Health Care Reform

Preventative Drug list

At Magellan Rx Management, we are driven to helping our clients most effectively manage changes in the prescription drug environment. As part of the Patient Protection and Affordable Care Act (PPACA), effective on or after August 1, 2012 non-grandfathered plans are required to cover select FDA-approved drug products related to preventive health services for Adults, Children and Women without a member having to pay a copayment, co-insurance, or meet a deductible. As your pharmacy benefits manager, we will support coverage of specific products at $0 copay as prescription benefit plans become subject to the law. Magellan Rx Management will also routinely update FDA-approved product lists to comply with the Preventive Health mandates and require prescriptions for product coverage.

MRx has created ten specific lists that address the preventive health requirements above. A plan is required to cover all the drug lists below, either through the pharmacy or medical benefits. If the plan needs advice regarding coverage, MRx recommends the plan connect with their respective legal counsel. The content of the list will be maintained by Magellan Rx Management and will be continually reviewed and updated to ensure compliance with healthcare reform mandates.

UPDATE: For plan years beginning on or after September 24, 2014 (January 1, 2015 for calendar year plans), non-grandfathered health plans are required to cover prescription medications designed to reduce the risk of breast cancer in women, without cost-sharing, subject to reasonable medical management. These required drugs have been added to the “Preventive Health for Adults, Children and Women: Prescription and OTC Products” list below. For plan years beginning on or after July 1, 2020 (January 1, 2021 for calendar year plans), non-grandfathered health plans are required to cover prescription medications designed for HIV Pre-Exposure Prophylaxis without cost-sharing, subject to reasonable medical management. These required drugs have been added to the Preventive Health for Adults: HIV Pre-Exposure Prophylaxis (PrEP). For plan years beginning on or after October 1, 2020 (January 1, 2021 for calendar year plans), non-grandfathered health plans are required to cover prescription medications designed for Breast Cancer without cost-sharing, subject to reasonable medical management. These required drugs have been added to the Preventive Health for Women: Breast Cancer.

1. Preventive Health for Adults, Children and Women: Prescription and OTC Products. Age edits may apply. Generic Name Label Name Rx or OTC Form aspirin Adult Aspirin Regimen Ec 81 Mg OTC ORAL aspirin Adult Low Dose Asa Ec 81 Mg Tb OTC ORAL aspirin Aspir Ec 81 Mg Tablet OTC ORAL aspirin Aspirin 325 Mg Tablet OTC ORAL

magellanrx.com Generic Name Label Name Rx or OTC Form aspirin Aspirin 81 Mg Chewable Tablet OTC ORAL aspirin Aspirin Ec 325 Mg Caplet OTC ORAL aspirin Aspirin Ec 325 Mg Tablet OTC ORAL aspirin Aspirin Ec 81 Mg Tablet OTC ORAL aspirin Aspir-Low Ec 81 Mg Tablet OTC ORAL aspirin Aspir-Trin Ec 325 Mg Tablet OTC ORAL aspirin Bayer Aspirin 325 Mg Caplet OTC ORAL aspirin Bayer Aspirin 325 Mg Tablet OTC ORAL aspirin Bayer Aspirin 81 Mg Chew Tab OTC ORAL aspirin Child Aspirin 81 Mg Chew Tab OTC ORAL aspirin Child Aspirin 81 Mg Tab Chew OTC ORAL ferrous sulfate Child Ferrous Sulfate 15 Mg/Ml OTC ORAL ferrous sulfate Children'S Iron 15 Mg/Ml Drops OTC ORAL aspirin Cvs Aspirin 325 Mg Caplet OTC ORAL aspirin Cvs Aspirin 325 Mg Tablet OTC ORAL aspirin Cvs Aspirin 81 Mg Chewable Tab OTC ORAL aspirin Cvs Aspirin Ec 325 Mg Tablet OTC ORAL aspirin Cvs Aspirin Ec 81 Mg Tablet OTC ORAL folic acid Cvs Folic Acid 800 Mcg Tablet OTC ORAL aspirin Ecotrin Ec 325 Mg Tablet OTC ORAL aspirin Ecotrin Ec 81 Mg Tablet OTC ORAL aspirin Ecpirin Ec 325 Mg Tablet OTC ORAL aspirin Eq Aspirin 325 Mg Tablet OTC ORAL aspirin Eq Aspirin 81 Mg Chewable Tab OTC ORAL aspirin Eq Aspirin Ec 325 Mg Tablet OTC ORAL aspirin Eq Aspirin Ec 81 Mg Tablet OTC ORAL aspirin Eql Aspirin 325 Mg Tablet OTC ORAL aspirin Eql Aspirin 81 Mg Chewable Tab OTC ORAL aspirin Eql Aspirin Ec 325 Mg Tablet OTC ORAL aspirin Eql Aspirin Ec 81 Mg Tablet OTC ORAL folic acid Fa-8 Capsules OTC ORAL ferrous sulfate Ferosul 220 Mg/5 Ml Elixir OTC ORAL ferrous sulfate Ferrous Sulf 15 Mg Iron/Ml Drp OTC ORAL ferrous sulfate Ferrous Sulf 220 Mg/5 Ml Elix OTC ORAL ferrous sulfate Ferrous Sulf 220 Mg/5 Ml Liq OTC ORAL ferrous sulfate Ferrous Sulf 300 Mg/5 Ml Liq OTC ORAL ferrous sulfate Ferrous Sulf 44 Mg Iron/5Ml Lq OTC ORAL fluoride (sodium) Fluoride 0.25 Mg Tablet Chew RX ORAL fluoride (sodium) Fluoride 0.5 Mg Tablet Chew RX ORAL fluoride (sodium) Fluoride 1 Mg Tablet Chewable RX ORAL fluoride (sodium) Fluoritab 0.5 Mg Tablet Chew RX ORAL fluoride (sodium) Fluoritab 1 Mg Tablet Chew RX ORAL fluoride (sodium) Flura-Drops 0.25 Mg/Drop RX ORAL folic acid Folic Acid 0.4 Mg Tablet OTC ORAL folic acid Folic Acid 0.8 Mg Tablet OTC ORAL folic acid Folic Acid 20 Mg Capsule OTC ORAL folic acid Folic Acid 400 Mcg Tablet OTC ORAL folic acid Folic Acid 800 Mcg Capsule OTC ORAL folic acid Folic Acid 800 Mcg Tablet OTC ORAL aspirin Gnp Aspirin 325 Mg Tablet OTC ORAL aspirin Gnp Aspirin 81 Mg Chewable Tab OTC ORAL aspirin Gnp Aspirin Ec 325 Mg Tablet OTC ORAL aspirin Gnp Aspirin Ec 81 Mg Tablet OTC ORAL folic acid Gnp Folic Acid 400 Mcg Tablet OTC ORAL aspirin Gnp Lite Coat Asa 325 Mg Tab OTC ORAL aspirin Gs Aspirin 325 Mg Tablet OTC ORAL aspirin Gs Aspirin 81 Mg Chewable Tab OTC ORAL

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Generic Name Label Name Rx or OTC Form aspirin Gs Aspirin Ec 325 Mg Tablet OTC ORAL aspirin Gs Aspirin Ec 81 Mg Tablet OTC ORAL aspirin Hm Aspirin 325 Mg Tablet OTC ORAL aspirin Hm Aspirin 81 Mg Chewable Tab OTC ORAL aspirin Hm Aspirin Ec 325 Mg Tablet OTC ORAL aspirin Hm Aspirin Ec 81 Mg Tablet OTC ORAL folic acid Hm Folic Acid 400 Mcg Tablet OTC ORAL ferrous sulfate Iron 65 Mg Tablet OTC ORAL aspirin Kro Aspirin 325 Mg Tablet OTC ORAL aspirin Kro Aspirin 81 Mg Chewable Tab OTC ORAL aspirin Kro Aspirin Ec 325 Mg Tablet OTC ORAL aspirin Kro Aspirin Ec 81 Mg Tablet OTC ORAL aspirin Lite Coat Aspirin 325 Mg Tab OTC ORAL aspirin Low Dose Aspirin Ec 81 Mg Tab OTC ORAL fluoride (sodium) Ludent Fluoride 0.25 Mg Tb Chw RX ORAL fluoride (sodium) Ludent Fluoride 0.5 Mg Tb Chew RX ORAL fluoride (sodium) Ludent Fluoride 1 Mg Tab Chew RX ORAL ferrous sulfate Pharm Chc Ped Iron 15Mg/Ml Drp OTC ORAL aspirin Pub Aspirin 325 Mg Tablet OTC ORAL aspirin Pub Aspirin 81 Mg Chewable Tab OTC ORAL aspirin Qc Aspirin 325 Mg Tablet OTC ORAL aspirin Qc Aspirin 81 Mg Chewable Tab OTC ORAL aspirin Qc Aspirin Ec 325 Mg Tablet OTC ORAL aspirin Qc Aspirin Ec 81 Mg Tablet OTC ORAL aspirin Qc Lo-Dose Aspirin Ec 81 Mg Tb OTC ORAL aspirin Ra Aspirin 325 Mg Tablet OTC ORAL aspirin Ra Aspirin 81 Mg Chewable Tab OTC ORAL aspirin Ra Aspirin Ec 325 Mg Tablet OTC ORAL aspirin Ra Aspirin Ec 81 Mg Tablet OTC ORAL folic acid Ra Folic Acid 0.4 Mg Tablet OTC ORAL folic acid Ra Folic Acid 800 Mcg Tablet OTC ORAL aspirin Sb Aspirin 325 Mg Tablet OTC ORAL aspirin Sm Aspirin 325 Mg Tablet OTC ORAL aspirin Sm Aspirin 81 Mg Chewable Tab OTC ORAL aspirin Sm Aspirin Ec 325 Mg Tablet OTC ORAL aspirin Sm Aspirin Ec 81 Mg Tablet OTC ORAL aspirin Sm Child Aspirin 81 Mg Chw Tab OTC ORAL folic acid Sm Folic Acid 0.4 Mg Tablet OTC ORAL folic acid Sm Folic Acid 400 Mcg Tablet OTC ORAL fluoride (sodium) Sodium Fluoride 0.25 (0.55) Mg RX ORAL fluoride (sodium) Sodium Fluoride 0.5 Mg(1.1 Mg) RX ORAL fluoride (sodium) Sodium Fluoride 0.5 Mg/Ml Drop RX ORAL fluoride (sodium) Sodium Fluoride 0.5 Mg/Ml Drop OTC ORAL fluoride (sodium) Sodium Fluoride 1 Mg (2.2 Mg) RX ORAL aspirin St. Joseph Aspirin 81 Mg Chew OTC ORAL aspirin St. Joseph Aspirin Ec 81 Mg Tb OTC ORAL folic acid Sv Folic Acid 800 Mcg Tablet OTC ORAL Bowel Prep Products: Quantity limit and age edits apply peg 3350/mannitol/sodium bicarbonate/citric acid/sucrose Base, Pcca Rapid Dissolve Powd OTC MISCELL peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride Gavilyte-C Solution RX ORAL peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride Gavilyte-G Solution RX ORAL sodium chloride/sodium bicarbonate/potassium chloride/peg Gavilyte-N Solution RX ORAL

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RX/OTC Generic Name Label Name Form (FDB) Bowel Prep Products: Quantity limit and age edits apply peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride Peg 3350 Electrolyte Soln RX ORAL sodium chloride/sodium bicarbonate/potassium chloride/peg Peg 3350-Electrolyte Solution RX ORAL peg 3350/sodium sulfate/sod chloride/kcl/ascorbate sod/vit c Peg3350 100-7.5-2.691-1.01-5.9 RX ORAL peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride Peg-3350 And Electrolytes Soln RX ORAL polyethylene glycol 3350 Polyethylene Glycol 3350 Powd OTC ORAL polyethylene glycol 3350 Polyethylene Glycol 3350 Powd RX MISCELL polyethylene glycol 3350 Polyethylene Glycol 3350 Powd OTC MISCELL sodium chloride/sodium bicarbonate/potassium chloride/peg Trilyte With Flavor Packets RX ORAL COVID 19 Vaccines covid-19 vaccine, mrna-1273, lnp-s (moderna)/pf Moderna Covid19 Vacc RX INTRAMUSC covid-19 vaccine, mrna, bnt162b2, lnp-s(pfizer)/pf Pfizer Covid19 Vacc RX INTRAMUSC Risk-Reducing Drugs for Breast Cancer: Gender edits apply raloxifene hcl Raloxifene Hcl 60 Mg Tablet RX ORAL tamoxifen citrate Tamoxifen 10 Mg Tablet RX ORAL tamoxifen citrate Tamoxifen 20 Mg Tablet RX ORAL Rx Statins Age Edits: Age edits apply atorvastatin calcium Atorvastatin 10 Mg Tablet RX ORAL atorvastatin calcium Atorvastatin 20 Mg Tablet RX ORAL lovastatin Lovastatin 10 Mg Tablet RX ORAL lovastatin Lovastatin 20 Mg Tablet RX ORAL lovastatin Lovastatin 40 Mg Tablet RX ORAL pravastatin sodium Pravastatin Sodium 10 Mg Tab RX ORAL pravastatin sodium Pravastatin Sodium 20 Mg Tab RX ORAL pravastatin sodium Pravastatin Sodium 40 Mg Tab RX ORAL pravastatin sodium Pravastatin Sodium 80 Mg Tab RX ORAL rosuvastatin calcium Rosuvastatin Calcium 10 Mg Tab RX ORAL rosuvastatin calcium Rosuvastatin Calcium 5 Mg Tab RX ORAL simvastatin Simvastatin 10 Mg Tablet RX ORAL simvastatin Simvastatin 20 Mg Tablet RX ORAL simvastatin Simvastatin 40 Mg Tablet RX ORAL simvastatin Simvastatin 5 Mg Tablet RX ORAL

2. Preventive Health for Women: Contraceptives —Prescription Contraceptive Products. Gender and Quantity Limits apply. Multi-source brands and select single source brands are not covered. RX/OTC Generic Name Label Name Form (FDB) Hormonal Contraceptives levonorgestrel/ethinyl estradiol Afirmelle-28 Tablet RX ORAL levonorgestrel/ethinyl estradiol Altavera-28 Tablet RX ORAL norethindrone-ethinyl estradiol Alyacen 1-35 28 Tablet RX ORAL norethindrone-ethinyl estradiol Alyacen 7-7-7-28 Tablet RX ORAL levonorgestrel/ethinyl estradiol and ethinyl estradiol Amethia 0.15-0.03-0.01 Mg Tab RX ORAL levonorgestrel/ethinyl estradiol and ethinyl estradiol Amethia Lo Tablet RX ORAL levonorgestrel/ethinyl estradiol Amethyst 90-20 Mcg Tablet RX ORAL desogestrel-ethinyl estradiol Apri 28 Day Tablet RX ORAL norethindrone-ethinyl estradiol Aranelle 28 Tablet RX ORAL levonorgestrel/ethinyl estradiol and ethinyl estradiol Ashlyna 0.15-0.03-0.01 Mg Tab RX ORAL magellanrx.com 4 | 2020 Magellan Rx Management, LLC. All Rights Reserved_1220

RX/OTC Generic Name Label Name Form (FDB) Hormonal Contraceptives levonorgestrel/ethinyl estradiol Aubra Eq-28 Tablet RX ORAL levonorgestrel/ethinyl estradiol Aubra-28 Tablet RX ORAL norethindrone acetate-ethinyl estradiol Aurovela 1 Mg-20 Mcg Tablet RX ORAL norethindrone acetate-ethinyl estradiol Aurovela 21 1.5-30 Tablet RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Aurovela 24 Fe 1 Mg-20 Mcg Tab RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Aurovela Fe 1.5 Mg-30 Mcg Tab RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Aurovela Fe 1-20 Tablet RX ORAL levonorgestrel/ethinyl estradiol Aviane-28 Tablet RX ORAL levonorgestrel/ethinyl estradiol Ayuna-28 Tablet RX ORAL desogestrel-ethinyl estradiol/ethinyl estradiol Azurette 28 Day Tablet RX ORAL norethindrone-ethinyl estradiol Balziva 28 Tablet RX ORAL desogestrel-ethinyl estradiol/ethinyl estradiol Bekyree 28 Day Tablet RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Blisovi 24 Fe Tablet RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Blisovi Fe 1.5-30 Tablet RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Blisovi Fe 1-20 Tablet RX ORAL norethindrone-ethinyl estradiol Briellyn Tablet RX ORAL norethindrone Camila 0.35 Mg Tablet RX ORAL levonorgestrel/ethinyl estradiol and ethinyl estradiol Camrese 0.15-0.03-0.01 Mg Tab RX ORAL levonorgestrel/ethinyl estradiol and ethinyl estradiol Camrese Lo Tablet RX ORAL desogestrel-ethinyl estradiol Caziant 28 Day Tablet RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Charlotte 24 Fe Chewable Tab RX ORAL levonorgestrel/ethinyl estradiol Chateal Eq-28 Tablet RX ORAL levonorgestrel/ethinyl estradiol Chateal-28 Tablet RX ORAL norgestrel-ethinyl estradiol Cryselle-28 Tablet RX ORAL norethindrone-ethinyl estradiol Cyclafem 1-35-28 Tablet RX ORAL norethindrone-ethinyl estradiol Cyclafem 7-7-7-28 Tablet RX ORAL desogestrel-ethinyl estradiol Cyred 28 Day Tablet RX ORAL desogestrel-ethinyl estradiol Cyred Eq 28 Day Tablet RX ORAL norethindrone-ethinyl estradiol Dasetta 1-35-28 Tablet RX ORAL norethindrone-ethinyl estradiol Dasetta 7/7/7-28 Tablet RX ORAL levonorgestrel/ethinyl estradiol and ethinyl estradiol Daysee 0.15-0.03-0.01 Mg Tab RX ORAL norethindrone Deblitane 0.35 Mg Tablet RX ORAL medroxyprogesterone acetate Depo-Subq Provera 104 Syringe RX SUBCUT desogestrel-ethinyl estradiol Desogest-Eth Estra 0.15-0.03Mg RX ORAL desogestrel-ethinyl estradiol/ethinyl estradiol Desogestr-Eth Estrad Eth Estra RX ORAL drospirenone/ethinyl estradiol/levomefolate calcium Drosp-Ee-Levomef 3-0.02-0.451 RX ORAL drospirenone/ethinyl estradiol/levomefolate calcium Drosp-Ee-Levomef 3-0.03-0.451 RX ORAL ethinyl estradiol/drospirenone Drospirenone-Ee 3-0.02 Mg Tab RX ORAL ethinyl estradiol/drospirenone Drospirenone-Ee 3-0.03 Mg Tab RX ORAL norgestrel-ethinyl estradiol Elinest-28 Tablet RX ORAL ulipristal acetate Ella 30 Mg Tablet RX ORAL desogestrel-ethinyl estradiol Emoquette 28 Day Tablet RX ORAL levonorgestrel/ethinyl estradiol Enpresse-28 Tablet RX ORAL desogestrel-ethinyl estradiol Enskyce 28 Tablet RX ORAL norethindrone Errin 0.35 Mg Tablet RX ORAL magellanrx.com 5 | 2020 Magellan Rx Management, LLC. All Rights Reserved_1220

RX/OTC Generic Name Label Name Form (FDB) Hormonal Contraceptives norgestimate-ethinyl estradiol Estarylla 0.25-0.035 Mg Tablet RX ORAL ethynodiol diacetate-ethinyl estradiol Ethynodiol-Eth Estra 1Mg-35Mcg RX ORAL ethynodiol diacetate-ethinyl estradiol Ethynodiol-Eth Estra 1Mg-50Mcg RX ORAL levonorgestrel/ethinyl estradiol Falmina-28 Tablet RX ORAL levonorgestrel/ethinyl estradiol and ethinyl estradiol Fayosim Tablet RX ORAL norgestimate-ethinyl estradiol Femynor 28 Tablet RX ORAL norethindrone acetate-ethinyl estradiol Fyavolv 0.5 Mg-2.5 Mcg Tablet RX ORAL norethindrone acetate-ethinyl estradiol Fyavolv 1 Mg-5 Mcg Tablet RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Gemmily 1 Mg-20 Mcg Capsule RX ORAL ethinyl estradiol/drospirenone Gianvi 3 Mg-0.02 Mg Tablet RX ORAL norethindrone acetate-ethinyl estradiol Hailey 21 1.5 Mg-30 Mcg Tab RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Hailey 24 Fe 1 Mg-20 Mcg Tab RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Hailey Fe 1.5-30 Tablet RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Hailey Fe 1-20 Tablet RX ORAL norethindrone Heather 0.35 Mg Tablet RX ORAL norethindrone Incassia 0.35 Mg Tablet RX ORAL levonorgestrel/ethinyl estradiol Introvale 0.15-0.03 Mg Tablet RX ORAL desogestrel-ethinyl estradiol Isibloom 28 Day Tablet RX ORAL levonorgestrel/ethinyl estradiol and ethinyl estradiol Jaimiess 0.15-0.03-0.01 Mg Tab RX ORAL ethinyl estradiol/drospirenone Jasmiel 3 Mg-0.02 Mg Tablet RX ORAL norethindrone Jencycla 0.35 Mg Tablet RX ORAL norethindrone acetate-ethinyl estradiol Jevantique Lo 0.5 Mg-2.5 Mcg RX ORAL norethindrone acetate-ethinyl estradiol Jinteli 1 Mg-5 Mcg Tablet RX ORAL levonorgestrel/ethinyl estradiol Jolessa 0.15 Mg-0.03 Mg Tablet RX ORAL norethindrone Jolivette Tablet RX ORAL desogestrel-ethinyl estradiol Juleber 28 Day Tablet RX ORAL norethindrone acetate-ethinyl estradiol Junel 1 Mg-20 Mcg Tablet RX ORAL norethindrone acetate-ethinyl estradiol Junel 1.5 Mg-30 Mcg Tablet RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Junel Fe 1 Mg-20 Mcg Tablet RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Junel Fe 1.5 Mg-30 Mcg Tablet RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Junel Fe 24 Tablet RX ORAL norethindrone-ethinyl estradiol/ferrous fumarate Kaitlib Fe Chewable Tablet RX ORAL desogestrel-ethinyl estradiol Kalliga 28 Day Tablet RX ORAL desogestrel-ethinyl estradiol/ethinyl estradiol Kariva 28 Day Tablet RX ORAL ethynodiol diacetate-ethinyl estradiol Kelnor 1-35 28 Tablet RX ORAL ethynodiol diacetate-ethinyl estradiol Kelnor 1-50 Tablet RX ORAL levonorgestrel/ethinyl estradiol Kurvelo-28 Tablet RX ORAL norethindrone acetate-ethinyl estradiol Larin 1.5 Mg-30 Mcg Tablet RX ORAL norethindrone acetate-ethinyl estradiol Larin 21 1-20 Tablet RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Larin 24 Fe 1 Mg-20 Mcg Tablet RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Larin Fe 1.5-30 Tablet RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Larin Fe 1-20 Tablet RX ORAL levonorgestrel/ethinyl estradiol Larissia-28 Tablet RX ORAL norethindrone-ethinyl estradiol/ferrous fumarate Layolis Fe Chewable Tablet RX ORAL norethindrone-ethinyl estradiol Leena 28 Tablet RX ORAL magellanrx.com 6 | 2020 Magellan Rx Management, LLC. All Rights Reserved_1220

RX/OTC Generic Name Label Name Form (FDB) Hormonal Contraceptives levonorgestrel/ethinyl estradiol Lessina-28 Tablet RX ORAL levonorgestrel/ethinyl estradiol Levonest-28 Tablet RX ORAL levonorgestrel/ethinyl estradiol and ethinyl estradiol Levono-E Estrad 0.15-0.03-0.01 RX ORAL levonorgestrel/ethinyl estradiol and ethinyl estradiol Levonor-E Estrad 0.1-0.02-0.01 RX ORAL levonorgestrel/ethinyl estradiol Levonor-Eth Estra 0.09-0.02 Mg RX ORAL levonorgestrel/ethinyl estradiol Levonor-Eth Estrad 0.1-0.02 Mg RX ORAL levonorgestrel/ethinyl estradiol Levonor-Eth Estrad 0.15-0.03 RX ORAL levonorgestrel/ethinyl estradiol Levonor-Eth Estrad Triphasic RX ORAL levonorgestrel/ethinyl estradiol and ethinyl estradiol Levonorg 0.15Mg-Ee 20-25-30Mcg RX ORAL levonorgestrel/ethinyl estradiol Levora-28 Tablet RX ORAL levonorgestrel/ethinyl estradiol Lillow-28 Tablet RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Lo Loestrin Fe 1-10 Tablet* RX ORAL levonorgestrel/ethinyl estradiol and ethinyl estradiol Lojaimiess 0.1-0.02-0.01 Tab RX ORAL ethinyl estradiol/drospirenone Loryna 3 Mg-0.02 Mg Tablet RX ORAL norgestrel-ethinyl estradiol Low-Ogestrel-28 Tablet RX ORAL ethinyl estradiol/drospirenone Lo-Zumandimine 3 Mg-0.02 Mg Tb RX ORAL levonorgestrel/ethinyl estradiol Lutera-28 Tablet RX ORAL norethindrone Lyza 0.35 Mg Tablet RX ORAL levonorgestrel/ethinyl estradiol Marlissa-28 Tablet RX ORAL medroxyprogesterone acetate Medroxyprogesterone 150 Mg/Ml RX INTRAMUSC norethindrone acetate-ethinyl estradiol/ferrous fumarate Melodetta 24 Fe Chewable Tab RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Mibelas 24 Fe Chewable Tablet RX ORAL norethindrone acetate-ethinyl estradiol Microgestin 21 1.5-30 Tab RX ORAL norethindrone acetate-ethinyl estradiol Microgestin 21 1-20 Tablet RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Microgestin 24 Fe 1 Mg-20 Mcg RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Microgestin Fe 1.5-30 Tab RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Microgestin Fe 1-20 Tablet RX ORAL norgestimate-ethinyl estradiol Mili 0.25-0.035 Mg Tablet RX ORAL norgestimate-ethinyl estradiol Mono-Linyah 28 Tablet RX ORAL norgestimate-ethinyl estradiol Mononessa 28 Tablet RX ORAL levonorgestrel/ethinyl estradiol Myzilra-28 Tablet RX ORAL norethindrone-ethinyl estradiol Necon 0.5-35-28 Tablet RX ORAL ethinyl estradiol/drospirenone Nikki 3 Mg-0.02 Mg Tablet RX ORAL norethindrone Nora-Be Tablet RX ORAL norethindrone-ethinyl estradiol/ferrous fumarate Noret-Estr-Fe 0.4-0.035(21)-75 RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Noreth-Ee-Fe 1.5-0.03Mg(21)-75 RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Noreth-Estrad-Fe 1-0.02(21)-75 RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Noreth-Estrad-Fe 1-0.02(24)-75 RX ORAL norethindrone acetate-ethinyl estradiol Norethind-Eth Estrad 0.5-2.5 RX ORAL norethindrone acetate-ethinyl estradiol Norethind-Eth Estrad 1-0.02 Mg RX ORAL norethindrone Norethindrone 0.35 Mg Tablet RX ORAL norethindrone acetate-ethinyl estradiol Norethin-Ee 1.5-0.03 Mg(21) Tb RX ORAL norethindrone-ethinyl estradiol/ferrous fumarate Norethin-Estra-Fe 0.8-0.025 Mg RX ORAL norethindrone acetate-ethinyl estradiol Norethin-Eth Estrad 1 Mg-5 Mcg RX ORAL magellanrx.com 7 | 2020 Magellan Rx Management, LLC. All Rights Reserved_1220

RX/OTC Generic Name Label Name Form (FDB) Hormonal Contraceptives norgestimate-ethinyl estradiol Norg-Ee 0.18-0.215-0.25/0.025 RX ORAL norgestimate-ethinyl estradiol Norg-Ee 0.18-0.215-0.25/0.035 RX ORAL norgestimate-ethinyl estradiol Norgestimate-Ee 0.25-0.035 Mg RX ORAL norgestimate-ethinyl estradiol Norg-Ethin Estra 0.25-0.035 Mg RX ORAL norethindrone Norlyda 0.35 Mg Tablet RX ORAL norethindrone-ethinyl estradiol Nortrel 0.5-35-28 Tablet RX ORAL norethindrone-ethinyl estradiol Nortrel 1-35 21 Tablet RX ORAL norethindrone-ethinyl estradiol Nortrel 1-35 28 Tablet RX ORAL norethindrone-ethinyl estradiol Nortrel 7-7-7-28 Tablet RX ORAL ethinyl estradiol/drospirenone Ocella 3 Mg-0.03 Mg Tablet RX ORAL norgestrel-ethinyl estradiol Ogestrel Tablet RX ORAL levonorgestrel/ethinyl estradiol Orsythia-28 Tablet RX ORAL norethindrone-ethinyl estradiol Philith 0.4-0.035 Mg Tablet RX ORAL desogestrel-ethinyl estradiol/ethinyl estradiol Pimtrea 28 Day Tablet RX ORAL norethindrone-ethinyl estradiol Pirmella 1-35 28 Tablet RX ORAL norethindrone-ethinyl estradiol Pirmella 1-35-28 Tablet RX ORAL norethindrone-ethinyl estradiol Pirmella 7-7-7-28 Tablet RX ORAL levonorgestrel/ethinyl estradiol Portia-28 Tablet RX ORAL norgestimate-ethinyl estradiol Previfem Tablet RX ORAL levonorgestrel/ethinyl estradiol Quasense 0.15-0.03 Mg Tablet RX ORAL desogestrel-ethinyl estradiol Reclipsen 28 Day Tablet RX ORAL levonorgestrel/ethinyl estradiol and ethinyl estradiol Rivelsa Tablet RX ORAL levonorgestrel/ethinyl estradiol Setlakin 0.15 Mg-0.03 Mg Tab RX ORAL norethindrone Sharobel 0.35 Mg Tablet RX ORAL desogestrel-ethinyl estradiol/ethinyl estradiol Simliya 28 Day Tablet RX ORAL levonorgestrel/ethinyl estradiol and ethinyl estradiol Simpesse 0.15-0.03-0.01 Mg Tab RX ORAL norgestimate-ethinyl estradiol Sprintec 28 Day Tablet RX ORAL levonorgestrel/ethinyl estradiol Sronyx 0.10-0.02 Mg Tablet RX ORAL ethinyl estradiol/drospirenone Syeda 28 Tablet RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Tarina 24 Fe 1 Mg-20 Mcg Tab RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Tarina Fe 1-20 Eq Tablet RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Tarina Fe 1-20 Tablet RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Tilia Fe 28 Tablet RX ORAL norgestimate-ethinyl estradiol Tri Femynor 28 Tablet RX ORAL norgestimate-ethinyl estradiol Tri-Estarylla Tablet RX ORAL norethindrone acetate-ethinyl estradiol/ferrous fumarate Tri-Legest Fe-28 Day Tablet RX ORAL norgestimate-ethinyl estradiol Tri-Linyah Tablet RX ORAL norgestimate-ethinyl estradiol Tri-Lo-Estarylla Tablet RX ORAL norgestimate-ethinyl estradiol Tri-Lo-Marzia Tablet RX ORAL norgestimate-ethinyl estradiol Tri-Lo-Mili Tablet RX ORAL norgestimate-ethinyl estradiol Tri-Lo-Sprintec Tablet RX ORAL norgestimate-ethinyl estradiol Tri-Mili 28 Tablet RX ORAL norgestimate-ethinyl estradiol Tri-Previfem Tablet RX ORAL norgestimate-ethinyl estradiol Tri-Sprintec Tablet RX ORAL levonorgestrel/ethinyl estradiol Trivora-28 Tablet RX ORAL norgestimate-ethinyl estradiol Tri-Vylibra 28 Tablet RX ORAL norgestimate-ethinyl estradiol Tri-Vylibra Lo Tablet RX ORAL norethindrone Tulana 0.35 Mg Tablet RX ORAL levonorgestrel/ethinyl estradiol Twirla 120-30 Mcg/Day Patch RX TRANSDERM magellanrx.com 8 | 2020 Magellan Rx Management, LLC. All Rights Reserved_1220

RX/OTC Generic Name Label Name Form (FDB) Hormonal Contraceptives levonorgestrel/ethinyl estradiol Tyblume 0.1-0.02 Mg Tablet RX ORAL drospirenone/ethinyl estradiol/levomefolate calcium Tydemy Tablet RX ORAL desogestrel-ethinyl estradiol Velivet 28 Day Tablet RX ORAL levonorgestrel/ethinyl estradiol Vienva-28 Tablet RX ORAL desogestrel-ethinyl estradiol/ethinyl estradiol Viorele 28 Day Tablet RX ORAL desogestrel-ethinyl estradiol/ethinyl estradiol Volnea 0.15-0.02-0.01 Mg Tab RX ORAL norethindrone-ethinyl estradiol Vyfemla 28 Tablet RX ORAL norgestimate-ethinyl estradiol Vylibra 28 Tablet RX ORAL norethindrone-ethinyl estradiol Wera 0.5/0.035 Mg 28 Tablet RX ORAL norethindrone-ethinyl estradiol/ferrous fumarate Wymzya Fe Chewable Tablet RX ORAL norelgestromin/ethinyl estradiol Xulane Patch RX TRANSDERM ethinyl estradiol/drospirenone Zarah Tablet RX ORAL ethynodiol diacetate-ethinyl estradiol Zovia 1-35 Tablet RX ORAL ethynodiol diacetate-ethinyl estradiol Zovia 1-35E Tablet RX ORAL ethinyl estradiol/drospirenone Zumandimine 3 Mg-0.03 Mg Tab RX ORAL Cervical Caps cervical cap Femcap 22 Mm Cervical Cap RX VAGINAL Diaphragms diaphragms, wide seal Wide Seal Diaphragm 60Mm RX VAGINAL diaphragms, wide seal Wide Seal Diaphragm 65Mm RX VAGINAL diaphragms, wide seal Wide Seal Diaphragm 70Mm RX VAGINAL diaphragms, wide seal Wide Seal Diaphragm 75Mm RX VAGINAL diaphragms, wide seal Wide Seal Diaphragm 80Mm RX VAGINAL diaphragms, wide seal Wide Seal Diaphragm 85Mm RX VAGINAL diaphragms, wide seal Wide Seal Diaphragm 90Mm RX VAGINAL diaphragms, wide seal Wide Seal Diaphragm 95Mm RX VAGINAL Other segesterone acetate/ethinyl estradiol Annovera Vaginal Ring* RX VAGINAL etonogestrel/ethinyl estradiol Eluryng Vaginal Ring RX VAGINAL etonogestrel/ethinyl estradiol Etonogestrel-Ee Vaginal Ring RX VAGINAL

3. Preventive Health for Women: Contraceptives—OTCs: Emergency Contraception, Condoms, and Spermicides. Quantity Limits apply. RX/OTC Generic Name Label Name Form (FDB) Emergency Contraception levonorgestrel Aftera 1.5 Mg Tablet OTC ORAL levonorgestrel Econtra Ez 1.5 Mg Tablet OTC ORAL levonorgestrel Econtra One-Step 1.5 Mg Tablet OTC ORAL levonorgestrel Levonorgestrel 1.5 Mg Tablet OTC ORAL levonorgestrel My Choice 1.5 Mg Tablet OTC ORAL levonorgestrel My Way 1.5 Mg Tablet OTC ORAL levonorgestrel New Day 1.5 Mg Tablet OTC ORAL levonorgestrel Opcicon One-Step 1.5 Mg Tablet OTC ORAL levonorgestrel Option 2 1.5 Mg Tablet OTC ORAL levonorgestrel Take Action 1.5 Mg Tablet OTC ORAL Condoms condoms, latex, lubricated Aimsco Latex Condom OTC MISCELL condoms, latex, lubricated Condoms Lubricated OTC MISCELL condoms, non-latex, lubricated Durex Avanti Real Feel Condom OTC MISCELL condoms, latex, lubricated Fantasy Condom OTC MISCELL condoms, female Fc2 Female Condom OTC MISCELL condoms, latex, non-lubricated Kimono Condoms OTC MISCELL condoms, latex, non-lubricated Kimono Maxx Condom OTC MISCELL magellanrx.com 9 | 2020 Magellan Rx Management, LLC. All Rights Reserved_1220

RX/OTC Generic Name Label Name Form (FDB) Condoms condoms, latex, lubricated Kimono Microthin Aqua Lube OTC MISCELL condoms, latex, non-lubricated Kimono Microthin Condom OTC MISCELL condoms, latex, lubricated Kimono Microthin Large Condom OTC MISCELL condoms, latex, lubricated Kimono Textured Condom OTC MISCELL condoms, latex, lubricated Trustex Condom OTC MISCELL condoms, latex, non-lubricated Trustex Condom OTC MISCELL condoms, latex, lubricated Trustex Latex Condom OTC MISCELL condoms, latex, lubricated Trustex-Ria Condom OTC MISCELL condoms, latex, non-lubricated Trustex-Ria Condom OTC MISCELL Spermicides nonoxynol 9 Gynol Ii 3% Gel OTC VAGINAL nonoxynol 9 Today Contraceptive Sponge OTC VAGINAL nonoxynol 9 Vcf Contraceptive Film OTC VAGINAL nonoxynol 9 Vcf Contraceptive Foam OTC VAGINAL

4. Preventive Health for Women: Contraceptives—Medical Drug Products: Implants and IUDs. Gender Edits and Quantity Limits apply. RX/OTC Generic Name Label Name Form (FDB) IUDS copper Paragard T 380-A Iud RX INTRAUTERI levonorgestrel Kyleena 19.5 Mg System RX INTRAUTERI levonorgestrel Mirena 52 Mg System RX INTRAUTERI levonorgestrel Skyla 13.5 Mg System RX INTRAUTERI Implants etonogestrel Nexplanon 68 Mg Implant RX INJ

5. Preventive Health for Adults, and Children: Vaccines. Gender Edits and Age Edits may apply. RX/OTC Generic Name Label Name Form (FDB) influenza virus vaccine quadrivalent /pf Afluria Quad RX INTRAMUSC influenza virus vaccine quadrival /pf Afluria Quad RX INTRAMUSC influenza virus vaccine quadrivalent Afluria Quad Vial RX INTRAMUSC influenza vaccine tvs/adjuvant mf59c.1/pf Fluad Syringe RX INTRAMUSC influenza vaccine quadrivalent/mf59c.1/pf Fluad Quad Syringe RX INTRAMUSC influenza virus vaccine quadrival /pf Fluarix Quad Syringe RX INTRAMUSC influenza virus vaccine qv rcmb/pf Flublok Quad Syringe RX INTRAMUSC flu vaccine quad cell derived/pf Flucelvax Quad Syr RX INTRAMUSC flu vaccine quadriv cell derived Flucelvax Quad Vial RX INTRAMUSC influenza virus vaccine quadrival /pf Flulaval Quad Syr RX INTRAMUSC influenza virus vaccine quadrivalent Flulaval Quad Vial RX INTRAMUSC influenza vaccine quadrivalent live Flumist Quad Nasal Vac RX NASAL influenza virus vaccine trival split/pf Fluzone High-Dose Syr RX INTRAMUSC influenza virus vaccine quadrival split/pf Fluzone High-Dose Quad RX INTRAMUSC influenza virus vaccine quadrival /pf Fluzone Quad Syringe RX INTRAMUSC influenza virus vaccine quadrival /pf Fluzone Quad Vial RX INTRAMUSC influenza virus vaccine quadrivalent Fluzone Quad Vial RX INTRAMUSC influenza virus vaccine quadrival /pf Fluzone Quad Pedi Syr RX INTRAMUSC hepatitis b vaccine recombinant/vaccine adjuvant Heplisav-B 20 Mcg/0.5 Ml Syrng RX INTRAMUSC cpg 1018/pf hepatitis b virus vaccine recombinant/pf Engerix-B 20 Mcg/Ml Syrn RX INTRAMUSC hepatitis b virus vaccine recombinant/pf Engerix-B 20 Mcg/Ml Vial RX INTRAMUSC hepatitis b virus vaccine recombinant/pf Engerix-B Pedi 10 Mcg/0.5 Syrn RX INTRAMUSC human papillomavirus vaccine, 9-valent/pf Gardasil 9 Syringe RX INTRAMUSC magellanrx.com 10 | 2020 Magellan Rx Management, LLC. All Rights Reserved_1220

RX/OTC Generic Name Label Name Form (FDB) human papillomavirus vaccine, 9-valent/pf Gardasil 9 Vial RX INTRAMUSC hepatitis a virus vaccine/pf Havrix 1,440 Units/Ml Syringe RX INTRAMUSC hepatitis a virus vaccine/pf Havrix 1,440 Units/Ml Vial RX INTRAMUSC hepatitis a virus vaccine/pf Havrix 720 Unit/0.5 Ml Syringe RX INTRAMUSC hepatitis a virus vaccine/pf Havrix 720 Units/0.5 Ml Vial RX INTRAMUSC hepatitis b vaccine recombinant/vaccine adjuvant Heplisav-B 20 Mcg/0.5 Ml Vial RX INTRAMUSC cpg 1018/pf meningococcalvaccine a, c,y,w-135,diphtheria Menactra Vial RX INTRAMUSC toxoid conj/pf meningococcalvaccine a, c,y,w-135,diphtheria Menveo A-C-Y-W-135-Dip Vial Kt RX INTRAMUSC toxoid conj/pf measles, mumps, and rubella vaccine live/pf M-M-R Ii Vaccine Vial RX SUBCUT hepatitis b virus vaccine recombinant/pf Recombivax Hb 10 Mcg/Ml Syr RX INTRAMUSC hepatitis b virus vaccine recombinant/pf Recombivax Hb 10 Mcg/Ml Vial RX INTRAMUSC hepatitis b virus vaccine recombinant/pf Recombivax Hb 40 Mcg/Ml Vial RX INTRAMUSC hepatitis b virus vaccine recombinant/pf Recombivax Hb 5 Mcg/0.5 Ml Syr RX INTRAMUSC hepatitis b virus vaccine recombinant/pf Recombivax Hb 5 Mcg/0.5 Ml Vl RX INTRAMUSC tetanus and diphtheria toxoids, adult Tdvax Vial RX INTRAMUSC tetanus and diphtheria toxoids, adsorbed, adult/pf Tenivac Syringe RX INTRAMUSC tetanus and diphtheria toxoids, adsorbed, adult/pf Tenivac Vial RX INTRAMUSC hepatitis a virus and hepatitis b virus vaccine/pf Twinrix Vaccine Syringe RX INTRAMUSC hepatitis a virus vaccine/pf Vaqta 25 Units/0.5 Ml Syringe RX INTRAMUSC hepatitis a virus vaccine/pf Vaqta 25 Units/0.5 Ml Vial RX INTRAMUSC hepatitis a virus vaccine/pf Vaqta 50 Units/Ml Syringe RX INTRAMUSC hepatitis a virus vaccine/pf Vaqta 50 Units/Ml Vial RX INTRAMUSC varicella virus vaccine live/pf Varivax Vaccine Vial RX SUBCUT varicella virus vaccine live/pf Varivax Vaccine with Diluent RX SUBCUT diphtheria,pertussis(acellular),tetanus vaccine/pf Adacel Tdap Syringe RX INTRAMUSC diphtheria,pertussis(acellular),tetanus vaccine/pf Adacel Tdap Vial RX INTRAMUSC diphtheria,pertussis(acellular),tetanus vaccine Boostrix Tdap Vaccine Syringe RX INTRAMUSC diphtheria,pertussis(acellular),tetanus vaccine Boostrix Tdap Vaccine Vial RX INTRAMUSC diphtheria, pertussis (acell), tetanus pediatric Daptacel Dtap Vaccine RX INTRAMUSC vaccine/pf pneumococcal 23-valent polysaccharide vaccine Pneumovax 23 Syringe RX INJECTION pneumococcal 23-valent polysaccharide vaccine Pneumovax 23 Vial RX INJECTION pneumococcal 13-valent conjugate vaccine Prevnar 13 Syringe RX INTRAMUSC (diphtheria crm)/pf vaccine adjuvant system, as01b/pf, component Shingrix Adjuvant Component RX INTRAMUSC vial 1 of 2 varicella-zoster virus glycoprotein Shingrix Ge Antigen Component RX INTRAMUSC e,rec,component 2 of 2 varicella-zoster virus glycoprotein e,rec/as01b Shingrix Vial Kit RX INTRAMUSC adjuvant/pf zoster vaccine live/pf Zostavax Vial RX SUBCUT

6. Preventive Health for Adults: Smoking Cessation (Prescription and OTC). Age Edits and Quantity Limits apply. RX/OTC Generic Name Label Name Form (FDB) bupropion hcl Bupropion Hcl Sr 150 Mg Tablet RX ORAL varenicline tartrate Chantix 0.5 Mg Tablet RX ORAL varenicline tartrate Chantix 1 Mg Cont Month Box RX ORAL varenicline tartrate Chantix 1 Mg Tablet RX ORAL varenicline tartrate Chantix Starting Month Box RX ORAL nicotine Cvs Nicotine 14 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Cvs Nicotine 2 Mg Chewing Gum OTC BUCCAL magellanrx.com 11 | 2020 Magellan Rx Management, LLC. All Rights Reserved_1220

RX/OTC Generic Name Label Name Form (FDB) nicotine polacrilex Cvs Nicotine 2 Mg Lozenge OTC BUCCAL nicotine polacrilex Cvs Nicotine 2 Mg Mini Lozenge OTC BUCCAL nicotine Cvs Nicotine 21 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Cvs Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Cvs Nicotine 4 Mg Lozenge OTC BUCCAL nicotine polacrilex Cvs Nicotine 4 Mg Mini Lozenge OTC BUCCAL nicotine Cvs Nicotine 7 Mg/24Hr Patch OTC TRANSDERM nicotine Eq Nicotine 14 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Eq Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Eq Nicotine 2 Mg Lozenge OTC BUCCAL nicotine polacrilex Eq Nicotine 2 Mg Mini Lozenge OTC BUCCAL nicotine Eq Nicotine 21 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Eq Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Eq Nicotine 4 Mg Lozenge OTC BUCCAL nicotine Eq Nicotine 7 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Eql Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Eql Nicotine 2 Mg Lozenge OTC BUCCAL nicotine polacrilex Eql Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Eql Nicotine 4 Mg Lozenge OTC BUCCAL nicotine Gnp Nicotine 14 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Gnp Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Gnp Nicotine 2 Mg Lozenge OTC BUCCAL nicotine polacrilex Gnp Nicotine 2 Mg Mini Lozenge OTC BUCCAL nicotine Gnp Nicotine 21 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Gnp Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Gnp Nicotine 4 Mg Lozenge OTC BUCCAL nicotine polacrilex Gnp Nicotine 4 Mg Mini Lozenge OTC BUCCAL nicotine Gnp Nicotine 7 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Gs Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Gs Nicotine 2 Mg Mini Lozenge OTC BUCCAL nicotine polacrilex Gs Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Gs Nicotine 4 Mg Lozenge OTC BUCCAL nicotine polacrilex Gs Nicotine 4 Mg Mini Lozenge OTC BUCCAL nicotine Hm Nicotine 14 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Hm Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Hm Nicotine 2 Mg Lozenge OTC BUCCAL nicotine polacrilex Hm Nicotine 2 Mg Mini Lozenge OTC BUCCAL nicotine Hm Nicotine 21 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Hm Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Hm Nicotine 4 Mg Lozenge OTC BUCCAL nicotine polacrilex Hm Nicotine 4 Mg Mini Lozenge OTC BUCCAL nicotine Hm Nicotine 7 Mg/24Hr Patch OTC TRANSDERM nicotine Kro Nicotine 14 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Kro Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Kro Nicotine 2 Mg Lozenge OTC BUCCAL nicotine polacrilex Kro Nicotine 2 Mg Mini Lozenge OTC BUCCAL nicotine polacrilex Kro Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Kro Nicotine 4 Mg Lozenge OTC BUCCAL nicotine polacrilex Kro Nicotine 4 Mg Mini Lozenge OTC BUCCAL nicotine Nicoderm Cq 14 Mg/24Hr Patch OTC TRANSDERM nicotine Nicoderm Cq 21 Mg/24Hr Patch OTC TRANSDERM nicotine Nicoderm Cq 7 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Nicorelief 2 Mg Gum OTC BUCCAL nicotine polacrilex Nicorette 4 Mg Chewing Gum OTC BUCCAL nicotine Nicotine 14 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Nicotine 2 Mg Lozenge OTC BUCCAL magellanrx.com 12 | 2020 Magellan Rx Management, LLC. All Rights Reserved_1220

RX/OTC Generic Name Label Name Form (FDB) nicotine polacrilex Nicotine 2 Mg Mini Lozenge OTC BUCCAL nicotine Nicotine 21 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Nicotine 4 Mg Lozenge OTC BUCCAL nicotine polacrilex Nicotine 4 Mg Mini Lozenge OTC BUCCAL nicotine Nicotine 7 Mg/24Hr Patch OTC TRANSDERM nicotine Nicotine Transdermal System OTC TRANSDERM nicotine polacrilex Pub Stop Smoking Aid 2 Mg Lozg OTC BUCCAL nicotine polacrilex Pub Stop Smoking Aid 4 Mg Lozg OTC BUCCAL nicotine polacrilex Quit 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Quit 2 Mg Lozenge OTC BUCCAL nicotine polacrilex Quit 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Quit 4 Mg Lozenge OTC BUCCAL nicotine Ra Nicotine 14 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Ra Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Ra Nicotine 2 Mg Lozenge OTC BUCCAL nicotine polacrilex Ra Nicotine 2 Mg Mini Lozenge OTC BUCCAL nicotine Ra Nicotine 21 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Ra Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Ra Nicotine 4 Mg Lozenge OTC BUCCAL nicotine polacrilex Ra Nicotine 4 Mg Mini Lozenge OTC BUCCAL nicotine Ra Nicotine 7 Mg/24Hr Patch OTC TRANSDERM nicotine Sm Nicotine 14 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Sm Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Sm Nicotine 2 Mg Lozenge OTC BUCCAL nicotine Sm Nicotine 21 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Sm Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Sm Nicotine 4 Mg Lozenge OTC BUCCAL nicotine Sm Nicotine 7 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Sw Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Sw Nicotine 2 Mg Lozenge OTC BUCCAL nicotine polacrilex Sw Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Sw Nicotine 4 Mg Lozenge OTC BUCCAL

7. Preventive Health for Adults: Smoking Cessation (Prescription Only). Age Edits and Quantity Limits apply. RX/OTC Generic Name Label Name Form (FDB) bupropion hcl Bupropion Hcl Sr 150 Mg Tablet RX ORAL varenicline tartrate Chantix 0.5 Mg Tablet RX ORAL varenicline tartrate Chantix 1 Mg Cont Month Box RX ORAL varenicline tartrate Chantix 1 Mg Tablet RX ORAL varenicline tartrate Chantix Starting Month Box RX ORAL

8. Preventive Health for Adults: Smoking Cessation (OTC Only). Age Edits and Quantity Limits apply. RX/OTC Generic Name Label Name Form (FDB) nicotine Cvs Nicotine 14 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Cvs Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Cvs Nicotine 2 Mg Lozenge OTC BUCCAL nicotine polacrilex Cvs Nicotine 2 Mg Mini Lozenge OTC BUCCAL nicotine Cvs Nicotine 21 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Cvs Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Cvs Nicotine 4 Mg Lozenge OTC BUCCAL nicotine polacrilex Cvs Nicotine 4 Mg Mini Lozenge OTC BUCCAL magellanrx.com 13 | 2020 Magellan Rx Management, LLC. All Rights Reserved_1220

RX/OTC Generic Name Label Name Form (FDB) nicotine Cvs Nicotine 7 Mg/24Hr Patch OTC TRANSDERM nicotine Eq Nicotine 14 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Eq Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Eq Nicotine 2 Mg Lozenge OTC BUCCAL nicotine polacrilex Eq Nicotine 2 Mg Mini Lozenge OTC BUCCAL nicotine Eq Nicotine 21 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Eq Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Eq Nicotine 4 Mg Lozenge OTC BUCCAL nicotine Eq Nicotine 7 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Eql Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Eql Nicotine 2 Mg Lozenge OTC BUCCAL nicotine polacrilex Eql Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Eql Nicotine 4 Mg Lozenge OTC BUCCAL nicotine Gnp Nicotine 14 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Gnp Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Gnp Nicotine 2 Mg Lozenge OTC BUCCAL nicotine polacrilex Gnp Nicotine 2 Mg Mini Lozenge OTC BUCCAL nicotine Gnp Nicotine 21 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Gnp Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Gnp Nicotine 4 Mg Lozenge OTC BUCCAL nicotine polacrilex Gnp Nicotine 4 Mg Mini Lozenge OTC BUCCAL nicotine Gnp Nicotine 7 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Gs Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Gs Nicotine 2 Mg Mini Lozenge OTC BUCCAL nicotine polacrilex Gs Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Gs Nicotine 4 Mg Lozenge OTC BUCCAL nicotine polacrilex Gs Nicotine 4 Mg Mini Lozenge OTC BUCCAL nicotine Hm Nicotine 14 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Hm Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Hm Nicotine 2 Mg Lozenge OTC BUCCAL nicotine polacrilex Hm Nicotine 2 Mg Mini Lozenge OTC BUCCAL nicotine Hm Nicotine 21 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Hm Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Hm Nicotine 4 Mg Lozenge OTC BUCCAL nicotine polacrilex Hm Nicotine 4 Mg Mini Lozenge OTC BUCCAL nicotine Hm Nicotine 7 Mg/24Hr Patch OTC TRANSDERM nicotine Kro Nicotine 14 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Kro Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Kro Nicotine 2 Mg Lozenge OTC BUCCAL nicotine polacrilex Kro Nicotine 2 Mg Mini Lozenge OTC BUCCAL nicotine polacrilex Kro Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Kro Nicotine 4 Mg Lozenge OTC BUCCAL nicotine polacrilex Kro Nicotine 4 Mg Mini Lozenge OTC BUCCAL nicotine Nicoderm Cq 14 Mg/24Hr Patch OTC TRANSDERM nicotine Nicoderm Cq 21 Mg/24Hr Patch OTC TRANSDERM nicotine Nicoderm Cq 7 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Nicorelief 2 Mg Gum OTC BUCCAL nicotine polacrilex Nicorette 4 Mg Chewing Gum OTC BUCCAL nicotine Nicotine 14 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Nicotine 2 Mg Lozenge OTC BUCCAL nicotine polacrilex Nicotine 2 Mg Mini Lozenge OTC BUCCAL nicotine Nicotine 21 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Nicotine 4 Mg Lozenge OTC BUCCAL nicotine polacrilex Nicotine 4 Mg Mini Lozenge OTC BUCCAL nicotine Nicotine 7 Mg/24Hr Patch OTC TRANSDERM magellanrx.com 14 | 2020 Magellan Rx Management, LLC. All Rights Reserved_1220

RX/OTC Generic Name Label Name Form (FDB) nicotine Nicotine Transdermal System OTC TRANSDERM nicotine polacrilex Pub Stop Smoking Aid 2 Mg Lozg OTC BUCCAL nicotine polacrilex Pub Stop Smoking Aid 4 Mg Lozg OTC BUCCAL nicotine polacrilex Quit 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Quit 2 Mg Lozenge OTC BUCCAL nicotine polacrilex Quit 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Quit 4 Mg Lozenge OTC BUCCAL nicotine Ra Nicotine 14 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Ra Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Ra Nicotine 2 Mg Lozenge OTC BUCCAL nicotine polacrilex Ra Nicotine 2 Mg Mini Lozenge OTC BUCCAL nicotine Ra Nicotine 21 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Ra Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Ra Nicotine 4 Mg Lozenge OTC BUCCAL nicotine polacrilex Ra Nicotine 4 Mg Mini Lozenge OTC BUCCAL nicotine Ra Nicotine 7 Mg/24Hr Patch OTC TRANSDERM nicotine Sm Nicotine 14 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Sm Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Sm Nicotine 2 Mg Lozenge OTC BUCCAL nicotine Sm Nicotine 21 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Sm Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Sm Nicotine 4 Mg Lozenge OTC BUCCAL nicotine Sm Nicotine 7 Mg/24Hr Patch OTC TRANSDERM nicotine polacrilex Sw Nicotine 2 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Sw Nicotine 2 Mg Lozenge OTC BUCCAL nicotine polacrilex Sw Nicotine 4 Mg Chewing Gum OTC BUCCAL nicotine polacrilex Sw Nicotine 4 Mg Lozenge OTC BUCCAL

9. Preventive Health for Adults: HIV Pre-Exposure Prophylaxis (PrEP). Quantity Limits May apply RX/OTC Generic Name Label Name Form (FDB) emtricitabine/tenofovir alafenamide fumarate Descovy 200-25 Mg Tablet RX ORAL emtricitabine/tenofovir disoproxil fumarate Emtricitabine-Tenofv 200-300Mg RX ORAL

10. Preventive Health for Women: Breast Cancer Age edits may apply. RX/OTC Generic Name Label Name Form (FDB) anastrozole Anastrozole 1 Mg Tablet RX ORAL exemestane Exemestane 25 Mg Tablet RX ORAL letrozole Letrozole 2.5 Mg Tablet RX ORAL

Drugs that are marked with * are not covered on Precision formulary