tier 3 PARTICLES EXTERNAL OINTMENT CRESEMBA CORTISPORIN-TC OTIC INTRAVENOUS Tier 3 Tier 3 PA; QL SUSPENSION SOLUTION CORVERT RECONSTITUTED INTRAVENOUS Tier 3 CRESEMBA ORAL Tier 3 PA; QL SOLUTION CAPSULE COSELA INTRAVENOUS CRINONE VAGINAL Tier 4 SP SOLUTION Tier 3 LD GEL 4 % RECONSTITUTED CRINONE VAGINAL Tier 4 PA; QL; SP COSENTYX (300 MG GEL 8 % DOSE) SUBCUTANEOUS Tier 4 PA; QL; LD; SP CRIXIVAN ORAL SOLUTION PREFILLED Tier 2 QL SYRINGE CAPSULE COSENTYX CROFAB INTRAVENOUS SENSOREADY (300 MG) SOLUTION Tier 3 SUBCUTANEOUS Tier 4 PA; QL; LD; SP RECONSTITUTED SOLUTION AUTO- cromolyn sodium inhalation Tier 1 INJECTOR nebulization solution cromolyn sodium ophthalmic Tier 1 solution cromolyn sodium oral Tier 1 concentrate

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 34 Drug Name Tier Notes Drug Name Tier Notes crotan external lotion Tier 1 cvs aspirin oral tablet Tier 1 $0 cvs b complex plus c oral cryselle-28 oral tablet Tier 1 $0 Tier 1 $0 tablet CRYSVITA SUBCUTANEOUS Tier 4 PA; QL; LD; SP cvs balanced b50 oral tablet Tier 1 $0 SOLUTION cvs bisacodyl oral tablet Tier 1 $0 CUBICIN delayed release INTRAVENOUS cvs citrate of magnesia oral Tier 3 Tier 1 $0 SOLUTION solution RECONSTITUTED cvs c-lax laxative oral tablet Tier 1 $0 CUBICIN RF delayed release INTRAVENOUS Tier 3 SOLUTION cvs folic acid oral tablet Tier 1 $0 RECONSTITUTED cvs gentle laxative oral tablet Tier 1 $0 cupric chloride intravenous delayed release Tier 1 solution cvs gentle laxative womens Tier 1 $0 curity sterile saline irrigation oral tablet delayed release Tier 1 solution cvs inner ear plus oral tablet Tier 1 $0 CUROSURF CVS LANCETS 21G Tier 2 QL INTRATRACHEAL Tier 3 CVS LANCETS MICRO Tier 2 QL SUSPENSION THIN 33G CURVULARIA CVS LANCETS Tier 2 QL SUBCUTANEOUS Tier 3 ORIGINAL SOLUTION CVS LANCETS THIN 26G Tier 2 QL CUTAQUIG CVS LANCETS ULTRA SUBCUTANEOUS Tier 4 PA; QL; LD Tier 2 QL SOLUTION THIN 30G CVS LANCETS ULTRA- CUVITRU Tier 2 QL SUBCUTANEOUS Tier 4 PA; QL; LD; SP THIN 30G SOLUTION CVS LANCING DEVICE Tier 2 CUVPOSA ORAL cvs magnesium citrate oral Tier 3 Tier 1 $0 SOLUTION solution cvs aspirin adult low dose cvs milk of magnesia oral Tier 1 $0 Tier 1 $0 oral tablet chewable suspension cvs aspirin adult low strength cvs nicotine mouth/throat Tier 1 $0 Tier 1 $0 oral tablet delayed release gum cvs aspirin ec oral tablet cvs nicotine mouth/throat Tier 1 $0 Tier 1 $0 delayed release lozenge cvs aspirin low dose oral cvs nicotine polacrilex Tier 1 $0 Tier 1 $0 tablet delayed release mouth/throat gum cvs aspirin low strength oral cvs nicotine polacrilex Tier 1 $0 Tier 1 $0 tablet delayed release mouth/throat lozenge

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 35 Drug Name Tier Notes Drug Name Tier Notes cvs nicotine transdermal Tier 1 $0 cycloserine oral capsule Tier 1 patch 24 hour CYCLOSET ORAL CVS PRENATAL ORAL Tier 3 Tier 2 $0 TABLET TABLET cyclosporine intravenous Tier 1 SP cvs purelax oral packet Tier 1 $0 solution cvs purelax oral powder Tier 1 $0 cyclosporine modified oral Tier 1 cvs super b complex/c oral capsule Tier 1 $0 tablet cyclosporine modified oral Tier 1 CVS ULTRA THIN solution Tier 2 QL LANCETS cyclosporine oral capsule Tier 1 cyanocobalamin injection Tier 1 CYKLOKAPRON solution 1000 mcg/ml INTRAVENOUS Tier 3 CYANOCOBALAMIN SOLUTION INJECTION SOLUTION Tier 3 cyproheptadine hcl oral Tier 1 2000 MCG/ML syrup CYANOKIT cyproheptadine hcl oral INTRAVENOUS Tier 1 Tier 3 tablet SOLUTION RECONSTITUTED CYRAMZA INTRAVENOUS Tier 3 PA; QL; LD; SP cyclafem 1/35 oral tablet Tier 1 $0 SOLUTION cyclafem 7/7/7 oral tablet Tier 1 $0 cyred eq oral tablet Tier 1 $0 cyclobenzaprine hcl oral Tier 1 cyred oral tablet Tier 1 $0 tablet CYSTADANE ORAL Tier 3 LD CYCLOGYL POWDER OPHTHALMIC Tier 3 SOLUTION CYSTADROPS OPHTHALMIC Tier 4 PA; QL; LD CYCLOMYDRIL SOLUTION OPHTHALMIC Tier 3 CYSTAGON ORAL SOLUTION Tier 4 LD; SP CAPSULE CYCLOPAK COMBINATION Tier 3 CYSTARAN THERAPY PACK OPHTHALMIC Tier 3 PA; QL; LD SOLUTION cyclopentolate hcl Tier 1 cytarabine (pf) injection ophthalmic solution Tier 1 SP solution cyclophosphamide injection Tier 1 SP solution reconstituted cytarabine injection solution Tier 1 SP CYCLOPHOSPHAMIDE CYTOGAM INTRAVENOUS Tier 3 SP INTRAVENOUS Tier 4 SP SOLUTION INJECTABLE cyclophosphamide oral CYTOMEL ORAL Tier 1 SP Tier 3 capsule TABLET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 36 Drug Name Tier Notes Drug Name Tier Notes CYTOTEC ORAL DANDELION Tier 3 TABLET SUBCUTANEOUS Tier 3 dacarbazine intravenous SOLUTION Tier 1 SP solution reconstituted DANTRIUM INTRAVENOUS DACOGEN Tier 3 INTRAVENOUS SOLUTION Tier 3 SP SOLUTION RECONSTITUTED RECONSTITUTED DANTRIUM ORAL Tier 3 dactinomycin intravenous CAPSULE Tier 1 SP solution reconstituted dantrolene sodium daily multiple vitamins oral intravenous solution Tier 1 Tier 1 $0 tablet reconstituted daily multiple vitamins/iron dantrolene sodium oral Tier 1 $0 Tier 1 oral tablet capsule daily value multivitamin oral DANYELZA Tier 1 $0 tablet INTRAVENOUS Tier 3 PA; QL; LD SOLUTION daily vitamin formula+iron Tier 1 $0 oral tablet dapsone external gel Tier 1 ST; QL daily vitamin oral tablet Tier 1 $0 dapsone oral tablet Tier 1 daily vitamins oral tablet Tier 1 $0 DAPTACEL INTRAMUSCULAR Tier 3 $0 daily vite multivitamin/iron Tier 1 $0 SUSPENSION oral tablet DAPTOMYCIN daily vite oral tablet Tier 1 $0 INTRAVENOUS daily vites oral tablet Tier 1 $0 SOLUTION Tier 3 daily-vitamin oral tablet Tier 1 $0 RECONSTITUTED 350 MG daily-vitamin/iron oral tablet Tier 1 $0 daptomycin intravenous daily-vite multivitamin oral Tier 1 $0 solution reconstituted 500 Tier 1 tablet mg daily-vite oral tablet Tier 1 $0 DARAPRIM ORAL Tier 3 PA; QL; LD dalfampridine er oral tablet TABLET Tier 4 PA; QL; SP extended release 12 hour darifenacin hydrobromide er DALIRESP ORAL oral tablet extended release Tier 1 Tier 3 PA; QL TABLET 24 hour DALVANCE DARZALEX FASPRO INTRAVENOUS SUBCUTANEOUS Tier 3 PA; QL; LD; SP Tier 3 SOLUTION SOLUTION RECONSTITUTED DARZALEX danazol oral capsule Tier 1 INTRAVENOUS Tier 3 PA; QL; LD; SP SOLUTION dasetta 1/35 oral tablet Tier 1 $0

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 37 Drug Name Tier Notes Drug Name Tier Notes dasetta 7/7/7 oral tablet Tier 1 $0 deferoxamine mesylate DAUNORUBICIN HCL injection solution Tier 4 SP INTRAVENOUS Tier 3 SP reconstituted SOLUTION DEFITELIO DAURISMO ORAL INTRAVENOUS Tier 4 Tier 3 PA; QL; LD; SP TABLET SOLUTION DEFLUX INJECTION DAYPRO ORAL TABLET Tier 3 Tier 3 PREFILLED SYRINGE daysee oral tablet Tier 1 $0 DELESTROGEN Tier 3 DAYTRANA INTRAMUSCULAR OIL TRANSDERMAL PATCH Tier 3 PA; DO; QL DELFLEX-LC/1.5% 10 MG/9HR, 15 MG/9HR DEXTROSE Tier 3 DAYTRANA INTRAPERITONEAL TRANSDERMAL PATCH Tier 3 PA; QL SOLUTION 20 MG/9HR, 30 MG/9HR DELFLEX-LC/2.5% DAYVIGO ORAL DEXTROSE Tier 3 ST; QL Tier 3 TABLET INTRAPERITONEAL DDAVP INJECTION SOLUTION Tier 3 SOLUTION DELFLEX-LC/4.25% DDAVP ORAL TABLET DEXTROSE Tier 3 DO Tier 3 0.1 MG INTRAPERITONEAL SOLUTION DDAVP ORAL TABLET Tier 3 0.2 MG DELFLEX-SM/1.5% DEXTROSE DDAVP RHINAL TUBE Tier 2 Tier 3 INTRAPERITONEAL NASAL SOLUTION SOLUTION deblitane oral tablet Tier 1 $0 DELFLEX-SM/2.5% DEXTROSE decadron oral tablet Tier 1 T1S Tier 3 INTRAPERITONEAL decitabine intravenous Tier 1 SP SOLUTION solution reconstituted DELSTRIGO ORAL deferasirox granules oral Tier 3 QL Tier 4 PA; QL; SP TABLET packet delyla oral tablet Tier 1 $0 deferasirox oral packet Tier 4 PA; QL; SP DELZICOL ORAL deferasirox oral tablet 180 Tier 4 SP CAPSULE DELAYED Tier 3 ST; QL mg RELEASE deferasirox oral tablet 360 Tier 4 PA; QL; SP demeclocycline hcl oral mg, 90 mg Tier 1 tablet deferasirox oral tablet Tier 4 PA; QL; SP DEMEROL INJECTION soluble Tier 3 QL SOLUTION deferiprone oral tablet Tier 4 PA; QL DEMSER ORAL Tier 3 PA; QL CAPSULE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 38 Drug Name Tier Notes Drug Name Tier Notes DENAVIR EXTERNAL desmopressin acetate oral Tier 3 PA; QL Tier 1 DO CREAM tablet 0.1 mg desmopressin acetate oral denta 5000 plus dental cream Tier 1 Tier 1 tablet 0.2 mg dentagel dental gel Tier 1 desmopressin acetate spray DEPEN TITRATABS Tier 1 Tier 3 PA; QL nasal solution ORAL TABLET desogestrel-ethinyl estradiol DEPO-ESTRADIOL Tier 3 oral tablet 0.15-0.02/0.01 mg Tier 1 $0 INTRAMUSCULAR OIL (21/5) DEPO-MEDROL desogestrel-ethinyl estradiol Tier 1 $0 INJECTION Tier 3 oral tablet 0.15-30 mg-mcg SUSPENSION desonide external cream Tier 1 DEPO-PROVERA INTRAMUSCULAR Tier 3 desonide external gel Tier 1 SUSPENSION desonide external lotion Tier 1 DEPO-PROVERA INTRAMUSCULAR desonide external ointment Tier 1 Tier 3 SUSPENSION desoximetasone external Tier 3 ST; QL PREFILLED SYRINGE cream DEPO-SUBQ PROVERA desoximetasone external gel Tier 3 ST; QL 104 SUBCUTANEOUS Tier 3 $0 desoximetasone external SUSPENSION Tier 3 ST; QL liquid PREFILLED SYRINGE desoximetasone external DEPO-TESTOSTERONE Tier 3 ST; QL INTRAMUSCULAR Tier 3 PA; QL ointment SOLUTION DESVENLAFAXINE ER ORAL TABLET DERMOTIC OTIC OIL Tier 3 Tier 3 ST; QL EXTENDED RELEASE 24 DESCOVY ORAL HOUR 100 MG Tier 3 QL; $0 TABLET DESVENLAFAXINE ER DESFERAL INJECTION ORAL TABLET Tier 3 ST; DO; QL SOLUTION Tier 4 SP EXTENDED RELEASE 24 RECONSTITUTED HOUR 50 MG desflurane inhalation solution Tier 1 desvenlafaxine succinate er oral tablet extended release Tier 1 desipramine hcl oral tablet Tier 1 24 hour 100 mg desloratadine oral tablet Tier 1 desvenlafaxine succinate er desloratadine oral tablet oral tablet extended release Tier 1 DO Tier 1 dispersible 24 hour 25 mg, 50 mg desmopressin ace spray DEXABLISS ORAL Tier 1 refrig nasal solution TABLET THERAPY Tier 3 PACK desmopressin acetate Tier 1 injection solution

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 39 Drug Name Tier Notes Drug Name Tier Notes DEXAMETHASONE DEXCOM G4 PLATINUM Tier 2 PA; QL INTENSOL ORAL Tier 2 RECEIVER DEVICE CONCENTRATE DEXCOM G4 PLATINUM Tier 2 PA; QL dexamethasone oral elixir Tier 1 T1S TRANSMITTER dexamethasone oral solution Tier 1 T1S DEXCOM G4 SENSOR Tier 2 PA; QL dexamethasone oral tablet Tier 1 T1S DEXCOM G5 MOB/G4 Tier 2 PA; QL dexamethasone oral tablet PLAT SENSOR Tier 1 therapy pack DEXCOM G5 MOBILE Tier 2 PA; QL dexamethasone sod RECEIVER DEVICE phosphate pf injection Tier 1 DEXCOM G5 MOBILE Tier 2 PA; QL solution TRANSMITTER DEXAMETHASONE SOD DEXCOM G5 RECEIVER Tier 2 PA; QL PHOSPHATE PF KIT DEVICE Tier 3 INJECTION SOLUTION DEXCOM G6 RECEIVER Tier 2 PA; QL PREFILLED SYRINGE DEVICE DEXAMETHASONE DEXCOM G6 SENSOR Tier 2 PA; QL SODIUM PHOSPHATE Tier 3 DEXCOM G6 INJECTION SOLUTION Tier 2 PA; QL 10 MG/ML, 4 MG/ML TRANSMITTER dexamethasone sodium DEXILANT ORAL phosphate injection solution CAPSULE DELAYED Tier 2 ST; QL Tier 1 100 mg/10ml, 120 mg/30ml, RELEASE 20 mg/5ml dexmedetomidine hcl in nacl Tier 1 dexamethasone sodium intravenous solution phosphate ophthalmic Tier 1 DEXMEDETOMIDINE solution HCL INTRAVENOUS DEXAMETHASONE- SOLUTION 1000 Tier 3 MOXIFLOXACIN MCG/10ML, 400 Tier 3 INTRAOCULAR MCG/4ML SOLUTION dexmedetomidine hcl DEXAMETH- intravenous solution 200 Tier 1 MOXIFLOX- mcg/2ml KETOROLAC Tier 3 DEXMEDETOMIDINE INTRAOCULAR HCL-DEXTROSE Tier 3 SOLUTION INTRAVENOUS DEXCOM G4 PLAT PED SOLUTION Tier 2 PA; QL RCV/SHARE DEVICE dexmethylphenidate hcl er DEXCOM G4 PLAT PED oral capsule extended release Tier 2 PA; QL Tier 1 PA; DO; QL RECEIVER DEVICE 24 hour 10 mg, 15 mg, 20 mg, 5 mg DEXCOM G4 PLATINUM Tier 2 PA; QL RCV/SHARE DEVICE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 40 Drug Name Tier Notes Drug Name Tier Notes dexmethylphenidate hcl er dextrose-nacl intravenous oral capsule extended release solution 10-0.45 %, 2.5-0.45 Tier 1 PA; QL Tier 1 24 hour 25 mg, 30 mg, 35 %, 5-0.2 %, 5-0.33 %, 5-0.45 mg, 40 mg %, 5-0.9 % dexmethylphenidate hcl oral DEXTROSE-SODIUM Tier 1 PA; QL tablet 10 mg CHLORIDE dexmethylphenidate hcl oral INTRAVENOUS Tier 3 Tier 1 PA; DO; QL tablet 2.5 mg, 5 mg SOLUTION 5-0.225 %, 5- 0.3 % DEXPANTHENOL Tier 3 INJECTION SOLUTION dextrose-sodium chloride intravenous solution 5-0.45 Tier 1 dexrazoxane hcl intravenous Tier 1 SP %, 5-0.9 % solution reconstituted DEXYCU DEXTENZA Tier 3 INTRAOCULAR Tier 3 OPHTHALMIC INSERT SUSPENSION dextroamphetamine sulfate er DIACOMIT ORAL Tier 4 PA; QL; LD oral capsule extended release Tier 1 PA; QL CAPSULE 24 hour 10 mg, 15 mg DIACOMIT ORAL Tier 4 PA; QL; LD dextroamphetamine sulfate er PACKET oral capsule extended release Tier 1 PA; DO; QL 24 hour 5 mg dialyvite 800 oral tablet Tier 1 $0 dextroamphetamine sulfate DIANEAL LOW Tier 1 PA; QL CALCIUM/1.5% DEX oral solution Tier 3 INTRAPERITONEAL dextroamphetamine sulfate Tier 1 PA; QL SOLUTION oral tablet 10 mg DIANEAL LOW dextroamphetamine sulfate CALCIUM/2.5% DEX Tier 1 PA; DO; QL Tier 3 oral tablet 5 mg INTRAPERITONEAL DEXTROSE SOLUTION 5%/ELECTROLYTE #48 Tier 3 DIANEAL LOW INTRAVENOUS CALCIUM/4.25% DEX Tier 3 SOLUTION INTRAPERITONEAL dextrose in lactated ringers SOLUTION Tier 1 intravenous solution DIANEAL PD-2/1.5% DEXTROSE dextrose intravenous solution Tier 3 10 %, 250 mg/ml, 30 %, 5 %, Tier 1 INTRAPERITONEAL 70 % SOLUTION DEXTROSE DIANEAL PD-2/2.5% DEXTROSE INTRAVENOUS Tier 3 Tier 3 SOLUTION 20 %, 40 % INTRAPERITONEAL SOLUTION DEXTROSE-NACL INTRAVENOUS Tier 3 SOLUTION 10-0.2 %, 5- 0.3 %

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 41 Drug Name Tier Notes Drug Name Tier Notes DIANEAL PD-2/4.25% diclofenac sodium Tier 1 DEXTROSE ophthalmic solution Tier 3 INTRAPERITONEAL diclofenac sodium oral tablet Tier 1 SOLUTION delayed release DIASTAT ACUDIAL diclofenac-misoprostol oral Tier 3 Tier 1 ST; QL RECTAL GEL tablet delayed release DIASTAT PEDIATRIC dicloxacillin sodium oral Tier 3 Tier 1 RECTAL GEL capsule DIATHRIVE LANCET dicyclomine hcl Tier 2 QL Tier 1 ULTRA THIN 30 intramuscular solution DIATHRIVE LANCETS Tier 2 QL dicyclomine hcl oral capsule Tier 1 DIATHRIVE LANCING Tier 2 DEVICE dicyclomine hcl oral solution Tier 1 DIATHRIVE PEN dicyclomine hcl oral tablet Tier 1 Tier 3 ST; QL NEEDLE diethylpropion hcl er oral diazepam injection solution Tier 1 tablet extended release 24 Tier 1 PA; QL hour diazepam intensol oral Tier 1 concentrate diethylpropion hcl oral tablet Tier 1 PA; QL DIAZEPAM DIFICID ORAL INTRAMUSCULAR SUSPENSION Tier 3 Tier 3 SOLUTION AUTO- RECONSTITUTED INJECTOR DIFICID ORAL TABLET Tier 3 diazepam oral concentrate Tier 1 diflorasone diacetate external Tier 3 ST; QL diazepam oral solution Tier 1 cream diflorasone diacetate external diazepam oral tablet Tier 1 Tier 3 ST; QL ointment diazepam rectal gel Tier 1 DIFLUCAN ORAL diazoxide oral suspension Tier 1 SUSPENSION Tier 3 RECONSTITUTED DIBENZYLINE ORAL Tier 3 PA; QL DIFLUCAN ORAL CAPSULE Tier 3 TABLET diclofenac potassium oral Tier 1 tablet diflunisal oral tablet Tier 1 diclofenac sodium er oral DIGIFAB INTRAVENOUS tablet extended release 24 Tier 1 Tier 3 hour SOLUTION RECONSTITUTED diclofenac sodium external Tier 1 gel 1 % digitek oral tablet Tier 1 diclofenac sodium external Tier 1 PA; QL digox oral tablet Tier 1 gel 3 % digoxin injection solution Tier 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 42 Drug Name Tier Notes Drug Name Tier Notes digoxin oral solution Tier 1 diltiazem hcl er coated beads oral tablet extended release Tier 1 digoxin oral tablet Tier 1 24 hour 240 mg, 300 mg, 360 dihydroergotamine mesylate mg, 420 mg Tier 1 PA; QL injection solution diltiazem hcl er oral capsule Tier 1 DILANTIN INFATABS extended release 12 hour ORAL TABLET Tier 3 diltiazem hcl er oral capsule CHEWABLE extended release 24 hour 120 Tier 1 DO DILANTIN ORAL mg, 180 mg Tier 3 CAPSULE 100 MG diltiazem hcl er oral capsule DILANTIN ORAL extended release 24 hour 240 Tier 1 Tier 2 CAPSULE 30 MG mg DILANTIN ORAL diltiazem hcl intravenous Tier 3 Tier 1 SUSPENSION solution DILATRATE-SR ORAL DILTIAZEM HCL INTRAVENOUS CAPSULE EXTENDED Tier 2 Tier 3 RELEASE SOLUTION RECONSTITUTED DILAUDID INJECTION Tier 3 QL diltiazem hcl oral tablet 120 SOLUTION Tier 1 mg, 90 mg DILAUDID ORAL Tier 3 QL diltiazem hcl oral tablet 30 LIQUID Tier 1 DO mg, 60 mg DILAUDID ORAL Tier 3 QL TABLET DILTIAZEM HCL- DEXTROSE Tier 3 diltiazem hcl er beads oral INTRAVENOUS capsule extended release 24 Tier 1 DO SOLUTION hour 120 mg, 180 mg, 360 mg DILTIAZEM HCL- SODIUM CHLORIDE diltiazem hcl er beads oral Tier 3 INTRAVENOUS capsule extended release 24 Tier 1 SOLUTION hour 240 mg, 300 mg, 420 mg dilt-xr oral capsule extended release 24 hour 120 mg, 180 Tier 1 DO diltiazem hcl er coated beads mg oral capsule extended release Tier 1 DO dilt-xr oral capsule extended 24 hour 120 mg, 180 mg Tier 1 release 24 hour 240 mg diltiazem hcl er coated beads oral capsule extended release DIMENHYDRINATE Tier 1 Tier 3 24 hour 240 mg, 300 mg, 360 INJECTION SOLUTION mg dimethyl fumarate oral Tier 4 PA; QL; LD; SP diltiazem hcl er coated beads capsule delayed release oral tablet extended release Tier 1 DO dimethyl fumarate starter Tier 4 PA; QL; SP 24 hour 180 mg pack oral

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 43 Drug Name Tier Notes Drug Name Tier Notes DIPENTUM ORAL dobutamine in d5w Tier 3 ST; QL Tier 1 CAPSULE intravenous solution diphen oral elixir Tier 1 DOCETAXEL INTRAVENOUS Tier 3 PA; QL; SP di-phen oral liquid Tier 1 CONCENTRATE diphenhydramine hcl Tier 1 DOCETAXEL injection solution INTRAVENOUS Tier 3 PA; QL; SP diphenhydramine hcl oral SOLUTION Tier 1 elixir dofetilide oral capsule Tier 1 diphenoxylate-atropine oral Tier 1 DOG EPITHELIUM liquid SUBCUTANEOUS Tier 3 diphenoxylate-atropine oral SOLUTION Tier 1 tablet DOG FENNEL DIPHTHERIA-TETANUS SUBCUTANEOUS Tier 3 TOXOIDS DT SOLUTION Tier 3 $0 INTRAMUSCULAR DOJOLVI ORAL LIQUID Tier 4 PA; QL; LD; SP SUSPENSION donepezil hcl oral tablet 10 Tier 1 DIPRIVAN mg, 23 mg INTRAVENOUS Tier 3 donepezil hcl oral tablet 5 EMULSION Tier 1 DO mg dipyridamole oral tablet Tier 1 donepezil hcl oral tablet Tier 1 DISCOVISC dispersible INTRAOCULAR Tier 3 dopamine hcl intravenous SOLUTION Tier 1 solution disopyramide phosphate oral Tier 1 dopamine in d5w intravenous capsule Tier 1 solution disulfiram oral tablet Tier 1 DOPRAM DIURIL ORAL INTRAVENOUS Tier 3 Tier 3 SUSPENSION SOLUTION divalproex sodium er oral DOPTELET ORAL Tier 4 PA; QL; LD; SP tablet extended release 24 Tier 1 TABLET hour DORAL ORAL TABLET Tier 3 ST; QL divalproex sodium oral dorzolamide hcl ophthalmic Tier 1 capsule delayed release Tier 1 solution sprinkle dorzolamide hcl-timolol mal divalproex sodium oral tablet Tier 1 Tier 1 ophthalmic solution delayed release dorzolamide hcl-timolol mal DIVIGEL Tier 1 Tier 2 pf ophthalmic solution TRANSDERMAL GEL dotti transdermal patch twice dobutamine hcl intravenous Tier 1 Tier 1 weekly solution

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 44 Drug Name Tier Notes Drug Name Tier Notes DOVATO ORAL TABLET Tier 2 DRECHSLERA SUBCUTANEOUS Tier 3 DOVONEX EXTERNAL Tier 3 SOLUTION CREAM DRISDOL ORAL doxazosin mesylate oral Tier 3 Tier 1 T1S CAPSULE tablet dronabinol oral capsule Tier 1 doxepin hcl external cream Tier 1 PA; QL doxepin hcl oral capsule Tier 1 T1S droperidol injection solution Tier 1 doxepin hcl oral concentrate Tier 1 T1S DROPERIDOL INTRAVENOUS Tier 3 doxepin hcl oral tablet Tier 1 ST; QL SOLUTION PREFILLED doxercalciferol intravenous SYRINGE Tier 1 PA; QL solution DROPLET GENTEEL Tier 2 doxercalciferol oral capsule Tier 1 PA; QL LANCING DEVICE DOXIL INTRAVENOUS DROPLET INSULIN Tier 3 PA; QL; SP INJECTABLE SYRINGE 29G X 1/2" 0.3 doxorubicin hcl intravenous ML, 29G X 1/2" 0.5 ML, Tier 1 SP solution 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" doxorubicin hcl liposomal Tier 1 PA; QL; SP 0.5 ML, 30G X 1/2" 1 ML, intravenous injectable 30G X 15/64" 0.3 ML, 30G doxy 100 intravenous X 15/64" 1 ML, 30G X Tier 3 ST; QL Tier 1 solution reconstituted 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, doxycycline hyclate 31G X 15/64" 0.3 ML, 31G intravenous solution Tier 1 X 15/64" 0.5 ML, 31G X reconstituted 15/64" 1 ML, 31G X 5/16" doxycycline hyclate oral Tier 1 0.3 ML, 31G X 5/16" 0.5 capsule ML, 31G X 5/16" 1 ML doxycycline hyclate oral Tier 1 DROPLET INSULIN tablet 100 mg, 20 mg, 50 mg SYRINGE 30G X 15/64" Tier 3 doxycycline hyclate oral 0.5 ML Tier 1 ST; QL tablet 150 mg, 75 mg DROPLET LANCETS Tier 2 QL doxycycline hyclate oral ULTRA THIN 30G Tier 1 ST; QL tablet delayed release DROPLET LANCING Tier 2 doxycycline monohydrate DEVICE Tier 1 oral capsule DROPLET MICRON Tier 3 doxycycline monohydrate DROPLET PEN Tier 1 Tier 3 ST; QL oral suspension reconstituted NEEDLES doxycycline monohydrate DROPLET PERSONAL Tier 1 Tier 2 QL oral tablet LANCETS 30G doxylamine-pyridoxine oral DROPSAFE SAFETY PEN Tier 1 PA; QL Tier 3 ST; QL tablet delayed release NEEDLES

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 45 Drug Name Tier Notes Drug Name Tier Notes drospiren-eth estrad- duloxetine hcl oral capsule Tier 1 $0 levomefol oral tablet delayed release particles 30 Tier 1 DO drospirenone-ethinyl mg Tier 1 $0 estradiol oral tablet DUOBRII EXTERNAL Tier 3 PA; QL DROXIA ORAL LOTION Tier 2 CAPSULE DUODOTE INTRAMUSCULAR droxidopa oral capsule Tier 1 PA; QL; SP Tier 3 SOLUTION AUTO- DRUG MART LANCETS Tier 2 QL INJECTOR THIN 26G DUOPA ENTERAL DRUG MART LANCING Tier 3 PA; QL; LD; SP Tier 2 SUSPENSION DEVICE DUOVISC DRUG MART ON-THE- Tier 3 Tier 2 QL INTRAOCULAR KIT GO LANCET 30G DUPIXENT DRUG MART UNIFINE SUBCUTANEOUS Tier 3 ST; QL Tier 4 PA; QL; SP PENTIPS SOLUTION PEN- DRUG MART UNIFINE INJECTOR Tier 3 ST; QL PENTIPS PLUS DUPIXENT DRUG MART UNILET SUBCUTANEOUS Tier 2 QL Tier 4 PA; QL; SP LANCETS 28G SOLUTION PREFILLED SYRINGE DRUG MART UNILET Tier 2 QL DURACLON EPIDURAL LANCETS 30G Tier 3 SOLUTION DRUG MART UNILET Tier 2 QL LANCETS 33G DURAGESIC-100 TRANSDERMAL PATCH Tier 3 PA; QL DSUVIA SUBLINGUAL Tier 3 72 HOUR TABLET SUBLINGUAL DURAGESIC-12 Tier 3 PA; QL DUAVEE ORAL TABLET TRANSDERMAL PATCH Tier 3 PA; QL ducodyl oral tablet delayed 72 HOUR Tier 1 $0 release DURAGESIC-25 DUET DHA 400 ORAL Tier 3 ST; QL TRANSDERMAL PATCH Tier 3 PA; QL DUET DHA BALANCED 72 HOUR Tier 3 ST; QL ORAL DURAGESIC-50 DUETACT ORAL TRANSDERMAL PATCH Tier 3 PA; QL Tier 3 ST; QL TABLET 72 HOUR dulcolax milk of magnesia DURAGESIC-75 Tier 1 $0 oral suspension TRANSDERMAL PATCH Tier 3 PA; QL 72 HOUR dulcolax oral suspension Tier 1 $0 duramorph injection solution Tier 1 QL duloxetine hcl oral capsule delayed release particles 20 Tier 1 DUREZOL mg, 40 mg, 60 mg OPHTHALMIC Tier 2 EMULSION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 46 Drug Name Tier Notes Drug Name Tier Notes DURLAZA ORAL EASY COMFORT Tier 3 ST; QL CAPSULE EXTENDED Tier 3 PA; QL INSULIN SYRINGE RELEASE 24 HOUR EASY COMFORT Tier 2 QL DUROLANE INTRA- LANCETS ARTICULAR Tier 4 PA; QL EASY COMFORT Tier 2 QL PREFILLED SYRINGE LANCETS TWIST TOP DURYSTA EASY COMFORT PEN Tier 3 ST; QL INTRAOCULAR Tier 4 PA; QL; LD; SP NEEDLES IMPLANT EASY GLIDE PEN Tier 3 ST; QL DUST MITE MIXED NEEDLES ALLERGEN EXT Tier 3 EASY MINI EJECT INJECTION SOLUTION Tier 2 LANCING DEVICE DUST MITE MIXED ALLERGEN EXT EASY MINI LANCING Tier 3 Tier 2 SUBCUTANEOUS DEVICE SOLUTION EASY TOUCH Tier 3 ST; QL dutasteride oral capsule Tier 1 FLIPLOCK INSULIN SY dutasteride-tamsulosin hcl EASY TOUCH INSULIN Tier 1 Tier 3 ST; QL oral capsule SAFETY SYR EASY TOUCH INSULIN DUTOPROL ORAL Tier 3 ST; QL TABLET EXTENDED Tier 3 SYRINGE RELEASE 24 HOUR EASY TOUCH LANCETS Tier 2 QL DXEVO 11-DAY ORAL 21G TABLET THERAPY Tier 3 EASY TOUCH LANCETS Tier 2 QL PACK 23G DYANAVEL XR ORAL EASY TOUCH LANCETS Tier 2 QL SUSPENSION Tier 3 PA; QL 26G EXTENDED RELEASE EASY TOUCH LANCETS Tier 2 QL DYMISTA NASAL 28G Tier 3 SUSPENSION EASY TOUCH LANCETS Tier 2 QL DYSPORT 28G/TWIST INTRAMUSCULAR EASY TOUCH LANCETS Tier 4 PA; QL; SP Tier 2 QL SOLUTION 30G RECONSTITUTED EASY TOUCH LANCETS Tier 2 QL e.e.s. 400 oral tablet Tier 1 30G/TWIST ear health formula oral tablet Tier 1 $0 EASY TOUCH LANCETS Tier 2 QL ear health plus oral tablet Tier 1 $0 32G EASY TOUCH LANCETS EASTERN Tier 2 QL COTTONWOOD 32G/TWIST Tier 3 SUBCUTANEOUS EASY TOUCH LANCETS Tier 2 QL SOLUTION 33G/TWIST

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 47 Drug Name Tier Notes Drug Name Tier Notes EASY TOUCH LANCING EDEX Tier 2 DEVICE INTRACAVERNOSAL Tier 3 PA; QL EASY TOUCH PEN KIT Tier 3 ST; QL NEEDLES EDLUAR SUBLINGUAL Tier 3 ST; QL EASY TOUCH SAFETY TABLET SUBLINGUAL Tier 2 QL LANCETS 21G EDURANT ORAL Tier 2 PA; QL EASY TOUCH SAFETY TABLET Tier 2 QL LANCETS 23G efavirenz oral capsule Tier 1 QL EASY TOUCH SAFETY efavirenz oral tablet Tier 1 QL Tier 2 QL LANCETS 26G efavirenz-emtricitab- Tier 1 EASY TOUCH SAFETY tenofovir oral tablet Tier 2 QL LANCETS 28G efavirenz-lamivudine- Tier 1 QL EASY TOUCH SAFETY tenofovir oral tablet Tier 3 ST; QL PEN NEEDLES EFUDEX EXTERNAL Tier 3 ST; QL EASY TOUCH CREAM SHEATHLOCK Tier 3 ST; QL EGRIFTA SV SYRINGE SUBCUTANEOUS Tier 4 PA; QL; LD easygel dental gel Tier 1 SOLUTION RECONSTITUTED ec-naproxen oral tablet Tier 1 delayed release ELAPRASE INTRAVENOUS Tier 4 PA; QL; LD; SP econazole nitrate external Tier 1 SOLUTION cream ELCYS INTRAVENOUS Tier 3 econtra ez oral tablet Tier 1 $0 SOLUTION econtra one-step oral tablet Tier 1 $0 ELELYSO ECOZA EXTERNAL INTRAVENOUS Tier 3 ST; QL Tier 4 PA; QL; LD; SP FOAM SOLUTION ecpirin oral tablet delayed RECONSTITUTED Tier 1 $0 release ELESTRIN Tier 3 EDARBI ORAL TABLET TRANSDERMAL GEL Tier 3 DO 40 MG eletriptan hydrobromide oral Tier 1 QL EDARBI ORAL TABLET tablet Tier 3 80 MG ELIGARD Tier 3 PA; QL; SP EDARBYCLOR ORAL SUBCUTANEOUS KIT Tier 3 TABLET ELIMITE EXTERNAL Tier 3 EDECRIN ORAL CREAM Tier 3 TABLET elinest oral tablet Tier 1 $0 EDETATE DISODIUM ELIQUIS DVT/PE INTRAVENOUS Tier 3 STARTER PACK ORAL Tier 2 SOLUTION TABLET THERAPY PACK

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 48 Drug Name Tier Notes Drug Name Tier Notes ELIQUIS ORAL TABLET Tier 2 EMGALITY SUBCUTANEOUS Tier 3 PA; QL ELITEK INTRAVENOUS SOLUTION PREFILLED SOLUTION Tier 3 PA; QL; SP SYRINGE RECONSTITUTED emoquette oral tablet Tier 1 $0 ELIXOPHYLLIN ORAL Tier 2 ELIXIR EMPLICITI INTRAVENOUS Tier 3 PA; QL; LD; SP ELLA ORAL TABLET Tier 3 $0 SOLUTION ELLENCE RECONSTITUTED INTRAVENOUS Tier 3 PA; QL; SP EMSAM SOLUTION TRANSDERMAL PATCH Tier 3 ELLIOTTS B 24 HOUR INTRATHECAL Tier 3 emtricitabine oral capsule Tier 1 $0 SOLUTION emtricitabine-tenofovir df ELMIRON ORAL Tier 3 oral tablet 100-150 mg, 133- Tier 1 CAPSULE 200 mg, 167-250 mg ELOCTATE emtricitabine-tenofovir df INTRAVENOUS Tier 1 QL; $0 Tier 4 PA; QL; LD; SP oral tablet 200-300 mg SOLUTION EMTRIVA ORAL RECONSTITUTED Tier 3 QL CAPSULE eluryng vaginal ring Tier 1 $0 EMTRIVA ORAL Tier 2 QL ELZONRIS SOLUTION INTRAVENOUS Tier 3 PA; QL; LD EMVERM ORAL SOLUTION Tier 3 TABLET CHEWABLE EMBRACE LANCETS Tier 2 QL ULTRA THIN 30G enalapril maleate oral tablet Tier 1 EMBRACE LANCING enalaprilat intravenous Tier 2 Tier 1 DEVICE/EJECTOR injectable EMCYT ORAL CAPSULE Tier 2 PA; QL enalapril-hydrochlorothiazide Tier 1 EMEND ORAL oral tablet SUSPENSION Tier 3 ENBRACE HR ORAL Tier 3 ST; QL RECONSTITUTED CAPSULE EMERPHED ENBREL MINI INTRAVENOUS Tier 3 SUBCUTANEOUS Tier 4 PA; QL; SP SOLUTION SOLUTION CARTRIDGE EMGALITY (300 MG ENBREL DOSE) SUBCUTANEOUS SUBCUTANEOUS Tier 4 PA; QL; SP Tier 3 PA; QL SOLUTION PREFILLED SOLUTION SYRINGE ENBREL EMGALITY SUBCUTANEOUS Tier 4 PA; QL; SP SUBCUTANEOUS SOLUTION PREFILLED Tier 3 PA; QL SOLUTION AUTO- SYRINGE INJECTOR

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 49 Drug Name Tier Notes Drug Name Tier Notes ENBREL entecavir oral tablet Tier 4 SUBCUTANEOUS Tier 4 PA; QL; SP ENTEREG ORAL SOLUTION Tier 3 RECONSTITUTED CAPSULE ENBREL SURECLICK ENTOCORT EC ORAL SUBCUTANEOUS CAPSULE DELAYED Tier 3 Tier 4 PA; QL; SP SOLUTION AUTO- RELEASE PARTICLES INJECTOR ENTRESTO ORAL Tier 3 PA; QL ENCARE VAGINAL TABLET Tier 2 $0 SUPPOSITORY ENTYVIO INTRAVENOUS ENDARI ORAL PACKET Tier 4 PA; QL; LD Tier 4 PA; QL; LD; SP SOLUTION ENDO AVITENE Tier 3 RECONSTITUTED EXTERNAL enulose oral solution Tier 1 endocet oral tablet Tier 1 QL ENVARSUS XR ORAL ENDOMETRIN Tier 3 PA; QL TABLET EXTENDED Tier 3 VAGINAL INSERT RELEASE 24 HOUR endur-b oral tablet extended EPANED ORAL Tier 1 $0 Tier 3 release SOLUTION ENFAMIL EXPECTA EPCLUSA ORAL Tier 2 $0 Tier 4 PA; QL; SP ORAL TABLET ENGERIX-B INJECTION Tier 3 $0 EPHEDRINE SULFATE SUSPENSION INTRAVENOUS Tier 3 ENHERTU SOLUTION INTRAVENOUS Tier 3 PA; QL; LD; SP EPHEDRINE SULFATE- SOLUTION NACL INTRAVENOUS Tier 3 RECONSTITUTED SOLUTION PREFILLED ENLITE GLUCOSE SYRINGE Tier 3 PA; QL SENSOR EPICOCCUM NIGRUM Tier 3 enoxaparin sodium injection INJECTION SOLUTION Tier 4 solution EPICOCCUM enoxaparin sodium SUBCUTANEOUS Tier 3 Tier 4 subcutaneous solution SOLUTION enpresse-28 oral tablet Tier 1 $0 EPICORD EXTERNAL Tier 3 enskyce oral tablet Tier 1 $0 SHEET EPIDIOLEX ORAL ENSPRYNG Tier 4 PA; QL; LD; SP SUBCUTANEOUS SOLUTION Tier 4 PA; QL; LD; SP SOLUTION PREFILLED EPIFIX EXTERNAL DISK Tier 3 SYRINGE EPIFIX EXTERNAL ENSTILAR EXTERNAL Tier 3 Tier 3 SHEET FOAM entacapone oral tablet Tier 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 50 Drug Name Tier Notes Drug Name Tier Notes EPIFIX MICRONIZED EPIVIR ORAL TABLET Tier 3 QL INJECTION Tier 3 eplerenone oral tablet Tier 1 SUSPENSION RECONSTITUTED EPOGEN INJECTION Tier 4 PA; QL; SP EPIFOAM EXTERNAL SOLUTION Tier 3 FOAM epoprostenol sodium epinastine hcl ophthalmic intravenous solution Tier 4 PA; QL; LD; SP Tier 1 solution reconstituted epinephrine (anaphylaxis) eptifibatide intravenous Tier 1 Tier 1 injection solution solution EPZICOM ORAL EPINEPHRINE HCL Tier 3 QL INTRAOCULAR TABLET Tier 3 SOLUTION PREFILLED eq aspirin adult low dose oral Tier 1 $0 SYRINGE tablet delayed release EPINEPHRINE HCL- eq aspirin low dose oral Tier 1 $0 NACL INTRAVENOUS Tier 3 tablet chewable SOLUTION eq aspirin oral tablet Tier 1 $0 epinephrine injection Tier 1 eq clearlax oral powder Tier 1 $0 solution auto-injector eq gentle laxative oral tablet Tier 1 $0 EPINEPHRINE delayed release INTRAVENOUS Tier 3 eq magnesium citrate oral SOLUTION Tier 1 $0 solution EPINEPHRINE INTRAVENOUS eq nicotine mouth/throat Tier 3 Tier 1 $0 SOLUTION PREFILLED lozenge SYRINGE eq nicotine polacrilex Tier 1 $0 EPINEPHRINE- mouth/throat gum DEXTROSE eq nicotine polacrilex Tier 3 Tier 1 $0 INTRAVENOUS mouth/throat lozenge SOLUTION eq nicotine step 3 Tier 1 $0 EPINEPHRINE-NACL transdermal patch 24 hour INTRAVENOUS Tier 3 eq nicotine transdermal patch SOLUTION Tier 1 $0 24 hour epirubicin hcl intravenous Tier 1 PA; QL; SP eql aspirin ec oral tablet solution Tier 1 $0 delayed release epitol oral tablet Tier 1 eql aspirin low dose oral Tier 1 $0 EPIVIR HBV ORAL tablet chewable Tier 4 SOLUTION eql aspirin low dose oral Tier 1 $0 EPIVIR HBV ORAL tablet delayed release Tier 4 TABLET eql b complex 50 oral tablet Tier 1 $0 EPIVIR ORAL eql b-100 complex oral tablet Tier 3 QL Tier 1 $0 SOLUTION extended release

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 51 Drug Name Tier Notes Drug Name Tier Notes eql clearlax oral powder Tier 1 $0 ERLEADA ORAL Tier 2 PA; QL; LD; SP EQL COLOR LANCETS TABLET Tier 2 QL 21G erlotinib hcl oral tablet Tier 1 PA; QL; SP EQL COLOR LANCETS errin oral tablet Tier 1 $0 Tier 2 QL MICRO 33G ERTACZO EXTERNAL Tier 3 ST; QL eql gentle laxative oral tablet CREAM Tier 1 $0 delayed release ertapenem sodium injection Tier 1 EQL INSULIN SYRINGE Tier 3 ST; QL solution reconstituted eql laxative oral tablet ERWINAZE INJECTION Tier 1 $0 delayed release SOLUTION Tier 3 PA; QL; LD; SP eql magnesium citrate oral RECONSTITUTED Tier 1 $0 solution ery external pad Tier 1 eql milk of magnesia oral ERYGEL EXTERNAL Tier 1 $0 Tier 3 suspension GEL eql nicotine polacrilex ery-tab oral tablet delayed Tier 1 $0 Tier 1 mouth/throat lozenge release EQL PRENATAL ERYTHROCIN FORMULA ORAL Tier 2 $0 LACTOBIONATE TABLET INTRAVENOUS Tier 3 eql super b complex/vitamin SOLUTION Tier 1 $0 c oral tablet RECONSTITUTED EQL SUPER THIN erythrocin stearate oral tablet Tier 1 Tier 2 QL LANCETS 30G erythromycin base oral EQL THIN LANCETS capsule delayed release Tier 1 Tier 2 QL 26G particles EQUETRO ORAL erythromycin base oral tablet Tier 1 CAPSULE EXTENDED Tier 3 erythromycin base oral tablet RELEASE 12 HOUR Tier 1 delayed release ERAXIS INTRAVENOUS erythromycin ethylsuccinate SOLUTION Tier 3 Tier 1 RECONSTITUTED oral suspension reconstituted erythromycin ethylsuccinate ERBITUX Tier 1 INTRAVENOUS Tier 3 PA; QL; SP oral tablet SOLUTION erythromycin external gel Tier 1 ergocalciferol oral capsule Tier 1 erythromycin external Tier 1 solution ergoloid mesylates oral tablet Tier 1 erythromycin ophthalmic ergotamine-caffeine oral Tier 1 Tier 1 ointment tablet erythromycin oral tablet ERIVEDGE ORAL Tier 1 Tier 2 PA; QL; LD; SP delayed release CAPSULE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 52 Drug Name Tier Notes Drug Name Tier Notes ESBRIET ORAL estradiol transdermal patch Tier 4 PA; QL; LD; SP Tier 1 T1S CAPSULE weekly ESBRIET ORAL TABLET Tier 4 PA; QL; LD; SP estradiol vaginal cream Tier 1 escitalopram oxalate oral Tier 1 estradiol vaginal tablet Tier 1 solution estradiol valerate escitalopram oxalate oral Tier 1 Tier 1 DO intramuscular oil tablet 10 mg, 5 mg estradiol-norethindrone acet escitalopram oxalate oral Tier 1 Tier 1 oral tablet tablet 20 mg ESTRING VAGINAL Tier 3 esgic oral capsule Tier 1 RING ESKATA EXTERNAL ESTROFACTORS ORAL Tier 3 Tier 2 $0 SOLUTION TABLET esmolol hcl intravenous ESTROGEL Tier 1 Tier 3 solution 100 mg/10ml TRANSDERMAL GEL ESMOLOL HCL ESTROSTEP FE ORAL Tier 3 INTRAVENOUS TABLET SOLUTION 2000 Tier 3 MG/100ML, 2500 eszopiclone oral tablet Tier 1 MG/250ML ethacrynate sodium ESMOLOL HCL intravenous solution Tier 1 INTRAVENOUS reconstituted Tier 3 SOLUTION PREFILLED ethacrynic acid oral tablet Tier 1 SYRINGE ethambutol hcl oral tablet Tier 1 esmolol hcl-sodium chloride Tier 1 intravenous solution ETHAMOLIN esomeprazole sodium INTRAVENOUS Tier 3 intravenous solution Tier 1 SOLUTION reconstituted ethosuximide oral capsule Tier 1 ESPEROCT ethosuximide oral solution Tier 1 INTRAVENOUS Tier 4 PA; QL; LD; SP ethynodiol diac-eth estradiol SOLUTION Tier 1 $0 RECONSTITUTED oral tablet ESSENTRA WIPES 9X9" ETHYOL Tier 3 INTRAVENOUS EXTERNAL Tier 3 PA; QL; SP SOLUTION estarylla oral tablet Tier 1 $0 RECONSTITUTED estazolam oral tablet Tier 1 etodolac er oral tablet Tier 1 ESTRADIOL IMPLANT extended release 24 hour Tier 3 PELLET etodolac oral capsule Tier 1 estradiol oral tablet Tier 1 T1S etodolac oral tablet Tier 1 estradiol transdermal patch Tier 1 twice weekly

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 53 Drug Name Tier Notes Drug Name Tier Notes etomidate intravenous EVOMELA Tier 1 solution INTRAVENOUS Tier 3 LD; SP etonogestrel-ethinyl estradiol SOLUTION Tier 1 $0 vaginal ring RECONSTITUTED ETOPOPHOS EVOTAZ ORAL TABLET Tier 3 QL INTRAVENOUS EVOXAC ORAL Tier 3 SP Tier 3 SOLUTION CAPSULE RECONSTITUTED EVRYSDI ORAL etoposide intravenous SOLUTION Tier 4 PA; QL; LD Tier 1 SP solution RECONSTITUTED etoposide oral capsule Tier 1 SP EXEL COMFORT POINT Tier 3 ST; QL EUCRISA EXTERNAL INSULIN SYR Tier 3 ST; QL OINTMENT EXEL COMFORT POINT Tier 3 ST; QL EUFLEXXA INTRA- PEN NEEDLE ARTICULAR SOLUTION Tier 4 PA; QL EXELDERM EXTERNAL Tier 3 ST; QL PREFILLED SYRINGE CREAM euthyrox oral tablet Tier 1 T1S EXELDERM EXTERNAL Tier 3 ST; QL EVAMIST SOLUTION TRANSDERMAL Tier 2 EXELON SOLUTION TRANSDERMAL PATCH Tier 3 ST; QL EVEKEO ODT ORAL 24 HOUR Tier 3 PA; QL TABLET DISPERSIBLE exemestane oral tablet Tier 1 $0 EVENITY EXJADE ORAL TABLET Tier 4 PA; QL; LD; SP SUBCUTANEOUS SOLUBLE Tier 4 PA; QL; SP SOLUTION PREFILLED ex-lax ultra oral tablet Tier 1 $0 SYRINGE delayed release everolimus oral tablet 0.25 Tier 1 EXONDYS 51 mg, 0.5 mg, 0.75 mg INTRAVENOUS Tier 4 PA; QL; LD everolimus oral tablet 2.5 SOLUTION Tier 1 PA; QL; SP mg, 5 mg, 7.5 mg EXTAVIA Tier 4 PA; QL; LD; SP EVERSENSE SUBCUTANEOUS KIT Tier 3 PA; QL SENSOR/HOLDER EXTINA EXTERNAL Tier 3 EVERSENSE SMART FOAM Tier 3 PA; QL TRANSMITTER EXTRANEAL EVISTA ORAL TABLET Tier 3 INTRAPERITONEAL Tier 3 SOLUTION EVKEEZA EYLEA INTRAVITREAL INTRAVENOUS Tier 4 LD Tier 4 PA; QL; LD; SP SOLUTION SOLUTION EVOCLIN EXTERNAL EYLEA INTRAVITREAL Tier 3 ST; QL FOAM SOLUTION PREFILLED Tier 4 PA; QL; LD SYRINGE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 54 Drug Name Tier Notes Drug Name Tier Notes EYSUVIS OPHTHALMIC FANAPT TITRATION Tier 3 PA; QL Tier 3 ST; QL SUSPENSION PACK ORAL TABLET E-Z JECT LANCET FARESTON ORAL Tier 2 QL Tier 3 MICRO-THIN 33G TABLET E-Z JECT LANCET FARXIGA ORAL Tier 2 QL Tier 2 ST; QL SUPER THIN 30G TABLET E-Z JECT LANCETS Tier 2 QL FARYDAK ORAL Tier 3 PA; QL; LD; SP E-Z JECT LANCETS 21G Tier 2 QL CAPSULE E-Z JECT LANCETS FASENRA PEN Tier 2 QL SUBCUTANEOUS THIN 26G Tier 4 PA; QL; LD SOLUTION AUTO- ezetimibe oral tablet Tier 1 ST; QL INJECTOR ezetimibe-simvastatin oral Tier 1 ST; QL FASENRA tablet SUBCUTANEOUS Tier 4 PA; QL; LD; SP EZ-LETS LANCETS 21G Tier 2 QL SOLUTION PREFILLED SYRINGE EZ-LETS LANCETS 26G Tier 2 QL FASLODEX EZ-LETS LANCETS 28G Tier 2 QL INTRAMUSCULAR Tier 3 PA; QL; SP EZ-LETS LANCETS 30G Tier 2 QL SOLUTION fa-8 oral capsule Tier 1 $0 fa-vitamin b-6-vitamin b-12 Tier 1 fa-8 oral tablet Tier 1 $0 oral tablet FABRAZYME fayosim oral tablet Tier 1 $0 INTRAVENOUS FC FEMALE CONDOM Tier 2 QL; $0 Tier 4 PA; QL; LD; SP SOLUTION FC2 FEMALE CONDOM Tier 2 QL; $0 RECONSTITUTED febuxostat oral tablet Tier 1 ST; QL FALESSA ORAL KIT Tier 3 feenamint oral tablet delayed Tier 1 $0 falmina oral tablet Tier 1 $0 release famciclovir oral tablet Tier 1 FEIBA INTRAVENOUS famotidine intravenous SOLUTION Tier 4 PA; QL; LD; SP Tier 1 solution RECONSTITUTED famotidine oral suspension felbamate oral suspension Tier 1 Tier 1 reconstituted felbamate oral tablet Tier 1 famotidine oral tablet Tier 1 FELDENE ORAL Tier 3 famotidine premixed CAPSULE Tier 1 intravenous solution felodipine er oral tablet FANAPT ORAL TABLET extended release 24 hour 10 Tier 1 Tier 3 ST; DO; QL 1 MG, 2 MG, 4 MG, 6 MG mg FANAPT ORAL TABLET felodipine er oral tablet Tier 3 ST; QL 10 MG, 12 MG, 8 MG extended release 24 hour 2.5 Tier 1 DO mg, 5 mg

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 55 Drug Name Tier Notes Drug Name Tier Notes FEMARA ORAL TABLET Tier 3 FENTANYL CITRATE INTRAVENOUS FEMCAP VAGINAL Tier 3 Tier 2 $0 SOLUTION PREFILLED DEVICE SYRINGE FEMHRT LOW DOSE Tier 3 FENTANYL CITRATE PF ORAL TABLET INJECTION SOLUTION Tier 3 FEMRING VAGINAL PREFILLED SYRINGE Tier 3 RING FENTANYL CITRATE- femynor oral tablet Tier 1 $0 NACL INTRAVENOUS Tier 3 fenofibrate micronized oral SOLUTION PREFILLED Tier 1 capsule SYRINGE FENTANYL CIT- fenofibrate oral capsule Tier 1 ROPIVACAINE-NACL Tier 3 fenofibrate oral tablet Tier 1 EPIDURAL SOLUTION fenofibric acid oral capsule fentanyl transdermal patch Tier 1 Tier 1 PA; QL delayed release 72 hour fenofibric acid oral tablet Tier 1 FENTANYL- BUPIVACAINE-NACL Tier 3 FENOGLIDE ORAL Tier 3 ST; QL EPIDURAL SOLUTION TABLET FENTORA BUCCAL fenoprofen calcium oral Tier 3 PA; QL Tier 1 TABLET tablet FERAHEME FENSOLVI (6 MONTH) Tier 3 PA; QL; LD INTRAVENOUS Tier 3 SUBCUTANEOUS KIT SOLUTION FENTANYL CITRATE FERRIPROX ORAL Tier 4 PA; QL; LD (PF) INJECTION SOLUTION SOLUTION 100 Tier 3 FERRIPROX ORAL MCG/2ML, 250 Tier 4 PA; QL; LD MCG/5ML, 50 MCG/ML TABLET FERRIPROX TWICE-A- fentanyl citrate (pf) injection Tier 4 PA; QL; LD solution 1000 mcg/20ml, DAY ORAL TABLET Tier 1 2500 mcg/50ml, 500 FERRLECIT mcg/10ml INTRAVENOUS Tier 3 fentanyl citrate (pf) injection SOLUTION Tier 1 solution cartridge FETROJA fentanyl citrate buccal INTRAVENOUS Tier 1 PA; QL Tier 3 lozenge on a handle SOLUTION RECONSTITUTED fentanyl citrate buccal tablet Tier 1 PA; QL FETZIMA ORAL FENTANYL CITRATE CAPSULE EXTENDED Tier 3 ST; QL INTRAVENOUS Tier 3 RELEASE 24 HOUR SOLUTION FETZIMA TITRATION ORAL CAPSULE ER 24 Tier 3 ST; QL HOUR THERAPY PACK

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 56 Drug Name Tier Notes Drug Name Tier Notes fexmid oral tablet Tier 1 ST; QL FLAGYL ORAL Tier 3 FIBRICOR ORAL CAPSULE Tier 3 ST; QL TABLET FLAGYL ORAL TABLET Tier 3 FIBRYGA FLAREX OPHTHALMIC INTRAVENOUS Tier 3 Tier 4 PA; QL; LD SUSPENSION SOLUTION RECONSTITUTED flavoxate hcl oral tablet Tier 1 FIFTY50 PEN NEEDLES Tier 3 ST; QL FLEBOGAMMA DIF INTRAVENOUS Tier 4 PA; QL; LD; SP FIFTY50 SAFETY SEAL Tier 2 QL SOLUTION LANCETS flecainide acetate oral tablet Tier 1 FIFTY50 SUPERIOR Tier 3 ST; QL COMFORT SYR flexbumin intravenous Tier 1 FIFTY50 UNILET solution Tier 2 QL LANCETS 33G FLEXIN EXTERNAL Tier 3 FINACEA EXTERNAL PATCH Tier 2 FOAM FLOLAN INTRAVENOUS SOLUTION Tier 4 PA; QL; LD; SP finasteride oral tablet Tier 1 RECONSTITUTED FINE 30 Tier 2 QL FLORIVA ORAL LIQUID Tier 3 FINGERSTIX LANCETS Tier 2 QL FLORIVA ORAL FINTEPLA ORAL Tier 3 Tier 4 PA; QL; LD TABLET CHEWABLE SOLUTION FLORIVA PLUS ORAL Tier 3 FIRAZYR SOLUTION SUBCUTANEOUS Tier 4 PA; QL; LD; SP SOLUTION FLOVENT DISKUS INHALATION AEROSOL FIRDAPSE ORAL Tier 2 Tier 4 PA; QL; LD POWDER BREATH TABLET ACTIVATED FIRE ANT FLOVENT HFA Tier 2 SUBCUTANEOUS Tier 3 INHALATION AEROSOL SOLUTION floxuridine injection solution Tier 1 SP FIRMAGON (240 MG reconstituted DOSE) SUBCUTANEOUS Tier 3 SP SOLUTION FLUAD INTRAMUSCULAR RECONSTITUTED Tier 2 QL; $0 SUSPENSION FIRMAGON PREFILLED SYRINGE SUBCUTANEOUS Tier 3 PA; QL; SP SOLUTION FLUAD QUADRIVALENT RECONSTITUTED Tier 2 $0 INTRAMUSCULAR FIRVANQ ORAL PREFILLED SYRINGE SOLUTION Tier 3 PA; QL RECONSTITUTED flac otic oil Tier 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 57 Drug Name Tier Notes Drug Name Tier Notes FLUARIX flunisolide nasal solution Tier 3 ST; QL QUADRIVALENT fluocinolone acetonide body Tier 1 ST; QL INTRAMUSCULAR Tier 2 QL; $0 external oil SUSPENSION fluocinolone acetonide PREFILLED SYRINGE Tier 1 external cream FLUBLOK fluocinolone acetonide QUADRIVALENT Tier 1 INTRAMUSCULAR Tier 2 QL; $0 external ointment SOLUTION PREFILLED fluocinolone acetonide Tier 1 SYRINGE external solution FLUCELVAX fluocinolone acetonide otic QUADRIVALENT Tier 1 Tier 2 QL; $0 oil INTRAMUSCULAR fluocinolone acetonide scalp SUSPENSION Tier 1 external oil FLUCELVAX fluocinonide emulsified base QUADRIVALENT Tier 1 external cream INTRAMUSCULAR Tier 2 QL; $0 SUSPENSION fluocinonide external cream Tier 1 PREFILLED SYRINGE fluocinonide external gel Tier 1 fluconazole in sodium Tier 1 fluocinonide external chloride intravenous solution Tier 1 ointment fluconazole oral suspension Tier 1 fluocinonide external reconstituted Tier 1 solution fluconazole oral tablet Tier 1 fluorescein-benoxinate Tier 1 flucytosine oral capsule Tier 1 PA; QL ophthalmic solution fludarabine phosphate Tier 1 SP FLUORESCITE intravenous solution INTRAVENOUS Tier 3 fludarabine phosphate SOLUTION intravenous solution Tier 1 SP fluoridex daily renewal Tier 1 reconstituted mouth/throat concentrate fludrocortisone acetate oral Tier 1 fluoridex dental paste Tier 1 tablet fluoridex enhanced Tier 1 FLULAVAL whitening dental paste QUADRIVALENT fluoridex sensitivity relief INTRAMUSCULAR Tier 2 QL; $0 Tier 1 SUSPENSION dental paste PREFILLED SYRINGE fluor-i-strips a.t. ophthalmic Tier 1 flumazenil intravenous strip Tier 1 solution fluoritab oral solution Tier 1 $0 FLUMIST fluorometholone ophthalmic Tier 1 QUADRIVALENT NASAL Tier 2 $0 suspension SUSPENSION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 58 Drug Name Tier Notes Drug Name Tier Notes FLUOROPLEX flurandrenolide external Tier 3 ST; QL Tier 3 ST; QL EXTERNAL CREAM ointment fluorouracil external cream FLURA-SAFE Tier 1 ST; QL 0.5 % OPHTHALMIC Tier 3 fluorouracil external cream 5 SOLUTION Tier 1 % flurazepam hcl oral capsule Tier 1 fluorouracil external solution Tier 1 flurbiprofen oral tablet Tier 1 fluorouracil intravenous flurbiprofen sodium Tier 1 SP Tier 1 solution ophthalmic solution fluoxetine hcl (pmdd) oral Tier 1 DO flutamide oral capsule Tier 1 tablet 10 mg fluticasone propionate fluoxetine hcl (pmdd) oral Tier 1 Tier 1 external cream tablet 20 mg fluticasone propionate fluoxetine hcl oral capsule 10 Tier 1 Tier 1 DO external lotion mg fluticasone propionate fluoxetine hcl oral capsule 20 Tier 1 Tier 1 external ointment mg, 40 mg fluticasone propionate nasal fluoxetine hcl oral capsule Tier 1 Tier 1 suspension delayed release fluticasone-salmeterol fluoxetine hcl oral solution Tier 1 inhalation aerosol powder Tier 1 fluoxetine hcl oral tablet 10 breath activated Tier 1 DO mg fluvastatin sodium er oral fluoxetine hcl oral tablet 20 tablet extended release 24 Tier 1 $0 Tier 1 mg hour FLUOXETINE HCL fluvastatin sodium oral Tier 3 Tier 1 DO; $0 ORAL TABLET 60 MG capsule fluphenazine decanoate fluvoxamine maleate er oral Tier 1 injection solution capsule extended release 24 Tier 1 hour fluphenazine hcl injection Tier 1 fluvoxamine maleate oral solution Tier 1 tablet 100 mg fluphenazine hcl oral Tier 1 fluvoxamine maleate oral concentrate Tier 1 DO tablet 25 mg, 50 mg fluphenazine hcl oral elixir Tier 1 FLUZONE HIGH-DOSE fluphenazine hcl oral tablet Tier 1 QUADRIVALENT flurandrenolide external INTRAMUSCULAR Tier 2 $0 Tier 3 ST; QL cream SUSPENSION PREFILLED SYRINGE flurandrenolide external Tier 3 ST; QL lotion

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 59 Drug Name Tier Notes Drug Name Tier Notes FLUZONE fondaparinux sodium Tier 4 QUADRIVALENT subcutaneous solution Tier 2 QL; $0 INTRAMUSCULAR FORA LANCETS Tier 2 QL SUSPENSION FORA LANCING Tier 2 FLUZONE DEVICE QUADRIVALENT FORANE INHALATION INTRAMUSCULAR Tier 2 QL; $0 Tier 3 SUSPENSION SOLUTION PREFILLED SYRINGE FORMALDEHYDE Tier 3 FML FORTE EXTERNAL SOLUTION OPHTHALMIC Tier 3 FORTAZ INJECTION SUSPENSION SOLUTION Tier 3 FML LIQUIFILM RECONSTITUTED OPHTHALMIC Tier 3 FORTAZ INTRAVENOUS SUSPENSION SOLUTION Tier 3 FML OPHTHALMIC RECONSTITUTED Tier 3 OINTMENT FORTEO FOCALIN ORAL SUBCUTANEOUS Tier 3 PA; QL Tier 4 PA; QL; SP TABLET 10 MG SOLUTION PEN- INJECTOR FOCALIN ORAL Tier 3 PA; DO; QL FOSAMAX ORAL TABLET 2.5 MG, 5 MG Tier 3 TABLET folate oral tablet Tier 1 $0 FOSAMAX PLUS D Tier 2 folding paddle walker Tier 1 $0 ORAL TABLET FOLGARD OS ORAL fosamprenavir calcium oral Tier 3 Tier 1 QL TABLET tablet FOLGARD RX ORAL Tier 3 fosaprepitant dimeglumine TABLET intravenous solution Tier 1 PA; QL folic acid injection solution Tier 1 reconstituted foscarnet sodium intravenous folic acid oral capsule Tier 1 $0 Tier 1 solution folic acid oral tablet 1 mg Tier 1 FOSCAVIR folic acid oral tablet 400 Tier 1 $0 INTRAVENOUS Tier 3 mcg, 800 mcg SOLUTION FOLOTYN fosfomycin tromethamine Tier 1 INTRAVENOUS Tier 3 SP oral packet SOLUTION fosinopril sodium oral tablet Tier 1 T1S foltabs 800 oral tablet Tier 1 $0 fosinopril sodium-hctz oral Tier 1 foltrin oral capsule Tier 1 tablet fomepizole intravenous fosphenytoin sodium Tier 1 Tier 1 solution injection solution

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 60 Drug Name Tier Notes Drug Name Tier Notes FOSRENOL ORAL fresenius propoven Tier 3 ST; QL Tier 1 PACKET intravenous emulsion FOSRENOL ORAL frovatriptan succinate oral Tier 3 ST; QL Tier 1 ST; QL TABLET CHEWABLE tablet FRAGMIN FULL SPECTRUM SUBCUTANEOUS Tier 4 QL B/VITAMIN C ORAL Tier 2 $0 SOLUTION TABLET FREAMINE HBC FULPHILA INTRAVENOUS Tier 3 SUBCUTANEOUS Tier 4 PA; QL; SP SOLUTION SOLUTION PREFILLED FREAMINE III SYRINGE INTRAVENOUS Tier 3 fulvestrant intramuscular Tier 1 PA; QL; SP SOLUTION solution FREDS PHARMACY FUROSEMIDE IN Tier 2 AUTOLET LANCING SODIUM CHLORIDE Tier 3 FREDS PHARMACY INTRAVENOUS Tier 3 ST; QL UNIFINE PENTIP+ SOLUTION FREDS PHARMACY furosemide injection solution Tier 1 Tier 3 ST; QL UNIFINE PENTIPS furosemide oral solution Tier 1 T1S FREDS PHARMACY Tier 2 QL furosemide oral tablet Tier 1 T1S UNILET LANC 28G FUSARIUM FREDS PHARMACY Tier 2 QL SUBCUTANEOUS Tier 3 UNILET LANC 30G SOLUTION FREESTYLE LANCETS Tier 2 QL FUZEON FREESTYLE LIBRE 14 SUBCUTANEOUS Tier 2 PA; QL Tier 2 PA; QL; LD DAY READER DEVICE SOLUTION RECONSTITUTED FREESTYLE LIBRE 14 Tier 2 PA; QL DAY SENSOR fyavolv oral tablet Tier 1 FREESTYLE LIBRE 2 FYCOMPA ORAL Tier 2 PA; QL Tier 3 READER DEVICE SUSPENSION FREESTYLE LIBRE 2 FYCOMPA ORAL Tier 2 PA; QL Tier 3 SENSOR TABLET FREESTYLE LIBRE Tier 2 PA; QL g tussin ac oral solution Tier 1 READER DEVICE gabapentin oral capsule Tier 1 FREESTYLE LIBRE Tier 2 PA; QL SENSOR SYSTEM gabapentin oral solution Tier 1 FREESTYLE PRECISION Tier 3 ST; QL gabapentin oral tablet Tier 1 INS SYR GABLOFEN FREESTYLE UNISTICK Tier 2 QL INTRATHECAL Tier 4 II LANCETS SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 61 Drug Name Tier Notes Drug Name Tier Notes GABLOFEN GANCICLOVIR SODIUM INTRATHECAL INTRAVENOUS Tier 4 SP Tier 4 SOLUTION PREFILLED SOLUTION SYRINGE ganciclovir sodium GALAFOLD ORAL intravenous solution Tier 4 SP Tier 4 PA; QL; LD CAPSULE reconstituted galantamine hydrobromide er GANIRELIX ACETATE oral capsule extended release Tier 1 SUBCUTANEOUS Tier 4 PA; QL; SP 24 hour 16 mg, 24 mg SOLUTION PREFILLED galantamine hydrobromide er SYRINGE oral capsule extended release Tier 1 DO GARDASIL 9 24 hour 8 mg INTRAMUSCULAR Tier 2 $0 galantamine hydrobromide SUSPENSION Tier 1 oral solution GARDASIL 9 galantamine hydrobromide INTRAMUSCULAR Tier 1 Tier 2 $0 oral tablet 12 mg, 8 mg SUSPENSION PREFILLED SYRINGE galantamine hydrobromide Tier 1 DO GASTROCROM ORAL oral tablet 4 mg Tier 3 CONCENTRATE GALZIN ORAL Tier 3 gatifloxacin ophthalmic CAPSULE Tier 1 solution GAMASTAN GATTEX INTRAMUSCULAR Tier 4 PA; QL; LD; SP Tier 3 PA; QL; LD; SP INJECTABLE SUBCUTANEOUS KIT GAMIFANT gavilax oral powder Tier 1 $0 INTRAVENOUS Tier 3 PA; QL; LD; SP gavilyte-c oral solution Tier 1 $0 SOLUTION reconstituted GAMMAGARD gavilyte-g oral solution Tier 4 PA; QL; LD; SP Tier 1 $0 INJECTION SOLUTION reconstituted GAMMAGARD S/D LESS gavilyte-h oral kit Tier 1 $0 IGA INTRAVENOUS gavilyte-n with flavor pack Tier 4 PA; QL; LD; SP Tier 1 $0 SOLUTION oral solution reconstituted RECONSTITUTED GAVRETO ORAL GAMMAKED Tier 3 PA; QL; LD Tier 4 PA; QL; LD; SP CAPSULE INJECTION SOLUTION GAZYVA GAMMAPLEX INTRAVENOUS Tier 3 PA; QL; LD; SP INTRAVENOUS Tier 4 PA; QL; LD; SP SOLUTION SOLUTION GEL-FLOW NT GAMUNEX-C Tier 4 PA; QL; LD; SP EXTERNAL PREFILLED Tier 3 INJECTION SOLUTION SYRINGE GANCICLOVIR GELFOAM INTRAVENOUS Tier 4 SP COMPRESSED SIZE 100 Tier 3 SOLUTION EXTERNAL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 62 Drug Name Tier Notes Drug Name Tier Notes GELFOAM DENTAL gentamicin sulfate injection Tier 1 PACK SIZE 4 Tier 3 solution EXTERNAL gentamicin sulfate Tier 1 GELFOAM ophthalmic solution MOUTH/THROAT Tier 3 GENTEEL BUTTERFLY Tier 2 QL POWDER TOUCH LANCET GELFOAM SPONGE GENTEEL CONTACT Tier 3 Tier 2 EXTERNAL TIPS (BLUE) GELFOAM SPONGE GENTEEL CONTACT Tier 3 Tier 2 SIZE 100 EXTERNAL TIPS (CLEAR) GELFOAM SPONGE GENTEEL CONTACT Tier 3 Tier 2 SIZE 200 EXTERNAL TIPS (GREEN) GELFOAM SPONGE GENTEEL CONTACT Tier 3 Tier 2 SIZE 50 EXTERNAL TIPS (ORANGE) GEL-ONE INTRA- GENTEEL CONTACT Tier 2 ARTICULAR Tier 4 PA; QL; SP TIPS (RAINBOW) PREFILLED SYRINGE GENTEEL CONTACT Tier 2 GELSYN-3 INTRA- TIPS (VIOLET) ARTICULAR SOLUTION Tier 4 PA; QL; SP GENTEEL CONTACT PREFILLED SYRINGE Tier 2 TIPS (YELLOW) GEMCITABINE HCL GENTEEL LANCING KIT INTRAVENOUS Tier 3 SP Tier 2 SOLUTION (BLUE) KIT gemcitabine hcl intravenous GENTEEL NOZZLES Tier 2 Tier 1 SP solution reconstituted GENTEEL PLUS Tier 2 gemfibrozil oral tablet Tier 1 LANCING (BLACK) GENTEEL PLUS gemmily oral capsule Tier 1 $0 Tier 2 LANCING (PURPLE) GENERESS FE ORAL Tier 3 GENTEEL PLUS TABLET CHEWABLE Tier 2 LANCING (WHITE) generlac oral solution Tier 1 GENTEEL PLUS Tier 2 gengraf oral capsule Tier 1 LANCING DEV(BLUE) GENTEEL PLUS gengraf oral solution Tier 1 Tier 2 LANCING DEV(PINK) gentak ophthalmic ointment Tier 1 gentle laxative oral tablet gentamicin in saline Tier 1 $0 Tier 1 delayed release intravenous solution gentlelax oral powder Tier 1 $0 gentamicin sulfate external Tier 1 GENTLE-LET GP cream Tier 2 QL LANCETS gentamicin sulfate external Tier 1 ointment GENTLE-LET LANCETS Tier 2 QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 63 Drug Name Tier Notes Drug Name Tier Notes GENTLE-LET glipizide xl oral tablet Tier 2 Tier 1 ST; QL; T1S PLATFORMS extended release 24 hour GENVOYA ORAL glipizide-metformin hcl oral Tier 2 QL Tier 1 ST; QL TABLET tablet GEODON GLOBAL EASE INJECT Tier 3 ST; QL INTRAMUSCULAR PEN NEEDLES Tier 3 SOLUTION GLOBAL EASY GLIDE RECONSTITUTED INSULIN SYR 31G X GERMAN COCKROACH 15/64" 0.3 ML, 31G X Tier 3 ST; QL SUBCUTANEOUS Tier 3 15/64" 0.5 ML, 31G X SOLUTION 5/16" 0.3 ML GIAPREZA GLOBAL EASY GLIDE INTRAVENOUS Tier 3 INSULIN SYR 31G X Tier 3 SOLUTION 15/64" 1 ML GILENYA ORAL GLOBAL EASY GLIDE Tier 4 PA; QL; SP Tier 3 ST; QL CAPSULE PEN NEEDLES GILOTRIF ORAL GLOBAL INJECT EASE Tier 3 PA; QL; LD Tier 3 ST; QL TABLET INSULIN SYR GILPHEX TR ORAL GLOBAL INJECT EASE Tier 3 Tier 2 QL TABLET LANCETS 28G GIMOTI NASAL GLOBAL INJECT EASE Tier 3 PA; QL Tier 2 QL SOLUTION LANCETS 30G GIVLAARI GLOBAL INSULIN Tier 3 ST; QL SUBCUTANEOUS Tier 4 PA; QL; LD SYRINGES SOLUTION GLOBAL LANCING Tier 2 GLASSIA DEVICE INTRAVENOUS Tier 4 PA; QL; LD; SP GLOPERBA ORAL Tier 3 ST; QL SOLUTION SOLUTION glatiramer acetate GLUCAGEN HYPOKIT subcutaneous solution Tier 4 PA; QL; SP INJECTION SOLUTION Tier 2 prefilled syringe RECONSTITUTED glatopa subcutaneous Tier 4 PA; QL; SP GLUCAGON solution prefilled syringe EMERGENCY Tier 2 GLEOSTINE ORAL INJECTION KIT Tier 3 PA; QL CAPSULE GLUCAGON GLIADEL WAFER EMERGENCY Tier 3 Tier 3 IMPLANT WAFER INJECTION SOLUTION glimepiride oral tablet Tier 1 ST; QL; T1S RECONSTITUTED glipizide er oral tablet GLUCOCOM LANCETS Tier 1 ST; QL; T1S Tier 2 QL extended release 24 hour 28G GLUCOCOM LANCETS glipizide oral tablet Tier 1 ST; QL; T1S Tier 2 QL 30G

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 64 Drug Name Tier Notes Drug Name Tier Notes GLUCOCOM LANCETS GLYNASE ORAL Tier 2 QL Tier 3 ST; QL 33G TABLET GLUCOPRO INSULIN GLYRX-PF INJECTION Tier 3 ST; QL Tier 3 SYRINGE SOLUTION GLUCOTROL ORAL GLYRX-PF INJECTION Tier 3 ST; QL TABLET SOLUTION PREFILLED Tier 3 GLUCOTROL XL ORAL SYRINGE TABLET EXTENDED Tier 3 ST; QL gnp adult aspirin low Tier 1 $0 RELEASE 24 HOUR strength oral tablet chewable GLUTARALDEHYDE gnp aspirin low dose oral Tier 2 Tier 1 $0 EXTERNAL SOLUTION tablet delayed release GLUTATHIONE gnp aspirin oral tablet Tier 1 $0 Tier 3 INJECTION SOLUTION gnp aspirin oral tablet Tier 1 $0 GLUTATHIONE delayed release INTRAVENOUS Tier 3 gnp b-100 complex oral Tier 1 $0 SOLUTION tablet extended release glyburide micronized oral Tier 1 ST; QL; T1S gnp b-50 balanced oral tablet Tier 1 $0 tablet gnp b-50 complex oral tablet Tier 1 $0 glyburide oral tablet Tier 1 ST; QL; T1S extended release glyburide-metformin oral gnp b-complex plus vitamin Tier 1 ST; QL Tier 1 $0 tablet c oral tablet GLYCATE ORAL gnp bisa-lax oral tablet Tier 3 PA; QL Tier 1 $0 TABLET delayed release GLYCINE INJECTION Tier 3 gnp clearlax oral packet Tier 1 $0 SOLUTION gnp clearlax oral powder Tier 1 $0 glycine irrigation solution Tier 1 GNP CLICKFINE PEN glycine urologic irrigation Tier 3 ST; QL Tier 1 NEEDLES solution gnp essential one daily oral Tier 1 $0 glycolax oral powder Tier 1 $0 tablet glycopyrrolate injection Tier 1 gnp folic acid oral tablet Tier 1 $0 solution gnp gentle laxative oral tablet glycopyrrolate oral tablet 1 Tier 1 $0 Tier 1 delayed release mg, 2 mg GNP INSULIN SYRINGE Tier 3 ST; QL GLYCOPYRROLATE Tier 3 PA; QL ORAL TABLET 1.5 MG GNP LANCETS Tier 2 QL GLYCOPYRROLATE PF GNP LANCETS 21G Tier 2 QL INJECTION SOLUTION Tier 3 GNP LANCETS MICRO Tier 2 QL PREFILLED SYRINGE THIN 33G glydo external prefilled GNP LANCETS SUPER Tier 1 Tier 2 QL syringe THIN 30G

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 65 Drug Name Tier Notes Drug Name Tier Notes GNP LANCETS THIN Tier 2 QL GOCOVRI ORAL GNP LANCETS THIN CAPSULE EXTENDED Tier 2 QL Tier 3 PA; DO; QL; LD 26G RELEASE 24 HOUR 68.5 MG gnp laxative oral tablet Tier 1 $0 GOJJI LANCING delayed release Tier 2 DEVICE/CLEAR CAP gnp magnesium citrate oral Tier 1 $0 GOJJI STERILE solution Tier 2 QL LANCETS GNP MICRO THIN Tier 2 QL LANCETS 33G GOLDENROD SUBCUTANEOUS Tier 3 gnp milk of magnesia oral Tier 1 $0 SOLUTION suspension GOLYTELY ORAL gnp nicotine mini Tier 1 $0 SOLUTION Tier 3 mouth/throat lozenge RECONSTITUTED gnp nicotine mouth/throat Tier 1 $0 GONAL-F INJECTION gum SOLUTION Tier 4 PA; QL; SP gnp nicotine polacrilex RECONSTITUTED Tier 1 $0 mouth/throat gum GONAL-F RFF gnp nicotine polacrilex REDIJECT Tier 1 $0 Tier 4 PA; QL; SP mouth/throat lozenge SUBCUTANEOUS SOLUTION gnp nicotine transdermal Tier 1 $0 patch 24 hour GONAL-F RFF SUBCUTANEOUS gnp one daily plus iron oral Tier 4 PA; QL; SP Tier 1 $0 SOLUTION tablet RECONSTITUTED GNP PRENATAL ORAL Tier 2 $0 GONITRO SUBLINGUAL TABLET Tier 3 PACKET GNP SUPER THIN goodsense aspirin adult low Tier 2 QL Tier 1 $0 LANCETS 30G st oral tablet chewable GNP ULTICARE PEN goodsense aspirin low dose Tier 3 ST; QL Tier 1 $0 NEEDLES oral tablet delayed release GNP ULTRA COM Tier 3 ST; QL goodsense aspirin oral tablet Tier 1 $0 INSULIN SYRINGE goodsense aspirin oral tablet gnp womens gentle laxative Tier 1 $0 Tier 1 $0 chewable oral tablet delayed release goodsense aspirin oral tablet gnp womens laxative oral Tier 1 $0 Tier 1 $0 delayed release tablet delayed release goodsense bisacodyl ec oral Tier 1 $0 GOCOVRI ORAL tablet delayed release CAPSULE EXTENDED Tier 3 PA; QL; LD goodsense clearlax oral RELEASE 24 HOUR 137 Tier 1 $0 MG powder

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 66 Drug Name Tier Notes Drug Name Tier Notes GOODSENSE GRANIX CLICKFINE PEN Tier 3 ST; QL SUBCUTANEOUS Tier 4 PA; QL; SP NEEDLE SOLUTION GOODSENSE COLOR GRANIX Tier 2 QL LANCETS 33G SUBCUTANEOUS Tier 4 PA; QL; SP GOODSENSE LANCETS SOLUTION PREFILLED Tier 2 QL 26G UNIV SYRINGE GOODSENSE LANCETS GRASS POLLEN(K-O-R- Tier 2 QL 30G T-SWT VERN) Tier 3 INJECTION SOLUTION GOODSENSE LANCETS Tier 2 QL GRASTEK SUBLINGUAL 30G UNIV Tier 3 PA; QL TABLET SUBLINGUAL GOODSENSE LANCETS Tier 2 QL griseofulvin microsize oral 33G Tier 1 suspension GOODSENSE LANCETS Tier 2 QL griseofulvin microsize oral 33G UNIV Tier 1 tablet GOODSENSE LANCING Tier 2 griseofulvin ultramicrosize DEVICE Tier 1 oral tablet goodsense magnesium citrate Tier 1 $0 oral solution guaiatussin ac oral syrup Tier 1 goodsense nicotine guaifenesin ac oral syrup Tier 1 Tier 1 $0 mouth/throat gum guaifenesin-codeine oral Tier 1 goodsense nicotine solution Tier 1 $0 mouth/throat lozenge guanfacine hcl er oral tablet GOODSENSE PEN extended release 24 hour 1 Tier 1 PA; DO; QL Tier 3 ST; QL NEEDLE PENFINE mg, 2 mg GOODSENSE guanfacine hcl er oral tablet PRENATAL VITAMINS Tier 2 $0 extended release 24 hour 3 Tier 1 PA; QL ORAL TABLET mg, 4 mg goodsense womens laxative Tier 1 $0 guanfacine hcl oral tablet Tier 1 oral tablet delayed release GUANIDINE HCL ORAL GOPRELTO NASAL Tier 3 Tier 3 TABLET SOLUTION GUARDIAN CONNECT GRALISE ORAL Tier 3 PA; QL Tier 2 PA; DO; QL TRANSMITTER TABLET 300 MG GUARDIAN LINK 3 GRALISE ORAL Tier 3 PA; QL Tier 2 PA; QL TRANSMITTER TABLET 600 MG GUARDIAN REAL-TIME granisetron hcl intravenous Tier 3 PA; QL Tier 1 REPLACE PED DEVICE solution GUARDIAN SENSOR (3) Tier 3 PA; QL granisetron hcl oral tablet Tier 1 QL GUARDIAN SENSOR 3 Tier 3 PA; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 67 Drug Name Tier Notes Drug Name Tier Notes GVOKE HYPOPEN 1- HALAVEN PACK SUBCUTANEOUS INTRAVENOUS Tier 3 PA; QL; SP Tier 3 SOLUTION AUTO- SOLUTION INJECTOR halcinonide external cream Tier 3 ST; QL GVOKE HYPOPEN 2- HALCION ORAL PACK SUBCUTANEOUS Tier 3 Tier 3 TABLET SOLUTION AUTO- INJECTOR HALDOL DECANOATE INTRAMUSCULAR Tier 3 GVOKE PFS SOLUTION SUBCUTANEOUS Tier 3 HALDOL INJECTION SOLUTION PREFILLED Tier 3 SYRINGE SOLUTION GYNAZOLE-1 VAGINAL halobetasol propionate Tier 3 Tier 1 CREAM external cream habitrol transdermal patch 24 halobetasol propionate Tier 1 $0 Tier 1 hour external ointment haloperidol decanoate HACKBERRY Tier 1 SUBCUTANEOUS Tier 3 intramuscular solution SOLUTION haloperidol lactate injection Tier 1 HAEGARDA solution SUBCUTANEOUS haloperidol lactate oral Tier 4 PA; QL; LD; SP Tier 1 SOLUTION concentrate RECONSTITUTED haloperidol oral tablet Tier 1 HAEMOLANCE Tier 2 QL HARVONI ORAL HAEMOLANCE LOW Tier 4 PA; QL Tier 2 QL PACKET FLOW LANCETS HARVONI ORAL Tier 4 PA; QL HAEMOLANCE PLUS Tier 2 QL TABLET 45-200 MG HAEMOLANCE PLUS HARVONI ORAL Tier 2 QL Tier 4 PA; QL; SP HIGH FLOW TABLET 90-400 MG HAEMOLANCE PLUS Tier 2 QL HAVRIX LOW FLOW INTRAMUSCULAR Tier 3 $0 HAEMOLANCE PLUS SUSPENSION Tier 2 QL MAX FLOW HEALON GV HAEMOLANCE PLUS INTRAOCULAR Tier 4 Tier 2 QL PEDIATRIC FLOW SOLUTION hailey 1.5/30 oral tablet Tier 1 $0 HEALON hailey 24 fe oral tablet Tier 1 $0 INTRAOCULAR Tier 4 SOLUTION hailey fe 1.5/30 oral tablet Tier 1 $0 HEALON PRO hailey fe 1/20 oral tablet Tier 1 $0 INTRAOCULAR Tier 4 SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 68 Drug Name Tier Notes Drug Name Tier Notes HEALON5 H-E-B INCONTROL PEN Tier 3 ST; QL INTRAOCULAR Tier 4 NEEDLES SOLUTION H-E-B INCONTROL Tier 3 ST; QL HEALON5 PRO UNIFINE PENTIP INTRAOCULAR Tier 4 HECTOROL SOLUTION INTRAVENOUS Tier 3 PA; QL HEALTH CARE SOLUTION Tier 2 LANCING DEVICE HELIDAC THERAPY Tier 3 ST; QL HEALTHWISE INSULIN ORAL Tier 3 ST; QL SYR/NEEDLE HEMABATE HEALTHWISE MICRON INTRAMUSCULAR Tier 3 Tier 3 ST; QL PEN NEEDLES SOLUTION HEALTHWISE MINI PEN HEMADY ORAL Tier 3 ST; QL Tier 3 NEEDLES TABLET HEALTHWISE PEN HEMANGEOL ORAL Tier 3 ST; QL Tier 3 NEEDLES SOLUTION HEALTHWISE SHORT HEMLIBRA Tier 3 ST; QL PEN NEEDLES SUBCUTANEOUS Tier 4 PA; QL; LD; SP HEALTHWISE UNIFINE SOLUTION Tier 3 ST; QL PENTIPS HEMOFIL M HEALTHY ACCENTS INTRAVENOUS Tier 2 Tier 4 PA; QL; LD; SP LANCING DEVICE SOLUTION RECONSTITUTED HEALTHY ACCENTS Tier 3 ST; QL HEPAGAM B UNIFINE PENTIP Tier 4 SP INJECTION SOLUTION HEALTHY ACCENTS Tier 2 QL UNILET LANCETS HEPARIN (PORCINE) IN NACL INTRAVENOUS Tier 3 healthy hair/skin/nails oral Tier 1 $0 SOLUTION tablet heparin lock flush Tier 1 healthylax oral packet Tier 1 $0 intravenous solution heather oral tablet Tier 1 $0 HEPARIN SOD h-e-b aspirin oral tablet (PORCINE) IN D5W Tier 1 $0 INTRAVENOUS delayed release Tier 3 SOLUTION 100 H-E-B INCONTROL ADV Tier 2 UNIT/ML, 25000-5 LANCING UT/500ML-% H-E-B INCONTROL Tier 2 QL heparin sod (porcine) in d5w LANCETS 28G intravenous solution 40-5 Tier 1 H-E-B INCONTROL unit/ml-% Tier 2 QL LANCETS 30G heparin sodium (porcine) Tier 1 H-E-B INCONTROL injection solution Tier 2 QL LANCETS 33G

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 69 Drug Name Tier Notes Drug Name Tier Notes HEPARIN SODIUM HIBERIX INJECTION (PORCINE) INJECTION SOLUTION Tier 3 $0 Tier 3 SOLUTION PREFILLED RECONSTITUTED SYRINGE HIGH POTENCY heparin sodium (porcine) pf MULTIVITAMIN ORAL Tier 2 $0 injection solution 5000 Tier 1 TABLET unit/0.5ml HIPREX ORAL TABLET Tier 3 HEPARIN SODIUM (PORCINE) PF HISTEX-AC ORAL Tier 3 Tier 3 INJECTION SOLUTION SYRUP 5000 UNIT/ML HIZENTRA heparin sodium lock flush SUBCUTANEOUS Tier 4 PA; QL; LD; SP Tier 1 intravenous solution SOLUTION hepatamine intravenous HIZENTRA Tier 1 SUBCUTANEOUS solution Tier 4 PA; QL; LD; SP SOLUTION PREFILLED HEPLISAV-B SYRINGE INTRAMUSCULAR Tier 3 $0 SOLUTION PREFILLED hm adult aspirin oral tablet Tier 1 $0 SYRINGE hm aspirin ec low dose oral Tier 1 $0 HEPSERA ORAL tablet delayed release Tier 4 SP TABLET hm aspirin ec oral tablet Tier 1 $0 HERCEPTIN HYLECTA delayed release SUBCUTANEOUS Tier 3 LD; SP hm aspirin oral tablet Tier 1 $0 SOLUTION hm aspirin oral tablet Tier 1 $0 HERCEPTIN chewable INTRAVENOUS hm aspirin oral tablet delayed Tier 3 LD; SP Tier 1 $0 SOLUTION release RECONSTITUTED hm b complex/c oral tablet Tier 1 $0 HERZUMA INTRAVENOUS hm clearlax oral packet Tier 1 $0 Tier 3 LD; SP SOLUTION hm clearlax oral powder Tier 1 $0 RECONSTITUTED hm folic acid oral tablet Tier 1 $0 HESPAN INTRAVENOUS Tier 3 hm laxative oral tablet SOLUTION Tier 1 $0 delayed release hetastarch-nacl intravenous Tier 1 hm magnesium citrate oral solution Tier 1 $0 solution HETLIOZ ORAL Tier 4 PA; QL; LD hm milk of magnesia oral CAPSULE Tier 1 $0 suspension HEXTEND hm nicotine polacrilex INTRAVENOUS Tier 3 Tier 1 $0 mouth/throat gum SOLUTION hm nicotine polacrilex Tier 1 $0 mouth/throat lozenge

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 70 Drug Name Tier Notes Drug Name Tier Notes hm nicotine transdermal HUMALOG KWIKPEN Tier 1 $0 patch 24 hour SUBCUTANEOUS Tier 2 HM ONE DAILY SOLUTION PEN- Tier 2 $0 PRENATAL ORAL INJECTOR hm one daily/iron oral tablet Tier 1 $0 HUMALOG MIX 50/50 KWIKPEN HM PRENATAL ORAL Tier 2 $0 SUBCUTANEOUS Tier 2 TABLET SUSPENSION PEN- hm super vitamin b INJECTOR Tier 1 $0 complex/c oral tablet HUMALOG MIX 50/50 HM ULTICARE INSULIN SUBCUTANEOUS Tier 2 Tier 3 ST; QL SYRINGE SUSPENSION HM ULTICARE MINI HUMALOG MIX 75/25 Tier 3 ST; QL PEN NEEDLES KWIKPEN SUBCUTANEOUS Tier 2 HM ULTICARE SHORT Tier 3 ST; QL SUSPENSION PEN- PEN NEEDLES INJECTOR hm vitamin b Tier 1 $0 HUMALOG MIX 75/25 complex/vitamin c oral tablet SUBCUTANEOUS Tier 2 hm vitamin b100 complex SUSPENSION Tier 1 $0 oral tablet HUMALOG hm vitamin b50 complex oral SUBCUTANEOUS Tier 2 Tier 1 $0 tablet SOLUTION HONEY BEE VENOM HUMALOG PROTEIN INJECTION SUBCUTANEOUS Tier 2 Tier 3 SOLUTION SOLUTION CARTRIDGE RECONSTITUTED human albumin grifols Tier 1 HONEY BEE VENOM intravenous solution SUBCUTANEOUS Tier 3 HUMATE-P SOLUTION INTRAVENOUS Tier 4 PA; QL; LD; SP RECONSTITUTED SOLUTION HORIZANT ORAL RECONSTITUTED Tier 3 PA; QL TABLET EXTENDED HUMATROPE RELEASE INJECTION SOLUTION Tier 4 PA; QL; SP HORSE EPITHELIUM RECONSTITUTED Tier 3 SUBCUTANEOUS HUMIRA PEDIATRIC SOLUTION CROHNS START HUMALOG JUNIOR SUBCUTANEOUS Tier 4 PA; QL; SP KWIKPEN PREFILLED SYRINGE SUBCUTANEOUS Tier 2 KIT SOLUTION PEN- HUMIRA PEN INJECTOR SUBCUTANEOUS PEN- Tier 4 PA; QL; SP INJECTOR KIT

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 71 Drug Name Tier Notes Drug Name Tier Notes HUMIRA PEN-CD/UC/HS HYALGAN INTRA- STARTER ARTICULAR SOLUTION Tier 4 PA; QL Tier 4 PA; QL; SP SUBCUTANEOUS PEN- PREFILLED SYRINGE INJECTOR KIT HYALURONIDASE HUMIRA PEN- (INTRAOCULAR) Tier 3 PS/UV/ADOL HS START INTRAOCULAR Tier 4 PA; QL; SP SUBCUTANEOUS PEN- SOLUTION INJECTOR KIT HYCAMTIN HUMIRA PEN- INTRAVENOUS Tier 3 SP PSOR/UVEIT STARTER SOLUTION Tier 4 PA; QL; SP SUBCUTANEOUS PEN- RECONSTITUTED INJECTOR KIT HYCAMTIN ORAL Tier 2 PA; QL; SP HUMIRA CAPSULE SUBCUTANEOUS Tier 4 PA; QL; SP HYCODAN ORAL SYRUP Tier 3 PREFILLED SYRINGE KIT hydralazine hcl injection Tier 1 HUMULIN 70/30 solution KWIKPEN hydralazine hcl oral tablet Tier 1 SUBCUTANEOUS Tier 2 HYDREA ORAL SUSPENSION PEN- Tier 3 INJECTOR CAPSULE hydrochlorothiazide oral HUMULIN 70/30 Tier 1 DO; T1S capsule SUBCUTANEOUS Tier 2 SUSPENSION hydrochlorothiazide oral Tier 1 DO; T1S HUMULIN N KWIKPEN tablet 12.5 mg, 25 mg SUBCUTANEOUS hydrochlorothiazide oral Tier 2 Tier 1 T1S SUSPENSION PEN- tablet 50 mg INJECTOR hydrocod polst-cpm polst er HUMULIN N oral suspension extended Tier 1 SUBCUTANEOUS Tier 2 release SUSPENSION hydrocodone-acetaminophen Tier 1 QL HUMULIN R INJECTION oral solution Tier 2 SOLUTION hydrocodone-acetaminophen Tier 1 QL HUMULIN R U-500 oral tablet (CONCENTRATED) hydrocodone-homatropine Tier 2 PA; QL Tier 1 SUBCUTANEOUS oral syrup SOLUTION hydrocodone-homatropine Tier 1 HUMULIN R U-500 oral tablet KWIKPEN hydrocodone-ibuprofen oral SUBCUTANEOUS Tier 2 PA; QL Tier 1 QL SOLUTION PEN- tablet INJECTOR hydrocortisone (perianal) Tier 1 HYALGAN INTRA- external cream Tier 4 PA; QL ARTICULAR SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 72 Drug Name Tier Notes Drug Name Tier Notes hydrocortisone ace- HYDROMORPHONE Tier 1 pramoxine external cream HCL PF INJECTION hydrocortisone butyr lipo SOLUTION 1 MG/ML, 10 Tier 3 QL Tier 3 ST; QL base external cream MG/ML, 2 MG/ML, 4 MG/ML hydrocortisone butyrate Tier 3 ST; QL external cream hydromorphone hcl pf injection solution 50 mg/5ml, Tier 1 QL hydrocortisone butyrate Tier 3 ST; QL 500 mg/50ml external lotion HYDROMORPHONE hydrocortisone butyrate Tier 3 ST; QL HCL-NACL external ointment INTRAVENOUS Tier 3 hydrocortisone butyrate SOLUTION PREFILLED Tier 3 ST; QL external solution SYRINGE hydrocortisone external hydroxocobalamin acetate Tier 1 Tier 1 cream intramuscular solution hydrocortisone external hydroxychloroquine sulfate Tier 1 Tier 1 QL lotion oral tablet hydrocortisone external hydroxyprogesterone Tier 1 Tier 4 PA; QL; SP ointment caproate intramuscular oil hydrocortisone oral tablet Tier 1 hydroxyprogesterone caproate intramuscular Tier 1 PA; QL; LD hydrocortisone rectal enema Tier 1 solution hydrocortisone valerate Tier 3 ST; QL hydroxyurea oral capsule Tier 1 external cream hydroxyzine hcl hydrocortisone valerate Tier 1 Tier 3 ST; QL intramuscular solution external ointment hydroxyzine hcl oral syrup Tier 1 hydrocortisone-acetic acid Tier 1 otic solution hydroxyzine hcl oral tablet Tier 1 hydroxyzine pamoate oral hydromet oral syrup Tier 1 Tier 1 capsule hydromorphone hcl er oral HYLENEX INJECTION tablet extended release 24 Tier 1 PA; QL Tier 3 hour SOLUTION hydromorphone hcl injection HYMOVIS INTRA- Tier 1 QL solution ARTICULAR SOLUTION Tier 4 PA; QL; LD; SP PREFILLED SYRINGE hydromorphone hcl oral Tier 1 QL liquid hyoscyamine sulfate er oral tablet extended release 12 Tier 1 hydromorphone hcl oral Tier 1 QL hour tablet hyoscyamine sulfate sl Tier 1 sublingual tablet sublingual hyoscyamine sulfate Tier 1 sublingual tablet sublingual

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 73 Drug Name Tier Notes Drug Name Tier Notes HYPERRAB INJECTION icosapent ethyl oral capsule Tier 1 PA; QL Tier 4 SP SOLUTION IDAMYCIN PFS HYPERRAB S/D INTRAVENOUS Tier 3 SP Tier 4 SP INJECTION SOLUTION SOLUTION HYPERRHO S/D idarubicin hcl intravenous Tier 1 SP INTRAMUSCULAR solution Tier 4 LD; SP SOLUTION PREFILLED IDELVION SYRINGE INTRAVENOUS Tier 4 PA; QL; LD; SP HYPERSAL SOLUTION INHALATION RECONSTITUTED Tier 3 NEBULIZATION IDHIFA ORAL TABLET Tier 3 PA; QL; LD; SP SOLUTION IFEX INTRAVENOUS HYPERTET S/D SOLUTION Tier 3 SP INTRAMUSCULAR Tier 3 RECONSTITUTED INJECTABLE ifosfamide intravenous HYPOLANCE AST Tier 1 SP Tier 2 solution LANCING KIT ifosfamide intravenous HYQVIA Tier 1 SP Tier 4 PA; QL; LD; SP solution reconstituted 1 gm SUBCUTANEOUS KIT IFOSFAMIDE HY-VEE LANCETS Tier 2 QL INTRAVENOUS Tier 3 SP HY-VEE THIN LANCETS Tier 2 QL SOLUTION ibandronate sodium RECONSTITUTED 3 GM Tier 4 intravenous solution ILARIS ibandronate sodium oral SUBCUTANEOUS Tier 4 PA; QL; LD; SP Tier 1 ST; QL tablet SOLUTION IBRANCE ORAL ILEVRO OPHTHALMIC Tier 2 PA; QL; LD; SP Tier 2 CAPSULE SUSPENSION IBRANCE ORAL ILIDERM EXTERNAL Tier 2 PA; QL; LD; SP Tier 3 TABLET EMULSION ibu oral tablet Tier 1 T1S ILUVIEN INTRAVITREAL Tier 4 PA; QL; LD; SP ibuprofen lysine intravenous Tier 1 IMPLANT solution imatinib mesylate oral tablet Tier 1 PA; QL; SP ibuprofen oral suspension Tier 1 T1S IMBRUVICA ORAL Tier 3 PA; QL; LD ibuprofen oral tablet Tier 1 T1S CAPSULE ibutilide fumarate IMBRUVICA ORAL Tier 1 Tier 3 PA; QL; LD intravenous solution TABLET icatibant acetate Tier 4 PA; QL; SP IMCIVREE subcutaneous solution SUBCUTANEOUS Tier 4 PA; QL; LD iclevia oral tablet Tier 1 $0 SOLUTION ICLUSIG ORAL TABLET Tier 2 PA; QL; LD

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 74 Drug Name Tier Notes Drug Name Tier Notes IMFINZI INTRAVENOUS INCRELEX Tier 3 PA; QL; LD; SP SOLUTION SUBCUTANEOUS Tier 4 PA; QL; LD; SP imipenem-cilastatin SOLUTION intravenous solution Tier 1 indapamide oral tablet Tier 1 T1S reconstituted INDERAL XL ORAL imipramine hcl oral tablet Tier 1 CAPSULE EXTENDED Tier 3 RELEASE 24 HOUR imipramine pamoate oral Tier 1 indomethacin er oral capsule capsule Tier 1 extended release imiquimod external cream Tier 1 ST; QL 3.75 % indomethacin oral capsule Tier 1 imiquimod external cream 5 indomethacin sodium Tier 1 % intravenous solution Tier 1 imiquimod pump external reconstituted Tier 1 ST; QL cream INFANRIX IMLYGIC INTRAMUSCULAR Tier 3 $0 INTRALESIONAL Tier 3 LD SUSPENSION SUSPENSION INFASURF IMOGAM RABIES-HT INTRATRACHEAL Tier 3 Tier 4 SP INJECTION SOLUTION SUSPENSION INFED INJECTION IMOVAX RABIES Tier 3 INTRAMUSCULAR Tier 3 SOLUTION INJECTABLE INFLECTRA IMPAVIDO ORAL INTRAVENOUS Tier 3 PA; QL Tier 4 PA; QL; LD; SP CAPSULE SOLUTION RECONSTITUTED IMURAN ORAL TABLET Tier 3 INFUGEM IMVEXXY INTRAVENOUS Tier 3 SP MAINTENANCE PACK Tier 3 SOLUTION VAGINAL INSERT INFUMORPH 200 Tier 3 IMVEXXY STARTER INJECTION SOLUTION Tier 3 PACK VAGINAL INSERT INFUMORPH 500 Tier 3 IN TOUCH LANCING INJECTION SOLUTION Tier 2 DEVICE INFUVITE ADULT IN TOUCH STERILE INTRAVENOUS Tier 3 Tier 2 QL LANCETS 30G INJECTABLE inatal gt oral tablet Tier 1 INFUVITE PEDIATRIC INTRAVENOUS Tier 3 INBRIJA INHALATION Tier 4 PA; QL; LD SOLUTION CAPSULE INGREZZA ORAL Tier 4 PA; DO; QL; LD incassia oral tablet Tier 1 $0 CAPSULE 40 MG INGREZZA ORAL Tier 4 PA; QL; LD CAPSULE 80 MG

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 75 Drug Name Tier Notes Drug Name Tier Notes INGREZZA ORAL INSUPEN ULTRAFIN Tier 3 ST; QL CAPSULE THERAPY Tier 4 PA; QL; LD INTEGRILIN PACK INTRAVENOUS Tier 3 INJECTAFER SOLUTION INTRAVENOUS Tier 3 INTELENCE ORAL Tier 2 PA; QL SOLUTION TABLET INLYTA ORAL TABLET Tier 2 PA; QL; LD; SP INTERCEED (TC7) Tier 3 inner ear plus oral tablet Tier 1 $0 EXTERNAL PAD INNOPRAN XL ORAL INTERCEED EXTERNAL Tier 3 CAPSULE EXTENDED Tier 3 PAD RELEASE 24 HOUR INTRALIPID INQOVI ORAL TABLET Tier 3 PA; QL; LD; SP INTRAVENOUS Tier 3 INREBIC ORAL EMULSION Tier 3 PA; QL; LD; SP CAPSULE INTRAROSA VAGINAL Tier 3 ST; QL INSERT INSPRA ORAL TABLET Tier 3 INTRON A INJECTION Tier 4 LD; SP INSTAT EXTERNAL PAD Tier 3 SOLUTION INSULIN LISPRO (1 INTRON A INJECTION UNIT DIAL) SOLUTION Tier 4 LD; SP SUBCUTANEOUS Tier 2 RECONSTITUTED SOLUTION PEN- INJECTOR introvale oral tablet Tier 1 $0 INSULIN LISPRO INVANZ INJECTION JUNIOR KWIKPEN SOLUTION Tier 3 SUBCUTANEOUS Tier 2 RECONSTITUTED SOLUTION PEN- INVEGA SUSTENNA INJECTOR INTRAMUSCULAR Tier 3 INSULIN LISPRO PROT SUSPENSION & LISPRO PREFILLED SYRINGE SUBCUTANEOUS Tier 2 INVEGA TRINZA SUSPENSION PEN- INTRAMUSCULAR Tier 3 INJECTOR SUSPENSION INSULIN LISPRO PREFILLED SYRINGE SUBCUTANEOUS Tier 2 INVELTYS SOLUTION OPHTHALMIC Tier 3 INSULIN SYRINGE Tier 3 ST; QL SUSPENSION INSULIN INVIRASE ORAL Tier 3 ST; QL Tier 2 QL SYRINGE/NEEDLE TABLET INSULIN SYRINGE- IODINE TINCTURE Tier 3 ST; QL Tier 3 NEEDLE U-100 EXTERNAL TINCTURE IODOFLEX EXTERNAL INSUPEN PEN NEEDLES Tier 3 ST; QL Tier 3 PAD INSUPEN SENSITIVE Tier 3 ST; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 76 Drug Name Tier Notes Drug Name Tier Notes IODOSORB EXTERNAL ISOLYTE-S Tier 3 GEL INTRAVENOUS Tier 3 IONOSOL-MB IN D5W SOLUTION INTRAVENOUS Tier 3 ISOLYTE-S PH 7.4 SOLUTION INTRAVENOUS Tier 3 IOPIDINE SOLUTION OPHTHALMIC Tier 3 isoniazid injection solution Tier 1 SOLUTION isoniazid oral syrup Tier 1 T1S IPOL INJECTION Tier 3 $0 INJECTABLE isoniazid oral tablet Tier 1 T1S ipratropium bromide isoproterenol hcl injection Tier 1 Tier 1 inhalation solution solution ipratropium bromide nasal ISOPROTERENOL- Tier 1 SODIUM CHLORIDE solution Tier 3 INTRAVENOUS ipratropium-albuterol Tier 1 SOLUTION inhalation solution ISOPTO ATROPINE irbesartan oral tablet 150 mg, Tier 1 DO OPHTHALMIC Tier 3 75 mg SOLUTION irbesartan oral tablet 300 mg Tier 1 ISOPTO CARPINE irbesartan- OPHTHALMIC Tier 3 hydrochlorothiazide oral Tier 1 SOLUTION tablet ISORDIL TITRADOSE Tier 3 IRESSA ORAL TABLET Tier 2 PA; QL; LD; SP ORAL TABLET irinotecan hcl intravenous isosorbide dinitrate oral Tier 1 SP solution tablet 10 mg, 20 mg, 30 mg, Tier 1 T1S 5 mg ISENTRESS HD ORAL Tier 3 QL isosorbide dinitrate oral TABLET Tier 1 tablet 40 mg ISENTRESS ORAL Tier 3 QL PACKET isosorbide mononitrate er oral tablet extended release Tier 1 T1S ISENTRESS ORAL Tier 2 QL 24 hour TABLET isosorbide mononitrate oral ISENTRESS ORAL Tier 1 T1S Tier 2 QL tablet TABLET CHEWABLE isotretinoin oral capsule Tier 2 PA; QL isibloom oral tablet Tier 1 $0 isradipine oral capsule Tier 1 isoflurane inhalation solution Tier 1 ISTODAX (OVERFILL) ISOLYTE-P IN D5W INTRAVENOUS Tier 3 PA; QL; LD; SP INTRAVENOUS Tier 3 SOLUTION SOLUTION RECONSTITUTED ISTURISA ORAL Tier 4 PA; QL; LD TABLET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 77 Drug Name Tier Notes Drug Name Tier Notes ISUPREL INJECTION JENLIVA Tier 3 SOLUTION PRENATAL/POSTNATAL Tier 2 itraconazole oral capsule Tier 1 PA; QL ORAL CAPSULE itraconazole oral solution Tier 1 PA; QL JEVTANA INTRAVENOUS Tier 3 PA; QL; LD; SP ivermectin external lotion Tier 1 SOLUTION ivermectin oral tablet Tier 1 jinteli oral tablet Tier 1 IXEMPRA KIT JIVI INTRAVENOUS INTRAVENOUS SOLUTION Tier 4 PA; QL; LD; SP Tier 3 PA; QL; SP SOLUTION RECONSTITUTED RECONSTITUTED JOHNSON GRASS IXIARO SUBCUTANEOUS Tier 3 INTRAMUSCULAR Tier 3 SOLUTION SUSPENSION jolessa oral tablet Tier 1 $0 IXINITY INTRAVENOUS JORNAY PM ORAL SOLUTION Tier 4 PA; QL; LD; SP CAPSULE EXTENDED Tier 3 PA; QL RECONSTITUTED RELEASE 24 HOUR 100 JADENU ORAL TABLET Tier 4 PA; QL; LD; SP MG, 60 MG, 80 MG JADENU SPRINKLE JORNAY PM ORAL Tier 4 PA; QL; LD; SP ORAL PACKET CAPSULE EXTENDED Tier 3 PA; DO; QL jaimiess oral tablet Tier 1 $0 RELEASE 24 HOUR 20 MG, 40 MG JAKAFI ORAL TABLET Tier 2 PA; QL; LD; SP JUBLIA EXTERNAL Tier 3 JALYN ORAL CAPSULE Tier 3 SOLUTION jantoven oral tablet Tier 1 T1S juleber oral tablet Tier 1 $0 JANUMET ORAL JULUCA ORAL TABLET Tier 3 PA; QL Tier 2 ST; QL TABLET JUNE GRASS POLLEN JANUMET XR ORAL STANDARDIZED Tier 3 TABLET EXTENDED Tier 2 ST; QL SUBCUTANEOUS RELEASE 24 HOUR SOLUTION JANUVIA ORAL junel 1.5/30 oral tablet Tier 1 $0 Tier 2 ST; QL TABLET junel 1/20 oral tablet Tier 1 $0 JARDIANCE ORAL Tier 2 ST; QL junel fe 1.5/30 oral tablet Tier 1 $0 TABLET junel fe 1/20 oral tablet Tier 1 $0 jasmiel oral tablet Tier 1 $0 junel fe 24 oral tablet Tier 1 $0 JATENZO ORAL Tier 3 PA; QL JUXTAPID ORAL CAPSULE Tier 3 PA; DO; QL; LD CAPSULE JELMYTO SOLUTION Tier 3 PA; QL; LD JYNARQUE ORAL RECONSTITUTED Tier 4 PA; QL; LD TABLET jencycla oral tablet Tier 1 $0

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 78 Drug Name Tier Notes Drug Name Tier Notes JYNARQUE ORAL kariva oral tablet Tier 1 $0 TABLET THERAPY Tier 4 PA; QL; LD KATERZIA ORAL Tier 3 PACK SUSPENSION KABIVEN KCENTRA Tier 3 INTRAVENOUS Tier 3 INTRAVENOUS KIT EMULSION KCL (IN NACL 0.9%) KADCYLA INTRAVENOUS Tier 3 INTRAVENOUS Tier 3 PA; QL; LD; SP SOLUTION SOLUTION RECONSTITUTED kcl in dextrose-nacl intravenous solution 10-5- kaitlib fe oral tablet chewable Tier 1 $0 0.45 meq/l-%-%, 20-5-0.2 KALBITOR meq/l-%-%, 20-5-0.45 meq/l- Tier 1 SUBCUTANEOUS Tier 4 PA; QL; LD; SP %-%, 20-5-0.9 meq/l-%-%, SOLUTION 30-5-0.45 meq/l-%-%, 40-5- KALETRA ORAL 0.45 meq/l-%-% Tier 3 QL SOLUTION KCL IN DEXTROSE- KALETRA ORAL NACL INTRAVENOUS Tier 2 QL TABLET SOLUTION 20-5-0.225 Tier 3 MEQ/L-%-%, 40-5-0.9 kalliga oral tablet Tier 1 $0 MEQ/L-%-% KALYDECO ORAL Tier 4 PA; QL; LD KCL-LACTATED PACKET RINGERS-D5W Tier 3 KANJINTI INTRAVENOUS INTRAVENOUS SOLUTION Tier 3 LD; SP SOLUTION kedbumin intravenous Tier 1 RECONSTITUTED solution KANUMA KEDRAB INJECTION Tier 4 SP INTRAVENOUS Tier 3 PA; QL; LD; SP SOLUTION SOLUTION KEFLEX ORAL Tier 3 KAPOK CAPSULE SUBCUTANEOUS Tier 3 SOLUTION kelnor 1/35 oral tablet Tier 1 $0 KAPSPARGO SPRINKLE kelnor 1/50 oral tablet Tier 1 $0 ORAL CAPSULE ER 24 Tier 3 KENALOG INJECTION Tier 3 HOUR SPRINKLE SUSPENSION KAPVAY ORAL TABLET KENALOG-80 EXTENDED RELEASE 12 Tier 3 PA; QL INJECTION Tier 3 HOUR SUSPENSION KARBINAL ER ORAL KENDALL HYDROGEL SUSPENSION Tier 3 WOUND DRESS Tier 3 EXTENDED RELEASE EXTERNAL KARDIAMEMBRANE Tier 3 EXTERNAL SHEET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 79 Drug Name Tier Notes Drug Name Tier Notes KENGREAL ketorolac tromethamine oral Tier 1 QL INTRAVENOUS tablet Tier 3 SOLUTION KEVEYIS ORAL Tier 4 PA; QL; LD RECONSTITUTED TABLET KEPIVANCE KEYTRUDA INTRAVENOUS Tier 4 INTRAVENOUS Tier 3 PA; QL; LD; SP SOLUTION SOLUTION RECONSTITUTED KHAPZORY KERYDIN EXTERNAL INTRAVENOUS Tier 3 ST; QL Tier 3 PA; QL; LD; SP SOLUTION SOLUTION KESIMPTA RECONSTITUTED SUBCUTANEOUS Tier 4 PA; QL; LD; SP KINNEY LANCETS Tier 2 QL SOLUTION AUTO- INJECTOR KINNEY THIN LANCETS Tier 2 QL KETALAR INJECTION KINRAY INSULIN Tier 3 Tier 3 ST; QL SOLUTION SYRINGE ketamine hcl injection KINRIX Tier 1 solution INTRAMUSCULAR Tier 3 $0 SUSPENSION KETAMINE HCL INTRAVENOUS KISQALI (200 MG DOSE) Tier 3 SOLUTION PREFILLED ORAL TABLET Tier 2 PA; QL; SP SYRINGE THERAPY PACK KETAMINE HCL- KISQALI (400 MG DOSE) SODIUM CHLORIDE ORAL TABLET Tier 2 PA; QL; SP INTRAVENOUS Tier 3 THERAPY PACK SOLUTION PREFILLED KISQALI (600 MG DOSE) SYRINGE ORAL TABLET Tier 2 PA; QL; SP ketoconazole external cream Tier 1 THERAPY PACK KISQALI FEMARA (400 ketoconazole external foam Tier 1 MG DOSE) ORAL Tier 2 PA; QL; SP ketoconazole external TABLET THERAPY Tier 1 shampoo PACK ketoconazole oral tablet Tier 1 KISQALI FEMARA (600 MG DOSE) ORAL ketoprofen er oral capsule Tier 2 PA; QL; SP Tier 1 TABLET THERAPY extended release 24 hour PACK ketoprofen oral capsule Tier 1 KISQALI FEMARA(200 ketorolac tromethamine MG DOSE) ORAL Tier 1 QL Tier 2 PA; QL; SP injection solution TABLET THERAPY PACK ketorolac tromethamine Tier 1 QL KLARON EXTERNAL intramuscular solution Tier 3 LOTION ketorolac tromethamine Tier 1 ophthalmic solution

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 80 Drug Name Tier Notes Drug Name Tier Notes KLISYRI EXTERNAL KOGENATE FS Tier 3 ST; QL Tier 4 PA; QL; LD; SP OINTMENT INTRAVENOUS KIT klor-con 10 oral tablet KORLYM ORAL Tier 1 T1S Tier 4 PA; QL; LD extended release TABLET klor-con m10 oral tablet KOSELUGO ORAL Tier 1 T1S Tier 3 PA; QL; LD extended release CAPSULE klor-con m15 oral tablet KOSHER PRENATAL Tier 1 T1S extended release PLUS IRON ORAL Tier 3 ST; QL klor-con m20 oral tablet TABLET Tier 1 T1S extended release KOVALTRY INTRAVENOUS klor-con oral packet Tier 1 T1S Tier 4 PA; QL; LD; SP SOLUTION klor-con oral tablet extended Tier 1 T1S RECONSTITUTED release kp aspirin oral tablet delayed kls aspirin ec oral tablet Tier 1 $0 Tier 1 $0 release delayed release kp b complex-c oral tablet Tier 1 $0 kls aspirin low dose oral Tier 1 $0 kp bisacodyl oral tablet tablet delayed release Tier 1 $0 delayed release kls laxaclear oral powder Tier 1 $0 kp folic acid oral tablet Tier 1 $0 kls quit2 mouth/throat gum Tier 1 $0 KP PRENATAL kls quit2 mouth/throat Tier 1 $0 MULTIVITAMINS ORAL Tier 2 $0 lozenge TABLET kls quit4 mouth/throat gum Tier 1 $0 K-PHOS NO 2 ORAL Tier 3 kls quit4 mouth/throat TABLET Tier 1 $0 lozenge K-PHOS ORAL TABLET Tier 2 KMART VALU INSULIN K-PHOS-NEUTRAL Tier 3 ST; QL Tier 3 SYRINGE 29G ORAL TABLET KMART VALU INSULIN KPN PRENATAL ORAL Tier 3 ST; QL Tier 2 $0 SYRINGE 30G TABLET KOATE INTRAVENOUS KRINTAFEL ORAL Tier 3 SOLUTION Tier 4 PA; QL; LD; SP TABLET RECONSTITUTED KRISTALOSE ORAL Tier 3 KOATE-DVI PACKET INTRAVENOUS Tier 4 PA; QL; LD; SP KROGER AUTOLET SOLUTION Tier 2 RECONSTITUTED LANCING DEVICE KROGER HEALTHPRO kobee oral tablet Tier 1 $0 Tier 2 QL LANCET 26G KOCHIA KROGER INSULIN SUBCUTANEOUS Tier 3 Tier 3 ST; QL SOLUTION SYRINGE KROGER LANCETS Tier 2 QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 81 Drug Name Tier Notes Drug Name Tier Notes KROGER LANCETS 21G Tier 2 QL lactulose encephalopathy oral Tier 1 KROGER LANCETS solution Tier 2 QL MICRO THIN 33G LACTULOSE ORAL Tier 1 KROGER LANCETS PACKET Tier 2 QL SUPER THIN lactulose oral solution Tier 1 KROGER LANCETS Tier 2 QL lamivudine oral solution Tier 1 QL THIN lamivudine oral tablet 100 KROGER LANCETS Tier 1 Tier 2 QL mg THIN 26G lamivudine oral tablet 150 KROGER LANCETS Tier 1 QL Tier 2 QL mg, 300 mg ULTRATHIN 30G lamivudine-zidovudine oral KROGER LANCING Tier 1 QL Tier 2 tablet DEVICE lamotrigine er oral tablet Tier 1 KROGER PEN NEEDLES Tier 3 ST; QL extended release 24 hour KRYSTEXXA lamotrigine oral kit Tier 1 INTRAVENOUS Tier 4 PA; QL; LD; SP SOLUTION lamotrigine oral tablet Tier 1 K-TAB ORAL TABLET lamotrigine oral tablet Tier 3 Tier 1 EXTENDED RELEASE chewable kurvelo oral tablet Tier 1 $0 lamotrigine oral tablet Tier 1 KUVAN ORAL PACKET Tier 4 PA; QL; LD; SP dispersible KUVAN ORAL TABLET lamotrigine starter kit-blue Tier 4 PA; QL; LD; SP Tier 1 SOLUBLE oral kit lamotrigine starter kit-green KYLEENA Tier 1 INTRAUTERINE oral kit Tier 4 LD; SP INTRAUTERINE lamotrigine starter kit-orange Tier 1 DEVICE oral kit KYNMOBI SUBLINGUAL Tier 3 PA; QL; LD LAMPIT ORAL TABLET Tier 3 FILM LANCET DEVICE Tier 2 KYPROLIS INTRAVENOUS LANCET DEVICE WITH Tier 3 PA; QL; LD; SP Tier 2 SOLUTION EJECTOR RECONSTITUTED LANCET Tier 2 labetalol hcl oral tablet Tier 1 TRANSPORTER CASE lactated ringers intravenous LANCETS Tier 2 QL Tier 1 solution LANCETS 30G Tier 2 QL lactated ringers irrigation LANCETS 33G Tier 2 QL Tier 1 solution LANCETS MICRO THIN Tier 2 QL lactic acid e external cream Tier 1 33G lactic acid external lotion Tier 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 82 Drug Name Tier Notes Drug Name Tier Notes LANCETS SUPER THIN LATUDA ORAL TABLET Tier 2 QL Tier 3 DO 28G 20 MG, 40 MG, 60 MG LANCETS THIN Tier 2 QL laxative oral tablet delayed Tier 1 $0 LANCETS ULTRA THIN Tier 2 QL release LANCETS ULTRA THIN layolis fe oral tablet Tier 2 QL Tier 1 $0 30G chewable LEADER ADVANCED LANCING DEVICE Tier 2 Tier 2 LANCING DEVICE LANOXIN INJECTION LEADER INSULIN Tier 3 Tier 3 ST; QL SOLUTION SYRINGE LANOXIN ORAL LEADER UNIFINE Tier 2 Tier 3 ST; QL TABLET PENTIPS LANOXIN PEDIATRIC LEADER UNIFINE Tier 2 Tier 3 ST; QL INJECTION SOLUTION PENTIPS PLUS lanthanum carbonate oral Tier 1 leena oral tablet Tier 1 $0 tablet chewable leflunomide oral tablet Tier 1 LANTUS SOLOSTAR SUBCUTANEOUS LEMTRADA Tier 2 SOLUTION PEN- INTRAVENOUS Tier 4 PA; QL; LD; SP INJECTOR SOLUTION LANTUS LENSCALE SUBCUTANEOUS Tier 2 SUBCUTANEOUS Tier 3 SOLUTION SOLUTION LANZO Tier 2 LENVIMA (10 MG DAILY DOSE) ORAL CAPSULE Tier 3 PA; QL; LD; SP lapatinib ditosylate oral Tier 1 PA; QL; SP THERAPY PACK tablet LENVIMA (12 MG DAILY larin 1.5/30 oral tablet Tier 1 $0 DOSE) ORAL CAPSULE Tier 3 PA; QL; LD; SP larin 1/20 oral tablet Tier 1 $0 THERAPY PACK larin 24 fe oral tablet Tier 1 $0 LENVIMA (14 MG DAILY larin fe 1.5/30 oral tablet Tier 1 $0 DOSE) ORAL CAPSULE Tier 3 PA; QL; LD; SP THERAPY PACK larin fe 1/20 oral tablet Tier 1 $0 LENVIMA (18 MG DAILY larissia oral tablet Tier 1 $0 DOSE) ORAL CAPSULE Tier 3 PA; QL; LD; SP LASIX ORAL TABLET Tier 3 THERAPY PACK latanoprost ophthalmic LENVIMA (20 MG DAILY Tier 1 solution DOSE) ORAL CAPSULE Tier 3 PA; QL; LD; SP THERAPY PACK LATISSE EXTERNAL Tier 3 SOLUTION LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE Tier 3 PA; QL; LD; SP LATUDA ORAL TABLET Tier 3 THERAPY PACK 120 MG, 80 MG

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 83 Drug Name Tier Notes Drug Name Tier Notes LENVIMA (4 MG DAILY LEVETIRACETAM IN DOSE) ORAL CAPSULE Tier 3 PA; QL; LD; SP NACL INTRAVENOUS Tier 3 THERAPY PACK SOLUTION LENVIMA (8 MG DAILY levetiracetam intravenous Tier 1 DOSE) ORAL CAPSULE Tier 3 PA; QL; LD; SP solution THERAPY PACK levetiracetam oral solution Tier 1 lessina oral tablet Tier 1 $0 levetiracetam oral tablet Tier 1 letrozole oral tablet Tier 1 $0 levobunolol hcl ophthalmic leucovorin calcium injection Tier 1 Tier 1 solution solution levocarnitine oral solution Tier 1 leucovorin calcium injection Tier 1 solution reconstituted levocarnitine oral tablet Tier 1 leucovorin calcium oral Tier 1 levocarnitine sf oral solution Tier 1 tablet levocetirizine LEUKERAN ORAL Tier 1 Tier 2 dihydrochloride oral solution TABLET levocetirizine Tier 1 LEUKINE INJECTION dihydrochloride oral tablet SOLUTION Tier 4 PA; QL; SP levofloxacin in d5w RECONSTITUTED Tier 1 intravenous solution leuprolide acetate injection Tier 1 PA; QL; SP levofloxacin intravenous kit Tier 1 solution LEUPROLIDE levofloxacin ophthalmic ACETATE- Tier 1 BUPIVACAINE Tier 3 solution INTRAMUSCULAR levofloxacin oral solution Tier 1 QL SOLUTION levofloxacin oral tablet Tier 1 QL levalbuterol hcl inhalation Tier 1 nebulization solution levoleucovorin calcium intravenous solution Tier 1 PA; QL levalbuterol tartrate Tier 1 reconstituted inhalation aerosol levoleucovorin calcium pf LEVAQUIN ORAL Tier 1 Tier 3 QL intravenous solution TABLET levonest oral tablet Tier 1 $0 LEVEMIR FLEXTOUCH levonorgest-eth est & eth est SUBCUTANEOUS Tier 1 $0 Tier 2 oral tablet SOLUTION PEN- INJECTOR levonorgest-eth estrad 91-day Tier 1 $0 oral tablet LEVEMIR SUBCUTANEOUS Tier 2 levonorgestrel oral tablet Tier 1 $0 SOLUTION levonorgestrel-ethinyl estrad levetiracetam er oral tablet oral tablet 0.1-20 mg-mcg, Tier 1 $0 Tier 1 extended release 24 hour 0.15-30 mg-mcg

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 84 Drug Name Tier Notes Drug Name Tier Notes levonorgestrel-ethinyl estrad LIBTAYO Tier 1 $0 oral tablet 90-20 mcg INTRAVENOUS Tier 3 PA; QL; LD levonorg-eth estrad triphasic SOLUTION Tier 1 $0 oral tablet LIDOCAINE LEVOPHED (ANORECTAL) RECTAL Tier 3 INTRAVENOUS Tier 3 SUPPOSITORY SOLUTION lidocaine external ointment Tier 1 levora 0.15/30 (28) oral Tier 1 $0 lidocaine external patch Tier 1 PA; QL tablet LIDOCAINE HCL levorphanol tartrate oral Tier 1 PA; QL (CARDIAC) tablet INTRAVENOUS Tier 3 levo-t oral tablet Tier 1 T1S SOLUTION PREFILLED SYRINGE 100 MG/10ML LEVOTHYROXINE SODIUM INTRAVENOUS Tier 3 LIDOCAINE HCL SOLUTION (CARDIAC) INTRAVENOUS Tier 3 levothyroxine sodium SOLUTION PREFILLED intravenous solution Tier 1 SYRINGE 100 MG/5ML reconstituted 100 mcg, 500 mcg lidocaine hcl (cardiac) intravenous solution prefilled Tier 1 LEVOTHYROXINE syringe 50 mg/5ml SODIUM INTRAVENOUS SOLUTION Tier 3 LIDOCAINE HCL (CARDIAC) PF RECONSTITUTED 200 Tier 3 MCG INTRAVENOUS SOLUTION levothyroxine sodium oral Tier 1 capsule lidocaine hcl (cardiac) pf intravenous solution prefilled Tier 1 levothyroxine sodium oral Tier 1 T1S syringe tablet lidocaine hcl (pf) injection Tier 1 levoxyl oral tablet Tier 1 T1S solution LEVULAN KERASTICK lidocaine hcl external Tier 1 EXTERNAL SOLUTION Tier 3 solution RECONSTITUTED lidocaine hcl injection LEXIVA ORAL Tier 1 Tier 2 QL solution SUSPENSION LIDOCAINE HCL LEXIVA ORAL TABLET Tier 3 QL INJECTION SOLUTION Tier 3 LIBERTY MEDICAL PREFILLED SYRINGE Tier 2 QL LANCETS lidocaine hcl intradermal jet- Tier 1 LIBERTY MINI injector Tier 2 LANCING DEVICE lidocaine hcl mouth/throat Tier 1 LIBRAX ORAL solution Tier 3 CAPSULE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 85 Drug Name Tier Notes Drug Name Tier Notes lidocaine hcl LINCOCIN INJECTION Tier 1 Tier 3 urethral/mucosal external gel SOLUTION lidocaine hcl lincomycin hcl injection Tier 1 urethral/mucosal external Tier 1 solution prefilled syringe lindane external shampoo Tier 1 lidocaine in d5w intravenous Tier 1 linezolid in sodium chloride solution Tier 1 intravenous solution LIDOCAINE IN Tier 3 DEXTROSE SOLUTION linezolid intravenous solution Tier 1 lidocaine viscous hcl linezolid oral suspension Tier 1 Tier 1 PA; QL mouth/throat solution reconstituted lidocaine-epinephrine linezolid oral tablet Tier 1 PA; QL Tier 1 injection solution LINZESS ORAL Tier 2 LIDOCAINE- CAPSULE EPINEPHRINE Tier 3 LIORESAL INTRAOCULAR INTRATHECAL Tier 3 SOLUTION SOLUTION LIDOCAINE- liothyronine sodium PHENYLEPHRINE Tier 1 Tier 3 intravenous solution INTRAOCULAR liothyronine sodium oral SOLUTION Tier 1 T1S tablet LIDOCAINE- lipo flavonoid plus oral tablet Tier 1 $0 PHENYLEPHRINE-BSS INTRAOCULAR Tier 3 LIPO INTRAMUSCULAR Tier 3 SOLUTION PREFILLED SOLUTION SYRINGE LIPO-B lidocaine-prilocaine external INTRAMUSCULAR Tier 3 Tier 1 cream SOLUTION lidocaine-prilocaine external LIPO-C Tier 1 kit INTRAMUSCULAR Tier 3 LIDOCAINE-SODIUM SOLUTION BICARBONATE LIPOFEN ORAL Tier 3 Tier 3 ST; QL INJECTION SOLUTION CAPSULE PREFILLED SYRINGE lipoflavonoid oral tablet Tier 1 $0 LIFESCAN UNISTIK 2 Tier 2 QL lipoflavovit oral tablet Tier 1 $0 LIFESCAN UNISTIK II lisinopril oral tablet 10 mg, Tier 2 QL Tier 1 DO; T1S LANCETS 2.5 mg, 20 mg, 5 mg LILETTA (52 MG) lisinopril oral tablet 30 mg, INTRAUTERINE Tier 1 T1S Tier 3 LD; SP 40 mg INTRAUTERINE DEVICE lisinopril- hydrochlorothiazide oral Tier 1 DO lillow oral tablet Tier 1 $0 tablet 10-12.5 mg

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 86 Drug Name Tier Notes Drug Name Tier Notes lisinopril- loestrin fe 1/20 oral tablet Tier 1 $0 hydrochlorothiazide oral Tier 1 lojaimiess oral tablet Tier 1 $0 tablet 20-12.5 mg, 20-25 mg LOKELMA ORAL Tier 3 LITE TOUCH LANCETS Tier 2 QL PACKET LITE TOUCH LANCING LOMAIRA ORAL Tier 2 Tier 3 PA; QL PEN TABLET LITETOUCH INSULIN LOMOTIL ORAL Tier 3 ST; QL Tier 3 SYRINGE TABLET LITETOUCH LANCETS Tier 2 QL LONGS INSULIN Tier 3 ST; QL LITETOUCH PEN SYRINGE Tier 3 ST; QL NEEDLES LONGS LANCETS Tier 2 QL lithium carbonate er oral STANDARD Tier 1 T1S tablet extended release LONGS LANCETS THIN Tier 2 QL lithium carbonate oral LONGS LANCETS Tier 1 T1S Tier 2 QL capsule ULTRA THIN lithium carbonate oral tablet Tier 1 T1S LONHALA MAGNAIR LITHIUM ORAL REFILL KIT Tier 2 Tier 3 ST; QL SOLUTION INHALATION LITHOSTAT ORAL SOLUTION Tier 3 TABLET LONHALA MAGNAIR LIVE BETTER ADV STARTER KIT Tier 2 Tier 3 ST; QL LANCING DEVICE INHALATION SOLUTION LIVE BETTER LANCET Tier 2 QL LONSURF ORAL SUPER THIN Tier 3 PA; QL; LD; SP TABLET LIVE BETTER LANCET Tier 2 QL ULTRA THIN loperamide hcl oral capsule Tier 1 lmd in d5w intravenous LOPID ORAL TABLET Tier 3 ST; QL Tier 1 solution lopinavir-ritonavir oral Tier 1 QL lmd in nacl intravenous solution Tier 1 solution LOPROX EXTERNAL Tier 3 ST; QL LO LOESTRIN FE ORAL CREAM Tier 2 TABLET LOPROX EXTERNAL Tier 3 LODINE ORAL TABLET Tier 3 SHAMPOO LODOSYN ORAL LOPROX EXTERNAL Tier 3 Tier 3 ST; QL TABLET SUSPENSION loestrin 1.5/30 (21) oral lorazepam injection solution Tier 1 Tier 1 $0 tablet lorazepam intensol oral Tier 1 loestrin 1/20 (21) oral tablet Tier 1 $0 concentrate loestrin fe 1.5/30 oral tablet Tier 1 $0 lorazepam oral concentrate Tier 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 87 Drug Name Tier Notes Drug Name Tier Notes loxapine succinate oral lorazepam oral tablet Tier 1 Tier 1 capsule LORBRENA ORAL Tier 3 PA; QL; LD; SP TABLET lo-zumandimine oral tablet Tier 1 $0 loryna oral tablet Tier 1 $0 lubiprostone oral capsule Tier 1 lorzone oral tablet Tier 1 ST; QL LUCEMYRA ORAL Tier 3 TABLET losartan potassium oral tablet Tier 1 LUCENTIS losartan potassium-hctz oral INTRAVITREAL Tier 4 PA; QL; LD; SP tablet 100-12.5 mg, 100-25 Tier 1 SOLUTION mg LUCENTIS losartan potassium-hctz oral INTRAVITREAL Tier 1 DO Tier 4 PA; QL; LD; SP tablet 50-12.5 mg SOLUTION PREFILLED LOSEASONIQUE ORAL SYRINGE Tier 3 TABLET luliconazole external cream Tier 1 ST; QL LOTEMAX Tier 2 LUMIGAN OPHTHALMIC GEL OPHTHALMIC Tier 2 LOTEMAX SOLUTION OPHTHALMIC Tier 3 LUMIZYME OINTMENT INTRAVENOUS Tier 4 PA; QL; LD; SP LOTEMAX SOLUTION OPHTHALMIC Tier 3 RECONSTITUTED SUSPENSION LUMOXITI LOTEMAX SM INTRAVENOUS Tier 3 Tier 3 PA; QL; LD; SP OPHTHALMIC GEL SOLUTION LOTENSIN HCT ORAL RECONSTITUTED Tier 3 DO TABLET 10-12.5 MG LUPANETA PACK Tier 4 PA; QL; SP LOTENSIN HCT ORAL COMBINATION KIT TABLET 20-12.5 MG, 20- Tier 3 LUPKYNIS ORAL Tier 4 PA; QL; LD 25 MG CAPSULE LOTENSIN ORAL LUPRON DEPOT (1- Tier 3 TABLET MONTH) Tier 4 PA; QL; SP loteprednol etabonate INTRAMUSCULAR KIT Tier 1 ophthalmic gel 3.75 MG loteprednol etabonate LUPRON DEPOT (1- Tier 1 MONTH) ophthalmic suspension Tier 3 PA; QL; SP INTRAMUSCULAR KIT LOTRONEX ORAL Tier 3 PA; QL 7.5 MG TABLET LUPRON DEPOT (3- lovastatin oral tablet 10 mg, MONTH) Tier 1 DO; $0 Tier 4 PA; QL; SP 20 mg INTRAMUSCULAR KIT lovastatin oral tablet 40 mg Tier 1 $0 11.25 MG low-ogestrel oral tablet Tier 1 $0

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 88 Drug Name Tier Notes Drug Name Tier Notes LUPRON DEPOT (3- M.V.I. ADULT MONTH) INTRAVENOUS Tier 3 Tier 3 PA; QL; SP INTRAMUSCULAR KIT INJECTABLE 22.5 MG M.V.I. PEDIATRIC LUPRON DEPOT (4- INTRAVENOUS Tier 3 MONTH) Tier 3 PA; QL; SP SOLUTION INTRAMUSCULAR KIT RECONSTITUTED LUPRON DEPOT (6- MACROBID ORAL Tier 3 MONTH) Tier 3 PA; QL; SP CAPSULE INTRAMUSCULAR KIT MACRODANTIN ORAL Tier 3 LUPRON DEPOT-PED (1- CAPSULE MONTH) Tier 4 PA; QL; SP mafenide acetate external Tier 1 INTRAMUSCULAR KIT packet LUPRON DEPOT-PED (3- MAGELLAN INSULIN Tier 3 ST; QL MONTH) Tier 4 PA; QL; SP SAFETY SYR INTRAMUSCULAR KIT magnesium citrate oral Tier 1 $0 LUTATHERA solution INTRAVENOUS Tier 3 PA; QL; LD SOLUTION MAGNESIUM SULFATE IN D5W INTRAVENOUS Tier 3 lutera oral tablet Tier 1 $0 SOLUTION LUZU EXTERNAL Tier 3 ST; QL MAGNESIUM SULFATE CREAM INTRAVENOUS Tier 3 lyleq oral tablet Tier 1 $0 SOLUTION lyllana transdermal patch MAKENA Tier 1 Tier 4 PA; QL; LD; SP twice weekly INTRAMUSCULAR OIL LYNPARZA ORAL MAKENA Tier 3 PA; QL; LD; SP TABLET SUBCUTANEOUS Tier 4 PA; QL; LD; SP LYRICA CR ORAL SOLUTION AUTO- TABLET EXTENDED INJECTOR Tier 3 PA; DO; QL RELEASE 24 HOUR 165 MALARONE ORAL Tier 3 MG, 82.5 MG TABLET LYRICA CR ORAL malathion external lotion Tier 1 TABLET EXTENDED Tier 3 PA; QL manganese chloride RELEASE 24 HOUR 330 Tier 1 MG intravenous solution LYSINE HCL mannitol intravenous Tier 3 Tier 1 INJECTION SOLUTION solution LYSODREN ORAL maprotiline hcl oral tablet Tier 1 Tier 2 LD TABLET MARATHON MEDICAL Tier 3 ST; QL LYSTEDA ORAL PENTIPS Tier 3 TABLET MARCAINE INJECTION Tier 3 lyza oral tablet Tier 1 $0 SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 89 Drug Name Tier Notes Drug Name Tier Notes MARCAINE MAVENCLAD (6 TABS) PRESERVATIVE FREE Tier 3 ORAL TABLET Tier 4 PA; QL; LD; SP INJECTION SOLUTION THERAPY PACK MARCAINE SPINAL MAVENCLAD (7 TABS) INTRATHECAL Tier 3 ORAL TABLET Tier 4 PA; QL; LD; SP SOLUTION THERAPY PACK MARCAINE/EPINEPHRI MAVENCLAD (8 TABS) NE INJECTION Tier 3 ORAL TABLET Tier 4 PA; QL; LD; SP SOLUTION THERAPY PACK MARCAINE/EPINEPHRI MAVENCLAD (9 TABS) NE PF INJECTION Tier 3 ORAL TABLET Tier 4 PA; QL; LD; SP SOLUTION THERAPY PACK MAR-COF BP ORAL MAXICOMFORT II PEN Tier 3 Tier 3 ST; QL LIQUID NEEDLE MAR-COF CG MAXI-COMFORT Tier 3 ST; QL EXPECTORANT ORAL Tier 2 INSULIN SYRINGE LIQUID MAXI-COMFORT Tier 3 ST; QL MARINOL ORAL SAFETY PEN NEEDLE Tier 3 CAPSULE MAXICOMFORT SYR Tier 3 ST; QL marlissa oral tablet Tier 1 $0 27G X 1/2" MARPLAN ORAL MAXIDEX Tier 3 TABLET OPHTHALMIC Tier 3 MARQIBO SUSPENSION INTRAVENOUS Tier 3 LD MAXITROL SUSPENSION OPHTHALMIC Tier 3 MATULANE ORAL OINTMENT Tier 2 LD CAPSULE MAXITROL matzim la oral tablet OPHTHALMIC Tier 3 extended release 24 hour 180 Tier 1 DO SUSPENSION mg maxi-tuss ac oral solution Tier 1 matzim la oral tablet MAXI-TUSS CD ORAL Tier 2 extended release 24 hour 240 Tier 1 LIQUID mg, 300 mg, 360 mg, 420 mg MAXZIDE ORAL Tier 3 MAVENCLAD (10 TABS) TABLET ORAL TABLET Tier 4 PA; QL; LD; SP MAXZIDE-25 ORAL THERAPY PACK Tier 3 TABLET MAVENCLAD (4 TABS) MAYZENT ORAL ORAL TABLET Tier 4 PA; QL; LD; SP Tier 4 PA; QL; LD; SP THERAPY PACK TABLET MAVENCLAD (5 TABS) MAYZENT STARTER ORAL TABLET Tier 4 PA; QL; LD; SP PACK ORAL TABLET Tier 4 PA; QL; LD; SP THERAPY PACK THERAPY PACK

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 90 Drug Name Tier Notes Drug Name Tier Notes M-CLEAR WC ORAL MEDLANCE Tier 2 Tier 2 QL SOLUTION UNIVERSAL 21G MEADOW FESCUE MEDROL ORAL GRASS POLLEN TABLET 16 MG, 32 MG, 4 Tier 3 Tier 3 SUBCUTANEOUS MG, 8 MG SOLUTION MEDROL ORAL Tier 2 meclizine hcl oral tablet 12.5 TABLET 2 MG Tier 1 mg, 25 mg MEDROL ORAL MECLIZINE HCL ORAL TABLET THERAPY Tier 3 Tier 3 TABLET 50 MG PACK meclizine hcl oral tablet medroxyprogesterone acetate Tier 1 Tier 1 $0 chewable intramuscular suspension meclofenamate sodium oral medroxyprogesterone acetate Tier 1 capsule intramuscular suspension Tier 1 $0 MEDIC INSULIN prefilled syringe Tier 3 ST; QL SYRINGE medroxyprogesterone acetate Tier 1 MEDICHOICE SAFETY oral tablet Tier 2 QL LANCET mefenamic acid oral capsule Tier 1 MEDICHOICE SAFETY Tier 2 QL mefloquine hcl oral tablet Tier 1 LANCET EXTRA mega multiple/chelated MEDICHOICE SAFETY Tier 1 $0 Tier 2 QL mineral oral tablet LANCET NORM megestrol acetate oral MEDICINE SHOPPE PEN Tier 1 Tier 3 ST; QL suspension NEEDLES megestrol acetate oral tablet Tier 1 MEDISENSE THIN Tier 2 QL LANCETS meijer aspirin ec oral tablet Tier 1 $0 MEDLANCE EXTRA 21G Tier 2 QL delayed release MEDLANCE LITE 25G Tier 2 QL MEIJER LANCETS Tier 2 QL MEDLANCE PLUS MEIJER LANCETS THIN Tier 2 QL Tier 2 QL EXTRA 21G MEIJER LANCETS Tier 2 QL MEDLANCE PLUS UNIVERSAL 21G Tier 2 QL LANCETS MEIJER LANCETS Tier 2 QL MEDLANCE PLUS LITE UNIVERSAL 30G Tier 2 QL 25G MEIJER LANCETS Tier 2 QL MEDLANCE PLUS UNIVERSAL 33G Tier 2 QL SPECIAL 0.8MM MEIJER PEN NEEDLES Tier 3 ST; QL MEDLANCE PLUS MEIJER SUPER THIN Tier 2 QL Tier 2 QL SUPERLITE 30G LANCETS MEDLANCE PLUS MEKINIST ORAL Tier 2 QL Tier 3 PA; QL; LD; SP UNIVERSAL 21G TABLET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 91 Drug Name Tier Notes Drug Name Tier Notes MEKTOVI ORAL MENTAX EXTERNAL Tier 3 PA; QL; LD Tier 3 ST; QL TABLET CREAM MELALEUCA MENVEO SUBCUTANEOUS Tier 3 INTRAMUSCULAR Tier 3 $0 SOLUTION SOLUTION melodetta 24 fe oral tablet RECONSTITUTED Tier 1 $0 chewable meperidine hcl injection Tier 1 QL solution meloxicam oral tablet Tier 1 meperidine hcl oral solution Tier 1 QL melphalan hcl intravenous Tier 1 SP solution reconstituted meperidine hcl oral tablet Tier 1 QL MEPHYTON ORAL melphalan oral tablet Tier 1 SP Tier 3 TABLET memantine hcl er oral capsule extended release 24 Tier 1 DO meprobamate oral tablet Tier 1 hour 14 mg, 7 mg MEPRON ORAL Tier 3 memantine hcl er oral SUSPENSION capsule extended release 24 Tier 1 MEPSEVII hour 21 mg, 28 mg INTRAVENOUS Tier 4 PA; QL; LD memantine hcl oral solution Tier 1 SOLUTION memantine hcl oral tablet 10 mercaptopurine oral tablet Tier 1 Tier 1 mg, 28 x 5 mg & 21 x 10 mg meropenem intravenous Tier 1 memantine hcl oral tablet 5 solution reconstituted Tier 1 DO mg MEROPENEM-SODIUM MEMBRANEBLUE CHLORIDE OPHTHALMIC Tier 3 INTRAVENOUS Tier 3 SOLUTION SOLUTION MENACTRA RECONSTITUTED INTRAMUSCULAR Tier 3 $0 MERREM INJECTABLE INTRAVENOUS Tier 3 M-END PE ORAL SOLUTION Tier 3 LIQUID RECONSTITUTED merzee oral capsule Tier 1 $0 MENEST ORAL TABLET Tier 2 mesalamine er oral capsule Tier 1 MENOPUR extended release 24 hour SUBCUTANEOUS Tier 4 PA; QL; SP mesalamine oral capsule SOLUTION Tier 1 RECONSTITUTED delayed release mesalamine oral tablet MENOSTAR Tier 1 TRANSDERMAL PATCH Tier 3 delayed release WEEKLY mesalamine rectal enema Tier 1 MENQUADFI mesalamine rectal Tier 1 INTRAMUSCULAR Tier 3 $0 suppository INJECTABLE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 92 Drug Name Tier Notes Drug Name Tier Notes mesalamine-cleanser rectal methenamine hippurate oral Tier 1 Tier 1 kit tablet mesna intravenous solution Tier 1 PA; QL methergine oral tablet Tier 1 MESNEX methimazole oral tablet Tier 1 T1S INTRAVENOUS Tier 3 PA; QL methocarbamol injection SOLUTION Tier 1 solution MESNEX ORAL TABLET Tier 2 PA; QL methocarbamol oral tablet Tier 1 MESQUITE SUBCUTANEOUS Tier 3 METHOHEXITAL SODIUM INTRAVENOUS SOLUTION Tier 3 SOLUTION PREFILLED MESTINON ORAL Tier 3 SYRINGE SOLUTION methotrexate oral tablet Tier 1 MESTINON ORAL Tier 3 TABLET methotrexate sodium (pf) Tier 1 MESTINON ORAL injection solution TABLET EXTENDED Tier 3 methotrexate sodium Tier 1 RELEASE injection solution metaxalone oral tablet Tier 1 ST; QL methotrexate sodium metformin hcl er oral tablet injection solution Tier 1 Tier 1 extended release 24 hour reconstituted methotrexate sodium oral metformin hcl oral solution Tier 1 PA; QL Tier 1 tablet metformin hcl oral tablet Tier 1 T1S methoxsalen rapid oral METHADONE HCL Tier 1 SP Tier 3 PA; QL capsule INJECTION SOLUTION methscopolamine bromide methadone hcl intensol oral Tier 1 Tier 1 PA; QL oral tablet concentrate METHYLCOBALAMIN methadone hcl oral Tier 1 PA; QL INJECTION SOLUTION Tier 3 concentrate RECONSTITUTED methadone hcl oral solution Tier 1 PA; QL methyldopa oral tablet Tier 1 T1S methadone hcl oral tablet Tier 1 PA; QL methyldopa- methadone hcl oral tablet hydrochlorothiazide oral Tier 1 Tier 1 PA; QL soluble tablet METHADOSE ORAL methylergonovine maleate Tier 3 PA; QL Tier 1 CONCENTRATE injection solution methylergonovine maleate methadose oral tablet soluble Tier 1 PA; QL Tier 1 oral tablet METHADOSE SUGAR- METHYLIN ORAL FREE ORAL Tier 3 PA; QL Tier 3 PA; QL CONCENTRATE SOLUTION methazolamide oral tablet Tier 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 93 Drug Name Tier Notes Drug Name Tier Notes methylphenidate hcl er (cd) methylphenidate hcl oral Tier 1 PA; DO; QL oral capsule extended release Tier 1 PA; DO; QL tablet chewable 2.5 mg, 5 mg 10 mg, 20 mg, 30 mg methylprednisolone oral Tier 1 methylphenidate hcl er (cd) tablet oral capsule extended release Tier 1 PA; QL methylprednisolone oral Tier 1 40 mg, 50 mg, 60 mg tablet therapy pack methylphenidate hcl er (la) methylprednisolone sodium oral capsule extended release Tier 1 PA; DO; QL succ injection solution Tier 1 24 hour 10 mg, 20 mg reconstituted methylphenidate hcl er (la) metoclopramide hcl injection oral capsule extended release Tier 1 Tier 1 PA; QL solution 24 hour 30 mg, 40 mg, 60 metoclopramide hcl oral mg Tier 1 T1S solution methylphenidate hcl er (xr) oral capsule extended release metoclopramide hcl oral Tier 1 PA; DO; QL Tier 1 T1S 24 hour 10 mg, 15 mg, 20 tablet mg, 30 mg METOCLOPRAMIDE methylphenidate hcl er (xr) HCL ORAL TABLET Tier 3 ST; QL oral capsule extended release DISPERSIBLE 10 MG Tier 1 PA; QL 24 hour 40 mg, 50 mg, 60 metoclopramide hcl oral Tier 1 ST; QL mg tablet dispersible 5 mg methylphenidate hcl er oral metolazone oral tablet Tier 1 tablet extended release 10 Tier 1 PA; DO; QL mg, 18 mg, 27 mg metoprolol succinate er oral tablet extended release 24 Tier 1 methylphenidate hcl er oral hour tablet extended release 20 Tier 1 PA; QL metoprolol tartrate mg, 36 mg, 54 mg Tier 1 intravenous solution methylphenidate hcl er oral tablet extended release 24 Tier 1 PA; QL metoprolol tartrate oral tablet Tier 1 T1S hour metoprolol- METHYLPHENIDATE hydrochlorothiazide oral Tier 1 HCL ER ORAL TABLET tablet Tier 3 PA; QL EXTENDED RELEASE 72 METROCREAM Tier 3 ST; QL MG EXTERNAL CREAM methylphenidate hcl oral Tier 1 PA; QL metronidazole external cream Tier 1 solution metronidazole external gel Tier 1 methylphenidate hcl oral Tier 1 PA; DO; QL tablet 10 mg, 5 mg metronidazole external lotion Tier 1 methylphenidate hcl oral Tier 1 PA; QL metronidazole in nacl tablet 20 mg intravenous solution 5-0.79 Tier 1 methylphenidate hcl oral mg/ml-%, 500-0.79 Tier 1 PA; QL tablet chewable 10 mg mg/100ml-%

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 94 Drug Name Tier Notes Drug Name Tier Notes METRONIDAZOLE IN MICROLET NEXT Tier 2 NACL INTRAVENOUS LANCING DEVICE Tier 3 SOLUTION 500-0.74 midazolam hcl (pf) injection Tier 1 MG/100ML-% solution metronidazole oral capsule Tier 1 midazolam hcl injection Tier 1 metronidazole oral tablet Tier 1 solution metronidazole vaginal gel Tier 1 midazolam hcl oral syrup Tier 1 metyrosine oral capsule Tier 1 PA; QL MIDAZOLAM HCL- SODIUM CHLORIDE Tier 3 mexiletine hcl oral capsule Tier 1 INTRAVENOUS MI PASTE DENTAL SOLUTION Tier 3 PASTE MIDAZOLAM HCL- MI PASTE PLUS SODIUM CHLORIDE Tier 3 DENTAL PASTE INTRAVENOUS Tier 3 SOLUTION PREFILLED MIACALCIN INJECTION Tier 4 SYRINGE SOLUTION MIDAZOLAM-SODIUM mibelas 24 fe oral tablet CHLORIDE Tier 1 $0 Tier 3 chewable INTRAVENOUS micafungin sodium SOLUTION intravenous solution Tier 1 MIDAZOLAM-SODIUM reconstituted CHLORIDE miconazole 3 vaginal INTRAVENOUS Tier 3 Tier 1 suppository SOLUTION PREFILLED SYRINGE miconazole-zinc oxide- Tier 1 petrolat external ointment midodrine hcl oral tablet Tier 1 MICRHOGAM ULTRA- MIFEPREX ORAL Tier 3 FILTERED PLUS TABLET INTRAMUSCULAR Tier 4 SP mifepristone oral tablet Tier 1 SOLUTION PREFILLED SYRINGE migergot rectal suppository Tier 1 MICRODOT PEN Tier 3 ST; QL miglitol oral tablet Tier 1 NEEDLE miglustat oral capsule Tier 4 PA; QL; SP microgestin 1.5/30 oral tablet Tier 1 $0 mili oral tablet Tier 1 $0 microgestin 1/20 oral tablet Tier 1 $0 milk of magnesia concentrate Tier 1 $0 microgestin 24 fe oral tablet Tier 1 $0 oral suspension microgestin fe 1.5/30 oral milk of magnesia oral Tier 1 $0 Tier 1 $0 tablet suspension microgestin fe 1/20 oral Tier 1 $0 millguard oral tablet Tier 1 $0 tablet MILLIPRED ORAL Tier 3 MICROLET LANCETS Tier 2 QL TABLET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 95 Drug Name Tier Notes Drug Name Tier Notes milrinone lactate in dextrose MIRENA (52 MG) Tier 1 intravenous solution INTRAUTERINE Tier 3 LD; SP milrinone lactate intravenous INTRAUTERINE Tier 1 solution DEVICE mimvey oral tablet Tier 1 mirtazapine oral tablet Tier 1 MINASTRIN 24 FE ORAL mirtazapine oral tablet Tier 3 Tier 1 TABLET CHEWABLE dispersible MIRVASO EXTERNAL mineral oil heavy oral oil Tier 1 Tier 3 GEL MINI LANCING DEVICE Tier 2 misoprostol oral tablet Tier 1 MINIPRESS ORAL MITE (D. FARINAE) Tier 3 Tier 3 CAPSULE INJECTION SOLUTION minitran transdermal patch Tier 1 MITE (D. FARINAE) 24 hour SUBCUTANEOUS Tier 3 MINOCIN SOLUTION INTRAVENOUS Tier 3 MITE (D. SOLUTION PTERONYSSINUS) Tier 3 RECONSTITUTED INJECTION SOLUTION minocycline hcl er oral tablet Tier 1 ST; QL MITE (D. extended release 24 hour PTERONYSSINUS) Tier 3 minocycline hcl oral capsule Tier 1 SUBCUTANEOUS SOLUTION minocycline hcl oral tablet Tier 1 mitigo injection solution Tier 1 QL minoxidil oral tablet Tier 1 MITOMYCIN MIOCHOL-E INTRAOCULAR Tier 3 INTRAOCULAR SOLUTION PREFILLED Tier 3 SOLUTION SYRINGE RECONSTITUTED mitomycin intravenous Tier 1 SP MIOSTAT solution reconstituted INTRAOCULAR Tier 3 MITOMYCIN SOLUTION INTRAVESICAL Tier 3 MIRAPEX ER ORAL SOLUTION PREFILLED TABLET EXTENDED Tier 3 SYRINGE RELEASE 24 HOUR MITOSOL Tier 3 MIRAPEX ORAL OPHTHALMIC KIT Tier 3 TABLET mitoxantrone hcl intravenous Tier 1 SP MIRCERA INJECTION concentrate SOLUTION PREFILLED Tier 4 PA; QL; LD MIXED ASPERGILLUS SYRINGE SUBCUTANEOUS Tier 3 MIRCETTE ORAL SOLUTION Tier 3 TABLET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 96 Drug Name Tier Notes Drug Name Tier Notes MIXED FEATHERS MONJUVI SUBCUTANEOUS Tier 3 INTRAVENOUS Tier 3 PA; QL; LD SOLUTION SOLUTION MIXED RAGWEED RECONSTITUTED SUBCUTANEOUS Tier 3 MONOFERRIC SOLUTION INTRAVENOUS Tier 3 MIXED VESPID VENOM SOLUTION PROTEIN INJECTION MONOJECT BONE Tier 3 SOLUTION MARROW BIOPSY Tier 3 RECONSTITUTED INJECTION KIT MIXED VESPID VENOM monoject flush syringe Tier 1 PROTEIN intravenous solution SUBCUTANEOUS Tier 3 MONOJECT INSULIN Tier 3 ST; QL SOLUTION SYRINGE RECONSTITUTED monoject sodium chloride Tier 1 mm clearlax oral powder Tier 1 $0 flush intravenous solution MM INSULIN MONOJECT ULTRA Tier 3 ST; QL Tier 3 ST; QL SYRINGE/NEEDLE COMFORT SYRINGE MM LANCING DEVICE Tier 2 MONOLET LANCETS Tier 2 QL MM PEN NEEDLES Tier 3 ST; QL MONOLET OPD Tier 2 QL MM TWIST LANCETS Tier 2 QL LANCETS MONOLETTOR SAFETY M-M-R II INJECTION Tier 2 QL SOLUTION Tier 3 $0 LANCETS RECONSTITUTED mono-linyah oral tablet Tier 1 $0 M-NATAL PLUS ORAL Tier 3 MONONINE TABLET INTRAVENOUS Tier 4 PA; QL; LD; SP modafinil oral tablet 100 mg Tier 1 PA; DO; QL SOLUTION RECONSTITUTED modafinil oral tablet 200 mg Tier 1 PA; QL MONOVISC INTRA- moexipril hcl oral tablet Tier 1 ARTICULAR SOLUTION Tier 4 PA; QL molindone hcl oral tablet Tier 1 PREFILLED SYRINGE mometasone furoate external montelukast sodium oral Tier 1 Tier 1 cream packet mometasone furoate external montelukast sodium oral Tier 1 Tier 1 ointment tablet mometasone furoate external montelukast sodium oral Tier 1 Tier 1 solution tablet chewable mometasone furoate nasal MONUROL ORAL Tier 3 ST; QL Tier 3 suspension PACKET mondoxyne nl oral capsule Tier 1 morgidox oral capsule Tier 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 97 Drug Name Tier Notes Drug Name Tier Notes morphine sulfate moxifloxacin hcl (2x day) Tier 1 QL Tier 1 (concentrate) oral solution ophthalmic solution morphine sulfate (pf) moxifloxacin hcl in nacl Tier 1 injection solution 0.5 mg/ml, Tier 1 QL intravenous solution 1 mg/ml MOXIFLOXACIN HCL MORPHINE SULFATE INTRAOCULAR Tier 3 (PF) INJECTION SOLUTION SOLUTION 10 MG/ML, 2 Tier 3 QL MOXIFLOXACIN HCL MG/ML, 4 MG/ML, 5 INTRAOCULAR Tier 3 MG/ML, 8 MG/ML SOLUTION PREFILLED MORPHINE SULFATE SYRINGE (PF) INTRAVENOUS Tier 3 QL MOXIFLOXACIN HCL SOLUTION INTRAVENOUS Tier 3 morphine sulfate er beads SOLUTION oral capsule extended release Tier 1 PA; QL moxifloxacin hcl ophthalmic Tier 1 24 hour solution morphine sulfate er oral moxifloxacin hcl oral tablet Tier 1 capsule extended release 24 Tier 1 PA; QL hour MOZOBIL morphine sulfate er oral SUBCUTANEOUS Tier 4 PA; QL; LD; SP Tier 1 PA; QL tablet extended release SOLUTION MORPHINE SULFATE MPD SAFETY LANCET Tier 3 Tier 2 QL INJECTION SOLUTION 21G morphine sulfate oral MPD SAFETY LANCET Tier 1 QL Tier 2 QL solution 23G MPD SAFETY LANCET morphine sulfate oral tablet Tier 1 QL Tier 2 QL 28G MOTOFEN ORAL Tier 3 MPD SAFETY LANCET TABLET Tier 2 QL 30G MOUNTAIN CEDAR SUBCUTANEOUS Tier 3 MS INSULIN SYRINGE Tier 3 ST; QL SOLUTION MUCOR INJECTION Tier 3 MOUSE EPITHELIUM SOLUTION SUBCUTANEOUS Tier 3 MUCOR INTRADERMAL Tier 3 SOLUTION SOLUTION MOVANTIK ORAL MUCOR Tier 2 TABLET SUBCUTANEOUS Tier 3 MOVIPREP ORAL SOLUTION SOLUTION Tier 3 MUGWORT RECONSTITUTED SUBCUTANEOUS Tier 3 MOXEZA OPHTHALMIC SOLUTION Tier 3 SOLUTION MULPLETA ORAL Tier 4 PA; QL; SP TABLET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 98 Drug Name Tier Notes Drug Name Tier Notes MULTAQ ORAL multi-vitamin/fluoride oral Tier 3 Tier 1 $0 TABLET solution MULTI PRENATAL multivitamin/fluoride oral Tier 2 $0 ORAL TABLET tablet chewable 0.25 mg, 0.5 Tier 1 $0 multi vitamin daily oral mg, 1 mg Tier 1 $0 tablet MULTIVITAMIN/FLUOR MULTI VITAMIN ORAL IDE ORAL TABLET Tier 2 $0 Tier 3 TABLET CHEWABLE 0.25-0.3 MG, 0.5-0.3 MG, 1-0.3 MG MULTI VITAMIN W/D-3 Tier 2 $0 multi-vitamin/fluoride/iron ORAL TABLET Tier 1 oral solution multi-day oral tablet Tier 1 $0 multi-vitamin/iron oral tablet Tier 1 $0 multi-day plus iron oral Tier 1 $0 tablet multi-vitamins oral tablet Tier 1 $0 MULTI-LANCET mupirocin calcium external Tier 2 Tier 1 DEVICE cream MULTI-LANCET mupirocin external ointment Tier 1 Tier 2 DEVICE 2 KIT MUSE URETHRAL Tier 3 PA; QL multiple vitamin-folic acid PELLET Tier 1 $0 oral tablet mutamycin intravenous Tier 1 SP multiple vitamins essential solution reconstituted Tier 1 $0 oral tablet MVASI INTRAVENOUS Tier 3 PA; QL; LD; SP multiple vitamins oral tablet Tier 1 $0 SOLUTION multiple vitamins/iron oral my choice oral tablet Tier 1 $0 Tier 1 $0 tablet my way oral tablet Tier 1 $0 multi-vit/iron/fluoride oral Tier 1 MYALEPT solution SUBCUTANEOUS Tier 4 PA; QL; LD MULTIVITAMIN ADULT SOLUTION Tier 2 $0 ORAL TABLET RECONSTITUTED multi-vitamin daily oral MYAMBUTOL ORAL Tier 1 $0 Tier 3 tablet TABLET multivitamin iron-free oral MYCAMINE Tier 1 $0 INTRAVENOUS tablet Tier 3 SOLUTION MULTIVITAMIN ORAL Tier 2 $0 RECONSTITUTED TABLET MYCAPSSA ORAL multi-vitamin oral tablet Tier 1 $0 CAPSULE DELAYED Tier 4 PA; QL; LD; SP multivitamin plus iron adult RELEASE Tier 1 $0 oral tablet MYCOBUTIN ORAL Tier 3 multivitamin/fluoride oral CAPSULE Tier 1 $0 solution

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 99 Drug Name Tier Notes Drug Name Tier Notes mycophenolate mofetil hcl MYTESI ORAL TABLET Tier 3 PA; QL; LD intravenous solution Tier 1 SP DELAYED RELEASE reconstituted MYXREDLIN mycophenolate mofetil oral INTRAVENOUS Tier 3 Tier 1 capsule SOLUTION mycophenolate mofetil oral na ferric gluc cplx in sucrose Tier 1 Tier 1 suspension reconstituted intravenous solution mycophenolate mofetil oral NABI-HB Tier 1 tablet INTRAMUSCULAR Tier 4 LD; SP mycophenolate sodium oral SOLUTION Tier 1 tablet delayed release nabumetone oral tablet Tier 1 MYDAYIS ORAL n-acetyl-l-cysteine oral Tier 1 CAPSULE EXTENDED Tier 3 PA; QL capsule RELEASE 24 HOUR nadolol oral tablet Tier 1 MYDRIACYL OPHTHALMIC Tier 3 NAFCILLIN SODIUM IN DEXTROSE SOLUTION Tier 3 INTRAVENOUS MYFORTIC ORAL SOLUTION TABLET DELAYED Tier 3 RELEASE nafcillin sodium injection solution reconstituted 1 gm, Tier 1 MYGLUCOHEALTH Tier 2 QL 2 gm LANCETS 30G NAFCILLIN SODIUM MYLERAN ORAL Tier 2 INJECTION SOLUTION Tier 3 TABLET RECONSTITUTED 10 GM MYLOTARG nafcillin sodium intravenous INTRAVENOUS Tier 1 Tier 3 PA; QL; LD; SP solution reconstituted SOLUTION RECONSTITUTED NAFRINSE DAILY ACIDULATED MYNATAL ORAL Tier 3 MOUTH/THROAT Tier 3 CAPSULE SOLUTION MYNATAL PLUS ORAL RECONSTITUTED Tier 2 TABLET NAFRINSE MYNATAL-Z ORAL DAILY/NEUTRAL Tier 2 TABLET MOUTH/THROAT Tier 3 MYOBLOC SOLUTION INTRAMUSCULAR Tier 4 PA; QL; SP RECONSTITUTED SOLUTION nafrinse drops oral solution Tier 1 $0 myorisan oral capsule Tier 2 PA; QL nafrinse oral tablet chewable Tier 1 $0 MYRBETRIQ ORAL NAFRINSE WEEKLY TABLET EXTENDED Tier 3 MOUTH/THROAT Tier 3 RELEASE 24 HOUR SOLUTION RECONSTITUTED

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 100 Drug Name Tier Notes Drug Name Tier Notes naftifine hcl external cream 1 Tier 1 ST; QL naproxen sodium oral tablet Tier 1 % naratriptan hcl oral tablet Tier 1 QL naftifine hcl external cream 2 Tier 1 % NARCAN NASAL LIQUID Tier 2 naftifine hcl external gel Tier 1 ST; QL NARDIL ORAL TABLET Tier 3 NAFTIN EXTERNAL NAROPIN INJECTION Tier 3 ST; QL Tier 3 GEL SOLUTION NAGLAZYME NATACHEW ORAL Tier 3 ST; QL INTRAVENOUS Tier 4 PA; QL; LD; SP TABLET CHEWABLE SOLUTION NATACYN nalbuphine hcl injection OPHTHALMIC Tier 3 Tier 1 solution SUSPENSION naloxone hcl injection NATALVIT ORAL Tier 1 Tier 3 solution TABLET naloxone hcl injection NATAZIA ORAL Tier 1 Tier 3 solution cartridge TABLET naloxone hcl injection Tier 1 nateglinide oral tablet Tier 1 solution prefilled syringe NATPARA naltrexone hcl oral tablet Tier 1 SUBCUTANEOUS Tier 3 PA; QL; LD; SP NAMENDA ORAL CARTRIDGE Tier 3 TABLET 10 MG NATROBA EXTERNAL Tier 3 NAMENDA ORAL SUSPENSION Tier 3 DO TABLET 5 MG nat-rul b-50 oral tablet Tier 1 $0 NAMENDA TITRATION nat-rul daily-vite+iron oral Tier 3 Tier 1 $0 PAK ORAL TABLET tablet NAMENDA XR NATURE-THROID ORAL Tier 3 TITRATION PACK TABLET ORAL CAPSULE Tier 2 NAVELBINE EXTENDED RELEASE 24 INTRAVENOUS Tier 3 SP HOUR SOLUTION NAMZARIC ORAL NAYZILAM NASAL Tier 3 PA; QL CAPSULE ER 24 HOUR Tier 2 SOLUTION THERAPY PACK NEBUPENT NAMZARIC ORAL INHALATION Tier 3 CAPSULE EXTENDED Tier 2 SOLUTION RELEASE 24 HOUR RECONSTITUTED naproxen oral suspension Tier 1 necon 0.5/35 (28) oral tablet Tier 1 $0 naproxen oral tablet Tier 1 NEEVO DHA ORAL Tier 3 ST; QL naproxen oral tablet delayed CAPSULE Tier 1 release nefazodone hcl oral tablet Tier 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 101 Drug Name Tier Notes Drug Name Tier Notes NEMBUTAL INJECTION NEOPROFEN Tier 3 SOLUTION INTRAVENOUS Tier 3 NEOMULTIVITE ORAL SOLUTION Tier 2 $0 TABLET NEORAL ORAL Tier 3 CAPSULE neomycin sulfate oral tablet Tier 1 NEORAL ORAL Tier 3 neomycin-bacitracin zn- SOLUTION polymyx ophthalmic Tier 1 ointment NEOSTIGMINE METHYLSULFATE neomycin-polymyxin b gu Tier 3 Tier 1 INTRAVENOUS irrigation solution SOLUTION neomycin-polymyxin- NEO-SYNALAR Tier 3 dexameth ophthalmic Tier 1 EXTERNAL CREAM ointment NEOX 100 EXTERNAL Tier 3 neomycin-polymyxin- SHEET dexameth ophthalmic Tier 1 NEOX CORD 1K suspension Tier 3 EXTERNAL SHEET neomycin-polymyxin- gramicidin ophthalmic Tier 1 NEPHRAMINE solution INTRAVENOUS Tier 3 SOLUTION neomycin-polymyxin-hc Tier 1 ophthalmic suspension nephro vitamins oral tablet Tier 1 $0 neomycin-polymyxin-hc otic NERLYNX ORAL Tier 1 Tier 3 PA; QL; LD; SP solution TABLET neomycin-polymyxin-hc otic NESACAINE INJECTION Tier 1 Tier 3 suspension SOLUTION NEONATAL + DHA NESACAINE-MPF Tier 3 ST; QL Tier 3 ORAL INJECTION SOLUTION NEONATAL 19 ORAL NESTABS DHA ORAL Tier 3 ST; QL Tier 3 ST; QL TABLET NESTABS ONE ORAL Tier 3 ST; QL NEONATAL COMPLETE CAPSULE Tier 3 ST; QL ORAL TABLET NESTABS ORAL Tier 3 ST; QL NEONATAL FE ORAL TABLET Tier 3 ST; QL TABLET neuac external gel Tier 1 NEONATAL PLUS ORAL Tier 3 ST; QL NEULASTA ONPRO TABLET SUBCUTANEOUS Tier 4 PA; QL; SP NEONATAL VITAMIN PREFILLED SYRINGE Tier 2 $0 ORAL TABLET KIT neo-polycin hc ophthalmic NEULASTA Tier 1 ointment SUBCUTANEOUS Tier 4 PA; QL; SP neo-polycin ophthalmic SOLUTION PREFILLED Tier 1 ointment SYRINGE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 102 Drug Name Tier Notes Drug Name Tier Notes NEUPOGEN INJECTION niacin (antihyperlipidemic) Tier 4 PA; QL; SP Tier 1 ST; QL SOLUTION oral tablet NEUPOGEN INJECTION niacin er SOLUTION PREFILLED Tier 4 PA; QL; SP (antihyperlipidemic) oral Tier 1 ST; QL SYRINGE tablet extended release NEUPRO niacor oral tablet Tier 1 ST; QL TRANSDERMAL PATCH Tier 3 NIASPAN ORAL TABLET Tier 3 ST; QL 24 HOUR EXTENDED RELEASE NEURIN-SL NICARDIPINE HCL IN SUBLINGUAL TABLET Tier 3 NACL INTRAVENOUS Tier 3 SUBLINGUAL SOLUTION NEVANAC NICARDIPINE HCL IN OPHTHALMIC Tier 3 NACL INTRAVENOUS Tier 3 SUSPENSION SOLUTION PREFILLED nevirapine er oral tablet SYRINGE extended release 24 hour 100 Tier 1 nicardipine hcl intravenous Tier 1 mg solution nevirapine er oral tablet nicardipine hcl oral capsule Tier 1 T1S extended release 24 hour 400 Tier 1 QL mg NICODERM CQ TRANSDERMAL PATCH Tier 2 $0 nevirapine oral suspension Tier 1 QL 24 HOUR nevirapine oral tablet Tier 1 QL nicorelief mouth/throat gum Tier 1 $0 new day oral tablet Tier 1 $0 NICORETTE MINI NEXAVAR ORAL MOUTH/THROAT Tier 2 $0 Tier 2 PA; QL; LD; SP TABLET LOZENGE NEXAVIR INJECTION NICORETTE Tier 3 Tier 2 $0 SOLUTION MOUTH/THROAT GUM NEXIUM I.V. NICORETTE INTRAVENOUS MOUTH/THROAT Tier 2 $0 Tier 3 SOLUTION LOZENGE RECONSTITUTED NICORETTE STARTER NEXLETOL ORAL KIT MOUTH/THROAT Tier 2 $0 Tier 3 PA; QL TABLET GUM NEXLIZET ORAL nicotine mini mouth/throat Tier 3 PA; QL Tier 1 $0 TABLET lozenge NEXPLANON nicotine polacrilex Tier 1 $0 SUBCUTANEOUS Tier 4 LD; SP mouth/throat gum IMPLANT nicotine polacrilex Tier 1 $0 NEXTERONE mouth/throat lozenge INTRAVENOUS Tier 3 nicotine step 1 transdermal Tier 1 $0 SOLUTION patch 24 hour

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 103 Drug Name Tier Notes Drug Name Tier Notes nicotine step 2 transdermal NIPRIDE RTU Tier 1 $0 patch 24 hour INTRAVENOUS Tier 3 nicotine step 3 transdermal SOLUTION Tier 1 $0 patch 24 hour nisoldipine er oral tablet NICOTINE extended release 24 hour 17 Tier 1 DO Tier 2 $0 TRANSDERMAL KIT mg, 20 mg, 8.5 mg nicotine transdermal patch 24 nisoldipine er oral tablet Tier 1 $0 extended release 24 hour hour Tier 1 25.5 mg, 30 mg, 34 mg, 40 NICOTROL Tier 3 PA; QL; $0 mg INHALATION INHALER nitazoxanide oral tablet Tier 1 NICOTROL NS NASAL Tier 3 PA; QL; $0 NITHIODOTE SOLUTION Tier 3 INTRAVENOUS KIT nifedipine er oral tablet extended release 24 hour 30 Tier 1 DO nitisinone oral capsule Tier 4 PA; QL; SP mg NITRO-BID nifedipine er oral tablet TRANSDERMAL Tier 3 extended release 24 hour 60 Tier 1 OINTMENT mg, 90 mg NITRO-DUR nifedipine er osmotic release TRANSDERMAL PATCH oral tablet extended release Tier 1 DO 24 HOUR 0.1 MG/HR, 0.2 Tier 3 24 hour 30 mg MG/HR, 0.4 MG/HR, 0.6 MG/HR nifedipine er osmotic release oral tablet extended release Tier 1 NITRO-DUR TRANSDERMAL PATCH 24 hour 60 mg, 90 mg Tier 2 24 HOUR 0.3 MG/HR, 0.8 nifedipine oral capsule Tier 1 MG/HR nikki oral tablet Tier 1 $0 nitrofurantoin macrocrystal Tier 1 NILANDRON ORAL oral capsule Tier 3 QL TABLET nitrofurantoin monohyd Tier 1 nilutamide oral tablet Tier 1 QL macro oral capsule NIMBEX INTRAVENOUS nitrofurantoin oral Tier 3 Tier 1 SOLUTION suspension nitroglycerin in d5w nimodipine oral capsule Tier 1 Tier 1 intravenous solution NINJACOF-XG ORAL Tier 3 LIQUID NITROGLYCERIN INTRAVENOUS Tier 3 NINLARO ORAL Tier 3 PA; QL; LD; SP SOLUTION CAPSULE nitroglycerin sublingual Tier 1 NIPENT INTRAVENOUS tablet sublingual SOLUTION Tier 3 SP nitroglycerin transdermal RECONSTITUTED Tier 1 patch 24 hour

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 104 Drug Name Tier Notes Drug Name Tier Notes nitroglycerin translingual norethin ace-eth estrad-fe Tier 1 Tier 1 $0 solution oral tablet NITROLINGUAL norethin ace-eth estrad-fe Tier 1 $0 TRANSLINGUAL Tier 3 oral tablet chewable SOLUTION norethindrone acetate oral Tier 1 NITROMIST tablet TRANSLINGUAL Tier 3 norethindrone acet-ethinyl Tier 1 $0 AEROSOL SOLUTION est oral tablet nitroprusside sodium Tier 1 norethindrone oral tablet Tier 1 $0 intravenous solution norethindrone-eth estradiol Tier 1 NITROSTAT oral tablet SUBLINGUAL TABLET Tier 3 norethin-eth estradiol-fe oral SUBLINGUAL Tier 1 $0 tablet chewable NITYR ORAL TABLET Tier 4 PA; QL; LD norgestimate-eth estradiol NIVA-PLUS ORAL Tier 1 $0 Tier 3 oral tablet TABLET norgestim-eth estrad triphasic NIVESTYM INJECTION Tier 1 $0 Tier 4 PA; QL; SP oral tablet SOLUTION NORITATE EXTERNAL Tier 3 ST; QL NIVESTYM INJECTION CREAM SOLUTION PREFILLED Tier 4 PA; QL; SP SYRINGE norlyda oral tablet Tier 1 $0 nizatidine oral capsule Tier 1 norlyroc oral tablet Tier 1 $0 normal saline flush nizatidine oral solution Tier 1 Tier 1 intravenous solution NOCDURNA NORMOSOL-M IN D5W SUBLINGUAL TABLET Tier 4 PA; QL INTRAVENOUS Tier 3 SUBLINGUAL SOLUTION nolix external lotion Tier 3 ST; QL NORMOSOL-R IN D5W nora-be oral tablet Tier 1 $0 INTRAVENOUS Tier 3 norepinephrine bitartrate SOLUTION Tier 1 intravenous solution NORMOSOL-R NOREPINEPHRINE- INTRAVENOUS Tier 3 DEXTROSE SOLUTION Tier 3 INTRAVENOUS NORMOSOL-R PH 7.4 SOLUTION INTRAVENOUS Tier 3 NOREPINEPHRINE- SOLUTION SODIUM CHLORIDE NORPACE CR ORAL Tier 3 INTRAVENOUS CAPSULE EXTENDED Tier 2 SOLUTION RELEASE 12 HOUR norethin ace-eth estrad-fe NORPACE ORAL Tier 1 $0 Tier 3 oral capsule CAPSULE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 105 Drug Name Tier Notes Drug Name Tier Notes NORPRAMIN ORAL NOVOSEVEN RT Tier 3 TABLET INTRAVENOUS Tier 4 PA; QL; LD; SP NORTHERA ORAL SOLUTION Tier 3 PA; QL; LD; SP CAPSULE RECONSTITUTED nortrel 0.5/35 (28) oral tablet Tier 1 $0 NOVOTWIST Tier 3 ST; QL nortrel 1/35 (21) oral tablet Tier 1 $0 NOXAFIL INTRAVENOUS Tier 3 nortrel 1/35 (28) oral tablet Tier 1 $0 SOLUTION nortrel 7/7/7 oral tablet Tier 1 $0 NOXAFIL ORAL Tier 3 PA; QL nortriptyline hcl oral capsule Tier 1 SUSPENSION NOXAFIL ORAL nortriptyline hcl oral solution Tier 1 TABLET DELAYED Tier 3 PA; QL NORVIR ORAL PACKET Tier 3 QL RELEASE NORVIR ORAL Tier 2 QL np thyroid oral tablet Tier 1 SOLUTION NPLATE NORVIR ORAL TABLET Tier 3 QL SUBCUTANEOUS NOURIANZ ORAL SOLUTION Tier 4 PA; QL Tier 4 PA; QL; LD; SP TABLET RECONSTITUTED 125 MCG NOVA SAFETY Tier 2 QL LANCETS 23G NPLATE SUBCUTANEOUS NOVA SAFETY Tier 2 QL SOLUTION Tier 4 PA; QL; SP LANCETS 28G RECONSTITUTED 250 NOVA SUREFLEX Tier 2 QL MCG, 500 MCG LANCETS NUBEQA ORAL TABLET Tier 3 PA; QL; LD; SP NOVA SUREFLEX Tier 2 NUCALA LANCING DEVICE SUBCUTANEOUS Tier 4 PA; QL; LD; SP NOVACHOR EXTERNAL Tier 3 SOLUTION AUTO- SHEET INJECTOR NOVAREL NUCALA INTRAMUSCULAR SUBCUTANEOUS Tier 4 PA; QL; SP Tier 4 PA; QL; LD; SP SOLUTION SOLUTION PREFILLED RECONSTITUTED SYRINGE NOVOEIGHT NUCALA INTRAVENOUS SUBCUTANEOUS Tier 4 PA; QL; LD; SP Tier 4 PA; QL; LD; SP SOLUTION SOLUTION RECONSTITUTED RECONSTITUTED NOVOFINE Tier 3 ST; QL NUCYNTA ORAL Tier 3 QL NOVOFINE TABLET Tier 3 ST; QL AUTOCOVER NUEDEXTA ORAL Tier 3 PA; QL NOVOFINE PLUS Tier 3 ST; QL CAPSULE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 106 Drug Name Tier Notes Drug Name Tier Notes NULOJIX NUWIQ INTRAVENOUS INTRAVENOUS SOLUTION Tier 4 PA; QL; LD; SP Tier 3 PA; QL; SP SOLUTION RECONSTITUTED RECONSTITUTED NUZYRA NULYTELY LEMON- INTRAVENOUS Tier 3 LD LIME ORAL SOLUTION Tier 3 SOLUTION RECONSTITUTED RECONSTITUTED NUMBRINO NASAL NUZYRA ORAL TABLET Tier 3 PA; QL; LD Tier 3 SOLUTION nyamyc external powder Tier 1 NUPLAZID ORAL Tier 4 PA; QL; LD; SP CAPSULE nylia 7/7/7 oral tablet Tier 1 $0 NUPLAZID ORAL NYMALIZE ORAL Tier 4 PA; QL; LD; SP Tier 3 TABLET SOLUTION NURTEC ORAL TABLET nymyo oral tablet Tier 1 $0 Tier 2 ST; QL DISPERSIBLE nystatin external cream Tier 1 NUSHIELD EXTERNAL Tier 3 nystatin external ointment Tier 1 DISK nystatin external powder Tier 1 NUSHIELD EXTERNAL Tier 3 SHEET nystatin mouth/throat Tier 1 NUTRILIPID suspension INTRAVENOUS Tier 3 nystatin oral tablet Tier 1 EMULSION nystatin-triamcinolone Tier 1 NUTROPIN AQ NUSPIN external cream 10 SUBCUTANEOUS Tier 4 PA; QL; LD; SP nystatin-triamcinolone SOLUTION PEN- Tier 1 external ointment INJECTOR NUTROPIN AQ NUSPIN nystop external powder Tier 1 20 SUBCUTANEOUS Tier 4 PA; QL; LD; SP NYVEPRIA SOLUTION PEN- SUBCUTANEOUS Tier 4 PA; QL; SP INJECTOR SOLUTION PREFILLED NUTROPIN AQ NUSPIN 5 SYRINGE SUBCUTANEOUS OB COMPLETE ONE Tier 4 PA; QL; LD; SP Tier 3 ST; QL SOLUTION PEN- ORAL CAPSULE INJECTOR OB COMPLETE ORAL NUVARING VAGINAL Tier 3 ST; QL Tier 3 TABLET RING OB COMPLETE PETITE NUVESSA VAGINAL Tier 3 ST; QL Tier 3 ORAL CAPSULE GEL OB COMPLETE NUWIQ INTRAVENOUS Tier 4 PA; QL; LD; SP PREMIER ORAL Tier 3 ST; QL KIT TABLET OB COMPLETE/DHA Tier 3 ST; QL ORAL CAPSULE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 107 Drug Name Tier Notes Drug Name Tier Notes OBIZUR INTRAVENOUS ocucoat viscoadherent Tier 1 SOLUTION Tier 4 PA; QL; LD; SP intraocular solution RECONSTITUTED OCUFLOX OBSTETRIX DHA ORAL Tier 3 OPHTHALMIC Tier 3 SOLUTION OBSTETRIX EC ORAL Tier 3 TABLET ODACTRA SUBLINGUAL TABLET Tier 3 PA; QL OBSTETRIX ONE ORAL Tier 3 SUBLINGUAL CAPSULE ODEFSEY ORAL O-CAL PRENATAL Tier 3 PA; QL Tier 3 TABLET ORAL TABLET ODOMZO ORAL OCALIVA ORAL Tier 3 PA; QL; LD; SP Tier 4 PA; QL; LD; SP CAPSULE TABLET OFEV ORAL CAPSULE Tier 4 PA; QL; LD; SP ocella oral tablet Tier 1 $0 OFIRMEV OCTAGAM INTRAVENOUS Tier 3 INTRAVENOUS SOLUTION SOLUTION 1 GM/20ML, ofloxacin ophthalmic 10 GM/100ML, 10 Tier 1 GM/200ML, 2 GM/20ML, Tier 4 PA; QL; LD; SP solution 2.5 GM/50ML, 20 ofloxacin oral tablet 300 mg Tier 1 QL GM/200ML, 25 GM/500ML, 5 GM/100ML, ofloxacin oral tablet 400 mg Tier 1 5 GM/50ML ofloxacin otic solution Tier 1 OCTAGAM OGIVRI INTRAVENOUS INTRAVENOUS Tier 4 PA; QL; LD SOLUTION Tier 3 LD; SP SOLUTION 30 GM/300ML RECONSTITUTED OCTAPLAS BLOOD olanzapine intramuscular GROUP A Tier 1 Tier 3 solution reconstituted INTRAVENOUS olanzapine oral tablet 10 mg, SOLUTION Tier 1 DO 2.5 mg, 5 mg, 7.5 mg OCTAPLAS BLOOD GROUP AB olanzapine oral tablet 15 mg, Tier 3 Tier 1 INTRAVENOUS 20 mg SOLUTION olanzapine oral tablet Tier 1 DO OCTAPLAS BLOOD dispersible 10 mg, 5 mg GROUP B olanzapine oral tablet Tier 3 Tier 1 INTRAVENOUS dispersible 15 mg, 20 mg SOLUTION olanzapine-fluoxetine hcl OCTAPLAS BLOOD oral capsule 12-25 mg, 12-50 Tier 1 GROUP O Tier 3 mg, 6-50 mg INTRAVENOUS olanzapine-fluoxetine hcl SOLUTION oral capsule 3-25 mg, 6-25 Tier 1 DO octreotide acetate injection Tier 4 PA; QL; SP mg solution

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 108 Drug Name Tier Notes Drug Name Tier Notes OLINVYK once daily oral tablet Tier 1 $0 INTRAVENOUS Tier 3 once daily/iron oral tablet Tier 1 $0 SOLUTION ondansetron hcl injection Tier 1 OLIVE TREE solution SUBCUTANEOUS Tier 3 SOLUTION ondansetron hcl oral solution Tier 1 QL olmesartan medoxomil oral ondansetron hcl oral tablet Tier 1 QL Tier 1 DO tablet 20 mg ondansetron oral tablet Tier 1 QL olmesartan medoxomil oral dispersible Tier 1 tablet 40 mg, 5 mg one daily essential oral tablet Tier 1 $0 olmesartan medoxomil-hctz one daily multivitamin adult Tier 1 DO Tier 1 $0 oral tablet 20-12.5 mg oral tablet olmesartan medoxomil-hctz one daily multivitamin/iron Tier 1 $0 oral tablet 40-12.5 mg, 40-25 Tier 1 oral tablet mg one daily oral tablet Tier 1 $0 olmesartan-amlodipine-hctz Tier 1 DO ONE VITE WOMENS oral tablet 20-5-12.5 mg Tier 2 $0 ORAL TABLET olmesartan-amlodipine-hctz oral tablet 40-10-12.5 mg, ONE VITE WOMENS Tier 1 Tier 3 40-10-25 mg, 40-5-12.5 mg, PLUS ORAL TABLET 40-5-25 mg ONE-A-DAY WOMENS Tier 2 $0 olopatadine hcl nasal PRENATAL ORAL Tier 1 solution one-daily multi vitamins oral Tier 1 $0 tablet OMECLAMOX-PAK Tier 3 ST; QL ORAL one-daily multi-vitamin oral Tier 1 $0 omega-3-acid ethyl esters tablet Tier 1 PA; QL oral capsule one-daily multi-vitamin/iron Tier 1 $0 oral tablet OMEGAVEN INTRAVENOUS Tier 3 one-daily/iron oral tablet Tier 1 $0 EMULSION ONETOUCH CLUB Tier 2 QL omeprazole oral capsule LANCETS FINE PT Tier 1 QL delayed release ONETOUCH DELICA Tier 2 QL OMIDRIA LANCETS 30G INTRAOCULAR Tier 3 ONETOUCH DELICA Tier 2 QL SOLUTION LANCETS 33G OMNICAP ORAL ONETOUCH DELICA Tier 2 $0 Tier 2 TABLET LANCING DEV OMNIFLEX ONETOUCH DELICA Tier 2 QL DIAPHRAGM VAGINAL Tier 3 PLUS LANCET30G DIAPHRAGM ONETOUCH DELICA ONCASPAR INJECTION Tier 2 QL Tier 3 PA; QL; SP PLUS LANCET33G SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 109 Drug Name Tier Notes Drug Name Tier Notes ONETOUCH DELICA Tier 2 oralone mouth/throat paste Tier 1 PLUS LANCING ORAPRED ODT ORAL ONETOUCH FINEPOINT Tier 2 QL TABLET DISPERSIBLE Tier 3 LANCETS 10 MG, 30 MG ONETOUCH SURESOFT Tier 2 ORAPRED ODT ORAL LANCING DEV TABLET DISPERSIBLE Tier 3 DO ONETOUCH ULTRA IN 15 MG Tier 2 ST; QL VITRO STRIP ORAVIG BUCCAL Tier 3 ONETOUCH TABLET Tier 2 QL ULTRASOFT LANCETS ORBACTIV ONETOUCH VERIO IN INTRAVENOUS Tier 2 QL Tier 3 VITRO STRIP SOLUTION RECONSTITUTED ONEXTON EXTERNAL Tier 2 GEL ORCHARD GRASS POLLEN ONGENTYS ORAL Tier 3 Tier 3 PA; QL SUBCUTANEOUS CAPSULE SOLUTION ONIVYDE ORENITRAM ORAL INTRAVENOUS Tier 3 LD TABLET EXTENDED Tier 4 PA; QL; LD; SP INJECTABLE RELEASE ONPATTRO ORFADIN ORAL Tier 4 PA; QL; LD INTRAVENOUS Tier 4 PA; QL; LD CAPSULE SOLUTION ORFADIN ORAL Tier 4 PA; QL; LD ONTRUZANT SUSPENSION INTRAVENOUS Tier 3 LD; SP ORGOVYX ORAL SOLUTION Tier 3 PA; QL; LD RECONSTITUTED TABLET ONUREG ORAL TABLET Tier 3 PA; QL; LD ORIAHNN ORAL CAPSULE THERAPY Tier 3 OPANA ORAL TABLET Tier 3 QL PACK opcicon one-step oral tablet Tier 1 $0 ORILISSA ORAL Tier 3 PA; QL OPDIVO INTRAVENOUS TABLET Tier 3 PA; QL; LD; SP SOLUTION ORKAMBI ORAL Tier 4 PA; QL; LD OPSUMIT ORAL PACKET Tier 4 PA; QL; LD; SP TABLET ORKAMBI ORAL Tier 4 PA; QL; LD option 2 oral tablet Tier 1 $0 TABLET OPTIONS GYNOL II ORLADEYO ORAL Tier 4 PA; QL; LD CONTRACEPTIVE Tier 2 $0 CAPSULE VAGINAL GEL orphenadrine citrate er oral ORABLOC INJECTION tablet extended release 12 Tier 1 Tier 3 SOLUTION CARTRIDGE hour ORALAIR SUBLINGUAL orphenadrine citrate injection Tier 3 PA; QL; LD Tier 1 TABLET SUBLINGUAL solution

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 110 Drug Name Tier Notes Drug Name Tier Notes orphenadrine-asa-caffeine OTOVEL OTIC Tier 1 ST; QL Tier 3 oral tablet SOLUTION orphengesic forte oral tablet Tier 1 ST; QL OTREXUP SUBCUTANEOUS orsythia oral tablet Tier 1 $0 Tier 4 PA; QL; SP SOLUTION AUTO- ORTHO MICRONOR Tier 3 INJECTOR ORAL TABLET OVIDE EXTERNAL ORTHO TRI-CYCLEN Tier 3 Tier 3 LOTION LO ORAL TABLET OVIDREL ORTHOVISC INTRA- SUBCUTANEOUS Tier 4 PA; QL; SP ARTICULAR SOLUTION Tier 4 PA; QL INJECTABLE PREFILLED SYRINGE OXACILLIN SODIUM IN ORTIKOS ORAL DEXTROSE Tier 3 CAPSULE EXTENDED Tier 3 INTRAVENOUS RELEASE 24 HOUR SOLUTION oseltamivir phosphate oral oxacillin sodium injection Tier 1 QL Tier 1 capsule solution reconstituted oseltamivir phosphate oral oxacillin sodium intravenous Tier 1 QL Tier 1 suspension reconstituted solution reconstituted osmitrol intravenous solution Tier 1 oxaliplatin intravenous Tier 1 SP OSMOLEX ER ORAL solution TABLET ER 24 HOUR Tier 3 PA; QL; LD oxaliplatin intravenous Tier 1 SP THERAPY PACK solution reconstituted OSMOLEX ER ORAL oxandrolone oral tablet Tier 1 PA; QL TABLET EXTENDED Tier 3 PA; DO; QL; LD oxaprozin oral tablet Tier 1 RELEASE 24 HOUR 129 MG OXAYDO ORAL TABLET Tier 3 QL OSMOLEX ER ORAL oxazepam oral capsule Tier 1 TABLET EXTENDED Tier 3 PA; QL; LD OXBRYTA ORAL RELEASE 24 HOUR 193 Tier 4 PA; QL; LD; SP MG, 258 MG TABLET OSMOPREP ORAL oxcarbazepine oral Tier 3 Tier 1 TABLET suspension OSPHENA ORAL oxcarbazepine oral tablet Tier 1 Tier 3 PA; QL TABLET OXERVATE OTEZLA ORAL TABLET Tier 4 PA; QL; SP OPHTHALMIC Tier 4 PA; QL; LD SOLUTION OTEZLA ORAL TABLET Tier 4 PA; QL; SP oxiconazole nitrate external THERAPY PACK Tier 1 cream OTIPRIO OXISTAT EXTERNAL INTRATYMPANIC Tier 3 Tier 3 ST; QL SUSPENSION CREAM

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 111 Drug Name Tier Notes Drug Name Tier Notes OXISTAT EXTERNAL OXYTOCIN-SODIUM Tier 3 ST; QL LOTION CHLORIDE Tier 3 OXLUMO INTRAVENOUS SUBCUTANEOUS Tier 4 PA; QL; LD SOLUTION SOLUTION OZEMPIC (0.25 OR 0.5 OXSORALEN ULTRA MG/DOSE) Tier 3 SP ORAL CAPSULE SUBCUTANEOUS Tier 2 ST; QL SOLUTION PEN- OXTELLAR XR ORAL INJECTOR TABLET EXTENDED Tier 3 RELEASE 24 HOUR OZEMPIC (1 MG/DOSE) SUBCUTANEOUS Tier 2 ST; QL oxybutynin chloride er oral SOLUTION PEN- tablet extended release 24 Tier 1 INJECTOR hour OZURDEX oxybutynin chloride oral Tier 1 INTRAVITREAL Tier 3 PA; QL; LD; SP syrup IMPLANT oxybutynin chloride oral Tier 1 pacerone oral tablet Tier 1 tablet paclitaxel intravenous oxycodone hcl er oral tablet Tier 1 SP Tier 3 PA; QL concentrate er 12 hour abuse-deterrent PADCEV INTRAVENOUS oxycodone hcl oral capsule Tier 1 QL SOLUTION Tier 3 PA; QL; LD; SP oxycodone hcl oral RECONSTITUTED Tier 1 QL concentrate PALFORZIA (12 MG Tier 4 PA; QL; LD; SP oxycodone hcl oral solution Tier 1 QL DAILY DOSE) ORAL oxycodone hcl oral tablet Tier 1 QL PALFORZIA (120 MG Tier 4 PA; QL; LD; SP oxycodone-acetaminophen DAILY DOSE) ORAL Tier 1 QL oral tablet PALFORZIA (160 MG Tier 4 PA; QL; LD; SP oxycodone-aspirin oral tablet Tier 1 QL DAILY DOSE) ORAL PALFORZIA (20 MG OXYCONTIN ORAL Tier 4 PA; QL; LD; SP TABLET ER 12 HOUR Tier 3 PA; QL DAILY DOSE) ORAL ABUSE-DETERRENT PALFORZIA (200 MG Tier 4 PA; QL; LD; SP oxymorphone hcl er oral DAILY DOSE) ORAL tablet extended release 12 Tier 1 PA; QL PALFORZIA (240 MG Tier 4 PA; QL; LD; SP hour DAILY DOSE) ORAL oxymorphone hcl oral tablet Tier 1 QL PALFORZIA (3 MG Tier 4 PA; QL; LD; SP DAILY DOSE) ORAL oxytocin injection solution Tier 1 PALFORZIA (300 MG OXYTOCIN-LACTATED MAINTENANCE) ORAL Tier 4 PA; QL; LD; SP RINGERS Tier 3 PACKET INTRAVENOUS SOLUTION PALFORZIA (300 MG TITRATION) ORAL Tier 4 PA; QL; LD; SP PACKET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 112 Drug Name Tier Notes Drug Name Tier Notes PALFORZIA (40 MG PALYNZIQ Tier 4 PA; QL; LD; SP DAILY DOSE) ORAL SUBCUTANEOUS Tier 4 PA; QL; LD; SP PALFORZIA (6 MG SOLUTION PREFILLED Tier 4 PA; QL; LD; SP DAILY DOSE) ORAL SYRINGE PALFORZIA (80 MG PAMELOR ORAL Tier 4 PA; QL; LD; SP Tier 3 DAILY DOSE) ORAL CAPSULE PALFORZIA INITIAL pamidronate disodium Tier 4 PA; QL; LD; SP ESCALATION ORAL intravenous solution 30 Tier 4 SP mg/10ml, 90 mg/10ml PALINGEN FLOW INJECTION Tier 3 PAMIDRONATE DISODIUM INJECTABLE Tier 4 SP INTRAVENOUS PALINGEN SOLUTION 6 MG/ML HYDROMEMBRANE Tier 3 EXTERNAL SHEET pamidronate disodium intravenous solution Tier 4 SP PALINGEN INOVOFLO reconstituted INJECTION Tier 3 INJECTABLE PANCREAZE ORAL CAPSULE DELAYED Tier 3 ST; QL PALINGEN MEMBRANE Tier 3 RELEASE PARTICLES EXTERNAL SHEET pancuronium bromide Tier 1 PALINGEN XPLUS intravenous solution HYDROMEMBRANE Tier 3 EXTERNAL SHEET PANHEMATIN INTRAVENOUS Tier 3 PALINGEN XPLUS SOLUTION MEMBRANE EXTERNAL Tier 3 RECONSTITUTED SHEET PANRETIN EXTERNAL Tier 3 SP paliperidone er oral tablet GEL extended release 24 hour 1.5 Tier 1 DO mg, 3 mg pantoprazole sodium intravenous solution Tier 1 paliperidone er oral tablet reconstituted extended release 24 hour 6 Tier 1 pantoprazole sodium oral mg, 9 mg Tier 1 QL tablet delayed release PALONOSETRON HCL INTRAVENOUS Tier 3 PA; QL PANZYGA SOLUTION 0.25 MG/2ML INTRAVENOUS Tier 4 PA; QL; LD; SP SOLUTION PALONOSETRON HCL papaverine hcl injection INTRAVENOUS Tier 1 PA; QL Tier 1 SOLUTION 0.25 MG/5ML solution palonosetron hcl intravenous PARAGARD Tier 1 PA; QL solution prefilled syringe INTRAUTERINE COPPER Tier 3 INTRAUTERINE INTRAUTERINE DEVICE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 113 Drug Name Tier Notes Drug Name Tier Notes paraplatin intravenous PEDIAPRED ORAL Tier 1 SP Tier 3 solution SOLUTION PAREMYD PEDIARIX OPHTHALMIC Tier 3 INTRAMUSCULAR Tier 3 $0 SOLUTION SUSPENSION paricalcitol intravenous PEDVAX HIB Tier 1 PA; QL solution INTRAMUSCULAR Tier 3 $0 paricalcitol oral capsule Tier 1 PA; QL SUSPENSION PARLODEL ORAL peg 3350 oral packet Tier 1 $0 Tier 3 CAPSULE peg 3350 oral powder Tier 1 $0 PARLODEL ORAL peg 3350-kcl-na bicarb-nacl Tier 3 Tier 1 $0 TABLET oral solution reconstituted PARNATE ORAL peg-3350/electrolytes oral Tier 3 Tier 1 $0 TABLET solution reconstituted paroex mouth/throat solution Tier 1 peg- 3350/electrolytes/ascorbat Tier 1 $0 paromomycin sulfate oral Tier 1 oral solution reconstituted capsule PEGASYS paroxetine hcl er oral tablet SUBCUTANEOUS Tier 4 LD; SP extended release 24 hour Tier 1 DO SOLUTION 12.5 mg PEGINTRON Tier 4 SP paroxetine hcl er oral tablet SUBCUTANEOUS KIT extended release 24 hour 25 Tier 1 peg-kcl-nacl-nasulf-na asc-c mg, 37.5 mg Tier 1 $0 oral solution reconstituted paroxetine hcl oral tablet 10 Tier 1 DO mg, 20 mg peg-prep oral kit Tier 1 $0 paroxetine hcl oral tablet 30 PEMAZYRE ORAL Tier 1 Tier 3 PA; QL; LD mg, 40 mg TABLET paroxetine mesylate oral PEN NEEDLES Tier 3 ST; QL Tier 1 capsule PEN NEEDLES 1/2" Tier 3 ST; QL PARSABIV PEN NEEDLES 5/16" Tier 3 ST; QL INTRAVENOUS Tier 4 PA; QL SOLUTION penicillamine oral capsule Tier 1 PA; QL penicillamine oral tablet Tier 1 PA; QL PASER ORAL PACKET Tier 3 PENICILLIN G POT IN PATANASE NASAL DEXTROSE Tier 3 Tier 3 SOLUTION INTRAVENOUS PAXIL ORAL SOLUTION Tier 3 ST; QL SUSPENSION penicillin g potassium PC LANCETS SUPER injection solution Tier 1 Tier 2 QL THIN 30G reconstituted PC UNIFINE PENTIPS Tier 3 ST; QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 114 Drug Name Tier Notes Drug Name Tier Notes PENICILLIN G PENTETATE ZINC PROCAINE TRISODIUM Tier 3 Tier 3 INTRAMUSCULAR COMBINATION SUSPENSION SOLUTION penicillin g sodium injection PENTIPS Tier 3 ST; QL Tier 1 solution reconstituted pentobarbital sodium Tier 1 penicillin v potassium oral injection solution Tier 1 solution reconstituted pentoxifylline er oral tablet Tier 1 penicillin v potassium oral extended release Tier 1 tablet PEPCID ORAL TABLET Tier 3 PENICILLIUM NOTATUM INJECTION Tier 3 PERENNIAL RYE GRASS SOLUTION POLLEN INJECTION Tier 3 SOLUTION PENICILLIUM NOTATUM PERFECT LANCETS 28G Tier 2 QL Tier 3 SUBCUTANEOUS PERFECT LANCETS 30G Tier 2 QL SOLUTION PERFOROMIST PENLET II BLOOD INHALATION Tier 2 Tier 2 SAMPLER KIT NEBULIZATION PENLET II SOLUTION Tier 2 REPLACEMENT CAP PERIDEX PENTACEL MOUTH/THROAT Tier 3 INTRAMUSCULAR SOLUTION Tier 3 $0 SUSPENSION PERIKABIVEN RECONSTITUTED INTRAVENOUS Tier 3 PENTAM INJECTION EMULSION SOLUTION Tier 3 perindopril erbumine oral Tier 1 RECONSTITUTED tablet pentamidine isethionate periogard mouth/throat Tier 1 inhalation solution Tier 1 solution reconstituted PERJETA pentamidine isethionate INTRAVENOUS Tier 3 PA; QL; LD; SP injection solution Tier 1 SOLUTION reconstituted permethrin external cream Tier 1 PENTASA ORAL CAPSULE EXTENDED Tier 2 perphenazine oral tablet Tier 1 RELEASE perphenazine-amitriptyline Tier 1 pentazocine-naloxone hcl oral tablet Tier 1 QL oral tablet PERRY PRENATAL Tier 2 $0 PENTETATE CALCIUM ORAL CAPSULE TRISODIUM Tier 3 COMBINATION SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 115 Drug Name Tier Notes Drug Name Tier Notes PERSERIS PHENYLEPHRINE HCL SUBCUTANEOUS Tier 3 INTRAOCULAR Tier 3 PREFILLED SYRINGE SOLUTION PREFILLED PERTZYE ORAL SYRINGE CAPSULE DELAYED Tier 3 ST; QL PHENYLEPHRINE HCL RELEASE PARTICLES INTRAVENOUS Tier 3 PEXEVA ORAL TABLET SOLUTION Tier 3 ST; DO; QL 10 MG, 20 MG phenylephrine hcl Tier 1 PEXEVA ORAL TABLET ophthalmic solution Tier 3 ST; QL 30 MG, 40 MG PHENYLEPHRINE HCL- pfizerpen injection solution NACL INTRAVENOUS Tier 3 Tier 1 reconstituted SOLUTION PHARMACIST CHOICE PHENYLEPHRINE HCL- Tier 2 QL NACL INTRAVENOUS LANCETS Tier 3 SOLUTION PREFILLED PHARMACY COUNTER Tier 2 QL SYRINGE LANCETS PHENYTEK ORAL Tier 3 phendimetrazine tartrate er CAPSULE oral capsule extended release Tier 1 PA; QL phenytoin infatabs oral tablet 24 hour Tier 1 chewable phendimetrazine tartrate oral Tier 1 PA; QL tablet phenytoin oral suspension Tier 1 phenytoin oral tablet phenelzine sulfate oral tablet Tier 1 Tier 1 chewable PHENERGAN Tier 3 phenytoin sodium extended INJECTION SOLUTION Tier 1 T1S oral capsule 100 mg phenobarbital oral elixir Tier 1 phenytoin sodium extended Tier 1 phenobarbital oral tablet Tier 1 oral capsule 200 mg, 300 mg phenobarbital sodium phenytoin sodium injection Tier 1 Tier 1 injection solution solution phenobarbital-belladonna alk PHESGO Tier 1 oral elixir SUBCUTANEOUS Tier 3 PA; QL; LD; SP SOLUTION phenohytro oral elixir Tier 1 PHEXXI VAGINAL GEL Tier 3 phenohytro oral tablet Tier 1 philith oral tablet Tier 1 $0 phenoxybenzamine hcl oral Tier 1 PA; QL phillips milk of magnesia capsule Tier 1 $0 oral suspension phentermine hcl oral capsule Tier 1 PA; QL PHOMA EXIGUA phentermine hcl oral tablet Tier 1 PA; QL SUBCUTANEOUS Tier 3 phentolamine mesylate SOLUTION injection solution Tier 1 PHOSLYRA ORAL Tier 3 ST; QL reconstituted SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 116 Drug Name Tier Notes Drug Name Tier Notes PHOSPHOLINE IODIDE pimozide oral tablet Tier 1 OPHTHALMIC Tier 3 SOLUTION pimtrea oral tablet Tier 1 $0 RECONSTITUTED pindolol oral tablet Tier 1 phosphorous oral tablet Tier 1 pioglitazone hcl oral tablet Tier 1 ST; QL phospho-trin 250 neutral oral pioglitazone hcl-glimepiride Tier 1 Tier 1 ST; QL tablet oral tablet PHOTOFRIN pioglitazone hcl-metformin Tier 1 ST; QL INTRAVENOUS hcl oral tablet Tier 3 SOLUTION PIP LANCETS 28G Tier 2 QL RECONSTITUTED PIP LANCETS 30G Tier 2 QL PHOTREXA VISCOUS OPHTHALMIC piperacillin sod-tazobactam Tier 3 SOLUTION PREFILLED so intravenous solution Tier 1 SYRINGE reconstituted PHOTREXA-PHOTREXA PIQRAY (200 MG DAILY VISCOUS KIT DOSE) ORAL TABLET Tier 3 PA; QL; SP OPHTHALMIC Tier 3 THERAPY PACK SOLUTION PREFILLED PIQRAY (250 MG DAILY SYRINGE DOSE) ORAL TABLET Tier 3 PA; QL; SP PHOXILLUM B22K4/0 THERAPY PACK INTRAVENOUS Tier 3 PIQRAY (300 MG DAILY SOLUTION DOSE) ORAL TABLET Tier 3 PA; QL; SP PHOXILLUM BK4/2.5 THERAPY PACK INTRAVENOUS Tier 3 pirmella 1/35 oral tablet Tier 1 $0 SOLUTION pirmella 7/7/7 oral tablet Tier 1 $0 physiolyte irrigation solution Tier 1 piroxicam oral capsule Tier 1 physiosol irrigation irrigation Tier 1 PITOCIN INJECTION solution Tier 3 SOLUTION phytonadione injection Tier 1 plasbumin-25 intravenous solution Tier 1 solution phytonadione oral tablet Tier 1 plasbumin-5 intravenous Tier 1 PICATO EXTERNAL solution Tier 3 ST; QL GEL PLASMA-LYTE 148 PIFELTRO ORAL INTRAVENOUS Tier 3 Tier 3 QL TABLET SOLUTION pilocarpine hcl ophthalmic PLASMA-LYTE A Tier 1 solution INTRAVENOUS Tier 3 SOLUTION pilocarpine hcl oral tablet Tier 1 PLASMANATE pimecrolimus external cream Tier 1 ST; QL INTRAVENOUS Tier 3 SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 117 Drug Name Tier Notes Drug Name Tier Notes PLEGRIDY POLIVY INTRAVENOUS INTRAMUSCULAR SOLUTION Tier 3 PA; QL; LD; SP Tier 4 PA; QL; LD; SP SOLUTION PREFILLED RECONSTITUTED SYRINGE polocaine injection solution Tier 1 PLEGRIDY STARTER PACK SUBCUTANEOUS polocaine-mpf injection Tier 4 PA; QL; LD; SP Tier 1 SOLUTION PEN- solution INJECTOR polycin ophthalmic ointment Tier 1 PLEGRIDY STARTER polyethylene glycol 3350 PACK SUBCUTANEOUS Tier 1 $0 Tier 4 PA; QL; LD; SP oral packet SOLUTION PREFILLED polyethylene glycol 3350 SYRINGE Tier 1 $0 oral powder PLEGRIDY polymyxin b sulfate injection SUBCUTANEOUS Tier 1 Tier 4 PA; QL; LD; SP solution reconstituted SOLUTION PEN- INJECTOR polymyxin b-trimethoprim Tier 1 ophthalmic solution PLEGRIDY SUBCUTANEOUS POLYTRIM Tier 4 PA; QL; LD; SP SOLUTION PREFILLED OPHTHALMIC Tier 3 SYRINGE SOLUTION plenamine intravenous POLY-TUSSIN AC ORAL Tier 1 Tier 2 solution LIQUID PLENVU ORAL POLY-VI-FLOR ORAL Tier 3 SOLUTION Tier 3 SUSPENSION RECONSTITUTED POLY-VI-FLOR ORAL Tier 3 PNEUMOVAX 23 TABLET CHEWABLE INJECTION Tier 2 $0 POLY-VI-FLOR/IRON Tier 3 INJECTABLE ORAL SUSPENSION PNV TABS 20-1 ORAL Tier 3 ST; QL POLY-VI-FLOR/IRON TABLET ORAL TABLET Tier 3 PNV TABS 29-1 ORAL CHEWABLE Tier 2 TABLET POMALYST ORAL Tier 3 PA; QL; LD; SP pnv-dha oral capsule Tier 1 ST; QL CAPSULE PNV-DHA+DOCUSATE portia-28 oral tablet Tier 1 $0 Tier 3 ST; QL ORAL CAPSULE PORTRAZZA PNV-OMEGA ORAL INTRAVENOUS Tier 3 LD; SP Tier 3 ST; QL CAPSULE SOLUTION posaconazole oral tablet pnv-select oral tablet Tier 1 Tier 1 PA; QL delayed release podofilox external solution Tier 1 pot & sod cit-cit ac oral POINT OF CARE LM-2.5 Tier 1 Tier 3 solution INJECTION KIT

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 118 Drug Name Tier Notes Drug Name Tier Notes potassium acetate POTELIGEO Tier 1 intravenous solution INTRAVENOUS Tier 3 LD; SP potassium chloride crys er SOLUTION Tier 1 T1S oral tablet extended release PRALUENT potassium chloride er oral SUBCUTANEOUS Tier 1 T1S Tier 3 PA; QL capsule extended release SOLUTION AUTO- INJECTOR potassium chloride er oral Tier 1 T1S tablet extended release pramipexole dihydrochloride er oral tablet extended Tier 1 potassium chloride in Tier 1 release 24 hour dextrose intravenous solution pramipexole dihydrochloride potassium chloride in nacl Tier 1 Tier 1 oral tablet intravenous solution PRAMOSONE Tier 2 POTASSIUM CHLORIDE EXTERNAL CREAM INTRAVENOUS PRAMOSONE SOLUTION 10 Tier 2 MEQ/100ML, 10 Tier 3 EXTERNAL LOTION MEQ/50ML, 20 PRAMOTIC OTIC Tier 3 MEQ/50ML, 40 LIQUID MEQ/100ML prasugrel hcl oral tablet 10 Tier 1 potassium chloride mg intravenous solution 2 Tier 1 prasugrel hcl oral tablet 5 mg Tier 1 DO meq/ml pravastatin sodium oral tablet potassium chloride oral Tier 1 DO; $0 Tier 1 T1S 10 mg, 20 mg, 40 mg packet pravastatin sodium oral tablet potassium chloride oral Tier 1 $0 Tier 1 T1S 80 mg solution PRAXBIND potassium citrate er oral Tier 1 INTRAVENOUS Tier 3 tablet extended release SOLUTION POTASSIUM praziquantel oral tablet Tier 1 PHOSPHATES INTRAVENOUS prazosin hcl oral capsule Tier 1 T1S Tier 3 SOLUTION 15 PRECEDEX MMOLE/5ML, 150 INTRAVENOUS Tier 3 MMOLE/50ML SOLUTION potassium phosphates PRECISION SUREDOSE Tier 3 ST; QL intravenous solution 45 Tier 1 PLUS SYR mmole/15ml PRECISION SURE-DOSE potassium phosphates(66 Tier 1 SYRINGE 28G X 1/2" 0.5 meq k) intravenous solution ML, 28G X 1/2" 1 ML, 29G Tier 3 ST; QL POTASSIUM X 1/2" 0.5 ML, 30G X PHOSPHATES(71 MEQ 5/16" 0.3 ML Tier 3 K) INTRAVENOUS SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 119 Drug Name Tier Notes Drug Name Tier Notes PRECISION SURE-DOSE PREFERRED PLUS Tier 3 ST; QL SYRINGE 30G X 3/8" 0.5 Tier 3 INSULIN SYRINGE ML PREFERRED PLUS Tier 2 QL PRECISION THINS GP LANCETS COLORED Tier 2 QL LANCETS PREFERRED PLUS Tier 2 QL PRECOSE ORAL LANCETS THIN Tier 3 TABLET PREFERRED PLUS Tier 3 ST; QL PRED MILD UNIFINE PENTIPS OPHTHALMIC Tier 3 PREFEST ORAL Tier 3 SUSPENSION TABLET PRED-G OPHTHALMIC Tier 3 pregabalin oral capsule Tier 1 SUSPENSION PRED-G S.O.P. pregabalin oral solution Tier 1 OPHTHALMIC Tier 3 PREGEN DHA ORAL Tier 3 ST; QL OINTMENT CAPSULE prednicarbate external cream Tier 1 PREGENNA ORAL Tier 3 ST; QL prednicarbate external TABLET Tier 1 ointment PREGNYL prednisolone acetate INTRAMUSCULAR Tier 1 Tier 4 PA; QL; SP ophthalmic suspension SOLUTION RECONSTITUTED prednisolone oral solution Tier 1 PREMARIN INJECTION PREDNISOLONE SOLUTION Tier 2 SODIUM PHOSPHATE RECONSTITUTED Tier 3 OPHTHALMIC PREMARIN ORAL Tier 2 SOLUTION TABLET prednisolone sodium PREMARIN VAGINAL Tier 1 Tier 2 phosphate oral solution CREAM prednisolone sodium PREMASOL phosphate oral tablet Tier 1 INTRAVENOUS Tier 3 dispersible 10 mg, 30 mg SOLUTION prednisolone sodium PREMESISRX ORAL Tier 2 ST; QL phosphate oral tablet Tier 1 DO TABLET dispersible 15 mg PREMPHASE ORAL Tier 2 PREDNISONE TABLET INTENSOL ORAL Tier 3 PREMPRO ORAL CONCENTRATE Tier 2 TABLET prednisone oral solution Tier 1 T1S PRENA 1 TRUE ORAL Tier 3 prednisone oral tablet Tier 1 T1S prednisone oral tablet PRENA1 ORAL TABLET Tier 1 T1S Tier 2 ST; QL therapy pack CHEWABLE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 120 Drug Name Tier Notes Drug Name Tier Notes PRENA1 PEARL ORAL PRENATAL VITAMIN Tier 2 $0 CAPSULE EXTENDED Tier 3 ST; QL ORAL TABLET RELEASE PRENATAL VITAMIN PRENAISSANCE ORAL PLUS LOW IRON ORAL Tier 2 Tier 3 ST; QL CAPSULE TABLET PRENAISSANCE PLUS PRENATAL VITAMINS Tier 3 ST; QL Tier 2 $0 ORAL CAPSULE ORAL TABLET PRENARA ORAL PRENATAL/IRON ORAL Tier 3 ST; QL Tier 2 $0 CAPSULE TABLET PRENATAL-U ORAL prenatabs rx oral tablet Tier 1 Tier 2 CAPSULE PRENATAL 19 ORAL Tier 3 PRENATE AM ORAL TABLET Tier 3 ST; QL TABLET prenatal 19 oral tablet Tier 1 PRENATE DHA ORAL chewable Tier 3 ST; QL CAPSULE PRENATAL 19 ORAL PRENATE ELITE ORAL TABLET CHEWABLE 29- Tier 3 Tier 3 ST; QL 1 MG TABLET PRENATAL COMPLETE PRENATE ENHANCE Tier 2 $0 Tier 3 ST; QL ORAL TABLET ORAL CAPSULE PRE-NATAL FORMULA PRENATE ESSENTIAL Tier 2 $0 Tier 3 ST; QL ORAL TABLET ORAL CAPSULE PRENATAL FORTE PRENATE MINI ORAL Tier 2 $0 Tier 3 ST; QL ORAL TABLET CAPSULE PRENATAL LOW IRON PRENATE ORAL Tier 2 $0 Tier 3 ST; QL ORAL TABLET TABLET CHEWABLE PRENATE PIXIE ORAL PRENATAL Tier 3 ST; QL MULTIVITAMIN + DHA Tier 2 $0 CAPSULE ORAL PRENATE RESTORE Tier 3 ST; QL PRENATAL ONE DAILY ORAL CAPSULE Tier 2 $0 ORAL TABLET PRENATRIX ORAL Tier 3 ST; QL PRENATAL ORAL TABLET TABLET 27-0.8 MG, 28- Tier 2 $0 PRENATRYL ORAL Tier 3 ST; QL 0.8 MG TABLET PRENATAL ORAL Tier 2 PRENATVITE TABLET 27-1 MG COMPLETE ORAL Tier 3 ST; QL PRENATAL PLUS IRON TABLET Tier 2 ORAL TABLET PRENATVITE PLUS Tier 3 ST; QL PRENATAL VITAMIN ORAL TABLET AND MINERAL ORAL Tier 2 $0 PRENATVITE RX ORAL Tier 3 ST; QL TABLET TABLET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 121 Drug Name Tier Notes Drug Name Tier Notes PREPIDIL VAGINAL PREVIDENT Tier 3 GEL MOUTH/THROAT Tier 3 PREPIV SUPPLY SOLUTION Tier 3 COMBINATION KIT previfem oral tablet Tier 1 $0 PREPLUS ORAL PREVNAR 13 Tier 2 TABLET INTRAMUSCULAR Tier 2 $0 PRESSURE ACTIVAT SUSPENSION Tier 2 QL SAFETY LANCET PREVYMIS PRESTALIA ORAL INTRAVENOUS Tier 4 PA; QL; SP Tier 3 TABLET 14-10 MG SOLUTION PREVYMIS ORAL PRESTALIA ORAL Tier 4 PA; QL; SP TABLET 3.5-2.5 MG, 7-5 Tier 3 DO TABLET MG PREZCOBIX ORAL Tier 3 QL TABLET PRETAB ORAL TABLET Tier 2 PREZISTA ORAL PRETOMANID ORAL Tier 2 QL Tier 3 SUSPENSION TABLET PREZISTA ORAL Tier 2 QL prevalite oral packet Tier 1 TABLET prevalite oral powder Tier 1 PRIALT INTRATHECAL Tier 4 PA; QL; LD PREVENT SAFETY PEN SOLUTION Tier 3 ST; QL NEEDLES PRIFTIN ORAL TABLET Tier 2 preventeza oral tablet Tier 1 $0 PRILO PATCH II Tier 3 PREVIDENT 5000 EXTERNAL KIT BOOSTER PLUS Tier 3 PRIMACARE ORAL Tier 3 ST; QL DENTAL PASTE CAPSULE PREVIDENT 5000 DRY Tier 3 PRIMAQUINE MOUTH DENTAL GEL PHOSPHATE ORAL Tier 3 PREVIDENT 5000 TABLET ENAMEL PROTECT Tier 3 PRIMAXIN IV DENTAL PASTE INTRAVENOUS Tier 3 PREVIDENT 5000 SOLUTION ORTHO DEFENSE Tier 3 RECONSTITUTED DENTAL PASTE primidone oral tablet Tier 1 T1S PREVIDENT 5000 PLUS PRIMSOL ORAL Tier 3 Tier 3 DENTAL CREAM SOLUTION PREVIDENT 5000 PRISMASOL B22GK 4/0 SENSITIVE DENTAL Tier 3 INTRAVENOUS Tier 3 PASTE SOLUTION PREVIDENT DENTAL Tier 3 PRISMASOL BGK 0/2.5 GEL INTRAVENOUS Tier 3 SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 122 Drug Name Tier Notes Drug Name Tier Notes PRISMASOL BGK 2/0 PROBUPHINE IMPLANT INTRAVENOUS Tier 3 KIT SUBCUTANEOUS Tier 3 PA; QL; LD SOLUTION IMPLANT PRISMASOL BGK 2/3.5 procainamide hcl injection Tier 1 INTRAVENOUS Tier 3 solution SOLUTION PROCALAMINE PRISMASOL BGK 4/0/1.2 INTRAVENOUS Tier 3 INTRAVENOUS Tier 3 SOLUTION SOLUTION PROCARDIA ORAL Tier 3 PRISMASOL BGK 4/2.5 CAPSULE INTRAVENOUS Tier 3 PROCARDIA XL ORAL SOLUTION TABLET EXTENDED Tier 3 DO PRISMASOL BK 0/0/1.2 RELEASE 24 HOUR 30 INTRAVENOUS Tier 3 MG SOLUTION PROCARDIA XL ORAL PRIVET TABLET EXTENDED Tier 3 SUBCUTANEOUS Tier 3 RELEASE 24 HOUR 60 SOLUTION MG, 90 MG PRIVIGEN procentra oral solution Tier 1 PA; QL INTRAVENOUS Tier 4 PA; QL; LD; SP prochlorperazine edisylate Tier 1 SOLUTION injection solution PRO COMFORT prochlorperazine maleate Tier 3 ST; QL Tier 1 INSULIN SYRINGE oral tablet PRO COMFORT prochlorperazine rectal Tier 2 QL Tier 1 LANCETS 30G suppository PRO COMFORT PROCRIT INJECTION Tier 2 QL Tier 4 PA; QL; SP LANCETS 31G SOLUTION PRO COMFORT PEN PROCTOCORT Tier 3 ST; QL Tier 3 NEEDLES EXTERNAL CREAM PROAIR DIGIHALER PROCTOFOAM HC INHALATION AEROSOL Tier 3 Tier 3 ST; QL EXTERNAL FOAM POWDER BREATH procto-med hc external ACTIVATED Tier 1 cream PROAIR HFA INHALATION AEROSOL Tier 2 ST; QL procto-pak external cream Tier 1 SOLUTION proctozone-hc external cream Tier 1 PROAIR RESPICLICK INHALATION AEROSOL PROCYSBI ORAL Tier 2 POWDER BREATH CAPSULE DELAYED Tier 4 ST; QL; LD ACTIVATED RELEASE PROCYSBI ORAL probenecid oral tablet Tier 1 Tier 4 ST; QL; LD PACKET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 123 Drug Name Tier Notes Drug Name Tier Notes PRODIGY INSULIN PROLIA Tier 3 ST; QL SYRINGE SUBCUTANEOUS Tier 3 PA; QL; SP PRODIGY LANCETS 28G Tier 2 QL SOLUTION PREFILLED SYRINGE PRODIGY LANCING Tier 2 PROMACTA ORAL PA; DO; QL; LD; DEVICE Tier 4 PACKET 12.5 MG SP PRODIGY SAFETY Tier 2 QL PROMACTA ORAL LANCETS 26G Tier 4 PA; QL; LD; SP PACKET 25 MG PRODIGY TWIST TOP Tier 2 QL PROMACTA ORAL PA; DO; QL; LD; LANCETS 28G Tier 4 TABLET 12.5 MG, 25 MG SP PROFILNINE INTRAVENOUS PROMACTA ORAL Tier 4 PA; QL; LD; SP Tier 4 PA; QL; LD; SP SOLUTION TABLET 50 MG, 75 MG RECONSTITUTED promethazine hcl injection Tier 1 progesterone intramuscular solution Tier 1 oil promethazine hcl oral Tier 1 progesterone micronized oral solution Tier 1 capsule promethazine hcl oral syrup Tier 1 PROGLYCEM ORAL Tier 3 promethazine hcl oral tablet Tier 1 SUSPENSION promethazine hcl rectal Tier 1 PROGRAF suppository INTRAVENOUS Tier 2 SP promethazine-codeine oral SOLUTION Tier 1 solution PROGRAF ORAL Tier 3 promethazine-codeine oral CAPSULE Tier 1 syrup PROGRAF ORAL Tier 3 PACKET promethazine-dm oral syrup Tier 1 PROLASTIN-C promethazine-phenyleph- Tier 1 INTRAVENOUS Tier 4 PA; QL; LD codeine oral syrup SOLUTION promethazine-phenylephrine Tier 1 PROLASTIN-C oral syrup INTRAVENOUS promethegan rectal Tier 4 PA; QL; LD Tier 1 SOLUTION suppository RECONSTITUTED propafenone hcl er oral PROLENSA capsule extended release 12 Tier 1 OPHTHALMIC Tier 3 hour SOLUTION propafenone hcl oral tablet Tier 1 PROLEUKIN INTRAVENOUS proparacaine hcl ophthalmic Tier 3 PA; QL; SP Tier 1 SOLUTION solution RECONSTITUTED proparacaine-fluorescein Tier 1 ophthalmic solution

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 124 Drug Name Tier Notes Drug Name Tier Notes PROPECIA ORAL Tier 3 protriptyline hcl oral tablet Tier 1 TABLET PROVAYBLUE PROPEL MINI NASAL Tier 3 INTRAVENOUS Tier 3 IMPLANT SOLUTION PROPEL NASAL Tier 3 PROVENGE IMPLANT INTRAVENOUS Tier 4 PA; QL; LD propofol intravenous SUSPENSION Tier 1 emulsion PROVENTIL HFA propranolol hcl er oral INHALATION AEROSOL Tier 3 ST; QL capsule extended release 24 Tier 1 T1S SOLUTION hour PROVERA ORAL Tier 3 propranolol hcl intravenous TABLET Tier 1 solution PROVIDA OB ORAL Tier 3 propranolol hcl oral solution Tier 1 T1S CAPSULE propranolol hcl oral tablet Tier 1 T1S PROVISC INTRAOCULAR Tier 4 propranolol-hctz oral tablet Tier 1 SOLUTION propylthiouracil oral tablet Tier 1 T1S pseudoeph-bromphen-dm Tier 1 PROQUAD oral syrup SUBCUTANEOUS PSS SELECT GP Tier 3 $0 Tier 2 QL SUSPENSION LANCETS RECONSTITUTED PSS SELECT PRO-RED AC ORAL Tier 2 Tier 3 PLATFORMS SYRUP PSS SELECT SAFETY PROSCAR ORAL Tier 2 QL Tier 3 LANCETS TABLET PULMOZYME PROSOL INTRAVENOUS Tier 3 INHALATION Tier 4 LD; SP SOLUTION SOLUTION PROSTIN E2 VAGINAL PURE COMFORT PEN Tier 3 Tier 3 ST; QL SUPPOSITORY NEEDLE PROSTIN VR PURIXAN ORAL Tier 3 Tier 3 PA; QL; LD INJECTION SOLUTION SUSPENSION protamine sulfate intravenous PUSH BUTTON SAFETY Tier 1 Tier 2 QL solution LANCETS PROTONIX PUSH BUTTON SAFETY INTRAVENOUS Tier 2 QL Tier 3 LANCETS 28G SOLUTION PX ADVANCED RECONSTITUTED Tier 2 LANCING DEVICE PROTOPAM CHLORIDE INTRAVENOUS px aspirin oral tablet Tier 1 $0 Tier 3 SOLUTION px aspirin oral tablet Tier 1 $0 RECONSTITUTED chewable

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 125 Drug Name Tier Notes Drug Name Tier Notes px b complex/vitamin c oral PYRIDOXINE HCL Tier 1 $0 Tier 3 tablet INJECTION SOLUTION px b-50 oral tablet Tier 1 $0 pyrimethamine oral tablet Tier 1 PA; QL px enteric aspirin oral tablet QBRELIS ORAL Tier 1 $0 Tier 3 delayed release SOLUTION PX EXTRA SHORT PEN QBREXZA EXTERNAL Tier 3 ST; QL Tier 3 PA; QL NEEDLES PAD px folic acid oral tablet Tier 1 $0 QC ADVANCED Tier 2 PX INSULIN SYRINGE Tier 3 ST; QL LANCING DEVICE PX LANCET AUTO qc aspirin low dose oral Tier 2 Tier 1 $0 INJECTOR tablet chewable PX LANCETS ULTRA qc aspirin low dose oral Tier 2 QL Tier 1 $0 THIN tablet delayed release PX LANCETS ULTRA qc aspirin oral tablet Tier 1 $0 Tier 2 QL THIN 28G qc aspirin oral tablet delayed Tier 1 $0 px laxative oral tablet release Tier 1 $0 delayed release qc b50 prolonged release oral Tier 1 $0 px milk of magnesia oral tablet extended release Tier 1 $0 suspension qc b-complex/vitamin c oral Tier 1 $0 PX MINI PEN NEEDLES Tier 3 ST; QL tablet qc childrens aspirin oral PX PEN NEEDLE Tier 3 ST; QL Tier 1 $0 tablet chewable PX PRENATAL qc daily multivitamins/iron MULTIVITAMINS ORAL Tier 2 $0 Tier 1 $0 TABLET oral tablet PX SHORTLENGTH PEN qc enteric aspirin oral tablet Tier 3 ST; QL Tier 1 $0 NEEDLES delayed release px stop smoking aid qc essentials oral tablet Tier 1 $0 Tier 1 $0 mouth/throat gum qc folic acid oral tablet Tier 1 $0 px stop smoking aid qc gentle laxative oral tablet Tier 1 $0 Tier 1 $0 mouth/throat lozenge delayed release PYLERA ORAL QC LANCETS SUPER Tier 3 ST; QL Tier 2 QL CAPSULE THIN 30G QC LANCETS ULTRA pyrazinamide oral tablet Tier 1 Tier 2 QL THIN pyridostigmine bromide er Tier 1 qc magnesium citrate oral oral tablet extended release Tier 1 $0 solution pyridostigmine bromide oral Tier 1 qc milk of magnesia oral solution Tier 1 $0 suspension pyridostigmine bromide oral Tier 1 tablet qc natura-lax oral powder Tier 1 $0

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 126 Drug Name Tier Notes Drug Name Tier Notes QC PEN NEEDLES Tier 3 ST; QL quetiapine fumarate er oral QC PRENATAL ORAL tablet extended release 24 Tier 1 DO Tier 2 $0 TABLET hour 150 mg, 200 mg QC UNIFINE PENTIPS Tier 3 ST; QL quetiapine fumarate er oral tablet extended release 24 Tier 1 QC UNILET LANCETS Tier 2 QL hour 300 mg, 400 mg, 50 mg 28G quetiapine fumarate oral QC UNILET LANCETS Tier 1 DO Tier 2 QL tablet 100 mg, 25 mg, 50 mg MICRO THIN quetiapine fumarate oral QDOLO ORAL Tier 3 QL tablet 200 mg, 300 mg, 400 Tier 1 SOLUTION mg QINLOCK ORAL QUFLORA FE ORAL Tier 3 PA; QL; LD Tier 3 TABLET TABLET CHEWABLE QSYMIA ORAL QUFLORA FE CAPSULE EXTENDED Tier 3 PA; QL PEDIATRIC ORAL Tier 3 RELEASE 24 HOUR LIQUID QUADRACEL QUFLORA GUMMIES INTRAMUSCULAR Tier 3 $0 ORAL TABLET Tier 2 SUSPENSION CHEWABLE QUADRAMET QUFLORA PEDIATRIC Tier 3 INTRAVENOUS Tier 3 ORAL SOLUTION SOLUTION QUFLORA PEDIATRIC QUALAQUIN ORAL Tier 3 PA; QL ORAL TABLET Tier 3 CAPSULE CHEWABLE QUARTETTE ORAL Tier 3 QUILLICHEW ER ORAL TABLET TABLET CHEWABLE Tier 3 PA; DO; QL quazepam oral tablet Tier 1 EXTENDED RELEASE 20 MG QUDEXY XR ORAL CAPSULE ER 24 HOUR Tier 3 ST; QL QUILLICHEW ER ORAL TABLET CHEWABLE SPRINKLE Tier 3 PA; QL EXTENDED RELEASE 30 QUEEN PALM MG, 40 MG SUBCUTANEOUS Tier 3 SOLUTION QUILLIVANT XR ORAL SUSPENSION Tier 3 QUELICIN INJECTION Tier 3 RECONSTITUTED ER SOLUTION quin b strong b-25 oral tablet Tier 1 $0 QUESTRAN LIGHT Tier 3 ORAL POWDER quinapril hcl oral tablet Tier 1 T1S QUESTRAN ORAL quinapril- Tier 3 PACKET hydrochlorothiazide oral Tier 1 tablet QUESTRAN ORAL Tier 3 quinidine gluconate er oral POWDER Tier 1 tablet extended release

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 127 Drug Name Tier Notes Drug Name Tier Notes quinidine sulfate oral tablet Tier 1 T1S RA INSULIN SYRINGE Tier 3 ST; QL quinine sulfate oral capsule Tier 1 PA; QL ra laxative oral powder Tier 1 $0 QUINTABS ORAL ra laxative oral tablet delayed Tier 2 $0 Tier 1 $0 TABLET release QUZYTTIR ra milk of magnesia oral Tier 1 $0 INTRAVENOUS Tier 3 suspension SOLUTION ra mini nicotine mouth/throat Tier 1 $0 QVAR REDIHALER lozenge INHALATION AEROSOL Tier 2 ra nicotine gum mouth/throat Tier 1 $0 BREATH ACTIVATED gum ra aspirin adult low dose oral Tier 1 $0 ra nicotine mouth/throat gum Tier 1 $0 tablet chewable ra nicotine polacrilex ra aspirin adult low strength Tier 1 $0 Tier 1 $0 mouth/throat lozenge oral tablet chewable ra nicotine transdermal patch ra aspirin childrens oral Tier 1 $0 Tier 1 $0 24 hour tablet chewable ra pain relief aspirin oral ra aspirin ec adult low st oral Tier 1 $0 Tier 1 $0 tablet tablet delayed release RA PEN NEEDLES Tier 3 ST; QL ra aspirin ec oral tablet Tier 1 $0 delayed release RA PRENATAL FORMULA ORAL Tier 2 $0 ra aspirin oral tablet Tier 1 $0 TABLET ra balanced b-100 cr oral RA PRENATAL ORAL Tier 1 $0 Tier 2 $0 tablet extended release TABLET ra balanced b-100 oral tablet Tier 1 $0 ra womens laxative oral Tier 1 $0 ra balanced b-50 oral tablet Tier 1 $0 tablet delayed release ra balanced b-50 tr oral tablet RABAVERT Tier 1 $0 extended release INTRAMUSCULAR Tier 3 ra b-complex oral tablet Tier 1 $0 SUSPENSION RECONSTITUTED ra b-complex with b-12 oral Tier 1 $0 tablet RABBIT EPITHELIUM SUBCUTANEOUS Tier 3 RA E-ZJECT LANCETS Tier 2 QL SOLUTION 28G RADIOGARDASE ORAL RA E-ZJECT LANCETS Tier 3 Tier 2 QL CAPSULE THIN 26G RAGWITEK RA E-ZJECT LANCETS Tier 2 QL SUBLINGUAL TABLET Tier 3 PA; QL THIN 28G SUBLINGUAL RA E-ZJECT LANCETS Tier 2 QL raloxifene hcl oral tablet Tier 1 $0 ULTRA THIN ramelteon oral tablet Tier 1 ST; QL ra folic acid oral tablet Tier 1 $0 ramipril oral capsule Tier 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 128 Drug Name Tier Notes Drug Name Tier Notes RANEXA ORAL TABLET REBIF REBIDOSE EXTENDED RELEASE 12 Tier 3 TITRATION PACK HOUR SUBCUTANEOUS Tier 4 PA; QL; SP ranolazine er oral tablet SOLUTION AUTO- Tier 1 extended release 12 hour INJECTOR RAPAMUNE ORAL REBIF SUBCUTANEOUS Tier 3 SOLUTION SOLUTION PREFILLED Tier 4 PA; QL; SP SYRINGE RAPAMUNE ORAL Tier 3 TABLET REBIF TITRATION PACK SUBCUTANEOUS Tier 4 PA; QL; SP RAPIVAB SOLUTION PREFILLED INTRAVENOUS Tier 3 SYRINGE SOLUTION REBINYN rasagiline mesylate oral INTRAVENOUS Tier 1 Tier 4 PA; QL; LD; SP tablet SOLUTION RASUVO RECONSTITUTED SUBCUTANEOUS Tier 4 PA; QL; SP REBLOZYL SOLUTION AUTO- SUBCUTANEOUS Tier 4 PA; QL; LD; SP INJECTOR SOLUTION RAVICTI ORAL LIQUID Tier 3 PA; QL; LD; SP RECONSTITUTED RAYALDEE ORAL RECARBRIO INTRAVENOUS CAPSULE EXTENDED Tier 3 PA; QL Tier 3 RELEASE SOLUTION RECONSTITUTED RAZADYNE ER ORAL CAPSULE EXTENDED RECLAST Tier 3 RELEASE 24 HOUR 16 INTRAVENOUS Tier 4 PA; QL; SP MG, 24 MG SOLUTION RAZADYNE ER ORAL reclipsen oral tablet Tier 1 $0 CAPSULE EXTENDED Tier 3 DO RECOMBINATE RELEASE 24 HOUR 8 MG INTRAVENOUS Tier 4 PA; QL; LD; SP react oral tablet Tier 1 $0 SOLUTION RECONSTITUTED READYLANCE SAFETY Tier 2 QL LANCETS RECOMBIVAX HB INJECTION Tier 3 $0 REALITY INSULIN Tier 3 ST; QL SUSPENSION SYRINGE RECOTHROM REALITY LANCETS Tier 2 QL EXTERNAL SOLUTION Tier 3 REALITY TRIGGER RECONSTITUTED Tier 2 QL LANCETS RECOTHROM SPRAY REBIF REBIDOSE KIT EXTERNAL Tier 3 SUBCUTANEOUS SOLUTION Tier 4 PA; QL; SP SOLUTION AUTO- RECONSTITUTED INJECTOR

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 129 Drug Name Tier Notes Drug Name Tier Notes RECTIV RECTAL RELION LANCING Tier 3 Tier 2 OINTMENT DEVICE RED MAPLE RELION LANCING Tier 2 SUBCUTANEOUS Tier 3 DEVICE KIT SOLUTION RELION MINI PEN Tier 3 ST; QL RED MULBERRY NEEDLES SUBCUTANEOUS Tier 3 RELION PEN NEEDLES Tier 3 ST; QL SOLUTION RELION SHORT PEN Tier 3 ST; QL RED TOP GRASS NEEDLES POLLEN Tier 3 RELION ULTRA THIN SUBCUTANEOUS Tier 2 QL SOLUTION LANCETS 30G RELION ULTRA THIN REDITREX Tier 2 QL SUBCUTANEOUS PLUS LANCETS Tier 4 PA; QL; LD SOLUTION PREFILLED RELISTOR ORAL Tier 3 ST; QL SYRINGE TABLET refissa external cream Tier 1 PA; QL RELISTOR REGLAN ORAL TABLET Tier 3 SUBCUTANEOUS Tier 3 ST; QL SOLUTION REGONOL RELNATE DHA ORAL INTRAVENOUS Tier 3 Tier 3 ST; QL SOLUTION CAPSULE REGRANEX EXTERNAL RELTONE ORAL Tier 3 Tier 3 GEL CAPSULE relafen oral tablet Tier 1 remergent hq external cream Tier 1 REMERON ORAL RELENZA DISKHALER Tier 3 INHALATION AEROSOL TABLET Tier 2 QL POWDER BREATH REMERON SOLTAB ACTIVATED ORAL TABLET Tier 3 RELEXXII ORAL DISPERSIBLE TABLET EXTENDED Tier 3 PA; QL REMESENSE DENTAL Tier 3 RELEASE REMICADE RELION INSULIN INTRAVENOUS Tier 3 ST; QL Tier 4 PA; QL; LD; SP SYRINGE SOLUTION RELION LANCET RECONSTITUTED Tier 2 DEVICES 30G remifentanil hcl intravenous Tier 1 RELION LANCETS solution reconstituted Tier 2 QL MICRO-THIN 33G REMODULIN Tier 4 PA; QL; LD; SP RELION LANCETS THIN INJECTION SOLUTION Tier 2 QL 26G RENACIDIN Tier 3 RELION LANCETS IRRIGATION SOLUTION Tier 2 QL ULTRA-THIN 30G

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 130 Drug Name Tier Notes Drug Name Tier Notes renal multivitamin formula RETAVASE HALF-KIT Tier 1 $0 Tier 3 oral tablet INTRAVENOUS KIT renal vitamin oral tablet Tier 1 $0 RETAVASE Tier 3 renal-vite oral tablet Tier 1 $0 INTRAVENOUS KIT RETEVMO ORAL rena-vite oral tablet Tier 1 $0 Tier 3 PA; QL; LD; SP CAPSULE RENOVA EXTERNAL Tier 3 PA; QL CREAM RETISERT INTRAVITREAL Tier 3 PA; QL; LD; SP RENOVA PUMP Tier 3 PA; QL IMPLANT EXTERNAL CREAM RETROVIR RENVELA ORAL Tier 3 ST; QL INTRAVENOUS Tier 2 PACKET SOLUTION RENVELA ORAL RETROVIR ORAL Tier 3 ST; QL Tier 3 QL TABLET CAPSULE repaglinide oral tablet Tier 1 RETROVIR ORAL Tier 3 QL REPATHA SYRUP PUSHTRONEX SYSTEM REVCOVI Tier 3 PA; QL SUBCUTANEOUS INTRAMUSCULAR Tier 4 PA; QL; LD SOLUTION CARTRIDGE SOLUTION REPATHA REVLIMID ORAL Tier 2 PA; QL; LD; SP SUBCUTANEOUS CAPSULE Tier 3 PA; QL SOLUTION PREFILLED revonto intravenous solution Tier 1 SYRINGE reconstituted REPATHA SURECLICK REXALL LANCETS SUBCUTANEOUS Tier 2 QL Tier 3 PA; QL ULTRA THIN 30G SOLUTION AUTO- INJECTOR REXULTI ORAL TABLET 0.25 MG, 0.5 Tier 3 ST; DO; QL RESECTISOL Tier 3 MG, 1 MG, 2 MG IRRIGATION SOLUTION REXULTI ORAL Tier 3 ST; QL RESTASIS MULTIDOSE TABLET 3 MG, 4 MG OPHTHALMIC Tier 3 PA; QL REYATAZ ORAL EMULSION Tier 3 QL CAPSULE RESTASIS REYATAZ ORAL OPHTHALMIC Tier 3 PA; QL Tier 2 QL EMULSION PACKET RESTORA RX ORAL RHIZOPUS Tier 3 CAPSULE SUBCUTANEOUS Tier 3 SOLUTION RESTORIL ORAL Tier 3 RHOFADE EXTERNAL CAPSULE Tier 3 CREAM RETACRIT INJECTION Tier 4 PA; QL; SP SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 131 Drug Name Tier Notes Drug Name Tier Notes RHOGAM ULTRA- riluzole oral tablet Tier 4 SP FILTERED PLUS rimantadine hcl oral tablet Tier 1 INTRAMUSCULAR Tier 4 SP SOLUTION PREFILLED RIMSO-50 SYRINGE INTRAVESICAL Tier 3 RHOPHYLAC SOLUTION INJECTION SOLUTION Tier 4 LD; SP ringers intravenous solution Tier 1 PREFILLED SYRINGE ringers irrigation irrigation Tier 1 RHOPRESSA solution OPHTHALMIC Tier 3 SOLUTION RINVOQ ORAL TABLET EXTENDED RELEASE 24 Tier 4 PA; QL; SP RIABNI INTRAVENOUS Tier 3 PA; QL; LD; SP HOUR SOLUTION RIOMET ORAL Tier 3 PA; QL RIASTAP SOLUTION INTRAVENOUS Tier 3 PA; QL; LD SOLUTION risanoid plus oral tablet Tier 1 $0 RECONSTITUTED risedronate sodium oral Tier 1 ribavirin inhalation solution tablet Tier 1 reconstituted risedronate sodium oral Tier 1 ribavirin oral capsule Tier 4 SP tablet delayed release ribavirin oral tablet Tier 4 SP RISPERDAL CONSTA INTRAMUSCULAR RIDAURA ORAL Tier 2 Tier 2 SUSPENSION CAPSULE RECONSTITUTED ER rifabutin oral capsule Tier 1 risperidone oral solution Tier 1 ST; QL RIFADIN risperidone oral tablet Tier 1 INTRAVENOUS Tier 3 risperidone oral tablet SOLUTION Tier 1 dispersible RECONSTITUTED rifampin intravenous solution RITALIN LA ORAL Tier 1 CAPSULE EXTENDED reconstituted Tier 3 PA; DO; QL RELEASE 24 HOUR 10 rifampin oral capsule Tier 1 MG, 20 MG RIGHT STEP PRENATAL RITALIN LA ORAL Tier 2 $0 ORAL TABLET CAPSULE EXTENDED Tier 3 PA; QL RIGHTEST ALTERNATE RELEASE 24 HOUR 30 Tier 2 SITE ADAPT MG, 40 MG RIGHTEST GD500 RITALIN ORAL TABLET Tier 2 Tier 3 PA; DO; QL LANCING DEVICE 10 MG, 5 MG RIGHTEST GL300 RITALIN ORAL TABLET Tier 2 QL Tier 3 PA; QL LANCETS 20 MG RILUTEK ORAL ritonavir oral tablet Tier 1 QL Tier 4 SP TABLET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 132 Drug Name Tier Notes Drug Name Tier Notes RITUXAN HYCELA ropinirole hcl er oral tablet Tier 1 SUBCUTANEOUS Tier 3 LD; SP extended release 24 hour SOLUTION ropinirole hcl oral tablet Tier 1 RITUXAN ropivacaine hcl injection INTRAVENOUS Tier 3 PA; QL; LD; SP Tier 1 SOLUTION solution rivastigmine tartrate oral ROPIVACAINE HCL- Tier 1 DO capsule 1.5 mg, 3 mg NACL EPIDURAL Tier 3 SOLUTION rivastigmine tartrate oral Tier 1 capsule 4.5 mg, 6 mg rosadan external cream Tier 1 rivastigmine transdermal rosadan external gel Tier 1 Tier 1 patch 24 hour rosuvastatin calcium oral Tier 1 DO; $0 rivelsa oral tablet Tier 1 $0 tablet 10 mg, 5 mg RIXUBIS INTRAVENOUS rosuvastatin calcium oral Tier 1 DO SOLUTION Tier 4 PA; QL; LD; SP tablet 20 mg RECONSTITUTED rosuvastatin calcium oral Tier 1 rizatriptan benzoate oral tablet 40 mg Tier 1 QL tablet ROTARIX ORAL rizatriptan benzoate oral SUSPENSION Tier 3 $0 Tier 1 QL tablet dispersible RECONSTITUTED ROBAXIN INJECTION ROTATEQ ORAL Tier 3 ST; QL Tier 3 $0 SOLUTION SOLUTION ROBAXIN-750 ORAL ROUGH MARSH ELDER Tier 3 ST; QL TABLET SUBCUTANEOUS Tier 3 ROCALTROL ORAL SOLUTION Tier 3 PA; QL CAPSULE ROWASA RECTAL KIT Tier 3 ROCALTROL ORAL Tier 3 PA; QL roweepra oral tablet Tier 1 SOLUTION ROXICODONE ORAL Tier 3 QL ROCKLATAN TABLET OPHTHALMIC Tier 3 ROZLYTREK ORAL SOLUTION Tier 3 PA; QL; LD; SP CAPSULE rocuronium bromide Tier 1 RUBRACA ORAL intravenous solution Tier 3 PA; QL; LD; SP TABLET ROCURONIUM BROMIDE RUCONEST INTRAVENOUS INTRAVENOUS Tier 3 Tier 4 PA; QL; LD; SP SOLUTION PREFILLED SOLUTION SYRINGE RECONSTITUTED ROMIDEPSIN rufinamide oral suspension Tier 1 INTRAVENOUS Tier 3 PA; QL; SP SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 133 Drug Name Tier Notes Drug Name Tier Notes RUKOBIA ORAL SAFETY LANCET Tier 2 QL TABLET EXTENDED Tier 3 PA; QL 23G/PRESSURE ACT RELEASE 12 HOUR SAFETY LANCET Tier 2 QL RUSSIAN THISTLE 28G/PRESSURE ACT SUBCUTANEOUS Tier 3 SAFETY LANCET Tier 2 QL SOLUTION 30G/PRESSURE ACT RUXIENCE SAFETY LANCETS Tier 2 QL INTRAVENOUS Tier 3 PA; QL; SP SOLUTION SAFETY LANCETS 21G Tier 2 QL RUZURGI ORAL SAFETY LANCETS 28G Tier 2 QL Tier 4 PA; QL; LD TABLET SAFYRAL ORAL Tier 3 RYANODEX TABLET INTRAVENOUS SALAGEN ORAL Tier 3 Tier 3 SUSPENSION TABLET RECONSTITUTED saline flush intravenous RYBELSUS ORAL Tier 1 Tier 2 QL solution TABLET saline flush zr intravenous Tier 1 ryclora oral solution Tier 1 solution RYDAPT ORAL SAMSCA ORAL TABLET Tier 3 PA; QL; LD; SP Tier 3 PA; QL; SP CAPSULE SANCUSO Tier 3 QL RYDEX ORAL LIQUID Tier 2 TRANSDERMAL PATCH RYTARY ORAL SANDIMMUNE CAPSULE EXTENDED Tier 3 INTRAVENOUS Tier 3 SP RELEASE SOLUTION SANDIMMUNE ORAL RYTHMOL SR ORAL Tier 3 CAPSULE EXTENDED Tier 3 CAPSULE RELEASE 12 HOUR SANDIMMUNE ORAL Tier 3 RYVENT ORAL TABLET Tier 1 SOLUTION SANDOSTATIN SACCHAROMYCES Tier 4 PA; QL; SP CEREVISIAE Tier 3 INJECTION SOLUTION INJECTION SOLUTION SANDOSTATIN LAR Tier 4 PA; QL; SP SACCHAROMYCES DEPOT CEREVISIAE INTRAMUSCULAR KIT Tier 3 SUBCUTANEOUS SANTYL EXTERNAL Tier 3 SOLUTION OINTMENT SAFE-T-LANCE Tier 2 QL SAPHRIS SUBLINGUAL Tier 3 ST; QL SAFE-T-LANCE PLUS Tier 2 QL TABLET SUBLINGUAL 10 MG SAFETY INSULIN Tier 3 ST; QL SYRINGES SAPHRIS SUBLINGUAL TABLET SUBLINGUAL Tier 3 ST; DO; QL SAFETY LANCET Tier 2 QL 2.5 MG, 5 MG 21G/PRESSURE ACT

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 134 Drug Name Tier Notes Drug Name Tier Notes sapropterin dihydrochloride sb magnesium citrate oral Tier 4 PA; QL; SP Tier 1 $0 oral packet solution sapropterin dihydrochloride sb milk of magnesia oral Tier 4 PA; QL; SP Tier 1 $0 oral tablet soluble suspension SAPS HEALTH TWIST sb polyethylene glycol 3350 Tier 2 QL Tier 1 $0 TOP LANCETS oral powder SAPS TWIST TOP SCENESSE Tier 2 QL LANCETS SUBCUTANEOUS Tier 3 PA; QL; LD SAPSCARE TWIST TOP IMPLANT Tier 2 QL LANCETS SCLEROSOL INTRAPLEURAL SARCLISA Tier 3 INTRAVENOUS Tier 3 PA; QL; LD; SP INTRAPLEURAL SOLUTION AEROSOL POWDER SAVELLA ORAL scopolamine transdermal Tier 2 Tier 1 TABLET patch 72 hour SAVELLA TITRATION SEASONIQUE ORAL Tier 2 Tier 3 PACK ORAL TABLET SAXENDA SECUADO SUBCUTANEOUS TRANSDERMAL PATCH Tier 3 ST; QL Tier 3 PA; QL SOLUTION PEN- 24 HOUR INJECTOR SECURESAFE INSULIN Tier 3 ST; QL sb aspirin adult low strength SYRINGE Tier 1 $0 oral tablet delayed release SECURESAFE SAFETY Tier 3 ST; QL sb aspirin ec oral tablet PEN NEEDLES Tier 1 $0 delayed release SELECT-LITE Tier 2 sb aspirin oral tablet Tier 1 $0 DEVICE/LANCETS KIT sb aspirin oral tablet delayed SELECT-LITE LANCING Tier 1 $0 Tier 2 release DEVICE sb bisacodyl laxative ec oral SELECT-OB ORAL Tier 1 $0 Tier 3 ST; QL tablet delayed release TABLET CHEWABLE sb childrens aspirin oral SELECT-OB+DHA ORAL Tier 3 ST; QL Tier 1 $0 tablet chewable selegiline hcl oral capsule Tier 1 sb gentle lax-women oral Tier 1 $0 selegiline hcl oral tablet Tier 1 tablet delayed release SELENIOUS ACID SB INSULIN SYRINGE Tier 3 ST; QL INTRAVENOUS Tier 3 SB LANCETS THIN Tier 2 QL SOLUTION SB LANCETS ULTRA selenium sulfide external Tier 2 QL Tier 1 THIN lotion sb low dose asa ec oral tablet SELZENTRY ORAL Tier 1 $0 Tier 3 QL delayed release SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 135 Drug Name Tier Notes Drug Name Tier Notes SELZENTRY ORAL sevelamer carbonate oral Tier 2 QL Tier 1 TABLET packet SEMGLEE sevelamer carbonate oral Tier 1 SUBCUTANEOUS Tier 3 tablet SOLUTION sevelamer hcl oral tablet Tier 1 SEMGLEE SUBCUTANEOUS SEVENFACT Tier 3 INTRAVENOUS SOLUTION PEN- Tier 4 PA; QL; LD; SP INJECTOR SOLUTION RECONSTITUTED SE-NATAL 19 ORAL Tier 2 sevoflurane inhalation TABLET Tier 1 solution SE-NATAL 19 ORAL Tier 2 TABLET CHEWABLE sf 5000 plus dental cream Tier 1 SENSIPAR ORAL sf dental gel Tier 1 Tier 4 PA; QL TABLET SFROWASA RECTAL Tier 3 sensorcaine injection solution Tier 1 ENEMA sensorcaine/epinephrine SHAGBARK HICKORY Tier 1 injection solution SUBCUTANEOUS Tier 3 SOLUTION sensorcaine-mpf injection Tier 1 solution sharobel oral tablet Tier 1 $0 sensorcaine-mpf/epinephrine SHEEP SORREL injection solution 0.25% - Tier 1 SUBCUTANEOUS Tier 3 1:200000, 0.5% -1:200000 SOLUTION SENSORCAINE- SHINGRIX MPF/EPINEPHRINE INTRAMUSCULAR Tier 3 Tier 3 $0 INJECTION SOLUTION SUSPENSION 0.75-1:200000 % RECONSTITUTED SHOPKO AUTOLET SEREVENT DISKUS Tier 2 INHALATION AEROSOL LANCING DEVICE Tier 2 POWDER BREATH SHOPKO ON-THE-GO Tier 2 QL ACTIVATED LANCETS 30G SEROSTIM SHOPKO UNIFINE SUBCUTANEOUS Tier 3 ST; QL Tier 4 PA; QL; LD PENTIPS SOLUTION SHOPKO UNIFINE RECONSTITUTED Tier 3 ST; QL PENTIPS PLUS sertraline hcl oral concentrate Tier 1 SHOPKO UNILET Tier 2 QL sertraline hcl oral tablet 100 LANCETS 28G Tier 1 mg SHOPKO UNILET Tier 2 QL sertraline hcl oral tablet 25 LANCETS 30G Tier 1 DO mg, 50 mg setlakin oral tablet Tier 1 $0

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 136 Drug Name Tier Notes Drug Name Tier Notes SHORT RAGWEED SIMPONI ARIA POLLEN EXT INTRAVENOUS Tier 4 PA; QL; SP Tier 3 SUBCUTANEOUS SOLUTION SOLUTION SIMPONI SHUR-SEAL SUBCUTANEOUS Tier 4 PA; QL; SP CONTRACEPTIVE Tier 2 $0 SOLUTION AUTO- VAGINAL GEL INJECTOR SIDE BUTTON SAFETY SIMPONI Tier 2 QL LANCET SUBCUTANEOUS Tier 4 PA; QL; SP SIGNIFOR LAR SOLUTION PREFILLED INTRAMUSCULAR SYRINGE Tier 4 PA; QL; LD SUSPENSION SIMULECT RECONSTITUTED ER INTRAVENOUS Tier 3 SIGNIFOR SOLUTION SUBCUTANEOUS Tier 4 PA; QL; LD RECONSTITUTED SOLUTION simvastatin oral tablet 10 mg, Tier 1 DO; T1S; $0 SIKLOS ORAL TABLET Tier 3 PA; QL; SP 20 mg, 40 mg, 5 mg sildenafil citrate intravenous simvastatin oral tablet 80 mg Tier 1 PA; QL; T1S Tier 4 PA; QL; SP solution SINEMET ORAL Tier 3 sildenafil citrate oral TABLET Tier 4 PA; QL; SP suspension reconstituted SINGLE-LET Tier 2 QL sildenafil citrate oral tablet Tier 4 PA; QL sirolimus oral solution Tier 1 100 mg, 25 mg, 50 mg sirolimus oral tablet Tier 1 sildenafil citrate oral tablet Tier 4 PA; QL; SP SIRTURO ORAL 20 mg Tier 3 TABLET SILENOR ORAL Tier 3 ST; QL TABLET SIVEXTRO INTRAVENOUS Tier 3 silodosin oral capsule Tier 1 SOLUTION SILVADENE EXTERNAL RECONSTITUTED Tier 3 CREAM SIVEXTRO ORAL Tier 3 PA; QL silver sulfadiazine external TABLET Tier 1 cream SKELAXIN ORAL Tier 3 ST; QL SIMBRINZA TABLET OPHTHALMIC Tier 2 SKLICE EXTERNAL Tier 3 SUSPENSION LOTION simliya oral tablet Tier 1 $0 SKYLA INTRAUTERINE simpesse oral tablet Tier 1 $0 INTRAUTERINE Tier 3 LD; SP DEVICE SIMPLE DIAGNOSTICS Tier 2 LANCING DEV

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 137 Drug Name Tier Notes Drug Name Tier Notes SKYRIZI (150 MG DOSE) sm multiple vitamins Tier 1 $0 SUBCUTANEOUS essential oral tablet Tier 4 PA; QL; SP PREFILLED SYRINGE sm multiple vitamins/iron Tier 1 $0 KIT oral tablet SLYND ORAL TABLET Tier 3 sm nicotine mouth/throat Tier 1 $0 sm aspirin adult low strength gum Tier 1 $0 oral tablet chewable sm nicotine mouth/throat Tier 1 $0 sm aspirin adult low strength lozenge Tier 1 $0 oral tablet delayed release sm nicotine polacrilex Tier 1 $0 sm aspirin ec low strength mouth/throat gum Tier 1 $0 oral tablet delayed release sm nicotine polacrilex Tier 1 $0 sm aspirin ec oral tablet mouth/throat lozenge Tier 1 $0 delayed release sm nicotine transdermal Tier 1 $0 sm aspirin low dose oral patch 24 hour Tier 1 $0 tablet chewable SM ONE DAILY Tier 2 $0 sm aspirin oral tablet Tier 1 $0 PRENATAL ORAL sm aspirin tri-buffered oral SM PRENATAL Tier 1 $0 tablet VITAMINS ORAL Tier 2 $0 TABLET sm b super vitamin complex Tier 1 $0 sm super b complex/c oral oral tablet Tier 1 $0 tablet sm b100 complex oral tablet Tier 1 $0 SM TRUEDRAW Tier 2 sm balanced b-100 oral tablet Tier 1 $0 LANCING DEVICE sm balanced b-50 oral tablet Tier 1 $0 sm vitamin b Tier 1 $0 sm b-complex oral tablet Tier 1 $0 complex/vitamin c oral tablet SM B- SMART DIABETES Tier 2 COMPLEX/VITAMIN C Tier 2 $0 VANTAGE LANCING ORAL TABLET SMART SENSE COLOR Tier 2 QL sm childrens aspirin oral LANCETS 33G Tier 1 $0 tablet chewable SMART SENSE Tier 2 QL sm clearlax oral powder Tier 1 $0 STANDARD LANCETS sm folic acid oral tablet Tier 1 $0 SMART SENSE SUPER Tier 2 QL sm gentle laxative oral tablet THIN LANCETS Tier 1 $0 delayed release SMART SENSE THIN Tier 2 QL SM LANCETS 33G Tier 2 QL LANCETS 26G sm magnesium citrate oral SMARTEST LANCETS Tier 1 $0 Tier 2 QL solution 28G sm milk of magnesia oral SMOFLIPID Tier 1 $0 suspension INTRAVENOUS Tier 3 EMULSION smooth lax oral packet Tier 1 $0

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 138 Drug Name Tier Notes Drug Name Tier Notes smooth lax oral powder Tier 1 $0 sodium fluoride 5000 Tier 1 sod benz-sod phenylacet sensitive dental paste Tier 1 intravenous solution sodium fluoride dental cream Tier 1 SODIUM ACETATE sodium fluoride dental gel Tier 1 INTRAVENOUS Tier 3 SOLUTION sodium fluoride oral solution Tier 1 $0 SODIUM BICARBONATE sodium fluoride oral tablet Tier 1 $0 Tier 3 ORAL POWDER sodium fluoride oral tablet Tier 1 $0 sodium chloride flush chewable Tier 1 intravenous solution SODIUM NITRITE sodium chloride inhalation INTRAVENOUS Tier 3 Tier 1 nebulization solution SOLUTION sodium chloride intravenous sodium nitroprusside Tier 1 Tier 1 solution intravenous solution sodium chloride irrigation sodium phenylbutyrate oral Tier 1 Tier 1 PA; QL solution powder sodium phenylbutyrate oral SODIUM CITRATE Tier 1 PA; QL LOCK FLUSH tablet Tier 3 INTRAVENOUS sodium phosphates Tier 1 SOLUTION intravenous solution SODIUM CITRATE sodium polystyrene sulfonate Tier 1 LOCK FLUSH oral powder INTRAVENOUS Tier 3 SOLUTION PREFILLED SODIUM SULFACETAMIDE- SYRINGE Tier 3 BAKUCHIOL SODIUM DIURIL EXTERNAL LIQUID INTRAVENOUS Tier 3 sodium tetradecyl sulfate SOLUTION Tier 1 intravenous solution RECONSTITUTED SOLESTA INJECTION SODIUM EDECRIN Tier 4 LD; SP INTRAVENOUS GEL Tier 3 SOLUTION solifenacin succinate oral Tier 1 RECONSTITUTED tablet sodium fluoride 5000 enamel SOLIQUA Tier 1 dental paste SUBCUTANEOUS Tier 3 ST; QL sodium fluoride 5000 plus SOLUTION PEN- Tier 1 dental cream INJECTOR sodium fluoride 5000 ppm SOLIRIS INTRAVENOUS Tier 1 Tier 4 PA; QL; LD; SP dental cream SOLUTION sodium fluoride 5000 ppm SOLOSEC ORAL Tier 1 Tier 3 ST; QL dental paste PACKET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 139 Drug Name Tier Notes Drug Name Tier Notes SOLTAMOX ORAL SOTALOL HCL Tier 2 $0 SOLUTION INTRAVENOUS Tier 3 SOLU-CORTEF SOLUTION INJECTION SOLUTION Tier 3 sotalol hcl oral tablet Tier 1 RECONSTITUTED SOTRADECOL SOLU-MEDROL INTRAVENOUS Tier 3 INJECTION SOLUTION Tier 3 SOLUTION 1 % RECONSTITUTED sotradecol intravenous Tier 1 SOLUS V2 LANCETS 28G Tier 2 QL solution 3 % SOLUS V2 LANCING SOTYLIZE ORAL Tier 2 Tier 3 DEVICE SOLUTION SOLUS V2 TWIST Tier 2 QL spinosad external suspension Tier 1 LANCETS 30G SPINY PIGWEED SOMA ORAL TABLET Tier 3 ST; QL SUBCUTANEOUS Tier 3 250 MG SOLUTION SOMA ORAL TABLET SPIRIVA HANDIHALER Tier 3 Tier 2 350 MG INHALATION CAPSULE SOMATULINE DEPOT SPIRIVA RESPIMAT SUBCUTANEOUS Tier 4 PA; QL; LD; SP INHALATION AEROSOL Tier 2 SOLUTION SOLUTION SOMAVERT spironolactone oral tablet Tier 1 T1S SUBCUTANEOUS Tier 4 PA; QL; LD; SP spironolactone-hctz oral SOLUTION Tier 1 RECONSTITUTED tablet SOOLANTRA SPORANOX ORAL Tier 3 Tier 3 PA; QL EXTERNAL CREAM CAPSULE SORBITOL IRRIGATION SPORANOX ORAL Tier 3 Tier 3 PA; QL SOLUTION SOLUTION SORBITOL-MANNITOL SPORANOX PULSEPAK Tier 3 Tier 3 PA; QL IRRIGATION SOLUTION ORAL CAPSULE SORIATANE ORAL SPRAVATO (56 MG Tier 3 DOSE) NASAL CAPSULE Tier 4 PA; QL; LD; SP SOLUTION THERAPY SORILUX EXTERNAL Tier 3 PACK FOAM SPRAVATO (84 MG sorine oral tablet Tier 1 DOSE) NASAL Tier 4 PA; QL; LD; SP SORREL/DOCK MIX SOLUTION THERAPY SUBCUTANEOUS Tier 3 PACK SOLUTION sprintec 28 oral tablet Tier 1 $0 sotalol hcl (af) oral tablet Tier 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 140 Drug Name Tier Notes Drug Name Tier Notes SPRITAM ORAL STELARA TABLET SUBCUTANEOUS Tier 3 Tier 4 PA; QL; SP DISINTEGRATING SOLUTION PREFILLED SOLUBLE SYRINGE SPRYCEL ORAL STEMPHYLIUM Tier 2 PA; QL; SP TABLET SUBCUTANEOUS Tier 3 SOLUTION sps oral suspension Tier 1 STERILANCE PA Tier 2 sronyx oral tablet Tier 1 $0 STERILANCE TL Tier 2 QL ssd external cream Tier 1 STERILE TALC SSKI ORAL SOLUTION Tier 3 POWDER st joseph aspirin oral tablet INTRAPLEURAL Tier 3 Tier 1 $0 delayed release SUSPENSION RECONSTITUTED st joseph low dose oral tablet Tier 1 $0 sterile water for irrigation chewable Tier 1 irrigation solution st joseph low dose oral tablet Tier 1 $0 delayed release STERITALC INTRAPLEURAL Tier 3 STALEVO 100 ORAL Tier 3 POWDER TABLET STIMATE NASAL STALEVO 125 ORAL Tier 3 Tier 3 SOLUTION TABLET STIOLTO RESPIMAT STALEVO 150 ORAL Tier 3 INHALATION AEROSOL Tier 2 TABLET SOLUTION STALEVO 200 ORAL STIVARGA ORAL Tier 3 Tier 2 PA; QL; LD; SP TABLET TABLET STALEVO 50 ORAL STRAVIX EXTERNAL Tier 3 Tier 3 TABLET SHEET STALEVO 75 ORAL Tier 3 STRENSIQ TABLET SUBCUTANEOUS Tier 4 PA; QL; LD STAMARIL INJECTION SOLUTION SUSPENSION Tier 3 streptomycin sulfate RECONSTITUTED intramuscular solution Tier 1 STARLIX ORAL TABLET Tier 3 reconstituted stress b complex/iron oral stavudine oral capsule Tier 1 QL Tier 1 $0 tablet STELARA INTRAVENOUS Tier 4 PA; QL; LD; SP stress formula oral tablet Tier 1 $0 SOLUTION stress formula/iron oral tablet Tier 1 $0 STELARA stresstabs energy oral tablet Tier 1 $0 SUBCUTANEOUS Tier 4 PA; QL; SP STRIBILD ORAL SOLUTION Tier 2 QL TABLET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 141 Drug Name Tier Notes Drug Name Tier Notes STRIVERDI RESPIMAT sulfacetamide sodium (acne) Tier 1 INHALATION AEROSOL Tier 3 external lotion SOLUTION sulfacetamide sodium Tier 1 STROMECTOL ORAL ophthalmic ointment Tier 3 TABLET sulfacetamide sodium Tier 1 STRONTIUM CHLORIDE ophthalmic solution SR-89 INTRAVENOUS Tier 3 sulfacetamide sod-sulfur Tier 1 PA; QL SOLUTION wash external liquid SUBLOCADE sulfacetamide-prednisolone SUBCUTANEOUS Tier 1 Tier 4 LD ophthalmic solution SOLUTION PREFILLED SULFADIAZINE ORAL SYRINGE Tier 3 TABLET subvenite oral tablet Tier 1 sulfamethoxazole- subvenite starter kit-blue oral Tier 1 trimethoprim intravenous Tier 1 kit solution subvenite starter kit-green sulfamethoxazole- Tier 1 Tier 1 oral kit trimethoprim oral suspension subvenite starter kit-orange sulfamethoxazole- Tier 1 Tier 1 oral kit trimethoprim oral tablet SUCCINYLCHOLINE SULFAMYLON Tier 3 CHLORIDE EXTERNAL CREAM INTRAVENOUS Tier 3 SULFAMYLON SOLUTION PREFILLED Tier 3 SYRINGE EXTERNAL PACKET SUCRAID ORAL sulfasalazine oral tablet Tier 1 T1S Tier 4 PA; QL; LD SOLUTION sulfasalazine oral tablet Tier 1 delayed release sucralfate oral suspension Tier 1 sulfatrim pediatric oral Tier 1 sucralfate oral tablet Tier 1 suspension SUFENTANIL CITRATE SULFURATED LIME Tier 3 INTRAVENOUS Tier 3 EXTERNAL SOLUTION SOLUTION sulindac oral tablet Tier 1 SULAR ORAL TABLET EXTENDED RELEASE 24 Tier 3 DO sumatriptan nasal solution Tier 1 QL HOUR 17 MG, 8.5 MG sumatriptan succinate oral Tier 1 QL SULAR ORAL TABLET tablet EXTENDED RELEASE 24 Tier 3 sumatriptan succinate refill HOUR 34 MG subcutaneous solution Tier 1 QL sulconazole nitrate external cartridge Tier 1 ST; QL cream sumatriptan succinate Tier 1 QL sulconazole nitrate external subcutaneous solution Tier 1 ST; QL solution

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 142 Drug Name Tier Notes Drug Name Tier Notes sumatriptan succinate SUPRAX ORAL subcutaneous solution auto- Tier 1 QL SUSPENSION Tier 3 injector RECONSTITUTED sumatriptan succinate SUPRAX ORAL TABLET Tier 3 subcutaneous solution Tier 1 QL CHEWABLE prefilled syringe SUPREP BOWEL PREP Tier 2 sumatriptan-naproxen KIT ORAL SOLUTION Tier 1 ST; QL sodium oral tablet SURE COMFORT Tier 3 ST; QL SUNOSI ORAL TABLET INSULIN SYRINGE Tier 3 PA; QL 150 MG SURE COMFORT Tier 2 QL SUNOSI ORAL TABLET LANCETS 18G Tier 3 PA; DO; QL 75 MG SURE COMFORT Tier 2 QL SUPARTZ FX INTRA- LANCETS 21G ARTICULAR SOLUTION Tier 4 PA; QL SURE COMFORT Tier 2 QL PREFILLED SYRINGE LANCETS 23G super b complex maxi oral SURE COMFORT Tier 1 $0 Tier 2 QL tablet LANCETS 28G super b complex/fa/vit c oral SURE COMFORT Tier 1 $0 Tier 2 QL tablet LANCETS 30G super b complex/vitamin c SURE COMFORT Tier 1 $0 Tier 2 oral tablet LANCING PEN super b-100 oral tablet Tier 1 $0 SURE COMFORT PEN Tier 3 ST; QL super b-50 oral tablet Tier 1 $0 NEEDLES super b-complex + vitamin c SURE-FINE PEN Tier 1 $0 Tier 3 ST; QL oral tablet NEEDLES super b-complex oral tablet Tier 1 $0 SURE-JECT INSULIN Tier 3 ST; QL super b-complex/vit c/fa oral SYRINGE Tier 1 $0 tablet SURE-LANCE FLAT Tier 2 QL super dec b-100 oral tablet Tier 1 $0 LANCETS SURE-LANCE LANCETS super quints b-50 oral tablet Tier 1 $0 Tier 2 QL 26G super stress b-complex cr Tier 1 $0 SURE-LANCE THIN oral tablet extended release Tier 2 QL LANCETS 28G SUPER THIN LANCETS Tier 2 QL SURE-LANCE ULTRA SUPPRELIN LA Tier 2 QL Tier 4 PA; QL; LD; SP THIN LANCETS SUBCUTANEOUS KIT SURELITE LANCETS Tier 2 QL SUPRANE INHALATION Tier 3 SOLUTION SURE-PEN Tier 2 SUPRAX ORAL SURE-TOUCH LANCETS Tier 3 Tier 2 QL CAPSULE UNIVERSAL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 143 Drug Name Tier Notes Drug Name Tier Notes SURGICEL FIBRILLAR SYMJEPI INJECTION Tier 3 EXTERNAL PAD SOLUTION PREFILLED Tier 2 QL SURGICEL NU-KNIT SYRINGE Tier 3 EXTERNAL PAD SYMLINPEN 120 SUBCUTANEOUS SURVANTA Tier 2 INTRATRACHEAL Tier 3 SOLUTION PEN- SUSPENSION INJECTOR SUSTIVA ORAL SYMLINPEN 60 Tier 3 QL SUBCUTANEOUS CAPSULE Tier 2 SOLUTION PEN- SUSTIVA ORAL TABLET Tier 3 QL INJECTOR SUSTOL SYMPAZAN ORAL FILM Tier 3 SUBCUTANEOUS Tier 3 SYMPROIC ORAL PREFILLED SYRINGE Tier 3 ST; QL TABLET SUTAB ORAL TABLET Tier 3 SYMTUZA ORAL SUTENT ORAL Tier 3 QL Tier 2 PA; QL; LD; SP TABLET CAPSULE SYNAGIS swabflush saline flush Tier 1 INTRAMUSCULAR Tier 4 PA; QL; LD; SP intravenous solution SOLUTION SWEET GUM SYNAREL NASAL Tier 4 PA; QL; SP SUBCUTANEOUS Tier 3 SOLUTION SOLUTION SYNDROS ORAL Tier 3 SWEET VERNAL GRASS SOLUTION POLLEN Tier 3 SUBCUTANEOUS SYNERCID INTRAVENOUS SOLUTION Tier 3 SOLUTION syeda oral tablet Tier 1 $0 RECONSTITUTED SYLVANT SYNJARDY ORAL INTRAVENOUS Tier 2 ST; QL Tier 4 PA; QL; LD; SP TABLET SOLUTION RECONSTITUTED SYNJARDY XR ORAL TABLET EXTENDED Tier 2 ST; QL SYMBICORT Tier 2 RELEASE 24 HOUR INHALATION AEROSOL SYNRIBO SYMBYAX ORAL SUBCUTANEOUS Tier 3 PA; QL; LD CAPSULE 12-50 MG, 6-50 Tier 3 SOLUTION MG RECONSTITUTED SYMBYAX ORAL SYNTHROID ORAL Tier 3 CAPSULE 3-25 MG, 6-25 Tier 3 DO TABLET MG SYNVISC INTRA- SYMDEKO ORAL ARTICULAR SOLUTION Tier 4 PA; QL TABLET THERAPY Tier 4 PA; QL; LD PREFILLED SYRINGE PACK

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 144 Drug Name Tier Notes Drug Name Tier Notes SYNVISC ONE INTRA- TAMIFLU ORAL Tier 3 QL ARTICULAR SOLUTION Tier 4 PA; QL CAPSULE PREFILLED SYRINGE TAMIFLU ORAL SYRINGE AVITENE SUSPENSION Tier 3 QL Tier 3 EXTERNAL RECONSTITUTED tab-a-vite oral tablet Tier 1 $0 tamoxifen citrate oral tablet Tier 1 $0 tab-a-vite/beta carotene oral Tier 1 $0 tamsulosin hcl oral capsule Tier 1 tablet TAPAZOLE ORAL Tier 3 tab-a-vite/iron oral tablet Tier 1 $0 TABLET TABLOID ORAL taperdex 12-day oral tablet Tier 2 Tier 1 TABLET therapy pack TABRECTA ORAL taperdex 6-day oral tablet Tier 3 PA; QL; SP Tier 1 TABLET therapy pack TACHOSIL EXTERNAL taperdex 7-day oral tablet Tier 3 Tier 1 PATCH therapy pack TACLONEX EXTERNAL TARCEVA ORAL Tier 3 Tier 3 PA; QL; LD; SP OINTMENT TABLET TACLONEX EXTERNAL TARGRETIN EXTERNAL Tier 3 Tier 2 PA; QL; SP SUSPENSION GEL tacrolimus external ointment Tier 1 ST; QL tarina 24 fe oral tablet Tier 1 $0 tacrolimus oral capsule Tier 1 tarina fe 1/20 eq oral tablet Tier 1 $0 tadalafil (pah) oral tablet Tier 4 PA; QL; SP tarina fe 1/20 oral tablet Tier 1 $0 tadalafil oral tablet Tier 4 PA; QL TARKA ORAL TABLET Tier 3 TAFINLAR ORAL EXTENDED RELEASE Tier 3 PA; QL; LD; SP CAPSULE TARON-PREX ORAL Tier 3 TAGRISSO ORAL CAPSULE Tier 3 PA; QL; LD; SP TABLET TAROXIA EXTERNAL Tier 3 take action oral tablet Tier 1 $0 GEL TASIGNA ORAL TAKHZYRO Tier 2 PA; QL; SP SUBCUTANEOUS Tier 4 PA; QL; LD; SP CAPSULE SOLUTION TASMAR ORAL TABLET Tier 3 PA; QL TALICIA ORAL TAURINE INJECTION Tier 3 CAPSULE DELAYED Tier 3 ST; QL SOLUTION RELEASE tavaborole external solution Tier 1 ST; QL TALL RAGWEED TAVALISSE ORAL Tier 4 PA; QL; LD SUBCUTANEOUS Tier 3 TABLET SOLUTION TAYTULLA ORAL TALZENNA ORAL Tier 3 Tier 3 PA; QL; LD; SP CAPSULE CAPSULE tazarotene external cream Tier 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 145 Drug Name Tier Notes Drug Name Tier Notes tazicef injection solution TEGSEDI Tier 1 reconstituted SUBCUTANEOUS Tier 4 PA; QL; LD TAZICEF SOLUTION PREFILLED INTRAVENOUS Tier 3 SYRINGE SOLUTION TEKTURNA HCT ORAL Tier 3 DO tazicef intravenous solution TABLET 150-12.5 MG Tier 1 reconstituted TEKTURNA HCT ORAL TAZORAC EXTERNAL TABLET 150-25 MG, 300- Tier 3 Tier 2 CREAM 12.5 MG, 300-25 MG TAZORAC EXTERNAL telmisartan oral tablet 20 mg, Tier 2 Tier 1 DO GEL 40 mg taztia xt oral capsule telmisartan oral tablet 80 mg Tier 1 extended release 24 hour 120 Tier 1 DO telmisartan-amlodipine oral mg, 180 mg, 360 mg tablet 40-10 mg, 80-10 mg, Tier 1 taztia xt oral capsule 80-5 mg extended release 24 hour 240 Tier 1 telmisartan-amlodipine oral Tier 1 DO mg, 300 mg tablet 40-5 mg TAZVERIK ORAL telmisartan-hctz oral tablet Tier 3 PA; QL; LD Tier 1 DO TABLET 40-12.5 mg TDVAX telmisartan-hctz oral tablet Tier 1 INTRAMUSCULAR Tier 3 $0 80-12.5 mg, 80-25 mg SUSPENSION temazepam oral capsule Tier 1 TECENTRIQ TEMIXYS ORAL INTRAVENOUS Tier 3 PA; QL; LD; SP Tier 3 QL SOLUTION TABLET TECHLITE AST TEMODAR Tier 2 QL INTRAVENOUS LANCETS Tier 2 PA; QL; SP SOLUTION TECHLITE INSULIN Tier 3 ST; QL RECONSTITUTED SYRINGE TEMODAR ORAL Tier 3 PA; QL; SP TECHLITE LANCETS Tier 2 QL CAPSULE TECHLITE LANCETS Tier 2 QL temozolomide oral capsule Tier 1 PA; QL; SP 30G temsirolimus intravenous TECHLITE PEN Tier 1 PA; QL; SP Tier 3 ST; QL solution NEEDLES tencon oral tablet Tier 1 TEFLARO INTRAVENOUS TENIPOSIDE Tier 3 SOLUTION INTRAVENOUS Tier 3 SP RECONSTITUTED SOLUTION TEGADERM AG MESH TENIVAC Tier 2 EXTERNAL PAD INTRAMUSCULAR Tier 3 $0 INJECTABLE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 146 Drug Name Tier Notes Drug Name Tier Notes tenofovir disoproxil fumarate TETANUS-DIPHTHERIA Tier 1 $0 oral tablet TOXOIDS TD Tier 3 $0 TENORETIC 100 ORAL INTRAMUSCULAR Tier 3 TABLET SUSPENSION TENORETIC 50 ORAL tetrabenazine oral tablet Tier 1 PA; QL; SP Tier 3 TABLET tetracaine hcl ophthalmic Tier 1 TEPADINA INJECTION solution SOLUTION Tier 3 SP tetracycline hcl oral capsule Tier 1 RECONSTITUTED TGT LANCET MICRO Tier 2 QL TEPEZZA THIN 33G INTRAVENOUS Tier 4 PA; QL; LD SOLUTION TGT LANCET THIN 26G Tier 2 QL RECONSTITUTED TGT LANCET ULTRA Tier 2 QL TEPMETKO ORAL THIN 30G Tier 3 PA; QL; LD TABLET TGT LANCING DEVICE Tier 2 terazosin hcl oral capsule Tier 1 THALOMID ORAL Tier 2 PA; QL; LD; SP CAPSULE terbinafine hcl oral tablet Tier 1 THAM INTRAVENOUS terbutaline sulfate injection Tier 3 Tier 1 SOLUTION solution THE LIQUILIFT TRACE Tier 3 terbutaline sulfate oral tablet Tier 1 T1S INTRAVENOUS KIT terconazole vaginal cream Tier 1 THEO-24 ORAL terconazole vaginal CAPSULE EXTENDED Tier 2 Tier 1 suppository RELEASE 24 HOUR theophylline er oral tablet TERIPARATIDE Tier 1 (RECOMBINANT) extended release 12 hour SUBCUTANEOUS Tier 4 PA; QL; SP theophylline er oral tablet Tier 1 SOLUTION PEN- extended release 24 hour INJECTOR THEOPHYLLINE IN terrell inhalation solution Tier 1 D5W INTRAVENOUS Tier 3 TESSALON PERLES SOLUTION Tier 3 ORAL CAPSULE theophylline oral solution Tier 1 TESTOPEL IMPLANT Tier 3 PA; QL; LD THERA ORAL TABLET Tier 2 $0 PELLET thera-mill oral tablet Tier 1 $0 testosterone cypionate Tier 1 PA; QL intramuscular solution thera-tabs oral tablet Tier 1 $0 testosterone enanthate THEREMS ORAL Tier 1 PA; QL Tier 2 $0 intramuscular solution TABLET thiamine hcl injection testosterone transdermal gel Tier 1 PA; QL Tier 1 solution testosterone transdermal Tier 1 PA; QL solution THINLETS GP LANCETS Tier 2 QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 147 Drug Name Tier Notes Drug Name Tier Notes THIOLA EC ORAL tiadylt er oral capsule TABLET DELAYED Tier 3 PA; QL; LD extended release 24 hour 120 Tier 1 DO RELEASE mg, 180 mg, 360 mg thioridazine hcl oral tablet Tier 1 tiadylt er oral capsule extended release 24 hour 240 Tier 1 thiotepa injection solution Tier 1 SP mg, 300 mg, 420 mg reconstituted tiagabine hcl oral tablet Tier 1 thiothixene oral capsule Tier 1 TIAZAC ORAL thrive mouth/throat gum Tier 1 $0 CAPSULE EXTENDED Tier 3 DO THRIVITE RX ORAL RELEASE 24 HOUR 120 Tier 2 TABLET MG, 180 MG, 360 MG THROMBATE III TIAZAC ORAL INTRAVENOUS CAPSULE EXTENDED Tier 3 Tier 3 SOLUTION RELEASE 24 HOUR 240 RECONSTITUTED MG, 300 MG, 420 MG THROMBI-GEL 10 TIBSOVO ORAL Tier 3 Tier 3 PA; QL; LD EXTERNAL PAD TABLET THROMBI-GEL 100 TICE BCG Tier 3 EXTERNAL PAD INTRAVESICAL Tier 4 SP THROMBI-GEL 40 SUSPENSION Tier 3 EXTERNAL PAD RECONSTITUTED THROMBIN-JMI TIGAN EPISTAXIS EXTERNAL Tier 3 INTRAMUSCULAR Tier 3 KIT SOLUTION THROMBIN-JMI TIGAN ORAL CAPSULE Tier 3 Tier 3 EXTERNAL KIT TIGECYCLINE INTRAVENOUS THROMBIN-JMI Tier 1 EXTERNAL SOLUTION Tier 3 SOLUTION RECONSTITUTED RECONSTITUTED THROMBI-PAD TIGLUTIK ORAL Tier 3 Tier 4 LD EXTERNAL PAD SUSPENSION THROMBOGEN tilia fe oral tablet Tier 1 $0 Tier 3 EXTERNAL KIT timolol maleate ophthalmic Tier 1 THROMBOGEN gel forming solution EXTERNAL SOLUTION Tier 3 timolol maleate ophthalmic Tier 1 RECONSTITUTED solution THYMOGLOBULIN timolol maleate oral tablet Tier 1 INTRAVENOUS Tier 3 SP timolol maleate pf SOLUTION Tier 1 RECONSTITUTED ophthalmic solution THYQUIDITY ORAL Tier 3 SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 148 Drug Name Tier Notes Drug Name Tier Notes TIMOPTIC OCUDOSE TOBRADEX OPHTHALMIC Tier 3 OPHTHALMIC Tier 2 SOLUTION OINTMENT TIMOPTIC TOBRADEX OPHTHALMIC Tier 3 OPHTHALMIC Tier 3 SOLUTION SUSPENSION TIMOPTIC-XE TOBRADEX ST OPHTHALMIC GEL Tier 3 OPHTHALMIC Tier 3 FORMING SOLUTION SUSPENSION TIMOTHY GRASS tobramycin inhalation Tier 4 SP POLLEN ALLERGEN Tier 3 nebulization solution INJECTION SOLUTION tobramycin ophthalmic Tier 1 TIMOTHY GRASS solution POLLEN ALLERGEN tobramycin sulfate injection Tier 3 Tier 1 SUBCUTANEOUS solution SOLUTION tobramycin sulfate injection Tier 1 tinidazole oral tablet Tier 1 solution reconstituted TIROSINT ORAL tobramycin-dexamethasone Tier 3 Tier 1 CAPSULE ophthalmic suspension TIROSINT-SOL ORAL TOBREX OPHTHALMIC Tier 3 Tier 3 SOLUTION OINTMENT TISSEEL EXTERNAL TOBREX OPHTHALMIC Tier 3 Tier 3 KIT SOLUTION TISSEEL EXTERNAL TODAY SPONGE Tier 3 Tier 2 $0 SOLUTION VAGINAL TISSUEBLUE TODAYS HEALTH INTRAOCULAR Tier 2 Tier 3 LANCING DEVICE SOLUTION PREFILLED TODAYS HEALTH MINI SYRINGE Tier 3 ST; QL PEN NEEDLES tis-u-sol irrigation solution Tier 1 TODAYS HEALTH PEN Tier 3 ST; QL TIVICAY ORAL TABLET Tier 3 QL NEEDLES TIVICAY PD ORAL TODAYS HEALTH Tier 3 QL Tier 3 ST; QL TABLET SOLUBLE SHORT PEN NEEDLE TODAYS HEALTH THIN tizanidine hcl oral capsule Tier 1 Tier 2 QL LANCETS 28G tizanidine hcl oral tablet Tier 1 TODAYS HEALTH THIN TNKASE INTRAVENOUS Tier 2 QL Tier 3 LANCETS 30G KIT tolbutamide oral tablet Tier 1 ST; QL TOBI PODHALER Tier 4 LD; SP INHALATION CAPSULE tolcapone oral tablet Tier 1 PA; QL tolmetin sodium oral capsule Tier 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 149 Drug Name Tier Notes Drug Name Tier Notes tolmetin sodium oral tablet Tier 1 TOUJEO SOLOSTAR SUBCUTANEOUS TOLSURA ORAL Tier 2 Tier 3 PA; QL SOLUTION PEN- CAPSULE INJECTOR tolterodine tartrate er oral tovet external foam Tier 1 capsule extended release 24 Tier 1 hour TOVIAZ ORAL TABLET EXTENDED RELEASE 24 Tier 3 tolterodine tartrate oral tablet Tier 1 HOUR tolvaptan oral tablet Tier 1 PA; QL TPN ELECTROLYTES TOPCARE CLICKFINE INTRAVENOUS Tier 3 Tier 3 ST; QL PEN NEEDLES CONCENTRATE TOPCARE LANCETS TRACLEER ORAL Tier 2 QL Tier 4 PA; QL; LD; SP MICRO-THIN 33G TABLET TOPCARE ULTRA TRACLEER ORAL Tier 3 ST; QL Tier 4 PA; QL; LD; SP COMFORT INS SYR TABLET SOLUBLE topiramate er oral capsule er TRALEMENT Tier 1 ST; QL 24 hour sprinkle INTRAVENOUS Tier 3 topiramate oral capsule SOLUTION Tier 1 sprinkle tramadol hcl er (biphasic) oral tablet extended release Tier 1 PA; QL topiramate oral tablet Tier 1 24 hour toposar intravenous solution Tier 1 SP tramadol hcl er oral tablet Tier 1 PA; QL TOPOTECAN HCL extended release 24 hour INTRAVENOUS Tier 3 SP tramadol hcl oral tablet Tier 1 QL SOLUTION tramadol-acetaminophen oral topotecan hcl intravenous Tier 1 QL Tier 1 SP tablet solution reconstituted trandolapril oral tablet Tier 1 T1S toremifene citrate oral tablet Tier 1 trandolapril-verapamil hcl er TORISEL oral tablet extended release Tier 1 DO INTRAVENOUS Tier 3 PA; QL; SP 1-240 mg SOLUTION trandolapril-verapamil hcl er torsemide oral tablet Tier 1 oral tablet extended release Tier 1 TOTECT INTRAVENOUS 2-180 mg, 2-240 mg, 4-240 SOLUTION Tier 3 SP mg RECONSTITUTED tranexamic acid intravenous Tier 1 TOUJEO MAX solution SOLOSTAR tranexamic acid oral tablet Tier 1 SUBCUTANEOUS Tier 2 SOLUTION PEN- TRANEXAMIC ACID- INJECTOR NACL INTRAVENOUS Tier 3 SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 150 Drug Name Tier Notes Drug Name Tier Notes tranylcypromine sulfate oral TRESIBA Tier 1 tablet SUBCUTANEOUS Tier 2 QL TRAVASOL SOLUTION INTRAVENOUS Tier 3 tretinoin (emollient) external Tier 1 PA; QL SOLUTION cream TRAVEL LANCETS Tier 2 QL tretinoin external cream Tier 1 PA; QL TRAVEL LANCETS tretinoin external gel Tier 1 PA; QL Tier 2 QL ADVANCED 28G tretinoin microsphere Tier 1 PA; QL travoprost (bak free) external gel Tier 1 ophthalmic solution tretinoin microsphere pump Tier 1 PA; QL TRAZIMERA external gel INTRAVENOUS Tier 3 SP tretinoin oral capsule Tier 1 SOLUTION RECONSTITUTED TRETTEN INTRAVENOUS trazodone hcl oral tablet Tier 1 Tier 4 PA; QL; LD; SP SOLUTION TREANDA RECONSTITUTED INTRAVENOUS TREXALL ORAL Tier 3 PA; QL; LD; SP Tier 2 SOLUTION TABLET RECONSTITUTED trezix oral capsule Tier 1 QL TRECATOR ORAL Tier 3 TABLET tri femynor oral tablet Tier 1 $0 triamcinolone acetonide TRELEGY ELLIPTA Tier 3 ST; QL INHALATION AEROSOL external aerosol solution Tier 2 POWDER BREATH triamcinolone acetonide Tier 1 ACTIVATED external cream TRELSTAR MIXJECT triamcinolone acetonide INTRAMUSCULAR Tier 1 Tier 3 PA; QL; SP external lotion SUSPENSION triamcinolone acetonide RECONSTITUTED external ointment 0.025 %, Tier 1 TREMFYA 0.1 %, 0.5 % SUBCUTANEOUS Tier 4 PA; QL; SP triamcinolone acetonide SOLUTION PEN- Tier 3 ST; QL external ointment 0.05 % INJECTOR triamcinolone acetonide TREMFYA Tier 1 mouth/throat paste SUBCUTANEOUS Tier 4 PA; QL; SP SOLUTION PREFILLED TRIAMCINOLONE- SYRINGE MOXIFLOXACIN Tier 3 treprostinil injection solution Tier 4 PA; QL; LD; SP INTRAOCULAR SUSPENSION TRESIBA FLEXTOUCH SUBCUTANEOUS TRI-AMINO INJECTION Tier 2 QL Tier 3 SOLUTION PEN- SOLUTION INJECTOR triamterene oral capsule Tier 1

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 151 Drug Name Tier Notes Drug Name Tier Notes triamterene-hctz oral capsule Tier 1 tri-legest fe oral tablet Tier 1 $0 triamterene-hctz oral tablet Tier 1 tri-linyah oral tablet Tier 1 $0 TRILIPIX ORAL triazolam oral tablet Tier 1 CAPSULE DELAYED Tier 3 ST; QL tri-buffered aspirin oral tablet Tier 1 $0 RELEASE TRICARE ORAL tri-lo-estarylla oral tablet Tier 1 $0 Tier 3 TABLET tri-lo-marzia oral tablet Tier 1 $0 TRICARE PRENATAL tri-lo-mili oral tablet Tier 1 $0 DHA ONE ORAL Tier 3 ST; QL CAPSULE tri-lo-sprintec oral tablet Tier 1 $0 TRI-LUMA EXTERNAL TRICHOPHYTON Tier 3 MENTAGROPHYTES CREAM Tier 3 SUBCUTANEOUS TRILURON INTRA- SOLUTION ARTICULAR SOLUTION Tier 4 PA; QL; SP TRICHOPHYTON PREFILLED SYRINGE SUBCUTANEOUS Tier 3 trimethobenzamide hcl oral Tier 1 SOLUTION capsule TRICOR ORAL TABLET Tier 3 ST; QL trimethoprim oral tablet Tier 1 triderm external cream Tier 1 tri-mili oral tablet Tier 1 $0 trientine hcl oral capsule Tier 1 PA; QL; SP trimipramine maleate oral Tier 1 TRIESENCE capsule INTRAOCULAR Tier 3 trinate oral tablet Tier 1 SUSPENSION TRINAZ ORAL TABLET Tier 3 ST; QL tri-estarylla oral tablet Tier 1 $0 TRINTELLIX ORAL Tier 3 DO TRIFERIC TABLET 10 MG, 5 MG HEMODIALYSIS Tier 3 TRINTELLIX ORAL PACKET Tier 3 TABLET 20 MG TRIFERIC HEMODIALYSIS Tier 3 tri-nymyo oral tablet Tier 1 $0 SOLUTION TRIOSTAT trifluoperazine hcl oral tablet Tier 1 INTRAVENOUS Tier 3 SOLUTION trifluridine ophthalmic Tier 1 solution tri-previfem oral tablet Tier 1 $0 trihexyphenidyl hcl oral TRIPTODUR Tier 1 INTRAMUSCULAR solution Tier 4 PA; QL; LD SUSPENSION trihexyphenidyl hcl oral Tier 1 RECONSTITUTED ER tablet TRISENOX TRIKAFTA ORAL INTRAVENOUS Tier 3 SP TABLET THERAPY Tier 4 PA; QL; LD SOLUTION PACK tri-sprintec oral tablet Tier 1 $0

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 152 Drug Name Tier Notes Drug Name Tier Notes TRISTART DHA ORAL TRUE COMFORT PEN Tier 3 ST; QL Tier 3 ST; QL CAPSULE NEEDLES TRISTART FREE ORAL TRUE COMFORT PRO Tier 3 ST; QL Tier 3 ST; QL CAPSULE INSULIN SYR TRISTART ONE ORAL TRUE COMFORT PRO Tier 3 ST; QL Tier 3 ST; QL CAPSULE PEN NEEDLES TRIUMEQ ORAL TRUE COMFORT TWIST Tier 2 QL Tier 2 QL TABLET TOP LANCETS TRI-VI-FLOR ORAL TRUEPLUS 5-BEVEL Tier 3 Tier 3 ST; QL SUSPENSION PEN NEEDLES TRI-VI-FLORO ORAL TRUEPLUS INSULIN Tier 3 Tier 3 ST; QL SUSPENSION SYRINGE tri-vite/fluoride oral solution Tier 1 $0 TRUEPLUS LANCETS Tier 2 QL trivora (28) oral tablet Tier 1 $0 26G TRUEPLUS LANCETS tri-vylibra lo oral tablet Tier 1 $0 Tier 2 QL 28G tri-vylibra oral tablet Tier 1 $0 TRUEPLUS LANCETS TRIZIVIR ORAL Tier 2 QL Tier 3 QL 30G TABLET TRUEPLUS LANCETS Tier 2 QL TRODELVY 33G INTRAVENOUS Tier 3 PA; QL; LD TRUEPLUS PEN SOLUTION Tier 3 ST; QL RECONSTITUTED NEEDLES TRUEPLUS SAFETY TROGARZO Tier 2 QL INTRAVENOUS Tier 3 PA; QL; LD LANCETS 28G SOLUTION TRULICITY SUBCUTANEOUS TROKENDI XR ORAL Tier 2 ST; QL CAPSULE EXTENDED Tier 2 SOLUTION PEN- RELEASE 24 HOUR INJECTOR TROPHAMINE TRUMENBA INTRAMUSCULAR INTRAVENOUS Tier 3 Tier 3 $0 SOLUTION SUSPENSION PREFILLED SYRINGE tropicamide ophthalmic Tier 1 TRUSKIN EXTERNAL solution Tier 3 SHEET trospium chloride er oral capsule extended release 24 Tier 1 TRUSOPT hour OPHTHALMIC Tier 3 SOLUTION trospium chloride oral tablet Tier 1 TRUVADA ORAL Tier 2 ST; QL TRUE COMFORT TABLET Tier 3 ST; QL INSULIN SYRINGE

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 153 Drug Name Tier Notes Drug Name Tier Notes TRUXIMA TYMLOS INTRAVENOUS Tier 3 PA; QL; SP SUBCUTANEOUS Tier 4 PA; QL; SP SOLUTION SOLUTION PEN- INJECTOR trymine cg oral liquid Tier 1 TYPHIM VI TUKYSA ORAL TABLET Tier 3 PA; QL; LD INTRAMUSCULAR Tier 3 tulana oral tablet Tier 1 $0 SOLUTION TURALIO ORAL TYSABRI Tier 3 PA; QL; LD CAPSULE INTRAVENOUS Tier 4 PA; QL; LD; SP CONCENTRATE TUSNEL C ORAL SYRUP Tier 2 TYVASO INHALATION Tier 4 PA; QL; LD; SP TUSSICAPS ORAL SOLUTION CAPSULE EXTENDED Tier 2 RELEASE 12 HOUR TYVASO REFILL INHALATION Tier 4 PA; QL; LD; SP TUXARIN ER ORAL SOLUTION TABLET EXTENDED Tier 3 RELEASE 12 HOUR TYVASO STARTER INHALATION Tier 4 PA; QL; LD; SP TUZISTRA XR ORAL SOLUTION SUSPENSION Tier 3 EXTENDED RELEASE UCERIS ORAL TABLET EXTENDED RELEASE 24 Tier 3 TWINRIX HOUR INTRAMUSCULAR Tier 3 $0 SUSPENSION UCERIS RECTAL FOAM Tier 3 PREFILLED SYRINGE UDENYCA TWIRLA SUBCUTANEOUS Tier 4 PA; QL; SP TRANSDERMAL PATCH Tier 3 SOLUTION PREFILLED WEEKLY SYRINGE TWYNSTA ORAL UKONIQ ORAL TABLET Tier 3 PA; QL; LD TABLET 40-10 MG, 80-10 Tier 3 ULTANE INHALATION Tier 3 MG, 80-5 MG SOLUTION TWYNSTA ORAL ULTICARE INSULIN Tier 3 DO Tier 3 ST; QL TABLET 40-5 MG SAFETY SYR TYBLUME ORAL ULTICARE INSULIN Tier 3 Tier 3 ST; QL TABLET SYRINGE TYBOST ORAL TABLET Tier 3 QL ULTICARE MICRO PEN Tier 3 ST; QL tydemy oral tablet Tier 1 $0 NEEDLES TYGACIL ULTICARE MINI PEN Tier 3 ST; QL INTRAVENOUS NEEDLES Tier 3 SOLUTION ULTICARE PEN Tier 3 ST; QL RECONSTITUTED NEEDLES TYKERB ORAL TABLET Tier 3 PA; QL; LD; SP ULTICARE SHORT PEN Tier 3 ST; QL NEEDLES

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 154 Drug Name Tier Notes Drug Name Tier Notes ULTIGUARD SAFEPACK ULTRABAG/DIANEAL Tier 3 ST; QL PEN NEEDLE PD-2/2.5% DEX Tier 3 ULTI-LANCE INTRAPERITONEAL Tier 2 AUTOMATIC SOLUTION ULTILET CLASSIC ULTRABAG/DIANEAL Tier 2 QL PD-2/4.25%DEX LANCETS Tier 3 INTRAPERITONEAL ULTILET INSULIN Tier 3 ST; QL SOLUTION SYRINGE ULTRABAG/DIANEAL/1. ULTILET INSULIN 5% DEXTROSE Tier 3 ST; QL Tier 3 SYRINGE SHORT INTRAPERITONEAL ULTILET LANCETS Tier 2 QL SOLUTION ULTILET PEN NEEDLE Tier 3 ST; QL ULTRABAG/DIANEAL/2. 5% DEXTROSE ULTILET SAFETY Tier 3 Tier 2 QL INTRAPERITONEAL LANCETS SOLUTION ULTILET SAFETY Tier 2 QL ULTRABAG/DIANEAL/4. LANCETS 23G 25% DEX Tier 3 ULTIVA INTRAVENOUS INTRAPERITONEAL SOLUTION Tier 3 SOLUTION RECONSTITUTED ULTRACARE INSULIN Tier 3 ST; QL ULTOMIRIS SYRINGE Tier 4 PA; QL; LD; SP INTRAVENOUS ULTRA-CARE LANCETS SOLUTION Tier 2 QL 30G ultra b-100 complex oral Tier 1 $0 ULTRACARE PEN tablet Tier 3 ST; QL NEEDLES ULTRA COMFORT ULTRA-COMFORT Tier 3 ST; QL Tier 3 ST; QL INSULIN SYRINGE INSULIN SYRINGE ULTRA FLO INSULIN Tier 3 ST; QL ULTRAFOAM SPONGE Tier 3 PEN NEEDLES 2X6.25X7CM EXTERNAL ULTRA FLO INSULIN Tier 3 ST; QL ULTRAFOAM SPONGE SYRINGE Tier 3 8X12.5X1CM EXTERNAL ULTRA THIN LANCETS ULTRAFOAM SPONGE Tier 2 QL Tier 3 31G 8X12.5X3CM EXTERNAL ULTRA THIN PEN Tier 3 ST; QL ULTRAFOAM SPONGE Tier 3 NEEDLES 8X25X1CM EXTERNAL ULTRABAG/DIANEAL ULTRAFOAM SPONGE PD-2/1.5% DEX Tier 3 Tier 3 8X6.25X1CM EXTERNAL INTRAPERITONEAL ULTRA-THIN II AUTO SOLUTION Tier 2 QL LANCET ULTRA-THIN II INS SYR Tier 3 ST; QL SHORT

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 155 Drug Name Tier Notes Drug Name Tier Notes ULTRA-THIN II INSULIN Tier 3 ST; QL UNISTIK 1 Tier 2 SYRINGE UNISTIK 2 Tier 2 ULTRA-THIN II Tier 2 QL LANCETS UNISTIK 2 COMFORT Tier 2 ULTRA-THIN II MINI Tier 3 ST; QL UNISTIK 2 EXTRA Tier 2 PEN NEEDLE UNISTIK 2 NEONATAL Tier 2 ULTRA-THIN II PEN Tier 3 ST; QL NEEDLE SHORT UNISTIK 2 NORMAL Tier 2 ULTRA-THIN II PEN Tier 3 ST; QL UNISTIK 2 SUPER Tier 2 NEEDLES UNISTIK 3 Tier 2 UNASYN INJECTION SOLUTION Tier 3 UNISTIK 3 COMFORT Tier 2 RECONSTITUTED UNISTIK 3 EXTRA Tier 2 UNASYN INTRAVENOUS UNISTIK 3 GENTLE Tier 2 QL SOLUTION Tier 3 RECONSTITUTED UNISTIK 3 NEONATAL Tier 2 UNIFINE PENTIPS Tier 3 ST; QL UNISTIK 3 NORMAL Tier 2 UNIFINE PENTIPS PLUS Tier 3 ST; QL UNISTIK CZT Tier 2 UNIFINE COMFORT SAFECONTROL PEN Tier 3 ST; QL UNISTIK CZT NORMAL Tier 2 NEEDLE UNISTIK PRO SAFETY UNILET Tier 2 QL LANCET COMFORTOUCH Tier 2 QL UNISTIK SAFETY LANCET Tier 2 QL LANCETS 28G UNILET EXCELITE Tier 2 QL UNISTIK SAFETY UNILET EXCELITE II Tier 2 QL Tier 2 QL LANCETS 30G UNILET G.P. LANCET Tier 2 QL UNISTIK TOUCH UNILET G.P. SUPERLITE Tier 2 QL Tier 2 QL SAFETY LANC 21G LANCET UNISTIK TOUCH UNILET GP 28 ULTRA Tier 2 QL Tier 2 QL SAFETY LANC 23G THIN UNISTIK TOUCH Tier 2 QL UNILET LANCET Tier 2 QL SAFETY LANC 28G UNILET MICRO-THIN UNISTIK TOUCH Tier 2 QL Tier 2 QL 33G SAFETY LANC 30G UNILET SUPERLITE Tier 2 QL unithroid oral tablet Tier 1 T1S LANCET UNITUXIN UNILET SUPER-THIN Tier 2 QL INTRAVENOUS Tier 3 LD 30G SOLUTION UNILET ULTRA-THIN UNIVERSAL 1 LANCETS Tier 2 QL Tier 2 QL 28G THIN 26G

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 156 Drug Name Tier Notes Drug Name Tier Notes UNIVERSAL 1 LANCETS valganciclovir hcl oral Tier 2 QL Tier 1 THIN 33G solution reconstituted UNIVERSAL 1 LANCETS Tier 2 QL valganciclovir hcl oral tablet Tier 1 ULTRA THIN valproate sodium intravenous Tier 1 UPLIZNA solution INTRAVENOUS Tier 4 PA; QL; LD SOLUTION valproic acid oral capsule Tier 1 UPNEEQ OPHTHALMIC valproic acid oral solution Tier 1 Tier 3 PA; QL SOLUTION valrubicin intravesical Tier 1 SP UPTRAVI ORAL solution Tier 4 PA; QL; LD; SP TABLET valsartan oral tablet Tier 1 UPTRAVI ORAL TABLET THERAPY Tier 4 PA; QL; LD; SP valsartan- hydrochlorothiazide oral PACK Tier 1 DO tablet 160-12.5 mg, 80-12.5 UROCIT-K 10 ORAL mg TABLET EXTENDED Tier 3 RELEASE valsartan- hydrochlorothiazide oral Tier 1 UROCIT-K 15 ORAL tablet 160-25 mg, 320-12.5 TABLET EXTENDED Tier 3 mg, 320-25 mg RELEASE VALSTAR UROCIT-K 5 ORAL INTRAVESICAL Tier 3 LD; SP TABLET EXTENDED Tier 3 SOLUTION RELEASE VALTOCO 10 MG DOSE URSO 250 ORAL Tier 3 PA; QL Tier 3 NASAL LIQUID TABLET VALTOCO 15 MG DOSE URSO FORTE ORAL Tier 3 NASAL LIQUID Tier 3 PA; QL TABLET THERAPY PACK ursodiol oral capsule Tier 1 VALTOCO 20 MG DOSE NASAL LIQUID Tier 3 PA; QL ursodiol oral tablet Tier 1 THERAPY PACK VABOMERE VALTOCO 5 MG DOSE INTRAVENOUS Tier 3 PA; QL Tier 3 NASAL LIQUID SOLUTION VALUE HEALTH RECONSTITUTED Tier 3 ST; QL INSULIN SYRINGE valacyclovir hcl oral tablet Tier 1 VALUE PLUS LANCET VALCHLOR EXTERNAL Tier 2 QL Tier 3 PA; QL; LD STANDARD 21G GEL VALUE PLUS LANCETS Tier 2 QL VALCYTE ORAL SUPER THIN SOLUTION Tier 3 VALUE PLUS LANCETS RECONSTITUTED Tier 2 QL THIN 26G VALCYTE ORAL Tier 3 TABLET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 157 Drug Name Tier Notes Drug Name Tier Notes VALUE PLUS LANCING VANISHPOINT INSULIN Tier 2 DEVICE SYRINGE 29G X 1/2" 1 VALUMARK LANCET ML, 29G X 5/16" 1 ML, Tier 2 QL Tier 3 ST; QL SUPER THIN 30G 30G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" VALUMARK LANCET Tier 2 QL 1 ML ULTRA THIN 28G VANISHPOINT INSULIN VALUMARK PEN Tier 3 ST; QL SYRINGE 30G X 3/16" 0.5 Tier 3 NEEDLES ML, 30G X 3/16" 1 ML VANCOCIN HCL ORAL VANTAS Tier 3 PA; QL Tier 3 PA; QL; LD; SP CAPSULE SUBCUTANEOUS KIT VANCOCIN ORAL Tier 3 PA; QL VAPRISOL CAPSULE INTRAVENOUS Tier 3 VANCOMYCIN HCL IN SOLUTION DEXTROSE Tier 3 VAQTA INTRAVENOUS INTRAMUSCULAR Tier 3 $0 SOLUTION SUSPENSION VANCOMYCIN HCL IN vardenafil hcl oral tablet Tier 4 PA; QL NACL INTRAVENOUS Tier 3 vardenafil hcl oral tablet SOLUTION Tier 4 PA; QL dispersible VANCOMYCIN HCL VARITHENA INTRAVENOUS Tier 3 Tier 3 LD SOLUTION INTRAVENOUS FOAM vancomycin hcl intravenous VARIVAX solution reconstituted 1 gm, SUBCUTANEOUS Tier 3 $0 Tier 1 10 gm, 100 gm, 1000 mg, 5 INJECTABLE gm, 500 mg, 750 mg VARIZIG VANCOMYCIN HCL INTRAMUSCULAR Tier 3 INTRAVENOUS SOLUTION SOLUTION Tier 3 VARUBI (180 MG DOSE) RECONSTITUTED 1.25 ORAL TABLET Tier 3 GM, 1.5 GM, 250 MG THERAPY PACK vancomycin hcl oral capsule Tier 1 PA; QL VASCEPA ORAL Tier 2 PA; QL VANCOMYCIN HCL CAPSULE ORAL SOLUTION Tier 3 PA; QL VASERETIC ORAL Tier 3 RECONSTITUTED TABLET vandazole vaginal gel Tier 1 VASOSTRICT INTRAVENOUS Tier 3 VANIQA EXTERNAL Tier 3 SOLUTION CREAM VAXCHORA ORAL SUSPENSION Tier 3 RECONSTITUTED

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 158 Drug Name Tier Notes Drug Name Tier Notes VAXELIS VENCLEXTA ORAL Tier 3 PA; QL; LD INTRAMUSCULAR Tier 3 TABLET SUSPENSION VENCLEXTA STARTING VAXELIS PACK ORAL TABLET Tier 3 PA; QL; LD INTRAMUSCULAR THERAPY PACK Tier 3 SUSPENSION VENEXA ORAL TABLET Tier 3 PREFILLED SYRINGE VAZCULEP VENIPUNCTURE PX1 INTRAVENOUS Tier 3 PHLEBOTOMY Tier 3 SOLUTION EXTERNAL KIT VCF VAGINAL venlafaxine hcl er oral CONTRACEPTIVE Tier 2 $0 capsule extended release 24 Tier 1 VAGINAL FILM hour 150 mg VCF VAGINAL venlafaxine hcl er oral CONTRACEPTIVE Tier 2 $0 capsule extended release 24 Tier 1 DO VAGINAL FOAM hour 37.5 mg, 75 mg VCF VAGINAL venlafaxine hcl er oral tablet CONTRACEPTIVE Tier 2 $0 extended release 24 hour 150 Tier 1 VAGINAL GEL mg, 225 mg VECAMYL ORAL venlafaxine hcl er oral tablet Tier 3 TABLET extended release 24 hour Tier 1 DO 37.5 mg, 75 mg VECTIBIX INTRAVENOUS Tier 3 PA; QL; SP venlafaxine hcl oral tablet Tier 1 SOLUTION VENOFER vecuronium bromide INTRAVENOUS Tier 3 intravenous solution Tier 1 SOLUTION reconstituted VENOMIL HONEY BEE Tier 3 VELCADE INJECTION VENOM INJECTION KIT SOLUTION Tier 3 PA; QL; SP VENOMIL MIXED RECONSTITUTED VESPID VENOM Tier 3 VELETRI INJECTION SOLUTION INTRAVENOUS RECONSTITUTED Tier 4 PA; QL; LD; SP SOLUTION VENOMIL WASP Tier 3 RECONSTITUTED VENOM INJECTION KIT velivet oral tablet Tier 1 $0 VENOMIL WHITE VELPHORO ORAL FACED HORNET Tier 3 Tier 3 ST; QL TABLET CHEWABLE INJECTION KIT VELTASSA ORAL VENOMIL YELLOW Tier 3 LD PACKET HORNET VENOM Tier 3 INJECTION KIT VEMLIDY ORAL Tier 4 SP TABLET VENOMIL YELLOW JACKET VENOM Tier 3 INJECTION KIT

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 159 Drug Name Tier Notes Drug Name Tier Notes VENTAVIS VERZENIO ORAL Tier 3 PA; QL; LD; SP INHALATION Tier 4 PA; QL; LD; SP TABLET SOLUTION VFEND ORAL VENTOLIN HFA SUSPENSION Tier 3 PA; QL INHALATION AEROSOL Tier 2 ST; QL RECONSTITUTED SOLUTION VFEND ORAL TABLET Tier 3 PA; QL veracolate oral tablet delayed Tier 1 $0 VIBATIV release INTRAVENOUS Tier 3 verapamil hcl er oral capsule SOLUTION extended release 24 hour 100 Tier 1 DO RECONSTITUTED mg, 120 mg, 180 mg VIBERZI ORAL TABLET Tier 3 PA; QL verapamil hcl er oral capsule VICTOZA extended release 24 hour 200 Tier 1 SUBCUTANEOUS Tier 2 ST; QL mg, 240 mg, 300 mg, 360 mg SOLUTION PEN- verapamil hcl er oral tablet INJECTOR Tier 1 extended release VIDA MIA AUTOLET Tier 2 verapamil hcl intravenous LANCING DEV Tier 1 solution VIDA MIA UNIFINE Tier 3 ST; QL verapamil hcl oral tablet Tier 1 PENTIPS VEREGEN EXTERNAL VIDA MIA UNILET Tier 3 Tier 2 QL OINTMENT LANCETS 28G VIDA MIA UNILET VERELAN ORAL Tier 2 QL CAPSULE EXTENDED LANCETS 30G Tier 3 DO RELEASE 24 HOUR 120 VIDAZA INJECTION MG, 180 MG SUSPENSION Tier 3 PA; QL; LD; SP VERELAN ORAL RECONSTITUTED CAPSULE EXTENDED Tier 3 vienva oral tablet Tier 1 $0 RELEASE 24 HOUR 240 MG, 360 MG vigabatrin oral packet Tier 1 LD; SP VERELAN PM ORAL vigabatrin oral tablet Tier 1 LD; SP CAPSULE EXTENDED vigadrone oral packet Tier 1 LD Tier 3 DO RELEASE 24 HOUR 100 VIGAMOX MG OPHTHALMIC Tier 3 VERELAN PM ORAL SOLUTION CAPSULE EXTENDED Tier 3 VILTEPSO RELEASE 24 HOUR 200 INTRAVENOUS Tier 4 PA; QL; LD MG, 300 MG SOLUTION VERQUVO ORAL Tier 3 PA; QL VIMIZIM TABLET INTRAVENOUS Tier 4 PA; QL; LD; SP VERSACLOZ ORAL SOLUTION Tier 3 SUSPENSION VIMPAT INTRAVENOUS Tier 3 SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 160 Drug Name Tier Notes Drug Name Tier Notes VIMPAT ORAL VIRT-PN PLUS ORAL Tier 3 Tier 3 ST; QL SOLUTION CAPSULE VIMPAT ORAL TABLET Tier 3 virtussin a/c oral solution Tier 1 VINATE DHA RF ORAL Tier 3 ST; QL virtussin ac w/alc oral liquid Tier 1 CAPSULE VIRTUSSIN DAC ORAL VINATE II ORAL Tier 2 Tier 2 SOLUTION TABLET VISCO-3 INTRA- VINATE ONE ORAL Tier 2 ARTICULAR SOLUTION Tier 4 PA; QL; SP TABLET PREFILLED SYRINGE vinblastine sulfate Tier 1 SP VISCOAT intravenous solution INTRAOCULAR Tier 3 vincristine sulfate SOLUTION Tier 1 SP intravenous solution VISIONBLUE vinorelbine tartrate OPHTHALMIC Tier 3 Tier 1 SP intravenous solution SOLUTION VIOKACE ORAL VISTARIL ORAL Tier 3 Tier 3 TABLET CAPSULE VISTOGARD ORAL viorele oral tablet Tier 1 $0 Tier 3 PA; QL; LD PACKET VIRACEPT ORAL Tier 2 QL TABLET VISUDYNE INTRAVENOUS VIRAMUNE ORAL Tier 4 LD; SP Tier 3 QL SOLUTION SUSPENSION RECONSTITUTED VIRAMUNE XR ORAL vit e-vit c-beta carotene oral Tier 1 $0 TABLET EXTENDED Tier 3 QL tablet RELEASE 24 HOUR VITAFOL FE+ ORAL Tier 3 ST; QL VIRAZOLE CAPSULE INHALATION Tier 3 SOLUTION VITAFOL GUMMIES RECONSTITUTED ORAL TABLET Tier 3 CHEWABLE VIREAD ORAL POWDER Tier 2 VITAFOL STRIPS ORAL Tier 3 VIREAD ORAL TABLET Tier 2 FILM VIRT-C DHA ORAL VITAFOL ULTRA ORAL Tier 3 Tier 3 ST; QL CAPSULE CAPSULE VIRT-NATE DHA ORAL VITAFOL-NANO ORAL Tier 3 ST; QL Tier 3 ST; QL CAPSULE TABLET virt-phos 250 neutral oral VITAFOL-OB ORAL Tier 1 Tier 3 ST; QL tablet TABLET VIRT-PN DHA ORAL VITAFOL-OB+DHA Tier 3 ST; QL Tier 3 ST; QL CAPSULE ORAL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 161 Drug Name Tier Notes Drug Name Tier Notes VITAFOL-ONE ORAL VIVAGUARD LANCING Tier 3 ST; QL Tier 2 CAPSULE DEVICE vitalee oral tablet Tier 1 $0 VIVITROL VITALINE BIOTIN INTRAMUSCULAR Tier 2 $0 Tier 4 SP FORTE ORAL TABLET SUSPENSION RECONSTITUTED VITAMEDMD ONE RX/QUATREFOLIC Tier 3 ST; QL VIVOTIF ORAL ORAL CAPSULE CAPSULE DELAYED Tier 2 RELEASE VITAMEDMD VIZIMPRO ORAL REDICHEW RX ORAL Tier 3 ST; QL Tier 3 PA; QL; LD; SP TABLET CHEWABLE TABLET vitamin b + c complex oral volnea oral tablet Tier 1 $0 Tier 1 $0 tablet VONVENDI INTRAVENOUS vitamin b complex oral tablet Tier 1 $0 Tier 4 PA; QL; LD; SP SOLUTION vitamin b50 complex oral Tier 1 $0 RECONSTITUTED tablet extended release VORAXAZE vitamin b-complex oral tablet Tier 1 $0 INTRAVENOUS Tier 3 LD vitamin d (ergocalciferol) SOLUTION Tier 1 oral capsule RECONSTITUTED voriconazole intravenous vitamin k1 injection solution Tier 1 Tier 1 solution reconstituted vitamin-b complex oral tablet Tier 1 $0 voriconazole oral suspension vitamins acd-fluoride oral Tier 1 PA; QL Tier 1 $0 reconstituted solution voriconazole oral tablet Tier 1 PA; QL VITAPEARL ORAL CAPSULE EXTENDED Tier 3 ST; QL VOSEVI ORAL TABLET Tier 4 PA; QL; SP RELEASE VOTRIENT ORAL Tier 2 PA; QL; LD; SP VITATHELY WITH TABLET Tier 3 ST; QL GINGER ORAL TABLET VP INSULIN SYRINGE Tier 3 ST; QL VITATRUE ORAL Tier 3 ST; QL VP-PNV-DHA ORAL Tier 3 ST; QL VITRAKVI ORAL CAPSULE Tier 3 PA; QL; LD; SP CAPSULE VPRIV INTRAVENOUS VITRAKVI ORAL SOLUTION Tier 4 PA; QL; LD; SP Tier 3 PA; QL; LD; SP SOLUTION RECONSTITUTED VITRANOL FE ORAL VRAYLAR ORAL Tier 3 Tier 3 ST; DO; QL TABLET CAPSULE 1.5 MG, 3 MG VITRASE INJECTION VRAYLAR ORAL Tier 3 Tier 3 ST; QL SOLUTION CAPSULE 4.5 MG, 6 MG VIVA DHA ORAL VRAYLAR ORAL Tier 3 ST; QL CAPSULE CAPSULE THERAPY Tier 3 ST; QL PACK VIVAGUARD LANCETS Tier 2 QL

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 162 Drug Name Tier Notes Drug Name Tier Notes VUSION EXTERNAL WALGREENS LANCETS Tier 3 Tier 2 QL OINTMENT MICRO THIN vyfemla oral tablet Tier 1 $0 WALGREENS LANCETS Tier 2 QL VYLEESI SUPER THIN SUBCUTANEOUS WALGREENS THIN Tier 3 PA; QL; LD Tier 2 QL SOLUTION AUTO- LANCETS INJECTOR WALGREENS ULTRA Tier 2 QL vylibra oral tablet Tier 1 $0 THIN LANCETS VYNDAMAX ORAL warfarin sodium oral tablet Tier 1 T1S Tier 4 PA; QL; LD; SP CAPSULE WASP VENOM PROTEIN VYNDAQEL ORAL INJECTION SOLUTION Tier 3 Tier 4 PA; QL; LD; SP CAPSULE RECONSTITUTED VYONDYS 53 WASP VENOM PROTEIN INTRAVENOUS Tier 4 PA; QL; LD SUBCUTANEOUS Tier 3 SOLUTION SOLUTION VYVANSE ORAL RECONSTITUTED CAPSULE 10 MG, 20 MG, Tier 2 PA; DO; QL water for irrigation, sterile Tier 1 30 MG irrigation solution VYVANSE ORAL WEGMANS UNIFINE Tier 3 ST; QL CAPSULE 40 MG, 50 MG, Tier 2 PA; QL PENTIPS PLUS 60 MG, 70 MG wera oral tablet Tier 1 $0 VYVANSE ORAL WESTAB PLUS ORAL Tier 3 ST TABLET CHEWABLE 10 Tier 2 PA; DO; QL TABLET MG, 20 MG, 30 MG WESTERN JUNIPER VYVANSE ORAL SUBCUTANEOUS Tier 3 TABLET CHEWABLE 40 Tier 2 PA; QL SOLUTION MG, 50 MG, 60 MG WESTGEL DHA ORAL Tier 3 ST; QL VYXEOS INTRAVENOUS CAPSULE SUSPENSION Tier 3 LD; SP WESTHROID ORAL RECONSTITUTED Tier 3 TABLET VYZULTA WEST-VITE W/FOLIC OPHTHALMIC Tier 3 Tier 2 $0 SOLUTION ACID ORAL TABLET WAKIX ORAL TABLET WHITE BIRCH Tier 4 PA; QL; LD; SP 17.8 MG SUBCUTANEOUS Tier 3 SOLUTION WAKIX ORAL TABLET PA; DO; QL; LD; Tier 4 4.45 MG SP WHITE FACED HORNET VENOM WALGREENS ADV Tier 2 QL SUBCUTANEOUS Tier 3 TRAVEL LANCETS SOLUTION WALGREENS LANCETS Tier 2 QL RECONSTITUTED

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 163 Drug Name Tier Notes Drug Name Tier Notes WHITE MULBERRY wixela inhub inhalation SUBCUTANEOUS Tier 3 aerosol powder breath Tier 1 SOLUTION activated WHITE OAK womans laxative oral tablet Tier 1 $0 SUBCUTANEOUS Tier 3 delayed release SOLUTION womens laxative oral tablet Tier 1 $0 WHITE PINE delayed release SUBCUTANEOUS Tier 3 WP THYROID ORAL Tier 3 SOLUTION TABLET WHITE-FACED HORNET wymzya fe oral tablet VENOM INJECTION Tier 1 $0 Tier 3 chewable SOLUTION WYNZORA EXTERNAL RECONSTITUTED Tier 3 CREAM WIDE-SEAL DIAPHRAGM 60 Tier 2 $0 XADAGO ORAL TABLET Tier 3 PA; QL VAGINAL DIAPHRAGM XALKORI ORAL Tier 2 PA; QL; LD; SP WIDE-SEAL CAPSULE DIAPHRAGM 65 Tier 2 $0 XARACOLL IMPLANT Tier 3 VAGINAL DIAPHRAGM IMPLANT WIDE-SEAL XARELTO ORAL Tier 2 DIAPHRAGM 70 Tier 2 $0 TABLET VAGINAL DIAPHRAGM XARELTO STARTER WIDE-SEAL PACK ORAL TABLET Tier 2 DIAPHRAGM 75 Tier 2 $0 THERAPY PACK VAGINAL DIAPHRAGM XATMEP ORAL Tier 3 PA; QL; SP WIDE-SEAL SOLUTION DIAPHRAGM 80 Tier 2 $0 VAGINAL DIAPHRAGM XCOPRI (250 MG DAILY DOSE) ORAL TABLET Tier 3 WIDE-SEAL THERAPY PACK DIAPHRAGM 85 Tier 2 $0 VAGINAL DIAPHRAGM XCOPRI (350 MG DAILY DOSE) ORAL TABLET Tier 3 WIDE-SEAL THERAPY PACK DIAPHRAGM 90 Tier 2 $0 VAGINAL DIAPHRAGM XCOPRI ORAL TABLET Tier 3 XCOPRI ORAL TABLET WIDE-SEAL Tier 3 DIAPHRAGM 95 Tier 2 $0 THERAPY PACK VAGINAL DIAPHRAGM XELJANZ ORAL Tier 4 PA; QL; SP WILATE INTRAVENOUS SOLUTION Tier 4 PA; QL; LD; SP KIT XELJANZ ORAL Tier 4 PA; QL; SP WILZIN ORAL CAPSULE Tier 3 TABLET WINRHO SDF Tier 4 SP INJECTION SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 164 Drug Name Tier Notes Drug Name Tier Notes XELJANZ XR ORAL XIAFLEX INJECTION TABLET EXTENDED SOLUTION Tier 4 PA; QL; LD Tier 4 PA; QL; SP RELEASE 24 HOUR 11 RECONSTITUTED MG XIFAXAN ORAL Tier 3 PA; QL XELJANZ XR ORAL TABLET TABLET EXTENDED Tier 4 PA; QL XIGDUO XR ORAL RELEASE 24 HOUR 22 TABLET EXTENDED Tier 2 ST; QL MG RELEASE 24 HOUR XELODA ORAL TABLET Tier 3 PA; QL; LD; SP XIIDRA OPHTHALMIC Tier 3 PA; QL XELPROS SOLUTION OPHTHALMIC Tier 3 XOFIGO INTRAVENOUS Tier 3 PA; QL; LD EMULSION SOLUTION XEMBIFY XOFLUZA (40 MG DOSE) SUBCUTANEOUS Tier 4 PA; QL; LD ORAL TABLET Tier 3 SOLUTION THERAPY PACK XENAZINE ORAL Tier 3 PA; QL; LD; SP XOFLUZA (80 MG DOSE) TABLET ORAL TABLET Tier 3 XENICAL ORAL THERAPY PACK Tier 3 PA; QL CAPSULE XOLAIR XENLETA SUBCUTANEOUS Tier 4 PA; QL; LD; SP INTRAVENOUS Tier 3 LD SOLUTION PREFILLED SOLUTION SYRINGE XENLETA ORAL XOLAIR Tier 3 PA; QL; LD TABLET SUBCUTANEOUS Tier 4 PA; QL; LD; SP XEOMIN SOLUTION INTRAMUSCULAR RECONSTITUTED Tier 4 PA; QL; LD; SP SOLUTION XOLEGEL EXTERNAL Tier 3 RECONSTITUTED GEL XEPI EXTERNAL XOPENEX HFA Tier 3 Tier 3 CREAM INHALATION AEROSOL XERAVA XOSPATA ORAL Tier 3 PA; QL; LD INTRAVENOUS TABLET Tier 3 SOLUTION XPOVIO (100 MG ONCE RECONSTITUTED WEEKLY) ORAL Tier 3 PA; QL; LD XERESE EXTERNAL TABLET THERAPY Tier 3 PA; QL CREAM PACK XERMELO ORAL XPOVIO (40 MG ONCE Tier 4 PA; QL; LD TABLET WEEKLY) ORAL Tier 3 PA; QL; LD XGEVA TABLET THERAPY SUBCUTANEOUS Tier 3 PA; QL; SP PACK SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 165 Drug Name Tier Notes Drug Name Tier Notes XPOVIO (40 MG TWICE XYNTHA Tier 4 PA; QL; LD; SP WEEKLY) ORAL INTRAVENOUS KIT Tier 3 PA; QL; LD TABLET THERAPY XYNTHA SOLOFUSE Tier 4 PA; QL; LD; SP PACK INTRAVENOUS KIT XPOVIO (60 MG ONCE XYREM ORAL WEEKLY) ORAL Tier 3 PA; QL; LD Tier 3 PA; QL; LD SOLUTION TABLET THERAPY YASMIN 28 ORAL PACK Tier 3 TABLET XPOVIO (60 MG TWICE WEEKLY) ORAL YAZ ORAL TABLET Tier 3 Tier 3 PA; QL; LD TABLET THERAPY YELLOW DOCK PACK SUBCUTANEOUS Tier 3 XPOVIO (80 MG ONCE SOLUTION WEEKLY) ORAL Tier 3 PA; QL; LD YELLOW HORNET TABLET THERAPY VENOM PROTEIN Tier 3 PACK INJECTION SOLUTION XPOVIO (80 MG TWICE RECONSTITUTED WEEKLY) ORAL Tier 3 PA; QL; LD YELLOW HORNET TABLET THERAPY VENOM PROTEIN PACK SUBCUTANEOUS Tier 3 XTANDI ORAL SOLUTION Tier 2 PA; QL; LD; SP CAPSULE RECONSTITUTED xulane transdermal patch YELLOW JACKET Tier 1 $0 weekly VENOM PROTEIN Tier 3 XULTOPHY INJECTION SOLUTION SUBCUTANEOUS RECONSTITUTED Tier 3 ST; QL SOLUTION PEN- YELLOW JACKET INJECTOR VENOM PROTEIN XURIDEN ORAL SUBCUTANEOUS Tier 3 Tier 3 PA; QL; LD PACKET SOLUTION RECONSTITUTED xylocaine dental injection Tier 1 solution YERVOY INTRAVENOUS Tier 3 PA; QL; LD; SP XYLOCAINE Tier 3 SOLUTION INJECTION SOLUTION YF-VAX XYLOCAINE/EPINEPHR SUBCUTANEOUS Tier 3 INE INJECTION Tier 3 INJECTABLE SOLUTION yl balanced b-100 oral tablet Tier 1 $0 XYLOCAINE-MPF Tier 3 INJECTION SOLUTION yl folic acid oral tablet Tier 1 $0 XYLOCAINE- YONDELIS INTRAVENOUS MPF/EPINEPHRINE Tier 3 Tier 3 LD; SP INJECTION SOLUTION SOLUTION RECONSTITUTED

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 166 Drug Name Tier Notes Drug Name Tier Notes YONSA ORAL TABLET Tier 3 PA; QL; LD; SP ZEMAIRA INTRAVENOUS YOSPRALA ORAL Tier 4 PA; QL; LD; SP TABLET DELAYED Tier 3 PA; QL SOLUTION RELEASE RECONSTITUTED YUPELRI INHALATION ZEMDRI INTRAVENOUS Tier 3 ST; QL Tier 3 SOLUTION SOLUTION YUTIQ INTRAVITREAL ZEMPLAR Tier 3 PA; QL; LD IMPLANT INTRAVENOUS Tier 3 PA; QL SOLUTION yuvafem vaginal tablet Tier 1 ZEMPLAR ORAL Tier 3 PA; QL zafirlukast oral tablet Tier 1 CAPSULE zaleplon oral capsule Tier 1 zenatane oral capsule Tier 2 PA; QL ZALTRAP ZENPEP ORAL INTRAVENOUS Tier 3 PA; QL; LD; SP CAPSULE DELAYED Tier 2 SOLUTION RELEASE PARTICLES zenzedi oral tablet 10 mg, 15 ZALVIT ORAL TABLET Tier 3 ST; QL Tier 1 PA; QL mg, 20 mg, 30 mg, 7.5 mg ZANAFLEX ORAL Tier 3 ST; QL zenzedi oral tablet 2.5 mg, 5 CAPSULE Tier 1 PA; DO; QL mg ZANAFLEX ORAL Tier 3 ST; QL TABLET ZEPOSIA 7-DAY STARTER PACK ORAL Tier 4 PA; QL; LD; SP ZANOSAR CAPSULE THERAPY INTRAVENOUS Tier 3 SP PACK SOLUTION ZEPOSIA ORAL RECONSTITUTED Tier 4 PA; QL; LD; SP CAPSULE zarah oral tablet Tier 1 $0 ZEPOSIA STARTER KIT ZARXIO INJECTION ORAL CAPSULE Tier 4 PA; QL; LD; SP SOLUTION PREFILLED Tier 4 PA; QL; SP THERAPY PACK SYRINGE ZEPZELCA ZCORT 7-DAY ORAL INTRAVENOUS Tier 3 PA; QL; LD; SP TABLET THERAPY Tier 3 SOLUTION PACK RECONSTITUTED zebutal oral capsule Tier 1 ZERBAXA ZEJULA ORAL INTRAVENOUS Tier 3 PA; QL; LD Tier 3 CAPSULE SOLUTION RECONSTITUTED ZELAPAR ORAL Tier 3 PA; QL ZESTORETIC ORAL TABLET DISPERSIBLE Tier 3 DO TABLET 10-12.5 MG ZELBORAF ORAL Tier 2 PA; QL; LD; SP TABLET ZESTORETIC ORAL TABLET 20-12.5 MG, 20- Tier 3 25 MG

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 167 Drug Name Tier Notes Drug Name Tier Notes ZEVALIN Y-90 ZIRGAN OPHTHALMIC Tier 3 PA; QL; LD Tier 3 INTRAVENOUS KIT GEL ZIAC ORAL TABLET Tier 3 ZITHROMAX INTRAVENOUS ZIAGEN ORAL Tier 3 Tier 3 QL SOLUTION SOLUTION RECONSTITUTED ZIAGEN ORAL TABLET Tier 3 QL ZITHROMAX ORAL Tier 3 QL zidovudine oral capsule Tier 1 QL PACKET zidovudine oral syrup Tier 1 QL ZITHROMAX ORAL zidovudine oral tablet Tier 1 QL SUSPENSION Tier 3 QL RECONSTITUTED ZIEXTENZO SUBCUTANEOUS ZITHROMAX ORAL Tier 4 PA; QL; LD; SP Tier 3 QL SOLUTION PREFILLED TABLET SYRINGE ZITHROMAX TRI-PAK Tier 3 QL ZILRETTA INTRA- ORAL TABLET ARTICULAR ZITHROMAX Z-PAK Tier 4 PA; QL; LD Tier 3 QL SUSPENSION ORAL TABLET RECONSTITUTED ER ZOFRAN ORAL TABLET Tier 3 QL ZILXI EXTERNAL ZOKINVY ORAL Tier 3 ST; QL Tier 4 PA; QL; LD FOAM CAPSULE zinc chloride intravenous Tier 1 ZOLADEX solution SUBCUTANEOUS Tier 3 PA; QL; SP zinc sulfate intravenous IMPLANT Tier 1 solution zoledronic acid intravenous Tier 1 PA; QL; SP ZINGO INTRADERMAL concentrate Tier 3 JET-INJECTOR ZOLEDRONIC ACID ZINPLAVA INTRAVENOUS Tier 4 PA; QL; SP INTRAVENOUS Tier 3 PA; QL SOLUTION 4 MG/100ML SOLUTION zoledronic acid intravenous Tier 4 PA; QL; SP ZIOPTAN OPHTHALMIC solution 5 mg/100ml Tier 3 SOLUTION ZOLINZA ORAL Tier 2 PA; QL; SP ziprasidone hcl oral capsule CAPSULE Tier 1 DO 20 mg, 40 mg zolmitriptan nasal solution Tier 1 ST; QL ziprasidone hcl oral capsule Tier 1 zolmitriptan oral tablet Tier 1 QL 60 mg, 80 mg zolmitriptan oral tablet Tier 1 QL ziprasidone mesylate dispersible intramuscular solution Tier 1 zolpidem tartrate er oral reconstituted Tier 1 ST; QL tablet extended release ZIRABEV INTRAVENOUS Tier 3 PA; QL; LD; SP zolpidem tartrate oral tablet Tier 1 SOLUTION

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 168 Drug Name Tier Notes Drug Name Tier Notes zolpidem tartrate sublingual ZYMAXID Tier 1 ST; QL tablet sublingual OPHTHALMIC Tier 3 ZOLPIMIST ORAL SOLUTION Tier 3 ST; QL SOLUTION ZYPREXA RELPREVV INTRAMUSCULAR zonisamide oral capsule Tier 1 Tier 3 SUSPENSION ZONTIVITY ORAL RECONSTITUTED Tier 3 PA; QL TABLET ZYTIGA ORAL TABLET Tier 3 PA; QL; LD; SP ZORBTIVE 250 MG SUBCUTANEOUS ZYTIGA ORAL TABLET Tier 4 PA; QL; SP Tier 2 PA; QL; LD; SP SOLUTION 500 MG RECONSTITUTED ZYVANA ORAL ZORTRESS ORAL Tier 3 Tier 3 CAPSULE TABLET ZYVOX INTRAVENOUS ZOSYN INTRAVENOUS Tier 3 Tier 3 SOLUTION SOLUTION ZYVOX ORAL zovia 1/35 (28) oral tablet Tier 1 $0 SUSPENSION Tier 3 PA; QL zovia 1/35e (28) oral tablet Tier 1 $0 RECONSTITUTED ZOVIRAX EXTERNAL ZYVOX ORAL TABLET Tier 3 PA; QL Tier 3 OINTMENT ZOVIRAX ORAL Tier 3 SUSPENSION ZUBSOLV SUBLINGUAL Tier 3 QL TABLET SUBLINGUAL ZULRESSO INTRAVENOUS Tier 4 PA; QL; LD; SP SOLUTION zumandimine oral tablet Tier 1 $0 ZUPLENZ ORAL FILM Tier 3 QL ZYCLARA EXTERNAL Tier 3 ST; QL CREAM ZYCLARA PUMP Tier 3 ST; QL EXTERNAL CREAM ZYDELIG ORAL Tier 3 PA; QL; LD; SP TABLET ZYKADIA ORAL Tier 3 PA; QL; LD; SP TABLET ZYLET OPHTHALMIC Tier 2 SUSPENSION ZYLOPRIM ORAL Tier 3 TABLET

Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type PA = Prior Authorization Required ST = Step Therapy Required QL = Quantity Limit DO = Dose Optimization Limit LD = Limited Distribution SP = Specialty Medication T1S = Tier 1 Select Effective 4/1/21 169 Most plans include our home delivery program at no extra cost to you. Find out more by going online to anthem.com or call 833-236-6196.

For information about your pharmacy benefit, log in at anthem.com.

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

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Rev. 9/20