Blue Rx Value Plus Formulary

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BLUE RX VALUE PLUSSM FORMULARY

HOW TO READ THE FORMULARY All drugs are listed by their generic names and/or most common proprietary (brand) name. Specific drug listings may be accessed either by generic (in lowercase) or brand name (in uppercase) and by therapeutic drug tier. Any drug not found in this formulary listing, or any formulary updates published by Wellmark, shall be considered excluded from your benefit. Once the product is located, the following items can be viewed:

Drug Tier: Drugs are categorized within tiers on the formulary. Each tier is assigned a cost, which is determined by the member’s pharmacy benefit plan. Tier Designation in Formulary Below Formulary Tier 1 Formulary Tier 2 Formulary Tier 3 Value Plus Plan 3 Tier Tier 1 Tier 2 Tier 3 Value Plus Plan 2 Tier Tier 1 Tier 2 and Tier 3 combined Value Plus Plan 1 Tier Tier 1, Tier 2 and Tier 3 combined

Specialty Drugs: Specialty drugs are high-cost injectable, infused, oral or inhaled drugs for the ongoing treatment of a chronic condition. These drugs generally require close supervision and monitoring of the patient’s drug therapy. Specialty drugs may be categorized within tiers on the formulary or as drugs covered under your medical benefit. • Specialty Drugs Preferred (SP-P): Drugs in this category will process with the preferred specialty drug cost-share. • Specialty Drugs Non-Preferred (SP-NP): Drugs in this category will process with the non-preferred specialty cost-share, and will have a higher cost share than preferred specialty drugs. • Specialty Medical (SP-M): Drugs in this category will be covered under your medical benefit. Drug Name: This lists the generic name for the product (lowercase) OR the brand name or common reference name for the product (UPPERCASE). Requirements/Limits: This lists Wellmark Pharmacy programs that may impact a particular drug or class of drugs and are described in the legend below.

HEALTH CARE REFORM PREVENTIVE DRUGS Preventive drugs with an “A” or “B” rating in the current recommendations of the United States Preventive Services Task Force (USPSTF) and immunizations as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention are not associated with any cost share for members on plans with this benefit. A complete list of recommendations and guidelines related to preventive services can be found at Healthcare.gov. Recommended preventive items and services are subject to change and are subject to medical management.

BENEFIT COVERAGE AND LIMITATIONS This printed formulary does not define benefit coverage and limitations. Many members have specific benefit inclusions, exclusions, copayments or a lack of coverage, which are not reflected in the Blue Rx Value Plus formulary. Members should contact their Plan Sponsor or Wellmark Customer Service at the number on the back of their ID card if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year. The following topics may or may not be applicable depending on the parameters of your specific benefits.

FORMULARY EXCEPTION PROCESS Drugs not included in this list shall be considered non-formulary and are NOT COVERED. In some instances, Wellmark will consider coverage exceptions. Coverage of non-formulary drugs may be requested by the health professional through an exception request

©2020 Wellmark, Inc. 1 for a non-formulary prescription drug (outlined below). Generally, one of the following following guidelines must be documented in order for an exception to be granted: • All covered formulary drugs on any tier will be ineffective; OR • All covered formulary drugs on any tier have been ineffective; OR • All covered formulary drugs on any tier would not be as effective as the non-formulary drug; OR • All covered formulary drugs would have adverse effects.

COMMON DRUG EXCLUSIONS Due to benefit design parameters, some plan sponsors may choose to exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded drugs may include, but are not limited to: • Over-the-counter (OTC) drugs or their equivalents unless otherwise specified in the formulary listing. • Drug products used for cosmetic purposes. • Experimental drug products, or any drug product used in an experimental manner. • Replacement of a lost or stolen drug. • Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA).

CONTACT INFORMATION The Blue Rx Value Plus formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Wellmark encourages your input and feedback on how we can assist in improving this document and the formulary management process. Please direct your communications to: Wellmark Blue Cross and Blue Shield 1331 Grand Avenue P.O. Box 9232 Des Moines, IA 50306 In addition to the Blue Rx Value Plus formulary, other quick reference guides are available at Wellmark.com.

© 2020 Wellmark, Inc. All Rights Reserved. Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Health Plan of Iowa, Inc., Wellmark Blue Cross and Blue Shield of South Dakota, and Wellmark Value Health Plan, Inc. are independent licensees of the Blue Cross and Blue Shield Association.

P-2318749N-T 01/20 A

1 TIER 1 2 TIER 2 3 TIER 3 4 SP-P 5 SP-NP 6 SP-M TYPE DESCRIPTION

There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame. Amounts over the QL Quantity Limit specified quantity limits are not a covered benefit unless Post- Quantity Limit Prior Authorization is available. This indicates a drug requires prior authorization before it is covered under your benefit. Your health care provider will need to contact our PA Prior Authorization Pharmacy program at 800-600-8065. Hours of operation are Monday- Friday: 8 a.m. to 6 p.m. CST. This prescription drug may only be covered if you meet the minimum AL Age Limit or maximum age limit. This indicates a drug requires prior authorization before it is covered under your benefit. Your health care provider will need to contact our Pharmacy program at 800-600- 8065. Hours of operation are Medical Necessity Prior MN-PA Monday - Friday: 8 a.m. to 6 p.m. CST. The intent of formulary Authorization medical necessity prior authorization is to confirm the appropriate coverage of the target drugs when evidence is provided documenting a trial and failure of the preferred formulary alternatives. A quantity limit on this drug limits the amount covered per prescription, or time period, and may vary based on the diagnosis. QLV Quantity Limit (Varies) Amounts over the quantity limit are not a covered benefit unless Post Quantity Limit Prior Authorization is available. This indicates a greater quantity may be covered under your benefit Post-Quantity Limit Prior if Post-Quantity Limit Prior Authorization is obtained. Your health PA-QL Authorization care provider will need to contact our Pharmacy program at 800-600- 8065. Hours of operation are Monday-Friday: 8 a.m. to 6 p.m. CST

©2020 Wellmark, Inc. 3 Indicates a generic equivalent is available for a brand name drug. In most cases, when you purchase a brand name drug that has an FDA-approved A-rated generic equivalent, Wellmark will pay only GA Generic Available what it would have paid for the equivalent generic drug. You will be responsible for your payment obligation for the equivalent generic drug and any remaining cost difference up to the maximum allowed fee for the brand name drug. Preventive drugs are prescribed to prevent the occurrence of a disease or condition and are defined by the Internal Revenue Service. The preventive drug enhanced benefit is available on PV Preventive specific high deductible health plans. This is an optional benefit that waives the deductible for preventive drugs. Please read your enrollment information to see how preventive drugs are covered specific to your plan.

BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS

ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

butalbital-asa-caffeine 50- butalbital-asa-caffeine TIER 1 325-40 mg cap butalbital-aspirin- butalbital-aspirin-caffeine TIER 1 caffeine 50-325-40 mg cap celecoxib (50 mg cap, 100 celecoxib mg cap, 200 mg cap, 400 TIER 1 QL (60 PER 30 DAYS) mg cap) choline-mag choline-mag trisalicylate TIER 1 trisalicylate 500 mg/5ml liquid diclofenac epolamine 1.3 % diclofenac epolamine TIER 1 PA, QL (60 PER 30 DAY(S)) patch diclofenac potassium 50 mg diclofenac potassium TIER 1 tab diclofenac sodium (25 mg diclofenac sodium tab dr, 50 mg tab dr, 75 mg TIER 1 tab dr) diclofenac sodium 1.5 % diclofenac sodium TIER 1 QL (300 PER 30 DAY(S)) solution diclofenac sodium er 100 diclofenac sodium er TIER 1 mg tab er 24h diclofenac-misoprostol (50- diclofenac- 0.2 mg tab dr, 75-0.2 mg TIER 1 misoprostol tab dr) diflunisal diflunisal 500 mg tab TIER 1 ec-naproxen ec-naproxen 500 mg tab dr TIER 1 etodolac (200 mg cap, 300 etodolac mg cap, 400 mg tab, 500 TIER 1 mg tab) etodolac er (er 400 mg tab etodolac er er 24h, er 500 mg tab er TIER 1 24h, er 600 mg tab er 24h) fenoprofen calcium (400 mg fenoprofen calcium TIER 1 cap, 600 mg tab) flurbiprofen (50 mg tab, 100 flurbiprofen TIER 1 mg tab) ibu (400 mg tab, 600 mg ibu TIER 1 tab, 800 mg tab) ibuprofen (400 mg tab, 600 ibuprofen TIER 1 mg tab, 800 mg tab)

©2020 Wellmark, Inc. 5 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS INDOCIN 25 MG/5ML INDOCIN SUSPENSION TIER 2 indomethacin INDOCIN 50 MG SUPPOS INDOCIN TIER 3 indomethacin indomethacin (25 mg cap, indomethacin TIER 1 50 mg cap) indomethacin er 75 mg cap indomethacin er TIER 1 er ketoprofen (50 mg cap, 75 ketoprofen TIER 1 mg cap) KETOPROFEN ER 200 MG KETOPROFEN ER CAP ER 24H TIER 1 ketoprofen ketorolac ketorolac tromethamine (10 TIER 1 tromethamine mg tab, 30 mg/ml solution) klofensaid ii klofensaid ii 1.5 % solution TIER 1 QL (300 PER 30 DAY(S)) MECLOFENAMATE MECLOFENAMATE SODIUM (50 MG CAP, 100 TIER 1 SODIUM MG CAP) meclofenamate sodium mefenamic acid 250 mg mefenamic acid TIER 1 cap meloxicam (7.5 mg tab, 15 meloxicam TIER 1 mg tab) nabumetone (500 mg tab, nabumetone TIER 1 750 mg tab) naproxen (250 mg tab, 375 naproxen TIER 1 mg tab, 500 mg tab) naproxen dr (dr 375 mg tab naproxen dr TIER 1 dr, dr 500 mg tab dr) naproxen sodium (275 mg naproxen sodium TIER 1 tab, 550 mg tab) oxaprozin oxaprozin 600 mg tab TIER 1 piroxicam (10 mg cap, 20 piroxicam TIER 1 mg cap) profeno profeno 600 mg tab TIER 1 relafen (500 mg tab, 750 relafen TIER 1 mg tab) salsalate (500 mg tab, 750 salsalate TIER 1 mg tab) sulindac (150 mg tab, 200 sulindac TIER 1 mg tab)

OPIOID ANALGESICS, LONG-ACTING

buprenorphine (5 patch wk, buprenorphine 7.5 patch wk, 10 patch wk, TIER 1 PA, QL (4 PER 25) 15 patch wk, 20 patch wk) fentanyl (12 patch 72hr, 25 patch 72hr, 37.5 patch 72hr, 50 patch 72hr, 62.5 fentanyl TIER 1 PA, QL (10 PER 25) patch 72hr, 75 patch 72hr, 87.5 patch 72hr, 100 patch 72hr) hydrocodone bitartrate er (er 10 mg cap er 12h, er 15 hydrocodone mg cap er 12h, er 20 mg TIER 1 PA, QL (60 PER 25) bitartrate er cap er 12h, er 30 mg cap er 12h, er 40 mg cap er 12h, er 50 mg cap er 12h) hydromorphone hcl er (er 8 mg tab er 24h, er 12 mg tab hydromorphone hcl er TIER 1 PA, QL (30 PER 25) er 24h, er 16 mg tab er 24h, er 32 mg tab er 24h) levorphanol tartrate 2 mg levorphanol tartrate TIER 1 PA, QL (120 PER 25) tab methadone hcl (10 mg tab, methadone hcl TIER 1 PA, QL (60 PER 25) 10 mg/ml conc) methadone hcl 10 mg/5ml methadone hcl TIER 1 PA, QL (300 PER 25) solution methadone hcl 40 mg tab methadone hcl TIER 1 sol methadone hcl methadone hcl 5 mg tab TIER 1 PA, QL (90 PER 25) methadone hcl 5 mg/5ml methadone hcl TIER 1 PA, QL (450 PER 25) solution methadone hcl methadone hcl intensol 10 TIER 1 PA, QL (60 PER 25) intensol mg/ml conc methadose methadose 10 mg tab TIER 1 PA, QL (60 PER 25) methadose methadose 40 mg tab sol TIER 1

©2020 Wellmark, Inc. 7 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS morphine sulfate er (er 10 mg cap er 24h, er 20 mg cap er 24h, er 30 mg cap er morphine sulfate er 24h, er 40 mg cap er 24h, TIER 1 PA, QL (60 PER 25) er 100 mg cap er 24h, er 100 mg tab er, er 200 mg tab er) morphine sulfate er (er 15 morphine sulfate er mg tab er, er 30 mg tab er, TIER 1 PA, QL (90 PER 25) er 60 mg tab er) morphine sulfate er (er 50 mg cap er 24h, er 60 mg morphine sulfate er TIER 1 PA, QL (30 PER 25) cap er 24h, er 80 mg cap er 24h) OXYCODONE HCL ER (ER 10 MG TB12 DETER, ER OXYCODONE HCL 20 MG TB12 DETER, ER TIER 2 PA, QL (60 PER 25) ER 80 MG TB12 DETER) oxycodone hcl oxycodone hcl er (er 15 mg oxycodone hcl er tb12 deter, er 30 mg tb12 TIER 1 PA, QL (60 PER 25) deter, er 60 mg tb12 deter) OXYCODONE HCL ER 40 OXYCODONE HCL MG TB12 DETER TIER 2 PA, QL (90 PER 25) ER oxycodone hcl OXYCONTIN (10 MG TB12 DETER, 15 MG TB12 DETER, 20 MG TB12 DETER, 30 MG TB12 OXYCONTIN TIER 2 PA, QL (60 PER 25) DETER, 60 MG TB12 DETER, 80 MG TB12 DETER) oxycodone hcl OXYCONTIN 40 MG TB12 OXYCONTIN DETER TIER 2 PA, QL (90 PER 25) oxycodone hcl oxymorphone hcl er (er 5 mg tab er 12h, er 7.5 mg tab er 12h, er 10 mg tab er oxymorphone hcl er TIER 1 PA, QL (60 PER 25) 12h, er 15 mg tab er 12h, er 30 mg tab er 12h, er 40 mg tab er 12h) oxymorphone hcl er 20 mg oxymorphone hcl er TIER 1 PA, QL (90 PER 25) tab er 12h tramadol hcl er (biphasic) tramadol hcl er (er 100 mg tab er 24h, er TIER 1 PA, QL (30 PER 25) (biphasic) 200 mg tab er 24h, er 300 mg tab er 24h)

©2020 Wellmark, Inc. 8 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS tramadol hcl er (er 100 mg tramadol hcl er tab er 24h, er 200 mg tab er TIER 1 PA, QL (30 PER 25) 24h, er 300 mg tab er 24h)

OPIOID ANALGESICS, SHORT-ACTING

acetaminophen- acetaminophen-codeine #2 TIER 1 QL (400 PER 25) codeine #2 300-15 mg tab acetaminophen- acetaminophen-codeine #3 TIER 1 QL (360 PER 25) codeine #3 300-30 mg tab acetaminophen- acetaminophen-codeine #4 TIER 1 QL (180 PER 25) codeine #4 300-60 mg tab acetaminophen- acetaminophen-codeine TIER 1 QL (2700 PER 25) codeine 120-12 mg/5ml solution acetaminophen- acetaminophen-codeine TIER 1 QL (400 PER 25) codeine 300-15 mg tab acetaminophen- acetaminophen-codeine TIER 1 QL (360 PER 25) codeine 300-30 mg tab acetaminophen- acetaminophen-codeine TIER 1 QL (180 PER 25) codeine 300-60 mg tab apap-caff-dihydrocodeine apap-caff- (320.5-30-16 mg cap, 325- TIER 1 QL (300 PER 25) dihydrocodeine 30-16 mg tab) ascomp-codeine 50-325- ascomp-codeine TIER 1 40-30 mg cap aspirin-caff- aspirin-caff-dihydrocodeine TIER 1 dihydrocodeine 356.4-30-16 mg cap butalbital-apap-caff-cod butalbital-apap-caff- (50-325-40-30 mg cap, 50- TIER 1 cod 300-40-30 mg cap) butalbital-asa-caff- butalbital-asa-caff-codeine TIER 1 codeine 50-325-40-30 mg cap butorphanol tartrate 10 butorphanol tartrate TIER 1 QL (4 PER 30 DAYS) mg/ml solution CAPITAL/CODEINE 120-12 CAPITAL/CODEINE MG/5ML SUSPENSION TIER 1 acetaminophen w/ codeine carisoprodol-aspirin- carisoprodol-aspirin- TIER 1 codeine codeine 200-325-16 mg tab codeine sulfate (15 mg tab, codeine sulfate TIER 1 PA, QL (42 PER 25) 30 mg tab, 60 mg tab) dvorah dvorah 325-30-16 mg tab TIER 1 QL (300 PER 25) endocet (2.5-325 mg tab, 5- endocet TIER 1 QL (360 PER 25) 325 mg tab) endocet endocet 10-325 mg tab TIER 1 QL (180 PER 25)

©2020 Wellmark, Inc. 9 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS endocet endocet 7.5-325 mg tab TIER 1 QL (240 PER 25) fentanyl citrate (100 mcg tab, 200 mcg tab, 400 mcg fentanyl citrate TIER 1 PA tab, 600 mcg tab, 800 mcg tab) fentanyl citrate (200 mcg loz handle, 400 mcg loz handle, 600 mcg loz fentanyl citrate handle, 800 mcg loz TIER 1 PA handle, 1200 mcg loz handle, 1600 mcg loz handle) hydrocodone- hydrocodone- acetaminophen (10-300 mg TIER 1 QL (180 PER 25 DAY(S)) acetaminophen tab, 10-325 mg tab) hydrocodone- acetaminophen (2.5-108 hydrocodone- mg/5ml solution, 5-217 TIER 1 QL (2700 PER 25) acetaminophen mg/10ml solution, 7.5-325 mg/15ml solution) hydrocodone- hydrocodone- acetaminophen (5-325 mg TIER 1 QL (240 PER 25) acetaminophen tab, 5-300 mg tab) hydrocodone- hydrocodone- acetaminophen (7.5-300 TIER 1 QL (180 PER 25) acetaminophen mg tab, 7.5-325 mg tab) hydrocodone- hydrocodone- acetaminophen 10-660 mg TIER 1 acetaminophen tab hydrocodone- hydrocodone- acetaminophen 2.5-325 mg TIER 1 QL (360 PER 25) acetaminophen tab hydrocodone-ibuprofen (5- hydrocodone- 200 mg tab, 7.5-200 mg TIER 1 QL (50 PER 25) ibuprofen tab, 10-200 mg tab) hydromorphone hcl 1 mg/ml hydromorphone hcl TIER 1 PA, QL (600 PER 25) liquid hydromorphone hcl 2 mg hydromorphone hcl TIER 1 PA, QL (180 PER 25) tab HYDROMORPHONE HCL HYDROMORPHONE 3 MG SUPPOS TIER 1 PA, QL (120 PER 25) HCL hydromorphone hcl hydromorphone hcl 4 mg hydromorphone hcl TIER 1 PA, QL (150 PER 25) tab hydromorphone hcl 8 mg hydromorphone hcl TIER 1 PA, QL (60 PER 25) tab

©2020 Wellmark, Inc. 10 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ibudone (5-200 mg tab, 10- ibudone TIER 1 QL (50 PER 25) 200 mg tab) lorcet lorcet 5-325 mg tab TIER 1 QL (240 PER 25) lorcet hd lorcet hd 10-325 mg tab TIER 1 QL (180 PER 25 DAY(S)) lorcet plus lorcet plus 7.5-325 mg tab TIER 1 QL (180 PER 25) lortab lortab 10-325 mg tab TIER 1 QL (180 PER 25 DAY(S)) lortab lortab 5-325 mg tab TIER 1 QL (240 PER 25) lortab lortab 7.5-325 mg tab TIER 1 QL (180 PER 25) meperidine hcl (50 mg tab, meperidine hcl TIER 1 PA, QL (18 PER 25) 100 mg tab) MEPERIDINE HCL 50 MEPERIDINE HCL MG/5ML SOLUTION TIER 1 PA, QL (90 PER 25) meperidine hcl morphine sulfate (30 mg morphine sulfate TIER 1 PA, QL (90 PER 25) tab, 30 mg suppos) MORPHINE SULFATE (5 MORPHINE MG SUPPOS, 10 MG TIER 1 PA, QL (180 PER 25) SULFATE SUPPOS, 15 MG TAB) morphine sulfate morphine sulfate morphine sulfate (concentrate) (20 mg/ml TIER 1 PA, QL (135 PER 25) (concentrate) solution, 100 mg/5ml solution) morphine sulfate 10 mg/5ml morphine sulfate TIER 1 PA, QL (900 PER 25) solution MORPHINE SULFATE 20 MORPHINE MG SUPPOS TIER 1 PA, QL (120 PER 25) SULFATE morphine sulfate morphine sulfate 20 mg/5ml morphine sulfate TIER 1 PA, QL (675 PER 25) solution oxycodone hcl (20 mg tab, oxycodone hcl TIER 1 PA, QL (90 PER 25) 100 mg/5ml conc) oxycodone hcl (5 mg cap, 5 oxycodone hcl TIER 1 PA, QL (180 PER 25) mg tab, 10 mg tab) oxycodone hcl oxycodone hcl 15 mg tab TIER 1 PA, QL (120 PER 25) oxycodone hcl oxycodone hcl 30 mg tab TIER 1 PA, QL (60 PER 25) oxycodone hcl 5 mg/5ml oxycodone hcl TIER 1 PA, QL (900 PER 25) solution oxycodone-acetaminophen oxycodone- (2.5-325 mg tab, 5-325 mg TIER 1 QL (360 PER 25) acetaminophen tab) oxycodone- oxycodone-acetaminophen TIER 1 QL (180 PER 25) acetaminophen 10-325 mg tab oxycodone- oxycodone-acetaminophen TIER 1 QL (180 PER 25) acetaminophen 300-10 mg tab

©2020 Wellmark, Inc. 11 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS oxycodone- oxycodone-acetaminophen TIER 1 QL (360 PER 25) acetaminophen 300-5 mg tab OXYCODONE- ACETAMINOPHEN 5-325 OXYCODONE- MG/5ML SOLUTION TIER 1 QL (1800 PER 25) ACETAMINOPHEN oxycodone w/ acetaminophen oxycodone- oxycodone-acetaminophen TIER 1 QL (240 PER 25) acetaminophen 7.5-325 mg tab oxycodone-aspirin 4.8355- oxycodone-aspirin TIER 1 QL (360 PER 25) 325 mg tab OXYCODONE- OXYCODONE- IBUPROFEN 5-400 MG TIER 1 QL (28 PER 25) IBUPROFEN TAB oxycodone-ibuprofen oxymorphone hcl oxymorphone hcl 10 mg tab TIER 1 PA, QL (90 PER 25) oxymorphone hcl oxymorphone hcl 5 mg tab TIER 1 PA, QL (180 PER 25) panlor panlor 325-30-16 mg tab TIER 1 QL (300 PER 25) pentazocine-naloxone pentazocine-naloxone hcl TIER 1 PA, QL (120 PER 25) hcl 50-0.5 mg tab reprexain reprexain 10-200 mg tab TIER 1 QL (50 PER 25) tramadol hcl tramadol hcl 50 mg tab TIER 1 PA, QL (180 PER 25) tramadol- tramadol-acetaminophen TIER 1 QL (40 PER 25) acetaminophen 37.5-325 mg tab trezix trezix 320.5-30-16 mg cap TIER 1 QL (300 PER 25) VERDROCET 2.5-325 MG TAB VERDROCET TIER 1 QL (360 PER 25), GA hydrocodone- acetaminophen vicodin vicodin 5-300 mg tab TIER 1 QL (240 PER 25) vicodin es vicodin es 7.5-300 mg tab TIER 1 QL (180 PER 25) vicodin hp vicodin hp 10-300 mg tab TIER 1 QL (180 PER 25 DAY(S)) xylon xylon 10-200 mg tab TIER 1 QL (50 PER 25) ZAMICET 10-325 MG/15ML SOLUTION ZAMICET TIER 1 QL (2700 PER 25 DAY(S)) hydrocodone- acetaminophen

ANESTHETICS

LOCAL ANESTHETICS

7t lido 7t lido 2 % gel TIER 1 glydo glydo 2 % prsyr TIER 1 lidocaine lidocaine 5 % ointment TIER 1

©2020 Wellmark, Inc. 12 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS lidocaine lidocaine 5 % patch TIER 1 QL (3 PER DAY) LIDOCAINE HCL 4 % LIDOCAINE HCL SOLUTION TIER 1 lidocaine hcl (mouth-throat) lidocaine hcl lidocaine hcl urethral/mucosal (2 % gel, TIER 1 urethral/mucosal 2 % prsyr) lidocaine pak lidocaine pak 5 % ointment TIER 1 lidocaine viscous hcl 2 % lidocaine viscous hcl TIER 1 solution lidocaine-prilocaine 2.5-2.5 lidocaine-prilocaine TIER 1 % cream NAYZILAM 5 MG/0.1ML NAYZILAM SOLUTION TIER 3 PA, QL (10 PER 30 DAY(S)) midazolam (anticonvulsant) premium lidocaine 5 % premium lidocaine TIER 1 ointment

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTS/ANTI-CRAVING

acamprosate calcium 333 acamprosate calcium TIER 1 PV mg tab dr disulfiram (250 mg tab, 500 disulfiram TIER 1 PV mg tab) naltrexone hcl naltrexone hcl 50 mg tab TIER 1 PV

OPIOID DEPENDENCE TREATMENTS

buprenorphine hcl (2 mg sl buprenorphine hcl TIER 1 PV tab, 8 mg sl tab) buprenorphine hcl-naloxone hcl (-naloxone 2-0.5 mg film, -naloxone 2-0.5 mg sl buprenorphine hcl- tab, -naloxone 4-1 mg film, TIER 1 PV naloxone hcl -naloxone 8-2 mg sl tab, - naloxone 8-2 mg film, - naloxone 12-3 mg film)

OPIOID REVERSAL AGENTS

naloxone hcl (0.4 mg/ml naloxone hcl soln cart, 2 mg/2ml soln TIER 1 prsyr) NARCAN 4 MG/0.1ML NARCAN LIQUID TIER 2 naloxone hcl

ANTIBACTERIALS

AMINOGLYCOSIDES

ARIKAYCE 590 MG/8.4ML ARIKAYCE SUSPENSION SP-P QL (236 PER 28 DAY(S)) amikacin sulfate liposome gentak gentak 0.3 % ointment TIER 1 gentamicin sulfate (0.1 % cream, 0.1 % ointment, 0.3 gentamicin sulfate TIER 1 % solution, 0.3 % ointment, 10 mg/ml solution) neomycin sulfate 500 mg neomycin sulfate TIER 1 tab paromomycin sulfate 250 paromomycin sulfate TIER 1 mg cap tobramycin tobramycin 0.3 % solution TIER 1 tobramycin sulfate (1.2 gm/30ml solution, 1.2 gm tobramycin sulfate recon soln, 2 gm/50ml TIER 1 solution, 10 mg/ml solution, 80 mg/2ml solution) TOBREX 0.3 % OINTMENT TOBREX TIER 3 tobramycin (ophth)

ANTIBACTERIALS, OTHER

azuphen mb azuphen mb 120 mg cap TIER 1 BACITRACIN 500 BACITRACIN UNIT/GM OINTMENT TIER 1 bacitracin (ophthalmic) benzoyl peroxide- benzoyl peroxide- TIER 1 erythromycin erythromycin 5-3 % gel CLEOCIN 100 MG SUPPOS CLEOCIN TIER 3 clindamycin phosphate vaginal CLEOCIN PHOSPHATE (300 MG/2ML SOLUTION, CLEOCIN 600 MG/4ML SOLUTION, TIER 1 GA PHOSPHATE 900 MG/6ML SOLUTION) clindamycin phosphate clindacin etz clindacin etz 1 % swab TIER 1 clindacin-p clindacin-p 1 % swab TIER 1 clindamycin hcl (75 mg cap, clindamycin hcl TIER 1 150 mg cap, 300 mg cap)

©2020 Wellmark, Inc. 14 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS clindamycin palmitate clindamycin palmitate hcl TIER 1 hcl 75 mg/5ml recon soln clindamycin phosphate (1 % lotion, 1 % gel, 1 % clindamycin swab, 2 % cream, 300 TIER 1 phosphate mg/2ml solution, 600 mg/4ml solution, 900 mg/6ml solution) clindamycin clindamycin phosphate 1 % TIER 1 PA phosphate foam clindamycin clindamycin phosphate 1 % TIER 1 QL (180 PER 30 DAY(S)) phosphate solution colistimethate sodium colistimethate sodium (cba) SP-M (cba) 150 mg recon soln COLY-MYCIN M 150 MG COLY-MYCIN M RECON SOLN SP-M GA colistimethate sodium FIRVANQ (25 MG/ML RECON SOLN, 50 MG/ML FIRVANQ TIER 2 QL (450 PER 23 DAY(S)) RECON SOLN) vancomycin hcl hyolev mb hyolev mb 81 mg tab TIER 1 HYOPHEN 81.6 MG TAB methenamine-hyosc- HYOPHEN TIER 1 GA methylene blue-benzoic acid-phenyl sal linezolid (100 mg/5ml recon linezolid TIER 1 susp, 600 mg tab) mafenide acetate 5 % mafenide acetate TIER 1 packet me/naphos/mb/hyo1 81.6 me/naphos/mb/hyo1 TIER 1 mg tab methenamine methenamine hippurate 1 TIER 1 hippurate gm tab methenamine methenamine mandelate TIER 1 mandelate (0.5 gm tab, 1 gm tab) metronidazole (0.75 % gel, metronidazole 250 mg tab, 375 mg cap, TIER 1 500 mg tab) MONUROL 3 GM PACKET MONUROL TIER 2 fosfomycin tromethamine mupirocin mupirocin 2 % ointment TIER 1 mupirocin calcium 2 % mupirocin calcium TIER 1 QL (60 PER 30 DAY(S)) cream nitrofurantoin 25 mg/5ml nitrofurantoin TIER 1 suspension

©2020 Wellmark, Inc. 15 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS nitrofurantoin macrocrystal nitrofurantoin (25 mg cap, 50 mg cap, TIER 1 macrocrystal 100 mg cap) nitrofurantoin nitrofurantoin monohyd TIER 1 monohyd macro macro 100 mg cap phosphasal phosphasal 81.6 mg tab TIER 1 PRIMSOL 50 MG/5ML PRIMSOL SOLUTION TIER 3 trimethoprim hcl SIVEXTRO 200 MG TAB SIVEXTRO TIER 3 tedizolid phosphate SULFAMYLON 85 MG/GM SULFAMYLON CREAM TIER 3 mafenide acetate tinidazole (250 mg tab, 500 tinidazole TIER 1 mg tab) trimethoprim trimethoprim 100 mg tab TIER 1 TRIMPEX 50 MG/5ML TRIMPEX SOLUTION TIER 3 trimethoprim hcl ur n-c ur n-c 81.6 mg tab TIER 1 uramit mb uramit mb 118 mg cap TIER 1 urelle urelle 81 mg tab TIER 1 uretron d/s uretron d/s 81.6 mg tab TIER 1 uribel uribel 118 mg cap TIER 1 URIMAR-T 120 MG TAB methenamine-hyosc- URIMAR-T TIER 1 methylene blue-sod phos- phenyl sal urin ds urin ds 81.6 mg tab TIER 1 uro-458 uro-458 81 mg tab TIER 1 uro-mp uro-mp 118 mg cap TIER 1 urolet mb urolet mb 81.6 mg tab TIER 1 urophen mb urophen mb 81.6 mg tab TIER 1 uryl uryl 81.6 mg tab TIER 1 ustell ustell 120 mg cap TIER 1 uticap uticap 120 mg cap TIER 1 utira-c utira-c 81.6 mg tab TIER 1 utrona-c utrona-c 81.6 mg tab TIER 1 vancomycin hcl (5 gm vancomycin hcl recon soln, 750 mg recon TIER 1 soln)

©2020 Wellmark, Inc. 16 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS vandazole vandazole 0.75 % gel TIER 1 vilamit mb vilamit mb 118 mg cap TIER 1 vilevev mb vilevev mb 81 mg tab TIER 1 XIFAXAN (200 MG TAB, XIFAXAN 550 MG TAB) TIER 2 rifaximin

BETA-LACTAM, CEPHALOSPORINS

cefaclor (125 mg/5ml recon susp, 250 mg cap, 250 cefaclor mg/5ml recon susp, 375 TIER 1 mg/5ml recon susp, 500 mg cap) CEFACLOR ER 500 MG CEFACLOR ER TAB ER 12H TIER 3 cefaclor monohydrate cefadroxil (1 gm tab, 250 mg/5ml recon susp, 500 cefadroxil TIER 1 mg/5ml recon susp, 500 mg cap) cefdinir (125 mg/5ml recon cefdinir susp, 250 mg/5ml recon TIER 1 susp, 300 mg cap) cefditoren pivoxil (200 mg cefditoren pivoxil TIER 1 tab, 400 mg tab) cefepime hcl (1 gm recon cefepime hcl TIER 2 soln, 2 gm recon soln) CEFEPIME-DEXTROSE 1- CEFEPIME- 5 GM-%(50ML) RECON TIER 2 DEXTROSE SOLN cefepime hcl-dextrose cefixime (100 mg/5ml recon cefixime susp, 200 mg/5ml recon TIER 1 susp, 400 mg cap) cefpodoxime proxetil (50 mg/5ml recon susp, 100 cefpodoxime proxetil TIER 1 mg/5ml recon susp, 100 mg tab, 200 mg tab) cefprozil (125 mg/5ml recon susp, 250 mg tab, 250 cefprozil TIER 1 mg/5ml recon susp, 500 mg tab) ceftibuten (180 mg/5ml ceftibuten TIER 1 recon susp, 400 mg cap)

©2020 Wellmark, Inc. 17 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ceftriaxone sodium (1 gm ceftriaxone sodium recon soln, 250 mg recon TIER 1 soln, 500 mg recon soln) cefuroxime axetil (250 mg cefuroxime axetil TIER 1 tab, 500 mg tab) cephalexin (125 mg/5ml recon susp, 250 mg cap, cephalexin 250 mg tab, 250 mg/5ml TIER 1 recon susp, 500 mg tab, 500 mg cap, 750 mg cap) MAXIPIME (1 GM RECON SOLN, 2 GM RECON MAXIPIME TIER 2 GA SOLN) cefepime hcl SUPRAX (100 MG CHEW TAB, 200 MG CHEW TAB, SUPRAX 500 MG/5ML RECON TIER 3 SUSP) cefixime

BETA-LACTAM, OTHER

AZACTAM 1 GM RECON AZACTAM SOLN TIER 2 GA aztreonam aztreonam aztreonam 1 gm recon soln TIER 2

BETA-LACTAM, PENICILLINS

amoxicillin (125 mg chew tab, 125 mg/5ml recon susp, 200 mg/5ml recon susp, 250 mg/5ml recon amoxicillin TIER 1 susp, 250 mg chew tab, 250 mg cap, 400 mg/5ml recon susp, 500 mg cap, 500 mg tab, 875 mg tab) amoxicillin-pot clavulanate (200-28.5 mg/5ml recon susp, 200-28.5 mg chew tab, 250-125 mg tab, 250- amoxicillin-pot 62.5 mg/5ml recon susp, TIER 1 clavulanate 400-57 mg chew tab, 400- 57 mg/5ml recon susp, 500- 125 mg tab, 600-42.9 mg/5ml recon susp, 875- 125 mg tab) amoxicillin-pot amoxicillin-pot clavulanate TIER 1 clavulanate er er 1000-62.5 mg tab er 12h

©2020 Wellmark, Inc. 18 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ampicillin (125 mg/5ml recon susp, 250 mg cap, ampicillin TIER 1 250 mg/5ml recon susp, 500 mg cap) BICILLIN L-A (600000 UNIT/ML SUSPENSION, 1200000 UNIT/2ML BICILLIN L-A TIER 1 SUSPENSION, 2400000 UNIT/4ML SUSPENSION) penicillin g benzathine dicloxacillin sodium (250 dicloxacillin sodium TIER 1 mg cap, 500 mg cap) penicillin v potassium (125 mg/5ml recon soln, 250 penicillin v potassium TIER 1 mg/5ml recon soln, 250 mg tab, 500 mg tab)

MACROLIDES

AZASITE 1 % SOLUTION AZASITE TIER 3 azithromycin (ophth) azithromycin (100 mg/5ml recon susp, 200 mg/5ml azithromycin TIER 1 recon susp, 250 mg tab, 500 mg tab, 600 mg tab) clarithromycin (125 mg/5ml recon susp, 250 mg/5ml clarithromycin TIER 1 recon susp, 250 mg tab, 500 mg tab) clarithromycin er 500 mg clarithromycin er TIER 1 tab er 24h ERY 2 % PAD ERY TIER 1 GA erythromycin (acne aid) ery-tab (250 mg tab dr, 333 ery-tab TIER 1 mg tab dr, 500 mg tab dr) ERYTHROCIN STEARATE ERYTHROCIN 250 MG TAB TIER 1 STEARATE erythromycin stearate erythromycin (2 % pad, 2 % gel, 2 % solution, 5 mg/gm erythromycin ointment, 250 mg tab dr, TIER 1 333 mg tab dr, 500 mg tab dr)

©2020 Wellmark, Inc. 19 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS erythromycin base (250 mg tab, 250 mg cp dr part, 250 erythromycin base TIER 1 mg tab dr, 333 mg tab dr, 500 mg tab, 500 mg tab dr) erythromycin ethylsuccinate erythromycin (200 mg/5ml recon susp, TIER 1 ethylsuccinate 400 mg tab, 400 mg/5ml recon susp) KLARITY-A 1 % KLARITY-A SOLUTION TIER 3 azithromycin (ophth) romycin romycin 5 mg/gm ointment TIER 1

QUINOLONES

BESIVANCE 0.6 % BESIVANCE SUSPENSION TIER 3 besifloxacin hcl CILOXAN 0.3 % CILOXAN OINTMENT TIER 3 ciprofloxacin hcl (ophth) ciprofloxacin (250 (5%) ciprofloxacin recon susp, 500 (10%) TIER 1 recon susp) ciprofloxacin hcl (0.2 % solution, 0.3 % solution, ciprofloxacin hcl TIER 1 100 mg tab, 250 mg tab, 500 mg tab, 750 mg tab) CIPROFLOXACIN- CIPROFLOX HCL ER (ER CIPROFLOXACIN- 500 MG TAB ER 24H, ER TIER 1 CIPROFLOX HCL ER 1000 MG TAB ER 24H) ciprofloxacin-ciprofloxacin hcl gatifloxacin gatifloxacin 0.5 % solution TIER 1 levofloxacin (0.5 % solution, 25 mg/ml solution, 250 mg levofloxacin TIER 1 tab, 500 mg tab, 750 mg tab) moxifloxacin hcl (0.5 % moxifloxacin hcl TIER 1 solution, 400 mg tab) moxifloxacin hcl (2x moxifloxacin hcl (2x day) TIER 1 day) 0.5 % solution ofloxacin (0.3 % solution, ofloxacin TIER 1 300 mg tab, 400 mg tab)

SULFONAMIDES

silver sulfadiazine 1 % silver sulfadiazine TIER 1 cream ssd ssd 1 % cream TIER 1 sulfacetamide sodium (10 sulfacetamide sodium TIER 1 % ointment, 10 % solution) sulfacetamide sodium sulfacetamide sodium TIER 1 (acne) (acne) 10 % lotion SULFADIAZINE 500 MG SULFADIAZINE TAB TIER 1 sulfadiazine sulfamethoxazole- sulfamethoxazole- trimethoprim (200-40 TIER 1 trimethoprim mg/5ml suspension, 400-80 mg tab, 800-160 mg tab) sulfatrim pediatric 200-40 sulfatrim pediatric TIER 1 mg/5ml suspension

TETRACYCLINES

avidoxy avidoxy 100 mg tab TIER 1 demeclocycline hcl (150 mg demeclocycline hcl TIER 1 tab, 300 mg tab) doxycycline hyclate (20 mg doxycycline hyclate tab, 50 mg cap, 100 mg TIER 1 tab, 100 mg cap) doxycycline hyclate (50 mg doxycycline hyclate tab dr, 75 mg tab dr, 100 TIER 1 PA mg tab dr, 150 mg tab dr) doxycycline monohydrate (25 mg/5ml recon susp, 50 doxycycline mg tab, 50 mg cap, 75 mg TIER 1 monohydrate tab, 100 mg cap, 100 mg tab) minocycline hcl (50 mg tab, 50 mg cap, 75 mg tab, 75 minocycline hcl TIER 1 mg cap, 100 mg cap, 100 mg tab) mondoxyne nl (50 mg cap, mondoxyne nl TIER 1 100 mg cap) morgidox (50 mg cap, 100 morgidox TIER 1 mg cap) okebo okebo 100 mg cap TIER 1

©2020 Wellmark, Inc. 21 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SOLODYN (55 MG TAB ER 24H, 65 MG TAB ER 24H, 80 MG TAB ER 24H, 105 SOLODYN TIER 1 PA, GA MG TAB ER 24H, 115 MG TAB ER 24H) minocycline hcl soloxide soloxide 150 mg tab dr TIER 1 PA tetracycline hcl (250 mg tetracycline hcl TIER 1 cap, 500 mg cap) VIBRAMYCIN 50 MG/5ML VIBRAMYCIN SYRUP TIER 3 doxycycline calcium

ANTICONVULSANTS

ANTICONVULSANTS, OTHER

DIACOMIT (250 MG CAP, PA, QL (360 PER 30 DIACOMIT 250 MG PACKET) SP-P DAY(S)) stiripentol DIACOMIT (500 MG PA, QL (180 PER 30 DIACOMIT PACKET, 500 MG CAP) SP-P DAY(S)) stiripentol EPIDIOLEX 100 MG/ML PA, QL (600 PER 30 EPIDIOLEX SOLUTION SP-P DAY(S)) cannabidiol levetiracetam (100 mg/ml solution, 250 mg tab, 500 levetiracetam TIER 1 PV mg tab, 750 mg tab, 1000 mg tab) levetiracetam er (er 500 mg levetiracetam er tab er 24h, er 750 mg tab er TIER 1 PV 24h) roweepra (500 mg tab, 750 roweepra TIER 1 PV mg tab, 1000 mg tab) roweepra xr (500 mg tab er roweepra xr TIER 1 PV 24h, 750 mg tab er 24h)

CALCIUM CHANNEL MODIFYING AGENTS

CELONTIN 300 MG CAP CELONTIN TIER 2 PV methsuximide ethosuximide (250 mg/5ml ethosuximide TIER 1 PV solution, 250 mg cap) zonisamide (25 mg cap, 50 zonisamide TIER 1 PV mg cap, 100 mg cap)

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

clobazam clobazam 10 mg tab TIER 1 PA, QL (120 PER 30 DAYS) clobazam 2.5 mg/ml PA, QL (480 PER 30 DAYS), clobazam TIER 1 suspension PV PA, QL (60 PER 30 DAYS), clobazam clobazam 20 mg tab TIER 1 PV diazepam (2.5 mg gel, 10 diazepam TIER 1 mg gel, 20 mg gel) divalproex sodium (125 mg divalproex sodium tab dr, 125 mg cap dr, 250 TIER 1 PV mg tab dr, 500 mg tab dr) divalproex sodium er (er divalproex sodium er 250 mg tab er 24h, er 500 TIER 1 PV mg tab er 24h) gabapentin (100 mg cap, 250 mg/5ml solution, 300 gabapentin mg cap, 300 mg/6ml TIER 1 solution, 400 mg cap, 600 mg tab, 800 mg tab) LYRICA CR (82.5 MG TAB ER 24H, 165 MG TAB ER LYRICA CR TIER 3 24H, 330 MG TAB ER 24H) pregabalin (once-daily) phenobarbital (15 mg tab, 16.2 mg tab, 20 mg/5ml elixir, 20 mg/5ml solution, phenobarbital TIER 1 PV 30 mg tab, 32.4 mg tab, 60 mg tab, 64.8 mg tab, 97.2 mg tab, 100 mg tab) primidone (50 mg tab, 250 primidone TIER 1 PV mg tab) SABRIL (500 MG TAB, 500 SABRIL MG PACKET) SP-NP QL (180 PER 30 DAYS), GA vigabatrin tiagabine hcl (2 mg tab, 4 tiagabine hcl mg tab, 12 mg tab, 16 mg TIER 1 PV tab) valproate sodium 250 valproate sodium TIER 1 PV mg/5ml solution valproic acid (250 mg cap, valproic acid TIER 1 PV 250 mg/5ml solution) VALTOCO 10 MG DOSE VALTOCO 10 MG 10 MG/0.1ML LIQUID TIER 3 PA, QL (5 PER 30 DAY(S)) DOSE diazepam (anticonvulsant)

©2020 Wellmark, Inc. 23 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VALTOCO 15 MG DOSE VALTOCO 15 MG 7.5 MG/0.1ML LIQD THPK TIER 3 PA, QL (10 PER 30 DAY(S)) DOSE diazepam (anticonvulsant) VALTOCO 20 MG DOSE VALTOCO 20 MG 10 MG/0.1ML LIQD THPK TIER 3 PA, QL (10 PER 30 DAY(S)) DOSE diazepam (anticonvulsant) VALTOCO 5 MG DOSE 5 VALTOCO 5 MG MG/0.1ML LIQUID TIER 3 PA, QL (5 PER 30 DAY(S)) DOSE diazepam (anticonvulsant) vigabatrin (500 mg tab, 500 vigabatrin SP-P QL (180 PER 30 DAYS) mg packet) vigadrone vigadrone 500 mg packet SP-P QL (180 PER 30 DAYS)

GLUTAMATE REDUCING AGENTS

felbamate (400 mg tab, 600 felbamate mg/5ml suspension, 600 TIER 1 PV mg tab) lamotrigine (5 mg chew tab, 25 mg tab, 25 mg chew tab, 25 mg tab disp, 50 mg tab lamotrigine TIER 1 PV disp, 100 mg tab disp, 100 mg tab, 150 mg tab, 200 mg tab disp, 200 mg tab) lamotrigine er (er 25 mg tab er 24h, er 50 mg tab er 24h, er 100 mg tab er 24h, er lamotrigine er TIER 1 PV 200 mg tab er 24h, er 250 mg tab er 24h, er 300 mg tab er 24h) subvenite (25 mg tab, 100 subvenite mg tab, 150 mg tab, 200 TIER 1 PV mg tab) topiramate (15 mg cap sprink, 25 mg cap sprink, topiramate TIER 1 PV 25 mg tab, 50 mg tab, 100 mg tab, 200 mg tab) topiramate er (er 25 mg cp24 sprnk, er 50 mg cp24 sprnk, er 100 mg cp24 topiramate er TIER 1 PV sprnk, er 150 mg cp24 sprnk, er 200 mg cp24 sprnk)

SODIUM CHANNEL AGENTS

BANZEL (200 MG TAB, PA, QL (240 PER 30 DAYS), BANZEL 400 MG TAB) TIER 2 PV rufinamide

©2020 Wellmark, Inc. 24 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BANZEL 40 MG/ML PA, QL (2400 PER 30 BANZEL SUSPENSION TIER 2 DAYS), PV rufinamide carbamazepine (100 mg carbamazepine chew tab, 100 mg/5ml TIER 1 PV suspension, 200 mg tab) carbamazepine er (er 100 mg tab er 12h, er 100 mg cap er 12h, er 200 mg tab carbamazepine er TIER 1 PV er 12h, er 200 mg cap er 12h, er 300 mg cap er 12h, er 400 mg tab er 12h) epitol epitol 200 mg tab TIER 1 PV oxcarbazepine (150 mg tab, oxcarbazepine 300 mg/5ml suspension, TIER 1 PV 300 mg tab, 600 mg tab) PEGANONE 250 MG TAB PEGANONE TIER 2 PV ethotoin phenytoin (50 mg chew tab, phenytoin 100 mg/4ml suspension, TIER 1 PV 125 mg/5ml suspension) phenytoin infatabs 50 mg phenytoin infatabs TIER 1 PV chew tab phenytoin sodium extended phenytoin sodium (100 mg cap, 200 mg cap, TIER 1 PV extended 300 mg cap) VIMPAT (10 MG/ML SOLUTION, 50 MG TAB, VIMPAT 100 MG TAB, 150 MG TAB, TIER 2 PV 200 MG TAB) lacosamide

ANTIDEMENTIA AGENTS

ANTIDEMENTIA AGENTS, OTHER

AJOVY 225 MG/1.5ML AJOVY SOLN A-INJ SP-P PA, QL (1 PER 28 DAY(S)) fremanezumab-vfrm ERGOLOID MESYLATES 1 ERGOLOID MG TAB TIER 1 MESYLATES ergoloid mesylates

CHOLINESTERASE INHIBITORS

donepezil hcl (5 mg tab, 5 donepezil hcl mg tab disp, 10 mg tab TIER 1 disp, 10 mg tab, 23 mg tab)

©2020 Wellmark, Inc. 25 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS galantamine hydrobromide galantamine (4 mg tab, 8 mg tab, 12 mg TIER 1 hydrobromide tab) galantamine hydrobromide galantamine er (er 8 mg cap er 24h, er TIER 1 hydrobromide er 16 mg cap er 24h, er 24 mg cap er 24h) rivastigmine (4.6 mg/24hr patch 24hr, 9.5 mg/24hr rivastigmine TIER 1 patch 24hr, 13.3 mg/24hr patch 24hr) rivastigmine tartrate (1.5 rivastigmine tartrate mg cap, 3 mg cap, 4.5 mg TIER 1 cap, 6 mg cap)

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST

memantine hcl (2 mg/ml memantine hcl solution, 5 mg tab, 10 mg TIER 1 tab, 10 mg/5ml solution) memantine hcl er (er 7 mg cap er 24h, er 14 mg cap er memantine hcl er TIER 1 24h, er 21 mg cap er 24h, er 28 mg cap er 24h)

ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER

bupropion hcl (75 mg tab, bupropion hcl TIER 1 PV 100 mg tab) bupropion hcl er (sr) (er 100 mg tab er 12h, er 150 mg bupropion hcl er (sr) TIER 1 PV tab er 12h, er 200 mg tab er 12h) bupropion hcl er (xl) (er 150 bupropion hcl er (xl) mg tab er 24h, er 300 mg TIER 1 PV tab er 24h) CHLORDIAZEPOXIDE- AMITRIPTYLINE (5-12.5 CHLORDIAZEPOXID MG TAB, 10-25 MG TAB) TIER 1 E-AMITRIPTYLINE chlordiazepoxide- amitriptyline mirtazapine (7.5 mg tab, 15 mg tab disp, 15 mg tab, 30 mirtazapine TIER 1 PV mg tab, 30 mg tab disp, 45 mg tab, 45 mg tab disp)

©2020 Wellmark, Inc. 26 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS olanzapine-fluoxetine hcl olanzapine-fluoxetine (3-25 mg cap, 6-25 mg cap, TIER 1 hcl 6-50 mg cap, 12-25 mg cap, 12-50 mg cap) PERPHENAZINE- AMITRIPTYLINE (2-10 MG PERPHENAZINE- TAB, 2-25 MG TAB, 4-50 TIER 1 AMITRIPTYLINE MG TAB, 4-25 MG TAB, 4- 10 MG TAB) perphenazine-amitriptyline

MONOAMINE OXIDASE INHIBITORS

MARPLAN 10 MG TAB MARPLAN TIER 2 PV isocarboxazid phenelzine sulfate 15 mg phenelzine sulfate TIER 1 PV tab tranylcypromine tranylcypromine sulfate 10 TIER 1 PV sulfate mg tab

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITOR/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)

citalopram hydrobromide citalopram (10 mg tab, 10 mg/5ml TIER 1 PV hydrobromide solution, 20 mg tab, 40 mg tab) desvenlafaxine er (er 50 mg desvenlafaxine er tab er 24h, er 100 mg tab er TIER 1 PA, QL (30 PER 30 DAYS) 24h) desvenlafaxine succinate er desvenlafaxine (er 25 mg tab er 24h, er 50 TIER 1 QL (30 PER 30 DAYS), PV succinate er mg tab er 24h, er 100 mg tab er 24h) escitalopram oxalate (5 escitalopram oxalate mg/5ml solution, 5 mg tab, TIER 1 PV 10 mg tab, 20 mg tab) FLUOXETINE HCL (10 MG CAP, 20 MG/5ML SOLUTION, 20 MG CAP, FLUOXETINE HCL TIER 1 PV 40 MG CAP, 90 MG CAP DR) fluoxetine hcl fluoxetine hcl (pmdd) (10 fluoxetine hcl (pmdd) TIER 1 mg cap, 20 mg cap) fluvoxamine maleate (25 fluvoxamine maleate mg tab, 50 mg tab, 100 mg TIER 1 PV tab)

©2020 Wellmark, Inc. 27 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS fluvoxamine maleate er (er fluvoxamine maleate 100 mg cap er 24h, er 150 TIER 1 PA, PV er mg cap er 24h) MAPROTILINE HCL (25 MG TAB, 50 MG TAB, 75 MAPROTILINE HCL TIER 1 PV MG TAB) maprotiline hcl nefazodone hcl (50 mg tab, nefazodone hcl 100 mg tab, 150 mg tab, TIER 1 PV 200 mg tab, 250 mg tab) paroxetine hcl (10 mg tab, paroxetine hcl 20 mg tab, 30 mg tab, 40 TIER 1 PV mg tab) paroxetine hcl er (er 12.5 mg tab er 24h, er 25 mg tab paroxetine hcl er TIER 1 PV er 24h, er 37.5 mg tab er 24h) paroxetine mesylate 7.5 mg paroxetine mesylate TIER 1 QL (30 PER 30 DAYS) cap sertraline hcl (20 mg/ml sertraline hcl conc, 25 mg tab, 50 mg tab, TIER 1 PV 100 mg tab) trazodone hcl (50 mg tab, trazodone hcl TIER 1 PV 100 mg tab, 150 mg tab) venlafaxine hcl (25 mg tab, venlafaxine hcl 37.5 mg tab, 50 mg tab, 75 TIER 1 PV mg tab, 100 mg tab) venlafaxine hcl er (er 37.5 mg cap er 24h, er 75 mg venlafaxine hcl er TIER 1 PV cap er 24h, er 150 mg cap er 24h)

TRICYCLICS

amitriptyline hcl (10 mg tab, 25 mg tab, 50 mg tab, 75 amitriptyline hcl TIER 1 PV mg tab, 100 mg tab, 150 mg tab) AMOXAPINE (25 MG TAB, 50 MG TAB, 100 MG TAB, AMOXAPINE TIER 1 PV 150 MG TAB) amoxapine clomipramine hcl (25 mg clomipramine hcl TIER 1 PV cap, 50 mg cap, 75 mg cap)

©2020 Wellmark, Inc. 28 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS desipramine hcl (10 mg tab, 25 mg tab, 50 mg tab, 75 desipramine hcl TIER 1 PV mg tab, 100 mg tab, 150 mg tab) doxepin hcl (10 mg cap, 10 mg/ml conc, 25 mg cap, 50 doxepin hcl TIER 1 PV mg cap, 75 mg cap, 100 mg cap, 150 mg cap) imipramine hcl (10 mg tab, imipramine hcl TIER 1 PV 25 mg tab, 50 mg tab) nortriptyline hcl (10 mg/5ml nortriptyline hcl solution, 10 mg cap, 25 mg TIER 1 PV cap, 50 mg cap, 75 mg cap) protriptyline hcl (5 mg tab, protriptyline hcl TIER 1 PV 10 mg tab) trimipramine maleate (25 trimipramine maleate mg cap, 50 mg cap, 100 mg TIER 1 PV cap)

ANTIEMETICS

ANTIEMETICS, OTHER

compro compro 25 mg suppos TIER 1 metoclopramide hcl (5 mg/5ml solution, 5 mg tab metoclopramide hcl TIER 1 disp, 5 mg tab, 10 mg tab, 10 mg/10ml solution) perphenazine (2 mg tab, 4 perphenazine mg tab, 8 mg tab, 16 mg TIER 1 PV tab) phenadoz (12.5 mg suppos, phenadoz TIER 1 25 mg suppos) phenergan (12.5 mg phenergan suppos, 25 mg suppos, 50 TIER 1 mg suppos) prochlorperazine 25 mg prochlorperazine TIER 1 suppos prochlorperazine prochlorperazine maleate TIER 1 maleate (5 mg tab, 10 mg tab) promethazine hcl (12.5 mg tab, 12.5 mg suppos, 25 mg promethazine hcl TIER 1 tab, 25 mg suppos, 50 mg suppos, 50 mg tab)

©2020 Wellmark, Inc. 29 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PROMETHEGAN (12.5 MG SUPPOS, 25 MG PROMETHEGAN SUPPOS, 50 MG TIER 1 GA SUPPOS) promethazine hcl scopolamine 1 mg/3days scopolamine TIER 1 patch 72hr trimethobenzamide trimethobenzamide hcl 300 TIER 1 hcl mg cap

EMETOGENIC THERAPY ADJUNCTS

ANZEMET (50 MG TAB, ANZEMET 100 MG TAB) TIER 2 dolasetron mesylate aprepitant (40 mg cap, 80 & aprepitant 125 mg cap, 80 mg cap, TIER 1 125 mg cap) CESAMET 1 MG CAP CESAMET TIER 2 nabilone dronabinol (2.5 mg cap, 5 dronabinol TIER 1 mg cap, 10 mg cap) EMEND 125 MG RECON EMEND SUSP TIER 2 aprepitant granisetron hcl granisetron hcl 1 mg tab TIER 1 ondansetron (4 mg tab ondansetron TIER 1 disp, 8 mg tab disp) ondansetron hcl (4 mg tab, ondansetron hcl TIER 1 8 mg tab, 24 mg tab) ondansetron hcl 4 mg/5ml ondansetron hcl TIER 1 QL (300 PER 30 DAYS) solution

ANTIFUNGALS

bio-statin bio-statin powder TIER 1 ciclodan (0.77 % cream, 8 ciclodan TIER 1 % solution) ciclopirox (0.77 % gel, 1 % ciclopirox TIER 1 shampoo, 8 % solution) ciclopirox olamine (0.77 % ciclopirox olamine TIER 1 cream, 0.77 % suspension) clotrimazole clotrimazole 10 mg troche TIER 1 econazole nitrate 1 % econazole nitrate TIER 1 QL (170 PER 30 DAY(S)) cream

©2020 Wellmark, Inc. 30 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS fluconazole (10 mg/ml recon susp, 40 mg/ml recon fluconazole susp, 50 mg tab, 100 mg TIER 1 tab, 150 mg tab, 200 mg tab) flucytosine (250 mg cap, flucytosine TIER 1 500 mg cap) griseofulvin microsize (125 griseofulvin microsize mg/5ml suspension, 500 TIER 1 mg tab) griseofulvin griseofulvin ultramicrosize TIER 1 ultramicrosize (125 mg tab, 250 mg tab) itraconazole (10 mg/ml itraconazole TIER 1 PA solution, 100 mg cap) ketoconazole (2 % ketoconazole TIER 1 shampoo, 200 mg tab) ketoconazole ketoconazole 2 % cream TIER 1 QL (240 PER 30 DAY(S)) ketoconazole ketoconazole 2 % foam TIER 1 QL (200 PER 30 DAY(S)) ketodan ketodan 2 % foam TIER 1 QL (200 PER 30 DAY(S)) luliconazole luliconazole 1 % cream TIER 1 miconazole-zinc oxide- miconazole-zinc petrolat 0.25-15-81.35 % TIER 1 oxide-petrolat ointment naftifine hcl (1 % cream, 1 naftifine hcl TIER 1 % gel, 2 % cream) NATACYN 5 % NATACYN SUSPENSION TIER 3 natamycin nyamyc 100000 unit/gm nyamyc TIER 1 powder nyata 100000 unit/gm nyata TIER 1 powder nystatin (100000 unit/gm powder, 100000 unit/ml suspension, 100000 nystatin TIER 1 unit/gm ointment, 100000 unit/gm cream, 500000 unit tab) nystatin-triamcinolone nystatin-triamcinolone TIER 1 (cream, ointment) nystop 100000 unit/gm nystop TIER 1 powder posaconazole 100 mg tab posaconazole TIER 1 dr sulconazole nitrate 1 % sulconazole nitrate TIER 1 solution

©2020 Wellmark, Inc. 31 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS terbinafine hcl terbinafine hcl 250 mg tab TIER 1 terconazole (0.4 % cream, terconazole 0.8 % cream, 80 mg TIER 1 suppos) VFEND IV 200 MG RECON VFEND IV SOLN TIER 2 GA voriconazole voriconazole (40 mg/ml voriconazole recon susp, 50 mg tab, 200 TIER 1 mg tab) voriconazole 200 mg recon voriconazole TIER 2 soln zazole zazole 0.8 % cream TIER 1

ANTIGOUT AGENTS

allopurinol (100 mg tab, 300 allopurinol TIER 1 mg tab) colchicine (0.6 mg tab, 0.6 colchicine TIER 1 mg cap) colchicine-probenecid 0.5- colchicine-probenecid TIER 1 500 mg tab febuxostat (40 mg tab, 80 febuxostat TIER 1 mg tab) probenecid probenecid 500 mg tab TIER 1

ANTIMIGRAINE AGENTS

ERGOT ALKALOIDS

dihydroergotamine dihydroergotamine TIER 1 mesylate mesylate 1 mg/ml solution ergotamine-caffeine 1-100 ergotamine-caffeine TIER 1 mg tab migergot migergot 2-100 mg suppos TIER 1

SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

almotriptan malate (6.25 almotriptan malate TIER 1 QL (12 PER 30 DAYS) mg tab, 12.5 mg tab) eletriptan eletriptan hydrobromide (20 TIER 1 PA, QL (12 PER 30 DAYS) hydrobromide mg tab, 40 mg tab) frovatriptan succinate 2.5 frovatriptan succinate TIER 1 PA, QL (18 PER 30 DAYS) mg tab naratriptan hcl (1 mg tab, naratriptan hcl TIER 1 QL (12 PER 30 DAYS) 2.5 mg tab)

©2020 Wellmark, Inc. 32 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS rizatriptan benzoate (5 mg rizatriptan benzoate tab, 5 mg tab disp, 10 mg TIER 1 QL (18 PER 30 DAYS) tab disp, 10 mg tab) sumatriptan 20 mg/act sumatriptan TIER 1 QL (12 PER 30 DAYS) solution sumatriptan 5 mg/act sumatriptan TIER 1 QL (24 PER 30 DAYS) solution SUMATRIPTAN SUCCINATE (6 MG/0.5ML SUMATRIPTAN SOLN PRSYR, 25 MG TIER 1 QL (12 PER 30 DAYS) SUCCINATE TAB, 50 MG TAB, 100 MG TAB) sumatriptan succinate sumatriptan succinate (6 sumatriptan succinate TIER 1 PA, QL (12 PER 30 DAYS) soln a-inj, 6 solution) sumatriptan succinate 4 sumatriptan succinate TIER 1 PA, QL (18 PER 30 DAYS) mg/0.5ml soln a-inj sumatriptan succinate sumatriptan succinate refill TIER 1 PA, QL (18 PER 30 DAYS) refill 4 mg/0.5ml soln cart sumatriptan succinate sumatriptan succinate refill TIER 1 PA, QL (12 PER 30 DAYS) refill 6 mg/0.5ml soln cart sumatriptan-naproxen sumatriptan-naproxen TIER 1 PA, QL (9 PER 30 DAYS) sodium sodium 85-500 mg tab zolmitriptan (2.5 mg tab zolmitriptan disp, 2.5 mg tab, 5 mg tab, TIER 1 QL (12 PER 30 DAYS) 5 mg tab disp)

ANTIMIGRAINE AGENTS, OTHER

AIMOVIG (140 MG DOSE) QL (1 PER 30 DAY(S)), MN- AIMOVIG (140 MG 70 MG/ML SOLN A-INJ SP-NP PA (Medically Necessary DOSE) erenumab-aooe Prior Authorization) AIMOVIG (70 MG/ML QL (1 PER 30 DAY(S)), MN- SOLN A-INJ, 140 MG/ML AIMOVIG SP-NP PA (Medically Necessary SOLN A-INJ) Prior Authorization) erenumab-aooe AJOVY 225 MG/1.5ML AJOVY SOLN PRSYR SP-P PA, QL (3 PER 90 DAY(S)) fremanezumab-vfrm EMGALITY (100 MG/ML SOLN PRSYR, 120 MG/ML EMGALITY SOLN A-INJ, 120 MG/ML SP-P PA, QL (1 PER 28 DAY(S)) SOLN PRSYR) galcanezumab-gnlm

PROPHYLACTIC

VYEPTI 100 MG/ML VYEPTI SOLUTION SP-M PA eptinezumab-jjmr

ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICS

GUANIDINE HCL 125 MG GUANIDINE HCL TAB TIER 3 guanidine hcl pyridostigmine pyridostigmine bromide (60 TIER 1 bromide mg tab, 60 mg/5ml solution) pyridostigmine pyridostigmine bromide er TIER 1 bromide er 180 mg tab er RUZURGI 10 MG TAB PA, QL (240 PER 30 RUZURGI SP-P amifampridine DAY(S))

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHER

dapsone (25 mg tab, 100 dapsone TIER 1 mg tab) rifabutin rifabutin 150 mg cap TIER 1

ANTITUBERCULARS

cycloserine cycloserine 250 mg cap TIER 1 ethambutol hcl (100 mg tab, ethambutol hcl TIER 1 400 mg tab) ISONIAZID (50 MG/5ML SYRUP, 100 MG TAB, 300 ISONIAZID TIER 1 MG TAB) isoniazid PASER 4 GM PACKET PASER TIER 1 aminosalicylic acid PRIFTIN 150 MG TAB PRIFTIN TIER 3 rifapentine pyrazinamide pyrazinamide 500 mg tab TIER 1 rifampin (150 mg cap, 300 rifampin TIER 1 mg cap) TRECATOR 250 MG TAB TRECATOR TIER 3 ethionamide

ANTINEOPLASTICS

ALKYLATING AGENTS

CYCLOPHOSPHAMIDE (1 CYCLOPHOSPHAMI GM/5ML SOLUTION, 500 SP-M DE MG/2.5ML SOLUTION) cyclophosphamide cyclophosphamide (25 mg cyclophosphamide TIER 1 cap, 50 mg cap) GLEOSTINE (5 MG CAP, 10 MG CAP, 40 MG CAP, GLEOSTINE TIER 2 100 MG CAP) lomustine HEXALEN 50 MG CAP HEXALEN TIER 2 altretamine LEUKERAN 2 MG TAB LEUKERAN TIER 2 chlorambucil MATULANE 50 MG CAP MATULANE TIER 2 procarbazine hcl melphalan melphalan 2 mg tab TIER 1 MYLERAN 2 MG TAB MYLERAN TIER 2 busulfan TEMODAR (5 MG CAP, 20 MG CAP, 100 MG CAP, TEMODAR 140 MG CAP, 180 MG SP-NP GA CAP, 250 MG CAP) temozolomide temozolomide (5 mg cap, 20 mg cap, 100 mg cap, temozolomide SP-P 140 mg cap, 180 mg cap, 250 mg cap) VALCHLOR 0.016 % GEL VALCHLOR mechlorethamine hcl SP-P (topical)

ANTIANDROGENS

abiraterone acetate 250 mg abiraterone acetate SP-P tab bicalutamide bicalutamide 50 mg tab TIER 1 ERLEADA 60 MG TAB ERLEADA SP-P apalutamide flutamide flutamide 125 mg cap TIER 1 nilutamide nilutamide 150 mg tab TIER 1

©2020 Wellmark, Inc. 35 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NUBEQA 300 MG TAB NUBEQA SP-P darolutamide XTANDI 40 MG CAP XTANDI SP-P enzalutamide YONSA 125 MG TAB YONSA SP-P abiraterone acetate ZYTIGA (250 MG TAB, 500 ZYTIGA MG TAB) SP-P abiraterone acetate

ANTIANGIOGENIC AGENTS

POMALYST (1 MG CAP, 2 MG CAP, 3 MG CAP, 4 MG POMALYST SP-P CAP) pomalidomide REVLIMID (2.5 MG CAP, 5 MG CAP, 10 MG CAP, 15 REVLIMID MG CAP, 20 MG CAP, 25 SP-P MG CAP) lenalidomide THALOMID (50 MG CAP, 100 MG CAP, 150 MG THALOMID SP-P CAP, 200 MG CAP) thalidomide

ANTIESTROGENS/MODIFIERS

EMCYT 140 MG CAP EMCYT estramustine phosphate SP-P sodium SOLTAMOX 10 MG/5ML SOLTAMOX SOLUTION TIER 2 PA, PV tamoxifen citrate tamoxifen citrate (10 mg tamoxifen citrate TIER 1 PA, PV tab, 20 mg tab) toremifene citrate 60 mg toremifene citrate TIER 1 tab

ANTIMETABOLITES

capecitabine (150 mg tab, capecitabine SP-P 500 mg tab) DROXIA (200 MG CAP, 300 MG CAP, 400 MG DROXIA CAP) TIER 3 hydroxyurea (sickle cell anemia)

©2020 Wellmark, Inc. 36 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FLUOROURACIL (2 % SOLUTION, 5 % FLUOROURACIL TIER 1 SOLUTION, 5 % CREAM) fluorouracil (topical) hydroxyurea hydroxyurea 500 mg cap TIER 1 mercaptopurine mercaptopurine 50 mg tab TIER 1 TABLOID 40 MG TAB TABLOID TIER 2 thioguanine XELODA (150 MG TAB, XELODA 500 MG TAB) SP-NP GA capecitabine

ANTINEOPLASTICS, OTHER

ALUNBRIG (30 MG TAB, 90 & 180 MG TAB THPK, ALUNBRIG SP-P 90 MG TAB, 180 MG TAB) brigatinib AYVAKIT (100 MG TAB, 200 MG TAB, 300 MG AYVAKIT SP-P TAB) avapritinib BALVERSA (3 MG TAB, 4 BALVERSA MG TAB, 5 MG TAB) SP-P erdafitinib BRUKINSA 80 MG CAP BRUKINSA SP-P zanubrutinib IDHIFA (50 MG TAB, 100 IDHIFA MG TAB) SP-P enasidenib mesylate leucovorin calcium (5 mg tab, 10 mg tab, 15 mg tab, leucovorin calcium TIER 1 25 mg tab, 50 mg recon soln) LONSURF (15-6.14 MG LONSURF TAB, 20-8.19 MG TAB) SP-P trifluridine-tipiracil LYSODREN 500 MG TAB LYSODREN TIER 2 mitotane NINLARO (2.3 MG CAP, 3 NINLARO MG CAP, 4 MG CAP) SP-P ixazomib citrate ONUREG (200 MG TAB, ONUREG 300 MG TAB) SP-P azacitidine

©2020 Wellmark, Inc. 37 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PEMAZYRE (4.5 MG TAB, PEMAZYRE 9 MG TAB, 13.5 MG TAB) SP-P pemigatinib PHESGO (60-60-2000 SOLUTION, 80-40-2000 PHESGO SOLUTION) SP-M pertuzumab-trastuzumab- hyaluronidase-zzxf QINLOCK 50 MG TAB QINLOCK SP-P ripretinib RETEVMO (40 MG CAP, RETEVMO 80 MG CAP) SP-P selpercatinib ROZLYTREK 100 MG CAP ROZLYTREK SP-P QL (30 PER 30 DAY(S)) entrectinib ROZLYTREK 200 MG CAP ROZLYTREK SP-P QL (90 PER 30 DAY(S)) entrectinib RUBRACA (200 MG TAB, 250 MG TAB, 300 MG RUBRACA SP-P TAB) rucaparib camsylate RYDAPT 25 MG CAP RYDAPT SP-P midostaurin SYLATRON (200 MCG KIT, 300 MCG KIT, 600 MCG SYLATRON KIT) SP-P peginterferon alfa-2b (antineoplastic) SYNRIBO 3.5 MG RECON SOLN SYNRIBO SP-M omacetaxine mepesuccinate TABRECTA (150 MG TAB, TABRECTA 200 MG TAB) SP-P capmatinib hcl TAZVERIK 200 MG TAB TAZVERIK SP-P tazemetostat hbr TECARTUS TECARTUS SUSPENSION SP-M brexucabtagene autoleucel TIBSOVO 250 MG TAB TIBSOVO SP-P ivosidenib TURALIO 200 MG CAP PA, QL (120 PER 30 TURALIO SP-P pexidartinib hcl DAY(S))

©2020 Wellmark, Inc. 38 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VITRAKVI (20 MG/ML SOLUTION, 25 MG CAP, VITRAKVI SP-P 100 MG CAP) larotrectinib sulfate VIZIMPRO (15 MG TAB, 30 VIZIMPRO MG TAB, 45 MG TAB) SP-P dacomitinib XOSPATA 40 MG TAB XOSPATA SP-P gilteritinib fumarate XPOVIO (100 MG ONCE XPOVIO (100 MG WEEKLY) 20 MG TAB SP-P ONCE WEEKLY) THPK selinexor XPOVIO (40 MG ONCE XPOVIO (40 MG WEEKLY) 20 MG TAB SP-P ONCE WEEKLY) THPK selinexor XPOVIO (40 MG TWICE XPOVIO (40 MG WEEKLY) 20 MG TAB SP-P TWICE WEEKLY) THPK selinexor XPOVIO (60 MG ONCE XPOVIO (60 MG WEEKLY) 20 MG TAB SP-P ONCE WEEKLY) THPK selinexor XPOVIO (60 MG TWICE XPOVIO (60 MG WEEKLY) 20 MG TAB SP-P TWICE WEEKLY) THPK selinexor XPOVIO (80 MG ONCE XPOVIO (80 MG WEEKLY) 20 MG TAB SP-P ONCE WEEKLY) THPK selinexor XPOVIO (80 MG TWICE XPOVIO (80 MG WEEKLY) 20 MG TAB SP-P TWICE WEEKLY) THPK selinexor ZEJULA 100 MG CAP ZEJULA SP-P niraparib tosylate ZOLINZA 100 MG CAP ZOLINZA SP-P vorinostat

AROMATASE INHIBITORS, 3RD GENERATION

anastrozole anastrozole 1 mg tab TIER 1 PA, PV exemestane exemestane 25 mg tab TIER 1 PA, PV letrozole letrozole 2.5 mg tab TIER 1 PV

ENZYME INHIBITORS

ETOPOSIDE 50 MG CAP ETOPOSIDE SP-P etoposide GAVRETO 100 MG CAP GAVRETO SP-P pralsetinib HYCAMTIN (0.25 MG CAP, HYCAMTIN 1 MG CAP) SP-P topotecan hcl LORBRENA (25 MG TAB, LORBRENA 100 MG TAB) SP-P lorlatinib PIQRAY (250 MG DAILY PIQRAY (250 MG DOSE) 200 & 50 MG TAB SP-P DAILY DOSE) THPK alpelisib PIQRAY 200MG DAILY PIQRAY 200MG DOSE 200 MG TAB THPK SP-P DAILY DOSE alpelisib PIQRAY 300MG DAILY PIQRAY 300MG DOSE 2X150 MG TAB SP-P DAILY DOSE THPK alpelisib

MOLECULAR TARGET INHIBITORS

AFINITOR (2.5 MG TAB, AFINITOR 7.5 MG TAB) SP-NP QL (60 PER 30 DAYS), GA everolimus AFINITOR 10 MG TAB AFINITOR SP-P QL (60 PER 30 DAYS) everolimus AFINITOR 5 MG TAB AFINITOR SP-NP QL (120 PER 30 DAYS), GA everolimus AFINITOR DISPERZ (2 MG TAB SOL, 3 MG TAB SOL, AFINITOR DISPERZ SP-P 5 MG TAB SOL) everolimus ALECENSA 150 MG CAP ALECENSA SP-P alectinib hcl BOSULIF (100 MG TAB, 400 MG TAB, 500 MG BOSULIF SP-P TAB) bosutinib BRAFTOVI (50 MG CAP, BRAFTOVI 75 MG CAP) SP-P encorafenib

©2020 Wellmark, Inc. 40 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CABOMETYX (20 MG TAB, CABOMETYX 40 MG TAB, 60 MG TAB) SP-P cabozantinib s-malate CALQUENCE 100 MG CAP CALQUENCE TIER 2 acalabrutinib CAPRELSA (100 MG TAB, CAPRELSA 300 MG TAB) SP-P vandetanib COMETRIQ (100 MG COMETRIQ (100 MG DAILY DOSE) 80 & 20 MG SP-P DAILY DOSE) KIT cabozantinib s-malate COMETRIQ (140 MG COMETRIQ (140 MG DAILY DOSE) 3 X 20 MG & SP-P DAILY DOSE) 80 MG KIT cabozantinib s-malate COMETRIQ (60 MG DAILY COMETRIQ (60 MG DOSE) 20 MG KIT SP-P DAILY DOSE) cabozantinib s-malate COPIKTRA (15 MG CAP, COPIKTRA 25 MG CAP) SP-P duvelisib COTELLIC 20 MG TAB COTELLIC SP-P cobimetinib fumarate DAURISMO (25 MG TAB, DAURISMO 100 MG TAB) SP-P glasdegib maleate ERIVEDGE 150 MG CAP ERIVEDGE SP-P vismodegib erlotinib hcl (25 mg tab, 100 erlotinib hcl SP-P mg tab, 150 mg tab) everolimus (2.5 mg tab, 7.5 everolimus SP-P QL (60 PER 30 DAYS) mg tab) everolimus everolimus 5 mg tab SP-P QL (120 PER 30 DAYS) FARYDAK (10 MG CAP, 15 FARYDAK MG CAP, 20 MG CAP) SP-P panobinostat lactate GILOTRIF (20 MG TAB, 30 GILOTRIF MG TAB, 40 MG TAB) SP-P afatinib dimaleate GLEEVEC (100 MG TAB, GLEEVEC 400 MG TAB) SP-NP GA imatinib mesylate

©2020 Wellmark, Inc. 41 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS IBRANCE (75 MG CAP, 75 MG TAB, 100 MG CAP, IBRANCE 100 MG TAB, 125 MG SP-P CAP, 125 MG TAB) palbociclib ICLUSIG (15 MG TAB, 45 ICLUSIG MG TAB) SP-P ponatinib hcl imatinib mesylate (100 mg imatinib mesylate SP-P tab, 400 mg tab) IMBRUVICA (70 MG CAP, 140 MG CAP, 140 MG IMBRUVICA TAB, 280 MG TAB, 420 MG SP-P TAB, 560 MG TAB) ibrutinib INLYTA (1 MG TAB, 5 MG INLYTA TAB) SP-P axitinib INREBIC 100 MG CAP INREBIC SP-P QL (120 PER 30 DAY(S)) fedratinib hcl IRESSA 250 MG TAB IRESSA SP-P gefitinib JAKAFI (5 MG TAB, 10 MG TAB, 15 MG TAB, 20 MG JAKAFI SP-P TAB, 25 MG TAB) ruxolitinib phosphate KISQALI (600 MG DOSE) KISQALI (600 MG 200 MG TAB THPK SP-P DOSE) ribociclib succinate KISQALI 200 DOSE 200 KISQALI 200 DOSE MG TAB THPK SP-P ribociclib succinate KISQALI 400 DOSE 200 KISQALI 400 DOSE MG TAB THPK SP-P ribociclib succinate KISQALI FEMARA 200 DOSE 200 & 2.5 MG TAB KISQALI FEMARA THPK SP-P 200 DOSE ribociclib succinate- letrozole KISQALI FEMARA 400 DOSE 200 & 2.5 MG TAB KISQALI FEMARA THPK SP-P 400 DOSE ribociclib succinate- letrozole

©2020 Wellmark, Inc. 42 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS KISQALI FEMARA 600 DOSE 200 & 2.5 MG TAB KISQALI FEMARA THPK SP-P 600 DOSE ribociclib succinate- letrozole KOSELUGO (10 MG CAP, KOSELUGO 25 MG CAP) SP-P PA, QL (4 PER DAY(S)) selumetinib sulfate lapatinib ditosylate 250 mg lapatinib ditosylate SP-P QL (180 PER 30 DAYS) tab LENVIMA 10 MG DAILY LENVIMA 10 MG DOSE 10 MG CAP THPK SP-P DAILY DOSE lenvatinib mesylate LENVIMA 12 MG DAILY LENVIMA 12 MG DOSE 4 (3) MG CAP THPK SP-P DAILY DOSE lenvatinib mesylate LENVIMA 14 MG DAILY LENVIMA 14 MG DOSE 10 & 4 MG CAP SP-P DAILY DOSE THPK lenvatinib mesylate LENVIMA 18 MG DAILY LENVIMA 18 MG DOSE 10 & 4 (2) MG CAP SP-P DAILY DOSE THPK lenvatinib mesylate LENVIMA 20 MG DAILY LENVIMA 20 MG DOSE 10 (2) MG CAP SP-P DAILY DOSE THPK lenvatinib mesylate LENVIMA 24 MG DAILY LENVIMA 24 MG DOSE 10 (2) & 4 MG CAP SP-P DAILY DOSE THPK lenvatinib mesylate LENVIMA 4 MG DAILY LENVIMA 4 MG DOSE 4 MG CAP THPK SP-P DAILY DOSE lenvatinib mesylate LENVIMA 8 MG DAILY LENVIMA 8 MG DOSE 4 (2) MG CAP THPK SP-P DAILY DOSE lenvatinib mesylate LYNPARZA (50 MG CAP, 100 MG TAB, 150 MG LYNPARZA SP-P TAB) olaparib MEKINIST (0.5 MG TAB, 2 MG TAB) MEKINIST SP-P trametinib dimethyl sulfoxide

©2020 Wellmark, Inc. 43 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MEKTOVI 15 MG TAB MEKTOVI SP-P binimetinib NERLYNX 40 MG TAB NERLYNX TIER 2 neratinib maleate NEXAVAR 200 MG TAB NEXAVAR SP-P sorafenib tosylate ODOMZO 200 MG CAP ODOMZO SP-P sonidegib phosphate SPRYCEL (20 MG TAB, 50 MG TAB, 70 MG TAB, 80 SPRYCEL MG TAB, 100 MG TAB, 140 SP-P MG TAB) dasatinib STIVARGA 40 MG TAB STIVARGA SP-P regorafenib SUTENT (12.5 MG CAP, 25 MG CAP, 37.5 MG CAP, SUTENT SP-P 50 MG CAP) sunitinib malate TAFINLAR (50 MG CAP, TAFINLAR 75 MG CAP) SP-P dabrafenib mesylate TAGRISSO (40 MG TAB, TAGRISSO 80 MG TAB) SP-P osimertinib mesylate TALZENNA (0.25 MG CAP, TALZENNA 1 MG CAP) SP-P PA talazoparib tosylate TARCEVA (25 MG TAB, 100 MG TAB, 150 MG TARCEVA SP-NP GA TAB) erlotinib hcl TASIGNA (50 MG CAP, 150 MG CAP, 200 MG TASIGNA SP-P CAP) nilotinib hcl TUKYSA (50 MG TAB, 150 TUKYSA MG TAB) SP-P tucatinib TYKERB 250 MG TAB TYKERB SP-NP QL (180 PER 30 DAYS), GA lapatinib ditosylate VENCLEXTA (10 MG TAB, VENCLEXTA 50 MG TAB, 100 MG TAB) SP-P venetoclax VENCLEXTA STARTING VENCLEXTA PACK 10 & 50 & 100 MG SP-P STARTING PACK TAB THPK venetoclax

©2020 Wellmark, Inc. 44 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VERZENIO (50 MG TAB, 100 MG TAB, 150 MG TAB, VERZENIO SP-NP 200 MG TAB) abemaciclib VOTRIENT 200 MG TAB VOTRIENT SP-P pazopanib hcl XALKORI (200 MG CAP, XALKORI 250 MG CAP) SP-P crizotinib ZELBORAF 240 MG TAB ZELBORAF SP-P vemurafenib ZYDELIG (100 MG TAB, ZYDELIG 150 MG TAB) SP-P idelalisib ZYKADIA (150 MG CAP, ZYKADIA 150 MG TAB) SP-P ceritinib

MONOCLONAL ANTIBODY/ANTIBODY-DRUG CONJUGATE

BLENREP 100 MG RECON BLENREP SOLN SP-M belantamab mafodotin-blmf DARZALEX FASPRO 1800-30000 MG-UT/15ML DARZALEX FASPRO SOLUTION SP-M daratumumab- hyaluronidase-fihj MONJUVI 200 MG RECON MONJUVI SOLN SP-M tafasitamab-cxix POLIVY (30 MG RECON SOLN, 140 MG RECON POLIVY SP-M SOLN) polatuzumab vedotin-piiq

RETINOIDS

bexarotene bexarotene 75 mg cap SP-P PANRETIN 0.1 % GEL PANRETIN TIER 3 alitretinoin TARGRETIN 1 % GEL TARGRETIN SP-P bexarotene (topical) TARGRETIN 75 MG CAP TARGRETIN SP-NP GA bexarotene tretinoin tretinoin 10 mg cap TIER 1

TREATMENT ADJUNCTS

MESNEX 400 MG TAB MESNEX TIER 2 mesna

ANTIPARASITICS

ANTIHELMINTHICS

albendazole albendazole 200 mg tab TIER 1 ivermectin ivermectin 3 mg tab TIER 1 praziquantel praziquantel 600 mg tab TIER 1

ANTIPROTOZOALS

ALINIA 100 MG/5ML QL (540 PER 10 DAY(S)), ALINIA RECON SUSP TIER 3 PA-QL (QL varies) nitazoxanide ALINIA 500 MG TAB QL (20 PER 10 DAY(S)), PA- ALINIA TIER 3 nitazoxanide QL (QL varies) atovaquone 750 mg/5ml atovaquone TIER 1 suspension atovaquone-proguanil hcl atovaquone-proguanil (62.5-25 mg tab, 250-100 TIER 1 PV hcl mg tab) chloroquine chloroquine phosphate (250 TIER 1 PV phosphate mg tab, 500 mg tab) DARAPRIM 25 MG TAB DARAPRIM TIER 2 GA pyrimethamine hydroxychloroquine hydroxychloroquine sulfate TIER 1 sulfate 200 mg tab IMPAVIDO 50 MG CAP IMPAVIDO TIER 3 miltefosine mefloquine hcl mefloquine hcl 250 mg tab TIER 1 pentamidine pentamidine isethionate TIER 1 isethionate 300 mg recon soln primaquine primaquine phosphate 26.3 TIER 1 PV phosphate mg tab pyrimethamine pyrimethamine 25 mg tab TIER 1 quinine sulfate quinine sulfate 324 mg cap TIER 1

PEDICULICIDES/SCABICIDES

acticin acticin 5 % cream TIER 1 CROTAN 10 % LOTION CROTAN TIER 1 crotamiton

©2020 Wellmark, Inc. 46 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS EURAX 10 % CREAM EURAX TIER 3 crotamiton lindane lindane 1 % shampoo TIER 1 malathion malathion 0.5 % lotion TIER 1 permethrin permethrin 5 % cream TIER 1 ULESFIA 5 % LOTION ULESFIA benzyl alcohol TIER 3 (pediculicide)

ANTIPARKINSON AGENTS

ANTICHOLINERGICS

benztropine mesylate (0.5 benztropine mesylate TIER 1 mg tab, 1 mg tab, 2 mg tab) trihexyphenidyl hcl (0.4 trihexyphenidyl hcl mg/ml solution, 2 mg tab, 5 TIER 1 mg tab)

ANTIPARKINSON AGENTS, OTHER

amantadine hcl (50 mg/5ml amantadine hcl syrup, 100 mg cap, 100 mg TIER 1 tab) carbidopa-levodopa- entacapone (12.5-50-200 mg tab, 18.75-75-200 mg carbidopa-levodopa- tab, 25-100-200 mg tab, TIER 1 entacapone 31.25-125-200 mg tab, 37.5-150-200 mg tab, 50- 200-200 mg tab) entacapone entacapone 200 mg tab TIER 1 NOURIANZ (20 MG TAB, NOURIANZ 40 MG TAB) SP-NP PA, QL (30 PER 30 DAY(S)) istradefylline ONGENTYS 50 MG CAP ONGENTYS TIER 3 PA, QL (30 PER 30 DAY(S)) opicapone tolcapone tolcapone 100 mg tab TIER 1 PA

DOPAMINE AGONISTS

APOKYN 30 MG/3ML APOKYN SOLN CART SP-M apomorphine hydrochloride bromocriptine bromocriptine mesylate (2.5 TIER 1 mesylate mg tab, 5 mg cap)

©2020 Wellmark, Inc. 47 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS pramipexole dihydrochloride (0.125 mg pramipexole tab, 0.25 mg tab, 0.5 mg TIER 1 dihydrochloride tab, 0.75 mg tab, 1 mg tab, 1.5 mg tab) pramipexole dihydrochloride er (er 0.375 mg tab er 24h, er 0.75 mg pramipexole tab er 24h, er 1.5 mg tab er TIER 1 PA dihydrochloride er 24h, er 2.25 mg tab er 24h, er 3 mg tab er 24h, er 3.75 mg tab er 24h, er 4.5 mg tab er 24h) ropinirole hcl (0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg ropinirole hcl TIER 1 tab, 3 mg tab, 4 mg tab, 5 mg tab) ropinirole hcl er (er 2 mg tab er 24h, er 4 mg tab er ropinirole hcl er 24h, er 6 mg tab er 24h, er TIER 1 PA 8 mg tab er 24h, er 12 mg tab er 24h)

DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS

carbidopa carbidopa 25 mg tab TIER 1 carbidopa-levodopa (10- 100 mg tab disp, 10-100 mg tab, 25-100 mg tab, 25- carbidopa-levodopa TIER 1 100 mg tab disp, 25-250 mg tab disp, 25-250 mg tab) carbidopa-levodopa er (er carbidopa-levodopa 25-100 mg tab er, er 50- TIER 1 er 200 mg tab er)

MONOAMINE OXIDASE B (MAO-B) INHIBITORS

rasagiline mesylate (0.5 mg rasagiline mesylate TIER 1 tab, 1 mg tab) selegiline hcl (5 mg tab, 5 selegiline hcl TIER 1 mg cap)

ANTIPSYCHOTICS

1ST GENERATION/TYPICAL

chlorpromazine hcl (10 mg chlorpromazine hcl tab, 25 mg tab, 50 mg tab, TIER 1 PV 100 mg tab, 200 mg tab)

©2020 Wellmark, Inc. 48 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FLUPHENAZINE HCL (1 MG TAB, 2.5 MG TAB, 2.5 FLUPHENAZINE MG/5ML ELIXIR, 5 MG/ML TIER 1 PV HCL CONC, 5 MG TAB, 10 MG TAB) fluphenazine hcl haloperidol (0.5 mg tab, 1 haloperidol mg tab, 2 mg tab, 5 mg tab, TIER 1 PV 10 mg tab, 20 mg tab) haloperidol lactate 2 mg/ml haloperidol lactate TIER 1 PV conc loxapine succinate (5 mg loxapine succinate cap, 10 mg cap, 25 mg cap, TIER 1 PV 50 mg cap) PIMOZIDE (1 MG TAB, 2 PIMOZIDE MG TAB) TIER 1 pimozide thioridazine hcl (10 mg tab, thioridazine hcl 25 mg tab, 50 mg tab, 100 TIER 1 PV mg tab) thiothixene (1 mg cap, 2 mg thiothixene TIER 1 PV cap, 5 mg cap, 10 mg cap) trifluoperazine hcl (1 mg trifluoperazine hcl tab, 2 mg tab, 5 mg tab, 10 TIER 1 PV mg tab)

2ND GENERATION/ATYPICAL

aripiprazole (1 mg/ml solution, 2 mg tab, 5 mg aripiprazole tab, 10 mg tab disp, 10 mg TIER 1 PV tab, 15 mg tab disp, 15 mg tab, 20 mg tab, 30 mg tab) LATUDA (20 MG TAB, 40 MG TAB, 60 MG TAB, 80 LATUDA TIER 3 MG TAB, 120 MG TAB) lurasidone hcl olanzapine (2.5 mg tab, 5 mg tab, 5 mg tab disp, 7.5 mg tab, 10 mg tab, 10 mg olanzapine TIER 1 PV tab disp, 15 mg tab disp, 15 mg tab, 20 mg tab disp, 20 mg tab) paliperidone er (er 1.5 mg tab er 24h, er 3 mg tab er paliperidone er TIER 1 PV 24h, er 6 mg tab er 24h, er 9 mg tab er 24h)

©2020 Wellmark, Inc. 49 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS quetiapine fumarate (25 mg tab, 50 mg tab, 100 mg tab, quetiapine fumarate TIER 1 PV 200 mg tab, 300 mg tab, 400 mg tab) quetiapine fumarate er (er 50 mg tab er 24h, er 150 quetiapine fumarate mg tab er 24h, er 200 mg TIER 1 PV er tab er 24h, er 300 mg tab er 24h, er 400 mg tab er 24h) risperidone (0.25 mg tab, 0.25 mg tab disp, 0.5 mg tab disp, 0.5 mg tab, 1 mg tab disp, 1 mg tab, 1 mg/ml risperidone TIER 1 PV solution, 2 mg tab disp, 2 mg tab, 3 mg tab disp, 3 mg tab, 4 mg tab disp, 4 mg tab) risperidone m-tab (0.5 mg tab disp, 1 mg tab disp, 2 risperidone m-tab TIER 1 PV mg tab disp, 3 mg tab disp, 4 mg tab disp) ziprasidone hcl (20 mg cap, ziprasidone hcl 40 mg cap, 60 mg cap, 80 TIER 1 PV mg cap)

TREATMENT-RESISTANT

clozapine (12.5 mg tab disp, 25 mg tab, 25 mg tab disp, 50 mg tab, 100 mg clozapine TIER 1 PV tab, 100 mg tab disp, 150 mg tab disp, 200 mg tab, 200 mg tab disp) CLOZAPINE (150 MG TAB CLOZAPINE DISP, 200 MG TAB DISP) TIER 1 GA clozapine

ANTISPASTICITY AGENTS

baclofen (10 mg tab, 20 mg baclofen TIER 1 tab) BOTOX (100 RECON BOTOX SOLN, 200 RECON SOLN) SP-M PA onabotulinumtoxina dantrolene sodium (25 mg dantrolene sodium cap, 50 mg cap, 100 mg TIER 1 cap) tizanidine hcl (2 mg tab, 4 tizanidine hcl TIER 1 mg tab)

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

JULUCA 50-25 MG TAB JULUCA dolutegravir sodium- TIER 2 rilpivirine hcl valganciclovir hcl (50 mg/ml valganciclovir hcl TIER 1 recon soln, 450 mg tab)

ANTI-HEPATITIS B (HBV) AGENTS

adefovir dipivoxil adefovir dipivoxil 10 mg tab TIER 1 entecavir (0.5 mg tab, 1 mg entecavir TIER 1 tab) EPIVIR HBV 5 MG/ML EPIVIR HBV SOLUTION TIER 3 lamivudine (hbv) lamivudine lamivudine 100 mg tab TIER 1 TYZEKA 600 MG TAB TYZEKA SP-P telbivudine VEMLIDY 25 MG TAB VEMLIDY tenofovir alafenamide SP-P fumarate

ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS

DAKLINZA (30 MG TAB, 60 QL (28 PER 28 DAY(S)), DAKLINZA MG TAB, 90 MG TAB) SP-NP MN-PA (Medically Necessary daclatasvir dihydrochloride Prior Authorization) EPCLUSA 400-100 MG EPCLUSA TAB SP-P PA, QL (28 PER 28 DAYS) sofosbuvir-velpatasvir HARVONI (33.75-150 MG PACKET, 45-200 MG TAB, HARVONI SP-P PA, QL (28 PER 28 DAY(S)) 45-200 MG PACKET) ledipasvir-sofosbuvir HARVONI 90-400 MG TAB HARVONI SP-P PA, QL (28 PER 28 DAYS) ledipasvir-sofosbuvir LEDIPASVIR- LEDIPASVIR- SOFOSBUVIR 90-400 MG SP-P PA, QL (28 PER 28 DAYS) SOFOSBUVIR TAB ledipasvir-sofosbuvir MAVYRET 100-40 MG TAB MAVYRET SP-P PA, QL (84 PER 28 DAY(S)) glecaprevir-pibrentasvir QL (28 PER 28 DAYS), MN- OLYSIO 150 MG CAP OLYSIO SP-NP PA (Medically Necessary simeprevir sodium Prior Authorization)

©2020 Wellmark, Inc. 51 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SOFOSBUVIR- SOFOSBUVIR- VELPATASVIR 400-100 SP-P PA, QL (28 PER 28 DAYS) VELPATASVIR MG TAB sofosbuvir-velpatasvir SOVALDI (150 MG QL (28 PER 28 DAY(S)), PACKET, 200 MG SOVALDI SP-NP MN-PA (Medically Necessary PACKET, 200 MG TAB) Prior Authorization) sofosbuvir QL (28 PER 28 DAYS), MN- SOVALDI 400 MG TAB SOVALDI SP-NP PA (Medically Necessary sofosbuvir Prior Authorization) TECHNIVIE 12.5-75-50 MG QL (56 PER 28 DAYS), MN- TAB TECHNIVIE SP-NP PA (Medically Necessary ombitasvir-paritaprevir- Prior Authorization) ritonavir VIEKIRA PAK 12.5-75-50 QL (112 PER 28 DAYS), MN- &250 MG TAB THPK VIEKIRA PAK SP-NP PA (Medically Necessary ombitasvir-paritaprevir- Prior Authorization) ritonavir-dasabuvir VIEKIRA XR 200-8.33-50- QL (84 PER 28 DAYS), MN- 33.33 MG TAB ER 24H VIEKIRA XR SP-NP PA (Medically Necessary ombitasvir-paritaprevir- Prior Authorization) ritonavir-dasabuvir VOSEVI 400-100-100 MG TAB VOSEVI SP-P PA, QL (28 PER 28 DAY(S)) sofosbuvir-velpatasvir- voxilaprevir QL (28 PER 28 DAYS), MN- ZEPATIER 50-100 MG TAB ZEPATIER SP-NP PA (Medically Necessary elbasvir-grazoprevir Prior Authorization)

ANTI-HEPATITIS C (HCV) AGENTS, OTHER

moderiba moderiba 200 mg tab TIER 1 PEG-INTRON REDIPEN PEG-INTRON (50 KIT, 80 KIT, 120 KIT, SP-P REDIPEN 150 KIT) peginterferon alfa-2b PEGASYS (180 MCG/0.5ML SOLUTION, PEGASYS SP-P PA, QL (4 PER 28 DAYS) 180 MCG/ML SOLUTION) peginterferon alfa-2a PEGASYS PROCLICK PEGASYS (135 SOLUTION, 180 SP-P PA, QL (4 PER 28 DAYS) PROCLICK SOLUTION) peginterferon alfa-2a

©2020 Wellmark, Inc. 52 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PEGINTRON (50 KIT, 80 PEGINTRON KIT, 120 KIT, 150 KIT) SP-P peginterferon alfa-2b ribasphere (200 mg tab, ribasphere TIER 1 200 mg cap) ribavirin (200 mg cap, 200 ribavirin TIER 1 mg tab)

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)

GENVOYA 150-150-200-10 MG TAB GENVOYA elvitegravir-cobicistat- TIER 2 emtricitabine-tenofovir alafenamide ISENTRESS (25 MG CHEW TAB, 100 MG ISENTRESS TIER 2 CHEW TAB, 400 MG TAB) raltegravir potassium ISENTRESS 100 MG ISENTRESS PACKET TIER 3 raltegravir potassium ISENTRESS HD 600 MG ISENTRESS HD TAB TIER 2 raltegravir potassium STRIBILD 150-150-200- 300 MG TAB STRIBILD TIER 2 elvitegravir-cobicistat- emtricitabine-tenofovir df SYMTUZA 800-150-200-10 MG TAB SYMTUZA darunavir-cobicistat- TIER 2 emtricitabine-tenofovir alafenamide TIVICAY (10 MG TAB, 25 TIVICAY MG TAB, 50 MG TAB) TIER 2 dolutegravir sodium TIVICAY PD 5 MG TAB TIVICAY PD SOL TIER 2 dolutegravir sodium VITEKTA (85 MG TAB, 150 VITEKTA MG TAB) TIER 2 elvitegravir

ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

COMPLERA 200-25-300 MG TAB COMPLERA emtricitabine-rilpivirine- TIER 2 tenofovir disoproxil fumarate DELSTRIGO 100-300-300 MG TAB DELSTRIGO doravirine-lamivudine- TIER 2 tenofovir disoproxil fumarate EDURANT 25 MG TAB EDURANT TIER 2 rilpivirine hcl efavirenz (50 mg cap, 200 efavirenz TIER 1 mg cap, 600 mg tab) efavirenz-emtricitab- efavirenz-emtricitab- tenofovir 600-200-300 mg TIER 1 tenofovir tab INTELENCE (25 MG TAB, 100 MG TAB, 200 MG INTELENCE TIER 2 TAB) etravirine nevirapine (50 mg/5ml nevirapine TIER 1 suspension, 200 mg tab) nevirapine er (er 100 mg nevirapine er tab er 24h, er 400 mg tab er TIER 1 24h) ODEFSEY 200-25-25 MG TAB ODEFSEY emtricitabine-rilpivirine- TIER 2 tenofovir alafenamide fumarate PIFELTRO 100 MG TAB PIFELTRO TIER 2 doravirine RESCRIPTOR (100 MG RESCRIPTOR TAB, 200 MG TAB) TIER 2 delavirdine mesylate

ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)

abacavir sulfate (20 mg/ml abacavir sulfate TIER 1 solution, 300 mg tab) abacavir sulfate- abacavir sulfate-lamivudine TIER 1 lamivudine 600-300 mg tab abacavir-lamivudine- abacavir-lamivudine- zidovudine 300-150-300 mg TIER 1 zidovudine tab

©2020 Wellmark, Inc. 54 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CIMDUO 300-300 MG TAB CIMDUO lamivudine-tenofovir TIER 2 disoproxil fumarate didanosine (200 mg cap dr, didanosine 250 mg cap dr, 400 mg cap TIER 1 dr) emtricitabine emtricitabine 200 mg cap TIER 1 EMTRIVA 10 MG/ML EMTRIVA SOLUTION TIER 2 emtricitabine lamivudine (10 mg/ml lamivudine solution, 150 mg tab, 300 TIER 1 mg tab) lamivudine- lamivudine-zidovudine 150- TIER 1 zidovudine 300 mg tab stavudine (15 mg cap, 20 stavudine mg cap, 30 mg cap, 40 mg TIER 1 cap) TEMIXYS 300-300 MG TAB TEMIXYS TIER 2 lamivudine-tenofovir disoproxil fumarate tenofovir disoproxil tenofovir disoproxil TIER 1 fumarate fumarate 300 mg tab TRUVADA (100-150 MG TAB, 133-200 MG TAB, 167-250 MG TAB, 200-300 TRUVADA TIER 2 PV MG TAB) emtricitabine-tenofovir disoproxil fumarate VIDEX (2 GM RECON SOLN, 4 GM RECON VIDEX TIER 3 SOLN) didanosine VIREAD (150 MG TAB, 200 MG TAB, 250 MG TAB) VIREAD TIER 2 tenofovir disoproxil fumarate VIREAD 40 MG/GM POWDER VIREAD TIER 3 tenofovir disoproxil fumarate zidovudine (50 mg/5ml zidovudine syrup, 100 mg cap, 300 mg TIER 1 tab)

ANTI-HIV AGENTS, OTHER

BIKTARVY 50-200-25 MG TAB BIKTARVY bictegravir-emtricitabine- TIER 2 tenofovir alafenamide fumarate DESCOVY 200-25 MG TAB DESCOVY emtricitabine-tenofovir TIER 2 PA, PV alafenamide fumarate DOVATO 50-300 MG TAB DOVATO dolutegravir sodium- TIER 2 lamivudine efavirenz-lamivudine- efavirenz-lamivudine- tenofovir (400-300-300 mg TIER 1 tenofovir tab, 600-300-300 mg tab) FUZEON 90 MG RECON FUZEON SOLN SP-P enfuvirtide RUKOBIA 600 MG TAB ER RUKOBIA 12H SP-P fostemsavir tromethamine SELZENTRY (25 MG TAB, 75 MG TAB, 150 MG TAB, SELZENTRY TIER 2 300 MG TAB) maraviroc SELZENTRY 20 MG/ML SELZENTRY SOLUTION TIER 3 maraviroc TRIUMEQ 600-50-300 MG TAB TRIUMEQ TIER 2 abacavir-dolutegravir- lamivudine TYBOST 150 MG TAB TYBOST TIER 2 cobicistat

ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS 100 MG/ML APTIVUS SOLUTION TIER 3 tipranavir APTIVUS 250 MG CAP APTIVUS TIER 2 tipranavir atazanavir sulfate (150 mg atazanavir sulfate cap, 200 mg cap, 300 mg TIER 1 cap)

©2020 Wellmark, Inc. 56 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CRIXIVAN (200 MG CAP, CRIXIVAN 400 MG CAP) TIER 2 indinavir sulfate EVOTAZ 300-150 MG TAB EVOTAZ TIER 3 atazanavir sulfate-cobicistat fosamprenavir fosamprenavir calcium 700 TIER 1 calcium mg tab INVIRASE (200 MG CAP, INVIRASE 500 MG TAB) TIER 2 saquinavir mesylate KALETRA (100-25 MG KALETRA TAB, 200-50 MG TAB) TIER 2 lopinavir-ritonavir LEXIVA 50 MG/ML LEXIVA SUSPENSION TIER 3 fosamprenavir calcium lopinavir-ritonavir 400-100 lopinavir-ritonavir TIER 1 mg/5ml solution NORVIR (80 MG/ML SOLUTION, 100 MG NORVIR TIER 3 PACKET) ritonavir NORVIR 100 MG CAP NORVIR TIER 2 ritonavir PREZCOBIX 800-150 MG PREZCOBIX TAB TIER 3 darunavir-cobicistat PREZISTA (75 MG TAB, 150 MG TAB, 600 MG TAB, PREZISTA TIER 2 800 MG TAB) darunavir ethanolate PREZISTA 100 MG/ML PREZISTA SUSPENSION TIER 3 darunavir ethanolate REYATAZ 50 MG PACKET REYATAZ TIER 3 atazanavir sulfate ritonavir ritonavir 100 mg tab TIER 1 VIRACEPT (250 MG TAB, VIRACEPT 625 MG TAB) TIER 2 nelfinavir mesylate

ANTI-INFLUENZA AGENTS

oseltamivir phosphate (6 oseltamivir phosphate mg/ml recon susp, 30 mg TIER 1 cap, 45 mg cap, 75 mg cap)

©2020 Wellmark, Inc. 57 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS RELENZA DISKHALER 5 RELENZA MG/BLISTER AER POW TIER 2 DISKHALER BA zanamivir RIMANTADINE HCL 100 RIMANTADINE HCL MG TAB TIER 1 rimantadine hydrochloride

ANTIHERPETIC AGENTS

acyclovir (5 % cream, 5 % ointment, 200 mg/5ml acyclovir TIER 1 suspension, 200 mg cap, 400 mg tab, 800 mg tab) famciclovir (125 mg tab, famciclovir TIER 1 250 mg tab, 500 mg tab) trifluridine trifluridine 1 % solution TIER 1 valacyclovir hcl (1 gm tab, valacyclovir hcl TIER 1 500 mg tab)

ANXIOLYTICS

ANXIOLYTICS, OTHER

buspirone hcl (5 mg tab, 7.5 buspirone hcl mg tab, 10 mg tab, 15 mg TIER 1 tab, 30 mg tab) meprobamate (200 mg tab, meprobamate TIER 1 400 mg tab)

BENZODIAZEPINES

alprazolam (0.25 mg tab, 0.25 mg tab disp, 0.5 mg alprazolam tab, 0.5 mg tab disp, 1 mg TIER 1 tab disp, 1 mg tab, 2 mg tab disp, 2 mg tab) alprazolam er (er 0.5 mg tab er 24h, er 1 mg tab er alprazolam er TIER 1 24h, er 2 mg tab er 24h, er 3 mg tab er 24h) ALPRAZOLAM INTENSOL ALPRAZOLAM 1 MG/ML CONC TIER 1 INTENSOL alprazolam alprazolam xr (0.5 mg tab er 24h, 1 mg tab er 24h, 2 alprazolam xr TIER 1 mg tab er 24h, 3 mg tab er 24h) chlordiazepoxide hcl (5 mg chlordiazepoxide hcl TIER 1 cap, 10 mg cap, 25 mg cap)

©2020 Wellmark, Inc. 58 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS clonazepam (0.125 mg tab disp, 0.25 mg tab disp, 0.5 clonazepam mg tab, 0.5 mg tab disp, 1 TIER 1 PV mg tab, 1 mg tab disp, 2 mg tab, 2 mg tab disp) clorazepate dipotassium clorazepate (3.75 mg tab, 7.5 mg tab, TIER 1 dipotassium 15 mg tab) diazepam (2 mg tab, 5 diazepam mg/5ml solution, 5 mg/ml TIER 1 conc, 5 mg tab, 10 mg tab) diazepam intensol 5 mg/ml diazepam intensol TIER 1 conc lorazepam (0.5 mg tab, 1 lorazepam mg tab, 2 mg tab, 2 mg/ml TIER 1 conc) lorazepam intensol 2 mg/ml lorazepam intensol TIER 1 conc oxazepam (10 mg cap, 15 oxazepam TIER 1 mg cap, 30 mg cap)

BIPOLAR AGENTS

MOOD STABILIZERS

LITHIUM 8 MEQ/5ML LITHIUM SOLUTION TIER 3 lithium lithium carbonate (150 mg lithium carbonate cap, 300 mg cap, 300 mg TIER 1 tab, 600 mg cap) lithium carbonate er (er 300 lithium carbonate er mg tab er, er 450 mg tab TIER 1 er)

BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTS

acarbose (25 mg tab, 50 acarbose TIER 1 PV mg tab, 100 mg tab) alogliptin benzoate (6.25 alogliptin benzoate mg tab, 12.5 mg tab, 25 mg TIER 1 PV tab) alogliptin-metformin hcl alogliptin-metformin (12.5-500 mg tab, 12.5- TIER 1 PV hcl 1000 mg tab)

©2020 Wellmark, Inc. 59 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS alogliptin-pioglitazone (12.5-30 mg tab, 12.5-45 alogliptin-pioglitazone mg tab, 12.5-15 mg tab, 25- TIER 1 PV 30 mg tab, 25-15 mg tab, 25-45 mg tab) AVANDAMET 2-1000 MG TAB AVANDAMET TIER 2 rosiglitazone maleate- metformin hcl BYDUREON (2 MG SRER, BYDUREON 2 MG PEN) TIER 2 QL (4 PER 28 DAYS), PV exenatide BYDUREON BCISE 2 BYDUREON BCISE MG/0.85ML A-INJ TIER 2 QL (4 PER 28 DAY(S)), PV exenatide BYETTA 10 MCG PEN 10 BYETTA 10 MCG MCG/0.04ML SOLN PEN TIER 3 QL (1 PER 30 DAYS) PEN exenatide BYETTA 5 MCG PEN 5 BYETTA 5 MCG PEN MCG/0.02ML SOLN PEN TIER 3 QL (1 PER 30 DAYS) exenatide CHLORPROPAMIDE (100 CHLORPROPAMIDE MG TAB, 250 MG TAB) TIER 1 PV chlorpropamide glimepiride (1 mg tab, 2 mg glimepiride TIER 1 PV tab, 4 mg tab) glipizide (5 mg tab, 10 mg glipizide TIER 1 PV tab) glipizide er (er 2.5 mg tab glipizide er er 24h, er 5 mg tab er 24h, TIER 1 PV er 10 mg tab er 24h) glipizide xl (2.5 mg tab er glipizide xl 24h, 5 mg tab er 24h, 10 TIER 1 PV mg tab er 24h) glipizide-metformin hcl (2.5- glipizide-metformin 250 mg tab, 2.5-500 mg TIER 1 PV hcl tab, 5-500 mg tab) glyburide (1.25 mg tab, 2.5 glyburide TIER 1 PV mg tab, 5 mg tab) glyburide micronized (1.5 glyburide micronized TIER 1 PV mg tab, 3 mg tab, 6 mg tab) glyburide-metformin (1.25- glyburide-metformin 250 mg tab, 2.5-500 mg TIER 1 PV tab, 5-500 mg tab)

©2020 Wellmark, Inc. 60 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS INVOKAMET (50-500 MG TAB, 50-1000 MG TAB, INVOKAMET 150-1000 MG TAB, 150- TIER 2 PV 500 MG TAB) canagliflozin-metformin hcl INVOKAMET XR (50-1000 MG TAB ER 24H, 50-500 MG TAB ER 24H, 150-1000 INVOKAMET XR TIER 2 PV MG TAB ER 24H, 150-500 MG TAB ER 24H) canagliflozin-metformin hcl INVOKANA (100 MG TAB, INVOKANA 300 MG TAB) TIER 2 PV canagliflozin JANUMET (50-1000 MG JANUMET TAB, 50-500 MG TAB) TIER 2 PV sitagliptin-metformin hcl JANUMET XR (50-500 MG TAB ER 24H, 50-1000 MG JANUMET XR TAB ER 24H, 100-1000 MG TIER 2 PV TAB ER 24H) sitagliptin-metformin hcl JANUVIA (25 MG TAB, 50 JANUVIA MG TAB, 100 MG TAB) TIER 2 PV sitagliptin phosphate JARDIANCE (10 MG TAB, JARDIANCE 25 MG TAB) TIER 2 PV empagliflozin metformin hcl (500 mg tab, metformin hcl TIER 1 PV 850 mg tab, 1000 mg tab) metformin hcl 500 mg/5ml PA, QL (765 PER 30 metformin hcl TIER 1 solution DAY(S)), PV metformin hcl er (er 500 mg metformin hcl er tab er 24h, er 750 mg tab er TIER 1 PV 24h) miglitol (25 mg tab, 50 mg miglitol TIER 1 PV tab, 100 mg tab) nateglinide (60 mg tab, 120 nateglinide TIER 1 PV mg tab) OZEMPIC (0.25 OR 0.5 OZEMPIC (0.25 OR MG/DOSE) 2 MG/1.5ML TIER 2 QL (1 PER 28 DAY(S)), PV 0.5 MG/DOSE) SOLN PEN semaglutide OZEMPIC (1 MG/DOSE) 2 OZEMPIC (1 MG/1.5ML SOLN PEN TIER 2 QL (2 PER 28 DAY(S)), PV MG/DOSE) semaglutide

©2020 Wellmark, Inc. 61 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS pioglitazone hcl (15 mg tab, pioglitazone hcl TIER 1 PV 30 mg tab, 45 mg tab) pioglitazone hcl- pioglitazone hcl-glimepiride TIER 1 PV glimepiride (30-2 mg tab, 30-4 mg tab) pioglitazone hcl-metformin pioglitazone hcl- hcl (-metformin 15-850 mg TIER 1 PV metformin hcl tab, -metformin 15-500 mg tab) repaglinide (0.5 mg tab, 1 repaglinide TIER 1 PV mg tab, 2 mg tab) REPAGLINIDE- REPAGLINIDE- METFORMIN HCL (1-500 TIER 1 METFORMIN HCL MG TAB, 2-500 MG TAB) repaglinide-metformin hcl RIOMET ER 500 MG/5ML PA, QL (765 PER 30 RIOMET ER SRER TIER 2 DAY(S)), PV metformin hcl SYMLINPEN 120 2700 SYMLINPEN 120 MCG/2.7ML SOLN PEN TIER 2 PV pramlintide acetate SYMLINPEN 60 1500 SYMLINPEN 60 MCG/1.5ML SOLN PEN TIER 2 PV pramlintide acetate SYNJARDY (5-1000 MG TAB, 5-500 MG TAB, 12.5- SYNJARDY 1000 MG TAB, 12.5-500 TIER 2 PV MG TAB) empagliflozin-metformin hcl SYNJARDY XR (5-1000 MG TAB ER 24H, 10-1000 MG TAB ER 24H, 12.5- SYNJARDY XR TIER 2 PV 1000 MG TAB ER 24H, 25- 1000 MG TAB ER 24H) empagliflozin-metformin hcl TOLAZAMIDE (250 MG TOLAZAMIDE TAB, 500 MG TAB) TIER 1 PV tolazamide TOLBUTAMIDE 500 MG TOLBUTAMIDE TAB TIER 1 PV tolbutamide VICTOZA 18 MG/3ML VICTOZA SOLN PEN TIER 2 QL (3 PER 30 DAYS), PV liraglutide

GLYCEMIC AGENTS

BAQSIMI ONE PACK 3 BAQSIMI ONE PACK MG/DOSE POWDER TIER 2 QL (2 PER RX) glucagon BAQSIMI TWO PACK 3 BAQSIMI TWO PACK MG/DOSE POWDER TIER 2 QL (2 PER RX) glucagon diazoxide 50 mg/ml diazoxide TIER 1 suspension GLUCAGEN HYPOKIT 1 GLUCAGEN MG RECON SOLN TIER 2 HYPOKIT glucagon hcl (rdna) GLUCAGON EMERGENCY GLUCAGON 1 MG KIT TIER 2 EMERGENCY glucagon (rdna) GLUCAGON EMERGENCY GLUCAGON 1 MG/ML RECON SOLN TIER 2 QL (2 PER RX) EMERGENCY glucagon hcl GVOKE HYPOPEN 1- PACK (0.5 MG/0.1ML GVOKE HYPOPEN SOLN A-INJ, 1 MG/0.2ML TIER 2 QL (2 PER FILL(S)) 1-PACK SOLN A-INJ) glucagon GVOKE HYPOPEN 2- PACK (0.5 MG/0.1ML GVOKE HYPOPEN SOLN A-INJ, 1 MG/0.2ML TIER 2 QL (2 PER FILL(S)) 2-PACK SOLN A-INJ) glucagon GVOKE PFS (0.5 MG/0.1ML SOLN PRSYR, GVOKE PFS 1 MG/0.2ML SOLN TIER 2 QL (2 PER RX) PRSYR) glucagon

INSULINS

BASAGLAR KWIKPEN 100 BASAGLAR UNIT/ML SOLN PEN TIER 2 PV KWIKPEN insulin glargine FIASP 100 UNIT/ML SOLUTION FIASP TIER 2 PV insulin aspart (with niacinamide) FIASP FLEXTOUCH 100 UNIT/ML SOLN PEN FIASP FLEXTOUCH TIER 2 PV insulin aspart (with niacinamide)

©2020 Wellmark, Inc. 63 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FIASP PENFILL 100 UNIT/ML SOLN CART FIASP PENFILL TIER 2 insulin aspart (with niacinamide) HUMULIN R U-500 HUMULIN R U-500 (CONCENTRATED) 500 TIER 2 PV (CONCENTRATED) UNIT/ML SOLUTION insulin regular (human) HUMULIN R U-500 HUMULIN R U-500 KWIKPEN 500 UNIT/ML TIER 2 PV KWIKPEN SOLN PEN insulin regular (human) INSULIN ASP PROT & ASP FLEXPEN (70-30) 100 INSULIN ASP PROT UNIT/ML SUSP PEN TIER 2 PV & ASP FLEXPEN insulin aspart protamine & aspart (human) INSULIN ASPART 100 INSULIN ASPART UNIT/ML SOLUTION TIER 2 PV insulin aspart INSULIN ASPART INSULIN ASPART FLEXPEN 100 UNIT/ML TIER 2 PV FLEXPEN SOLN PEN insulin aspart INSULIN ASPART INSULIN ASPART PENFILL 100 UNIT/ML TIER 2 PV PENFILL SOLN CART insulin aspart INSULIN ASPART PROT & ASPART (70-30) 100 INSULIN ASPART UNIT/ML SUSPENSION TIER 2 PV PROT & ASPART insulin aspart protamine & aspart (human) LEVEMIR 100 UNIT/ML LEVEMIR SOLUTION TIER 2 PV insulin detemir LEVEMIR FLEXTOUCH LEVEMIR 100 UNIT/ML SOLN PEN TIER 2 PV FLEXTOUCH insulin detemir NOVOLIN 70/30 (70-30) 100 UNIT/ML NOVOLIN 70/30 SUSPENSION TIER 2 PV insulin nph isophane & reg (human)

©2020 Wellmark, Inc. 64 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NOVOLIN 70/30 FLEXPEN (70-30) 100 UNIT/ML NOVOLIN 70/30 SUSP PEN TIER 2 FLEXPEN insulin nph isophane & reg (human) NOVOLIN 70/30 FLEXPEN RELION (70-30) 100 NOVOLIN 70/30 UNIT/ML SUSP PEN TIER 2 FLEXPEN RELION insulin nph isophane & reg (human) NOVOLIN 70/30 RELION (70-30) 100 UNIT/ML NOVOLIN 70/30 SUSPENSION TIER 2 PV RELION insulin nph isophane & reg (human) NOVOLIN N 100 UNIT/ML SUSPENSION NOVOLIN N TIER 2 PV insulin nph (human) (isophane) NOVOLIN N FLEXPEN 100 NOVOLIN N UNIT/ML SUSP PEN TIER 2 PV FLEXPEN insulin nph (human) (isophane) NOVOLIN N FLEXPEN RELION 100 UNIT/ML NOVOLIN N SUSP PEN TIER 2 PV FLEXPEN RELION insulin nph (human) (isophane) NOVOLIN N RELION 100 UNIT/ML SUSPENSION NOVOLIN N RELION TIER 2 PV insulin nph (human) (isophane) NOVOLIN R 100 UNIT/ML NOVOLIN R SOLUTION TIER 2 PV insulin regular (human) NOVOLIN R FLEXPEN 100 NOVOLIN R UNIT/ML SOLN PEN TIER 2 PV FLEXPEN insulin regular (human) NOVOLIN R FLEXPEN NOVOLIN R RELION 100 UNIT/ML TIER 2 PV FLEXPEN RELION SOLN PEN insulin regular (human) NOVOLIN R RELION 100 NOVOLIN R RELION UNIT/ML SOLUTION TIER 2 PV insulin regular (human) NOVOLOG 100 UNIT/ML NOVOLOG SOLUTION TIER 2 PV insulin aspart

©2020 Wellmark, Inc. 65 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NOVOLOG FLEXPEN 100 NOVOLOG UNIT/ML SOLN PEN TIER 2 PV FLEXPEN insulin aspart NOVOLOG MIX 70/30 (70- 30) 100 UNIT/ML NOVOLOG MIX SUSPENSION TIER 2 PV 70/30 insulin aspart protamine & aspart (human) NOVOLOG MIX 70/30 FLEXPEN (70-30) 100 NOVOLOG MIX UNIT/ML SUSP PEN TIER 2 PV 70/30 FLEXPEN insulin aspart protamine & aspart (human) NOVOLOG PENFILL 100 NOVOLOG PENFILL UNIT/ML SOLN CART TIER 2 PV insulin aspart TRESIBA 100 UNIT/ML TRESIBA SOLUTION TIER 2 PV insulin degludec TRESIBA FLEXTOUCH TRESIBA (100 SOLN PEN, 200 TIER 2 PV FLEXTOUCH SOLN PEN) insulin degludec

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS

ANTICOAGULANTS

COUMADIN (1 MG TAB, 2 MG TAB, 2.5 MG TAB, 3 MG TAB, 4 MG TAB, 5 MG COUMADIN TIER 2 GA TAB, 6 MG TAB, 7.5 MG TAB, 10 MG TAB) warfarin sodium ELIQUIS (2.5 MG TAB, 5 ELIQUIS MG TAB) TIER 2 PV apixaban ELIQUIS DVT/PE ELIQUIS DVT/PE STARTER PACK 5 MG TIER 2 PV STARTER PACK TAB THPK apixaban

©2020 Wellmark, Inc. 66 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS enoxaparin sodium (30 mg/0.3ml solution, 40 mg/0.4ml solution, 60 mg/0.6ml solution, 80 enoxaparin sodium mg/0.8ml solution, 100 TIER 1 PV mg/ml solution, 120 mg/0.8ml solution, 150 mg/ml solution, 300 mg/3ml solution) fondaparinux sodium (2.5 mg/0.5ml solution, 5 fondaparinux sodium mg/0.4ml solution, 7.5 TIER 1 PV mg/0.6ml solution, 10 mg/0.8ml solution) FRAGMIN (2500 UNIT/0.2ML SOLUTION, 5000 UNIT/0.2ML SOLUTION, 7500 UNIT/0.3ML SOLUTION, 10000 UNIT/ML SOLUTION, 12500 FRAGMIN TIER 2 PV UNIT/0.5ML SOLUTION, 15000 UNIT/0.6ML SOLUTION, 18000 UNT/0.72ML SOLUTION, 95000 UNIT/3.8ML SOLUTION) dalteparin sodium HEPARIN LOCK FLUSH (1 SOLUTION, 2 SOLUTION, HEPARIN LOCK 10 SOLUTION, 100 TIER 1 FLUSH SOLUTION) heparin sodium (porcine) lock flush heparin sodium (porcine) heparin sodium (5000 solution, 10000 TIER 1 (porcine) solution) heparin sodium heparin sodium (porcine) pf TIER 1 (porcine) pf 5000 unit/0.5ml solution heparin sodium lock heparin sodium lock flush TIER 1 flush 100 unit/ml solution IPRIVASK 15 MG RECON IPRIVASK SOLN SP-M desirudin

©2020 Wellmark, Inc. 67 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS jantoven (1 mg tab, 2 mg tab, 2.5 mg tab, 3 mg tab, 4 jantoven TIER 1 PV mg tab, 5 mg tab, 6 mg tab, 7.5 mg tab, 10 mg tab) monoject flush monoject flush syr/hep lock TIER 1 syr/hep lock (10 solution, 100 solution) monoject prefill adv monoject prefill adv heparin TIER 1 heparin 10 unit/ml solution warfarin sodium (1 mg tab, 2 mg tab, 2.5 mg tab, 3 mg warfarin sodium tab, 4 mg tab, 5 mg tab, 6 TIER 1 PV mg tab, 7.5 mg tab, 10 mg tab) XARELTO (2.5 MG TAB, 10 MG TAB, 15 MG TAB, XARELTO TIER 2 PV 20 MG TAB) rivaroxaban

BLOOD FORMATION MODIFIERS

anagrelide hcl (0.5 mg cap, anagrelide hcl TIER 1 1 mg cap) ARANESP (ALBUMIN FREE) (10 MCG/0.4ML SOLN PRSYR, 25 MCG/0.42ML SOLN PRSYR, 25 MCG/ML SOLUTION, 40 MCG/ML SOLUTION, 40 MCG/0.4ML SOLN PRSYR, 60 MCG/ML SOLUTION, 60 MCG/0.3ML SOLN ARANESP (ALBUMIN PRSYR, 100 MCG/ML SP-P FREE) SOLUTION, 100 MCG/0.5ML SOLN PRSYR, 150 MCG/0.3ML SOLN PRSYR, 200 MCG/0.4ML SOLN PRSYR, 200 MCG/ML SOLUTION, 300 MCG/ML SOLUTION, 300 MCG/0.6ML SOLN PRSYR, 500 MCG/ML SOLN PRSYR) darbepoetin alfa CABLIVI 11 MG KIT CABLIVI SP-P caplacizumab-yhdp DOPTELET 20 MG TAB DOPTELET SP-P QL (60 PER 30 DAY(S)) avatrombopag maleate

©2020 Wellmark, Inc. 68 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS EPOGEN (2000 SOLUTION, 3000 SOLUTION, 4000 EPOGEN SOLUTION, 10000 SP-P SOLUTION, 20000 SOLUTION) epoetin alfa FULPHILA 6 MG/0.6ML FULPHILA SOLN PRSYR SP-P pegfilgrastim-jmdb GRANIX (300 MCG/0.5ML SOLN PRSYR, 300 MCG/ML SOLUTION, 480 MN-PA (Medically Necessary GRANIX MCG/0.8ML SOLN PRSYR, SP-NP Prior Authorization) 480 MCG/1.6ML SOLUTION) tbo-filgrastim LEUKINE 250 MCG MN-PA (Medically Necessary LEUKINE RECON SOLN SP-NP Prior Authorization) sargramostim MIRCERA (30 SOLN PRSYR, 150 SOLN MIRCERA PRSYR) SP-P methoxy polyethylene glycol-epoetin beta MOZOBIL 24 MG/1.2ML MOZOBIL SOLUTION SP-M plerixafor MULPLETA 3 MG TAB MULPLETA SP-P QL (7 PER 14 DAY(S)) lusutrombopag NEULASTA 6 MG/0.6ML NEULASTA SOLN PRSYR SP-P pegfilgrastim NEULASTA ONPRO 6 NEULASTA ONPRO MG/0.6ML PREF SY KT SP-P pegfilgrastim NEUPOGEN (300 MCG/ML SOLUTION, 300 MCG/0.5ML SOLN PRSYR, MN-PA (Medically Necessary NEUPOGEN 480 MCG/1.6ML SP-NP Prior Authorization) SOLUTION, 480 MCG/0.8ML SOLN PRSYR) filgrastim

©2020 Wellmark, Inc. 69 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NIVESTYM (300 MCG/ML SOLUTION, 300 MCG/0.5ML SOLN PRSYR, NIVESTYM 480 MCG/0.8ML SOLN SP-P PRSYR, 480 MCG/1.6ML SOLUTION) filgrastim-aafi NPLATE (125 MCG RECON SOLN, 250 MCG NPLATE RECON SOLN, 500 MCG SP-M RECON SOLN) romiplostim PROCRIT (2000 SOLUTION, 3000 SOLUTION, 4000 SOLUTION, 10000 PROCRIT SP-P SOLUTION, 20000 SOLUTION, 40000 SOLUTION) epoetin alfa PROMACTA (12.5 MG PROMACTA PACKET, 25 MG PACKET) SP-P QL (90 PER 30 DAY(S)) eltrombopag olamine PROMACTA (25 MG TAB, PROMACTA 50 MG TAB) SP-P QL (90 PER 30 DAYS) eltrombopag olamine PROMACTA 12.5 MG TAB PROMACTA SP-P QL (30 PER 30 DAYS) eltrombopag olamine PROMACTA 75 MG TAB PROMACTA SP-P QL (60 PER 30 DAYS) eltrombopag olamine REBLOZYL 25 MG RECON REBLOZYL SOLN SP-M PA luspatercept-aamt REBLOZYL 75 MG RECON REBLOZYL SOLN SP-M PA luspatercept-aamt RETACRIT (2000 SOLUTION, 3000 SOLUTION, 4000 RETACRIT SOLUTION, 10000 SP-P SOLUTION, 40000 SOLUTION) epoetin alfa-epbx TAVALISSE (100 MG TAB, TAVALISSE 150 MG TAB) SP-P PA fostamatinib disodium

©2020 Wellmark, Inc. 70 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS UDENYCA 6 MG/0.6ML UDENYCA SOLN PRSYR SP-P pegfilgrastim-cbqv ZARXIO (300 MCG/0.5ML SOLN PRSYR, 480 ZARXIO SP-P MCG/0.8ML SOLN PRSYR) filgrastim-sndz ZIEXTENZO 6 MG/0.6ML ZIEXTENZO SOLN PRSYR SP-P pegfilgrastim-bmez

HEMOSTASIS AGENTS

ADVATE (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 1500 RECON SOLN, 2000 ADVATE RECON SOLN, 3000 SP-M RECON SOLN, 4000 RECON SOLN) antihemophilic factor rahf- pfm ADYNOVATE (250 RECON SOLN, 500 RECON SOLN, 750 RECON SOLN, 1000 RECON SOLN, 1500 ADYNOVATE RECON SOLN, 2000 SP-M RECON SOLN, 3000 RECON SOLN) antihemophilic factor (recombinant) pegylated AFSTYLA (250 KIT, 500 KIT, 1000 KIT, 1500 KIT, 2000 KIT, 2500 KIT, 3000 AFSTYLA SP-M KIT) antihemophilic factor (recombinant) single chain ALPHANATE/VWF COMPLEX/HUMAN (250 RECON SOLN, 500 RECON SOLN, 1000 ALPHANATE/VWF RECON SOLN, 1500 SP-M COMPLEX/HUMAN RECON SOLN, 2000 RECON SOLN) antihemophilic factor/von willebrand factor complex (human)

©2020 Wellmark, Inc. 71 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ALPHANINE SD (500 RECON SOLN, 1000 ALPHANINE SD RECON SOLN, 1500 SP-M RECON SOLN) coagulation factor ix ALPROLIX (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 2000 RECON SOLN, 3000 ALPROLIX RECON SOLN, 4000 SP-M RECON SOLN) coagulation factor ix (recomb) fc fusion protein (rfixfc) aminocaproic acid (0.25 aminocaproic acid gm/ml solution, 500 mg tab, TIER 1 1000 mg tab) BEBULIN 200-1200 UNIT BEBULIN RECON SOLN SP-M factor ix complex BENEFIX (250 KIT, 500 KIT, 1000 KIT, 2000 KIT, BENEFIX 3000 KIT) SP-M coagulation factor ix (recombinant) COAGADEX (250 RECON SOLN, 500 RECON SOLN) COAGADEX SP-M coagulation factor x (human) ELOCTATE (250 RECON SOLN, 500 RECON SOLN, 750 RECON SOLN, 1000 RECON SOLN, 1500 RECON SOLN, 2000 RECON SOLN, 3000 ELOCTATE RECON SOLN, 4000 SP-M RECON SOLN, 5000 RECON SOLN, 6000 RECON SOLN) antihemophilic factor (recomb) fc fusion protein (rfviiifc) FEIBA (500 RECON SOLN, 1000 RECON SOLN, 2500 FEIBA RECON SOLN) SP-M antiinhibitor coagulant complex

©2020 Wellmark, Inc. 72 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FEIBA NF RECON SOLN FEIBA NF antiinhibitor coagulant SP-M complex HELIXATE FS (250 KIT, 500 KIT, 1000 KIT, 2000 HELIXATE FS KIT, 3000 KIT) SP-M antihemophilic factor (recombinant) HEMLIBRA (30 MG/ML SOLUTION, 60 MG/0.4ML SOLUTION, 105 MG/0.7ML HEMLIBRA SP-M SOLUTION, 150 MG/ML SOLUTION) emicizumab-kxwh HEMOFIL M (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 1700 HEMOFIL M SP-M RECON SOLN) antihemophilic factor (human) HUMATE-P (250-600 RECON SOLN, 500-1200 RECON SOLN, 1000-2400 HUMATE-P RECON SOLN) SP-M antihemophilic factor/von willebrand factor complex (human) IDELVION (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 2000 RECON SOLN, 3500 IDELVION SP-M RECON SOLN) coagulation factor ix recomb albumin fusion protein (rix-fp) IXINITY (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 1500 RECON SOLN, 2000 IXINITY SP-M RECON SOLN, 3000 RECON SOLN) coagulation factor ix (recombinant)

©2020 Wellmark, Inc. 73 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS JIVI (500 RECON SOLN, 1000 RECON SOLN, 2000 RECON SOLN, 3000 JIVI RECON SOLN) SP-M antihemophilic factor (recombinant) pegylated- aucl KOATE (250 RECON SOLN, 500 RECON SOLN, KOATE 1000 RECON SOLN) SP-M antihemophilic factor (human) KOATE-DVI (250 RECON SOLN, 500 RECON SOLN, KOATE-DVI 1000 RECON SOLN) SP-M antihemophilic factor (human) KOGENATE FS (250 KIT, 500 KIT, 1000 KIT, 2000 KOGENATE FS KIT, 3000 KIT) SP-M antihemophilic factor (recombinant) KOGENATE FS BIO-SET (250 KIT, 500 KIT, 1000 KOGENATE FS BIO- KIT, 2000 KIT, 3000 KIT) SP-M SET antihemophilic factor (recombinant) KOVALTRY (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 2000 KOVALTRY RECON SOLN, 3000 SP-M RECON SOLN) antihemophilic factor rahf- pfm MONOCLATE-P (1000 KIT, 1500 KIT) MONOCLATE-P SP-M antihemophilic factor (human) MONONINE 1000 UNIT MONONINE RECON SOLN SP-M coagulation factor ix

©2020 Wellmark, Inc. 74 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NOVOEIGHT (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 1500 RECON SOLN, 2000 NOVOEIGHT SP-M RECON SOLN, 3000 RECON SOLN) antihemophilic factor (rcmb) bd truncated (bd trunc-rfviii) NOVOSEVEN RT (1 MG RECON SOLN, 2 MG RECON SOLN, 5 MG NOVOSEVEN RT RECON SOLN, 8 MG SP-M RECON SOLN) coagulation factor viia (recombinant) NUWIQ (250 KIT, 250 RECON SOLN, 500 RECON SOLN, 500 KIT, 1000 KIT, 1000 RECON SOLN, 2000 KIT, 2000 RECON SOLN, 2500 NUWIQ RECON SOLN, 2500 KIT, SP-M 3000 RECON SOLN, 3000 KIT, 4000 KIT, 4000 RECON SOLN) antihemophilic factor (recomb b-domain deleted) (bdd-rfviii) OBIZUR 500 UNIT RECON SOLN OBIZUR antihemophilic factor SP-M (recombinant porcine) (rpfviii) PROFILNINE (500 RECON SOLN, 1000 RECON PROFILNINE SOLN, 1500 RECON SP-M SOLN) factor ix complex PROFILNINE SD 500 UNIT PROFILNINE SD RECON SOLN SP-M factor ix complex REBINYN (500 RECON SOLN, 1000 RECON SOLN, 2000 RECON REBINYN SOLN) SP-M coagulation factor ix (recombinant) glycopegylated

©2020 Wellmark, Inc. 75 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS RECOMBINATE (220-400 RECON SOLN, 401-800 RECON SOLN, 801-1240 RECON SOLN, 1241-1800 RECOMBINATE SP-M RECON SOLN, 1801-2400 RECON SOLN) antihemophilic factor (recombinant) RIXUBIS (250 RECON SOLN, 500 RECON SOLN, 1000 RECON SOLN, 2000 RIXUBIS RECON SOLN, 3000 SP-M RECON SOLN) coagulation factor ix (recombinant) SEVENFACT (1 MG RECON SOLN, 5 MG SEVENFACT RECON SOLN) SP-M coagulation factor viia (recombinant)-jncw tranexamic acid tranexamic acid 650 mg tab TIER 1 VONVENDI (650 RECON SOLN, 1300 RECON VONVENDI SOLN) SP-M von willebrand factor (recombinant) WILATE (500-500 KIT, 1000-1000 KIT) WILATE antihemophilic factor/von SP-M willebrand factor complex (human) XYNTHA (250 KIT, 500 KIT, 1000 KIT, 2000 KIT) XYNTHA antihemophilic factor SP-M (recombinant) plasma/albumin free XYNTHA SOLOFUSE (250 KIT, 500 KIT, 1000 KIT, 2000 KIT, 3000 KIT) XYNTHA SOLOFUSE SP-M antihemophilic factor (recombinant) plasma/albumin free

PLATELET MODIFYING AGENTS

ADAKVEO 100 MG/10ML ADAKVEO SOLUTION SP-M PA crizanlizumab-tmca aspirin-dipyridamole aspirin-dipyridamole er 25- TIER 1 PV er 200 mg cap er 12h

©2020 Wellmark, Inc. 76 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BRILINTA (60 MG TAB, 90 BRILINTA MG TAB) TIER 2 PV ticagrelor cilostazol (50 mg tab, 100 cilostazol TIER 1 mg tab) clopidogrel bisulfate (75 mg clopidogrel bisulfate TIER 1 PV tab, 300 mg tab) dipyridamole (25 mg tab, 50 dipyridamole TIER 1 PV mg tab, 75 mg tab) OXBRYTA 500 MG TAB PA, QL (84 PER 28 DAY(S)), OXBRYTA SP-NP voxelotor PA-QL (140/28 days) prasugrel hcl (5 mg tab, 10 prasugrel hcl TIER 1 PV mg tab)

COAGULANTS

phytonadione phytonadione 5 mg tab TIER 1

CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

clonidine (0.1 mg/24hr patch wk, 0.2 mg/24hr clonidine TIER 1 PV patch wk, 0.3 mg/24hr patch wk) clonidine hcl (0.1 mg tab, clonidine hcl TIER 1 PV 0.2 mg tab, 0.3 mg tab) guanfacine hcl (1 mg tab, 2 guanfacine hcl TIER 1 QL (30 PER 30 DAY(S)), PV mg tab) methyldopa (250 mg tab, methyldopa TIER 1 PV 500 mg tab) midodrine hcl (2.5 mg tab, 5 midodrine hcl TIER 1 mg tab, 10 mg tab)

ALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate (1 mg doxazosin mesylate tab, 2 mg tab, 4 mg tab, 8 TIER 1 mg tab) phenoxybenzamine phenoxybenzamine hcl 10 TIER 1 hcl mg cap prazosin hcl (1 mg cap, 2 prazosin hcl TIER 1 mg cap, 5 mg cap) terazosin hcl (1 mg cap, 2 terazosin hcl mg cap, 5 mg cap, 10 mg TIER 1 cap)

ANGIOTENSIN II RECEPTOR ANTAGONISTS

candesartan cilexetil (4 mg candesartan cilexetil tab, 8 mg tab, 16 mg tab, TIER 1 PV 32 mg tab) EPROSARTAN EPROSARTAN MESYLATE 600 MG TAB TIER 1 PV MESYLATE eprosartan mesylate irbesartan (75 mg tab, 150 irbesartan TIER 1 PV mg tab, 300 mg tab) losartan potassium (25 mg losartan potassium TIER 1 PV tab, 50 mg tab, 100 mg tab) olmesartan medoxomil (5 olmesartan mg tab, 20 mg tab, 40 mg TIER 1 PV medoxomil tab) telmisartan (20 mg tab, 40 telmisartan TIER 1 PV mg tab, 80 mg tab) valsartan (40 mg tab, 80 valsartan mg tab, 160 mg tab, 320 TIER 1 PV mg tab)

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

benazepril hcl (5 mg tab, 10 benazepril hcl mg tab, 20 mg tab, 40 mg TIER 1 PV tab) captopril (12.5 mg tab, 25 captopril mg tab, 50 mg tab, 100 mg TIER 1 PV tab) enalapril maleate (2.5 mg enalapril maleate tab, 5 mg tab, 10 mg tab, TIER 1 PV 20 mg tab) fosinopril sodium (10 mg fosinopril sodium TIER 1 PV tab, 20 mg tab, 40 mg tab) lisinopril (2.5 mg tab, 5 mg lisinopril tab, 10 mg tab, 20 mg tab, TIER 1 PV 30 mg tab, 40 mg tab) moexipril hcl (7.5 mg tab, moexipril hcl TIER 1 PV 15 mg tab) perindopril erbumine (2 mg perindopril erbumine TIER 1 PV tab, 4 mg tab, 8 mg tab) quinapril hcl (5 mg tab, 10 quinapril hcl mg tab, 20 mg tab, 40 mg TIER 1 PV tab) ramipril (1.25 mg cap, 2.5 ramipril mg cap, 5 mg cap, 10 mg TIER 1 PV cap)

ANTIARRHYTHMICS

amiodarone hcl (100 mg amiodarone hcl tab, 200 mg tab, 400 mg TIER 1 PV tab) disopyramide disopyramide phosphate TIER 1 PV phosphate (100 mg cap, 150 mg cap) dofetilide (125 mcg cap, dofetilide TIER 1 PV 250 mcg cap, 500 mcg cap) flecainide acetate (50 mg flecainide acetate tab, 100 mg tab, 150 mg TIER 1 PV tab) mexiletine hcl (150 mg cap, mexiletine hcl TIER 1 200 mg cap, 250 mg cap) MULTAQ 400 MG TAB MULTAQ TIER 3 dronedarone hcl NORPACE CR (100 MG CAP ER 12H, 150 MG CAP NORPACE CR TIER 3 ER 12H) disopyramide phosphate pacerone (100 mg tab, 200 pacerone TIER 1 PV mg tab, 400 mg tab) propafenone hcl (150 mg propafenone hcl tab, 225 mg tab, 300 mg TIER 1 PV tab) propafenone hcl er (er 225 mg cap er 12h, er 325 mg propafenone hcl er TIER 1 PV cap er 12h, er 425 mg cap er 12h) quinidine gluconate er 324 quinidine gluconate er TIER 1 mg tab er QUINIDINE SULFATE (200 QUINIDINE MG TAB, 300 MG TAB) TIER 1 SULFATE quinidine sulfate sorine (80 mg tab, 120 mg sorine tab, 160 mg tab, 240 mg TIER 1 PV tab) sotalol hcl (80 mg tab, 120 sotalol hcl mg tab, 160 mg tab, 240 TIER 1 PV mg tab) sotalol hcl (af) (80 mg tab, sotalol hcl (af) TIER 1 PV 120 mg tab, 160 mg tab)

BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl (200 mg cap, acebutolol hcl TIER 1 PV 400 mg cap) atenolol (25 mg tab, 50 mg atenolol TIER 1 PV tab, 100 mg tab) betaxolol hcl (10 mg tab, 20 betaxolol hcl TIER 1 PV mg tab) bisoprolol fumarate (5 mg bisoprolol fumarate TIER 1 PV tab, 10 mg tab) carvedilol (3.125 mg tab, carvedilol 6.25 mg tab, 12.5 mg tab, TIER 1 PV 25 mg tab) carvedilol phosphate er (er carvedilol phosphate 10 mg cap er 24h, er 20 mg TIER 1 PV er cap er 24h, er 40 mg cap er 24h, er 80 mg cap er 24h) labetalol hcl (100 mg tab, labetalol hcl TIER 1 PV 200 mg tab, 300 mg tab) metoprolol succinate er (er metoprolol succinate 25 mg tab er 24h, er 50 mg TIER 1 PV er tab er 24h, er 100 mg tab er 24h, er 200 mg tab er 24h) metoprolol tartrate (25 mg metoprolol tartrate TIER 1 PV tab, 50 mg tab, 100 mg tab) nadolol (20 mg tab, 40 mg nadolol TIER 1 PV tab, 80 mg tab) pindolol (5 mg tab, 10 mg pindolol TIER 1 PV tab) propranolol hcl (10 mg tab, 20 mg tab, 20 mg/5ml propranolol hcl solution, 40 mg/5ml TIER 1 PV solution, 40 mg tab, 60 mg tab, 80 mg tab) propranolol hcl er (er 60 mg cap er 24h, er 80 mg cap er propranolol hcl er TIER 1 PV 24h, er 120 mg cap er 24h, er 160 mg cap er 24h) timolol maleate (5 mg tab, timolol maleate TIER 1 PV 10 mg tab, 20 mg tab)

CALCIUM CHANNEL BLOCKING AGENTS

afeditab cr (30 mg tab er afeditab cr TIER 1 PV 24h, 60 mg tab er 24h) amlodipine besylate (2.5 amlodipine besylate mg tab, 5 mg tab, 10 mg TIER 1 PV tab)

©2020 Wellmark, Inc. 80 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS cartia xt (120 mg cap er 24h, 180 mg cap er 24h, cartia xt TIER 1 PV 240 mg cap er 24h, 300 mg cap er 24h) dilt-xr (120 mg cap er 24h, dilt-xr 180 mg cap er 24h, 240 mg TIER 1 PV cap er 24h) diltiazem cd (120 mg cap er 24h, 180 mg cap er 24h, diltiazem cd TIER 1 PV 240 mg cap er 24h, 300 mg cap er 24h) diltiazem hcl (25 mg/5ml diltiazem hcl solution, 30 mg tab, 60 mg TIER 1 PV tab, 90 mg tab, 120 mg tab) diltiazem hcl er (er 60 mg cap er 12h, er 90 mg cap er 12h, er 120 mg cap er 12h, diltiazem hcl er TIER 1 PV er 120 mg cap er 24h, er 180 mg cap er 24h, er 240 mg cap er 24h) diltiazem hcl er beads (er beads 120 mg cap er 24h, er beads 180 mg cap er 24h, er beads 240 mg cap diltiazem hcl er beads TIER 1 PV er 24h, er beads 300 mg cap er 24h, er beads 360 mg cap er 24h, er beads 420 mg cap er 24h) diltiazem hcl er coated beads (er beads 120 mg cap er 24h, er beads 180 mg tab er 24h, er beads 180 mg cap er 24h, er beads 240 mg cap er 24h, diltiazem hcl er er beads 240 mg tab er TIER 1 PV coated beads 24h, er beads 300 mg cap er 24h, er beads 300 mg tab er 24h, er beads 360 mg cap er 24h, er beads 360 mg tab er 24h, er beads 420 mg tab er 24h) felodipine er (er 2.5 mg tab felodipine er er 24h, er 5 mg tab er 24h, TIER 1 PV er 10 mg tab er 24h) isradipine (2.5 mg cap, 5 isradipine TIER 1 PV mg cap)

©2020 Wellmark, Inc. 81 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS matzim la (180 mg tab er 24h, 240 mg tab er 24h, matzim la 300 mg tab er 24h, 360 mg TIER 1 PV tab er 24h, 420 mg tab er 24h) nicardipine hcl (20 mg cap, nicardipine hcl TIER 1 PV 30 mg cap) nifediac cc (30 mg tab er nifediac cc TIER 1 PV 24h, 60 mg tab er 24h) nifedical xl (30 mg tab er nifedical xl TIER 1 PV 24h, 60 mg tab er 24h) nifedipine (10 mg cap, 20 nifedipine TIER 1 PV mg cap) nifedipine er (er 30 mg tab nifedipine er er 24h, er 60 mg tab er 24h, TIER 1 PV er 90 mg tab er 24h) nifedipine er osmotic nifedipine er osmotic release (er 30 mg tab er TIER 1 PV release 24h, er 60 mg tab er 24h, er 90 mg tab er 24h) nimodipine nimodipine 30 mg cap TIER 1 nisoldipine er (er 8.5 mg tab er 24h, er 17 mg tab er 24h, er 20 mg tab er 24h, er 25.5 nisoldipine er TIER 1 PV mg tab er 24h, er 30 mg tab er 24h, er 34 mg tab er 24h, er 40 mg tab er 24h) taztia xt (120 mg cap er 24h, 180 mg cap er 24h, taztia xt 240 mg cap er 24h, 300 mg TIER 1 PV cap er 24h, 360 mg cap er 24h) tiadylt er (er 120 mg cap er 24h, er 180 mg cap er 24h, er 240 mg cap er 24h, er tiadylt er TIER 1 PV 300 mg cap er 24h, er 360 mg cap er 24h, er 420 mg cap er 24h) verapamil hcl (40 mg tab, verapamil hcl TIER 1 PV 80 mg tab, 120 mg tab)

©2020 Wellmark, Inc. 82 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VERAPAMIL HCL ER (ER 100 MG CAP ER 24H, ER 120 MG TAB ER, ER 120 MG CAP ER 24H, ER 180 MG TAB ER, ER 180 MG CAP ER 24H, ER 200 MG VERAPAMIL HCL ER TIER 1 PV CAP ER 24H, ER 240 MG CAP ER 24H, ER 240 MG TAB ER, ER 300 MG CAP ER 24H, ER 360 MG CAP ER 24H) verapamil hcl

CARDIOVASCULAR AGENTS, OTHER

aliskiren fumarate (150 mg aliskiren fumarate TIER 1 PV tab, 300 mg tab) amiloride- amiloride- hydrochlorothiazide 5-50 TIER 1 PV hydrochlorothiazide mg tab amlodipine besy-benazepril hcl (2.5-10 mg cap, 5-20 amlodipine besy- mg cap, 5-10 mg cap, 5-40 TIER 1 PV benazepril hcl mg cap, 10-40 mg cap, 10- 20 mg cap) amlodipine besylate- amlodipine besylate- valsartan (5-160 mg tab, 5- TIER 1 PV valsartan 320 mg tab, 10-320 mg tab, 10-160 mg tab) amlodipine-atorvastatin (2.5-40 mg tab, 2.5-10 mg tab, 2.5-20 mg tab, 5-80 mg amlodipine- tab, 5-20 mg tab, 5-40 mg TIER 1 PV atorvastatin tab, 5-10 mg tab, 10-40 mg tab, 10-80 mg tab, 10-20 mg tab, 10-10 mg tab) amlodipine-olmesartan (5- amlodipine- 20 mg tab, 5-40 mg tab, 10- TIER 1 PV olmesartan 40 mg tab, 10-20 mg tab) amlodipine-valsartan-hctz (5-160-12.5 mg tab, 5-160- amlodipine-valsartan- 25 mg tab, 10-160-25 mg TIER 1 PV hctz tab, 10-160-12.5 mg tab, 10-320-25 mg tab) atenolol- atenolol-chlorthalidone (50- TIER 1 PV chlorthalidone 25 mg tab, 100-25 mg tab)

©2020 Wellmark, Inc. 83 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS benazepril- benazepril- hydrochlorothiazide (5-6.25 TIER 1 PV hydrochlorothiazide mg tab, 10-12.5 mg tab, 20- 12.5 mg tab, 20-25 mg tab) bisoprolol- bisoprolol- hydrochlorothiazide (2.5- TIER 1 PV hydrochlorothiazide 6.25 mg tab, 5-6.25 mg tab, 10-6.25 mg tab) candesartan cilexetil-hctz candesartan cilexetil- (16-12.5 mg tab, 32-25 mg TIER 1 PV hctz tab, 32-12.5 mg tab) CAPTOPRIL- HYDROCHLOROTHIAZIDE CAPTOPRIL- (25-15 MG TAB, 25-25 MG HYDROCHLOROTHI TAB, 50-15 MG TAB, 50-25 TIER 1 PV AZIDE MG TAB) captopril & hydrochlorothiazide digitek (125 mcg tab, 250 digitek TIER 1 mcg tab) digox (125 mcg tab, 250 digox TIER 1 mcg tab) digoxin (0.05 mg/ml digoxin solution, 125 mcg tab, 250 TIER 1 mcg tab) enalapril- enalapril- hydrochlorothiazide (5-12.5 TIER 1 PV hydrochlorothiazide mg tab, 10-25 mg tab) ENTRESTO (24-26 MG TAB, 49-51 MG TAB, 97- ENTRESTO TIER 3 PA, QL (60 PER 30 DAYS) 103 MG TAB) sacubitril-valsartan fosinopril sodium-hctz (10- fosinopril sodium-hctz 12.5 mg tab, 20-12.5 mg TIER 1 PV tab) irbesartan- irbesartan- hydrochlorothiazide (150- TIER 1 PV hydrochlorothiazide 12.5 mg tab, 300-12.5 mg tab) isoxsuprine hcl (10 mg tab, isoxsuprine hcl TIER 1 20 mg tab) lisinopril- lisinopril- hydrochlorothiazide (10- TIER 1 PV hydrochlorothiazide 12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab)

©2020 Wellmark, Inc. 84 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS losartan potassium-hctz losartan potassium- (50-12.5 mg tab, 100-12.5 TIER 1 PV hctz mg tab, 100-25 mg tab) METHYLDOPA- HYDROCHLOROTHIAZIDE METHYLDOPA- (250-15 MG TAB, 250-25 HYDROCHLOROTHI TIER 1 PV MG TAB) AZIDE methyldopa & hydrochlorothiazide metoprolol- metoprolol- hydrochlorothiazide (50-25 TIER 1 PV hydrochlorothiazide mg tab, 100-25 mg tab, 100-50 mg tab) metyrosine metyrosine 250 mg cap TIER 1 moexipril- moexipril- hydrochlorothiazide (7.5- TIER 1 PV hydrochlorothiazide 12.5 mg tab, 15-25 mg tab, 15-12.5 mg tab) nadolol- nadolol- bendroflumethiazide (40-5 TIER 1 PV bendroflumethiazide mg tab, 80-5 mg tab) olmesartan medoxomil-hctz olmesartan (20-12.5 mg tab, 40-12.5 TIER 1 PV medoxomil-hctz mg tab, 40-25 mg tab) olmesartan-amlodipine-hctz (20-5-12.5 mg tab, 40-10- olmesartan- 25 mg tab, 40-5-12.5 mg TIER 1 PV amlodipine-hctz tab, 40-10-12.5 mg tab, 40- 5-25 mg tab) pentoxifylline er 400 mg tab pentoxifylline er TIER 1 er PROPRANOLOL-HCTZ (40-25 MG TAB, 80-25 MG PROPRANOLOL- TAB) TIER 1 PV HCTZ propranolol & hydrochlorothiazide quinapril- quinapril- hydrochlorothiazide (10- TIER 1 PV hydrochlorothiazide 12.5 mg tab, 20-25 mg tab, 20-12.5 mg tab) ranolazine er (er 500 mg ranolazine er tab er 12h, er 1000 mg tab TIER 1 er 12h) spironolactone-hctz 25-25 spironolactone-hctz TIER 1 PV mg tab

©2020 Wellmark, Inc. 85 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS telmisartan-amlodipine (40- telmisartan- 10 mg tab, 40-5 mg tab, 80- TIER 1 PV amlodipine 5 mg tab, 80-10 mg tab) telmisartan-hctz (40-12.5 telmisartan-hctz mg tab, 80-12.5 mg tab, 80- TIER 1 PV 25 mg tab) trandolapril-verapamil hcl er trandolapril-verapamil (er 1-240 mg tab er, er 2- TIER 1 PV hcl er 180 mg tab er, er 2-240 mg tab er, er 4-240 mg tab er) triamterene-hctz (37.5-25 mg cap, 37.5-25 mg tab, triamterene-hctz TIER 1 PV 50-25 mg cap, 75-50 mg tab) valsartan- hydrochlorothiazide (80- valsartan- 12.5 mg tab, 160-25 mg TIER 1 PV hydrochlorothiazide tab, 160-12.5 mg tab, 320- 12.5 mg tab, 320-25 mg tab) VYNDAMAX 61 MG CAP VYNDAMAX SP-P PA, QL (30 PER 30 DAY(S)) tafamidis VYNDAQEL 20 MG CAP PA, QL (120 PER 30 VYNDAQEL tafamidis meglumine SP-P DAY(S)) (cardiac)

DIURETICS, CARBONIC ANHYDRASE INHIBITORS

acetazolamide (125 mg tab, acetazolamide TIER 1 250 mg tab) acetazolamide er 500 mg acetazolamide er TIER 1 cap er 12h KEVEYIS 50 MG TAB KEVEYIS SP-P dichlorphenamide

DIURETICS, LOOP

bumetanide (0.5 mg tab, 1 bumetanide TIER 1 mg tab, 2 mg tab) ethacrynic acid ethacrynic acid 25 mg tab TIER 1 furosemide (8 mg/ml solution, 10 mg/ml solution, furosemide TIER 1 20 mg tab, 40 mg tab, 80 mg tab) torsemide (5 mg tab, 10 mg torsemide TIER 1 tab, 20 mg tab, 100 mg tab)

DIURETICS, POTASSIUM-SPARING

amiloride hcl amiloride hcl 5 mg tab TIER 1 eplerenone (25 mg tab, 50 eplerenone TIER 1 mg tab) spironolactone (25 mg tab, spironolactone TIER 1 50 mg tab, 100 mg tab) triamterene (50 mg cap, triamterene TIER 1 100 mg cap)

DIURETICS, THIAZIDE

chlorothiazide (250 mg tab, chlorothiazide TIER 1 PV 500 mg tab) chlorthalidone (25 mg tab, chlorthalidone TIER 1 PV 50 mg tab) DIURIL 250 MG/5ML DIURIL SUSPENSION TIER 3 chlorothiazide hydrochlorothiazide (12.5 hydrochlorothiazide mg tab, 12.5 mg cap, 25 TIER 1 PV mg tab, 50 mg tab) indapamide (1.25 mg tab, indapamide TIER 1 PV 2.5 mg tab) METHYCLOTHIAZIDE 5 METHYCLOTHIAZID MG TAB TIER 1 PV E methyclothiazide metolazone (2.5 mg tab, 5 metolazone TIER 1 mg tab, 10 mg tab)

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

fenofibrate (48 mg tab, 50 mg cap, 54 mg tab, 67 mg fenofibrate cap, 134 mg cap, 145 mg TIER 1 PV tab, 150 mg cap, 160 mg tab, 200 mg cap) fenofibrate micronized (43 mg cap, 67 mg cap, 130 mg fenofibrate micronized TIER 1 PV cap, 134 mg cap, 200 mg cap) fenofibric acid (35 mg tab, fenofibric acid 45 mg cap dr, 105 mg tab, TIER 1 PV 135 mg cap dr) gemfibrozil gemfibrozil 600 mg tab TIER 1 PV

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

atorvastatin calcium (10 mg atorvastatin calcium tab, 20 mg tab, 40 mg tab, TIER 1 PV 80 mg tab) fluvastatin sodium (20 mg fluvastatin sodium TIER 1 PV cap, 40 mg cap) fluvastatin sodium er 80 mg fluvastatin sodium er TIER 1 PV tab er 24h LIVALO (1 MG TAB, 2 MG LIVALO TAB, 4 MG TAB) TIER 2 PV pitavastatin calcium lovastatin (10 mg tab, 20 lovastatin TIER 1 PV mg tab, 40 mg tab) pravastatin sodium (10 mg pravastatin sodium tab, 20 mg tab, 40 mg tab, TIER 1 PV 80 mg tab) rosuvastatin calcium (5 mg rosuvastatin calcium tab, 10 mg tab, 20 mg tab, TIER 1 PV 40 mg tab) simvastatin (5 mg tab, 10 simvastatin mg tab, 20 mg tab, 40 mg TIER 1 PV tab, 80 mg tab) ZYPITAMAG (1 MG TAB, 2 ZYPITAMAG MG TAB, 4 MG TAB) TIER 2 pitavastatin magnesium

DYSLIPIDEMICS, OTHER

cholestyramine (4 gm/dose cholestyramine TIER 1 PV powder, 4 gm packet) cholestyramine light (4 gm cholestyramine light TIER 1 PV packet, 4 gm/dose powder) colesevelam hcl (3.75 gm colesevelam hcl TIER 1 packet, 625 mg tab) colestipol hcl (1 gm tab, 5 colestipol hcl TIER 1 PV gm packet, 5 gm granules) ezetimibe ezetimibe 10 mg tab TIER 1 PV ezetimibe-simvastatin (10- 20 mg tab, 10-40 mg tab, ezetimibe-simvastatin TIER 1 10-10 mg tab, 10-80 mg tab)

©2020 Wellmark, Inc. 88 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS JUXTAPID (5 MG CAP, 10 MG CAP, 20 MG CAP, 30 JUXTAPID MG CAP, 40 MG CAP, 60 SP-P PA, QL (30 PER 30 DAYS) MG CAP) lomitapide mesylate KYNAMRO 200 MG/ML KYNAMRO SOLN PRSYR SP-P PA, QL (4 PER 28 DAYS) mipomersen sodium niacin er niacin er (antihyperlipidemic) (er 500 TIER 1 PV (antihyperlipidemic) mg tab er, er 750 mg tab er, er 1000 mg tab er) PRALUENT (75 MG/ML QL (2 PER 28 DAY(S)), MN- SOLN A-INJ, 150 MG/ML PRALUENT TIER 3 PA (Medically Necessary SOLN A-INJ) Prior Authorization) alirocumab PRALUENT (75 MG/ML SOLN PRSYR, 150 MG/ML PRALUENT SP-NP PA SOLN PRSYR) alirocumab prevalite (4 gm packet, 4 prevalite TIER 1 PV gm/dose powder) REPATHA 140 MG/ML REPATHA SOLN PRSYR TIER 3 PA, QL (2 PER 28 DAY(S)) evolocumab REPATHA PUSHTRONEX REPATHA SYSTEM 420 MG/3.5ML PUSHTRONEX TIER 3 PA, QL (1 PER 30 DAYS) SOLN CART SYSTEM evolocumab REPATHA SURECLICK REPATHA 140 MG/ML SOLN A-INJ TIER 3 PA, QL (2 PER 28 DAY(S)) SURECLICK evolocumab

VASODILATORS, DIRECT-ACTING ARTERIAL

hydralazine hcl (10 mg tab, hydralazine hcl 25 mg tab, 50 mg tab, 100 TIER 1 PV mg tab) minoxidil (2.5 mg tab, 10 minoxidil TIER 1 PV mg tab)

VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS

isoditrate er isoditrate er 40 mg tab er TIER 1 ISOSORBIDE DINITRATE ISOSORBIDE ER 40 MG TAB ER TIER 1 PV, GA DINITRATE ER isosorbide dinitrate isosorbide isosorbide mononitrate (10 TIER 1 PV mononitrate mg tab, 20 mg tab)

©2020 Wellmark, Inc. 89 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS isosorbide mononitrate er isosorbide (er 30 mg tab er 24h, er 60 TIER 1 PV mononitrate er mg tab er 24h, er 120 mg tab er 24h) minitran (0.1 patch 24hr, minitran 0.2 patch 24hr, 0.4 patch TIER 1 PV 24hr, 0.6 patch 24hr) NITRO-BID 2 % NITRO-BID OINTMENT TIER 3 nitroglycerin NITRO-TIME (2.5 MG CAP ER, 6.5 MG CAP ER, 9 MG NITRO-TIME TIER 1 PV, GA CAP ER) nitroglycerin nitroglycerin (0.1 mg/hr patch 24hr, 0.2 mg/hr patch 24hr, 0.3 mg sl tab, 0.4 mg/hr patch 24hr, 0.4 mg sl nitroglycerin TIER 1 PV tab, 0.4 mg/spray solution, 0.6 mg/hr patch 24hr, 0.6 mg sl tab, 400 mcg/spray aero soln) nitroglycerin er (er 2.5 mg nitroglycerin er cap er, er 6.5 mg cap er, er TIER 1 PV 9 mg cap er)

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

amphetamine- dextroamphet er (er 5 mg cap er 24h, er 10 mg cap er amphetamine- 24h, er 15 mg cap er 24h, TIER 1 PA dextroamphet er er 20 mg cap er 24h, er 25 mg cap er 24h, er 30 mg cap er 24h) amphetamine- dextroamphetamine (5 mg amphetamine- tab, 7.5 mg tab, 10 mg tab, TIER 1 dextroamphetamine 12.5 mg tab, 15 mg tab, 20 mg tab, 30 mg tab) dexedrine (5 mg tab, 10 mg dexedrine TIER 1 tab) dextroamphetamine sulfate dextroamphetamine (5 mg/5ml solution, 5 mg TIER 1 sulfate tab, 10 mg tab)

©2020 Wellmark, Inc. 90 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS dextroamphetamine sulfate dextroamphetamine er (er 5 mg cap er 24h, er TIER 1 PA sulfate er 10 mg cap er 24h, er 15 mg cap er 24h) methamphetamine hcl 5 mg methamphetamine hcl TIER 1 tab procentra procentra 5 mg/5ml solution TIER 1 VYVANSE (10 MG CAP, 10 MG CHEW TAB, 20 MG CHEW TAB, 20 MG CAP, 30 MG CAP, 30 MG CHEW TAB, 40 MG CAP, 40 MG VYVANSE CHEW TAB, 50 MG CAP, TIER 3 PA 50 MG CHEW TAB, 60 MG CAP, 60 MG CHEW TAB, 70 MG CAP) lisdexamfetamine dimesylate zenzedi (5 mg tab, 10 mg zenzedi TIER 1 tab)

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES

atomoxetine hcl (10 mg atomoxetine hcl cap, 18 mg cap, 25 mg cap, TIER 1 QL (60 PER 30 DAYS) 40 mg cap, 60 mg cap) atomoxetine hcl (80 mg atomoxetine hcl TIER 1 QL (30 PER 30 DAYS) cap, 100 mg cap) clonidine hcl er 0.1 mg tab clonidine hcl er TIER 1 er 12h dexmethylphenidate hcl dexmethylphenidate (2.5 mg tab, 5 mg tab, 10 TIER 1 hcl mg tab) dexmethylphenidate hcl er (er 5 mg cap er 24h, er 10 mg cap er 24h, er 15 mg dexmethylphenidate cap er 24h, er 20 mg cap er TIER 1 PA hcl er 24h, er 25 mg cap er 24h, er 30 mg cap er 24h, er 35 mg cap er 24h, er 40 mg cap er 24h) guanfacine hcl er (er 1 mg tab er 24h, er 2 mg tab er guanfacine hcl er TIER 1 24h, er 3 mg tab er 24h, er 4 mg tab er 24h) metadate er metadate er 20 mg tab er TIER 1 PA

©2020 Wellmark, Inc. 91 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS methylphenidate hcl (2.5 mg chew tab, 5 mg tab, 5 mg chew tab, 5 mg/5ml methylphenidate hcl TIER 1 solution, 10 mg/5ml solution, 10 mg tab, 10 mg chew tab, 20 mg tab) methylphenidate hcl er (cd) (er 10 mg cap er, er 20 mg methylphenidate hcl cap er, er 30 mg cap er, er TIER 1 PA er (cd) 40 mg cap er, er 50 mg cap er, er 60 mg cap er) methylphenidate hcl er (er 10 mg tab er, er 18 mg tab er, er 18 mg tab er 24h, er 20 mg tab er, er 27 mg tab methylphenidate hcl er, er 27 mg tab er 24h, er TIER 1 PA er 36 mg tab er, er 36 mg tab er 24h, er 54 mg tab er 24h, er 54 mg tab er, er 72 mg tab er) methylphenidate hcl er (la) (er 10 mg cap er 24h, er 20 methylphenidate hcl mg cap er 24h, er 30 mg TIER 1 PA er (la) cap er 24h, er 40 mg cap er 24h, er 60 mg cap er 24h)

CENTRAL NERVOUS SYSTEM, OTHER

AUSTEDO (6 MG TAB, 9 AUSTEDO MG TAB, 12 MG TAB) SP-P deutetrabenazine butalbital- butalbital-acetaminophen TIER 1 acetaminophen 50-325 mg tab butalbital-apap 50-325 mg butalbital-apap TIER 1 tab butalbital-apap-caffeine butalbital-apap- (50-300-40 mg cap, 50- TIER 1 caffeine 325-40 mg cap, 50-325-40 mg tab) capacet capacet 50-325-40 mg cap TIER 1 esgic esgic 50-325-40 mg cap TIER 1 INGREZZA (40 MG CAP, INGREZZA 80 MG CAP) SP-P PA valbenazine tosylate margesic 50-325-40 mg margesic TIER 1 cap marten-tab marten-tab 50-325 mg tab TIER 1

©2020 Wellmark, Inc. 92 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS phrenilin forte 50-300-40 phrenilin forte TIER 1 mg cap RADICAVA 30 MG/100ML RADICAVA SOLUTION SP-M PA edaravone riluzole riluzole 50 mg tab TIER 1 TEGSEDI 284 MG/1.5ML TEGSEDI SOLN PRSYR SP-P PA, QL (4 PER 28 DAY(S)) inotersen sodium TENCON 50-325 MG TAB TENCON TIER 1 GA butalbital-acetaminophen tetrabenazine tetrabenazine 12.5 mg tab SP-P QL (240 PER 30 DAYS) tetrabenazine tetrabenazine 25 mg tab SP-P QL (120 PER 30 DAYS) XENAZINE 12.5 MG TAB XENAZINE SP-NP QL (240 PER 30 DAYS), GA tetrabenazine XENAZINE 25 MG TAB XENAZINE SP-NP QL (120 PER 30 DAYS), GA tetrabenazine zebutal zebutal 50-325-40 mg cap TIER 1

FIBROMYALGIA AGENTS

duloxetine hcl (20 mg cp dr part, 30 mg cp dr part, 40 duloxetine hcl TIER 1 PV mg cp dr part, 60 mg cp dr part) pregabalin (25 mg cap, 50 mg cap, 75 mg cap, 100 mg pregabalin cap, 150 mg cap, 200 mg TIER 1 cap, 225 mg cap, 300 mg cap) pregabalin 20 mg/ml PA, QL (900 PER 30 pregabalin TIER 1 solution DAY(S))

MULTIPLE SCLEROSIS AGENTS

AMPYRA 10 MG TAB ER AMPYRA 12H SP-NP QL (60 PER 30 DAYS), GA dalfampridine AUBAGIO (7 MG TAB, 14 AUBAGIO MG TAB) SP-P PA, QL (30 PER 30 DAYS) teriflunomide AVONEX 30 MCG KIT AVONEX SP-NP PA, QL (4 PER 28 DAYS) interferon beta-1a AVONEX PEN 30 AVONEX PEN MCG/0.5ML AUT-IJ KIT SP-NP PA, QL (4 PER 28 DAYS) interferon beta-1a

©2020 Wellmark, Inc. 93 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS AVONEX PREFILLED 30 AVONEX MCG/0.5ML PREF SY KT SP-NP PA, QL (4 PER 28 DAYS) PREFILLED interferon beta-1a BAFIERTAM 95 MG CAP QL (4 PER DAY(S)), MN-PA BAFIERTAM DR SP-NP (Medically Necessary Prior monomethyl fumarate Authorization) BETASERON 0.3 MG KIT BETASERON SP-P PA, QL (15 PER 30 DAYS) interferon beta-1b COPAXONE 40 MG/ML PA, QL (12 PER 28 DAYS), COPAXONE SOLN PRSYR SP-P GA glatiramer acetate dalfampridine er 10 mg tab dalfampridine er SP-P QL (60 PER 30 DAYS) er 12h dimethyl fumarate (120 mg dimethyl fumarate SP-P PA, QL (60 PER 30 DAYS) cap dr, 240 mg cap dr) dimethyl fumarate dimethyl fumarate starter SP-P PA, QL (1 PER FILL) starter pack pack 120 & 240 mg misc QL (15 PER 30 DAYS), MN- EXTAVIA 0.3 MG KIT EXTAVIA SP-NP PA (Medically Necessary interferon beta-1b Prior Authorization) GILENYA 0.25 MG CAP GILENYA SP-P PA, QL (30 PER 30 DAY(S)) fingolimod hcl GILENYA 0.5 MG CAP GILENYA SP-P PA, QL (30 PER 30 DAYS) fingolimod hcl glatiramer acetate 40 mg/ml glatiramer acetate SP-P PA, QL (12 PER 28 DAYS) soln prsyr glatopa glatopa 40 mg/ml soln prsyr SP-P PA, QL (12 PER 28 DAYS) LEMTRADA 12 MG/1.2ML MN-PA (Medically Necessary LEMTRADA SOLUTION SP-M Prior Authorization) alemtuzumab (ms) MAVENCLAD (10 TABS) MAVENCLAD (10 10 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis) MAVENCLAD (4 TABS) 10 MAVENCLAD (4 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis) MAVENCLAD (5 TABS) 10 MAVENCLAD (5 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis) MAVENCLAD (6 TABS) 10 MAVENCLAD (6 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis)

©2020 Wellmark, Inc. 94 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MAVENCLAD (7 TABS) 10 MAVENCLAD (7 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis) MAVENCLAD (8 TABS) 10 MAVENCLAD (8 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis) MAVENCLAD (9 TABS) 10 MAVENCLAD (9 MG TAB THPK PA, QL (20 PER 9 SP-P TABS) cladribine (multiple MONTH(S)) sclerosis) MAYZENT 0.25 MG TAB PA, QL (112 PER 28 MAYZENT SP-P siponimod fumarate DAY(S)) MAYZENT 2 MG TAB MAYZENT SP-P PA, QL (30 PER 30 DAY(S)) siponimod fumarate MAYZENT STARTER MAYZENT STARTER PACK 0.25 MG TAB THPK SP-P PA, QL (12 PER 5 DAY(S)) PACK siponimod fumarate OCREVUS 300 MG/10ML OCREVUS SOLUTION SP-M PA ocrelizumab PLEGRIDY (125 SOLN PLEGRIDY PEN, 125 SOLN PRSYR) SP-NP PA, QL (2 PER 28 DAYS) peginterferon beta-1a PLEGRIDY STARTER PACK (PACK 63 94 SOLN PLEGRIDY PRSYR, PACK 63 94 SP-NP PA, QL (1 PER 28 DAYS) STARTER PACK SOLN PEN) peginterferon beta-1a REBIF (22 SOLN PRSYR, REBIF 44 SOLN PRSYR) SP-P PA, QL (12 PER 28 DAYS) interferon beta-1a REBIF REBIDOSE (22 SOLN A-INJ, 44 SOLN A- REBIF REBIDOSE SP-P PA, QL (12 PER 28 DAYS) INJ) interferon beta-1a REBIF REBIDOSE REBIF REBIDOSE TITRATION PACK 6X8.8 & SP-P PA, QL (12 PER 28 DAYS) TITRATION PACK 6X22 MCG SOLN A-INJ interferon beta-1a REBIF TITRATION PACK REBIF TITRATION 6X8.8 & 6X22 MCG SOLN SP-P PA, QL (12 PER 28 DAYS) PACK PRSYR interferon beta-1a

©2020 Wellmark, Inc. 95 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TECFIDERA (120 MG CAP PA, QL (60 PER 30 DAYS), TECFIDERA DR, 240 MG CAP DR) SP-P GA dimethyl fumarate TECFIDERA 120 & 240 MG TECFIDERA MISC SP-P PA, QL (1 PER FILL), GA dimethyl fumarate TYSABRI 300 MG/15ML TYSABRI CONC SP-M PA, QL (1 PER 28 DAYS) natalizumab VUMERITY (STARTER) QL (106 PER 30 DAY(S)), VUMERITY 231 MG CAP DR SP-NP MN-PA (Medically Necessary (STARTER) diroximel fumarate Prior Authorization) VUMERITY 231 MG CAP QL (120 PER 30 DAY(S)), VUMERITY DR SP-NP MN-PA (Medically Necessary diroximel fumarate Prior Authorization) QL (30 PER 30 DAY(S)), ZEPOSIA 0.92 MG CAP ZEPOSIA SP-NP MN-PA (Medically Necessary ozanimod hcl Prior Authorization) ZEPOSIA 7-DAY STARTER PACK 4 X QL (1 PER LIFETIME), MN- ZEPOSIA 7-DAY 0.23MG & 3 X 0.46MG SP-NP PA (Medically Necessary STARTER PACK CAP THPK Prior Authorization) ozanimod hcl ZEPOSIA STARTER KIT QL (1 PER LIFETIME), MN- ZEPOSIA STARTER 0.23MG & 0.46MG & SP-NP PA (Medically Necessary KIT 0.92MG CAP THPK Prior Authorization) ozanimod hcl

DENTAL AND ORAL AGENTS

cevimeline hcl cevimeline hcl 30 mg cap TIER 1 chlorhexidine chlorhexidine gluconate TIER 1 gluconate 0.12 % solution DEBACTEROL 30-50 % SOLUTION DEBACTEROL TIER 3 sulfuric acid-sulfonated phenolics oralone oralone 0.1 % paste TIER 1 paroex paroex 0.12 % solution TIER 1 periogard periogard 0.12 % solution TIER 1 pilocarpine hcl (5 mg tab, pilocarpine hcl TIER 1 7.5 mg tab) triamcinolone triamcinolone acetonide TIER 1 acetonide (0.1 % paste, 0.1 % cream)

DERMATOLOGICAL AGENTS

acitretin (10 mg cap, 17.5 acitretin TIER 1 mg cap, 25 mg cap) adapalene adapalene 0.3 % gel TIER 1 PA amnesteem (10 mg cap, 20 amnesteem TIER 1 mg cap, 40 mg cap) avita (0.025 % cream, avita TIER 1 PA 0.025 % gel) azelaic acid azelaic acid 15 % gel TIER 1 calcipotriene (0.005 % calcipotriene solution, 0.005 % ointment, TIER 1 0.005 % foam) calcipotriene 0.005 % calcipotriene TIER 1 QL (120 PER 30 DAY(S)) cream calcipotriene-betameth calcipotriene- diprop 0.005-0.064 % TIER 1 QL (120 PER 30 DAY(S)) betameth diprop ointment calcipotriene-betameth calcipotriene- diprop 0.005-0.064 % TIER 1 betameth diprop suspension calcitrene calcitrene 0.005 % ointment TIER 1 calcitriol calcitriol 3 mcg/gm ointment TIER 1 claravis (10 mg cap, 20 mg claravis TIER 1 cap, 30 mg cap, 40 mg cap) clindamycin phos-benzoyl clindamycin phos- perox (1-5 % gel, 1.2-2.5 % TIER 1 PA benzoyl perox gel, 1.2-5 % gel) clindamycin-tretinoin 1.2- clindamycin-tretinoin TIER 1 PA 0.025 % gel clotrimazole- clotrimazole- betamethasone (% cream, TIER 1 betamethasone % lotion) COSENTYX (300 MG COSENTYX (300 MG DOSE) 150 MG/ML SOLN SP-P PA, QL (2 PER 28 DAYS) DOSE) PRSYR secukinumab COSENTYX COSENTYX SENSOREADY (300 MG) SENSOREADY (300 SP-P PA, QL (2 PER 28 DAYS) 150 MG/ML SOLN A-INJ MG) secukinumab dapsone (5 % gel, 7.5 % dapsone TIER 1 PA gel)

©2020 Wellmark, Inc. 97 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DUPIXENT (200 MG/1.14ML SOLN PRSYR, 300 MG/2ML SOLN DUPIXENT SP-P PA, QL (2 PER 28 DAY(S)) PRSYR, 300 MG/2ML SOLN PEN) dupilumab DUROLANE 60 MG/3ML PRSYR MN-PA (Medically Necessary DUROLANE SP-M sodium hyaluronate Prior Authorization) (viscosupplement) FLUOROPLEX 1 % FLUOROPLEX CREAM TIER 3 PA fluorouracil (topical) fluorouracil fluorouracil 0.5 % cream TIER 1 PA fluorouracil fluorouracil 5 % cream TIER 1 hydrocort-pramoxine hydrocort-pramoxine TIER 1 (perianal) (perianal) 2.5-1 % cream hydrocortisone ace- hydrocortisone ace- TIER 1 pramoxine pramoxine 1-1 % cream ILUMYA 100 MG/ML SOLN QL (1 PER 84 DAY(S)), MN- ILUMYA PRSYR SP-NP PA (Medically Necessary tildrakizumab-asmn Prior Authorization) imiquimod imiquimod 5 % cream TIER 1 IMIQUIMOD PUMP 3.75 % IMIQUIMOD PUMP CREAM TIER 1 PA imiquimod isotretinoin (10 mg cap, 20 isotretinoin mg cap, 30 mg cap, 40 mg TIER 1 cap) ivermectin ivermectin 1 % cream TIER 1 PA lidocaine-hydrocort lidocaine-hydrocort TIER 1 (perianal) (perianal) 3-0.5 % cream lidocaine-hydrocortisone lidocaine- ace (2.8-0.55 % gel, 3-2.5 TIER 1 hydrocortisone ace % kit, 3-0.5 % kit, 3-1 % kit) methoxsalen rapid 10 mg methoxsalen rapid TIER 1 cap metronidazole (0.75 % gel, metronidazole 0.75 % lotion, 0.75 % TIER 1 cream, 1 % gel) myorisan (10 mg cap, 20 myorisan mg cap, 30 mg cap, 40 mg TIER 1 cap) neuac neuac 1.2-5 % gel TIER 1 PA pimecrolimus pimecrolimus 1 % cream TIER 1 QL (100 PER 30 DAY(S))

©2020 Wellmark, Inc. 98 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PODOCON 25 % PODOCON SOLUTION TIER 1 podophyllum resin podofilox podofilox 0.5 % solution TIER 1 pramcort pramcort 1-1 % cream TIER 1 PROCORT 1.85-1.15 % CREAM PROCORT TIER 3 hydrocortisone acetate w/ pramoxine PROCTOFOAM HC 1-1 % FOAM PROCTOFOAM HC TIER 3 hydrocortisone acetate w/ pramoxine REGRANEX 0.01 % GEL REGRANEX TIER 3 becaplermin rosadan (0.75 % gel, 0.75 rosadan TIER 1 % cream) SANTYL 250 UNIT/GM SANTYL OINTMENT TIER 3 collagenase SCENESSE 16 MG SCENESSE IMPLANT SP-M PA afamelanotide acetate selenium sulfide 2.5 % selenium sulfide TIER 1 lotion SILIQ 210 MG/1.5ML QL (2 PER 28 DAY(S)), MN- SILIQ SOLN PRSYR SP-NP PA (Medically Necessary brodalumab Prior Authorization) SKYRIZI (150 MG DOSE) SKYRIZI (150 MG 75 MG/0.83ML PREF SY SP-P PA, QL (2 PER 56 DAY(S)) DOSE) KT risankizumab-rzaa STELARA (45 MG/0.5ML SOLN PRSYR, 45 PA, QLV (Quantity Limit STELARA MG/0.5ML SOLUTION, 90 SP-P Varies) MG/ML SOLN PRSYR) ustekinumab STELARA 130 MG/26ML STELARA SOLUTION SP-M PA, QL (4 PER FILL) ustekinumab (iv) SULFACETAMIDE- SULFUR IN UREA 10-5 % SULFACETAMIDE- GEL TIER 1 SULFUR IN UREA sulfacetamide sodium- sulfur in urea vehicle tacrolimus (0.03 % tacrolimus TIER 1 ointment, 0.1 % ointment)

©2020 Wellmark, Inc. 99 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TALTZ (80 MG/ML SOLN QL (1 PER 28 DAY(S)), MN- A-INJ, 80 MG/ML SOLN TALTZ SP-NP PA (Medically Necessary PRSYR) Prior Authorization) ixekizumab tazarotene tazarotene 0.1 % cream TIER 1 TREMFYA (100 MG/ML QL (1 PER 56 DAY(S)), MN- SOLN PRSYR, 100 MG/ML TREMFYA SP-NP PA (Medically Necessary SOLN PEN) Prior Authorization) guselkumab tretinoin (0.01 % gel, 0.025 % gel, 0.025 % cream, 0.05 tretinoin TIER 1 PA % cream, 0.05 % gel, 0.1 % cream) tretinoin microsphere (0.04 tretinoin microsphere TIER 1 PA % gel, 0.1 % gel) tretinoin microsphere pump tretinoin microsphere (pump 0.04 % gel, pump TIER 1 PA pump 0.1 % gel) VEREGEN 15 % VEREGEN OINTMENT TIER 3 PA sinecatechins zenatane (10 mg cap, 20 zenatane mg cap, 30 mg cap, 40 mg TIER 1 cap)

ELECTROLYTES/MINERALS/METALS/VITAMINS

ELECTROLYTE/MINERAL REPLACEMENT

bd posiflush bd posiflush 0.9 % solution TIER 1 calcium acetate calcium acetate 667 mg tab TIER 1 CRYSVITA (10 MG/ML SOLUTION, 20 MG/ML CRYSVITA SOLUTION, 30 MG/ML SP-M PA SOLUTION) burosumab-twza effervescent pot effervescent pot chloride 25 TIER 1 chloride meq effer tab K-PHOS 500 MG TAB K-PHOS potassium phosphate TIER 3 monobasic klor-con (8 tab er, 20 klor-con TIER 1 packet) klor-con 10 klor-con 10 10 meq tab er TIER 1 klor-con m10 klor-con m10 10 meq tab er TIER 1

©2020 Wellmark, Inc. 100 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS KLOR-CON M15 15 MEQ TAB ER KLOR-CON M15 potassium chloride TIER 1 microencapsulated crystals er klor-con m20 klor-con m20 20 meq tab er TIER 1 klor-con sprinkle (8 cap er, klor-con sprinkle TIER 1 10 cap er) levocarnitine (1 gm/10ml levocarnitine TIER 1 solution, 330 mg tab) levocarnitine sf 1 gm/10ml levocarnitine sf TIER 1 solution LOKELMA (5 GM PACKET, 10 GM PACKET) LOKELMA SP-P sodium zirconium cyclosilicate MONOFERRIC 1000 MONOFERRIC MG/10ML SOLUTION SP-M ferric derisomaltose monoject flush monoject flush syringe 0.9 TIER 1 syringe % solution monoject sodium monoject sodium chloride TIER 1 chloride flush flush 0.9 % solution normal saline flush 0.9 % normal saline flush TIER 1 solution pot bicarb-pot pot bicarb-pot chloride 25 TIER 1 chloride meq effer tab potassium chloride (20 meq packet, 20 meq/15ml (10%) potassium chloride TIER 1 solution, 40 meq/15ml (20%) solution) potassium chloride crys er potassium chloride (crys er 10 tab er, crys er TIER 1 crys er 20 tab er) potassium chloride er (er 8 cap er, er 8 tab er, er 10 potassium chloride er TIER 1 cap er, er 10 tab er, er 20 tab er) PRENATE STAR 20-1 MG TAB PRENATE STAR TIER 2 prenatal vitamins w/ fe asparto glycinate-folic acid saline flush saline flush 0.9 % solution TIER 1 saline flush zr 0.9 % saline flush zr TIER 1 solution

©2020 Wellmark, Inc. 101 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS sodium bicarbonate (4.2 % sodium bicarbonate TIER 1 solution, 7.5 % solution) sodium chloride (0.9 % sodium chloride solution, 4 meq/ml solution, TIER 1 23.4 % solution) sodium chloride (pf) 0.9 % sodium chloride (pf) TIER 1 solution sodium chloride flush 0.9 % sodium chloride flush TIER 1 solution swabflush saline flush 0.9 swabflush saline flush TIER 1 % solution

ELECTROLYTE/MINERAL/METAL MODIFIERS

CHEMET 100 MG CAP CHEMET TIER 2 succimer clovique clovique 250 mg cap SP-P deferasirox (90 mg tab, 125 mg tab sol, 180 mg tab, 250 deferasirox SP-P mg tab sol, 360 mg tab, 500 mg tab sol) deferasirox granules (granules 90 mg packet, deferasirox granules SP-P granules 180 mg packet, granules 360 mg packet) deferiprone deferiprone 500 mg tab SP-P EXJADE (125 MG TAB SOL, 250 MG TAB SOL, EXJADE SP-NP GA 500 MG TAB SOL) deferasirox FERRIPROX (100 MG/ML FERRIPROX SOLUTION, 1000 MG TAB) SP-P deferiprone FERRIPROX 500 MG TAB FERRIPROX SP-NP GA deferiprone FERRIPROX TWICE-A- FERRIPROX TWICE- DAY 1000 MG TAB SP-P A-DAY deferiprone JADENU (90 MG TAB, 180 JADENU MG TAB, 360 MG TAB) SP-NP GA deferasirox JADENU SPRINKLE (90 MG PACKET, 180 MG JADENU SPRINKLE PACKET, 360 MG SP-NP GA PACKET) deferasirox

©2020 Wellmark, Inc. 102 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS JYNARQUE (15 MG TAB THPK, 30 & 15 MG TAB THPK, 45 & 15 MG TAB JYNARQUE THPK, 60 & 30 MG TAB SP-P PA, QL (56 PER 28 DAY(S)) THPK, 90 & 30 MG TAB THPK) tolvaptan JYNARQUE (15 MG TAB, PA, QL (60 PER 30 DAYS), JYNARQUE 30 MG TAB) SP-P GA tolvaptan kionex kionex (15gm/60mlsuspension, TIER 1 powder) SAMSCA 15 MG TAB SAMSCA SP-P PA, QL (60 PER 30 DAYS) tolvaptan SAMSCA 30 MG TAB PA, QL (60 PER 30 DAYS), SAMSCA SP-NP tolvaptan GA sodium polystyrene sulfonate (15 gm/60ml sodium polystyrene suspension, 30 gm/120ml TIER 1 sulfonate suspension, 50 gm/200ml suspension, powder) sps sps 15 gm/60ml suspension TIER 1 SYPRINE 250 MG CAP SYPRINE SP-NP GA trientine hcl tolvaptan tolvaptan 30 mg tab SP-P PA, QL (60 PER 30 DAYS) trientine hcl trientine hcl 250 mg cap SP-P

PHOSPHATE BINDERS

calcium acetate (phos calcium acetate (phos binder) (667 mg tab, 667 TIER 1 binder) mg cap) lanthanum carbonate (500 lanthanum carbonate mg chew tab, 750 mg chew TIER 1 tab, 1000 mg chew tab) phospha 250 neutral 155- phospha 250 neutral TIER 1 852-130 mg tab phospho-trin 250 phospho-trin 250 neutral TIER 1 neutral 155-852-130 mg tab phosphorous 155-852-130 phosphorous TIER 1 mg tab sevelamer carbonate (0.8 sevelamer carbonate gm packet, 2.4 gm packet, TIER 1 800 mg tab) sevelamer hcl (400 mg tab, sevelamer hcl TIER 1 800 mg tab)

©2020 Wellmark, Inc. 103 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VELTASSA (8.4 GM PACKET, 16.8 GM VELTASSA PACKET, 25.2 GM SP-P PACKET) patiromer sorbitex calcium virt-phos 250 neutral 155- virt-phos 250 neutral TIER 1 852-130 mg tab

VITAMINS

ATABEX EC 29-1 MG TAB DR ATABEX EC TIER 2 PV prenatal vit w/ docusate- iron carbonyl-folic acid ATABEX OB 29-1 MG TAB prenatal vit w/ fe ATABEX OB TIER 2 PV bisglycinate chelate-folic acid BP FOLINATAL PLUS B 1 MG TAB BP FOLINATAL prenatal w/ calcium TIER 2 PLUS B carbonate-vit b6-vit b12- folic acid BP MULTINATAL PLUS (30-1 MG TAB, 40-1 MG BP MULTINATAL CHEW TAB) TIER 2 PV PLUS prenatal without a vit w/ fe fumarate-folic acid COMPLETE NATAL DHA 29-1-200 & 250 MG MISC COMPLETE NATAL prenatal mv & min w/fe TIER 2 PV DHA bisglyc-fe prot succ-fa-ca- omega 3 COMPLETENATE 29-1 MG CHEW TAB COMPLETENATE TIER 2 PV prenatal vit w/ ferrous fumarate-folic acid CONCEPT OB 130-92.4-1 MG CAP CONCEPT OB prenatal without a vit w/ fe TIER 2 PV fum-iron polysacch complex -fa cyanocobalamin 1000 cyanocobalamin TIER 1 mcg/ml solution

©2020 Wellmark, Inc. 104 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FOLIVANE-OB 130-92.4-1 MG CAP FOLIVANE-OB prenatal without a vit w/ fe TIER 2 PV fum-iron polysacch complex -fa HEMENATAL OB + DHA 28-6-1 & 203 MG MISC HEMENATAL OB + prenatal vit w/ fe poly TIER 2 PV DHA cmplx-fe heme polypept-fa & omega 3 INATAL GT TAB INATAL GT prenatal vit w/ docusate- TIER 2 PV iron carbonyl-folic acid MYNATAL (90-1MGTAB, CAP) MYNATAL TIER 2 PV prenatal vit w/ docusate- iron carbonyl-folic acid MYNATAL ADVANCE TAB MYNATAL ADVANCE TIER 2 PV prenatal vit w/ docusate- iron carbonyl-folic acid MYNATE 90 PLUS TAB ER MYNATE 90 PLUS TIER 2 PV prenatal vit w/ docusate-fe fumarate-folic acid NATALVIT TAB NATALVIT prenatal vit w/ ferrous TIER 2 PV fumarate-folic acid NEONATAL COMPLETE NEONATAL 29-1 MG TAB TIER 2 PV COMPLETE prenatal vit w/ ferrous fumarate-folic acid O-CAL PRENATAL TAB O-CAL PRENATAL prenatal vit w/ ferrous TIER 2 PV fumarate-folic acid OBSTETRIX DHA 29-1 & 387 MG MISC OBSTETRIX DHA TIER 2 PV prenatal w/fe carbonyl-fa- dss-omega 3 fatty acids OBSTETRIX EC 29-1 MG TAB OBSTETRIX EC TIER 2 PV prenatal vit w/ docusate- iron carbonyl-folic acid

©2020 Wellmark, Inc. 105 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PNV FE PNV FE FUM/DOCUSATE/FOLIC FUM/DOCUSATE/FO ACID 29-1 MG TAB TIER 2 PV LIC ACID prenatal vit w/ docusate-fe fumarate-folic acid PNV PRENATAL PLUS MULTIVIT+DHA 27-1 & 312 PNV PRENATAL MG MISC PLUS TIER 2 prenatal vit w/ ferrous MULTIVIT+DHA fumarate-fa-omega 3 fatty acids PNV TABS 29-1 29-1 MG TAB PNV TABS 29-1 TIER 2 PV prenatal vit w/ iron carbonyl-folic acid PNV-VP-U 106.5-1 MG CAP PNV-VP-U TIER 2 PV prenatal without a vit w/ fe fumarate-folic acid PR NATAL 400 29-1-200 & 400 MG MISC PR NATAL 400 prenatal mv & min w/fe TIER 2 PV bisglyc-fe prot succ-fa-ca- omega 3 PR NATAL 400 EC 29-1- 200 & 400 MG (DR) MISC PR NATAL 400 EC prenatal mv & min w/fe TIER 2 PV bisglyc-fe prot succ-fa-ca- omega 3 PR NATAL 430 29-1-200 & 430 MG MISC PR NATAL 430 prenatal mv & min w/fe TIER 2 PV bisglyc-fe prot succ-fa-ca- omega 3 PR NATAL 430 EC 29-1- 200 & 430 MG (DR) MISC PR NATAL 430 EC prenatal mv & min w/fe TIER 2 PV bisglyc-fe prot succ-fa-ca- omega 3 PRENAISSANCE NEXT PRENAISSANCE 1.2 MG TAB TIER 2 PV NEXT prenatal w/ calcium-vit b6- folic acid-ginger PRENATA 29-1 MG CHEW TAB PRENATA TIER 2 PV prenatal without a vit w/ fe fumarate-folic acid

©2020 Wellmark, Inc. 106 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PRENATABS FA 29-1 MG TAB PRENATABS FA TIER 2 PV prenatal vit w/ ferrous fumarate-folic acid PRENATABS RX 29-1 MG TAB PRENATABS RX TIER 2 PV prenatal vit w/ iron carbonyl-folic acid PRENATAL 19 (19CHEWTAB, 19TAB, 1929-1MGCHEWTAB, PRENATAL 19 TIER 2 PV 1929-1MGTAB) prenatal vit w/ docusate-fe fumarate-folic acid PRENATAL PLUS IRON PRENATAL PLUS 29-1 MG TAB TIER 2 PV IRON prenatal vit w/ iron carbonyl-folic acid PRENATAL-U 106.5-1 MG CAP PRENATAL-U TIER 2 PV prenatal without a vit w/ fe fumarate-folic acid PREQUE 10 15-25-0.5-50 MG TAB PREQUE 10 prenatal mv & min w/fe TIER 2 carbonyl-docusate-folic acid-dha PRETAB 29-1 MG TAB PRETAB prenatal vit w/ ferrous TIER 2 PV fumarate-folic acid PROVIDA OB 20-20-1.25 MG CAP PROVIDA OB prenatal without a vit w/ fe TIER 2 PV fum-iron polysacch complex -fa PUREFE OB PLUS 162- 115.2-1 MG CAP PUREFE OB PLUS prenatal without a vit w/ fe TIER 2 PV fum-iron polysacch complex -fa SE-NATAL 19 (19 MG TAB, 19 MG CHEW TAB) SE-NATAL 19 TIER 2 PV prenatal vit w/ docusate-fe fumarate-folic acid

©2020 Wellmark, Inc. 107 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TARON-BC 20-1 MG & 2 X 25 MG MISC TARON-BC TIER 2 PV prenatal without vit a w/ iron carbonyl-folic acid & vit b6 THRIVITE RX 29-1 MG TAB THRIVITE RX TIER 2 PV prenatal vit w/ iron carbonyl-folic acid TL FOLATE 27-0.5-0.5 MG TAB TL FOLATE prenatal vit w/ ferrous TIER 2 PV fumarate-l methylfolate-folic acid TRIADVANCE 90-1 MG TAB TRIADVANCE TIER 2 PV prenatal vit w/ docusate- iron carbonyl-folic acid TRINATAL GT 90-1 MG TAB TRINATAL GT TIER 2 PV prenatal vit w/ docusate- iron carbonyl-folic acid TRINATAL RX 1 60-1 MG TAB TRINATAL RX 1 TIER 2 PV prenatal vit w/ ferrous fumarate-folic acid TRINATE TAB TRINATE prenatal vit w/ ferrous TIER 2 PV fumarate-folic acid TRIVEEN-DUO DHA 29-1- 200 & 400 MG MISC TRIVEEN-DUO DHA prenatal mv & min w/fe TIER 2 PV bisglyc-fe prot succ-fa-ca- omega 3 VIL-RX 29-1 MG TAB VIL-RX prenatal vit w/ iron TIER 2 PV carbonyl-folic acid VINATE AZ EXTRA 29-1 MG TAB VINATE AZ EXTRA prenatal vit w/ fe TIER 2 PV bisglycinate chelate-folic acid VINATE C 30-1 MG TAB VINATE C prenatal without a vit w/ fe TIER 2 fumarate-folic acid

©2020 Wellmark, Inc. 108 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VINATE CALCIUM 27-1 MG TAB VINATE CALCIUM prenatal vit w/ iron TIER 2 carbonyl-fe gluconate-folic acid VINATE IC 162-115.2-1 MG CAP VINATE IC prenatal without a vit w/ fe TIER 2 PV fum-iron polysacch complex -fa VINATE II 29-1 MG TAB prenatal vit w/ fe VINATE II TIER 2 PV bisglycinate chelate-folic acid VINATE M 27-1 MG TAB VINATE M prenatal vit w/ selenium-fe TIER 2 PV fumarate-folic acid VINATE ONE 60-1 MG TAB VINATE ONE TIER 2 PV prenatal vit w/ ferrous fumarate-folic acid VIRT NATE 28-1 MG TAB VIRT NATE prenatal vit w/ ferrous TIER 2 PV fumarate-folic acid VIRT-ADVANCE 90-1 MG TAB VIRT-ADVANCE TIER 2 PV prenatal vit w/ docusate- iron carbonyl-folic acid VIRT-VITE GT 90-1 MG TAB VIRT-VITE GT TIER 2 PV prenatal vit w/ docusate- iron carbonyl-folic acid VITAMEDMD PLUS RX/QUATREFOLIC 30-0.6- VITAMEDMD PLUS 0.4 &300 MG MISC TIER 2 RX/QUATREFOLIC prenatal without a w/ fe chelate-l methylfolate-fa- dha VOL-NATE 28-1 MG TAB VOL-NATE prenatal vit w/ ferrous TIER 2 PV fumarate-folic acid VOL-TAB RX 29-1 MG TAB VOL-TAB RX prenatal vit w/ iron TIER 2 PV carbonyl-folic acid

©2020 Wellmark, Inc. 109 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VP-GGR-B6 PRENATAL VP-GGR-B6 1.2 MG TAB TIER 2 PV PRENATAL prenatal w/ calcium-vit b6- folic acid-ginger VP-HEME OB + DHA 28-6- 1 & 203 MG MISC VP-HEME OB + DHA prenatal vit w/ fe poly TIER 2 PV cmplx-fe heme polypept-fa & omega 3

GASTROINTESTINAL AGENTS

ANTISPASMODICS, GASTROINTESTINAL

chlordiazepoxide- chlordiazepoxide-clidinium TIER 1 clidinium 5-2.5 mg cap CUVPOSA 1 MG/5ML PA, QL (1350 PER 30 CUVPOSA SOLUTION TIER 3 DAY(S)) glycopyrrolate dicyclomine hcl (10 mg/5ml dicyclomine hcl solution, 10 mg cap, 20 mg TIER 1 tab) ed-spaz ed-spaz 0.125 mg tab disp TIER 1 glycopyrrolate (1 mg tab, 2 glycopyrrolate TIER 1 mg tab) hyoscyamine sulfate (0.125 mg tab disp, 0.125 mg/5ml hyoscyamine sulfate elixir, 0.125 mg sl tab, TIER 1 0.125 mg/ml solution, 0.125 mg tab) hyoscyamine sulfate hyoscyamine sulfate er TIER 1 er 0.375 mg tab er 12h hyoscyamine sulfate hyoscyamine sulfate sl TIER 1 sl 0.125 mg sl tab hyosyne (0.125 mg/ml hyosyne solution, 0.125 mg/5ml TIER 1 elixir) methscopolamine methscopolamine bromide TIER 1 bromide (2.5 mg tab, 5 mg tab) nulev nulev 0.125 mg tab disp TIER 1 oscimin (0.125 mg tab, oscimin 0.125 mg sl tab, 0.125 mg TIER 1 tab disp) oscimin sr 0.375 mg tab er oscimin sr TIER 1 12h

©2020 Wellmark, Inc. 110 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PROPANTHELINE PROPANTHELINE BROMIDE 15 MG TAB TIER 1 BROMIDE propantheline bromide symax-sl symax-sl 0.125 mg sl tab TIER 1 symax-sr 0.375 mg tab er symax-sr TIER 1 12h

GASTROINTESTINAL AGENTS, OTHER

amoxicill-clarithro- amoxicill-clarithro-lansopraz TIER 1 lansopraz misc CHENODAL 250 MG TAB CHENODAL TIER 2 chenodiol cromolyn sodium 100 cromolyn sodium TIER 1 mg/5ml conc DIPHENOXYLATE- DIPHENOXYLATE- ATROPINE (MG TAB, TIER 1 ATROPINE MG/5ML LIQUID) diphenoxylate w/ atropine ENTEREG 12 MG CAP ENTEREG TIER 3 alvimopan GATTEX 5 MG KIT GATTEX SP-M teduglutide (rdna) MOVANTIK (12.5 MG TAB, MOVANTIK 25 MG TAB) TIER 2 PA naloxegol oxalate opium 10 mg/ml (1%) opium TIER 1 tincture PAREGORIC 2 MG/5ML PAREGORIC TINCTURE TIER 1 paregoric ursodiol (250 mg tab, 300 ursodiol TIER 1 mg cap, 500 mg tab)

HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

cimetidine (300 mg tab, 400 cimetidine TIER 1 mg tab, 800 mg tab) CIMETIDINE HCL 300 CIMETIDINE HCL MG/5ML SOLUTION TIER 1 cimetidine hcl famotidine (40 mg/5ml famotidine TIER 1 recon susp, 40 mg tab) nizatidine (15 mg/ml nizatidine solution, 150 mg cap, 300 TIER 1 mg cap)

©2020 Wellmark, Inc. 111 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ranitidine hcl (15 mg/ml syrup, 75 mg/5ml syrup, ranitidine hcl 150 mg cap, 150 mg/10ml TIER 1 syrup, 300 mg tab, 300 mg cap)

IRRITABLE BOWEL SYNDROME AGENTS

alosetron hcl (0.5 mg tab, 1 alosetron hcl TIER 1 mg tab) AMITIZA (8 MCG CAP, 24 AMITIZA MCG CAP) TIER 2 lubiprostone LINZESS (72 MCG CAP, 145 MCG CAP, 290 MCG LINZESS TIER 2 CAP) linaclotide TRULANCE 3 MG TAB TRULANCE TIER 3 plecanatide

LAXATIVES

CASCARA SAGRADA 1 CASCARA GM/ML FL EXTRACT TIER 2 SAGRADA cascara sagrada constulose 10 gm/15ml constulose TIER 1 solution enulose 10 gm/15ml enulose TIER 1 solution GAVILYTE-C 240 GM RECON SOLN GAVILYTE-C TIER 1 PV, GA peg 3350-kcl-sod bicarb- sod chloride-sod sulfate gavilyte-g 236 gm recon gavilyte-g TIER 1 PV soln gavilyte-n with flavor gavilyte-n with flavor pack TIER 1 PV pack 420 gm recon soln generlac 10 gm/15ml generlac TIER 1 solution lactulose (10 gm/15ml lactulose solution, 20 gm/30ml TIER 1 solution) lactulose lactulose encephalopathy TIER 1 encephalopathy 10 gm/15ml solution OSMOPREP 1.102-0.398 GM TAB OSMOPREP sodium phosphate TIER 2 PV monobasic-sodium phosphate dibasic

©2020 Wellmark, Inc. 112 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS peg 3350-kcl-na peg 3350-kcl-na bicarb-nacl TIER 1 PV bicarb-nacl 420 gm recon soln peg 3350/electrolytes 240 peg 3350/electrolytes TIER 1 PV gm recon soln peg-3350/electrolytes 236 peg-3350/electrolytes TIER 1 PV gm recon soln peg- peg- 3350/electrolytes/asc 3350/electrolytes/ascorbat TIER 1 PV orbat 100 gm recon soln peg-kcl-nacl-nasulf-na peg-kcl-nacl-nasulf-na asc- TIER 1 PV asc-c c 100 gm recon soln SUPREP BOWEL PREP KIT 17.5-3.13-1.6 SUPREP BOWEL GM/177ML SOLUTION TIER 2 PV PREP KIT sodium sulfate-potassium sulfate-magnesium sulfate trilyte trilyte 420 gm recon soln TIER 1 PV

PROTECTANTS

misoprostol (100 mcg tab, misoprostol TIER 1 200 mcg tab) sucralfate (1 gm tab, 1 sucralfate TIER 1 gm/10ml suspension)

PROTON PUMP INHIBITORS

esomeprazole magnesium esomeprazole (10 mg packet, 20 mg PA, QL (60 PER 30 DAYS), TIER 1 magnesium packet, 40 mg packet, 40 PA-QL (90 / 30 days) mg cap dr) lansoprazole (15 mg tab dr PA, QL (60 PER 30 DAYS), lansoprazole TIER 1 disp, 30 mg tab dr disp) PA-QL (90 / 30 days) QL (60 PER 30 DAYS), PA- lansoprazole lansoprazole 30 mg cap dr TIER 1 QL (90 / 30 days) omeprazole (10 mg cap dr, QL (60 PER 30 DAYS), PA- omeprazole TIER 1 40 mg cap dr) QL (90 / 30 days) pantoprazole sodium (20 QL (60 PER 30 DAYS), PA- pantoprazole sodium TIER 1 mg tab dr, 40 mg tab dr) QL (90 / 30 days) pantoprazole sodium 40 mg PA, QL (60 PER 30 DAYS), pantoprazole sodium TIER 1 packet PA-QL (90 / 30 days) rabeprazole sodium 20 mg PA, QL (60 PER 30 DAYS), rabeprazole sodium TIER 1 tab dr PA-QL (90 / 30 days)

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

ALDURAZYME 2.9 ALDURAZYME MG/5ML SOLUTION SP-M laronidase BUPHENYL (3 GM/TSP BUPHENYL POWDER, 500 MG TAB) SP-NP GA sodium phenylbutyrate CARBAGLU 200 MG TAB CARBAGLU SP-P carglumic acid CERDELGA 84 MG CAP CERDELGA SP-P PA eliglustat tartrate CEREZYME 400 UNIT CEREZYME RECON SOLN SP-M PA imiglucerase CREON (3000-9500 CP DR PART, 6000 CP DR PART, 12000 CP DR PART, 24000-76000 CP DR CREON TIER 2 PART, 36000 CP DR PART) pancrelipase (lipase- protease-amylase) CYSTADANE POWDER CYSTADANE SP-P betaine CYSTAGON (50 MG CAP, CYSTAGON 150 MG CAP) TIER 2 cysteamine bitartrate ELAPRASE 6 MG/3ML ELAPRASE SOLUTION SP-M idursulfase ELELYSO 200 UNIT MN-PA (Medically Necessary ELELYSO RECON SOLN SP-M Prior Authorization) taliglucerase alfa FABRAZYME (5 MG RECON SOLN, 35 MG FABRAZYME SP-M RECON SOLN) agalsidase beta GALAFOLD 123 MG CAP GALAFOLD SP-P PA, QL (14 PER 28 DAY(S)) migalastat hcl GIVLAARI 189 MG/ML GIVLAARI SOLUTION SP-M PA givosiran

©2020 Wellmark, Inc. 114 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS KUVAN (100 MG PACKET, 100 MG TAB SOL, 500 MG KUVAN SP-NP GA PACKET) sapropterin dihydrochloride LUMIZYME 50 MG RECON LUMIZYME SOLN SP-M alglucosidase alfa miglustat miglustat 100 mg cap SP-P PA NAGLAZYME 1 MG/ML NAGLAZYME SOLUTION SP-M galsulfase nitisinone (2 mg cap, 5 mg nitisinone SP-P cap, 10 mg cap) OCALIVA 10 MG TAB OCALIVA SP-P PA, QL (60 PER 30 DAYS) obeticholic acid OCALIVA 5 MG TAB OCALIVA SP-P PA, QL (30 PER 30 DAYS) obeticholic acid ORFADIN (2 MG CAP, 5 ORFADIN MG CAP, 10 MG CAP) SP-NP GA nitisinone ORFADIN (4 MG/ML SUSPENSION, 20 MG ORFADIN SP-P CAP) nitisinone PALYNZIQ (2.5 MG/0.5ML SOLN PRSYR, 10 PALYNZIQ MG/0.5ML SOLN PRSYR, SP-P PA 20 MG/ML SOLN PRSYR) pegvaliase-pqpz PANCREAZE (2600 CP DR PART, 4200 CP DR PART, 10500 CP DR PART, PANCREAZE 16800 CP DR PART, TIER 2 21000 CP DR PART) pancrelipase (lipase- protease-amylase) PERTZYE (4000 CP DR PART, 8000 CP DR PART, 16000 CP DR PART, PERTZYE 24000-86250 CP DR TIER 2 PART) pancrelipase (lipase- protease-amylase)

©2020 Wellmark, Inc. 115 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PROCYSBI (25 MG CAP DR, 75 MG CAP DR, 75 PROCYSBI MG PACKET, 300 MG SP-P PACKET) cysteamine bitartrate RAVICTI 1.1 GM/ML RAVICTI LIQUID SP-P PA, QL (525 PER 30 DAYS) glycerol phenylbutyrate sapropterin dihydrochloride sapropterin (100 mg tab sol, 100 mg SP-P dihydrochloride packet, 500 mg packet) sodium phenylbutyrate (3 sodium gm/tsp powder, 500 mg SP-P phenylbutyrate tab) STRENSIQ (18 MG/0.45ML SOLUTION, 28 MG/0.7ML SOLUTION, 40 MG/ML STRENSIQ SP-P PA SOLUTION, 80 MG/0.8ML SOLUTION) asfotase alfa SUCRAID 8500 UNIT/ML SUCRAID SOLUTION TIER 2 sacrosidase VIOKACE (10440 TAB, 20880 TAB) VIOKACE TIER 2 pancrelipase (lipase- protease-amylase) VPRIV 400 UNIT RECON MN-PA (Medically Necessary VPRIV SOLN SP-M Prior Authorization) velaglucerase alfa ZAVESCA 100 MG CAP ZAVESCA SP-NP PA, GA miglustat ZENPEP (3000-14000 CP DR PART, 5000-24000 CP DR PART, 10000-32000 CP DR PART, 15000- 47000 CP DR PART, ZENPEP 20000-63000 CP DR TIER 2 PART, 25000-79000 CP DR PART, 40000-126000 CP DR PART) pancrelipase (lipase- protease-amylase)

GENITOURINARY AGENTS

ANTISPASMODICS, URINARY

darifenacin hydrobromide darifenacin er (er 7.5 mg tab er 24h, er TIER 1 hydrobromide er 15 mg tab er 24h) flavoxate hcl flavoxate hcl 100 mg tab TIER 1 oxybutynin chloride (5 mg oxybutynin chloride TIER 1 tab, 5 mg/5ml syrup) oxybutynin chloride er (er 5 mg tab er 24h, er 10 mg tab oxybutynin chloride er TIER 1 er 24h, er 15 mg tab er 24h) solifenacin succinate (5 mg solifenacin succinate TIER 1 tab, 10 mg tab) tolterodine tartrate (1 mg tolterodine tartrate TIER 1 tab, 2 mg tab) tolterodine tartrate er (er 2 tolterodine tartrate er mg cap er 24h, er 4 mg cap TIER 1 er 24h) trospium chloride trospium chloride 20 mg tab TIER 1 trospium chloride er 60 mg trospium chloride er TIER 1 cap er 24h

BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin hcl er 10 mg tab alfuzosin hcl er TIER 1 er 24h dutasteride dutasteride 0.5 mg cap TIER 1 dutasteride- dutasteride-tamsulosin hcl TIER 1 tamsulosin hcl 0.5-0.4 mg cap finasteride finasteride 5 mg tab TIER 1 silodosin (4 mg cap, 8 mg silodosin TIER 1 QL (30 PER 30 DAYS) cap) tadalafil (10 mg tab, 20 mg tadalafil TIER 1 QL (6 PER 30 DAYS) tab) tadalafil (2.5 mg tab, 5 mg tadalafil TIER 1 QL (30 PER 30 DAYS) tab) tamsulosin hcl tamsulosin hcl 0.4 mg cap TIER 1

GENITOURINARY AGENTS, OTHER

bethanechol chloride (5 mg bethanechol chloride tab, 10 mg tab, 25 mg tab, TIER 1 50 mg tab)

©2020 Wellmark, Inc. 117 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS cytra k crystals 3300-1002 cytra k crystals TIER 1 mg packet D-PENAMINE 125 MG TAB D-PENAMINE TIER 2 penicillamine ELMIRON 100 MG CAP ELMIRON pentosan polysulfate TIER 3 sodium LITHOSTAT 250 MG TAB LITHOSTAT TIER 3 acetohydroxamic acid penicillamine penicillamine 250 mg tab TIER 1 phenazo phenazo 200 mg tab TIER 1 phenazopyridine hcl 200 phenazopyridine hcl TIER 1 mg tab pot & sod cit-cit ac 550- pot & sod cit-cit ac TIER 1 500-334 mg/5ml solution potassium citrate er (er 5 potassium citrate er (540 tab er, er 10 (1080 tab TIER 1 er, er 15 (1620 tab er) potassium citrate-citric acid potassium citrate- (1100-334 mg/5ml solution, TIER 1 citric acid 3300-1002 mg packet) sildenafil citrate (25 mg tab, sildenafil citrate TIER 1 QL (6 PER 30 DAYS) 50 mg tab, 100 mg tab) sod citrate-citric acid 500- sod citrate-citric acid TIER 1 334 mg/5ml solution taron-crystals 3300-1002 taron-crystals TIER 1 mg packet THIOLA 100 MG TAB THIOLA TIER 2 tiopronin THIOLA EC (EC 100 MG TAB DR, EC 300 MG TAB THIOLA EC TIER 2 DR) tiopronin tricitrates 550-500-334 tricitrates TIER 1 mg/5ml solution vardenafil hcl (2.5 mg tab, 5 vardenafil hcl mg tab, 10 mg tab disp, 10 TIER 1 QL (6 PER 30 DAYS) mg tab, 20 mg tab) virtrate-2 500-334 mg/5ml virtrate-2 TIER 1 solution virtrate-3 550-500-334 virtrate-3 TIER 1 mg/5ml solution virtrate-k 1100-334 mg/5ml virtrate-k TIER 1 solution

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

ala-cort ala-cort 2.5 % cream TIER 1 alclometasone dipropionate alclometasone (0.05 % cream, 0.05 % TIER 1 dipropionate ointment) AMCINONIDE (0.1 % CREAM, 0.1 % AMCINONIDE OINTMENT, 0.1 % TIER 1 LOTION) amcinonide baycadron baycadron 0.5 mg/5ml elixir TIER 1 beser beser 0.05 % lotion TIER 1 betamethasone betamethasone dipropionate (0.05 % lotion, TIER 1 dipropionate 0.05 % cream, 0.05 % ointment) betamethasone betamethasone dipropionate aug (0.05 % TIER 1 dipropionate aug cream, 0.05 % lotion, 0.05 % ointment, 0.05 % gel) betamethasone valerate betamethasone (0.1 % ointment, 0.1 % TIER 1 valerate lotion, 0.1 % cream, 0.12 % foam) clobetasol prop clobetasol prop emollient TIER 1 emollient base base 0.05 % cream clobetasol propionate (0.05 % cream, 0.05 % lotion, 0.05 % foam, 0.05 % clobetasol propionate TIER 1 solution, 0.05 % ointment, 0.05 % liquid, 0.05 % shampoo, 0.05 % gel) clobetasol propionate clobetasol propionate e TIER 1 e 0.05 % cream clobetasol propionate clobetasol propionate TIER 1 emulsion emulsion 0.05 % foam clocortolone pivalate 0.1 % clocortolone pivalate TIER 1 QL (90 PER 30 DAY(S)) cream clocortolone pivalate clocortolone pivalate pump TIER 1 QL (90 PER 30 DAY(S)) pump 0.1 % cream clodan clodan 0.05 % shampoo TIER 1 cormax scalp cormax scalp application TIER 1 application 0.05 % solution

©2020 Wellmark, Inc. 119 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS decadron (0.5 mg tab, 0.5 decadron mg/5ml elixir, 0.75 mg tab, TIER 1 4 mg tab, 6 mg tab) deltasone deltasone 20 mg tab TIER 1 DEPO-MEDROL 20 MG/ML DEPO-MEDROL SUSPENSION TIER 1 methylprednisolone acetate desonide (0.05 % cream, desonide 0.05 % ointment, 0.05 % TIER 1 lotion, 0.05 % gel) desoximetasone (0.05 % ointment, 0.05 % cream, desoximetasone 0.05 % gel, 0.25 % cream, TIER 1 0.25 % liquid, 0.25 % ointment) dexamethasone (0.5 mg tab, 0.5 mg/5ml elixir, 0.5 dexamethasone mg/5ml solution, 0.75 mg TIER 1 tab, 1 mg tab, 1.5 mg tab, 2 mg tab, 4 mg tab, 6 mg tab) DEXAMETHASONE DEXAMETHASONE INTENSOL 1 MG/ML TIER 1 INTENSOL CONC dexamethasone dexamethasone sod dexamethasone sod phosphate pf 10 mg/ml TIER 1 phosphate pf solution dexamethasone sodium dexamethasone phosphate 20 mg/5ml TIER 1 sodium phosphate solution EMFLAZA (6 MG TAB, 18 MG TAB, 22.75 MG/ML EMFLAZA SUSPENSION, 30 MG SP-P PA TAB, 36 MG TAB) deflazacort EPIFOAM 1-1 % FOAM EPIFOAM TIER 3 pramoxine-hc fludrocortisone fludrocortisone acetate 0.1 TIER 1 acetate mg tab fluocinolone acetonide fluocinolone (0.01 % solution, 0.01 % TIER 1 acetonide cream, 0.025 % cream, 0.025 % ointment) fluocinolone fluocinolone acetonide body TIER 1 acetonide body 0.01 % oil fluocinolone fluocinolone acetonide TIER 1 acetonide scalp scalp 0.01 % oil

©2020 Wellmark, Inc. 120 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS fluocinonide (0.05 % cream, fluocinonide 0.05 % ointment, 0.05 % TIER 1 gel, 0.05 % solution) fluocinonide fluocinonide 0.1 % cream TIER 1 QL (120 PER 30 DAY(S)) fluocinonide fluocinonide emulsified TIER 1 emulsified base base 0.05 % cream flurandrenolide (0.05 % flurandrenolide TIER 1 ointment, 0.05 % cream) flurandrenolide 0.05 % flurandrenolide TIER 1 QL (120 PER 30 DAY(S)) lotion fluticasone propionate fluticasone propionate (0.005 % ointment, 0.05 % TIER 1 lotion, 0.05 % cream) halobetasol propionate halobetasol (0.05 % ointment, 0.05 % TIER 1 propionate cream) HP ACTHAR 80 UNIT/ML HP ACTHAR GEL SP-M PA corticotropin hydrocort-pramoxine hydrocort-pramoxine TIER 1 (perianal) (perianal) 2.5-1 % cream hydrocortisone (2.5 % cream, 2.5 % lotion, 2.5 % hydrocortisone TIER 1 ointment, 5 mg tab, 10 mg tab, 20 mg tab) hydrocortisone ace- hydrocortisone ace- TIER 1 pramoxine pramoxine 2.5-1 % cream hydrocortisone butyr hydrocortisone butyr lipo TIER 1 QL (60 PER 30 DAY(S)) lipo base base 0.1 % cream hydrocortisone butyrate hydrocortisone (0.1 % ointment, 0.1 % TIER 1 butyrate solution, 0.1 % lotion) hydrocortisone hydrocortisone butyrate 0.1 TIER 1 QL (60 PER 30 DAY(S)) butyrate % cream hydrocortisone hydrocortisone valerate (0.2 TIER 1 valerate % cream, 0.2 % ointment) ISTURISA 1 MG TAB PA, QL (240 PER 30 ISTURISA SP-NP osilodrostat phosphate DAY(S)) ISTURISA 10 MG TAB PA, QL (180 PER 30 ISTURISA SP-NP osilodrostat phosphate DAY(S)) ISTURISA 5 MG TAB PA, QL (360 PER 30 ISTURISA SP-NP osilodrostat phosphate DAY(S)) KORLYM 300 MG TAB PA, QL (120 PER 30 KORLYM mifepristone SP-P DAY(S)) (hyperglycemia)

©2020 Wellmark, Inc. 121 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS lokara lokara 0.05 % lotion TIER 1 methylprednisolone (4 mg methylprednisolone tab thpk, 4 mg tab, 8 mg TIER 1 tab, 16 mg tab, 32 mg tab) methylprednisolone methylprednisolone sodium TIER 1 sodium succ succ 500 mg recon soln mometasone furoate (0.1 % mometasone furoate ointment, 0.1 % solution, TIER 1 0.1 % cream) nolix nolix 0.05 % cream TIER 1 nolix nolix 0.05 % lotion TIER 1 QL (120 PER 30 DAY(S)) NUCORT 2 % LOTION NUCORT hydrocortisone acetate TIER 3 (topical) PRAMOSONE (1-1 % CREAM, 1-2.5 % LOTION, PRAMOSONE TIER 1 1-1 % LOTION) pramoxine-hc PREDNICARBATE (0.1 % CREAM, 0.1 % PREDNICARBATE TIER 1 OINTMENT) prednicarbate prednisolone (15 syrup, 15 prednisolone TIER 1 solution) prednisolone sodium phosphate (6.7 (5 base) mg/5ml solution, 10 mg/5ml prednisolone sodium solution, 10 mg tab disp, 15 TIER 1 phosphate mg tab disp, 15 mg/5ml solution, 20 mg/5ml solution, 25 mg/5ml solution, 30 mg tab disp) prednisolone sodium prednisolone sodium phosphate 25 mg/5ml TIER 1 phosphate solution prednisone (1 mg tab, 2.5 mg tab, 5 mg (21) tab thpk, 5 mg (48) tab thpk, 5 prednisone mg/5ml solution, 5 mg tab, TIER 1 10 mg (21) tab thpk, 10 mg tab, 10 mg (48) tab thpk, 20 mg tab, 50 mg tab) PREDNISONE INTENSOL PREDNISONE 5 MG/ML CONC TIER 1 INTENSOL prednisone scalacort scalacort 2 % lotion TIER 1

©2020 Wellmark, Inc. 122 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SOLU-CORTEF (100 MG RECON SOLN, 250 MG RECON SOLN, 500 MG SOLU-CORTEF TIER 1 RECON SOLN) hydrocortisone sod succinate SOLU-MEDROL 500 MG RECON SOLN SOLU-MEDROL TIER 1 GA methylprednisolone sod succ tovet tovet 0.05 % foam TIER 1 triamcinolone acetonide (0.025 % ointment, 0.025 % cream, 0.025 % lotion, 0.1 triamcinolone % ointment, 0.1 % lotion, TIER 1 acetonide 0.1 % cream, 0.5 % cream, 0.5 % ointment, 40 mg/ml suspension) triamcinolone triamcinolone acetonide TIER 1 QL (4.5 PER 1 DAY(S)) acetonide 0.147 mg/gm aero soln triderm (0.1 % cream, 0.5 triderm TIER 1 % cream)

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

desmopressin ace desmopressin ace rhinal TIER 1 rhinal tube tube 0.01 % solution desmopressin ace desmopressin ace spray TIER 1 spray refrig refrig 0.01 % solution desmopressin acetate (0.1 desmopressin acetate TIER 1 mg tab, 0.2 mg tab) desmopressin acetate desmopressin acetate TIER 1 spray spray 0.01 % solution GENOTROPIN (5 MG RECON SOLN, 12 MG MN-PA (Medically Necessary GENOTROPIN SP-NP RECON SOLN) Prior Authorization) somatropin

©2020 Wellmark, Inc. 123 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GENOTROPIN MINIQUICK (0.2 MG RECON SOLN, 0.4 MG RECON SOLN, 0.6 MG RECON SOLN, 0.8 MG RECON SOLN, 1 MG GENOTROPIN RECON SOLN, 1.2 MG MN-PA (Medically Necessary SP-NP MINIQUICK RECON SOLN, 1.4 MG Prior Authorization) RECON SOLN, 1.6 MG RECON SOLN, 1.8 MG RECON SOLN, 2 MG RECON SOLN) somatropin HUMATROPE (5 MG RECON SOLN, 6 MG RECON SOLN, 12 MG MN-PA (Medically Necessary HUMATROPE SP-NP RECON SOLN, 24 MG Prior Authorization) RECON SOLN) somatropin INCRELEX 40 MG/4ML INCRELEX SOLUTION SP-P PA mecasermin NORDITROPIN FLEXPRO (5 MG/1.5ML SOLN PEN, NORDITROPIN 10 MG/1.5ML SOLN PEN, SP-P PA FLEXPRO 15 MG/1.5ML SOLN PEN, 30 MG/3ML SOLN PEN) somatropin NUTROPIN AQ NUSPIN 10 NUTROPIN AQ MN-PA (Medically Necessary 10 MG/2ML SOLN PEN SP-NP NUSPIN 10 Prior Authorization) somatropin NUTROPIN AQ NUSPIN 20 NUTROPIN AQ MN-PA (Medically Necessary 20 MG/2ML SOLN PEN SP-NP NUSPIN 20 Prior Authorization) somatropin NUTROPIN AQ NUSPIN 5 NUTROPIN AQ MN-PA (Medically Necessary 5 MG/2ML SOLN PEN SP-NP NUSPIN 5 Prior Authorization) somatropin NUTROPIN AQ PEN 20 MN-PA (Medically Necessary NUTROPIN AQ PEN MG/2ML SOLUTION SP-NP Prior Authorization) somatropin OMNITROPE (5 MG/1.5ML SOLN CART, 5.8 MG OMNITROPE RECON SOLN, 10 SP-NP PA MG/1.5ML SOLN CART) somatropin SAIZEN (5 MG RECON SOLN, 8.8 MG RECON MN-PA (Medically Necessary SAIZEN SOLN) SP-NP Prior Authorization) somatropin (non- refrigerated)

©2020 Wellmark, Inc. 124 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SAIZEN CLICK.EASY 8.8 MG RECON SOLN MN-PA (Medically Necessary SAIZEN CLICK.EASY SP-NP somatropin (non- Prior Authorization) refrigerated) SAIZENPREP 8.8 MG RECON SOLN MN-PA (Medically Necessary SAIZENPREP SP-NP somatropin (non- Prior Authorization) refrigerated) SEROSTIM (4 MG RECON SOLN, 5 MG RECON SOLN, 6 MG RECON MN-PA (Medically Necessary SEROSTIM SP-NP SOLN) Prior Authorization) somatropin (non- refrigerated) ZOMACTON (5 MG RECON SOLN, 10 MG MN-PA (Medically Necessary ZOMACTON SP-NP RECON SOLN) Prior Authorization) somatropin ZOMACTON (FOR ZOMA- ZOMACTON (FOR JET 10) 10 MG RECON MN-PA (Medically Necessary SP-NP ZOMA-JET 10) SOLN Prior Authorization) somatropin ZORBTIVE 8.8 MG RECON SOLN MN-PA (Medically Necessary ZORBTIVE SP-NP somatropin (non- Prior Authorization) refrigerated)

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)

ANABOLIC STEROIDS

ANADROL-50 50 MG TAB ANADROL-50 TIER 2 oxymetholone oxandrolone (2.5 mg tab, oxandrolone TIER 1 10 mg tab)

ANDROGENS

ANDROXY 10 MG TAB ANDROXY TIER 3 fluoxymesterone danazol (50 mg cap, 100 danazol TIER 1 mg cap, 200 mg cap) methyltestosterone 10 mg methyltestosterone TIER 1 PA cap

©2020 Wellmark, Inc. 125 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS testosterone (1.62 % gel, 12.5 mg/act (1%) gel, 20.25 mg/act (1.62%) gel, 20.25 mg/1.25gm (1.62%) gel, 25 testosterone TIER 2 PA mg/2.5gm (1%) gel, 30 mg/act solution, 40.5 mg/2.5gm (1.62%) gel, 50 mg/5gm (1%) gel) testosterone cypionate (100 testosterone mg/ml solution, 200 mg/ml TIER 1 cypionate solution) testosterone testosterone enanthate 200 TIER 1 enanthate mg/ml solution

ESTROGENS

afirmelle 0.1-20 mg-mcg afirmelle TIER 1 PV tab altavera 0.15-30 mg-mcg altavera TIER 1 PV tab alyacen 1/35 1-35 mg-mcg alyacen 1/35 TIER 1 PV tab alyacen 7/7/7 0.5/0.75/1-35 alyacen 7/7/7 TIER 1 PV mg-mcg tab amabelz (0.5-0.1 mg tab, 1- amabelz TIER 1 0.5 mg tab) amethia 0.15-0.03 &0.01 amethia TIER 1 PV mg tab amethia lo 0.1-0.02 & 0.01 amethia lo TIER 1 PV mg tab amethyst amethyst 90-20 mcg tab TIER 1 PV apri apri 0.15-30 mg-mcg tab TIER 1 PV aranelle 0.5/1/0.5-35 mg- aranelle TIER 1 PV mcg tab ashlyna 0.15-0.03 &0.01 ashlyna TIER 1 PV mg tab aubra aubra 0.1-20 mg-mcg tab TIER 1 PV aubra eq 0.1-20 mg-mcg aubra eq TIER 1 PV tab aurovela 1.5/30 1.5-30 mg- aurovela 1.5/30 TIER 1 PV mcg tab aurovela 1/20 1-20 mg-mcg aurovela 1/20 TIER 1 PV tab aurovela 24 fe 1-20 mg- aurovela 24 fe TIER 1 PV mcg(24) tab

©2020 Wellmark, Inc. 126 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS aurovela fe 1.5/30 1.5-30 aurovela fe 1.5/30 TIER 1 PV mg-mcg tab aurovela fe 1/20 1-20 mg- aurovela fe 1/20 TIER 1 PV mcg tab aviane aviane 0.1-20 mg-mcg tab TIER 1 PV ayuna ayuna 0.15-30 mg-mcg tab TIER 1 PV azurette 0.15-0.02/0.01 mg azurette TIER 1 PV (21/5) tab balziva balziva 0.4-35 mg-mcg tab TIER 1 PV bekyree 0.15-0.02/0.01 mg bekyree TIER 1 PV (21/5) tab blisovi 24 fe 1-20 mg- blisovi 24 fe TIER 1 PV mcg(24) tab blisovi fe 1.5/30 1.5-30 mg- blisovi fe 1.5/30 TIER 1 PV mcg tab blisovi fe 1/20 1-20 mg-mcg blisovi fe 1/20 TIER 1 PV tab briellyn briellyn 0.4-35 mg-mcg tab TIER 1 PV camrese 0.15-0.03 &0.01 camrese TIER 1 PV mg tab camrese lo 0.1-0.02 & 0.01 camrese lo TIER 1 PV mg tab caziant 0.1/0.125/0.15 - caziant TIER 1 PV 0.025 mg tab charlotte 24 fe 1-20 mg- charlotte 24 fe TIER 1 PV mcg(24) chew tab chateal 0.15-30 mg-mcg chateal TIER 1 PV tab chateal eq 0.15-30 mg-mcg chateal eq TIER 1 PV tab CLIMARA PRO 0.045- CLIMARA PRO 0.015 MG/DAY PATCH WK TIER 3 estradiol-levonorgestrel COMBIPATCH (0.05-0.14 PATCH TW, 0.05-0.25 COMBIPATCH PATCH TW) TIER 3 estradiol & norethindrone acetate covaryx covaryx 1.25-2.5 mg tab TIER 1 covaryx hs 0.625-1.25 mg covaryx hs TIER 1 tab cryselle-28 0.3-30 mg-mcg cryselle-28 TIER 1 PV tab cyclafem 1/35 1-35 mg-mcg cyclafem 1/35 TIER 1 PV tab

©2020 Wellmark, Inc. 127 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS cyclafem 7/7/7 0.5/0.75/1- cyclafem 7/7/7 TIER 1 PV 35 mg-mcg tab cyred cyred 0.15-30 mg-mcg tab TIER 1 PV cyred eq 0.15-30 mg-mcg cyred eq TIER 1 PV tab dasetta 1/35 1-35 mg-mcg dasetta 1/35 TIER 1 PV tab dasetta 7/7/7 0.5/0.75/1-35 dasetta 7/7/7 TIER 1 PV mg-mcg tab daysee 0.15-0.03 &0.01 mg daysee TIER 1 PV tab DELESTROGEN (20 MG/ML OIL, 40 MG/ML DELESTROGEN TIER 1 GA OIL) estradiol valerate delyla delyla 0.1-20 mg-mcg tab TIER 1 PV DEPO-ESTRADIOL 5 DEPO-ESTRADIOL MG/ML OIL TIER 1 estradiol cypionate desogestrel-ethinyl desogestrel-ethinyl estradiol (0.15-0.02/0.01 TIER 1 PV estradiol mg (21/5) tab, 0.15-30 mg- mcg tab) dotti (0.025 mg/24hr patch tw, 0.0375 mg/24hr patch dotti tw, 0.05 mg/24hr patch tw, TIER 1 QL (8 PER 28 DAYS) 0.075 mg/24hr patch tw, 0.1 mg/24hr patch tw) drospiren-eth estrad- drospiren-eth estrad- levomefol (3-0.02-0.451 mg TIER 1 PV levomefol tab, 3-0.03-0.451 mg tab) drospirenone-ethinyl drospirenone-ethinyl estradiol (3-0.03 mg tab, 3- TIER 1 PV estradiol 0.02 mg tab) eemt eemt 1.25-2.5 mg tab TIER 1 eemt hs eemt hs 0.625-1.25 mg tab TIER 1 elinest elinest 0.3-30 mg-mcg tab TIER 1 PV eluryng 0.12-0.015 mg/24hr eluryng TIER 1 PV ring emoquette 0.15-30 mg-mcg emoquette TIER 1 PV tab enpresse-28 enpresse-28 tab TIER 1 PV enskyce 0.15-30 mg-mcg enskyce TIER 1 PV tab

©2020 Wellmark, Inc. 128 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS est estrogens- est estrogens-methyltest TIER 1 methyltest 1.25-2.5 mg tab est estrogens- est estrogens-methyltest ds TIER 1 methyltest ds 1.25-2.5 mg tab est estrogens- est estrogens-methyltest hs TIER 1 methyltest hs 0.625-1.25 mg tab estarylla 0.25-35 mg-mcg estarylla TIER 1 PV tab estradiol (0.025 mg/24hr patch tw, 0.0375 mg/24hr patch tw, 0.05 mg/24hr estradiol TIER 1 QL (8 PER 28 DAYS) patch tw, 0.075 mg/24hr patch tw, 0.1 mg/24hr patch tw) estradiol (0.025 mg/24hr patch wk, 0.0375 mg/24hr patch wk, 0.05 mg/24hr patch wk, 0.06 mg/24hr estradiol patch wk, 0.075 mg/24hr TIER 1 patch wk, 0.1 mg/24hr patch wk, 0.1 mg/gm cream, 0.5 mg tab, 1 mg tab, 2 mg tab, 10 mcg tab) estradiol valerate (20 mg/ml estradiol valerate TIER 1 oil, 40 mg/ml oil) estradiol-norethindrone estradiol- acet (0.5-0.1 mg tab, 1-0.5 TIER 1 norethindrone acet mg tab) ESTRING 2 MG RING ESTRING TIER 3 estradiol vaginal ESTROPIPATE (0.75 MG TAB, 1.5 MG TAB, 3 MG ESTROPIPATE TIER 1 TAB) estropipate ethynodiol diac-eth ethynodiol diac-eth estradiol (1-50 tab, 1-35 TIER 1 PV estradiol tab) etonogestrel-ethinyl etonogestrel-ethinyl estradiol 0.12-0.015 TIER 1 PV estradiol mg/24hr ring falmina falmina 0.1-20 mg-mcg tab TIER 1 PV fayosim 42-21-21-7 days fayosim TIER 1 PV tab femynor 0.25-35 mg-mcg femynor TIER 1 PV tab fyavolv (0.5-2.5 tab, 1-5 fyavolv TIER 1 tab)

©2020 Wellmark, Inc. 129 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS gianvi gianvi 3-0.02 mg tab TIER 1 PV gildagia gildagia 0.4-35 mg-mcg tab TIER 1 PV hailey 1.5/30 1.5-30 mg- hailey 1.5/30 TIER 1 PV mcg tab hailey 24 fe 1-20 mg- hailey 24 fe TIER 1 PV mcg(24) tab hailey fe 1.5/30 1.5-30 mg- hailey fe 1.5/30 TIER 1 PV mcg tab hailey fe 1/20 1-20 mg-mcg hailey fe 1/20 TIER 1 PV tab introvale introvale 0.15-0.03 mg tab TIER 1 PV isibloom 0.15-30 mg-mcg isibloom TIER 1 PV tab jaimiess 0.15-0.03 &0.01 jaimiess TIER 1 PV mg tab jasmiel jasmiel 3-0.02 mg tab TIER 1 PV jevantique lo 0.5-2.5 mg- jevantique lo TIER 1 mcg tab jinteli jinteli 1-5 mg-mcg tab TIER 1 jolessa jolessa 0.15-0.03 mg tab TIER 1 PV juleber juleber 0.15-30 mg-mcg tab TIER 1 PV junel 1.5/30 1.5-30 mg-mcg junel 1.5/30 TIER 1 PV tab junel 1/20 junel 1/20 1-20 mg-mcg tab TIER 1 PV junel fe 1.5/30 1.5-30 mg- junel fe 1.5/30 TIER 1 PV mcg tab junel fe 1/20 1-20 mg-mcg junel fe 1/20 TIER 1 PV tab junel fe 24 1-20 mg- junel fe 24 TIER 1 PV mcg(24) tab kaitlib fe 0.8-25 mg-mcg kaitlib fe TIER 1 PV chew tab kalliga kalliga 0.15-30 mg-mcg tab TIER 1 PV kariva 0.15-0.02/0.01 mg kariva TIER 1 PV (21/5) tab kelnor 1/35 1-35 mg-mcg kelnor 1/35 TIER 1 PV tab kelnor 1/50 1-50 mg-mcg kelnor 1/50 TIER 1 PV tab kimidess 0.15-0.02/0.01 mg kimidess TIER 1 PV (21/5) tab kurvelo 0.15-30 mg-mcg kurvelo TIER 1 PV tab

©2020 Wellmark, Inc. 130 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS larin 1.5/30 1.5-30 mg-mcg larin 1.5/30 TIER 1 PV tab larin 1/20 larin 1/20 1-20 mg-mcg tab TIER 1 PV larin 24 fe 1-20 mg-mcg(24) larin 24 fe TIER 1 PV tab larin fe 1.5/30 1.5-30 mg- larin fe 1.5/30 TIER 1 PV mcg tab larin fe 1/20 1-20 mg-mcg larin fe 1/20 TIER 1 PV tab larissia larissia 0.1-20 mg-mcg tab TIER 1 PV layolis fe 0.8-25 mg-mcg layolis fe TIER 1 PV chew tab leena 0.5/1/0.5-35 mg-mcg leena TIER 1 PV tab lessina lessina 0.1-20 mg-mcg tab TIER 1 PV levonest levonest tab TIER 1 PV levonorg-eth estrad levonorg-eth estrad triphasic 50-30/75-40/ 125- TIER 1 PV triphasic 30 mcg tab levonorgest-eth est & levonorgest-eth est & eth TIER 1 PV eth est est 42-21-21-7 days tab levonorgest-eth estrad 91- levonorgest-eth day (0.1-0.02 & 0.01 mg TIER 1 PV estrad 91-day tab, 0.15-0.03 &0.01 mg tab, 0.15-0.03 mg tab) levonorgestrel-ethinyl levonorgestrel-ethinyl estrad (0.1-20 mg-mcg tab, TIER 1 PV estrad 0.15-30 mg-mcg tab, 90-20 mcg tab) levora 0.15/30 (28) 0.15-30 levora 0.15/30 (28) TIER 1 PV mg-mcg tab lillow lillow 0.15-30 mg-mcg tab TIER 1 PV lo-zumandimine 3-0.02 mg lo-zumandimine TIER 1 PV tab lojaimiess 0.1-0.02 & 0.01 lojaimiess TIER 1 PV mg tab lomedia 24 fe 1-20 mg- lomedia 24 fe TIER 1 PV mcg(24) tab lopreeza (0.5-0.1 mg tab, 1- lopreeza TIER 1 0.5 mg tab) loryna loryna 3-0.02 mg tab TIER 1 PV low-ogestrel 0.3-30 mg-mcg low-ogestrel TIER 1 PV tab lutera lutera 0.1-20 mg-mcg tab TIER 1 PV

©2020 Wellmark, Inc. 131 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS marlissa 0.15-30 mg-mcg marlissa TIER 1 PV tab melodetta 24 fe 1-20 mg- melodetta 24 fe TIER 1 PV mcg(24) chew tab mibelas 24 fe 1-20 mg- mibelas 24 fe TIER 1 PV mcg(24) chew tab microgestin 1.5/30 1.5-30 microgestin 1.5/30 TIER 1 PV mg-mcg tab microgestin 1/20 1-20 mg- microgestin 1/20 TIER 1 PV mcg tab microgestin 24 fe 1-20 mg- microgestin 24 fe TIER 1 PV mcg tab microgestin fe 1.5/30 1.5-30 microgestin fe 1.5/30 TIER 1 PV mg-mcg tab microgestin fe 1/20 1-20 microgestin fe 1/20 TIER 1 PV mg-mcg tab mili mili 0.25-35 mg-mcg tab TIER 1 PV mimvey mimvey 1-0.5 mg tab TIER 1 mimvey lo mimvey lo 0.5-0.1 mg tab TIER 1 mono-linyah 0.25-35 mg- mono-linyah TIER 1 PV mcg tab mononessa 0.25-35 mg- mononessa TIER 1 PV mcg tab myzilra myzilra tab TIER 1 PV necon 0.5/35 (28) 0.5-35 necon 0.5/35 (28) TIER 1 PV mg-mcg tab necon 1/35 (28) 1-35 mg- necon 1/35 (28) TIER 1 PV mcg tab necon 7/7/7 0.5/0.75/1-35 necon 7/7/7 TIER 1 PV mg-mcg tab nikki nikki 3-0.02 mg tab TIER 1 PV norethin ace-eth estrad-fe (1-20 mg-mcg(24) chew norethin ace-eth tab, 1-20 mg-mcg tab, 1-20 TIER 1 PV estrad-fe mg-mcg(24) tab, 1.5-30 mg-mcg tab) norethin-eth estradiol-fe norethin-eth estradiol- (0.4-35 chew tab, 0.8-25 TIER 1 PV fe chew tab) norethindrone acet-ethinyl norethindrone acet- est (1-20 mg-mcg tab, 1-20 TIER 1 PV ethinyl est mg-mcg(24) chew tab, 1.5- 30 mg-mcg tab) norethindrone-eth norethindrone-eth estradiol TIER 1 estradiol (0.5-2.5 tab, 1-5 tab)

©2020 Wellmark, Inc. 132 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS norgestim-eth estrad norgestim-eth estrad triphasic (mg-25 mcg tab, TIER 1 PV triphasic mg-35 mcg tab) norgestimate-eth norgestimate-eth estradiol TIER 1 PV estradiol 0.25-35 mg-mcg tab nortrel 0.5/35 (28) 0.5-35 nortrel 0.5/35 (28) TIER 1 PV mg-mcg tab nortrel 1/35 (21) 1-35 mg- nortrel 1/35 (21) TIER 1 PV mcg tab nortrel 1/35 (28) 1-35 mg- nortrel 1/35 (28) TIER 1 PV mcg tab nortrel 7/7/7 0.5/0.75/1-35 nortrel 7/7/7 TIER 1 PV mg-mcg tab ocella ocella 3-0.03 mg tab TIER 1 PV OGESTREL 0.5-50 MG- MCG TAB OGESTREL TIER 1 PV norgestrel & ethinyl estradiol orsythia orsythia 0.1-20 mg-mcg tab TIER 1 PV philith philith 0.4-35 mg-mcg tab TIER 1 PV pimtrea 0.15-0.02/0.01 mg pimtrea TIER 1 PV (21/5) tab pirmella 1/35 1-35 mg-mcg pirmella 1/35 TIER 1 PV tab pirmella 7/7/7 0.5/0.75/1-35 pirmella 7/7/7 TIER 1 PV mg-mcg tab portia-28 0.15-30 mg-mcg portia-28 TIER 1 PV tab PREMARIN (0.3 MG TAB, 0.45 MG TAB, 0.625 MG TAB, 0.625 MG/GM PREMARIN TIER 2 CREAM, 0.9 MG TAB, 1.25 MG TAB) estrogens, conjugated PREMPHASE 0.625-5 MG TAB PREMPHASE conjugated estrogens- TIER 2 medroxyprogesterone acetate

©2020 Wellmark, Inc. 133 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PREMPRO (0.3-1.5 MG TAB, 0.45-1.5 MG TAB, 0.625-5 MG TAB, 0.625-2.5 PREMPRO MG TAB) TIER 2 conjugated estrogens- medroxyprogesterone acetate previfem 0.25-35 mg-mcg previfem TIER 1 PV tab quasense quasense 0.15-0.03 mg tab TIER 1 PV rajani rajani 3-0.02-0.451 mg tab TIER 1 PV reclipsen 0.15-30 mg-mcg reclipsen TIER 1 PV tab rivelsa rivelsa 42-21-21-7 days tab TIER 1 PV setlakin setlakin 0.15-0.03 mg tab TIER 1 PV simliya 0.15-0.02/0.01 mg simliya TIER 1 PV (21/5) tab simpesse 0.15-0.03 &0.01 simpesse TIER 1 PV mg tab sprintec 28 0.25-35 mg- sprintec 28 TIER 1 PV mcg tab sronyx sronyx 0.1-20 mg-mcg tab TIER 1 PV syeda syeda 3-0.03 mg tab TIER 1 PV tarina 24 fe 1-20 mg- tarina 24 fe TIER 1 PV mcg(24) tab tarina fe 1/20 1-20 mg-mcg tarina fe 1/20 TIER 1 PV tab tarina fe 1/20 eq 1-20 mg- tarina fe 1/20 eq TIER 1 PV mcg tab tilia fe 1-20/1-30/1-35 mg- tilia fe TIER 1 PV mcg tab tri femynor 0.18/0.215/0.25 tri femynor TIER 1 PV mg-35 mcg tab tri-estarylla 0.18/0.215/0.25 tri-estarylla TIER 1 PV mg-35 mcg tab tri-legest fe 1-20/1-30/1-35 tri-legest fe TIER 1 PV mg-mcg tab tri-linyah 0.18/0.215/0.25 tri-linyah TIER 1 PV mg-35 mcg tab tri-lo-estarylla tri-lo-estarylla 0.18/0.215/0.25 mg-25 mcg TIER 1 PV tab tri-lo-marzia tri-lo-marzia 0.18/0.215/0.25 mg-25 mcg TIER 1 PV tab

©2020 Wellmark, Inc. 134 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS tri-lo-mili 0.18/0.215/0.25 tri-lo-mili TIER 1 PV mg-25 mcg tab tri-lo-sprintec tri-lo-sprintec 0.18/0.215/0.25 mg-25 mcg TIER 1 PV tab tri-mili 0.18/0.215/0.25 mg- tri-mili TIER 1 PV 35 mcg tab tri-previfem 0.18/0.215/0.25 tri-previfem TIER 1 PV mg-35 mcg tab tri-sprintec 0.18/0.215/0.25 tri-sprintec TIER 1 PV mg-35 mcg tab tri-vylibra 0.18/0.215/0.25 tri-vylibra TIER 1 PV mg-35 mcg tab tri-vylibra lo 0.18/0.215/0.25 tri-vylibra lo TIER 1 PV mg-25 mcg tab trinessa (28) trinessa (28) 0.18/0.215/0.25 mg-35 mcg TIER 1 PV tab trinessa lo 0.18/0.215/0.25 trinessa lo TIER 1 PV mg-25 mcg tab trivora (28) trivora (28) tab TIER 1 PV tydemy 3-0.03-0.451 mg tydemy TIER 1 PV tab velivet 0.1/0.125/0.15 - velivet TIER 1 PV 0.025 mg tab vestura vestura 3-0.02 mg tab TIER 1 PV vienva vienva 0.1-20 mg-mcg tab TIER 1 PV viorele 0.15-0.02/0.01 mg viorele TIER 1 PV (21/5) tab volnea 0.15-0.02/0.01 mg volnea TIER 1 PV (21/5) tab vyfemla vyfemla 0.4-35 mg-mcg tab TIER 1 PV vylibra vylibra 0.25-35 mg-mcg tab TIER 1 PV wera wera 0.5-35 mg-mcg tab TIER 1 PV wymzya fe 0.4-35 mg-mcg wymzya fe TIER 1 PV chew tab XULANE 150-35 MCG/24HR PATCH WK XULANE TIER 1 PV norelgestromin-ethinyl estradiol yuvafem yuvafem 10 mcg tab TIER 1 zarah zarah 3-0.03 mg tab TIER 1 PV zenchent 0.4-35 mg-mcg zenchent TIER 1 PV tab

©2020 Wellmark, Inc. 135 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS zenchent fe 0.4-35 mg-mcg zenchent fe TIER 1 PV chew tab zovia 1/35e (28) 1-35 mg- zovia 1/35e (28) TIER 1 PV mcg tab zovia 1/50e (28) 1-50 mg- zovia 1/50e (28) TIER 1 PV mcg tab zumandimine zumandimine 3-0.03 mg tab TIER 1 PV

PROGESTINS

camila camila 0.35 mg tab TIER 1 PV CRINONE 4 % GEL CRINONE TIER 3 progesterone (vaginal) deblitane deblitane 0.35 mg tab TIER 1 PV errin errin 0.35 mg tab TIER 1 PV heather heather 0.35 mg tab TIER 1 PV HYDROXYPROGESTERO NE CAPROATE 1.25 HYDROXYPROGEST GM/5ML SOLUTION SP-M ERONE CAPROATE hydroxyprogesterone caproate (antineoplastic) hydroxyprogesterone hydroxyprogesterone SP-M QL (250 PER 7 DAY(S)) caproate caproate 250 mg/ml oil incassia incassia 0.35 mg tab TIER 1 PV jencycla jencycla 0.35 mg tab TIER 1 PV jolivette jolivette 0.35 mg tab TIER 1 PV KYLEENA 19.5 MG IUD KYLEENA SP-M levonorgestrel (iud) LILETTA (52 MG) 19.5 LILETTA (52 MG) MCG/DAY IUD SP-M levonorgestrel (iud) lyza lyza 0.35 mg tab TIER 1 PV MAKENA 250 MG/ML OIL MAKENA hydroxyprogesterone SP-M QL (250 PER 7 DAY(S)), GA caproate MAKENA 275 MG/1.1ML SOLN A-INJ MAKENA SP-M QL (4 PER 28 DAY(S)) hydroxyprogesterone caproate medroxyprogesterone acetate (2.5 mg tab, 5 mg medroxyprogesterone tab, 10 mg tab, 150 mg/ml TIER 1 acetate suspension, 150 mg/ml susp prsyr)

©2020 Wellmark, Inc. 136 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS megestrol acetate (20 mg tab, 40 mg/ml suspension, megestrol acetate 40 mg tab, 400 mg/10ml TIER 1 suspension, 625 mg/5ml suspension) MIRENA (52 MG) 20 MIRENA (52 MG) MCG/24HR IUD SP-M levonorgestrel (iud) NEXPLANON 68 MG NEXPLANON IMPLANT SP-M etonogestrel nora-be nora-be 0.35 mg tab TIER 1 PV norethindrone norethindrone 0.35 mg tab TIER 1 PV norethindrone acetate 5 mg norethindrone acetate TIER 1 tab norlyda norlyda 0.35 mg tab TIER 1 PV norlyroc norlyroc 0.35 mg tab TIER 1 PV progesterone progesterone 50 mg/ml oil TIER 1 progesterone progesterone micronized TIER 1 micronized (100 mg cap, 200 mg cap) sharobel sharobel 0.35 mg tab TIER 1 PV SKYLA 13.5 MG IUD SKYLA SP-M levonorgestrel (iud) tulana tulana 0.35 mg tab TIER 1 PV

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS

raloxifene hcl raloxifene hcl 60 mg tab TIER 1 PA, PV

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

euthyrox (25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 mcg tab, 112 euthyrox TIER 1 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab) levo-t (25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 mcg tab, 112 mcg levo-t tab, 125 mcg tab, 137 mcg TIER 1 tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 300 mcg tab)

©2020 Wellmark, Inc. 137 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS levothyroxine sodium (25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 levothyroxine sodium mcg tab, 112 mcg tab, 125 TIER 1 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 300 mcg tab) levoxyl (25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 mcg tab, 112 levoxyl TIER 1 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab) liothyronine sodium (5 mcg liothyronine sodium tab, 25 mcg tab, 50 mcg TIER 1 tab) np thyroid (15 mg tab, 30 np thyroid mg tab, 60 mg tab, 90 mg TIER 1 tab, 120 mg tab) SYNTHROID (25 MCG TAB, 50 MCG TAB, 75 MCG TAB, 88 MCG TAB, 100 MCG TAB, 112 MCG SYNTHROID TAB, 125 MCG TAB, 137 TIER 2 GA MCG TAB, 150 MCG TAB, 175 MCG TAB, 200 MCG TAB, 300 MCG TAB) levothyroxine sodium thyroid (15 mg tab, 30 mg thyroid tab, 60 mg tab, 90 mg tab, TIER 1 120 mg tab) unithroid (25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 mcg tab, 112 unithroid mcg tab, 125 mcg tab, 137 TIER 1 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 300 mcg tab) unithroid direct (25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 mcg tab, 112 unithroid direct TIER 1 mcg tab, 125 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 300 mcg tab)

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

BYNFEZIA PEN 2500 MCG/ML (2.8 ML) SOLN BYNFEZIA PEN SP-P PEN octreotide acetate cabergoline cabergoline 0.5 mg tab TIER 1 ELIGARD (7.5 MG KIT, 22.5 MG KIT, 30 MG KIT, ELIGARD SP-M 45 MG KIT) leuprolide acetate FENSOLVI (6 MONTH) 45 FENSOLVI (6 MG (PED) KIT SP-M MONTH) leuprolide acetate (cpp) (6 month) FIRMAGON (240 MG FIRMAGON (240 MG DOSE) 120 MG/VIAL SP-M DOSE) RECON SOLN degarelix acetate FIRMAGON 80 MG FIRMAGON RECON SOLN SP-M degarelix acetate LUPANETA PACK (PACK3.755MGKIT, LUPANETA PACK PACK11.255MGKIT) SP-M leuprolide acetate & norethindrone acetate LUPRON DEPOT (1- LUPRON DEPOT (1- MONTH) (3.75 MG KIT, 7.5 SP-M MONTH) MG KIT) leuprolide acetate LUPRON DEPOT (3- MONTH) (11.25 MG KIT, LUPRON DEPOT (3- 22.5 MG KIT) SP-M MONTH) leuprolide acetate (3 month) LUPRON DEPOT (4- LUPRON DEPOT (4- MONTH) 30 MG KIT SP-M MONTH) leuprolide acetate (4 month) LUPRON DEPOT (6- LUPRON DEPOT (6- MONTH) 45 MG KIT SP-M MONTH) leuprolide acetate (6 month)

©2020 Wellmark, Inc. 139 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS LUPRON DEPOT-PED (1- LUPRON DEPOT- MONTH) (7.5 MG KIT, SP-M PED (1-MONTH) 11.25 MG KIT, 15 MG KIT) leuprolide acetate (cpp) LUPRON DEPOT-PED (3- MONTH) (11.25 MG KIT, LUPRON DEPOT- 30 MG KIT) SP-M PED (3-MONTH) leuprolide acetate (cpp) (3 month) octreotide acetate (50 mcg/ml solution, 100 mcg/ml solution, 200 octreotide acetate mcg/ml solution, 500 SP-P mcg/ml solution, 1000 mcg/5ml solution, 1000 mcg/ml solution) SANDOSTATIN (50 MCG/ML SOLUTION, 100 MCG/ML SOLUTION, 200 SANDOSTATIN MCG/ML SOLUTION, 500 SP-NP GA MCG/ML SOLUTION, 1000 MCG/ML SOLUTION) octreotide acetate SANDOSTATIN LAR SANDOSTATIN LAR DEPOT (10 MG KIT, 20 MN-PA (Medically Necessary SP-M DEPOT MG KIT, 30 MG KIT) Prior Authorization) octreotide acetate SIGNIFOR (0.3 MG/ML SOLUTION, 0.6 MG/ML SIGNIFOR SOLUTION, 0.9 MG/ML SP-P SOLUTION) pasireotide diaspartate SOMATULINE DEPOT (60 MG/0.2ML SOLUTION, 90 SOMATULINE MG/0.3ML SOLUTION, 120 SP-M DEPOT MG/0.5ML SOLUTION) lanreotide acetate SOMAVERT (10 MG RECON SOLN, 15 MG RECON SOLN, 20 MG MN-PA (Medically Necessary SOMAVERT RECON SOLN, 25 MG SP-P Prior Authorization) RECON SOLN, 30 MG RECON SOLN) pegvisomant TRELSTAR (3.75 MG RECON SUSP, 11.25 MG TRELSTAR SP-M RECON SUSP) triptorelin pamoate

©2020 Wellmark, Inc. 140 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TRELSTAR MIXJECT (3.75 MG RECON SUSP, 11.25 TRELSTAR MIXJECT MG RECON SUSP, 22.5 SP-M MG RECON SUSP) triptorelin pamoate

HORMONAL AGENTS, SUPPRESSANT (THYROID)

ANTITHYROID AGENTS

methimazole (5 mg tab, 10 methimazole TIER 1 mg tab) propylthiouracil propylthiouracil 50 mg tab TIER 1

IMMUNOLOGICAL AGENTS

ANGIOEDEMA AGENTS

BERINERT 500 UNIT KIT MN-PA (Medically Necessary BERINERT c1 esterase inhibitor SP-M Prior Authorization) (human) CINRYZE 500 UNIT RECON SOLN CINRYZE SP-M PA c1 esterase inhibitor (human) FIRAZYR 30 MG/3ML FIRAZYR SOLUTION SP-NP PA, GA icatibant acetate HAEGARDA (2000 RECON SOLN, 3000 RECON HAEGARDA SOLN) SP-P PA c1 esterase inhibitor (human) icatibant acetate 30 mg/3ml icatibant acetate SP-P PA solution KALBITOR 10 MG/ML KALBITOR SOLUTION SP-M PA ecallantide RUCONEST 2100 UNIT RECON SOLN RUCONEST SP-M PA c1 esterase inhibitor (recombinant) TAKHZYRO 300 MG/2ML TAKHZYRO SOLUTION SP-P PA lanadelumab-flyo

IMMUNE SUPPRESSANTS

ASTAGRAF XL (0.5 MG CAP ER 24H, 1 MG CAP ASTAGRAF XL ER 24H, 5 MG CAP ER SP-P PV 24H) tacrolimus AVSOLA 100 MG RECON AVSOLA SOLN SP-M PA infliximab-axxq azathioprine azathioprine 50 mg tab TIER 1 CELLCEPT (200 MG/ML RECON SUSP, 250 MG CELLCEPT TIER 2 GA CAP, 500 MG TAB) mycophenolate mofetil MN-PA (Medically Necessary CIMZIA 2 X 200 MG KIT CIMZIA SP-NP Prior Authorization), QLV certolizumab pegol (Quantity Limit Varies) CIMZIA PREFILLED 2 X MN-PA (Medically Necessary CIMZIA PREFILLED 200 MG/ML KIT SP-NP Prior Authorization), QLV certolizumab pegol (Quantity Limit Varies) CIMZIA STARTER KIT 6 X QL (1 PER LIFETIME), MN- CIMZIA STARTER 200 MG/ML KIT SP-NP PA (Medically Necessary KIT certolizumab pegol Prior Authorization) cyclosporine (25 mg cap, cyclosporine TIER 1 PV 100 mg cap) cyclosporine modified (25 mg cap, 50 mg cap, 100 cyclosporine modified TIER 1 PV mg/ml solution, 100 mg cap) ENBREL (25 MG RECON SOLN, 25 MG/0.5ML SOLN ENBREL PRSYR, 50 MG/ML SOLN SP-P PA, QL (8 PER 28 DAYS) PRSYR) etanercept ENBREL 25 MG/0.5ML ENBREL SOLUTION SP-P PA, QL (8 PER 28 DAY(S)) etanercept ENBREL MINI 50 MG/ML ENBREL MINI SOLN CART SP-P PA, QL (8 PER 28 DAY(S)) etanercept ENBREL SURECLICK 50 ENBREL MG/ML SOLN A-INJ SP-P PA, QL (8 PER 28 DAYS) SURECLICK etanercept ENTYVIO 300 MG RECON ENTYVIO SOLN SP-M PA vedolizumab

©2020 Wellmark, Inc. 142 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ENVARSUS XR (0.75 MG TAB ER 24H, 1 MG TAB ENVARSUS XR ER 24H, 4 MG TAB ER SP-P 24H) tacrolimus everolimus (0.25 mg tab, everolimus SP-P 0.5 mg tab, 0.75 mg tab) gengraf (25 mg cap, 50 mg gengraf cap, 100 mg cap, 100 TIER 1 PV mg/ml solution) HUMIRA (10 MG/0.1ML PREF SY KT, 20 MG/0.2ML PREF SY KT, HUMIRA SP-P PA, QL (4 PER 28 DAY(S)) 40 MG/0.4ML PREF SY KT) adalimumab HUMIRA (10 MG/0.2ML PREF SY KT, 20 MG/0.4ML PREF SY KT, HUMIRA SP-P PA, QL (4 PER 28 DAYS) 40 MG/0.8ML PREF SY KT) adalimumab HUMIRA PEDIATRIC CROHNS START (80 & HUMIRA PEDIATRIC 40MG/0.4ML PREF SY KT, SP-P PA, QL (1 PER LIFETIME) CROHNS START 80 PREF SY KT) adalimumab HUMIRA PEDIATRIC HUMIRA PEDIATRIC CROHNS START 40 SP-P PA, QL (4 PER 28 DAYS) CROHNS START MG/0.8ML PREF SY KT adalimumab HUMIRA PEN 40 HUMIRA PEN MG/0.4ML PEN KIT SP-P PA, QL (4 PER 28 DAY(S)) adalimumab HUMIRA PEN 40 HUMIRA PEN MG/0.8ML PEN KIT SP-P PA, QL (4 PER 28 DAYS) adalimumab HUMIRA PEN-CD/UC/HS HUMIRA PEN- STARTER 40 MG/0.8ML SP-P PA, QL (4 PER 28 DAYS) CD/UC/HS STARTER PEN KIT adalimumab HUMIRA PEN-CD/UC/HS HUMIRA PEN- STARTER 80 MG/0.8ML SP-P PA, QL (1 PER LIFETIME) CD/UC/HS STARTER PEN KIT adalimumab HUMIRA PEN- HUMIRA PEN- PS/UV/ADOL HS START PS/UV/ADOL HS SP-P PA, QL (4 PER 28 DAYS) 40 MG/0.8ML PEN KIT START adalimumab

©2020 Wellmark, Inc. 143 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HUMIRA PEN- HUMIRA PEN- PS/UV/ADOL HS START PS/UV/ADOL HS 80 MG/0.8ML & SP-P PA, QL (1 PER LIFETIME) START 40MG/0.4ML PEN KIT adalimumab INFLECTRA 100 MG INFLECTRA RECON SOLN SP-M PA infliximab-dyyb KINERET 100 MG/0.67ML MN-PA (Medically Necessary KINERET SOLN PRSYR SP-NP Prior Authorization), QLV anakinra (Quantity Limit Varies) METHOTREXATE (ANTI- METHOTREXATE RHEUMATIC) 2.5 MG TAB TIER 2 (ANTI-RHEUMATIC) methotrexate sodium (antirheumatic) methotrexate methotrexate 2.5 mg tab TIER 1 methotrexate sodium (2.5 methotrexate sodium mg tab, 50 mg/2ml solution, TIER 1 250 mg/10ml solution) methotrexate sodium (pf) (1 gm/40ml solution, 50 methotrexate sodium mg/2ml solution, 100 TIER 1 (pf) mg/4ml solution, 200 mg/8ml solution, 250 mg/10ml solution) mycophenolate mofetil (200 mycophenolate mg/ml recon susp, 250 mg TIER 1 PV mofetil cap, 500 mg tab) mycophenolate sodium mycophenolate (180 mg tab dr, 360 mg tab TIER 1 PV sodium dr) NEORAL (25 MG CAP, 100 MG/ML SOLUTION, 100 NEORAL MG CAP) TIER 3 GA cyclosporine modified (for microemulsion) OLUMIANT (1 MG TAB, 2 QL (30 PER 30 DAY(S)), OLUMIANT MG TAB) SP-NP MN-PA (Medically Necessary baricitinib Prior Authorization) ORENCIA (50 MG/0.4ML SOLN PRSYR, 87.5 QL (4 PER 28 DAY(S)), MN- ORENCIA MG/0.7ML SOLN PRSYR, SP-NP PA (Medically Necessary 125 MG/ML SOLN PRSYR) Prior Authorization) abatacept ORENCIA 250 MG RECON ORENCIA SOLN SP-M PA, QL (4 PER 28 DAY(S)) abatacept

©2020 Wellmark, Inc. 144 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ORENCIA CLICKJECT 125 QL (4 PER 28 DAY(S)), MN- ORENCIA MG/ML SOLN A-INJ SP-NP PA (Medically Necessary CLICKJECT abatacept Prior Authorization) OTREXUP (7.5 SOLN A- INJ, 10 SOLN A-INJ, 12.5 SOLN A-INJ, 15 SOLN A- INJ, 17.5 SOLN A-INJ, 20 OTREXUP SP-M SOLN A-INJ, 22.5 SOLN A- INJ, 25 SOLN A-INJ) methotrexate (antirheumatic) PROGRAF (0.2 MG PACKET, 0.5 MG CAP, 1 PROGRAF MG CAP, 1 MG PACKET, 5 TIER 3 GA MG CAP) tacrolimus RASUVO (7.5 MG/0.15ML SOLN A-INJ, 10 MG/0.2ML SOLN A-INJ, 12.5 MG/0.25ML SOLN A-INJ, 15 MG/0.3ML SOLN A-INJ, 17.5 MG/0.35ML SOLN A- INJ, 20 MG/0.4ML SOLN A- RASUVO SP-M INJ, 22.5 MG/0.45ML SOLN A-INJ, 25 MG/0.5ML SOLN A-INJ, 27.5 MG/0.55ML SOLN A-INJ, 30 MG/0.6ML SOLN A-INJ) methotrexate (antirheumatic) REMICADE 100 MG REMICADE RECON SOLN SP-M PA infliximab RENFLEXIS 100 MG RENFLEXIS RECON SOLN SP-M PA infliximab-abda RHEUMATREX 2.5 MG TAB RHEUMATREX TIER 2 methotrexate sodium (antirheumatic) RINVOQ 15 MG TAB ER RINVOQ 24H SP-P PA, QL (30 PER 30 DAY(S)) upadacitinib SANDIMMUNE (25 MG CAP, 100 MG CAP, 100 SANDIMMUNE TIER 3 GA MG/ML SOLUTION) cyclosporine

©2020 Wellmark, Inc. 145 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SIMPONI (50 MG/0.5ML SOLN A-INJ, 50 MG/0.5ML QL (1 PER 30 DAYS), MN- SOLN PRSYR, 100 MG/ML SIMPONI SP-NP PA (Medically Necessary SOLN A-INJ, 100 MG/ML Prior Authorization) SOLN PRSYR) golimumab SIMPONI ARIA 50 MG/4ML SIMPONI ARIA SOLUTION SP-M PA golimumab sirolimus (0.5 mg tab, 1 sirolimus mg/ml solution, 1 mg tab, 2 TIER 1 PV mg tab) tacrolimus (0.5 mg cap, 1 tacrolimus TIER 1 PV mg cap, 5 mg cap) XELJANZ 10 MG TAB XELJANZ SP-P PA, QL (60 PER 30 DAY(S)) tofacitinib citrate XELJANZ 5 MG TAB XELJANZ SP-P PA, QL (60 PER 30 DAYS) tofacitinib citrate XELJANZ XR 11 MG TAB XELJANZ XR ER 24H SP-P PA, QL (30 PER 30 DAYS) tofacitinib citrate XELJANZ XR 22 MG TAB XELJANZ XR ER 24H SP-P PA, QL (30 PER 30 DAY(S)) tofacitinib citrate ZORTRESS (0.25 MG TAB, 0.5 MG TAB, 0.75 MG TAB, ZORTRESS 1 MG TAB) SP-P everolimus (immunosuppressant)

IMMUNIZING AGENTS, PASSIVE

ASCENIV 5 GM/50ML SOLUTION ASCENIV SP-M PA immune globulin (human)- slra BIVIGAM (5 GM/50ML SOLUTION, 10 GM/100ML BIVIGAM SP-M PA SOLUTION) immune globulin (human) iv CARIMUNE NF (6 GM RECON SOLN, 12 GM CARIMUNE NF SP-M PA RECON SOLN) immune globulin (human) iv

©2020 Wellmark, Inc. 146 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CUTAQUIG (1 GM/6ML SOLUTION, 1.65 GM/10ML SOLUTION, 2 GM/12ML SOLUTION, 3.3 GM/20ML CUTAQUIG SOLUTION, 4 GM/24ML SP-M PA SOLUTION, 8 GM/48ML SOLUTION) immune globulin (human)- hipp CUVITRU (1 GM/5ML SOLUTION, 2 GM/10ML SOLUTION, 4 GM/20ML SOLUTION, 8 GM/40ML CUVITRU SP-M PA SOLUTION, 10 GM/50ML SOLUTION) immune globulin (human) subcutaneous CYTOGAM 50 MG/ML INJECTABLE CYTOGAM SP-M cytomegalovirus immune globulin (human) FLEBOGAMMA DIF (0.5 GM/10ML SOLUTION, 2.5 GM/50ML SOLUTION, 5 GM/100ML SOLUTION, 5 GM/50ML SOLUTION, 10 FLEBOGAMMA DIF SP-M PA GM/100ML SOLUTION, 10 GM/200ML SOLUTION, 20 GM/400ML SOLUTION, 20 GM/200ML SOLUTION) immune globulin (human) iv GAMASTAN INJECTABLE GAMASTAN SP-M immune globulin (human) im GAMMAGARD (1 GM/10ML SOLUTION, 2.5 GM/25ML SOLUTION, 5 GM/50ML SOLUTION, 10 GAMMAGARD GM/100ML SOLUTION, 20 SP-M PA GM/200ML SOLUTION, 30 GM/300ML SOLUTION) immune globulin (human) iv or subcutaneous GAMMAGARD S/D LESS GAMMAGARD S/D IGA (5 GM RECON SOLN, SP-M PA LESS IGA 10 GM RECON SOLN) immune globulin (human) iv

©2020 Wellmark, Inc. 147 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS GAMMAKED (1 GM/10ML SOLUTION, 2.5 GM/25ML SOLUTION, 5 GM/50ML SOLUTION, 10 GM/100ML GAMMAKED SP-M PA SOLUTION, 20 GM/200ML SOLUTION) immune globulin (human) iv or subcutaneous GAMMAPLEX (5 GM/50ML SOLUTION, 5 GM/100ML SOLUTION, 10 GM/100ML SOLUTION, 10 GM/200ML GAMMAPLEX SP-M PA SOLUTION, 20 GM/200ML SOLUTION, 20 GM/400ML SOLUTION) immune globulin (human) iv GAMUNEX-C (1 GM/10ML SOLUTION, 2.5 GM/25ML SOLUTION, 5 GM/50ML SOLUTION, 10 GM/100ML GAMUNEX-C SOLUTION, 20 GM/200ML SP-M PA SOLUTION, 40 GM/400ML SOLUTION) immune globulin (human) iv or subcutaneous HIZENTRA (1 GM/5ML SOLUTION, 1 GM/5ML SOLN PRSYR, 2 GM/10ML SOLN PRSYR, 2 GM/10ML SOLUTION, 4 GM/20ML HIZENTRA SP-M PA SOLN PRSYR, 4 GM/20ML SOLUTION, 10 GM/50ML SOLUTION) immune globulin (human) subcutaneous HYPERRHO S/D (250 SOLN PRSYR, 1500 SOLN HYPERRHO S/D PRSYR) SP-M rho d immune globulin (human)

©2020 Wellmark, Inc. 148 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS HYQVIA (2.5 GM/25ML KIT, 5 GM/50ML KIT, 10 GM/100ML KIT, 20 GM/200ML KIT, 30 HYQVIA SP-M PA GM/300ML KIT) immune globulin (human)- hyaluronidase (human recombinant) MICRHOGAM ULTRA- MICRHOGAM FILTERED PLUS 250 UNIT ULTRA-FILTERED SOLN PRSYR SP-M PLUS rho d immune globulin (human) OCTAGAM (1 GM/20ML SOLUTION, 2 GM/20ML SOLUTION, 2.5 GM/50ML SOLUTION, 5 GM/100ML SOLUTION, 5 GM/50ML SOLUTION, 10 GM/100ML OCTAGAM SP-M PA SOLUTION, 10 GM/200ML SOLUTION, 20 GM/200ML SOLUTION, 25 GM/500ML SOLUTION, 30 GM/300ML SOLUTION) immune globulin (human) iv PANZYGA (1 GM/10ML SOLUTION, 2.5 GM/25ML SOLUTION, 5 GM/50ML SOLUTION, 10 GM/100ML PANZYGA SOLUTION, 20 GM/200ML SP-M PA SOLUTION, 30 GM/300ML SOLUTION) immune globulin (human)- ifas PRIVIGEN (5 GM/50ML SOLUTION, 10 GM/100ML SOLUTION, 20 GM/200ML PRIVIGEN SP-M PA SOLUTION, 40 GM/400ML SOLUTION) immune globulin (human) iv RHOGAM ULTRA- FILTERED PLUS 1500 RHOGAM ULTRA- UNIT SOLN PRSYR SP-M FILTERED PLUS rho d immune globulin (human) RHOPHYLAC 1500 UNIT/2ML SOLN PRSYR RHOPHYLAC SP-M rho d immune globulin (human)

©2020 Wellmark, Inc. 149 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS VARIZIG 125 UNIT/1.2ML SOLUTION VARIZIG SP-M varicella-zoster immune globulin (human) XEMBIFY 4 GM/20ML SOLUTION XEMBIFY SP-M PA immune globulin (human)- klhw

IMMUNOMODULATORS

ACTEMRA (80 MG/4ML SOLUTION, 200 MG/10ML ACTEMRA SOLUTION, 400 MG/20ML SP-M PA, QL (40 PER 28 DAYS) SOLUTION) tocilizumab ACTEMRA 162 MG/0.9ML QL (4 PER 28 DAYS), MN- ACTEMRA SOLN PRSYR SP-NP PA (Medically Necessary tocilizumab Prior Authorization) ACTEMRA ACTPEN 162 QL (4 PER 28 DAY(S)), MN- ACTEMRA ACTPEN MG/0.9ML SOLN A-INJ SP-NP PA (Medically Necessary tocilizumab Prior Authorization) ACTIMMUNE 2000000 ACTIMMUNE UNIT/0.5ML SOLUTION SP-P interferon gamma-1b ARCALYST 220 MG ARCALYST RECON SOLN SP-P rilonacept BENLYSTA (200 MG/ML SOLN A-INJ, 200 MG/ML BENLYSTA SP-P SOLN PRSYR) belimumab ILARIS (150 MG RECON SOLN, 150 MG/ML ILARIS SP-M SOLUTION) canakinumab KEVZARA (150 SOLN PRSYR, 150 SOLN A-INJ, QL (2 PER 28 DAY(S)), MN- KEVZARA 200 SOLN PRSYR, 200 SP-NP PA (Medically Necessary SOLN A-INJ) Prior Authorization) sarilumab leflunomide (10 mg tab, 20 leflunomide TIER 1 mg tab) OTEZLA 10 & 20 & 30 MG OTEZLA TAB THPK SP-P PA, QL (1 PER FILL) apremilast

©2020 Wellmark, Inc. 150 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS OTEZLA 30 MG TAB OTEZLA SP-P PA, QL (60 PER 30 DAYS) apremilast PALFORZIA (12 MG DAILY DOSE) 2 X 1 MG & 10 MG PALFORZIA (12 MG CSPK SP-NP PA, QL (1 PER FILL(S)) DAILY DOSE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA (120 MG DAILY DOSE) 20 MG & PALFORZIA (120 MG 100 MG CSPK SP-NP PA, QL (1 PER FILL(S)) DAILY DOSE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA (160 MG DAILY DOSE) 3 X 20 MG & PALFORZIA (160 MG 100 MG CSPK SP-NP PA, QL (1 PER FILL(S)) DAILY DOSE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA (20 MG DAILY PALFORZIA (20 MG DOSE) 20 MG CSPK SP-NP PA, QL (1 PER FILL(S)) DAILY DOSE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA (200 MG DAILY DOSE) 2 X 100 MG PALFORZIA (200 MG CSPK SP-NP PA, QL (1 PER FILL(S)) DAILY DOSE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA (240 MG DAILY DOSE) 2 X 20 MG & PALFORZIA (240 MG 2 X 100 MG CSPK SP-NP PA, QL (1 PER FILL(S)) DAILY DOSE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA (3 MG DAILY PALFORZIA (3 MG DOSE) 3 X 1 MG CSPK SP-NP PA, QL (1 PER FILL(S)) DAILY DOSE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA (300 MG MAINTENANCE) 300 MG PALFORZIA (300 MG PACKET SP-NP PA, QL (30 PER 30 DAY(S)) MAINTENANCE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA (300 MG TITRATION) 300 MG PALFORZIA (300 MG PACKET SP-NP PA, QL (30 PER 30 DAY(S)) TITRATION) peanut (arachis hypogaea) allergen powder-dnfp

©2020 Wellmark, Inc. 151 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PALFORZIA (40 MG DAILY PALFORZIA (40 MG DOSE) 2 X 20 MG CSPK SP-NP PA, QL (1 PER FILL(S)) DAILY DOSE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA (6 MG DAILY PALFORZIA (6 MG DOSE) 6 X 1 MG CSPK SP-NP PA, QL (1 PER FILL(S)) DAILY DOSE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA (80 MG DAILY PALFORZIA (80 MG DOSE) 4 X 20 MG CSPK SP-NP PA, QL (1 PER FILL(S)) DAILY DOSE) peanut (arachis hypogaea) allergen powder-dnfp PALFORZIA INITIAL ESCALATION 0.5 & 1 & 1.5 PALFORZIA INITIAL & 3 & 6 MG CSPK SP-NP PA, QL (1 PER FILL(S)) ESCALATION peanut (arachis hypogaea) allergen powder-dnfp RIDAURA 3 MG CAP RIDAURA TIER 2 auranofin SYNAGIS (50 MG/0.5ML SOLUTION, 100 MG/ML SYNAGIS SP-M PA SOLUTION) palivizumab

VACCINES

ACTHIB RECON SOLN ACTHIB haemophilus b polysac conj TIER 2 PV vac ADACEL 5-2-15.5 LF- MCG/0.5 SUSPENSION ADACEL tetanus toxoid-diphtheria- TIER 2 PV acellular pertussis adsorb (tdap) AFLURIA SUSPENSION AFLURIA TIER 2 PV influenza virus vaccine split AFLURIA PRESERVATIVE AFLURIA FREE 0.5 ML SUSP PRESERVATIVE PRSYR TIER 2 PV FREE influenza virus vaccine split preservative free AFLURIA QUADRIVALENT (0.25 ML SUSP PRSYR, AFLURIA 0.5 ML SUSP PRSYR, TIER 2 PV QUADRIVALENT SUSPENSION) influenza virus vaccine split quadrivalent

©2020 Wellmark, Inc. 152 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS BEXSERO SUSP PRSYR meningococcal vac group b BEXSERO TIER 2 PV (recombant omv adjuvanted) BOOSTRIX 5-2.5-18.5 LF- MCG/0.5 SUSPENSION BOOSTRIX tetanus toxoid-diphtheria- TIER 2 PV acellular pertussis adsorb (tdap) CERVARIX SUSPENSION CERVARIX human papillomavirus (hpv) TIER 2 bivalent (types 16, 18) recmb vac DAPTACEL 23-15-5 SUSPENSION DAPTACEL TIER 2 PV diphtheria, acellular pertussis & tetanus toxoids DIPHTHERIA-TETANUS DIPHTHERIA- TOXOIDS DT 25-5 TETANUS TOXOIDS LFU/0.5ML SUSPENSION TIER 2 PV DT diphtheria-tetanus toxoids (dt) ENGERIX-B (10 MCG/0.5ML SUSPENSION, 20 ENGERIX-B TIER 2 PV MCG/ML SUSPENSION) hepatitis b vaccine (recomb) FLUAD 0.5 ML SUSP PRSYR FLUAD influenza virus vaccine TIER 2 PV types a & b surface antigen adjuvant FLUAD QUADRIVALENT 0.5 ML PRSYR FLUAD influenza virus vacc types a TIER 2 PV QUADRIVALENT & b surf antigen adjuvant quad FLUARIX QUADRIVALENT FLUARIX 0.5 ML SUSP PRSYR TIER 2 PV QUADRIVALENT influenza virus vaccine split quadrivalent FLUBLOK SOLUTION influenza virus vaccine FLUBLOK TIER 2 PV recombinant hemagglutinin (ha)

©2020 Wellmark, Inc. 153 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FLUBLOK QUADRIVALENT 0.5 ML FLUBLOK SOLN PRSYR TIER 2 PV QUADRIVALENT influenza virus vac recomb hemagglutinin (ha) quadrivalent FLUCELVAX 0.5 ML SUSP PRSYR FLUCELVAX TIER 2 PV influenza virus vaccine tissue-cultured subunit FLUCELVAX QUADRIVALENT (0.5MLSUSPPRSYR, FLUCELVAX SUSPENSION) TIER 2 PV QUADRIVALENT influenza virus vaccine tissue-cultured subunit quadrivalent FLULAVAL QUADRIVALENT FLULAVAL (0.5MLSUSPPRSYR, TIER 2 PV QUADRIVALENT SUSPENSION) influenza virus vaccine split quadrivalent FLUMIST 10E6.5-7.5 FLUMIST LIQUID TIER 2 PV influenza virus vaccine live FLUMIST QUADRIVALENT FLUMIST SUSPENSION TIER 2 PV QUADRIVALENT influenza virus vaccine live quadrivalent FLUVIRIN (0.5MLSUSPPRSYR, FLUVIRIN SUSPENSION) TIER 2 PV influenza virus vaccine types a & b surface antigen FLUZONE HIGH-DOSE 0.5 FLUZONE HIGH- ML SUSP PRSYR TIER 2 PV DOSE influenza virus vaccine split high-dose preservative free FLUZONE HIGH-DOSE QUADRIVALENT 0.7 ML FLUZONE HIGH- SUSP PRSYR DOSE TIER 2 PV influenza virus vac split QUADRIVALENT high-dose quad preservative free

©2020 Wellmark, Inc. 154 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS FLUZONE QUADRIVALENT (0.25 ML SUSP PRSYR, 0.5 ML SUSPENSION, 0.5 ML FLUZONE SUSP PRSYR, 9 TIER 2 PV QUADRIVALENT MCG/STRAIN SUSP PEN, SUSPENSION) influenza virus vaccine split quadrivalent GARDASIL SUSPENSION GARDASIL human papillomavirus (hpv) TIER 2 quadrivalent recombinant vaccine GARDASIL 9 (9SUSPPRSYR, 9SUSPENSION) GARDASIL 9 TIER 2 PV human papillomavirus (hpv) 9-valent recombinant vaccine HAVRIX (720 U/0.5ML SUSPENSION, 1440 U/ML HAVRIX TIER 2 PV SUSPENSION) hepatitis a vaccine HEPLISAV-B (20 SOLUTION, 20 SOLN HEPLISAV-B PRSYR) TIER 2 PV hepatitis b vaccine recombinant adjuvanted HIBERIX 10 MCG RECON SOLN HIBERIX TIER 2 PV haemophilus b polysac conj vac INFANRIX 25-58-10 SUSPENSION INFANRIX TIER 2 PV diphtheria, acellular pertussis & tetanus toxoids IPOL INJECTABLE IPOL TIER 2 PV poliovirus vaccine, ipv KINRIX SUSPENSION diph-tetanus tox ad-acell KINRIX TIER 2 PV pertussis & polio virus, ipv vac M-M-R II RECON SOLN M-M-R II measles, mumps & rubella TIER 2 PV virus vaccines

©2020 Wellmark, Inc. 155 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS MENACTRA (4MCG/0.5MLINJECTABLE , INJECTABLE) MENACTRA TIER 2 PV meningococcal (a,c,y&w- 135) polysaccharide conjugate vaccine MENHIBRIX 5-5-2.5 MCG RECON SOLN MENHIBRIX meningococcal (c & y)- TIER 2 haemophilus b tetanus tox conj vaccine MENOMUNE RECON SOLN MENOMUNE meningococcal (a,c,y&w- TIER 2 135) polysaccharide vaccine MENQUADFI INJECTABLE MENQUADFI meningococcal (a,c,y&w- TIER 2 PV 135) polysaccharide conjugate vaccine MENVEO RECON SOLN meningococcal (a,c,y&w- MENVEO TIER 2 PV 135) oligosaccharide conjugate vac PEDIARIX SUSPENSION diph-tetanus tox-acell pert- PEDIARIX TIER 2 PV hepatitis b recomb-polio ipv vac PEDVAX HIB 7.5 MCG/0.5ML SUSPENSION PEDVAX HIB TIER 2 PV haemophilus b polysac conj vac PENTACEL RECON SUSP PENTACEL TIER 2 PV diph-ac pert-tet tox ad-polio ipv-haemophil b poly vac PNEUMOVAX 23 25 MCG/0.5ML INJECTABLE PNEUMOVAX 23 TIER 2 PV pneumococcal vac polyvalent PREVNAR 13 SUSPENSION PREVNAR 13 TIER 2 PV pneumococcal 13-valent conjugate vaccine

©2020 Wellmark, Inc. 156 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PROQUAD RECON SUSP PROQUAD TIER 2 PV measles-mumps-rubella- varicella virus vaccines QUADRACEL SUSPENSION QUADRACEL diph-tetanus tox ad-acell TIER 2 PV pertussis & polio virus, ipv vac RECOMBIVAX HB (5 MCG/0.5ML SUSPENSION, 10 MCG/ML SUSPENSION, RECOMBIVAX HB TIER 2 PV 40 MCG/ML SUSPENSION) hepatitis b vaccine (recomb) ROTARIX RECON SUSP ROTARIX TIER 2 PV rotavirus vaccine, live oral ROTATEQ SOLUTION ROTATEQ rotavirus vaccine, live oral TIER 2 PV pentavalent SHINGRIX 50 MCG/0.5ML RECON SUSP SHINGRIX TIER 2 AL (At least 50 yrs old), PV zoster vaccine recombinant adjuvanted TDVAX 2-2 LF/0.5ML SUSPENSION TDVAX TIER 2 PV tetanus-diphtheria toxoids (td) TENIVAC 5-2 LFU INJECTABLE TENIVAC TIER 2 PV tetanus-diphtheria toxoids (td) TETANUS-DIPHTHERIA TETANUS- TOXOIDS TD 2-2 LF/0.5ML DIPHTHERIA SUSPENSION TIER 2 PV TOXOIDS TD tetanus-diphtheria toxoids (td) TRUMENBA SUSP PRSYR TRUMENBA TIER 2 PV meningococcal group b vaccine (recombinant)

©2020 Wellmark, Inc. 157 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TWINRIX (SUSP PRSYR, SUSPENSION) TWINRIX hepatitis a (inactivated)- TIER 2 PV hepatitis b (recombinant) vaccines VAQTA (25 UNIT/0.5ML SUSPENSION, 50 VAQTA TIER 2 PV UNIT/ML SUSPENSION) hepatitis a vaccine VARIVAX 1350 PFU/0.5ML VARIVAX INJECTABLE TIER 2 PV varicella virus vaccine live XOFLUZA (20 MG TAB XOFLUZA THPK, 40 MG TAB THPK) TIER 3 baloxavir marboxil ZOSTAVAX 19400 UNT/0.65ML RECON ZOSTAVAX TIER 2 PV SUSP zoster vaccine live

INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATES

balsalazide disodium 750 balsalazide disodium TIER 1 mg cap DIPENTUM 250 MG CAP DIPENTUM TIER 2 olsalazine sodium mesalamine (1.2 gm tab dr, 4 gm enema, 400 mg cap mesalamine TIER 1 dr, 800 mg tab dr, 1000 mg suppos) mesalamine er 0.375 gm mesalamine er TIER 1 cap er 24h PENTASA (250 MG CAP PENTASA ER, 500 MG CAP ER) TIER 3 mesalamine

GLUCOCORTICOIDS

anucort-hc anucort-hc 25 mg suppos TIER 1 budesonide budesonide 3 mg cp dr part TIER 1 budesonide er 9 mg tab er budesonide er TIER 1 24h colocort 100 mg/60ml colocort TIER 1 enema hemmorex-hc (25 mg hemmorex-hc TIER 1 suppos, 30 mg suppos)

©2020 Wellmark, Inc. 158 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS hydrocortisone hydrocortisone (perianal) (1 TIER 1 (perianal) % cream, 2.5 % cream) hydrocortisone 100 hydrocortisone TIER 1 mg/60ml enema hydrocortisone hydrocortisone acetate (25 TIER 1 acetate mg suppos, 30 mg suppos) procto-med hc procto-med hc 2.5 % cream TIER 1 procto-pak procto-pak 1 % cream TIER 1 proctosol hc proctosol hc 2.5 % cream TIER 1 proctozone-hc proctozone-hc 2.5 % cream TIER 1

SULFONAMIDES

sulfasalazine (500 mg tab sulfasalazine TIER 1 dr, 500 mg tab)

METABOLIC BONE DISEASE AGENTS

alendronate sodium (5 mg alendronate sodium tab, 10 mg tab, 35 mg tab, TIER 1 PV 40 mg tab, 70 mg tab) calcitonin (salmon) 200 calcitonin (salmon) TIER 1 PV unit/act solution calcitriol (0.25 mcg cap, 0.5 calcitriol TIER 1 mcg cap) cinacalcet hcl (30 mg tab, cinacalcet hcl SP-P 60 mg tab, 90 mg tab) doxercalciferol (0.5 mcg doxercalciferol cap, 1 mcg cap, 2.5 mcg TIER 1 cap) ergocalciferol 50000 unit ergocalciferol TIER 1 cap ETIDRONATE DISODIUM ETIDRONATE (200 MG TAB, 400 MG TIER 1 DISODIUM TAB) etidronate disodium EVENITY 105 MG/1.17ML EVENITY SOLN PRSYR SP-M PA, QL (2 PER 28 DAY(S)) romosozumab-aqqg FORTEO 600 MCG/2.4ML QL (24 PER MONTH(S)), FORTEO SOLN PEN SP-P MN-PA (Medically Necessary teriparatide (recombinant) Prior Authorization) ibandronate sodium 150 mg ibandronate sodium TIER 1 PV tab

©2020 Wellmark, Inc. 159 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NATPARA (25 MCG CARTRIDGE, 50 MCG CARTRIDGE, 75 MCG NATPARA CARTRIDGE, 100 MCG SP-M CARTRIDGE) parathyroid hormone (recombinant) paricalcitol (1 mcg cap, 2 paricalcitol TIER 1 mcg cap, 4 mcg cap) PROLIA 60 MG/ML SOLN PROLIA PRSYR SP-M denosumab RECLAST 5 MG/100ML RECLAST SOLUTION SP-M GA zoledronic acid risedronate sodium (5 mg risedronate sodium tab, 30 mg tab, 35 mg tab TIER 1 PV dr, 35 mg tab, 150 mg tab) SENSIPAR (30 MG TAB, SENSIPAR 60 MG TAB, 90 MG TAB) SP-NP GA cinacalcet hcl TERIPARATIDE TERIPARATIDE (RECOMBINANT) 620 SP-P PA (RECOMBINANT) MCG/2.48ML SOLN PEN teriparatide (recombinant) TYMLOS 3120 QL (24 PER MONTH(S)), TYMLOS MCG/1.56ML SOLN PEN SP-P MN-PA (Medically Necessary abaloparatide Prior Authorization) vitamin d (ergocalciferol) vitamin d (1.25 mg (50000 ut) cap, TIER 1 (ergocalciferol) 50000 unit cap) XGEVA 120 MG/1.7ML XGEVA SOLUTION SP-M denosumab zoledronic acid (4 mg recon soln, 4 mg/100ml solution, zoledronic acid SP-M 4 mg/5ml conc, 5 mg/100ml solution) ZOMETA (4 MG/5ML CONC, 4 MG/100ML ZOMETA SP-M GA SOLUTION) zoledronic acid

MISCELLANEOUS THERAPEUTIC AGENTS

QL (150 PER 30 DAYS), MN- ACCU-CHEK AVIVA PLUS ACCU-CHEK AVIVA PA (Medically Necessary STRIP TIER 3 PLUS Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2020 Wellmark, Inc. 160 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- ACCU-CHEK COMPACT ACCU-CHEK PA (Medically Necessary PLUS STRIP TIER 3 COMPACT PLUS Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ACCU-CHEK GUIDE PA (Medically Necessary ACCU-CHEK GUIDE STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ACCU-CHEK SMARTVIEW ACCU-CHEK PA (Medically Necessary STRIP TIER 3 SMARTVIEW Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ACCUTREND GLUCOSE ACCUTREND PA (Medically Necessary STRIP TIER 3 GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ACURA BLOOD GLUCOSE ACURA BLOOD PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ADVANCE INTUITION ADVANCE PA (Medically Necessary TEST STRIP TIER 3 INTUITION TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ADVOCATE REDI-CODE ADVOCATE REDI- PA (Medically Necessary STRIP TIER 3 CODE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ADVOCATE REDI-CODE+ ADVOCATE REDI- PA (Medically Necessary TEST STRIP TIER 3 CODE+ TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ADVOCATE TEST STRIP PA (Medically Necessary ADVOCATE TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- AGAMATRIX AMP TEST AGAMATRIX AMP PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- AGAMATRIX JAZZ TEST AGAMATRIX JAZZ PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- AGAMATRIX KEYNOTE AGAMATRIX PA (Medically Necessary TEST STRIP TIER 3 KEYNOTE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2020 Wellmark, Inc. 161 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- AGAMATRIX PRESTO AGAMATRIX PA (Medically Necessary TEST STRIP TIER 3 PRESTO TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) ASCENSIA AUTODISC ASCENSIA TEST DISK TIER 3 AUTODISC TEST glucose blood QL (150 PER 30 DAYS), MN- ASSURE 4 TEST STRIP PA (Medically Necessary ASSURE 4 TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- ASSURE II CHECK PA (Medically Necessary ASSURE II CHECK STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ASSURE PLATINUM PA (Medically Necessary ASSURE PLATINUM STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ASSURE PRISM MULTI ASSURE PRISM PA (Medically Necessary TEST STRIP TIER 3 MULTI TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ASSURE PRO TEST PA (Medically Necessary ASSURE PRO TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) BAYER BREEZE 2 TEST BAYER BREEZE 2 DISK TIER 3 TEST glucose blood BD SWAB SINGLE USE BD SWAB SINGLE REGULAR PAD TIER 2 USE REGULAR alcohol swabs QL (150 PER 30 DAYS), MN- BLOOD GLUCOSE TEST BLOOD GLUCOSE PA (Medically Necessary (TESTSTRIP, TESTSTRIP) TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) BREEZE 2 TEST DISK BREEZE 2 TEST TIER 3 glucose blood QL (150 PER 30 DAYS), MN- CAREONE BLOOD CAREONE BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- CARESENS N GLUCOSE CARESENS N PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2020 Wellmark, Inc. 162 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- CARETOUCH TEST PA (Medically Necessary CARETOUCH TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) CHEK-STIX CONTROL CHEK-STIX STRIP TIER 2 CONTROL acetone (urine) test CHEMSTRIP 10 MD CHEMSTRIP 10 MD STRIP TIER 2 multiple urine tests CHEMSTRIP 10/SG CHEMSTRIP 10/SG STRIP TIER 2 multiple urine tests CHEMSTRIP 2 GP STRIP CHEMSTRIP 2 GP TIER 2 multiple urine tests CHEMSTRIP 5 OB STRIP CHEMSTRIP 5 OB TIER 2 multiple urine tests CHEMSTRIP 7 STRIP CHEMSTRIP 7 TIER 2 multiple urine tests CHEMSTRIP 9 STRIP CHEMSTRIP 9 TIER 2 multiple urine tests CHEMSTRIP K STRIP CHEMSTRIP K TIER 2 acetone (urine) test CHEMSTRIP UGK STRIP CHEMSTRIP UGK TIER 2 urine glucose-ketones test QL (150 PER 30 DAYS), MN- CLEVER CHEK AUTO- CLEVER CHEK PA (Medically Necessary CODE TEST STRIP TIER 3 AUTO-CODE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- CLEVER CHEK AUTO- CLEVER CHEK PA (Medically Necessary CODE VOICE STRIP TIER 3 AUTO-CODE VOICE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- CLEVER CHEK TEST CLEVER CHEK PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- CLEVER CHOICE AUTO- CLEVER CHOICE PA (Medically Necessary CODE TEST STRIP TIER 3 AUTO-CODE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- CLEVER CHOICE MICRO CLEVER CHOICE PA (Medically Necessary TEST STRIP TIER 3 MICRO TEST Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2020 Wellmark, Inc. 163 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- CLEVER CHOICE NO CLEVER CHOICE PA (Medically Necessary CODING STRIP TIER 3 NO CODING Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- CLEVER CHOICE TALK CLEVER CHOICE PA (Medically Necessary SYSTEM STRIP TIER 3 TALK SYSTEM Prior Authorization), PA-QL glucose blood (300 / 30 days) CLINISTIX STRIP CLINISTIX glucose urine test-(glucose TIER 2 PV oxidase) COMBISTIX STRIP COMBISTIX TIER 2 multiple urine tests QL (150 PER 30 DAYS), MN- CONTOUR NEXT TEST CONTOUR NEXT PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- CONTOUR TEST STRIP PA (Medically Necessary CONTOUR TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- CONTROL AST STRIP PA (Medically Necessary CONTROL AST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- CONTROL TEST STRIP PA (Medically Necessary CONTROL TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- COOL BLOOD COOL BLOOD GLUCOSE PA (Medically Necessary GLUCOSE TEST TEST STRIPS STRIP TIER 3 Prior Authorization), PA-QL STRIPS glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- CVS ADVANCED CVS ADVANCED PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- CVS GLUCOSE CVS GLUCOSE METER PA (Medically Necessary METER TEST TEST STRIPS STRIP TIER 3 Prior Authorization), PA-QL STRIPS glucose blood (300 / 30 days) CVS KETONE CARE CVS KETONE CARE STRIP TIER 2 urine glucose-ketones test QL (150 PER 30 DAYS), MN- D-CARE BLOOD D-CARE BLOOD PA (Medically Necessary GLUCOSE STRIP TIER 3 GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2020 Wellmark, Inc. 164 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DIASTIX STRIP DIASTIX glucose urine test-(glucose TIER 2 PV oxidase) QL (150 PER 30 DAYS), MN- DIATHRIVE BLOOD DIATHRIVE BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- DIATHRIVE GLUCOSE DIATHRIVE PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- DIATHRIVE+ GLUCOSE DIATHRIVE+ PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- DIATRUE PLUS TEST DIATRUE PLUS PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) DURAXIN 300-200-20 MG CAP DURAXIN acetaminophen- TIER 1 GA salicylamide- phenyltoloxamine QL (150 PER 30 DAYS), MN- EASY PLUS BLOOD EASY PLUS BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EASY PLUS II GLUCOSE EASY PLUS II PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EASY STEP TEST STRIP PA (Medically Necessary EASY STEP TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- EASY TALK BLOOD EASY TALK BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EASY TOUCH TEST PA (Medically Necessary EASY TOUCH TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EASY TRAK BLOOD EASY TRAK BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2020 Wellmark, Inc. 165 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- EASY TRAK II GLUCOSE EASY TRAK II PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EASYGLUCO STRIP PA (Medically Necessary EASYGLUCO TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- EASYGLUCO PLUS PA (Medically Necessary EASYGLUCO PLUS STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EASYMAX 15 TEST PA (Medically Necessary EASYMAX 15 TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EASYMAX TEST STRIP PA (Medically Necessary EASYMAX TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- EASYPLUS BLOOD EASYPLUS BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EASYPRO PLUS STRIP PA (Medically Necessary EASYPRO PLUS TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) ed-flex ed-flex 300-200-20 mg cap TIER 1 QL (150 PER 30 DAYS), MN- ELEMENT COMPACT ELEMENT PA (Medically Necessary TEST STRIP TIER 3 COMPACT TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ELEMENT TEST STRIP PA (Medically Necessary ELEMENT TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- EMBRACE BLOOD EMBRACE BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EMBRACE EVO EMBRACE EVO BLOOD PA (Medically Necessary BLOOD GLUCOSE GLUCOSE TEST STRIP TIER 3 Prior Authorization), PA-QL TEST glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EMBRACE PRO EMBRACE PRO PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2020 Wellmark, Inc. 166 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- EMBRACE TALK EMBRACE TALK PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EQ BLOOD GLUCOSE EQ BLOOD PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) EUFLEXXA 20 MG/2ML SOLN PRSYR MN-PA (Medically Necessary EUFLEXXA SP-M sodium hyaluronate Prior Authorization) (viscosupplement) QL (150 PER 30 DAYS), MN- EVENCARE + EVENCARE + BLOOD PA (Medically Necessary BLOOD GLUCOSE GLUCOSE TEST STRIP TIER 3 Prior Authorization), PA-QL TEST glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EVENCARE BLOOD EVENCARE BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EVENCARE G2 TEST EVENCARE G2 PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EVENCARE G3 TEST EVENCARE G3 PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EVENCARE MINI EVENCARE MINI PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EVENCARE EVENCARE PROVIEW PA (Medically Necessary PROVIEW GLUCOSE TEST STRIP TIER 3 Prior Authorization), PA-QL GLUCOSE TEST glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EVOLUTION AUTOCODE EVOLUTION PA (Medically Necessary STRIP TIER 3 AUTOCODE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EZ SMART BLOOD EZ SMART BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- EZ SMART PLUS EZ SMART PLUS PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2020 Wellmark, Inc. 167 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- FASTTAKE TEST STRIP PA (Medically Necessary FASTTAKE TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- FIFTY50 GLUCOSE TEST FIFTY50 GLUCOSE PA (Medically Necessary 2.0 STRIP TIER 3 TEST 2.0 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA BLOOD GLUCOSE FORA BLOOD PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA D15G BLOOD FORA D15G BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA D20 BLOOD FORA D20 BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA D40/G31 BLOOD FORA D40/G31 PA (Medically Necessary GLUCOSE STRIP TIER 3 BLOOD GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA G20 BLOOD FORA G20 BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA G30/PREM V10 FORA G30/PREM PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 V10 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA GD20 TEST STRIP PA (Medically Necessary FORA GD20 TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA GD50 BLOOD FORA GD50 BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA GTEL BLOOD FORA GTEL BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) FORA GTEL BLOOD FORA GTEL BLOOD KETONE TEST STRIP TIER 2 KETONE TEST ketone blood test

©2020 Wellmark, Inc. 168 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- FORA TN'G/TN'G VOICE FORA TN'G/TN'G PA (Medically Necessary STRIP TIER 3 VOICE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA V10 BLOOD FORA V10 BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA V12 BLOOD FORA V12 BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA V20 BLOOD FORA V20 BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORA V30A BLOOD FORA V30A BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORACARE GD40 TEST FORACARE GD40 PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORACARE PREMIUM FORACARE PA (Medically Necessary V10 TEST STRIP TIER 3 PREMIUM V10 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORACARE TEST N GO FORACARE TEST N PA (Medically Necessary TEST STRIP TIER 3 GO TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FORTISCARE TEST PA (Medically Necessary FORTISCARE TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FREESTYLE INSULINX FREESTYLE PA (Medically Necessary TEST STRIP TIER 3 INSULINX TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FREESTYLE LITE TEST FREESTYLE LITE PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- FREESTYLE FREESTYLE PRECISION PA (Medically Necessary PRECISION NEO NEO TEST STRIP TIER 3 Prior Authorization), PA-QL TEST glucose blood (300 / 30 days)

©2020 Wellmark, Inc. 169 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- FREESTYLE TEST PA (Medically Necessary FREESTYLE TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GE100 BLOOD GLUCOSE GE100 BLOOD PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) GEL-ONE 30 MG/3ML PA, MN-PA (Medically GEL-ONE PRSYR SP-M Necessary Prior cross-linked hyaluronate Authorization) GELSYN-3 16.8 MG/2ML SOLN PRSYR MN-PA (Medically Necessary GELSYN-3 SP-M sodium hyaluronate Prior Authorization) (viscosupplement) QL (150 PER 30 DAYS), MN- GENSTRIP 50 STRIP PA (Medically Necessary GENSTRIP 50 TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- GENULTIMATE TEST GENULTIMATE PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) GENVISC 850 25 MG/2.5ML SOLN PRSYR MN-PA (Medically Necessary GENVISC 850 SP-M sodium hyaluronate Prior Authorization) (viscosupplement) QL (150 PER 30 DAYS), MN- GHT TEST STRIP PA (Medically Necessary GHT TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- GLUCO PERFECT 3 TEST GLUCO PERFECT 3 PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GLUCOCARD 01 SENSOR GLUCOCARD 01 PA (Medically Necessary PLUS STRIP TIER 3 SENSOR PLUS Prior Authorization), PA-QL glucose blood (300 / 30 days) GLUCOCARD QL (150 PER 30 DAYS), MN- GLUCOCARD EXPRESSION TEST PA (Medically Necessary TIER 3 EXPRESSION TEST STRIP Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GLUCOCARD SHINE GLUCOCARD SHINE PA (Medically Necessary TEST STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2020 Wellmark, Inc. 170 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- GLUCOCARD VITAL TEST GLUCOCARD VITAL PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GLUCOCARD X-SENSOR GLUCOCARD X- PA (Medically Necessary STRIP TIER 3 SENSOR Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GLUCOCOM TEST PA (Medically Necessary GLUCOCOM TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GLUCONAVII GLUCONAVII BLOOD PA (Medically Necessary BLOOD GLUCOSE GLUCOSE TEST STRIP TIER 3 Prior Authorization), PA-QL TEST glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GLUCOSE METER TEST GLUCOSE METER PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GNP EASY TOUCH GNP EASY TOUCH PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GOJJI BLOOD GLUCOSE GOJJI BLOOD PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) GOJJI BLOOD KETONE GOJJI BLOOD TEST STRIP TIER 2 KETONE TEST ketone blood test QL (150 PER 30 DAYS), MN- GOJJI BLOOD TEST GOJJI BLOOD TEST PA (Medically Necessary STRIP/LANCETS STRIP TIER 3 STRIP/LANCETS Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- GOODSENSE BLOOD GOODSENSE PA (Medically Necessary GLUCOSE STRIP TIER 3 BLOOD GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- HARMONY BLOOD HARMONY BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) HEMA-COMBISTIX HEMA-COMBISTIX STRIP TIER 2 multiple urine tests

©2020 Wellmark, Inc. 171 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- HW EMBRACE PRO HW EMBRACE PRO PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- HW EMBRACE TALK HW EMBRACE TALK PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) HYALGAN (20 SOLN PRSYR, 20 SOLUTION) MN-PA (Medically Necessary HYALGAN SP-M sodium hyaluronate Prior Authorization) (viscosupplement) HYMOVIS 24 MG/3ML MN-PA (Medically Necessary HYMOVIS SOLN PRSYR SP-M Prior Authorization) hyaluronan QL (150 PER 30 DAYS), MN- IGLUCOSE TEST STRIPS IGLUCOSE TEST PA (Medically Necessary STRIP TIER 3 STRIPS Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- IN TOUCH BLOOD IN TOUCH BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- INFINITY BLOOD INFINITY BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- INFINITY VOICE STRIP PA (Medically Necessary INFINITY VOICE TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) INSULIN PEN INSULIN PEN NEEDLE TIER 2 PV NEEDLE insulin pen needle INSULIN SYRINGE INSULIN SYRINGE TIER 2 insulin syringe INSULIN SYRINGE INSULIN SYRINGE NEEDLE TIER 2 NEEDLE insulin syringe needle isometheptene- isometheptene-caffeine- TIER 1 caffeine-apap apap 65-20-325 mg tab KETO-DIASTIX STRIP KETO-DIASTIX TIER 2 urine glucose-ketones test KETONE TEST STRIP KETONE TEST TIER 2 acetone (urine) test KETOSTIX STRIP KETOSTIX TIER 2 acetone (urine) test

©2020 Wellmark, Inc. 172 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- KROGER BLOOD KROGER BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- KROGER KROGER HEALTHPRO PA (Medically Necessary HEALTHPRO GLUCOSE TEST STRIP TIER 3 Prior Authorization), PA-QL GLUCOSE TEST glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- KROGER PREMIUM KROGER PREMIUM PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- KROGER TEST STRIP PA (Medically Necessary KROGER TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) LABSTIX STRIP LABSTIX TIER 2 multiple urine tests LANCETS LANCETS TIER 2 QL (150 PER 30 DAY(S)) lancets LANCETS QL (150 PER 30 DAYS), PA- LANCETS TIER 2 lancets QL (300 / 30 days), PV LIBERTY NEXT QL (150 PER 30 DAYS), MN- LIBERTY NEXT GENERATION TEST PA (Medically Necessary TIER 3 GENERATION TEST STRIP Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- LIBERTY TEST STRIP PA (Medically Necessary LIBERTY TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- MAXIMA BLOOD MAXIMA BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- MEIJER BLOOD MEIJER BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- MEIJER ESSENTIAL MEIJER ESSENTIAL PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- MEIJER PREMIUM MEIJER PREMIUM PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2020 Wellmark, Inc. 173 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- MEIJER TRUETEST TEST MEIJER TRUETEST PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- MEIJER TRUETRACK MEIJER PA (Medically Necessary TEST STRIP TIER 3 TRUETRACK TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) methergine methergine 0.2 mg tab TIER 1 methylergonovine methylergonovine maleate TIER 1 maleate 0.2 mg tab QL (150 PER 30 DAYS), MN- MICRODOT TEST STRIP PA (Medically Necessary MICRODOT TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- MM EASY TOUCH MM EASY TOUCH PA (Medically Necessary GLUCOSE STRIP TIER 3 GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) MONOVISC 88 MG/4ML MN-PA (Medically Necessary MONOVISC SOLN PRSYR SP-M Prior Authorization) hyaluronan MULTISTIX STRIP MULTISTIX TIER 2 multiple urine tests MULTISTIX 10 SG STRIP MULTISTIX 10 SG TIER 2 multiple urine tests MULTISTIX 5 STRIP MULTISTIX 5 TIER 2 multiple urine tests MULTISTIX 7 STRIP MULTISTIX 7 TIER 2 multiple urine tests MULTISTIX 8 STRIP MULTISTIX 8 TIER 2 multiple urine tests MULTISTIX 9 STRIP MULTISTIX 9 TIER 2 multiple urine tests MULTISTIX 9 SG STRIP MULTISTIX 9 SG TIER 2 multiple urine tests QL (150 PER 30 DAYS), MN- MYGLUCOHEALTH TEST MYGLUCOHEALTH PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- NEUTEK 2TEK TEST PA (Medically Necessary NEUTEK 2TEK TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2020 Wellmark, Inc. 174 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- NOVA MAX GLUCOSE NOVA MAX PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) NOVA MAX PLUS NOVA MAX PLUS KETONE TEST STRIP TIER 2 KETONE TEST ketone blood test ON CALL EXPRESS QL (150 PER 30 DAYS), MN- ON CALL EXPRESS BLOOD GLUCOSE PA (Medically Necessary TIER 3 BLOOD GLUCOSE STRIP Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ON CALL PLUS BLOOD ON CALL PLUS PA (Medically Necessary GLUCOSE STRIP TIER 3 BLOOD GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ON CALL VIVID BLOOD ON CALL VIVID PA (Medically Necessary GLUCOSE STRIP TIER 3 BLOOD GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ONE DROP TEST STRIP PA (Medically Necessary ONE DROP TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) ONETOUCH TEST STRIP QL (150 PER 30 DAYS), PA- ONETOUCH TEST TIER 2 glucose blood QL (300 / 30 days) ONETOUCH ULTRA QL (150 PER 30 DAYS), PA- ONETOUCH ULTRA STRIP TIER 2 QL (300 / 30 days), PV glucose blood ONETOUCH VERIO QL (150 PER 30 DAYS), PA- ONETOUCH VERIO STRIP TIER 2 QL (300 / 30 days), PV glucose blood QL (150 PER 30 DAYS), MN- OPTIUM TEST STRIP PA (Medically Necessary OPTIUM TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- OPTIUMEZ TEST STRIP PA (Medically Necessary OPTIUMEZ TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- OPTUMRX BLOOD OPTUMRX BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) ORTHOVISC 30 MG/2ML ORTHOVISC SOLN PRSYR SP-M PA hyaluronan

©2020 Wellmark, Inc. 175 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PARAGARD PARAGARD INTRAUTERINE COPPER INTRAUTERINE SP-M IUD COPPER copper (iud) QL (150 PER 30 DAYS), MN- PHARMACIST CHOICE PHARMACIST PA (Medically Necessary AUTOCODE STRIP TIER 3 CHOICE AUTOCODE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- PHARMACIST PHARMACIST CHOICE PA (Medically Necessary CHOICE NO NO CODING STRIP TIER 3 Prior Authorization), PA-QL CODING glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- POCKETCHEM EZ TEST POCKETCHEM EZ PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- PRECISION PCX STRIP PA (Medically Necessary PRECISION PCX TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- PRECISION PCX PLUS PRECISION PCX PA (Medically Necessary TEST STRIP TIER 3 PLUS TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- PRECISION POINT OF PRECISION POINT PA (Medically Necessary CARE TEST STRIP TIER 3 OF CARE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- PRECISION QID TEST PRECISION QID PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- PRECISION XTRA BLOOD PRECISION XTRA PA (Medically Necessary GLUCOSE STRIP TIER 3 BLOOD GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) PRECISION XTRA PRECISION XTRA KETONE STRIP TIER 2 KETONE ketone blood test QL (150 PER 30 DAYS), MN- PREMIUM BLOOD PREMIUM BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- PRO VOICE V8/V9 PRO VOICE V8/V9 PA (Medically Necessary GLUCOSE STRIP TIER 3 GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2020 Wellmark, Inc. 176 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- PRODIGY NO PRODIGY NO CODING PA (Medically Necessary CODING BLOOD BLOOD GLUC STRIP TIER 3 Prior Authorization), PA-QL GLUC glucose blood (300 / 30 days) PTS PANELS KETONE PTS PANELS TEST STRIP TIER 2 KETONE TEST ketone blood test QL (150 PER 30 DAYS), MN- QUINTET AC BLOOD QUINTET AC BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- QUINTET BLOOD QUINTET BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) RA ALCOHOL SWABS 70 RA ALCOHOL % PAD TIER 2 SWABS alcohol swabs QL (150 PER 30 DAYS), MN- RA TRUETEST TEST PA (Medically Necessary RA TRUETEST TEST (TESTSTRIP, TESTSTRIP) TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- REFUAH PLUS REFUAH PLUS BLOOD PA (Medically Necessary BLOOD GLUCOSE GLUCOSE TEST STRIP TIER 3 Prior Authorization), PA-QL TEST glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- RELION BLOOD RELION BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- RELION RELION CONFIRM/MICRO PA (Medically Necessary CONFIRM/MICRO TEST STRIP TIER 3 Prior Authorization), PA-QL TEST glucose blood (300 / 30 days) RELION KETONE STRIP RELION KETONE TIER 2 acetone (urine) test RELION KETONE TEST RELION KETONE STRIP TIER 2 TEST acetone (urine) test QL (150 PER 30 DAYS), MN- RELION PREMIER TEST RELION PREMIER PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- RELION PRIME TEST RELION PRIME PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2020 Wellmark, Inc. 177 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS QL (150 PER 30 DAYS), MN- RELION ULTIMA TEST RELION ULTIMA PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- REVEAL BLOOD REVEAL BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- REXALL BLOOD REXALL BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- RIGHTEST GS100 BLOOD RIGHTEST GS100 PA (Medically Necessary GLUCOSE STRIP TIER 3 BLOOD GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- RIGHTEST GS300 BLOOD RIGHTEST GS300 PA (Medically Necessary GLUCOSE STRIP TIER 3 BLOOD GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- RIGHTEST GS550 BLOOD RIGHTEST GS550 PA (Medically Necessary GLUCOSE STRIP TIER 3 BLOOD GLUCOSE Prior Authorization), PA-QL glucose blood (300 / 30 days) SM ALCOHOL PREP SM ALCOHOL PREP (70%PAD, PAD) TIER 2 alcohol swabs QL (150 PER 30 DAYS), MN- SMART SENSE PREMIUM SMART SENSE PA (Medically Necessary TEST STRIP TIER 3 PREMIUM TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- SMART SENSE VALUE SMART SENSE PA (Medically Necessary TEST STRIP TIER 3 VALUE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- SMARTEST BLOOD SMARTEST BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) SODIUM HYALURONATE SODIUM 20 MG/2ML SOLN PRSYR MN-PA (Medically Necessary SP-M HYALURONATE sodium hyaluronate Prior Authorization) (viscosupplement) SOLESTA 50-15 MG/ML GEL SOLESTA SP-M dextranomer-sodium hyaluronate

©2020 Wellmark, Inc. 178 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS SOLIRIS 300 MG/30ML SOLIRIS SOLUTION SP-M PA eculizumab QL (150 PER 30 DAYS), MN- SOLUS V2 TEST STRIP PA (Medically Necessary SOLUS V2 TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) SUPARTZ 25 MG/2.5ML SOLN PRSYR MN-PA (Medically Necessary SUPARTZ SP-M sodium hyaluronate Prior Authorization) (viscosupplement) SUPARTZ FX 25 MG/2.5ML SOLN PRSYR MN-PA (Medically Necessary SUPARTZ FX SP-M sodium hyaluronate Prior Authorization) (viscosupplement) QL (150 PER 30 DAYS), MN- SURE EDGE TEST PA (Medically Necessary SURE EDGE TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- SURE-TEST SURE-TEST EASYPLUS PA (Medically Necessary EASYPLUS MINI MINI TEST STRIP TIER 3 Prior Authorization), PA-QL TEST glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- SURECHEK BLOOD SURECHEK BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- SURESTEP TEST STRIP PA (Medically Necessary SURESTEP TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) SYNVISC 16 MG/2ML SYNVISC SOLN PRSYR SP-M PA hylan SYNVISC ONE 48 MG/6ML SYNVISC ONE SOLN PRSYR SP-M PA hylan QL (150 PER 30 DAYS), MN- TELCARE BLOOD TELCARE BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- TGT BLOOD GLUCOSE TGT BLOOD PA (Medically Necessary TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) THYROGEN 1.1 MG THYROGEN RECON SOLN SP-M thyrotropin alfa

©2020 Wellmark, Inc. 179 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS TRILURON 20 MG/2ML SOLN PRSYR MN-PA (Medically Necessary TRILURON SP-M sodium hyaluronate Prior Authorization) (viscosupplement) TRIVISC 25 MG/2.5ML SOLN PRSYR MN-PA (Medically Necessary TRIVISC SP-M sodium hyaluronate Prior Authorization) (viscosupplement) QL (150 PER 30 DAYS), MN- TRUE FOCUS TRUE FOCUS BLOOD PA (Medically Necessary BLOOD GLUCOSE GLUCOSE STRIP STRIP TIER 3 Prior Authorization), PA-QL STRIP glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- TRUE METRIX TRUE METRIX BLOOD PA (Medically Necessary BLOOD GLUCOSE GLUCOSE TEST STRIP TIER 3 Prior Authorization), PA-QL TEST glucose blood (300 / 30 days) TRUE METRIX PRO QL (150 PER 30 DAYS), MN- TRUE METRIX PRO BLOOD GLUCOSE PA (Medically Necessary TIER 3 BLOOD GLUCOSE STRIP Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- TRUETEST TEST STRIP PA (Medically Necessary TRUETEST TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) QL (150 PER 30 DAYS), MN- TRUETRACK TEST PA (Medically Necessary TRUETRACK TEST STRIP TIER 3 Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ULTIMA TEST STRIP PA (Medically Necessary ULTIMA TEST TIER 3 glucose blood Prior Authorization), PA-QL (300 / 30 days) ULTOMIRIS 300 MG/30ML ULTOMIRIS SOLUTION SP-M PA ravulizumab-cwvz QL (150 PER 30 DAYS), MN- ULTRATRAK PRO TEST ULTRATRAK PRO PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- ULTRATRAK ULTIMATE ULTRATRAK PA (Medically Necessary TEST STRIP TIER 3 ULTIMATE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- UNISTRIP1 GENERIC UNISTRIP1 PA (Medically Necessary STRIP TIER 3 GENERIC Prior Authorization), PA-QL glucose blood (300 / 30 days)

©2020 Wellmark, Inc. 180 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS URISTIX STRIP URISTIX TIER 2 multiple urine tests URISTIX 4 STRIP URISTIX 4 TIER 2 multiple urine tests QL (150 PER 30 DAYS), MN- VERASENS BLOOD VERASENS BLOOD PA (Medically Necessary GLUCOSE TEST STRIP TIER 3 GLUCOSE TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- VICTORY AGM-4000 TEST VICTORY AGM-4000 PA (Medically Necessary STRIP TIER 3 TEST Prior Authorization), PA-QL glucose blood (300 / 30 days) VISCO-3 25 MG/2.5ML SOLN PRSYR MN-PA (Medically Necessary VISCO-3 SP-M sodium hyaluronate Prior Authorization) (viscosupplement) VISTOGARD 10 GM PACKET VISTOGARD SP-P uridine triacetate (emergency treatment) QL (150 PER 30 DAYS), MN- VIVAGUARD INO TEST VIVAGUARD INO PA (Medically Necessary STRIPS STRIP TIER 3 TEST STRIPS Prior Authorization), PA-QL glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- VOCAL POINT VOCAL POINT BLOOD PA (Medically Necessary BLOOD GLUCOSE GLUCOSE TEST STRIP TIER 3 Prior Authorization), PA-QL TEST glucose blood (300 / 30 days) QL (150 PER 30 DAYS), MN- WAVESENSE PRESTO WAVESENSE PA (Medically Necessary STRIP TIER 3 PRESTO Prior Authorization), PA-QL glucose blood (300 / 30 days)

OPHTHALMIC AGENTS

OPHTHALMIC AGENTS, OTHER

ak-poly-bac 500-10000 ak-poly-bac TIER 1 unit/gm ointment AKTEN 3.5 % GEL AKTEN TIER 3 lidocaine hcl (ophth) altacaine altacaine 0.5 % solution TIER 1 altafrin (2.5 % solution, 10 altafrin TIER 1 % solution) atropine sulfate (1 % atropine sulfate TIER 1 solution, 1 % ointment) bacitra-neomycin- bacitra-neomycin- TIER 1 polymyxin-hc polymyxin-hc 1 % ointment

©2020 Wellmark, Inc. 181 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS bacitracin-polymyxin bacitracin-polymyxin b 500- TIER 1 b 10000 unit/gm ointment BETADINE OPHTHALMIC BETADINE PREP 5 % SOLUTION TIER 3 OPHTHALMIC PREP povidone-iodine (ophth) BLEPHAMIDE 10-0.2 % SUSPENSION BLEPHAMIDE TIER 3 sulfacetamide sod- prednisolone BLEPHAMIDE S.O.P. 10- 0.2 % OINTMENT BLEPHAMIDE S.O.P. TIER 3 sulfacetamide sod- prednisolone cyclopentolate hcl (0.5 % cyclopentolate hcl solution, 1 % solution, 2 % TIER 1 solution) CYSTARAN 0.44 % CYSTARAN SOLUTION SP-P cysteamine hcl HOMATROPAIRE 5 % HOMATROPAIRE SOLUTION TIER 1 GA homatropine hbr homatropine hbr 5 % homatropine hbr TIER 1 solution ISOPTO ATROPINE 1 % SOLUTION ISOPTO ATROPINE TIER 1 GA atropine sulfate (ophthalmic) LACRISERT 5 MG INSERT LACRISERT TIER 3 artificial tear insert mydral (0.5 % solution, 1 % mydral TIER 1 solution) neo-polycin 3.5-400-10000 neo-polycin TIER 1 ointment neo-polycin hc 1 % neo-polycin hc TIER 1 ointment neomycin-bacitracin zn- neomycin-bacitracin polymyx (3.5-400- TIER 1 zn-polymyx 10000ointment, 5-400- 10000ointment) neomycin-polymyxin- neomycin-polymyxin- dexameth (ointment, TIER 1 dexameth suspension)

©2020 Wellmark, Inc. 182 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS NEOMYCIN-POLYMYXIN- NEOMYCIN- GRAMICIDIN 1.75-10000- POLYMYXIN- .025 SOLUTION TIER 1 GRAMICIDIN neomycin-polymyxin- gramicidin NEOMYCIN-POLYMYXIN- HC 3.5-10000-1 NEOMYCIN- SUSPENSION TIER 1 POLYMYXIN-HC neomycin-polymyxin-hc (ophth) OXERVATE 0.002 % OXERVATE SOLUTION SP-P PA, QL (8 PER LIFETIME) cenegermin-bkbj phenylephrine hcl (2.5 % phenylephrine hcl TIER 1 solution, 10 % solution) poly-dex 3.5-10000-0.1 poly-dex TIER 1 ointment polycin 500-10000 unit/gm polycin TIER 1 ointment polymyxin b-trimethoprim polymyxin b- 10000-0.1 unit/ml-% TIER 1 trimethoprim solution PRED-G 0.3-1 % SUSPENSION PRED-G TIER 3 gentamicin-prednisolone acetate PRED-G S.O.P. 0.3-0.6 % OINTMENT PRED-G S.O.P. TIER 3 gentamicin-prednisolone acetate proparacaine hcl 0.5 % proparacaine hcl TIER 1 solution RESTASIS 0.05 % RESTASIS EMULSION TIER 2 cyclosporine (ophth) RESTASIS MULTIDOSE RESTASIS 0.05 % EMULSION TIER 2 MULTIDOSE cyclosporine (ophth) sulfacetamide- sulfacetamide-prednisolone TIER 1 prednisolone 10-0.23 % solution TEPEZZA 500 MG RECON TEPEZZA SOLN SP-M PA teprotumumab-trbw tetcaine tetcaine 0.5 % solution TIER 1 tetracaine hcl 0.5 % tetracaine hcl TIER 1 solution

©2020 Wellmark, Inc. 183 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS tetravisc tetravisc 0.5 % solution TIER 1 tetravisc forte 0.5 % tetravisc forte TIER 1 solution TOBRADEX 0.3-0.1 % TOBRADEX OINTMENT TIER 3 tobramycin-dexamethasone tobramycin- tobramycin-dexamethasone TIER 1 dexamethasone 0.3-0.1 % suspension tropicamide (0.5 % solution, tropicamide TIER 1 1 % solution) VISUDYNE 15 MG RECON VISUDYNE SOLN SP-M verteporfin XIIDRA 5 % SOLUTION XIIDRA TIER 2 lifitegrast ZYLET 0.5-0.3 % SUSPENSION ZYLET TIER 3 loteprednol etabonate- tobramycin

OPHTHALMIC ANTI-ALLERGY AGENTS

ALOCRIL 2 % SOLUTION ALOCRIL TIER 3 nedocromil sodium (ophth) ALOMIDE 0.1 % ALOMIDE SOLUTION TIER 3 lodoxamide tromethamine azelastine hcl 0.05 % azelastine hcl TIER 1 solution BEPREVE 1.5 % BEPREVE SOLUTION TIER 3 bepotastine besilate cromolyn sodium 4 % cromolyn sodium TIER 1 solution EMADINE 0.05 % EMADINE SOLUTION TIER 3 emedastine difumarate epinastine hcl 0.05 % epinastine hcl TIER 1 solution

OPHTHALMIC ANTI-INFLAMMATORIES

ACUVAIL 0.45 % SOLUTION ACUVAIL TIER 3 ketorolac tromethamine (ophth)

©2020 Wellmark, Inc. 184 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ALREX 0.2 % ALREX SUSPENSION TIER 3 loteprednol etabonate bromfenac sodium bromfenac sodium (once- TIER 1 (once-daily) daily) 0.09 % solution BROMFENAC SODIUM BROMFENAC 0.09 % SOLUTION TIER 1 SODIUM bromfenac sodium (ophth) DEXAMETHASONE DEXAMETHASONE SODIUM PHOSPHATE 0.1 SODIUM % SOLUTION TIER 1 PHOSPHATE dexamethasone sodium phosphate (ophth) diclofenac sodium 0.1 % diclofenac sodium TIER 1 solution DUREZOL 0.05 % DUREZOL EMULSION TIER 3 difluprednate FLAREX 0.1 % FLAREX SUSPENSION TIER 3 fluorometholone acetate fluorometholone 0.1 % fluorometholone TIER 1 suspension flurbiprofen sodium 0.03 % flurbiprofen sodium TIER 1 solution FML 0.1 % OINTMENT FML TIER 3 fluorometholone (ophth) ketorolac tromethamine ketorolac (0.4 % solution, 0.5 % TIER 1 tromethamine solution) LOTEMAX (0.5 % GEL, 0.5 LOTEMAX % OINTMENT) TIER 3 loteprednol etabonate LOTEMAX SM 0.38 % GEL LOTEMAX SM TIER 3 loteprednol etabonate loteprednol etabonate 0.5 loteprednol etabonate TIER 1 % suspension MAXIDEX 0.1 % MAXIDEX SUSPENSION TIER 3 dexamethasone (ophth) PRED MILD 0.12 % SUSPENSION PRED MILD TIER 3 prednisolone acetate (ophth) prednisolone acetate 1 % prednisolone acetate TIER 1 suspension

©2020 Wellmark, Inc. 185 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS PREDNISOLONE SODIUM PREDNISOLONE PHOSPHATE 1 % SODIUM SOLUTION TIER 1 PHOSPHATE prednisolone sodium phosphate (ophth)

OPHTHALMIC ANTIGLAUCOMA AGENTS

apraclonidine hcl 0.5 % apraclonidine hcl TIER 1 solution AZOPT 1 % SUSPENSION AZOPT TIER 3 brinzolamide betaxolol hcl betaxolol hcl 0.5 % solution TIER 1 BETIMOL (0.25 % SOLUTION, 0.5 % BETIMOL TIER 2 SOLUTION) timolol BETOPTIC-S 0.25 % BETOPTIC-S SUSPENSION TIER 2 betaxolol hcl (ophth) brimonidine tartrate (0.15 % brimonidine tartrate TIER 1 solution, 0.2 % solution) carteolol hcl carteolol hcl 1 % solution TIER 1 dorzolamide hcl 2 % dorzolamide hcl TIER 1 solution dorzolamide hcl- dorzolamide hcl-timolol mal TIER 1 timolol mal 22.3-6.8 mg/ml solution dorzolamide hcl- dorzolamide hcl-timolol mal TIER 1 timolol mal pf pf 2-0.5 % solution IOPIDINE 1 % SOLUTION IOPIDINE TIER 3 apraclonidine hcl levobunolol hcl 0.5 % levobunolol hcl TIER 1 solution methazolamide (25 mg tab, methazolamide TIER 1 50 mg tab) METIPRANOLOL 0.3 % METIPRANOLOL SOLUTION TIER 1 metipranolol PHOSPHOLINE IODIDE PHOSPHOLINE 0.125 % RECON SOLN TIER 3 IODIDE echothiophate iodide pilocarpine hcl (1 % pilocarpine hcl solution, 2 % solution, 4 % TIER 1 solution)

©2020 Wellmark, Inc. 186 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS timolol maleate (0.25 % gel f soln, 0.25 % solution, 0.5 timolol maleate TIER 1 % solution, 0.5 % gel f soln, 0.5 % (daily) solution)

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS

bimatoprost bimatoprost 0.03 % solution TIER 1 DURYSTA 10 MCG DURYSTA IMPLANT SP-M bimatoprost latanoprost 0.005 % latanoprost TIER 1 solution LUMIGAN 0.01 % LUMIGAN SOLUTION TIER 2 bimatoprost travoprost (bak free) 0.004 travoprost (bak free) TIER 1 % solution

OTIC AGENTS

acetasol hc acetasol hc 2-1 % solution TIER 1 acetic acid acetic acid 2 % solution TIER 1 ACETIC ACID-ALUMINUM ACETIC ACID- ACETATE 2 % SOLUTION ALUMINUM TIER 1 acetic acid-aluminum ACETATE acetate CIPRO HC 0.2-1 % SUSPENSION CIPRO HC TIER 3 ciprofloxacin- hydrocortisone ciprofloxacin- ciprofloxacin- dexamethasone 0.3-0.1 % TIER 1 dexamethasone suspension COLY-MYCIN S 3.3-3-10- 0.5 MG/ML SUSPENSION COLY-MYCIN S TIER 3 neomycin-colistin-hc- thonzonium CORTISPORIN-TC 3.3-3- 10-0.5 MG/ML CORTISPORIN-TC SUSPENSION TIER 3 neomycin-colistin-hc- thonzonium exotic-hc 10-10-1 mg/ml exotic-hc TIER 1 solution flac flac 0.01 % oil TIER 1 fluocinolone fluocinolone acetonide 0.01 TIER 1 acetonide % oil

©2020 Wellmark, Inc. 187 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS hydrocortisone-acetic hydrocortisone-acetic acid TIER 1 acid 1-2 % solution neomycin-polymyxin-hc (1 % solution, 3.5-10000-1 neomycin-polymyxin- solution, 3.5-10000-1 TIER 1 hc suspension, 3.5-10000-1 solution) otomax-hc 10-10-1 mg/ml otomax-hc TIER 1 solution

RESPIRATORY TRACT/PULMONARY AGENTS

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

ASMANEX (120 METERED DOSES) 220 MCG/INH ASMANEX (120 AER POW BA TIER 1 PV METERED DOSES) mometasone furoate (inhalation) ASMANEX (14 METERED DOSES) 220 MCG/INH ASMANEX (14 AER POW BA TIER 1 PV METERED DOSES) mometasone furoate (inhalation) ASMANEX (30 METERED DOSES) 220 MCG/INH ASMANEX (30 AER POW BA TIER 1 PV METERED DOSES) mometasone furoate (inhalation) ASMANEX (60 METERED DOSES) 220 MCG/INH ASMANEX (60 AER POW BA TIER 1 PV METERED DOSES) mometasone furoate (inhalation) ASMANEX 30 METERED DOSES 110 MCG/INH AER ASMANEX 30 POW BA TIER 1 PV METERED DOSES mometasone furoate (inhalation) ASMANEX 7 METERED DOSES 110 MCG/INH AER ASMANEX 7 POW BA TIER 1 PV METERED DOSES mometasone furoate (inhalation)

©2020 Wellmark, Inc. 188 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ASMANEX HFA (50 AEROSOL, 100 AEROSOL, 200 ASMANEX HFA TIER 1 PV AEROSOL) mometasone furoate (inhalation) budesonide (0.25 budesonide suspension, 0.5 TIER 1 PV suspension, 1 suspension) FLUNISOLIDE 25 MCG/ACT (0.025%) FLUNISOLIDE TIER 1 SOLUTION flunisolide (nasal) mometasone furoate 50 mometasone furoate TIER 1 PA mcg/act suspension QVAR (40 AERO SOLN, 80 AERO SOLN) QVAR TIER 1 PV beclomethasone dipropionate QVAR REDIHALER (40 AERO BA, 80 AERO BA) QVAR REDIHALER TIER 1 PV beclomethasone dipropionate hfa TRELEGY ELLIPTA 100- 62.5-25 MCG/INH AER TRELEGY ELLIPTA POW BA TIER 2 PV fluticasone-umeclidinium- vilanterol

ANTIHISTAMINES

arbinoxa (4 mg tab, 4 arbinoxa TIER 1 mg/5ml solution) azelastine hcl (0.1 % azelastine hcl solution, 0.15 % solution, TIER 1 137 mcg/spray solution) brompheniramine brompheniramine tannate TIER 1 tannate 12 mg chew tab carbinoxamine carbinoxamine maleate (4 TIER 1 maleate mg tab, 4 mg/5ml solution) clemastine fumarate 2.68 clemastine fumarate TIER 1 mg tab cyproheptadine hcl (2 cyproheptadine hcl TIER 1 mg/5ml syrup, 4 mg tab)

©2020 Wellmark, Inc. 189 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DESLORATADINE (2.5 MG TAB DISP, 5 MG TAB DESLORATADINE TIER 1 DISP, 5 MG TAB) desloratadine diphenhydramine hcl 50 diphenhydramine hcl TIER 1 mg/ml solution hydroxyzine hcl (10 mg/5ml hydroxyzine hcl syrup, 10 mg tab, 25 mg TIER 1 tab, 50 mg tab) hydroxyzine pamoate (25 hydroxyzine pamoate mg cap, 50 mg cap, 100 mg TIER 1 cap) olopatadine hcl 0.6 % olopatadine hcl TIER 1 solution promethazine hcl (6.25 promethazine hcl TIER 1 solution, 6.25 syrup) RESPA-BR 11 MG TAB ER RESPA-BR 12H TIER 3 brompheniramine maleate

ANTILEUKOTRIENES

montelukast sodium (4 mg montelukast sodium chew tab, 4 mg packet, 5 TIER 1 PV mg chew tab, 10 mg tab) zafirlukast (10 mg tab, 20 zafirlukast TIER 1 PV mg tab) zileuton er 600 mg tab er zileuton er TIER 1 PV 12h

BRONCHODILATORS, ANTICHOLINERGIC

ATROVENT HFA 17 ATROVENT HFA MCG/ACT AERO SOLN TIER 2 ipratropium bromide hfa ipratropium bromide (0.02 ipratropium bromide % solution, 0.03 % solution, TIER 1 0.06 % solution) SPIRIVA HANDIHALER 18 SPIRIVA MCG CAP TIER 2 HANDIHALER tiotropium bromide monohydrate SPIRIVA RESPIMAT (1.25 AERO SOLN, 2.5 AERO SPIRIVA RESPIMAT SOLN) TIER 2 PV tiotropium bromide monohydrate

BRONCHODILATORS, SYMPATHOMIMETIC

ADRENACLICK (0.15 MG/0.15ML SOLN A-INJ, ADRENACLICK 0.3 MG/0.3ML SOLN A- TIER 3 QL (2 PER RX), GA INJ) epinephrine (anaphylaxis) ADRENALIN 1 MG/ML ADRENALIN SOLUTION TIER 1 epinephrine (anaphylaxis) albuterol sulfate (0.63 mg/3ml nebu soln, 1.25 mg/3ml nebu soln, 2 mg tab, 2 mg/5ml syrup, (2.5 albuterol sulfate TIER 1 mg/3ml) 0.083% nebu soln, 2.5 mg/0.5ml nebu soln, 4 mg tab, (5 mg/ml) 0.5% nebu soln) albuterol sulfate er (er 4 mg albuterol sulfate er tab er 12h, er 8 mg tab er TIER 1 12h) albuterol sulfate hfa 108 (90 MN-PA (Medically Necessary albuterol sulfate hfa TIER 1 base) mcg/act aero soln Prior Authorization) BROVANA 15 MCG/2ML BROVANA NEBU SOLN TIER 2 PV arformoterol tartrate epinephrine (0.15 mg/0.3ml soln a-inj, 0.15 mg/0.15ml epinephrine TIER 3 QL (2 PER RX) soln a-inj, 0.3 mg/0.3ml soln a-inj) epinephrine hcl epinephrine hcl (nasal) 0.1 TIER 1 (nasal) % solution epinephrine hcl 1 mg/ml epinephrine hcl TIER 1 solution EPIPEN 2-PAK 0.3 EPIPEN 2-PAK MG/0.3ML SOLN A-INJ TIER 2 QL (2 PER RX), GA epinephrine (anaphylaxis) EPIPEN JR 2-PAK 0.15 EPIPEN JR 2-PAK MG/0.3ML SOLN A-INJ TIER 2 QL (2 PER RX), GA epinephrine (anaphylaxis) levalbuterol hcl (0.31 mg/3ml nebu soln, 0.63 levalbuterol hcl mg/3ml nebu soln, 1.25 TIER 1 mg/3ml nebu soln, 1.25 mg/0.5ml nebu soln) levalbuterol tartrate 45 levalbuterol tartrate TIER 2 mcg/act aerosol

©2020 Wellmark, Inc. 191 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS METAPROTERENOL SULFATE (10 MG/5ML METAPROTERENOL SYRUP, 10 MG TAB, 20 TIER 1 SULFATE MG TAB) metaproterenol sulfate PERFOROMIST 20 PERFOROMIST MCG/2ML NEBU SOLN TIER 2 PV formoterol fumarate PROAIR HFA 108 (90 BASE) MCG/ACT AERO PROAIR HFA TIER 1 GA SOLN albuterol sulfate PROAIR RESPICLICK 108 PROAIR (90 BASE) MCG/ACT AER TIER 1 RESPICLICK POW BA albuterol sulfate PROVENTIL HFA 108 (90 BASE) MCG/ACT AERO MN-PA (Medically Necessary PROVENTIL HFA TIER 2 SOLN Prior Authorization), GA albuterol sulfate SEREVENT DISKUS 50 SEREVENT DISKUS MCG/DOSE AER POW BA TIER 2 PV salmeterol xinafoate STRIVERDI RESPIMAT 2.5 STRIVERDI MCG/ACT AERO SOLN TIER 3 RESPIMAT olodaterol hcl SYMJEPI (0.15 SOLN PRSYR, 0.3 SOLN SYMJEPI TIER 2 QL (2 PER FILL(S)) PRSYR) epinephrine (anaphylaxis) terbutaline sulfate (2.5 mg terbutaline sulfate TIER 1 tab, 5 mg tab) VENTOLIN HFA 108 (90 BASE) MCG/ACT AERO MN-PA (Medically Necessary VENTOLIN HFA TIER 2 SOLN Prior Authorization), GA albuterol sulfate

CYSTIC FIBROSIS AGENTS

BETHKIS 300 MG/4ML BETHKIS NEBU SOLN SP-NP GA tobramycin CAYSTON 75 MG RECON CAYSTON SOLN SP-P aztreonam lysine KALYDECO (50 MG PACKET, 75 MG PACKET, KALYDECO SP-P PA, QL (56 PER 28 DAYS) 150 MG TAB) ivacaftor

©2020 Wellmark, Inc. 192 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS KALYDECO 25 MG KALYDECO PACKET SP-P PA, QL (56 PER 28 DAY(S)) ivacaftor KITABIS PAK 300 MG/5ML KITABIS PAK NEBU SOLN SP-NP GA tobramycin ORKAMBI (100-125 MG PACKET, 150-188 MG ORKAMBI SP-P PA, QL (56 PER 28 DAY(S)) PACKET) lumacaftor-ivacaftor ORKAMBI (100-125 MG ORKAMBI TAB, 200-125 MG TAB) SP-P PA, QL (112 PER 28 DAYS) lumacaftor-ivacaftor PULMOZYME 1 MG/ML PULMOZYME SOLUTION SP-P dornase alfa SYMDEKO (50-75 75 MG TAB THPK, 100-150 150 SYMDEKO SP-P PA, QL (56 PER 28 DAY(S)) MG TAB THPK) tezacaftor-ivacaftor TOBI 300 MG/5ML NEBU TOBI SOLN SP-NP GA tobramycin TOBI PODHALER 28 MG TOBI PODHALER CAP SP-P tobramycin tobramycin (300 mg/4ml tobramycin nebu soln, 300 mg/5ml SP-P nebu soln) TRIKAFTA 100-50-75 & 150 MG TAB THPK TRIKAFTA SP-P PA, QL (84 PER 28 DAY(S)) elexacaftor-tezacaftor- ivacaftor

MAST CELL STABILIZERS

cromolyn sodium 20 cromolyn sodium TIER 1 PV mg/2ml nebu soln

PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE

caffeine citrate (20 mg/ml caffeine citrate solution, 60 mg/3ml TIER 1 solution) theochron (100 mg tab er theochron 12h, 200 mg tab er 12h, TIER 1 300 mg tab er 12h) theophylline 80 mg/15ml theophylline TIER 1 solution

©2020 Wellmark, Inc. 193 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS theophylline er (er 100 mg tab er 12h, er 200 mg tab er 12h, er 300 mg tab er 12h, theophylline er TIER 1 er 400 mg tab er 24h, er 450 mg tab er 12h, er 600 mg tab er 24h)

PULMONARY ANTIHYPERTENSIVES

ADCIRCA 20 MG TAB PA, QL (60 PER 30 DAYS), ADCIRCA tadalafil (pulmonary SP-NP GA hypertension) ADEMPAS (0.5 MG TAB, 1 MG TAB, 1.5 MG TAB, 2 ADEMPAS SP-P PA, QL (90 PER 30 DAYS) MG TAB, 2.5 MG TAB) riociguat alyq alyq 20 mg tab SP-P PA, QL (60 PER 30 DAYS) ambrisentan (5 mg tab, 10 ambrisentan SP-P PA, QL (30 PER 30 DAYS) mg tab) bosentan (62.5 mg tab, 125 bosentan SP-P PA, QL (60 PER 30 DAY(S)) mg tab) epoprostenol sodium (0.5 epoprostenol sodium mg recon soln, 1.5 mg SP-M PA recon soln) FLOLAN (0.5 MG RECON SOLN, 1.5 MG RECON FLOLAN SP-M PA, GA SOLN) epoprostenol sodium LETAIRIS (5 MG TAB, 10 PA, QL (30 PER 30 DAYS), LETAIRIS MG TAB) SP-NP GA ambrisentan OPSUMIT 10 MG TAB OPSUMIT SP-P PA, QL (30 PER 30 DAYS) macitentan ORENITRAM (0.125 MG TAB ER, 0.25 MG TAB ER, ORENITRAM 1 MG TAB ER, 2.5 MG TAB SP-P PA ER, 5 MG TAB ER) treprostinil diolamine REMODULIN (20 SOLUTION, 50 SOLUTION, 100 REMODULIN SP-M PA, GA SOLUTION, 200 SOLUTION) treprostinil REVATIO 10 MG/12.5ML SOLUTION REVATIO SP-M PA, GA sildenafil citrate (pulmonary hypertension)

©2020 Wellmark, Inc. 194 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS REVATIO 10 MG/ML RECON SUSP PA, QL (720 PER 30 DAYS), REVATIO SP-NP sildenafil citrate (pulmonary GA hypertension) REVATIO 20 MG TAB PA, QL (360 PER 30 DAYS), REVATIO sildenafil citrate (pulmonary SP-NP GA hypertension) sildenafil citrate 10 sildenafil citrate SP-M PA mg/12.5ml solution sildenafil citrate 10 mg/ml sildenafil citrate SP-P PA, QL (720 PER 30 DAYS) recon susp sildenafil citrate sildenafil citrate 20 mg tab SP-P PA, QL (360 PER 30 DAYS) tadalafil (pah) tadalafil (pah) 20 mg tab SP-P PA, QL (60 PER 30 DAYS) TRACLEER (62.5 MG TAB, PA, QL (60 PER 30 DAY(S)), TRACLEER 125 MG TAB) SP-NP GA bosentan TRACLEER 32 MG TAB PA, QL (120 PER 30 TRACLEER SOL SP-P DAY(S)) bosentan treprostinil (20 solution, 50 treprostinil solution, 100 solution, 200 SP-M PA solution) TYVASO 0.6 MG/ML TYVASO SOLUTION SP-P PA, QL (30 PER 30 DAYS) treprostinil TYVASO REFILL 0.6 TYVASO REFILL MG/ML SOLUTION SP-P PA, QL (30 PER 30 DAYS) treprostinil TYVASO STARTER 0.6 TYVASO STARTER MG/ML SOLUTION SP-P PA, QL (30 PER 30 DAYS) treprostinil UPTRAVI (200 MCG TAB, 400 MCG TAB, 600 MCG TAB, 800 MCG TAB, 1000 UPTRAVI MCG TAB, 1200 MCG SP-P PA, QL (60 PER 30 DAYS) TAB, 1400 MCG TAB, 1600 MCG TAB) selexipag UPTRAVI 200 & 800 MCG UPTRAVI TAB THPK SP-P PA, QL (1 PER LIFETIME) selexipag VELETRI (0.5 MG RECON SOLN, 1.5 MG RECON VELETRI SP-M PA, GA SOLN) epoprostenol sodium

PULMONARY FIBROSIS AGENTS

ESBRIET (267 MG TAB, PA, QL (2403 PER 1 ESBRIET 801 MG TAB) SP-P DAY(S)) pirfenidone ESBRIET 267 MG CAP ESBRIET SP-P PA, QL (270 PER 30 DAYS) pirfenidone OFEV (100 MG CAP, 150 OFEV MG CAP) SP-P PA, QL (60 PER 30 DAYS) nintedanib esylate

RESPIRATORY TRACT AGENTS, OTHER

acetylcysteine (10 % acetylcysteine TIER 1 solution, 20 % solution) ADVAIR DISKUS (100-50 AER POW BA, 250-50 AER ADVAIR DISKUS POW BA, 500-50 AER TIER 1 PV, GA POW BA) fluticasone-salmeterol ADVAIR HFA (45-21 AEROSOL, 115-21 ADVAIR HFA AEROSOL, 230-21 TIER 2 PV AEROSOL) fluticasone-salmeterol ANORO ELLIPTA 62.5-25 ANORO ELLIPTA MCG/INH AER POW BA TIER 2 umeclidinium-vilanterol azelastine-fluticasone 137- azelastine-fluticasone TIER 1 PA 50 mcg/act suspension benzonatate (100 mg cap, benzonatate TIER 1 200 mg cap) BREO ELLIPTA (100-25 AER POW BA, 200-25 AER BREO ELLIPTA POW BA) TIER 2 PV fluticasone furoate- vilanterol bromfed dm 30-2-10 bromfed dm TIER 1 mg/5ml syrup budesonide-formoterol budesonide- MN-PA (Medically Necessary fumarate (80-4.5 aerosol, TIER 1 formoterol fumarate Prior Authorization), PV 160-4.5 aerosol)

©2020 Wellmark, Inc. 196 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS CINQAIR 100 MG/10ML CINQAIR SOLUTION SP-M PA reslizumab COMBIVENT RESPIMAT COMBIVENT 20-100 MCG/ACT AERO TIER 2 RESPIMAT SOLN ipratropium-albuterol DULERA (50-5 AEROSOL, 100-5 AEROSOL, 200-5 AEROSOL) DULERA TIER 2 PV mometasone furoate- formoterol fumarate dihydrate FASENRA 30 MG/ML MN-PA (Medically Necessary FASENRA SOLN PRSYR SP-M Prior Authorization) benralizumab FASENRA PEN 30 MG/ML MN-PA (Medically Necessary FASENRA PEN SOLN A-INJ SP-M Prior Authorization) benralizumab fluticasone-salmeterol (55- 14 aer pow ba, 113-14 aer fluticasone-salmeterol TIER 1 PV pow ba, 232-14 aer pow ba) giltuss pediatric 2.5-7.5-88 giltuss pediatric TIER 1 mg/ml liquid hydrocod polst-cpm hydrocod polst-cpm polst er TIER 1 polst er 10-8 mg/5ml susp hydrocodone- hydrocodone-homatropine TIER 1 homatropine (mg tab, mg/5ml syrup) hydromet 5-1.5 mg/5ml hydromet TIER 1 syrup ipratropium-albuterol 0.5- ipratropium-albuterol TIER 1 2.5 (3) mg/3ml solution nebusal nebusal 3 % nebu soln TIER 1 NUCALA (100 MG/ML SOLN PRSYR, 100 MG/ML NUCALA SP-M PA, QL (1 PER 28 DAY(S)) SOLN A-INJ) mepolizumab NUCALA 100 MG RECON NUCALA SOLN SP-M PA, QL (1 PER 28 DAYS) mepolizumab phenylephrine- phenylephrine-guaifenesin TIER 1 guaifenesin 1.5-20 mg/ml liquid promethazine vc plain 6.25- promethazine vc plain TIER 1 5 mg/5ml solution promethazine promethazine vc/codeine TIER 1 vc/codeine 6.25-5-10 mg/5ml syrup

©2020 Wellmark, Inc. 197 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS promethazine- promethazine-codeine TIER 1 codeine (solution, syrup) promethazine-dm (solution, promethazine-dm TIER 1 syrup) promethazine-phenyleph- promethazine- codeine 6.25-5-10 mg/5ml TIER 1 phenyleph-codeine syrup PROMETHAZINE- PHENYLEPHRINE 6.25-5 PROMETHAZINE- MG/5ML SYRUP TIER 1 GA PHENYLEPHRINE promethazine & phenylephrine pseudoeph- pseudoeph-bromphen-dm TIER 1 bromphen-dm 30-2-10 mg/5ml syrup pseudoeph-chlorphen- pseudoeph- hydrocod 60-4-5 mg/5ml TIER 1 chlorphen-hydrocod solution pulmosal pulmosal 7 % nebu soln TIER 1 sodium chloride (0.9 % nebu soln, 3 % nebu soln, 7 sodium chloride TIER 1 % nebu soln, 10 % nebu soln) STIOLTO RESPIMAT 2.5- 2.5 MCG/ACT AERO SOLN STIOLTO RESPIMAT TIER 2 tiotropium bromide- olodaterol hcl tussigon tussigon 5-1.5 mg tab TIER 1 XOLAIR 150 MG RECON XOLAIR SOLN SP-M PA, QL (6 PER 28 DAYS) omalizumab XOLAIR 150 MG/ML SOLN XOLAIR PRSYR SP-M PA, QL (4 PER 28 DAY(S)) omalizumab XOLAIR 75 MG/0.5ML XOLAIR SOLN PRSYR SP-M PA, QL (2 PER 28 DAY(S)) omalizumab

SKELETAL MUSCLE RELAXANTS

carisoprodol (250 mg tab, carisoprodol TIER 1 350 mg tab) carisoprodol-aspirin 200- carisoprodol-aspirin TIER 1 325 mg tab chlorzoxazone (375 mg tab, chlorzoxazone TIER 1 500 mg tab, 750 mg tab) cyclobenzaprine hcl (5 mg cyclobenzaprine hcl TIER 1 tab, 10 mg tab)

©2020 Wellmark, Inc. 198 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS DYSPORT (300 RECON DYSPORT SOLN, 500 RECON SOLN) SP-M PA abobotulinumtoxina lorzone (375 mg tab, 750 lorzone TIER 1 mg tab) metaxall metaxall 800 mg tab TIER 1 metaxalone (400 mg tab, metaxalone TIER 1 800 mg tab) methocarbamol (500 mg methocarbamol TIER 1 tab, 750 mg tab) MYOBLOC (2500 UNIT/0.5ML SOLUTION, 5000 UNIT/ML SOLUTION, MN-PA (Medically Necessary MYOBLOC SP-M 10000 UNIT/2ML Prior Authorization) SOLUTION) rimabotulinumtoxinb orphenadrine citrate orphenadrine citrate er 100 TIER 1 er mg tab er 12h vanadom vanadom 350 mg tab TIER 1 XEOMIN (50 RECON SOLN, 100 RECON SOLN, XEOMIN SP-M PA 200 RECON SOLN) incobotulinumtoxina

SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORS

estazolam (1 mg tab, 2 mg estazolam TIER 1 tab) eszopiclone (1 mg tab, 2 eszopiclone TIER 1 PA mg tab, 3 mg tab) FLURAZEPAM HCL (15 FLURAZEPAM HCL MG CAP, 30 MG CAP) TIER 1 flurazepam hcl temazepam (7.5 mg cap, temazepam 15 mg cap, 22.5 mg cap, 30 TIER 1 mg cap) triazolam (0.125 mg tab, triazolam TIER 1 0.25 mg tab) zaleplon (5 mg cap, 10 mg zaleplon TIER 1 cap) zolpidem tartrate (1.75 mg zolpidem tartrate TIER 1 PA sl tab, 3.5 mg sl tab) zolpidem tartrate (5 mg tab, zolpidem tartrate TIER 1 10 mg tab)

SLEEP DISORDERS, OTHER

armodafinil (50 mg tab, 150 armodafinil mg tab, 200 mg tab, 250 TIER 1 PA, QL (30 PER 30 DAYS) mg tab) BUTISOL SODIUM 30 MG BUTISOL SODIUM TAB TIER 3 butabarbital sodium doxepin hcl (3 mg tab, 6 mg doxepin hcl TIER 1 PA tab) HETLIOZ 20 MG CAP HETLIOZ SP-P PA, QL (30 PER 30 DAYS) tasimelteon modafinil (100 mg tab, 200 modafinil TIER 1 PA, QL (60 PER 30 DAYS) mg tab) ramelteon ramelteon 8 mg tab TIER 1 PA SECONAL 100 MG CAP SECONAL TIER 3 secobarbital sodium XYREM 500 MG/ML XYREM SOLUTION SP-P PA, QL (540 PER 30 DAYS) sodium oxybate

SLEEP DISORDER AGENTS, OTHERS

WAKIX (4.45 MG TAB, 17.8 WAKIX MG TAB) SP-NP PA, QL (60 PER 30 DAY(S)) pitolisant hcl

©2020 Wellmark, Inc. 200 Index of covered drugs Adakveo 76 A ADALIMUMAB 143,144 ABACAVIR SULFATE 54 ADAPALENE 97 ABACAVIR SULFATE-LAMIVUDINE 54 Adcirca 194 ABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE 54 ADEFOVIR DIPIVOXIL 51 ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE 56 Adempas 194 ABALOPARATIDE 160 Adrenaclick 191 ABATACEPT 144,145 Adrenalin 191 ABEMACICLIB 45 Advair Diskus 196 ABIRATERONE ACETATE 35,36 Advair HFA 196 ABOBOTULINUMTOXINA 199 Advance Intuition Test 161 ACALABRUTINIB 41 Advate 71 ACAMPROSATE CALCIUM 13 Advocate Redi-Code 161 ACARBOSE 59 Advocate Redi-Code+ Test 161 Accu-Chek Aviva Plus 160 Advocate Test 161 Accu-Chek Compact Plus 161 Adynovate 71 Accu-Chek Guide 161 AFAMELANOTIDE ACETATE 99 Accu-Chek SmartView 161 AFATINIB DIMALEATE 41 Accutrend Glucose 161 Afinitor 40 ACEBUTOLOL HCL 80 Afinitor Disperz 40 ACETAMINOPHEN W/ CODEINE 9 Afluria 152 ACETAMINOPHEN-CAFF-DIHYDROCOD 9,12 Afluria Preservative Free 152 Acetaminophen-Salicylamide- Afluria Quadrivalent 152 Phenyltoloxamine 165,166 Afstyla 71 ACETAZOLAMIDE 86 AGALSIDASE BETA 114 ACETIC ACID (OTIC) 187 AgaMatrix AMP Test 161 ACETIC ACID-ALUMINUM ACETATE 187 AgaMatrix Jazz Test 161 Acetic Acid-Aluminum Acetate 187 AgaMatrix KeyNote Test 161 ACETOHYDROXAMIC ACID 118 AgaMatrix Presto Test 162 ACETONE (URINE) TEST 163,172,177 Aimovig 33 Acetone (Urine) Test 172 Aimovig (140 MG Dose) 33 ACETYLCYSTEINE 196 Ajovy 25,33 ACITRETIN 97 Akten 181 Actemra 150 ALBENDAZOLE 46 Actemra ACTPen 150 ALBUTEROL SULFATE 191,192 ActHIB 152 ALCLOMETASONE DIPROPIONATE 119 Actimmune 150 ALCOHOL SWABS 162,177,178 Acura Blood Glucose Test 161 Aldurazyme 114 Acuvail 184 Alecensa 40 ACYCLOVIR 58 ALECTINIB HCL 40 Adacel 152 ALEMTUZUMAB (MS) 94

©2020 Wellmark, Inc. 201 ALENDRONATE SODIUM 159 AMLODIPINE BESYLATE-BENAZEPRIL HCL 83 ALFUZOSIN HCL 117 AMLODIPINE BESYLATE-OLMESARTAN ALGLUCOSIDASE ALFA 115 MEDOXOMIL 83 Alinia 46 AMLODIPINE BESYLATE-VALSARTAN 83 ALIROCUMAB 89 AMLODIPINE-VALSARTAN- ALISKIREN FUMARATE 83 HYDROCHLOROTHIAZIDE 83 ALITRETINOIN 45 AMOXAPINE 28 ALLOPURINOL 32 Amoxapine 28 ALMOTRIPTAN MALATE 32 AMOXICILLIN 18 Alocril 184 AMOXICILLIN & POT CLAVULANATE 18 ALOGLIPTIN BENZOATE 59 AMOXICILLIN-CLARITHROMYCIN W/ ALOGLIPTIN-METFORMIN HCL 59 LANSOPRAZOLE 111 ALOGLIPTIN-PIOGLITAZONE 60 AMPHETAMINE-DEXTROAMPHETAMINE 90 Alomide 184 AMPICILLIN 19 ALOSETRON HCL 112 Ampyra 93 ALPELISIB 40 Anadrol-50 125 Alphanate/VWF Complex/Human 71 ANAGRELIDE HCL 68 AlphaNine SD 72 ANAKINRA 144 ALPRAZOLAM 58 ANASTROZOLE 39 ALPRAZolam Intensol 58 Androxy 125 Alprolix 72 Anoro Ellipta 196 Alrex 185 ANTIHEMOPHILIC FACTOR (HUMAN) 73,74 ALTRETAMINE 35 ANTIHEMOPHILIC FACTOR (RCMB) BD Alunbrig 37 TRUNCATED (BD TRUNC-RFVIII) 75 ALVIMOPAN 111 ANTIHEMOPHILIC FACTOR (RECOMB B-DOMAIN AMANTADINE HCL 47 DELETED) (BDD-RFVIII) 75 AMBRISENTAN 194 ANTIHEMOPHILIC FACTOR (RECOMB) FC FUSION AMCINONIDE 119 PROTEIN (RFVIIIFC) 72 Amcinonide 119 ANTIHEMOPHILIC FACTOR (RECOMBINANT AMIFAMPRIDINE 34 PORCINE) (RPFVIII) 75 AMIKACIN SULFATE LIPOSOME 14 ANTIHEMOPHILIC FACTOR AMILORIDE & HYDROCHLOROTHIAZIDE 83 (RECOMBINANT) 73,74,76 AMILORIDE HCL 87 ANTIHEMOPHILIC FACTOR (RECOMBINANT) AMINOCAPROIC ACID 72 PEGYLATED 71 AMINOSALICYLIC ACID 34 ANTIHEMOPHILIC FACTOR (RECOMBINANT) AMIODARONE HCL 79 PEGYLATED-AUCL 74 Amitiza 112 ANTIHEMOPHILIC FACTOR (RECOMBINANT) AMITRIPTYLINE HCL 28 PLASMA/ALBUMIN FREE 76 AMLODIPINE BESYLATE 80 ANTIHEMOPHILIC FACTOR (RECOMBINANT) AMLODIPINE BESYLATE-ATORVASTATIN SINGLE CHAIN 71 CALCIUM 83 ANTIHEMOPHILIC FACTOR RAHF-PFM 71,74

©2020 Wellmark, Inc. 202 ANTIHEMOPHILIC FACTOR/VON WILLEBRAND ATAZANAVIR SULFATE 56,57 FACTOR COMPLEX (HUMAN) 71,73,76 ATAZANAVIR SULFATE-COBICISTAT 57 ANTIINHIBITOR COAGULANT COMPLEX 72 ATENOLOL 80 Antiinhibitor Coagulant Complex 73 ATENOLOL & CHLORTHALIDONE 83 Anzemet 30 ATOMOXETINE HCL 91 APALUTAMIDE 35 ATORVASTATIN CALCIUM 88 APIXABAN 66 ATOVAQUONE 46 Apokyn 47 ATOVAQUONE-PROGUANIL HCL 46 APOMORPHINE HYDROCHLORIDE 47 Atropine Sulfate (Ophthalmic) 181 APRACLONIDINE HCL 186 ATROPINE SULFATE (OPHTHALMIC) 182 APREMILAST 150,151 Atrovent HFA 190 APREPITANT 30 Aubagio 93 Aptivus 56 AURANOFIN 152 Aranesp (Albumin Free) 68 Austedo 92 Arcalyst 150 Avandamet 60 ARFORMOTEROL TARTRATE 191 AVAPRITINIB 37 Arikayce 14 AVATROMBOPAG MALEATE 68 ARIPIPRAZOLE 49 Avonex 93 ARMODAFINIL 200 Avonex Pen 93 ARTIFICIAL TEAR INSERT 182 Avonex Prefilled 94 Asceniv 146 Avsola 142 Ascensia Autodisc Test 162 AXITINIB 42 ASFOTASE ALFA 116 Ayvakit 37 Asmanex (120 Metered Doses) 188 AZACITIDINE 37 Asmanex (14 Metered Doses) 188 Azactam 18 Asmanex (30 Metered Doses) 188 AzaSite 19 Asmanex (60 Metered Doses) 188 AZATHIOPRINE 142 Asmanex 30 Metered Doses 188 AZELAIC ACID 97 Asmanex 7 Metered Doses 188 AZELASTINE HCL 189 Asmanex HFA 189 AZELASTINE HCL (OPHTH) 184 ASPIRIN-CAFFEINE-DIHYDROCODEINE AZELASTINE HCL-FLUTICASONE PROPIONATE 196 BITARTRATE 9 AZITHROMYCIN 19 ASPIRIN-DIPYRIDAMOLE 76 AZITHROMYCIN (OPHTH) 19,20 Assure 4 Test 162 Azopt 186 Assure II Check 162 AZTREONAM 18 Assure Platinum 162 AZTREONAM LYSINE 192 Assure Prism multi Test 162 Assure Pro Test 162 B Astagraf XL 142 Bacitracin 14 Atabex EC 104 BACITRACIN (OPHTHALMIC) 14 Atabex OB 104 BACITRACIN-POLY-NEOMYCIN-HC 181,182

©2020 Wellmark, Inc. 203 BACITRACIN-POLYMYXIN B (OPHTH) 181,182,183 BETAXOLOL HCL (OPHTH) 186 BACLOFEN 50 BETHANECHOL CHLORIDE 117 Bafiertam 94 Bethkis 192 BALOXAVIR MARBOXIL 158 Betimol 186 BALSALAZIDE DISODIUM 158 Betoptic-S 186 Balversa 37 BEXAROTENE 45 Banzel 24,25 BEXAROTENE (TOPICAL) 45 Baqsimi One Pack 63 Bexsero 153 Baqsimi Two Pack 63 BICALUTAMIDE 35 BARICITINIB 144 Bicillin L-A 19 Basaglar KwikPen 63 BICTEGRAVIR-EMTRICITABINE-TENOFOVIR Bayer Breeze 2 Test 162 ALAFENAMIDE FUMARATE 56 BD Swab Single Use Regular 162 Biktarvy 56 Bebulin 72 BIMATOPROST 187 BECAPLERMIN 99 BINIMETINIB 44 BECLOMETHASONE DIPROPIONATE 189 BISOPROLOL & HYDROCHLOROTHIAZIDE 84 BECLOMETHASONE DIPROPIONATE HFA 189 BISOPROLOL FUMARATE 80 BELANTAMAB MAFODOTIN-BLMF 45 Bivigam 146 BELIMUMAB 150 Blenrep 45 BENAZEPRIL & HYDROCHLOROTHIAZIDE 84 Blephamide 182 BENAZEPRIL HCL 78 Blephamide S.O.P. 182 BeneFIX 72 Blood Glucose Test 162 Benlysta 150 Boostrix 153 BENRALIZUMAB 197 BOSENTAN 194,195 BENZONATATE 196 Bosulif 40 BENZOYL PEROXIDE-ERYTHROMYCIN 14 BOSUTINIB 40 BENZTROPINE MESYLATE 47 Botox 50 BENZYL ALCOHOL (PEDICULICIDE) 47 BP FoliNatal Plus B 104 BEPOTASTINE BESILATE 184 BP MultiNatal Plus 104 Bepreve 184 Braftovi 40 Berinert 141 Breeze 2 Test 162 BESIFLOXACIN HCL 20 Breo Ellipta 196 Besivance 20 BREXUCABTAGENE AUTOLEUCEL 38 Betadine Ophthalmic Prep 182 BRIGATINIB 37 BETAINE 114 Brilinta 77 BETAMETHASONE DIPROPIONATE (TOPICAL) 119 BRIMONIDINE TARTRATE 186 BETAMETHASONE DIPROPIONATE BRINZOLAMIDE 186 AUGMENTED 119 BRODALUMAB 99 BETAMETHASONE VALERATE 119 Bromfenac Sodium 185 Betaseron 94 BROMFENAC SODIUM (OPHTH) 185 BETAXOLOL HCL 80 BROMOCRIPTINE MESYLATE 47

©2020 Wellmark, Inc. 204 Brompheniramine Maleate 190 CALCIPOTRIENE 97 Brompheniramine Tannate 189 CALCIPOTRIENE-BETAMETHASONE Brovana 191 DIPROPIONATE 97 Brukinsa 37 CALCITONIN (SALMON) 159 BUDESONIDE 158 CALCITRIOL 159 BUDESONIDE (INHALATION) 189 CALCITRIOL (TOPICAL) 97 BUDESONIDE-FORMOTEROL FUMARATE CALCIUM ACETATE (PHOSPHATE BINDER) 100,103 DIHYDRATE 196 Calquence 41 BUMETANIDE 86 CANAGLIFLOZIN 61 Buphenyl 114 CANAGLIFLOZIN-METFORMIN HCL 61 BUPRENORPHINE 7 CANAKINUMAB 150 BUPRENORPHINE HCL 13 CANDESARTAN CILEXETIL 78 BUPRENORPHINE HCL-NALOXONE HCL CANDESARTAN CILEXETIL- DIHYDRATE 13 HYDROCHLOROTHIAZIDE 84 BUPROPION HCL 26 CANNABIDIOL 22 BUROSUMAB-TWZA 100 CAPECITABINE 36,37 BUSPIRONE HCL 58 Capital/Codeine 9 BUSULFAN 35 CAPLACIZUMAB-YHDP 68 BUTABARBITAL SODIUM 200 CAPMATINIB HCL 38 BUTALBITAL-ACETAMINOPHEN 92,93 Caprelsa 41 BUTALBITAL-ACETAMINOPHEN-CAFFEINE 92,93 CAPTOPRIL 78 BUTALBITAL-ACETAMINOPHEN-CAFFEINE W/ CAPTOPRIL & HYDROCHLOROTHIAZIDE 84 CODEINE 9 Captopril-Hydrochlorothiazide 84 BUTALBITAL-ASPIRIN-CAFFEINE 5 Carbaglu 114 BUTALBITAL-ASPIRIN-CAFFEINE W/COD 9 CARBAMAZEPINE 25 Butisol Sodium 200 Carbamazepine 25 BUTORPHANOL TARTRATE 9 CARBIDOPA 48 Bydureon 60 CARBIDOPA-LEVODOPA 48 Bydureon BCise 60 CARBIDOPA-LEVODOPA-ENTACAPONE 47 Byetta 10 MCG Pen 60 CARBINOXAMINE MALEATE 189 Byetta 5 MCG Pen 60 CareOne Blood Glucose Test 162 Bynfezia Pen 139 CareSens N Glucose Test 162 CareTouch Test 163 C CARGLUMIC ACID 114 C1 ESTERASE INHIBITOR (HUMAN) 141 Carimune NF 146 C1 ESTERASE INHIBITOR (RECOMBINANT) 141 CARISOPRODOL 198,199 CABERGOLINE 139 CARISOPRODOL W/ ASPIRIN 198 Cablivi 68 CARISOPRODOL W/ ASPIRIN & CODEINE 9 Cabometyx 41 CARTEOLOL HCL (OPHTH) 186 CABOZANTINIB S-MALATE 41 CARVEDILOL 80 CAFFEINE CITRATE 193 CARVEDILOL PHOSPHATE 80

©2020 Wellmark, Inc. 205 CASCARA SAGRADA 112 CHENODIOL 111 Cascara Sagrada 112 CHLORAMBUCIL 35 Cayston 192 CHLORDIAZEPOXIDE HCL 58 CEFACLOR 17 CHLORDIAZEPOXIDE HCL-CLIDINIUM Cefaclor ER 17 BROMIDE 110 CEFACLOR MONOHYDRATE 17 CHLORDIAZEPOXIDE-AMITRIPTYLINE 26 CEFADROXIL 17 Chlordiazepoxide-Amitriptyline 26 CEFDINIR 17 CHLORHEXIDINE GLUCONATE (MOUTH- CEFDITOREN PIVOXIL 17 THROAT) 96 CEFEPIME HCL 17,18 CHLOROQUINE PHOSPHATE 46 CEFEPIME HCL-DEXTROSE 17 CHLOROTHIAZIDE 87 Cefepime-Dextrose 17 CHLORPROMAZINE HCL 48 CEFIXIME 17,18 CHLORPROPAMIDE 60 CEFPODOXIME PROXETIL 17 ChlorproPAMIDE 60 CEFPROZIL 17 CHLORTHALIDONE 87 CEFTIBUTEN 17 CHLORZOXAZONE 198,199 CEFTRIAXONE SODIUM 18 CHOLESTYRAMINE 88 CEFUROXIME AXETIL 18 CHOLESTYRAMINE LIGHT 88,89 CELECOXIB 5 CHOLINE & MAG SALICYLATE 5 CellCept 142 CHOLINE FENOFIBRATE 87 Celontin 22 CICLOPIROX 30 CENEGERMIN-BKBJ 183 CICLOPIROX OLAMINE 30 CEPHALEXIN 18 CILOSTAZOL 77 Cerdelga 114 Ciloxan 20 Cerezyme 114 Cimduo 55 CERITINIB 45 CIMETIDINE 111 CERTOLIZUMAB PEGOL 142 CIMETIDINE HCL 111 Cervarix 153 Cimetidine HCl 111 Cesamet 30 Cimzia 142 CEVIMELINE HCL 96 Cimzia Prefilled 142 Chek-Stix Control 163 Cimzia Starter Kit 142 Chemet 102 CINACALCET HCL 159,160 Chemstrip 10 MD 163 Cinqair 197 Chemstrip 10/SG 163 Cinryze 141 Chemstrip 2 GP 163 Cipro HC 187 Chemstrip 5 OB 163 CIPROFLOXACIN 20 Chemstrip 7 163 CIPROFLOXACIN HCL 20 Chemstrip 9 163 CIPROFLOXACIN HCL (OPHTH) 20 Chemstrip K 163 Ciprofloxacin-Ciproflox HCl ER 20 Chemstrip uGK 163 CIPROFLOXACIN-CIPROFLOXACIN HCL 20 Chenodal 111 CIPROFLOXACIN-DEXAMETHASONE 187

©2020 Wellmark, Inc. 206 CIPROFLOXACIN-HYDROCORTISONE 187 COAGULATION FACTOR IX 72,74 CITALOPRAM HYDROBROMIDE 27 COAGULATION FACTOR IX (RECOMB) FC FUSION CLADRIBINE (MULTIPLE SCLEROSIS) 94,95 PROTEIN (RFIXFC) 72 CLARITHROMYCIN 19 COAGULATION FACTOR IX CLEMASTINE FUMARATE 189 (RECOMBINANT) 72,73,76 Cleocin 14 COAGULATION FACTOR IX (RECOMBINANT) Cleocin Phosphate 14 GLYCOPEGYLATED 75 Clever Chek Auto-Code Test 163 COAGULATION FACTOR IX RECOMB ALBUMIN Clever Chek Auto-Code Voice 163 FUSION PROTEIN (RIX-FP) 73 Clever Chek Test 163 COAGULATION FACTOR VIIA (RECOMBINANT) 75 Clever Choice Auto-Code Test 163 COAGULATION FACTOR VIIA (RECOMBINANT)- Clever Choice Micro Test 163 JNCW 76 Clever Choice No Coding 164 COAGULATION FACTOR X (HUMAN) 72 Clever Choice Talk System 164 COBICISTAT 56 Climara Pro 127 COBIMETINIB FUMARATE 41 CLINDAMYCIN HCL 14 CODEINE SULFATE 9 CLINDAMYCIN PALMITATE HYDROCHLORIDE 15 COLCHICINE 32 CLINDAMYCIN PHOSPHATE 14,15 COLCHICINE W/ PROBENECID 32 CLINDAMYCIN PHOSPHATE (TOPICAL) 14,15 COLESEVELAM HCL 88 CLINDAMYCIN PHOSPHATE VAGINAL 14 COLESTIPOL HCL 88 CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE COLISTIMETHATE SODIUM 15 (REFRIGERATE) 97,98 COLLAGENASE 99 CLINDAMYCIN PHOSPHATE-TRETINOIN 97 Coly-Mycin M 15 Clinistix 164 Coly-Mycin S 187 CLOBAZAM 23 CombiPatch 127 CLOBETASOL PROPIONATE 119 Combistix 164 CLOBETASOL PROPIONATE EMOLLIENT BASE 119 Combivent Respimat 197 CLOBETASOL PROPIONATE EMULSION 119,123 Cometriq (100 mg Daily Dose) 41 CLOCORTOLONE PIVALATE 119 Cometriq (140 mg Daily Dose) 41 CLOMIPRAMINE HCL 28 Cometriq (60 mg Daily Dose) 41 CLONAZEPAM 59 Complera 54 CLONIDINE 77 Complete Natal DHA 104 CLONIDINE HCL 77 CompleteNate 104 CLONIDINE HCL (ADHD) 91 Concept OB 104 CLOPIDOGREL BISULFATE 77 CONJUGATED ESTROGENS- CLORAZEPATE DIPOTASSIUM 59 MEDROXYPROGESTERONE ACETATE 133,134 CLOTRIMAZOLE 30 Contour Next Test 164 CLOTRIMAZOLE W/ BETAMETHASONE 97 Contour Test 164 CLOZAPINE 50 Control AST 164 cloZAPine 50 Control Test 164 Coagadex 72 Cool Blood Glucose Test Strips 164

©2020 Wellmark, Inc. 207 Copaxone 94 CYSTEAMINE BITARTRATE 114,116 Copiktra 41 CYSTEAMINE HCL 182 COPPER (IUD) 176 Cytogam 147 CORTICOTROPIN 121 CYTOMEGALOVIRUS IMMUNE GLOBULIN Cortisporin-TC 187 (HUMAN) 147 Cosentyx (300 MG Dose) 97 Cosentyx Sensoready (300 MG) 97 D Cotellic 41 D-Care Blood Glucose 164 Coumadin 66 D-Penamine 118 Creon 114 DABRAFENIB MESYLATE 44 Crinone 136 DACLATASVIR DIHYDROCHLORIDE 51 Crixivan 57 DACOMITINIB 39 CRIZANLIZUMAB-TMCA 76 Daklinza 51 CRIZOTINIB 45 DALFAMPRIDINE 93,94 CROMOLYN SODIUM 193 DALTEPARIN SODIUM 67 CROMOLYN SODIUM (MASTOCYTOSIS) 111 DANAZOL 125 CROMOLYN SODIUM (OPHTH) 184 DANTROLENE SODIUM 50 CROSS-LINKED HYALURONATE 170 DAPSONE 34 CROTAMITON 46,47 DAPSONE (TOPICAL) 97 Crotan 46 Daptacel 153 Crysvita 100 Daraprim 46 Cutaquig 147 DARATUMUMAB-HYALURONIDASE-FIHJ 45 Cuvitru 147 DARBEPOETIN ALFA 68 Cuvposa 110 DARIFENACIN HYDROBROMIDE 117 CVS Advanced Glucose Test 164 DAROLUTAMIDE 36 CVS Glucose Meter Test Strips 164 DARUNAVIR ETHANOLATE 57 CVS Ketone Care 164 DARUNAVIR-COBICISTAT 57 CYANOCOBALAMIN 104 DARUNAVIR-COBICISTAT-EMTRICITABINE- CYCLOBENZAPRINE HCL 198 TENOFOVIR ALAFENAMIDE 53 CYCLOPENTOLATE HCL 182 Darzalex Faspro 45 CYCLOPHOSPHAMIDE 35 DASATINIB 44 Cyclophosphamide 35 Daurismo 41 CYCLOSERINE 34 Debacterol 96 CYCLOSPORINE 142,145 DEFERASIROX 102 CYCLOSPORINE (OPHTH) 183 DEFERIPRONE 102 CYCLOSPORINE MODIFIED (FOR DEFLAZACORT 120 MICROEMULSION) 142,143,144 DEGARELIX ACETATE 139 CYPROHEPTADINE HCL 189 DELAVIRDINE MESYLATE 54 Cystadane 114 Delestrogen 128 Cystagon 114 Delstrigo 54 Cystaran 182 DEMECLOCYCLINE HCL 21

©2020 Wellmark, Inc. 208 DENOSUMAB 160 DIAZEPAM 59 Depo-Estradiol 128 DIAZEPAM (ANTICONVULSANT) 23,24 DEPO-Medrol 120 DIAZOXIDE 63 Descovy 56 DICHLORPHENAMIDE 86 DESIPRAMINE HCL 29 DICLOFENAC EPOLAMINE 5 DESIRUDIN 67 DICLOFENAC POTASSIUM 5 DESLORATADINE 190 DICLOFENAC SODIUM 5 Desloratadine 190 DICLOFENAC SODIUM (OPHTH) 185 DESMOPRESSIN ACETATE 123 DICLOFENAC SODIUM (TOPICAL) 5,6 DESMOPRESSIN ACETATE REFRIGERATED 123 DICLOFENAC W/ MISOPROSTOL 5 DESMOPRESSIN ACETATE SPRAY 123 DICLOXACILLIN SODIUM 19 DESMOPRESSIN ACETATE SPRAY DICYCLOMINE HCL 110 REFRIGERATED 123 DIDANOSINE 55 DESOGESTREL & ETHINYL DIFLUNISAL 5 ESTRADIOL 126,128,130,134 DIFLUPREDNATE 185 DESOGESTREL-ETHINYL ESTRADIOL DIGOXIN 84 (BIPHASIC) 127,130,133,134,135 DIHYDROERGOTAMINE MESYLATE 32 DESOGESTREL-ETHINYL ESTRADIOL DILTIAZEM HCL 81 (TRIPHASIC) 127,135 DILTIAZEM HCL COATED BEADS 81,82 DESONIDE 120,122 DILTIAZEM HCL EXTENDED RELEASE BEADS 81,82 DESOXIMETASONE 120 DIMETHYL FUMARATE 94,96 DESVENLAFAXINE 27 Dipentum 158 DESVENLAFAXINE SUCCINATE 27 DIPH-AC PERT-TET TOX AD-POLIO IPV- DEUTETRABENAZINE 92 HAEMOPHIL B POLY VAC 156 Dexamethasone 119 DIPH-TETANUS TOX AD-ACELL PERTUSSIS & DEXAMETHASONE 120 POLIO VIRUS, IPV VAC 155,157 DEXAMETHASONE (OPHTH) 185 DIPH-TETANUS TOX-ACELL PERT-HEPATITIS B Dexamethasone Intensol 120 RECOMB-POLIO IPV VAC 156 DEXAMETHASONE SODIUM PHOSPHATE 120 DIPHENHYDRAMINE HCL 190 Dexamethasone Sodium Phosphate 185 DIPHENOXYLATE W/ ATROPINE 111 DEXAMETHASONE SODIUM PHOSPHATE Diphenoxylate-Atropine 111 (OPHTH) 185 DIPHTHERIA, ACELLULAR PERTUSSIS & TETANUS DEXMETHYLPHENIDATE HCL 91 TOXOIDS 153,155 DEXTRANOMER-SODIUM HYALURONATE 178 DIPHTHERIA-TETANUS TOXOIDS (DT) 153 DEXTROAMPHETAMINE SULFATE 90,91 Diphtheria-Tetanus Toxoids DT 153 Diacomit 22 DIPYRIDAMOLE 77 Diastix 165 DIROXIMEL FUMARATE 96 Diathrive Blood Glucose Test 165 DISOPYRAMIDE PHOSPHATE 79 Diathrive Glucose Test 165 DISULFIRAM 13 Diathrive+ Glucose Test 165 Diuril 87 DiaTrue Plus Test 165 DIVALPROEX SODIUM 23

©2020 Wellmark, Inc. 209 DOFETILIDE 79 DOLASETRON MESYLATE 30 E DOLUTEGRAVIR SODIUM 53 Easy Plus Blood Glucose Test 165 DOLUTEGRAVIR SODIUM-LAMIVUDINE 56 Easy Plus II Glucose Test 165 DOLUTEGRAVIR SODIUM-RILPIVIRINE HCL 51 Easy Step Test 165 DONEPEZIL HYDROCHLORIDE 25 Easy Talk Blood Glucose Test 165 Doptelet 68 Easy Touch Test 165 DORAVIRINE 54 Easy Trak Blood Glucose Test 165 DORAVIRINE-LAMIVUDINE-TENOFOVIR Easy Trak II Glucose Test 166 DISOPROXIL FUMARATE 54 EasyGluco 166 DORNASE ALFA 193 EasyGluco Plus 166 DORZOLAMIDE HCL 186 EasyMax 15 Test 166 DORZOLAMIDE HCL-TIMOLOL MALEATE 186 EasyMax Test 166 Dovato 56 EasyPlus Blood Glucose Test 166 DOXAZOSIN MESYLATE 77 EasyPRO Plus 166 DOXEPIN HCL 29 ECALLANTIDE 141 DOXEPIN HCL (SLEEP) 200 ECHOTHIOPHATE IODIDE 186 DOXERCALCIFEROL 159 ECONAZOLE NITRATE 30 DOXYCYCLINE (MONOHYDRATE) 21 ECULIZUMAB 179 DOXYCYCLINE CALCIUM 22 EDARAVONE 93 DOXYCYCLINE HYCLATE 21,22 Edurant 54 DRONABINOL 30 EFAVIRENZ 54 DRONEDARONE HCL 79 EFAVIRENZ-EMTRICITABINE-TENOFOVIR DROSPIRENONE-ETHINYL DISOPROXIL FUMARATE 54 ESTRADIOL 128,130,131,132,133,134,135,136 EFAVIRENZ-LAMIVUDINE-TENOFOVIR DROSPIRENONE-ETHINYL ESTRADIOL- DISOPROXIL FUMARATE 56 LEVOMEFOLATE CALCIUM 128,134,135 Elaprase 114 Droxia 36 ELBASVIR-GRAZOPREVIR 52 Dulera 197 Elelyso 114 DULOXETINE HCL 93 Element Compact Test 166 DUPILUMAB 98 Element Test 166 Dupixent 98 ELETRIPTAN HYDROBROMIDE 32 Duraxin 165 ELEXACAFTOR-TEZACAFTOR-IVACAFTOR 193 Durezol 185 Eligard 139 Durolane 98 ELIGLUSTAT TARTRATE 114 Durysta 187 Eliquis 66 DUTASTERIDE 117 Eliquis DVT/PE Starter Pack 66 DUTASTERIDE-TAMSULOSIN HCL 117 Elmiron 118 DUVELISIB 41 Eloctate 72 Dysport 199 ELTROMBOPAG OLAMINE 70 ELVITEGRAVIR 53

©2020 Wellmark, Inc. 210 ELVITEGRAVIR-COBICISTAT-EMTRICITABINE- ENTRECTINIB 38 TENOFOVIR ALAFENAMIDE 53 Entresto 84 ELVITEGRAVIR-COBICISTAT-EMTRICITABINE- Entyvio 142 TENOFOVIR DF 53 Envarsus XR 143 Emadine 184 ENZALUTAMIDE 36 Embrace Blood Glucose Test 166 Epclusa 51 Embrace Evo Blood Glucose Test 166 Epidiolex 22 Embrace Pro Glucose Test 166 Epifoam 120 Embrace Talk Glucose Test 167 Epinastine HCl (Ophth) 184 Emcyt 36 EPINEPHRINE (ANAPHYLAXIS) 191,192 EMEDASTINE DIFUMARATE 184 Epinephrine HCl 191 Emend 30 EPINEPHRINE HCL (NASAL) 191 Emflaza 120 EpiPen 2-Pak 191 Emgality 33 EpiPen Jr 2-Pak 191 EMICIZUMAB-KXWH 73 Epivir HBV 51 EMPAGLIFLOZIN 61 EPLERENONE 87 EMPAGLIFLOZIN-METFORMIN HCL 62 EPOETIN ALFA 69,70 EMTRICITABINE 55 EPOETIN ALFA-EPBX 70 EMTRICITABINE-RILPIVIRINE-TENOFOVIR Epogen 69 ALAFENAMIDE FUMARATE 54 EPOPROSTENOL SODIUM 194,195 EMTRICITABINE-RILPIVIRINE-TENOFOVIR EPROSARTAN MESYLATE 78 DISOPROXIL FUMARATE 54 Eprosartan Mesylate 78 EMTRICITABINE-TENOFOVIR ALAFENAMIDE EPTINEZUMAB-JJMR 34 FUMARATE 56 EQ Blood Glucose Test 167 EMTRICITABINE-TENOFOVIR DISOPROXIL ERDAFITINIB 37 FUMARATE 55 ERENUMAB-AOOE 33 Emtriva 55 Ergocalciferol 159 ENALAPRIL MALEATE 78 ERGOCALCIFEROL 160 ENALAPRIL MALEATE & ERGOLOID MESYLATES 25 HYDROCHLOROTHIAZIDE 84 Ergoloid Mesylates 25 ENASIDENIB MESYLATE 37 ERGOTAMINE W/ CAFFEINE 32 Enbrel 142 Erivedge 41 Enbrel Mini 142 Erleada 35 Enbrel SureClick 142 ERLOTINIB HCL 41,44 ENCORAFENIB 40 Ery 19 ENFUVIRTIDE 56 Erythrocin Stearate 19 Engerix-B 153 ERYTHROMYCIN (ACNE AID) 19 ENOXAPARIN SODIUM 67 Erythromycin (Ophth) 20 ENTACAPONE 47 ERYTHROMYCIN BASE 19,20 ENTECAVIR 51 ERYTHROMYCIN ETHYLSUCCINATE 20 Entereg 111 ERYTHROMYCIN STEARATE 19

©2020 Wellmark, Inc. 211 Esbriet 196 EvenCare ProView Glucose Test 167 ESCITALOPRAM OXALATE 27 Evenity 159 ESOMEPRAZOLE MAGNESIUM 113 EVEROLIMUS 40,41 ESTAZOLAM 199 EVEROLIMUS (IMMUNOSUPPRESSANT) 143,146 ESTERIFIED ESTROGENS & EVOLOCUMAB 89 METHYLTESTOSTERONE 127,128,129 Evolution Autocode 167 ESTRADIOL 128,129 Evotaz 57 ESTRADIOL & NORETHINDRONE EXEMESTANE 39 ACETATE 126,127,129,131,132 EXENATIDE 60 ESTRADIOL CYPIONATE 128 Exjade 102 ESTRADIOL VAGINAL 129,135 Extavia 94 ESTRADIOL VALERATE 128,129 Ez Smart Blood Glucose Test 167 ESTRADIOL-LEVONORGESTREL 127 Ez Smart Plus Glucose Test 167 ESTRAMUSTINE PHOSPHATE SODIUM 36 EZETIMIBE 88 Estring 129 EZETIMIBE-SIMVASTATIN 88 ESTROGENS, CONJUGATED 133 ESTROPIPATE 129 F Estropipate 129 Fabrazyme 114 ESZOPICLONE 199 FACTOR IX COMPLEX 72,75 ETANERCEPT 142 FAMCICLOVIR 58 ETHACRYNIC ACID 86 FAMOTIDINE 111 ETHAMBUTOL HCL 34 Farydak 41 ETHIONAMIDE 34 Fasenra 197 ETHOSUXIMIDE 22 Fasenra Pen 197 ETHOTOIN 25 FastTake Test 168 ETHYNODIOL DIACET & ETH ESTRAD 129,130,136 FEBUXOSTAT 32 ETIDRONATE DISODIUM 159 FEDRATINIB HCL 42 Etidronate Disodium 159 Feiba 72 ETODOLAC 5 Feiba NF 73 ETONOGESTREL 137 FELBAMATE 24 ETONOGESTREL-ETHINYL ESTRADIOL 128,129 FELODIPINE 81 ETOPOSIDE 40 FENOFIBRATE MICRONIZED 87 Etoposide 40 FENOPROFEN CALCIUM 5,6 ETRAVIRINE 54 Fensolvi (6 Month) 139 Euflexxa 167 FENTANYL 7 Eurax 47 FENTANYL CITRATE 10 EvenCare + Blood Glucose Test 167 FERRIC DERISOMALTOSE 101 EvenCare Blood Glucose Test 167 Ferriprox 102 EvenCare G2 Test 167 Ferriprox Twice-A-Day 102 EvenCare G3 Test 167 Fiasp 63 EvenCare Mini Glucose Test 167 Fiasp FlexTouch 63

©2020 Wellmark, Inc. 212 Fiasp PenFill 64 FLUoxetine HCl 27 Fifty50 Glucose Test 2.0 168 Fluoxetine HCl (PMDD) 27 FILGRASTIM 69 FLUOXYMESTERONE 125 FILGRASTIM-AAFI 70 FLUPHENAZINE HCL 49 FILGRASTIM-SNDZ 71 FluPHENAZine HCl 49 FINASTERIDE 117 FLURANDRENOLIDE 121,122 FINGOLIMOD HCL 94 FLURAZEPAM HCL 199 Firazyr 141 Flurazepam HCl 199 Firmagon 139 FLURBIPROFEN 5 Firmagon (240 MG Dose) 139 FLURBIPROFEN SODIUM 185 Firvanq 15 FLUTAMIDE 35 Flarex 185 FLUTICASONE FUROATE-VILANTEROL 196 FLAVOXATE HCL 117 FLUTICASONE PROPIONATE 119,121 Flebogamma DIF 147 FLUTICASONE-SALMETEROL 196,197 FLECAINIDE ACETATE 79 FLUTICASONE-UMECLIDINIUM-VILANTEROL 189 Flolan 194 FLUVASTATIN SODIUM 88 Fluad 153 Fluvirin 154 Fluad Quadrivalent 153 FLUVOXAMINE MALEATE 27,28 Fluarix Quadrivalent 153 Fluzone High-Dose 154 Flublok 153 Fluzone High-Dose Quadrivalent 154 Flublok Quadrivalent 154 Fluzone Quadrivalent 155 Flucelvax 154 FML 185 Flucelvax Quadrivalent 154 Folivane-OB 105 FLUCONAZOLE 31 FONDAPARINUX SODIUM 67 FLUCYTOSINE 31 FORA Blood Glucose Test 168 FLUDROCORTISONE ACETATE 120 FORA D15g Blood Glucose Test 168 Flulaval Quadrivalent 154 FORA D20 Blood Glucose Test 168 FluMist 154 Fora D40/G31 Blood Glucose 168 FluMist Quadrivalent 154 FORA G20 Blood Glucose Test 168 Flunisolide 189 FORA G30/Prem V10 Glucose Test 168 FLUNISOLIDE (NASAL) 189 Fora GD20 Test 168 FLUOCINOLONE ACETONIDE 120 FORA GD50 Blood Glucose Test 168 FLUOCINOLONE ACETONIDE (OTIC) 187 FORA GTel Blood Glucose Test 168 FLUOCINONIDE 121 FORA GTel Blood Ketone Test 168 FLUOCINONIDE EMULSIFIED BASE 121 Fora TN'G/TN'G Voice 169 FLUOROMETHOLONE (OPHTH) 185 FORA V10 Blood Glucose Test 169 FLUOROMETHOLONE ACETATE 185 FORA V12 Blood Glucose Test 169 Fluoroplex 98 FORA V20 Blood Glucose Test 169 Fluorouracil 37 FORA V30a Blood Glucose Test 169 FLUOROURACIL (TOPICAL) 37,98 ForaCare GD40 Test 169 FLUOXETINE HCL 27 ForaCare premium V10 Test 169

©2020 Wellmark, Inc. 213 ForaCare Test N Go Test 169 GEFITINIB 42 FORMOTEROL FUMARATE 192 Gel-One 170 Forteo 159 Gelsyn-3 170 FortisCare Test 169 GEMFIBROZIL 87 FOSAMPRENAVIR CALCIUM 57 Genotropin 123 FOSFOMYCIN TROMETHAMINE 15 Genotropin MiniQuick 124 FOSINOPRIL SODIUM 78 GenStrip 50 170 FOSINOPRIL SODIUM & Gentamicin Sulfate 14 HYDROCHLOROTHIAZIDE 84 GENTAMICIN SULFATE (OPHTH) 14 FOSTAMATINIB DISODIUM 70 GENTAMICIN-PREDNISOLONE ACETATE 183 FOSTEMSAVIR TROMETHAMINE 56 GenUltimate Test 170 Fragmin 67 GenVisc 850 170 FreeStyle InsuLinx Test 169 Genvoya 53 FreeStyle Lite Test 169 GHT Test 170 FreeStyle Precision Neo Test 169 Gilenya 94 FreeStyle Test 170 Gilotrif 41 FREMANEZUMAB-VFRM 25,33 GILTERITINIB FUMARATE 39 FROVATRIPTAN SUCCINATE 32 Givlaari 114 Fulphila 69 GIVOSIRAN 114 FUROSEMIDE 86 GLASDEGIB MALEATE 41 Fuzeon 56 GLATIRAMER ACETATE 94 GLECAPREVIR-PIBRENTASVIR 51 G Gleevec 41 GABAPENTIN 23 Gleostine 35 Galafold 114 GLIMEPIRIDE 60 GALANTAMINE HYDROBROMIDE 26 GLIPIZIDE 60 GALCANEZUMAB-GNLM 33 GLIPIZIDE-METFORMIN HCL 60 GALSULFASE 115 GlucaGen HypoKit 63 GamaSTAN 147 GLUCAGON 63 Gammagard 147 GLUCAGON (RDNA) 63 Gammagard S/D Less IgA 147 Glucagon Emergency 63 Gammaked 148 GLUCAGON HCL 63 Gammaplex 148 GLUCAGON HCL (RDNA) 63 Gamunex-C 148 Gluco Perfect 3 Test 170 Gardasil 155 Glucocard 01 Sensor Plus 170 Gardasil 9 155 Glucocard Expression Test 170 GATIFLOXACIN (OPHTH) 20 Glucocard Shine Test 170 Gattex 111 Glucocard Vital Test 171 GaviLyte-C 112 Glucocard X-Sensor 171 Gavreto 40 GlucoCom Test 171 GE100 Blood Glucose Test 170 GlucoNavii Blood Glucose Test 171

©2020 Wellmark, Inc. 214 GLUCOSE Helixate FS 73 BLOOD 160,161,162,163,164,165,166,167,168,169,17 Hema-Combistix 171 0,171,172,173,174,175,176,177,178,179,180,181 HemeNatal OB + DHA 105 Glucose Hemlibra 73 Blood 161,162,166,168,171,173,175,176,177,179 Hemofil M 73 Glucose Meter Test 171 Heparin Lock Flush 67 Glucose Urine Test-(Glucose Oxidase) 164 HEPARIN SODIUM (PORCINE) 67 GLUCOSE URINE TEST-(GLUCOSE OXIDASE) 165 Heparin Sodium (Porcine) 67 GLYBURIDE 60 Heparin Sodium (Porcine) Lock Flush 67 GLYBURIDE MICRONIZED 60 HEPARIN SODIUM (PORCINE) LOCK FLUSH 67,68 GLYBURIDE-METFORMIN 60 HEPATITIS A (INACTIVATED)-HEPATITIS B GLYCEROL PHENYLBUTYRATE 116 (RECOMBINANT) VACCINES 158 GLYCOPYRROLATE 110 HEPATITIS A VACCINE 155,158 GNP Easy Touch Glucose Test 171 HEPATITIS B VACCINE (RECOMB) 153,157 Gojji Blood Glucose Test 171 HEPATITIS B VACCINE RECOMBINANT Gojji Blood Ketone Test 171 ADJUVANTED 155 Gojji Blood Test Strip/Lancets 171 Heplisav-B 155 GOLIMUMAB 146 Hetlioz 200 GoodSense Blood Glucose 171 Hexalen 35 GRANISETRON HCL 30 Hiberix 155 Granix 69 Hizentra 148 GRISEOFULVIN MICROSIZE 31 Homatropaire 182 GRISEOFULVIN ULTRAMICROSIZE 31 HOMATROPINE HBR 182 GUANFACINE HCL 77 HP Acthar 121 GUANFACINE HCL (ADHD) 91 HUMAN PAPILLOMAVIRUS (HPV) 9-VALENT GUANIDINE HCL 34 RECOMBINANT VACCINE 155 Guanidine HCl 34 HUMAN PAPILLOMAVIRUS (HPV) BIVALENT GUSELKUMAB 100 (TYPES 16, 18) RECMB VAC 153 Gvoke HypoPen 1-Pack 63 HUMAN PAPILLOMAVIRUS (HPV) QUADRIVALENT Gvoke HypoPen 2-Pack 63 RECOMBINANT VACCINE 155 Gvoke PFS 63 Humate-P 73 Humatrope 124 H Humira 143 Haegarda 141 Humira Pediatric Crohns Start 143 HAEMOPHILUS B POLYSAC CONJ VAC 152,155,156 Humira Pen 143 HALOBETASOL PROPIONATE 121 Humira Pen-CD/UC/HS Starter 143 HALOPERIDOL 49 Humira Pen-Ps/UV/Adol HS Start 143,144 HALOPERIDOL LACTATE 49 HumuLIN R U-500 (CONCENTRATED) 64 Harmony Blood Glucose Test 171 HumuLIN R U-500 KwikPen 64 Harvoni 51 HW Embrace Pro Glucose Test 172 Havrix 155 HW Embrace Talk Glucose Test 172

©2020 Wellmark, Inc. 215 Hyalgan 172 HyperRHO S/D 148 HYALURONAN 172,174,175 Hyqvia 149 Hycamtin 40 HYDRALAZINE HCL 89 I HYDROCHLOROTHIAZIDE 87 IBANDRONATE SODIUM 159 HYDROCODONE BITARTRATE 7 Ibrance 42 HYDROCODONE POLISTIREX- IBRUTINIB 42 CHLORPHENIRAMINE POLISTIREX 197 IBUPROFEN 5 HYDROCODONE W/ HOMATROPINE 197,198 ICATIBANT ACETATE 141 HYDROCODONE-ACETAMINOPHEN 10,11,12 Iclusig 42 Hydrocodone-Acetaminophen 10 IDELALISIB 45 HYDROCODONE-IBUPROFEN 10,11,12 Idelvion 73 HYDROCORTISONE 121 IDHIFA 37 HYDROCORTISONE (INTRARECTAL) 158,159 IDURSULFASE 114 HYDROCORTISONE (RECTAL) 159 iGlucose Test Strips 172 HYDROCORTISONE (TOPICAL) 119,122 Ilaris 150 HYDROCORTISONE ACETATE (RECTAL) 158,159 ILOPROST 196 HYDROCORTISONE ACETATE (TOPICAL) 122 Ilumya 98 HYDROCORTISONE ACETATE W/ IMATINIB MESYLATE 41,42 PRAMOXINE 98,99,121 Imbruvica 42 HYDROCORTISONE BUTYRATE 121 IMIGLUCERASE 114 HYDROCORTISONE BUTYRATE HYDROPHILIC IMIPRAMINE HCL 29 LIPO BASE 121 IMIQUIMOD 98 HYDROCORTISONE SOD SUCCINATE 123 Imiquimod Pump 98 HYDROCORTISONE VALERATE 121 IMMUNE GLOBULIN (HUMAN) IM 147 HYDROCORTISONE W/ACETIC ACID 187,188 IMMUNE GLOBULIN (HUMAN) IV 146,147,148,149 HYDROMORPHONE HCL 7,10 IMMUNE GLOBULIN (HUMAN) IV OR HYDROmorphone HCl 10 SUBCUTANEOUS 147,148 HYDROXYCHLOROQUINE SULFATE 46 IMMUNE GLOBULIN (HUMAN) HYDROXYprogesterone Caproate 136 SUBCUTANEOUS 147,148 HYDROXYPROGESTERONE CAPROATE 136 IMMUNE GLOBULIN (HUMAN)-HIPP 147 HYDROXYPROGESTERONE CAPROATE IMMUNE GLOBULIN (HUMAN)-HYALURONIDASE (ANTINEOPLASTIC) 136 (HUMAN RECOMBINANT) 149 HYDROXYUREA 37 IMMUNE GLOBULIN (HUMAN)-IFAS 149 HYDROXYUREA (SICKLE CELL ANEMIA) 36 IMMUNE GLOBULIN (HUMAN)-KLHW 150 HYDROXYZINE HCL 190 IMMUNE GLOBULIN (HUMAN)-SLRA 146 HYDROXYZINE PAMOATE 190 Impavido 46 HYLAN 179 In Touch Blood Glucose Test 172 Hymovis 172 Inatal GT 105 Hyophen 15 INCOBOTULINUMTOXINA 199 HYOSCYAMINE SULFATE 110,111 Increlex 124

©2020 Wellmark, Inc. 216 INDAPAMIDE 87 Inrebic 42 INDINAVIR SULFATE 57 Insulin Asp Prot & Asp FlexPen 64 Indocin 6 INSULIN ASPART 64,65,66 INDOMETHACIN 6 Insulin Aspart 64 Infanrix 155 INSULIN ASPART (WITH NIACINAMIDE) 63,64 Infinity Blood Glucose Test 172 Insulin Aspart FlexPen 64 Infinity Voice 172 Insulin Aspart PenFill 64 Inflectra 144 Insulin Aspart Prot & Aspart 64 INFLIXIMAB 145 INSULIN ASPART PROTAMINE & ASPART INFLIXIMAB-ABDA 145 (HUMAN) 64,66 INFLIXIMAB-AXXQ 142 INSULIN DEGLUDEC 66 INFLIXIMAB-DYYB 144 INSULIN DETEMIR 64 INFLUENZA VIRUS VAC RECOMB INSULIN GLARGINE 63 HEMAGGLUTININ (HA) QUADRIVALENT 154 INSULIN NPH (HUMAN) (ISOPHANE) 65 INFLUENZA VIRUS VAC SPLIT HIGH-DOSE QUAD INSULIN NPH ISOPHANE & REG (HUMAN) 64,65 PRESERVATIVE FREE 154 INSULIN PEN NEEDLE 172 INFLUENZA VIRUS VACC TYPES A & B SURF INSULIN REGULAR (HUMAN) 64,65 ANTIGEN ADJUVANT QUAD 153 INSULIN SYRINGE 172 Influenza Virus Vaccine Live 154 INSULIN SYRINGE NEEDLE 172 INFLUENZA VIRUS VACCINE LIVE Intelence 54 QUADRIVALENT 154 INTERFERON BETA-1A 93,94,95 INFLUENZA VIRUS VACCINE RECOMBINANT INTERFERON BETA-1B 94 HEMAGGLUTININ (HA) 153 INTERFERON GAMMA-1B 150 Influenza Virus Vaccine Split 152 Invirase 57 INFLUENZA VIRUS VACCINE SPLIT HIGH-DOSE Invokamet 61 PRESERVATIVE FREE 154 Invokamet XR 61 INFLUENZA VIRUS VACCINE SPLIT Invokana 61 PRESERVATIVE FREE 152 Iopidine 186 INFLUENZA VIRUS VACCINE SPLIT Ipol 155 QUADRIVALENT 152,153,154,155 IPRATROPIUM BROMIDE (NASAL) 190 INFLUENZA VIRUS VACCINE TISSUE-CULTURED IPRATROPIUM BROMIDE HFA 190 SUBUNIT 154 IPRATROPIUM-ALBUTEROL 197 INFLUENZA VIRUS VACCINE TISSUE-CULTURED Iprivask 67 SUBUNIT QUADRIVALENT 154 IRBESARTAN 78 INFLUENZA VIRUS VACCINE TYPES A & B IRBESARTAN-HYDROCHLOROTHIAZIDE 84 SURFACE ANTIGEN 154 Iressa 42 INFLUENZA VIRUS VACCINE TYPES A & B Isentress 53 SURFACE ANTIGEN ADJUVANT 153 Isentress HD 53 Ingrezza 92 ISOCARBOXAZID 27 Inlyta 42 ISOMETHEPTENE-CAFFEINE- INOTERSEN SODIUM 93 ACETAMINOPHEN 172

©2020 Wellmark, Inc. 217 ISONIAZID 34 KETOCONAZOLE (TOPICAL) 31 Isoniazid 34 KETONE BLOOD TEST 168,171,175,176,177 Isopto Atropine 182 Ketone Test 172 Isosorbide Dinitrate 89 KETOPROFEN 6 ISOSORBIDE DINITRATE 89 Ketoprofen ER 6 Isosorbide Dinitrate ER 89 KETOROLAC TROMETHAMINE 6 ISOSORBIDE MONONITRATE 89,90 KETOROLAC TROMETHAMINE (OPHTH) 184,185 ISOTRETINOIN 97,98,100 Ketostix 172 ISOXSUPRINE HCL 84 Keveyis 86 ISRADIPINE 81 Kevzara 150 ISTRADEFYLLINE 47 Kineret 144 Isturisa 121 Kinrix 155 ITRACONAZOLE 31 Kisqali (600 MG Dose) 42 IVACAFTOR 192,193 Kisqali 200 Dose 42 IVERMECTIN 46 Kisqali 400 Dose 42 IVERMECTIN (ROSACEA) 98 Kisqali Femara 200 Dose 42 IVOSIDENIB 38 Kisqali Femara 400 Dose 42 IXAZOMIB CITRATE 37 Kisqali Femara 600 Dose 43 IXEKIZUMAB 100 Kitabis Pak 193 Ixinity 73 Klarity-A 20 Klor-Con M15 101 J Koate 74 Jadenu 102 Koate-DVI 74 Jadenu Sprinkle 102 Kogenate FS 74 Jakafi 42 Kogenate FS Bio-Set 74 Janumet 61 Korlym 121 Janumet XR 61 Koselugo 43 Januvia 61 Kovaltry 74 Jardiance 61 Kroger Blood Glucose Test 173 Jivi 74 Kroger HealthPro Glucose Test 173 Juluca 51 Kroger Premium Glucose Test 173 Juxtapid 89 Kroger Test 173 Jynarque 103 Kuvan 115 Kyleena 136 K Kynamro 89 K-Phos 100 Kalbitor 141 L Kaletra 57 LABETALOL HCL 80 Kalydeco 192,193 Labstix 173 Keto-Diastix 172 LACOSAMIDE 25 KETOCONAZOLE 31 Lacrisert 182

©2020 Wellmark, Inc. 218 LACTULOSE 112 LEUPROLIDE ACETATE (4 MONTH) 139 LACTULOSE (ENCEPHALOPATHY) 112 LEUPROLIDE ACETATE (6 MONTH) 139 LAMIVUDINE 55 LEUPROLIDE ACETATE (CPP) 140 LAMIVUDINE (HBV) 51 LEUPROLIDE ACETATE (CPP) (3 MONTH) 140 LAMIVUDINE-TENOFOVIR DISOPROXIL LEUPROLIDE ACETATE (CPP) (6 MONTH) 139 FUMARATE 55 LEVALBUTEROL HCL 191 LAMIVUDINE-ZIDOVUDINE 55 LEVALBUTEROL TARTRATE 191 LAMOTRIGINE 24 Levemir 64 LANADELUMAB-FLYO 141 Levemir FlexTouch 64 LANCETS 173 Levetiracetam 22 LANREOTIDE ACETATE 140 LEVETIRACETAM 22 LANSOPRAZOLE 113 LEVOBUNOLOL HCL 186 LANTHANUM CARBONATE 103 LEVOCARNITINE (METABOLIC MODIFIERS) 101 LAPATINIB DITOSYLATE 43,44 LEVOFLOXACIN 20 LARONIDASE 114 LEVONORGESTREL & ETH LAROTRECTINIB SULFATE 39 ESTRADIOL 126,127,128,129,130,131,132,133,134,13 LATANOPROST 187 5 Latuda 49 LEVONORGESTREL (IUD) 136,137 LEDIPASVIR-SOFOSBUVIR 51 LEVONORGESTREL-ETH ESTRADIOL Ledipasvir-Sofosbuvir 51 (TRIPHASIC) 128,131,132,135 LEFLUNOMIDE 150 LEVONORGESTREL-ETHINYL ESTRADIOL (91- Lemtrada 94 DAY) 126,127,128,129,130,131,134 LENALIDOMIDE 36 LEVONORGESTREL-ETHINYL ESTRADIOL LENVATINIB MESYLATE 43 (CONTINUOUS) 126,131 Lenvima 10 MG Daily Dose 43 LEVORPHANOL TARTRATE 7 Lenvima 12 MG Daily Dose 43 LEVOTHYROXINE SODIUM 137,138 Lenvima 14 MG Daily Dose 43 Lexiva 57 Lenvima 18 MG Daily Dose 43 Liberty Next Generation Test 173 Lenvima 20 MG Daily Dose 43 Liberty Test 173 Lenvima 24 MG Daily Dose 43 LIDOCAINE 12,13 Lenvima 4 MG Daily Dose 43 LIDOCAINE HCL 12,13 Lenvima 8 MG Daily Dose 43 Lidocaine HCl 13 Letairis 194 LIDOCAINE HCL (MOUTH-THROAT) 13 LETROZOLE 39 LIDOCAINE HCL (OPHTH) 181 LEUCOVORIN CALCIUM 37 LIDOCAINE-HYDROCORTISONE ACETATE Leukeran 35 (RECTAL) 98 Leukine 69 LIDOCAINE-PRILOCAINE 13 LEUPROLIDE ACETATE 139 LIFITEGRAST 184 LEUPROLIDE ACETATE & NORETHINDRONE Liletta (52 MG) 136 ACETATE 139 LINACLOTIDE 112 LEUPROLIDE ACETATE (3 MONTH) 139 LINDANE 47

©2020 Wellmark, Inc. 219 LINEZOLID 15 Lupron Depot-Ped (3-Month) 140 Linzess 112 LURASIDONE HCL 49 LIOTHYRONINE SODIUM 138 LUSPATERCEPT-AAMT 70 LIRAGLUTIDE 62 LUSUTROMBOPAG 69 LISDEXAMFETAMINE DIMESYLATE 91 Lynparza 43 LISINOPRIL 78 Lyrica CR 23 LISINOPRIL & HYDROCHLOROTHIAZIDE 84 Lysodren 37 LITHIUM 59 Lithium 59 M LITHIUM CARBONATE 59 M-M-R II 155 Lithostat 118 MACITENTAN 194 Livalo 88 MAFENIDE ACETATE 15,16 LODOXAMIDE TROMETHAMINE 184 Makena 136 Lokelma 101 MALATHION 47 LOMITAPIDE MESYLATE 89 MAPROTILINE HCL 28 LOMUSTINE 35 Maprotiline HCl 28 Lonsurf 37 MARAVIROC 56 LOPINAVIR-RITONAVIR 57 Marplan 27 LORAZEPAM 59 Matulane 35 Lorbrena 40 Mavenclad (10 Tabs) 94 LORLATINIB 40 Mavenclad (4 Tabs) 94 LOSARTAN POTASSIUM 78 Mavenclad (5 Tabs) 94 LOSARTAN POTASSIUM & Mavenclad (6 Tabs) 94 HYDROCHLOROTHIAZIDE 85 Mavenclad (7 Tabs) 95 Lotemax 185 Mavenclad (8 Tabs) 95 Lotemax SM 185 Mavenclad (9 Tabs) 95 LOTEPREDNOL ETABONATE 185 Mavyret 51 LOTEPREDNOL ETABONATE-TOBRAMYCIN 184 Maxidex 185 LOVASTATIN 88 Maxima Blood Glucose Test 173 LOXAPINE SUCCINATE 49 Maxipime 18 LUBIPROSTONE 112 Mayzent 95 LULICONAZOLE 31 Mayzent Starter Pack 95 LUMACAFTOR-IVACAFTOR 193 MEASLES, MUMPS & RUBELLA VIRUS Lumigan 187 VACCINES 155 Lumizyme 115 MEASLES-MUMPS-RUBELLA-VARICELLA VIRUS Lupaneta Pack 139 VACCINES 157 Lupron Depot (1-Month) 139 MECASERMIN 124 Lupron Depot (3-Month) 139 MECHLORETHAMINE HCL (TOPICAL) 35 Lupron Depot (4-Month) 139 MECLOFENAMATE SODIUM 6 Lupron Depot (6-Month) 139 Meclofenamate Sodium 6 Lupron Depot-Ped (1-Month) 140 MEDROXYPROGESTERONE ACETATE 136

©2020 Wellmark, Inc. 220 MEFENAMIC ACID 6 Metaproterenol Sulfate 192 MEFLOQUINE HCL 46 METAXALONE 199 MEGESTROL ACETATE (APPETITE) 137 METFORMIN HCL 61,62 Meijer Blood Glucose Test 173 Metformin HCl 61 Meijer Essential Glucose Test 173 METHADONE HCL 7 Meijer Premium Glucose Test 173 Methadone HCl 7 Meijer TRUEtest Test 174 METHAMPHETAMINE HCL 91 Meijer TRUEtrack Test 174 METHAZOLAMIDE 186 Mekinist 43 METHENAMINE HIPPURATE 15 Mektovi 44 METHENAMINE MANDELATE 15 MELOXICAM 6 METHENAMINE-HYOSC-METHYLENE BLUE- MELPHALAN 35 BENZOIC ACID-PHENYL SAL 15,16 MEMANTINE HCL 26 METHENAMINE-HYOSC-METHYLENE BLUE-SOD Menactra 156 PHOS-PHENYL SAL 14,15,16,17 Menhibrix 156 METHENAMINE-HYOSCAMINE-METHYLENE BLUE- MENINGOCOCCAL (A,C,Y&W-135) SODIUM PHOSPHATE 15,16 OLIGOSACCHARIDE CONJUGATE VAC 156 METHIMAZOLE 141 Meningococcal (A,C,Y&W-135) Polysaccharide METHOCARBAMOL 199 Conjugate Vaccine 156 Methotrexate (Anti-Rheumatic) 144 MENINGOCOCCAL (A,C,Y&W-135) METHOTREXATE (ANTIRHEUMATIC) 145 POLYSACCHARIDE CONJUGATE VACCINE 156 METHOTREXATE SODIUM 144 MENINGOCOCCAL (A,C,Y&W-135) METHOTREXATE SODIUM POLYSACCHARIDE VACCINE 156 (ANTIRHEUMATIC) 144,145 MENINGOCOCCAL (C & Y)-HAEMOPHILUS B METHOXSALEN RAPID 98 TETANUS TOX CONJ VACCINE 156 METHOXY POLYETHYLENE GLYCOL-EPOETIN MENINGOCOCCAL GROUP B VACCINE BETA 69 (RECOMBINANT) 157 METHSCOPOLAMINE BROMIDE 110 MENINGOCOCCAL VAC GROUP B (RECOMBANT METHSUXIMIDE 22 OMV ADJUVANTED) 153 METHYCLOTHIAZIDE 87 Menomune 156 Methyclothiazide 87 MenQuadfi 156 METHYLDOPA 77 Menveo 156 METHYLDOPA & HYDROCHLOROTHIAZIDE 85 MEPERIDINE HCL 11 Methyldopa-Hydrochlorothiazide 85 Meperidine HCl 11 METHYLERGONOVINE MALEATE 174 MEPOLIZUMAB 197 METHYLPHENIDATE HCL 91,92 MEPROBAMATE 58 METHYLPREDNISOLONE 122 MERCAPTOPURINE 37 METHYLPREDNISOLONE ACETATE 120 MESALAMINE 158 METHYLPREDNISOLONE SOD SUCC 122,123 MESNA 46 METHYLTESTOSTERONE 125 Mesnex 46 METIPRANOLOL 186 METAPROTERENOL SULFATE 192 Metipranolol 186

©2020 Wellmark, Inc. 221 METOCLOPRAMIDE HCL 29 MONOMETHYL FUMARATE 94 METOLAZONE 87 Mononine 74 METOPROLOL & HYDROCHLOROTHIAZIDE 85 Monovisc 174 METOPROLOL SUCCINATE 80 MONTELUKAST SODIUM 190 METOPROLOL TARTRATE 80 Monurol 15 METRONIDAZOLE 15 MORPHINE SULFATE 8,11 METRONIDAZOLE (TOPICAL) 98,99 Morphine Sulfate 11 METRONIDAZOLE VAGINAL 17 Movantik 111 METYROSINE 85 MOXIFLOXACIN HCL 20 MEXILETINE HCL 79 MOXIFLOXACIN HCL (OPHTH) 20 MICONAZOLE-ZINC OXIDE-WHITE PETROLATUM31 Mozobil 69 MICRhoGAM Ultra-Filtered Plus 149 Mulpleta 69 Microdot Test 174 Multaq 79 MIDAZOLAM (ANTICONVULSANT) 13 MULTIPLE URINE TESTS 163,164,171,173,174,181 MIDODRINE HCL 77 Multistix 174 MIDOSTAURIN 38 Multistix 10 SG 174 MIFEPRISTONE (HYPERGLYCEMIA) 121 Multistix 5 174 MIGALASTAT HCL 114 Multistix 7 174 MIGLITOL 61 Multistix 8 174 MIGLUSTAT 115,116 Multistix 9 174 MILTEFOSINE 46 Multistix 9 SG 174 MINOCYCLINE HCL 21,22 MUPIROCIN 15 MINOXIDIL 89 MUPIROCIN CALCIUM (TOPICAL) 15 MIPOMERSEN SODIUM 89 MYCOPHENOLATE MOFETIL 142,144 Mircera 69 MYCOPHENOLATE SODIUM 144 Mirena (52 MG) 137 MyGlucoHealth Test 174 MIRTAZAPINE 26 Myleran 35 MISOPROSTOL 113 Mynatal 105 MITOTANE 37 Mynatal Advance 105 MM Easy Touch Glucose 174 Mynate 90 Plus 105 MODAFINIL 200 Myobloc 199 MOEXIPRIL HCL 78 MOEXIPRIL-HYDROCHLOROTHIAZIDE 85 N MOMETASONE FUROATE 122 NABILONE 30 MOMETASONE FUROATE (INHALATION) 188,189 NABUMETONE 6 MOMETASONE FUROATE (NASAL) 189 NADOLOL 80 MOMETASONE FUROATE-FORMOTEROL NADOLOL & BENDROFLUMETHIAZIDE 85 FUMARATE DIHYDRATE 197 NAFTIFINE HCL 31 Monjuvi 45 Naglazyme 115 Monoclate-P 74 NALOXEGOL OXALATE 111 Monoferric 101 NALOXONE HCL 13

©2020 Wellmark, Inc. 222 NALTREXONE HCL 13 NILUTAMIDE 35 NAPROXEN 5,6 NIMODIPINE 82 NAPROXEN SODIUM 6 Ninlaro 37 NARATRIPTAN HCL 32 NINTEDANIB ESYLATE 196 Narcan 13 NIRAPARIB TOSYLATE 39 Natacyn 31 NISOLDIPINE 82 NATALIZUMAB 96 NITAZOXANIDE 46 Natalvit 105 NITISINONE 115 NATAMYCIN 31 Nitro-Bid 90 NATEGLINIDE 61 Nitro-Time 90 Natpara 160 NITROFURANTOIN 15 Nayzilam 13 NITROFURANTOIN MACROCRYSTAL 16 NEDOCROMIL SODIUM (OPHTH) 184 NITROFURANTOIN MONOHYD MACRO 16 NEFAZODONE HCL 28 NITROGLYCERIN 90 NELFINAVIR MESYLATE 57 Nivestym 70 NEOMYCIN SULFATE 14 NIZATIDINE 111 NEOMYCIN-BACITRACIN ZN-POLYMYXIN 182 Norditropin FlexPro 124 NEOMYCIN-COLISTIN-HC-THONZONIUM 187 NORELGESTROMIN-ETHINYL ESTRADIOL 135 NEOMYCIN-POLYMY-DEXAMETH 182 NORETHIN ACET & ESTRAD- Neomycin-Polymy-Dexameth 183 FE 126,127,130,131,132,134 NEOMYCIN-POLYMYXIN-GRAMICIDIN 183 NORETHINDRONE & ETH Neomycin-Polymyxin-Gramicidin 183 ESTRADIOL 126,127,128,130,132,133,135 Neomycin-Polymyxin-HC 183 NORETHINDRONE & ETHINYL ESTRADIOL- NEOMYCIN-POLYMYXIN-HC (OPHTH) 183 FE 130,131,132,135,136 Neomycin-Polymyxin-HC (Otic) 188 NORETHINDRONE (CONTRACEPTIVE) 136,137 Neonatal Complete 105 NORETHINDRONE ACET & ETH Neoral 144 ESTRA 126,130,131,132 NERATINIB MALEATE 44 NORETHINDRONE ACETATE 137 Nerlynx 44 NORETHINDRONE ACETATE-ETHINYL Neulasta 69 ESTRADIOL 129,130,132 Neulasta Onpro 69 NORETHINDRONE ACETATE-ETHINYL Neupogen 69 ESTRADIOL-FE 134 Neutek 2Tek Test 174 NORETHINDRONE-ETH ESTRADIOL NEVIRAPINE 54 (TRIPHASIC) 126,128,131,132,133 NexAVAR 44 NORGESTIMATE-ETHINYL Nexplanon 137 ESTRADIOL 129,132,133,134,135 NIACIN (ANTIHYPERLIPIDEMIC) 89 NORGESTIMATE-ETHINYL ESTRADIOL NICARDIPINE HCL 82 (TRIPHASIC) 133,134,135 NIFEDIPINE 80,82 NORGESTREL & ETHINYL Nifedipine 82 ESTRADIOL 127,128,131,133 NILOTINIB HCL 44 Norpace CR 79

©2020 Wellmark, Inc. 223 NORTRIPTYLINE HCL 29 Obstetrix DHA 105 Norvir 57 Obstetrix EC 105 Nourianz 47 Ocaliva 115 Nova Max Glucose Test 175 OCRELIZUMAB 95 Nova Max Plus Ketone Test 175 Ocrevus 95 Novoeight 75 Octagam 149 NovoLIN 70/30 64 OCTREOTIDE ACETATE 139,140 NovoLIN 70/30 FlexPen 65 Odefsey 54 NovoLIN 70/30 FlexPen Relion 65 Odomzo 44 NovoLIN 70/30 ReliOn 65 Ofev 196 NovoLIN N 65 OFLOXACIN 20 NovoLIN N FlexPen 65 Ogestrel 133 NovoLIN N FlexPen ReliOn 65 OLANZAPINE 49 NovoLIN N ReliOn 65 OLANZAPINE-FLUOXETINE HCL 27 NovoLIN R 65 OLAPARIB 43 NovoLIN R FlexPen 65 OLMESARTAN MEDOXOMIL 78 NovoLIN R FlexPen ReliOn 65 OLMESARTAN MEDOXOMIL-AMLODIPINE- NovoLIN R ReliOn 65 HYDROCHLOROTHIAZIDE 85 NovoLOG 65 OLMESARTAN MEDOXOMIL- NovoLOG FlexPen 66 HYDROCHLOROTHIAZIDE 85 NovoLOG Mix 70/30 66 OLODATEROL HCL 192 NovoLOG Mix 70/30 FlexPen 66 OLOPATADINE HCL (NASAL) 190 NovoLOG PenFill 66 OLSALAZINE SODIUM 158 NovoSeven RT 75 Olumiant 144 Nplate 70 Olysio 51 Nubeqa 36 OMACETAXINE MEPESUCCINATE 38 Nucala 197 OMALIZUMAB 198 NuCort 122 OMBITASVIR-PARITAPREVIR-RITONAVIR 52 Nutropin AQ NuSpin 10 124 OMBITASVIR-PARITAPREVIR-RITONAVIR- Nutropin AQ NuSpin 20 124 DASABUVIR 52 Nutropin AQ NuSpin 5 124 OMEPRAZOLE 113 Nutropin AQ Pen 124 Omnitrope 124 Nuwiq 75 On Call Express Blood Glucose 175 NYSTATIN 30,31 On Call Plus Blood Glucose 175 NYSTATIN (TOPICAL) 31 On Call Vivid Blood Glucose 175 NYSTATIN-TRIAMCINOLONE 31 ONABOTULINUMTOXINA 50 Ondansetron 30 O ONDANSETRON HCL 30 O-Cal Prenatal 105 One Drop Test 175 OBETICHOLIC ACID 115 OneTouch Test 175 Obizur 75 OneTouch Ultra 175

©2020 Wellmark, Inc. 224 OneTouch Verio 175 Ozempic (1 MG/DOSE) 61 Ongentys 47 Onureg 37 P OPICAPONE 47 PALBOCICLIB 42 OPIUM TINCTURE 111 Palforzia (12 MG Daily Dose) 151 Opsumit 194 Palforzia (120 MG Daily Dose) 151 Optium Test 175 Palforzia (160 MG Daily Dose) 151 OptiumEZ Test 175 Palforzia (20 MG Daily Dose) 151 OptumRx Blood Glucose Test 175 Palforzia (200 MG Daily Dose) 151 Orencia 144 Palforzia (240 MG Daily Dose) 151 Orencia ClickJect 145 Palforzia (3 MG Daily Dose) 151 Orenitram 194 Palforzia (300 MG Maintenance) 151 Orfadin 115 Palforzia (300 MG Titration) 151 Orkambi 193 Palforzia (40 MG Daily Dose) 152 ORPHENADRINE CITRATE 199 Palforzia (6 MG Daily Dose) 152 OrthoVisc 175 Palforzia (80 MG Daily Dose) 152 OSELTAMIVIR PHOSPHATE 57 Palforzia Initial Escalation 152 OSILODROSTAT PHOSPHATE 121 PALIPERIDONE 49 OSIMERTINIB MESYLATE 44 PALIVIZUMAB 152 OsmoPrep 112 Palynziq 115 Otezla 150,151 Pancreaze 115 Otrexup 145 PANCRELIPASE (LIPASE-PROTEASE- OXANDROLONE 125 AMYLASE) 114,115,116 OXAPROZIN 6 PANOBINOSTAT LACTATE 41 OXAZEPAM 59 Panretin 45 Oxbryta 77 PANTOPRAZOLE SODIUM 113 OXCARBAZEPINE 25 Panzyga 149 Oxervate 183 Paragard Intrauterine Copper 176 OXYBUTYNIN CHLORIDE 117 PARATHYROID HORMONE (RECOMBINANT) 160 OXYCODONE HCL 8,11 PAREGORIC 111 OxyCODONE HCl ER 8 Paregoric 111 OXYCODONE W/ ACETAMINOPHEN 9,10,11,12 PARICALCITOL 160 Oxycodone-Acetaminophen 12 PAROMOMYCIN SULFATE 14 OXYCODONE-ASPIRIN 12 PAROXETINE HCL 28 OXYCODONE-IBUPROFEN 12 Paroxetine HCl 28 Oxycodone-Ibuprofen 12 PAROXETINE MESYLATE (VASOMOTOR) 28 OxyCONTIN 8 Paser 34 OXYMETHOLONE 125 PASIREOTIDE DIASPARTATE 140 OXYMORPHONE HCL 8,12 PATIROMER SORBITEX CALCIUM 104 OZANIMOD HCL 96 PAZOPANIB HCL 45 Ozempic (0.25 or 0.5 MG/DOSE) 61

©2020 Wellmark, Inc. 225 PEANUT (ARACHIS HYPOGAEA) ALLERGEN PERMETHRIN 47 POWDER-DNFP 151,152 PERPHENAZINE 29 Pediarix 156 PERPHENAZINE-AMITRIPTYLINE 27 Pedvax HIB 156 Perphenazine-Amitriptyline 27 PEG 3350-KCL-NACL-NA SULFATE-NA PERTUZUMAB-TRASTUZUMAB-HYALURONIDASE- ASCORBATE-ASCORBIC ACID 113 ZZXF 38 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD Pertzye 115 SULFATE 112,113 PEXIDARTINIB HCL 38 PEG 3350-POTASSIUM CHLORIDE-SOD Pharmacist Choice Autocode 176 BICARBONATE-SOD CHLORIDE 112,113 Pharmacist Choice No Coding 176 PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod PHENAZOPYRIDINE HCL 118 Chloride 113 PHENELZINE SULFATE 27 Peg-Intron Redipen 52 PHENOBARBITAL 23 Peganone 25 PHENOXYBENZAMINE HCL 77 Pegasys 52 PHENYLEPHRINE HCL (OPHTH) 181,183 Pegasys ProClick 52 PHENYLEPHRINE W/ DM-GG 197 PEGFILGRASTIM 69 Phenylephrine-Guaifenesin 197 PEGFILGRASTIM-BMEZ 71 PHENYTOIN 25 PEGFILGRASTIM-CBQV 71 PHENYTOIN SODIUM EXTENDED 25 PEGFILGRASTIM-JMDB 69 Phesgo 38 PEGINTERFERON ALFA-2A 52 Phospholine Iodide 186 PEGINTERFERON ALFA-2B 52,53 PHYTONADIONE 77 PEGINTERFERON ALFA-2B (ANTINEOPLASTIC) 38 Pifeltro 54 PEGINTERFERON BETA-1A 95 PILOCARPINE HCL 186 PegIntron 53 PILOCARPINE HCL (ORAL) 96 PEGVALIASE-PQPZ 115 PIMECROLIMUS 98 PEGVISOMANT 140 PIMOZIDE 49 Pemazyre 38 Pimozide 49 PEMIGATINIB 38 PINDOLOL 80 PENICILLAMINE 118 PIOGLITAZONE HCL 62 PENICILLIN G BENZATHINE 19 PIOGLITAZONE HCL-GLIMEPIRIDE 62 PENICILLIN V POTASSIUM 19 PIOGLITAZONE HCL-METFORMIN HCL 62 Pentacel 156 Piqray (250 MG Daily Dose) 40 PENTAMIDINE ISETHIONATE 46 Piqray 200MG Daily Dose 40 Pentasa 158 Piqray 300MG Daily Dose 40 PENTAZOCINE W/ NALOXONE 12 PIRFENIDONE 196 PENTOSAN POLYSULFATE SODIUM 118 PIROXICAM 6 PENTOXIFYLLINE 85 PITAVASTATIN CALCIUM 88 Perforomist 192 PITAVASTATIN MAGNESIUM 88 PERINDOPRIL ERBUMINE 78 PITOLISANT HCL 200 Permethrin 46 PLECANATIDE 112

©2020 Wellmark, Inc. 226 Plegridy 95 Praluent 89 Plegridy Starter Pack 95 PRAMIPEXOLE DIHYDROCHLORIDE 48 PLERIXAFOR 69 PRAMLINTIDE ACETATE 62 PNEUMOCOCCAL 13-VALENT CONJUGATE Pramosone 122 VACCINE 156 PRAMOXINE-HC 120,121,122 PNEUMOCOCCAL VAC POLYVALENT 156 PRAMOXINE-HC-CHLOROXYLENOL 187,188 Pneumovax 23 156 PRASUGREL HCL 77 PNV Fe Fum/Docusate/Folic Acid 106 PRAVASTATIN SODIUM 88 PNV Prenatal Plus Multivit+DHA 106 PRAZIQUANTEL 46 PNV Tabs 29-1 106 PRAZOSIN HCL 77 PNV-VP-U 106 Precision PCx 176 PocketChem EZ Test 176 Precision PCX Plus Test 176 Podocon 99 Precision Point of Care Test 176 PODOFILOX 99 Precision QID Test 176 PODOPHYLLUM RESIN 99 Precision Xtra Blood Glucose 176 POLATUZUMAB VEDOTIN-PIIQ 45 Precision Xtra Ketone 176 POLIOVIRUS VACCINE, IPV 155 Pred Mild 185 Polivy 45 Pred-G 183 POLYMYXIN B-TRIMETHOPRIM 183 Pred-G S.O.P. 183 POMALIDOMIDE 36 PREDNICARBATE 122 Pomalyst 36 Prednicarbate 122 PONATINIB HCL 42 PREDNISOLONE 122 POSACONAZOLE 31 PREDNISOLONE ACETATE (OPHTH) 185 POT & SOD CITRATES W/CITRIC AC 118 PREDNISOLONE SODIUM PHOSPHATE 122 POT PHOSPHATE MONOBASIC W/ SOD PrednisoLONE Sodium Phosphate 186 PHOSPHATE DIBASIC & MONOBASIC 103,104 PREDNISOLONE SODIUM PHOSPHATE POTASSIUM BICARB & CHLORIDE 100 (OPHTH) 186 Potassium Bicarb & Chloride 101 PREDNISONE 120,122 POTASSIUM CHLORIDE 100,101 PredniSONE Intensol 122 POTASSIUM CHLORIDE MICROENCAPSULATED PREGABALIN 93 CRYSTALS ER 100,101 PREGABALIN (ONCE-DAILY) 23 POTASSIUM CITRATE (ALKALINIZER) 118 Premarin 133 POTASSIUM CITRATE-CITRIC ACID 118 Premium Blood Glucose Test 176 Potassium Citrate-Citric Acid 118 Premphase 133 POTASSIUM PHOSPHATE MONOBASIC 100 Prempro 134 POVIDONE-IODINE (OPHTH) 182 Prenaissance Next 106 PR Natal 400 106 PreNata 106 PR Natal 400 ec 106 Prenatabs FA 107 PR Natal 430 106 Prenatabs Rx 107 PR Natal 430 ec 106 Prenatal 19 107 PRALSETINIB 40

©2020 Wellmark, Inc. 227 PRENATAL MV & MIN W/FE BISGLYC-FE PROT PRENATAL WITHOUT A VIT W/ FE FUMARATE- SUCC-FA-CA-OMEGA 3 104,106,108 FOLIC ACID 106,107 PRENATAL MV & MIN W/FE CARBONYL- PRENATAL WITHOUT A W/ FE CHELATE-L DOCUSATE-FOLIC ACID-DHA 107 METHYLFOLATE-FA-DHA 109 Prenatal Plus Iron 107 PRENATAL WITHOUT VIT A W/ IRON CARBONYL- PRENATAL VIT W/ DOCUSATE-FE FUMARATE- FOLIC ACID & VIT B6 108 FOLIC ACID 105,106,107 Prenatal-U 107 PRENATAL VIT W/ DOCUSATE-IRON CARBONYL- Prenate Star 101 FOLIC ACID 104,105,108,109 PreQue 10 107 Prenatal Vit w/ Docusate-Iron Carbonyl-Folic Acid 105 PreTAB 107 PRENATAL VIT W/ FE BISGLYCINATE CHELATE- Prevnar 13 156 FOLIC ACID 104 Prezcobix 57 Prenatal Vit w/ Fe Bisglycinate Chelate-Folic Prezista 57 Acid 108,109 Priftin 34 PRENATAL VIT W/ FE POLY CMPLX-FE HEME PRIMAQUINE PHOSPHATE 46 POLYPEPT-FA & OMEGA 3 105,110 PRIMIDONE 23 PRENATAL VIT W/ FERROUS FUMARATE-FA- Primsol 16 OMEGA 3 FATTY ACIDS 106 Privigen 149 PRENATAL VIT W/ FERROUS FUMARATE-FOLIC Pro Voice V8/V9 Glucose 176 ACID 104,105,107,108,109 ProAir HFA 192 PRENATAL VIT W/ FERROUS FUMARATE-L ProAir RespiClick 192 METHYLFOLATE-FOLIC ACID 108 PROBENECID 32 PRENATAL VIT W/ IRON CARBONYL-FE PROCARBAZINE HCL 35 GLUCONATE-FOLIC ACID 109 PROCHLORPERAZINE 29 PRENATAL VIT W/ IRON CARBONYL-FOLIC PROCHLORPERAZINE MALEATE 29 ACID 106,107,108,109 ProCort 99 PRENATAL VIT W/ SELENIUM-FE FUMARATE- Procrit 70 FOLIC ACID 109 Proctofoam HC 99 PRENATAL VITAMINS W/ FE ASPARTO Procysbi 116 GLYCINATE-FOLIC ACID 101 Prodigy No Coding Blood Gluc 177 PRENATAL W/ CALCIUM CARBONATE-VIT B6-VIT Profilnine 75 B12-FOLIC ACID 104 Profilnine SD 75 PRENATAL W/ CALCIUM-VIT B6-FOLIC ACID- PROGESTERONE 137 GINGER 106,110 PROGESTERONE (VAGINAL) 136 PRENATAL W/FE CARBONYL-FA-DSS-OMEGA 3 PROGESTERONE MICRONIZED 137 FATTY ACIDS 105 Prograf 145 PRENATAL WITHOUT A VIT W/ FE FUM-IRON Prolia 160 POLYSACCH COMPLEX -FA 104,105,107,109 Promacta 70 Prenatal without A Vit w/ Fe Fumarate-Folic PROMETHAZINE & PHENYLEPHRINE 197,198 Acid 104,108 PROMETHAZINE HCL 29,30,190 PROMETHAZINE W/CODEINE 198

©2020 Wellmark, Inc. 228 PROMETHAZINE-DM 198 Promethazine-Phenylephrine 198 R PROMETHAZINE-PHENYLEPHRINE- RA Alcohol Swabs 177 CODEINE 197,198 RA TRUEtest Test 177 Promethegan 30 RABEPRAZOLE SODIUM 113 PROPAFENONE HCL 79 Radicava 93 PROPANTHELINE BROMIDE 111 RALOXIFENE HCL 137 Propantheline Bromide 111 RALTEGRAVIR POTASSIUM 53 PROPARACAINE HCL 183 RAMELTEON 200 PROPRANOLOL & HYDROCHLOROTHIAZIDE 85 RAMIPRIL 78 PROPRANOLOL HCL 80 RANITIDINE HCL 112 Propranolol-HCTZ 85 RANOLAZINE 85 PROPYLTHIOURACIL 141 RASAGILINE MESYLATE 48 ProQuad 157 Rasuvo 145 PROTRIPTYLINE HCL 29 Ravicti 116 Proventil HFA 192 RAVULIZUMAB-CWVZ 180 Provida OB 107 Rebif 95 PSEUDOEPHED-BROMPHEN-DM 196,198 Rebif Rebidose 95 PSEUDOEPHED-CPM W/ HYDROCOD 198 Rebif Rebidose Titration Pack 95 PTS Panels Ketone Test 177 Rebif Titration Pack 95 Pulmozyme 193 Rebinyn 75 PureFe OB Plus 107 Reblozyl 70 PYRAZINAMIDE 34 Reclast 160 PYRIDOSTIGMINE BROMIDE 34 Recombinate 76 PYRIMETHAMINE 46 Recombivax HB 157 RefuAH Plus Blood Glucose Test 177 Q REGORAFENIB 44 Qinlock 38 Regranex 99 Quadracel 157 Relenza Diskhaler 58 QUETIAPINE FUMARATE 50 ReliOn Blood Glucose Test 177 Quinapril HCl 78 ReliOn Confirm/micro Test 177 QUINAPRIL-HYDROCHLOROTHIAZIDE 85 ReliOn Ketone 177 QUINIDINE GLUCONATE 79 ReliOn Ketone Test 177 QUINIDINE SULFATE 79 ReliOn Premier Test 177 QuiNIDine Sulfate 79 ReliOn Prime Test 177 QUININE SULFATE 46 ReliOn Ultima Test 178 Quintet AC Blood Glucose Test 177 Remicade 145 Quintet Blood Glucose Test 177 Remodulin 194 Qvar 189 Renflexis 145 Qvar RediHaler 189 REPAGLINIDE 62 REPAGLINIDE-METFORMIN HCL 62

©2020 Wellmark, Inc. 229 Repaglinide-Metformin HCl 62 RISANKIZUMAB-RZAA 99 Repatha 89 RISEDRONATE SODIUM 160 Repatha Pushtronex System 89 RISPERIDONE 50 Repatha SureClick 89 RITONAVIR 57 Rescriptor 54 RIVAROXABAN 68 RESLIZUMAB 197 RIVASTIGMINE 26 Respa-BR 190 RIVASTIGMINE TARTRATE 26 Restasis 183 Rixubis 76 Restasis Multidose 183 RIZATRIPTAN BENZOATE 33 Retacrit 70 ROMIPLOSTIM 70 Retevmo 38 ROMOSOZUMAB-AQQG 159 Revatio 194,195 ROPINIROLE HYDROCHLORIDE 48 Reveal Blood Glucose Test 178 ROSIGLITAZONE MALEATE-METFORMIN HCL 60 Revlimid 36 ROSUVASTATIN CALCIUM 88 Rexall Blood Glucose Test 178 Rotarix 157 Reyataz 57 RotaTeq 157 Rheumatrex 145 ROTAVIRUS VACCINE, LIVE ORAL 157 RHO D IMMUNE GLOBULIN (HUMAN) 148,149 ROTAVIRUS VACCINE, LIVE ORAL RhoGAM Ultra-Filtered Plus 149 PENTAVALENT 157 Rhophylac 149 Rozlytrek 38 RIBAVIRIN (HEPATITIS C) 52,53 Rubraca 38 RIBOCICLIB SUCCINATE 42 RUCAPARIB CAMSYLATE 38 RIBOCICLIB SUCCINATE-LETROZOLE 42,43 Ruconest 141 Ridaura 152 RUFINAMIDE 24,25 RIFABUTIN 34 Rukobia 56 RIFAMPIN 34 RUXOLITINIB PHOSPHATE 42 RIFAPENTINE 34 Ruzurgi 34 RIFAXIMIN 17 Rydapt 38 Rightest GS100 Blood Glucose 178 Rightest GS300 Blood Glucose 178 S Rightest GS550 Blood Glucose 178 Sabril 23 RILONACEPT 150 SACROSIDASE 116 RILPIVIRINE HCL 54 SACUBITRIL-VALSARTAN 84 RILUZOLE 93 Saizen 124 RIMABOTULINUMTOXINB 199 Saizen Click.Easy 125 RiMANTAdine HCl 58 Saizenprep 125 RIMANTADINE HYDROCHLORIDE 58 SALMETEROL XINAFOATE 192 Rinvoq 145 SALSALATE 6 RIOCIGUAT 194 Samsca 103 Riomet ER 62 SandIMMUNE 145 RIPRETINIB 38 SandoSTATIN 140

©2020 Wellmark, Inc. 230 SandoSTATIN LAR Depot 140 SIROLIMUS 146 Santyl 99 SITAGLIPTIN PHOSPHATE 61 SAPROPTERIN DIHYDROCHLORIDE 115,116 SITAGLIPTIN-METFORMIN HCL 61 SAQUINAVIR MESYLATE 57 Sivextro 16 SARGRAMOSTIM 69 Skyla 137 SARILUMAB 150 Skyrizi (150 MG Dose) 99 Scenesse 99 SM Alcohol Prep 178 SCOPOLAMINE 30 Smart Sense Premium Test 178 Se-Natal 19 107 Smart Sense Value Test 178 SECOBARBITAL SODIUM 200 Smartest Blood Glucose Test 178 Seconal 200 Sodium Bicarbonate 102 SECUKINUMAB 97 SODIUM CHLORIDE 102 SELEGILINE HCL 48 SODIUM CHLORIDE (INHALANT) 197,198 SELENIUM SULFIDE 99 SODIUM CHLORIDE FLUSH 100,101,102 SELEXIPAG 195 Sodium Chloride Flush 101 SELINEXOR 39 SODIUM CITRATE & CITRIC ACID 118 SELPERCATINIB 38 Sodium Hyaluronate 178 SELUMETINIB SULFATE 43 SODIUM HYALURONATE Selzentry 56 (VISCOSUPPLEMENT) 98,167,170,172,178,179,180,1 SEMAGLUTIDE 61 81 Sensipar 160 Sodium Hyaluronate (Viscosupplement) 179 Serevent Diskus 192 SODIUM OXYBATE 200 Serostim 125 SODIUM PHENYLBUTYRATE 114,116 SERTRALINE HCL 28 SODIUM PHOSPHATE MONOBASIC-SODIUM SEVELAMER CARBONATE 103 PHOSPHATE DIBASIC 112 SEVELAMER HCL 103 SODIUM POLYSTYRENE SULFONATE 103 Sevenfact 76 SODIUM SULFATE-POTASSIUM SULFATE- Shingrix 157 MAGNESIUM SULFATE 113 Signifor 140 SODIUM ZIRCONIUM CYCLOSILICATE 101 SILDENAFIL CITRATE 118 SOFOSBUVIR 52 SILDENAFIL CITRATE (PULMONARY SOFOSBUVIR-VELPATASVIR 51,52 HYPERTENSION) 194,195 Sofosbuvir-Velpatasvir 52 Siliq 99 SOFOSBUVIR-VELPATASVIR-VOXILAPREVIR 52 SILODOSIN 117 Solesta 178 SILVER SULFADIAZINE 21 SOLIFENACIN SUCCINATE 117 SIMEPREVIR SODIUM 51 Soliris 179 Simponi 146 Solodyn 22 Simponi Aria 146 Soltamox 36 SIMVASTATIN 88 Solu-CORTEF 123 SINECATECHINS 100 SOLU-medrol 123 SIPONIMOD FUMARATE 95 Solus V2 Test 179

©2020 Wellmark, Inc. 231 SOMATROPIN 123,124,125 SUMAtriptan Succinate 33 SOMATROPIN (NON-REFRIGERATED) 124,125 SUMATRIPTAN-NAPROXEN SODIUM 33 Somatuline Depot 140 SUNITINIB MALATE 44 Somavert 140 Supartz 179 SONIDEGIB PHOSPHATE 44 Supartz FX 179 SORAFENIB TOSYLATE 44 Suprax 18 SOTALOL HCL 79 Suprep Bowel Prep Kit 113 SOTALOL HCL (AFIB/AFL) 79 Sure Edge Test 179 Sovaldi 52 Sure-Test EasyPlus Mini Test 179 Spiriva HandiHaler 190 SureChek Blood Glucose Test 179 Spiriva Respimat 190 SureStep Test 179 SPIRONOLACTONE 87 Sutent 44 SPIRONOLACTONE & HYDROCHLOROTHIAZIDE 85 Sylatron 38 Sprycel 44 Symdeko 193 STAVUDINE 55 Symjepi 192 Stelara 99 SymlinPen 120 62 Stiolto Respimat 198 SymlinPen 60 62 STIRIPENTOL 22 Symtuza 53 Stivarga 44 Synagis 152 Strensiq 116 Synjardy 62 Stribild 53 Synjardy XR 62 Striverdi Respimat 192 Synribo 38 SUCCIMER 102 Synthroid 138 Sucraid 116 Synvisc 179 SUCRALFATE 113 Synvisc One 179 SULCONAZOLE NITRATE 31 Syprine 103 SULFACETAMIDE SOD-PREDNISOLONE 182,183 SULFACETAMIDE SODIUM (ACNE) 21 T SULFACETAMIDE SODIUM (OPHTH) 21 Tabloid 37 SULFACETAMIDE SODIUM-SULFUR IN UREA Tabrecta 38 VEHICLE 99 TACROLIMUS 142,143,145,146 Sulfacetamide-Sulfur in Urea 99 TACROLIMUS (TOPICAL) 99 SULFADIAZINE 21 TADALAFIL 117 SulfADIAZINE 21 TADALAFIL (PULMONARY HYPERTENSION)194,195 SULFAMETHOXAZOLE-TRIMETHOPRIM 21 TAFAMIDIS 86 Sulfamylon 16 TAFAMIDIS MEGLUMINE (CARDIAC) 86 SULFASALAZINE 159 TAFASITAMAB-CXIX 45 SULFURIC ACID-SULFONATED PHENOLICS 96 Tafinlar 44 SULINDAC 6 Tagrisso 44 SUMATRIPTAN 33 Takhzyro 141 SUMATRIPTAN SUCCINATE 33 TALAZOPARIB TOSYLATE 44

©2020 Wellmark, Inc. 232 TALIGLUCERASE ALFA 114 TERIFLUNOMIDE 93 Taltz 100 TERIPARATIDE (RECOMBINANT) 159,160 Talzenna 44 Teriparatide (Recombinant) 160 TAMOXIFEN CITRATE 36 TESTOSTERONE 126 TAMSULOSIN HCL 117 TESTOSTERONE CYPIONATE 126 Tarceva 44 TESTOSTERONE ENANTHATE 126 Targretin 45 TETANUS TOXOID-DIPHTHERIA-ACELLULAR Taron-Bc 108 PERTUSSIS ADSORB (TDAP) 152,153 Tasigna 44 TETANUS-DIPHTHERIA TOXOIDS (TD) 157 TASIMELTEON 200 Tetanus-Diphtheria Toxoids Td 157 Tavalisse 70 TETRABENAZINE 93 TAZAROTENE 100 TETRACAINE HCL (OPHTH) 181,183,184 TAZEMETOSTAT HBR 38 TETRACYCLINE HCL 22 Tazverik 38 TEZACAFTOR-IVACAFTOR 193 TBO-FILGRASTIM 69 TGT Blood Glucose Test 179 TDVAX 157 THALIDOMIDE 36 Tecartus 38 Thalomid 36 Tecfidera 96 THEOPHYLLINE 193,194 Technivie 52 THIOGUANINE 37 TEDIZOLID PHOSPHATE 16 Thiola 118 TEDUGLUTIDE (RDNA) 111 Thiola EC 118 Tegsedi 93 THIORIDAZINE HCL 49 TELBIVUDINE 51 THIOTHIXENE 49 Telcare Blood Glucose Test 179 Thrivite Rx 108 TELMISARTAN 78 Thyrogen 179 TELMISARTAN-AMLODIPINE 86 THYROID 138 TELMISARTAN-HYDROCHLOROTHIAZIDE 86 THYROTROPIN ALFA 179 TEMAZEPAM 199 TIAGABINE HCL 23 Temixys 55 Tibsovo 38 Temodar 35 TICAGRELOR 77 TEMOZOLOMIDE 35 TILDRAKIZUMAB-ASMN 98 Tencon 93 TIMOLOL 186 Tenivac 157 TIMOLOL MALEATE 80 TENOFOVIR ALAFENAMIDE FUMARATE 51 TIMOLOL MALEATE (OPHTH) 187 TENOFOVIR DISOPROXIL FUMARATE 55 TINIDAZOLE 16 Tepezza 183 TIOPRONIN 118 TEPROTUMUMAB-TRBW 183 TIOTROPIUM BROMIDE MONOHYDRATE 190 TERAZOSIN HCL 77 TIOTROPIUM BROMIDE-OLODATEROL HCL 198 TERBINAFINE HCL 32 TIPRANAVIR 56 TERBUTALINE SULFATE 192 Tivicay 53 TERCONAZOLE VAGINAL 32 Tivicay PD 53

©2020 Wellmark, Inc. 233 TIZANIDINE HCL 50 TREPROSTINIL DIOLAMINE 194 TL Folate 108 Tresiba 66 Tobi 193 Tresiba FlexTouch 66 Tobi Podhaler 193 TRETINOIN 97,100 TobraDex 184 TRETINOIN (CHEMOTHERAPY) 45 TOBRAMYCIN 192,193 TRETINOIN MICROSPHERE 100 TOBRAMYCIN (OPHTH) 14 TriAdvance 108 TOBRAMYCIN SULFATE 14 TRIAMCINOLONE ACETONIDE 123 TOBRAMYCIN-DEXAMETHASONE 184 TRIAMCINOLONE ACETONIDE (MOUTH) 96 Tobrex 14 TRIAMCINOLONE ACETONIDE (TOPICAL) 123 TOCILIZUMAB 150 TRIAMTERENE 87 TOFACITINIB CITRATE 146 TRIAMTERENE & HYDROCHLOROTHIAZIDE 86 TOLAZAMIDE 62 TRIAZOLAM 199 TOLAZamide 62 TRIENTINE HCL 102,103 TOLBUTAMIDE 62 TRIFLUOPERAZINE HCL 49 TOLBUTamide 62 TRIFLURIDINE 58 TOLCAPONE 47 TRIFLURIDINE-TIPIRACIL 37 TOLMETIN SODIUM 7 TRIHEXYPHENIDYL HCL 47 Tolmetin Sodium 7 Trikafta 193 TOLTERODINE TARTRATE 117 Triluron 180 TOLVAPTAN 103 TRIMETHOBENZAMIDE HCL 30 TOPIRAMATE 24 TRIMETHOPRIM 16 TOPOTECAN HCL 40 TRIMETHOPRIM HCL 16 TOREMIFENE CITRATE 36 TRIMIPRAMINE MALEATE 29 TORSEMIDE 86 Trimpex 16 Tracleer 195 Trinatal GT 108 TRAMADOL HCL 8,9,12 Trinatal Rx 1 108 TRAMADOL-ACETAMINOPHEN 12 Trinate 108 TRAMETINIB DIMETHYL SULFOXIDE 43 TRIPTORELIN PAMOATE 140,141 TRANDOLAPRIL 79 Triumeq 56 TRANDOLAPRIL-VERAPAMIL HCL 86 Triveen-Duo DHA 108 TRANEXAMIC ACID 76 TriVisc 180 TRANYLCYPROMINE SULFATE 27 Tropicamide 182 TRAVOPROST 187 TROPICAMIDE 184 Trazodone HCl 28 TROSPIUM CHLORIDE 117 Trecator 34 True Focus Blood Glucose Strip 180 Trelegy Ellipta 189 True Metrix Blood Glucose Test 180 Trelstar 140 True Metrix Pro Blood Glucose 180 Trelstar Mixject 141 TRUEtest Test 180 Tremfya 100 TrueTrack Test 180 TREPROSTINIL 194,195 Trulance 112

©2020 Wellmark, Inc. 234 Trumenba 157 VALPROATE SODIUM 23 Truvada 55 VALSARTAN 78 TUCATINIB 44 VALSARTAN-HYDROCHLOROTHIAZIDE 86 Tukysa 44 Valtoco 10 MG Dose 23 Turalio 38 Valtoco 15 MG Dose 24 Twinrix 158 Valtoco 20 MG Dose 24 Tybost 56 Valtoco 5 MG Dose 24 Tykerb 44 VANCOMYCIN HCL 15,16 Tymlos 160 VANDETANIB 41 Tysabri 96 Vaqta 158 Tyvaso 195 VARDENAFIL HCL 118 Tyvaso Refill 195 VARICELLA VIRUS VACCINE LIVE 158 Tyvaso Starter 195 VARICELLA-ZOSTER IMMUNE GLOBULIN Tyzeka 51 (HUMAN) 150 Varivax 158 U VariZIG 150 Udenyca 71 VEDOLIZUMAB 142 Ulesfia 47 VELAGLUCERASE ALFA 116 Ultima Test 180 Veletri 195 Ultomiris 180 Veltassa 104 UltraTRAK PRO Test 180 Vemlidy 51 UltraTRAK Ultimate Test 180 VEMURAFENIB 45 UMECLIDINIUM-VILANTEROL 196 Venclexta 44 Unistrip1 Generic 180 Venclexta Starting Pack 44 UPADACITINIB 145 VENETOCLAX 44 Uptravi 195 VENLAFAXINE HCL 28 URIDINE TRIACETATE (EMERGENCY Venlafaxine HCl 28 TREATMENT) 181 Ventavis 196 Urimar-T 16 Ventolin HFA 192 URINE GLUCOSE-KETONES TEST 163,164,172 VERAPAMIL HCL 82,83 Uristix 181 Verapamil HCl ER 83 Uristix 4 181 Verasens Blood Glucose Test 181 URSODIOL 111 Verdrocet 12 USTEKINUMAB 99 Veregen 100 USTEKINUMAB (IV) 99 VERTEPORFIN 184 Verzenio 45 V Vfend IV 32 VALACYCLOVIR HCL 58 Vibramycin 22 VALBENAZINE TOSYLATE 92 Victory AGM-4000 Test 181 Valchlor 35 Victoza 62 VALGANCICLOVIR HCL 51 Videx 55

©2020 Wellmark, Inc. 235 Viekira Pak 52 Vumerity (Starter) 96 Viekira XR 52 Vyepti 34 VIGABATRIN 23,24 Vyndamax 86 Vil-Rx 108 Vyndaqel 86 Vimpat 25 Vyvanse 91 Vinate AZ Extra 108 Vinate C 108 W Vinate Calcium 109 Wakix 200 Vinate IC 109 WARFARIN SODIUM 66,68 Vinate II 109 Warfarin Sodium 68 Vinate M 109 WaveSense Presto 181 Vinate One 109 Wilate 76 Viokace 116 Viracept 57 X Viread 55 Xalkori 45 Virt Nate 109 Xarelto 68 Virt-Advance 109 Xeljanz 146 Virt-Vite GT 109 Xeljanz XR 146 Visco-3 181 Xeloda 37 VISMODEGIB 41 Xembify 150 Vistogard 181 Xenazine 93 Visudyne 184 Xeomin 199 VitaMedMD Plus Rx/Quatrefolic 109 Xgeva 160 Vitekta 53 Xifaxan 17 Vitrakvi 39 Xiidra 184 VivaGuard Ino Test Strips 181 Xofluza 158 Vizimpro 39 Xolair 198 Vocal Point Blood Glucose Test 181 Xospata 39 Vol-Nate 109 Xpovio (100 MG Once Weekly) 39 Vol-Tab Rx 109 Xpovio (40 MG Once Weekly) 39 VON WILLEBRAND FACTOR (RECOMBINANT) 76 Xpovio (40 MG Twice Weekly) 39 Vonvendi 76 Xpovio (60 MG Once Weekly) 39 VORICONAZOLE 32 Xpovio (60 MG Twice Weekly) 39 VORINOSTAT 39 Xpovio (80 MG Once Weekly) 39 Vosevi 52 Xpovio (80 MG Twice Weekly) 39 Votrient 45 Xtandi 36 VOXELOTOR 77 Xulane 135 VP-GGR-B6 Prenatal 110 Xyntha 76 VP-Heme OB + DHA 110 Xyntha Solofuse 76 Vpriv 116 Xyrem 200 Vumerity 96

Z ZAFIRLUKAST 190 ZALEPLON 199 Zamicet 12 ZANAMIVIR 58 ZANUBRUTINIB 37 Zarxio 71 Zavesca 116 Zejula 39 Zelboraf 45 Zenpep 116 Zepatier 52 Zeposia 96 Zeposia 7-Day Starter Pack 96 Zeposia Starter Kit 96 ZIDOVUDINE 55 Ziextenzo 71 ZILEUTON 190 ZIPRASIDONE HCL 50 ZOLEDRONIC ACID 160 Zolinza 39 ZOLMITRIPTAN 33 ZOLPIDEM TARTRATE 199,200 Zolpidem Tartrate 199 Zomacton 125 Zomacton (for Zoma-Jet 10) 125 Zometa 160 ZONISAMIDE 22 Zorbtive 125 Zortress 146 Zostavax 158 ZOSTER VACCINE LIVE 158 ZOSTER VACCINE RECOMBINANT ADJUVANTED 157 Zydelig 45 Zykadia 45 Zylet 184

Discrimination is against the law Wellmark complies with applicable federal civil rights laws and If you believe that Wellmark has failed to provide these services or does not discriminate on the basis of race, color, national origin, discriminated in another way on the basis of race, color, national age, disability or sex. Wellmark does not exclude people or treat origin, age, disability or sex, you can file a grievance with: Wellmark them differently because of their race, color, national origin, age, Civil Rights Coordinator, 1331 Grand Avenue, Station 5W189, disability or sex. Des Moines, IA 50309-2901, 515-376-4500, TTY 888-781-4262, Fax 515-376-9073, Email [email protected]. You can file a Wellmark provides: grievance in person, by mail, fax or email. If you need help filing • Free aids and services to people with disabilities so they may a grievance, the Wellmark Civil Rights Coordinator is available to communicate effectively with us, such as: help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services Office for Civil Rights • Qualified sign language interpreters electronically through the Office for Civil Rights Complaint Portal • Written information in other formats (large print, audio, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail, accessible electronic formats, other formats) phone or fax at: U.S. Department of Health and Human Services, • Free language services to people whose primary language is 200 Independence Avenue S.W., Room 509F, HHH Building, not English, such as: Washington DC 20201, 800-368-1019, 800-537-7697 (TDD). • Qualified interpreters Complaint forms are available at http://www.hhs.gov/ocr/office/file/ • Information written in other languages index.html. If you need these services, call 800-524-9242.

ATENCIÓN: Si habla español, los servicios de asistencia de idiomas Geb Acht: Wann du Deitsch schwetze duscht, kannscht du Hilf in dei se encuentran disponibles gratuitamente para usted. Comuníquese al eegni Schprooch koschdefrei griege. Ruf 800-524-9242 odder (TTY: 800-524-9242 o al (TTY: 888-781-4262). 888-781-4262) uff.

注意：如果您说普通话，我们可免费为您提供语言协助服务。请拨打 โปรดทราบ: หากคุณพูด ไทย เรามีบริการช่วยเหลือด้านภาษาสำ�หรับคุณโดยไม่คิด 800-524-9242 或（听障专线： 888-781-4262）。 ค่าใช้จ่าย ติดต่อ 800-524-9242 หรือ (TTY: 888-781-4262)

CHÚ Ý: Nếu quý vị nói tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ miễn phí có PAG-UKULAN NG PANSIN: Kung Tagalog ang wikang ginagamit mo, sẵn cho quý vị. Xin hãy liên hệ 800-524-9242 hoặc (TTY: 888-781-4262). may makukuha kang mga serbisyong tulong sa wika na walang bayad. Makipag-ugnayan sa 800-524-9242 o (TTY: 888-781-4262). NAPOMENA: Ako govorite hrvatski, dostupna Vam je besplatna podrška na Vašem jeziku. Kontaktirajte 800-524-9242 ili (tekstualni telefon za w>'k;oh.ng= erh>uwdR unDusdm< usdmw>rRpXRw>zH;w>rRwz.< vXwb.vXmbl;vJ< td.vXe*D>vDRI qJ;usd;ql osobe oštećena sluha: 888-781-4262). 800=524=9242 rhwrh> (TTY: 888=781=4262) wuh>I

ACHTUNG: Wenn Sie deutsch sprechen, stehen Ihnen kostenlose ВНИМАНИЕ! Если ваш родной язык русский, вам могут быть sprachliche Assistenzdienste zur Verfügung. Rufnummer: 800-524-9242 предоставлены бесплатные переводческие услуги. Обращайтесь oder (TTY: 888-781-4262). 800-524-9242 (телетайп: 888-781-4262).

सावधान: यदि तपाℂ नेपाली बोल्नन㔛 भने, तपाℂका लागि नि:शुल् 셂पमा भाषा सहायता تنبيه: إذا كنت تتحدث اللغة العربية, فإننا نوفر لك خدمات المساعدة اللغوية، المجانية. اتصل بالرقم सेवाह셂 उपलब㔧 गराइन㔛 । 800-524-9242 वा (TTY: 888-781-4262) मा सम्प㔕 गर्नुोस ् । 9242-524-800 أو )خدمة الهاتف النصي: 888-781-4262(.

ማሳሰቢያ፦ አማርኛ የሚናገሩ ከሆነ፣ የቋንቋ እገዛ አገልግሎቶች፣ ከክፍያ ነፃ፣ ສ່ ງຄວນເອິ ົາໃຈໃສ,່ ພາສາລາວ ຖາທ້ ານເວ່ າົ້ : ພວກເຮາມົ ບີ ລໍ ການິ ຄວາມຊວຍເຫ່ ຼອດື ານພາສາ້ ያገኛሉ። በ ወይም (በ ) ደውለው ያነጋግሩን። ໃຫທ້ ານໂດຍບ່ ່ ເສຍໍ ຄາ່ ຫຼ ື 800-524-9242 ຕດຕິ ່ ໍທ່ .ີ (TTY: 888-781-4262.) 800-524-9242 TTY: 888-781-4262

주의: 한국어 를 사용하시는 경우, 무료 언어 지원 서비스를 이용하실 HEETINA To a wolwa Fulfulde laabi walliinde dow wolde, naa e njobdi, ene 수 있습니다. 800-524-9242번 또는 (TTY: 888-781-4262)번으로 연락해 ngoodi ngam maaɗa. Heɓir 800-524-9242 malla (TTY: 888-781-4262). 주십시오. FUULEFFANNAA: Yo isin Oromiffaa, kan dubbattan taatan, tajaajiloonni ध्봾न रखᴂ : अगर आपकी भाषा हिन्饀 है, तो आपके लिए भाषा सहायता सेवाएँ, निःशुल् gargaarsa afaanii, kaffaltii malee, isiniif ni jiru. 800-524-9242 yookin (TTY: उपलब㔧 हℂ। 800-524-9242 पर संपर㔕 करᴂ या (TTY: 888-781-4262)। 888-781-4262) quunnamaa.

ATTENTION : si vous parlez français, des services d’assistance dans votre УВАГА! Якщо ви розмовляєте українською мовою, для вас доступні langue sont à votre disposition gratuitement. Appelez le 800 524 9242 (ou la безкоштовні послуги мовної підтримки. Зателефонуйте за номером ligne ATS au 888 781 4262). 800-524-9242 або (телетайп: 888-781-4262).

Ge’: Diné k’ehj7 y1n7[ti’go n7k1 bizaad bee 1k1’ adoowo[, t’11 jiik’4, n1h0l=. Koj8’ h0lne’ 800-524-9242 doodaii’ (TTY: 888-781-4262)

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